From certain perspectives, it seems relatively easy to talk about HIV/AIDS. It seems in some way that we could understand a lot about HIV as a virus, and about AIDS as its physical, biological consequence. And with only a little larger stretch of the imagination, it seems that we could talk about AIDS from a strictly social perspective: HIV has produced a plague. The working of a plague on a community also seems to be a relatively discrete social question for study. But clinical psychology of HIV/AIDS can in no way pretend to be studied independent of both of these dimensions. This Borromean linkage, the one that governs this web site, is especially important for understanding the psychological dimensions of HIV/AIDS. It would be preferable if the social work reader would come to this page after having read the biological and the sociological perspectives.
Aside from helping the client
to a realistic personal plan of action in regard to HIV/AIDS, assessment
provides an important opportunity for educating clients about the HIV virus.
This presumes that the clinician has taken the trouble to inform herself
about what the HIV virus is and how it is transmitted. There are many sources
for such information. It is imperative that the clinician consults such
a source periodically in order to keep up-to-date. Moreover, the clinician
must be willing to pursue these topics without prudery. We may hope that
everyone understands the general rudiments: unprotected sex and intravenous
drug use are the most likely forms of transmission. The clinician should
not stop with this outline for prevention. She must be able to address
the varieties and ingredients of sexual contact and risk (vaginal intercourse,
anal intercourse, oral sex, condoms, dental dams, rimming, etc.) She must
also be able to address the simple, cheap and effective forms of needle
cleaning. It may seem ideal to dissuade clients from using needles or having
multiple sex partners, but in light of the dire consequences of HIV infection,
and the realities of sexual desire and addiction, the clinician must be
able to recommend strategies of harm reduction.
One of the many other faces of denial that has been directed at the disease has been the unwillingness to be tested. Although a reliable test has been available since the mid-1980’s, with more exact tests being developed since, many have in fact avoided being tested. From a social perspective, for the sake of preventing further transmission it may always have made sense to encourage clients to take stock of their HIV risk and to test for it if appropriate. But in those days, when an AIDS diagnosis carried with it little prospect for hope and much danger of ostracism, some clients may understandably have preferred not to have their HIV status confirmed. If the client was willing to live "as if," perhaps then it was ethically acceptable for the clinician to limit herself somewhat to educating the client on prevention. Given the growth of treatment options this is no longer true. Because timing and compliance are so crucial for successful treatment by combination therapies, the clinician must pursue the assessment of risk and encourage testing. Anonymous testing centers are available in almost every geographic locality in the United States. Learn where yours are.
HIV/AIDS is a chronic and life-threatening illness. Adjusting to the
illness is a life-long process. It seems unnecessarily pathologizing to
see news of HIV/AIDS as inevitably producing this diagnosis, but something
like an adjustment disorder must be anticipated almost always. After testing
seropositive, individuals must address a number of issues common to those
suffering from a chronic, life-threatening illness. How shall one live
the “rest” of a life? How shall one pay staggering medical expenses? What
shall one do in the face of the likelihood of death. Moreover, the discovery
of infection precipitates many of the emotional dilemmas described for
such illnesses. Shock, anger, denial, guilt and anxiety are just some of
the emotions one must expect. However there are also a number of questions
specific to this particular illness: Shall one disclose one’s serostatus
to others? How shall one face the immediate and practical worries of stigmatization,
e.g. the possible abandonment of social circle, the possible loss of work?
Consequently, although the high rates of attempted suicide upon discovery
of seroconversion -- predicted earlier in the history of the disease --
have not developed, adjustment to HIV/AIDS is never easy. Persons who are
young, undereducated, unemployed, make heavy use of avoidance coping, or
perceive themselves as having a low level of social support are particularly
The most prevalent other clinical conditions associated with HIV infection from a mental health perspective are anxiety syndromes, mood disorders, psychotic disorders and substance use disorders. Studies show that each of these enters the HIV/AIDS picture in different ways.
As one would expect, studies have shown that, among seropositive individuals,
there is a higher rate of that anxiety described by the DSM-IV as Generalized
In fact studies have also shown that more than 40% of both seronegative and seropositive homosexual men report episodes of clinical anxiety lasting from one to several months, with the majority of onsets being related to seroconversions or commencing after the advent of the AIDS pandemic. In other words, it has been suggested that the very existence of HIV/AIDS is responsible for a significant rise in prevalence rates for clinically diagnosable persistent anxiety.
Remarkably, a number of studies have shown that the rates of other major anxiety disorders (panic disorder, obsessive compulsive disorder) do not appear to be markedly above community standards in HIV seropositive individuals, even though HIV can be the manifest content of these conditions.
In its clinical dimensions, there is a significant decrease in anxiety reported with both psychotherapy and psychopharmacology.
Most substance use disorders among seropositive individuals commence
long before infection. Nevertheless it is even more significant that
these disorders are addressed in people with HIV where it may lead to noncompliance
with medical regimens. The common forms of combination therapy involve
complex regimens, with special dietary and timing constraints. It
is encouraging to note that the stress of HIV/AIDS does not appear to increase
rates of developing a substance use disorder. In fact, for many the
discovery of seroconversion brings about a healthier lifestyle.
With regard to the seronegative community, it is important to note that drugs and alcohol may also impair judgment, lead to impulsive behavior, or otherwise increase the risk of HIV acquisition and transmission. That means it is important for the clinician to understand the risks of HIV infection when treating persons with substance use disorders. Special emphasis must be placed on the direct role of shared needles in the spread of HIV/AIDS. (See the Biology page.)
HIV-Associated Dementia (HAD), a.k.a. AIDS-Related Dementia (ARD)
HIV can cross the blood-brain barrier and enter the central nervous system through virus-infected macrophages. Hence a significant proportion of HIV-infected persons will develop this neurologically based cognitive disorder. For some that will entail subtle impairments in cognitive function (attention deficits, slower processing of information.) Less commonly, and specifically with frank AIDS, some will develop more pronounced cognitive deficits (including linguistic disturbances and psychomotor slowing.) Some patients with this dementia become severely withdrawn and uncommunicative. Occasionally, this dementia progresses to psychosis and delirium. Since the advent of early treatment of AZT, an antiviral which apparently succeeds in crossing the blood-brain barrier, there has been a significant decrease in this most extreme form of ARD. Milder forms of HAD can be ameliorated by compensatory skills training. Anecdotally, central nervous stimulants such as Ritalin can be helpful. It is important for clinicians to work closely with psychiatrists to coordinate care.
Care for persons with a catastrophic illness such as HIV/AIDS carries a lot of potential for overwhelming a caregiver. Of course, social workers and the like are trained in helping others cope. But in the case of a disease such as AIDS, morally and mortally charged, there are some obvious countertransferential traps looming.
Therapists, like most others, may harbor unexamined fears of being exposed to HIV and contracting AIDS. They may also harbor unexamined prejudices against the populations that, for the moment, represent the typical affected individuals. But, more subtle issues will certainly trouble even the fearless and unprejudiced. Caregivers may experience discomfort with the patient’s sense of anguish or helplessness. Or they may have difficulty addressing issues of death and dying directly with the patient. Some may experience concern over the use of “unauthorized” drugs, such as marijuana, which seems to provide so many from relief from the nausea common to combination therapy.
In general, one can anticipate that there will be a tendency for the therapist to create distance from the patient because of the discomfort of facing the potential loss of the person through death or serious illness.