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Psychotherapy and HIV: Assessment and Intervention. PHASE, Canadian Psychological Association and Health Canada Module developed by Paul C. Veilleux, Ph.D. UHRESS - Centre Hospitalier de l’Université de Montréal Montreal, Quebec. HIV and CD4 Cell Counts Typical of an Untreated HIV Infection.

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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


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HIV and CD4 Cell Counts Typicalof an Untreated HIV Infection



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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%.


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HAART

  • Highly active antiretroviral therapies

    • Adherence to treatment regimens

    • Renewed hope and optimism

    • Coping with treatment failures

    • Prevention implications


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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.


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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.


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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


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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.).


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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.


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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


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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


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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.


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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.


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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?


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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).


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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?


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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


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Adaptation to HIV

  • Emotional

  • Cognitive

  • Behavioural


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Diagnosis can be difficult...

  • Is it depression?

  • Or a side effect of medication ?

  • Or due to HIV ?


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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)


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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)


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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)


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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?


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Interferon (Kaposi’s sarcoma)

Depression, weakness, headaches, myalgia, confusion

Confusion, anxiety, emotional lability, hallucinations

...

Is it an adverse drug reaction?

  • Pentamidine (PPC)

  • etc.


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Or is it due to HIV?

  • Fatigue

  • Weight loss

  • Loss of libido

  • Sleep disturbance

  • Preoccupation with illness

  • etc.


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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


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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


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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


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Flexibility

Knowledge of biomedical aspects

Client-centred

Team approach

Setting goals

Multicultural variables

Framework

session length

location

frequency.

What’s unique about HIV psychotherapy ?


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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)


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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.)


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Support

Crisis management

Guidance

Normalization

Stress and coping

Behaviour modification

Cognitive-behavioural

Insight-oriented

Solution-focused

Systemic

Existential

Case management.

Types of Intervention


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Types of Intervention

  • Individual

  • Couple

  • Family

  • Group

  • Consultation with team members.


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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.


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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)


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Choosing Interventions

  • Psychodynamic psychotherapy

  • Cognitive-behavioural therapy

  • Interpersonal psychotherapy

  • Humanistic psychotherapy

  • Counselling

  • Crisis intervention.


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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)


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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)


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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)


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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)


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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)


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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


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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).


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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).


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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).


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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.


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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).


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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.


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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.


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Psychological Consequences

  • A failure in treatment may produce many emotions, such as:

    • A sense of injustice (why me?)

    • Anger and resentment toward the physician or the team

    • A sense of betrayal

    • Guilt about not being able to tolerate side effects

    • Anxiety and despair.


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Psychotherapy

When treatment fails, psychotherapy may return to focus on processes of grieving and loss

  • loss of hope

  • anger

  • guilt

  • resentment

  • sadness.


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General Principles for Psychotherapists

  • Anticipate the emerging needs of clients and assess services before the needs become desperate.

  • Know the resources in your community and how to use them.

  • Don’t work alone; team work is essential.


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Psychological Support

  • Maintain the balance between bad news and hope.

  • Reduce the feeling of loneliness; be part of the social network; provide confidence and trust so he or she can talk about what’s going on in his or her life.

  • Facilitate grieving of losses of work, autonomy, health, etc.


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Preparing to Die

  • Evaluate the needs of the person and his or her family.

  • Where does he or she want to die (home, hospital, hospice)?

  • Who does he or she want to have close to him or her?

  • What are his or her last needs, desires and requests?


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Ethical and Legal Issues

  • Duty to warn

  • Confidentiality

  • Suicide and euthanasia

  • Competence

  • Boundaries.


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Countertranference: What we Bring into the Process

Our attitudes, beliefs, experiences about:

  • sexuality, sexual orientation

  • drug use

  • sex trade

  • illness

  • death

  • professional omnipotence.


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Helping Others may Hurt

  • Increased irritability

  • AIDS-related nightmares

  • Physical exhaustion, illness

  • Reduced interest in work and personal life

  • Distancing from, or devaluing of, patients

  • Intrusive thoughts.


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Prescription for Psychologists

  • Be reflective – seek out supervision or a personal therapy if necessary.

  • Do your own grief work.

  • Limit your caseload.

  • Vary your cases.

  • Set clear boundaries.

  • Use stress management skills.

  • Cultivate a healthy personal lifestyle.


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