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Role/s Of The Therapist
We turn now to problems related to inevitable changes that occur in the treatment process when AIDS-related symptoms, such as early dementia, appear, and when the patient is ill and dying. Here we are faced with the question: At what point does one finally terminate analysis, or at what point is one's work as a psychotherapist over? Defining termination is fraught with the possibility of leaving a patient vulnerable and in a state of abandonment which may simply undo the work of analysis. Still further, how can the analytic relationship continue if dementia or other related illnesses have set in?
Ultimately, Sadowy's stance is resoundingly complicated once the patient's ability to move and speak ceases. In her words: "I had to go beyond the usual therapeutic parameters and trust in another therapeutic communication. In continuing this treatment, I had to believe in and use a type of communication between two inner selves. I had to be willing to gratify a symbiotic connection with my patient as we attempted to disengage from her rapidly dying external reality and to enter a living vibrant internal reality."
Dealing with the dying patient also challenges the therapist's ideas about responsiveness and gratification in treatment. In this regard, issues of simple gratification may be necessary. To frustrate certain needs may be to ignore a wound and convey a fear to the patient.
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. Overinvestment on the therapist's part is a crucial dilemma at this point and often emerges in reaction to the pending limitations of the analyst's role. Overinvolvement 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 overinvolvement, 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 where he could no longer see, and his psychotic behavior greatly distressed his family and home caregivers.
Case 1 (cont'd): I 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, while 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.
Containment And Interpretation
The interpretation of anxieties and transference derivatives have to be finely conducted on the basis of an appreciation for the patients' internalization of HIV as a traumatizing object and their overall physical condition and attendant medical regimens. Interpretations, linking behavior, emotions, and fantasies to the patients' seropositivity, if not accurate, run the risk of replaying stigmatization, rewounding them, reminding them they are sick when they do not feel ill at all.
The third function of interpretation is related to the restoration of the symbolic function that allows meaning to aggregate around traumatic material. 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.
Case 1 (cont'd): Guy's dream, for instance, presented symbolic foci that enabled the therapeutic dyad to move out of the barren space of nebulous fear into a space filled by objects onto which anxiety could be attached and elaborated. For instance, his dream about land mines, presented earlier, 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.
Feelings of hopelessness, the therapist's personal struggle with issues of death and illness, and the degree of uncertainty that underlies the diagnosis make 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.
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. Purnell, for instance, emphasizes the need for the therapist to actively attend to his/her own mourning during the process. Feldmann, on the other hand, points out the need to have clear, limited goals and expectations of treatment to prevent a sense of feeling overwhelmed by the processes. Feldmann also suggests that the therapist take regular breaks from this type of work to preserve his/her capacity to work with HIV sufferers. Certainly, support groups and supervision are indispensable in helping the therapist attend to his/her own containment.
Countertransference management is complicated further by the changes that occur in the therapist's role. If the therapist changes his/her therapeutic stance due to inevitable complications in the treatment process, how are we to distinguish this from enactment? Here, a distinction between enactment and behavior motivated by external factors is useful. Theoretically, one might say that enactment, whether evoked by the patient or not, stems solely from the analyst's unconscious motivation while a realistic response to complications is motivated by an external situation beyond the therapeutic dyad. The former threatens to foreclose the analytic space whereas the latter is an attempt at preservation.
Case 1 (cont'd): When Guy began to present with signs of dementia, I was faced with the dilemma of deciding whether my care at this point needed to be more active and direct. It was clearly a struggle for him to come for therapy and because his cognitive functioning was deteriorating, interpretative work was clearly out of the question. My therapeutic role was no longer clearly defined. Around this period, a medical consultant informed me that Guy needed to go for an eye consultation where he was not going to receive good news. It was clear that Guy's parents were extremely elderly and frail and physically unable to attend to Guy outside of the home and there was, at the time, no one else available. With few options, I eventually decided to assist and accompany him to the local hospital. This meant much running about, securing a wheelchair, and waiting until we were attended to.
In dynamic terms, this could be construed as a simple case of a crude kind of enactment on my part. However, it may also be conceptualized as a response to a constraining external situation that outweighs the need for a more removed therapeutic stance at this point.
Reflection Exercise #6
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A second case of HIV transmission from someone interrupting their HIV therapy as part of a cure study has been published. The report, by Dr Ainoa Ugarte, Dr Lorna Leal and colleagues from Barcelona University Hospital (Ugarte reference below) has prompted discussion about whether the HIV-negative partners of people involved in studies that feature so-called analytical treatment interruptions (ATIs) should be offered PrEP as a matter of course.
A survey of German PrEP users reported at the recent 17th European AIDS Conference (EACS 2019) found that one in nine of them had not had a single HIV, STI or renal function test during the time they were on PrEP. Of those who had taken an HIV test while on PrEP, 15.5% had taken a test less often than the recommended interval of three months, and 8.5% had had an STI check-up less often than the recommended once every six months.
Several qualitative studies have already found that gay and bisexual men using the preventative medication PrEP have reported benefits in terms of reduced anxiety about HIV, but until now there has been scarcely any quantitative data to confirm this. Now, an Australian study shows a statistically significant reduction in HIV anxiety among men who were eligible for PrEP and who were using it.
A study from rural Tanzania, published online ahead of print in HIV Medicine, provides more evidence on the importance of appropriate management of clinically relevant drug-drug interactions for people living with HIV who are on antiretroviral therapy. As life expectancy of people living with HIV has increased due to improved access to antiretroviral therapy (ART), co-morbidities and co-medications are also on the rise. But appropriate management of clinically relevant drug-drug interactions is sub-optimal, especially in low-resource settings.
A Canadian study which compared the HIV status of gay men’s recent sexual partners with what would be expected if they chose partners regardless of status has found that HIV-negative men who used PrEP were nearly twice as likely to have HIV-positive partners as those who did not. It also found that men using PrEP were more likely to have sex with other PrEP users than with men not using PrEP. Conversely, non-users were more likely to have sex with non-users.