Positive impact: a community-based mental health center for people affected by HIV.
Comorbid psychiatric illnesses are more common in people with HIV than in the general population (Brown et al., 1992; Kessler et al., 1994). Recent studies have indicated that HIV-infected adults receiving medical care have screened positive for a mental disorder or drug dependence in the past year at a rate nearly five times higher than the general population (Bing et al., 2001; Burnam et al., 2001; Kessler et al.). Although a substantial amount of mental health and substance abuse services are provided to those with known HIV infection, inequalities in access to care are clearly evident (Burnam et al.). Poorer mental health in people who are HIV-positive is associated with lower levels of education and income, which is believed to reflect poorer access to high-quality care (Cunningham et al., 1998; Hays et al., 2000). Furthermore, the use of outpatient mental health services and psychotherapeutic medication is significantly lower among ethnic minority groups and those with lower education and income levels (Burnam et al.).
The purpose of this article is to describe the efforts of one agency to address inequities in access to mental health services among people who are affected by HIV and face barriers to mental health care because of their financial status. Located in Atlanta, Georgia, Positive Impact, Inc., is a nonprofit, community-based organization that provides free mental health services to low-income individuals, groups, and families affected by HIV by using an extensive network of volunteer mental health professionals and graduate student interns.
PROVISION OF MENTAL HEALTH SERVICES
Intake and Assessment
Following referral by local AIDS service organizations and other social services providers, clients initially contact Positive Impact by telephone and participate in a brief screening process to determine the nature of their mental health needs and their financial eligibility for service. People who have an annual income of less than 300 percent of the federal poverty level (currently $26,580), or who have inadequate mental health coverage meet eligibility requirements. Those with adequate insurance coverage or income are referred to an area mental health care provider who can appropriately address their mental health needs. If financial eligibility requirements are met, the individual is scheduled for an interview to develop a comprehensive biopsychosocial assessment that includes measurement of psychological distress, HIV-related stigma, perceived barriers to care, substance use, and level of engagement with the primary care system. The assessment is used to determine appropriate services and to match the client with a provider who best meets his or her mental health needs.
Past program evaluations revealed that one-third of those who completed the assessment process failed to return for care after the initial interview. Reece (2001) found that the dropout rate was attributable primarily to three factors: perceived barriers to care, HIV-related stigma, and ethnic-minority status. In response, a "bridging" intervention has been developed to increase the likelihood that participants will become engaged in their mental health care and subsequently remain enrolled for a length of time sufficient to achieve positive psychological change. Designed for clients with no previous experience in mental health care or high levels of stigma and other perceived barriers to care, the bridging intervention consists of four 90-minute groups that focus on increasing understanding of different types of mental health care; developing and articulating realistic expectations of the benefits of mental health care; increasing understanding of confidentiality standards associated with care; making an informed choice regarding need, readiness, and willingness to participate in mental health care; increasing understanding of how mental health care is supportive of engagement with other HIV services, such as primary care, substance abuse treatment, and other social services; and managing stress, anxiety, and depression to increase therapy readiness and effectiveness.
Psychotherapeutic and Psychiatric Services
After completion of the bridging intervention, participants are scheduled for an initial appointment with a mental health care provider. The theoretical orientation of providers varies, although many would describe their approach as eclectic. Many providers see Positive Impact clients in their own offices for individual, couples, and family therapy; others provide these services at Positive Impact's offices. A variety of therapy and support groups are facilitated, including specialized groups for long-term survivors, prevention groups, bereavement groups, caregivers groups, and recovery groups. A staff psychiatrist provides psychiatric evaluation, prescribes psychotropic medications, and assists clients with medication and symptom management.
In an effort to engage hard-to-reach groups in the HIV community, Positive Impact has developed specialized services, including bilingual counseling for Spanish-speaking clients, case management for those who are homeless or at risk of homelessness, HIV-prevention services aimed at people who are at high risk because of substance abuse or compulsive sexual behavior, a specialized therapeutic arts and recreation program for children, and neuropsychological testing and assessments. The agency initiated the Georgia Comprehensive HIV/AIDS Minority Psychosocial Services Project funded by the Substance Abuse and Mental Health Services Administration. This initiative facilitates the provision of mental health services in rural areas and in substance abuse treatment facilities, specifically targeting ethnic minority populations.
A unique feature of Positive Impact is that services are provided primarily by a network of more than 80 community-based mental health care professionals, including social workers, psychiatrists, psychologists, professional counselors, and marital and family therapists. Volunteers are recruited through relationships with social services agencies, professional organizations, graduate schools, and current volunteers. Most of the volunteers see one client at a time, but several volunteers have two or three clients, and others facilitate agency groups. The clinical director refers clients to a volunteer, with consideration of the volunteer's area of expertise and accessibility for the client.
Those interested in becoming volunteers complete an application and are interviewed by the volunteer coordinator, a full-time staff member. All volunteers are either licensed mental health care professionals or are actively working toward licensure and maintain their own liability insurance. Copies of relevant licenses and certifications, liability insurance, and verification of supervision (for those working toward licensure) are obtained during the application process. Once a volunteer is accepted, he or she receives an orientation to the agency's policies and procedures and signs a contract that delineates expectations of service provision by the volunteer and support by Positive Impact. The expectations for volunteers include procedural issues such as timeliness of treatment plan completion and documentation of termination. In addition to an extensive mental health training program developed for volunteers and community providers, Positive Impact provides ongoing group supervision and clinical consultation as requested.
A graduate intern training program supplements the services provided by volunteers. The agency collaborates with eight graduate programs throughout Georgia and intermittently has interns from other programs across Georgia and the United States. Students undergo a professional employment application process that includes an in-depth interview. A cohort of six to eight interns is selected annually, and these students perform the majority of intake assessments and provide individual therapy and group facilitation under supervision.
The supervision of the student interns is coordinated by the clinical director, who also provides group supervision. Each student is assigned to a group of no more than four students depending on level of skill, knowledge, and goodness of fit. Each group meets weekly on-site for two hours and addresses clinical and procedural issues. All students receive one hour a week of individual supervision provided by one of the agency's mental health care volunteers. Positive Impact provides diverse, experienced, and licensed professionals to meet the supervision requirements of the student interns' educational disciplines. Students also have the opportunity to cofacilitate therapy and support groups with volunteers and receive group-specific supervision from their coleaders. All supervision is provided free.
Improvement of mental health problems can result in improvement in health-related quality of life, which, in turn, may benefit people who are HIV-positive by increasing medication adherence, health promotion behaviors, and positive health outcomes (Elliott et al., 2002). Unfortunately, people who are HIV-positive with lower incomes appear to have poorer access to quality mental health care (Burnam et al., 2001; Hays et al., 2000). In an effort to address such inequities, Positive Impact, a community-based agency, provides no-cost mental health services to people who are both financially disadvantaged and affected by HIV. By relying on volunteers and student interns to provide the majority of services, Positive Impact is able to serve a population that would otherwise be without access to mental health care. The cost savings attributable to this model allows Positive Impact to provide a range of mental health services to a greater number of clients than would be possible with a smaller, salaried staff.
Bing, E. G., Burnam, A., Longshore, D., Fleischman, J. A., Sherbourne, C. D., London, A. S., Turner, B. J., Eggan, F., Beckman, R, Vitiello, B., Morton, S. C., Orlando, M., Bozzette, S. A., Ortiz-Barron, L., & Shapiro, M. (2001). Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States. Archives of General Psychiatry, 58, 721-728.
Brown, G. R., Rundell, J. R., McManis, S. E., Kendall, S. N., Zachary, R., & Temoshok, L. (1992). Prevalence of psychiatric disorders in early stages of HIV infection. Psychosomatic Medicine, 54, 588-601.
Burnam, M. A., Bing, E. G., Morton, S. C., Sherbourne, C., Fleischman, J. A., London, A. S., Vitiello, B., Stein, M., Bozette, S. A., & Shapiro, M. F. (2001). Use of mental health and substance abuse treatment services among adults with HIV in the United States. Archives of General Psychiatry, 58, 729-736.
Centers for Disease Control and Prevention. (2001). HIV/AIDS Surveillance Report, 13(2), 1-44.
Cunningham, W. E., Hays, R. D., Ettl, M. K., Dixon, W. J., Liu, R. C., Beck, C. K., & Shapiro, M. F. (1998). The prospective effect of access to medical care on health-related quality of life outcomes in patients with symptomatic HIV disease. Medical Care, 36, 295-306.
Elliott, A. J., Russo, J., & Roy-Byrne, P. P. (2002). The effect of changes on health related quality of life (HRQoL) in HIV infection. General Hospital Psychiatry, 24, 43-47.
Fairfield, K. M., Libman, H., Davis, R. B., Eisenberg, D. M., & Phillips, R. S. (1999). Delays in protease inhibitor use in clinical practice. Journal of General Internal Medicine, 14, 395-401.
Hays, R. D., Cunningham, W. E., Sherbourne, C. D., Wilson, I. B., Wu, A. W., Cleary, P. D., McCaffrey, D. F., Flieschman, J. A., Crystal, S., Collins, R., Eggan, F., Shapiro, M. F., & Bozette, S. A. (2000). Health-related quality of life in patients with human immunodeficiency virus infection in the United States: Results from the HIV Cost and Services Utilization Study. American Journal of Medicine, 108, 714-722.
Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. B., Hughes, M., Eshleman, S., Wittchen, H. U., & Kendler, K. S. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: Results from the National Comorbidity Survey. Archives of General Psychiatry, 45, 859-964.
Reece, M. D. (2001). Dropout from community-based, HIV-related psychotherapy: The influence of health beliefs and perceptions of stigma. Unpublished doctoral dissertation, University of Georgia, Athens.
Sherbourne, C. D., Hays, R. D., Fleischman, J. A., Vitiello, B., Magruder, K. M., Bing, E. G., McCaffrey, D., Burnam, A., Longshore, D., Eggan, F., Bozette, S. A., & Shapiro, M. F. (2000). Impact of psychiatric conditions on health-related quality of life in persons with HIV infection. American Journal of Psychiatry, 157, 248-254.
Ullery, E. K., & Carney, J. S. (2000). Mental health counselors' training to work with persons with HIV disease, Journal of Mental Health Counseling, 22, 334-342.
Bryce D. Smith, LCSW, is the former clinical director, Positive Impact, Inc., 139 Ralph McGill Boulevard, Suite 301, Atlanta, GA 30308; e-mail: firstname.lastname@example.org. Brian E. Bride, PhD, LCSW, is assistant professor, College of Social Work, University of Tennessee, Nashville.