HIV-Infected People Benefit From Narrative Therapy

Finding out that one was HIV-positive used to be viewed as a death sentence. No more. Thanks to the arrival of highly active antiretroviral therapy, the average life expectancy of a person who contracted HIV between 1996 and 1999 and has access to antiretroviral medications is 20 years on average.

Nonetheless, people who are HIV positive are psychologically far from “home free,” as the saying goes. This fact was stressed by three Canadian psychiatrists who have had experience caring for them and spoke at the annual meeting of the Canadian Psychiatric Association in November in Banff, Alberta.

HIV-positive persons used to need to grieve about their state and prepare to die, Kenneth Citron, M.D., an assistant professor of psychiatry at the University of Toronto, pointed out, but now they need to focus on living with their illness. For instance, if they are on disability, they may need to retrain for their old jobs or to find new ones. Or if they have lost partners to AIDS, they may want to find new partners. Or if the antiretroviral drugs have given them sunken cheeks, “buffalo humps,” or other physical disfigurements, they may need to learn to live with the disfigurement and not go off their antiretroviral drugs in order to avoid it.

“One of the most important issues we see now is body image,” Citron said.

HIV-positive individuals, in fact, may suffer not just from adjustment disorder, but also from anxiety or depression, Stephen Fitzpatrick, M.D., a clinical assistant professor of psychiatry at the University of British Columbia, added. “Depression is probably the most common problem in our own patient setting,” he said. In fact, he added, “It is safe to say that every patient with HIV will develop at least one psychiatric disorder during his illness.”

So what can psychiatrists do to help meet the psychological needs of patients infected with HIV? Psychotropic medications can help, Fitzpatrick said. But because of these patients’ extra sensitivity to such medications, psychiatrists should “start low, go slow” with prescribing, he advised.

Interpersonal therapy, psychodynamic psychotherapy, and cognitive-behavioral therapy are all effective with HIV-infected patients, Citron reported. However, he and his colleagues have found that cognitive-behavioral therapy works fastest.

Narrative therapy—writing about one’s life—may also give HIV-infected patients a psychological boost, Allan Peterkin, M.D., an assistant professor of psychiatry and family and community medicine, added.

In 2000, a study was reported in the Journal of the American Medical Association suggesting that if rheumatoid arthritis patients or asthma patients wrote about stressful events in their lives, it reduced their pain and some of their other symptoms. This study, plus some others on writing and mental health, prompted Peterkin and his colleagues to set up a pilot program to see whether narrative therapy might benefit patients infected with HIV. To date, they have some 50 patients writing stories on various topics for a 16-week period. The stories can be about either negative or positive events. One patient, for instance, wrote about visiting a bakery when he was 10 years old and picking out his favorite sweet. The patients also share their stories with each other.

So far, the patients seem to be reaping some psychological benefits from this story writing, Peterkin said. First, it fills them with satisfaction at having achieved something concrete—especially something concrete that they can share with others. Second, since their stories have a beginning, middle, and end, the stories help them achieve clarity about their lives. And third, their stories are helping them work through some of their problems. One patient, for example, came to realize that each story he wrote was a metaphor for the deep emotional pain he felt at losing his lover to AIDS.

Peterkin and his colleagues will now be undertaking a study with a control group to explore further the psychological benefits that can accrue to HIV-infected patients from doing narrative therapy. ▪