As the human immunodeficiency virus has taken its toll in lives, so too has it impacted psychotherapy practices—particularly those of therapists who specialize in treating gay men. The effect of the illness on those practices is perhaps most evident now that life-sustaining drug combinations have transformed the prognosis of HIV-infected men from poor to cautiously optimistic. With longer life expectancies, the stresses wrought by the illness are expanded and exacerbated.

"It used to be that most of us didn’t get referred patients until they were facing dying, and so a lot of the work then, which was deeply depressing for the patient and the therapist, was essentially what is sometimes called anticipatory grief," said Joan A. Lang, M.D., chair of the department of psychiatry at St. Louis University School of Medicine.

That meant "having to look ahead at the fact that death was inevitable and that all of the expectations that the person—usually a young male—would have had for life, the accomplishments and the movements through the various milestones of life, were being drastically curtailed," she said. "That has changed."

As potent drug cocktails slow the progression of the disease, therapists are confronting a new set of problems, particularly in patients who had expected to die.

"There are a lot of people who had really kind of resigned themselves to the death trajectory and who are quite healthy again," said R. Dennis Shelby, Ph.D., a candidate at the Chicago Institute of Psychoanalysis and a faculty member at the Institute for Clinical Social Work.

"I’ve seen people who had prepared themselves to die. . . Now all of a sudden they find themselves with no detectable virus, gaining weight again and back to normal health," Lang said. "This is wonderful. No one should mistake that for a bad thing, but it does face the patient with a whole bunch of new crises."

Many patients have given up jobs and gone on disability, or they’ve stayed in positions that weren’t challenging for them just to maintain their health insurance. A considerable number have become recluses. Struggling to step back into society is complicated and difficult for them, both therapists said.

"I am working with a couple of guys who are coming out of that kind of cocoon," Shelby said. "It is horribly traumatic for them. What you hear is the fear that ‘if I really get up and going again, then it is going to get me. The infection is going to kick up,’ " he said.

In addition, those with renewed energy must confront a staggering number of losses. "Delayed mourning is a big issue and also rage. You feel as though you should just be grateful that you got your life back, but in fact, what you now have is the energy that before had to go into survival, now going into all the losses, all the abandonment, all the backlash of renewed stigma," Lang said.

"You have a cohort who are experiencing these massive losses, way out of the usual course of life," Shelby said. "One of the things you would see, and often still do see, is complicated mourning in survivors of partners who are HIV-positive themselves. The HIV is a tie to the partner. The surviving person’s HIV infection becomes the lost object," he said.

It can be difficult to handle, Shelby said. "As people mourn, it gets very dodgy, especially around feelings of anger, for fear that getting angry at the partner is going to set off the HIV infection. It is something I have heard over and over again. The feelings are so intense, you have to get a very deep transference just to let people [address it]," he said.

At the height of the epidemic, 80 percent of Shelby’s practice was made up of men who were either HIV-positive or in a relationship with someone who was. While that number has dropped to around 30 percent, that period influenced him substantially. He remembers a group he ran for HIV-positive men in the early 1990s as "the most profound and humbling group I ever ran. A lot of these guys had really stopped living. Even though they were high-functioning professionals, they had all kind of hunkered down. Over the course of the two-year group, everybody got up and was running again."

Shelby also noticed his experience with HIV-positive patients and their partners has made him more aware of the specter of death. "It has made me very sensitive to subtle anniversary reactions. That’s the big one—an acute sensitivity to hearing a dead object rumble," he said, cautioning other therapists to look for the same. "It can be very subtle."

When gay men "come in with a kind of mixed depression and anxiety and you get into the history, there are all the losses, some central, some not so central. Imagine hitting your midlife and you’ve lost both of your parents, at least one partner, a few friends. You are hitting midlife with this huge reservoir of losses. You have to listen for it," he said.