Treatment of a dually diagnosed gay male patient: a psychotherapy perspective.

Abstract

Back to table of contents Previous article Next article Clinical Case ConferenceFull AccessTreatment of a Dually Diagnosed Gay Male Patient: A Psychotherapy PerspectivePedro Ruiz, M.D., Buddy Lile, M.D., and Anu A. Matorin, M.D.Pedro RuizSearch for more papers by this author, M.D., Buddy LileSearch for more papers by this author, M.D., and Anu A. MatorinSearch for more papers by this author, M.D.Published Online:1 Feb 2002https://doi.org/10.1176/appi.ajp.159.2.209AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Case Presentation“John” was a 35-year-old white gay man who was referred to Dr. Ruiz for psychiatric care by a local family practitioner. John suffered primarily from bouts of depression and anxiety and also used cocaine quite regularly.At about age 16, John began to use pot with his high school friends during social parties. He also realized around this time that he was gay, although he kept it primarily to himself out of shame, guilt, embarrassment, and fears of rejection by family and friends. By age 18, John was occasionally using alcohol and LSD and had engaged in a few homosexual encounters. During college, he stepped up his addiction to stimulants and continued to have occasional homosexual encounters. Upon finishing college, he earned a master’s degree in education. During this period, his use of cocaine and amphetamines as well as his homosexual activities became more regular. Since earning his master’s degree, he had been working as a high school math teacher for about 10 years.Initial AssessmentWhen John was interviewed for the first time, he demonstrated anxiety and mood swings of moderate degree. Specific symptoms included mild difficulties in falling asleep, muscle tension, constant worries, apathy, occasional sadness and tearfulness, mild mood swings consistent with irritability, and guilt feelings about his covert gay life. His worries focused primarily on fears of contracting HIV and his ongoing use of stimulants, particularly in relation to his homosexual activities.These symptoms were present for years, although they were never so severe that they interfered with his occupational, personal, or social activities. John denied any history of other psychiatric illness or a family history of psychiatric disorders; he additionally denied any history of surgical procedures or major medical illnesses. He was being treated by the referring family practitioner for “irritable bowel syndrome.” His treatment for this condition consisted of diet, counseling, and over-the-counter high-fiber remedies. Despite his long history of substance abuse, mood swings, and occasional bouts of anxiety, he had never sought psychiatric care. John’s childhood was a happy and uneventful one, as was his adaptation to elementary and high school and later on through college and graduate school. He had also adapted well to his occupational life.With respect to the remaining aspects of his mental status examination, John was oriented to person, place, and time; he denied any loss of appetite, loss of weight, ongoing crying spells, or suicidal thoughts. He also denied the presence of delusions or hallucinatory experiences. Cognitive functions were intact; he recalled three objects in 5 minutes and was able to subtract seven from 100 without difficulties. His fund of knowledge was excellent, as was his capacity to abstract, his insight, and his judgment. He was in denial, however, regarding the risks related to his ongoing cocaine and amphetamine use and, in particular, its use in relation to his homosexual activities. He additionally denied having any phobias, panic attacks, or obsessive-compulsive manifestations. Moreover, he denied ever having problems with the law. Finally, he showed no loosening of associations, serious ambivalent feelings, or autistic behavior.At the end of the interview, it was thought that John was suffering from dysthymic disorder, generalized anxiety disorder, and polysubstance-related disorder. Dr. Ruiz asked to see John again to discuss treatment options.John returned 1 week later. His treatment was discussed at length, and his willingness to engage in psychotherapy was explored. Dr. Ruiz advised John to start with supportive and cognitive behavior psychotherapy, with antidepressant treatment, perhaps with an SSRI, being reserved for later, if needed, to treat the mood swings and the anxiety. Dr. Ruiz also proposed that John initially approach treatment of his cocaine and amphetamine abuse through individual psychotherapy but also to keep in mind Cocaine Anonymous and other types of biopsychosocially related interventions if individual psychotherapy was not enough for this condition.It was clear that besides his dual diagnosis problem there were also some strong issues related to his gay life that had to be kept in mind and addressed during the psychotherapeutic intervention: concerns with “coming out,” internalization of homophobia, low self-esteem and shame, limited social support network, participation in a bar-centered culture, spirituality-related issues, strong gay-related guilt feelings, and HIV infection fears.By the time of the second interview, Dr. Ruiz felt that already he had been able to secure John’s trust and confidence. On the basis of this, Dr. Ruiz proposed that John be treated by a psychiatric colleague, Dr. Lile, who was gay. Dr. Ruiz indicated that he would remain available for consultation if needed or for treatment if John ever felt unhappy with the treatment provided by Dr. Lile. Dr. Ruiz additionally reinforced the fact that many of the issues related to his gay life also played a role in his dual diagnosis condition (mood and anxiety as well as amphetamine abuse). Furthermore, Dr. Ruiz explained to John that Dr. Lile was also an expert in addiction psychiatry. John agreed with the treatment recommendations. Dr. Ruiz informed the family practitioner who initially referred John about the treatment plan, and John began psychotherapy with Dr. Lile.Dr. Lile first met with John the following week. Initially, John focused on his substance abuse problems. He related his history as he felt comfortable. Toward the end of the session, he mentioned that at times while intoxicated he did things of which he “wasn’t very proud.” At this moment, Dr. Lile underlined his sexual orientation and assured John that the sessions would provide a safe environment for him to disclose any aspect of his sexuality. This comment and assurances of confidentiality and an accepting environment helped John to better relate his life history.HistoryJohn spent his childhood and adolescence in a suburb of a large Southern city. He was raised Southern Baptist and reported that his parents were fervent believers. He remembered enjoying the sense of community in the congregation and his excellent relations with the “entire town” who attended church on a regular basis. However, one of his earliest memories was of a summer revival preacher stating, “Homosexuals are the spawn of Satan and will be cast into the lake of fire and brimstone,” to which everyone responded with “AMEN!” Although not comprehending the meaning of this incident at the time, he was distressed by it as he came to question his sexuality.He also reported that he had a good relationship with both of his parents but later related that he felt more attached to his father. He described his father as hypermasculine—an avid outdoorsman who enjoyed hunting, camping, and sports. John additionally reported that everyone regarded his father as “a man’s man,” and his father would liberally reference weaker men as “sissies” or “queers.” John also mentioned his intense desire to please his father and his strong attachment to him. However, he did not share his father’s interest in his hobbies and felt that his father disapproved of him. When John was 5 years old, a younger brother was born who ultimately turned out to be more “conventionally masculine” and who shared his father’s passions. John reported a great deal of anger and jealousy over his father’s perceived withdrawal and his shifting attention to his younger brother.Although he did well in school and was liked by both students and teachers, John reported always feeling “different” from his classmates. He was not interested in sports but engaged in them throughout school to please his father. During adolescence, he reported that his friends started developing an interest in the opposite sex. Although he professed an interest in the opposite sex to appease his father and friends, he remembered feeling as though it “wasn’t right for me” and rarely dated. He never confided his lack of interest to anyone except for a school counselor, who responded, “All boys go through this with girls,” and that John would “meet a nice girl soon.” Further, John recalled one episode of joining in the taunting of another student with homophobic epithets—he did this to “fit in” but reported lingering guilt about this experience.John related never having any sexual thoughts about or sexual encounters with women. While masturbating, he would imagine being the submissive, receptive partner of masculine and powerful men. His first sexual encounter was with one of his team members, which also led to his first experience with smoking marijuana. He reported feeling exceptionally drawn to this young man. However, the experience was frightening and thus led to cutting off further sexual contact with him. He also reported having other sexual encounters with peer students during his high school years, which were always associated with increasing alcohol and marijuana use, followed by feelings of guilt and shame.After graduation from high school, he moved east for “a change—a place where people didn’t know me.” His first experience with stimulants was during his freshman year at college with a man whom he met at a heterosexual bar. He reported that this man also introduced him to cocaine and “crystal” (methamphetamine) and to the local gay bathhouse and bar scene. He also reported feeling strongly attracted to this man—defining it as his “first crush,” despite having limited contact with him. However, he was deeply ashamed about his sexual activities and used drugs and alcohol both to “relax and have sex” and to absolve his guilt.He quickly fell into a pattern of anonymous sex that was fueled by his increasing substance use. Although he would receive phone numbers and offers for further sexual contacts, he reported never calling any of these men because of his feelings of shame. While sober, he reported that he would worry a great deal about being “found out” and about contracting HIV, which was becoming more prominent at the time. He additionally reported no significant interactions with people in the gay community except for when he was under the influence; he reported feeling increasingly isolated from his friends from college and graduate school. He also had increasing problems with attending his Monday morning classes because he would be “crashing off the crystal,” although he managed to maintain passing grades and was able to complete his master’s thesis.After graduation, he felt that he needed to get away from the local drug scene, so he moved to the Southwest and accepted a high school teaching position. While he was well regarded and liked for his teaching abilities, he reported feeling increasingly nervous—“paranoid”—that someone would find out his “secret.” He reported feeling very lonely, with no social contacts outside of the work environment. At this time, he acquired a computer and started chatting on a bulletin board service. This venue provided a chance to interact anonymously with other gay/bisexual men. His conversations largely consisted of “cybersex,” although he occasionally would meet and have sex after consumption of alcohol or marijuana. After meeting someone from the bulletin board service who was a stimulant user, he resumed his previous use of cocaine and methamphetamine and started frequenting bookstores and bathhouses. He acknowledged increasing anxiety over going to these venues and would attempt to park in a place where his license plate would not be easily noticed by anyone and result in his being “reported.” He decided to seek treatment through his family doctor after nearly getting arrested at a bookstore, coupled with his increasing substance use, anxiety, and depressive symptoms.Course of TreatmentAt the time he began psychotherapy with Dr. Lile, John reported binge-using behavior in which he would abstain for a week or two and then use large amounts. He denied ever having alcohol withdrawal symptoms. He reported an increase in depressive symptoms after using cocaine or methamphetamine and would occasionally miss work. He reported having attended Cocaine Anonymous a few times in the past but had felt markedly uncomfortable and isolated when the group would discuss problems with heterosexual relationships. He had no close friends, very little contact with his parents, and no engagement in organized religion (although he considered himself to be a spiritual person).John expressed a strong desire to receive HIV testing, having not been tested in over a 3-year period. The positive and negative aspects of testing at this particular time were carefully explored, especially how he would handle the stress of a “positive” result. He ultimately decided to postpone testing until he had established a better social support network. The importance of safer sex practices and of discontinuing the use of substances were discussed.Dr. Lile then examined John’s experiences with religion and spirituality. John reiterated his enjoyment of the social aspects of church and reported that the ministers with whom he had contact had always been kind and affectionate to him. He demonstrated feelings of sadness and loss related to the lack of this important social support network. Dr. Lile related that there were several local congregations that were more gay-positive and asked if he would be willing to explore these potential alternatives to the religion of his childhood. After discussing options, John decided to attend services at a local Methodist church, which had been suggested because of its “mixed” congregation of heterosexuals and homosexuals and the presence of Lambda AA (a gay Alcoholics Anonymous group).He came back from this “homework” assignment appearing somewhat relieved, stating that he enjoyed the religious services and felt very comfortable with the congregation. He expressed considerable amazement at gay couples interacting with heterosexuals in a positive fashion. Continued attendance was encouraged as long as he felt comfortable. Dr. Lile also suggested that John explore contacts with people he met at church for social interactions outside the church and mentioned the idea of attending Lambda AA meetings either at the church or at an alternate location when and if he felt comfortable.At each therapy session, John would discuss his substance abuse over the past week. Although he reported occasional lapses with alcohol and marijuana, he also reported continued abstinence from stimulants and no work-related difficulties. In addition, he reported occasional sexual encounters with men from the bulletin board service but that he was adhering to safer sex practices and that he no longer felt the need to consume alcohol or drugs to interact sexually. He reported more appropriate socializations with gay men and lesbians at the church. He additionally reported that one couple from church that attended Lambda AA encouraged him to come along. This resulted in positive results and further increased feelings of comfort and social connectedness.Several sessions centered on the injustices of rigid heterosexism (i.e., the lack of acknowledgment by certain sectors of society of any other sexual orientation besides heterosexuality). Treatment also focused on issues related to homophobia. John expressed a great deal of anger and resentment toward heterosexual men, particularly toward his father. Dr. Lile provided John with a supportive environment in which to ventilate; occasionally, direct questions were asked about the “nice” heterosexuals with whom he had contact. Significant session time was spent talking about how Dr. Lile handled his sexuality and how he dealt with the heterosexual world. Dr. Lile served as a role model for John and provided a balanced view that corresponded with his experiences with his newfound friends at church. Dr. Lile also let John borrow various texts about gay culture and identity, which led to related discussions during sessions and with his growing support network.As therapy progressed and John became more comfortable in his role as a gay man, he reported decreases in his anxiety and depressive symptoms and also fewer bouts of irritable bowel syndrome. He developed more friendships with both heterosexuals and homosexuals at church as well as consistent involvement with Lambda AA. He also reported curtailing his anonymous sexual involvements in favor of a few friends with whom he occasionally had sex. He additionally stated satisfaction with his current level and kinds of sexual activities.Given John’s increased support system, his comfort level with his sexuality, and his abstinence from substance use, Dr. Lile readdressed the issue of HIV testing. John agreed, and arrangements were made to have testing done on an anonymous basis, with the results sent to Dr. Lile’s office for discussion. Fortunately, John was HIV negative. At this point, the need for ongoing safer sex practices and the importance of sobriety in reducing risk-taking behavior were discussed again.Toward the end of the psychotherapy sessions, John began to discuss work and sexually related issues. He expressed realistic concerns about being openly gay as a high school teacher and the potential for negative consequences. He already had attempted to “feel out” his colleagues but had not received any ideas regarding their feelings about homosexuality. These concerns were explored and were acknowledged as being warranted. John also expressed an interest in either changing careers entirely or pursuing a teaching career at a college level, where he hoped the concerns about his sexuality would be lessened. He also expressed desires to reveal his orientation to his parents. He decided to write a letter after working through in therapy the potential good and bad outcomes of this disclosure. He also agreed to bring in any letters received for discussion during therapy. Dr. Lile and John worked on the wording of the letter. Both parents wrote back; his mother’s response was fairly neutral in tone. Unfortunately, John’s father was not quite so accommodating. He condemned John, stating that he would “burn in Hell with the rest of the Sodomites.” Dr. Lile and John discussed the process that parents go through when their children “come out,” and that this process takes time; also addressed were the realistic expectations related to someone with the worldview of John’s father. Dr. Lile suggested contact with the mother after an appropriate period of cooling down, reiterating that all parents go through this period of adjustment. Dr. Lile related his experiences about “coming out” to his parents and the period of adjustment that followed and encouraged John to speak to others in his support network regarding their own experiences in this area.At this point, John initiated termination of his therapy, reporting that he felt his support group could assist him in handling future problems successfully. He expressed the desire to “touch base” on occasions and to come back for further psychotherapy if it became necessary. Approximately 9 months after psychotherapy treatment, John called and reported that he had changed jobs and that he was now working at a local college, where his sexual orientation was less of an issue. He also reported that he had been in a successful and ongoing dating relationship for the past 3 months with a man he met at church; he additionally reported about other new and significant friendships and ongoing engagement with Lambda AA. He also reported no problems with depressive or anxious symptoms and only mild problems with irritable bowel syndrome after conversations with his mother. In addition, he reported that his mother seemed to be accepting his sexual identity better after further conversations. He also had some contacts with his father, who stated that while still loving him, he had not accepted as yet his “lifestyle.” During our conversation, John depicted a sense of realistic expectations about his relationships with both his mother and his father.DiscussionHomosexual identity development is long and complex, with many interrelated factors. In retrospect, most gay men acknowledge the presence of their sexual orientation from an early age (1). Serious difficulties arise when attempting to reconcile sexual orientation with societal norms—difficulties that intensify with the strong sexual urges of adolescence. Because of fears of rejection and outright violence from family and friends, gay men create a false heterosexual front—“the closet”—that may involve entering into heterosexual relationships (1, 2). The unfortunate consequence of entering said closet is a significant internal conflict between the true desires of the gay man and the desire to fit into mainstream society (3, 4). This conflict may be particularly intense in gay men who come from very rigid religious backgrounds. Unfortunately, very few organized religions are tolerant or accepting of homosexuality (5, 6). The homophobic messages presented by church, family, and friends can result in chronic feelings of being “sinful,” “evil,” or even unloved or hated by the God of their understanding because of their sexual orientation (7).The process of “coming out” refers to the reconciliation between homosexual orientation and mainstream society, including the presence of rigid heterosexism and homophobia (8). This process is highly variable and affected by characteristics such as family, religion, personality factors, age of recognition of being homosexual, ethnicity, and urban or rural settings (9, 10). Many different theories exist with respect to the process of coming out, including a model that attempts to integrate individual identity development and growth within a social context (11). Along these lines, it is postulated that as long as issues regarding coming out are well explored, developmental integration can be achieved whether the person stays closeted or publicly acknowledges homosexual identity. In this regard, an important part of this patient’s treatment was to explore his career choices and help him arrive at a decision regarding his professional life in the context of his homosexuality.The abuse of substances is also an issue to be addressed among homosexual populations (12–14). Postulated reasons include the stigma of being in a marginalized class, a “social lubricant” used to interact with other gay men, the predominance of bars as meeting places, a method to decrease internalized homophobia, and a tool to allow sexual intimacy to occur (3, 15). This patient used substances to allow expression of his true identity in a sexual fashion but suffered intense self-loathing after substance use and sex practices that was related to not having successfully navigated the “coming out” process (2, 16). Further, substance use and abuse and sex practices can be so linked that the patient cannot imagine having sex without using substances. Sex and intimacy can be completely dissociated by this sort of substance use and can lead to future relationship problems (1). Serious consequences may stem from using substances, such as development of a secondary addiction disorder, kindling of a preexisting genetic vulnerability to addiction, and risky sex behavior while under the influence (2, 13). In this case, the potential consequences were addressed very successfully through psychotherapeutic intervention.The stress of a closeted life can also have significant adverse physical and mental consequences. Patients troubled by their sexual orientation may complain of various somatic symptoms to their primary care physicians, such as the gastrointestinal complaints in this case. Patients may also seek psychiatric help with complaints of depression, anxiety, chronic stress, eating disorders, or substance use disorders (7, 15, 17). An open, sensitive, and affirmative stance must be present in order to treat gay patients optimally. In order to provide this sort of environment, the therapist—whether heterosexual or homosexual—must be aware of his or her own biases regarding gay patients. If these biases cannot be resolved for any reason, a referral to a gay-affirmative therapist is indicated (5, 18, 19). Asking honest and nonjudgmental questions about sexual orientation, having inclusive language in initial assessment forms, early self-disclosure from therapists who are homosexual, or simply having textbooks about homosexuality on the office bookshelf can help patients feel at ease in discussing sexual issues regardless of the presence or absence of sexual conflicts (4). Further, an accepting and positive therapeutic attitude can do much to correct negative experiences regarding sexual orientation (1, 20).While there are no clear guidelines as to the gender or sexual orientation of the therapist who treats the gay male patient, the therapist can be of help as long as he or she has adequate knowledge about homosexuality, can maintain an accepting and unbiased stance, and is capable of monitoring countertransference (19–23). Frequently, a gay male patient will prefer a gay or lesbian therapist, with the presumption that the therapist will be more knowledgeable about gay issues and that rapport can be established more quickly. The therapist may share this belief as well (21). However, it bears repeating that being gay or lesbian does not guarantee the ability to provide gay-affirmative therapy or a lack of rigid heterosexism or homophobia on the part of the therapist (18, 21). Further, assumptions of similar backgrounds based solely on sharing sexual orientation can impair therapeutic progress and thus should be closely monitored (21). On the positive side, an openly gay therapist can serve as a role model to a patient struggling with his sexual orientation and positively influence both the course of therapy and the patient’s self-esteem (18, 21). However, a heterosexual therapist with an adequate knowledge base about homosexuality can also be quite effective in this regard. Moreover, much therapeutic benefit can be realized by the simple acceptance of the patient by a heterosexual therapist. The critical point to remember with any patient, and especially with a gay male patient, is to assume nothing (3). In this case, early revelation of the therapist’s sexual orientation, coupled with a nonjudgmental and open environment, led to much progress in therapy.The psychiatric evaluation of a gay male patient should also include a spiritual history, emotional history, substance abuse history, a sexual history, and assessment of support networks and relationships. Many gay male patients have had negative experiences vis-à-vis their religious and spiritual encounters and thus may have significant spiritual conflicts. To leave out spiritual assessment may lead to marked deficits in understanding the gay male patient (24). A substance use or abuse history is also of particular importance for gay male patients during their early stages of coming out. Typically, they have increased negative feelings that may fuel alcohol and drug use. A thorough sexual history involves a frank exploration of positive or negative emotions related to sex and is much aided by a working knowledge of the gay male’s social and sexual settings (i.e., bars, bathhouses, social/sexual groups, etc.) (15, 25). Not taking a sexual history can potentially place the gay male patient at further risk through unsafe sex practices (23, 25). Finally, the evaluation of relationships will also provide relevant information about the gay male patient’s support network and offer clues as to potential allies during the therapeutic process.After addressing the basic concerns for patient safety and pharmacological interventions, an integrated treatment approach sensitive to the gay male patient’s comfort level with his sexuality is vital. The gay male patient’s comfort level with his sexuality will affect the timing and focus of therapy. For example, a recommendation for this patient to go to Lambda AA at the onset of therapy would have been ill timed, given his discomfort with his sexual identity and with other gay men. If hospitalization is indicated, gay-affirmative psychiatric treatment centers or recovery centers should be considered.Sexuality is frequently a conflicted area associated with shame and self-loathing. Substance use and abuse effectively suppressed this patient’s superego, thus allowing engagement in the mechanical aspects of sex practices. The downside is that deeper needs for intimacy and love remained unfulfilled. This unfortunate dissociation may continue even after achieving sobriety and thus lead to unsatisfying, compulsive, and potentially risky sexual practices (2, 15). On the other hand, it is important not to confuse sexual frequency with sexual compulsivity. A number of gay men engage in relatively frequent casual sex or couple in ways that do not mimic standard heterosexual dyadic relationships and are able to achieve great satisfaction with these “nonstandard” sexual relationships (7). Toward the end of therapy, this patient was still engaging in sexual contacts with more than one partner and reporting enjoyment and satisfaction with th