Counselling the HIV Affected Individual

8/10/2019 Counselling the HIV Affected Individual

1/10

This article was downloaded by: [University of Derby]On: 03 March 2013, At: 01:05Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House37-41 Mortimer Street, London W1T 3JH, UK

Counselling Psychology QuarterlyPublication details, including instructions for authors and subscription information:

http://www.tandfonline.com/loi/ccpq20

Counselling the HIV affected individual: A case studyShelley Gurney

a

aDepartment of Psychology, City University, Northampton Square, London, EC1V OHB, UK

Version of record first published: 27 Sep 2007.

To cite this article:Shelley Gurney (1995): Counselling the HIV affected individual: A case study, Counselling PsychologyQuarterly, 8:1, 17-25

To link to this article: http://dx.doi.org/10.1080/09515079508258693

PLEASE SCROLL DOWN FOR ARTICLE

Full terms and conditions of use: http://www.tandfonline.com/page/terms-and-conditions

This article may be used for research, teaching, and private study purposes. Any substantial or systematicreproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form toanyone is expressly forbidden.

The publisher does not give any warranty express or implied or make any representation that the contentswill be complete or accurate or up to date. The accuracy of any instructions, formulae, and drug doses shouldbe independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims,

proceedings, demand, or costs or damages whatsoever or howsoever caused arising directly or indirectly inconnection with or arising out of the use of this material.
http://www.tandfonline.com/page/terms-and-conditionshttp://www.tandfonline.com/page/terms-and-conditionshttp://dx.doi.org/10.1080/09515079508258693http://www.tandfonline.com/loi/ccpq20


2/10

Counselling Psychology Quarterly , Vol. 8, No.

1 1995 pp. 17-25

SYMPOSIUM

ON

MEDICAL COUNSELLING

Counselling

the

HIV

affected

individual:

a case

study

SHELLEY

GURNEY

Department

of

Psychology, City Univers i ty, North am pton Square ,

London EC1 V

OHB,

UK

ABSTRACT

Th e literature on HIV disease has largely centred on the virus biological, psycholog-

ical and social impact o n the infected individua l. There

is

however, an increasing recognition of the

impact of this virus and the extent

to

which it reaches beyond the infected person an d ajhects partners,

families, f i e n d and carers. This

focus,

f iom a family systems perspective, on the impact of illness

Rolland, 1994 and death WaLrh McG oldrick, 1991 , attempts to give attention to both the

immediate and

long

te rn effects on nuclear and extended fa mi ly members, whilst the work

of

Bor,

Miller Goldman

1992

specifically offers a fam ily systems approach to psychotherapy fo r people

affected by HIV. The following case is an illustration of the complex and challenging issues

encountered in working with a n affected fa mi ly member and the w ay 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 fam ily unit i s experienced Wals h McG oldrick, 1991).

Background

information

Mrs R, is a 4 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 responsi-

bility 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 1995 Journals Oxford Ltd


3/10

18

Shelley

urney

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.

Referral and assessment

h4rs

R

approached me directly for an appointment at her GPs suggestion. Although

her GP practice employed a counsellor the implication was that a specialist HIV/

AIDS

counsellor might be able to offer advice or information relating to the problem

with her stepson.

Mrs

Rs

primary purpose in coming to me was to seek practical support and

financial assistance. In this respect she was typical of clients presenting for coun-

selling in a medical context where both medical and non-medical concerns are

recognized and seen as appropriate Abel Smith et al . 1989) and many patients are

living in difficult circumstances, often with quite insoluble health or social prob-

lems Weinman Goulston, 1991).

Whilst recounting her situation she became extremely distressed, expressing her

sense of being completely overwhelmed and hopeless in the face of what seemed to

be an insoluble problem. She said that she couldnt cope anymore and was

frightened of cracking up. She felt extremely confused and unstable in her emo-

tions and her GP had referred her to a psychiatrist.

Mrs

R

made reference to the transition period in her life and her sense of

impending loss; with her children gaining independence and separating she feared

being left alone without a relationship, no longer needed b y her children and

therefore without a role and a future. She was also anxious about the effect t ha t

Geralds impending death might have on her husband. She particularly stressed the

absence of the telephone which increased her sense

of

isolation since she felt it

denied her access to support and communication with Gerald.

It was important at this time to both acknowledge her needs and disabuse her

of expectations which were inappropriate and impossible to fulfil. Mearns

Thorne, 1988, p.

100) I

therefore clarified my role as counselling psychologist and

suggested that

a

social worker might respond to the practical and financial aspect of

her problems. At the same time I reflected back her feelings of being overwhelmed

by the enormity and complexity of the situation and her distress. My aim was to

show empathic understanding which would have the effect of defusing a crisis, of

slowing down the pace and relieving to some extent the crippling sense of anxiety

and dread which the client may be undergoing Mearns Thorne, 1988, p. 104).

I

offered to see Mrs R again to explore some of the issues she had raised in this


4/10

Counselling HZV aflected individuals 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.

Assessment

and

contract

My assessment was that

Mrs R

was presenting with issues relating to both actual and

anticipatory

loss

and change which are often typical to the person in crisis. Her

psychological state reflected Caplans 196 1) definition of the disorganization and

upset that results when customary coping behaviour and problem-solving methods

seem ineffective.

My dilemma was whether

a

person-centred approach would be effective for a

client clearly presenting with a form of conflict or confusion which might require a

more problem solving focus, rather than desiring exploration for personal develop-

ment and growth, an issue which Hudson-Allez 1994) identifies as common to the

context of counselling in general practice.

At her second appointment

Mrs R

spoke with much sadness of the losses she

had experienced over the past

two

years-the death of her father, the death of the

family dog, the loss of her husband, both psychological, in his depression, and

physical, in their subsequent separation, her children due to their growing indepen-

dence, and the self-imposed loss of the family home. Again she expressed despon-

dency and despair-she had nothing left in her life, she felt alone and didnt know

what was happening to her or what she should do; it seemed pointless carrying on

and she felt useless. She became very distressed, and again expressed fears that she

was cracking up since she had always been able to cope before. She mentioned she

had now received

a

psychiatric appointment and her ambivalence about this. She

stated she would prefer to continue seeing me since it was helpful to talk to someone

who understood her situation and did not treat her as if she was crazy.

This feedback affirmed my belief that at our previous interview

I

had estab-

lished the basis of

a

therapeutic alliance and that the client felt received and

understood sufficiently to be able to express her emotions.

I

also understood that my

own sense of being overwhelmed by the situation was empathic and that the client

was offered the security of knowing that although he may feel desperate and lost in

his world the counsellor will be someone who remains reliable and coherent, as well

as sensitive Mearns L Thorne, 1988). I shared my concern about working with

someone who had been referred elsewhere. We made

a

further appointment where

we would renegotiate our contract once

I

had clarified the psychiatric referral with

the GP.

Following this session

I

contacted the

GP

who told me that

Mrs R

had been in

contact with the surgery for over 12 months, she was experiencing symptoms related

to a gynaecological problem and had been referred for hospital treatment. The GP

had offered her regular appointments to monitor her well-being and had finally


5/10

20 Shelley urney

diagnosed depression. She had refused anti-depressant medication and the

GP

suggested a psychiatric referral and

a

referral to a specialist H N service in view of

the situation with Gerald. The GP agreed it would be appropriate for Mrs R to see

me for counselling on

a

regular basis in place of psychiatric intervention.

h4rs R came to the third session full of feelings of anger and despair. She had

contacted the duty social worker who had said she could not, as a carer, have social

work SUPPOR, and had offered her a list of AIDS charities who might help to

reconnect the telephone. Each of these had stated t ha t they only offered financial

help to people infected with IV and therefore she did not qualify for financial

support. Mrs R was angry with the social worker for wasting her time and also

despairing. I reflected to Mrs R the degree of responsibility she was taking for

finding a solution to this and other problems. She agreed but was frightened that

unless the money was found the family would disintegrate and she would be left with

nothing.

Having clarified earlier concerns we negotiated a contract. I restated that a

counselling psychologist would not offer her practical support but hoped she might

be able to support herself and regain a sense of control over her situation if she were

able to express and clarify her thoughts and feelings. We agreed to meet at a regular

time for one hour on a weekly basis and to review the contract at the end of three

months. Mrs R understood the boundaries of confidentiality extended to my staff

team and supervisor and that I would not discuss her case with her GP or any other

person without her express permission.

Case formulation

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

1

99

1)

has identified as separation anxiety, existential alone-

ness, 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


6/10

Counselling

HZV

affected individuals

21

McGoldrick 1989) who see women as having been socialized into assuming the

major role in dealing with the social and emotional tasks of bereavement, from the

expression of grief to care-giving for the terminally

ill

My decision to use a person centred approach was based on

Mrs

Rs

confusion

about the different emotions she was experiencing in relation to her multiple losses,

that this confusion was affecting her ability to think clearly and rationally and her

feelings and emotions seemed out of control. My purpose was to focus on and

explore her feelings in order that she could develop more awareness and begin to act

in

a

way which was more congruent with the feeling she was experiencing Murga-

troyd, 1985).

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 1994).

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.


7/10

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 resent-

ment 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

psychological fixity 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-


8/10

Counselling

HZV

affected individuals

23

oured to offer were sufficient for change to take place and whether this mirrored her

own doubts about the process.

In consequence I introduced the cognitive theory of depression focussing

specifically on cognitive distortions.

h4rs

R

identified very quickly with the concepts

of dichotomous thinking, catastrophizing and personalisation and after this

session often referred to the fact that she was able to identify and check her

automatic negative thoughts and found

it

helpful as a strategy for monitoring and

checking her anxiety. In this instance I had become an expert in the relationship

but had not directed the therapy, rather I had offered an informative intervention

which the client had chosen to adopt as a helphl strategy.

In the tenth session Mrs

R

developed the theme of disappointment further

through talking of her fathers illness and death. Her father had developed senile

dementia about four years prior to his death and as a result had lost the ability to

care both for himself and, by implication, for her. h4rs

R

had always relied on an

image of her father as strong, capable and independent and had espoused these

qualities herself. She felt both betrayed and abandoned by her father and recognized

that this pattern had repeated itself when her husband became depressed and again

in

Geralds off-time illness.

Mrs R

remarked later that she had found this session difficult, that she had been

upset for days afterwards having re-experienced the trauma of her fathers illness and

its

subsequent impact on her. She had felt angry, seeing me as responsible for this

distress but afterwards had been able to look at photographs and videos of her father

for the first time since the funeral and had regained an image of him as he was rather

than as he had become due to his illness. She then showed me photographs of the

family home and members of her family including her father. Her fear that the

family would deteriorate dissipated as she recounted various events they had

participated in together.

Subsequently Mrs

R

made a number of significant decisions. She decided to

apply for medical retirement on the basis of her injury. She no longer regarded the

injury

as a

loss of ability but as a way of releasing herself from her commitment to

work and the compulsion to provide financial support for the family. She started

attending physiotherapy once she made this decision. Furthermore she decided to

pursue an offer of independent housing, having concluded that she no longer needed

to define herself through her husband and family and recognizing a more congruent

desire for independence.

Mrs

R

expressed anxiety about finishing the counselling at

a

time when she felt vulnerable and in

a

state of transition; it was agreed to extend

the

contract for

a

further eight sessions with the focus on ending this relationship.

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.


9/10

24 Shelley

urney

By acknowledging her losses and experiencing the emotions associated with

them

Mrs

R assimilated feelings of vulnerability and dependence, previously denied,

into her self-concept, thus becoming more congruent with her ideal self and

increasing self-acceptance.

My

conclusion is

t ha t

the continued commitment to

the

person-centred approach was beneficial and reconfirmed for me that:

...

it is the client who knows what hurts, what directions to go, what

problems are crucial, what experiences have been deeply buried ...

Rogers, 1

9

6 1

The counselling processwt 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 appropri-

ate 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 feel-

ings 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)

References

ABEL

MITH

A.

et

al.

1989) Counselling in the medical context, in:

W .

DRYDEN

Ed.)

Handbook

of

BECK, .T. 1976)

Cognitive Therapy and the Emotional Disorders

New York, Penguin).

BLUEGLASS, . 1986 ) Caring for the family, in: B. A. ST OLL Ed.)

Coping With Cancer Stress

BOND,

T.

1993)

Standards and Ethics of Counselling in Action

London, Sage).

BOR,R.,

MILLER,

. GOLDMAN,

.

1 992)

Theory and fiactic e

of

HI V Counselling: A Systemic Approach

CAPIAN, . 1961) An Approach to Com munity Mental Health London, Tavistock).

CLARKE,. T . 1 994) A person-centred approach to stress management, Brizish Journal o Guidance and

HUDSON-ALLEz, . 1994) What the client wants, Counselling N ews 9, pp. 18-19.

MEARNS . THORNE,. 1988) Person-Centred Counselling in Action London, Sage).

MURGATROYD, S. 1985) Counselling and Helping London, M ethuen).

ROLLAM ,

.S.

1991 ) Helping fam ilies with anticipatory

loss,

in:

F.

WAISH

M. MCGOLDRICKEds.)

ROLLAND,.S. 1994) Helping Families Wit h Chronic a nd Life-Threatening Disorders New York, Basic

ROGERS, . 1951) Client Centred Therapy Boston, Houghton M i n ) .

ROGERS, . 1961)

On Becoming A Person

London, Constable).

S ~ O N ,. 1989) The evaluation of counselling: a goal-attainment approach, in: W . DRYDENEd.)

Counselling in Britain

London, TavistocWRoutledge).

Dordrecht, Maninus Nijhoff).

London, Cassell).

Counselling 22, pp. 27-37.

Living Beyond

Loss

New York, W .

W .

Norton Co. .

Books).

Key

Issues jor Counselling in Action London, Sage).


10/10

ounsellingHIV aflected individuals 25

WALSH,F. MCGOLDRICK,. 1991) Living

Beyond

Loss Death in the farnib New York, Norton).

WEINMAN,

.

GOULSTON, .

1991)

The role and development of counselling skills in General

Practice, in: H . DAVIS L.

FALLOWFIELD

Eds.) CounseUing nd Communication in Health Care

Chichester, Wiley).

Documents

Counselling the HIV Affected Individual