RESPONSE TO CHRIS PURNELL'S ARTICLE:AN ATTACHMENT-BASED APPROACH TO WORKING WITH

CLIENTS AFFECTED BY HIV AND AIDS

Jill Brown

I have worked in HIV services during the past decade and for the past five years I have beenrunning a small psychodynamic counselling service for people affected by HIV, AIDS andother life-threatening conditions. I was, therefore, very interested to read Chris Purnell's (1996) paper in which he describes his work with people affected by HIV and AIDS andlooks at the relevance of attachment theory. I agree that Bowlby's ideas about attachmentand the concept of a secure base are very helpful in understanding our clients' earlyattachment figures and how those experiences can be enacted with us. The provision of asecure base seems to me to be essential and fundamental in any kind of therapy which issuccessful in its reliability and its capacity to contain. The crisis of HIV or AIDS mayintensify the need for the secure base for some clients which is perhaps what Purnell isstressing in his paper. I would like to respond to some of Purnell's ideas by indicating thedifficulties and challenges in working with this group and finally by describing my workwith a client at the end of his life.

Purnell describes a number of different approaches which he takes with clients, some ofwhich I think arise from powerful countertransference feelings and perhaps from theprimitive anxieties which are provoked in this work. With some clients Purnell feels heneeds to offer a shoulder to cry on rather than offering counselling because these clientsequate counselling and therapy with problems. Avoiding the problem focus of counsellingor therapy in this way could be a collusion with the client's denial of the pain he or she is in.I am reminded of a paper by Coleman and Etchegoyen (1992) which examines the powerfuleffect on staff of patients in a STD clinic. They noticed that alongside `the patients'insatiable demand for exclusive care' was the defensive denial of severe problems inrelation to dependence and loss. There is throughout Purnell's paper an attempt to be allthings for his clients so that sometimes he is masking his therapy, sometimes he is workingexclusively within the external relationship system of the client, sometimes he is needing tovalidate his client's sadomasochistic relationship (because nobody else does), sometimes heis pursuing his angry and upset client who leaves the session early and, finally, he isattending to the emotional, physical and spiritual needs of his dying client. It sounds andfeels like extremely hard work which is perhaps driven by anxiety and, possibly, by a needto counter the negative transference.

JILL BROWN is the Founder/Director of The Harbour, which provides psychodynamic counselling forpeople affected by HIV, AIDS and other life-threatening conditions. She is a psychodynamic counsellorand a trainee with The Severnside Institute for Psychotherapy. Address for correspondence: TheHarbour, 30 Frogmore Street, Bristol BSI 5NA.

British Journal of Psychotherapy, 13(4), 1997© The author

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Working with people with HIV and AIDS without doubt provokes strong and disturbingfeelings. This group is marginalized, life-threatened, threatening of life, destructive in itsuse of drugs, threatening of heterosexuality in its homosexual majority, contaminated andpotentially contaminating, the focus of public and government attention, and the group inreceipt of specialist services across the country. Within the group some members areperceived as perpetrators and others as victims of HIV infection. Not only might we hate,fear, resent or pity this group, we might also wish to be close to and a part of this `special'and stigmatized group. We might also wish to suggest that there is a particular and differentway to counsel the members of this group rather than the group having its different issuesand individualities. The collective anxiety provoked by this group can perhaps lead to thedrive to overly manage and to behave as if the group required a new model of counselling. Itis not surprising that with the growth of specialist HIV services during the past 15 yearsHIV counselling was born with its own courses and qualifications. Marion Burgner (1994)concludes from her work with HIV patients that the practitioners who take a psychoanalyticapproach need to stay within the analytic framework and that this framework does not haveto be unduly altered for these patients.

The longing to be `special' to this `special' group is within my experience and, likePurnell, with his upset client whom he `phones because if he didn't `it would be the end ofthe contact', I have also worked hard (and anxiously) to `keep' clients. I would suggest thatthe pursuing of clients, as illustrated in this case, apart from being intrusive, is much moreto do with difficulties with the transference/countertransference situation and generalanxieties evoked by this client group. In Purnell's example of the client who leaves thesession prematurely it is not clear what the setting for the work is, and indeed who isleaving whom but what I am struck by is the client's attack on the work and Purnell'sfeelings of guilt and failure. He was unable to wait to see if the client returned because ofhis anxiety about failing his client and losing the contact. This brief example of his workraises the problem of acting on countertransference feelings rather than thinking aboutthem. It also illustrates the powerful impact that clients can have and how we can becomepushed into doing rather than thinking.

The capacity to think and to remain thoughtful with and about the client who is at theend of life can be extremely difficult and is possibly one of the major challenges of thework. Purnell's thoughts about working with the dying client illustrate some of thesedifficulties which can arise in this last stage of the work. He writes about the need for anactive engagement with the client's dying process which means `that as a therapist youbecome drawn into the client's drama with all its hopes, fears, terrors and uncertainties, andin doing so this range of emotions then becomes shared'. For me, the `being drawn in' andsharing the dying experience is the temptation and the notion of being together `sharing asilent moment' can be a substitute for thinking about the client. In the grip of primitiveanxieties about life and death it can be terribly difficult to remain thoughtful about the clientwho is dying. We can find ourselves thought-less and speech-less so that actively attendingto physical and spiritual needs can become a solution to relieve the intense anxiety and thefeelings of helplessness. The writer Bernard Bail has made a passionate plea for us not toforeclose our enquiry into the unconscious with patients at the end of their lives, saying thatthe patient's struggle is eased by truth and that there can be much avoidance of the truth inthe relationship with the dying patient. When interpretations are replaced by comfort,

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gifts and merging, the therapist may be operating under the influence of primitive anxieties.In the dying scenario Purnell refers to overwhelming feelings of helplessness and

unbearable feelings which abound for both client and therapist. In this description thereseems to be a loss of boundary between them and a sense of merging together. I feel that thecrucial task for the counsellor is to contain the anxiety, to remain separate from andemotionally available for the client, a task which is not new or different from before but onewhich may be more difficult to fulfil in the last stage of life. The challenge at this stage ofthe work is to remain thoughtful about the client's inner world and to communicate thosethoughts in an appropriate and helpful way. The translation or interpretation of the anxiety,which is often expressed as fear of death, is an integral part of the containment that thetherapeutic relationship can continue to offer. There is an important distinction to be madebetween death and dying and, as Bail has remarked, while there is nothing to say aboutdeath, it is the process of dying or the last period of living which is of interest to the analyst.

In offering a counselling service to a client group whose immediate future andsometimes present inevitably include serious physical illness and dying, we have to be ableto transport the therapeutic relationship into other settings including hospital, home andhospice. The change of setting from counselling room to hospital ward or bedroom can be atricky business. Boundaries change and weaken. Negotiating privacy and uninterrupted timefor the sessions with hospital staff, family members and others requires diplomacy and tact,and success is not always achieved.

As an illustration of some the points raised I would like to refer briefly to my work witha man with haemophilia and AIDS during the last months of his life. He had been seeingme over a period of five years, the sessions having taken place in the counsellingorganization where I work. He spent the last four months of his life in hospital where hedied. He wanted our sessions to continue during the last stage of his life which required thatboth he and I negotiated some regular private time in the hospital. At the beginning he wasvery successful in finding us this time but, as he became more ill and more anxious, theboundaries around our relationship began to crumble and it was often impossible for us tohave any privacy at all. The breakdown of boundaries, I believe, related to the intensity ofhis anxiety and its effect on others. Much of his childhood had been spent in hospital due tothe haemophilia and his predominant childhood experience was one of being left inphysical and emotional pain. His parents' visits felt like a continual abandonment of him ashe felt they were unable to listen to or contain his pain when they were there, and then theyleft him alone and in pain. He felt himself to be a victim twice over: firstly, a victim of hismother's contamination of him with haemophilia and, secondly, a victim of the HealthServices who gave him blood products contaminated with HIV infection. He was deeplydisappointed and often felt bitter and envious towards those of us who had a future and whowere not infected. Equally he had a love of life and a profound desire and hope that lifewould improve particularly in the arena of relationships. I think he did succeed indeepening some of his relationships and he certainly had some of the longed-forconversations with his mother before he died. However, what I want to focus on here is theissue of fear of death and infantile anxiety and how we respond as counsellors to the fear ofour dying client.

As his illness progressed his anxiety became more intense and difficult to hold. Hiswish, during these last months in hospital, was not to be left alone. He succeeded in

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recruiting a multidisciplinary team including nursing staff, friends, parents, spiritual healersand various carers who between them provided him with 24-hour cover so that he did nothave to experience aloneness. So great was his fear that he could not sleep since sleepingwas too much like dying and, if he slept, he risked being left. His team felt his and its ownanxiety and believed that he was not to be left. Some people spent long hours in the hospitaland his parents virtually lived there for the last months of their son's life. The team's taskwas not to abandon him to a lonely death and to provide him with comfort, support andreassurance. My job as his counsellor was different, which I will illustrate by referring to apart of one session which took place in hospital in this atmosphere of terror and high anxietyand lack of sleep. He spoke again of his fear of death and I asked him to describe what hethought it would be like after death. He thought it would be like being eternally conscious ofbeing unconscious, or like being forever conscious of being dead which was a state of beingin pain and alone. I said that I thought that what he feared in death had already happened inhis childhood. I said that we do not know what happens after death but that, from what weknew about his life, I thought that his fears about death came from his childhood experienceof being left in pain and from the infantile fantasy that at end of each visit his parents wereleaving him to die alone. Being in hospital again, ill and in pain and this time really dying,provoked the infantile terror to an unbearable degree so that a minute of aloneness could notbe tolerated. Each person who left his room had to be immediately replaced by another inorder to avoid the pain of separation. I said that my leaving him felt cruel and abandoning ashad the visits in the hospitals of childhood. We spoke of other aspects of his experience inthis session but the crucial part was the translation of his terror. It is important to stress herethat these interpretations of his fear of death were not new in our work. During the fiveyears there had been considerable exploration of his anxieties about illness and death. Whatwas different at this stage was that he was now dying and therefore the interpretations wereparticularly poignant. I left the hospital not knowing whether he had taken in my thoughtsand wondering if there would be another session. I saw him once more for a short periodduring which we said goodbye and he told me that he had slept for 16 hours after theprevious session. He died not long after.

Acknowledgements

I would like to thank Kim Hastings and Mike Snudden (counsellors with The Harbour) fortheir helpful comments in the writing of this response.

References

Burgner, M. (1994) Working with the HIV patient: a psychoanalytic approach. In PsychoanalyticPsychotherapy 8(3): 201-13.

Coleman, R. & Etchegoyen, A. (1992) The psychodynamics of the STD clinic: secrecy, splitting andisolation. In British Journal of Medical Psychology 65: 319-26.

Holmes, J. (1994) The clinical implications of attachment theory. In British Journal of Psychotherapy11(1): 62-76.

Purnell, C. (1996) An attachment-based approach to working with clients affected by HIV and AIDS.In British Journal of Psychotherapy 12(4): 521-31.