HIV PREVENTION AMONG PSYCHIATRIC INPATIENTS: A PILOT RISK REDUCTION STUDY Ilan Meyer, M.A., M.Phil., Francine Cournos, M.D., Maureen Empfield, M.D., Brenda Agosin, M.A., and Paulette Floyd, C.S.W.
An HIV prevention program was piloted on an acute inpatient admission ward. Patients who volunteered to participate had significantly higher rates of histories of substance use than non-participants, suggesting that patients participated based on rational concerns about past HIV risk behavior. The program consisted of 75 minute sessions once a week for seven weeks and was co-led by an HIV counselor and the ward's social worker. Each session focused on a specific topic and included a short presentation of informational material, viewing of an educational videotape, a discussion, and role play and other educational games. In spite of a wide range in functioning among the participants, discussion was lively and participation was good. The pilot program demonstrates that chronic mentally ill patients can engage in, and benefit from, risk reduction programs and that frank and explicit discussion of sexual issues is well tolerated. Recommendations for improvement in the program are discussed.
At the time of this research Mr. Meyer was research coordinator, Dr. Empfield was clinical director, Ms. Agosin was HIV counselor, and Ms. Floyd was a social worker at Creedmoor Psychiatric Center; Dr. Cournos is director, Washington Heights Community Service, New York State Psychiatric Institute. Address correspondence to Ilan Meyer, M.A., M.Phil., Columbia University, 100 Haven Avenue 3-17H, New York NY 10032. PSYCHIATRIC QUARTERLY, Vol. 63, No. 2, Summer 1992 0033-2720/92/9600-0187508.50/0 © 1992 H u m a n Sciences Press, Inc.
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INTRODUCTION Current sexual behavior and past drug use place the mentally ill at risk for HIV infection (1). With an HIV seroprevalence of 5-7% (2,3,4,5) the mentally ill have increased rates of HIV infection as compared with abortion clinics (with HIV seroprevalence rate of 1.6%), New York City Department of Health study of sentinel hospitals (1.4% and 2.7%) (6) and the mentally retarded in the metropolitan New York City area (0%) (7). Subgroup seroprevalence rates for this population indicate that women's rate of infection is similar to men's, (2,3,4) and that Black patients are at higher risk t h a n other ethnic groups in this population (2). Few interventions for risk reduction are described in the literature to date. Carmen and Brady (8) developed an AIDS prevention program in a large inner-city mental health center. This program had the format of a weekly drop-in group which met for an hour with two clinical facilitators. An important part of the intervention was the distribution of condoms. The program was designed to be an ongoing weekly meeting and did not follow a specified curriculum but covered a variety of topics related to HIV risk reduction. The efficacy of this intervention was not assessed. We designed an HIV risk reduction psychoeducational program and conducted a small pilot study on an acute admission ward in a state psychiatric hospital. In this report we describe the intervention and discuss lessons learned from conducting this pilot. In designing the program we followed a general AIDS risk reduction model (9) and other psychological models for illness prevention (10,11). According to the health belief model, for an HIV risk reduction program to be effective a person must first understand the risk of HIV infection, and feel personally at risk. This is referred to as perceived risk. Chronic mentally ill patients, in particular, need to be helped through symptomatological interference with cognitive-emotional processing of information about HIV infection. Ideally, patients' perceived risk, and resultant anxiety, need to be neither unrealistically low nor too high for effective treatment. In addition to perceived risk, patients need to understand t h a t behavioral changes can reduce risk for HIV infection (response efficacy). Furthermore, patients must see that they themselves will be capable of making the necessary behavioral changes t h a t will reduce their personal risk for infection (self efficacy). As
ILAN MEYER, ET AL.
189
with other disenfranchised populations, this component is especially important because a sense of repeated past failures will adversely affect personal efficacy expectations. Finally competence and social skills are necessary in order to follow risk reduction recommendations. For example, assertiveness, self-esteem, and a sense of independence are all necessary components in negotiating condom use with a resistant threatening partner. The purpose of the pilot study was to test the feasibility of administering an HIV risk-reduction psychoeducational program to chronic mentally ill patients. We wanted to learn about patients' interest, attention and level of participation in sessions, and their ability to comprehend and follow educational materials. We also wanted to see whether psychiatric symptomatology would interfere with integration of the material, and whether discussion of sexual issues would exacerbate psychiatric symptomatology. In addition we were interested in the response and level of cooperation of ward staff. Before initiation, the program was introduced and discussed in a staff meeting. Although most staff had a favorable response, there was concern that discussion of sexual matters with patients might aggravate patients' psychiatric symptomatology. We shared with staff our positive experience in interviewing psychiatric patients at the same hospital for a separate study on HIV risk behavior that we conducted at the same time. These interviews included detailed questions about sexual behavior, and we found no adverse reaction to the interview (12). This information was helpful in reassuring the staff and convincing them that patients were unlikely to deteriorate when exposed to the educational material.
METHOD The program consisted of seven sessions occurring once a week. An HIV counselor together with a ward social worker co-led the group. Patients were solicited for participation at regular ward meetings. Twelve of the 30 patients who were on the ward elected to participate. We recorded select demographic and clinical characteristics on all 30 patients using clinical charts. Participants completed an AIDS Knowledge Questionnaire, and a Perceived Risk Questionnaire (PRQ)-both designed by our re-
190
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search t e a m - i m m e d i a t e l y before and after the program. The PRQ assesses attitudes toward HIV risk prevention, for example, the extent to which the respondent believes that AIDS can be prevented by safe sex. High scores on the PRQ indicate less functional attitudes. Participants were also asked to volunteer for a research interview. The research interview consisted of a questionnaire concerning sexual risk behavior (13). The research interview was not required for participation in the intervention group, but volunteers were reimbursed by a payment of $15. Nine of the 12 participants consented to the research interview. Patients were assured confidentiality and were asked not to disclose information which may be relayed in the group by another patient. In order to make the group process familiar and non-threatening, the structure of each session was similar. Each session focused on a distinct topic, although there was much overlap in the content of sessions to allow rehearsal and integration of the material. Each session included a short presentation of informational material, viewing of an educational videotape, a discussion, role play and other educational games, and concluding statements by the facilitators. Sessions lasted 60-75 minutes (depending on the length of the videotape). A break in the middle of the session was used for refreshments and informal socializing. Topics covered in each session and the videotapes used are described in Table 1.
RESULTS Patients' demographic and clinical characteristics are described in Table 2. We compared participants to non-participants and found that they did not differ in gender, age, educational level, ethnicity, and legal status on admission to the ward. The only significant difference between these groups was that 10 (83%) of the participants as compared to only 7 (39%) of the non-participants had a history of substance use (Chi2 = 5.8, df = 1, p = .02). Because a history of substance use is associated with HIV risk behavior, this suggests that participants may have been at higher risk for HIV infection than non-participants. It seems that patients discriminated among programs offered on the ward according to their needs, and that participation in HIV risk reduction program was motivated by rational concerns. This is also suggested by the fact
ILAN MEYER, ET AL.
191
TABLE 1 HIV Risk Reduction Psychoeducational Program Session's Topic
Videotape Title and Description
1. Introduction Describe program; discuss motivation for participation; confidentiality and privacy; review general AIDS knowledge. 2. AIDS Knowledge Discuss AIDS and HIV knowledge including risk for transmission, self protection, and misconceptions. 3. Heterosexual Transmission Discuss sexuality; HtV prevention; other sexually transmitted diseases; emotional and situational factors related to risk taking behavior. 4. Homosexual Transmission Discuss homosexual identity (stigma and resistance to self-label), bisexuality, and same sex sexual behavior; HIV transmission; safe sex; emotional and situational factors. 5. I V Drug Use Discuss alcohol and drug use as contributors to risk taking behavior; risk of injecting drugs; needle cleaning; available rehabilitation programs for treating substance dependence. 6. H I V Testing What the test determines and what it doesn't; deciding on whether to take the test; confidentiality issues; need for support. 7. Coping with AIDS The spectrum of HIV related diseases; available treatment options; psychological, emotional, and social-familial issues.
Eddie's Story ~ Eddie encourages his 3 friends to reduce their risk of infection from HIV and other sexually transmitted diseases. Y A I AIDS Training Tape 2 Explicit and simple description of HIV transmission and prevention. AIDS Is About Secrets a Women confront the possibility of HIV infection as a result of their o w n or their sexual partner's-injection drug use. AIDS Not Us a A gay youth and his straight friends discuss heterosexual and homosexual transmission and prevention.
A First Step 1 An injecting drug user tries to ignore his risk of getting AIDS. But when his girlfriend contracts HIV, he must face what his drug use is doing to his life. Joan's Story ~ Friends aware of Joan's boyfriend's drug use discuss HIV transmission~ self protection, and taking the HIV test. Facing AIDS 1 A young man with AIDS answers questions about being a person with AIDS.
Source of Tapes: 1. New York State Health Department, AIDS Institute: Albany, N.Yo 2. Young Adult Institute: New York, N.Y. 3. HIV Center, New York State Psychiatric Institute: New York, N.Y.
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TABLE 2 Demographic Characteristics of P a r t i c i p a n t s in a n HIV Risk Reduction Psychoeducational Program Characteristics
N (%)
Age (mean)
35.5
Ethnicity White Non-white
5 (45) 6 (55)
Education < Grade School > Grade School
3 (27) 8 (73)
Legal Status (ADM) Voluntary Non-Voluntary
10 (83) 2 (17)
Hx Substance No Yes
2 (17) 10 (83)
that more than half (56%) of the participants reported knowing someone with HIV or AIDS. We do not have a comparable figure for the non-participants however. Six of the 12 patients completed the full seven-session program. One very withdrawn patient dropped out because he was no longer interested in the program, and five patients were discharged or transferred to another ward before the end of the program. The group's atmosphere was pleasant and informal. In spite of a wide range in functioning level of the participants, discussion was lively and participation was good. We took much care in selecting videotapes that discuss issues in HIV prevention in an entertaining narrative manner. Patients seemed to enjoy these videotapes greatly. The sexual content in some of the tapes presented no problem and in fact helped maintain interest in the videotapes. Sometimes explicit sexual discussion was met with giggling or laughter. This was used by the co-facilitators therapeutically to address anxieties related to sexuality and AIDS.
ILAN MEYER, ET AL.
193
Role playing was one of the most successful techniques used in the program. Scenarios and roles which dealt with the session's topic (e.g. negotiating condom use with a resistant partner) were assigned to volunteers. Following the role playing, observers and the co-facilitators discussed the players' behavior, and suggested alternative solutions. At times, other participants volunteered to replay a certain scenario which they thought should have been handled differently. Role playing seemed to provide a good opportunity for reviewing the material discussed in the sessions and for practicing important risk reduction behaviors. In addition to HIV risk reduction concerns, a variety of related issues were addressed in life-like situations through role playing. For example, in role playing condom use negotiation before sexual intercourse, issues of dependency, self-esteem and empowerment were addressed. After participants became familiar with the technique, suggestions for role playing spontaneously came from participants and included topics which staff had not planned for in the intervention program. For example, through role playing requests participants raised the problem of asking staff for condoms, and acted out scenes in which they demanded condoms from a resistant psychiatrist or nurse. This provided opportunities for patients to practice assertiveness with staff, insisting, for example, that it is their "right to receive condoms in order to protect" themselves while on a home pass. Sexual Risk Behavior
Participants had varied sexual experiences. One patient was a high functioning woman who had multiple relationships, another was a married man who had a few extramarital relationships, and yet another man had no intimate relationships but had occasional homosexual sexual encounters at a community residence. Of the nine participants who consented to the research interview, 1 of 3 females and 5 of 6 males had been heterosexually active in the past six months. Although none of the men admitted to any homosexual activity in the past six months, three of the six men had had some homosexual activity since 1978. The sexually active woman admitted to homosexual activity as well. One of the men and the woman admitted to engaging in sexual behavior in exchange of money in the past six months. In spite of the risk behavior and the seeming
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concern about HIV, none of the patients used condoms in any sexual activity. A I D S Knowledge
Upon entering the program AIDS knowledge was satisfactory for this population. Most patients knew the routes of transmission for HIV and, for example, correctly responded that a healthy looking person could be HIV-infected, or that HIV infection has a long incubation period. Patients were least accurate in answering questions that required more integration of information. For example, patients incorrectly identified donating blood as a risk behavior, and mistakenly failed to identify sexual intercourse with an IV drug user as a risk behavior if the patient him/her self is not an IV drug user. The mean score on the AIDS knowledge questionnaire before we began our psychoeducational program was 21.4 (SD = 4.4) representing 21 (75%) correct responses to 28 questions. In spite of this substantial pre-existing knowledge, we detected some improvement in participants' knowledge following the program. Mean knowledge score increased to 23.9 (SD = 4.3) representing an improvement of 0.6 standard deviation to 24 (86%) correct responses. Risk Related Attitudes
Patients showed a decrease of 0.5 standard deviation in non-functional attitudes from 34.2 (SD 7.5) before to 30.3 (SD 8.9) after the program. Thus, patients' attitude show some movement to holding more functional attitudes, such as "I can avoid getting the AIDS virus by protecting myself when I have sex," and ~there's a lot I can do to make sure that I stay healthy and free from AIDS."
DISCUSSION We set out to test the feasibility of administering a psychoeducational program for HIV risk prevention to chronic mentally ill patients. We were concerned with patients utilization of the program and with potential risks and benefits. Our experience with a program pilot on an acute admission ward is promising. Our find-
ILAN MEYER, ET AL.
195
ings suggest that patients who elected to participate in the program were at greater risk for HIV infection than patients who did not participate. It therefore appears that psychiatric patients are motivated to participate in HIV educational programs based on rational concerns and will voluntarily participate in such programs if they are available. Patients seemed to enjoy the group discussion, the videotapes, and role-playing of life-like situations related to risk prevention. Only one patient withdrew from the program and this patient did so following the first session. In spite of initial concern over patients' response to discussion of sexually explicit material, ward staff was supportive of the program once their concerns were addressed. None of the patients experienced any adverse effects due to program attendance, and no exacerbation of psychiatric symptomatology was noted in response to program participation. Like other investigations (14,15), our pilot study suggests that patients' knowledge about AIDS is satisfactory. In spite of this, risk prevention as indicated by condom use was alarmingly absent. This confirms theories of illness prevention which suggest that functional attitudes and skills rather than knowledge are at the crux of preventive behavior. Our conclusions are limited by the small sample size of this pilot, which prevents us from examining our measures of efficacy for statistical significance. Moreover, the small sample size did not allow us to correlate the number of sessions actually attended with the measures of efficacy. In a larger sample such an analysis would likely show that benefits increase with increased attendance (16). Also, our pilot does not attempt to address the long term effects of the program. Our results suggest some future directions for an HIV risk reduction program. We learned that patients often do not disclose possibly stigmatizing information about their risk behavior to the group. For example, although 3 of the 5 sexually active men admitted to homosexual relations in the past in an individual interview, none discussed this in group sessions. We recognize that addressing patients' individual risk behavior, and making concrete recommendations for prevention, in private will improve the program. As a result, we developed a program which integrates a component of individualized risk reduction recommendations with the group intervention. The program would augment the group
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sessions with individual sessions in which each patient discusses his or her risk behaviors and appropriate risk prevention techniques with one of the group co-facilitators. This would allow patients to disclose personal material which they might be reluctant to discuss in the group. Allowing patients to make their own videotapes would be another useful technique to add to the program (Rotheram-Borus, private communication). Role playing, which was used successfully with the patients, may be used in combination with video making. Patients would work toward producing short films of some of the role play skits. This technique would help make the program attractive and interesting to participants while building on and consolidating the benefits of role playing. In addition, based on other studies (16) we believe that a longer program consisting of about 15 sessions may be necessary to generate solid behavioral changes. Also, we do not expect that a onetime intervention will suffice. Like other interventions with the chronic mentally ill, we believe that continued support is an essential part of a comprehensive risk reduction policy. This can be achieved by following the intensive intervention with an on-going maintenance group which discusses AIDS and HIV infection within the context of patients need for intimacy. In conclusion, chronic psychiatric patients are at significant risk for HIV infection. Mental health professionals must address this problem by providing patients with appropriate HIV risk reduction programs. Our experience suggests that the chronic mentally ill can engage in, and benefit from, psychoeducational programs that are specifically designed to address their needs.
ACKNOWLEDGMENTS This study was funded in part by a grant from the National Institute of Mental Health (NH-46251) and the New York State Office of Mental Health. In addition, the work of the first author was in part supported by a National Research Service Award research training grant #5T32MH13043. The authors wish to t h a n k Elizabeth Margoshes, Ph.D., Kaj Neve, MD, and the patients who participated in the program.
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REFERENCES 1. McKinnon K, Cournos F, Horwath E, et al: HIV risk behavior in severely mentally ill. Paper presented at the 144th Annual Meeting of the American Psychiatric Association, New Orleans, May 1991 2. Cournos F, Empfield M, Horwath E, et al: HIV seroprevalence among patients admitted to two psychiatric hospitals. American Journal of Psychiatry 148:1225-1230, 1991 3. Empfield M, Meyer I, Schrage H, et al: HIV seroprevalence and psychosocial and medical characteristics of severely mentally ill homeless (submitted for publication). 4. Empfield M, Cournos F, Meyer I, et al: HIV sereprevalence among street homeless patients admitted to a psychiatric inpatient unit. American Journal of Psychiatry (in press). 5. Sacks M, Dermatis H, Looser-Ott, Perry S: HIV seroprevalence and risk factors in psychiatric patients. Hospital and Community Psychiatry: 43:736-737, 1992. 6. New York City Department of Health, AIDS Surveillance Unit: AIDS surveillance update, March 1990 7. Pincus SH, Schoenbaum EE, Webber M: Seroprevalence survey for human immunodeficiency virus antibodies in mentally retarded adults. NYS Journal of Medicine: 139-142, March 1990 8. Carmen E, and Brady SM: AIDS risk and prevention for the chronic mentally ill. Hospital and Community Psychiatry 41(6): 652-657, 1990 9. Catania JA, Kegeles SM, Coates TJ: Toward an understanding of risk behavior: An AIDS risk reduction model. Health Education Quarterly 17: 53-72, 1990 10. Wallston BS, Wallston KA: Social psychological models of health behavior: An examination and integration. In A Baum, SE Taylor, and JE Singer, Eds., Handbook of Psychology and Health (Vol. IV): Social Psychological Aspects of Health. Hillsdale, NJ: Lawrence Earlbaum, 1984 11. Bandura A: The role of perceived self-efficacy in exercising control over AIDS, in Women and AIDS. Edited by Eichler A., Washington, DEC.: American Psychiatric Association Press, (in press). 12. McKinnon K, Cournos F, Meyer~Bahlburg HFL, et al: Reliability of sexual risk behavior interviews with psychiatric patients. Submitted for publication. 13. Meyer-Bahlburg HFL, Ehrhardt AA, Exner TM, Gruen RS: Sexual Risk Behavior Assessment Schedule-Adult-Psychiatric IP Interview, 1990 14. Baer JW, Dwyer PC, Lewitter-Koehler S: Knowledge about AIDS among psychiatric inpatients. Hospital and Community Psychiatry 39(9): 986-988, 1988 15. Aruffo JF, Coverdale JH, Chacko RC, Dworkin RJ: Knowledge about AIDS among women psychiatric outpatients. Hospital and Community Psychiatry 41(3): 326-328, 1990 16. Rotheram-Borus MJ, Koopman C, Haignere C, Davies M: Reducing HIV sexual risk behavior among runaway adolescents. Journal of the American Medical Association 266:1237-1241, 1991
An HIV prevention program was piloted on an acute inpatient admission ward. Patients who volunteered to participate had significantly higher rates of histories of substance use than non-participants, suggesting that patients participated based on rational concerns about past HIV risk behavior. The program consisted of 75 minute sessions once a week for seven weeks and was co-led by an HIV counselor and the ward's social worker. Each session focused on a specific topic and included a short presentation of informational material, viewing of an educational videotape, a discussion, and role play and other educational games. In spite of a wide range in functioning among the participants, discussion was lively and participation was good. The pilot program demonstrates that chronic mentally ill patients can engage in, and benefit from, risk reduction programs and that frank and explicit discussion of sexual issues is well tolerated. Recommendations for improvement in the program are discussed.
At the time of this research Mr. Meyer was research coordinator, Dr. Empfield was clinical director, Ms. Agosin was HIV counselor, and Ms. Floyd was a social worker at Creedmoor Psychiatric Center; Dr. Cournos is director, Washington Heights Community Service, New York State Psychiatric Institute. Address correspondence to Ilan Meyer, M.A., M.Phil., Columbia University, 100 Haven Avenue 3-17H, New York NY 10032. PSYCHIATRIC QUARTERLY, Vol. 63, No. 2, Summer 1992 0033-2720/92/9600-0187508.50/0 © 1992 H u m a n Sciences Press, Inc.
187
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PSYCHIATRIC QUARTERLY
INTRODUCTION Current sexual behavior and past drug use place the mentally ill at risk for HIV infection (1). With an HIV seroprevalence of 5-7% (2,3,4,5) the mentally ill have increased rates of HIV infection as compared with abortion clinics (with HIV seroprevalence rate of 1.6%), New York City Department of Health study of sentinel hospitals (1.4% and 2.7%) (6) and the mentally retarded in the metropolitan New York City area (0%) (7). Subgroup seroprevalence rates for this population indicate that women's rate of infection is similar to men's, (2,3,4) and that Black patients are at higher risk t h a n other ethnic groups in this population (2). Few interventions for risk reduction are described in the literature to date. Carmen and Brady (8) developed an AIDS prevention program in a large inner-city mental health center. This program had the format of a weekly drop-in group which met for an hour with two clinical facilitators. An important part of the intervention was the distribution of condoms. The program was designed to be an ongoing weekly meeting and did not follow a specified curriculum but covered a variety of topics related to HIV risk reduction. The efficacy of this intervention was not assessed. We designed an HIV risk reduction psychoeducational program and conducted a small pilot study on an acute admission ward in a state psychiatric hospital. In this report we describe the intervention and discuss lessons learned from conducting this pilot. In designing the program we followed a general AIDS risk reduction model (9) and other psychological models for illness prevention (10,11). According to the health belief model, for an HIV risk reduction program to be effective a person must first understand the risk of HIV infection, and feel personally at risk. This is referred to as perceived risk. Chronic mentally ill patients, in particular, need to be helped through symptomatological interference with cognitive-emotional processing of information about HIV infection. Ideally, patients' perceived risk, and resultant anxiety, need to be neither unrealistically low nor too high for effective treatment. In addition to perceived risk, patients need to understand t h a t behavioral changes can reduce risk for HIV infection (response efficacy). Furthermore, patients must see that they themselves will be capable of making the necessary behavioral changes t h a t will reduce their personal risk for infection (self efficacy). As
ILAN MEYER, ET AL.
189
with other disenfranchised populations, this component is especially important because a sense of repeated past failures will adversely affect personal efficacy expectations. Finally competence and social skills are necessary in order to follow risk reduction recommendations. For example, assertiveness, self-esteem, and a sense of independence are all necessary components in negotiating condom use with a resistant threatening partner. The purpose of the pilot study was to test the feasibility of administering an HIV risk-reduction psychoeducational program to chronic mentally ill patients. We wanted to learn about patients' interest, attention and level of participation in sessions, and their ability to comprehend and follow educational materials. We also wanted to see whether psychiatric symptomatology would interfere with integration of the material, and whether discussion of sexual issues would exacerbate psychiatric symptomatology. In addition we were interested in the response and level of cooperation of ward staff. Before initiation, the program was introduced and discussed in a staff meeting. Although most staff had a favorable response, there was concern that discussion of sexual matters with patients might aggravate patients' psychiatric symptomatology. We shared with staff our positive experience in interviewing psychiatric patients at the same hospital for a separate study on HIV risk behavior that we conducted at the same time. These interviews included detailed questions about sexual behavior, and we found no adverse reaction to the interview (12). This information was helpful in reassuring the staff and convincing them that patients were unlikely to deteriorate when exposed to the educational material.
METHOD The program consisted of seven sessions occurring once a week. An HIV counselor together with a ward social worker co-led the group. Patients were solicited for participation at regular ward meetings. Twelve of the 30 patients who were on the ward elected to participate. We recorded select demographic and clinical characteristics on all 30 patients using clinical charts. Participants completed an AIDS Knowledge Questionnaire, and a Perceived Risk Questionnaire (PRQ)-both designed by our re-
190
PSYCHIATRIC QUARTERLY
search t e a m - i m m e d i a t e l y before and after the program. The PRQ assesses attitudes toward HIV risk prevention, for example, the extent to which the respondent believes that AIDS can be prevented by safe sex. High scores on the PRQ indicate less functional attitudes. Participants were also asked to volunteer for a research interview. The research interview consisted of a questionnaire concerning sexual risk behavior (13). The research interview was not required for participation in the intervention group, but volunteers were reimbursed by a payment of $15. Nine of the 12 participants consented to the research interview. Patients were assured confidentiality and were asked not to disclose information which may be relayed in the group by another patient. In order to make the group process familiar and non-threatening, the structure of each session was similar. Each session focused on a distinct topic, although there was much overlap in the content of sessions to allow rehearsal and integration of the material. Each session included a short presentation of informational material, viewing of an educational videotape, a discussion, role play and other educational games, and concluding statements by the facilitators. Sessions lasted 60-75 minutes (depending on the length of the videotape). A break in the middle of the session was used for refreshments and informal socializing. Topics covered in each session and the videotapes used are described in Table 1.
RESULTS Patients' demographic and clinical characteristics are described in Table 2. We compared participants to non-participants and found that they did not differ in gender, age, educational level, ethnicity, and legal status on admission to the ward. The only significant difference between these groups was that 10 (83%) of the participants as compared to only 7 (39%) of the non-participants had a history of substance use (Chi2 = 5.8, df = 1, p = .02). Because a history of substance use is associated with HIV risk behavior, this suggests that participants may have been at higher risk for HIV infection than non-participants. It seems that patients discriminated among programs offered on the ward according to their needs, and that participation in HIV risk reduction program was motivated by rational concerns. This is also suggested by the fact
ILAN MEYER, ET AL.
191
TABLE 1 HIV Risk Reduction Psychoeducational Program Session's Topic
Videotape Title and Description
1. Introduction Describe program; discuss motivation for participation; confidentiality and privacy; review general AIDS knowledge. 2. AIDS Knowledge Discuss AIDS and HIV knowledge including risk for transmission, self protection, and misconceptions. 3. Heterosexual Transmission Discuss sexuality; HtV prevention; other sexually transmitted diseases; emotional and situational factors related to risk taking behavior. 4. Homosexual Transmission Discuss homosexual identity (stigma and resistance to self-label), bisexuality, and same sex sexual behavior; HIV transmission; safe sex; emotional and situational factors. 5. I V Drug Use Discuss alcohol and drug use as contributors to risk taking behavior; risk of injecting drugs; needle cleaning; available rehabilitation programs for treating substance dependence. 6. H I V Testing What the test determines and what it doesn't; deciding on whether to take the test; confidentiality issues; need for support. 7. Coping with AIDS The spectrum of HIV related diseases; available treatment options; psychological, emotional, and social-familial issues.
Eddie's Story ~ Eddie encourages his 3 friends to reduce their risk of infection from HIV and other sexually transmitted diseases. Y A I AIDS Training Tape 2 Explicit and simple description of HIV transmission and prevention. AIDS Is About Secrets a Women confront the possibility of HIV infection as a result of their o w n or their sexual partner's-injection drug use. AIDS Not Us a A gay youth and his straight friends discuss heterosexual and homosexual transmission and prevention.
A First Step 1 An injecting drug user tries to ignore his risk of getting AIDS. But when his girlfriend contracts HIV, he must face what his drug use is doing to his life. Joan's Story ~ Friends aware of Joan's boyfriend's drug use discuss HIV transmission~ self protection, and taking the HIV test. Facing AIDS 1 A young man with AIDS answers questions about being a person with AIDS.
Source of Tapes: 1. New York State Health Department, AIDS Institute: Albany, N.Yo 2. Young Adult Institute: New York, N.Y. 3. HIV Center, New York State Psychiatric Institute: New York, N.Y.
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TABLE 2 Demographic Characteristics of P a r t i c i p a n t s in a n HIV Risk Reduction Psychoeducational Program Characteristics
N (%)
Age (mean)
35.5
Ethnicity White Non-white
5 (45) 6 (55)
Education < Grade School > Grade School
3 (27) 8 (73)
Legal Status (ADM) Voluntary Non-Voluntary
10 (83) 2 (17)
Hx Substance No Yes
2 (17) 10 (83)
that more than half (56%) of the participants reported knowing someone with HIV or AIDS. We do not have a comparable figure for the non-participants however. Six of the 12 patients completed the full seven-session program. One very withdrawn patient dropped out because he was no longer interested in the program, and five patients were discharged or transferred to another ward before the end of the program. The group's atmosphere was pleasant and informal. In spite of a wide range in functioning level of the participants, discussion was lively and participation was good. We took much care in selecting videotapes that discuss issues in HIV prevention in an entertaining narrative manner. Patients seemed to enjoy these videotapes greatly. The sexual content in some of the tapes presented no problem and in fact helped maintain interest in the videotapes. Sometimes explicit sexual discussion was met with giggling or laughter. This was used by the co-facilitators therapeutically to address anxieties related to sexuality and AIDS.
ILAN MEYER, ET AL.
193
Role playing was one of the most successful techniques used in the program. Scenarios and roles which dealt with the session's topic (e.g. negotiating condom use with a resistant partner) were assigned to volunteers. Following the role playing, observers and the co-facilitators discussed the players' behavior, and suggested alternative solutions. At times, other participants volunteered to replay a certain scenario which they thought should have been handled differently. Role playing seemed to provide a good opportunity for reviewing the material discussed in the sessions and for practicing important risk reduction behaviors. In addition to HIV risk reduction concerns, a variety of related issues were addressed in life-like situations through role playing. For example, in role playing condom use negotiation before sexual intercourse, issues of dependency, self-esteem and empowerment were addressed. After participants became familiar with the technique, suggestions for role playing spontaneously came from participants and included topics which staff had not planned for in the intervention program. For example, through role playing requests participants raised the problem of asking staff for condoms, and acted out scenes in which they demanded condoms from a resistant psychiatrist or nurse. This provided opportunities for patients to practice assertiveness with staff, insisting, for example, that it is their "right to receive condoms in order to protect" themselves while on a home pass. Sexual Risk Behavior
Participants had varied sexual experiences. One patient was a high functioning woman who had multiple relationships, another was a married man who had a few extramarital relationships, and yet another man had no intimate relationships but had occasional homosexual sexual encounters at a community residence. Of the nine participants who consented to the research interview, 1 of 3 females and 5 of 6 males had been heterosexually active in the past six months. Although none of the men admitted to any homosexual activity in the past six months, three of the six men had had some homosexual activity since 1978. The sexually active woman admitted to homosexual activity as well. One of the men and the woman admitted to engaging in sexual behavior in exchange of money in the past six months. In spite of the risk behavior and the seeming
194
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concern about HIV, none of the patients used condoms in any sexual activity. A I D S Knowledge
Upon entering the program AIDS knowledge was satisfactory for this population. Most patients knew the routes of transmission for HIV and, for example, correctly responded that a healthy looking person could be HIV-infected, or that HIV infection has a long incubation period. Patients were least accurate in answering questions that required more integration of information. For example, patients incorrectly identified donating blood as a risk behavior, and mistakenly failed to identify sexual intercourse with an IV drug user as a risk behavior if the patient him/her self is not an IV drug user. The mean score on the AIDS knowledge questionnaire before we began our psychoeducational program was 21.4 (SD = 4.4) representing 21 (75%) correct responses to 28 questions. In spite of this substantial pre-existing knowledge, we detected some improvement in participants' knowledge following the program. Mean knowledge score increased to 23.9 (SD = 4.3) representing an improvement of 0.6 standard deviation to 24 (86%) correct responses. Risk Related Attitudes
Patients showed a decrease of 0.5 standard deviation in non-functional attitudes from 34.2 (SD 7.5) before to 30.3 (SD 8.9) after the program. Thus, patients' attitude show some movement to holding more functional attitudes, such as "I can avoid getting the AIDS virus by protecting myself when I have sex," and ~there's a lot I can do to make sure that I stay healthy and free from AIDS."
DISCUSSION We set out to test the feasibility of administering a psychoeducational program for HIV risk prevention to chronic mentally ill patients. We were concerned with patients utilization of the program and with potential risks and benefits. Our experience with a program pilot on an acute admission ward is promising. Our find-
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ings suggest that patients who elected to participate in the program were at greater risk for HIV infection than patients who did not participate. It therefore appears that psychiatric patients are motivated to participate in HIV educational programs based on rational concerns and will voluntarily participate in such programs if they are available. Patients seemed to enjoy the group discussion, the videotapes, and role-playing of life-like situations related to risk prevention. Only one patient withdrew from the program and this patient did so following the first session. In spite of initial concern over patients' response to discussion of sexually explicit material, ward staff was supportive of the program once their concerns were addressed. None of the patients experienced any adverse effects due to program attendance, and no exacerbation of psychiatric symptomatology was noted in response to program participation. Like other investigations (14,15), our pilot study suggests that patients' knowledge about AIDS is satisfactory. In spite of this, risk prevention as indicated by condom use was alarmingly absent. This confirms theories of illness prevention which suggest that functional attitudes and skills rather than knowledge are at the crux of preventive behavior. Our conclusions are limited by the small sample size of this pilot, which prevents us from examining our measures of efficacy for statistical significance. Moreover, the small sample size did not allow us to correlate the number of sessions actually attended with the measures of efficacy. In a larger sample such an analysis would likely show that benefits increase with increased attendance (16). Also, our pilot does not attempt to address the long term effects of the program. Our results suggest some future directions for an HIV risk reduction program. We learned that patients often do not disclose possibly stigmatizing information about their risk behavior to the group. For example, although 3 of the 5 sexually active men admitted to homosexual relations in the past in an individual interview, none discussed this in group sessions. We recognize that addressing patients' individual risk behavior, and making concrete recommendations for prevention, in private will improve the program. As a result, we developed a program which integrates a component of individualized risk reduction recommendations with the group intervention. The program would augment the group
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sessions with individual sessions in which each patient discusses his or her risk behaviors and appropriate risk prevention techniques with one of the group co-facilitators. This would allow patients to disclose personal material which they might be reluctant to discuss in the group. Allowing patients to make their own videotapes would be another useful technique to add to the program (Rotheram-Borus, private communication). Role playing, which was used successfully with the patients, may be used in combination with video making. Patients would work toward producing short films of some of the role play skits. This technique would help make the program attractive and interesting to participants while building on and consolidating the benefits of role playing. In addition, based on other studies (16) we believe that a longer program consisting of about 15 sessions may be necessary to generate solid behavioral changes. Also, we do not expect that a onetime intervention will suffice. Like other interventions with the chronic mentally ill, we believe that continued support is an essential part of a comprehensive risk reduction policy. This can be achieved by following the intensive intervention with an on-going maintenance group which discusses AIDS and HIV infection within the context of patients need for intimacy. In conclusion, chronic psychiatric patients are at significant risk for HIV infection. Mental health professionals must address this problem by providing patients with appropriate HIV risk reduction programs. Our experience suggests that the chronic mentally ill can engage in, and benefit from, psychoeducational programs that are specifically designed to address their needs.
ACKNOWLEDGMENTS This study was funded in part by a grant from the National Institute of Mental Health (NH-46251) and the New York State Office of Mental Health. In addition, the work of the first author was in part supported by a National Research Service Award research training grant #5T32MH13043. The authors wish to t h a n k Elizabeth Margoshes, Ph.D., Kaj Neve, MD, and the patients who participated in the program.
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