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I have worked in HIV services during the past decade and for the past five years I have been running a small psychodynamic counselling service for people affected by HIV, AIDS and other life-threatening conditions. I was, therefore, very interested to read Chris Purnell's (1996) paper in which he describes his work with people affected by HIV and AIDS and looks at the relevance of attachment theory. I agree that Bowlby's ideas about attachment and the concept of a secure base are very helpful in understanding our clients' early attachment figures and how those experiences can be enacted with us. The provision of a secure base seems to me to be essential and fundamental in any kind of therapy which is successful in its reliability and its capacity to contain. The crisis of HIV or AIDS may intensify the need for the secure base for some clients which is perhaps what Purnell is stressing in his paper. I would like to respond to some of Purnell's ideas by indicating the difficulties and challenges in working with this group and finally by describing my work with a client at the end of his life.
Purnell describes a number of different approaches which he takes with clients, some of which I think arise from powerful countertransference feelings and perhaps from the primitive anxieties which are provoked in this work. With some clients Purnell feels he needs to offer a shoulder to cry on rather than offering counselling because these clients equate counselling and therapy with problems. Avoiding the problem focus of counselling or therapy in this way could be a collusion with the client's denial of the pain he or she is in. I am reminded of a paper by Coleman and Etchegoyen (1992) which examines the powerful effect on staff of patients in a STD clinic. They noticed that alongside ‘the patients' insatiable demand for exclusive care’ was the defensive denial of severe problems in relation to dependence and loss. There is throughout Purnell's paper an attempt to be all things