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.