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Helping AIDS sufferers contd ...


Collapse of the symbolic function

Julia would often go into extensive detail about her week, her chores, routine, and her interactions with others. The material left the therapist both bored and frustrated as I (D.C.) was unable to think with her in the session. Later, reflecting on her therapy, Julia articulated this more clearly along with the underlying defensiveness that accompanied this process. In her words: "I used to think well I've got the virus, the virus is in my body, a virus is a virus, it cannot think, so there is no point in thinking about it or talking about it anymore".

An important consequence of the traumatizing process is the collapse of that particular functional aspect of thinking, the type that enriches the psyche with new meaning, the symbolic function. 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 causes a kind of psychic death where mental aliveness is compromised. Only once the object or trauma is re-presented and elaborated upon internally can any degree of mourning and reparation occur.

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. The ability to re-present HIV, and therefore face such implications, is illustrated in the following vignette where Guy is able to attribute meaning to his experience using a dream.

Guy initially made little reference to his HIV status. However, a change came about once his relationship with his partner broke down. Feeling the reality of his loss with me (M.C), he was able to begin relating to 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: 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'.


Ideally, the therapeutic couple need to strike a delicate balance between acknowledging the harsh realities of infection whilst maintaining a sense of meaning, hope and purpose about ones life. Part of this means having to find a way of living with uncertainty with the patient that creates hope, whilst acknowledging real difficulties and losses; a way of bearing difficult feelings of anger, thoughts of illness and death, without rejecting love and support from others.

With our understanding of the traumatising process, we are guided by a focus on the process of integration of split-off parts of the self made possible by the restoration of symbolic thinking. Given this, the containment of anxieties and split-off aspects of the self is an essential part of the treatment process and makes possible the eventual withdrawal of defensive projections in a way that is less traumatizing to the patient.

Although often under-emphasized in dealing with HIV/AIDS, interpretation also holds a number of important functions when focused on the internal consequences of the traumatizing process. Firstly, interpretation serves to give meaning to experiences that are often difficult to put into words. In this sense these kinds of interpretations are more about the 'translation', rather than the interpretation of conflict. Secondly, interpretation is an important means of addressing the defensive splitting that occurs as a result of the traumatizing process. A focused transference analysis, similar to that used in brief psychodynamic approaches, where emphasis is placed on the analysis of splitting and its consequences, appears to work best here.

Importantly, interpretation also allows new meaning and symbolism to aggregate around traumatic material so as to address the sense of meaninglessness brought on by infection. The required depth and attainment of a finer, deeper, and more effective interpretative role provides the atmosphere for mental enlivening and exploration of the symbolic.

Guy's dream about landmines presented symbolic foci which enabled the therapeutic couple to move out of the barren space of nebulous fear, into a space filled by objects onto which anxiety could be attached and elaborated. His dream allowed for interpretation related to the paradoxical representation of fragility/destructiveness and robustness, enabling Guy to realize that, even in the face of impending death, life has purpose and continuance.

Transference/countertransference issues

As illustrated earlier, the traumatising process can manifest in the transference in a number of ways. Most commonly it oscillates between the therapist representing a split-off, bad/infected part of the self and the therapist representing an idealized figure invested in an immaculate cure for HIV.

The balance between successful and failed treatments often hinges on the appropriate management of countertransference. Much has been written about countertransference and enactment in working in this area. Some of the commonly identified enactments include:

• Over involvement,

• Expressions of anger,

• Neglect,

• Collusion,

• Assuming the role of a surrogate parent, and

• Claims of omnipotent healing powers.

• Countertransference states related to irrational fears of contamination, death anxiety, denial and morality.

Feelings of hopelessness, the therapist's personal struggle with issues of death and illness, and the degreeof uncertainty that underlies the diagnosis, makes this work more prone to enactment. All this is often fuelled by a deep sense of inadequacy about one's therapeutic role and realistic capabilities in dealing with chronic illness. Still further, the suspension of the symbolic function also makes the therapist more vulnerable to communicating through action rather than words.

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