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Counselling Psychology Quarterly

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Counselling the HIV affected individual: A case study

Shelley Gurney

Department 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 Psychology
Quarterly, 8:1, 17-25
To link to this article: http://dx.doi.org/10.1080/09515079508258693

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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 University, Northampton Square, London EC1 V

OHB,

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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.

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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 counselling 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 problems (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 emotions and her G P 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 by her children and
therefore without a role and a future. She was also anxious about the effect that
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

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.

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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 development 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 independence, and the self-imposed loss of the family home. Again she expressed despondency 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 established 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

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20

Shelley Gurney

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 that they only offered financial
help to people infected with HIV 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 (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

Counselling HZV affected individuals 2 1

& 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 (Murgatroyd, 1985).

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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.

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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-

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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.

24

Shelley Gurney

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 that the continued commitment to the
person-centred approach was beneficial and reconfirmed for me that:

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... 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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