Academic journal article American Journal of Psychotherapy

Working with HIV/AIDS Sufferers: "When Good Enough Is Not Enough"

Academic journal article American Journal of Psychotherapy

Working with HIV/AIDS Sufferers: "When Good Enough Is Not Enough"

Article excerpt

The authors begin by examining the intrapsychic implications that HIV/ AIDS presents after knowledge of infection. Using examples drawn from two cases, they explore how knowledge of infection precipitates an insidious traumatizing process that comprises a number of key defensive strategies and dynamic processes. Particular kinds of defensive splitting, projective dynamics, and key identifications, as well as the collapse of the symbolic function, are isolated as being central to understanding the traumatizing process. With this in mind, the role and aim of the insight-oriented therapist is considered. The authors argue that much of the therapeutic work in this area revolves around a central organizing fantasy about the limitations of "good enough" objects in helping them with their diagnosis and its implications. This is linked to a number of technical dilemmas that the therapist will inevitability have to face if he or she chooses to work analytically. Particular technical problems explored include: 1. the management of frame deviations, 2. the therapist's role/s, 3. the use of interpretation, and 4. countertransference experience and enactment.

INTRODUCTION

In this article we want to explore what the analytically oriented therapist has to offer in the treatment of individuals who seek help in dealing with the consequences of HIV/AIDS. Among all the daunting problems that we face as a result of the epidemic, preferences related to therapeutic style may appear somewhat insignificant. This is especially the case given that we are, of course, not talking about "a cure," although this often forms part of the general ambit of countertransference reactions engendered in health care workers dealing with HIV/AIDS. But the way we understand and care for HIV/AIDS patients, the specific issues raised by such cases, still remains an important area of exploration, particularly in terms of applying analytic ideas to the problem.

The analytic community has been relatively slow in addressing AIDS-- related issues. Otero and Escardo (1), reflecting on sexuality in the age of AIDS, report on a continued disavowal of the reality of HIV/AIDS and a level of phobic anxiety within psychoanalytic circles as being the reason for little work in this area. Although this may be the case, perhaps this is also because the work requires, we believe, some deviation from traditional analytic technique and thus may not be considered by some to be "psychoanalytic" in the narrow sense of the word.

From our own experience, we have found it important to conceptualize the intrapsychic world of the individual in terms of an insidious traumatizing process that threatens to endanger psychic life in a way that is isolating, immobilizing, and akin to a kind of psychic death. This is, of course, not helped by the internalized stigma that HIV infection carries. Importantly, however, this is not just an internal issue, it belongs very much to the world that HIV sufferers have to contend with. In our view, the role of the external reality is essential to consider with this group of patients, leaving the therapist having to deal with issues related to the reality of physical illness, medical treatments and advances, prejudice and even sexual practice. Along with the trauma precipitated by the knowledge of infection, these factors make specific demands on the therapist who wishes to work analytically. Some of these demands include the management of difficult countertransference states, a focused analysis of the traumatizing process, and the careful management of the analytic boundaries in a way that best assists the patient to live with HIV/AIDS. Many of these demands are driven by an often-felt central dilemma that "good enough" therapeutic practice is not enough in dealing with such cases. We shall consider this dilemma further in terms of its influences on the treatment dyad. Firstly, however, our conceptualization of the psychological consequences of infection, which we believe helps provide a guiding model for management, shall be explored. …

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