THE SWORD OF DAMOCLES

(A Report on a Demonstration Project Involving 3 Week-long Workshops in 1998 directed by Dr. Lewis Yablonsky with Mental Health Professionals who work with The HIV/AIDS Problem. The Workshops were held at the Centro Torinese Solidarieta Therapeutic Community in Torino, Italy.)

by Dr. Lewis Yablonsky, Emeritus Professor of Sociology,
California State University-Northridge

INTRODUCTION
In a cogent summary of the l998 12th World AIDS in Geneva, Dr. Jay A. Levy, an AIDS researcher at the University of California-San Francisco told the final gathering of 14,00 delegates from over 175 nations, "If there is one word that pinpoints the lasting message of this Conference in basic, it is immunology." At the 11th Conference in Vancouver the message was dominantly related to the hope that anti-viral therapy would block all detectable replication of the AIDS virus. Many research reports indicate that there are negative complications to this approach, and that this result can not be accomplished in the near future. Both Conferences, focussed almost entirely on the biological-physical-medical aspects of HIV-AIDS, with a very limited attention to the social-psychological and emotional impacts on the 1 million people in the United States and the 30.6 million people around the world, estimated in a UN Report, to be living with the HIV virus that causes AIDS.

There are, two general broad types of sub-issues that flow from the overall HIV-AIDS problem: (1) the medical-physiological, and (2) the social-psychological and emotional issues that impact on people who test HIV positive. The medical-physiological problem is basic, and we certainly are advocates of all of the research efforts into this aspect of the disease with a focus on immunology. Moreover we are enormously interested in and concerned about the future possibilities of medical science developing a vaccine for prevention, and effective treatments for controlling the disease in AIDS patients. We note, however, that at these important Conferences and others, limited attention is devoted to the treatment of the social-psychological and emotional problems that surround the disease, and impact on people and their families who live in the target area of this complex malady.

In l998 the U.S. Department of Health and Human Services stated: "age-adjusted deaths for people with the HIV/AIDS virus fell by an unprecedented 47% from l996 to 1997." The 1997 data indicated that the 5.9 deaths per 1000 population was the lowest since 1987. The peak year
for HIV/AIDS deaths was1995 when HIV/AIDS deaths were 15.6 per 1000 population.
This recent data supports the assertion by a physician, Dr. Ben Krentzman, who has worked with HIV-AIDS patients and is knowledgeable about the data, that a significant aspect of the HIV-AIDS medical problem is that around 50% of the people who test positive for HIV live out their normal life expectancy, and do not die from AIDS. All of the millions of people who test positive for HIV, however, whether they develop the AIDS disease or not, live in the shadow of the dreaded disease.

This shadow is like the apocryphal "Sword of Damocles" hanging over their head by a thin thread. Damocles, in classical Greek mythology, became a sycophant at the court of Dionysius, and constantly praised Dionysius for his wealth and power. The story goes that Dionysius, in order to show Damocles the precarious nature of status and power, gave a banquet, and had a sword suspended above the head of Damocles by a single hair. The expression, "The Sword of Damocles" represents the ever-present perils that exist in life.

People who test HIV positive may enjoy normal health, however, living in the shadow of this "sword", there is always the fear that the brutal consequences of the disease may fall upon them at any time. This anticipation of the potential dire medical aspects of testing positive creates many complex social-psychological and emotional problems for those who escape the worst physiological impact of the disease, and these problems are even more severe for the individuals who suffer the health ravages of AIDS.

This viewpoint and data was derived, in part, from an ANSLAID demonstration project involving my direction in l998 of three weeklong intensive psychodrama and group psychotherapy training sessions for around 30 mental health professionals from around Italy at the CTS Torino therapeutic community. This ANSLAID demonstration project was based on my directing over 20 weeklong training sessions in psychodrama and group psychotherapy for European mental health professionals since l986. Many of the people in these workshops had been or were working with HIV-AIDs patients. These prior weeklong workshop were held at several European therapeutic communities including: the CTS-Torino facility, the Centro Italiano Solidarieta TC in Rome, and the Kethea TC in Athens.

In addition to the university trained mental health professionals in my training workshops, most of the groups included ex-addict personell working in TCs and a number of people who were HIV positive or had AIDS. These prior intensive psychodrama workshops over an 18 year period, and the focussed ANLAID demonstration project in Torino in 1998, in addition to effectively training the participants to become more competent psychodramatists and group therapists, produced considerable knowledge about the overall social-psychological and emotional problems that plague people who are HIV positive or have developed AIDS, their families and loved ones. In this context, we believe we have garnered some important information on this aspect of the problem, and developed some strategies for dealing with these issues that will be useful to other workers in the
field.

PSYCHODRAMA APPLIED TO HIV/AIDS ISSUES AND PROBLEMS
Before describing some of the HIV/AIDS issues and problems that were explored in our training groups that can be effectively alleviated through psychodrama, it is useful to briefly delineate the theory and method of psychodrama.

Psychodrama was created by Dr, J. L. Moreno, a psychiatrist in Austria in 1910. He developed the theory and method of psychodrama, along with many of his students, in the United States, where he practiced psychiatry and directed the Psychodrama Institute in New York from 1924 untiI his death in 1978. His wife Zerka Moreno and his son Jonathan Moreno carry on his important work. Psychodrama group therapy Is now utilized as a significant and respected therapeutic method around the world. Psychodrama is basically an exploration, by dramatic methods, of relationships a person has to others and the problems they encounter in their relationships. It may be viewed as an experimental procedure In which the Individual may test his relationship with others by using an "auxiliary ego", another person who plays the mother, father, or other role. In the course of a psychodrama, the subject recognizes and can clarify for themselves the existence of his of their problems. They can in the process become aware of alternative solutions, and resolve their problems.

A psychodrama director begins a session through a "warming up" process in which he helps the group to select an issue and a protagonist or subject, the person around whose problems the group therapy session will revolve. The protagonist is asked to present themselves on their stage of life and to enact situations that are relevant to their problem. The session can be an issue in the past, the present, or their anticipation of a future problem. In the context of HIV/AIDS problems, a person can explore the how and where of contracting the disease, their current emotional situation, and their projected concerns about their future under this ominous "sword".

The group present is not an audience as in a theatrical production. The group present is crucial to a psychodrama because all members are considered participants. Many members will participate actively at some point in the session as auxiliary egos to the protagonist playing such roles as parents, son, daughter, or spouse. However, even those who sit through a session without speaking are expected to be empathetic and identify with the protagonist and the problem being presented for their benefit and the protagonists.


There are generally three phases to a classic psychodrama session: The warmup, which involves members of the group tuning- in to each other's concerns and focusing on a protagonist and a problem. The heart of the session involves the role-playing portrayal of various key scenes and the use of various techniques necessary to reveal the problem and move toward its solution. And finally there is the sharing at the end of the session which involves an intensive examination by the director, the protagonist, and the group on the meaning of the session.

In the process, some of the methods utilized include: (l) "role-reversal," a method that enables protagonists to see themselves from another point of view; (2) "doubling," which can facilitate members of the group to participate by sharing their viewpoint with the protagonist; (3) "soliloquizing," a method that enables a protagonist to share their most intimate thoughts in a crucial situation in their life; (4) "future-projection," a method that presents the opportunity for the protagonist to project himself into his future life; and (4) "group-sharing," the significant process which enables members of the group to share their emotions and possible solutions they derived from the session. In action, a group exploring an HIV/AIDS problem through psychodrama can learn more about how others perceive the problem, the emotional aspects of the problem, and possible solutions to the emotional pain and suffering that surrounds the problem.

In psychodrama, the protagonist and the group present are encountering their conflicts and psychological pain in a setting that more closely approximates their real-life situation than in other therapeutic approaches. Psychodrama can produce peak experiences, and exciting modes of acting-out, that often results in positive behavioral change in the person's real life situation.

In most psychodrama sessions, therapeutic benefits accrue to members of the group other than the central protagonist who is center stage. Group participants, other than the main subject of the session, are encouraged to witness aspects of their own lives that became manifest in the session, as if watching a dramatic play that projects their own behavior onto the psychodrama stage In front of them. This kind of personal participation either as a subject or member of a group in a psychodrama produces maximum emotional impact and therapeutic benefits. Our Psychodrama Demonstration Project in Torino focussed on, and revealed many significant aspects of the emotional problems confronted by people living under the "sword" of the HIV/AIDS complex, and revealed possible solutions to their problems.

SOME OF THE CURRENT AND PREVALENT ISSUES REVEALED IN THE TORINO PROJECT
Following are some of the social-psychological and emotional issues that have surfaced and have been explored through the methodologies of psychodrama and group psychotherapy in the Torino and other training workshops I directed in Europe.
l. Confronting Death and Dying. In our workshops we had numerous psychodrama sessions on this key issue, including: future-projection psychodramas on what people believe happens to a person after death; how a therapist has to deal with the death of a patient with whom he has emotionally bonded; the fact that young therapists, who ordinarily, don't think of death and dying, are now forced to directly confront this issue in their own lives; and how some patients have great difficulty in getting their life in order--in preparation for their possible death. A debatable issue that has surfaced in several groups is that some patient's credit their illness with being a "positive learning experience" about life and death.

2. Prejudice and Discrimination. People's reactions to persons who test HIV positive are often problematic. The situation tends to produce personal and job prejudice and discrimination. We have had many psychodramas related to the different way people view individuals who are HIV, and how they sometimes lose their jobs, and other important relationships in their life.

3. The "Sword of Damocles" Concept. We have had psychodramas on this concept which refers to the serious imminent negative change in the patient's health that, in some cases hangs by a slender thread over their illness. Whether or not the HIV positive persons health changes, it is a constant issue in their life.

4. Informing Family and Friends. When a person first learns of their HIV positive condition, they tend to have great difficulty informing the people who are close to them. Prototypical psychodramas on this issue include: a divorced father's emotional difficulty in directly telling his daughter that he is HIV positive; and a session about how parents react to their child's contraction of HIV and the illnesses of AIDS. The primary issue that we have explored through psychodrama are the varied ways, (positive and negative) in which different family members react to the patient's illness.

5. Spousal Problems. Married couples, with one or both HIV positive, have to confront the fact that they can't normally have children. One psychodrama we had involved an HIV positive husband dealing with his rage about the issue that his new wife and him can't have children because he has to use a condom to protect against his transmission of the disease.

6. The Sporadic Cycles of Hopelessness and Depression. Most patients and their therapists experience roller-coaster emotional feelings of hopelessness and depression about the disease and its impact on their lives at different times. The depression is often a manifestation of undisclosed rage related to "Why me?" Psychodrama is effective in surfacing this often repressed rage and helps the patient to deal with this issue.


7. Self-Concept Factors. The enormous changes that take place in a patient's self-concept and self-esteem when they learn they are HIV positive are usually quite profound. In our groups we have had several psychodrama sessions with patient's who have an enormous sense of self-hatred and guilt about their past lives and their "stupidity" related to having been a drug addict who acquired the disease through their addiction behavior. As one former addict, now HIV positive, commented in a psychodrama session, "I am furious at myself. How could I have been so incredibly stupid".

8. Medical Treatment Impacts. Another issue that has surfaced in our groups, and was explored in psychodrama is related to why some patients feel "the cure is, at times, worse than the disease." These psychodrama sessions focussed on the enormous hostility many HIV patients have about being sick, and requiring the enormous daily quantities of drugs and "blockers" they have to take to avert the more severe illness of AIDS. Many have also noted that some physicians who administer the medicines, only focus on the medical treatment, and do not deal with the patients emotional problems.

(January, 1999-Draft)

REFERENCES:

l. Lewis Yablonsky, PSYCHODRAMA: RESOLVING EMOTIONAL PROBLEMS THROUGH ROLE PLAYING (Basic Books/Harper Collins, l976.); PSICODRAMMA (The Italian Edition, Rome: Astrolabio, 1978)

2. Lewis Yablonsky, THE THERAPEUTIC COMMUNITY (New York: Gardner Press, 1994); LA COMMUNITA THERAPEUTICA (The Italian Edition, Rome: Astrolabio, 1978)

3. Lewis Yablonsky, FATHERS AND SONS (New York: Simon & Schuster, 1982); (The Italian Edition, Rome: Astrolabio, 1988)

Dr. Lewis Yablonsky
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