The coping improvement group intervention described here is based on Lazarus and Folkman's (1984) theoretical model of stress and coping and uses cognitive-behavioural principles to improve skills in stress appraisal, coping and obtaining social support during stressful situations. Specifically, the intervention emphasizes: (a) identifying stressors and decomposing global stressors into more specific issues; (b) the development of problem-focused and emotion-focused coping strategies suitable for stressors common to HIV-infected older adults; (c) determining the fit between stressor changeability and the appropriateness of potential coping strategies; and (d) optimizing levels and use of social support.
The intervention also includes several sessions developed specifically to address stressors common to HIV-infected older adults (e.g. longer periods of hospitalization and the presence of comorbid health conditions). In the current article, we provide the intervention's format, a session-by-session description of the intervention, and also present preliminary data evaluating the intervention's efficacy for this group.
The coping improvement group intervention was structured around ten face-to-face group sessions, each lasting approximately 75 minutes in length. Group sessions were facilitated by two Masters-level practitioners with experience in AIDS and aging. The size of each group ranged from four to six persons and was intentionally kept small to allow sufficient time for participants to share personal histories, engage in role-play scenarios, and participate in intervention-related exercises.
The intervention employed a closed-group format; once a group began, no new members were permitted to join the group. The closed-group format was employed given the need for confidentiality and the challenge of building a cohesive bond among participants. In order to increase perceptions of communality, groups were homogeneous in gender and sexual orientation.
Session 1: Introductions, building rapport and establishing trust. Session 1 was devoted to introducing group facilitators and participants, discussing guidelines that would govern each session and building rapport. Following this, participants discussed common stressors and characterized their efforts to cope with these stressors.
Session 2: Stressor identification and cognitive appraisal training. In Session 2, the concepts of primary appraisal (i.e. identifying the seriousness of the stressor and its potential impact) and secondary appraisal (i.e. evaluating coping resources available to the individual) were introduced. Participants first learned the importance of decomposing general stressors into more specific challenges.
Participants then worked through a process in which changeable and unchangeable aspects of stressors common to HIV-infected older adults were discussed (e.g. the 'changeability' of comorbid health conditions such as osteoarthritis and the difficulty of informing their children and grandchildren of their HIV infection). This process led to a brief introduction of problem-and emotion-focused coping and highlighted how each type of coping is most appropriate depending upon the changeability of the target stressor.
Sessions 3 and 4: Problem-focused coping. In Sessions 3 and 4, participants discussed problem-focused coping and set goals for applying problem-focused coping strategies to changeable stressors in their life. For example, for individuals with health concerns, potential coping strategies included: (1) differentiating health changes associated with normal aging from those that are AIDS-related; (2) developing skills to improve relationships with health care providers; (3) identifying and establishing relationships with AIDS-wise medical and mental health care professionals; and (4) identifying strategies that promote consistent HIV treatment adherence. Sessions 3 and 4 concluded with participants setting the goal of applying problem-focused coping strategies to stressors that were appraised as changeable.
Sessions 5 and 6: Emotion-focused coping. In Sessions 5 and 6, participants shared their experiences of implementing problem-focused coping strategies during the previous weeks. The group then transitioned to emotion-focused coping. Situations where emotion-focused coping was most adaptive were discussed. Special emphasis was devoted to differentiating adaptive emotion-focused coping (e.g. seeking spiritual assistance) from that which was maladaptive (e.g. excessive alcohol/drug use and high-risk sexual behaviour). Participants were then given the homework assignment of applying emotion-focused coping strategies to stressors that were less amenable to change.
Session 7: Social support and living with HIV as an older adult. There are few sources of social and emotional support for older adults living with HIV/AIDS. Session 7 addressed the importance of establishing and maintaining social support resources to assist one's coping efforts. Participants discussed ways to expand their current support networks using a series of group exercises, such as evaluating existing support networks, identifying currently unmet support needs and using problem-solving skills established earlier to increase supportive networks.
Session 8: Obtaining and maintaining social support through HIV serostatus disclosure. Session 8 was devoted to using skills-building techniques to provide participants with interpersonal skills for assessing the risk of disclosing their HIV serostatus to potential sources of support and seeking support from formal and informal sources of support. Disclosure of HIV serostatus was addressed in group discussions, where participants were asked to list barriers to disclosing their serostatus to persons in several types of relationship contexts, including family, health care providers and sex partners.
Following an examination of personal experiences with disclosure, participants practised disclosure in role-play scenarios with facilitators and peers providing feedback on performance. The goal of this component was for participants to be able to decide if, how, with whom, when and under what circumstances to disclose their HIV serostatus.
Session 9: Hospitalizations, treatment concerns and planning adequate home health care environments. Research indicates that the hospitalizations of HIV-infected older adults are longer than those of their younger counterparts (Crystal & Sambaroothi, 1998). These extended hospitalizations occur, in part, because older adults are more likely to live alone, have inadequate networks of informal support, and less often participate in discharge planning.
In response to these findings, Session 9 was devoted to providing skills to help HIV-infected older adults arrange adequate home health care environments following discharge from the hospital setting. Coping training focused on helping older adults to develop a specific plan in the event that they were hospitalized, highlighted communication skills that could facilitate conversations with family members and friends about future hospitalizations and discharge planning, and discussed the importance of creating home health care environments that afforded optimal comfort and safety.
Session 10: Review and group closure. Session 10 summarized how stressors and limited support related to living with HIV/AIDS as an older adult could be resolved using skills covered in the intervention. Participants were encouraged to exchange addresses and phone numbers if they wished to continue correspondence following the intervention's completion.
- Heckman, TG et al; A pilot coping improvement intervention for late middle-aged and older adults living with HIV/AIDS in the USA; AIDS Care; February 2001; Vol. 13 Issue 1
Reflection Exercise #6
The preceding section contained information
about coping improvement group interventions for HIV positive clients. Write three case study examples
regarding how you might use the content of this section in your practice.
In Heckman’s intervention program, what were four problem-focused coping strategies to changeable stressors in participants lives during Sessions 3 and 4?
Record the letter of the correct answer the