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

On the last track we discussed emotions.  Three emotions regarding positive diagnoses of HIV are fear, guilt, and uncertainty.      

On this track we will discuss disclosure strategies.  Three aspects of disclosure regarding a client’s HIV positive status that we will discuss are who to tell, feelings about disclosure, and dual disclosure.

Remember Thomas from the last track?  After dealing with his fears regarding HIV, Thomas had questions about disclosure.  Thomas wasn’t sure who he should or shouldn’t tell.  Thomas also didn’t know how to disclose his infection.  If you are treating a client who is learning to live with HIV, perhaps the information and strategies on this track can be applied to your next session.

#1  Who to Tell
First, we discussed who to tell.  Thomas was nervous about disclosing his HIV positive status due to uncertainty and fear regarding the reactions of coworkers, friends, and family.  I stated to Thomas, "It may be easier to keep the news to a select few until you become more comfortable with it yourself.  However, ultimately you don’t have to tell anyone about your HIV status.  This includes family, friends, employers or co-workers.  If you need to leave work early for a doctor’s appointment, just leave it at that." 

You may find that your HIV positive client is concerned over the possible reactions of coworkers.  Could the knowledge that your client doesn’t have to disclose his or her HIV status help alleviate concern over who to tell?

I continued to discuss who to tell with Thomas.  Thomas mentioned that he felt as though it would be easier to tell his best friend, Karen, than to hide his HIV status from her.  I stated, "If telling someone will make things easier, then the benefits might outweigh the consequences.  However, here are some things you should consider before telling someone about your HIV status.

• "Be clear about why you want to tell Karen.  Do you want sympathy, special treatment, or support?"  Thomas made it clear that he wanted support.  Clearly, one reason Thomas was reluctant to disclose his HIV status was that he didn’t want special treatment.
• I then stated, "Consider the worst case scenario.  Some people may become hysterical.  Are you ready for that?"  Thomas felt that he knew enough about HIV to deal with his friend Karen if she became hysterical.
• Third, I stated, "Give Karen plenty of time to process the information.  Things may seem fine at first, and then change later.  Conversely, people may handle the news badly at first, and then gain acceptance later."
• Finally, I asked Thomas to consider choosing a setting that offered plenty of time and privacy. 

Think of your HIV positive client.  Could Thomas’ considerations regarding disclosure help your client disclose his or her HIV status?

#2  Feelings About Disclosure
The second topic regarding disclosure that I discussed with Thomas was his feelings about disclosure.  Thomas stated, "So I can tell who I want.  That doesn’t change how hard it is to decide who to tell.  I don’t know why, I just get anxious when I think about bringing it up."  To help Thomas understand why he was anxious about disclosure, I shared some statistics.  The following statistics, as I explained them to Thomas, are adapted from Brett Grodek’s book, HIV.
-- First, I explained to Thomas that he wasn’t alone in his uncertainty and anguish regarding disclosure.
-- Next, I stated, "40 percent of HIV positive clients report indecision regarding disclosure.  31 percent plan to never tell certain people, 28 percent want to tell a specific person, and 21 percent regret having told someone." 

Thomas stated, "If there’s a one in five chance I’m going to regret it, and almost half of the people with HIV are undecided about disclosure, why should I bother telling anyone at all?"  I gave Thomas five reasons that I have heard for wanting to disclose HIV status.  As you listen to these five reasons, consider your client.  Do any of these reasons characterize your client’s desire to disclose?  Here is reason number one:

1. First some clients have stated, The right for others to know.
2.  Need for emotional support from others.
3.  Access to medical resources or services.
4.  The need for intimacy.  And
5.  Integrity
Thomas considered the five reasons for disclosure.  He stated, "So whether or not I tell people about my infection is my choice, but I have to live with that choice.  I should tell Karen, then, since she is my best friend."

Do you have a client like Thomas who could benefit from considering who to tell and why to tell them?  For example, your client may tell a spouse or partner to recieve emotional support or for the spouse’s health.  However, your client may not tell his or her children because they are not old enough to understand HIV.  Perhaps playing this track for your client can help him or her productively analyze the risks and benefits of disclosure.

#3  Dual Disclosure
In addition to who to tell and feelings about disclosure, a third aspect regarding disclosure is dual disclosure.  Take Billy for example.  Billy was having a hard time telling his parents that he was HIV positive due to the fact that his parents did not know that he was gay.  At the time Billy was 25 years old, and had been having sexual encounters with other men for several years.  Therefore, Billy was faced with dual disclosure because he felt that he could not disclose his HIV positive status without disclosing his sexual orientation. 

Billy stated, "The first question that comes to people’s mind when you tell them is ‘How did you get it?’  Well, when I told mom and dad, I just decided to answer that first."  Billy had called his parents in advance to tell them he was coming over and had something important to tell them.  Billy had sat with his parents in the living room for a few minutes before rising and stating that he needed to tell them something.  Billy stated, "First, I said ‘Mom.  Dad.  The good news is:  I’m gay.’" 

Before Billy’s parents could respond, Billy added that he was also HIV positive.  Billy stated, "My mother cried and my dad looked like he was petrified.  I gave them some brochures about HIV and left.  I’m sure they’ll come around."  Whether Billy’s approach was appropriate clearly depends on the direction his relationship with his parents went following Billy’s dual disclosure. 

Does your client have two disclosures to make instead of one?  If your client feels as though he or she needs to disclose the reason for HIV infection as well as the diagnosis, you might consider discussing how the client can approach the subject with those he or she plans to tell.   Perhaps playing this track for your client or in a group session might be beneficial.  Would you agree?

On this track we discussed disclosure strategies.  Three aspects of disclosure regarding a client’s HIV positive status that we discussed are who to tell, feelings about disclosure, and dual disclosure.

On the next track we will discuss dating and sex.  Topics will include additional disclosure tactics, sex, and the dangers of sex. 

Reducing HIV-Related Stigma: Lessons Learned from Horizons
Research and Programs

- Pulerwitz, J., Michaelis, A., Weiss, E., Brown, L., and Mahendra, V. (2010). Reducing HIV-Related Stigma: Lessons Learned from Horizons Research and Programs. Public Health Reports, 125. p. 272-281.

QUESTION 3
What are four things an HIV positive client might consider before disclosure?
To select and enter your answer go to Answer Booklet.