Helping HIV/AIDS sufferers: A psychodynamic approach

By Duncan Cartwright and Michael Cassidy


South Africa has the dubious honour of having among the highest rates of HIV infection in the world. At antenatal clinics, as many as one in three pregnant mothers test positive for the virus. The implications of this pandemic are terrifying and devastating. South African therapists can reasonably expect to see at least one HIV/AIDS positive person in their practices in the coming decade as the pandemic of positive infections turns into a pandemic of active AIDS sufferers. The implications of this are even more terrifying.

Michael Cassidy, a private practitioner in KwaZulu-Natal, the province which hosts the highest rates of HIV infection in the world, has been focusing his attention for the past 15 years on therapy with HIV/AIDS sufferers. In this article, he and colleague Duncan Cartwright offer a timous insight into the nuances and complications of working psychoanalytically with people who are staring down the social, physical and personal implications of their HIV/AIDS status.

A psychodynamic approach to psycho-therapy with HIV/AIDS sufferers offers some specific theoretical insights that help us better understand therapeutic problems that emerge in the treatment process. Once diagnosed, HIV sufferers often have to contend with an ongoing internalized traumatizing process that needs to be arrested if psychotherapy is to be successful. We have identified a number of key dynamic factors that one needs to keep an eye out for in order to help in this regard. We shall explore these shortly.

As well as having to deal with the internal consequences of this process, however, the role of external reality also requires special consideration. The therapist has to deal with issues related to the reality of physical illness, medical treatments and advances, prejudice and even sexual practice, that can be very much 'in your face' in the treatment process. HIV makes specific demands on the therapist who wishes to work psychodynamically. Some of these demands include the management of difficult countertransference states, retaining 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.

These observations can be applied in one-to-one therapy, and in more accessible settings such as in group psychotherapy programmes, support groups and post-test counselling. In exploring some of these issues, we will use two cases, Guy and Julia, to illustrate our observations.


Learning that one is HIV positive is a traumatic event, in an immediate, intrusive, and overwhelming sense, and usually generates an insidious internal process of adaptation or defence against the real implications of infection. The dynamic processes that are most apparent here are:

1. Splitting defenses directly related to the meaning of HIV;

2. The use of projection; and

3. The collapse of the ability to think in a meaningful and creative way.

1. Splitting

The use of splitting can be seen in the following scenario in the first session with Guy, a 40 year old man, who had just been diagnosed HIV positive:

Guy's initial resistance and hostility, was based on an insistence that I (M.C.) would not be able to understand him and accurately empathise with him, as only another HIV positive person could do the same for another. At the time I was left feeling branded, judged, rejected, containing a helpless feeling, and a strange sense of survivor guilt. It was clear that at this point he 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.

The extent to which splitting takes place will, of course, depend on the nature of the predisposing personality, and also allows for some degree of dissociation and denial to take place. In the absence of apparent symptoms, the initial trauma and what it means for the future are often readily split off with little sustained work being done to make life adjustments.

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 may feel 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.

Julia was a 29 year-old black woman who had contracted the virus from her ex-husband and had only recently learned of her infection on coming to therapy. The first two months of once-a-week therapy were spent dealing with the shock of her diagnosis and the implications thereof. Soon she began to find it very difficult to relate to the reality of her diagnosis, not associating it with anything else in her life. Notably, she never mentioned the words 'AIDS' or 'HIV' for about the next six months of her therapy. Even when I (D.C) was able to say something about this to her and interpret its significance, she was unable to feel its real implications. Only much later in her therapy was she able to begin to deal with the consequences that her diagnosis was having on her internal world.

Splitting may also occur in parts of the self associated with sexuality. In some cases, after diagnosis, sexuality is entirely split off. Although this may simply be due to fears about infection and re-infection, unconscious associations about the confirmation of oedipal fears often run alongside this. Here sex, badness and death are associated in a fixed constellation.

At various points, an irritable Guy, who eventually decided to return to therapy, spent considerable time talking about his friend's 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, and they withdrew and became for him abandoning and attacking. In contrast, he spoke about himself in a desexualised way, and described his desire for non-genital 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 erectile dysfunction and anxiety about the ejaculation of semen. 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 expressing the thought that HIV was his punishment for his enjoyment.

Some key projections and identifications

The projection of parts of the self associated with illness which are felt to be dangerous and toxic is a common observable dynamic in the therapeutic process. Alternatively, the patient may present the diagnosis as a wound resulting from an attack, projecting onto the therapist a need for balming with differential and preferential treatment.

Along with the stigma associated with infection, split off bad parts of the self are often identified with in a way that leads to masochistic and depriving behaviours.

After her relationship broke down, Julia took to locking herself in her flat for long periods of time often not seeing anyone at all over the weekends. She also began to deprive herself of food for long periods and had lost a significant amount of weight. With some help, she came to the realization that loss to her felt very much like she was dying and that her isolation and deprivation, an identification with the dying process, was her way of communicating what she could not yet say to others. Her isolation from care also had the effect of confirming her perception that all friends and family where essentially unloving and untrustworthy.

Projective identification of the infected 'bad' part of the self may also be observed. This creates a situation where the infection of others, either through high risk sexual behaviour or through more intentional anti-social behaviours, becomes a means, in fantasy, of unburdening the self.

Continued on the next page ...


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