mental health AIDS

Fall 2006 Newsletter / Volume 8, Issue 1

New Thinking on Not Thinking About HIV Risk

"Theories underpinning HIV prevention generally do not
account for ... nonrational aspects of sexuality ..."
                                                                                                           –– Martin, 2006, p. 214
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In 1996, McKirnan, Ostrow, and Hope observed that "[e]xplanatory models that link [HIV-related] risk-taking and prevention to rational processes such as knowledge, social norms, behavioural intentions, or perceived vulnerability to infection ... cannot fully account for the continued risk behaviours observed in virtually all cohorts of gay men" and that "innovative conceptions of risk and risk prevention are needed, that emphasize non-rational, affective processes in risk-taking and decision-making" (p. 655).

McKirnan and colleagues further contend that "for many people risk behavior is not the result of limited resources, misinformation, or inappropriate attitudes. Rather, many people find it aversive to be continually aware of HIV and restrictive sexual norms. By cognitively 'escaping' from this awareness, they may be particularly vulnerable to sexual risk. Alcohol or drug use, or the approach of highly stimulating sexual contexts, may facilitate this cognitive escape" (p. 656).

an attempt to control cognitive activity through conscious escape (suppression) activates the "unconscious ironic monitoring process," which searches the ... [unconscious] to catch the unwanted thought before it breaks through to conscious awareness. The result is that the very thoughts that are least desirable become more highly accessible to the conscious mind, and more difficult to avoid, than would occur without suppression (hence the term ironic). Individuals who attempt to suppress certain thoughts soon become overwhelmingly preoccupied with them ... . This in turn may lead to increased unwanted emotional, cognitive, and behavioral expression so that cognitive escape might, in fact, be a pathway to risk behaviors and other negative affective and cognitive consequences. (Hoyt, Nemeroff, & Huebner, 2006, p. 456)

In their synthesis of these two areas of investigation, Hoyt and colleagues "hypothesized that thought suppression might increase risk by leading MSM [men who have sex with men] to 'escape' from sexual safety norms and engage in risky sex behaviors and, via a paradoxical process, increase future use of community prevention services" (p. 455). To test out this hypothesis, Hoyt and colleagues surveyed a convenience sample of MSM at baseline (n = 709) and again approximately 6 months later (n = 399).

As expected, ... findings suggest that suppressing HIV-related thoughts is associated with concurrent, but not future increased sexual risk behavior. Conversely, thought suppression was associated with future increased use of HIV/AIDS-related community prevention services yet not concurrent use of these services. Although the magnitude of effects observed in this study is small, this pattern of results supports the hypothesized framework, in which suppressing HIV-related thoughts is associated with current health risk behavior and a later rebound in attending to protective and preventive services. (Hoyt, Nemeroff, & Huebner, 2006, pp. 458-459)

Hoyt and colleagues conclude that, "[a]lthough thought suppression may be only one component of a more broadly conceptualized phenomenon of cognitive escape ..., the present study provides support for the association between cognitive escape and risk behavior, as thought suppression may lead to slips in safety practices that might otherwise be maintained" (p. 459).

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"The importance of the cognitive variable would not be predicted
on the basis of any well-recognized theory of HIV risk behavior ..."
                                                    –– Stacy, Ames, Ullman, Zogg, & Leigh, 2006, p. 204

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Cruising on Automatic

Stacy, Ames, Ullman, Zogg, and Leigh (2006) enlarge this focus on the relationship between cognition and HIV risk behavior in their recent reporting on the phenomenon of "spontaneous cognition." According to these investigators, "spontaneous forms of cognition ... do not address or encourage consideration of pros or cons, judgments of effects, self-perceptions, or other processes characteristic of executive control functions ... . The focus is simply on activation of content in memory ... " (p. 196). "Risk-consistent spontaneous cognitions ... represent both chronically accessible cognitions and cognitions that are readily prompted by related cues. In both cases, these cognitions are ... important for risk behavior because they color one's train of thought, delimit the range of behavioral options available for subsequent processing, and essentially steer behavior in the direction of risky actions" (p. 197).

Stacy and colleagues administered three measures of spontaneous cognition (i.e., a letter-completion task, a behavior-completion task, and an event-completion task, in each of which sex-related responses were noted) to an ethnically diverse sample of 502 adults participating in drug diversion and drug treatment programs in greater Los Angeles. Additional measures focused on impulsivity, sensation seeking, acculturation, drug use, and sexual behavior. All measures were completed anonymously.

Importantly, Stacy and colleagues found that

spontaneous cognition has statistically predictive effects on risk tendencies, even in competition with much more frequently emphasized constructs of major focus in HIV-related research. Spontaneous cognition was a better independent predictor of HIV risk behavior tendencies overall than was drug use, which is often a focus of sex-related research. Spontaneous cognition is not merely a symptom of problem behaviors associated with drug use. The independent predictive effects of spontaneous cognition usually were comparable with the prediction power of sensation seeking, a personality trait frequently related to HIV risk behavior. Spontaneous cognition also fared well when investigated after adjusting for a range of other variables, including possible ethnic or acculturation effects. (p. 203)

Stacy and colleagues anticipate that "[f]uture research may further elucidate the process through which spontaneous cognition and risky sex are linked" (p. 205). The investigators expect that such research efforts "should advance theories relating basic processes to behavior as well as interventions that typically focus only on explicit cognition or rational models of a frequently irrational behavior" (p. 205).

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"Under conditions of cognitive disengagement, knowledge or intentions,
no matter how appropriate, cannot have a decisive influence on behaviour."
                                                                    –– McKirnan, Ostrow, & Hope, 1996, p. 666
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Countering Cognitive Disengagement

Anticipating the above-referenced research on spontaneous cognition, McKirnan and colleagues suggest that "negative affect over HIV may lead people to 'cognitively disengage' within the sexual situation, ... not ... follow their norms or intentions toward safety[, and instead] ... enact 'automatic' sexual scripts and/or become more responsive to external pressures toward risk" (p. 655). Moreover, "[i]f HIV-related thought suppression is associated with sexual risk behaviors," reason Hoyt and colleagues, "this cognitive process could be systematically undermining education and prevention efforts" (p. 456).

Speaking to education efforts, Gold (2000) shares this concern, contending that "the beliefs [regarding sexual risk] that are accessible at the time [AIDS] education is being received – the beliefs with which ... [information] comes into contact, as it were – are 'cold light of day' beliefs. To the extent that self-justifications [for risky sexual behavior] arise out of reasoning that is rejected in the cold light of day, they may be untouched by the educational information; the information may just pass the self-justifications by" (pp. 269-270).

Therefore, according to Gold, "AIDS education needs to make contact ... with the reasoning that is present during actual sexual encounters" (p. 270), as it is this reasoning, in his view, that enables high-risk sexual behavior to proceed. Gold examined "studies in which gay men who had engaged in unprotected anal intercourse recalled the occasion concerned in detail, including any self-justifications they had used; and ... controlled intervention studies, in which gay men who had engaged in unprotected anal intercourse were confronted with the thinking they had employed in the heat of the moment" (p. 267). Drawing on these studies, Gold proposes that "(1) at the time they are deciding to have high-risk sex, gay men generally engage in an 'internal dialogue' that justifies this decision to themselves; (2) the AIDS-related thinking underpinning such self-justifications can differ appreciably from the AIDS-related thinking that takes place outside the sexual context; and (3) AIDS education can profitably exploit this difference between 'heat of the moment' and 'cold light of day' thinking" (p. 267).

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"Clinical interventions should promote adaptive coping strategies
that emphasize maintaining healthy behavior, effective
problem solving skills, and stress management techniques."
                                                                                   –– Brady & Donenberg, 2006, p. 673
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Waking Up One's Mind

Referencing their findings and, in particular, the small magnitude of effect sizes overall, Hoyt and colleagues suspect that

thought suppression is relatively less important for some individuals and more important for others. Recent research suggests that individually tailored interventions might more effectively address individual differences in risk factors for HIV infection ... . Such individualized clinical interventions could focus on fostering alternative coping responses to thought suppression (e.g., accessing social support, cognitive restructuring strategies to alter fear appraisal) and might be appropriate adjuncts to current prevention efforts. Further, expressive writing interventions specific to HIV prevention that are designed to address threat appraisal, as well as targeting moments of sexual safety decision making may also prove effective. (p. 460)

In planning an intervention, McKirnan and colleagues observe that "[a]n escape model raises paradoxes for both the structure and the content of HIV prevention. If people are motivated to not be aware of HIV risk, how do we structure HIV interventions so that people will be willing to participate? As well, intervention content that stresses the danger of unsafe sex may, by increasing anxiety, make self-awareness of HIV risk even more aversive, and cognitive escape from such awareness more appealing" (p. 663).

As with psychotherapy generally ..., most intensive HIV prevention programmes consist of several common factors: information, behavioural skills training, identification and problem-solving for individual risk patterns, group or normative feedback about risk, a non-judgemental atmosphere, and a comprehensible 'model' of how risk occurs ... . By increasing commitment to prevention and fostering behavioural skills these basic ingredients are integral to any structured intervention approach.

An escape perspective adds to cognitive-behavioural or related approaches the concept that whatever a person's skills or commitment to safety, in the 'real world' of sexual interactions specific moods or sexual contexts may lead him temporarily to abandon the larger safer sex enterprise. Further, extremely strong intentions to be safe may actually increase escape motivation by increasing anxiety or inducing shame over previous risk-taking. Getting high-risk men to recognize that cognitive escape may be implicit in certain patterns of substance use or sexual activity, and to recognize the precursors of an escape process, may enable them to apply their safer sex strategies more consistently.

Of course for some men safer sex is itself an 'automatic' response, and cognitive disengagement is not a health risk. Alternatively some men may simply decide, within a perfectly mindful state, to be risky. However, ... [McKirnan and colleagues] propose that for many men the most immediate 'cause' of risk is not a decision to be unsafe, but temporary cognitive disengagement regarding HIV. In this view, effective interventions must not simply strengthen skills or intentions, but must include strategies for maintaining self-awareness in very high-risk settings or states of mind.

An escape-based intensive intervention attempts to induce awareness that using sex or drugs to become cognitively disengaged is not 'accidental', but reflects a larger pattern of cognitive disengagement and risk, particularly among men who combine substance use with sex. As with motivational interviewing or cognitive-behavioural approaches, participants must 'deconstruct' recent episodes of sexual risk to articulate their personal risk pattern, i.e., in terms of settings, partners, or other elements that make sexual control difficult. Unlike more standard approaches, an escape-based intervention assists men to understand not simply the conditions under which they are risky, but when they become 'mindless' about sexual risk. Thus, intervention materials attempt to clarify the moods and emotions, as well as expectancies and coping styles, that make men vulnerable to a pattern of cognitive escape.

The escape framework ... posits that awareness of HIV risk induces negative affect, and safety requires 'effortful' cognitive restraint that detracts from the immediate sexual experience. This makes cognitive escape during sex attractive. Vulnerability for a particular form of cognitive escape depends upon other variables, such [as] the expectancy that substance use reduces anxiety, a sensation-seeking or avoidant coping style, low self-esteem, or a risk-oriented social network. High vulnerability for escape may lead men to be responsive to – or actively approach – situations where they have learned to be cognitively disengaged during sex, e.g., specific settings, partners, or substance use. Risk patterns may be lessened through structured exercises to self-diagnose personal vulnerabilities, plus directed behavioural skills, training in self-monitoring, substance use control strategies, or interventions to alter coping styles or social networks. (McKirnan, Ostrow, & Hope, 1996, p. 665)

In short, according to McKirnan and colleagues, "[r]ather than simply strengthening resolve to 'be safe', interventions should assist people to remain mindful of their safety standards while 'in the trenches' of the sexual situation" (p. 666).

References

Brady, S.S., & Donenberg, G.R. (2006). Mechanisms linking violence exposure to health risk behavior in adolescence: Motivation to cope and sensation seeking. Journal of the American Academy of Child & Adolescent Psychiatry, 45(6), 673-680.

Gold, R.S. (2000). AIDS education for gay men: Towards a more cognitive approach. AIDS Care, 12(3), 267-272.

Hoyt, M.A., Nemeroff, C.J., & Huebner, D.M. (2006). The effects of HIV-related thought suppression on risk behavior: Cognitive escape in men who have sex with men. Health Psychology, 25(4), 455-461.

Martin, J.I. (2006). Transcendence among gay men: Implications for HIV prevention. Sexualities, 9(2), 214-235.

McKirnan, D.J., Ostrow, D.G., & Hope, B. (1996). Sex, drugs and escape: A psychological model of HIV-risk sexual behaviours. AIDS Care, 8(6), 655-669.

Stacy, A.W., Ames, S.L., Ullman, J.B., Zogg, J.B., & Leigh, B.C. (2006). Spontaneous cognition and HIV risk behavior. Psychology of Addictive Behavior, 20(2), 196-206.

– Compiled by Abraham Feingold, Psy.D.

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