Few issues stir up more emotion than those revolving around HIV/AIDS.  While the face of the disease has changed radically in the U.S., sero-conversion to HIV+ is not as rare as it should be.  While my own views are no doubt colored by 3 decades of working with people with HIV/AIDS, I can be particularly blunt when confronted with a patient who is practicing unsafe sex.

Even though I always express thoughts with care and concern, my directness runs countercurrent to much of what I’ve been taught — that the expression of opinion should be kept out of the treatment.  However, when dealing with HIV and AIDS, my concern for my patients’ physical wellbeing trumps my training.

An HIV+ patient was frequenting sex clubs and not always practicing safe sex.  He justified this by assuming everyone else who didn’t practice safe sex was HIV+ or didn’t care.  When I probed a little deeper, it became clear that he mostly feared stigma and rejection.  My patient claimed that it was the equal responsibility of the other person to inquire about or divulge HIV status.  He stated that his partners bear the ultimate responsibility for their own actions.  After continuing to press the subject, I let go of my reservations and made clear the importance of self-disclosure for keeping both my patient safe from further infection and any of his partners safe.  Clearly this was my own agenda, not my patient’s, and trumped any of my analytic training.

 Another patient, who for many years had been desperately seeking a romantic relationship, was finally falling in love with a man with similar feelings.  My patient also periodically went though strong hypocondrical fears around minor health issues.  Two months into the relationship, my patient and his new boyfriend went to get tested for HIV.  Delighted when the tests both came back negative, my patient made it clear upon inquiry that they were now going to have unprotected sex.  After exploring the issue in session, I asked my patient if I could give my thoughts on the subject.  He readily agreed.  I expressed my concern that after two months of dating he barely knew his new boyfriend and was making a potentially devastating decision of trust extremely early in the relationship.  He listened attentively and showed appreciation, but at the same time pointed out that my point of view was colored by my own experiences with AIDS during the ‘80s and 90s.  Despite my feeling strongly that my history was not relevant to my concern, I refrained from pressing the issue.

Some therapists might view such patient behavior in an even more dismal light, and equate it with inflicting inward or outward violence.  While this is a common attitude, the issues involved are much more nuanced and complicated and while I’m certain that my interventions were appropriate, I must remain vigilante in avoiding the simple expression of opinion instead of vital and necessary intervention.