Therapeutic writing as a tool to facilitate therapeutic process in the context of living with HIV: A case study examining partner loss

Introduction

For people with HIV/AIDS (PWHA), partner loss can have unique factors that complicate the grieving process and lead to disenfranchised grief (Blando, Graves-Ferrick, & Goecke, 2004; Curtin & Garrison, 2018). Disenfranchised grief typically occurs when an individual experiences a loss that is not openly acknowledged, publicly mourned, or socially supported. Disenfranchised grief is attributed to unprocessed feelings and unresolved grief, which makes it difficult for the individual to create a new identity beyond loss. In the case of PWHA, social networks can disenfranchise grief by not recognizing one or more of the following: the relationship between the deceased and a survivor, the importance of the loss, or the need of an individual to be a griever. In these cases, therapy needs to effectively enable the patient to process the loss in a manner that becomes the catalyst of grief resolution. This article will focus on Pat (a pseudonym), a former patient whose partner loss was complicated by lack of closure around the termination of his six-year long relationship, the death of that partner without the family informing him, and his anger surrounding his partner infecting him with HIV.

Loss of a partner/spouse is a common human experience, and the accompanying grief and bereavement process impacts physical, psychological, and social well-being. Early theories examined the process of bereavement as a staged or phased approach (Kübler-Ross, 1969; Hamilton, 2016); however, recent theories have moved to a more active view of the grief and bereavement process (Stroebe & Schut, 1999; 2016). An active view of the process enables us to better contextualize the complications faced in the context of HIV, substance use, and traumatic events. This active view of the bereavement process examines how coping with stressors such as the loss of a partner, reorienting to life in the absence of a partner, and the overload of stressors created from these simultaneous processes can shape an individual’s bereavement experience and lead to an exacerbated or protracted grief process. In the case of Pat, he lacked the resources to cope with the loss of his partner while trying to find a way to move on and build a new life. Active bereavement can be conceptualized as the integration of two sources of stress: 1) loss-oriented stressors, which include loss of companionship and loss of instrumental/tangible support, and 2) restoration-oriented stressors, which include things like attending to life changes and the assumption of new roles (Stroebe & Schut, 2010; Stroebe & Schut, 2015). The process of regulating emotions between these two stressors involves an oscillation from loss to reorientation. As an individual oscillates between both sources of stress, having more stressors than available resources to cope with the stressors is known as “overload” (Stroebe & Schut, 2016). In situations that have greater complications, such as the loss of a partner in the context of HIV, overload may be more common and extend the grief process. In the case of Pat, the lack of integration with his partner’s family at the time of death left him out of the grieving ritual of having a funeral, burying a body, and receiving public acknowledgment of his loss of a partner. While stressors shape the grief process, ultimately resolution lies in constructing a new relationship with the deceased and developing a new identity that respects the loss of that partnership (Cadell & Marshall, 2007). This made finding ways that Pat could process his loss stressors and restoration stressors and construct a new identity paramount.

First, it is important to note that partner loss in the context of disenfranchised grief is associated with greater social isolation (Bristowe, Marshall, & Harding, 2016) and greater depression (Satterfield, Folkman, & Acree, 2002; Moskowitz, Folkman, & Acree, 2003) over an extended time period. When Pat presented for treatment he had been grieving for approximately five years. Second, lack of social recognition (e.g., not getting invited to the funeral, as was the case for Pat), is another factor that can complicate grief in the context of partner loss for PWHA, particularly in the context of same-sex relationships such as Pat’s (Cadel & Marshall, 2007). In 2016, gay and bisexual men accounted for 67% of all new HIV diagnoses (26,844) and 82% of diagnoses amount males aged 13 and older.” When not married, the interactions the living partner has with their dying partner’s family prior to and at the time of death in a same-sex relationship are crucial to obtaining social recognition. When families do not acknowledge the living partner or provide them with an opportunity to be publicly recognized, the living partner’s access to needed support is limited (Bristowe, Marshall, & Harding, 2016). These interactions can lead to exclusion from decision-making, leaving the living partner out of official arrangements and potentially denying them the opportunity to say goodbye. Third, legal and financial battles heighten the bereavement process and make reorienting to a life without that partner particularly challenging. While Pat did not have legal battles, he was not allowed access to any of his former partner’s valued keepsakes. Fourth, caregiving becomes a role that is a part of one’s identity and is therefore lost when one’s partner dies (Cadell & Marshall, 2007). As a nurse whose partner needed care both emotionally and physically, caregiving was a major part of Pat’s identity in his relationship. Finally, difficulties accessing appropriate professional support fosters greater isolation (Bristowe, Marshall, & Harding, 2016). Bereavement groups and other resources are often heteronormative, with little or no consideration of the configurations of other relationships. Pat was in need of a treatment plan that not only addressed his depressive symptomatology, but also one that allowed him to process his anger, loss, and grief.

The Clinical Gap

Therapeutic writing, which Nyssen and colleagues (2016) define as using writing in a structured or unstructured manner “as a form of therapy to improve physical or mental health,” has long been accepted as an important therapeutic tool. However, the impact of facilitated therapeutic writing on conditions such as HIV remains under scrutiny (Nyssen et al., 2016). Currently, limited evidence-based treatment exists to address and support the resolution of grief and the complications of partner loss in the context of HIV. The premise of a writing interventions is that writing as a method to confront difficult emotions will lead to a reduction in inhibition and thereby facilitate disclosure. In the process of writing, cognitive and affective changes develop, often leading to improved psychological functioning (Pennebaker, Kiecolt-Glasser, & Glasser, 1988; Pennebaker, Mayne, & Francis, 1997). Therefore, therapeutic writing is a potential therapeutic tool to address emotional trauma in the context of living with HIV.

Purpose

The purpose of the current article is to illustrate use of therapeutic writing as part of a comprehensive approach to treatment for PWHA coping with partner loss using the case study of Pat, a former therapy patient. First, we will present Pat’s background information, the protocol used to incorporate therapeutic writing into the therapeutic process, and the thematic progression towards resolution of grief. Then we will provide recommendations for the use of therapeutic writing for PWHA.

Method

Therapy and Supervision

This case was seen by a graduate trainee – Gabriel Cartagena, MS – who was closely supervised by the attending psychologist, Dr. Ennis. The case was assigned to Mr. Cartagena after Dr. Ennis completed the clinical intake and baseline assessment. Pre-supervision, the meeting before the first session, consisted of a broad overview of the case and a list of goals for the first session. After each session, Dr. Ennis and Mr. Cartagena met for 30–45 minutes to process the session content. All sessions were videotaped with the patient’s consent. Dr. Ennis watched sessions live and reviewed videotaped content with Mr. Cartagena in supervision. Pat was seen from July 2018-January 2019 for a total of 12 sessions over six months, with the first six sessions on a weekly basis and then a tapering protocol that went from biweekly to monthly sessions. Therapeutic writing was started in session 2 and continued through session 5. The patient’s progress and the treatment plan were assessed during supervision and adjustments were made as needed. Additionally, the patient provided written consent for this evidence-based case study, including the use of de-identified information related to the case and verbatim exchanges.

Patient Background Information

Pat is a 48-year-old, single, gay-identified, cisgender, White male (pronouns: he, him, his) who presented with worsening symptoms of depression and anxiety due to the death of his former partner (Bob, a pseudonym) in 2012. Pat characterized his relationship with Bob as “difficult.” He described providing continual emotional support for Bob and remaining in the relationship even in the context of Bob’s problem gambling, substance use disorder, emotional abuse in the form of demeaning language, and, his risky sexual behavior, which Pat reported led to him contracting HIV. He characterized his mood since his partner’s passing as “pretty flat” and reported crying “every other day” – emotional triggers included movies, television shows, and commercials surrounding happiness and/or demonstrations of affection between loved ones or family members. Pat noted that his most prominent concern was related to experiencing “significant grief” that he was “never able to actually process.” While Pat and Bob were not in a relationship at the time Bob passed away, Pat reported that, to his surprise, he was “shut out completely” by Bob’s family, finding himself unable to communicate with them concerning the nature of Bob’s passing. Pat was not informed of funeral services, and, aside from a passing conversation with a family member of Bob’s approximately two years prior to him beginning psychotherapy, his ability to grieve Bob was non-existent. Pat recalled the pain and confusion of being unable to discuss the death of the man he loved, as well as the frustration of being “left in the dark,” unable to say his piece.

Approximately three years after Bob’s passing, Pat relocated to a new city closer to family with the hopes of “starting fresh.” Having begun antiretroviral medication upon diagnosis five years earlier, it was not until after his move that Pat began proactively addressing additional medical needs. In addition to noting changes in mood at this time, Pat reported struggling with a “wall” of anxiety, feeling physically unable to walk through his front door to go out for dinner or socialize. This precipitated a significant reduction in Pat’s social interactions overall; where once he described himself as “charming” and “outgoing,” Pat now characterized himself as “out-of-the-way” (i.e. social isolated). Pat reduced his interactions with coworkers with the goal of not sharing his past with Bob or his diagnosis for fear of workplace discrimination. When coworkers discussed their personal lives (e.g., family, dating, partner histories, etc.), Pat experienced a racing heart, sweatiness, and difficulty breathing. He also experienced significant difficulty concentrating and processing tasks at work. At home, he found his sleep quality worsening (poor sleep onset and an average of 5 hours a night) and increased appetite and weight gain since 2012. Pat stated he “lost [his] vitality” and had “wasted the past five years of [his] life.” He denied current suicidal ideation and previous suicide attempts or self-harm.

Conceptualization

Dr. Ennis (clinical supervisor), having worked with PWHA for over 20 years, knew that Mr. Cartagena (psychology trainee) was a good match with Pat due to his previous experience working with PWHA in both clinical and research contexts. Mr. Cartagena’s professional background in HIV treatment, stigma, and mental health sequelae provided the needed foundation for Pat to begin engaging in psychotherapy. Dr. Ennis and Mr. Cartagena conceptualized Pat’s case as an experience of both major depression and generalized anxiety in the context of disenfranchised grief. A prominent feature of Pat’s presentation was disconnection from his emotions. While Pat could identify and label his emotions, he struggled to express them in a congruent manner (e.g., smiling while discussing his anger regarding potential workplace discrimination due to his diagnosis or laughing while describing his low sense of self-worth from years of unsupportive partnerships). Pat disclosed that, in the context of his depressed mood, he felt emotionally “numb.” Most profound of all was Pat’s difficulty expressing in a congruent manner how his partner’s lack of reciprocal validation and support made him feel. While he was aware of the hurt he felt not receiving support and validation from Bob, he made light of it and often expressed these difficult emotions in an upbeat manner, thereby minimizing their emotional impact. Similarly, when Pat revealed that he was sexually molested by his older brother at a young age, he minimized his anger at his brother’s actions and their impact on his sense of self-worth. Pat clearly evidenced disconnection from his emotions in numerous contexts.

Therapeutic Writing Protocol

Cognitive Behavioral Therapy (CBT) was introduced as an evidence-based practice to address cognitive distortions that informed Pat’s depressive and anxious symptomatology. This modality served as the foundation of treatment, in addition to supportive psychotherapy. Pat was consistently engaged with each tenet of CBT, though he continually evidenced difficulty with emotional material. As Pat began attempting behavioral activation, he continued experiencing difficulties in accessing and expressing his emotions appropriately. Though he was actively engaged in recording maladaptive thoughts and engaging in pleasurable activities, he continued experiencing irritability, sadness, and angry outbursts more days than not. For instance, during session two Pat recounted responding angrily to a series of questions posed by a coworker concerning his past, a response he retrospectively knew to be incongruent to the situation.

It became apparent that Pat’s emotional dysregulation, mood disturbances, and anxiety were intrinsically associated with his unaddressed grief evidenced by his inability to discuss both the negative and positive aspects of his previous relationship. Bob’s passing and Pat’s subsequent alienation led to an internalization of emotions expressed vividly in kinetic ways – physical expressions of distress such as outbursts of anger, heart racing, tearfulness, and even weight gain. It was crucial to identify a conduit of communication that could assist Pat in processing his grief and the implications of his experiences. Considering Pat’s context was the first step toward the selection of an appropriate, evidence-based, supplementary therapeutic tool. For Pat, lack of autonomy was tied to his experiences (e.g., his inability to grieve) and associated with unresolved emotional expression. Therapeutic writing was chosen because it provided an opportunity for autonomous expression.

The first session focused on establishing a therapeutic relationship and better understanding Pat’s current difficulties and therapeutic concerns. In the second session, facilitated therapeutic writing was introduced as an evidence-based practice utilized for expression of emotion related to grief. Facilitated therapeutic writing was integrated in sessions three, four, and five as a means of processing emotional content discussed in the previous session, respectively. In the context of Pat’s grief, each therapeutic writing exercise was developed as a letter to himself or his partner, with the subject relating to emotional distress that informed Pat’s cognitive distortions and anxieties. For the current case study, we used the guidelines for therapeutic writing established by Pennebaker and Beall (1986) including: 1) the establishment of a writing topic for each letter, 2) the establishment of frequency (three consecutive sessions) and duration (15–20 minute writing periods, as much writing as was comfortable), 3) the establishment of length (letters could be as long or as short as time and comfort allow), and 4) the establishment of personal boundaries, including writing wholly for oneself and stopping when in severe distress.

The first therapeutic writing exercise was assigned in the second session. The letter was read at the beginning of the third session, and its content was processed through a CBT framework. Content that emanated from this therapeutic encounter provided the basis for the following exercise, and a topic was assigned accordingly. This process was repeated for the remaining two sessions. The three therapeutic writing exercises provided anchors with which to process, understand, and regulate emotional content, as well as begin to identify and challenge cognitive distortions and continue to develop skills to manage anxiety and depression.

Measures

Depression.

The 21-item Beck Depression Inventory-II (BDI-II) assesses the severity of depressive symptoms, with scores 0–9 representing minimal depressive symptoms; scores of 10–16 indicating mild depressive symptoms; scores of 17–29 indicating moderate depression; and scores of 30–63 representing severe depression. The BDI-II has high test-retest reliability (ρ = 0.93) and internal consistency (α = 0.91) (Wang & Gorenstein, 2013). This measure has also evidenced good internal consistency (α = 0.93) and fair test-retest reliability (ICC = 0.83) among a national sample of PWHA (Hobkirk et al., 2015).

Anxiety.

The State-Trait Anxiety Inventory (STAI) is a commonly used measure of trait and state anxiety (Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983) State anxiety items include: “I am tense; I am worried” and “I feel calm; I feel secure.” Trait anxiety items include: “I worry too much over something that really doesn’t matter” and “I am content; I am a steady person.” All items are rated on a 4-point scale (e.g., from “Almost Never” to “Almost Always”). Higher scores indicate greater anxiety. Extant literature does not describe specific psychometric properties for PWHA. However, in the general population, the internal consistency coefficients for this scale have ranged from.86 to.95; test-retest reliability coefficients have ranged from.65 to.75 over a 2-month interval (Spielberger et al., 1983).

Results

In the first letter, Pat began by expressing emotions of disappointment and anger at the larger construct of time. He then identified and took ownership of his emotions by reflecting and questioning what to do since so much time had passed and he had not yet processed his grief over the loss of Bob on his own terms. The content of this excerpt speaks to Pat’s continued difficulties expressing his concerns, emotions, and perspective on his relationship with Bob in the absence of an opportunity to properly mourn the relationship.

Therapeutic Writing Exercise 1, Session 3: A Letter of Sadness and Grief

Pat: [reading from his letter to himself] “You didn’t get time to grieve. One moment he’s there, the next he’s gone, and suddenly everything is different. You didn’t get to say goodbye to his parents, you didn’t get to put flowers at his tombstone. You didn’t get an apology, and you didn’t get anything back. Now you’re mad and it’s been so long. When are things going to change?”

Cartagena: That’s a powerful way to end your letter.

Pat: It felt powerful to write. There’s a lot there.

Cartagena: One of the things you expressed concern about in our first session was that you were feeling numb, or noticing there are moments where you feel less…

Pat: Less than I used to, yeah.

Cartagena: What did it feel like to write the letter?

Pat: It feels like I can breathe a little.

In the fourth session, Pat reflected specifically on his feelings of anger within the context of his partner’s emotional neglect toward him. Pat discussed the negotiation of a frustrating emotional dichotomy – feeling love for his partner and acknowledging that the pain endured in the relationship was detrimental to his wellbeing. During the session, Pat identified the mistrust in the relationship, stemming from the undisclosed transmission of HIV, as crucial component of his anger and his inability to let go of Bob. During this session, the therapist’s knowledge of HIV stigma enabled a deeper examination of the patient’s automatic cognitions and assumptions by providing a space in which there was validation of the vivid realities of disclosure, not only within the LGBTQ community, but also within an abusive partnership. In an already stigmatized community, distress can be exacerbated for PWHA. Furthermore, to disclose his status to others and engage with the world may not only incite discrimination among his coworkers, but also further any discrimination or shame Pat may have been projecting onto himself. Therapist knowledge, acknowledgment, and discussion of the HIV-related stigma that created Pat’s difficulties facilitated open conversations throughout the course of treatment. It also allowed for validating emotions and challenging cognitive distortions.

Therapeutic Writing Exercise 2, Session 4: A Letter of Anger

Cartagena: This past week, the focus [in reference to the content of the weekly letter] was anger. What was this process like for you?

Pat: This one was interesting. [pauses, then begins to read from the letter to his partner] “I’ve been so mad at you for years. Every time you said things would be different and I did not think of how any of it was affecting me. It hurt when you would lie to me. It hurt when other people knew that you were positive. That you gave it to me. And I kept going back because I love you. I still love you. We left things in a fight and I wish they had been different. You chose that life. You chose it over me. You always chose it over me. I’m so mad at you for it. I got so mad that I thought about [taking] a gun to your grave and shooting into the ground three times, just so I could let go. I want to start letting go of you.”

Cartagena: What did you feel when you wrote this?

Pat: I was mad all over again. I started feeling it come back.

Cartagena: How long has this been sitting in you?

Pat: A really long time. [pauses] You know, reading this now, the whole shooting thing sounds dramatic. I would never do it…

Cartagena: How does he still remain in the present?

Pat: When I don’t talk to people, when I stay locked in. When I’m afraid of what people say, that’s when I know he’s still around.

In the fifth session, Pat attempted to engage in a letter of self-worth and compassion to himself, reorienting the direction of his therapeutic writing. This proved to be the most difficult assignment for Pat to engage with, though it was the most formative in facilitating the insight and cognitive restructuring pivotal to CBT. Pat initially perceived his approach to the assignment as incomplete which opened up space for the therapist to engage him in self-compassion in vivo. This provided a foundation to process emotional difficulties associated with writing the letter, including negative cognitions about self, internalization of the relationship’s outcomes, as well as a sense of ‘tiredness’ in bearing the weight of his intense emotions.

Therapeutic Writing Exercise 3, Session 5: A Letter to Self

Cartagena: Looking back on the past week, the assignment was a letter of compassion. How was this for you?

Pat: I started trying to write it […] I didn’t think it would be so hard, but it was. I couldn’t write it. I couldn’t write anything for it.

Cartagena: What was the most difficult part for you?

Pat: I couldn’t think of ways to be […] compassionate to myself. I started [writing] stuff like, ‘You are kind,” “You are respectful.” I felt uncomfortable.

Cartagena: It sounds like you made good headway, but along the way you found yourself outside of your comfort zone. Tell me about that uncomfortable space.

Pat: I noticed it too much, I think. Last time [referring to the first letter written for session], we talked about the ways I describe myself. I describe myself sometimes for other people [referring to statements from previous sessions “I am a good friend/partner/employee”]. I realized I keep doing that.

Cartagena: It seems like as you wrote you reflected on what was coming out. That’s a lot to take in.

Pat: It was. I don’t like that I do that. I keep taking on the blame…

Cartagena: Blame from your previous relationship?

Pat: Yeah. I don’t believe myself when I say ‘I’m a good partner, I’m a good friend.’ I don’t believe any of that about myself. I got anxious when I started writing. Couldn’t finish. [pauses] And now I’m anxious because I didn’t really finish it.

Cartagena: You gave the letter your best effort when you attempted it. Do you think, maybe, even in trying to write it you learned just as much about yourself as if you were to write a whole letter?

Pat: Yeah, I guess you’re right. I realized I’m tired. I’m tired of talking about myself like that. I didn’t even know I do it that much.

Symptoms at Termination

Table 1 includes the baseline and termination scores for the BDI-II and STAI. Pat completed the BDI-II to assess his symptoms of depression within the past two weeks. Pat’s total score of 21 on the BDI-II is indicative of moderate symptoms of depression, the most prominent of which were fatigue, crying, loss of pleasure and interest, decreased energy, difficulty sleeping, and loss of interest in sex. Notably, he denied sadness and self-criticism, as well as feelings of past failure, guilt, and punishment. He denied suicidal ideation. On the STAI, a self-report measure assessing anxiety symptoms, Pat reported experiencing anxiety within normal limits at the time of the evaluation (State SS = 45, 36^th percentile), and trait (general) anxiety within normal limits (Trait SS = 45, 38^th percentile).

Table 1.

Depressive and Anxious Symptomatology Outcomes

	Baseline Score (%)	Interpretation	Termination Score (%)	Interpretation
Depressive Symptomatology
BDI-II (Raw)	21	Moderate	5	Minimal
Anxious Symptomatology
STAI State (Standardized)	45(36)	Elevated	38(12)	Minimal
STAI Trait (Standardized)	45(38)	Elevated	39(l5)	Minimal

With regard to depression, Pat noted feeling “pretty flat” and described “wasting the past five years of [his] life” Since Bob passed away. He reported experiencing significant symptoms of anhedonia, fatigue, tearfulness, and changes in appetite and sleep. His score on the BDI-II is reflective of moderate depressive symptoms. Though Pat denied experiencing overwhelming general worry, he noted feeling pronounced anxiety associated with attending social events. Pat saw significant decreases in symptoms of major depressive disorder as evidenced by self-report and his termination score of five on the BDI-II and standardized STAI scores. Upon termination, Pat described this process as formative and communicated an understanding that difficulties with self-worth and anxiety are lifelong but manageable using the tools he had developed over the course of psychotherapy. He expressed confidence in his ability to engage with and manage future difficulties, and he reported feeling like his “old self” again, engaging in activities he found pleasant and congruent with his values.

Discussion

At three-month follow-up, Pat reported improvements in his psychological and social functioning, as well as maintaining a positive outlook and elevated mood. He discussed recent frustrations, including a difficult vacation and instances of depressed mood with greater ease and congruence between his behavior and emotional expression. Pat reported he was able to manage his negative emotions by acknowledging them while using positive reframing and engagement in pleasurable activities to not become overwhelmed by them. He described his coping strategies which included planning new activities with friends/family and engaging in self-care (e.g., exercising, shopping, etc.) he finds relaxing. This approach has allowed him to reappraise situations, contemplate solutions, and reduce depressive and anxiety symptoms. Furthermore, Pat reported that he was able to disclose his past relationship to friends he’d recently met without feeling shame or regret. He further reported that he is able to look at old photographs of himself and his partner and smile, acknowledging “what used to be.” While the loss of a partner is a common human experience, the ramifications of this loss are magnified for both LGBTQ+ individuals and PWHA, providing significant stressors that require concerted efforts in therapy. It is necessary for a therapist to be mindful that both PWHA and LGBTQ+ may have additional or different care needs due to stigmatization and the nature of their support systems. It is essential that the therapeutic process carefully explore the relationship and the bereaved individual’s identity, including the degree to which the relationship and its facets were disclosed and acknowledged in life. As seen in the case of Pat, through the process of integrating careful questioning that acknowledged his former identity in the partnership, avoiding heteronormative assumptions about the bereavement process, and asking sensitive questions about how social forces provided or did not provide support, the therapist created a safe environment for him to process his grief. However, additional intervention beyond in session processing was needed to address unprocessed emotions. Therapeutic writing served as an ideal tool in this case to facilitate emotion processing.

Specific to HIV, a study by Petrie and colleagues (2004) found that PWHA who were randomized to a therapeutic writing intervention showed increased in CD41 T lymphocyte cell counts compared to those in the control group whose writing did not involve emotional content. Therapeutic writing has also been shown to improve depressed mood among PWHA (Kraaij et al., 2010). More recently, Ironson et al. (2013) found that women living with HIV who had experienced trauma who were randomized to the therapeutic writing condition showed a reduction in symptoms of posttraumatic stress disorder, depression, and HIV-related symptoms compared to women in the control group. However, the evidence for men living with HIV has been mixed (Ironson et al., 2013; Carrico et al., 2015). Ironson and colleagues (2013) found that men living with HIV in the control condition who were told to write about their daily lives had significant reductions in depressive mood versus men who were told to write about a traumatic event. Similarly, Carrico and colleagues (2015) found that acceptability of the therapeutic writing intervention was high among men who have sex with men living with HIV. However, men in the control condition reported greater decrease in HIV-related traumatic stress than men in the control condition who again wrote about general daily life. While men in the intervention condition did not show a reduction in HIV-related traumatic stress, men in the intervention condition showed decreased stimulant use (for a limited time period) compared to men in the control condition. Rivkin and colleagues (2006) found that in examining adjustment to HIV those told to write about their day found the process just as valuable as those instructed to examine the trauma of adjustment to status. Taken together, this evidence suggests that therapeutic writing can be a beneficial tool to process emotions in the context of a more comprehensive approach to treatment.

Limitations

There are several limitations of the current case study worthy of note. First, due to the limited space, we condensed twelve 50–60 minute psychotherapy sessions into a few paragraphs, which means meaningful points of change have been omitted for brevity and continuity. Further, the sessions contained other subjects not discussed in the current presentation such as coping with aging parents, childhood sexual abuse, and managing familial demands and sibling confrontations. Additionally, Pat did not have a linear progression in treatment, with depressive symptom remittance coming early in session 3 but rebounding with ferocity in session 5 and a more realistic management of depressive symptomatology manifesting in sessions 9–12. We also did not obtain clinical measures at every session as that is not our standard practice. Measures used were clinically valid and normed clinical cutoffs were used as evidence of improvement, however these were not specific to PWHA. And finally, it is important to note that additional research is needed for best practices for using therapeutic writing with men living with HIV.

Summary

An environment of acceptance and support can facilitate a therapeutic rapport that provides high-quality individualized care to PWHA who are adjusting to loss. Important aspects of the process in this case were establishing an understanding of the writing process, building in flexibility and openness in the therapeutic writing process, establishing consistent attempts at writing, and utilizing writing exercises and attempts as anchors for processing emotions and engaging in further CBT. In this case, encouraging flexibility in writing allowed Pat to engage with therapeutic writing in a way that was most comfortable for him. Furthermore, this allowed him to openly express and negotiate thoughts and emotions that are often difficult to process.

Clinical Impact Statement.

Question:

Can therapeutic writing enhance emotional processing in the context of partner loss among people with HIV/AIDS?

Findings:

Therapeutic writing can be added to a comprehensive treatment approach to deepen emotional processing.

Meaning:

A tailored facilitated writing protocol is beneficial in processing loss and grief in the context of living with HIV.

Next Steps:

It is important to examine how gender differences influence how patients interact with and benefit from therapeutic writing protocols.