Journal of Social Development in Africa (1995), 10,2,35-52 
CRISIS AS CHALLENGE: 
COUNSELLING COUNSELLORS, 
PERSONS LIVING WITH HIV/AIDS 
AND SURVIVORS 
MICHELLE L CROWLEY * 
ABSTRACT 
The following paper focuses upon the crises and challenge facing all South 
Africans as the AIDS pandemic escalates. It briefly discusses the broader implications 
of the pandemic for the economic and social well-being of the South African 
population at large, and then attends to issues associated with the counselling of 
persons living with HIV, the counselling of counsellors and the counselling of the 
survivors of families and groups affected by AlDS-related deaths. 
The paper first distinguishes between reality-based concerns and transference 
responses for persons with HIV, and suggests that counselling these persons is supportive 
rather than dynamic in its focus. Thereafter various countertransference 
responses are identified. The paper suggests that counsellors will themselves 
require counselling and support if their continued involvement in the counselling 
and care of persons with HIV is to be assured. Finally, the possibility of large scale 
delayed and complicated grief reactions among the population at large, as a result 
of multiple and continuous losses of friends and family to AIDS-related deaths, is 
addressed. 
The paper evaluates possible intervention strategies for dealing with the 
pandemic and argues that while education programmes are laudable, more emphasis 
will need to be placed upon dealing with the crisis at hand. The training of 
counsellors and caregivers, as well as bereavement counselling of the population 
at large will thus need to take priority. The paper concludes that while AIDS is a 
devastating and tragic pandemic that will affect all levels of our society, the 
pandemic also offers an opportunity to rebuild and reintegrate South Africa's 
shattered 'community of communities'. 
* Lecturer & Clinical Psychologist, Rhodes University, Grahamstown, South 
Africa
36 Michelle Crowley 
Introduction 
AIDS, or the acquired immune deficiency syndrome, was first formally diagnosed 
in the United States of America in 1979 (D'Anzi, 1987). While in developed 
countries most infected persons apparently remain homosexually active men, 
intravenous drug abusers, and/or the recipients of contaminated blood products 
(Gong, 1985; Cochran & Mays, 1989), incidence of the disease has been reported 
worldwide and is manifest pandemically in both males and females in central 
(Biggar, 1986) and southern Africa. 
On a local level, Department of Health statistics (Jackson, 1994) suggest that 
HIV-infection cases in South Africa are doubling every 11 to 13 months, with 95 
per cent of new infections being heterosexually transmitted. These estimates, 
based on blood tests of pregnant women and extrapolated to the population at large 
for the age group 15 to 40 (and allowing for a 30 per cent lower infection rate for 
men) suggests that there were 550,000 economically active HI V-positive persons 
in November 1993. Allowing for a conservative doubling period of 15 months, the 
figure for the end of 1994 is estimated to be between 850,000 and one million 
persons. In view of these statistics, AIDS can no longer be termed a 'gay plague'; 
rather, it must be viewed as abehaviourally transmitted disease (Cochran & Mays, 
1989) that resists safe sex education initiatives (Odets, 1993). 
The following paper focuses upon the crisis and challenge facing all South 
Africans as the pandemic escalates. It discusses the issues pertaining to the 
counselling of HIV-positive persons, the counselling of counsellors, and the 
counselling of the survivors of families and groups affected by AIDS-related 
deaths. It argues that while AIDS is a devastating pandemic that will affect all 
levels of our society, like the Chinese symbol for crisis, it also offers an opportunity 
and challenge - to care for our bodies, to care for others and to face the inevitability 
of our human mortality with dignity rather than fear and denial. 
Prevalence and Controversies of Cause: Implications 
On an individual level, no person has been known to recover fully from H1Vlnfection 
(Dunkel & Hatfield, 1986), and the vast majority of persons (as much as 
^r °ent^ ^ w i t h i n s e v e n t0 t e n v e a r s ^tet contracting the virus (Jackson, s e v e n t0 t e n v e a r s ^tet c o t a c t g the virus (Jackson, 
. In other words d , infection is almost always fatal, although there are a number 
ot long-term survivors. 
The transmission of HIV, however, remains something of a mystery despite 
medical advances. Medical researchers such as Deusberg (cited in Guccione, 
'and Root-Bernstein (1993) continue to challenge every single theory about
Crisis as Challenge: HIV/AIDS & Counselling 37 
how AIDS is caused and how it should be treated. As Dunkel & Hatfield 
(1986:114) suggest: 
"...the underlying cause of the disorder has not been determined nor which 
riskfactors are causative andwhichare contributory.. Researchers suspect 
that it is a transmissible agent., .and suggest that the viral infection is spread 
through sexual contact andbloodcontact andby vertical transmissionfrom 
infected mothers in utero or during delivery. Currently, no evidence 
indicates that AIDS is spread by any other method" (emphasis added). 
Moreover, these and other authors in the field (Evian, cited in Jackson, 1994; Isaacs 
& McKendrick, 1993; Hays, 1984) propose several co-factors that either create the 
conditions under which HIV becomes activated, or determine a person's 
susceptibility to the virus. These co-factors include: poor nutrition; substance 
abuse; low levels of self-esteem due to social marginalisation, dislocation and 
oppression; excessive levels of stress; and, difficulties with integrating a healthy 
attitude towards the body, particularly in the area of sexuality. 
The disease does not discriminate on the basis of social class and/or group 
affiliation, but does appear to affect the sexually active, and therefore potentially 
economically active, sections of the population. The AIDS pandemic therefore has 
economic implications and AIDS-related deaths will directly and indirectly affect 
the availability of both physical and mental health resources. Directly because 
several million infected persons will fill hospital beds while a vast number will 
require out-patient care. Indirectly because the budget for health services comes 
from taxable earnings. Moreover, in South Africa Kaposi's Sarcoma is less 
common than AIDS-related Tuberculosis and neurological deterioration, such as 
Delirium and Dementia. The latter are associated with cognitive, behavioural and 
motor symptoms (Dilley & Boccellari, 1989). This will have direct implications for 
underdeveloped mental health services. 
HIV infection also appears to be more prevalent among socially marginalised 
people. Cochran & Mays (1989) note that women at highest risk for HIV infection 
in the USA are among the least advantaged groups in society: poor, urban ethnic 
minority women. Closer to home, Evian (cited in Jackson, 1994), an AIDS health 
careconsultant, suggests that AIDS reflects the disparities in South African society 
in so much as those people who are dislocated in their society or community life 
are at higher risk. This would include communities in a state of transition such as 
informal settlements, migrants working away from home in unfavourable circumstances, 
and/or communities which are ravaged by violence and upheaval. 
While in the USA the vast proportion of persons living with the virus are 
homosexual men and/or drug abusers, in Africa HIV is for the most part heterosexually 
transmitted. Given that the receptive partner is thirty percent more
38 Michelle Crowley 
vulnerable to infection (Jackson, 1994) women in South Africa will make up the 
larger proportion of persons with the virus. The AIDS pandemic therefore has 
profound social implications, in so much as the children of women in this situation 
stand a chance of themselves being infected. More mothers with HIV thus means 
more children infected by the virus, most of whom will not live beyond childhood 
and many of whom will themselves be abandoned. 
Counselling the HIV-Positive Person 
Essentially HTV/AIDS counselling aims to support rather than transform the 
person living with the virus - it focuses upon the restoration of functioning to preexisting 
levels of comfort rather than personality growth and change (Tartaglia, 
1989). The latter, if it occurs, is regarded as a bonus rather than the focus of 
counselling. Counselling persons with HTV therefore aims to address the here and 
now rather than upon linking past issues with the present Given this supportive 
rather than dynamic focus, it is critically important to distinguish between normal 
or spontaneous responses to a positive diagnosis and various transference issues 
evident in the relationship between counsellor and person with the virus. The 
former constitute reality-based concerns such as internal pressure to attend to 
unfinished business, reconciliation with alienated others; holding onto existing 
relationships, issues of self-esteem and identity, finding purpose and meaning in 
day-to-day activities, and where appropriate, preserving a sense of personal 
control. 
Transference issues, on the other hand, whilst no less significant, reflect issues 
and expectations which have been displaced from a past source and are projected 
onto the present relationship. The immediacy of these "infantile prototypes" 
(Lapalanche & Pontalis, 1973) constitute the focus of more dynamic therapies. 
Thus, whilst transference issues certainly affect the level of empathy available in 
any helping relationship, they are not the focus of interaction between counsellor 
and person living with the virus and are important only in so far as they affect the 
counsellor's willingness to be available as a support for the person with HTV. 
Reality Based Responses to HIV Infection 
AIDS is not only physically devastating - it is also emotionally and psychologically 
devastating. The person diagnosed HIV-positive experiences painful emotions 
associated with an acute existential crisis in the face of his/her death sentence, 
the possibility of new medical problems and continued dehabilitating illness and 
social isolation through multiple losses (Dilley & Boccellari, 1989). These 
responses can be considered normal responses to the threat of impending death
Crisis as Challenge: HIV/AIDS & Counselling 39 
(Jackson, 1988) and the stigma associated with a sexually transmitted disease 
(Tartaglia, 1989). 
Anxiety disorders are most frequently encountered among the uninfected at 
high risk (Goldblum & Moulton, 1989), but are relatively uncommon (Bialer, 
Wallack & Snyder, 1991), or virtually non-existent (Williams, Rabkin & Remien, 
1991) among the infected. Where anxiety is manifest it tends to be a symptom of 
other psychiatric disorders (Bialer, et al, 1991), such as adjustment disorder with 
mixed emotional features (D'Anzi, 1987). The most common psychiatric disorders 
are mood disorders, particularly depression (D'Anzi, 1987; Tartaglia, 1989; 
Bialer, etal, 1991;Baker, 1993). This may range from a transient sadness to a fullblown 
major depression. Clinical depression can be induced in a number of ways. 
Firstly, it may be brought about directly by HIV infection or other viral/bacterial 
infections of the central nervous system, by tumours or strokes, or by abnormal 
functioning of the thyroid or adrenal glands (Baker, 1993). Where the central 
nervous system has been affected, the early stages would therefore include the 
classical signs and symptoms of depression and would progress to more neurologically 
malignant signs, such as mental disorientation, seizures, mutism, dementia 
and coma (D'Anzi, 1987; Dilley & Boccellari, 1989). Secondly, medical treatments 
with immune modulating agents can cause depression and sometimes mania 
(Baker, 1993) thus further exacerbating the existing organic mood disorder, while 
chronic and persistent use of recreational and escapist drugs may serve the same 
function. 
Finally, there are a number of situational factors that compound a patient's 
existing mood disorder: the experience of living with a life-threatening disease; the 
stigma associated with HIV infection; theheartacheofwatchingfriends and family 
become ill and die; the torment of losing physical strength, memory, financial and 
vocational capability; and, increasing dependence on others as the illness progresses. 
The person with HIV's experience of loss is therefore realistic on a wide variety 
of levels (D'Anzi, 1987; Jackson, 1988; Silven & Cardarola, 1989). There is the 
loss of a possible future in terms of establishing social support networks and an 
intimate relationship and/or family, as well as the loss associated with deteriorating 
physical and mental well-being. The person may also fear the loss of confidentiality, 
anonymity and privacy; and because AIDS is not well understoodhe/she may 
feel somewhat like a bug under a microscope, as being of value only as the object 
of medical and laboratory interest (D'Anzi, 1987). As such, aloss of human dignity 
is implied. In addition, the stigma associated with the disease is associated with a 
loss of self-esteem, while the person also suffers, like the uninfected, from the 
social and psychological ramifications of continual loss as friends, family and 
lovers succumb to the disease.
40 Michelle Crowley 
Persons receiving a positive diagnosis may experience all sorts of fears 
concerning disease, such as thepossibility of disablementanddisfigurement. Fears 
of death, the unknown, blame, stigmatisation, social isolation, rejection, financial 
difficulties, leaving dependents unprovided for and being unable to cope (D'Anzi, 
1987) may also be experienced. Apprehension may accompany attempts to 
monitor the course of infection and status of the antibody and immune function 
(Tartaglia, 1989). Fear of becoming dependent upon others may also become an 
issue, since recurrent secondary infections leave the person with HIV/AIDS weak 
and eventually bedridden, and towards the end, often incontinent Moreover, as the 
disease progresses the person becomes about as helpless as a new-born infant 
While Aorki (1989) draws attention to cultural differences with respect to the need 
for autonomy, increased dependency is experienced as exceedingly difficult for 
those persons living with the virus who value their sense of independence and selfsufficiency. 
Some persons may experience acute guilt at having contracted a sexually 
transmitted disease, perhaps from an extra-marital relationship. Guilt may also 
arise where the person thinks he/she may have inadvertently infected others, such 
asprevious sexual partners and/orfamily members (D'Anzi, 1987; Jackson, 1988). 
Guilt may also be fed by pre-existing shame and guilt concerning sexuality 
(Tartaglia, 1989) and may be associated with attempts to withdraw from others 
and/or remain silent about infection. 
Given the controversy surrounding HIV infection, many persons may also 
experience a great deal of confusion and uncertainty about what this means, while 
misunderstandings concerning the Western disease concept (Zazayokwe, undated) 
may exacerbate the existing confusion and uncertainty. 
Finally, many persons infected by the virus may feel angry with themselves and/ 
or various authorities, be they real or more mystical. Sometimes the anger will be 
redirected toward whomever is immediately available, thus constituting a transference 
reaction with respect to the caregiver or counsellor. At other times, the anger 
will be acted out on a personal or social level, such as rational suicide or when the 
person with HIV deliberately infects other people. 
Whilst the list of possible responses above has focused on more negative and 
rehabilitating emotional and feeling states, there may also be an initial relief of 
anxiety when HIV infection is positively diagnosed when since previously inexplicable 
illnesses are clarified (Tartaglia, 1989). 
Transference Issues Associated with HIV Infection 
Tartaglia (1989, p. 172) observes that:
Crisis as Challenge: HP/IAIDS & Counselling 41 
"Patients with life-threatening diagnoses are subject to a powerful regressive 
force which will tend, at times, to make them regard themselves as 
childlike and often to behave accordingly". 
Tartaglia thus warns that persons with HIV are subject to strong transference responses. 
These responses present a problem in so much as they jeopardise the 
counsellor's ability and willingness to offer support as well as increase die chances 
that the counsellor will collude with these regressive and infantile responses. 
The success of a therapeutic relationship is based upon trust, upon the establishment 
of a working alliance between the person with HIV and the counsellor. Due 
to previous unsuccessful involvement in the mental health system (Goldblum & 
Moulton, 1989) and an innate distrust of (Tartaglia, 1989) and refusal to put 
themselves at the establishment's mercy (Aorki, 1989), the socially marginalised 
person may experience difficulty misting members of the establishment, such as 
mental health professionals. 
Persons living with the virus may direct their anger at the counsellor, not only 
due to immediate frustrations, but also due to years of feeling oppressed for their 
cultural and/or class difference (Aorki, 1989), because the counsellor does not 
possess a magic cure (D'Anzi,1987), and/or because the counsellor is not him/ 
herself HIV-positive. The person may also direct anger against him/herself, such 
as in the instance of rational suicide (Jones & Dilley, 1993; Beckett & Shenson, 
1993), at parents and friends for their detachment, distancing and lack of responsiveness 
(Silven & Cardarola, 1989), and at God for allowing the illness to occur 
(D'Anzi, 1987). Anger may also be directed toward the person who presumably 
infected him/her (Jackson, 1988). 
On a more ideological level, Western society perpetuates the belief that bad 
things happen to bad people - that illness is a retribution for past transgressions 
(D'Anzi, 1987). Persons with HIV are thus often plagued by a sense of innate 
badness, of being contaminated and dirty - they internalise and appropriate the 
belief that they have got what they deserved (Silven & Cardarola, 1989) and this 
belief feeds both the person's anger at him/herself and his/her growing sense of 
isolation from others. 
The sense of isolation is further exacerbated when persons who were previously 
available to support others with HTV/AIDS begin to distance themselves in preparation 
for the inevitable loss of life. This may lead to feelings of loneliness, 
expendability and rejection on the part of the person with HIV/AIDS (D'Anzi, 
1987; Silven & Cardarola, 1989). Basic routines for infection control such as 
gloves further exacerbate the person's sense of isolation because the comfort of 
human touch and connection is lost (D'Anzi, 1987). While Shaw (1989) emphasises 
the importance of professional and personal boundaries when reaching out to
42 Michelle Crowley 
persons with HIV/AIDS, Tartaglia (1989) draws attention to the value of touch 
when contamination beliefs are present He warns, however, that the reaching out 
should be neither patronising nor infantalising if the counsellor is not to collude 
with transference phenomena. 
While fears of helplessness and dependence are realistic given the dehabilitating 
course of the disease, and should not be underestimated, Aorki (1989) also suggests 
that the intensity of such fears are culturally specific. Oriental and African cultures 
would seem to foster a sense of connection to the community, whereas in Western 
cultures individualism and independence are valued. For persons with HIV/AIDS 
who have been socialised according to Western values their sense of autonomy and 
independence is challenged as their physical and mental status deteriorates. 
Finally, knowledge provides people with asense of control (D'Anzi, 1987). For 
the person living with the virus, however, this belief and desire is challenged as a 
result of the many unknowns about AIDS, including the cause, the length of time 
still available to finish unfinished business and the possibility of a cure. 
Counselling Counsellors 
Tartaglia's (1989) suggestion that counsellors should not get caught up in the 
transference issues of persons with HIV/AIDS provides the grounds for a discussion 
of countertransference responses, since awareness of such enables the counsellor 
to avoid feeding the patient's feelings of distrust and anger towards others, 
as well as his/her sense of internalised inferiority. 
Countertransference, as an unconscious process involving a counsellor's unresolved 
conflicts in relation to his/her client, was first identified by Freud who 
viewed these feelings as an impediment to the treatment process. Heimann (1950) 
later reinterpreted countertransference to include all feelings experienced by the 
counsellor toward the client, and like Beitman (1983), viewed these feelings as 
useful for accessing the counsellor's unconscious complexes, for making diagnoses 
and for establishing intervention strategies. 
For the purposes of this paper, Dunkel & Hatfield's (1986:115) definition of 
countertransference will be adopted. In other words, countertransference refers to: 
"...those conscious.preconscious, andunconsciousresponsesandfeelings 
of the (counsellor) that can be both a problem (with respect to establishing 
an empathic relationship with the infected person) and a valuable therapeutic 
and diagnostic tool." 
This definition suggests that the counsellor's capacity and willingness to understand 
and work through his/her own responses to the infected person's transference 
responses offers improved care to the infected person, as well as personal and 
professional development for the counsellor
Crisis as Challenge: HIV/AIDS & Counselling 43 
A variety of emotional issues may cloud a counsellor's judgment In the first 
instance, the counsellor may suffer from a wide variety of fears. Perhaps most 
difficult to deal with is his/her fear of death and dying which increases in the 
presence of persons with HIV/AIDS (D'Anzi, 1989; Dunkel & Hatfield, 1986), as 
if death too might be contagious. Working with a dying patient therefore challenges 
the counsellor's own unresolved feelings with respect to his/her mortality. 
Acriticalrequirementforworkingwith those livingwith HIV/AIDS is the counsellor's 
availability, reliability, empathy and ability to respond emotionally to the 
person (Tartaglia, 1989). The counsellor, in his/her attempt to preserve and protect 
him/herself from experiencing the pain of loss or death of another may attempt to 
distance him/herself from the person. On a psychological level, this blocks the 
possibility for empathy, since the counsellor fails to acknowledge that this illness 
involves a major psychological and emotional component. On a physical level, the 
superficial social conventions of greeting and exchanging pleasantries is allowed, 
but without the substantive confirming human touch. The counsellor's need to 
psychologically and physically distance him/herself from the person with HIV/ 
AIDS can thus result in the counsellor denying the personhood of the individual 
and the person reducing the number of contacts with the counsellor. 
In the second instance, medical science places a high priority on beating death 
(D'Anzi, 1987; Chopra, 1991). While this may be helpful for instilling hope in an 
effort to treat the syndrome, the counsellor's denial of his/her fundamental 
helplessness often engenders a situation in which he/she tries to gain control of the 
situation through a magical belief in his/her own omnipotence. When this fails, ie 
the person succumbs to the disease, the counsellor may experience a sense of 
helplessness, personal failure and guilt (Shaw, 1989), and ultimately refuse to treat 
those who are HIV-infected. 
Anger and frustration may also be experienced by the counsellor when despite 
his/her best intentions the person's condition continues to deteriorate (D'Anzi, 
1989), as it inevitably will. In order to defend against these feelings the counsellor 
may attempt to blame the victim (Dunkel & Hatfield, 1986; Shaw, 1989) in an 
unconscious attempt to punish the person with AIDS. Blaming the victim, when 
combined with unconscious hostility and a fear of contagion, may also take the 
form of distancing, either physically or psychologically, and thus further exacerbate 
the person's sense of isolation. 
A great deal of uncertainty exists with respect to the course and treatment of the 
disease. At the same time, the medical practitioner is expected to make major 
medical decisions. For instance, does he/she treat with AZT when AZT itself 
suppresses the immune system? Does he/she put a profoundly depressed person on 
a full therapeutic dose of anti-depressant medication while simultaneously attempting 
to monitor the person's mental status? Uncertainty about the disease thus
44 Michelle Crowley 
also exacerbates the practioner's fears of professional inadequacy (Shaw, 1989). 
Moreover, theperson with HIV/AIDS may also very often know more about AIDS 
than does the counsellor. This may threaten the power base of the relationship 
between counsellor and person, since it further challenges the counsellor's claim 
to professional adequacy. Treating persons with HIV/AIDS thus demands a willingness 
to learn from and share information with them, and thus develop a relationship 
of mutuality rather than power, since AIDS is an incurable illness and cannot 
be beaten. The emphasis in counselling thus rests upon exploring the meaning of 
the symptom for the person living with the virus, rather than debating the 
possibility of a cure. 
In the third instance AIDS is, for the most part, a sexually transmitted disease. 
Discomfort with sex, sexuality and sexual behaviour (Shaw, 1989) may threaten 
the level of empathy available to the person with HIV/AIDS, since as Shernoff 
(1989:76) observes: "...the majority of mental health professionals have received 
relatively little or no training in human sexuality or sexuality counselling". HIV 
infection, however, brings sexuality into sharp focus.This can be uncomfortable 
for both person and counsellor where the former feels intruded upon or angered by 
discussion of safer sex and/or interprets the counsellor's discussions about sexuality 
as a negative parental injunction. Moreover, whether conscious or unconsciously, 
the counsellor's disapproval and hostility towards the presumed promiscuous 
lifestyle and/or sexual orientation of the person is perceived with exquisite 
sensitivity (D'Anzi, 1987). A judgmental attitude undermines the person's trust of 
the counsellor, and thus the efficacy of both the support and the advice offered. It 
is therefore critically important that the counsellor maintain his/her sense of 
neutrality with respect to the person with HIV/AIDS' sexual orientation and/or 
behaviour, since professional neutrality concerning these issues leads to generalised 
trust and the breakdown of social isolation (Tartaglia, 1989) and this tends to 
remedy the person's sense of internalised inferiority and badness. 
In the fourth instance, despite relative certainty concerning how HIV is 
transmitted, namely by means of body fluids, even the trained counsellor may 
suffer from irrational and hysterical fears of contagion (Dunkel & Hatfield, 1986; 
D'Anzi, 1987; Shaw, 1989). In some instances the population, as exemplified by 
one person, easily takes on the status of the 'other' and detachment replaces the 
process of empathy (Dunkel & Hatfield, 1986). The counsellor's fear of contagion 
therefore colludes with the person's belief that he/she is untouchable. 
Finally, inherent in the empathic process is the ability to feel with the person. 
Identification with the person living with HIV/AIDS is therefore a necessary part 
of the therapeutic process and relationship (Dunkel & Hatfield, 1986; Silven & 
Cardarola, 1989). Over-identification, however, occurs when the counsellor's 
ability to return to an autonomous stance is lost. This can result in the counsellor
Crisis as Challenge: HIV/AIDS & Counselling 45 
investing unrealistic amounts of time and/or energy in the person, or in familiarising 
him/herself with the literature. In extreme instances, over- identification 
results in burn-out. 
Counselling Survivors 
Given the predicted escalation of the AIDS pandemic and the apparent limited 
availability of formal health care services the care and support of persons with HIV/ 
AIDS will need to move beyond the support that can be offered by trained health 
professionals. In other words, the community at large (partners, family and friends) 
will need to take increasing responsibility for their care. Involvement by the wider 
community, however, has multiple implications for the general well-being of the 
population. 
In the first instance, the stress and fatigue of caring for persons living with HIV/ 
AIDS will need to be addressed, since as Weiss (1989:272) observes: 
"The work required to keep the dying person fed, clean, and medicated 
appropriately along with the emotional strain and disruption of usual life 
activities can be overwhelming". 
At the same time, the caregiver may feel guilty about not doing more for the person 
with HIV/AIDS and blame themselves for having their own personal needs. It is 
likely therefore that counsellors will be called to counsel the person's caregivers, 
particularly with respect to their limitations. In addition, counsellors will need to 
assist caregivers in reducing their level of guilt when caregiving is no longer 
possible. This suggests that the counselling of persons with HIV/AIDS's caregiving 
networks is an important intervention strategy for the future. 
Losing a significant other to death is considered one of the most stressful events 
in a person's life (Weiss, 1989) and presents survivors with multiple challenges. 
The loss of a significant other to death not only confronts the survivor with his/her 
own human mortality, but also fragments his/her attempts to self-regulate (Kast, 
1990). Initially the individual in mourning experiences shock at the loss a 
significant other. This is accompanied by a tendency to focus upon the absence of 
the significantother rather than upon the presenceof surviving others. At this point 
the survivor withdraws from the world and the support of others in order to 
reorganise andreintegrate his/her sense of self. If successful, thesurvivor re-enters 
the world of others. 
The predicted prevalence of HIV/AIDS-related deaths in the future suggests 
that a substantial proportion of our society will be working through a mourning 
process, ie will be attempting to reconstitute their lives without the physical
46 Michelle Crowley 
presence of significant others upon whom they depended for their sense of self. 
While it is presumed that most persons are capable of working through the 
mourningprocesswithoutprofessionalintervention,asubstantialproportionofthe 
population are likely to suffer from complicated and delayed grief reactions 
triggered by new and continuous losses. 
The mourning and bereavement process associated with an AIDS-related death 
is further complicated by the stigma associated with infection since it draws 
attentiontoanumber of cultural taboos, mostprimarily human sexuality (Zazayokwe, 
undated). This may inhibit survivors' attempts to re-enter the world of others. In 
addition, fears of rejection, survivors' worry about their own health status and, if 
infected, the anticipated loss of their own health, further complicates the bereavement 
process. It is possible, therefore, that a substantial proportion of our population 
will suffer from complicated grief reactions characterised by depression and/ 
or phobic responses. The latter may be directed towards surviving persons with 
HIV/AIDS and thus further reduce the amount of support available. 
Discussion 
There is no doubt that individuals' self-management of their sexual behaviour is 
the key to preventing HIV transmission (Shaw, 1989). For the most part, however, 
educational programmes for the promotion of safe sex have proven ineffective 
(Odets, 1993) due to the use of rational cognitive strategies for the control of what 
is essentially a passionate form of human expression. In addition, the initial 
tendency to phrase risk for HIV infection in terms of risk groups rather than risk 
behaviours has facilitated individuals' tendency to deny their personal risk of 
infection since if the individual does not belong to an identified 'risk group' he/she 
defensively believes that he/she is invulnerable to infection (Isaacs & McKendrick, 
1992). Safer sex educational strategies for the prevention of HIV infection 
are therefore likely to have only a limited impact on the pandemic's escalation. 
The likelihood that various co-factors contribute towards susceptibility to HIV 
infection provides a second possible level of intervention. Such intervention 
strategies would need to include a wide variety of practical educational programmes 
which attend to, inter alia, nutritional issues, drug use/abuse issues and 
the meaning of illness. Nutritional programmes, however, would need to be both 
culturally sensitive and practical, in the sense that they include creative and 
constructive agricultural methods and practice. Drug education programmes may 
also be relevant given that increased levels of toxicity and immune system 
suppression are associated with imbibing nitrate-based substances (Duesberg 
cited in Guccione, 1993), while drug use/abuse also contributes to less responsible
Crisis as Challenge: HIV/AIDS & Counselling 47 
attitudes towards safer sex. Education programmes aimed towards the reclamation 
and care of the body, and particularly human sexual functioning, may also prove 
particularly helpful, since as Kast (1990) suggests, the initial purpose of every 
illness is that we pay more attention our the body. HIV infection and the threat of 
imminent AIDS symptoms and secondary infections thus challenges persons with 
the virus to pay more attention to their corporeal existence. And, given that every 
symptom is an embodied symbol (Kast, 1990) or metaphor (Romanyshyan, 1975) 
the prevalence, risk and manner of transmitting HIV infection challenges us to look 
toward the manner in which we relate to our sexuality - a phenomenon that also 
inevitably involves the manner in which we relate to each other as sexual beings. 
Culturally influenced attitudes to death, illness and sexuality (Aorki, 1989; 
Zazayokwe, undated), and the changing demographic nature of the groups affected 
by HIV, suggests that educational interventions would need to be both culturally 
sensitive (Aorki, 1989) and designed specifically for each population (Dilley, Pies 
& Helquist, 1989). Among African populations, for instance, body care programmes 
may need to focus upon access to nourishment (which for a wide variety 
of historical, economic and political reasons has been limited), whereas among 
Western populations the opposition and split between mind and body may need to 
be addressed. In other words, body care programmes would need to focus upon the 
ideologies underlying each population's view of corporeal existence and its 
demands. 
The development and efficacy of any of these proposed interventions above 
rests, however, upon our willingness to face the reality of our human and historical 
situation. The existential truth of the human condition, and our only certainty, is 
that human being is finite: we grow old and die. Moreover, right now hundreds of 
thousands of people are infected and the infection rate promises to increase in the 
foreseeable future. The most appropriate intervention strategies are thus those 
directed towards dealing with rather than preventing the transmission of HIV. This 
inevitably involves concerted efforts to involve the community in the care of the 
dying and the timeous teaching of caregiving and counselling skills to individuals 
within these communities. Such training would need to include information 
concerning the pressing reality-based concerns of the individual living with HIV, 
as well as knowledge about the various transference and countertransference responses 
that serve to complicate the counsellor and caregivers' availability and 
willingness to care. 
It is, in the first instance, critically important to both clarify and work through 
the reality-based responses following a positive diagnosis. These include feelings 
of loss, fear, guilt, confusion and anger. At the same time, the prevalence of 
psychiatric disorders associated with HIV infection, and the ambiguity around 
these disorders' organic and/or functional status, suggests that it is also crucial that
48 Michelle Crowley 
counsellors avoid dismissing depressive symptoms as understandable responses to 
the stresses theperson with HIV endures and refer for medical and psychiatric help 
where appropriate. 
Transference refers to those conscious, preconscious and unconscious feelings 
and responses that the person with HIV feels and expresses in the presence of, and 
towards, the counsellor. These responses may be based upon distrust of the 
establishment, anger at authority figures and experts who fail to cure the disease 
and an internalised sense of inferiority. With respect to the latter, persons with HIV 
may presume themselves to be an untouchable caste who are denied human 
comfort and connection, and depending upon cultural factors, many may also 
resent their loss of independence, autonomy and control over their lives. To 
inadvertently collude with these beliefs, says Tartaglia (1989), reinforces the 
person with HIV/AIDS's sense of helplessness and thus undermines their adult 
sense of identity and self-esteem. It is critically important, therefore, that the 
counsellor relates to theperson in a manner that re-establishes and maintains the 
his/her sense of human dignity. 
Failure in counselling relationships occur for two reasons: ignorance on the part 
of the counsellor (Kohut, 1971), which is correctable by further training; and 
failure to recognise and properly utilise countertransference responses (Langs, 
1978). Given the highly emotional nature of Ihe work with persons living with HIV/ 
AIDS, it is unavoidable that the counsellor's biases will emerge and rigidify in 
reaction to the threat confronting theperson (Aorki, 1989). This makes the work 
both highly challenging and rewarding, since the counsellor's own dynamics are 
illuminated through the process. At the same time, such responses can lead to 
burnout for the counsellor. It is thus critically important, as Shaw (1989:274) 
observes, that: 
"...mental health providers...acknowledge their own concerns in order to 
identify and correct those factors which...interfere with their work 
with...clients." 
Counsellingthusnotonlyrequiresabalancebetweenoverreactingtotransference 
issues and under-reacting to reality-based issues, but also requires that the 
counsellor deal with his/her personal responses and attitudes towards persons with 
HIV/AIDS. Moreover, the tremendous ambiguity that must be faced in working 
with persons with this condition, as well as what constitutes an appropriate 
therapeutic approach, provides fertile ground for the generation of further 
countertransference issues. Thus, while a basis for empathy (Peabody & Gelso, 
1989), countertransference responses may also jeopardise the counselling 
relationship. This suggests thatcounsellorsneedtobe trained to examine their own 
attitudes to the issues involved, to acknowledge the uncertainty of the situation, and
Crisis as Challenge: HIV/AIDS & Counselling 49 
to recognise the limits of their expertise and refer appropriately. This would serve 
to both develop the counsellor and ensure that he/she creates an accepting and 
healing, rather than defensive and persecutory, space for the person living with 
fflV/AIDS. 
Several more pragmatic measures also need to be considered with respect to 
counselling. In the first instance, treating persons with HIV/AIDS demands a team 
approach, not only because AIDS is a physical disease that requires careful monitoring 
and medication, but because it is also a behaviourally transmitted disease 
with severe emotional and psychological consequences. Moreover, and in terms of 
caring for the counsellor, the team approach provides both a potential source of 
support for the counsellor and an opportunity for co-supervision, or a safe space in 
which counsellors' areas of vulnerability can be identified and worked through 
constructively. Counsellors also require continued updated clinical and scientific 
information in order to provide quality care. A team approach thus also presents a 
forum for debating and assisting each other's understanding of the complex issues. 
Finally, the counselling of caregivers also requires that the limits to which 
caregivers can beexpectedtopreventthe death of persons with AIDS and their guilt 
for not having done so be addressed. In addition, the likelihood of delayed and 
complicated grief reactions due to continual and repetitive losses and the stigma associated 
with caring for a significant other with a sexually transmitted disease will 
also need to be addressed if the general wellbeing of the broader population is to 
be maintained. 
Conclusions: Challenge or Crisis 
The prevalence of the AIDS pandemic and its various social and economic 
implications suggests that South African society as a whole will be profoundly 
affected by the disease, particularly that group of people invested with responsibility 
of reproducing the nation, namely women. 
The expected pressure on both primary and secondary health care services 
implies that both professional and lay persons will be called to treat and support 
persons with HIV/AIDS, while at the same time being expected to cope with thenown 
inevitable sense of loss; for it is unlikely that anyone will escape the passing 
of either close friends and/or family members. Moreover, and in view of the 
medical professions' apparent helplessness with respect to securing a cure for HIV 
infection and/or AIDS, and the controversy surrounding the HIV-AIDS link, it 
would seem that prevention and treatment strategies will need to focus upon cofactors 
associated with susceptibility to infection, and more specifically upon the 
counselling of persons with the illness, their counsellors, and the family and friends 
who care for and survive the person's death.
50 Michelle Crowley 
Accompanying a person on their journey to the edge of the abyss, or death, is 
always difficult and challenging, for it confronts us with our own human mortality. 
A counsellor's understanding of how the person responds to his/her own challenge, 
in terms of both his/her normal and transference responses, enables deeper 
empathy. It also enables the counsellor to allow the infected person his/her natural 
responses and the opportunity to reality test his/her notion of inferiority and 
untouchability. 
Failure in counselling occurs where the counsellor has not been made aware of 
and trained to deal with his/her own countertransference issues. A counsellor's 
understanding of how he/she responds to the person with HIV/AIDS, in terms of 
the ambiguities and prejudice surrounding infection, the limits of his/her expertise 
and the inevitable loss of the patient to death it thus critical. It allows the counsellor 
to examine and understand where the empathic relationship is jeopardised by his/ 
her own natural responses and to remedy the relationship through self-correction. 
The willingness to self-examine these responses not only promotes efficacious 
care but personal development for the counsellor. It also serves to prevent 
counsellor burn-out and/or withdrawal from caregiving. 
On a broader social level, the loss of a significant other initiates a mourning 
process, which if itproceeds normally enables the person toreintegrate and reenter 
the community witharenewed sense of autonomy. Aparticulardangerwith respect 
to the AIDS pandemic, however, is that continual and repetitive losses leave 
survivors trapped in their grief, and thus either depressed or alternatively isolated, 
in so much as they avoid contact with surviving persons with HIV/AIDS. 
As Weiss (1989:274) suggests, however: 
"Healing the pain of secrecy and isolation comes from reinvolvement in the 
community, either as a helper, volunteer, professional, or recipient of 
services." 
This wisdom holds true not only for the isolated person who believes he/she is 
untouchable and contaminated but also for survivors of AIDS-related deaths. In 
other words, the pandemic offers opportunities for rebuilding and reintegrating 
South Africa's shattered community of communities - it is a call to reach out to 
others with renewed compassion and understanding of our shared humanity. 
References 
Aorki, B K (1989) "Cross-cultural counselling: The extra dimension", in J W 
Dilley, C Res & M Helquist (eds) Face to face: A guide to AIDS counselling, 
Celestial Arts, California, pp 26-33.
Crisis as Challenge: HIV/AIDS & Counselling 51 
Baker, J (1993) "Treatment of mood disorders", in Focus: A Guide to AIDS 
Research and Counselling, 8(8), p 1-4. 
Beckett, A & Shenson, D (1993) "Suicide risk in patients with human 
immunodeficiency virus infection and acquired immunodeficiency syndrome, 
Harvard Review of Psychiatry, 1(1), pp 27-35. 
Beitman, B (1983) "Categories of countertransference", in Journal of Operational 
Psychiatry, 14(2), pp 82-90. 
Bialer, P A; Wallack, J J & Snyder, S L (1991) "Psychiatric diagnosis in fflV 
spectrum disorders", in Psychiatric Medicine, 9(3) pp 361-375. 
Biggar, J (1986) "The AIDS problem in Africa", in The Lancet, i, pp 79-82. 
Chopra, D (1991) The unconditional life: Mastering the forces that shape 
personal reality, Bantam Books, USA. 
Cochran, S D & Mays, V M (1989) "Women and AIDS-related concerns: Roles for 
psychologists in helping the worried well", in American Psychologist, 44(3), 
pp 529-535. 
D' Anzi, F A (1987) "Transference and countertransference issues in the treatment 
of persons with AIDS", in Journal of Louisiana State Medical Society, 139, 
pp 80-84. 
Dilley, J W & Boccellari, A (1989) "Neuropsychiatric complications of HIV 
infection", in J W Dilley; C Pies & M Helquist (eds) Face to face: A guide to 
AIDS counselling, Celestial Arts, California, pp 138-151. 
Dilley, J W; Pies, C & Helquist, M (eds) (1989) Face to face: A guide to AIDS 
counselling, Celestial Arts, California. 
Dunkel, J & Hatfield, S (1986) "Countertransference issues in working with 
Persons with AIDS, in Social Work, 31(2), pp 114-117. 
Goldblum, P B & Moulton, J (1989) "HIV disease and suicide", in J W Dilley; C 
Pies & M Helquist (eds) Face to face: A guide to AIDS counselling, Celestial 
Arts, California, pp 152-164. 
Gong, V (1985) "Update on AIDS research", in V Gong (ed) Understanding 
AIDS: A comprehensive guide, Cambridge University Press, Cambridge, pp 
xv-xxii. 
Guccione, B (1994) "The deadly sex scam", in Bigblue, Feb/Mar. 
Hays, L L (1984) You can heal your life, Aliveness Unlimited Movement, 
Observatory, Cape Town. 
Heimann, P (1950) "On countertransference", in International Journal of 
Psycho-Analysis, 3i, pp 81-84. 
Isaacs, G & McKendrick, B (1992) Male homosexuality in South Africa: 
Identity formation culture and crisis, Oxford University Press, Cape Town. 
Jackson, D (1994) AIDS and the workplace, Sunday Times Business Times, 
November 27, pp 10-11. 
Jackson, H (1988) AIDS: Action now - information, prevention and support in 
Zimbabwe, NCR City Printers, Harare. 
Jones, J R & Dilley, J W (1993) "Rational Suicide and HIV Disease", in Focus: A 
Guide to AIDS Research and Counseling, 8(8), p 5-6. 
Kast, V (1990) The dynamics of symbols: Fundamentals of Jungian 
Psychotherapy (Trans. S A Schwarz) Fromm International, New York.
52 Michelle Crowley 
Kohut, H (1971) The analysis of self, International Universities Press, New York. 
Langs, R (1978) The listening process, Jason Aronson, New York. 
Lapalanche, J. & Pontalis, J B (1973) The language of psychoanalysis, WW 
Norton, New York. 
Odets, W (1993) "AIDS education and prevention: Why it has gone almost 
completely wrong and some things we can do about it", Paper delivered to the 
National Gay and Lesbian Health Conference in Houston, July 23. 
Peabody, S A & Gelso, C J (1982) "Countertransference and empathy: The 
complex relationship between two divergent concepts in counselling", in 
Journal of Counselling Psychology, 29(3), pp 240-245. 
Root-Bernstein, R (1993) Rethinking AIDS: The tragic cost of premature 
conclusions/The Free Press, New York. 
Romanyshyn, R D (1975) "Metaphors and human behaviour", in Journal of 
Phenomenological Psychology, 5(2), pp 441-460. 
Shaw, N S (1989) "HIV disease: Issues for women", in J W Dilley; C Pies & M 
Helquist (eds) Face to face: A guide to AIDS counselling, Celestial Arts, 
California, pp 241-248. 
Shernoff, M (1989) "AIDS prevention counselling in clinical practice", in J W 
Dilley; C Pies & M Helquist (eds) Face to face: A guide to AIDS counselling, 
Celestial Arts, California, pp 76-83. 
Silven, D&Cardarola,TJ(1989) 'The HIV-positive client",in JW Dilley; C Pies 
& M Helquist (eds) Face to face: A guide to AIDS counselling, Celestial Arts, 
California, pp 15-25. 
Tartaglia, C R (1989) "AIDS and anxiety syndromes", in J W Dilley; C Pies & M 
Helquist (eds) Face to face: A guide to AIDS counselling, Celestial Arts, 
California, pp 165-174. 
Weiss, A (1989) "The AIDS bereaved: counselling strategies", in J W Dilley; C 
Pies & M Helquist (eds) Face to face: A guide to AIDS counselling, Celestial 
Arts, California, pp 277-275. 
Williams, JBW; Rabkin,JG & Remien R H(1991) "Multi-disciplinary 
baseline assessment of homosexual men with and without human immunodeficiency 
virus infection", in Archives of General Psychiatry, 48(2),pp 124- 
Zazayonkwe, M (undated) "Some barriers to education about AIDS in the 
black community", in Aids Training and Information Centre, South African 
Institute for Medical Research.