HIV / AIDS Prevention: A Model for Educating the Inpatient, Psychiatric Population

Frederic B. Tate, Rh. D., LPC, and Dan A. Longo, Ph.D.
Eastern State Hospital

Submitted: September 1, 1999

Dr.s Tate and Longo are psychologists in the Psychosocial Program at Eastern State Hospital in Williamsburg, Virginia. Eastern State is the oldest, public hospital in the nation. Both have worked in the field of HIV/AIDS since 1982.

Author's Note - Reprints and correspondence concerning this article should be addressed to the first author:

Dr. Frederic B. Tate, Psychologist
Building 26
Eastern State Hospital
P.O. Box 8791
Williamsburg, VA 23187-8791
Phone: 757-253-5538
Fax: 757-253-4318

Abstract

Scientific and medical research in the field of HIV/AIDS prevention has recently moved closer to finding a vaccine and a cure. Behavior change, however, is currently the only available means to decrease new cases of HIV, and the proper use of condoms is the most effective preventative measure for people with severe and persistent psychiatric disabilities who are sexually active. It is now well-documented that educating this population about safer-sex practices can reduce their risk of getting HIV/AIDS and other sexually transmitted diseases (STDs). The following article is a brief review of a model used to educate clients in an inpatient, state psychiatric hospital. Strategies that focus on developing behavioral skills are outlined.

There have been many dramatic advances in fighting HIV/AIDS, offering those infected with, and affected by this disease, numerous reasons to be optimistic. These advances are, in part, secondary to the increased understanding of the pathogenesis of HIV, new medications, as well as the ability to more accurately measure viral load. However, the relatively new protease inhibitors, for example, do not work for everyone and due to the costs (often as high as $15,000 per year), are often out of reach for many clients. Despite all the progress made, there is still an AIDS-related death in this country every 15 minutes. The one facet of the epidemic that has remained unchanged over the years is that behavioral change is the paramount method of prevention.

PSYCHIATRIC CLIENTS: THEIR RISK FOR HIV/AIDS

Research indicates that HIV/AIDS does pose a more substantial risk to clients in psychiatric hospitals than it does to the general population. Goodman (1991)1 reported an infection rate in three inpatient, psychiatric hospitals in New York City that was double the rate in the general population of that same city. Clients with certain diagnoses also appear to be more vulnerable to HIV/AIDS. Cournos et al (1990)2 found that the clients at greatest risk are those diagnosed with a mood disorder (manic type), and those holding a dual diagnosis of substance abuse. Manic clients may experience sexual interactions that are frequent and indiscriminate, and often use poor judgment leading to an imprudent and uncharacteristic involvement in many activities, including sex. As with the general population, psychiatric clients who abuse or are addicted to intravenous (IV) drugs, are at a high risk for HIV/AIDS (Stall et al, 1986)3. Many individuals who use IV drugs rarely carry their own needles, and few have been taught how to properly clean a needle or syringe prior to sharing them. Though other countries have repeatedly demonstrated that needle exchange programs significantly decrease incidents of AIDS and hepatitis, there are currently few such programs in this country due to the political sensitivity of the issue. Studies also indicate that clients diagnosed with both a clinical syndrome and a personality disorder are at a higher risk for HIV infection than those with a clinical syndrome alone (Kalichman et al, 1996)4.

There are many other issues that may increase the risk of disease for those with severe psychiatric disabilities. Limited financial resources and homelessness are examples. Kelly et al (1992) 5 examined the high-risk behaviors of psychiatric clients once discharged and confirmed what many mental health workers have feared for years. About 62% of those followed were sexually active during the previous year, many had multiple sexual contacts, and the use of condoms was infrequent. Some clients had traded sex for money or a place to stay, others were coerced to engage in unwanted sex, and as many as a third of the sample had been treated for STDs. This data, when paired with the fact that most clients have difficulty with interpersonal relationships and negotiating safer-sex, underscore the need for safer-sex programs for those who are persistently mentally ill.

ROADBLOCKS TO ESTABLISHING EFFECTIVE SAFER-SEX EDUCATION

The stereotype of the inpatient, psychiatric population as asexual remains, unfortunately, real and results in dangerous consequences and attitudes such as a lack of interest among professionals for teaching clients about safer-sex practices. When one reviews statistics on pregnancy and STDs among this group of individuals, for example, it is obvious that someone is having sex (Menon et al, 1994)6. In addition to the myths surrounding psychiatric clients, many mental health workers are faced with the incongruity of policy that is opposed to sexual activity in many psychiatric hospitals, versus the need for the clients to have easy access to condoms and safer-sex education. The old myth that safer-sex will "promote sexual activity" is one of the more illogical refrains that continue to be repeated, resulting in an inadequate, watered-down approach to safer-sex. Although most hospitals will educate clients about the dangers of cigarettes to decrease smoking and about the dangers of alcohol to decrease its abuse, all too often they refuse to educate clients about the dangers of unsafe sex. In contrast, Kalichman et al (1996)7 have demonstrated that the more information clients have about HIV/AIDS prevention, the lower their risk of contacting the disease.

In addition to the above, lack of time appears to be a frequent and often valid excuse why safer-sex education is not offered in busy hospitals. An informal survey conducted by these authors at their hospital indicated that almost all employees felt that AIDS prevention and safer-sex education were needed. Surprisingly, the majority also stated they would be comfortable talking with clients about explicit sexual issues. However, other than addressing the topic at an individual level, or occasionally showing an AIDS-related video, little else was done, reportedly due to a lack of time. Adding yet another task, no matter how important, to an already over-worked staff can be a challenge. A supportive administration can facilitate the resolution of many of the above roadblocks, resulting in a strong foundation on which effective safer-sex education can be built.

ELEMENTS OF AN EFFECTIVE SAFER-SEX MODULE

There is substantial research to document that safer-sex education can result in behavioral change and decrease the risk of becoming infected with HIV (Goisman et al, 1991)8. Following, are some of the chief elements that are crucial for effective safer-sex education.

It is important to remember that the amount of information be appropriate for the functioning level of participants. Though not always possible in psychiatric hospitals, it is of course, best to match participants as closely as possible to functioning level. Not all psychiatric clients are able to sit for an entire hour, their attention span may be limited and they easily become overloaded with too much information. Instead of one hour sessions twice a week, for example, some groups may be better served with thirty minute sessions four times a week. Minimum requirements to attend the group might include the ability to sit appropriately for thirty minutes, fair concentration, and being well-oriented. However, these authors have had very successful sessions even with clients who were delusional and with those with fairly severe attention deficits.

Participation can be strongly encouraged and highly reinforced. Though less than ideal, there will be times when clients are required to participate. Many clients who appear uninvolved will still learn by observing. Also, until a group has established trust and rapport, it is recommended that facilitators use anonymous questions. A simple technique is to pass out index cards at the beginning of each group. Clients are asked not to write down any questions they have about sex or HIV/AIDS, and not to write their names on the card. They are also told not to worry about using medical terminology--that slang or street language " is perfectly acceptable. These cards are collected and read. Clients are not always comfortable asking questions they need to know in front of their peers; this technique affords them a safe alternative.

Facilitators should also be cautious not to use heterosexist language, and module leaders should not assume that all participants are heterosexual. The module presented here discusses safer-sex for all sexual orientations, and uses same-sex couples in the examples and for role-playing. An AIDS prevention module offers many opportunities for the sensitive facilitator to address issues related to homophobia and sexism. In general, an environment where all clients feel safe, knowing that they will not be judged, is important. If facilitators are uncomfortable using slang language for body parts and sexual acts, then they must be sure to define the terms so that all group members are "singing off of the same sheet of music". For example, following a lecture where the term "anal intercourse" was used, one of the authors was approached by a client who asked if anal meant having sex "...just once a year". Clearly, terms like fellatio or copulation only confuse the majority of our clients and should probably be avoided.

A well-designed module will work just as effectively used with a group or taught to a client who needs one-to-one sessions. There are times that conducting the module with a specific group such as one in which the participants are all female or all gay men, may be helpful. Having males and females in the same group results in some very important dialogue, role modeling, and peer education. Women with a history of sexual abuse, however, may be uncomfortable discussing explicit sexual issues with men. In this case the advantages of a same-sex group will outweigh the disadvantages. Though not always possible in psychiatric hospitals, it is of course, best to match participants as closely as possible to functioning level.

It is ideal to have two facilitators, a male and a female since many clients may prefer discussing explicit sexual issues with a member of the same sex. One facilitator can direct activities as the other monitors progress, offers feedback, and helps keep the group focused and on task. On more than one occasion, secondary to illness or emergencies on the unit, these authors would have had to cancel a group if there had not been two facilitators. Hospitals working within a psychosocial context may also want to have a client who is comfortable with the topic and has completed the module help with other groups. With staff supervision, peer teaching has the potential of modeling appropriate safer-sex behavior. It is essential that only staff willing to teach the curriculum be enlisted to do so, however, all staff should be encouraged to attend the module. The better educated the staff, the greater the opportunities for clients to get accurate information. Staff too, often have inaccurate information about HIV/AIDS.

The objectives for the module need not be complex. Participants should simply leave the group with accurate, basic knowledge about HIV/AIDS prevention. This objective can be measured by administering a one page test during the first and last sessions, and comparing the pre and post-test scores. Several of the test questions on the true/false test include, for example, items on proper lubricants, safer sex, the safety of donating blood, and dangers of mixing alcohol/drugs with sex.

Use repetition to help teach safer-sex. Each session should begin with a review of the previous session, and end with time for questions and a review of what will be presented in the next session. Also, education should be basic and simple. Clients do not, for example, need to understand the physiology of a retro virus in order to protect themselves from HIV/AIDS. It is recommended that those offering safer-sex education to psychiatric clients in hospitals be sure to encourage people who are HIV+ to attend. Individuals living with HIV need to learn to protect themselves from further infections, as well as protecting their sexual partners. During the sessions where HIV+ participants decided to disclose their status, these authors were supportive and the experience was positive for the entire group. The best way to change stereotypes and decrease the irrational fear that some hold toward people who are HIV+, is for them to get to know someone who is HIV+.

In most psychiatric hospitals is would be wise to inform the group during the first session that the facilitators are not opposed to abstinence or celibacy if a participant chooses such. However, it needs to be stressed that these are not realistic options for most, therefore the goal is to teach safer-sex. When resistant clients state that they do not need the group because, "I do not plan to ever have sex again," a good response is to ask them to participate so they can help educate others.

Several of the teaching modalities that can be used during the course of a module addressing AIDS prevention include experiential learning, role-playing, video, lecture, handouts, discussion, written assignments, and safer-sex flash-cards. Role-playing is necessary to help clients learn how to negotiate safer-sex and how to say "no". It is necessary when working with the female participants to teach them how to deal with a male partner who refuse condoms. Equally as important, but rarely discussed, is the need to teach male participants about sexual harassment, rape, and sexual abuse. It is also important to teach them that a women has the right to change her mind about having sex, even if she has previously agreed to it, and that when she says "no", that what she really means is "no".

Though these authors believe that fear, within limits, can be a motivator for change, and that "shock-value" may have an appropriate place in safer-sex education, they should never be used in isolation. The goal is to bring the reality of HIV/AIDS to the participants, without immobilizing them with fear. A "sex-positive" message, that safer-sex can be fun and erotic, is the objective. These authors purchased realistic dildos (one white and one black) for condom demonstrations. Using a banana is better than no demonstration at all, but is insulting to most adults. Though there may have initially been some nervous laughter, not one client in this study reacted inappropriately to the dildo. A vaginal model is helpful when discussing birth control and the female condom.

The importance of flexibility cannot be over-stated. A good module is structured and planned, but the best facilitators are those who are able to put the plans aside, following, within limits, the needs and direction of the group. For example, when a group asked questions about other STDs, these authors invited a nurse with expertise in infectious disease to talk with the group. Group members often like to cut articles related to AIDS out of newspapers and discuss those during groups.

For the best models of behavior changes related to sexual activity, one must review the techniques used by the gay, male community in San Francisco. Kelly (1992)9 studied the significant decrease in the seroprevalence rate of this population. He stated that these changes in behavior were attributable to fear, aggressive community education via outreach programs, and to evolving peer norms that discourage high-risk behavior and make safer-sex practices the accepted social norm. In addition, these authors would add that gay males have had a higher success rate for marketing condom use as erotic--an important factor in getting males of any orientation to use them. Also, these authors have found a much higher success rate of having male, psychiatric clients buy into the need to use condoms when the benefits to them are presented. For example, stating that condoms protect the male from disease, and that they do slightly reduce sensitivity levels allowing the male to perform longer prior to ejaculating, helps sell the idea of condom use.

Kelly (1992)10 has outlined five factors that influence HIV/AIDS risk behavior change and that these should be taken into consideration when designing education modules. The factors are risk education, perceived personal vulnerability, self-efficacy, implementation skills, and reinforcement of behavior change efforts. The first of these factors, risk education, is the understanding of behaviors that are risky, teaching behavior changes needed to decrease or eliminate these risks, and presenting the logic underlying risk education changes. Perceived personal vulnerability suggests that risk factors must be personalized to bring about effective change. According to the author, participants in educational groups must believe that they are potentially vulnerable for contracting HIV/AIDS. Self-efficacy is the belief that one is capable of successfully making behavior changes--a form of empowerment. Implementation skills are the behavioral competence necessary for change implementation such as condom use, safer-sex negotiation skills, and needle cleaning. Reinforcement of behavior change effort is defined as the positive outcome associated with behavior change such as self-praise and the belief that behavior change is consistent with peer group norms.

Several authors (Kalichman et al, 1996; Volavka et al, 1992; McGurk et al, 1994)11 also identified factors that have been associated with enhanced risk related to HIV/AIDS and the psychiatric population. These factors included the severity of psychopathology, extent to which substance abuse is proximal to sexual behavior, misinformation about HIV transmission, and perceptions of invulnerability. Understanding these specific characteristics of comorbidity can lead to improved HIV/AIDS preventive models.

THE MODEL

A brief synopsis of what is presented in the safer-sex module is shown in Table 1. The module consists of ten sessions and the general content of each is also outlined in the table.

Homework assignments address such topics as the participants' opinion on the use of condoms and passing them out within a psychiatric hospital, reasons why people have unsafe sex, birth control, being tested for HIV, and how to respond when we meet someone who has AIDS.

TABLE 1 - CONTENT OF THE SAFER-SEX MODULE:

Session 1: What is safer-sex? During the first session introductions are made and a basket filled with condoms is presented--clients are encouraged to take several with them at the end of each session. Group rules are set, goals of group reviewed, the pre-test is administered, and an activity (sexual synonyms) is conducted to increase the comfort level for using sexual words.

Session 2: Myths about AIDS and what I need to know. The facilitators present basic facts about HIV/AIDS, and the group reviews various specific, sexual practices and their degree of safety. The myths surrounding AIDS are also discussed.

Session 3: How to use a rubber. Condoms are passed out and there is a demonstration of the proper use of condoms. Participants are given the opportunity to practice condom use. The female condom is also presented at this time and its advantages/disadvantages are discussed.

Session 4: How serious is the threat of AIDS to me? The safer-sex flash-cards are introduced as a way to review basic information, and an exercise designed to demonstrate why knowing potential sex partners is important, is conducted.

Session 5: High risk situations. Group members anonymously identify circumstances under which they might be tempted to engage in unsafe sex. The dangers of rationalization are discussed and participants role play scripts depicting risky situations.

Session 6: Communicating self-confidently. During this session the facilitators introduce the use of self-confident communications, and then practice making requests related to sexual activity, through role-playing.

Session 7: Coping with abusive and coercive behaviors. Abusive / coercive behaviors are defined and explored, as are ways of avoiding them.

Session 8: HIV and substance abuse. Cleaning a syringe is demonstrated and the relation between alcohol/drugs and HIV is outlined.

Session 9: Review.For the purposes of review, a safer-sex video is shown. Facilitators review the highlights from each chapter. This is followed by a question and answer session.

Session 10: Celebration! The post-test and module evaluation are administered. Certificates of completion are presented and a celebration with cake and ice cream follows.

SUMMARY

In general, psychiatric clients at the greatest risk for STDs share three primary characteristics: a) poor judgement secondary to impaired cognitive ability or affective instability, b) hypersexuality, and c) impulsivity (Carmen & Brady, 1990)12. It is beneficial to address these when designing and implementing safer-sex programs that will be used with the inpatient, psychiatric population. These authors have had several clients in the HIV/AIDS prevention module who were diagnosed with depression . When depressed, they were much less motivated to take precautions during sexual activity. When processing this they disclosed that at those times they felt helpless and simply did not care if they got sick. Attempts as stabilizing affect via therapy, behavioral interventions, and medication, are most effective if they occur prior to participation in the safer-sex module.

The model presented above is an initial, working model that can form the basis for a practical approach to safer-sex education with inpatient, psychiatric clients. At this time, data supporting the model's effectiveness are not available. Pre-test scores and the results of a questionnaire measuring high-risk behaviors, will be compared to post-test scores when sufficient numbers have been collected over time, yielding a large sample.

This model as presented, has evolved from a review of literature and from years of clinical practice working with individuals with psychiatric illnesses. The clients who have successfully completed modules, have also provided invaluable suggestions, comments, and feedback in the form of a one-page evaluation completed during the last session. Almost all of the clients considered the group beneficial, and felt that they had learned important information that they would use. Many stated that the "relaxed", "open", and "nonjudgmental" environment of the group made discussion of personal and sexual issues, easier. The major criticism of the group, one with which the facilitators could easily live, was that it was too brief in duration.

Though a few staff were initially concerned that clients who were impulsive may show an increase of inappropriate behaviors secondary to participating in the module, these authors can report no incidents of sexually inappropriate behavior increasing. The opposite occurred with some of these clients--they modeled the appropriate behaviors of the other group members and responded to pressure from their peers to behave in a more mature fashion. These authors support the research of Goisman et al (1991)13 who found that most clients can tolerate exposure to sexually charged material without risk of decompensation or sexual acting-out.

In addition to the need for empirical research demonstrating the model's effectiveness, future studies should address the model's utility with other populations such as juvenile delinquents, clients with mental retardation, and individuals who are chemically dependent. Also, an item analysis of the pre-test questions may be helpful. Pre and post-test data will be stronger if paired with other measures obtained through chart reviews such as sexual behavior, data on STDs, etc. Self-report scales also hold potential.

In conclusion, those of us working with individuals who have severe and persistent psychiatric disabilities, must be committed to continued preventive education, doing our part in slowing the spread of the AIDS epidemic.

REFERENCES

1. Goodman, H. (1991). HIV infection and the severely mentally ill patients: Risky behaviors and risk reduction. HIV & Mental Health: A Newsletter for Professionals. 1(1), 2. New York: Department of Mental Health, Mental Retardation, and Alcoholism Services.

2. Cournos, F., Empfield, M., Horwath, E., & Schrage, H. (1990). HIV infection in state hospitals: Case reports and long-term management strategies. Hospital Community Psychiatry, 41 (6),163-166.

3. Stall, R., McKusick, L., & Wikley, J. (1986). Alcohol and drug use during sexual activity and compliance with safe sex guidelines for AIDS. Health Education Quarterly, 13(4), 3-16.

4., 7., 11. Kalichman, S., Carey, M., & Carey, K. (1996). HIV risk among the seriously mentally ill. Clinical Psychology: Science and Practice, 3(2), 130-142.

5. Kelly, A., Murphy, D., Bahr, G. Brasfield, T., Davis, D., Hauth, A., Morgan, M., Stevenson, L., & Dilers, M. (1992). AIDS/HIV risk behavior among the chronic mentally ill. American Journal of Psychiatry, 149(7), 886-889.

6. Menon, A., Pomerantz, S., Harowitz, S., Appelbaum, D., Nuthi, U., Peacock, E., & Cohen, C. (1994). The high prevalence of unsafe sexual behaviors among acute psychiatric inpatients. The Journal of Nervousness and Mental Disease, 182, 661-666.

8., 13. Goisman, R., Kent, A., Montgomery, B., & Cheevers, M. (1991). AIDS education for patients with chronic mental illness. Community Mental Health Journal, 27(3), 189-197.

9., 10. Kelly, A. (1992). AIDS prevention: Strategies that work. The AIDS Reader, July/August, 135-141.

11. Volavka, J., Convit, A., O'Donnel, J. Douyon, R., Evangelista, C., & Crobor, P. (1992). Assessment of risk behaviors for HIV infection among psychiatric inpatients. Hospital and Community Psychiatry, 43(5), 482-485.

11. McGurk, D., Miller, T., & Eggerth, D. (1994). HIV status, substance dependency, and psychiatric diagnosis. AIDS Patient Care, December, 328-330.

12. Carmen, E., & Brady, S. (1990). AIDS risk and prevention for the chronic mentally ill. Hospital and Community Psychiatry, 41(6), 652-657.