You have been working at an addiction placement with a client for the last 4 months who is a heroin addict. This client injects in order to take their daily dose of the drug. You know that they share needles with their girlfriend and others. Your client comes back to session from a midweek doctors appointment to discover that they have contracted H.I.V. but they tell you in the session, seemingly nonplussed that they will continue to share needles with their girlfriend and others and “just wont tell anyone”. How do you address this situation?

Suzie Chick (Psychotherapist) Says:

“This for me raises several issues which need immediate consideration:

• Firstly in session I’d want to explore what’s behind my client’s nonplussed response. I am assuming this might be a defence to avoid the reality of the diagnosis. As therapist I will gently but firmly act as a reality check for my client. My initial thought is by keeping their H.I.V a secret it’s a way of pretending it hasn’t happened. So hopefully by giving this issue space in session, the reality might finally hit. It might be useful for me to name my own personal reaction, e.g. shock and worry, for the client to respond to.
• I’d also want to remind my client about our agreed contract (assuming there would be one from the start) and the point around confidentiality. I’d especially highlight my duty to act if I believed my client or others were at risk of being harmed. With my client’s H.I.V and their intention to not inform others with whom he shares needles with, there is an absolute risk of others, such as his girlfriend, contracting H.I.V also. I would tell my client that I would need to consult with my supervisor/ the clinical manager of the placement to decide how/if confidentiality needs to be breached.
• My hope is by naming the possibility that I may need to break confidentiality; my client might feel compelled to own their reality and their responsibility, which comes with such a diagnosis. If nothing else it will certainly cause a debate and some tension in session as I come into direct conflict with my client. This may help shed further light on the client’s casual attitude towards their diagnosis.
• After session, I would immediately raise this issue with the clinical manager of the placement and my supervisor so I can clarify how best to proceed on an ethical basis.

Nick Opyrchal (Psychotherapist) says:

For me, like Suzie I would be wondering about how much denial (as a form of defence) would factor in to the decision by the client to not inform the their partner, as well as the nonplussed attitude around sharing injecting materials. I wonder if the dismissal of the risk to the clients partner could be a way of dismissing the emotions around the situation that the client finds themselves in. It may be a way of treating the experience as ‘nothing to worry about’ and therefore bypassing coming to terms with it.

I also wonder about the fact that it is the clients girlfriend that they are attempting to conceal their diagnosis from. How much does stigma and shame play into this decision? How worried is the client about how the diagnosis might affect their sex life and sexual relationship with their girlfriend. Are they afraid of being abandoned? Is it shame as much as denial which is preventing them from being open around it? 

Whilst these are issues that I would need to discuss with the client, I would also have to inform them that knowingly infecting other people with HIV would be considered a criminal offence and would therefore put us outside of the boundaries of therapeutic confidentiality, and that I would be legally obliged to talk to an authority if they were to do this. I would hope that I could get them to re-contract with me around this: that they would not share needles and would also have protected sex whilst we worked together on the psychological material which had emerged around the diagnosis, hopefully getting them to a point where they could talk about their issue with their girlfriend. I would be very aware of the potential to trigger further shame by the mentioning of the potential legal issues, as I would not want them to feel that their diagnosis made them into a criminal as a result. This may be playing out through the countertransference otherwise. 

Next Issues Dilemma – The Racist

You have been working with a client for a month when they come in furious that they have had a difficult encounter with a particular ethnicity on their way to their session with you. This encounter acts as a means of opening up material and they engage in an hour long diatribe laden with racial slurs around this particular ethnic group, including wishes of genocide. You sit there uncomfortably in the knowledge that you have been dating someone from this ethnic group for the last year. Your client obviously believes that you share their beliefs around race and makes this clear in session. How do you cope with this situation?