Mental Health Counselors' Training to Work with Persons with HIV Disease.
The number of persons in the United States with human immunodeficiency virus (HIV) disease continues to grow, reaching virtually every segment of the population (Centers for Disease Control and Prevention [CDC], 2000). Furthermore, many families, friends, and partners are dealing with the implications of having a loved one infected with this disease. The ramifications of HIV disease for those directly and indirectly effected can be significant. The impact can encompass social, vocational, economic, developmental, and psychological components of one's life. Holt, Houg, and Romano (1999) point out this epidemic has also resulted in a growing population of consumers who need mental health services to deal with these complex and diverse problems.
Professionally, there has been discussion about the preparation of counselors to address the needs of this population (Britton, Cimini, & Rak, 1999; Hunt, 1996). There are some indications that counselors may experience responses to working with this population ranging from moderate discomfort to negative or biased attitudes (Crawford, Humfleet, Ribordy, Ho, & Vickers, 1991; St. Lawrence, Kelly, Owen, Hogan, & Wilson, 1990). Moreover, there are concerns that mental health professionals may have deficits in knowledge or in understanding of critical aspects of the disease (Carney, Werth, & Emanuelson, 1994). While it is difficult to determine specifically how these attitudes or deficits in knowledge would influence the counseling process, research suggests that it could be detrimental (Britton, Rak, Cimini, & Shepherd, 1999; Dworkin & Pincu, 1993; Huitt & Elston, 1991).
While this research supports a call in the counseling profession for training on working with persons with HIV disease (American Association for Counseling and Development, 1989 [now American Counseling Association]; Britton, Cimini, et al., 1999; Hunt, 1996), there is limited research to direct this process. Several models of training have been proposed. Most recently Britton, Rak, et al. (1999) proposed a model of training for counselors-in-training focusing on improvement of general and treatment-specific knowledge as well as attitudinal exploration. Their research suggested that such training can positively impact these factors. However, this research, as with similar studies (Carney et al., 1994) focused largely on professionals-in-training. An essential component of understanding the counseling process as it relates to persons with HIV disease is to assess practice and training among working mental health professionals. This information can provide a critical context to developing training models and assisting mental health practitioners. The intent of this study was to provide such a context. Specifically the study focused on mental health practitioners regarding their training and counseling experiences with PWAs (persons with AIDS).
The primary focus of this study was an assessment of the nature and type of training mental health professionals may have received to work with this population. Researchers suggest that adequate preparation for counseling persons with HIV disease includes both knowledge about the disease and information specific to counseling persons with or impacted by this disease (Britton, Rak, et al., 1999; Werth, 1993; Werth & Carney, 1994, 1996). Based on this information, we assessed whether counselors had received knowledge-focused or treatment-focused training. Furthermore, there are clear indications that contact, attitudes and knowledge may influence interactions with PWAs (Werth & Lord, 1992). In view of that, we also examined mental health practitioners' attitudes, knowledge, and contact as they pertain to working with PWAs as clients. Lastly we asked participants whether they have had actual counseling experiences with PWAs.
The purpose of this study was an exploration of HIV disease knowledge and attitudes among current practitioners. Specifically, this preliminary study assessed HIV disease knowledge levels, attitudes, and contact with PWAs. In addition, the study investigated whether professional mental health counselors had received training to work with persons with HIV disease and the nature and content of that training. Status of training, and whether training and contact related to knowledge and attitudes, were also considered.
Participants and Procedure
Participants consisted of mental health counselors in two states in the southern region of the United States. A nonrandom sample of voluntary participants were recruited from counselors employed at public mental health agencies, private mental health facilities, and in private practice. Two methods of recruitment were used. First, administrators or supervisors of mental health agencies were contacted to gain approval to survey professional counseling personnel. Sites granting permission were furnished with instrument packets for their counseling staff. Packets contained a cover flier with an invitation and instructions for participation, a signed informed-consent form, and a copy of each instrument. Following a time limit, the researchers retrieved the packets at designated pick-up sites. Secondly, the first author attended regional mental health provider professional meetings during which attendees were invited to participate in the study. Packets were distributed among interested individuals and included self-addressed, stamped envelopes. Both methods ensured participant anonymity and all responses were pooled together for the purposes of data collection. Research materials were distributed to 298 individuals of whom 128 (43%) responded. Inclusion in the study was limited to those who had a minimum of a master's degree in counseling and related fields (e.g. psychology, social work) and who were currently practicing counselors/therapists. Eight participants were disqualified, resulting in 120 participants included in this study. Participants were comprised of 74 (61.7%) females and 46 (38.3%) males, 102 (85%) holding master's degrees and 18 (15%) having doctoral degrees.
Demographic data form. This form contained questions pertaining to gender, highest educational degree earned, current employment status, participation in HIV disease training, nature and content of training, and prior contact with persons with HIV disease (i.e., met a PWA(s), know a PWA(s), counseled a PWA(s)). To delineate between met a PWA(s) and know a PWA(s) participants were provided examples (know a PWA(s): e.g., a personal relationship, a family member, or a friend).
HIV disease training questions were categorized along dimensions of content and source. Content was separated into two categories: basic HIV disease training (e.g., disease transmission) and treatment training concerning counseling persons with HIV disease (e.g., treatment issues and planning). Source of training was categorized into either educational (e.g., counselor preparation program) or professional (e.g., workshops, in-service) setting. Four categories of training resulted: 1) Educational basic HIV training; 2) Educational HIV treatment training; 3) Professional basic HIV training; and 4) Professional HIV treatment training.
AIDS Attitude Scale (AAS). The AAS (Shrum, Turner, & Bruce, 1989) is a 54-item scale measuring attitudes toward AIDS and PWAs. Respondents indicate degree of agreement with item statements using a 5-point Likert scale, ranging from Strongly Agree to Strongly Disagree. Scores can range from 0 to 100, with high scores indicating more tolerant or positive attitudes towards AIDS and PWAs. The authors report an internal reliability alpha of .96 (Bruce & Reid, 1995; Shrum et al., 1989).The authors identified three factors for this instrument--Contact/Proximity to PWAs, Moral Issues, and Legal/Social Welfare--which accounted for 45% of the variance. Individual scores for the AAS were computed by the following formula: 25([Sigma]X - N)/N, where [Sigma]X = item totals and N = scored items (Shrum et al., 1989).
HIV/AIDS Knowledge Inventory (HAKI). The HAKI (Carney et al., 1994) is a 25-item true-false instrument developed to assess respondents' level of general knowledge about HIV disease (e.g., the transmission, symptomology, testing, and prevalence). The authors reported a Cronbach alpha coefficient of .71 and a significant correlation (r = .34, p[is less than].001) to the AAS (Carney et al., 1994). Correct responses are totaled and higher scores on the instrument indicate higher levels of HIV/AIDS knowledge.
The AAS was used to measure mental health counselors' attitudes toward PWAs. Scores on this instrument can range from 0 to 100 with higher scores indicating more tolerant attitudes. The total sample (n = 120) mean AAS score was 77.97 (SD = 11.87), with a minimum score of 37.04 and a maximum of 96.76. These results are considerably higher than those reported by Shrum et al. (1989) for their norm group of 131 undergraduate and graduate students in various disciplines (M = 59.78, SD = 15.33). The AAS mean in this study for females was 79.87 (median = 82.64), and 76.41 for males (median = 77.78). The reliability alpha for this sample was .95. Overall attitudes were positive with only a few specific item responses indicating less tolerant attitudes. In reference to factors identified for this instrument by Shrum et al. (1989), participants demonstrated the highest levels of tolerance on the factor of Moral Issues. For example on item 10, "Only disgusting people get AIDS," 100% of the participants indicated that they Disagree Strongly or Disagree with the item statement and on item 11, "I think that people with AIDS get what they deserve," a total of 95% of the participants indicated that they Disagree or Strongly Disagree with the statement.
The mean score (n = 120) on the HAKI was 18.83 (SD = 2.38) out of a possible score of 25, with a minimum score of 12 and a maximum score of 24. The reliability alpha for this sample was .40, a level considered acceptable for criterion-referenced tests (Kane, 1986). These data demonstrate moderate general knowledge of HIV disease and are similar to HAKI results obtained by Carney et al. (1994) on their sample of 86 counselors-in-training (M = 18, SD = 2.24). In general, item totals indicated that participants were most knowledgeable about HIV disease prevention and symptomology and least knowledgeable about HIV testing, assessment, and trends in infection rates or modes.
HIV Disease Training and Contact
The results indicated that a majority of the participants had some degree of contact with persons with HIV disease. Participants indicated all categories of contact and training that applied to them, therefore categories are not exclusive. Specifically, in response to type and degree of contact with PWAs, the participants reported the following types of contact: Met a PWA(s): 94.2%; Know a PWA(s): 40.8%; and Counseled a PWA(s): 71.7%. Additionally, of those indicating they had counseled a PWA, the mean number of clients seen was 4.9. In reference to training, a total of 114 (95%) of participants indicated they had received some form of HIV training, with professional basic HIV training being the most common (mode = 25%). In particular, 40% had received educational basic HIV training, 20% educational HIV treatment training, 70% professional basic HIV training, and 46.7% professional HIV treatment training. These results demonstrate participants received proportionally more training outside of educational settings and that this training focused on basic or general knowledge.
Relationship Among Variables
A multiple regression procedure was used to evaluate the relationship among the variables in this study. Bivariate correlations were used to assess the relationship between specific variables. Overall HAKI scores were found to correlate with attitudes (r = .19, p = .029). When knowledge was considered in reference to training, knowledge was found to positively correlate with educational treatment training (r = .22, p = .008) and negatively correlate with professional basic training (r = -.22, p = .007). Regarding contact categories, only "Know a PWA(s)" correlated with either knowledge (r = .22, p = .007) or attitudes (r = .18, p = .034). Surprisingly, attitudes were not found to correlate with any of the specific training variables.
This study certainly indicates that mental health counselors are serving clients with HIV disease. In this sample upwards of 70% had clinical experience with a client with HIV disease. This finding in and of itself suggests the need to adequately prepare counselors to work with this population. While overall general knowledge levels were high, knowledge concerning prevalence (or trends) and testing and assessment demonstrated some deficits. One potential concern is that counselors may be missing some vital information that may not only help them effectively counsel clients, but also assess risk and help clients gain access to the services them may need. For example, the sample demonstrated limited knowledge about testing policies and practice differences across states. This is of special interest since some of the participants work in a state where anonymous testing is available, and other participants work in a state in which only confidential testing is available (CDC, 1998).
This trend is also reflected in the findings on training. The majority of the participants reported that the training they received covered more general knowledge, in both educational and professional settings (e.g., workshops, in-services). Of those receiving training, most received this outside of educational settings. This finding is not surprising considering research that suggests counselor preparation programs may not be integrating this type of specialized training into their programs (see Britton, Cimini, et al., 1999). Furthermore, the development of training models is still relatively recent with many models being proposed in the 1990s (for example, Britton, Rak, et al., 1999; Holt et al., 1999; Werth & Carney, 1994).
Thus many programs may have not had ample time to integrate these components into existing training practices. A limitation of this study was that information regarding possible time lapses between entering the profession and acquisition of HIV disease training was not included. Additionally, it is not known how many participants obtained their degrees prior to the appearance of HIV disease. Such information may have provided a more detailed context in which to consider these findings.
However, this study did demonstrate that counselors are working with persons with HIV disease and that there may be some limitations to the nature and type of knowledge they may have concerning counseling persons with HIV disease. While professional training is a valuable tool for continuing education, and for many mental health professionals the means to advance their skills and knowledge, it may not be a sufficient way to prepare counselors to work with this population. The limitations of the study make it difficult to assess specifically the implications of differences in training. The sample is restricted to one geographical region, limiting the generalizability of the results, furthermore, the researchers did not include an investigation of the specific content of training and relied on categorical data. Future research can focus on the effectiveness and outcomes of different training models, both in professional and educational settings.
When training is considered in reference to attitudes and knowledge, it was surprising to see that training did not relate to attitudes. One explanation may have been that the sample demonstrated very positive and tolerant attitudes towards persons with HIV disease, not allowing for much variance in scores. In addition, several studies and theories have suggested that attitudes are comprised of cognitive, behavioral, and emotional components (Antonek & Livneh, 1988; Rajecki, 1990). Thus if training only focuses on the cognitive aspects or knowledge and does not address attitudinal factors, then the training may not address components related to emotional or behavioral responses. For example, in our study we found that having a personal relationship with a PWA did correlate with attitudes. This may indicate that this type of contact has more potential for impacting attitudes than do casual or professional contacts with PWAs. More importantly, the research may provide support for the need for training that includes both knowledge and attitude exploration (Britton, Rak, et al., 1999). Furthermore, it seems reasonable that future exploration also consider attitudes in reference to types of interactions with persons with HIV disease.
In regard to knowledge, it is also important to note that knowledge correlated with contact; specifically counselors who reported personal contact with PWAs demonstrated higher knowledge levels. While this is not surprising, it is interesting given that training did not correlate with knowledge levels. It may be that some participants who work with persons with HIV disease may have acquired their knowledge from sources outside of professional or educational training, however the study did not examine other types of training that may be more informal such as books, community-based AIDS outreach programs, and even clients. Once again a valuable component of future research is a more intensive examination of the specific practices of mental health professionals who work with this population. This may include consideration of how mental health counselors prepare to work with persons with HIV disease beyond formal training methods.
This study provides some very important information for practicing mental health counselors, supervisors, and creators of counselor-preparation programs. First, it is apparent that mental health counselors are providing services to persons with HIV disease. This is to be expected, considering both the increase in the number of persons with this disease and the complex mental health issues facing this population. However, this does pose concerns about the preparation of mental health counselors to adequately meet this need. Our study suggests that there are concerns about the nature and content of training that these counseling professionals may have received. Further, there is some indication that attainment of HIV disease knowledge may be linked to individual counselors' motivation to acquire it. That is, although most of the participants in this study report working with PWAs as clients, their knowledge levels appear to be related to personal rather than professional contact with PWAs. This provides some impetus for supervisors and counselor educators to evaluate and improve training. Furthermore, it suggests the need for practicing mental health counselors to evaluate and consider their own training. All of this can be a direct factor in the value and benefit of mental health services offered to persons with HIV disease.
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Elizabeth K. Ullery, Ph.D., is an assistant professor with Troy State University-Phenix City, AL. Jamie S. Carney, Ph.D., is an associate professor with Auburn University, AL.
Correspondence concerning this manuscript can be sent to Dr. Ullery at Department of Counseling and Psychology, One University Place, Troy State University, Phenix City, AL 36869. Email firstname.lastname@example.org.
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|Author:||Carney, Jamie S.|
|Publication:||Journal of Mental Health Counseling|
|Article Type:||Brief Article|
|Date:||Oct 1, 2000|
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