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HIV: Therapeutic Strategies for Guilt. Uncertainty, and Taking Control Abbreviated, Part II
HIV: Therapeutic Strategies for Guilt. Uncertainty, and Taking Control Abbreviated, Part II

Section 12
Issues in Analytical Therapy for HIV Positive Clients

Question 12 | Answer Booklet | Table of Contents | HIV/AIDS CEU Courses
Social Worker CEUs, Psychologist CEs, Counselor CEUs, MFT CEUs

Role/s Of The Therapist
In terms of gaining knowledge about the virus, Schaffner argues that this becomes an inevitable part of the analyst's role. This would especially be the case where access to other resources is problematic. It mayDilemma HIV Therapeutic Strategies social work continuing ed however also simply be dealt with by referring individuals to appropriate sources, so as not to unduly sidetrack the analytic work. Other motivations for unsafe sexual practice appear best dealt with using routine interpretations related to motive. Although AIDS education may not always be the therapist's role, recent information about treatment and developments in the field is crucial to the success of the therapeutic relationship. Such information allows us to more finely tune our analytic gaze, and develop more appropriate and accurate empathy so as to offer interpretations that alleviate anxiety, rather than rewound the patient.

We turn now to problems related to inevitable changes that occur in the treatment process when AIDS-related symptoms, such as early dementia, appear, and when the patient is ill and dying. Here we are faced with the question: At what point does one finally terminate analysis, or at what point is one's work as a psychotherapist over? Defining termination is fraught with the possibility of leaving a patient vulnerable and in a state of abandonment which may simply undo the work of analysis. Still further, how can the analytic relationship continue if dementia or other related illnesses have set in?
A number of authors have written about the need to change one's role at this point. Sadowy, for instance, reports on variations on her therapeutic stance with a patient dying of AIDS. From an initial treatment involving a more rigid analytic stance to deal with depression and ambivalence, the patient returns with AIDS, bringing to the therapist a reconsideration of fixed assumptions, most notably the issue of charging for treatment. Sadowy renegotiates her traditional role, framing affordable uncompromised treatment, remaining an interpreter of symbolic communication.

Ultimately, Sadowy's stance is resoundingly complicated once the patient's ability to move and speak ceases. In her words: “I had to go beyond the usual therapeutic parameters and trust in another therapeutic communication. In continuing this treatment, I had to believe in and use a type of communication between two inner selves. I had to be willing to gratify a symbiotic connection with my patient as we attempted to disengage from her rapidly dying external reality and to enter a living vibrant internal reality.”

Dealing with the dying patient also challenges the therapist's ideas about responsiveness and gratification in treatment. In this regard, issues of simple gratification may be necessary. To frustrate certain needs may be to ignore a wound and convey a fear to the patient.

There is no simple answer to the question of termination. Ideally, we would hope that much of the work in dealing with the internal trauma would have been done by this stage so the patient feels he could be left to be cared for by family and friends. Overinvestment on the therapist's part is a crucial dilemma at this point and often emerges in reaction to the pending limitations of the analyst's role. Overinvolvement not only compromises therapeutic involvement, it may also be obstructive to the caring of others closer to the patient. Here, the patient's needs, close adherence to the goals of therapy, an analysis of external support and close supervision are the best help in terms of guidance.

Perhaps the most effective analytic position at this point is one that lies between termination and overinvolvement, where the therapist takes on a removed containing position for all involved. This was the case with Guy when he had deteriorated to a point where he could no longer see, and his psychotic behavior greatly distressed his family and home caregivers.

Case 1 (cont'd): I felt a resurgence of my own helplessness and was left battling with the idea that all that could have been done for him directly by me had been done, while acknowledging a sense that this did not feel adequate or "good enough." To withdraw at this point felt as if I would be behaving as if Guy had already died. At the same time, I felt that offering direct care as part of the home-care team would simply fuel an enactment of a fantasy to cure till the end.
With this in mind, I shifted focus to simple family support, assisting them with understanding and managing Guy's shifting mental state, impulses, and behavior. In the last few weeks of his life, he became agitated and manic, implementing frantic relocation plans, involving an expensive accommodation purchase after insisting that the move would cure him. His family, while floundering, were unsure of how they should deal with his last-ditch denial. An interpretative stance, suggesting to his family that this was his way of negotiating a move from life to death, allayed their confusion and enabled them to be calmer and supportive of his last concerns at hand.

Containment And Interpretation
The containment of anxieties and split-off aspects of the self is an essential part of the treatment process and makes possible the eventual withdrawal of defensive projections in a way that is less traumatizing to the patient. Interpretation is often underemphasized in dealing with the trauma of HIV/AIDS. In our experience, however, it still holds a number of important functions when focused on the internal consequences of the traumatizing process. Firstly, interpretation serves to give meaning to experiences that are often difficult to put into words. In this sense, these kinds of interpretations are more about the "translation", than the interpretation of conflict. Secondly, interpretation is an important means of addressing the defensive splitting that occurs as a result of the traumatizing process. This includes a more focused transference analysis, similar to that used in brief psychodynamic approaches, where emphasis is placed on the analysis of splitting and its consequences.

The interpretation of anxieties and transference derivatives have to be finely conducted on the basis of an appreciation for the patients' internalization of HIV as a traumatizing object and their overall physical condition and attendant medical regimens. Interpretations, linking behavior, emotions, and fantasies to the patients' seropositivity, if not accurate, run the risk of replaying stigmatization, rewounding them, reminding them they are sick when they do not feel ill at all.

The third function of interpretation is related to the restoration of the symbolic function that allows meaning to aggregate around traumatic material. The required depth and attainment of a finer, deeper, and more effective interpretative role provides the atmosphere for mental enlivening and exploration of the symbolic.

Case 1 (cont'd): Guy's dream, for instance, presented symbolic foci that enabled the therapeutic dyad to move out of the barren space of nebulous fear into a space filled by objects onto which anxiety could be attached and elaborated. For instance, his dream about land mines, presented earlier, allowed for interpretation related to the paradoxical representation of fragility/ destructiveness, and robustness enabling Guy to realize that even in the face of impending death, life has purpose and continuance.

Countertransference
As Mayers & Svartberg and Rogers point out, the balance between successful and failed treatments often hinges on the appropriate management of countertransference. Much has been written about countertransference and enactment in working in this area. Some of the commonly identified enactments include: Overinvolvement, expressions of anger, neglect, collusion, assuming the role of a surrogate parent, and claims of omnipotent healing powers. Countertransference states related to irrational fears of contamination, death anxiety, denial, and morality have also been noted.

Feelings of hopelessness, the therapist's personal struggle with issues of death and illness, and the degree of uncertainty that underlies the diagnosis make this work more prone to enactment. All this is often fuelled by a deep sense of inadequacy about one's therapeutic role and realistic capabilities in dealing with chronic illness. Still further, the suspension of the symbolic function also makes the therapist more vulnerable to communicating through action rather than words.

Apart from the general need for the therapist to acknowledge and work through countertransference states that hamper the therapeutic process, attention to particular tasks may assist in managing countertransference states. Purnell, for instance, emphasizes the need for the therapist to actively attend to his/her own mourning during the process. Feldmann, on the other hand, points out the need to have clear, limited goals and expectations of treatment to prevent a sense of feeling overwhelmed by the processes. Feldmann also suggests that the therapist take regular breaks from this type of work to preserve his/her capacity to work with HIV sufferers. Certainly, support groups and supervision are indispensable in helping the therapist attend to his/her own containment.

Countertransference management is complicated further by the changes that occur in the therapist's role. If the therapist changes his/her therapeutic stance due to inevitable complications in the treatment process, how are we to distinguish this from enactment? Here, a distinction between enactment and behavior motivated by external factors is useful. Theoretically, one might say that enactment, whether evoked by the patient or not, stems solely from the analyst's unconscious motivation while a realistic response to complications is motivated by an external situation beyond the therapeutic dyad. The former threatens to foreclose the analytic space whereas the latter is an attempt at preservation.
Although this is a far more difficult distinction to make in practice, it points to a need to constantly evaluate one's stance against external realities bigger than the analytic process.

Case 1 (cont'd): When Guy began to present with signs of dementia, I was faced with the dilemma of deciding whether my care at this point needed to be more active and direct. It was clearly a struggle for him to come for therapy and because his cognitive functioning was deteriorating, interpretative work was clearly out of the question. My therapeutic role was no longer clearly defined. Around this period, a medical consultant informed me that Guy needed to go for an eye consultation where he was not going to receive good news. It was clear that Guy's parents were extremely elderly and frail and physically unable to attend to Guy outside of the home and there was, at the time, no one else available. With few options, I eventually decided to assist and accompany him to the local hospital. This meant much running about, securing a wheelchair, and waiting until we were attended to.

In dynamic terms, this could be construed as a simple case of a crude kind of enactment on my part. However, it may also be conceptualized as a response to a constraining external situation that outweighs the need for a more removed therapeutic stance at this point.
- Cartwright, Duncan, and Michael Cassidy; Working with HIV/AIDS Sufferers: "When Good Enough Is Not Enough"; American Journal of Psychotherapy; Spring 2002; Vol. 56 Issue 2
The article above contains foundational information. Articles below contain optional updates.

Personal Reflection Exercise #6
The preceding section contained information about issues in analytical therapy for HIV positive clients.  Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 12
What are two key concepts of analytical therapy to keep in mind when treating an HIV positive client? Record the letter of the correct answer the Answer Booklet

 
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