Relationships With HIV-Impacted Couples

What We've Learned from Psychological Testing and Compliance to Treatment and How Therapy Impacts on Patients' Overall Health

Clinical Measures Predict Likelihood of HIV Dementia

Psychological Cofactors in HIV Disease; Strategies for Enhancement of One's Health Status

Relationships With HIV-Impacted Couples

Resolving Conflicts Friendly Advise

By Greg Sarlo Psy-D Licensed Clinical Psychologist

Negotiating conflicts during the course of a relationship can be difficult; facing the added stress of HIV is usually more imposing. Often times many issues are not discussed because HIV is present. In many instances the HIV becomes the focus between couples and basic communication skills are lost in the shuffle. We often think that because HIV is such a big issue and we are handling it, other issues such as basic communication and conflict resolution may not seem as important. But, in reality, the opposite is true.

When we first look to enter a relationship, we do so with the reasonable hope that it meet our desires for companionship, emotionally and sexually. We expect mutual growth. In the beginning, we go out of our way to accommodate each other. Pleasing our partner is paramount and our love often outweighs petty annoyances.

After a short period of time in a relationship, being on our best behavior becomes a strain, and conflicts surface. For instance, the HIV positive individual may hold back in discussing test results he has just received for fear that it could burden or worry their newly gained partner. Unfortunately, this lack of communication bottles up and the couple may eventually have a major disagreement. The first major disagreement can lead to a premature breakup, or be so unsettling that we develop unspoken agreements not to touch certain topics. But avoidance of conflict, or certain topics, restricts the areas in which we interact, and decreases feelings of closeness. Our attempt to avoid confrontation of this issue actually increases the risk for future problems brewing and boiling. But not talking about how we feel, leads to increasing distance inthe relationship, especially the couple im-pacted by HIV. So much of the relation-ship can become prematurely focused on HIV. However, HIV in some situations should be focused upon. This fails to occur due to denial. In either case, avoidance of conflict or rejection is often the primary cause. So how can we approach conflicts with more confidence that we will be able to resolve them? By facing the conflict!

Conflict in any relationship is inevitable. Much of how we resolve our conflicts is determined by how our families did so when we were being raised. It is how we deal with the conflict that determines whether or not our relationship is damaged or strengthened. If we anticipate the conflict, we wonГ•t feel so overwhelmed when we encounter differences.

Conflict is healthy. Differences exist. When we resolve them successfully, we feel closer. Although it may feel threatening to acknowledge differences, intimacy flourishes. It is by revealing who we really are, rather than projecting an image of how we would like to be seen, that we continue to grow in our relationships.

Changes are inevitable as one grows older, and a relationship develops. There are career opportunities and financial obligations outside of the relationship; outside interests and friendship networks shift, your health, HIV, and different HIV status may become an issue, and levels of sexual involvement change. In other words, expectations from the relationship is altered on many levels. This is particularly true if the health status of the HIV positive person changes. One may wonder whether or not one will be able to adjust successfully.

Maintaining a sense of yourself as an individual while still affirming the importance of your relationship is a significant task for any member of the couple regardless if you are HIV+, or not. Men are socialized to function independently, so a male couple may have a difficult time finding the balance of Г’who am I,Г“ Г’who are you,Г“ and Г’who are we together?Г“ A sense of self allows a genuine exchange between you and your partner. You cannot really feel close unless you experience yourself as a separate individual. Otherwise, there is no Г’youГ“ to appre-ciate the closeness. Similarly, taking your relationship into consider-ation, not just your own personal desires, allows you to weather the differences that inevitably arise.

Conflict is inevitable but one can be skeptical whether or not it is all that healthy. We need a way to talk about problems, instead of arguing about them and then withdrawing. One way to improve the relationship is for both partners to improve their ability as a couple to empathize, express, and avoid pitfalls that commonly escalate conflict. One way to achieve this is through Г’couples therapyГ“. Many people think that a couple should only enter therapy when there is something seriously wrong in the relationship or when there has been a health crisis. Typically, when it reaches this stage, it may be too late: dysfunctional avoidant patterns in the relationship might be beyond the point of no return. There are times when, of course, you are too upset to remember any of these skills, and you end up in arguments and withdraw for while anyway. But instead of ignoring the conflict and letting it build up again, you need to learn how to approach each other to work through your differences.

The following are some ways to resolve conflicts in a relationship:

1. Try not to be so defensive.

When your partner is angry with you, it may be difficult to keep still while he expresses his feelings. But when you are preoccupied with defending yourself, you stop listening. You may try to convince him there is no reason to be upset by giving excuses, arguing about the facts, offering advice, reassurance, counter-complaints, or analyzing his behavior. Remember, a defensive response is basically an attempt to get your partner to stop feeling, so you wonГ•t feel blamed.

2. Try to listen more.

Listening seems quite simple and passive, yet it can be a powerfully active process. It takes a lot of concentration to listen accurately, especially when your partner is upset with you. Remember you must pay attention. The closer attention you pay to him, the quieter you become yourself. Since he is able to explain how he feels without being interrupted, your partner will have a better sense that he feels heГ•s getting through to you. Eventually he will be more apt to pay you attention, himself.

3. Remember to paraphrase.

Paraphrasing consists of telling your partner, in your own words, that you have heard him. For the moment you donГ•t have to justify or answer yourself; just say what you understood. Once he feels heard, it will be easier for him to listen to you.

4. Try to reflect the feelings of the other person.

You should always try to imagine what your partner is feeling. That does not mean you need to make assumptions or psychoanalyze or tell him what he is really feeling. It simply is a way to find out if you understand what he is feeling.

5. Empathize.

Empathy is the ability to put yourself in your partnerГ•s place and imagine how you would feel if you had the same experience. Some ways to do this are to observe his body posture, listen to his voice, look at his eyes, and say what you imagine he is feeling. It is not necessary that you are right. Your concern and effort is to understand him and help him figure out how he feels.

6. Listen for positive intent.

Positive intent is the wish for better relations, which lay behind many hostile interactions. Hurtful statements often arise from a desire to demonstrate oneГ•s own pain. Remember that behind the expression of pain, there is a wish that things could be different. You can use your own feelings as a clue to what your partner may feel. If you feel hurt, he probably does too.

If you are too upset to listen, you, more than likely, will go through the following cycle: you have a quarrel, in which neither of you feels heard, you withdraw for a while, and then you try to make up in some fashion.

During the quarrel it is very difficult to listen. Both of you feel frustrated because neither feels heard. You may exaggerate your points, dredge up past conflicts, and say spiteful things to demonstrate your hurt. One doesnГ•t have to end the world or the relationship due to a little tiff. What typically happens next is that you both withdraw for a while to cool off. Sometimes you both need a "time out" from one another. That is ok. One reason for withdrawing after a fight is the fear that talking about what happened will just start the quarrel all over again. Withdrawal is one strategy for keeping out of each otherГ•s way for a while.

Making up is very important. Simply ignoring the conflict leads to increasing distance, and it is likely that the same issue will build up again. Though you both may have said a lot of foolish things, the quarrel may have revealed some hidden resentments that need to be discussed. So you need a way to get back together and talk about what happened.

One way is to approach your partner to see whether or not he is ready to talk about your argument. Disclosing the hurt and fear behind your anger will help you listen to each other. Acknowledging your own role in escalating the conflict can also help. Ask yourself the following questions after a conflict:

1. Did you give advice?

2. Did you make excuses?

3. Did you accuse him?

If you practice these techniques with one another, you should see a difference in your communication with one another. Of course, there can be other longstanding issues that may need the help of your favorite Psychologist; if the problems persist, consider giving him or her a call.

What We've Learned from Psychological Testing and Compliance to Treatment and How Therapy Impacts on Patients' Overall Health

Gregory M. Sarlo, M.A., LCPC, Psychology Doctoral Candidate

Symptoms of HIV infection and physical symptoms of depression and anxiety overlap and often confound the clinical assessments of persons with HIV infection. Lately we have seen in the research, the extent of confounding factors which add to the difficulties of predicting a patients' likelihood for continued and ongoing mental health treatment and compliance. The difficulty with patients has been that individuals consistently present themselves in crisis upon the onset of their treatment, both medically and psychologically. After a few visits to their physicians and therapists, the likelihood of them continuing treatment and complying with their health care professionals during certain situations, appears to diminish. This is most unfortunate, because this is the time that patients may benefit most from psychotherapy.

One of the questions we, professional psychologists ask is, "Is it likely that these individuals would stay in ongoing treatment and comply with their doctors, or terminate after the first few visits?"

Some of the factors in my research found that persons who suffer chronic life-threatening illnesses are likely to experience psychological distress, particularly clinical depression and generalized anxiety. HIV infection, the cause of AIDS, is a condition that has been closely associated with distress reactions. However, depression and anxiety among persons with HIV infection is often related to specific HIV-related disease processes. The specific symptoms of depression, anxiety, and the physical symptoms associated with these emotional conditions, among persons with HIV infection were closely related to perceived HIV illness symptoms. In other words, patients may be experiencing depressive symptoms but these may be due to HIV related problems. Are oneГ•s HIV symptoms due to a high viral load or due to depression- or is the high viral load due more to being depressed? Further do lower T cell counts influence depressive symptoms? Studies using several clinical and psychological tests demonstrated, symptoms of HIV disease correlate positively with levels of depression and inversely with the amount of time since the diagnosis. This would mean that the more someone was depressed the less likely they would be to pursue treatment on an ongoing basis.

Nevertheless, the relationships between HIV-related illnesses, depression and anxiety are confounded by overlapping symptoms of HIV disease, depression, and anxiety related syndromes. Research has found that physical symptoms of HIV infection were most closely related with representing somatic symptoms of depression. The research related that persons reporting four or more HIV-related symptoms were twice likely to report two or three HIV-related symptoms. Hence the more physical and somatic symptoms, the more likely a person would pursue treatment. The question is, "Would someone like to wait until they are physically ill in order to pursue treatment and then be dealing with the physical illness at the same time while trying to cope emotionally?"

There were results from two larger studies which further illustrate how HIV-related disease and depression and anxiety symptoms overlap. 20% of patients exceeded the clinical depression cutoff on several examinations. Similarly, Lyketsos and colleagues (1993) found their test scores were associated with HIV symptoms including persistent diarrhea, fatigue, skin rashes, and weight loss. Which means, persons who met criteria depression scores on the test reported twice as many physical symptoms of HIV disease as non-depressed HIV positive persons. Lyketos and colleagues concluded that overlapping symptoms of HIV disease and depression accounted for much of the depression observed among HIV positive samples. What this means is that there are symptoms associated with depression as well as the physical symptoms of HIV and both of these factors account for some of the depression innate in positive individuals.

Some investigators have addressed the HIV disease, depression, and anxiety symptoms overlap by using measures of cognitive-affective depression omitting somatic symptoms. Some investigators assessed persons with HIV infection using a depression screening measure that consisted of six items and two Diagnostic Interview Schedule Items reflecting dysphoric (depressed) mood, restless sleep, and social distancing. The study found that 42% of the sample could be classified as depressed and anxious and that the scores were significantly related to frequencies of HIV-related illness symptoms. However, depression and anxiety were closely associated with the number of days persons were bed-bound due to HIV-related illnesses. But, because this data was drawn from a community based care program of very sick patients, (more that half of which spent their days bed-bound,) participants mostly represented late stage HIV disease and are not comparable to our average patient from the clinic who are out and about, often part of the work force. However the number of illness symptoms and degree of physical disability are associated with concerns about health, neuropsychological complaints, sleep disturbances, and fitness to obtain employment. What one can take from these conclusions is that the more someone experiences complications with their health, the more likely he/she could experience depression and anxiety. Psychotherapy could be very helpful in these instances to help one cope with the rapid changes in the individualsГ• life due to the changes in his/her health.

Researchers have been particularly interested in the idea that Г’a sense of controlГ“ can buffer or moderate the effects of naturally occurring stressful life events. Some of those researchers have suggested that one of the effects of such events is to challenge his/her control beliefs, and that successful adaptation in part involves reestablishing a sense of control or mastery over the event in particular and over oneГ•s life in general. This sense of control improving oneГ•s mental and emotional well-being would imply that ongoing treatment in psychotherapy with someone who is compliant about their treatment would significantly improve somatic and emotional well-being. Again, talking about oneГ•s fears and feelings relating to theirГ• own beliefs about having control over their own health can greatly improve the individualГ•s emotional and physical well-being.

Studies assessing the effects of control-related beliefs have tended to focus exclusively on contingency beliefs. One researcher believed that generalized control beliefs would exert an influence primarily in novel situations. In more familiar settings, like a therapistГ•s office, a person would have formed situation-specific control beliefs that would take precedence over more general expectations.

Similarly, studies that have examined situation-specific control in beliefs in populations with serious disease have suggested that these feelings of control are associated with positive adjustment to physical illness. Breast cancer patients who believed that they could exert control over the course of their cancer, or over the likelihood of its recurrence, were significantly better adjusted than those who lacked such feelings of control. Positive relationships between perceptions of control over disease-specific dimensions and adjustment were also found in a study of male patients who had suffered myocardial infarction (heart attacks), and in patients with rheumatoid arthritis. Importantly, in a sample of men and women at high risk for sudden cardiac death, perceptions of control were positively associated with adequate adjustment of their lifeГ•s situation.

A final issue addressed by this investigation relates to the possibility that some other variable may determine both adjustment and feelings of control. Research has suggested that a pervasive personality predisposition to view the self and events in a negative manner may be associated with a wide range of adverse reactions to stressful events. Meaning, the more depressed one is, the more likely they are not going to be compliant with their doctors and the more likely they may have somatic complaints and illness related to their medical condition. The factors all work together. Researchers have found that this general trait, termed negative affectivity, to be associated with health complaints, physical symptoms, and less effective coping. There has been some suspicion that negative affectivity may account for relationships between various psychological predictors and positive outcomes that were previously ascribed to other factors. In particular, the hardiness concepts of which a sense of personal control is a central component, has come under scrutiny as potentially confounded with negative affectivity. Conceivably, then , feeling of psychological control over a stressful event may be an outgrowth of a more general personality predisposition to view events in a positive manner rather than in a negative way. In other words, feeling more in control of a situation and developing a positive attitude about a particular situation will better your chances of a positive outcome than being negative and pessimistic. So if you are concerned about your counts, discussion and intervention at these times with your doctor and psychotherapist will foster a sense of positive attitude; this is one form of taking some control. Your chances for success are improved with this kind of proactive stance and positive attitude.

Consequently, negative affectivity has several aspects--for example feelings of nervousness, tension, worry, anger, scorn, revulsion, guilt, self-dissatisfaction, and a sense of rejection, it nevertheless appears to be unitary dimension, with what earlier researchers referred to as Г’trait anxietyГ“ or Г’neuroticismГ“ as one of its central features.

Although independently studied, various psychological testing tools have been widely researched. There has not been much in the area of using these tools together and focusing on the HIV population in an effort to predict medical and psychological compliance with ongoing treatment especially during the unique situation of initially learning about oneГ•s HIV-positive status. Considering that control, denial, anxiety, and depression are related in some ways regarding the physiological and emotional impact of HIV impacted individuals, compliance with treatment and taking control is one key to living a much happier and healthier life.

Clinical Measures Predict Likelihood Of HIV Dementia

HIV-positive patients with fewer than 100 CD4+ T cells per microliter and anemia or an AIDS-defining condition have a high probability of developing dementia within 2 years, according to Atlanta, Georgia-based researchers.

Dr. Adnan I. Qureshi of Emory University and coinvestigators at the Centers for Disease Control and Prevention conducted a longitudinal review of the medical records of 19,462 HIV-positive subjects to detect factors associated with the development of dementia.

In the February issue of Neurology, Dr. Qureshi's group reports that such factors included "...anemia, low CD4+ T-lymphocyte count, diagnosis of an OI [opportunistic infection], blood platelet count of fewer than 100,000 cells per microliter, age 50 years or more at initial observation, and ethnicity." They also found that patients with the lowest 2-year probability of developing HIV dementia had CD4 T cell counts greater than 200 cells per microliter and no other risk factors.

The researchers conclude that commonly available clinical and laboratory findings can be used to estimate the probability of developing HIV dementia. Although there is currently no proven prophylactic treatment for HIV dementia, it may be possible to identify at-risk patients who could benefit from standard and experimental treatment.

Neurology 1998;50:392-397.

PSYCHOLOGICAL COFACTORS IN HIV DISEASE; STRATEGIES FOR ENHANCEMENT OF ONE'S HEALTH STATUS

By Cheryl L. Mejta, Ph.D. and Gregory M. Sarlo, M.A.

HIV is widely accepted as the virus responsible for immune dysfunctions underlying AIDS. Among people infected with HIV, however, there is considerable variability in onset, progression, and outcome of the disease; people infected with HIV do not follow the same clinical course within the same time frame. As biomedical research on the prevention and treatment of AIDS continues, a search for cofactors to explain differences in AIDS onset and progression has begun (Solomon and Temoshok, 1987).

There is an emerging literature examining psychological influences on immune function, disease onset and progression and health outcome. Although not always specific to HIV, this literature has important implications for HIV and other immunologically-mediated diseases. In a review of the literature on the psychological influences on immune function, kiecolt-Glaser and Glaser (1988) concluded that there is good evidence for psychological mediation of immune function. They further noted that "...psychological or behavioral variables are among the possible cofactors that may influence HIV infection and disease progression " (p.892). Current findings on the psychological influences on health are reviewed below.

PSYCHOLOGICAL CO-FACTORS AFFECTING HEALTH STATUS

Several psychological factors have been associated with poorer health status and with suppressed or compromised immune function. These include: stress, certain coping and personality styles, certain emotional and affective states, and interpersonal relationships and social supports.

Even commonplace stressful events have immunological consequences for our immune systems; stress appears to suppress immune responses. The immunosuppressing effects of chronic stress accumulates through time increasing the chances of illness

The way we tend to cope with life also influences the functioning of our immune systems. A particular coping or personality style, sometimes referred to as Type C coping style or immunosuppression prone personality, is associated with poorer health status and outcomes, especially among cancer patients (Solomon, 1987; Temoshok, 1985). The characteristics of the Type C or immunosuppression prone coping style include: nonexpression or denial of emotions especially hostility or anger; focusing on other people’s needs while neglecting one’s own needs;  a personal sense of being unable to influence or change negative events in one’s life; and a tendency to conform to or comply with other people’s expectations.

Our emotional or affective states can impact our health status. Compromised immune function has been found among people who are depressed, unhappy, or lonely (Glaser and Kiecolt-Glaser, 1988). The chronicity of these emotional states seems to be one of the critical factors in assessing their effects on immune function.

The final major psychosocial factor which appears to influence health status is our social support system. Both the nature and quality of our social supports can modulate immune function. People who are lonely, who are dissatisfied with their current relationships, or who recently separated from their partner show alterations in immune function.

STRATEGIES TO ENHANCE PSYCHOLOGICAL HEALTH

Research on the effects of psychosocial interventions on disease progression and outcome, especially HIV, is in the stages of infancy. Based upon current findings, however, the following psychological interventions may have beneficial effects.

1) Talk about what bothers you with supportive friends, support group members and / or a therapist. There is some research suggesting that self-disclosure of traumatic or upsetting events can have beneficial physiological consequences (Kiecolt-Glaser and Gaser, 1988).

2) Express your feelings, especially anger and frustration, rather than deny or suppress them. There is some research suggesting that lack of emotional expression, particularly negative emotions, is associated with poorer health status (Temoshok, 1988).

3) Develop a supportive network of friends and/or participate in a support group which provides problem-solving help in addition to emotional support. There is some research suggesting that having people available to help you solve problems through their suggestions or advice or experiences can be helpful ( Temoshok 1988).

4) Identify the stressors in your life. Where possible, eliminate stressors from your life. Learn how to better manage the remaining stressors. Relaxation techniques, mediation, and cognitive reframing are among the approaches that can help you better manage the stress in your file.

5) Increase your use of health-enhancing coping strategies. Kobasa and her colleagues (1980) identified a coping style coined hardiness which seems to have health protecting qualities. This coping style has three components: (a) control- the belief that one can influence or affect outcomes; (b) commitment-finding meaning in one's work, values and personal relationships; and challenge-interpreting potentially stressful events as challenges to be met with success.

6) Work with a therapist or counselor to understand and work through long standing emotional and affective patterns such as depression, unhappiness, loneliness, and grief.

7) Reduce or eliminate behaviors which further compromise your immune system. This includes reducing or eliminating alcohol and other illicit drug use, avoiding repeated infection with HIV by practicing safe sex, and avoiding contracting STDs by using condoms (Guydish and Ekstrand, 1989).

While improving your psychological health can have positive effects on your physical health status, the psychological interventions suggested do not replace good medical care. Instead, these psychological interventions should be viewed as adjuncts and enhancement to your medical care. They may he you maximum the benefits you derive from your medical treatments.

Future articles will describe in more detail some specific approaches you can take to enhance your psychological health and well - being. Should you have any questions about strategies to maintain your psychological health, a consultation with a psychologist should be considered