2.1 Presenting Problem and Client Description
Michael is a 55-year-old gay man who has lived in the San Francisco Bay area his entire life. Michael has a history of chronic low-grade depression, with occasional periods of severe depression. He also is HIV+ which is medically well managed. He has been receiving supportive psychotherapy for the last couple of years at an LGBTQ+ serving outpatient mental health service for his depression. The treatment was helpful. He felt part of a community of sexual and gender minority (SGM) people and, for the very first time in his life, shared something about his past. He described his childhood experiences of family rejection, the euphoria of finding a gay community in late adolescence, that joy being demolished by the onset of the AIDS epidemic and the fear, grief and loss he experienced in the many years since. An ongoing problem is Michael’s relentless anger about minor and major ways in which he was degraded, shamed and rejected due to his gay identify. His basic needs such as health care services can be denied him and civility in routine social exchanges cannot be assured. Seeing heterosexual couples holding hands can fill him with rage and depression as he feels he cannot have the experience of showing his affection in a free and easy way.
His first years on his own in his late teens in the gay community were thrilling. He felt accepted and that he was coming into his own. He was experiencing emerging pride in his identity and mastery in his work in the publishing industry. The AIDS crisis increased stigma, criticism and even hatred of the gay community. Michael’s “first love” and partner had died during the AIDS epidemic as well as many friends. He saw many men his age with physical wasting and dementia. Worse, he saw his friend’s families ignore their deaths, not attend funerals nor make efforts to mark their passing. This period of life defined him. Everyone he loved died. Moreover, the homophobic reaction of families who did not attend funerals sent the message: you are trash, you will never be lovable.
Despite these harrowing experiences, Michael never viewed them as traumas. They were simply events that had shaped his life. His therapist stated that what he had experienced was a trauma and that perhaps a trauma-specific treatment might help move him out of the depression and anger he was experiencing. Michael first rejected this option. The depression felt monolithic and the anger a part of his personality. He noted “The past is the past. I can’t change it, so why focus on it?”
The therapist described the process of talking about traumatic events for the purpose of understanding their impact on his life and more importantly critically re-evaluating their meaning in a more adaptive way. The current supportive therapy was in a stable perhaps even stagnant state. The therapist expressed curiosity about whether a trauma-focused treatment might be helpful to him in a new way, different from the work that had been accomplished thus far. Michael became more interested in this option. Complex PTSD symptoms were assessed. Michael was surprised to see that he endorsed all symptoms of CPTSD. The assessment shifted problems that had been on the periphery of his awareness to center view. He had intrusive thoughts and nightmares about the AIDS-related deaths. He experienced reminders of his traumas whenever he went out of his apartment or even when he shut himself away in his apartment as he watched the news on COVID. In addition, the assessment allowed him to consider that his emotional reactivity, some of the negative views he had about himself and the often-negative ways he interacted with people might be related to his traumatic experiences. This made him hopeful that the treatment might work for him. He agreed to the treatment.