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Apart from the general need for the therapist to acknowledge and work through countertransference states that hamper the therapeutic process, attention to particular tasks may assist in managing countertransference states. Two factors are crucial here:

1. The therapist needs to actively attend to his/her own mourning during the process.

2. Realistic goals and expectations need to be clearly outlined to prevent a sense of feeling overwhelmed by the processes. Of course, support groups and supervision are indispensable in helping the therapist attend to his/her own containment.


Maintenance of a flexible frame

In working with HIV patients, the frame is often compromised by necessary liaisons with doctors, periods of hospitalization, hospital visits, dilemmas regarding payment of fees, requests for increases in the frequency of sessions, and the like.

Although the above factors have clear implications for the frame, leading sometimes to the therapist discarding therapeutic boundaries, the frame remains an important part of the analytic treatment process. Many of these frame deviations are realistic inevitabilities of working with such patients, and in this sense, it is useful to build these into the initial treatment agreement so that some means of establishing a more flexible frame is established. Such frame breaks would include:

• Important inquires into the health of the patient as relayed from medical professionals;

• Addressing family concerns after disclosure;

• Addressing concerns and reassurance needs about one's health;

• Making changes in the actual location of the therapy when needed.

The maintenance of some aspects of the analytic frame, however, still remain important. In this respect deviations related to treatment times and dates, hours available, the agreed therapeutic contract and the role the therapist holds, still need to be addressed as they serve a number of key functions in the treatment process. First and foremost, the therapist's adherence to the boundaries of the therapeutic process helps usher in the mourning process by acknowledging the realistic limitations of the patient's situation.

In Julia's case, there was a time when she insisted over a number of sessions, that I (D.C.) telephone her ex-husband and talk to him about how she was progressing in therapy. It was clear that this was an attempt on her part to get him to reunite with her using her HIV status to try and win my favour. Being able to interpret her motives here, rather than act on her wish, raised a number of problems and frustrations for her about the limitations of psychotherapy in helping her, in turn, helping her deal with some of the losses she had to face as a consequence of her HIV status.

In the second instance, the consistent maintenance of the frame, whilst acknowledging inevitable frame breaks, also helps reestablish a consistent 'trusting relationship' or a secure attachment base; something that comes under threat in the traumatizing process. Thirdly, adherence to the frame also offers the therapist a degree of structure and containment as to where treatment commitments begin and end.

Moral questions

Should the therapist be a 'moral policeman' in the treatment process? If we are informed of unsafe sex practices that endanger others, what should we do? This may emerge as a simple issue related to inadequate knowledge about the virus. But there may, of course, also be conscious or unconscious motivations for such behaviour.

Either way, we believe that the therapist will need to attend to the matter. In most cases however, this need not be about taking a moral position on the matter, but more about dealing with difficulties that threaten the therapeutic alliance and the therapist's commitment to the process in the long term. It would be difficult, for instance, to do productive work with a patient knowing that he may be in danger of infecting others.

Therapist as AIDS educator.

Disseminating knowledge about the virus is an inevitable part of the therapist's role. It may however also simply be dealt with by referring individuals to appropriate sources, so as not to unduly sidetrack the analytic work. Other motivations for unsafe sexual practice appear best dealt with using routine interpretations related to motive.

Although AIDS education may not always be taken on by the therapist, recent information about treatment and developments in the field are crucial to the success of the therapeutic relationship. Such information allows us to more finely tune our analytic gaze, and develop more appropriate and accurate empathy so as to offer interpretations that alleviate anxiety, rather than rewound the patient.

Dealing with a dying patient

Dealing with a dying patient challenges the therapist's ideas about responsiveness and gratification in treatment. Once AIDS-related illnesses such as dementia set in, a more supportive and gratifying role is needed. To frustrate certain needs may be to ignore a wound and convey a fear to the patient.

Ending therapy at this time is fraught with the possibility of leaving a patient vulnerable and in a state of abandonment which may simply undo the work of therapy. There is no simple answer to the question of termination. Ideally, we would hope that much of the work in dealing with the internal trauma would have been done by this stage so the patient feels he could be left to be cared for by family and friends.

Over-investment on the therapist's part is a crucial dilemma at this point and often emerges in reaction to feeling that the therapeutic role is limited and inadequate. Over-involvement not only compromises therapeutic involvement, it may also be obstructive to the caring of others closer to the patient. Here, the patient's needs, close adherence to the goals of therapy, an analysis of external support, and close supervision, are the best help in terms of guidance.

Perhaps the most effective analytic position at this point is one that lies between termination and over involvement where the therapist takes on a removed containing position for all involved. This was the case with Guy when he had deteriorated to a point when he could no longer see and his psychotic behaviour greatly distressed his family and home caregivers.

I (M.C.) felt a resurgence of my own helplessness and was left battling with the idea that all that could have been done for him directly by me had been done, whilst acknowledging a sense that this did not feel adequate or 'good enough'. To withdraw at this point felt as if I would be behaving as if Guy had already died. At the same time I felt that offering direct care as part of the home care team would simply fuel an enactment of a fantasy to cure till the end.

With this in mind, I shifted focus to simple family support, assisting them with understanding and managing Guy's shifting mental state, impulses, and behaviour. In the last few weeks of his life he became agitated and manic, implementing frantic relocation plans, involving an expensive accommodation purchase after insisting that the move would cure him. His family, while floundering, were unsure of how they should deal with his last-ditch denial. An interpretative stance, suggesting to his family that this was his way of negotiating a move from life to death, allayed their confusion and enabled them to be calmer and supportive of his.

When 'good enough' is not enough

In essence, work with HIV/AIDS patients is about restoring mental aliveness through support and containment of the traumatizing process. In turn, the therapist aims to curb the defensiveness that restricts one from living a meaningful and fulfilling life with HIV. Through all this, however, the therapist has to bear the difficulty of knowing that whatever is done will never be 'good enough' whilst, at the same time, holding onto to a sense of purpose in the therapeutic work. In an area where it is so easy for the therapist to feel at sea with all the complications of treating HIV patients, the need for a clear understanding of the specific problems and goals of treatment is essential. We have presented a model that offers some technical leverage or vision to guide therapeutic work in this area.


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