2022 California Council of Community Behavioral Health Agencies (CBHA) Conference

River Angel: Therapy and Loss in the Early Days of AIDS

It’s been 17 years since Keith Braverman* washed down a bottle of valium with a fifth of vodka, left his wallet and keys on his kitchen table, and jumped into the Hudson River. Keith wrote one suicide note, and it was addressed to me. He attached a postcard to the note: the two embracing angels in Caravaggio’s The Seven Acts of Mercy.

Keith was my patient at the Greenberg/Manhattan West Clinic of JBFCS for nearly two years prior to his disappearance. This act was what he would have called his “rational suicide,” although the resulting loss for his family, friends, doctors, and me was as deep as any other. As a gay man with AIDS in 1995, prior to the availability of the protease inhibitors, Keith believed that the deterioration of his body and mind was his inevitable future, and he couldn’t bear the thought of wasting away, in pain and alone.

Keith was a 43-year-old, white, non-practicing Jewish gay artist and writer, in recovery for five years from alcohol abuse, who was transferred to me for ongoing weekly psychotherapy after his prior therapist left the agency. Keith had been diagnosed with AIDS less than a year before. His longtime lover, Joey, had died of AIDS six years earlier. Keith’s current on-again/off-again lover, Kevin, (who lived with another man in a long-term relationship) also had AIDS but was not as ill as Keith. Keith reported to me that all of his friends had AIDS.

When Keith came to JBFCS, he had a T cell count of 3. That was our marker in those days; we geared ourselves for the proximity of death by the dwindling number of lingering T cells. We soon learned that our patients’ T cell counts could rise and fall over a long period of time and that the “viral load” was a better predictor of their longevity.

Keith was an attractive man with dark eyes and hair, tall and slender, emanating intelligence and vulnerability. He was losing weight rapidly. He always wore boots, claiming it made it easier for him to walk with the KS (Kaposi’s sarcoma) lesions on the bottoms of his feet. Rolling up his pant leg, he showed me the other dark purple lesions on his calf. He also had a few on his nose that embarrassed him. He periodically got radiation to burn them off his face.

Our clinic, under the wise tutelage of the late Marilyn Brodsky, LCSW, had formed a connection with GMHC (Gay Men’s Health Crisis, the organization founded in 1981 by Larry Kramer and others), and we had a continuous flow of gay men in various stages of the disease sent to us for outpatient weekly therapy and, if necessary, psychotropic medication monitoring.

Keith was immediately matched with our psychiatrist, the late Dr. Eugene Glynn, an expert on issues of gay men in therapy and AIDS. Dr. Glynn was a brilliant, older gay psychiatrist who treated hundreds of sick and dying young men throughout the worst of the AIDS epidemic. He also taught the JBFCS community of social workers and psychologists about the medical and psychic traumas of the disease.

Dr. Glynn and I were partners in working with Keith, who was struggling with acute anxiety since his diagnosis. Dr. Glynn prescribed 5 mg of Valium daily, a common anti-anxiety medication in Dr. Glynn’s time. Given the sad predictability of the foreshortened lifespan of these very ill patients, there was less concern about the habit-forming nature of this medication. As the year progressed, Keith became more depressed, prompting Dr. Glynn to add 20 mg of Prozac to the daily medication regimen.

Keith told both Dr. Glynn and me that if he started to get sicker without any hope of improvement, he would consider taking his own life while he still had control over his ultimate destiny. At this time, there were no approved antiretrovirals, no hope for a cure, just the certainty of a painful withering away. According to Dr. Glynn, many of his patients had similar plans but became too sick too quickly. It was a controversial topic for us, given our mission to help people to stay alive at all costs.

6/29/94: Progress Note. Keith reports his health is improving (T cells 6) although his KS lesions are increasing. Reports AIDS represents “the cruelty of nature.

In the early stages of the AIDS epidemic, there was little knowledge of the origins or the course of the disease. It was erroneously called the “Gay Plague” because it appeared with alarming frequency in white gay male communities. Gradually our patients included gay men of color, IV drug users, the female partners of IV drug users or bisexual men, and heartbreakingly, the babies and children of women with AIDS. HIV positive mothers unknowingly passed the virus to their babies through the birth canal or in their breast milk. We lost several children in the clinic in the early days of AIDS.

As a social worker in the late 1980s and continuing throughout the mid-1990s, there was no foolproof medication cocktail to prolong the lives of our patients. Thus, we had to learn to provide therapy to a generation of mostly gay young men whose friends and lovers were dying in droves. Obituaries of 30- and 40-year-olds appeared daily in The New York Times—men of enormous promise, withering away in their prime. Our patients reported going from one memorial service to another, and they were becoming numb. The high number of death notices of young men had not been this significant in America since the losses from the 1919 influenza outbreak.

At first I wasn’t sure if I was up to the task of doing psychotherapy with a man dying of AIDS. I had no special training for this, other than the courses Dr. Glynn had been giving us. Although there was literature on working with physically ill patients, nothing of this magnitude had ever occurred with such virulent insistence, decimating the young. In addition, once the means of transmission was understood, gay men were accused of “bringing it on themselves” with their “promiscuous” lifestyles. A disease that was transmitted via sex and needles did not initially get much sympathy from the larger community.

7/8/94: Progress Note. Keith is relieved, because his CMV test was negative. [CMV causes, among other things, blindness.] Feels he has gotten a reprieve. Gives me herbs he grew in his garden.

Keith had never come out as a gay man to his parents or to his sister. Although he had lived with Joey for many years, he told his family Joey was his close friend and roommate. Even when Joey died, there was no discussion of AIDS or of being gay. A great deal of our treatment focused on how to tell his parents that he was sick and then to reveal to them that he was gay and had known since he was four years old.

11/3/94: Progress Note. Keith continues to struggle with whether to tell parents about diagnosis. We examine the pros and cons. He admits there is a part of him that wishes to punish them by keeping them in the dark.

Instead of telling his family, he decided to confide in the rabbi—who happened to be gay—in the town where his parents lived so that once Keith died, the rabbi could help the family deal with the many facets of the complicated loss. He felt this was a good outcome of our discussions in therapy.

Keith’s main source of pleasure and support came from his best friend and sometimes lover, Kevin. Kevin was slowly starting to pull away, however, dedicating himself to his live-in partner, his career, and his own health. Keith continued to have numerous medical tests and tried to fight off the spread of the KS lesions on his face. He was no longer sexually active and this led to a deep sense of alienation.

12/8/94: Progress Note. Keith feels depressed, lonely, yearning for physical affection, especially from Kevin. Feels that he is “rotten fruit” and no one would want him. Never imagined he would have AIDS and be alone.

Our relationship seemed unusually close—and different—given that I was his therapist. Yet he knew absolutely nothing about me other than how I looked, the art on my walls, and my responses to our discussions about his fears of dying and loneliness. Sometimes he came in excitedly, reporting about a party he had attended at Friends Indeed, a gay men’s organization. He balanced his urge for human, sexual connection with a haunted feeling of tiptoeing through a graveyard, fearing that he would soon be among the dead. We talked about how he had stopped painting when Joey died, as he didn’t want to belong to the meaningless “gallery scene” anymore. His doctor had told him this would be the last year of his life, and his primary search would now be for love. For Christmas he gave me a candle and a postcard of an angel, a beatific creature with no defined gender. On the back he wrote, “Happy whatever, but mostly, thanks. K.”

1/20/95: Progress Note. Keith is experiencing pain from his KS lesions on the bottom of his foot and leg. Worries that he has begun a gradual decline. Wonders if he could possibly meet anyone to love at this late stage. Feels lonely, wants companionship.

1/26/95: Progress Note. Has gotten all of his legal and financial documents in order, in case he dies suddenly.

A few months after this session, Keith drank some vodka and took an unknown quantity of Valium, unbeknownst to Dr. Glynn and to me, as a “dry run” for his eventual suicide. Dr. Glynn evaluated him and assessed that Keith was not an immediate suicide risk and that he did not need to be hospitalized. He increased Keith’s dosage of Prozac. We all discussed that for an alcoholic in recovery to take a drink represented a serious loss of faith.

Keith admitted that seeing friends in love, Kevin going away for two months, and the terrible feeling of having nothing to look forward to had led to this event. Although he contracted for safety and expressed he still had the will to live, he acknowledged how acutely painful it was to live with the specter of death beside him. He felt it as a palpable presence.

3/9/95: Progress Note. Makes attempts to meet someone, feels rejected. Thinks the KS lesions make him completely unappealing. Thinks he must give up on hoping for more affection from Kevin, which fills him with grief.

Over the course of our work together, Keith’s doctors told him that he could go blind from CMV, that his KS was worsening, and at one point, that he might have lymphoma and that his stomach lining was thickening. His T cells remained low; his viral load increased. In addition, he began drinking socially again after five solid years of sobriety. Our treatment focused on the meaning of giving up on sobriety, since it had given him such strength and self-esteem. He admitted he wanted me and others to notice, he wanted to provoke his friends to worry about him and maybe attract Kevin back to his side. In addition, one of Keith’s primary doctors, a woman, suffered a nervous breakdown and took a leave of absence.

In September 1995, after a short reprieve in the Hamptons over the summer, Keith returned depressed and hopeless. His distress intensified as his bouts of diarrhea increased and he felt like he was on his final decline. Dr. Glynn saw him more frequently to assess for suicidal ideation, but Keith insisted that he didn’t need to go to a hospital.

9/15/95: Progress Note. Keith continues to feel very depressed. Has a KS lesion on his penis and feels no one will ever want him. He’s angry about this disease, doesn’t know if he can accept it.

At this point, in spite of our attempts to keep him connected, Keith initiated a gradual pulling away from Dr. Glynn and me. At the time, he described it as a financial necessity, even though I offered to lower his fee. I encouraged him to keep going to GMHC and to Friends Indeed, where he had often found solace, but he insisted his diarrhea kept him from going. We had some talks with one of his doctors to assess the progression of the disease.

9/29/95: Progress Note. Keith continues to feel depressed since his return from summer vacation. Is finding it harder to discover any meaning in his life now. Is still pining for Kevin. Hates being alone and sick. He says he is “rotting.” Wants to come every other week. Feels depressed, detached from his own life, frightened of the future.

His symptoms also included fever and chills, and he had a hard time concentrating or working. I tried again to get him a Buddy from GMHC, but he continued to refuse. His worries about finances intensified, and he feared he might need to leave his apartment or get a roommate, stating, “I never expected to live this long.”

In what would end up being our final session, Keith reported a feeling of desolation about his medical condition but denied suicidal thinking. He reported he stayed in bed all day the day before and didn’t take his medication. He achingly described that he was in mourning for his lover, Joey, his fear of getting sicker, and his deepening financial problems. He met with Dr. Glynn after the session and denied a suicidal plan or intent, claiming he was just grieving the loss of love in his life.

Two weeks later Keith was gone. Kevin left me many messages on my office voicemail as did a detective from the 6th Precinct. Keith was missing, his wallet and keys were on his kitchen table, and there was a suicide note addressed to me. I don’t remember who called to read me the content of the note:

Julie, Please try not to feel bad about this. You’ve done nothing but help me. Thank you forever. K.

I took the blow hard, like a punch in the gut. Later, on the phone, Kevin said Keith had gone into the Hudson River, that his plan, his rational suicide had always been to kill himself before his living body and mind decomposed. And Kevin knew that Keith’s plan was to mix Valium with vodka and then drown himself. Nonetheless, Kevin was enraged; he couldn’t believe Keith had given up before the disease took him. Kevin was heartbroken.

It was a Saturday. I was home that day. I couldn’t feel anything at first. It was a shocking absence, a void. Although I normally shed tears easily, none came. I started fixating on the idea of Keith’s body on the bottom of the Hudson River. Then the terror set in. Gentle, talented, intelligent, and frightened Keith was being tossed over sharp rocks, rolling over and over in polluted waters, his body battered and cold. His dreams of a late, last love dashed, knowing he was dying, he made a calm decision to take control of his own demise.

I couldn’t stop obsessing about Keith in the freezing waters. I told my supervisor about it. She understood grief and loss, but I needed more than that. After being the container for this man’s last two years of life, I needed something more to find some peace.

Dr. Robert Abramovitz called me at home after he heard what had happened. He was the Chief Psychiatrist of the agency and the head of the newly founded Trauma Center. I had known him since I started at JBFCS in 1987, and I felt he might be able to help.

When he asked me how I was holding up, I finally became tearful. I told him about my intrusive thoughts of Keith being enveloped in the freezing grip of the dark water. About the man who had suffered such pain and solitude as the disease wiped out his generation and was about to carry him into the vortex. I kept imagining him under tons of heavy water and the thoughts would not stop.

“Julie,” Dr. Abramovitz said, in the gentlest voice possible, “That is not Keith in the water. That is just the shell that housed his spirit. Keith is free, Keith is not there at all.”

Those simple words released me. I could then feel the strong connection I had had to Keith and to the bravery that he had shown me while dealing not only with his own physical deterioration but also with the horrors of an epidemic that had been killing his friends and lovers since 1981. The sadness I felt was not only that we hadn’t been able to help him to stay alive, but also the hopelessness about losing all the young men, women, and children who had been dying for more than 15 years.

In the following days, I spoke with Keith’s parents, who were truly devastated. They called me in great distress, not having known he had AIDS or that he was gay. They were trying to understand the enormity of this loss, wanted answers that nobody had. Kevin came in to meet with me to give me the note and the postcard. We cried together and embraced when he left.

Sometime later I was told they found Keith’s body. It was no longer under the waters of the Hudson River.

My colleagues, including peers and supervisors, were kind and empathetic. Some whispered, “It’s her first suicide,” and it was. Dr. Glynn and I talked a lot about Keith. Dr. Glynn had lost many patients in his long career, most to natural causes, some to suicide, and he told me that some of the men with AIDS chose to take control of their deaths the way Keith had. At that moment in time, they had no way to fight the vicious speed of the disease.

In time the void became a sharp missing of my visits with Keith and an insight into his utter necessity for love. In some ways I wondered if he died more from loneliness than from AIDS itself.

Given that the only note he left was for me, I wondered what my role in his life had been. I posited that perhaps leaving me the note had been a gift. He didn’t want me to feel like I had failed him, he didn’t want me to feel responsible or guilty. Leaving the note also kept me tied to him forever, as one can see by the fact that I kept all of his session notes, the angel postcard, the suicide note, and the postcard of Seven Acts of Mercy. I have kept Keith with me every day for these 17 years, and this article is my way of bearing witness to his brave struggle and the battles his compatriots fought against a merciless enemy.

Postscript

There is an even crueler irony to the timing of Keith’s premature death. In the middle of 1995, an experimental class of drugs was starting to become available to certain patients with advanced AIDS. By 1996, a class of drugs, known as protease inhibitors, was shown to have extended the lives of some of the very ill. Although the cost was astronomically high, more than $15,000 a year per person, the benefits were so great that people were actually living with AIDS. By 1997, the domestic AIDS death rate dropped by 47 percent. ** Could Keith still be alive today if he had waited for the medication cocktail? We’ll never know, nor will we know whether he would have died on his own shortly before he took his own life.

Julie List, LCSW, is a clinical social worker and psychotherapist at JBFCS. Currently she is the Director of the Harry Blumenfeld Pelham Counseling Center in the Bronx.

* All names have been changed in this article.

** John Henkel, “Attacking AIDS with a ‘Cocktail’ Therapy,” HealingWell.com (http://HealingWell.com), accessed March 19, 2012. The article originally appeared in the July/August issue of FDA Consumer Magazine, 1999.

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