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Stress Management
Sikkema et al. (2007) conducted a randomized controlled trial of a group intervention for coping with HIV/AIDS and childhood sexual abuse (CSA). A total of 202 men and women living with HIV – diverse with regard to ethnicity and sexual orientation, as well as gender – who had also been sexually abused as children, were "randomly assigned to one of three conditions: the HIV and trauma coping group experimental intervention, an HIV time-matched support group comparison condition, or a waitlist control condition. ... In both group conditions, co-therapists delivered the interventions in a local community health center over a course of 15 weekly 90-min sessions" (p. 52).
In the HIV and trauma coping group intervention,
[p]articipants identified stressors that they perceived to be related to their sexual abuse experiences and those related to their HIV diagnosis. Parallels between these two traumatic experiences in terms of stress response and coping strategies were emphasized and processed during group discussion. For instance, participants expressed that, when diagnosed with HIV, they felt just as powerless as they had felt when sexually abused as children. Results of coping efforts were then reappraised and new coping strategies tried if results were not satisfactory. (p. 52)
Study participants assigned to the waitlist control condition were later randomly assigned to either the coping intervention or support group comparison condition. "Traumatic stress symptoms were assessed at baseline and post-intervention, with analysis conducted for the three-condition comparison followed by analysis of the two-condition comparison between the coping and support group interventions" (p. 49). Sikkema and colleagues report that
[t]he HIV and trauma coping group intervention significantly reduced symptoms of traumatic stress when compared to both ... [the] support group comparison and waitlist control condition within the respective three- and two-condition phases of the study. … [I]n the two-condition comparison, both intervention[s] … reduced intrusive symptoms, likely at least partially attributable to desensitization achieved through actively addressing traumatic experiences in the groups. However, only the coping intervention, and not the support group intervention, demonstrated significant change in intrusive symptoms when compared to the waitlist control condition in the three-condition comparison. Additionally, the coping intervention, which focused on active approaches to confronting and coping with stress, provided the most benefit in addressing avoidance symptoms, particularly in the two-condition comparison. ...
Further, in a test of clinical significance, individuals in the HIV and trauma coping group intervention condition were more likely to show recovery or reliable improvement in traumatic stress symptoms. These results not only confirm the effectiveness of the coping intervention ..., but also document the meaningfulness of the change in symptoms experienced. Clinically significant change was evidenced by 50% of participants receiving the coping intervention ... . (p. 57)
The investigators conclude that "a group intervention tailored for coping with CSA and HIV/AIDS is beneficial in reducing traumatic stress among both men and women with HIV disease. This type of treatment approach provides an integration of interventions currently available to address CSA and HIV mental health issues, and thus extends the limited number of effective interventions available for those with HIV/AIDS that are facing multiple stressors, including sexual trauma" (p. 58).
Care for Caregivers
Engler et al. (2006)
examined the role of coping in the experience of caregiver burden among a heterogeneous sample of [176] caregivers for [persons living with HIV]. The results indicated that three types of coping – blame-withdrawal, active-approach, and distancing – were significantly positively correlated with caregiver burden. Furthermore, active-approach and distancing coping moderated the relationship between caregiver stress and caregiver burden even after controlling for demographic variables and caregiver depression; blame-withdrawal coping approached significance. (p. 990)
Engler and colleagues conclude from these findings that
caregivers' coping mitigated the effects of stress on burden; as coping efforts increased, the impact of stress on burden decreased. Still, some caregivers were likely to experience burden even at low levels of stress or caregiver demand. That is, despite perceiving few HIV symptoms in the [person living with HIV], a subset of caregivers reported high levels of caregiver burden. This is an important finding given that the majority of the caregivers reported relatively low levels of stress from the [person living with HIV]'s symptoms in the era of HAART in which patient symptoms and immunosuppression are better controlled. ... These results ... seem to suggest that caregivers may benefit from any attempt to cope with stress. Healthcare providers may facilitate this process when working with people living with HIV and their informal caregivers. (p. 990)
Coping, Social Support, & Quality of Life
Dutch investigators (van der Veek, Kraaij, Van Koppen, Garnefski, & Joekes, 2007) explored relationships among cognitive coping, frustration in the attainment of higher-order goals (e.g., "being as healthy as possible"; "experiencing as little bodily discomfort or pain as possible"; "being ill as little as possible") and psychological distress in a sample of 43 adults living with HIV who were members of HIV societies in the Netherlands. The investigators found that study "[p]articipants who reported more higher-order goal hindrance ... also reported more depressive symptoms and a reduced quality of life" (p. 228). van der Veek and colleagues conclude that clinicians "may usefully pay attention to disturbance[s] in [the] attainment of higher-order goals, which ... result from the illness itself, the medical regimen or related side-effects. Patients might also benefit from support in the process of abandoning unattainable goals and (re)formulating new, realistic goals" (p. 228).
Remien et al. (2006) interviewed an ethnically diverse, predominantly low-income sample of 978 women living with HIV in four U.S. cities (New York, Los Angeles, San Francisco, and Milwaukee) and found that study participants self-identified high levels of depressive symptomatology. In fact,
[f]orty-one percent of women reported moderate to severe levels of depression. ... The findings ... suggest that women living with HIV, especially those who are socially and economically marginalized, continue to experience significant distress, even when they receive ongoing medical care and have access to HAART. While there was no relationship between depression and HAART utilization or standard clinical markers of disease status (i.e., CD4+ count or detectable/undetectable viral load), depressive symptomatology was related to the experience of physical symptoms of disease and the degree of perceived intrusiveness of these symptoms. This suggests that the women in this study were more distressed by the experience of feeling sick than by the biological markers of disease progression that clinicians deem to be most relevant. Increased viral load and decreased CD4+ count are not necessarily accompanied by feelings of illness. The overall high levels of depressive symptoms in this sample suggest that clinicians working with HIV-positive women should consistently inquire about physical symptoms of illness, their level of "bother" and associated feelings of distress, in the course of routine evaluation, regardless of health status as measured by routine laboratory markers. (p. 281)
The investigators also found that
stress mediate[d] ... the effects of symptoms and illness intrusiveness, and that coping mediate[d] ... the effects of social ... [support] on depression, strongly suggest[ing] ... that interventions that enhance coping skills are important to help women better utilize their social resources and manage stress, and thereby, reduce the negative impact of poor physical health on mental health. Thus, although health status (i.e., physical symptoms) and stress can lead to depressive symptoms, it should not be accepted as a given that depression is an inevitable outcome of poor health in the context of HIV illness or that a greater frequency of HIV-related physical symptoms should necessarily lead to the experience of depressed symptomatology for women living with HIV. ... [These] results also underscore the importance of understanding factors associated with better coping and ways to enhance self-efficacy for coping among HIV-positive women. It seems that the level of confidence in one's ability to effectively handle stress influences the extent to which supportive resources are utilized, and ... can directly influence depression. (p. 282)
In closing, Remien and colleagues point out that these findings highlight "the need for the routine integration of mental health services into HIV primary care settings ... [and] the widespread need for psychological support and ongoing mental health services for women living with HIV. ... In addition to current standard mental health interventions, peer support (either one-on-one or in group) and counselor and volunteer led HIV support groups, common in many community[-]based organizations across the country, can be more formally linked to standard medical treatment and referral practices" (pp. 282-283).
On the topic of social support, Emlet (2006) conducted interviews to examine social networks and social isolation in two matched samples: 44 older adults (ages 50 and older) living with HIV/AIDS and 44 younger adults (ages 20-39) living with HIV/AIDS in the Pacific Northwest. The investigator found that "[b]oth groups' social networks had similar patterns; however, older adults were more likely to live alone. More than 38 percent of older adults and 54 percent of older adults of color were at risk of social isolation compared with 25 percent of those 20 to 39 years of age. Older men and older adults of color had significantly lower scores on the social network scale than others. Having a confidant and receiving instrumental support were significantly correlated with reduced HIV stigma" (p. 299). These findings, according to Emlet,
suggest that age, coupled with race, ethnicity, or gender, can further affect the potential for social isolation. Therefore, ... [clinicians] can and should respectfully ask older clients if they have questions or concerns about HIV or AIDS, thereby normalizing the issue and giving the client permission to speak about it[.] ... [In work] with HIV-infected clients, particularly older individuals, systematic methods should be used for assessing sources of social support. The most abbreviated version of the LSNS [Lubben Social Network Scale] (six items) ... is an example of a short, clinically oriented scale that can be easily administered as part of the standardized assessment and takes less than five minutes to complete. HIV-related stigma in all populations infected or affected by HIV should be carefully considered, and any potential negative impact of stigma addressed. At a very practical level, ... [clinicians] need to be knowledgeable about services funded through mechanisms such as the Older Americans Act and the Ryan White CARE Act to provide referrals to formal services. Formal services may augment or take the place of lacking informal networks. (pp. 306-307)
Lastly, Mphande-Finn and Sommers-Flanagan (2007) analyzed interview data provided by 7 white women living with HIV/AIDS in rural communities in the northwestern United States. "Based on these interviews, eight themes emerged. These included (a) daily powerful emotions, (b) emotional and physical abandonment, (c) romantic betrayal, (d) medical treatment issues, (e) loss and grief, (f) appreciating a good support system, (g) renewed purpose for living, and (h) personal growth and transformation" (p. 3). The investigators translate these findings into a number of treatment recommendations:
The identification and articulation of powerful emotions ... may occur on a daily basis. Community-based interventions, particularly for women, may be enhanced if services are constructed so as to allow regular emotional exploration and expression ... .
The women spoke about the abandonment they experienced following their ... diagnoses. This suggests that it may be helpful for women to prepare for abandonment related to the HIV/AIDS diagnoses and to have more social-emotional support systems in place before and during their disease experience. They also might benefit from analyzing and expanding their own support-seeking behavioral repertoire ... .
Rural women are most likely to contract HIV/AIDS from heterosexual intercourse ... . In this small rural sample, the women were universally infected by long-term romantic partners. When women contract HIV from partners, they may benefit from directly working through the deep feelings of betrayal that are likely to emerge ... .
The women were clear about the burden of their medical/health issues, experience of grief and loss, and appreciation of support from individuals and health care systems. ... Some women … may [therefore] benefit from structured support groups in the medical care system focusing, in part, on grief, loss, betrayal, and other deep feelings ... .
Perhaps the most interesting findings in this study were the themes of renewed purpose for living and personal growth and transformation. This suggests that for some rural women with HIV/AIDS, the news is not all bad. ... It is reasonable to conclude that some women who contract HIV/AIDS may feel an urge to contribute to society. It may be appropriate for health care and mental health professionals to cultivate this impulse in ... women [living with HIV/AIDS].
Rural settings include unique obstacles to … prevention and treatment ... . Acquiring treatment may be difficult, and rural … patients often travel hours to obtain medical care because getting tested for HIV, discussing sexual practices with health care providers, and practicing safe[r] sex are difficult to do privately near their homes ... . If these obstacles are overcome, rural women might move more quickly toward renewed purpose and personal growth. There may be a link between rural women who receive social-medical-psychological support and regaining hope, trust, and a desire to contribute to community ... . (pp. 9-10)
– Compiled by Abraham Feingold, Psy.D.
__________
1 "The intervention consisted of 5 weekly individual counseling sessions (90-min each) followed by 3 booster sessions at three-week intervals (90-min each), which were designed to reinforce behavior change. ... [S]kill-training was used to help participants increase their knowledge, self-efficacy, and positive outcome expectancies in relation to a number of critical areas such as condom use, negotiation of safer sex practices (including sexual assertiveness), and disclosure of HIV serostatus to sex partners. The mechanisms of behavioral change involved observation, role modeling, skill performance (i.e., practice and rehearsal), positive feedback, reinforcement, and the development of supportive referents. The intervention was not designed to arrest or abate drug use. Instead, the focus was to reduce high risk sexual practices of [meth]-using HIV-positive MSM. Therefore, the behavioral strategies mentioned above were placed in the context of drug use. For example, the participant and counselor discussed how the use of [meth] interferes with motivation and preparedness for safer sex. Participants problem-solved ways in which they could be prepared to practice safer sex or how they could lower risk levels in the context of drug use (i.e., ... seeking out HIV-positive partners, practicing oral sex instead of anal sex, limiting number and type of sex partners)" (p. 251).
2 "Childhood trauma was measured with eight indicators representing a multiagent perspective on childhood abuse: (a) lifetime trauma (Traumatic Stress Schedule) ..., (b) documented physical abuse, (c) documented sexual abuse, (d) self-reported sexual abuse (Childhood Sexual Experiences Questionnaire) ..., (e) the witnessing of domestic violence, (f) the experience of parent incarceration, (g) the number of parental transitions, and (h) the number of our-of-home placements" (p. 348).
3 For more information on this topic, see the Tool Box in the Summer 2003 issue of mental health AIDS entitled "Remain Objective Regarding Subjective, HIV-Related Cognitive Complaints."
4 "Among adolescents who have not been told of their mothers' HIV infection, support may be just as crucial for them as for adolescents who have been informed of their mothers' serostatus. For such adolescents in ... [this] sample, as for those to whom disclosure has been made, participation in delinquent acts occurred less frequently among those who had greater attachment to either their mother or their peers. However, unlike those who were told of their mother's HIV infection, adolescents to whom disclosure had not been made were more likely to participate in delinquent acts when they were older and when they had a boyfriend or girlfriend, and having a boyfriend or girlfriend occurred more frequently among those who scored lower on attachment to their mothers. It may be that older adolescents who had not been informed of their mothers' HIV serostatus were more likely than their younger counterparts to be aware that something was amiss with their mothers, and this awareness may have triggered externalizing behavior among those who were less engaged with their mothers but more engaged with, and perhaps dependent upon, their peers. In contrast, among adolescents who knew their mothers' HIV status, participation in delinquent acts appeared to be more of a reaction to their mothers' poor physical or mental health and to be less related to what was going on in the adolescent's life outside the family" (p. 38).
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Spring 2007 Newsletter / Volume 8, Issue 3
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