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influence over men's sexual performance, but it can persist. In fact, some opt for celibacy as a way to avoid these feelings, and others have decided to forego anal sex. Validation of these feelings and assistance in finding alternative means of sexual expression may help seropositive men to resume a (relatively) normal sex life.

Coping With ARC

Whereas asymptomatic individuals seem able to ignore their serostatus at least periodically, the emergence of new symptoms is difficult to overlook. Each new symptom can contribute to increased anxiety and discouragement, heralding a step in the progression of immune system dysfunction toward death. This interpretation can be particularly demoralizing if one has been especially attentive in efforts to protect one's health. Mental health practitioners should be aware of and prepared to address the possibility for discouragement, depression, and anxiety when symptoms progress.

New symptom emergence also leads to increasingly frequent and intensive physician visits. Physicians understandably want to monitor new symptoms and to provide appropriate treatment when possible. In their interactions with physicians, gay men frequently ask more questions regarding treatment and seem to express more interest in experimental protocols than do other patient groups. For physicians accustomed to working with patients who simply accept treatment, this level of treatment participation can be disconcerting, and some physicians resent or resist such patient assertiveness in treatment decisions. Therapists working with symptomatic individuals may need to assist them in finding constructive ways of asserting themselves or in finding physicians who can accommodate this desire for participation.

When traditional medical approaches fail to ameliorate symptoms or stem immune system dysfunction, gay men frequently look for alternative treatment strategies (cf. Hay, 1987). Although respectable alternatives are available, there are also an increasing number of opportunists who present themselves as experts on HIV infection. Therapists should be aware of legitimate resources available for HIV-infected individuals, and although they should not prescribe medical or alternative treatments, they can steer clients/patients toward sources that provide updated information regarding new approaches in combatting HIV infection. In many urban areas, medical schools conduct experimental protocols for treatment of HIV infection. Project Inform (347 Dolores, Suite 301, San Francisco, CA 94110) compiles a monthly newsletter that provides updated information on treatment and experimental approaches. The American Federation for AIDS Research (40 West 57th Street, Suite 406, New York, NY 10019-4001) publishes a quarterly compilation of experimental treatments. When clients opt for alternative or experimental treatments, therapists should encourage them to inform their physicians.

ARC symptoms can range from being relatively minor to severe and life-threatening. Some symptoms, such as fatigue, may be profound but vague and difficult to document. Because they typically base disability on diagnosis, physicians frequently are unprepared to document the extent of disability associated with symptoms. Whereas an AIDS diagnosis typically results in presumptive disability, an ARC diagnosis does not, and symptom severity and its effect on functioning must be documented for the patient to qualify for compensation. Therapists may assist patients in describing the nature of their symptoms and their functional interference to physicians, who

can, in turn, provide the necessary documentation for disability compensation. In other cases such as mental function, psychologists may submit reports documenting disability with physicians' reports or assist in neuropsychological screening and referral. Finally, therapists may become directly involved as patient advocates in the disability evaluation process. Depression accompanying increased disability and dependence on others should not be overlooked or minimized. Assistance in finding jobs or positions that accommodate their disability may help preserve ARC patients' sense of self-sufficiency. Some have returned to school to learn new vocations with fewer physical demands. Volunteer involvement in AIDS-related selfhelp organizations or local gay and lesbian community service agencies may be an option for those unable to engage in either fullor part-time employment.

Coping With AIDS

We have observed in our clinic that some individuals report relief on confirmation of an AIDS diagnosis. For individuals who have attempted and failed to obtain disability compensation in the past, an AIDS diagnosis can mean an end to the tiring application process and uncertainty over whether compensation will be available from one month to the next. Many who previously have been tested and who have developed symptoms have lived in fear of the day they would be diagnosed, and confirmation of the diagnosis can remove reasons for anticipatory anxiety and free them to cope with AIDS. On the other hand, individuals for whom an AIDS diagnosis is the first indication of HIV infection frequently experience the gamut of emotions that first follows verification of a positive HIV antibody test. Still others view an AIDS diagnosis as another step toward death.

AIDS patients frequently must undergo painful and frightening diagnostic and medical treatment procedures. In addition to providing emotional support during periods of anxiety, psychologists can help patients undergoing such procedures with education, relaxation and guided imagery, and assistance in using existing coping methods that have been used successfully in the past. For example, diagnosis of pneumocystis pneumonia is based on bronchoscopy, a procedure entailing insertion of a tube into a lower lung through the mouth and trachea. Although patients are given muscle relaxants and local anesthesia, they are conscious during the procedure and it can be frightening. We have found clinically that patients can be prepared in advance through the provision of initial briefing and relaxation and guided imagery exercises that they can use during the procedure. Patients who are intubated (and therefore cannot speak) may convey thoughts and feelings by writing them on a pad of paper with assistance. Interventions may be similarly adapted to other medical procedures as they have been in a number of other medical settings with other illnesses (cf. Anderson & Masur, 1983).

Although not well documented, reports of "posttreatment euphoria" have emerged in reference to feelings of unusual well-being and optimism following treatment of the first episode of pneumocystis pneumonia. As additional episodes of pneumonia occur and other symptoms emerge, resignation to the illness progression may appear. Although not documented empirically, it has been suggested that a "fighting spirit" helps prolong life in people with AIDS. It is also possible that optimism and a fighting spirit emerge early after diagnosis and that it is replaced with resignation to new symptoms and increased coping efforts in other domains (such as emotion-

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focused coping, dealing with family members, coping with declining health, and so forth) as the illness progresses. Reports from the coping and death and dying literature suggest that this is a normal process (Kübler-Ross, 1969; Taylor, 1983).

As patients near death, previously unfinished business and new issues must be confronted. For some individuals, making out wills and implementing durable power of attorney for health care are among the last preparations for death because they represent final acknowledgment of this possibility. Decisions regarding where, how, and when to die must be confronted. These decisions should be documented in order that they be followed. Therapists can assist by helping in the search for and weighing of options and in clarification of the patients' desires. When patients' decisions conflict with the desires of their families, friends, lovers, and health-care providers, therapists may need to assist them in accepting patient decisions. Individual significant others also may require assistance in coping with the feelings of impotence, grief, and anger engendered by the patient's impending death, and therapists should be aware of resources available. In some areas, support groups for AIDS-affected family members, lovers, and others exist.

NEUROPSYCHOLOGICAL ASSESSMENT

As awareness of the neuropsychological sequelae of HIV infection has increased (cf. Levy, Bredesen, & Rosenblum, 1985; Lowenstein & Sharfstein, 1983-1984), concern over its detection and management has emerged. Review of the literature on neuropsychological testing In HIV-infected individuals (cf. Van Gorp, Satz, Hinkin, & Evans, in press) has suggested that among asymptomatic seropositive individuals, such testing is of limited utility. Among persons with AIDS, however, neuropsychological testing, combined with history and assessment of current everyday functioning, may be of assistance in planning interventions for individuals coping with cognitive deficits. For example, if patients experience forgetfulness, therapists may assist them in making lists or creating routines to manage everyday activities and in creating environments to accommodate these deficits. In cases of frank dementia, caregivers may require education in the management of an incompetent loved one, as well as outside resources on which to draw for assistance.

SUICIDE AND HIV INFECTION

Recent research (Kizer, Green, Perkins, Doebert, & Hughes, 1988; Marzuk et al., 1988) has indicated that men with AIDS between the ages of 20 and 59 are much more likely to commit suicide than are comparably aged men who do not have AIDS. Although data relating to asymptomatic seropositive men or men with ARC are unavailable, these studies underscore the need to assess for suicidal ideation and intent in HIV-infected individuals. Goldblum (1987) has suggested that the following factors are important in the assessment of suicide risk among persons with AIDS: multiple losses related to AIDS, intimate involvement with a person who died from AIDS, stage of illness, recent disclosure of positive test results, discrimination and insults, personal history of homophobia-related loss, prevailing sense of danger in being gay, "closetedness," unsettled sexual identity, and lack of adequate social and financial support.

HIV Infection and the Gay Community

GRIEF IN THE GAY

AND LESBIAN COMMUNITIES

Grief over the loss of friends and associates has touched many members of the gay and lesbian communities (cf. J.L. Martin, 1988). Although gay-lesbian community members have provided much mutual support in the grieving process, for some, individual intervention is necessary. Therapists working with gay and lesbian clientele should be prepared to address grief-related issues as they emerge. When symptoms such as unusual fatigue and lethargy, unexplained anger, depression and anxiety emerge in individuals who have lost friends to AIDS-related illnesses, the possibility of grief reactions should be explored and addressed.

For some individuals who have lost many friends and who have others remaining who are ill, the possibility of a chronic posttraumatic stress disorder should be entertained. Posttraumatic stress disorder is characterized by symptom development following a distressing event or events outside the range of usual human experience, such as multiple and continuing deaths in one's immediate surroundings. Characteristic symptoms of posttraumatic stress disorder include persistent re-experience of the event(s), persistent avoidance of situations associated with the trauma caused by the event, numbing of general responsiveness, and persistent symptoms of increased arousal. Symptom duration is at least 1 month. Use of this diagnostic category instead of others, such as adjustment disorders, emphasizes that the reaction is a normal response to a catastrophic event rather than a maladaptive reaction to a normal stressor.

CONCLUSION

Clinicians should be aware of and look for HIV-related issues in their work with gay clients. Work with HIV-affected individuals should focus on reinforcement of coping, enhancement of self-esteem, and encouragement of optimism and flexibility (Namir, 1986). Additional information and resource material are available for both clinicians (e.g., see Helquist, 1987b; Kelly & St. Lawrence, 1988) and clients (e.g., see Delaney & Goldblum, 1987; Moffat, Spiegel, Parrish, & Helquist, 1987).

REFERENCES

Acevedo, J. (1986). Understanding ARC: The broader spectrum of AIDS. Focus: A Review of AIDS Research, 1(2), 1-2. Anderson, H.O., & Masur, F.T. (1983). Psychological preparation for invasive medical and dental procedures. Journal of Behavioral Medicine, 6, 1-40.

Centers for Disease Control. (1988). Quarterly report to the Domestic Policy Council on the prevalence and rate of spread of HIV and AIDS-United States. MMWR, 37, 551-554, 559.

Centers for Disease Control. (1989, May 23). Acquired immune deficiency syndrome: Weekly surveillance report-United States AIDS Program. Centers for Infectious Diseases.

Coates, T.J., Morin, S.F., & McKusick, L. (1987, June). Consequences of AIDS antibody testing among gay men: The AIDS Behavioral Research Project. Paper presented at the III International Conference on AIDS, Washington, DC.

Communication Technologies. (1987). A report on: Designing an effective AIDS prevention campaign strategy for San Francisco: Results from the fourth probability sample of an urban gay male community. Prepared for the San Francisco AIDS Foundation. San Francisco: Author. Corby, N.H. (1987, March). Short-term support groups for individuals who are HIV antibody positive. Paper presented at the annual meeting of the California State Psychological Association, Coronado, CA. Curran, J.W. (1985). The epidemiology and prevention of acquired immune deficiency syndrome. Annals of Internal Medicine, 103, 657662.

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