Using behavioral psychotherapy techniques to address HIV patients’ pain, depression, and well-being

Abstract

For persons with HIV (PWH), aims of psychotherapy can extend beyond HIV-related topics. Issues such as HIV stigmatization and disclosure, and HIV-related self-care including treatment adherence might be ongoing concerns, but, patients often need support to develop skills to manage other problems, whether functional or psychiatric. In the context of an ongoing randomized clinical trial, we delivered an individual, behavioral activation-based intervention to PWH with comorbid chronic pain and depression. Our primary treatment target was to reduce pain-related interference in physical and psychosocial functioning. Throughout the course of the 7-session intervention, clinicians used four core strategies to help patients improve a variety of domains related to their health and well-being: (1) teaching values-based goal setting; (2) developing skills to be an activated and informed patient; (3) focusing on changing behavior despite discomfort; and, (4) facilitating access to care (e.g., flexible scheduling, primarily phone sessions). The application of these strategies to HIV-related and non-HIV-related problems are presented to illustrate how and when clinicians can utilize these strategies. These practical lessons will inform a flexible approach to helping PWH address a myriad of health and functional issues related to their overall well-being.

People with HIV (PWH) face numerous behavioral and social challenges associated with their illness. These include adhering to antiretroviral therapy (ART) for their health (DHHS, 2018) and to reduce HIV transmission risk (Cohen et al., 2016; Skarbinski et al., 2015), navigating disclosure of serostatus to others (Kennedy, Haberlen, Amin, Baggaley, & Narasimhan, 2015), and risk of being stigmatized (Turan et al., 2017). Additionally, research shows that PWH are highly likely to have comorbid medical and psychological conditions. Examples include: anxiety and depressive disorders (Brandt et al., 2017; Nanni, Caruso, Mitchell, Meggiolaro, & Grassi, 2015), chronic pain (Jiao et al., 2016; Koeppe, Armon, Lyda, Nielsen, & Johnson, 2010; Miaskowski et al., 2011; Uebelacker et al., 2015), hypertension (Nduka, Stranges, Sarki, Kimani, & Uthman, 2016), and substance misuse (O’Cleirigh, Magidson, Skeer, Mayer, & Safren, 2015). In the context of psychotherapy, clinicians might be overwhelmed by these diverse issues and feel uncertain about how to address these problems efficiently and successfully. This is particularly relevant for PWH who demonstrate treatment adherence, meaning that HIV is likely well-controlled and not the primary clinical concern. A possible solution is the use of transdiagnostic therapy approaches that might be relevant to a range of concerns.

Theoretical rationale for behavioral activation-based psychotherapy for PWH

An overarching psychotherapy approach from which to develop effective techniques that can address multiple conditions for PWH is behavioral activation (Hopko, Lejuez, Ruggiero, & Eifert, 2003; Kanter, Busch, & Rusch, 2009). Behavioral activation theory is based on and grew out of the more general behavior analytic theory of human behavior (Skinner, 1953), which highlights the important function that environmental context plays in shaping behavior. In the 1970s, this theory was expanded to include a behavioral conceptualization of clinical depression (e.g., (Ferster, 1973)), which posited that depression is the result of a loss of or chronically low levels of positive reinforcement. In the mid-1970s, these conceptualizations were translated into the first behavioral activation treatments (Lewinsohn, 1974). These early behavioral activation treatments focused on increasing patient contact with positive reinforcement through structured scheduling of more pleasant events and behaviors in patients’ lives. Contemporary behavioral activation manuals still target increased contact with positive reinforcement, but focus more on scheduling activities that are consistent with patient values and long-term goals (Kanter et al., 2009; Lejuez, Hopko, Acierno, Daughters, & Pagoto, 2011; Martell, Addis, & Jacobson, 2001). Using this behavioral activation theory framework, clinicians can provide a rationale and encouragement for PWH to start to increase and maintain contact with reliable sources of positive reinforcement, thereby improving mood and hopefully increasing motivation and energy, thus increasing engagement in valued activities and reversing the downward spiral. We suggest that discussion of values is particularly important in the context of treating individuals with chronic pain, as it is possible that meeting short-term goals may increase pain severity in the short-term. However, the patient and therapist may decide these goals are worth pursuing anyway because of their alignment with important patient values.

Empirical research for behavioral activation

There is a growing body of research supporting the use of behavioral activation psychotherapy techniques. Numerous studies show that behavioral activation can help patients reduce anxiety (Hopko, Lejuez, Ryba, Shorter, & Bell, 2016) and depression (Ekers et al., 2014). Moreover, data show behavioral activation can facilitate mood improvement in samples of medical patients (e.g., (MacPherson et al., 2010)). Pilot data indicates that behavioral activation may be effective for chronic pain management among PWH (Uebelacker et al., 2016). Additionally, research shows that behavioral activation can impact psychiatric symptoms and adherence behaviors among PWH. This was shown in two small, uncontrolled studies (Magidson, Seitz-Brown, Safren, & Daughters, 2014; Tull, Berghoff, Bardeen, Schoenleber, & Konkle-Parker, 2018) and a series of case studies among PWH with substance misuse (Daughters, Magidson, Schuster, & Safren, 2010). Moreover, data show that behavioral activation theory can help explain medication nonadherence among PWH, potentially because of the indirect effects of environmental punishments (Magidson, Listhaus, et al., 2015) or the loss of daily structure due to limited routinization of activities (Magidson, Blashill, Safren, & Wagner, 2015; Wagner & Ryan, 2004). In sum, behavioral activation can be an efficacious psychotherapy approach among PWH with the potential to improve adherence, symptoms, and quality of life.

Source of material

This manuscript is intended for clinicians who treat PWH but might be less familiar with behavioral activation. Although rooted in behavioral activation, the techniques described below were developed in part from the chronic disease self-management literature and other behaviorally-based psychotherapy techniques. Four core strategies described below were tested in the context of an ongoing randomized trial of a behavioral activation-based, 7-session psychotherapy intervention delivered to adult PWH with comorbid chronic pain and depression. In addition to the core strategies described below, the intervention included an initial joint session with each patient’s primary care physician to review the individual’s medical treatment and diagnoses, potential physical activity recommendations or limitations, and to establish coordination of care between the physician and the study interventionist. Subsequent sessions also included psychoeducation about chronic pain and time-based pacing. The psychotherapy was administered by Master’s- and Doctoral-level clinical psychologists. Although the study focused on chronic pain and depression, these core strategies may be used to help PWH improve a variety of life domains. Participants signed an informed consent form, which explicitly stated that sessions would be audiotaped and that this information could be shared in a de-identified manner. The clinical exchanges presented here were modified to protect patients’ confidentiality.

Teaching values-based goal setting

The ability to set behavioral activities in line with one’s goals is an essential skill taught in behavioral activation-oriented psychotherapy. For instance, Lejuez and colleagues (2011) developed an activity hierarchy to guide between-session activities. (Lejuez et al., 2011). In this program, we took a broad approach to goal-setting, allowing values and longer-term goals to guide short-term goals from the perspective that values can give one’s life meaning. The first step involves helping patients consider each domain of their life including relationships, work, physical health, financial well-being, recreational interests, self-care, and spirituality, and then to reflect on their personal values consistent with these life areas. We use these values to identify long-term goals, which will then be broken down into short-term weekly or daily goals (i.e., small steps) connected to those long-term goals. These goals might vary depending on patients’ immediate priorities and possible facilitators or barriers to completing a goal prior to the next session. We move back and forth between identifying values, long-, and short-term goals (e.g., sometimes a therapist might start with a value and use it to identify goals; other times, a patient might identify a short-term goal, such as exercise, and the therapist then helps to connect it to an important value in an effort to make the activity more reinforcing). Although it is a straightforward approach, values-based goal setting is not a skill that is typically practiced or mastered by most people on their own. In our experience with patients, many individuals reported feeling consumed by multiple enduring and acute life stressors and psychosocial health issues. We hypothesize that by helping PWH focus on what they value and think is important through goal setting, and helping them to take actions towards these goals, PWH not only may engage in reinforcing activities, but they also have an opportunity to connect with the positive aspects of their life in addition to problems and distress they are experiencing.

The long-term goals and the values they represent are diverse. For instance, they range from HIV-related concerns including “managing my HIV treatment” to non-HIV-related concerns such as “maintaining my social connections” and “being more physically active.” However, these concerns can be related. Clarification is needed when patients are asked to think of the values driving their goals, and when they attempt to link values to long-term goals. This clarification is done early in treatment, typically in the first session, as the following exchange illustrates. Over time, because goals are met, discarded, newly created, or modified to more accurately pursue their values, it is also critical to teach patients to continually reflect on the association between goals and values. In the session below, the therapist first learns that the patient wants to “do more with my life” and “be more active.” Later in the session, through value-directed questioning, they connect these goals with the patient’s value of being a caretaker.

Therapist: We were talking about what gives life meaning. What’s important to you?

Patient: Family. My mom and my daughter. My mom has always been there for me, even after I was diagnosed. I take care of her now. My daughter, well, we used to not get along when her father was around but she’s older now and I think we have a better relationship. I’m helping her find an apartment right now.

Therapist: It sounds like your family has been with you through some tough times and now you want to be there for them. Perhaps you value being a caretaker?

Patient: Yes, exactly. It is important to me to take care of others in my family. It’s just been really hard to do after my stroke − I can’t be there for them the way I want.

Therapist: Ok. So your stroke has made it much harder to be the family member you want to be, but this remains important to you. I can work with you to think about how to get back to taking care of your family in the manner you did in the past if possible, and I would also like us to think of new ways you can pursue this value that might be a better fit for your post-stroke reality. For the moment, I am wondering what is keeping you from being the caretaker you want to be?

Patient: I know I need to be stronger physically. After having a stroke, they told me to start walking more and be more active. I want to, but I just haven’t done it.

Therapist: Ok, well let’s think about what you can do between now and our next session to get just a little bit more active. As you consider this goal, I want you to think about getting some walking in this week as a first, small step towards being able to take care of your family members in the ways that are important to you.

Developing skills to be an activated and informed patient

PWH face a lifetime of healthcare interactions. They are responsible for attending appointments, obtaining antiretroviral medication, taking medication daily, dealing with comorbid health and mood issues, and maintaining a healthy lifestyle through diet and exercise which supports their medical treatments. Research has shown that when PWH demonstrate higher degrees of knowledge, skills, and confidence in treatment self-management, they are more likely to evidence better ART adherence, viral suppression, and higher CD4 counts (Marshall et al., 2013). The skill of being an activated and informed patient fits with behavioral activation psychotherapeutic principles. The behaviors associated with managing one’s own HIV care can be a source of positive reinforcement. For many, these behaviors are also direct steps towards pursuing value-driven, long-term life goals such as “being as healthy as I can be.” We note that values underlying such a long-term goal can vary, and it is useful to elucidate them by asking questions like: “And why is it important to you to be as healthy as you can be?”

A starting point for being a more activated and informed patient could be the patientprovider encounter. PWH range widely in how long they have worked with providers; while some are being seen for the first time, others have a 20-year relationship with their provider. Regardless of the duration, based on our observations, the ability to be an activated and informed patient tends to be diminished when PWH do not feel like their providers are listening to them, feel like their concerns are being dismissed, or have trouble discussing sensitive topics and this can negatively impact HIV-related health (Beach, Keruly, & Moore, 2006). For example, the following patient with chronic pain had a history of opioid use disorder. They reported that discussing problems related to back pain with their current provider was overwhelming for them. They often became angry with the provider’s response, which they felt reflected the provider’s distrust of them. In this situation, their therapist encouraged self-advocacy.

Patient: She’s not hearing me. Every time I bring it up, she starts talking about how she’s not going to give me another script for opioids like my old doctor in Florida. I get that but I’m in pain!

Therapist: That sounds frustrating. You said she doesn’t hear you. What does she need to hear about your pain?

Patient: I need her to know that it’s all the time, constant. I don’t want opiates - I’m off them. But I’ll try anything, anything. My back is killing me.

Therapist: It sounds like you feel that your doctor thinks you’re just looking for opioids and this makes you upset. I bet when you’re upset it’s hard to talk to her.

Patient: Yeah, I just shut down.

Therapist: Sometimes it helps to plan what you want to say ahead of time, so you don’t forget things, and you are able to make your most important points clearly. You might even write them down. What do you think of that idea? …. Perhaps we could set as one of your goals to write down your concerns for your doctor and then bring them to your next appointment with them?

Following their next doctor’s appointment, the patient returned to therapy to report on the interaction with their provider. The therapist focused on the patient’s ability to meet value-based goals, as well as the positive aspects of the experience and the influence it had on their mood.

Patient: I told her I had some things to say about my pain. I told her I even wrote them down. I talked about how it gets so bad at night, especially after work. I also told her right away that I didn’t want opioids, but I did want her advice and help.

Therapist: How did she respond?

Patient: She listened… I think. She didn’t mention opioids. I would have flipped. She talked about strategies I could try including a new drug.

Therapist: Wow, that’s different than last time. How do you think the visit went?

Patient: Eh, ok I guess. I’m not really sure I want to try that new medication. But it felt good just telling her how I really feel.

Therapist: You did great. I’m glad it feels good! And your talk with her doesn’t seem to have made you angry and frustrated like last time. Overall, it sounds like a positive experience. It’s exactly what you talked about doing. Because you value your physical well-being, you took this one step towards your long-term goal of managing your chronic health conditions. Your doctor probably responded differently because you were in more control of what you said and how you said it. Maybe before your next visit we can practice telling her about your concerns with the new medication?

Changing behavior despite discomfort

Helping patients focus on healthy behaviors to achieve values-based goals may turn their attention away from distressing thoughts, emotions, and physical sensations, including pain. By changing behavior first, negative cognitions may change after or become less salient or more acceptable (Lejuez et al., 2011). Further, a focus on behavior means that less time is spent in the therapy session processing thoughts and feelings outside the context of barriers to goal setting or other skill development.

This can be a new approach for patients, particularly if prior psychotherapy interactions were more process-oriented. In our treatment, we strive for a gentle balance, which involves validating the patient’s emotional experiences while reminding them, through psychoeducation, of our particular approach to psychotherapy. This includes our goal of helping them live the life they want despite distress and discomfort. The following patient reported having thoughts about being worthless, on and off, for most of their life. Interpersonal interactions often triggered them. They would then spend much of their time isolated and focused on these thoughts. Here, the therapist expresses empathy for their most recent experience with these thoughts and then redirects them to behaviorally-oriented steps they can take towards their values.

Patient: That social worker shows me no respect. We used to be good but now she never calls me back. I feel like nobody cares about me.

Therapist: I’m sorry about your experience with her. Feeling like nobody cares about you must be awful. I’d feel incredibly sad.

Patient: Yeah, sad… really sad and depressed. And frustrated.

Therapist: Is that why you didn’t refill your medication?

Patient: Like it feels like nobody cares if I live or die so what’s the point.

Therapist: I care that you live. You know your family does too. You’ve had a difficult week, first the problems at work and then that fight with your son. I wonder if that also makes you feel sad and have the thought that nobody cares about you? Having that thought must be really stressful.

Patient: Yeah. I just end up at home and in my room. I don’t want to see no one.

Therapist. I know you’re stressed now, but in my experience, if you’re working towards the things you value in life, like being in control of your health, then you might feel less stressed. I wonder what steps you could take this week to refill your prescription despite these negative experiences. Remind me why it might be important to you to fill the prescription even when you are feeling distressed?

Facilitating access to care

Delivery of psychotherapeutic interventions using a patient-centered and accessible framework may also increase the opportunity for PWH to engage in these treatments. As noted previously, PWH frequently have comorbid medical and mental health concerns (e.g., (Dobalian, Tsao, & Duncan, 2004; Koeppe et al., 2010; Pence, Miller, Whetten, Eron, & Gaynes, 2006)). Patients with chronic health problems may also face additional barriers in accessing care such as difficulties with transportation (Syed, Gerber, & Sharp, 2013), particularly low-income patients. Together, these factors can lead to attending frequent medical appointments with multiple providers; appointments which may be time-consuming and difficult. For many patients, the addition of psychotherapy appointments may not seem feasible.

Non-traditional formats for psychotherapy sessions, such as telephone sessions, may be a useful alternative or complement to more traditional in-person sessions. Though not widely used, telephone interventions have shown promise in the treatment of depression (Mohr, Vella, Hart, Heckman, & Simon, 2008; Simon, Ludman, & Rutter, 2009) and in increasing ART adherence (Cook, McCabe, Emiliozzi, & Pointer, 2009). A meta-analysis by Mohr and colleagues (2008) found that telephone-administered psychotherapy may result in lower attrition rates than traditional approaches. Telephone psychotherapy sessions offer increased convenience to patients, and may help to overcome barriers related to in-person attendance. A majority of our psychotherapy sessions are conducted by telephone for these reasons. Unfortunately, within the managed care climate, conducting psychotherapy by telephone has not been a reimbursable approach. However, using technology in treatment is becoming more common and billable (Park, Erikson, Han, & Iyer, 2018), and may be an increasingly viable option for treatment of rural or house-bound patients.

Our telephone-based psychotherapy sessions have been well-received by patients. The following patient discusses obtaining transportation to their medical appointments, a major barrier to meeting their goal of greater treatment adherence. In comparison, they indicate how easy it is for them to participate in our intervention.

Patient: This is the second time they [a free transportation service] didn’t come pick me up.

Therapist: That’s frustrating. You worked so hard to get that service.

Patient: It’s a relief we can do this [counseling session] over the phone. I haven’t missed one yet.

Suggestions, limitations, and future directions

Psychotherapy strategies discussed here can be used to facilitate a flexible, patient-centered treatment approach in which clinicians can confidently support and help empower PWH to manage their health issues and improve their mood and quality of life. Teaching values-based goal setting, developing skills to be an activated and informed patient, and focusing on changing behavior despite discomfort, could be an efficient and impactful approach to helping patients address a range of concerns which may dominate the clinical picture once HIV is well-managed. Therapists should seek to clarify values early in care as they provide a lens through which opportunities for meaningful behavior change can be identified.

There are, of course, limitations to these approaches. As with any intervention focused on behavior change, it is important to be aware that altering patterns of behavior can have effects beyond the patient. There is the potential for increased conflict with those in the patient’s life who may not approve of changes the patient chooses to make. For instance, a patient’s friends might not approve of them spending less time drinking with them because they value saving money instead. With this awareness, the clinician can help the patient navigate such situations, acting in line with their values. Second, the perspectives presented here reflect our experience’s working with PWH with comorbid chronic pain and depression, thus our perspectives may not apply to all PWH. However, it is notable that BA techniques are proving to be widely generalizable, as they have been used successfully with a wide range of medical and psychiatric populations. Thus, BA techniques may be useful for many PWH with a variety of psychiatric and medical co-morbidities.

In sum, we presented four core strategies that can be useful to clinicians in working with PWH to increase their health and well-being. The principles discussed are transdiagnostic and patient-centered. As highlighted through case examples, they can be applied to a range of patient concerns, including those related and unrelated to HIV. It is our hope that these practical lessons will inform a patient-centered approach to helping PWH address a myriad of health and functional issues related to their overall well-being.

Clinical Impact Statement.

Question:

This paper describes transdiagnostic behavioral activation-based psychotherapy approaches that can be used with HIV patients.

Findings:

Clinicians can use these psychotherapy skills to address a wide range of functional and psychiatric problems in their HIV patients.

Meaning:

Behavioral activation-based psychotherapy approaches can empower HIV patients to manage their health concerns.

Next Steps:

Future studies should test these psychotherapy approaches in other chronically ill patient populations.