Counselling gay men with multiple loss survival problems: the bereavement group as a transitional object


ABSTRACT: When AIDS is becoming a chronic disease, gay men with multiple loss experiences can easily turn into a forgotten group of widowers. Due to new medical treatment HIV infected gay men are living longer and also have to deal with loss and surviving. This paper argues in favour of group grief therapy for multiple loss and survival problems, within the scope of peer support in the gay community during the AIDS era. In this group psychotherapy special attention is given to the influence of a low gay self-esteem on the grief process and surviving strategies.

INTRODUCTION
Gay men are confronted with loss of partners, friends and health because of AIDS. If AIDS is becoming a chronic disease, they can easily turn into a forgotten group of widowers with grief issues. Moreover HIV-infected persons with loss experiences are nowadays confronted with grief and survival issues. Facilitating the mourning process in gay men with multiple loss experiences is the main aim of this paper, as well as creating new future perspectives for seropositive persons, under treatment of combination therapy, who also suffer from losses. After describing symptoms of multiple loss, special attention is given to the methods of managing a gay bereavement group, the development of the grief group process, and the complication of a negative self evaluation on the wish to survive in the AIDS era.
Multiple loss differs from single loss because the confrontations are extensive, progressive, accumulative and traumatic. The tasks of mourning are interrupted by new losses. Multiple loss is defined as 'chronic bereavement that involves not only chronic grief, but also anticipatory grief and unresolved grief, and the experience of several losses simultaneously' (Cho & Cassidy, 1994). The exposure of ongoing loss to gay men can easily result in bereavement overload.
This complicated loss is characterized by the fact that no aspect of life or identity is unaffected. There is no safe haven, no place to get away from the impact of loss (Marion, 1996). Loss includes also work, health and a future (Klein, 1994). Symptoms of this pervasive loss are: depression, survivor guilt and shame of being gay. AIDS is associated with a gay lifestyle and with gay (anal) sex: 'bad things happen to bad people' is the explanation one group member expressed. The trauma is still ongoing and gets integrated in the personality, which means it becomes chronic and will complicate the mourning process.
The mouming process can be complicated by factors such as the serostatus, type of relationship, circumstances surrounding loss, personality variables and disappearing social support network. This is very near to pathological grief or chronic trauma (Klein, 1997; Worden 1991).
Due to the hopeful treatment with protease inhibitors many HIV-infected persons have new future perspectives, which means that psychological problems because of loss and survival are more and more blending into one another.
Bereavement groups can constitute a preventive intervention for the high-risk population of bereaved persons (Yalom, 1988). The context of a group offers emotional support, and for the high-risk group of gay men in the HIV epidemic it can be a very effective way of mourning, of re-evaluating the authentic self, and developing new bonding strategies.

METHODS
Due to the experiences of multiple loss in the gay community the limits of individual psychotherapy became clear. A growing group of gay men with these loss experiences suffered from severe social isolation. Individual psychotherapy could only partly meet the indispensable social support and affirmation in a face-to-face contact. For those reasons group psychotherapy was set up for gay men, in the hope that it could offer more results like other peer group initiatives.
In January 1996 a bereavement group for gay survivors with complicated and multiple loss started at the SAD-Schorer Foundation in Amsterdam. The participants had lost three or more partners or friends. The group is open-ended, the meetings are once a week, 90 minutes in length. A maximum of eight gay men participate in the sessions. Since the start of the group five members have completed their psychotherapy and left, after participating for one year up to one year and nine months. The average age of the participants is 42.5 years.
As a result of the new medication with protease inhibitors many HIV-infected persons live longer and become gay grievers as well as long-term survivors. So seropositive gay men become also participants of the bereavement group. The group started with seronegative members only. After one and a half year three new participants did engage with a seropositive serostatus. These new circumstances are adding an extra dimension to the survival aspect in the bereavement group: handling medical compliance, finding again a joie de vivre' and filling in an unexpected future, which at the same time is yet uncertain.
The coping strategy to loss is characterized by a regulating process of attachment versus detachment, a pendulum swinging between disintegration and restoration (Stroebe et al., 1993). Oscillating between the loss-orientation and the restoration-orientation is supposed to have a healing effect. The grief process in gay men with multiple losses is characterized by switching between these two orientations, but now for each unique loss this swinging movement has to be repeated. In this way grieving is moving into a circular process (Marion, 1996). As more seropositive persons are going to live longer - due to the combination therapy - new survival strategies have to be developed, which implicates a shift from death-orientation to long term surviving. Until a few years ago people with AIDS had been prepared to die sooner or later, and today many of them are not ready for surviving (Rothman, 1996).
Surplus value of a group setting in comparison with individual therapy can be considered: breaking through social isolation; delivering peer support; creating reciprocal affirmation as gay widowers; confrontations by members with different grief reactions; approval of a gay life style; and an installation of hope each time a member completes the group therapy (Sandstrom, 1996). The psychodynamic interactions of the group were assumed to develop through different stages characterized by: dependency, conflict, cohesion and intimacy (Yalom, 1975). Because the group is open-ended these stages are developing into a continuum.
In group psychotherapy transference reactions are not limited to the working alliance between one client and a therapist. In a group setting of grief work with gay men who suffer from multiple loss, reciprocal transferences between the gay members can be useful in the therapeutic process. The processes of idealizing, mirroring or twinship bonds are expected to develop more frequently between participants in a group. These transference reactions can be used to reveal early deficits of the bereaved gay men, and explore core conflicts in their relationships, which can stagnate the grief process and interfere with new future bonding. The psychotherapeutical interventions in this bereavement group are based on the frame of reference of self psychology (Kohut, 1972; Shelby, 1995) and object relation theory (Cornett, 1993; Winnicott, 1958).
The potential group members are selected through indication criteria such as: number of grief experiences; social network; acceptance and appreciation of gay lifestyle; serostatus and HIV infection; handling safe sex; family of origin; psychiatric symptoms (depression, anxiety, suicidal ideation); medication schedule; Global Assessment of Functioning Scale (among other things participation in the working process); and personality organization. These criteria indicate the level of psychological functioning of the person, attending the way of handling multiple losses and the way of dealing with a gay lifestyle, an eventual HIV infection, medical compliance and survival problems.
The selection process also includes an indication concerning the participation in a group: motivation for group therapy; dominant defence mechanisms (early versus mature); ego strength; capacity of communication; and potential cohesive attitude. Contraindications to participate in the bereavement group are: suicidal ideation; acute grief due to very recent losses; personality disturbances of cluster A (DSM-IV) and a lower borderline state.
This paper on multiple grief processes and survival problems in a bereavement group is based on interviews with gay men (N= 14), and on content analyses of protocols from 50 sessions of group psychotherapy With clients who suffered from multiple loss experiences. First, attention is given to the need to borrow an identity from gay grief (Mein & Fletcher, 1987), second, to the tendency to act out rage towards the 'outside hostile' world; and finally, a developing insight of group members in their psychological conflicts about being gay and eventually being HIV infected is described.

RESULTS
Identity borrowed from gay grief
During the grief work the group members exchanged their experiences and shared all kind of aspects of their losses. They disclosed the desire to talk about the deceased, to look at photographs and bring up memories. In this stage, the tendency to over-idealize the deceased dominates, neutralizing the rage that cannot yet be contained. Again and again the feelings of missing and sadness were repeated. Two members pretended that they still were in touch with their deceased lover. They talked about having dialogues, receiving advice, and even visiting a medium who pretends to keep on the contact.
In this way the members are opposing the therapeutic aim of separation. Detachment is not yet possible. The therapeutic interventions are loss-oriented: focusing on grief and pain with regard to the loss of partners, friends, work, home, health, and survival guilt.
Right from the start of the group, dependency dominated between members, brought about by the loss experiences they had in common. The desire to break through the grinding loneliness and to affirm a feeling of regained sameness was so strong, that between the sessions members started to meet each other socially. A ritual developed of drinking coffee together after each session. Two members did meet each other for cultural activities, which they had not frequented for more then a year.
These initiatives show once more that a new identity is born out of gay grief, just like the need for mirroring and bonding. It is, moreover, a cry for affirmation, which so suddenly disappeared. 'Me need for new self objects is perceptible: new twinship brothers filling up the empty places.
The bonding with other widowers involved cherishing symbiotic illusions: members hoped that friendships would develop among them and might continue beyond the life of the group. Two members were making plans for a joint holiday; a journey one of them made for the very last time with his lover. In the end, the renewed 'honeymoon' was cancelled, because it appeared that one of them did fall in love. The intended participant could not fulfil the expectations.
In the sessions those erotic transferences were interpreted as a premature attempt to regain a new affirmating love object to avoid the pain of loss and to pass by the grief. So, from one point of view of mouming, these fantasies and meetings between sessions can be considered as denial of grief and regression, excluding the therapist's influence. From another view, one of the tasks of mouming is allowing new people into one's life. So these meetings can also be interpreted as a progressive development, provided that illusions, erotic fantasies and meetings are explored with regard to the specific missing needs, instead of only cherishing them for the time being.
When interdependency has developed into group cohesion and a new 'temporary identity' is found as gay grievers, the group is ready to change into a transitional object. Such an object facilitates separation from the deceased love object. It is time for a further step in grief work.

Acting out murderous rage
In the dependency stage, the group is functioning like a 'consoling mother'. Later on the process turns into a stage characterized by authority conflicts, and the group is ready to contain the externalized rage.
The very first conflict was about the authority of the therapist, attacking the ground rules of the group psychotherapy such as not talking about therapy issues outside the sessions. The expression of this rage can be explored and interpreted as an attempt to ward off grief.
After about ten sessions, the anger was directed towards the family of origin of the deceased by three participants. Rivalry, especially with the 'mother-in-law', was remarkable: she accused the former partner of not caring enough, and having infected her son. She took her son away to the parental home, and did not allow the cause of death to be mentioned at the memorial service, refused to add the survivor's name to the death notice, removed personal artifacts of the beloved friend from her son's home and excluded the survivor from the inheritance. Each time a member disclosed such painful experiences a wave of rage and a cry of indignation went through the group. Affirmation and recognition were reinforcing the cohesion between the group members.
In this stage of the grief process, five survivors were also angry at their own parents. Disappointment and anger towards their fathers was mentioned: he did not support them during the illness of their partners and friends. Those survivors did not feel the recognition as gay widowers from their parents. Sometimes families were avenged for it afterwards. For instance, the survivor who was forbidden to disclose being gay designed a provocative tombstone with a pink triangle.
The expression of this rage is only partly realistic, because the externalization seems also part of an unresolved internal conflict about being gay. It refers to the emotional rather than the real loss of the love object (Freud, 1917). Later on in the mouming process we will see that the rage also appears to be directed internally. Destroying oneself, fantasies about suicide, can be the ultimate consequence.
After externalization of the rage to the outside world, feelings of anger were directed toward the deceased who left the survivors behind. Four members expressed their anger about their partner because they hid their illness and their sexual preference, did not allow friends to pay a visit, did not make a will, took health risks and had sexual contacts with others. In the end, they left them (the survivors) alone. What was expressed here towards the partners was meanwhile also directed toward close friends who passed away because of AIDS.
Two seropositive participants could admit feelings of anger because they probably were infected by the deceased partner. These feelings were triggered by the new circumstances of the medical treatment of HIV which is changing their future perspectives. They had still expected to 'join' the deceased partner and friends in the near future. Now, they probably had to deal with surviving alone which, in this stage of the grief process, caused feelings of anger towards the beloved one who took too many risks. One participant expressed feeling guilty about his partner when he realizes he may survive and this problem is interfering with his medical compliance behaviour in a negative way.
In this stage, the (over-) idealization of deceased partners and friends is corrected by devaluative remarks, an adjustment toward reality. This is an important step on the way to detachment. After a period of strong cohesion, the group members become able to differentiate their personal identities.
After 25 sessions an awareness develops that twinship bonding in the bereavement group has a temporary character, and is unlikely to constitute new lifelong friendships. Grief tasks about the lost friends are coming to an end now. Symbiotic illusions are no longer cherished. The bereavement group is now functioning like a transitional object, that in the end is left alone. Before that moment has appeared it is important to be able again to meet new significant friends.

False or true self?
When the group has achieved the stage of intimacy, the core conflict of each member with regard to separation and autonomy becomes clear. Restrictive solutions are no longer effective. The interventions are focused on the main question: what does the way group members managed their conflicts reveal about their self-esteem?
Participants were able to look back at their dependent attitude towards the beloved person during the course of the disease. After periods of severe depression and even suicidal ideation, three members were consequently angry with themselves for having co-operated in hiding the fact that they were gay or AIDS as the cause of the partner's illness. Now they realized how, in fact, they were denying themselves. At that time they collaborated, because they were afraid that openness could result in their partner leaving them.
The same members discovered that earlier on the affirmative power of sexuality had been more important than the drive for survival. Also, out of fear of abandonment, they had unsafe sex and were tested seropositive. They could not bear at that time further lack of affirmation, whatever happened. These feelings of shame were expressed and explored.
These explorations reveal strong dependent, avoidant and passive-aggressive traits, which refer to a 'false self strategy' (Comett, 1995). Many group members recognized a common experience relating to this point. In response to the painful experiences of rejection, group members remembered that they were easily rejecting the part of their identities or character that they perceived as offending. They essentially developed a false self, based on what they came to understand as their fathers' expectations.
Defense mechanisms like reaction formation and identification with the aggressor can, apparently, easily be reactivated by confrontations with an incurable disease, losses and chronic trauma. Should such confrontations arise, the family of origin and gay men are once again forced to look each other in the eye. Gay persons with a weak sense of self, who lack the necessary affirmation from peers and father objects, are frequently inclined to yearn for confirmation through mirroring their false selves (Isay, 1989; Maasen, 1996; Ulman & Brothers, 1988).
Many group members recognized, at this stage of the therapy, how they had hidden away their true selves during their adolescence. They relapsed into those early coping strategies when their damaged true self was severely threatened by the loss of partners, friends, work and health. Together, in group sessions, they could try to discover their repressed true selves and touch their emptiness. Interventions in this stage were mainly oriented to restoration: integrating fragmented parts of the self that were split off into the 'good guy' and the 'bad gay'. In the end, group members developed 'a capacity to be alone' (Winnicott, 1958); that is, the capacity to detach from the deceased friends and separate from the group, and at the same time be able to develop new bonding strategies.

CONCLUSIONS
For gay men who are severely traumatized by loss of friends and health because of AIDS, psychotherapy may be indicated. Individual grief therapy is provided to them through psychotherapists, but a face-to-face setting often cannot meet the indispensable social support and affirmation for socially isolated gay survivors. For this reason, group psychotherapy was set up to break through social isolation, delivering peer support, and stimulating reciprocal affirmation as gay survivors. A bereavement group can function as a temporary 'holding environment' (Winnicott, 1958), where gay survivors can find recognition, help each other to go through grief processes, defeat their feelings of survival guilt, and learn to enter into new meaningful bonding.
Although the bereavement group offers strong social support for gay survivors, this effect can at the same time turn into a pitfall in group psychotherapy. This can happen when the interventions are predominantly oriented on loss. The danger exists that the curing aspect of grief therapy will not be achieved, and over-identification becomes a permanent state. Therapeutic interventions focusing on survival options and new perspectives can stimulate the healing process. So the participation of seropositive group members with survival issues are in this respect a useful addition.
From the beginning of the HIV epidemic the concept of peer initiatives was mobilized and played a crucial role in the support and care for gay men, as is shown through buddy projects, AIDS memorial rituals, quilt projects, etc. Those initiatives were a necessary answer to the fragmentation and destruction of natural social networks of gay friends. Setting up bereavement and survival groups-on a self-help or psychotherapeutic level-can be considered from the concept of peer support.
In urban gay communities where multiple loss and HIV infections are more prevalent, setting up peer group support is recommended because of the severe social isolation from which gay survivors can suffer. 'nose self-help facilities can be stimulated by gay communitybased organizations, and hopefully result in prevention of high-risk behaviour, survival problems and further severe pathology in gay grief.

ACKNOWLEDGEMENTS
I would like to thank the group members for their contributions and Marty PN van Kerkhof for his critical comments.

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Created: 11-12-98 Updated: 20-12-03