Author: Paweł Kurczak
This article was written for people working with people living with HIV or planning to start such work, who do not have the psychological training aimed at clinical help. For the specialists it might serve as a reminder.
The main goal is to point out the aspects of the psychological experience of people living with HIV, in the face of which the helper (such as a social worker, party / street worker, physician) may feel overwhelmed and helpless so that his or hers assistance is ineffective or even an additional burden to the already helpless client. To avoid this, beyond ‚technical‘ knowledge about HIV, without which this work is not possible, you should equip yourself with an adequate self-awareness. Remember when we choose the path of psychological help we become a working tool, and every tool, without proper preparation, quickly becomes useless. In other words, if you do not take care of your own mental hygiene, you can work at the expense of your own mental health. I will not dwell any longer on this aspect of mental hygiene. I will only mention that the work in an interdisciplinary team of people with whom you can talk about your difficulties is the condition of safety, and the exchange of experience during team meetings and individual conversations is a good safety valve to prevent burnout. Of course, I mean the team that offers their work for evaluation to a supervisor experienced in psychological counseling. This is an ideal situation, but practice shows that specialists often work alone, and have difficulty with real-time access to their colleagues from other disciplines. These are the type of people who I especially urge to examine this article, because they are more likely than others to have bad results in their work. What to remember is shown by the following paragraphs.
Awareness of client’s psychological difficulties and the scale of his emotional experiences.
Any person who becomes aware of HIV infection, consciously or not, gets in touch with his mortality. Healthy person represses thoughts of death, in order to function properly. The reality of death is the most terrifying fact about existence. It is of course important for the client to have adequate information on how to treat their illness and are aware of the facts concerning it, for example, the effectiveness of treatment, life expectancy etc. However, when a client tells about his fear of death, pointing to the rational arguments can be seen as rejection, and the person you are talking to will feel misunderstood. Before we begin to explain and comfort – let’s hear about the drama he is going through. When he will feel that he is understood, and he’ll realize that we ourselves do not run away from this fear, there is a chance for him to learn how to reduce this fear and teach him not to deal with it on his own.
Thus, fear is often the dominant emotion in the subjective experience of the client. As you know, deep fear affects the functioning of the whole nervous system, resulting in, for example, a worse frame of mind, but also in deterioration of cognitive functions. The very fact of having HIV, coupled with rejection (or presumed rejection) by friends, can negatively affect the self-esteem. Awareness of this cognitive deterioration may further enhance this effect. The natural response to this is the attitude of superiority. It is also a passive form of expressing anger, which possibly is a way for this person to function relatively well. Take this into account before you react with defensive anger towards your client. Of course this does not mean that you should allow violations of your own borders.
If you work with people who have just learned about their infection, it is likely that you will meet the reaction of denial. Patients may refuse to accept that they have HIV, try to convince you of your mistake, require more research etc. A similar phenomenon can be observed in the prevention work. Clients don’t want to test for HIV, because they believe that this problem is not affecting them, and they want to keep this illusion at any price. If it is possible, do not deny the patient’s negation and accept it. Accept the client with his difficulties and remember that it is a natural step for him to accept this difficult knowledge and provides the necessary time to prepare for the experience of shock. Being sure that you’re right doesn’t obligate you to convince your client about it.
Although the described phenomena are natural, it’s not your job to provide this knowledge to your client. Sometimes, in the course of an emotionally difficult conversation, we tend to escape to intellectualization. The problems that the client is talking about can easily be ignored by changing it into a “lecture” about psychological mechanisms that might affect him in this situation. During diagnosis or prevention there is no point in getting into the psychological nuances of his functioning. In this way, you will move away from the very issue with which he came to you. Intellectualization can also be noticed during the conversation with the clients. They often refer to more or less well-known discoveries about HIV, its treatment, routes of infection, etc. This is also the phenomenon that is used to cope with the information that we try to convey to him, which can be frightening. If you notice that the client uses this method to deal with anxiety, yet what he says does not break the important safety rules, it is not worth arguing with him at the beginning. Give him time to cope with his fear, because only then he will be able to hear and understand what you say to him. Even the most accurately phrased knowledge is not going to have any effect, if it is not accepted.
Feelings described above are not the only ones that your client may experience. However, it seems that fear and anger, but also sadness or even despair, may arise at a later stage to cope with the realization of the presence of HIV. This is one of the most difficult feelings that may occur in contact with your client. Often when we meet a sad person we are trying to comfort him. But before you start doing that you should realize that grief – though not easy to survive – is not in itself undesirable. These emotions also give time for a person to deal with the virus. Some clients may fall into a sort of apathy, which usually is a sign of „mourning for their lost health.“ Usually, a person needs some time, perhaps even a retreat from daily activities, to deal with this experience of grief. It is usually assumed that such a state of mind can last up to a year and if it doesn’t completely paralyze a person’s life, he shouldn’t be pressured to reach out for help. Of course, if the client himself feels the need to improve in this area, it means that he is near the end of his mental strength and we should not dissuade him from doing so on the grounds of mourning.
Awareness of one’s own emotions.
In Section 1 I pointed out that sometimes, when a client reveals his fear of death, we might feel a strong need to appeal to rational argument. This is a kind of disregard for the client’s experience. One important reason for this behavior is an often unconscious desire to escape from our own fear of death. Every one of us in some way has a tendency to repress this frightening fact out of our consciousness. However, while working with people living with HIV we are constantly confronted with the reality of death. So we have no other way but to deal with our own lack of acceptance of this fact. Going through an intensive, introspective psychotherapy, which is an essential requirement for each helper, we can avoid making this mistake. In conversation with clients living with HIV we can often experience difficult emotions like anger, helplessness and sadness. Those might roughly be a mirror image of the patient’s emotional state. Without understanding their origin, we can react defensively with aggression, which will make it difficult or even impossible to establish good contact. Without the knowledge of your own emotional dispositions it will be difficult to adequately define your borders, which may be too rigid or too “transmissive”. An additional difficulty is that your client might be convinced that he is not experiencing those aforementioned emotions. This is because cutting off from one’s feelings is a potent and highly effective way to maintain well-being. The power of this state of being cut off from emotions can be only appreciated when we had the opportunity to observe it on our selves. It will be easier then not to fall for strong, sometimes unconscious signals, from a client to ignore his feelings. One of the biggest challenges that we have to deal with in the contact with the HIV positive client is being a companion in his sadness. As with other difficult feelings, sadness may provoke our disassociation from it. If this happens in, it will be difficult to support our client. Being a companion in his suffering we cannot also excessively go through this sadness. This is a particular challenge for counselors who are themselves HIV positive (but also for those who have suffered a significant loss in their life). In this situation, it might be particularly difficult to separate a sadness coming from empathizing and understanding of the client’s experience, from our own sadness, sources of which we do not completely recognize and/or sadness that we haven’t coped with.
Being aware of limitations in providing assistance.
People’s limitations in helping those living ith HIV often do not stem from a lack of technical knowledge. Experience shows that, in this respect, most people are well prepared. As indicated above, the limitations of possibilities to help are most often associated with insufficient understanding of our experiences. We have to have a good awareness of our own mental strength, our personal limits, and be able to recognize our emotions and manage the expression of those emotions appropriately. Otherwise our client may become our comforter or an object on which we unconsciously unload our anger resulting from helplessness. That helplessness is the aspect of the experience, which can be difficult to deal with. Those who report to us, in various unconscious ways, „wish“ to pass on to us their helplessness, as if „expecting“ that HIV will magically disappear. The acquisition of this vulnerability may deprive us of the very strength we need to show to be able to help .It can be said that the help is based on showing the client his helplessness and his limitations (and therefore the impact) to cope in life with the virus. Awareness of HIV infection combined with a weak personality types can result in very severe psychological symptoms. Sometimes we might even consider that the client’s behavior goes beyond a certain norm, which we would expect from him in this situation. An advanced case of AIDS can significantly influence the behavior of the patient through neurological changes. You should be aware that some people will not have sufficient strength to cope with their problems alone. If you think that the client’s behavior is bizarre or he or she is experiencing emotions that can lead to self-destructive behavior, do not hesitate to send him to a psychologist or psychiatrist. Specialists will be able to assess what kind of help would be the most appropriate for the individual. Don’t do it automatically though, because not everyone you will meet is going to need such help and he or she can feel like you’ve ignored them. Remember that you’re not the only one who can help. You do not carry the responsibility for the decisions made by your client. Even if you think your client should behave in a certain way, you have to accept the fact that he alone is responsible for his past and his future actions.
This article pointed to limitations in helping those living with HIV due to emotional states of a helper. Emotions that undermine the effectiveness of aid are primarily fear, anger and sadness. Both clients and helpers can unconsciously use the mechanisms that isolate them from those feelings. Initially, they promote adaptation, but after some time they may hinder the functioning at all. These mechanisms include, among others, denial and intellectualization. The task of a counselor is primarily to accompany his client, rather than solving his problems for him. Not taking the responsibility for the client decisions, and his ability to cope (or not) with his or hers life, will allow him or her to deal with the knowledge of living with HIV, and return to psychological balance more quickly. In situations where you have a problem, do not be afraid to propose a visit to a mental health professional.