The patient’s name is Marta Ruiz, 52 years old, female, clinically diagnosed as HIV Symptomatic with a CD4 count of 600+ with a detectable but not high viral load. She has been a person living with HIV/AIDS (PLHA) for five years. She resides at Jackson Heights, Queens, New York City after migrating from the Dominican Republic and is living on assistance provided by DASIS. She requested assistance from this social worker on a crisis precipitated by a fear of contagion transferred sexually by her to a lover named Ruben, with whom she has recently resumed intimate relations with after being separated for many years.
This paper presents stigma as seen in this case, its effects on social systems and proposed social work interventions for the client. Stigma and Its Effects HIV stigma is defined as “prejudice, discounting, discrediting and discrimination directed at people perceived to have HIV or AIDS which may be enacted or felt” (Green and Platt, as cited in Emlet, 2006). What is apparent in this case is a form of felt or internalized stigma characterized by Marta’s feelings of shame, guilt, and fear of enacted stigma.
Marta has not yet experienced stigma deliberated upon her by society because she has placed herself in “protective silence” in order to shield herself from what she views as terrible repercussions once she tells the truth about her condition. This is a type of stigma management used by PLHA. She treats her disease as something shameful, because of a preconditioned belief prevalent in her home country that AIDS is a disease contracted by loose women, drug addicts and homosexuals. Moreover, she has an overwhelming fear of rejection and abandonment that could eventually result from a disclosure of her disease.
This type of stigma has resulted to self-discriminating behavior and poorly-made decisions that led to several effects, including a possible contagion transfer: Non-disclosure, feelings of denial. As a way of managing stigma, Marta chose to be silent about her condition and did not reveal it to anyone except with her medical providers. This reflects feelings of denial which eventually had negative effects in terms of the quality of her judgments and decision-making. Physical isolation. Fearing anticipated stigma, Marta subjected herself to physical isolation.
She left her brother’s home in New York to live alone in a one-bedroom apartment in Jackson Heights. This is a type of avoidance behavior common among PLHA (Delahanty et. al. , as cited in Emlet, 2006). Depression and stoppage of social activities. Stigma also led Marta to discontinue social activities like music and dance which she regularly engaged in previous to her HIV diagnosis. She also experienced increasing levels of stress and depression accompanying her illness. Failure to acquire social support.
Stigma also resulted to an absence of social support from family or friends, without which, Marta lacked the emotional backup to handle the problems and circumstances related to her condition. Possible contagion transfer. Perhaps the most damning effect of stigma in this case is the possibility of HIV/AIDS infection from Marta to her lover Ruben because of the former’s decision not to disclose her disease. Effects of HIV/AIDS on Social Systems Various social systems are affected by HIV/AIDS (Emlet, 2006).
The individual, family and community have experienced or are likely to experience the impact of Marta’s case in different ways. Individual. Aside from degenerating health, HIV/AIDS had a negative impact on Marta’s psychosocial well-being. Because of practiced avoidance behaviors, she suffered stress, depression and loneliness. All this stems from fear of societal rejection that she believes would naturally come down on her as a result of her HIV status. This led her to isolate herself from her family and abandon some of her previous social engagements.
It also led to poor self-confidence, emotional vulnerability and poor self-efficacy. It is important to note this because empirical literature seems to suggest that above all factors, personal characteristics and beliefs predict successful adherence interventions among PLHA. Family. Marta’s nondisclosure has created no visible effects on her family system as of yet because her family does not know of her condition. However, by physically separating herself from her immediate family in New York, she has effectively cut all lines of communication and support from her family in the Dominican Republic.
Judging on a description she made of her family, it is likely that if she reveals her condition to her family, the reality of rejection will come in. While this may be true, and granting that her family seems predisposed to discriminate and stigmatize her, PLHA can derive so much emotional support from family. If she continues to keep her condition secret from her family, managing her disease would be difficult, considering that she has no strong social support systems in New York. This has grave implications on how social workers can address social support concerns among PLHA.
Social support has been repeatedly associated with psychological well-being and mental health, positive states of mind, coping with the disease-related stress and quality of life (Catz, Gore-Felton,&McClure, as cited in Emlet, 2006). Community. Marta’s case, along with all HIV/AIDS cases, continue to become a community concern especially because much of the stigma that befall PLHA come from a collective fear of the disease due to ignorance or lack of HIV/AIDS awareness or education.
This is the premise why anti-stigmatization campaigns have been directed on the community level because lately, discriminatory practices against PLHA are often unleashed by entire groups, not by individuals. Addressing the spread of HIV/AIDS is a community challenge, too. Stigma and discrimination have been identified internationally as major barriers to HIV control and prevention (UNAIDS, 2003). Because of stigma, people refuse to undergo testing and take part in prevention and awareness campaigns.
In Marta’s case, poor education and complicity toward unprotected sexual behaviors led to a nondisclosure of HIV status and eventually, the possibility of infection. This is the type of situation HIV/AIDS education campaigns and advocacy is trying to prevent. Proposed Interventions There are more than one possible modes of intervention for the social worker to handle Marta’s case as far as crisis management and her adherence to treatments. Her current predicament can possibly affect how she views and regards management of her disease and must be resolved.
From the crisis report, it could be gleaned that Marta demonstrates a willingness to participate in treatments and programs that may be instrumental in helping her cope with the disease. She is currently enrolled in a DASIS program that assists her in terms of housing and basic needs which she also supplements with employment as a house cleaner. It could be safely assumed that she is undergoing medication under a treatment regimen possibly set for her by health care providers. Case management does not need be used in Marta’s case but the social worker can still do follow-ups on treatments and medical therapies recommended.
Interventions must ensure that Marta sustains a positive view of future treatments in light of the immediate emotional crisis she is experiencing. The forms of intervention that find application in Marta’s case are: (1) individual counseling or therapy; and (2) social support. Individual counseling and therapy is the most immediate form of intervention needed to resolve Marta’s immediate crisis. Marta has demonstrated incapacity to formulate good judgments and decisions, possible due to a confused state of mind.
One initially marvels at how a 52-year old woman could yield sexually to a man who has suddenly resurfaced in her life knowing full well that she has a sexually contagious disease. Her near-hysterical behavior after her sexual encounter with her former lover is indicative of a “weakness” she describes that might be a result of past experiences and beliefs. Individual therapy will be advisable in Marta’s case because it allows her to discuss confidentially and on a personal level, unresolved issues she currently face such as guilt, anger, fear, and remorse.
During counseling sessions and therapy, she may be able to overcome her fear of disclosure, the greatest obstacle in her case. Therapy must be done in order to resolve these issues on an ongoing basis. Another intervention appropriate for Marta is social support. Her lack of social support systems is one of the salient features in her psychosocial evaluation. Since she was diagnosed five years ago, Marta has distanced herself from close associations and has lived in isolation. She is a PLHA with virtually no stable emotional foothold to start from.
The only immediate family she has in New York is a brother with whom she finds difficulty in reaching out to, because of mistrust in a sister-in-law she views as hostile. However, she still maintains a few woman acquaintances which could be helpful to her. The social worker can assist Marta by introducing her to self-help groups which would be a great venue for her to feel acceptance. These groups provide an opportunity for PLHA to share experiences with others of like situation and condition. By participating in self-help groups, PLHA meet their own needs as well as others’.
It will make feel Marta belong to a community which is ready to accept her and treat her normally. These new relationships will be crucial in helping Marta overcome fear and allow her to be comfortable with disclosing her HIV status to others. Barriers to Intervention In helping Marta come to terms with her disease and sustain her adherence to much-needed treatment regimen and therapy, factors such as transference and counter-transference pose a probability of affecting her relationship with the social worker.
Transference is the conscious and unconscious “reproduction of emotions relating to repressed experiences, especially of childhood, and the substitution of another person for the original object of the repressed impulses” (Racker, 2001). This phenomenon may lead to the patient’s mistrust of the worker because of a minor resemblance to a person associated with the emotion. In Marta’s case, the worker must avoid exhibiting a dominant or authoritative stance because this might cause her non-cooperation.
As a girl living amongst nine overly dominant brothers with violent tendencies, she might unconsciously transfer her feelings of fear to the worker and this may be an obstacle to her counseling or therapy. She might also associate a female worker with her sister-in-law, Betty, who she mistrusts above all. The social worker must take this into consideration because any transference on Betty will make her feel doubtful of the worker’s ability to maintain confidentiality. In this regard, transference can become a barrier to effective intervention.
On the other hand, counter-transference, or the “redirection of a therapist’s feelings toward a client, or a therapist’s emotional entanglement with a client” can influence with the development of a functional working relationship. The social worker must not allow herself or himself to be swayed or pitted against whatever emotion the client is trying to elicit in him or her. Instead, any attempts on counter-transference must be examined and discussed so that the client can objectively view his own motivations, fears and desires.
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