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To cite this article: Shelley Gurney (1995): Counselling the HIV affected individual: A case study, Counselling Psychology
Quarterly, 8:1, 17-25
To link to this article: http://dx.doi.org/10.1080/09515079508258693
OHB,
UK
The literature on HIV disease has largely centred on the virus biological, psychological and social impact on the infected individual. There is, however, an increasing recognition of the
impact of this virus and the extent to which it reaches beyond the infected person and ajhects partners,
families, f i e n d and carers. This focus, fiom a family systems perspective, on the impact of illness
(Rolland, 1994) and death (WaLrh & McGoldrick, 1991), attempts to give attention to both the
immediate and long tern effects on nuclear and extended family members, whilst the work of Bor,
Miller & Goldman (1 992) specifically offers a family systems approach to psychotherapy for people
affected by HIV. The following case is an illustration of the complex and challenging issues
encountered in working with an affected family member and the way in which a range of feelings
depending on the unique meaning of the releationship and its loss for each member and the
implications of the death for the family unit i s experienced (Walsh & McGoldrick, 1991).
ABSTRACT
Background information
Mrs R, is a 40 year old woman of Scottish origin. At the age of seventeen she
travelled to Cornwall to take holiday employment, where she met her husband and,
as a result, remained in Cornwall and did not return to Scotland to finish her
education. She had little contact with her family, as she thought they would
disapprove of her lifestyle, until she mamed and became more settled. The couple
now have a 19 year old daughter who lives close by with her boyfhend and a 17 year
old son who lives at home and is in full-time education. Her husband has a 27 year
old son (Gerald) from a previous marriage who has always had close contact with
them but lives in Cornwall. Gerald has an AIDS diagnosis.
Mrs Rs father died two years ago, her mother continues to live in Scotland with
Mrs Rs older sister. She also has an older brother who lives in Australia.
Following the failure of his business four years ago, Mr R became severely
depressed and has been unemployed since. The family suffered financial difficulties
and as a result the relationship became very strained. The couple separated for a
temporary period 18 months ago. However Mrs R has continued to take responsibility for the family, has been in constant contact and visited regularly and has also
taken a full-time job to pay off the debts incurred. Recently Mrs R and her husband
0951-5070/95/010017-09 0 1995 Journals Oxford Ltd
18 Shelley Gurney
wanted to live together again but discovered that her return to the family home
would be financially disadvantageous because of the loss of welfare benefits. The
couple continue to be officially separated but Mrs R has spent increasing periods at
the family home and currently cares for Gerald who is wheelchair-bound and visiting
the family from Cornwall. She believes her husband is not fit to provide this care in
his current depressed state.
The telephone has been disconnected for non-payment and Mrs R is concerned
that they will not be able to stay in touch with Gerald during the terminal stages of
his illness.
19
session and we agreed an appointment time for the following week. I explained that
the content of the session would remain confidential.
The clients sense of urgency and confusion about expectations and role meant
that the initial contract was a very simple agreement to meet again. Bond (1993)
suggests that contracts become more elaborate and specific as the counselling
relationship is clarified.
20
Shelley Gurney
My formulation was that Mrs Rs crisis arose from a threat to her self-concept based
on conditions of worth. Conditions of worth entail not only internalized evaluations
of how an individual should behave but also how they should feel about themselves
if they perceive that they are not the way they should be.
In order to gain acceptance and approval Mrs R had adopted the dual role of
carer and provider both as a parent and as a partner. She also perceived herself as
strong and independent having always been able to cope with the struggle to bring
up a family on limited means. In the current circumstances she perceived herself as
both a failure and as useless since this role was now threatened. In addition she was
experiencing strong feelings of anger and resentment which conflicted with this
self-concept.
The anxiety and stress caused by the threat to the self-concept (or ideal self)
had been further intensified by Geralds illness and the anticipatory loss which raises
feelings that Rolland (199 1) has identified as separation anxiety, existential aloneness, sadness, disappointment, anger, resentment, guilt, exhaustion and desperation.
The awareness of the possibility of death within the family brings in a reality which
challenges the immortality of the family and the anticipated loss had further eroded
Mrs Rs self-concept. As a woman, she was also responding to a societal role in
which she would accept primary caretaker responsibilities and would be more
prone ... to attributions involving blame, shame or guilt, a view echoed by Walsh
Subsequent sessions
Mrs R continued to attend for counselling. During the three month period she
attended her psychiatric appointment and as a result was referred to an occupational
therapy centre where she accessed social work support. The financial difficulties
increased when she sustained a further loss as her income was reduced as a result of
an injury at work. She described living a hand to mouth existence and was constantly
worried about how the family would survive. Geralds condition improved during
this time and he returned to Cornwall.
In the next two sessions Mrs R seemed more positive. She had exploded with
anger at her husband and described herself as having gone completely mad. She
was now embarrassed at having lost control in this way but felt relieved and more
sane now that she had released all that tension. This episode seemed to have a
positive effect on her husband who was shocked into action and for the first time
showed concern about the situation and her own physical and emotional state.
She announced that she intended to keep her appointment with the psychiatrist.
My response was that she should choose the treatment she felt was most helpful and
that we could discuss this after the appointment. This episode raised my original
doubts about using a non-directive facilitative style. However in group supervision
I concluded that the client was exploring her options and right to exercise choice
over her own healing process.
Following this we renegotiated our contract and met on a fortnightly basis. Mrs
R was referred to an occupational therapist and was finding practical support but
needed more time for the numerous appointments this required. I perceived this as
positive; Mrs R was taking charge of her situation, reconciling the apparent paradox
between stress management and a non-directive therapeutic approach discussed by
Clarke (1 994). As a counselling psychologist I became increasingly a companion in
her progress towards problem-solving.
It was in this session she disclosed that both she and her husband had been
addicted to heroin (but had never injected the drug) at the time of their marriage
and had kicked the habit through their own willpower. She thought that this
experience had created a fear of dependency and a reluctance to seek help. In
making this connection she had become aware of the link between her past
experience and current behaviour.
22 Shelley Gurney
At this point the counselling process had reached a critical stage. It seemed that
our relationship had established and developed enough trust for Mrs R to share
secrets and discuss taboo subjects. In the next three sessions she began to disclose
previously unspoken and unacknowledged feelings. She expressed anger and resentment towards Gerald and his illness, which she had previously denied since these
were unacceptable emotions and resulted in painful guilt feelings. Blueglass (1986)
has noted that the stress caused by responding to both the patients and the familys
demands can lead to guilt, anger and resentment directed at the patient but often
unexpressed. This was further evidence for me of the conflict between Mrs Rs real
and ideal self. She also began to recognize the deep feeling of disappointment in her
husband who she felt had let her down through his depression, and began to
recognize the conflict between her own needs and responses to loss (dependency)
and her self-concept of independence and coping.
For the first time she acknowledged that she no longer wanted to be competent
and coping. I believe that offering Mrs R a genuine and accepting relationship
challenged the guilt and self-rejection she was experiencing as a result of her failure
to fulfil self-imposed conditions of worth and was leading to an acceptance of herself
as vulnerable and in need of support:
It is only when the client begins ... to value himself ... that real movement
can take place ... this first self-valuing is the direct outcome of sensing the
counsellors valuing of them and accepting that such an attitude is possible.
(Mearns & Thorne, 1988, p. 62).
As she moved through the stages of process described by Rogers (1951) Mrs R
experienced herself as deteriorating. Prior to this crisis she had been in a state of
psychologicalfixity with her problems and feelings unrecognized. She had come to
counselling exhibiting but not owning her feelings and had progressed to a point
where they were more fully expressed and experienced in the present and she was
beginning to accept them and recognize some of the contradictions within herself.
As Sutton (1989) remarks:
Sometimes the relief of sharing strong or unacknowledged feelings may
itself markedly reduce the misery and hopelessness with which people
come. Sometimes there may be minimal relief because the difficulties have
no solution. ... They come with personal tragedies overlaid with financial
problems, with relationship difficulties exacerbated by disadvantages of
housing environment, and with private miseries compounded by mental
and physical illness.
In supervision I raised again my doubts about using a person-centred approach since
Mrs R exhibited all the features of the cognitive triad in depression-a negative
perception of herself, her situation and the future which had been activated by both
actual and anticipated loss (Beck, 1976). I wondered whether a cognitive approach
would have been more helpful. I was aware that I was finding it difficult to stay with
Mrs Rs despair and hopelessness, wondering whether the core conditions I endeav-
Conclusion
Geralds illness occurred at a time when Mrs R and her family were particularly
vulnerable due to multiple and concurrent losses; unresolved issues relating to illness
and loss which had remained unacknowledged were triggered by the presence of a
chronic and life-threatening illness.
24
Shelley Gurney
... it is the client who knows what hurts, what directions to go, what
problems are crucial, what experiences have been deeply buried ...
(Rogers, 19 6 1)
The counselling process with Mrs R has helped me to understand that it is possible
and indeed desirable to adopt a flexible approach when working with clients,
particularly those who present in crisis and extreme distress. Furthermore I have
recognized that it is appropriate to have a range of strategies and approaches to
respond to the expressed needs of the client and as a result have increased
confidence to explore the integration of other therapeutic strategies where appropriate whilst at the same time preserving an essentially person-centred approach.
This case highlights the impact of H N disease beyond the infected individual
and its effect on the family:
Strong emotions may surface at different moments, including mixed feelings of anger, disappointment, helplessness, guilt and abandonment ... the
multiple meanings of any death are transformed throughout the life cycle
as they are experienced and integrated with life experiences, including ...
other losses. (Walsh & McGoldrick, p. 9)
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