Working with gay males who are HIV positive or symptomatic - Research Paper Example

Introduction In working with gay males who are HIV positive or symptomatic, a familiar undercurrent is the presence of shame and guilt within these men. Lee et al. 2001) distinguishes these two emotions. According to Lee, external shame is the feeling that others look down upon oneself, which leads to a feeling of inferiority; internal shame is the feeling that oneself is devalued, thus damaging the self-identity. Guilt, on the other hand, stems from a sense of responsibility and the fear that one has harmed others through some act of wrong-doing, whether real or perceived (Lee et al., 2001, p. 456). Whether the shame stems from a lifetime of being told that they are wrong for the way that they feel, or are going to hell, or being bullied, or all of the above, shame is a prevalent emotion in the gay community. Guilt in this community may stem from the fear that they have infected somebody else, even unknowingly, or it may stem from some other perception of wrong-doing towards others. Because these emotions are so prominent in the HIV positive gay community, this research will examine not only how prominent it is, but also the best method in treating these emotions in this community. The approach will center around the hypothesis that group therapy is the best course of action for treating these toxic emotions. The research question is “is there shame and guilt with all HIV positive individuals?” Secondary research questions are how to approach and assess this, and with models should we use to alleviate these emotions in this population? This paper will be structured as follows. First, the literature regarding the treatment of shame and guilt within a group therapy setting will be examined, as well as a study on HIV patients with depression and how group therapy assists this population. A methodology section follows, which explains the method used, ethnography, critically examining the method and demonstrating why this method is appropriate for the study at hand. Finally, a learning autobiography will be presented, in which I relate my life’s experiences to the project at hand, and how these experiences have both shaped me and taught me the skills in dealing with the gay population. a. Literature Review In reviewing the literature, it seems that depression in gay men with symptomatic AIDS or HIV positive is prevalent and may be alleviated with cognitive-behavioral group therapy (Lee et al., 1999). Lee et al. evaluated fifteen patients diagnosed with AIDS or symptomatic HIV infection who also were diagnosed with major depressive disorder. These men were then put through a regime that included group cognitive-behavioral therapy, and the majority of the patients also received pharmacological assistance in the form of antidepressant medication. The group cognitive-behavioral therapy consisted of therapy with a licensed social worker who specialized in cognitive behavioral therapy for the gay community. The therapy centered around an approach that taught the men how to control irrational perceptions and beliefs, with the goal of easing depression through interrupting the depressive thought processes and relieve or prevent depressive symptoms. Lee et al. found that, after 20 weeks of this training, the patients all showed substantial improvement in their depression symptoms, and, at the one-year mark after this therapy, the men’s depression had lessened even more. Lee et al. discovered that it was the knowledge that they are not alone, combined with empathy for the others, which enhanced their self-esteem, that helped the men the most. Moreover, the group provided a social opportunity for men who previously felt alone (Lee et al., 2007, pp. 951-952). The Lee study thus provides an excellent springboard for the project at hand. It shows the value of group therapy for men who are suffering from AIDS or HIV, and, although it does not focus upon shame or guilt per se, it does show that the camaraderie, combined with empathy, is what healed these men. The findings can be extrapolated to this research project, as these men may find the same comfort in camaraderie in healing their guilt and shame as the men in the Lee project felt in healing their depression. While Lee et al. shows the value of group therapy in easing depression in men with HIV or AIDS, other literature demonstrates the value of group therapy in addressing guilt and shame in other populations. Talbot et al. (1998) studied women who were victims of childhood sexual abuse, noting that shame is one of the hallmarks of this population. They found that the group treatments had a positive impact on the women studied, partially because some of the women had problems with authority figures, and the power of the peer group mitigated the therapist’s perceived power (Talbot et. Al, 1998, p. 214). Gilbert & Procter (2006) approached treating people with high shame and self-criticism with a group therapy approach known as compassionate mind training (CMT). Their approach was based upon the theory that people with high shame lack the ability to self-soothe, and failing in a task brings these people to fear being shamed. The CMT attempts to teach the participants to self-soothe with cognitive behavioral therapy in a group setting, combined with a lesson on focusing upon compassionate images when distressed. Gilbert & Procter found that this group training significantly reduced shame (Gilbert & Procter, 2006, p. 371). Gilbert & Irons (2004) made a similar finding when treating self-critical individuals with compassionate images and self-soothing techniques, although this research was done one-on-one. As with the usage of these techniques in a group setting, the participants studied by Gilbert & Irons were significantly aided in their ability to self-soothe (Gilbert & Irons, 2004, p. 512). Urlic et al. (1996) studied shame and researched two approaches on two different populations – group analysis for neurotic individuals and those with borderline personality disorders; and group psychotherapy for “normal” individuals who had been through war, thus were suffering from post-traumatic stress disorder (PTSD). Urlic et al. found that both group analysis and group psychotherapy helped both populations immensely, as it helped the members of the group open up about their shame, while recognizing their situation in the other group members. The group members were able to vicariously detoxify their own shame by seeing other group members purge their own. Moreover, with group psychotherapy, the individuals are helped when a member of group works through his or her defenses with the therapist. This helps all members who might be experiencing the same thing, and it is especially helpful to members who are passive, as these people might not be able to open up, yet are able to identify with the others and are able to use the advice given to the others and apply to their own lives (Urlic et al., 1996, p. 328). The common theme running through the literature is that, no matter what approach is taken, group therapy and group analysis is helpful in alleviating shame. As Urlic noted, all group members benefit from the group therapy approach because of the vicarious way that the group members are able to deal with their own problems and emotions by witnessing others dealing with the same thing. Group therapy is especially helpful when there is a psychotherapist leading the group. A more vocal group member may work through his shame with the advice and guidance of the psychotherapist, while another man, who is shy and introverted, therefore not prone to speak, may silently absorb the advice given to the others and apply the advice to his own life. Just as Lee et al. found, the camaraderie was helpful to all involved. Meanwhile, Gilbert & Procter adds to the literature by proposing a specific type of psychotherapy which has shown to be useful in group settings, CMT. Thus, combining Gilbert & Procter’s findings with those of Lee et al. and Urlic et al. shows that the camaraderie and vicarious aspects of the group may be strengthened still by adding a focused approach that helps shamed participants overcome negative thoughts. Talbot et al. further assists our knowledge of dealing with shame in group settings, as they suggest that the presence of peers takes the focus off of authority figures, thus assisting individuals in opening up, even if they are intimidated by the authority figures. For all these reasons, group therapy appears to be extremely beneficial for treating shame, as well as depression related to HIV or AIDS, and compassionate imagery and self-soothing techniques should be included in the group therapy sessions. 2. Methodology The data collection method that I will be using is ethnography. The critical evaluation of ethnography may be examined by examining the broad category of qualitative research, as it is under this rubric that the category of ethnography falls. Because ethnography is a type of qualitative research, it is useful to examine the characteristics of qualitative research, along with the problems with this type of research and the ways of assuring validity and reliability of this type of research. Qualitative research is research which is in-depth and generally uses a limited amount of participants, and, as such, qualitative research seeks to build a relationship with the participants of the studied phenomenon. (Langelett, 2003, p. 7). The researcher accomplishes this by making friends with his or her subjects by spending time with them and gaining their trust. The questions in qualitative research are open-ended, and geared towards the focus of the inquiry, which is set by the researcher. The raw data that is collected from the qualitative study is then analysed for patterns. Once a pattern is discerned, more data is collected to flesh out these patterns, while reconfirming the earlier themes and topics. (Langelett, 2003, p. 8). Qualitative research is used for interpretivists paradigms, and the underlying assumption governing qualitative research is that individuals experience social and physical realities in different ways, and qualitative researchers look to find “a rich and complex description of how people think, react and feel under certain contextually specific situations.” (Hossain, 2008, p. 3). Qualitative research is presented in a thematic way and eschews statistics, and, as mentioned above, the sample size of the qualitative researcher is small and not randomly selected. (Hossain, 2008, p. 4). The setting of qualitative research is also important, as this type of research aims to take place in as natural of a setting as possible, and the behavior of the participants is captured through dialog, observations, interviews and pictures and uses these social interactions to make a holistic observation about the studied phenomenon. The hypothesis is generally not preconceived in qualitative research, but, rather, the hypotheses is formed after the research has been completed, and the researcher generally sees where the research goes. (Langelett, 2003, pp. 8-9). Also, qualitative research is interpretive, where the data is filtered through a personal lens that reflects a specific historical and sociopolitical moment. (Hossain, 2008, p. 7). Because qualitative research is somewhat “soft,” in that it does not deal with concrete data and figures, as is the case with other types of research, the researcher must ensure that the study if valid and reliable. The reliability of the data can be protected by the keeping of meticulous records of the interviews and observations. The utterances must be coded, and it is also helpful to either audiotape and or videotape the proceedings, and it also helpful for the transcripts to be examined by multiple researchers. The ultimate way to prove reliability is that the same result is obtained by multiple researchers who examine the data (Mays & Pope, 1995, p. 110). Validity is another important variable that must be established, and the way to establish validity would be to feed the findings back to the participants, to discover if the participants regard the findings as accurate and in line with their experiences. (Mays & Pope, 1995, p. 111). Triangulation or using multiple methods of data gathering and multiple informants are considered to be recursive checks against the validity of the researcher's interpretations. (Ambert et al., 1995, p. 885). Cross-checking, triangulation and depth of research are all important in strengthening validity. (Ambert et al., 1995, p. 885). Also important is, if there are cases that are examined that are deviant from the norm of that which is studied, is contradicted by other evidence or appears weak, the researcher must explain the variance in the data. (Mays & Pope, 1995, p. 111). As stated above, the narrow kind of qualitative research that will be used in this project is ethnography. Ethnography as a method of research looks at the study participants as part of a community and a culture, and the culture and other complex descriptions are carefully examined before forming a hypotheses. This results in what is known as a “thick” description of the studied phenomenon. A “thick” description is one which focuses not on superficial or simplistic explanations for what is studied, but, rather, examines the study by looking at aspects such as culture, religion and other background information of the participant and uses these aspects as possible explanations for what is occurring in the research (Hall, 2007, p. 212). So, in the project at hand, the question is whether shame and guilt are present in all individuals who are HIV positive. The superficial researcher might only look at the participant’s behaviour, and look at how that behaviour led to the person getting HIV, and use this as a springboard towards examining the question. An ethnographer, on the other hand, looks at the participants’ culture and religious background, and uses these aspects of the men’s lives to determine where the root of the shame and guilt might lie. Seymour (2007) states that, before deciding whether to undertake ethnography as the research method of choice, the researcher should first examine if this type of research is appropriate for the study. This research is appropriate if the study demands a design that is flexible and evolving, in that the research might take unexpected paths which demand to be examined, and if the subject of the research would benefit from this type of approach, ethnography would be appropriate. Also important is that the type of study would benefit from an approach which emphasizes the views of the participants and the context surrounding the participants. Finally, if the study would benefit from an approach that features the researcher as the data collector, ethnography would be the appropriate vehicle for the study (Hall, 2007, p. 216). The study population at hand will be gay males who are HIV positive who seek group therapy. The data will be collected by the method of participant observation, which means that I will be a part of the group and will be recording what the participants say organically, and this will be enhanced by informal interviews with the participants. Ethnography is appropriate to study the presence of shame and guilt in this population for a variety of reasons. One of the main reasons is that the shame and the guilt of these men may stem from a variety of sources, and ethnography is an excellent way to tease out from where a particular man’s shame and guilt may be rooted. As stated above, the cultural background and the religion of the men are pertinent areas of study in ethnography, and the focus on this background will provide salient answers to the research question. It is very important to get to the root of where the shame and guilt stems, in order to properly treat these men in a therapeutic way. Ethnography provides a way for the researcher to do just this. Further, ethnography, as with all qualitative research, is successful when the researcher is able to form a bond with the participants. This is crucial, because the men must be able to trust me, or else they might not open up. Thus, it is important the research take place in a naturalistic setting, so that the men see me as being one of them. With a topic as sensitive as that of HIV in the gay male population, this level of trust is especially important, and ethnography provides a way for this level of trust to manifest. The complementary approach of using participant observation along with informal interviewing is the best way to approach this population, as the research question is very specifically tailored towards the presence of guilt and shame in the HIV patients, so the informal interview questions may be tailored towards this topic, while the participant observation part of the data collection will provide insight on other aspects of the men’s lives and will encourage them to talk about anything that comes to mind. This freedom to speak about any topic they wish may lead the research down unexpected paths which might further enhance and provide rich background to the research question. 3. Challenges and How to Overcome Them The project at hand will present some very clear challenges. One of the major challenge is that I will be working with a population that is dealing with a very sensitive issue, that of being HIV positive, and my research question is narrowly tailored towards shame and guilt. These are emotions that these men might find difficulty in expressing. This challenge will be compounded by the fact that I am an outsider, in that I am not HIV positive, so it might be difficult to gain the level of trust necessary for this project to be successful. The men might feel that I cannot understand what they are going through, so they might not be willing to truly open up about how they are feeling. These men, being homosexuals, have probably been subjected to ridicule and harassment all of their lives, and this might make it difficult to trust outsiders, so this adds to the level of challenge. The best way to overcome these challenges would be by using the approach detailed by Seymour (2007), in which she reiterated some common-sense ways for the researcher to ingratiate him or herself to the participants, which helps the participants relax and open up. First, she recommends that the researcher be unobtrusive at the beginning of the process, which means that the researcher begins by being more of an observer then a participant. It is at this stage that the researcher is attempting to “fit in” with the population, so it is important to observe the group to find out the best way to go about doing this (Hall, 2007, p. 219). This means that, at the beginning, it will be important for me to go to the group meetings and attempt to find out the culture of the meetings and observe the interactions, without speaking too much and drawing too much attention to myself. This type of observation may lead me to subtle clues about the dynamics of the group, which will help me with the task of assuring the men that I am “one of them.” The next tip that Seymour conveys is for the researcher to be honest (Hall, 2007, p. 219). So, when the men ask about me, or ask me to talk, it is important that I respond in an honest way. Therefore, I will inform the men, right up front, who I am and what my mission is. However, it is not necessary to explain, right up front, that I am focusing on shame and guilt. As qualitative research is focused upon organically and naturally researching the subject, with an eye towards discovering new phenomenon in addition to discovering if the research question is fulfilled, it is important that I not artificially manipulate the participants into eliciting information just because it suits my agenda. In other words, I don’t want the men to focus on talking exclusively about shame and guilt, because that would limit the inquiry. I therefore will only tell the men about my basic role as researcher, and explain briefly my methodology. The third tip proffered by Seymour is to be unassuming (Hall, 2007, p. 219). What this means in this context is that, while I know a lot about the topic at hand, being a psychotherapist who deals with gay rights issues, this information does not need to be conveyed to the participants, and, in fact, it should not be conveyed. This is because, according to Seymour, when the research acts as if he or she knows a lot about the setting, this may be perceived as a threat to the participants. This is particularly true because I don’t want the men to think that I am psychoanalyzing them, and this might understandably be the case if they know my true role of psychotherapist. This might be a barrier against true communication, and it might breed suspicion. Therefore, it is best to infer to the men that I am a researcher, not a psychotherapist, and not necessarily let on my background regarding HIV positive men. The fourth tip that Seymour puts forth is for the researcher to be a reflective listener (Hall, 2007, p. 219). This is important because I might need clarification on some of the salient points these men are making, so it important that I understand what is being said. It is through reflective listening that I can truly understand the culture of these men, and it will help me to set aside personal biases that might otherwise preclude me from understanding the background and emotions of the men. Finally, Seymour recommends that the researcher be self-revealing (Hall, 2007, p. 219). By this, she means that the researcher should discuss common interests and personal information which may lead the participants to feel that there is reciprocity in the exchange, and this further enhances communication and trust. In this case, it is important for me to offer information that helps the men to know that I, too, have suffered difficulties and challenges in life, which will help me not only convince the men that I have empathy for their challenges, but also that I am willing to reciprocate. In particular, I plan to reveal to the men instances where I felt guilt and shame, and why I felt these emotions, so this, ideally, will help the men elicit similar emotions. Further, this will help in the gathering of the data as it might focus the conversation, organically, on the topics which are the focus of this project. Another major challenge that might be faced will be that of access. Because this is a topic that is so sensitive, the group therapy might be restricted, and this is understandable. I expect to find it difficult to secure access because of this, as the men in these meetings have a right to privacy and the feeling is that this privacy might be violated by entertaining an outsider, such as myself, to observe these meetings. This is a challenge for which there are no easy answers. However, I believe that it will be helpful if I approach the group facilitator or the psychotherapist in charge of the group and let them know that I, too, am a psychotherapist and that I am active in the gay rights movement. This may help the leader know that I am sympathetic to the men, and that my motives for doing this research are legitimate. It would also be helpful if I let the facilitator or psychotherapist know what I hope to achieve with my research, which is that I hope to be able to find ways to better help these men with their feelings of shame and guilt, and find models for these men which will help them in the long run. Because this research is important to ultimately helping the population that I am studying, this would be helpful in securing access to the men. While these are just some of the challenges I might face in researching this population, I anticipate that there will be other challenges as well, ones that I might not be anticipating. In any event, the best way to conquer any of the challenges which might arise is by using my knowledge and expertise which I have gained as a psychotherapist, as well as the knowledge and expertise which I have attained in previous research endeavors. With this level of knowledge, I anticipate that I can overcome any challenge which I might face in this project. 3. Learning Autobiography In assessing what I have learned which will help me with my project, and why I got involved in psychotherapy, I have to hearken back to my days in elementary school. I was always the new kid in school, so it was very difficult to break into the established cliques that apparently form when children are very young. Because of this, I became a kind of outsider. I dreaded recess because none of the other children would play with me, and I sometimes ended up talking to the teachers at recess because none of the other kids would talk to me. I did not get invited to do things on Friday nights, so, while the other kids were with their friends at the roller rink or the local hangout for elementary school kids, I was at home alone. I also had to walk home alone every day, even though there was another child who lived close to me, so could have walked with me. In short, my time as a child was lonely and I desperately needed a friend. Even though I overcame these difficulties, in that I blossomed in middle school and found friends, and at university I also had friends, this experience in early childhood never left me. Even when I found friends, I felt uncertain about their motivations in hanging out with me. I was so used to being rejected in my early life that I felt that anybody who wanted to be my friend must have something else up their sleeve. I also found it difficult to approach people to become friends because I automatically felt that I would be rejected. These experiences have definitively shaped me and have helped me in understanding the gay population and their feelings of shame and guilt. This is because gay men often feel like outsiders, because of their status in society and because of the fact that they have often been teased and made to feel unworthy. I can relate to this outsider status, because this is the way it was with me in my formative years. I always felt that there was something wrong with me, and this helps me relate to the feelings that these men might have regarding the same thing. Because of my background, I have felt an affinity with the underdog, because I feel that I was always an underdog as well, so this has also helped me relate to the gay population. At the same time, although these experiences seemed negative at the time, they have also been positive because these experiences helped me choose my path as a psychotherapist. I wanted to learn about why people form cliques and why some people feel superior to others, because this is the way that I felt growing up – that all the other kids felt superior to me and did not want to include me in anything. These early experiences got me involved in psychology classes in high school and university, because I really wanted to learn what makes people “tick.” Taking these psychology classes was fascinating for me. I found a passion for the subject, and I wanted to learn more and more about it. Because I developed this passion, I decided to devote myself professionally to the study of psychology. This way, I was able to combine two passions – psychology and assisting the underdog. I knew that a great many people have outsider status, just as I did when I was young. I also know that this feeling of rejection is a major reason why people might seek professional help, and I was eager to be able to help these people as a way of paying it forward. I felt the same way, and I was helped by some understanding people who befriended me, so I wanted to do the same for others. At the same time, the nuts and bolts of psychology fascinated me, in a way that no other subject has captured my imagination. So, I was excited to embark up on a career where I could help people while learning so much about a subject that I could endlessly study. I would also venture to say that I have learned more from my clinical patients then they have learned from me. I have learned the art of compassion and active listening, and the importance of reflective listening. These are all traits which will definitively help me with my current project, as empathy and reflective listening are two skills which make a good ethnographic researcher. My background as an outsider will further help me, as I can share my feelings with the group and this will help them to open up as well. They can see that I have struggled, maybe not to the same extent that they have, but I have problems too. I can make them feel that we are all in this together, and that I truly understand what it feels like to be an other and rejected. If I had lived a more privileged life of popularity, then I doubt that I would have chosen the career path that I have chosen. I would not have been driven to psychology classes in a desperate effort to understand why I was rejected, and I would not have the same level of empathy that I currently have for the oppressed and the rejected. In short, my life and my career would be profoundly different if I did not have the early experiences that I have, and for this, I am grateful. So, in retrospect, I feel that my negative experiences early in life have turned into fantastic positives for me now. Not only do I know about adversity, which might not otherwise be the case, but I feel that I can handle life’s challenges while being empathetic to those who society shuns. So my formative years have become the foundation upon which I have built my character, career and empathy, and for this I will be eternally grateful that I have been able to learn from my early rejection instead of going down a different path. Bibliography Addington, J., Bruera, E., Higgingson, I., Payne, S. 2007 Research Methods in Palliative Care. Oxford: Oxford University Press. Ambert, A., Adler, P., Adler, P. &Dentzner, D. (1995) “Understanding and Evaluating Qualitative Research” Journal of Marriage and the Family 57.4: 879-893. 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