Table 2.

Detailed Intervention Outline

SESSION 1
Agenda item	Goal and Sample Text
Overview of intervention goals	Orient participant to what s/he can expect over the next several weeks Many HIV-positive individuals have talked to us about how difficult it is to receive an HIV diagnosis, from trying to figure out whether to keep your diagnosis a secret, to trying to manage the sadness and anxiety you experience as a result of your diagnosis. We have developed a program of tools to assist you in dealing with this distress. Our hope is that at the end of this time, you will feel less distressed as well as more confident that you have some answers and skills you can use when you are distressed in the future.
Explore diagnosis story	Normalize and validate reactions to diagnosis process Develop rapport with participant Please tell me more about your diagnosis story. How did you feel when you received your diagnosis? Have you told anyone about your diagnosis? How did you decide to do this? How did they react?
Explore existing coping skills	Informal assessment of participant’s familiarity with and acceptability of psychological skills How have you handled your diagnosis so far? What are some ways you have coped with it? In what ways are you proud of how you have been handling it?
Explore current functioning, including family functioning, social support, and distress	Informal assessment of participants’ social support network, interpersonal relationships, and psychological functioning What is your social support network like? How are your relationships with your family members? What are some HIV-related stressors you have experienced?
Highlight example of catastrophic thinking; psychoeducation of automatic thought cycle	From participant’s previous description of stressors, identify example where automatic negative thinking likely occurred. Teaching point: research on people who are distressed shows that they are more likely to engage in automatic thinking that is more negative and more extreme. For example, “I can’t do this” might turn into “I will never be able to do it,” or “I am sick right now” might become “I will never, ever get better.” We call this catastrophizing, which is thinking about the worst possible outcome. Have you found yourself doing this?
Psychoeducation of the cognitive-behavioral triangle	Describe ways that thoughts, behaviors, and emotions are connected We know that people’s thoughts (what they are thinking) are closely connected to their emotions (what they are feeling) as well as their behaviors (what they are doing). Each aspect of the triangle affects the others. This means that when we start automatically thinking catastrophic thoughts, we can feel very distressed.
Teach Automatic Thought Record	Describe objective of skill and teach skill using participant’s example - The main take-away from today’s session is to learn a new way of thinking that may decrease automatic negative thoughts. An automatic thought record is used when you notice significant negative emotion. We will fill this Automatic Thought Record out together with the example you described to learn a new way of thinking through it. In the first column is we will write down the situation you described briefly. E.g., you received your diagnosis from the doctor, who said that you have HIV. - In the second column we write down the emotions you felt at the time (e.g., sad, angry, scared), and on a scale of 0 – 100 with 0 being not intense at all and 100 being very intense. E.g., you felt fear at an 80 and sadness at an 80 - In the third column, we write down the automatic thoughts that went through your mind. E.g., “I am going to die”, “I brought shame to my family”. How much did you believe them? - In the fourth column, we take a step back and think about the FACTS (remember, facts are points about reality that are completely true and not just our interpretation) that support this automatic thought. E.g., “HIV can lead to a disease that sounds scary and I know people who have died from it” - In the fifth column, we will think about facts that do NOT support this automatic though. E.g., “I know people who have lived with HIV for a long time” - In the sixth column, we think of a more realistic/balanced thought, e.g., “Having HIV can be and people are able to live with it” - In the last column, we re-rate your feeling of fear and sadness. Are they both still at 80?
Assign homework	Explain function of homework Research suggests that practicing a new skill consolidates learning. I’d like you to fill out at least one automatic thought record in the next week, when you notice yourself suddenly feeling bad. This could be feeling sad, down, angry, or any kind of strong emotion that is uncomfortable.
Close session	Reinforce participant, build rapport, and generate hope We have covered a lot today. Thank you for spending the time to talk with me about your HIV, your family, and how you have felt since receiving an HIV diagnosis. This is a difficult process, and my hope is that as we continue working together, we can help you experience less distress related to HIV as well as increase your ability to cope with stress. See you next week.
SESSION 2
Agenda item	Goal and Sample Text
Review homework	Reinforce participant for homework completion, troubleshoot barriers, clarify understanding, consolidate learning of Skill 1 - Welcome back! How did your last week go in terms of learning to use the automatic thought record? Did you get a chance to go through the worksheet? - Let’s review the worksheet (if you did not do it, that is okay, let’s do it together now). Tell me about the situation that happened that caused you to have strong negative emotions. What happened at that moment? What were the emotions you felt, and how intense on a scale of 0 – 100? What were the automatic catastrophic thoughts you had? How much did you believe in them? What were the facts supporting those beliefs? What were the facts that did NOT support those beliefs? What was the more realistic thought that you arrived at? And after all of this, what were your emotions at the end again, from 0 – 100? - What was it like going through this automatic thought record? What did you find helpful or unhelpful about it? Can you think of a time in the future when you might want to use this, or anybody in your life that you might want to teach this skill/tool to?
Teach TRAP/TRAC	Describe objective of skill and teach skill using a relevant example. Match name to participant’s demographic - Today we are going to learn about a new skill. The goal of this skill is to increase behavioral engagement by thinking about a negative pattern in your life that you have started to engage in, as a result of your HIV. I’m going to start by giving you an example that many HIV-positive people describe experiencing. There are three steps in this process. A trigger/situation, a response, and an avoidance pattern. - Xiao Ming is a 30-year-old man who has just received an HIV diagnosis. After receiving the diagnosis, he has many emotions of sadness, shame, and fear. The Trigger – His friends call him to go out to dinner with them, something they do often. The emotional Response – As he sees his friend’s contact image coming up on his phone, he feels shame about his HIV status and worries that if he eats with his friends and they find out later he has HIV, they might be upset at him, so he doesn’t pick up the phone call. The Avoidance Pattern – Because he doesn’t pick up the phone, he doesn’t make plans with his friends to go out to dinner. He ends up staying at home and just staying in bed. This isolation means that he doesn’t get to have the positive experience of going out with his friends to enjoy a good time hanging out. As a result, he feels even worse. The Avoidance Pattern feeds on itself as a feedback cycle that gets more severe over time. Each time his friends call, he doesn’t pick up the phone, so his friends start to call him less and less. - Instead of perpetuating this avoidance pattern, Alternative Coping is a more adaptive way to address the situation. With the same Trigger and emotional Response (where Xiao Ming’s friends call him to have dinner and he feels shame when he sees the incoming call), an Alternative Coping method would be for him to engage in opposite action to the shame, pick up the phone and make plans to meet up with his friends. He goes out and has a good time with his friends, just like they usually do. By doing this action, he has allowed himself to receive evidence that his friends still care about him as they always have, he gets to engage in a positive evening, and therefore he feels better. Additionally, he maintains good relationships with his friends, rather than in the avoidance situation where he distances himself from them. As a result, he breaks the cycle of isolation and avoidance, and feels better overall. - So as you can see, instead of AVOIDING, when he APPROACHES it is very likely that he starts to feel more energized, better, and cared for, and he can see that his friends still like him and want to be around him. This is called an alternative coping method that breaks the vicious cycle of avoidance.
Use participant example for TRAP/TRAC worksheet	Find example of TRAP in participant’s life and collaboratively brainstorm alternative coping - Are there examples from your life of avoidance patterns similar to what Xiao Ming was experiencing? Are there things you avoid or no longer do as a result of receiving an HIV diagnosis, such as things you used to enjoy or people you used to see? Tell me about them. - We will use your example to fill in this worksheet. The Trigger refers to the situation that happens; Response is what you typically think, feel and do, and Avoidance Pattern refers to what you do that is withdrawing, avoiding, or escaping. We will fill the boxes in based on your example. What are the short and long term consequences of this avoidance pattern? - What are some possibilities we put instead for Alternative Coping, where you respond in a way that is more in line with your values and will keep you from an avoidance pattern?
Create a plan for Alternative Coping and assign homework	Be behaviorally specific in setting a goal for Alternative Coping action steps to take this week - What steps are involved in alternative coping? Let’s make a plan for those steps. What would get in the way? - What would it look like for you to take some steps in terms of alternative coping this week? - Your homework for this week is to take X of those steps we discussed. If you'd like to, you may take home this TRAP/TRAC worksheet as a reminder of the pattern and the coping steps to take.
SESSION 3
Agenda Item	Goal and Sample Text
Review homework	Reinforce participant for homework completion, troubleshoot barriers, clarify understanding, consolidate learning of Skill 2 - Welcome back! How did your last week go in terms taking steps to get out of your TRAP and get back on TRAC? Did you get a chance to do any of the steps we discussed? - Troubleshoot barriers that participant experienced in terms of taking active steps, reinforce any movement toward change that participant engaged in.
Teach Paced Breathing	Describe objective of skill and practice in session - Oftentimes, patients living with HIV tell us that they experience anxiety or ruminative cycles. What this means is that sometimes you can start worrying about something, and find yourself unable to stop worrying. The more you think about it, the worse and worse it gets. Or, you find yourself in a situation where you might be having an anxiety attack — this is when you might experience a lot of symptoms at one time, such as increased heart rate, sweatiness, shaking, feeling like it’s hard to breathe, feeling pressure on your chest, and it happens all of a sudden. Have you ever had an experience like that? - In situations like what we just discussed, when you notice an increase in your anxiety, a skill called "paced breathing" could be really helpful. - Paced breathing is simply breathing out longer than breathing in. We do this because the human peripheral autonomic nervous system is divided into two parts, a parasympathetic nervous system and sympathetic nervous system. The parasympathetic nervous system is responsible for rest and digest functions whereas the sympathetic nervous system is responsible for fight or flight. - When we breathe in, the sympathetic fight or flight nervous system is activated; when we breathe out, the parasympathetic rest and digest nervous system is activated. Both of these are necessary for different versions of equilibrium for daily living. For example, if you breathe in more than you breathe out and do it rapidly, it can feel like you’re getting ready to move quickly or even hyperventilating/gasping if you do it long enough. We’ll try it together; can you feel your body getting activated? - When we do paced breathing for anxiety, we are going for the opposite effect. Just like breathing in a lot and rapidly can quickly elevate your heart rate and kick you into gear, breathing out more deeply can lower your arousal. - We are going to try it out together. We want our out-breath to be longer than our in-breath. Pay attention to your breathing right now without trying to change it. What is your natural breath count? A comfortable paced breathing count depends on each person’s own lung capacity and comfort with deep breathing. For example, my natural breath is about 4 counts, so when I do paced breathing, I will breathe in for 4 counts and breathe out for 6 counts. We will try paced breathing together with our individual counts for a few minutes. - What do you notice in your body after that exercise? - In the future when you notice yourself getting anxious, try to pace breathe for a few minutes. This skill is useful because it is easy to do and you can do it anywhere, even when people are around without them even realizing.
Review all 3 skills	Consolidate learning, troubleshoot barriers, and answer questions - We have learned 3 skills in total for different forms of distress. We have the Automatic Thought Record that is for practicing a new way of thinking that may decrease automatic negative and catastrophic thoughts, TRAP/TRAC to help break avoidance patterns that lead to isolation, escaping and withdrawing, as well as paced breathing to lower anxiety. What questions do you have?