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HIV: Therapeutic Strategies for Guilt, Uncertainty, Taking Control
HIV: Therapeutic Strategies for Guilt, Uncertainty, Taking Control

Section 17
Treating the Traumatizing Process in HIV Positive Clients

Question 17 | Test | Table of Contents
Psychologist CEs, Counselor CEUs, Social Worker CEUs, MFT CEUs

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.

The extent to which splitting takes place will, of course, depend on the nature of the predisposing personality. But it is our experience that it is always present, to a greater or lesser extent, allowing for some degree of dissociation and denial to take place. This can be deafly observed in the case of Guy, a 40-year-old man, who had been referred after presenting voluntarily for testing at a community clinic.

Case 1: Initially, Guy was very resistant and hostile about the consultation. Despite coming to the session, he insisted that because I was HIV negative, and would not be able to understand him and accurately empathize with him. I could be of no help. In short, only a HIV-positive person could help another. I did not interpret this, but simply provided information for him, leaving the door open for him to return should he ever feel the need. It was all I could do given how stymying the situation was, yet I was left feeling branded, judged, rejected, containing a helpless feeling, and a strange sense of survivor guilt. At the time it was early days in our history of the disease and early days in my therapeutic career. It was clear, however, that at this point Guy was dealing with the shock of his diagnosis by splitting and projecting the useless, helpless, and branded parts of himself into me with such force that he could not continue therapy.

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.
Because HIV infection is not often grounded in any symptoms, the initial trauma and its future implications are often readily split off with little sustained work being done to make life adjustments. Indeed, some patients, as was the case with Guy, ironically express some relief when overt symptoms confirm the diagnosis. The ongoing uncertainty that surrounds HIV also makes dealing with the implications particularly difficult to tolerate. Often this can be observed in the psychotherapeutic process where, after the initial "external" trauma is dealt with, HIV becomes a "taboo subject." The therapist's countertransference is marked by a sense of feeling unable to return to the issue for fear of retraumatizing the patient or going over something that ostensibly had long been dealt with and forgotten.

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.
Given HIV/AIDS' associations with death, issues of loss, dying, and even change, are often vigorously defended against. Most patients have to face fantasies about significant "good enough" objects failing in their protection and care. Here, the forced internalization of a traumatizing object propels the individual into questioning relationships that were once perceived to be warm and nurturing. This leads to feelings of isolation that are not always triggered by external objects. Coming to terms with this usually begins when past relationships are questioned with the above inquiry in mind.

Key Projections And Identifications
The projective dynamics and identifications that occur as a consequence of the splitting process are varied and have different consequences. Perhaps the most common is the projection of parts of the self associated with illness that are felt to be dangerous and toxic. The patient may present the diagnosis as a wound resulting from an attack, projecting onto the therapist a need for soothing with differential and preferential treatment. However, the part of the self associated with infection is not always projected outwards. It is often the case, along with the stigma associated with infection, that split-off bad parts of the self are identified within a way that leads to masochistic and depriving behaviors.

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
An important consequence of the traumatizing process is the collapse of the symbolic function where thinking ceases to enrich the psyche with new meaning. The emphatic medicalization of the virus, obsessiveness with the body and its functioning, and the concretization of thought processes are some of the signs of the suspension of the ability to represent the world symbolically. In this state, it is often very difficult to get the patient to associate freely to the presented material. Although this is a normal part of adjustment, it can also become a retreat away from having to think and work though the consequences of infection. At its extreme, it is akin to a kind of psychic death where mental aliveness is compromised.

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."
Hopefully, this brief description illustrates Guy's progress from a period where projection and other evacuative defenses were predominant, to a period where he was able to gradually re-present HIV as a symbolic part of himself. The dream appeared to confirm this as well as represent the beginnings of his being able to deal with this part of himself in a reparative manner. We shall now turn to exploring some of the implications this conceptualization may have for treatment.

Challenges Facing Analytic Technique When "Good Enough" Is Not Enough
Given the above formulation, the most important therapeutic goal is to work towards a depressive integration of the traumatizing process. In doing so, it is our experience that the therapeutic dyad has to deal with a central organizing fantasy related to the limitations of "good enough" objects in saving one from infection and death, without prolonged withdrawal and restricted engagement. We borrow the expression "good enough" from Winnicott because it emphasizes that we are talking about realistic notions of good caring objects, as opposed to idealized ones.

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.
- 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

Personal Reflection Exercise #10
The preceding section contained information about treating the traumatizing process in HIV positive clients.  Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Breslow, A. S., & Brewster, M. E. (2020). HIV is not a crime: Exploring dual roles of criminalization and discrimination in HIV/AIDS minority stress. Stigma and Health, 5(1), 83–93.

Mitzel, L. D., Vanable, P. A., & Carey, M. P. (2019). HIV-related stigmatization and medication adherence: Indirect effects of disclosure concerns and depression. Stigma and Health, 4(3), 282–292.

Wong, C. C. Y., Paulus, D. J., Lemaire, C., Leonard, A., Sharp, C., Neighbors, C., Brandt, C. P., & Zvolensky, M. J. (2019). Emotion dysregulation: An explanatory construct in the relation between HIV-related stigma and hazardous drinking among persons living with HIV/AIDS. Stigma and Health, 4(3), 293–299.

What are three early steps in the traumatizing process of an HIV positive client?
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