Psychotherapy and HIV: Assessment and Intervention

1. Psychotherapy and HIV: Assessment and Intervention PHASE, Canadian Psychological Association and Health CanadaModule developed by Paul C. Veilleux, Ph.D. UHRESS - Centre Hospitalier de l’Université de Montréal Montreal, Quebec

2. HIV and CD4 Cell Counts Typicalof an Untreated HIV Infection

3. CDC Criteria for Diagnosisof AIDS

4. HAART • Highly active antiretroviral therapies (HAART) consist typically of one protease inhibitor and two reverse transcriptase inhibitors, although four drugs and more combinations may also be used. • HAART alone requires as many as 20 pills or more to be taken on a strict schedule. Required adherence is about 90%.

5. HAART • Highly active antiretroviral therapies • Adherence to treatment regimens • Renewed hope and optimism • Coping with treatment failures • Prevention implications

6. Ethical Issue • Non-adherence to HAART jeopardizes the effectiveness of the medication for the patient and also for anyone to whom the person might transmit a drug-resistant strain of HIV. • Younger age, substance abuse and mental illness are risk factors related to non-adherence.

7. Factors Related to Adherence With Treatment Regimens • Complexity of regimen • Beliefs and perceptions about treatment efficacy • Trusting and stable relationships with physicians and other providers • Participation and involvement in treatment decisions.

8. Factors Related to Adherence With Treatment Regimens • Negative factors • Younger men with lower socio-economic status • Unstable housing • Substance abuse • Serious mental illness • Neurocognitive deficits

9. Counselling, Psychotherapy and Adherence • Counselling and psychotherapy may play an important role in medication adherence • Behavioral medicine (daily reminders, scheduling techniques, timers, memory aids) • Cognitive restructuring, self-exploration (personal goals clarification, motivation issues and medical treatment, readiness of client to adhere to treatment, client-physician relationship, etc.).

10. A thorough assessment is essential. • The assessment must address the psychological, medical and social situation of the person, which provides useful knowledge in two ways (Winiarski, 1991) : • Is the fit right? Can the psychologist provide what is needed or should he or she refer? • The assessment provides a baseline against which to gauge psychological, cognitive and other medical changes in the future.

11. Intake Assessment The assessment must include: • Medical condition • Current status of HIV, HIV-related illnesses, name of the physician and members of the treatment team, current prescriptions, treatment adherence, response to treatment • Patient’s knowledge about his or her medical condition con’t

12. Intake Assessment The assessment must include: • Medical condition • Circumstances of transmission • How and when diagnosed, and how he of she reacted at that time • Perception of disease progression • Beliefs about diagnosis • Role changes due to HIV • Knowledge about HIV

13. Intake Assessment • Cognitive functioning • This aspect is useful for monitoring future cognitive functioning of the patient. Cognitive functions can be altered by infections, the virus itself or medication.

14. Intake Assessment • Psychiatric/psychological history • Diagnoses for Axis I and II disorders. • Consider the possibility that the disorder could have organic sources. • Assess suicidal ideation and intent.

15. Intake Assessment • History of substance use and abuse • Any experience with alcohol, heroin, cocaine or other drugs? Assess type of drug, frequency and mode of use (inhalation, injection). • Past treatment for drug use? When? How often? How well did it work? For how long?

16. Intake Assessment • Sexual functioning, past and current • Heterosexual, homosexual, bisexual • Monogamy, casual sex, number of partners. • Have sexual behaviours changed since the diagnosis? • Practicing safer sex? • Past history of sexual abuse (incest, rape).

17. Intake Assessment • Psychosocial background • Social support (family, friends, partner)? Who to contact in an emergency? • Social isolation? If yes, what is the cause (schizoid, depression)? • Does he or she get help at home with the chores?

18. Individual’s Life Situation • Circumstance of transmission • How and when diagnosed? • How did the person react to the announcement? • Perception of disease progression. • Beliefs about prognosis • Role changes due to HIV • Knowledge about HIV

19. Adaptation to HIV • Emotional • Cognitive • Behavioural

20. Diagnosis can be difficult... • Is it depression? • Or a side effect of medication ? • Or due to HIV ?

21. AZT (antiretoviral) Headaches, feeling ill, asthenia, insomnia, dreams, agitation, mania, auditory hallucinations, confusion Headaches, asthenia, feeling ill, confusion, depression, convulsions, excitability, anxiety, mania, early wakening, insomnia Is it an adverse drug reaction? • d4T (antiretrovirale)

22. Ddc (antiretroviral) Headaches, confusion, trouble concentrating, somnolence, asthenia, depression, convulsions, peripheral neuropathy Nervousness, anxiety, confusion, convulsions, insomnia, peripheral neuropathy, pain Insomnia, delirium Is it an adverse drug reaction? • ddI (antiretroviral) • 3TC (antiretrovirale)

23. Acyclovir (herpes encephalitis) Visual hallucinations, depersonalization, tearfulness,confusion, thought insertion,insomnia Delirium, peripheral neuropathy Paresthesia, convulsions, headaches, irritability, hallucinations, confusion Is it an adverse drug reaction? • Amphotericine B (cryptococcosis) • Foscarnet (Cytomegalovirus)

24. Beta-lactamines (infections) Co-trimozacole (PPC) Cycloserine (tuberculose) Confusion, paranoia, hallucinations, mania, coma Depression, loss of appetite, insomnia, apathy Psychosis, somnolence, depression, confusion, shaking, vertigo, paresia, convulsions Is it an adverse drug reaction?

25. Interferon (Kaposi’s sarcoma) Depression, weakness, headaches, myalgia, confusion Confusion, anxiety, emotional lability, hallucinations ... Is it an adverse drug reaction? • Pentamidine (PPC) • etc.

26. Or is it due to HIV? • Fatigue • Weight loss • Loss of libido • Sleep disturbance • Preoccupation with illness • etc.

27. Disclosure Stigma Lifestyle changes Health promotion Treatment decisions Drug/Alcohol Adherence vs compliance Transmission of HIV Communication Losses Life planning Self-esteem Uncertainty Control Relationships Coping skills Sense of one’s life Possible Issues and Themes

28. Why me? Denial Shame and guilt Abandonment Betrayal Dependency, Loss of control Fear of dying Loss of a future Uncertainty Living fully Family issues Financial concerns Envy of the healthy Disclosure Relationship with medical professionals Winiarski, 1991 Psychotherapy Themes

29. Education Compliance Coming to terms Planning for the future Community support Interpersonal (partner, family, friends…) Institutional (employment, community and medical services…) Exploration/ resolution of family issues Working through grief and loss Managing: pain suffering uncertainty Goals of Psychotherapy

30. Flexibility Knowledge of biomedical aspects Client-centred Team approach Setting goals Multicultural variables Framework session length location frequency. What’s unique about HIV psychotherapy ?

31. The Therapeutic Contract • A thorough assessment provides the psychologist with important information for anticipating issues that may arise during the psychotherapy. In this context: • What type of therapeutic contract will be most effective? • Can the psychologist fulfill this type of contract? (Winiarski, 1991)

32. The therapeutic contract “… movement along a continuum of psychotherapeutic care is suggested – ranging from encouragement of exploration to interpersonal dialogues to, if necessary and mutually agreed upon, case management. The professional should feel free, within one’s competence, to respond therapeutically to the ever-changing situations caused by HIV-related chronicity.” (Winiarski, 1991, p. 48.)

33. Support Crisis management Guidance Normalization Stress and coping Behaviour modification Cognitive-behavioural Insight-oriented Solution-focused Systemic Existential Case management. Types of Intervention

34. Types of Intervention • Individual • Couple • Family • Group • Consultation with team members.

35. Choosing Interventions • Be flexible – bend the frame. • Work with client to prioritize goals. • Increase client’s sense of control and self-efficacy. • Coordinate treatment with other professionals. • Help client connect with other resources.

36. Choosing Interventions At the present time, there are probably too few studies to be able to answer the question about which is the “best” psychotherapy approach with a patient who is living with HIV. Individual, couple, family and group therapies have all produced good results. (Brouillette & Citron, 1997, pp. 64)

37. Choosing Interventions • Psychodynamic psychotherapy • Cognitive-behavioural therapy • Interpersonal psychotherapy • Humanistic psychotherapy • Counselling • Crisis intervention.

38. Choosing Interventions With the exeption of the ongoing risk of crisis and the fear that their infection and their feelings inspire in their therapist, people living with HIV are indistinguishable from other patients.(Le VIH et la psychiatrie, 1997, pp. 64)

39. Crises Characteristics of a person in crisis : • Perceives a precipiting event as being meaningful and threatening • Appears unable to modify or lessen the impact of stressful events with traditional coping methods • Experiences increased fear, tension and/or confusion • Exhibits a high level of subjective discomfort • Proceeds rapidly to an active state of crisis – a state of disequilibrium. (Roberts (1990), p. 9)

40. Crisis Intervention Process of working through the crisis event so that the person is assisted in exploring the traumatic experience and his or her reaction to it. (Roberts (1990). Crisis intervention handbook, p. 11)

41. Crisis Counselling Strategies • Make psychological contact and rapidly establish a relationship. • Examine the dimensions of the problem in order to define it. • Encourage an exploration of feelings and emotions. • Explore and assess past coping attempts. • Generate and explore alternatives and specific solutions. • Restore cognitive functioning through implementation of an action plan. • Follow up. (Roberts (1990), p. 12)

42. Suicidal Evaluation • Suicidal emergency (plan, date, availability of the means) • Suicidal risk (history of suicidal attempts, sex, age, mental illness, drug and alcohol abuse, losses at an early age)

43. HIV testing HIV diagnosis Fear of disclosure Viral load & T4 count results Concerns about negotiating safer sex and/or needle use First opportunistic infection First hospitalization Treatment failure Disability Hospice situation Confronting losses and death etc. Events that might trigger a crisis

44. Hope Medical treatment for HIV infection is one important source of hope because it offers a chance to live longer with a better quality of life. Medical breakthroughs in treating HIV/AIDS have occurred on two fronts: a) the prophylaxis and treatment of opportunistic illnesses that develop when the immune system becomes severely compromised b) the treatment of HIV infection itself. Since the beginning of AIDS, advances in medical treatment have doubled the life expectancy for people living with HIV (Kalichman, Ostrow & Ramachandran,1998).

45. Non-progressors A non-progressor is a person with HIV whose infection does not appear to progress toward AIDS after 10 or more years of infection (O’Connor, 1997).

46. Hope and A Second Chance • Hope and optimism are characteristics of long-term survivors ( Rabkin, Remien, Katoff & Williams, 1993). • A positive attitude about one’s prognosis may increase survival time (Reed, Kemeny, Taylor, Wang, & Visscher,1994).

47. Hope and A Second Chance • Future goals may be set with uncertainty but are still needed. • Psychotherapy will help to maintain the fragile balance between preventing a possible disappointing decline of health and encouraging the person to move forward.

48. Long-term Survivors • A long-term survivor is a person with AIDS who has survived five or more years since their AIDS diagnosis (CD4< 200) (O’Connor, 1997).

49. When the Treatment Fails • 15 to 35% of those treated with HAART do not seem to obtain clinical results • no reduction of viral load • intolerable side effects • short period of improvement followed by no effect.

50. The Syndrome of Lazarus • Like Lazarus who rose from the dead, the person with AIDS might revive, but he or she may keep some of the deficits like blindness. The sword of Damocles is still hanging over his or her head.