FOCUS: A Guide to AIDS Research and Counseling Volume 9, Number 6 - May 1994 ---------------------------------------------- Editorial: Seronegatives and Scarcity Robert Marks, Editor Until recently, many have viewed the concerns of seronegative gay men with suspicion. Post-traumatic stress syndrome, survivor guilt, and dwindling feelings of community were seen as self-indulgent preoccupations compared to the life-threatening challenges of HIV-infected people. Studies have shown, however, that the stress of living in the war zone of the epidemic is severe, authentic, and a natural psychological response to multiple loss. It can lead not only to depression and other mood disorders, but also to self- destructive acts, and, in particular, to unsafe sex. Health planners now recognize that services for seronegatives are a crucial component of HIV prevention as well as a way to maintain the integrity of the hardest hit communities and to enable people in these communities to continue supporting their seropositive friends and partners. Outside gay, lesbian, and bisexual communities, there is another pocket of seronegative angst, a place where being infected is commonplace and the stresses of being uninfected are significant and unrecognized. Seronegative children living with seropositive parents or siblings are often swept up in the crisis of infection as their normal developmental needs become secondary to the demands of HIV disease. These children often live in communities that have disproportionately high rates of HIV infection and so experience multiple loss on the scale of any gay community. These communities are often poor, disenfranchised, and already occupied with the challenges of basic survival. In this atmosphere, it is difficult to imagine any of us being able to focus on the needs of ostensibly "well" children. In this issue of FOCUS, James Dilley and Thomas Moon present the results of a study of seronegative men in San Francisco and compare those who have been receiving support services with those who have not. Phyllis Hansell, Wendy Budin, and Phyllis Russo describe the developmental dangers faced by seronegative children. Both articles support the necessity for paying attention to uninfected people living in the midst of the epidemic. When the concept of seronegative services arose for the first time--about five or six years ago--the response was derisive. Survivor guilt!, the commentators were amazed. You're alive--get over it, they instructed. Fear of death and grief can blind even the best of us, but what these commentators really seemed to be responding to was scarcity--scarcity of money and scarcity of time. Their responses, while insensitive and extreme, were natural in a world where social service provision is by definition an act of triage. Today, there is greater need and no greater abundance than there was six years ago, and scarcity-related fears remain rational. But the needs of seronegative people are demonstrably legitimate, even for the most cynical of us: provide support for seronegatives and they are less likely to become infected and more likely to help in the volunteer efforts that HIV-related care has always required. ****************************************** Supporting Uninfected Gay and Bisexual Men James Dilley, MD and Thomas Moon, MS Gay and bisexual men who are not infected with HIV have nevertheless been keenly affected by the epidemic. This is especially true of those living in urban areas with large gay and bisexual populations. Seronegative men watch as their friends and lovers wither and die, and, in addition to fulfilling significant roles as caregivers, must develop intimate and emotionally sustaining relationships in an environment that poses clear potential for HIV infection. The resulting tension is exacerbated by the required strict adherence to safer sex practices. Researchers and AIDS service organizations are only beginning to address the mental health consequences of living with such stressors. Nevertheless, clinicians working with this population have seen the effects of the epidemic on the psychological and social lives of seronegative gay men: they have witnessed the depression, the grief over lost loved ones, the uncertainty about and loss of faith in the future, and perhaps most ominously, the sometimes worn out commitment to safer sexual practices. In a very few instances, programs have attempted to address these needs. This article reports on a survey of 83 gay and bisexual seronegative men in San Francisco. It documents the effects of the stressors these men face, and demonstrates significant differences between men who avail themselves of seronegative-specific support services and those who do not. Further, it suggests several steps therapists might take in addressing these issues with their clients. Background Health professionals have noted throughout the epidemic that uninfected gay and bisexual men experience major psychological dislocations. Mindy Fullilove described the difficulties of the "worried noninfected": "Symptoms are anxiety-related and include panic attacks and generalized anxiety. Similarly, symptoms of obsessive compulsive disorder and hypochondriasis can occur... Some of these individuals suffer from sufficient distress to severely disrupt their social and occupational functioning."[1] In 1990, Walt Odets suggested that a "psychological epidemic" existed among uninfected gay and bisexual men.[2] He noted as a consequence symptoms of social isolation, depression, anxiety disorders, adjustment disorders, post traumatic stress disorder, hypochondriasis, sexual dysfunction, and repeated engagement in unsafe sex. Quantitative studies support his impressions. In a study of 745 New York gay men, John L. Martin found that there was a "direct dose-response relation between bereavement episodes and the experience of traumatic stress response symptoms, demoralization symptoms, and sleep disturbance symptoms."[3] The use of licit drugs and sedatives also increased proportionally to bereavement episodes, and men with one or more bereavements were four to five times as likely to seek mental health assistance to deal with concerns about their own health than were men with no bereavements. In another New York study of 139 asymptomatic gay men and 236 AIDS and "ARC" patients, researchers found that 39 percent of the "healthy" control group qualified for a diagnosis of Adjustment Disorder with Depressed or Anxious Features.[4] The widely publicized concern about a "second wave" of HIV infections among gay men has raised the question of the relationship between HIV-related emotional stressors and engagement in unsafe sex. A 1993 San Francisco survey examined this question and summarized key findings from 12 focus groups of gay men in which 133 men discussed their attitudes and feelings about the epidemic.[5] Participants reported a number of stresses that led to relapse behavior including: overwhelming grief and loss; problems with self-esteem and homophobia; a sense of hopelessness about the future; survivor guilt; a lack of a sense of community; and the feeling that having AIDS is an inevitable part of the gay experience. The study called for a "new generation" of prevention efforts that would go beyond education and address the emotional needs of gay and bisexual men. Methods and Demographic Data The UCSF AIDS Health Project (AHP) adapted a survey questionnaire developed at Columbia University* and distributed it to two groups of seronegative gay and bisexual men. One group included men who had received AHP services within the past year, and the second group was a convenience sample that included acquaintances of AHP staff and men who responded to a street-based solicitation in San Francisco's Castro district. The men in the first group received services through AHP's Negatives Being Positive support group program or attended an event sponsored by the Negatives Being Positive social program. The survey concentrated on four areas personal information; attitudes towards HIV infection status and safer sex practices; the effect of the epidemic on individuals; and managing these effects. Differences in responses between the groups were tested using chi-square statistics. The survey comprised 32 men who had received services and 51 men who had not. Both groups were predominately White and middle-class. The group that received services tended to be older: their mean age was 44 compared to 38 in the non-service group. Of note is that the mode age--the age reported most frequently--was 44 in the services group and 30 in the non-service group. While drawing conclusions from this small, relatively homogenous sample requires some caution, the data confirm clinical reports about the needs of seronegative men. Attitudes Toward Relationships The majority of men in both groups reported not being in primary relationships. Men who sought out services, however, were significantly more likely than those who did not to be single and to state that they wanted to start a relationship. Attitudes towards relationships with people already infected did not differ greatly between the groups: the majority of both-- roughly 60 percent--felt it was "very important" to know the HIV infection status of prospective partners. Further, a small number of respondents--6 percent of the services group and 14 percent of the non-service group (this difference was not statistically significant)--reported currently being in relationships with seropositive men. Further, the two groups did not differ in their willingness to start a relationship with a seropositive partner or in terms of having been in relationship with a seropositive person in the past. Two other items, while not statistically significant, were of interest. Respondents in the services group were somewhat more likely to have known more than 10 "people close to you who have died of AIDS"--59 percent versus 43 percent of those who had not--and were slightly less likely to have had a lover who had died of AIDS--24 percent compared to 19 percent. These findings suggest that seronegative gay and bisexual men who seek services are more likely to be socially isolated and are more interested in developing a relationship than the comparison group. These men may also make the effort to avail themselves of services partly because they are, in fact, looking for a relationship. Respondents from both groups have experienced a considerable loss of friends to HIV disease. At the same time, the survey does not support fears that seronegative-specific services would foster "viral apartheid," hostility toward or social separation from HIV-infected peers. Attitudes Towards HIV Status and Safer Sex There was no significant difference between the groups in their assessment of why they had not become infected with HIV: both attributed their seronegative status primarily to "changes in their sexual behavior" and "luck." When asked to rank order the factors responsible for their status, more than three-quarters of respondents in both groups identified "changes in sexual behavior" as the most important reason they have remained seronegative. At the same time, a substantial number of both groups--60 percent of the services group and 71 percent of the non--services group-ranked "luck" as the first or second most important factor in explaining their seronegative status. The frequent endorsement of luck suggests that, despite acknowledging the importance of behavior change, respondents feel an element of wonder about having remained uninfected. The fact that these men say they have escaped infection may suggest that they have occasionally "slipped" into unsafe sex, or that they have ongoing concerns that their practices, while technically safe, may not fully protect them. In fact, the survey suggests that "slipping" is a real concern. In answer to the question, "Over the last six months, how often have you found yourself engaging in sex that is higher risk than you would have liked?" respondents in the services group were significantly less likely than those not receiving services to endorse "Never" or "Rarely." One respondent noted, "As irrational as it may seem, it is a daily struggle to not give in to the virus." Similarly, those who had received services were less certain of their abilities to maintain their seronegative status in the future. While this finding did not quite reach statistical significance, slightly less than one-third of the services group stated they would "Definitely" be uninfected in the future compared to 50 percent in the non-services group. These findings suggest that men receiving services fight an ongoing battle to remain committed to protecting themselves and that it is likely in part because of this struggle that these men avail themselves of services. Conversely, it may be that men who have not availed themselves of services have been more successful at "making peace" with the behavior changes needed to remain safe. One factor that may be important in this regard is age: since the services group was generally older and thus, likely to have been more sexually active in the era before AIDS, this group may have greater difficulty remaining committed to the limitations of safer sex. Finally, substantial numbers of respondents in both groups were unable to state that they would "Definitely" be seronegative in the future, again attesting to the difficulties seronegative men have in expressing confidence about the future. Not surprisingly, virtually all men in both groups reported that in general the HIV epidemic had had a "moderate or major" effect on their quality of life and had caused increased stress in their lives In response to questions about mood, however, those receiving services were significantly more distressed. For example, one in four of those receiving services stated they felt "Very or Somewhat" hopeless in the last six months compared to one in five of those not receiving services. Conversely, while not statistically significant, only about one-third of the services group versus almost half of the non-service group felt "Somewhat or Very" hopeful. These findings further suggest a relationship between greater distress and greater difficulty maintaining safer sex practices. Implications for Therapy For seronegative gay and bisexual men. living in the epidemic poses challenges that at first glance may not be obvious, or may be overshadowed by the needs of those living with HIV disease. Many respondents spoke to the feeling that their needs have been neglected. One man wrote, "Being HIV-negative should be valued, but sometimes it is not." Another man admitted that he keeps his serostatus a secret: "I keep my mouth shut and I know there are people who think I am positive." Others reported that they feel out of place: "Out of sync with the gay male community. So many people are HIV positive." These responses suggest that therapists need to be alert to these issues and, by asking directly, to validate the struggle of seronegative men who must go on, caring for infected friends and lovers while striving to maintain meaningful lives. The survey also supports the need for group approaches and services for seronegative gay and bisexual men. The results clearly suggest that AHP's services currently attract a group of seronegative gay and bisexual men who are at high risk for HIV infection and who have significant mental health needs as a consequence of the epidemic. Several men echoed a wish for additional support when they wrote about their hope that this research would lead to more programs for seronegative men. Others expressed concern that "people think we're just feeling sorry for ourselves" and noted that, as a result, it was difficult to accept their own needs. Two comments eloquently summarize the issues for many seronegative men. One man wrote: "The questionnaire helps to 'break the silence' around issues HIV-negative gay men have been reluctant to face, and hopefully this research will lead to new prevention programs that assist men to remain HIV negative." Another wrote: "Programs need to be developed to assist survivors in rebuilding extended family, rebuilding community, and having a shared sense of the future, while we live with the reality that AIDS will be a part of us for the rest of our lives." ~ A p-value of <.003 indicates a markedly strong statistical significance for the relationship between seeking and being single. References 1. Fullilove MT. Anxiety and stigmatizing aspects of HIV infection. Journal of Clinical Psychiatry. 1989;50(N11, Supp 1):5-8. 2. Martin J.L. Psychological consequences of AIDS-related bereavement among gay men. Journal of Consulting and Clinical Psychology, 1988;56(6):856-862. 3. Odets W. The homosexualization of AIDS, FOCUS: A Guide to AIDS Research and Counseling, 1990;5(11):1-2. 4. Tross S. Psychological impact of AIDS spectrum disorders in New York City. Presentation at the American Psychological Association Annual Meeting. Washington, D.C. 1986. 5. Communication Technologies. A Call for a New Generation of AIDS Prevention for Gay and Bisexual Men in San Francisco: Communication Technologies, 1993. Authors James W. Dilley, MD is Associate Clinical Professor of Psychiatry at the University of California San Francisco, Executive Director of the UCSF AIDS Health Project, and Executive Director of FOCUS. Thomas Moon, MS is a therapist in private practice in San Francisco and is doing doctoral research on seronegative gay men. ********************************************** Seronegative Children in HIV-Affected Families Phyllis Shanley Hansell, EdD, RN, Wendy C. Budin, MSN, RN, and Phyllis Russo, EdD, RN Seronegative children-so called because they live in families where a parent or sibling is HIV-infected-face unique developmental and psychosocial challenges in the context of families in crisis. Acquired at birth, early in childhood, or during adolescence, a seronegative status in an HIV-affected family leads to stressors that vary with the stage of the child's psychosocial and cognitive development. These stressors can contribute to the development of an immature adult, burdened with poor problem-solving skills, ineffective coping, depression, and low self-esteem. This article describes the psychosocial issues of uninfected children in terms of situational and developmental stressors. Families with seronegative children typically reside in urban areas, are from under-represented minority groups, and are likely to include members who are using or have used injection drugs. These families are often unstable, headed by a single parent, usually the mother and usually HIV-infected. They are often encumbered by poverty, reliant on public assistance, and enduring persistent unmet needs. In response, AIDS becomes a multi-generational disease: siblings or children of HIV-infected family members may be separated from their biological families, and sent to live with extended family members or foster parents. Young Children All of these psychosocial factors interact with each other, with the stresses of HIV disease, and with the emotional response to HIV disease-anger, fear, sadness, and even violence can become commonplace-to complicate the normal developmental tasks for seronegative children. Seronegative children may encounter several problems including: the deteriorating health and death of other family members; unmet physical needs; loss of social interaction; loss of emotional support; interruptions in education; and fragmentation of schooling. These stresses are to a great extent developmentally determined, and infants, toddlers, preschool-age children, school-age children, and adolescents will respond in different ways. Very young children under the age of two are by nature dependent, need continuous loving attention, and have limited verbal abilities to express loss and anxiety. Their understanding of the world and HIV-related stresses is restricted by an inability to deal in the abstract. Major stressors for these children are related to interruptions in continuity of both physical and emotional care, a situation likely to occur as a parent's HIV disease progresses. Unmet needs can become all encompassing at this age and may result in the complete breakdown of the child's world, affecting the normal progression of development. A parent's deterioration may also lead to a child being placed under the care of an extended family member or a foster parent. Removing the child from the biological parents is an extremely traumatic experience for the young child, and seronegative children are at a particularly high risk for this trauma because most come from single-parent families. Preschool children, between the ages of two and five, have a better grasp of family membership than younger children and are better able to express their feelings verbally. For these children, verbal expression provides an important outlet and is a means of effective coping. While preschool children understand what it means to be sick, to go to the doctor, and to take medicine, they do not comprehend the irreversible nature of HIV disease progression. Their greatest stressors are the lack of continuity of the family--which they understand only at very concrete levels--and illness and loss of family members. They readily perceive changes in caregivers from biological parents to extended family members; however, they do not easily comprehend the duration of these changes and the underlying rationale for them. Disruptions in the family are particularly difficult for preschool children and may result in reversion to a less mature level of behavior, including loss of toilet training, difficulty sleeping, and social withdrawal. The lack of continuity may extend beyond the family when a preschool child must deal with a new family composition, a new home, or new preschool. School-Age Children School-age seronegative children--between the ages of 5 and 12--are better able to understand the changes that are taking place in their families and the irreversible progression of HIV disease. HIV-related stressors for them are connected to the family's functional and socioeconomic status, progression of illness, and loss of life. Since achieving tasks, acquiring knowledge, and forging positive social relationships are the primary developmental tasks for school-age children, one of the most significant stressors for them is lack of continuity in school and the resulting disruptions in social situations. Changing schools--because of moving--and assuming caregiving responsibilities for ill parents may hinder achievement in school, leaving children to lose focus on these developmental tasks. These stressors can be so substantial that normal developmental tasks become completely subverted and the orderly progression of life becomes totally disrupted. The outcome is often failure in school and withdrawal from peer relationships, leaving such children with a limited foundation to enter adolescence. Adolescence is normally an extremely difficult and challenging stage of development. It is a time when children struggle to achieve self-identity and to establish a sense of intimacy and intimate relationships. They must also make important decisions concerning schooling and vocation. In the HIV-affected family, the seronegative adolescent often shoulders the greatest burden of all: many take on caregiving responsibilities as the head of the household, while others end up dropping out of school and leaving their families. The normal establishment of identity and intimacy are often put on hold. In many cases, these children are completely devastated by the effects of HIV disease and have little hope of regaining a normal adolescence without in-depth counseling and emotional support. Conclusion In response to these stressors and to achieve developmental goals, age-appropriate counseling and support is essential. It is important to remember that coping, like stress, is developmentally determined, and for each stage of development, there will be healthy and unhealthy coping. At any age, seronegative children will lack the coping skills that adults attain only through achieving developmental milestones: skills that make a horrific epidemic approach able. Counselors can support these children by helping them develop these coping skills and complete their psychological development. References 1. Butler KM, Pizzo R. HIV infection in children. In Devita VI; Hellman S. Rosenberg SA. AIDS Etiology, Diagnosis, Treatment and Prevention, (3rd ed.). Philadelphia: JB Lippincott, 1992. 2. Center for Disease Control. HIV/AIDS Surveillance Report 1993; 5(3):17. 3. Grosz J. Hopkins K. Family circumstances affecting caregivers and brothers and sisters. In Crocker AC, Cohen HJ, Kastner TA, eds. HIV Infection and Developmental Disabilities. Baltimore: Paul H. Brookes Co., 1992. 4. Hansell P. Hughes C, Caliandro G. et al. Stress, coping, social support and problems experienced by caregivers of HIV-infected children: A comparison of HIV-infected caregivers to non-HIV-infected caregivers. Presentation from the IXth International Conference on AIDS, Berlin, Germany, I 993. Authors Phyllis Shanley Hansell, EdD, RN is a Professor and Director of Nursing Research, Seton Hall University, College of Nursing, in South Orange, New Jersey. Wendy Budin, MSN, RN, is Assistant Professor, Seton Hall University, College of Nursing. Phyllis Russo, EdD, RN, is Associate Professor, Seton Hall University, College of Nursing. ************** Recent Reports Partner Preferences and Serostatus Colleen C, Hoff BA, McKusick L, et al. The Impact of HIV antibody status on gay men's partner preferences: A community perspective. AIDS Education and Prevention. 1992; 4(3): 197-204. (University of California San Francisco.) Serostatus may influence the formation of primary partner bonds in gay male communities, according to a large San Francisco study. Seronegative and untested men were more likely to prefer seronegative men than seropositive men for romantic relationships, while seropositive men were more likely to prefer other seropositive men or to report that serostatus did not matter. In November 1988, researchers surveyed 540 gay men by mail. The survey included measures of sexual behavior, antibody testing status, AIDS loss and relationship status, and partner preference. Of the respondents, 9.3 percent were White and 69 percent were college educated. Twenty-nine percent were sero- positive, 38 percent were seronegative, and 29 percent had not been tested. The mean age of respondents was 35 years old. Eighty-three percent of seronegative men and 74 percent of untested men preferred uninfected partners for romantic relationships, whereas 68 percent of seropositive men indicated that antibody status did not matter. Seropositive men were less likely to report antibody status preferences for friendships: 89 percent of those who tested antibody positive versus 76 percent of those who tested antibody negative and 79 percent who had not taken the test did not have preferences for friendships based on antibody status. Of those who stated a preference, however, seronegative men were more likely than seropositive men to prefer seronegative men for friendship. Researchers found no connection between current relationship status and serostatus preference for romantic relationships or friendship. The one exception was that single men were more likely than men in relationships to base a preference for friendship on serostatus. --------------------- Bereavement Reactions Neugebauer R. Rabkin JG, Williams JBW, et al. Bereavement reactions among homosexual men experiencing multiple losses in the AIDS epidemic. American Journal of Psychiatry. 1992; 149(10): 1374-1379. (Columbia University.) A New York City study of gay men found no association between loss and depressive symptoms for either seropositive or seronegative men. In contrast, the study found for both groups an increase in thoughts and feelings specifically focused on the deceased person and in preoccupation with and searching for the deceased. Researchers interviewed, in 1988 and 1989, 84 seronegative and 123 seropositive gay and bisexual men and subjected them to medical, psychiatric, and psychosocial examinations. Researchers measured depression using two self-report symptom check lists, the Hamilton Rating Scale for Depression, and the Structured Clinical Interview for DSM-III-R. Of the 207 participants, 87 percent were White, 7 percent Hispanic, and the remainder were Black or Asian. The mean number of years of education was 16 and the mean age was 38 years old. Half of the group reported one or more losses since the start of the epidemic, and more than 20 percent had experienced a loss in the six months preceding the interview. Men with greater numbers of losses reported more subjective experiences characteristic of preoccupation with and searching for the deceased than did men with fewer losses. Tearfulness at the thought of the deceased, inability to accept death, or pain and distress when thinking about the deceased were common symptoms. In contrast, neither level of depressive symptoms nor rate of diagnosed depressive disorder was related to number of losses. The lack of association between loss and depressive symptoms held for seropositive and seronegative men separately, and held on three different depression scales. ----------------------- Gay Male Survivor Guilt Boykin FF. The AIDS crisis and gay male survivor guilt. Smith College Studies in Social Work. 1991; 61 (3): 247-259. (Smith College.) A small urban study found modest yet prevalent survival guilt among gay men. Surprisingly, seropositive men tended to have higher survivor guilt scores than seronegative men. There was no clear correlation between survivor guilt and the number of friends, ex-lovers, and lovers affected by HIV disease, and there was a high correlation between involvement in gay or AIDS organizations and relief from survivor guilt feelings. Of the 92 subjects, 77 completed a written questionnaire and 15 responded to a face-to-face interview. The study was based on an original survey, in which the subjects self-identified the presence and magnitude of survivor guilt. Participants had a mean age of 36 years; all but two were White. Overall there was a modest amount of survivor guilt in both the interview and the questionnaire groups. On a scale of 1 to 10, with 10 the highest, the survivor guilt score averaged 3.1 for the interview group and 2.5 for the questionnaire group, with seropositive men scoring slightly higher than seronegative men. It is notable that one-third of interviewees and one-quarter of the questionnaire group experienced survivor guilt at an intensity of 5. Sixty percent of interviewees and 53 percent of those who completed the questionnaire reported that involvement in AIDS organizations helped alleviate feelings of survival guilt. -------------------------------------------- Partners of HIV-infected Men with Hemophilia Klimes I, Catalan J. Garrod A, et al. Partners of men with HIV infection and haemophilia: Controlled investigation of factors associated with psychological morbidity. AIDS Care. 1992; 4(2): 149-156. (Oxford Haemophilia Centre, Oxford University and Westminster Medical School, London.) No differences were found in the psychological status of female partners of HIV seronegative and HIV seropositive men with hemophilia according to a study that determined the prevalence of psychosocial problems in partners of men with hemophilia and HIV infection. However, partners of men with hemophilia, regardless of serostatus, had twice the number of psychological symptoms of women in a general community survey. The interviews focused on psychological status, sexual functioning, and past psychiatric history, and included the following self-administered scales: Modified Social Adjustment Scale; Self-Control Schedule; Hardiness Scale; and Health Locus of Control Scale. Partners of 17 seropositive and 19 seronegative men with hemophilia were interviewed. The two groups of women were comparable in terms of age, their own and their partner's employment status, and social class. All women in the study were tested and confirmed HIV antibody negative. On the average, the seronegative couples had been together for 14 years, while the couples with a seropositive partner had been together for an average of seven years. In both instances, the women had known about their partner's serostatus for at least three years. More than four- fifths of the seropositive men were asymptomatic. Despite having to cope with their husband's psychological state, changes in sexual relationships, and concerns about HIV transmission, 78 percent of partners of seropositive men reported their general relationship was unchanged since their partners first took the antibody test. The heightened level of psychological distress among all partners suggests that living with and managing hemophilia is more stressful and of more immediate concern than the challenges of living with asymptomatic HIV disease. While the men's serostatus was not an indication of psychological distress among partners, the women's past psychiatric history and poor social adjustment were associated with psychological morbidity. Next Month In the new world of health care reform and managed care, long-term psychotherapy may become a luxury. In response, many practitioners are considering brief psychotherapy, particularly for issue-specific treatment- for example, to cope with bereavement and stress response syndromes. In the June issue of FOCUS, John Devine, MD, Director of the Psychiatric Outpatient Service AIDS Program of the San Francisco Veterans' Administration Hospital, compares long-term and brief psychotherapy, describes two approaches to brief psychotherapy and applies them to HIV-related situations. Group support is central to the HIV-related psychotherapeutic response, and group psychotherapy is also seen as a response to shrinking resources, especially when trained volunteers can facilitate groups without compromising quality. Also in the June issue, Louis Piccarello, a group facilitator with the UCSF AIDS Health Project, describes the group facilitation experience from the perspective of a volunteer. Copyright (c) 1994 - Reproduced with Permission. Reproduction of FOCUS must be cleared through the Editor, FOCUS --UCSF AIDS Health Project, Box 0884, San Francisco, CA 94143-0884, (415) 476-6430. Subscription information: 12 monthly issues- $36 individuals; $90 institutions.