The Ohio State University Press
Richard Ruth - Infecting the Treatment: Being an HIV-Positive Analyst (review) - Journal for the Psychoanalysis of Culture and Society 8:1 Journal for the Psychoanalysis of Culture and Society 8.1 (2003) 174-177

Cole, Gilbert W.Infecting the Treatment: Being an HIV-positive Analyst.Hillsdale, NJ: The Analytic P.

What do I look for in good psychoanalytic writing? One way of answering my question might be, I [End Page 174] look for books like this one. It is one of the most enjoyable and useful analytic books I have read in a long time—open, thoughtful, creative, wide-ranging, deep, integrative, challenging; also messy, non-linear, relatively lacking in prescriptions and clear conclusions, and touching on as many interesting points in passing as it does in its core intent. (Perhaps that is part of its core intent.) And what does it mean that such qualities would come to dwell in a book about the experiences of an HIV-positive psychoanalyst?

I would offer the perhaps uncomfortable proposition that the lives of all psychoanalysts have been shaped by (and have helped shape) the course of the HIV/AIDS epidemic; the past two decades have been very different from what we would have foreseen for our futures. Sometimes we have been conscious, active participants in work with and for people with HIV/AIDS, as theorists, clinicians, consultants, and researchers. Less often analysts have been among those who have been obstacles to those of us doing the work; more often, to our collective shame, analysts have been spectators. That was so when the epidemic first erupted, when my waiting room, as many others, was occupied by men with purple spots of their faces, and it is true in different, more interesting and also more troubling, ways now, when it sometimes seems that AIDS (at least lethal AIDS, AIDS-beyond-reach), like factories, has largely migrated to the Third World. Though, of course, that is not entirely true. It is still, indeed like the Third World, quite powerfully present among us.

One might also say, or at least try the proposition on for size, that the past two decades have seen a trajectory for psychoanalysis very different from what it might have predicted for itself in an earlier time. Our field—or should that be a plural?—has experienced rich theoretical, empirical, and practical developments, and we find ourselves now with a decentered official establishment, no medical monopoly, and no hegemonic theory. But we have also, perhaps, like people living with HIV/AIDS, wandered far from the center of public consciousness.

Some psychoanalytic thinkers and clinicians have made important contributions in work for people with HIV/AIDS and in conceptualizing and thus defeating the epidemic. Others have argued explicitly that, if HIV/AIDS is a clinical problem, it is one for other kinds of mental health professionals, not analysts—one of those instances where perceptions become dangerous realities. But such arguments are not the context for this book. Paralleling the shift in gay fiction and Black fiction away from writing defined by its appeal and response to heterosexual and white audiences, this is a book written from a reasonably comfortable location inside psychoanalysis, inside gay life, inside psychoanalytic work by gay/lesbian/bisexual analysts, and inside a psychoanalytic engagement with HIV/AIDS. It is also written from an immersion in the content and process of postmodern psychoanalytic thinking—in many ways it seems to me an excellent example of such thinking—and thus will be familiar and comfortable to some readers, and disquieting, in its basic approach and ideas, to others.

The method behind this book is very attractive. There is a mix of selected personal experiences, reflections upon them in considerable depth (thus, there is nothing in the book that has the feel or limitations of confessional writing), explorations of diverse relevant literatures (among these: psychology and social work ethics, the philosophical legacies of Plato and of Kant vs. Nietzsche, literary and cultural theory, and method acting), and a qualitative research project that inquired about the experiences of other HIV-positive analysts.

What is most fascinating to me about this bringing-together of multiple methods to consider the book's subject is not only that it mirrors the content of one of the author's core arguments—that the experience of being an HIV-positive analyst is possible, to be embraced, and complex—but that it brings something of the living psychoanalytic method into the writing. Reading the text, I felt myself moving with tides of different identifications—at times engaged as a supervisor, at times in the position of an analyst in conversation with a peer, and at still other times feeling like a patient reacting—at moments highly uncomfortably, at moments with deep gratitude—to an engaged analyzing instrument.

This makes it dangerous, and difficult, to try to summarize some of Cole's ideas, a specific risk being [End Page 175] that summarizing would lose some of this essential process. (Nor would I want to make the book feel schematic enough that a reader of this review could easily decide to skip the book. This is a very important book, and deserves to be widely read and discussed.) Nevertheless, I want to try to highlight some of the ideas that seemed most evocative to me.

First, Cole discusses the various strands of identity that have intersected for him in considering what it means to be an HIV-positive analyst. These include what seems to be a recapitulation of a developmental coming-out process; the embodiment of the qualities of a man who chooses to be penetrated by another man, inherent in the fantasy lives of patients encountering, whether they consciously know it or not, an HIV-positive analyst and thus reintrojected in a new way by the analyst; links to the history of other illnesses, such as syphilis, that are socially constructed as marking those infected as Other; and HIV/AIDS as "an intersection with masculine fantasies concerning [bodily] interiority that carry particular salience in the question of the construction of identity," leaving the infected man "pregnant with badness" and in a condition where "the body can so easily become a traitor." These facets of an analyst's interior life are juxtaposed with meditations on the psychoanalyst as "the specialist of otherness," in which the categories of identity assume new meaning when they are constructed in the context of relationships, therapeutic and personal, in which "the otherness of the self" is confronted and transformed.

Second, Cole re-casts the issue of disclosure in psychoanalysis—in two chapters, with an elegiac rhythm, including extensive case material—as one that must be responsive to both the analyst's and the analysand's subjectivities. He does this somewhat in the nature of a report on clinical experiments: feeling at some points that it was not only problematic to his patients' needs not to disclose his HIV-positivity (one, for instance, had lived through the death of a previous analyst that had been handled dishonestly; others were gay men with multiple layers of issues around losing people they cared about to AIDS), but inauthentic to his own needs and desires, Cole tells the stories of these disclosures, what they evoked for him and what they evoked for his patients (at least one of whom reviewed the chapter in which he is written about). Cole concludes that the disclosures did not seem to foreclose possibilities of an analytic process, but actually freed up the process to move into terrain it might not have encountered without the disclosure, and the subsequent analysis of the disclosure with both the analyst and the analysand empowered as subjects.

Third, Cole's research project is fascinating. Diplomatically worded letters to psychoanalytic societies inviting HIV-positive analysts to contact him yielded no response. It is good when negative results are reported in the literature, and all too rare. He ended up meeting three such analysts through professional contacts, and, he tells us, wrote a rich chapter analyzing the interviews he had with each of them. But it is a chapter we will never read, because Cole realized, after it was written, that there was no way to sufficiently disguise the identities of those he calls his "co-researchers." As he wrestles with this problem, he comes to feel as well that even verbatim transcripts may not accurately capture their subjectivities.

As a substitute, Cole presents a heuristic analysis of things he and his co-researchers shared, and then a textual analysis of the forms of their experiences of HIV-positivity—one lyrical romance, one ironic absurdist satire, and one Gothic horror tale. I was at first incredulous; I have spent a career rarely if ever reading the literary critiques in psychoanalytic journals (usually at the back), and I had a visceral reaction to considering the epidemic that has killed hundreds of personal friends and many of my patients as a text for formal analysis. I don't know if I can say that I was won over, but I was certainly impressed. The privileging of subjectivities was respectfully embodied, and in my reading this created a productive space for thinking about what this kind of analysis has the potential to offer us clinically.

In the book's final chapter and on its farthest shore, Cole looks at ways in which his experience of being an analyst who is HIV-positive helped deconstruct his previous idealization of who analysts are, and ways in which this idealization [End Page 176] had "complicated the process of thinking through decisions as to how to begin and to conduct treatments with certain patients." Invoking Barthes and Ricoeur to help understand "the problem of difference as difference" in the psychoanalytic process construed as one in which "the task is to attend to the action of approaching the limits of what can be known," Cole sees the inevitability of enactment, and then its subsequent in-depth analysis, as the method through which such questions can be most satisfactorily engaged and the "traumatic inscription" that infects the identity of the patient can be worked through.

On the National Public Radio news, the day I finished this review, it was announced that rates of resistance to HIV/AIDS drugs are on the aggressive rise, affecting as many as one in four people with new infections. Medically, this means that those newly infected will die more quickly and more morbidly, as was the case in the earlier days of the epidemic, at least if they are not diagnosed soon after infection and helped to comply with no errors with the complex medication regimens that are the only chance for people with drug-resistant HIV strains, often with extremely difficult side effects.

Our medical infrastructure is unprepared for this new wave. The necessary tests for HIV viral load and type are technically complex and thus expensive; people still resist getting tested; the same factors that make good mental health treatment difficult to get also make good HIV treatment difficult to get. And we live in an interconnected world; when the new, resilient virus migrates to the global south, as it will, the access to treatment some manage to get here will be difficult, most often impossible.

Psychoanalysis is still, despite this excellent book, wholly unprepared for a new wave of morbid AIDS—unprepared institutionally, unprepared in the necessary technical innovations Cole's book helps us consider, and unprepared in the internal lives of most analysts. Not only do we have work to do to prepare to treat a new generation of patients with HIV/AIDS who will come to us for psychoanalysis and for psychoanalytic psychotherapy, but we need to sort out how our discoveries can be made applicable to the vast numbers of people we will never be able to treat with these methods, a topic Cole does not address. In this sense Cole has given us more Leif Ericsson's Map of Vinland than a treatment manual: more terrifying, more interesting, vitally necessary to our survival and development, and vitally useful.

 



Richard Ruth

Richard Ruth is on the steering committee of the Child and Adolescent psychotherapy Program of the Washington School of Psychiatry and in private practice in Wheaton, Maryland.

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