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Understanding and counseling special populations with HIV seropositive disease.

People infected with the human immunodeficiency virus (HIV) will likely constitute a growing number of rehabilitation clients in the years ahead. HIV positive (HIV+) patients are considered disabled under the law (Americans with Disabilities Act) and the new legislation will guarantee to them certain civil rights in employment, facility and service accessibility, and others for which the counselor may advocate. The absolute number of HIV+ people is growing geometrically, with 1 million people now affected (Angell, 1991) and their lifespan with new drugs having risen to 10-15 years post-diagnosis. This disease will present new challenges to rehabilitation counselors, although rehabilitation professionals have had other clients with life threatening illnesses (e.g., cancer, heart disease). Those new challenges will come from two directions:

* HIV+ patients will often have secondary disabilities. For example, IV drug users constitute 29 percent of AIDS patients (Devita, Hellman, & Rosenberg, 1988).

* Counselors will be increasingly faced with problems of countertransference (Macks, 1988; Sorenson, Costantini, & London, 1989).

Besides these new challenges, special subpopulations within this group will require either special attention to or emphasis on specific variables or may require completely unique approaches in assessment and counseling (e.g., clients with cultural backgrounds different from those of the rehabilitation counselor). These subpopulations include rural clientele, women, minority clientele, addicts, and homosexuals.

The stigma which will attach to these clients may be much greater than that experienced by other, more traditional rehabilitation, clientele, and many clients may be doubly stigmatized since AIDS usually affects people already stigmatized (Angell, 1991). The demands on confidentiality and psychosocial counseling skills of the counselor will be commensurately greater with this group (Faltz & Madover, 1987; Sorenson, 1989). In addition to these skills the counselor will need to pay close attention to skill areas which he or she may not have developed in the past, such as medical case management and sexuality counseling (Carballo & Miller, 1989).

The authors subscribe to the view of rehabilitation counseling offered by Thomas, Thoreson, Butler, and Parker (1992): "... the importance of a professional counseling relationship to rehabilitation is in the amelioration of handicaps created from the cumulative impact of psychosocial and physical barriers by people with disabilities" (p. 207). This paper, then, will elaborate these handicaps caused by HIV infection for special populations in particular, with a relevant literature review and suggestions for counseling programs which we have found promising for dealing with these handicaps.

Models of Psychosocial Reactions to HIV+

Holland and Tross (1985) noted that a person's response to HIV infection is mediated by medical (symptoms, course, and complications), psychological (personality, coping, and support), and sociocultural (stigma, custom, belief, and value) factors. A phase theory of reaction to HIV infection has been developed by Nichols (1985), where reactions can be ascribed to three stages:

* crisis

* transitional

* deficiency

The reactions to each phase can be described along a continuum from maladaptive to adaptive.

The crisis phase involves periods of anxiety and denial, with shock, guilt, anger, sadness, bargaining, and acceptance. The negative reactions (denial, anger, bargaining, and guilt) may cause additional problems for the person, such as further physical damage, social isolation, and other maladaptive behavior, such as drug abuse and dangerous sexual bravado (Devita, Hellman, & Rosenberg, 1988).

The transitional phase begins when denial is no longer the dominant emotion, but is superseded by periods of anger, guilt, self-pity, and anxiety. According to Nichols (1985), patients attempt to find meaning in their disease ("Why me?"), which is aggravated by social rejections, loss of self-esteem, changes in identity, and personal values. At this stage, the person is in great need of psychological counseling because of the great threat of social withdrawal.

Finally, in the deficiency stage, the person achieves and becomes comfortable with a new identity and accepts the limits imposed by his/her disease on his/her life. Oftentimes, people who are HIV+ "feel less victimized by life, become less ego-centric, and find satisfaction in altruistic and community activities" (Nichols, 1985, p. 766).

Another model of psychosocial adaptation to HIV+ disease is that of Hoffman (1991), which postulates four primary components:

* the special characteristics of the infection;

* the role of social support in the infected person's life;

* the characteristics of the situations or transitions the infected person faces; and

* the characteristics of the client.

Special Characteristics

Three characteristics apply to this component:

* HIV infection is a chronic progressive disease with a terminal prognosis, and proceeds from a state of being symptom-free to decline (characterized by full-blown AIDS);

* social stigma is associated with the disease itself and also with those previously stigmatized, such as gay men or needle-using addicts; and

* HIV infection strikes a certain age group, usually young adults aged 25 to 45 whose productive years are being severely disrupted.

Social Support

This model views social support from both personal and institutional perspectives.

First, the patient experiences a fear of interpersonal isolation and loss of relationships; and these fears are often realized. The patient often may feel "toxic" and withdraw from intimacy with others, including friends, families, and lovers. Hoffman reports that it is in this area in which support groups are particularly helpful and that patients who are involved with them are less dysphoric.

Second, the data on gay men suggest that they often have very limited number of people in their support systems and that this number may diminish with a diagnosis of HIV infection. When combined with other loss problems, this diminution becomes acute.

Third, institutional support is reduced, and takes the forms of unemployment (as the disease progresses), religious disaffiliation (since some religions see HIV infection as associated with sin), and a scarcity of community services available to seropositive people. Oftentimes, even AIDS support groups tend to target only white gay males as their primary members.

Characteristics of the Situation

This category has several subelements:

* the source of the infection;

* timing and latency period from infection to symptoms;

* role changes; and

* the variability in response to each of these factors.

Each person will respond differently to the manner in which the disease was contacted. Feelings ranging from guilt to blame are often associated with such attribution. Secondly, because of the long latency period that exists between the time of infection and the outbreak of symptoms, people may be living lifestyles at the time when symptoms appear that are totally different than those associated with the period of infection. There is also the sense of being cheated out of life, of being old before one's time. People who become seropositive face multiple role and role identity changes. They may be rejected by friends, families, or lovers. They may move from employed to unemployed, from healthy to sick, from independent to dependent, and so on. Finally, people move through various stages in response and adjustment to their disease. Such stages have been described as: "initial crisis, early adjustment, acceptance, and preparation for their death" (p. 483). Each stage is dealt with by the person in his/her own idiosyncratic style. Each of the variables associated with the characteristics of the situation or transition plays a major role in the individual's response to life and each is responded to in terms of the personality and social circumstances of the individual.

Characteristics of the Client

This category focuses on six variables:

* the psychosocial competence of the person;

* the person's cognitive appraisal of his/her disease;

* the person's gender and gender role identity;

* the person's race, ethnicity and social class;

* the state of the person's health; and

* the person's lifestyle associated with HIV infection.

Psychosocial competence is associated with self-esteem, coping skill, emotional hardiness, and beliefs of self-efficacy. Interactions among these variables may explain the person's success or failure in handling life events. Also, the way a person evaluates and appraises an event or circumstance governs the way he or she will emotionally and behaviorally respond to it. Characteristics of special populations engender a still broader diversity of response that complicates medical and psychosocial management of the disease.

Hoffman also mentions that medical perspective of HIV infection has changed, from one in which people were said to have either ARC or AIDS to one in which HIV+ people are diagnosed as asymptomatic or symptomatic or as having AIDS. Changes in health yield changes in life performance; the fact that specific behaviors (alcohol abuse, illicit drug use, venereal disease, etc.) suppress the immune system places behaviors and health status in a reciprocal dance which treatment personnel must acknowledge.

Countertransference

There is an entire body of research which treats the problem of negative counselor attitudes towards clients with disabilities, but the HIV+ patient presents a completely new twist on the problem.

First of all, the counselor may worry about problems of contagion. Gerbert, Maguire, Badner, Altman, and Stone studied the reactions of health professionals to AIDS (cited in Sorenson, 1989), and found the main reaction was that of fear.

Second, the counselor may have to deal with negative attitudes towards secondary disabilities (e.g., drug addiction) and feelings of homophobia. For instance, Faltz and Madover (1987) noted that counselors often take the attitude that substance abuse will somehow make the AIDS patient's life easier to endure. Or, according to these authors, they may take moralistic approaches, such as believing that the patient must hit bottom before intervention may be successful or that "they got what they deserved."

And, third (and perhaps most important), the counselor must deal with his or her own feelings about death, which are usually handled through denial (Yalom, 1980). Moreover, the counselor may be confronted with difficult client adjustment problems whose central referent is death anxiety, and the counselor may have difficulty in handling these problems. Yalom (1980) cites various empirical studies which allude to the central role of death anxiety in severe obsessional illness, hyperventilation syndrome, hypochondriasis, and depersonalization syndrome. However, the major concomitant of death anxiety in the succumbing direction seems to be depression, which has implications not only for management of the disease, but for rehabilitation programming as well.

Skill in grief counseling will need to take into account the pain, anger, fear, guilt, helplessness, and hopelessness of patients' families (Carballo & Miller, 1989). Additionally, counselors will have to become involved in areas of counseling which they may have avoided previously, such as that of sexuality.

Americans with Disabilities Act

The 1990 Americans with Disabilities Act (ADA) provides protection for HIV+ people in employment and accessibility to services. According to Batchelor (1984), HIV+ patients have been victims of job terminations and have been refused nursing and hospital services. ADA not only proscribes discrimination against these patients in medical and other public services, but it also protects HIV+ people who wish to compete for new employment or keep their present jobs. Under ADA, they need not reveal their disease to potential employers, since employers are enjoined from taking medical histories except in post-offer physical examinations (which must be administered to all people in a specific occupation). Even in the case of medical examinations, these must be related to essential job functions or to a direct threat to others in the employment situation (Turley & Beck, 1991). This direct threat could take the form of a kitchen worker's Hepatitis B, in which there is specific evidence that the worker could transmit the illness through food or kitchenware, or perhaps of a person who has poorly controlled paranoid schizophrenia in the job of police officer. HIV infection is relatively difficult to transmit, therefore, the ADA's standards offer plenty of protection for the person who is HIV+. Apparently, the only occupations which may be precluded for a person who is HIV+ are those in which there may be an occasion in which bodily fluid is exchanged. Rehabilitation counselors may perform a valuable service by advising their HIV+ clients that they are not required to respond to preemployment inquiries regarding their disease.

Rural Clientele

The incidence of HIV infection is rapidly increasing in the nation's rural areas (Centers for Disease Control, 1992). Moreover, the reported incidence of HIV in these areas may vastly underrepresent actual cases, since many rural residents are not aware of testing sites in their area; also, these sites may be so far from their homes that even when people are aware that there is something physically wrong with them they may still not be tested. Concerns about confidentiality may also impede testing.

HIV+ clients in rural areas have problems which are directly proportional to the rurality of the locale in which they live. The smaller the town, the more rural the residence. The fewer the jobs, services, and facilities available in the area, the more likely the HIV+ person is to be concerned with stigma (the grapevine effect in small towns) and accessible services (transportation, doctors, dentists, and other professionals) and to become fatalistic or depressed. In addition, the support systems available to these people, especially self-help groups, may be lacking because of distance or because people who are HIV+ may not be aware of each other or of these services.

The cultural overtones in rural areas often aggravate the problems mentioned above. First, rural people are often more religious and fundamentalist in their orientation. This may be a factor in stigmatization if the disease is interpreted as a plague from God on sinners. Second, it may add to the destruction of the person's support system if the person is rejected by family members, friends, employers, or others; this rejection may occur more frequently in conservative areas. Finally, if the person who is HIV+ shares these same cultural beliefs and values, that person may experience commensurately more guilt and shame, with their concomitant isolation and depression.

Women

The counseling needs of women with HIV infection will differ from those of men because of five differences between men and women:

* differences in mode of transmission;

* differences in clinical progression;

* cultural differences;

* women's reproductive capabilities; and

* women's social role of mothering.

Mode of Transmission

By July 1992, 24,323 women had become HIV+. Of these, 50 percent acquired the virus through intravenous drugs use, while another 35 percent contracted it through heterosexual contact. The majority (61 percent) of cases involving heterosexual contact were with partners who were also intravenous drug users (IVDU's) (Centers for Disease Control, 1992).

The problems of women IDVU's are many. Typically, they have few resources and must also care for children (Wofsy, 1987). If they have a sexual partner, it is most likely that he too is an IVDU (Cohen, Hauer, & Wofsy, 1989). In addition, these women have more medical problems, including malnutrition, anemia, hepatitis, high blood pressure, diabetes, urinary tract infections, dental disease, and sexually transmitted disease (Cohen, Hauer, & Wofsy, 1989; Mondanaro, 1988). The reason many have no financial support may be due to the family of origin being sexually or physically abusive (Chaffee, 1989) or it may be due to the stigmatization that results from drug use and/or prostitution (Cohen, Hauer, & Wofsy, 1989). All of these problems lead to increased stress and lower self-esteem for drug dependent women (Mondanaro, 1987).

HIV is about 12 times more likely to be transmitted from a man to a woman than from a woman to a man (Padian, Shiboski, & Jewell, 1990). There appear to be two factors which account for this. The first is the greater number of infected men which increases the probability that a woman's partner will be infected. The second possibility is that male-to-female transmission is more efficient. This is hypothesized to be due to the larger mucosal surface in the female genital tract (Alexander, 1990; Friedland & Klein, 1987).

Women are most typically infected in a heterosexual relationship by a drug using partner or a bisexual male (CDC, 1992). Women who have contracted HIV from a drug using partner may have many of the same economic and emotional problems as women who use intravenous drugs (Cohen, Hauer & Wofsy, 1989). Additionally, they may not feel they are at risk because they do not use drugs themselves (Karan, 1989). A different set of issues arises when a woman learns she has been infected by a partner she did not realize was bisexual. Typically there are feelings of betrayal and a questioning of her own femininity (Buckingham and Rehm, 1987).

Prostitution has also been cited as a major cause of the spread of HIV. However, the risk of HIV infection for prostitutes seems to be more a function either of their own intravenous drug use or the neglect of practicing safer sex in their personal relationships (Miller, Turner, & Moses, 1990).

Clinical Progression

Initially, it appeared that the clinical expression of HIV/AIDS in women was similar to the expression of HIV infection in men, with the exception that women seldom develop Kaposi's sarcoma (Poole, 1988; Wofsy, 1987). Later studies (Carpenter, Mayer, Fisher, Stein, & Danforth, 1990) have suggested that there may be a different clinical course. In their study of women in Rhode Island, Carpenter et al. (1989) found that esophagitis was the AIDS identifying infection in most (38 percent) of the women. This differs from other sources (Kristal, 1986) which have shown pneumocystis pneumonia to be the most frequent AIDS defining diagnosis. In addition, Candida albicans was found in 23 of the 24 women. Imam et al. (1990) have found a hierarchical, progressive pattern of Candida in women described in the following.

"Recurrent, often severe, vaginal candidiasis may occur in HIV-seropositive individuals with little or no suppression of CD4 or CD4/CD8.(1) Oral candidiasis generally develops after more marked immunosuppression, and esophageal candidiasis occurs only with severe immunocompromise" (p. 145).

The study by Carpenter, et al. (1989), also found an increased rate of chronic perianal herpes simplex virus in their subjects which may be gender related. Seropositive women also seem to be at an increased risk of human papillomavirus (a virus that causes warts) which is a precursor of cervical neoplasia (tumors of the cervix) (Sillman, Stanek, Sedlis, Rosenthal, Lanks, Buchhagen, Nicastri, & Boyce, 1984). From this study it is hypothesized, "... that cervical lesions may represent an early clinical manifestation of HIV in women" (Ickovics & Rodin, 1992, p. 6). Given these differences, women may need very different treatment from that which has been effective for men (Carpenter et al., 1989).

There are conflicting reports on whether women die earlier after a diagnosis of AIDS. Studies by Friedland, Saltzman, Vileno, Freeman, Schrager, and Klein (1991) and Rothenberg, Woelfel, Stoneburner, Nilberg, Parker, and Truman (1987) state that women die significantly sooner after an AIDS diagnosis than men. However, a report by Ellerbrock, Bush, Chamberland, and Oxtoby (1991) showed no significant differences in survival times between women and heterosexual males with AIDS. If there truly is a difference in survival times, it may be due to diagnosis and treatment occurring later in the disease process for women (Ickovics & Rodin, 1992). Women with HIV/AIDS may have a difficult time finding an AIDS-wise physician who is familiar with this disease in their gender (Rodin & Ickovics, 1990). Prevention efforts to this point have been geared toward opportunistic infections which affect men. Since these may be different in women, the counselor may need to help the client find a physician familiar with the clinical expression of AIDS in women. The counselor may also wish to help the woman push to be included in clinical trials. This will be difficult as women traditionally are excluded from clinical trials. According to Rodin and Ickovics (1990), this is true even in animal models and they state the reasons as follows:

"Female animals and humans are often dismissed as study subjects because their normal hormonal fluctuations are seen as potentially contaminating research results. An additional explanation for women's exclusion from this research includes avoiding possible toxic exposure to women of childbearing age" (p. 1025).

A few women were included in the trials of AZT (Fischl, Richman, et al., 1987). Given the increasing number of women who are HIV-infected, it is hoped that more will be included in future studies.

Pregnancy

It has been recommended that women who are HIV+ postpone pregnancy until more is known about the impact of the disease (Centers for Disease Control, 1986). It has also been recommended that women who are infected be informed of all reproductive options, including abortion (American College of Obstetricians and Gynecologists, 1988). The reasoning behind this is if a woman knows she is HIV+ and receives counseling about the dangers of infecting her child as well as possible increasing her own chances of developing AIDS, she will choose not to become pregnant (Sunderland, Minkoff, Handte, Moroso, & Landesman, 1992). This has not been the case in many instances (Selwyn, Carter, Schoenbaum, Robertson, Klein & Rogers, 1989; Sunderland et al., 1992). The reasons women risk having an infected baby are many. For both black and Hispanic cultures, a great value is placed on a woman's ability to reproduce. For these women, having a child may improve their status in the community. Often, pregnancy is the one time a chemically dependent woman may feel good about herself.

For some women, a baby is the one thing they have to love that will love them back. Many times, the risk is taken so that a child is left as a legacy (Levine & Dubler, 1990). Others may have a child to replace a child lost to death or foster care. Still, for others who are asymptomatic there may be an element of denial that they have the disease (Miller, Turner, & Moses, 1990). Finally, "the birth of a child may also serve as a social bond to a continuing relationship with a Black male who, because of the scarcity of men, is a precious commodity" (Mays & Cochran, 1988, p. 953). Whether or not a pregnancy hastens the progression of a woman's HIV infection to AIDS is not known for certain. Studies by Biggar, Panwa, Minkoff, Mendes, Willoughby, Landesman, and Goedert (1989) as well as Minkoff, Nanda, Menez, and Fikrig (1987) indicate that there is an acceleration. A study by Selwyn, Schoenbaum, Davenny, Robertson, Feingold, Shulman, Mayers, Klein, Freidland, and Rogers (1989) found no acceleration of infection during pregnancy. Minkoff et al. (1987) have suggested that pregnant seropositive women are only at risk of acceleration of their disease if their CD4+ count is below 300.

The AIDS epidemic is posing a threat to the reproductive rights of women (Mantell et al., 1988). Many women are afraid that women, especially those of color, will be forced to submit to court-ordered fetal lifesaving obstetrical interventions (Kilder, Gallagher, & Parsons, 1987). Others are concerned that involuntary sterilization of infected women as well as involuntary testing of high-risk groups will be proposed (Newman, 1987).

Mothering

Currently, 85 percent of pediatric cases of AIDS have been contracted through perinatal transmission (Center for Disease Control, 1992). These children, then, have mothers who are HIV+. In most households it is the mother who assumes the caretaker role when a child is ill. However, in these cases the mother is often too ill to care for her children (Campbell, 1990). A summary of these women's needs relative to child care is given in the introduction to the Women and AIDS: Clinical Resource Guide (1987). It states:

"Women with children need child care services not only for the times they are too ill to care for their children, but for the time consuming task of dealing with a life threatening illness. In order to comply with medical care and treatment protocols, keep social service appointments, and seek mental health and support services, child care services need to be available" (p. 7).

Mothers who are chemically dependent may have even more concerns. These women may be facing legal problems because of drugs or prostitution. Many times, a spouse will leave a chemically dependent woman, who may therefore need legal help in the areas of divorce or child custody (Reed, 1988).

According to Ybarra (1991), the major needs of HIV+ mothers is help to forgive themselves and preparation for leaving their children behind. She also notes that the counselor may need to help find homes for the children.

Minority Clientele

Counselors may have traditional problems with countertransference towards minority clients (Jones, 1987), which are compounded by the fears that counselors have with issues related to HIV+ infection (contagion, death anxiety, homophobia). According to the National Clearinghouse for Alcohol and Drug Information (1990), blacks and Hispanics make up 39 percent of all IVDU-HIV+ related cases and 71 percent of all HIV+ cases among women, even though blacks and Hispanics are only 20 percent of the population. Also, counselors may misinterpret information about culturally different clients to the point that the client leaves the counseling situation or the counselor actually inflicts harm unintentionally. Minority clients also have specific medical case management needs which the counselor may encounter. Some clients who are marginally acculturated and who still depend upon traditional cultural mores may choose either to deny symptoms and their illness or to seek help from shamans rather than medical personnel. These tendencies may promote the spread of the disease within specific minority communities. Counselors who are sensitive to utilitarian ethics (the greatest good for the greatest number) may wish to consider prevention tactics in order to combat this spread.

One area which prevention-minded counselors may consider is that of sex education for ethnic people. Peterson and Marin (1988) point out that among some black men, there exists a belief that they are not at risk for HIV+ as long as they do not engage in sex with a white gay male. Briggs (1987) ascribed the increase of HIV+ in the black community to economic factors (e.g., joblessness) and Fullilove and Fullilove (1989) reported that the increase of crack-cocaine use leads to high-risk practices such as the exchange of sex for drugs or money. As was pointed out above, Mays and Cochran (1988) argued that the scarcity of eligible black men was a factor in pressuring some black women to give into unsafe sex to maintain a relationship. Dalton (1989) points out that the African-American church, being fundamentalist and conservative, has stood in the way of AIDS education. The same author noted that many African-Americans view the AIDS epidemic as genocide aimed at blacks. Finally, Jordan (1991) has described attitudes on the part of many black women in which they are unwilling to "tell her business" outside the family and a moral imperative that she be able to handle things on her own.

The Hispanic population of the United States (including Mexican-Americans, Puerto Ricans, Cubans, and others) is seen by various researchers as having increased risk for HIV infection. Amaro (1988) noted the younger mean age of Hispanics, which means relatively more experimentation with sex and drugs. Mays and Cochran (1988) mention that their risk is one more item which is wrapped up in their culture of poverty. Ventura (1987) mentions Hispanic women's higher fertility rate and their propensity to bear children earlier and continue later than Anglo women. Other culturally-based beliefs and values in the Hispanic community which interact with the HIV epidemic are a belief in folk healers(2) and a fatalistic, external locus of control (Comas-Diaz, 1990); a tolerance for extramarital affairs by men (Carrier, 1985; Espin, 1985); and a reluctance to disclose private matters outside the family combined with a preference to cope by praying and/or withdrawal into daydreaming or drug use (Nyamathi & Vasquez, 1989).

Addicts

HIV infection interacts with two principal groups of addicts: alcoholics and intravenous drug users. Both alcohol and opiate derivatives adversely affect the body's immune system (Ferrando & Batki, 1991; Institute of Medicine, 1986), which in turn makes the body more vulnerable to HIV disease progression. Malnutrition also is a complication of alcohol and other drug addictions, which indirectly affects the immune system. An example of the price being paid by immunosuppression is the recent rise in tuberculosis, a disease once thought to have been eradicated (Langone, 1988). Other diseases which are complications of being HIV+ interact with alcohol and drugs. These include pneumocystis carini (Langone, 1988), muscle damage and weakness, cancer (West, 1984), and neurological diseases, such as headaches, aphasia, seizures, gait disturbance, visual disturbances, incontinence, and forgetfulness (Falvo, 1991). Medical management of HIV patients who are also addicts is complicated because addicts engage in lowering inhibitions regularly-(which promotes high-risk behaviors); they ignore their nutritional necessities; and they neglect treatment elements which have been prescribed by their medics.

Counselors who are engaged in helping addicts may encounter three problems which have arisen with the HIV virus:

The first is that of the spread of HIV through contaminated needle sharing. The corollary of this problem is that public laws and policies, which make drug paraphernalia illegal, actually promote needle sharing to avoid prosecution and safehouses as loci in which drug subcultures exist to provide these illegal items.

The second problem is the drug and alcohol interaction with human immune systems. Thus, a person who is abusing or addicted to alcohol and/or drugs is actually hastening the onset of symptoms and death by further suppressing the immune system.

The third problem is that the focus of most substance abuse counselors is on abstinence, and those life problems (work, secondary disabilities, meaning-of-life issues, etc.) which may interfere with abstinence are either seen as justification for rationalization and denial or as distractions from the main goal of abstinence. The problems most immediate for HIV sufferers may be in the areas of depression, grief, and loss, rather than addiction itself. Counselors must therefore be trained to deal with these other areas and have the ability to "change gears" as needed in order to deal with' the person as a whole. It seems apparent that traditional drug and alcohol counseling and rehabilitation needs to look at abstention as being inextricably intertwined with psychosocial sequelae of HIV infection.

Homosexuals

Homosexuals have traditionally had the highest incidence of HIV infection than any other group, although this is rapidly changing. Two significant problem areas that gay HIV+ people may experience are those of double stigmatization and depression. The stigmatization may be experienced in interactions with friends, lovers, family, employers, professionals, and others. When turned inward, the stigmatization often is productive of exogenous depression which tends to aggravate the discrimination which being either HIV+ or gay may already pose. That is, the person joins in his or her own victimization and abuse by self-denigration. The Institute of Medicine (1986) cited a longitudinal study which compared levels of distress in homosexuals and found that those who suffered from AIDS-related complex (ARC) had greater psychological problems.

Treatment

According to Coates, Temoshok, and Mandel (1984), social support has a direct positive effect on the person's health. Thus, self-help or support groups are essential for the person with HIV infection to fulfill educational, moral support, spiritual, and/or religious needs. These groups can counteract negative reactions, especially those which are related to withdrawal. The release from sympathetic nervous system reactions involved in anger, or those involved with the parasympathetic system such as depression, have improved immunological functioning (Smith, 1989). And finally, support groups may, through mutual support and encouragement, prevent life-negating acts involved in self-neglect and suicide. This fact alone points out the importance and urgency of support groups. Male AIDS patients between the ages of 20 and 59 are 36 times more likely to commit suicide than other men (Marzuk, Turney, Gross, Tarcliff, Morgan, Mann, & Hsu, 1988).

Counseling and therapy need to be modified to accommodate HIV patients. First of all, counselors need to address their own feelings with regard to death and dying and isolation and their reactions to culturally different clients or homosexuals. Kelly (1985) states that counselors should examine their own beliefs about God, death, and the afterlife because these beliefs may have a powerful effect on the course of counseling, such as in the tendency to blame the victim for a religious transgression. Counselor denial or rejection can be detected by clients, which then can deepen their depression and aggravate their self-esteem problems, not to mention increase their drop-out rate.

Counselors in substance abuse treatment centers need to attend to the way HIV patients use drugs and alcohol. The sudden removal of them may also deprive the client of a coping mechanism; besides, the client may be much more motivated to deal with grief issues rather than the need to abstain (Batki, Sorensen, Faltz, & Madover, 1988). Also, Stall, Watters, and Case (1989) ask how treatment personnel can demand abstinence of a client when they are showing them safe ways to sterilize their injection equipment.

Methadone maintenance programs for IVDU-HIV patients have several advantages: Their retention rate is higher than outpatient detox and residential therapeutic communities (Ferrando & Batki, 1991); these programs obviate the need for unsafe injection; methadone clinics may also treat the client for their other needs--social, psychiatric, and vocational--besides their addiction ones (Ferrando & Batki, 1991); and methadone is not as harmful as street heroin in suppressing the immune system (Ferrando & Batki, 1991).

Because of the stigma and isolation that women with AIDS encounter, the counselor working with women who have AIDS may also be a case manager and a support system. Stigma affects women in a variety of ways:

* HIV infection has long been identified as a man's disease, thus giving infected women a profound sense of isolation;

* because seropositive women are such a diverse group, there is little peer support available;

* if the woman has been infected by a male, she faces the stigma associated with his behavior; and

* a woman always faces stigma if she does something that seemed harmful to the developing fetus during pregnancy (Women and AIDS: Clinical Resource Guide, 1987).

Counseling a seropositive woman may progress through three phases:

The first occurs immediately after the diagnosis when the counselor may need to work with the client on concerns such as anger and denial.

The second phase presents the woman with three tasks: getting on with life, facing and grieving the losses, and coping with the unpredictability of the disease (Women and AIDS: Clinical Resource Guide, 1987). The counselor may wish to use strategies such as assertiveness training, teaching coping skills, thought stopping, cognitive reframing, relaxation, and meditation to assist the client with these tasks (Hoffman, 1991). In addition, the counselor may wish to help the client develop or strengthen her support system.

The final phase of the counseling process occurs as the client nears death. The tasks at this time may involve facing fears of death or the dying process, pain management, and supporting those left behind. "Interventions must be designed to work with the entire support system by honoring the patient's wishes and facilitating the dying process for all involved" (Women and AIDS: Clinical Resource Guide, 1987, p. 10).

Notes

1. CD4 and CD8 are T-cell subgroups; these cells are analyzed in the evaluation of the health of the immune system.

2. Folk healers refer to practitioners of spiritual healing; in Mexico, for example, practitioners of "brujeria" and in Puerto Rico, "santeria." Some Hispanic people may go to folk healers instead of, or prior to, a medical physician.

Dr. Beck is Assistant Professor, Rehabilitation Counselor Programs, at Southern Illinois University at Carbondale. Mr. Carlton was formerly with Jackson Community Workshop, Murphysboro, Illinois. Dr. Allen is a professor at Southern Illinois University at Carbondale. Ms. Rosenkoetter and Ms. Hardy are graduates of the Rehabilitation Counselor Training Program at Southern Illinois University at Carbondale and are now in rehabilitation practice.

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