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Persons living with HIV/AIDS contemplating a return to work: a Social Cognitive Career Theory and Constructivist Theory perspective.

Contemporary career counselors are serving populations that are becoming increasingly diverse and they are helping populations that the progenitors of the field could not have anticipated. One such population that has been seeking the assistance of career and rehabilitation counselors more frequently is persons living with HIV/AIDS (PLWHA). With this new clientele comes the need for an increased understanding of multitude of barriers to employment, and the need for postmodern theoretical approaches that give the counselor a unique lens in which to view the client's context and the multiple realities in which these clients experience life.

Counselors are seeing an increase in PLWHA seeking career services because these clients are living longer and healthier lives due to new and improved medications and treatments. The CDC (2008) reported that in 2006 there were over a million people living with HIV infection in the United States and these numbers have consistently risen each year with African Americans and Latinos having the highest rate of infections. This information is significant to career and rehabilitation counselors as PLWHA are considering re-entering the workforce with more frequency as they come to terms with the reality of living longer.

The barriers and issues that PLWHA face in seeking a career are unique and vary from person to person. The CDC (2008) noted that the population of PLWHA is varied in terms of ethnicity, gender, sexual orientation, and socioeconomic status; therefore, there is no "typical" client a counselor will meet when working with PLWHA. This means that there is a need not only for understanding the unique employment needs and barriers for PLWHA, but there is also an imperative need for counselors to operate from a theoretical perspective that views the client holistically and considers their individual life experiences in assessing their path to re-enter the workforce and choose a career.

This paper will seek to explain the motivations and barriers related to PLWHA who are considering returning to work by examining studies related to PLWHA and work. The basic tenets of Social Cognitive Career Theory and Constructivist Theory, which inform the theoretical framework that will be used to conceptualize this population, will then be outlined. Additionally, a discussion of how Social Cognitive Career Theory and Constructivist Theory work to explain the career development of PLWHA who are considering returning to work, and the theories shortcomings in assessing the population will be presented. Finally, recommendations for further research on this subject will be suggested.

Literature Review

Motivations to Return to Work

Finances. There are a variety of reasons why PLWHA decide to return to work. One such reason identified by researchers is that many PLWHA believe that returning to work will help bring them more financial stability (Brooks & Klosinski, 1999; Conyers, 2004; Goldblum & Kohlenberg, 2005). In one study Brooks and Klosinski conducted a focus group study with PLWHA. The group was composed of primarily low-income individuals from AIDS Project Los Angeles, and a standardized set of questions to identify what issues PLWHA faced when considering returning to work was used. They found that need for money was a significant indicator for seeking employment for almost all participants in the study. In her qualitative study with PLWHA, who varied in age and ethnicity, Conyers observed that the role finances played in the motivation to return to work varied depending on the degree to which their current income could provide them with enough stability and security. Since many PLWHA who are not currently working rely on the limited sources of Social Security Income (SSI) or Social Security Disability Income (SSDI), they are often concerned whether employment will bring them better solidity or if it will adversely affect their ability to receive a steady source of income.

Physical and mental health. In some cases many PLWHA believed that returning to work would signify an improvement in physical health and move them from a perception of being sick to one of being healthy (Brooks & Klosinski, 1999: McReynolds, 2001; Conyers, 2004; Goldblum & Kohlenberg, 2005). Brooks, Martin, Ortiz, and Veniegas (2004) administered a survey to 757 PLWHA, the majority of whom were male, homosexual, and ethnic minorities, and found that "the best predictor of whether or not PL[W]HA were contemplating a return to work was if they felt that their health would improve if employed" (p, 762). For PLWHA working is a way to establish some sort of routine and take part in an activity society associates with more positive mental and physical health (Conyers; Goldblum & Klosinski). McReynolds, in her in-depth interviews with seven PLWHA, found that these participants also often view work as a way to engage in an activity that meant that there was a future. They saw employment as potentially contributing to the idea that they were no longer simply a person with a life threatening illness; they could then be seen as healthy.

Contributing to, and interacting with, society. In modern society when an individual works it may be viewed as a method of positively contributing to society. Brooks and Klosinski (1999), Yallop (1999), and McReynolds (2001) all cited that feeling like a contributing member to society was an important reason why many PLWHA wanted to rejoin the workforce. Not only did work make PLWHA feel like an important member of society, it also made them feel more connected to society. The social nature of the workplace was a good way to help PLWHA maintain a communal network, accessing societal connections that they would not have otherwise. These researchers also found that PLWHA reported that it is also a good way to provide distraction from negative feelings such as low self-esteem and feeling like a burden upon society because of lack of contribution to society. PLWHA may find that work gives them a sense of value and helps shake the stigma that unemployment holds after long periods of not working (Conyers, 2004).

Medical and financial benefits. One of the most cited barriers to work for PLWHA has to do with the possibility of losing benefits (Brooks & Klosinski, 1999; Yallop, 1999; Hunt, Jaques, Niles & Wierzalis, 2003; Brooks,et al., 2004; Conyers, 2004; Razzano & Hamilton, 2005). In a study by Razzano and Hamilton 63 PLWHA from a variety of ethnic, educational, and economic backgrounds were interviewed to find out their perception of health status and the various sources of insurance and health benefits. Many participants in the study were reliant upon Medicaid for health insurance. It became apparent that the participants felt that in order to keep these benefits they may not be able to enter the workforce. Similarly, in the Brooks, et al. study, they found that more than half of their 767 participants surveyed believed that the potential of losing publically funded health insurance and income were barriers to work. In her study Conyers found that even though finances served as a motivator for returning to work it also served as a barrier. The participants noted that it would be difficult to pay for the expensive medications needed for HIV/AIDS if they returned to work and did not have benefits like Medicaid to help pay for them.

Health on the job. Although many studies as previously mentioned found that PLWHA believed that returning to work would improve their health there are also many issues surrounding health as it relates to work that can act as barriers to re-entering the workforce. Several studies showed that a big concern in being able to go back to work for PLWHA was the fact that their health tends to be very unstable and requires a lot of attention (Brooks & Klosinski, 1999; Conyers, 2004; Goldblum & Kohlenberg, 2005; Razzano & Hamilton, 2005). Not only do medications for HIV/AIDS cause a variety of side effects, including headaches, insomnia, kidney stones, and nausea that could greatly affect work performance, but also the very nature of the disease can cause a certain amount of fluctuation in overall health (Salt, 2000). Maintaining health involves a strict regimen of medication which is essential to fighting HIV/AIDS, attending regular medical check-ups to monitor the illness and making sure that medication is working properly. Many PLWHA are concerned that they may not be able to keep up this regimen if they go back to work (Brooks & Klosinski; Conyers; Goldblum & Kohlenberg). PLWHA may have difficulty maintaining a healthy status while holding a job if they are unable to take breaks to take medication at work or if they do not have enough time offto attend their medical appointments.

Stigma and discrimination. There are many stigmas that are associated with PEWHA including intravenous drug use and homosexuality that may prevent them from returning to the work environment. Moreover, they may fear that they will be morally judged and discriminated against (Goldblum & Kohlenberg, 2005). As discussed previously, the medical regimen that PLWHA must endure in order to maintain health is highly involved and it would be very difficult to keep hidden. If a fear exists regarding disclosure because of stigma and potential discrimination, it serves as a major barrier for PLWHA in returning to work (Brooks & Klosinski, 1999; Hunt, et al., 2003; Brooks, et al., 2004; Goldblum & Kohlenberg). The process of getting a job may also involve a small amount of disclosure if there are large gaps in the resume of PLWHA and they have to explain why they were not working for a certain amount of time (Yallop, 1999).

There is persistent worry for many PLWHA surrounding the issue of stigma and discrimination, and even though there are laws that protect against discrimination, it may be difficult for some PLWHA to have the energy and resources available to fight against such discrimination.

Theoretical Framework

Social Cognitive Career Theory

The first theory that will form the basis for the conceptualization of PLWHA as relates to career development is Social Cognitive Career Theory (SCCT). SCCT is based on Bandura's Social Cognitive Theory (Lent, Brown & Hackett, 1994). Social Cognitive Theory was utilized by Lent, Brown and Hackett to inform their SCCT, in which they emphasized how clients develop career interests, make career choices, and ascertain their level of performance. Throughout the theory, Bandura's concepts of self-efficacy and outcome expectations play an integral and influential role in determining client's development in these three areas. Bandura (1986) postulated that self-efficacy refers to "people's judgements of their capabilities to organize and execute courses of action required to attain designated types of performances" (as cited in Lent, et al., p.83). These beliefs in self are dynamic, and they interact with many other aspects of people's lives (Lent, et al.). Lent et al. described outcome expectations as "personal beliefs about probable response outcomes," and noted that they "involve imagined consequences of performing particular behaviors" (p.83).

In SCCT, self efficacy and outcome expectations ultimately shape interests and career goals. Self-efficacy and outcome expectations are influenced by several factors. In their model, Lent, et al. (1994) described three sources of influence on self-efficacy and outcome expectations. The first is experimental sources, which includes personal performances accomplishments, vicarious learning, social persuasion, and physiological states and reactions. The second factor involves person factors, which includes predispositions, gender ethnicity, disability, and health status. The third factor is contextual influences, which includes environmental influences such as family and socialization, role model availability, emotional and financial support, career network contacts, and structural barriers. These three sources of influences are what build learning experiences and ultimately shape perceptions of outcome expectations that relate to career development and planning. Self-efficacy and outcome expectancies influence interests, which then predict goals, which then leads to behaviors related to actively achieving goals, which then leads to goal fulfillment and the level at which individuals will perform.

Constructivist Theory

Constructivism is a theory that is based on a philosophical framework, and Constructivist career counseling has a few basic tenets outlined by Peavy (1996) that are used to guide counseling practice. One of these tenets is that there are multiple realities, and therefore, multiple meanings of realities as each person views the world and creates meanings through their own unique lens. Another is that perceptions of events are constructed by actions in, and interpretations of, the world and for each person this construction is different. People are self-organizing because they lead dynamic lives that are constantly evolving and need to make constant revisions in order to make meaning reflective of their concept of self and "life story". A person's life story is important in determining the formation of career choices, which means that people must be reflective in order to understand their motivations as relates to actions; in turn, this helps lead to and empowered and fulfilled life. Overall, constructivist theory looks at the person in a holistic manner and takes into all aspects of the person's life and how they affect career development.

The meaning of work is an important concept related to constructing the life plan. Peavy (1996) noted that finding meaningful work is related to the idea that constructivism emphasizes about creating meaning from personal experience by reflecting on life experiences and the conceptions they hold of those experiences as they relate to self, life, and work. It is in this capacity that the clients, along with their counselors, begin to make meaning of their life experiences, and to create an awareness of their personal and unique perceptions of self, life, and work through the use of story telling.

Using Theory to Conceptualize PLHWA Re-Entering the Workforce

Blending SCCT with Constructivist Theory

As the review of the literature has shown, PLWHA face a variety of challenges when considering returning to work. As cited by the CDC, this population is undoubtedly a diverse one, and the need for a theoretical framework that considers individual life experiences and examines persons according to their entire life context is essential. It is for this reason that both SCCT and Constructivist Theory can be used together to understand the various perceptions of motivations and barriers PLWHA face when considering re-entering the workforce and how those perceptions relate to their career planning.

As delegated by Constructivist Theory, the understanding of a person's life story can help one begin to comprehend a person's career choice. The life story is made up of several factors including unique life experiences, which SCCT defines as the experiential influences, person factors, and life context, and learning experiences that shape one's sense of self-efficacy and outcome expectations. For PLWHA, their life story is comprised of these factors. In deciding on a career, PLWHA will be influenced by experiential sources such as past work experiences, if they have had them, other PLWHA who they may know are successfully working, society's pressure to contribute by being a responsible worker, and how they are emotionally responding to the idea of re-entering the workforce. Person factors that will shape career decision making of PLWHA include their gender, sexual orientation, disability status of HIV/AIDS, socioeconomic status, and their current physical health status.

Finally life context, which is comprised mostly of environmental influences will shape the unique life experiences of their story. This includes how their family perceives their illness and the level of acceptance of family members. The level of family acceptance will inevitably vary because, as mentioned in the literature review, stigma associated with the illness is common. Other support systems include financial support, which, as cited earlier, may be uncertain if PLHWA are unsure if they can attain better stability through work. Additionally, PLWHA may have few role models they can rely upon to associate positive career outcomes. Most importantly, structural barriers, which may include the complicated systems related to SSI, SSDI, Medicare and Medicaid, and acquiring appropriate accommodations in the workplace under the Americans With Disabilities Act (ADA), may prove to be quite difficult for PLWHA to obtain if they are uncertain of their legal rights.

Each of these unique life experiences shapes the learning experiences, which lead to perceptions of self-efficacy and outcome expectations of PLWHA. As PLWHA interpret these various life influences and learning experiences, they begin to make meaning of their perceptions of self as relates to work. Outcome expectations include some of the before-mentioned motivations to return to work, which includes financial stability, physical and mental health, and contributing to and interacting with society. According to SCCT, if PLWHA see these motivators as leading to probable and desired outcomes, it will guide them in choosing a career that serves their interests and meets these desired outcomes. The self-efficacy beliefs that are derived from the unique experiences of PLWHA relates to the previously mentioned perceived barriers to work for PLWHA, which includes medical and financial benefits, health on the job, and stigma and discrimination. These barriers were not the same for all PLWHA, and they are reflective of the interactions with the other domains of individual's lives. If PLWHA see these barriers as blocks to their ability to achieve work, their self-efficacy view may be low, and it will affect what types of work in which they are interested. They may not be able to, or choose not to, move on to achieving their specific goal of gaining employment.

Once PLWHA have made the meaning of their outcome expectancies and self-efficacy perceptions, they will be able to assess what their specific interests are and what jobs will be most appropriate for them based on this construction of personal reality. To discover interests, the whole life story is explored including their unique experiences, their person factors, their life context, their learning experiences, their self-efficacy, and their outcome expectations. Once the life story is examined a specific career goal can be formed and steps can be taken to reach this goal. Eventually they will have fulfillment in their lives through work, and according to SCCT, the desired outcome will be achieved and their level of performance in the workforce will be measured. However, because of the nature of the HIV/AIDS illness, revisions to this career choice may need to be made as they gain more experience as a worker with HIV/AIDS and learn from this experience. See Figure 1 for a diagram of this blended framework as used with PLWHA who are considering returning to work.

This final process of deciding on a career and taking steps to achieve this career goal is not an easy one for PLWHA. The barriers that are perceived by PLWHA are significant and in some instances are not simply matters of cognition related to self-efficacy. Understanding the system related to medical and financial benefits is one that may be out of the scope of practice for career counselors and referrals to benefits counseling through Aids Service Organizations may need to be made in order to best serve the client. Also, if counselors are familiar with what types of accommodations PLWHA are eligible for in the workplace, it may help quell the fears of being unable to take medication at work or go to all their medical appointments. Counselors can work with clients to help them feel more efficient at verbalizing their situation when they need to and not feel a sense of shame or fear related to disclosing their illness. However, discrimination in the workplace is real and even though there may be laws protecting PLWHA against discrimination, that doesn't mean it will not happen.

Additional work in social justice advocacy is required of counselors in working with PLWHA and the role of the counselor will inevitably be extended. Toporek and Chope (2006) outline ways that counselors can address discrimination in the workplace and better serve clients when they bring this issue to counseling. First, it is recommended that counselors become familiar with documents that are relevant to issues regarding discrimination. For PLWHA this includes the ADA and Section 504 of the Rehabilitation Act of 1973. It may also be relevant to look at the policies of particular workplaces in which PLWHA are interested in working. Second, Toporek and Chope recommend that counselors understand the potential context of the discrimination and gather information about similar discriminatory situations. For PLWHA considering returning to work it may be helpful for counselors to review legal cases related to discrimination in the workplace for PLWHA and find out what the outcomes were in those situations to hopefully reassure the client that if a discriminatory situation arises positive outcomes can be achieved via legal action. Making the client aware of any advocacy and community support groups in the area may also be helpful in assuring clients that additional support is available if needed.

Finally, Toporek and Chope (2006) proposed that appropriate roles and interventions should be assessed. For PLWHA the illness takes a tremendous toll on their body and the idea of potentially entering into a legal battle may not only sound unappealing but the stress related to the ordeal may have negative impacts on their health. It will be important for the counselor to establish a sense of empowerment in the client and identify sources of support in the community (Toporek and Chope). If PLWHA feel like they are empowered and that they have not only the support of the counselor but the support of the community as well, they will be more likely to face the potential barrier of discrimination than to walk away from achieving their desired outcome of attaining employment. This is of course based on an individual reality of the client and the result of this action will vary depending on their perception of the level of potential discrimination and their desire to fight against it. Overall, removing many of the barriers related to going back to work for PLWHA could be done by providing them with sufficient knowledge and a sense of empowerment so that a higher level of self-efficacy can be achieved.


Recommendations and Conclusion

Very little literature exists for using career theory to understand career decision making of PLWHA who are considering reentering the workforce. As the life expectancy of this population grows greater, there is a need to gain a better understanding of the challenges they face related to returning to work and what career theory models are most appropriate for counseling. More research on how sexual identity affects the career decision making of PLWHA would also be helpful in gaining a more thorough understanding of the population. The CDC (2008) stated that many of the people affected by HIV/AIDS are gay and bisexual men, and sexual orientation may cause additional barriers for these workers.

Although much of the literature reviewed came from studies that surveyed PLWHA across races/ethnicities, more research on the barriers associated with people of specific races/ethnicities would be beneficial. The life experiences of various minority groups varies and even though they may have similar barriers and motivations to return to work in a generalized sense, there may be slight group differences that may change the perceptions of these barriers and motivations and how they are perceived by those specific minority groups. Additionally, research related specifically to the different experiences of PLWHA based on what age they are when considering returning to work would generate a better understanding of this issue.

The demographics of the populations that counselors work with will be constantly changing over time and it will be important for counselors to be equipped with tools that will help better serve these evolving populations. PLWHA will need counselors who not only meet basic counseling competencies and multicultural counseling competencies, but who use a theoretical framework that examines the client as a whole. Integrating the life story of PLWHA into a new reality that meets their outcome expectancies and breaks through their perceived barriers, along with a counseling model that includes social justice advocacy, will aid PLWHA in achieving their career goals and assist in providing the best and most comprehensive counseling services.


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Misty Trujillo

San Francisco State University

Misty Trujillo, San Francisco State University, Rehabilitation Counseling Candidate, 261 San Carlos Street, San Francisco, CA 94110.

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Title Annotation:Graduate Literary Award Winner
Author:Trujillo, Misty
Publication:The Journal of Rehabilitation
Geographic Code:1USA
Date:Jan 1, 2010
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