Counseling older adults with HIV/AIDS: a strength-based model of treatment. (Practice).

This article outlines a strength-based assessment and treatment model applicable for the mental health counseling of those aging with HIV. By focusing on the specific areas of life where clients are functioning effectively, this model works to decrease attention to pathology and stigma and, subsequently, works to empower clients to concentrate on areas of their lives that are controllable.

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As HIV infection rates rise in today's society, there is an increased focus on HIV disease in older adults. Recent estimates suggest that 11% of new AIDS cases have been identified in people 50 years of age and older (Centers for Disease Control and Prevention, 2001). It is projected that this number will continue to increase as prevention efforts are not effectively reaching older adults involved in high-risk behaviors (Ory & Mack, 1998; Zablotsky, 1998). In addition, with the advent of protease inhibitors, persons with AIDS are living longer and moving into older stages of life (Manton & Stallard, 1998). As a result, many are facing new and complex stressors, such as comorbid health conditions and fewer resources (Kalichman, Heckman, Kochman, Sikkema, & Bergholte, 2000; Meadows, Le Marechal, & Catalan, 1998), and thus there has been an increase in psychological symptomatology among older adults with HIV (Heckman et al., 2002). Subsequently, mental health interventions that enhance the coping skills of older persons with HIV/AIDS are urgently needed (Heckman, Kochman, Sikkema, & Kalichman, 1999; Linsk, 1994). As the face of AIDS continues to evolve, mental health practitioners are being called upon to respond to the psychosocial needs of this growing group of older adults (Crisologo, Campbell, & Forte, 1996), which includes sensitivity to these clients' age cohort, cultural beliefs, values, and practices (Sankar, Luborsky, Rwabuhemba, & Songwathana, 1998; Zablotsky).

In response to the AIDS epidemic and the unique psychosocial issues that impact persons with HIV, there has been a large emphasis placed on the training of mental health practitioners regarding appropriate and effective intervention strategies (Britton, Cimini, & Rak, 1999; Britton, Rak, Cimini, & Shepherd, 1999; Hunt, 1996; Knox, Dow, & Cotton, 1989). As a result, more therapists are willing and prepared to deal with the multitude of issues surrounding HIV infection. However, mental health practitioner training and subsequent treatment regarding older adults is less developed than the assessment and treatment efforts with other groups afflicted with HIV/AIDS. Therefore, effective training and treatment models that focus on the unique and diverse presentations of older adults are urgently needed.

This article outlines a strength-based, biopsychosocial assessment and treatment model applicable for the mental health counseling of those aging with HIV. By focusing on the specific areas of life where clients are functioning effectively, this model works to decrease attention to pathology and stigma, and thus empowers clients to concentrate on areas of their lives that are controllable.

POPULATION OVERVIEW

Early in the HIV epidemic, infection occurred disproportionately among older persons as a result of transmission through the receipt of contaminated blood. However, this is no longer the case, due to routine screening of blood donations (CDC, 1998). Among older adults, men who have sex with men is the highest exposure category, but heterosexual contact and injecting drug use have dramatically increased as modes of transmission (CDC). Of those with AIDS aged 50 or over in 1996, 48% were aged 50-54, 26% were 55-59, 14% were aged 60-64, and 12% were 65 or older. The gender and ethnic distribution among older adults with AIDS is similar to that of the younger age groups, with a majority of cases being male and minority populations being over-represented (Brown & Sankar, 1998; CDC; Ory & Mack, 1998). For older adults, the emergence of HIV/AIDS evolves along two distinct pathways: those who are considered long-term survivors and those who are infected later in life.

Long-Term Survivors

This group includes persons who have been living with HIV for a long period of time and have since entered into older adulthood. This number continues to increase as new drugs and treatments make it possible for more persons to live with HIV/AIDS long enough to enter into the older age groups (Ory & Mack, 1998). Through the years, many long-term survivors have found successful ways of coping and living with HIV and, thus, have had limited exposure to mental health interventions (Barroso, 1996; Remien, Rabkin, & Williams, 1992). However, as long-term survivors enter older adulthood, a new set of mental health issues related to the aging process may emerge and generate the need for mental health treatment. For example, as survivors age, their support systems may change as a result of loss or isolation. Other persons may find that their HIV infection has accelerated since reaching a later stage of life, and they may be dealing with more opportunistic infections (Adler et al., 1997; Skiest, Rubinstien, Carley, Gioiella, & Lyons, 1996). As a result, coping strategies and resources that were historically successful may no longer be effective or available.

Adults Contracting HIV in Older Age

The second group of older adults includes persons who have contracted HIV during the later stages of life and, thus, present with a very different set of mental health issues and needs. From 1990 to 1996, the increase in the number of new cases of HIV/AIDS among older persons was more than double the increase in the number of new cases for persons aged 13 to 49, that is 22% for older persons compared to 9% for younger persons (Ory & Mack, 1998). Many of these older adults are dealing with the shock and shame of finding out their HIV status and are challenged to adjust to the various cognitive, physical, and social changes brought on by the aging process and possibly accelerated by HIV infection. Because older adults are not often thought of to be at risk for HIV infection, a diagnosis of HIV or AIDS is often delayed; and many times the diagnosis is made only after assessment for other more mainstream diseases has been unsuccessful (Szirony, 1999). Symptoms that might point to HIV/AIDS in a younger patient may be overlooked in an older adult, partially due to existing biased attitudes regarding this population (Chiao, Ries, & Sande, 1999). As a result, this group of older adults may not receive the prompt medical or psychological treatment they need. This is particularly alarming as older adults have poorer outcomes regarding opportunistic infections when compared to their younger counterparts (Adler et al., 1997).

For both of the above-mentioned groups, isolation, shame, and depression are prevalent (Heckman et al., 1999). These persons may also be experiencing forms of ageism. Having AIDS is not what most people think of as an older adult issue, and denial about an older adult's potential to be HIV-infected is prevalent among many care providers, including mental health practitioners (Hillman & Stricker, 1998). Inasmuch as service providers maintain negative or naive attitudes about older persons or their behavior, the development of assessment and treatment services for older adults will be impeded. Many older adults with HIV do not conform to age-based stereotypes due to their sexuality, sexual preference, or drug use; and they are often stigmatized (Linsk, 2000). As a result, clients' shame can be more pronounced. Also, as the number of older adults who are affected by HIV/AIDS has disproportionately grown, support systems and treatment services may not be as well developed as they are for others who are afflicted by HIV/AIDS (Strombeck, & Levy, 1998). Thus, it is imperative that mental health practitioners become aware of these issues in order to appropriately handle the unique treatment needs of their older adult clients who have been infected with HIV disease.

STRENGTH-BASED ASSESSMENT AND TREATMENT

Over the past 15 to 20 years, a variety of treatment models, such as Solution-focused or Narrative therapy, have come from a constructivist perspective that focuses on an individual's strengths (Berg, 1994; Cade & O'Hanlon, 1993; De Jong & Berg, 2002; De Shazer, 1985, 1988; Durrant, 1993; Freedman & Combs, 1996; Gilligan & Price, 1993; Rapp, 1998; Saleebey, 1992; White & Epston, 1990). In contrast to medical models that stress the identification and treatment of pathology, strength-based models work to assist clients in living more productive and satisfying lives. In addition, medical models, with emphases on disease, symptoms, and behaviors that have negatively contributed to one's current health, may further victimize clients in that the models focus on what is wrong and bad about them. Strength-based models are designed to empower clients, "helping people discover the considerable power within themselves, their families and their neighborhoods" (Saleebey, p. 8). Implied within the strength-based framework is the assumption that all people have assets that can be marshaled. Using such an approach, mental health counselors can assist in helping clients discover and reinforce these strengths, thus contributing to thoughts of living in the moment and enjoying the present (Saleebey). Differences between a strength-based model and more traditional models of therapy are outlined (See Table). Overall, more traditional models of assessment and treatment are potentially biasing to clients with HIV disease. Many of the physical symptoms of HIV/AIDS as well as side effects of medications (e.g. lethargy, loss of weight, loss of sexual desire, mood changes) can be confused with mental health diagnoses such as depression, anxiety, or bipolar disorder (Britton, 2000, 2001). As a result, symptoms in older persons with HIV are often diagnosed improperly due to stereotypical beliefs that older adults are unsusceptible to HIV/AIDS (Currier & Fliesler, 1995).

Reviews of outcome research on strength-based models have supported their efficacy (e.g., George, Iveson, & Ratner, 1999; Gingerich & Eisengart, 2000; McKeel, 1996). Consequently, the application of such models to older adults is being emphasized in the literature and appears to be promising for a range of individuals (e.g., Kropf & Tandy, 1998; Dahl, Bathel, & Carreon, 2000; Orsulic-Jeras, Judge, & Camp, 2000).

STRENGTH-BASED ASSESSMENT AND TREATMENT

When beginning counseling with an older adult with HIV using a strength-based model, it is important to conduct an initial assessment of the client's well-functioning aspects of physical, psychological, and social areas of life. The practitioner should be interested in exploring what is working well in the client's life now and how he or she has been able to create and maintain that positive functioning. More specifically, assessment information is gathered through a clinical interview that is organized using a biopsychosocial perspective (Crisologo et al., 1996). Clients are probed to discuss their assets in each of the following areas: physical, social support, life roles, employment/hobbies/recreation, history/culture, and coping. Treatment planning follows directly from the assessment, and it involves acknowledging strengths, working to increase them, and then applying them to current challenges.

Physical

Because HIV and aging are both progressive processes that affect the body, it is important to determine the aspects of the client's physical health that are currently intact and could potentially be utilized as a resource. The empowering quality of this strength-based model is that during assessment and subsequent treatment, the mental health counselor is not concerned with the cause of this physical symptom, whether it is HIV, the aging process, depression, or a combination of causes. For example, lack of energy is a physical symptom that is often reported by persons with HIV. When developing a treatment plan to deal with this concern, the focus remains on what can be done with the level of energy that is remaining within that client. If a client reports not having enough energy to put the laundry away, a mental health counselor may work with the client to develop an energy conservation plan. This plan would work on minimizing the number of steps it takes to complete a task, thereby conserving the client's level of energy and maximizing the strength in this area.

Social support

The level of social support given to an individual during a health crisis has been documented to have a profound impact on a person's physical and psychological well-being (Barroso, 1997). As a result, it is important to include social support when conducting a strength-based assessment. To begin, the mental health counselor must determine who serves as the client's primary source of social support, whether it is a partner, family member, friend, or another professional involved in the client's life. In addition, identifying secondary sources of social support comprised of additional individuals or groups is equally important, because they may be used in combination with the primary source of support to develop a "social support tree."

The social support tree may serve as a visual representation of (a) the amount of love and support a person may have in his or her life, and (b) how meaningful one's well-being is to others. The client is being held up or supported by a primary source of support while being surrounded by his or her secondary sources of support at the same time. This approach to assessment also has the benefit of having a therapeutic impact, identifying a solution prior to defining the problem. For example, if a client reports not having any primary or secondary sources of support, a goal in treatment may be to focus on filling in the blocks on the social support tree, which can later serve as a visual example of progress the client has made over time. This outcome may be particularly true of newly infected clients whose social support networks may be significantly disrupted due to ageism and the stigma associated with disclosure of HIV status.

Life Roles

Continuing to fulfill important life roles is important in maintaining feelings of productivity, usefulness, purpose, and identity (Alterkuse& Ray, 1998). For example, a 75-year-old woman may have spent most of her adulthood caring for her spouse, children, and grandchildren, but now finds herself the one being cared for. In this situation, the woman may become depressed as a result of feeling like she is dependent and a burden on her family. In assessing this client and developing a treatment plan using a strength-based approach, it would be important to document the resources that she still possesses. These assets could be utilized to give her an opportunity to nurture and take care of someone or something. More specifically, if the client demonstrates strength as a caregiver based on her life role as a wife and mother, yet is widowed and currently lives alone, having a pet may provide responsibility and companionship, or planting flowers or tending to a garden may provide growth and purpose. The reliance on life roles in such a manner can be utilized to accomplish a sense of fulfillment and meaning.

Employment/hobbies/recreation

As the retirement age has continued to increase from 65, there are older adults living with HIV/AIDS that continue to remain employed as a means of financial support as well as maintaining a sense of meaning to their life. In addition, volunteering or mentoring is a popular avenue for older adults who are retired or too sick to maintain full-time or even part-time employment. From an Adlerian perspective, social interest offers encouragement for older adults to remain active and to enjoy the remainder of their lives, knowing that they continue to impact the lives of others (Kern, 1998). However, similar to the assessment of social support, social connectedness through one's activities may be a source of distress for many older adults with HIV because of the fear and experience of rejection, particularly among those who are recently infected. Determining the client's social interests can be utilized to develop additional activities that allow him or her to take on appropriate responsibilities in society and focus on filling voids that may exist in his or her life.

History/culture

Because much of the counseling literature is based on individuals from mainstream society, there may be problems with applying these interventions to people with more nontraditional lifestyles. Data on the epidemiology of HIV/AIDS underscore the importance of focusing attention on minority populations. Many of the older persons presenting with HIV disease come from minority cultures that reflect non-mainstream worldviews (Brown & Sankar, 1998). Additionally, the cultures of drug abuse and homosexuality are often met with resistance in the majority culture, especially among older adults (Levy, 1998). People from oppressed groups frequently have difficulty trusting outsiders and institutions. This can be particularly true for older adults who may feel a deep sense of shame and embarrassment (Brown & Sankar). There are also cultural differences regarding how clients conceptualize illness, death, and dying. Due to the nature of HIV/AIDS, many people are uncomfortable discussing personal information with someone outside of the most intimate circle of supports. For many older adults, counseling may be a sign of weakness, indicating that they are unable to handle their own lives. Thus, mental health counselors need to maintain a multicultural awareness as well as awareness of generational issues, in order to ensure a perspective that honors and respects diversity (Winiarski, 1997).

One of the advantages of strength-based models is that they celebrate the differences in people, framing diversity as a strength (De Jong & Berg, 2002). A mental health counselor from this perspective would be curious about how a client's unique cultural makeup contributes to self-views and impacts disease management. More specifically, a mental health counselor might ask a client what culturally based coping mechanisms has he or she learned as a result of being a part of a stigmatized or marginalized group that might provide some resources now. In recognizing and validating this diversity in therapy, clients may feel more open to embrace their backgrounds and cultural heritage as well as their age, to strengthen their functioning and independence. Acceptance of differences and a nonjudgmental attitude is essential, particularly toward persons demonstrating behaviors that may be perceived by society as negative (Hillman & Stricker, 1998).

Coping

A final component of the strength-based assessment involves determining the client's historical patterns of coping. Persons who have been living with HIV for many years often have developed numerous coping strategies (Barroso, 1996, 1997; Remien et al., 1992) that can be generalized to assist in dealing with issues of aging. Even older adults who are not accustomed to coping with the stigma of HIV/AIDS, due to their recent diagnosis, can recognize coping skills that can be enlisted to deal with the current crises. For example, an assessment focal point might include asking how a client dealt with previous medical problems or losses. Using this strategy may enable the client to see strengths in coping and identify negative styles of dealing with stress, such as avoidance or substance usage.

IMPLICATIONS FOR APPLICATION AND PREVENTION

Historically, strength-based models have been conceptualized as short-term interventions leading to the solution of the problem at hand (Cade & O'Hanlon, 1993; De Shazer, 1985, 1988). However, application of the model has been found effective in both short- and long-term treatment milieus (George et al., 1999). Applying strength-based models to treating older clients in residential settings is a good fit. In such settings, reviewing treatment goals regularly is encouraged; so the objectives can be tailored to the client's current functioning, resulting in improved quality of care. Although the clients in these settings may be physically or cognitively deteriorating, the focus in treatment should continue to remain on the domains where the client remains functional, because AIDS remains incurable. As clients deteriorate, the mental health counselor continues to be interested, not in their deficits, but in what strengths remain.

Assisting older adults in identifying and amplifying their life skills and strengths could have implications for prevention and assist in behavior change. For instance, this approach has been effectively applied to clients with Alzheimer's disease, which resembles HIV disease in that it is progressive and has no medical cure. When conducing recreation therapy with older adults with Alzheimer's disease, strength-based interventions brought about statistically significant increased levels of client engagement with their environment (Orsulic-Jeras, Judge, & Camp, 2000; Orsulic-Jeras, Schneider, & Camp, 2000; Orsulic-Jeras, Schneider, Camp, Nicholson, & Helbig, 2001). The method assessed clients' existing motor, cognitive, and sensory strengths and used them to develop a Montessori-based treatment plan, effective for even for those clients with advanced stages of Alzheimer's disease (Camp, Koss, & Judge, 1999). In addition, prevention of HIV in older adults is imperative, yet challenging (Strombeck & Levy, 1998). Through strength-based treatment, older adults may be motivated to educate their peers, particularly those who see themselves as unsusceptible to HIV/AIDS. An older woman may learn skills that assist her in asking her partner to wear a condom. An older male, through the help of a strength-based mental health counselor, may enlist the social support needed to assist him in seeking help for substance abuse.

Nonetheless, there are potential limitations in the application of this approach with older adults. Many older adults have been accustomed to a more traditional model of help, and they may resist taking a more active role in their treatment. Clearly, research is needed to test the efficacy of this or other strength-based models of assessment and treatment with older adults afflicted with HIV/AIDS. Additionally, most agencies as well as third party payees are organized around an assessment and treatment of pathology. Most require Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) diagnoses and treatment goals based on such. However, clinicians can become skilled at assessing clients from a medical model while also using a strength-based assessment. For example, an older client with HIV who reports lethargy, sadness, and loss of motivation may be given a diagnoses of depression, while also assessing his level of strength in getting to appointments on time.

The number of persons over 50 who are infected with and affected by HIV continues to rise (Ory & Mack, 1998). With more exposure being brought to the public through research findings and media reports, much attention will be placed on prevention efforts targeting this population. As mental health professionals continue to wait and hope for the medical community to find a cure for AIDS, long-term survivors as well as newly diagnosed persons over the age of 50 remain in need of effective and safe mental health treatment. Using a strength-based model such as the one described herein can assist a mental health counselor in creating a therapeutic environment that serves as a shelter for clients, filled with growth, empowerment, and acceptance.

Traditional Versus Strength-Based Models

        Traditional                vs.         Strength-based

Diagnostic assessment involves        Assessment includes identifying
  identifying symptoms and              strengths, uses a biopsycho-
  pathology                             social model
Focus is on illness                   Focus is on strengths
Counseling directed at suppressing    Counseling directed at supporting
  negative symptoms                     coping behavior, change, and
                                        growth
Emphasis on insight of emotional      Emphasizes new possibilities,
  problems through understanding of     options, and amplifying
  past events                           successes
Client receives treatment             Client is active in treatment
Therapist is the expert               Therapist is a partner
Client is categorized and labeled     Each client is unique
Focus on what is wrong and why        Focus on what is right and how

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Silvia Orsulic-Jeras, is an independent researcher in Mentor, OH. E-mail:[e-mail] J. Brad Shepherd. Ph.D., is an assistant professor, Department of Psychology, Kent State University Stark Campus, Canton, OH. Paula J. Britton, Ph.D., is an associate professor, Department of Education and Allied Studies, John Carroll University, University Heights, OH.