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HIV Mental Health for the 21st Century

EDITED BY Mark G. Winiarski
Copyright Date: 1997
Published by: NYU Press
Pages: 392
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  • Book Info
    HIV Mental Health for the 21st Century
    Book Description:

    As we approach the 21st century, we also approach the third decade of the AIDS epidemic. Mental health care providers must face the crucial fact that the human immunodeficiency virus (HIV) and the condition it causes, Acquired Immune Deficiency Syndrome (AIDS) is the leading cause of death among Americans aged 25-44 years. HIV Mental Health for the 21st Century provides a roadmap for mental health professionals who seek to develop new strategies aimed at increasing the longevity and quality of life for people living with HIV/AIDS, as well as at controlling the future spread of the disease. Divided into five sections, this volume covers basic concepts in HIV/AIDS mental health; specialized aspects of HIV/AIDS clinical care; models of clinical care; program evaluation; and HIV mental health policy and programs. Chapters treat issues such as feelings of caregivers, the role of spirituality in mental health care, rural practice, mental health home care, and working with children.

    eISBN: 978-0-8147-8460-0
    Subjects: Psychology

Table of Contents

  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-x)
  3. Foreword
    (pp. xi-xxiv)
    G. Stephen Bowen

    Since 1981, when the first clinical descriptions of cancers and opportunistic infections associated with what is now known as the Acquired Immune Deficiency Syndrome (AIDS) were reported, the epidemic of the causative agent, the Human Immunodeficiency Virus (HIV), has spread substantially. With that epidemic, which has substantially affected public health, have come many changes: The epidemic’s epidemiology has changed, governmental responses have evolved, and systems of health financing are being transformed.

    These changes now challenge mental health providers and those in training for HIV/AIDS care in the next century. Above all, providers have learned that compassion is necessary but insufficient;...

  4. Introduction
    (pp. xxv-xxxiv)
    Mark G. Winiarski

    As we approach the 21st century and the third decade of the AIDS epidemic, mental health care providers must face a crucial fact: The human immunodeficiency virus (HIV) and the condition it causes, Acquired Immune Deficiency Syndrome (AIDS), threatens everyone’s communities and everyone’s clients. All mental health providersmustbe HIV/AIDS-knowledgeable. And the many clinicians who feel a special calling to work with HIV/AIDS-affected individuals must prepare themselves to go beyond basic training into specialized clinical work.

    This book has two goals. The first is to introduce students and professional practitioners in the fields of psychology, behavioral medicine, nursing, social...

  5. Part I: Basic Concepts in HIV/AIDS Mental Health

    • 1 Understanding HIV/AIDS Using the Biopsychosocial/Spiritual Model
      (pp. 3-22)
      Mark G. Winiarski

      Our everyday lives are complicated enough and, too often, painful and hard to understand. Imagine, then, being faced with a condition that in the early 1980s manifested itself through a quick and unexplained illness and death. Then, within a decade and with medical progress, the condition became a long-term chronic condition, rather than a death sentence rendered quickly. Now we know this condition as Acquired Immune Deficiency Syndrome (AIDS), which is also called human immunodeficiency virus-related disease, named for the virus (HIV) that causes the disorder.

      Imagine, also, as HIV/AIDS comes to public consciousness, mental health providers having to learn...

    • 2 Psychotherapy and Counseling: Bending the Frame
      (pp. 23-38)
      Thomas Eversole

      Human immunodeficiency virus and AIDS are established among the general population, and traditional notions of counseling, psychotherapy, and case management are being tested as never before.

      Mental health practitioners have responded to the challenges presented by the medical, psychological, social, and spiritual aspects of HIV/AIDS by expanding their range of services and by combining professional roles, thus “bending the frame” of psychotherapeutic practice. In addition to making home visits (see chapter 14) and counseling clients on spiritual issues (see chapter 4) and safer sexual practices (see chapter 8), some practitioners speak at memorial services, serve as client advocates, and facilitate...

    • 3 Countertransference Issues in HIV-Related Psychotherapy
      (pp. 39-51)
      Robert L. Barret

      Since Freud (1910/1959) first suggested the ideas of transference and countertransference, clinicians have learned to be especially aware of the ways their own emotional issues may influence the course of psychotherapy. While the debate about the validity and the application of these two concepts will never be completely resolved, contemporary practitioners are using terms such as boundaries (Rosica, 1995), overidentification (Caldwell, 1994), and compassion (Winiarski, 1995) to describe what is at least a similar phenomenon.

      As the incidence of HIV infection has increased, mental health workers and researchers have reported the highly complex issues that force the practitioner to step...

    • 4 Spirituality
      (pp. 52-66)
      Pascal Conforti

      In the early years of my practice with HIV-infected patients in an acute-care hospital, I met Edwin. Ed, who died several years ago, was an Hispanic man in his early forties, born a Roman Catholic in New York City. He had spent most of his adult life in and out of prison, and for most of the time I knew him, he remained an inmate in the New York State correctional system.

      One day Ed was musing on his life. “You know,” he told me, “when I was growing up, I was sure that I wasn’t lovable, that I wasn’t...

    • 5 Grief and Loss in HIV/AIDS Work
      (pp. 67-81)
      Noel Elia

      Loss and grieving echo throughout the course of HIV/AIDS. For persons infected and for those who care for them, including the mental health provider, one of the greatest challenges is the relationship we are invited to make with loss.

      The instant the client receives test results showing infection, the client becomes a participant in an ongoing grieving process. This individual immediately grieves the loss of his or her HIV-negative status. Now he or she is living with HIV, and the future, as previously imagined, is changed forever. Concurrently, the individual has to begin the process of integrating the new status...

    • 6 Cross-Cultural Mental Health Care
      (pp. 82-97)
      Mark G. Winiarski

      Most of us would readily admit that our society is multicultural, encompassing many complex differences in values, beliefs, and perceptions of self and others, not to mention idiom and language. And most of us would say we are sensitive to the cultural difference of our clients.

      Why, then, is mental health training and practice so devoid of multicultural influence? It reflects not the multicultural society we acknowledge but rather European-American white male middle-class heterosexual values (see, for example, Sue & Sue, 1987; Tyler, Sussewell, & Williams-McCoy, 1985).

      Too often mental health practitioners regard a client from a different culture as many do...

    • 7 The Role of Psychiatry in HIV Care
      (pp. 98-115)
      Karina K. Uldall

      Psychiatry plays a significant role in the treatment of the immense and complex mental health needs related to HIV/AIDS. Although psychiatrists have a unique place in overseeing psychopharmacological interventions, it would be a travesty if the role of psychiatry in HIV care were to be limited to prescription of psychiatric medications. As HIV disease develops into a chronic illness, psychiatry has the opportunity to span the gulf between biological and psychosocial/spiritual approaches.

      Because the virus is prevalent in groups with multiple problems, such as homelessness, chronic mental illness, and substance use, diagnosis and treatment planning become increasingly complicated. One must...

    • 8 Secondary Prevention: Working with People with HIV to Prevent Transmission to Others
      (pp. 116-134)
      Kathy Parish

      When John and Susan married eighteen years ago, they thought his hemophilia would be their greatest health challenge. Having learned to live with its unpredictability and treatment needs, they went on to have two children, at which point they decided that their family was complete. John had a vasectomy, and they threw away Susan’s diaphragm. About twelve years ago, though, they started hearing concerns about AIDS being transmitted through the blood supply. John was told that he might be at risk for contracting the AIDS virus but that the blood supply was thought to be pretty safe by then and...

  6. Part II: Specialized Aspects of HIV/AIDS Clinical Care

    • 9 Psychoeducational Group Work for Persons with AIDS Dementia Complex
      (pp. 137-156)
      Michele Killough Nelson

      In the early 1980s, a number of neurological manifestations of HIV were noted, most commonly a decline in cognitive and behavioral functioning. It is now widely recognized that most HIV-infected individuals have at least mild neurobehavioral changes that are related to the virus (Koralnik et al., 1990), but the prevalence rates of AIDS Dementia Complex (ADC) vary from 6 to 30 percent (Day et al., 1992; Janssen, Nwanyanwu, Selik, & Stehr-Green, 1992; Maj et al., 1994; McArthur et al., 1993).

      ADC is characterized by a gradual decline in cognitive functioning with specific deficits in the integration of motor functioning, informationprocessing speed,...

    • 10 Rural Practice
      (pp. 157-172)
      I. Michael Shuff

      HIV disease has come to small-town and rural America. It may be less visible because of the relatively thin spread of cases over larger geographic areas and because those affected by the disease in less populated areas feel that they must keep it secret.

      Thought to be a problem of the big city, AIDS doesn’t fit in with the heartland’s conventional self-perception. But HIV/AIDS is here, now, and the longer the epidemic drags on the more undeniable that fact becomes. In the Midwestern state in which I live, Indiana, one half of all the reported AIDS cases live in towns...

    • 11 Mental Health Issues of HIV-Negative Gay Men
      (pp. 173-189)
      Ariel Shidlo

      These words were spoken in a therapy session by a high-functioning, intelligent, and successful gay man. This patient was suffering from the physical pain of a shingles episode and he was anxious about whether this meant he was HIV-positive. He was obsessively reviewing his sexual past to make sure that he had not done anything “risky,” questioning whether the shingles inflammation was a sign from God to stop having sex with other men, and revisiting internalized homophobia that associated being gay with disease and punishment.

      This HIV-negative gay man was angry. His recent experience of dating a man, falling in...

    • 12 Working with and for Children
      (pp. 190-206)
      Dottie Ward-Wimmer

      We sat together on his hospital bed. Beautiful dark eyes looked up at me and then at the picture he had just drawn. It was a six-year-old’s typical rendition of a house. I asked, “Are you in this picture?” He pointed to the center of the paper and said quietly, “Sure I am …, but I’m so far in no one can see me.”

      Children with AIDS sometimes feel very alone.

      More than anything else, he wanted to run and play with other kids. But he had hypertonic leg muscles. AIDS wasn’t his problem; not being able to walk was....

  7. Part III: Models of Clinical Care

    • 13 HIV Mental Health Services Integrated with Medical Care
      (pp. 209-223)
      Barbara C. Kwasnik, Rosemary T. Moynihan and Marjorie H. Royle

      HIV-affected clients in the inner city present with a Gordian knot of biopsychosocial and spiritual problems. For many, HIV is just one more strand in the knot that already includes medical problems such as diabetes, asthma, and hypertension; emotional disturbances; substance abuse and dependence; chaotic and violent living situations; and lack of resources (Gellin & Rodgers, 1992; Leukefeld, 1989; McKenzie, 1991).

      For these individuals, medical needs most often take priority over mental health issues. Even if they recognize the need for mental health assistance, too many of them lack the energy to negotiate yet another treatment system and fail to get...

    • 14 Delivering Mental Health Services to the Home
      (pp. 224-240)
      Dennee Frey, Karen Oman and William R. Wagner

      In the mid-1980s, when persons with AIDS first began to survive bouts ofPneumocystis cariniipneumonia with the help of intravenous antibiotics, home infusion team nurses with the Visiting Nurse Association of Los Angeles (VNA-LA) began observing unusual behaviors in patients.

      One field nurse remembers going into a patient’s home to find that he had ripped open a line of sutures and pulled out his porta-catheter, a tube surgically inserted into a central blood vessel to provide medication. He then presented her with a basin full of blood, saying, with no emotional expression, “I want to die.”

      Another nurse recalls...

    • 15 Case Management: Coordination of Service Delivery for HIV-Infected Individuals
      (pp. 241-256)
      David D. Barney and Betty E. S. Duran

      Case management is an essential component of HIV care because most individuals living with HIV/AIDS have complex needs that exceed those caused by medical or health conditions. Individuals with HIV infection are likely to require additional assistance with emotional, financial, legal, and social problems throughout different stages of their HIV-disease progression (Sonsel, 1989).

      While there is no one standardized definition of case management, it can usually be agreed that the primary function of case management for HIV-infected persons is to coordinate care (Sierra Health Foundation, 1991). Piette, Thompson, Fleishman, and Mor (1993) have identified two dominant goals for case management:...

    • 16 A Comprehensive Center for Women with HIV
      (pp. 257-272)
      Karen Meredith and Rebecca Bathon

      For HIV-infected women, HIV/AIDS is at the nexus of who they are in society — daughter, mother and mate — how they are positioned in society — in terms of power and control over their own lives — and who they are within themselves. To care for them cannot simply be a biomedical task. HIV/AIDS caregivers must care for the entirety of a woman’s being.

      While programs of the early epidemic focused primarily on white gay males (Novello, 1993; Rosser, 1991), the increasing impact of HIV disease on women has necessitated a rethinking of our response to the disease (Health...

  8. Part IV: How Do We Know It Works?

    • 17 How Do We Know It Works? Quantitative Evaluation
      (pp. 275-290)
      Michael Mulvihill

      In these times of shrinking resources and cost containment, flinders and providers of HIV-related services want more than ever to know that they get results for dollars spent. In fact, the pressures to demonstrate whether health service programs have a measurable effect are probably greater than at any other time in recent memory. Until the political pendulum swings back to the days of “The Great Society,” budget cuts will most likely affect those service areas that fail to demonstrate that they make a difference.

      Government funding agencies and foundations now require that sophisticated evaluations be conducted to determine whether mental...

    • 18 Qualitative Approaches to Evaluation
      (pp. 291-304)
      Martha Ann Carey

      Qualitative evaluation is a much underused and underappreciated tool that can help mental health professionals answer questions that quantitative techniques cannot address. Questions that qualitative techniques can answer include these: Why do adolescents engage in behaviors that put them at risk for HIV infection? What are the psychosocial concerns of women who live with injection drug users?

      With the answers to these questions, one can create relevant and specific intervention programs. Then, when the programs are operating, qualitative techniques can help determine if they are meeting their goals.

      Government agencies and foundations appreciate needs assessments as bases for program development....

  9. Part V: HIV Mental Health Policy and Programs

    • 19 HIV/AIDS Mental Health Care: Politics, Public Policy, and Funding Decisions
      (pp. 307-324)
      Douglas A. Wirth

      Most HIV/AIDS mental health providers — and certainly almost all who work in institutions such as hospitals or community health and mental health centers — provide services that are paid for by federal programs. Two federal programs in particular have significantly shaped that care — the Ryan White Comprehensive AIDS Resources Emergency (C.A.R.E.) Act of 1990, reauthorized with modifications in 1996, and Medicaid.

      The Ryan White C.A.R.E. Act was passed in 1990 to provide funding for HIV-related primary health care and support services. With other funding streams such as Medicaid supporting a variety of AIDS services, this legislation was designed...

  10. Afterword: New Treatments, New Hopes, and New Uncertainties
    (pp. 325-334)
    Mark G. Winiarski

    In 1996 something extraordinary occurred in the clinical care of persons with HIV/AIDS, which had stagnated after years of only moderate biomedical gains through the use of zidovudine (ZDV, AZT, Retrovir) and many disappointing clinical trials: The testing and licensing of new kinds of antiretroviral drugs, and the use of new combinations of drugs, began to suggest that improved and longer lives were possible, and there were hints that sometime in the near future the virus could be eradicated.

    It seemed that everyone knew someone whose life had been renewed by use of a newly licensed drug or a combination...

  11. Appendix A: Medical Primer
    (pp. 335-342)
  12. Appendix B: Resources — Obtaining HIV/AIDS Information Fast
    (pp. 343-346)
  13. Contributors
    (pp. 347-352)
  14. Index
    (pp. 353-358)
  15. Back Matter
    (pp. 359-359)