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Over the years many have outlined the phases of mourning that occur in attempting to come to terms with an HIV diagnosis. Most go through initial shock, numbness and disbelief, followed by bouts of idealization, anxiety, and anger. In finally coming to terms with the diagnosis, individuals are able to engage with the realistic losses that follow and achieve a level of integration and a new sense of purpose about their lives.
This process, however, is only successful if the initial phases can be tolerated and worked through. Even then, patients are likely to regress to these points during the changing phases of HIV infection. In our view, one of the difficulties here lies with the ongoing traumatizing process that often becomes entrenched in the internal world of the patient. A number of dynamic processes appear to underlie part of this process. These include: 1. a defensive form of splitting that occurs along particular lines associated with the nature of HIV infection, 2. specific kinds of identifications and projections, and 3. the collapse of the symbolic function.
Guy returned two years later as he felt depressed and was experiencing difficulties in his primary relationship. He expressed a nonchalant, somewhat hapless attitude toward his HIV status, and this apparent emotional detachment contrasted strongly with the intensity of feeling around his primary relationship. It appeared he was using his relationship to convince himself of his object goodness, and became excessive in generosity. He was overly giving of time, energy, emotion, ideas, beyond the usual expected intensity. He wanted to provide for the partner, but would go overboard, giving his partner very little space to explore his own concerns and capabilities. Not surprisingly, within a short time, the relationship broke down.
Colluding with the patient in avoiding his deeper issues, psychotherapeutic work was undertaken around his relationship where all affect was concentrated. In a similar way to what had occurred in his relationship, I think I had been caught up in his attempt to split off all affect related to real concerns about infection, which immobilized me in the process. After the breakup of his relationship and the disruption of this defensive maneuvre, Guy's defensive nonchalance around his HIV status wore off as depressive anxiety set in around his perceived failures and the loss of the relationship. At this stage, the patient had not disclosed to his family or work colleagues, but did manage to disclose his status to a few friends.
At various points in his therapy, Guy spent considerable time talking about a growing irritation with his friends, particularly around their sexual relationships. It appeared that they had become the containers of lascivious sexual impulses and habits. His friends disgusted him and he began actively avoiding them. The use of splitting here and the exportation of badness to his friends drastically impoverished his life, as they withdrew and became for him abandoning and attacking. The final stage of this defensive maneuvre was completed by him asserting that they were withdrawing from him because he was HIV positive. In contrast, he spoke about himself in a desexualized way, and described his desire for nongenital sexual relationships, imagining sanitized "kiss and cuddle" type contacts. Interpretation of the splitting and sexual disavowal, as seeming to mean the death of genital sex in future relationships, provided a setting for Guy to reveal complaints of occasional impotency and anxiety about the ejaculation of semen. Faced now with the obvious link between sex and potential death, my comments that not only were friends now cut off but so was genital energy, caused him to become exasperated with me for implying remotely that it was a choice. He felt all of this "happened to him" and that these responses had not been consciously chosen, but were a forced compromise. At one point, he reflected on long-past pleasurable sexual encounters, vividly describing them and then commented: "When you're naughty, God gets you baby." He concluded by telling me about how he thought HIV was his punishment for his enjoyment.
Ultimately, analytic work at this level involves teasing apart the need for sexual continuance in the person's life from his/her own realistic contagiousness. Disclosure to significant others, old and new, means negotiating new intimate attachments and a "safer sexuality" on an ongoing basis. The process of reparation here is ongoing in what is felt to be a fatally damaged part of the self.
Key Projections And Identifications
Case 1 (cont'd): In Guy's case, this began with his experience of there being something rageful and destructive within. He became afraid of doing anything because he constantly anticipated failure emanating from this part of himself. This static state reached stultifying proportions. The patient remained indoors most of the time doing very little. He could no longer allow himself access to activities he had previously found nurturing and fulfilling, such as social engagements and recreational activities, he even passed up the opportunity to use a prize of a free two-week overseas holiday he had won in a work merit competition. Instead, he became preoccupied with secluding his felt badness from the rest of the world.
Most of the time he would manage this in the transference by splitting and transferring onto me a sense of happiness and contentment, complete with all the object goodness he had disinvested himself of. As a consequence of this projection, he would often express fear that his feelings might get out of control and that his internal "badness" would take over, leaving him little access to anything else. During this period, he would voice fears of violence towards himself and others, giving way to a lost ability to censor or control.
Lastly, manic maneuvres are often used to override painful representations and affects. These include the inevitable and necessary search for other better and more satisfying objects along with a host of quasimedical "cures." Often patients act on magical fantasies vis-à-vis a "cure" that eventually lead to regressive disappointments and prolongs any real acceptance of the situation.
Collapse Of The Symbolic Function
Case 1 (cont'd): Guy initially made little reference to his HIV status. Instead, he spent much of his time in therapy talking about his achievements and his overzealous need to satisfy his partner's wishes. At times, when his thoughts on the matter did not seem to go anywhere, he would grow irritated for reasons that escaped him. He was only able to convey this by expressing anger toward friends, family, and myself, whom he experienced as devious. At this point, interpretation about the projected material apparent here had no effect. However, a change came about in the therapeutic relationship once his relationship with his partner broke down. Feeling the reality of his loss with me, he was able to begin telling me about other losses in his life and how they had left him feeling unlovable. Along similar lines, he began to voice his worries about his HIV status.
Later in his therapy, he reported a short dream he had had: He was in Bosnia walking amongst the war-torn and ravaged landscape. He felt that he wanted to go and search for undetonated time bombs to save the innocent from destruction. Exploring the dream, Guy was able to associate time bombs with his own pressured sense of having limited time left and an internal sense of destruction. Other associations were of war-time, depth charges, and a sense of bravery related to a motto that "if one is going to die, one may as well save others and do something meaningful in order to conquer fear."
Challenges Facing Analytic Technique When "Good Enough" Is Not Enough
In terms of the therapeutic process, this means that the therapeutic dyad needs to strike a delicate balance between acknowledging the harsh realities of infection while maintaining a sense of meaning, hope, and purpose about one's life. Part of this means having to find a way of living with uncertainty for the patient that creates hope, while acknowledging real difficulties and losses; a way of bearing difficult feelings of anger, and thoughts of illness and death, without rejecting love and support from others.
In addition to these particular concerns, there are a number of other factors that challenge psychoanalytic technique and need some revision for this kind of work. It is not enough, as some have argued, to say that psychoanalytic psychotherapy with these patients would not essentially differ from work with other patients. To go along with this simply does not prepare one for the multiple roles that we are inevitably drawn into playing when taking on such patients. In considering some of these challenges related to frame deviations, the role of the therapist, interpretation, and countertransference management, we are guided by: 1. A focus on the process of integration made possible by the restoration of the symbolic function. 2. An acknowledgment of the significance of external factors in the treatment process.
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