for People Living With or Affected by HIV/AI

A PRACTICAL GUIDE 

Authors: 

Catherine Acuff, Ph.D 

John Archambeault, L.C

Brain Greenberg, Ph.D 

Jeff Hoeltzel, M.Sc. 

J. Stephen McDaniel. M

Phil Meyer. L.C.S.W.
 

Craig Packer, B.A.
 

Francisco Javier Parga, 

Michelle Beaulieu Phille

Andrea Ronhovde, L.C.

Martha Saldarriaga, L.C

Mickey J. W. Smith, M.S

David Stroff, Ph.D
 

Doug Wagner, Ph.D
 
Mental Health Care forPeople Living With or Affected by HIV / AIDS: 

A PRACTICAL GUIDE—1999

By:
 

Catherine Acuff, Ph.D.
 

John Archambeault, L.C.S.W.
 

Brian Greenberg, Ph.D.
 

Jeff Hoeltzel, M.Sc.
 

J. Stephen McDaniel, M.D.
 

Phil Meyer, L.C.S.W.
 

Craig Packer, B.A.
 

Francisco Javier Parga, Ph.D.
 

Michelle Beaulieu Pillen, Ph.D.
 

Andrea Ronhovde, L.C.S.W.
 

Martha Saldarriaga, L.C.S.W.
 

Mickey J.W. Smith, M.S.W., C.A.C.
 

David Stoff, Ph.D.
 

Doug Wagner, Ph.D.
 
Acknowledgements
 

This Practical Guide would not have been possible had it not been for the hard 

work and support of several individuals. 

The authors of this Practical Guide would like to offer a special acknowledgement 

to CAPT Elaine Dennis, former Government Project Officer for the HIV/AIDS Mental 

Health Services Demonstration Program. Her vigorous leadership gave the 11 

Demonstration projects the direction and guidance they needed to manage their 

programs effectively, and her willingness to listen to and respect our ideas as clinicians, case managers, evaluators, and project directors was a major factor in making the Demonstration Program a success. 

Elaine, we thank you and send our warmest wishes for all your future endeavors. 

We also would like to recognize Melvyn R. Haas, M.D., Associate Director for 

Medical Affairs at the Center for Mental Health Services. His unswerving support 

for this initiative provided us with the assurance that the Demonstration Program 

would survive a climate of funding cuts and uncertainty. 

To one of our fellow authors, Catherine Acuff, Ph.D., who assumed responsibility 

for managing the Demonstration Program shortly before it ended and nurtured 

the development of this Practical Guide, we would like to express our gratitude. 

Her prudent direction and determination to make this Guide “happen” provided 

the rest of us with the motivation we needed to finish what seemed at times to be 

an insurmountable and impossible undertaking. 

To another fellow author, Craig Packer, who took on the Herculean task of collecting and coordinating this text from multiple authors, providing editorial direction, 

and keeping us on deadline. We especially appreciate his good cheer throughout 

this process. 

Our appreciation to the Research Triangle Institute (RTI), which served as the 

Coordinating Center for the HIV/AIDS Mental Health Services Demonstration 

Program and facilitated the publication of this Practical Guide. RTI staff were an 

integral part of the Program over its four years. 

To Trae Underwood, who served as the production coordinator, our thanks for 

creating the design concept for this Guide. 
ACKNOWLEDGEMENTS 

Finally, we would like to humbly express our deepest appreciation to William “Bill” A. 

Bailey, who years ago articulated and communicated his vision for the HIV/AIDS Mental 

Health Services Demonstration Program. Throughout his career, Bill Bailey was a champion of AIDS prevention and a vigorous supporter of AIDS programs at the national, 

state, and local levels. As one of the preeminent “movers and shakers” among national 

leaders who recognized the importance of mental health services for people living with 

or affected by HIV, Bill Bailey used his position at the American Psychological Association’s 

Office of Legislative and Federal Affairs to advocate for the inclusion of mental health 

services in the 1990 Ryan White Comprehensive AIDS Resources Emergency Act. Bill 

also played a major role in strengthening community-based AIDS prevention programs 

at the Centers for Disease Control and Prevention, and he founded and co-chaired two 

political action committees. 

Bill died of complications associated with HIV on April 23, 1994. He was only 34 years 

old. All of us who knew him and respected him still feel a tremendous sense of loss and 

sadness. However, at the same time, we are able to rest comfortably in the knowledge 

that Bill Bailey’s legacy lives on in every community-based program that provides mental 

health services at Ryan White-funded facilities. It lives on in mental health-specific HIV 

programs created by Congress and a broad range of national associations and organizations. It lives on in our memories and our work. 

Bill Bailey’s legacy lives on in this Practical Guide. 

Without Bill Bailey and his tireless efforts, the Demonstration Program and this Practical 

Guide would never have existed, and the more than 5,000 people served by the 

Demonstration Program most likely would have had nowhere to turn for HIV-specific 

mental health services. 

Bill, we are honored and privileged to have been a part of making your vision a reality. 

It is our deepest hope that this Practical Guide conveys the values and principles to 

which you dedicated both your career and every aspect of your life. 

The Authors 

1999 
This manual was written and edited by representatives of Grantees of the U.S. 

Department of Health and Human Services, who acted in an independent 

capacity. No official support or endorsement by the Department of Health 

and Human Services is intended or should be inferred. 
Mental Health Care forPeople Living With or Affected by HIV / AIDS: 

A PRACTICAL GUIDE—1999 

TABLE OF CONTENTS 

Preamble........................................................................................................................1
 

Principles of Care..........................................................................................................5
 

Introduction..............................................................................................................................9
 

EPIDEMIOLOGICAL TRENDS...........................................................................................10
 

STIGMA ..............................................................................................................................11
 

MULTICULTURAL SENSITIVITY ........................................................................................12
 

A SPECIALIZED BIOPSYCHOSOCIAL APPROACH TO CARE ........................................12
 

CREATING PROGRAMS 

Chapter 1: Establishing Services.........................................................................................17
 

DETERMINING THE NEED FOR SERVICES....................................................................18
 

DESIGNING A RESPONSIVE PROGRAM ........................................................................19
 

SELECTING THE SERVICE MODEL .................................................................................20
 

DETERMINING THE FEASIBILITY OF THE PROGRAM..................................................24
 

IMPLEMENTING THE PROGRAM ....................................................................................26
 

SUSTAINING THE PROGRAM ..........................................................................................28
 

Chapter 2: Collaborative Networks....................................................................................29
 

WHAT A COLLABORATIVE NETWORK MAY LOOK LIKE............................................31
 

DEVELOPING, MAINTAINING, AND EVALUATING NETWORKS ................................34
 

Chapter 3: Staffing ................................................................................................................35
 

STAFF COMPOSITION......................................................................................................36
 

STAFF CHARACTERISTICS................................................................................................36
 

STAFF TRAINING ..............................................................................................................40
 

TRAINING INITIATIVES CONDUCTED BY DEMONSTRATION PROJECTS ..................41
 

SUPERVISION....................................................................................................................43
 

SPECIAL STAFFING ISSUES..............................................................................................44
 

A PRACTICAL GUIDE—1999
II TABLE OF CONTENTS 

DELIVERING SERVICES 

Chapter 4: Mental Health Services...................................................................................49
 

ENTERING THE MENTAL HEALTH SYSTEM...................................................................50
 

SERVICES OFFERED.........................................................................................................51
 

COMPLEMENTARY TREATMENTS ...................................................................................54
 

ENGAGING CLIENTS THROUGH OUTREACH...............................................................55
 

COORDINATION OF CARE..............................................................................................56
 

Chapter 5: Clinical Assessment.........................................................................................57
 

AREAS TO BE COVERED IN THE CLINICAL ASSESSMENT ..........................................58
 

CONDUCTING THE CLINICAL ASSESSMENT.................................................................62
 

CONNECTING THE CLINICAL ASSESSMENT WITH THE TREATMENT PLAN ............63
 

ADDITIONAL CLINICAL ASSESSMENT TOOLS ..............................................................64
 

Chapter 6: Psychiatric and Neurologic Conditions.........................................................67
 

DISORDERS ATTRIBUTED TO HIV IN THE BRAIN ........................................................69
 

DISORDERS DUE TO MEDICAL COMPLICATIONS OF HIV INFECTION.....................70
 

PSYCHIATRIC DISORDERS ...............................................................................................71
 

SERIOUS MENTAL ILLNESS .............................................................................................74
 

Chapter 7: Case Management .............................................................................................75
 

CASE MANAGEMENT ACTIVITIES...................................................................................76
 

CASE MANAGEMENT TREATMENT PHASES .................................................................78
 

CASE MANAGEMENT PROVIDERS AND SETTINGS......................................................80
 

BUILDING A STRONG HELPING RELATIONSHIP..........................................................81
 

BARRIERS TO EFFECTIVE CASE MANAGEMENT ..........................................................82
 

Chapter 8: Psychotherapy and Counseling .......................................................................83
 

PROFESSIONAL INTERVENTIONS ..................................................................................84
 

GROUP INTERVENTIONS ................................................................................................86
 

PEER COUNSELING..........................................................................................................88
 

Chapter 9: Counseling Themes and Clinical Considerations .......................................89
 

SENSE OF SELF AND SELF-ESTEEM...............................................................................91
 

PARENTING.......................................................................................................................91
 

FEAR ..................................................................................................................................92
 

DISCLOSURE .....................................................................................................................92
 

SEXUAL ORIENTATION....................................................................................................93
 

LOSS OF LOVED ONES ...................................................................................................93
 

ADHERENCE .....................................................................................................................94
 

LAZARUS SYNDROME......................................................................................................94
 

SPIRITUALITY.....................................................................................................................95
 

Chapter 10: Substance Abuse Treatment..........................................................................97
 

TREATMENT APPROACHES .............................................................................................98
 

TREATMENT MODALITIES ...............................................................................................99
 

RELAPSE PREVENTION..................................................................................................101
 

CLINICAL CONCERNS ....................................................................................................102
 

PROGRAMMATIC CHALLENGES ...................................................................................104
 

BARRIERS ........................................................................................................................106
 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
TABLE OF CONTENTS III 

Chapter 11: Risk Reduction...............................................................................................107
 

FACTORS AND BEHAVIORS ..........................................................................................108
 

IMPLEMENTING RISK REDUCTION ACTIVITIES ..........................................................109
 

OTHER CONSIDERATIONS ............................................................................................110
 

Chapter 12: Permanency Planning...................................................................................111
 

WHY PERMANENCY PLANNING IS IMPORTANT........................................................114
 

THE PARTIES INVOLVED IN PERMANENCY PLANNING ...........................................115
 

BENEFITS OF INVOLVING FAMILIES ...........................................................................116
 

WHEN TO GET FAMILIES INVOLVED..........................................................................117
 

LEGAL OPTIONS AVAILABLE TO PARENTS.................................................................118
 

Chapter 13: Psychosocial Rehabilitation.........................................................................121
 

PSYCHOSOCIAL REHABILITATION PRINCIPLES ..........................................................122
 

STAFF/CLIENT THERAPEUTIC RELATIONSHIP GOALS...............................................122
 

PROGRAM OBJECTIVES.................................................................................................123
 

POTENTIAL BARRIERS ...................................................................................................126
 

EVALUATING SERVICES AND PROGRAMS 

Chapter 14: Program Evaluation.......................................................................................129
 

DEFINITION OF PROGRAM EVALUATION ..................................................................130
 

REASONS TO EVALUATE THE PROGRAM...................................................................131
 

IDENTIFYING THE PRIMARY USERS OF THE EVALUATION......................................132
 

DOING AN EVALUABILITY ASSESSMENT OF THE PROGRAM..................................133
 

FINDING A PROGRAM EVALUATOR............................................................................134
 

IDENTIFYING AND FRAMING EVALUATION QUESTIONS ........................................137
 

IMPLEMENTING THE EVALUATION .............................................................................142
 

ANALYZING AND INTERPRETING THE DATA .............................................................145
 

DISSEMINATING THE EVALUATION FINDINGS..........................................................146
 

REFERENCES & SUGGESTED READING ................................................................147
 

APPENDICES......................................................................................................................159
 

APPENDIX A: THE 11 HIV/AIDS MENTAL HEALTH SERVICES 

DEMONSTRATION PROGRAM SITES....................................................159
 

APPENDIX B: SAMPLE PROCESS RECORDING OUTLINE ..........................................161
 

APPENDIX C: CHICAGO PROJECT PSYCHOSOCIAL ASSESSMENT 

SCREENING TOOL .................................................................................165
 

APPENDIX D: THE MENTAL HEALTH SPECTRUM CLINICAL 


DIAGNOSTIC ASSESSMENT...................................................................168
 

APPENDIX E: ALEXANDRIA PROJECT ASSESSMENT TOOLS ....................................174
 

APPENDIX F: SAMPLE CONSULTANT AGREEMENT FOR SERVICES ........................187
 

APPENDIX G: CHICAGO PROJECT LOGIC MODEL ....................................................189
 

APPENDIX H: WRITTEN PROCEDURES FOR STAFF 


ADMINISTERING SERVICE ENCOUNTER RECORD.............................190
 

APPENDIX I: LIST OF AUTHORS...................................................................................195
 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 

1 

Preamble
 

Since the advent of the AIDS epidemic, people living with 

HIV who also have mental and/or substance use disorders have been forced to navigate complex, fragmented, and 

uncoordinated health care systems in order to access the services they need. Over time, health and human service providers 

have begun to recognize that these problems are interwoven 

and present a broad range of challenges for the service provider 

on practical, economic, and treatment levels. 

To address some of these concerns, the Substance Abuse and 

Mental Health Services Administration (SAMHSA), the Health 

Resources and Services Administration (HRSA), and the 

National Institutes of Health (NIH) launched the HIV/AIDS 

Mental Health Services Demonstration Program—the first federal 

initiative to focus on the mental health needs of people living with 

or affected by HIV. Funded at more than $4 million per year over 

four years, the Demonstration was designed to: 

• increase access to integrated mental health, primary care, 

and support services 

• develop effective mental health care models that can be 

replicated elsewhere 

• improve quality of life for those living with or affected by HIV 

• prevent further transmission by reducing high-risk behaviors 

• promote cultural competence in service delivery 
2 PREAMBLE 

...created to 

generate 

new knowledge... 

This initiative was unique at the time it 

was conceived because it was intended to 

accomplish far more than the mere provision of mental health services to 

people living with or affected by HIV. It 

also was created to generate new knowledge about the role of mental health 

services in primary medical treatment for 

people living with or affected by HIV 

and to identify characteristics of the 

clients served, the types of services they 

used, and other lessons learned in implementing integrated care. 

The 11 service delivery projects listed in 

Appendix A were located in eight states 

and Puerto Rico. In addition to implementing programs tailored to the unique 

needs of their target population, the 

projects tested a variety of mental health 

service interventions, including: 

• mental health services co-located with HIV 

primary care centers 

• integrated outreach, case management, 

and mental health programs 

• psychosocial rehabilitation programs 

• HIV mental health services integrated into 

residential drug treatment 

More than 5,000 clients received mental 

health services from the Demonstration 

projects. Figure 1 provides a demographic 

breakdown of clients by gender, race/ethnicity, and age. Figures 2 through 4 provide 

information on a subset of the clients served 

in the Demonstration projects for which 

comprehensive data are available. Although 

there was demographic and socioeconomic 

diversity among clients, three characteristics were common across all service sites: 

1	 Clients served were financially disadvantaged, with poverty and reliance 

on public sector service systems as the 

norm. Forty percent of the clients 

were covered by Medicaid, while 

another 40 percent had no health 

insurance coverage at all. 

2	 The racial and gender composition of 

the clients resembled the changing 

face of the AIDS epidemic, with 

racial/ethnic minorities constituting the 

majority of the clients and substantial 

proportions of women, heterosexuals, 

and injecting drug users included. The 

projects also served a large number of 

men who have sex with men and a 

few transgendered individuals. 

3	 Clients presented with high rates of 

serious mental and substance use disorders. Three out of four clients met 

criteria for major depression, one in 

four met criteria for alcohol dependence, and half met criteria for drug 

dependence. Comorbidity of mental 

and substance use disorders was 

common, complicating treatment of 

both disorders. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
 

Figure 1 

Demographic Characteristics of Clients Served in the Demonstration Program 

Total % % % African % % White * Mean 

Served Male Female American Hispanic and Other Age 

5583 69.5 30.5 47.3 23.2 29.5 34.6
 

* “Other” includes Asian Pacific Islander, American Indian/Alaskan Natives, Mixed, and Others 

Figure 2 

Housing Status of 1,837 Clients Served in the Demonstration Program * 

Independent With family/friends/other Dependent Homeless 

52.0 31.1 11.9 5.0
 

* The San Francisco project was excluded from this data set because it is a residential substance abuse treatment program 

Figure 3 

Monthly Income/Source of Income of 1,837 Clients Served in the 

Demonstration Program 

Median Monthly Income ($) % With Employment % With Public Assistance Only 

575 21.0 31.7 

Figure 4 

Health Insurance Coverage of 1,837 Clients Served in the Demonstration 

Program 

% With Private Insurance/Other % With Medicaid % With No Source of Coverage 

13.6 42.3 44.1 

PREAMBLE 3 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
4 PREAMBLE 

...this 

Practical Guide 

is just the

beginning... 

From the beginning, Demonstration 

Program participants expressed a desire to 

share their cumulative wisdom and experience with individuals and organizations 

that provide HIV, mental health, and substance abuse services. It is hoped that this 

knowledge also will be useful to others 

who are responsible for the organization 

and financing of HIV and mental health 

treatment systems and who are positioned 

to improve the availability and accessibility of HIV, mental health, and substance 

abuse treatment. With the rapid development of more effective treatments, it is 

essential that this new knowledge be 

applied in the clinical setting so that, as 

people with HIV live longer, service 

providers are equipped with the knowhow and skills they need to assist clients 

in living happier and healthier lives. 

This Practical Guide was developed as a 

collaborative effort of the 11 projects that 

participated in the Demonstration 

Program and is based on experience 

gained in the clinical setting over a fouryear period. It is designed to assist service 

providers and others in developing comprehensive and coordinated systems of 

care for people living with or affected by 

HIV. The Practical Guide provides information on a broad range of topics, such as 

how to set up and establish services, how 

to deliver services, how to evaluate services, and several other important clinical 

and service delivery concerns. 

The writers recognize that this Practical 

Guide is just the beginning. It is not 

meant to stand alone. The authors also 

recognize that no single agency or service 

organization can realistically put all of 

these ideas or principles into clinical 

practice. The reader is encouraged to 

consider the ideas and principles contained in this publication, to compare 

his/her own personal and clinical experience with those of the authors, to consider the needs of the target population, and 

to incorporate these ideas and approaches 

based on the resources available. As these 

approaches are implemented, this 

Practical Guide may serve as a valuable 

reference for clinicians and program planners, as well as a useful training tool for 

service staff. 

Ultimately, the writers hope that this 

Guide will inspire a new generation of 

providers and professionals who are committed to ensuring that all individuals living with or affected by HIV have full and 

immediate access to a broad range of mental health and support services that will 

improve both their well-being and their 

quality of life. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
5 

Principles ofCare 

The following principles reflect the experience of the 11 

Demonstration projects in delivering primary medical, 

mental health, substance abuse, and related support services 

to people living with or affected by HIV. These principles 

are based on the knowledge gained by the projects during the 

Demonstration Program and are designed to provide 

guidance to administrators, program planners, and service 

providers as they establish and implement HIV-specific 

mental health care service programs. While not empirically 

based, these principles represent the ideals of the 11 projects. 
6 PRINCIPLES OF CARE 

...these principles
 

represent the 


ideals
 

of the 11 projects... 

PRINCIPLE 1 

• Clients need access to comprehensive primary medical, mental health, substance 

use, and related support services. Some clients will need access to free or affordable 

transportation to attend appointments. Others will need assistance obtaining 

affordable housing, food, child care, permanency planning, HIV risk reduction education services, medications, and supportive residential services. 

PRINCIPLE 2 

• Services should be flexible and client-centered. Clients will present with a broad range 

of medical, mental health, substance use, and psychosocial needs. While some clients 

will benefit from psychotherapy, others may need only support groups or case management. Service plans need to be adapted to meet changing client needs. 

PRINCIPLE 3 

• HIV, mental health, and substance use treatment services should be adequately coordinated and integrated. Often, service providers from different systems of care do not 

communicate with one another, even though they may be responsible for delivering care 

to the same individuals. Service systems should establish formal linkages and networks to 

enhance service coordination and integration. Likewise, service providers representing 

multiple disciplines should take a “team” approach to meeting each client’s needs. 

PRINCIPLE 4 

• Services should be delivered in a way that is consistent with each client’s cultural needs 

and expectations. This may require that service systems employ multilingual and multicultural staff. Multicultural sensitivity is essential for those staff who are not culturally 

matched with their clients. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
PRINCIPLES OF CARE 7 

PRINCIPLE 5 

• Services should promote individual self-respect and personal dignity. Services can only 

be delivered effectively when an individual’s self-worth and contributions to society are 

recognized. In addition, people with HIV who also have mental and/or substance use 

disorders typically have been stigmatized by both society and the traditional health care 

delivery system. To meet their needs, service systems must take steps to ensure that the 

system itself does not stigmatize its clients further. 

PRINCIPLE 6 

• Services should promote healthier behaviors. Providers can work together to promote 

safe sexual behaviors by clients and to strengthen family relationships. Promoting 

healthier behaviors involves being comfortable with discussing issues such as risk and 

harm reduction. 

PRINCIPLE 7 

• Service delivery programs should work to reduce barriers to care for “hard-to-reach” 

populations. Some service systems have failed to reach populations that desperately 

need access to HIV primary medical treatment and mental health services, including 

people in jails and prisons, people who are homeless, substance abusers, and individuals with severe mental illness. 

PRINCIPLE 8 

• Programs should develop and deliver services that are clinically informed and 

research-based. Many programs have developed and conducted evaluations of their 

clinical services. The knowledge gained from these undertakings, as well as the latest 

research on HIV-related mental health services, can be used to enhance service delivery and program policy. 

PRINCIPLE 9 

• Persons living with HIV need to be empowered to make decisions in collaboration with 

the service provider. In addition, all segments of the community, including consumer 

and family advocacy groups, should be actively involved in the establishment, delivery, 

and quality improvement of services. 

PRINCIPLE 10 

• Programs should work to create an “HIV Community.” Service systems can play a major 

role in creating a community of individuals, agencies, and organizations that work in 

partnership to increase access to the broadest, most comprehensive range of services 

possible and to foster the development of an HIV Community that offers a sophisticated network of support for clients. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
9 

Introduction
 

As HIV invades the body, it creates rippling and 

profound biological and social consequences for those 

persons infected. In addition to attacking the body’s immune 

system and causing a broad spectrum of health complications, 

HIV may present a host of mental and emotional problems by 

disrupting the infected person’s emotional equilibrium, sense 

of self, relations with others, and purpose in life. HIV also has 

socioeconomic consequences that affect one’s most basic 

human needs, such as housing, food, financial security, and 

employment. Substance abuse confounds these issues, leading 

to deteriorating physical and mental health, and the poor 

judgment that may result in risk-taking behaviors of both a 

sexual and criminal nature. When addictions become severe 

and refractory, every aspect of life is affected. 

The very complexity of these biological, psychological, and social 

needs springing from HIV infection argues in favor of an integrated 

and coordinated approach to care. Failure to address the needs in 

any one sphere can lead to a breakdown in the effectiveness of 

treatment in the others. As HIV approaches its third decade of 

existence, the changing demographics of HIV infection reinforces 

the need for service integration and coordination. 
10 INTRODUCTION 

EPIDEMIOLOGICAL TRENDS 

In the early days of the epidemic, HIV primarily affected gay white males from a 

broad range of socioeconomic strata. 

Since 1994, when the HIV/AIDS Mental 

Health Services Demonstration Program 

was launched, HIV rates have increased 

rapidly among disenfranchised ethnic 

minorities and women. Today, those 

infected are more often from communities 

of poverty (i.e., intravenous drug users and 

their partners, persons who are incarcerated, individuals with serious mental 

illness, people who are homeless, and the 

foreign-born) and those engaged in the 

sex trade. According to the Centers for 

Disease Control and Prevention’s data 

from 25 states with integrated HIV and 

AIDS reporting systems, 63 percent of 

young persons between the ages of 13 and 

24 diagnosed between January 1994 and 

June 1997 were African American (CDC 

Update, April 23, 1998). Recent estimates 

indicate that 25 percent of those living 

with HIV in the U.S. were infected 

through unsafe injection drug use, while 

15 percent became infected through 

unsafe heterosexual sex (CDC, 1997). 

New and effective medical treatments for 

HIV, including protease inhibitors, have 

had a profound effect on those living with 

HIV. The hope that HIV, for some, has 

become a chronic, treatable condition 

instead of a fatal one brings with it an 

energizing optimism—and a host of 

additional psychosocial complications. 

At the same time, there are widespread 

treatment implications for the future. 

While the death rate from HIV-related 

complications decreased 47 percent 

between 1996 and 1999, the rate of HIV 

infection has remained steady for some 

populations and is increasing in others. 

With those who are infected living 

longer, caseloads will increase, and the 

demand for services supporting adherence 

to a complex array of medical treatments 

will climb. 

These epidemiological changes, coupled 

with the complex biological and social 

needs of a growing number of people living with or affected by HIV, call for a 

comprehensive, coordinated, and integrated approach to care—one that recognizes the importance of mental health 

issues in providing services to people living with HIV. A specialized approach to 

HIV mental health service delivery car-

...a 

changing
 

epidemic... 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
INTRODUCTION 11 

ries many advantages for the client. 

Sharing the struggle with others who are 

living with HIV can provide a sense of 

mutual support, alleviate the stigma 

encountered in society, and promote a 

sense of safety. Issues of confidentiality, 

risk reduction, advocacy, and medication 

adherence may be emphasized and effectively addressed with appropriately 

trained staff. Efforts to reach this alienated and heavily stigmatized population 

require specialized and targeted 

approaches that involve close collaboration among a broad range of disciplines 

and service providers. 

As this manual was being developed, 

three themes repeatedly emerged that 

bear special significance for the provision 

of mental health services to people 

affected by HIV—stigma, multicultural 

sensitivity, and a biopsychosocial 

approach to care. Although these themes 

are woven throughout the Practical 

Guide, their critical impact upon service 

delivery warrants highlighting them in 

this introduction. 

...three themes
 

repeatedly
 

emerged... 


STIGMA 

Central to an understanding of the person 

with HIV who seeks mental health services is an understanding of the concept of 

stigma and its corrosive and debilitating 

effects. The archaic definition of stigma is 

“a mark burned into the skin of a criminal 

or slave (Webster’s New Riverside 

University Dictionary, 1139).” The HIVinfected client often finds himself/herself 

stigmatized in many ways—for having a 

fatal, transmittable disease; for being 

“crazy;” for being gay; for being sexual; for 

being a substance user; for being African 

American; for being poor; for being 

Hispanic; for being an illegal immigrant; 

for being unemployed; for being homeless; or for being an ex-offender. HIVrelated stigmatization constitutes an 

epidemic in itself—an epidemic of fear, 

prejudice, and discrimination. 

The fear of being stigmatized keeps many 

from seeking services. It also can prevent 

many clients from remaining in 

treatment or adhering to a treatment 

regimen. The feelings resulting from 

stigmatization may include fear, shame, 

distrust, rejection, exile, guilt, isolation, 

hopelessness, helplessness, alienation, 

lack of self-worth, powerlessness, and 

aloneness. Empathy for those facing the 

painful reality of this multiple stigmatization is what propels many to work in 

the HIV field. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
12 INTRODUCTION 

MULTICULTURAL SENSITIVITY 

An effective HIV treatment team includes 

clinical providers who are dedicated to the 

work and possess a depth of knowledge of 

HIV, mental health, substance abuse, and 

community resources. The successful 

worker possesses a sensitivity to, and 

understanding of, individual differences, 

different cultures, and subcultures, as well 

as a broad understanding of the biopsychosocial effects of HIV infection on the 

client’s everyday life. 

The culturally competent provider must 

be able to interact in a way that demonstrates an openness, understanding, and 

respect for the experiences, value systems, 

and beliefs of others. The culturally sensitive provider will convey to the client an 

appreciation of the varied cultural perceptions of power and control over one’s 

life and an understanding of why and how 

clients may have learned adaptational 

skills that seem to promote dependency 

and social marginalization. 

Prejudgments—of how persons should 

have lived their lives, avoided HIV infection, or adjusted to a majority culture that 

all too often discriminates, stigmatizes, 

and oppresses—lead to a breakdown of 

trust. As a result, the therapeutic alliance 

that is the bedrock of effective intervention may be severely compromised. HIV 

infection has different meanings in different cultures, communities, and families. 

A person’s internal perceptions of his/her 

external life is unique and evolves in large 

part from the individual’s cultural roots. 

Cultures and subcultures have contrasting 

interpretations of what constitutes 

pathology, and the culturally competent 

provider must tread carefully in making a 

diagnosis and prescribing treatment. 

Providers should be comfortable with 

diverse educational levels, sexual orientations, physical and mental disabilities, substance use, class, and other psychosocial 

variables. Staff competence and sensitivity 

results from ongoing self-reflection that 

diminishes judgmental thinking and promotes tolerance and a sensitive curiosity 

toward care. By accompanying clients to 

public agencies to access services, 

providers gain an appreciation of power 

and control differentials. Developing a 

sensitivity to certain marginalized subcultures requires a willingness to enter a 

“virtual reality” that sees events and 

attitudes from the client’s perspective. 

A SPECIALIZED BIOPSYCHOSOCIAL 

APPROACH TO CARE 

In 1990, AIDS was described as a paradigm 

of an illness requiring a biopsychosocial 

approach. With the advent of new and 

effective medications, such a designation is 

increasingly apt. HIV infection is a medical 

illness caused by a virus often transmitted 

through socially stigmatized behaviors— 

unprotected sex and injection drug use— 

that biologically affects the brain and the 

immune system. At the same time, a diagnosis of HIV creates a series of immense 

psychological burdens that occur within a 

larger, more complex psychosocial arena. 

As the importance of adhering to complex 

antiretroviral medication regimens gains 

acceptance, the spotlight focuses increasingly on the whole person and his/her 

capacity for medication adherence. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
INTRODUCTION 13 

To increase the likelihood of treatment adherence and to promote wellness, the provider must address client-specific concerns on many levels: 

•	 Social and Environmental 

Circumstances. These include 

poverty, access to care, family relationships, housing, financial needs, 

food, child care, transportation, and 

legal status. Such concerns may be 

further complicated by homelessness, incarceration, and prostitution. 

• Psychological Factors. These include 

stress; depression; anxiety; cognitive 

impairments due to HIV-associated 

dementia; psychosis; mania; preexisting serious mental illness, 

including schizophrenia and bipolar 

disorder; and poor judgment and 

impulsivity associated with personality disorders. Defense mechanisms, 

such as avoidance and denial, also 

may interfere with seeking and 

accepting treatment. 

• Biological Aspects. The health issues 

associated with HIV include the 

client’s medical condition; health of 

the immune system; symptoms and 

common opportunistic infections 

(e.g., of the brain); medications prescribed both prophylactically and for 

symptom relief; and co-existing 

chronic illnesses, such as diabetes, 

renal and liver disease, and high 

blood pressure. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
14 INTRODUCTION 

...social, 

psychological, 

and biological factors 

interact with one another... 

The biopsychosocial framework is a useful 

guide in assembling a specialized HIV 

mental health delivery system. The 

model helps the treatment provider to 

remain alert to the interactivity of disorders and stressors, to frame a complete 

diagnostic picture of the client, and to 

construct an appropriate and comprehensive treatment plan. 

To provide examples of how this 

biopsychosocial approach to service 

delivery may be implemented throughout 

different stages in the treatment process, 

the authors will share the experiences of 

clients served by the Demonstration 

Program. (Case material has been disguised to protect client confidentiality.) 

Their stories, as told throughout this 

manual, will enable the reader to better 

understand how the social, psychological, 

and biological factors described in this 

introduction interact with one another 

and define the approach to treatment. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
CREATING PROGRAMS 

17 

CHAPTER 1: 

Establishing
 Services 

From the early years of the HIV pandemic, clinicians and 

program planners have recognized that HIV can exact an 

enormous toll on an individual’s emotional health. Over the 

years, some AIDS service organizations (ASOs) and 

community-based organizations (CBOs) have tried to make 

mental health a service priority. However, since most of these 

organizations lack the necessary resources to meet the mental 

health needs of their clients, mental health services largely 

have been restricted to providing referrals to other 

community programs (e.g., community mental health 

centers) or offering limited on-site counseling for people 

living with or affected by HIV. 

One of the lessons learned by the 11 sites that participated in the 

Demonstration Program was that programs interested in serving 

HIV-infected and -affected individuals need to augment their 

traditional mental health approaches with a biopsychosocial 

perspective. They also need to be responsive to persons who are 

hard-to-reach and have multiple service needs. This chapter 

presents steps for programs to consider and pursue in establishing 

services to address the HIV-specific mental health needs of their 

communities. 
18 CREATING PROGRAMS Chapter 1: Establishing Services 

DETERMINING THE NEED FOR SERVICES 

The types of services offered by a program 

should encompass the range of service 

alternatives required to meet the needs of 

the program's target population. Program 

planners and clinicians should recognize 

the need for mental health services when 

clients are not adhering to treatment, 

having interpersonal difficulties with 

medical service providers, missing 

appointments, or presenting with indicators of depression or anxiety. There are 

other indicators that can help administrators and clinicians determine what 

types of services should be provided. For 

example, changes in the demographics of 

persons affected by HIV underscore the 

need for "refined” or "different" services. 

The first step in establishing services is to 

determine the need for HIV-specific mental health services. This may be done 

through: 

• Holding focus groups. Invite the sharing 

of ideas and experiences by people living 

with or affected by HIV, medical providers, 

substance abuse treatment providers, mental health providers, program planners 

from ASOs and CBOs, and other local 

experts. 

• Seeking client input. Set up suggestion 

boxes at the facilities where HIV-positive 

clients go for services. Periodically ask 

clients to fill out surveys. Invite persons 

living with HIV to participate on an 

advisory group. In addition to asking them 

to articulate their service needs, these 

venues provide an opportunity to gather 

information on service utilization patterns, 

program evaluations from a client 

perspective, and other information that 

can provide insight into how services can 

be improved and enhanced. Throughout 

these processes, program administrators 

and staff should keep an open mind. It 

may appear that the services being 

offered by a particular program are effective and operating in a smooth fashion, 

but some clients served by a program 

may not feel the same way. Program 

administrators and staff should be receptive to new ideas and consider all suggestions carefully and thoughtfully. 

• Conducting a needs assessment. It may 

be wise to conduct a formal evaluation of 

service needs, to review recently published literature on needs assessments 

conducted with a similar population, and 

to distribute the needs assessment to key 

members in the community. A needs 

assessment will likely uncover unmet service needs in the community, as well as 

identify organizations and agencies that 

may be interested in collaborating in the 

establishment of HIV-specific mental 

health services. 

• Observing trends. Program staff should 

continue to monitor local epidemiological 

data, as well as data from other areas that 

are ethnically, geographically, or socioeconomically similar for emerging trends in 

service needs and utilization patterns. 

• Listening to anecdotal information. 

Service providers who work with HIVinfected and -affected individuals often talk 

in loose terms about the number of "mental health," "psychological," "family-related," 

or "depression/anxiety" complaints presented by clients. This type of anecdotal 

information may be useful in determining 

specific service needs that are not being 

addressed. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
CREATING PROGRAMS Chapter 1: Establishing Services 19 

DESIGNING A RESPONSIVE PROGRAM 

Once specific population needs are identified and documented, program planners and 

service providers can begin developing an action plan designed to meet the needs of 

a specifically defined target population or geographic service area. An action plan 

should identify how the program can address unmet needs. Designing a program and 

determining the feasibility of actually providing services happens almost simultaneously. (See the following section on "Determining Feasibility" in this chapter). Figure 

5 presents examples of unmet mental health needs and possible treatment 

models/services. 

Figure 5 

Matching Client Services with the Target Population 

Population/Unmet Need Treatment Model/Services 

Single mothers in advanced stages of HIV	 Permanency planning 

Intensive case management 

Individual counseling in the home 

Injection drug users	 Traditional case management 

Relapse prevention 

Methadone maintenance 

Harm reduction 

Detoxification 

Clients in advanced stages of HIV infection	 Neurologic and psychiatric services 

Family education 

Support groups 

Psychiatric hospitalization case management 

Pastoral care 

Home services 

Telephone contacts 

HIV testing Individual counseling 

Case management 

Risk reduction services 

(psychotherapy and counseling) 

Marginalized populations	 Support groups 

Intensive case management 

Advocacy 

Homeless Aggressive outreach 

Field visits 

HIV-infected women	 Child care 

Parenting support/education groups 

Individual counseling 

HIV-affected children	 Family counseling and education 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
20 CREATING PROGRAMS Chapter 1: Establishing Services 

Service Delivery 

Approaches Used 

in the Demonstration: 

Traditional services 

with psychiatric 

evaluations, 

psychotherapy, and 

psychopharmacological 

management 

Traditional services 

that integrated 

proactive community 

outreach and case 

management 

Psychosocial 

rehabilitation and 

support services as 

the primary treatment 

modality 

SELECTING THE SERVICE MODEL 

In addition to considering the needs of the 

target population, program planners need to 

consider what the most appropriate services 

are and where they will be located within 

the existing service delivery model. Each of 

the 11 Demonstration sites devised a service 

model that was based on local needs, the 

capacity for community linkages, and funding allocations. Although each site provided 

a unique constellation of services, the mental health service delivery approaches fell 

into three broad categories: 

• Traditional mental health service models 

that offered psychiatric evaluations, psychotherapy, and psychopharmacological 

management (Atlanta, Chicago, Los 

Angeles, New York, Richmond, San 

Francisco, and San Juan). While each of 

these projects implemented similar service 

models, there was significant diversity in the 

populations served. For example, the Special 

Needs Clinic, located at Presbyterian Hospital 

in New York, primarily served children and 

families. Walden House in San Francisco 

served a predominantly substance using 

population. The Puerto Rico HIV/AIDS Mental 

Health Services Demonstration Project served 

a Latino population. The other projects 

implemented a traditional mental health service model that served large numbers of ethnic minorities, women, substance abusers, 

persons with severe mental illness, homeless 

individuals, men who have sex with men, 

and a few transgendered individuals. This 

diverse range of clients provided an opportunity to test the effectiveness of the traditional mental health service model across 

different target populations. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
CREATING PROGRAMS Chapter 1: Establishing Services 21 

• Traditional mental health service models 

that integrated proactive community 

outreach and case management 

(Alexandria and Elizabeth). Both of these 

projects served typically hard-to-reach populations. For example, the Alexandria 

Mental Health HIV/AIDS Project focused on 

people with serious mental illness and substance use disorders, as well as homeless 

and incarcerated individuals. Kinship 

Connection in Elizabeth, New Jersey, identified women with HIV, their affected children and caregivers, and their 

reconfigured families as its target population. Given the composition of the target 

populations, these projects provided an 

excellent opportunity to identify effective 

ways to integrate assertive community outreach and case management into a traditional mental health service model. 

• 	Psychosocial rehabilitation and support 

services as the primary treatment 

modality (Omaha and Philadelphia). The 

Harambee Project in Omaha targeted a 

diverse range of African Americans, including homeless individuals, women, injection 

drug users, and men who have sex with 

men. Consequently, the Harambee model 

emphasized group support and culturally relevant services as the primary means of treatment. Similarly, the Community Living Room 

in Philadelphia, which served an ethnically 

and socially diverse inner-city population, 

implemented a psychosocial rehabilitation 

model that emphasized peer support, social 

and support networks, education and 

empowerment, and helping clients acquire 

the knowledge and skills they need to live 

independently in the community. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
22 CREATING PROGRAMS Chapter 1: Establishing Services 

A critical factor influencing the treatment 

approach for HIV-specific mental health 

service models is the location of services. 

The sites represented in the Demonstration 

Program reflect the creativity required to 

successfully match service delivery with 

client needs. Examples of site locations for 

HIV-specific mental health service models 

include: 

• Models co-located with HIV primary care 

facilities (Atlanta, Chicago, Los Angeles, 

New York, Richmond, and San Juan). 

These projects typically focused on integrating mental health and HIV primary medical 

care to the greatest extent possible. For 

example, Atlanta's Center for HIV/AIDS 

Mental Health Services and the Los Angeles 

SPECTRUM Project created consortia of academic, state, and community-based ASOs 

to coordinate mental health services for 

people living with HIV throughout Atlanta 

and South Central Los Angeles. Chicago's 

HIV Health and Psychological Support 

Project replicated an integrated model of 

primary medical and mental health care at 

three community-based health centers, 

while the Mini Mental Health Center at the 

Medical College of Virginia in Richmond 

provided services in a university-based 

medical setting. 

• Models co-located with general mental 

health treatment facilities (Alexandria 

and Philadelphia). The Alexandria project, 

an outpatient program within a community mental health center, provided traditional mental health treatment along with 

community outreach and close coordination with the city health clinic. Mental 

health and intensive case management 

services were offered in client homes, shelters, jails, and in the African American 

church. The Philadelphia project is a satellite program of a comprehensive community mental health center. 

• Models co-located with residential substance abuse treatment facilities (San 

Francisco). The Walden House program in 

San Francisco provided mental health services for people with HIV in a structured 

substance abuse treatment setting. 

Depending on the client's needs, he/she 

had access to mental health counseling, 

substance abuse treatment, HIV counseling, housing, financial and legal assistance, 

medical treatment, education services, and 

vocational training. 

• 	Models that are free-standing in the 

community (Elizabeth and Omaha). These 

two projects were unique in that they 

operated as their own entities within their 

respective communities and were not 

closely affiliated with a larger community 

organization or service program. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
CREATING PROGRAMS Chapter 1: Establishing Services 23 

While factors such as funding and existing linkages within one's health care system are practical considerations guiding 

the approach and location of service 

models, one of the key lessons learned as 

a result of the Demonstration Program 

was the role of support structures. 

Developing or participating on existing 

advisory boards, networks, and consortia 

can put program staff in touch with others who may have confronted similar 

issues in the past and who can provide 

technical assistance on how to develop 

workable and effective solutions to unexpected and unanticipated challenges. 

Some of the support structures found to 

be helpful include: 

• 	Consumer Advisory Boards. Typically 

comprised of clients, their significant others, and interested service providers, consumer advisory boards can provide 

program planners with the benefits of 

consumer input and perspectives on 

developing, monitoring, and improving 

service delivery. Meetings should be held 

regularly, and specific agendas should be 

established for each meeting. Program 

managers, administrators, clinicians, and 

other staff who keep an open mind when 

working with a consumer advisory board 

can gain valuable insight and ideas for 

achieving their program goals. 

• Collaborative Networks. A collaborative 

network is composed of a series of formal 

or informal relationships among service 

providers and organizations with the purpose of furthering programmatic goals 

and objectives, and improving overall 

client care. Among other features, collaborative networks can also ensure that services are available and accessible to clients. 

(See Chapter 2 on Collaborative Networks.) 

...put program 


staff
 

in touch 


with 

others... 

• Consortia. Similar to networks, a consortia 

usually evolves out of formal agreements 

among service providers from different 

organizations who pledge to coordinate 

services. The difference between consortia 

and networks, however, is that members of 

a consortia also share and distribute funding resources. Many HIV-specific consortia 

were established in response to the requirements of the Ryan White Comprehensive 

AIDS Resources Emergency (CARE) Act. In 

fact, most states and territories have at least 

one consortia in place. These consortia 

have administrative structures and procedures designed to increase client access to 

care and to equitably distribute funding 

among participating organizations. As a 

general rule, any "new" service would benefit from establishing a formal linkage with 

local consortia. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
24 CREATING PROGRAMS Chapter 1: Establishing Services 

DETERMINING THE FEASIBILITY 

OF THE PROGRAM 

Once service needs are concretely identified 

and possible service model solutions are 

drafted, program planners can consider the 

feasibility of offering HIV-specific mental 

health services. Numerous questions may 

arise regarding such issues as implementation, cost, staffing, and the political environment. Some of the most critical areas 

identified by the Demonstration Program 

are described below. 

Existing organization. Adding a new, 

HIV-specific mental health program to 

an existing administrative structure can 

have both advantages and disadvantages. 

Personnel at all levels of an organization 

may be affected by the challenge of 

changing an existing service delivery 

structure. Program administrators may 

want to conduct a careful analysis of 

these pros and cons prior to proposing 

such a dramatic change in an organization's scope of services. Some key areas 

to consider regarding the organizational 

factors are: 

• Historical responses to change. How has 

the organization changed to adapt to client 

needs in the past? Do staff or administrators 

view change negatively? Is organizational 

change usually a random occurrence, causing anxiety among staff and clients? Or is 

change a routine and ongoing process? It is 

important to define change as a positive 

action and to set an agenda for regular 

review and revision of organizational and 

programmatic efforts. This approach can 

help staff anticipate and prepare for the possible outcomes of change. 

• Mission and vision. Does the organization have a clearly stated and clearly articulated mission? Does the program itself 

have a realistic vision for the kind of positive impact it can have on the lives of 

clients? Do existing staff, administrators, 

board members, and other relevant personnel support the program’s vision and 

share a commitment to making the vision 

a reality? If the answer to any of these 

questions is “no,” then the program’s 

ability to meet the needs of its clients in a 

unified fashion may be severely 

compromised. 

• Philosophical approach to working with 

clients. Too often, health care professionals 

assume that everyone in the field is equally 

committed to the general goal of doing 

what is best for the client. In reality, however, there are many ways to serve clients 

effectively, and different professionals may 

have different values or perspectives when 

it comes to delivering services. 

• 	Flexibility around established procedures. Will staff in the new program be 

required to complete organizational 

paperwork that does not pertain to their 

work with clients? What are the costs to 

the organization if established procedures 

are not undertaken by staff? It is important 

to weigh the costs and benefits of requiring program staff to perform established 

procedures, especially since they will have 

the additional task of serving HIV-infected 

and -affected individuals that other organizational staff may not have. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
CREATING PROGRAMS Chapter 1: Establishing Services 25 

Funding (short-term and long-term). 

Funding for services is the fuel that 

enables a program to run efficiently and 

effectively. Far too often, service planners 

underestimate the costs associated with 

providing certain services. To avoid this 

problem, program staff should carefully 

consider the range of services that are 

essential to meet client needs, the number 

and type of service providers available to 

the program, necessary equipment and 

materials, overhead, and indirect costs. 

An old-fashioned and carefully crafted 

budget is still the best way to determine if 

the available financial resources are sufficient to meet the program's service goals. 

This budget may include: 

• Sources of reimbursement, such as client 

payment for services, Medicare and 

Medicaid, and private health insurance 

• Outside funding sources, such as federal, 

state, county and city governments, private 

foundations, charitable organizations, and 

United Way funds 

• Ryan White CARE Act funding 

• In-kind contributions, such as staff, office 

space, utilities, furniture, or equipment 

Once funding sources are identified, program planners and administrators can 

become better positioned to determine the 

economic feasibility of providing the range 

of services that were originally planned. 

Sources of 

reimbursement: 

Outside 

funding sources 

Ryan White 


CARE Act
 

In-kind 


contributions
 

Political climate. The level of support for 

a new HIV-mental health program may 

be closely tied to, or dependent upon, the 

current political climate in which the 

program will operate. Some program 

efforts (e.g., needle exchange or condom 

distribution programs) may not receive 

support from certain parts of the community. Many political leaders have different 

points of view about funding priorities 

(e.g., whether limited resources should be 

allocated to local, county, or state levels). 

Programs that opt to provide a certain 

service may find themselves in competition for funds with other organizations 

providing similar services. Administrators 

will want to discuss plans for new services 

with representatives of other community 

or state organizations to determine if new 

services will be supported and embraced 

by state and local political leaders. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
26 CREATING PROGRAMS Chapter 1: Establishing Services 

IMPLEMENTING THE PROGRAM 

After funding has been secured, the 

organizational factors have been considered and managed, and the program 

design has been established, it is time to 

put the program into action. Once the 

program begins the implementation 

phase, staff may find that there is a 

greater demand for services than the program is able to provide. To manage funding, human, and service resources 

effectively, program planners and administrators will have to establish priorities. 

Triage plan. Most programs would like to 

provide services to everyone who needs 

them, but trying to meet everyone's 

needs will probably result in depleting 

already limited resources sooner than 

expected. Before things get to this point, 

it is wise to establish a detailed, yet flexible, triage procedure that outlines specific inclusion and exclusion criteria. 

Space. The provision of mental health 

services requires a safe, confidential 

atmosphere. Offices in which clients will 

receive services need to be enclosed to 

prevent others from eavesdropping on 

conversations between the service 

provider and the client. In designing or 

planning the use of office space, reception areas, and waiting rooms, consideration needs to be given to ensuring 

confidentiality, equal treatment, and 

handicapped access. 

Staff. The recruitment of trained and 

motivated staff is critical to establishing 

new services. Administrators need to 

determine if an adequate supply of 

human resources is already available or if 

additional staff need to be recruited. (For 

additional discussion about staffing issues, 

see Chapter 3.) 

Service Intensity. Different persons not 

only need different services, but they also 

need varying "doses" of services. Too many 

agencies establish a service model that 

expects the services offered to be sufficient for all clients who walk through the 

door. The fact is that no single organization can provide all the possible combinations of services needed by persons living 

with HIV. Programs need to consider the 

following questions: 

• Will the program provide support services 

in addition to mental health services? 

• To what extent is the program able to 

meet the transportation needs of clients, 

such as giving clients bus tickets or taxi 

vouchers, so they can attend their sessions 

and other health-related appointments? 

• What kind of formal and informal linkages 

will the program have with other providers 

who serve people living with or affected 

by HIV? 

Resources for staff. In addition to having 

an enclosed, private space to meet with 

clients, staff may need access to passwordsecured computers and locked file cabinets 

for storing confidential materials. Staff who 

conduct work outside of an office setting 

(e.g., outreach workers) may need pagers or 

cellular telephones to maintain contact 

with clients and other service providers. If 

a program intends to provide transportation, agency cars or vans are needed. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
CREATING PROGRAMS Chapter 1: Establishing Services 27 

...service, 

training, and 

evaluation... 

Publicity and marketing. Existing service 

organizations cannot assume that clients 

will simply hear about new services and 

request them. Services need to be marketed to clients and other service 

providers. Service providers and potential 

clients need to know what mental health 

services are and how clients can benefit 

from them. 

Clients and service providers also need to 

be educated about the warning signs of 

diagnosable and treatable mental disorders. For example, many individuals living 

with or affected by HIV often may feel 

"sad," not realizing that they may be experiencing a depressive disorder. How a program informs and educates potential 

clients and referral sources about mental 

health issues and new services is a key 

challenge. Inviting service providers and 

potential clients to educational workshops 

that explain what mental health services 

are and how they can help people living 

with or affected by HIV is one suggestion. 

Publicizing services can be done by handing out flyers at a local grocery store or 

sending a one-page description of the program to other service providers in the 

community. 

Staff training. Program administrators 

have to provide awareness training to all 

personnel within their facility to make 

sure they understand what the newly 

established services are, when a potential 

client should be referred for mental health 

services, and what the benefits are for the 

clients. In addition, existing staff need to 

know how these new services may change 

the scope of their duties. Staff may express 

anxiety or anger about taking on new 

responsibilities, or they may fear that they 

will lose their jobs when new (and perhaps 

more experienced) staff are hired. (See 

Chapter 3 on Staffing.) 

Policy and procedures manual. It may be 

useful and beneficial to develop a "Policy 

and Procedures Manual" that can be modified as new situations arise. The manual 

may include up-to-date copies of all organizational and program forms, such as 

intakes and assessments. New procedures 

can be reviewed frequently by appropriate 

staff early in the program implementation 

process. 

Program evaluation. An important lesson 

learned from the Demonstration Program 

was that the evaluation of services should 

be considered early on in the program 

development process. Program administrators need to set aside funding for evaluation and for educating staff about the 

importance of evaluation in informing 

program decisions and policies. (For a 

more comprehensive presentation of these 

issues, see Chapter 14 on Evaluation.) 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
28 CREATING PROGRAMS Chapter 1: Establishing Services 

SUSTAINING THE PROGRAM 

Sustaining an HIV-specific mental health 

program is about much more than funding. 

It is also about recruiting and retaining 

staff; providing staff training; engaging and 

retaining clients; coordinating services 

within the network of available services; 

keeping providers informed of emerging 

clinical issues and procedural changes; and 

preventing or reducing provider burnout. 

These program development issues are 

discussed in more detail later in the 

Practical Guide and are critical to the 

program implementation process. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
29 

CHAPTER 2: 

Collaborative Networks 

Because HIV affects a person along the entire 

biopsychosocial spectrum, clients need access to a variety of systems of care. One of the key lessons learned by the 

Demonstration projects was that collaborative networks can 

be vehicles to help ensure that service provision systems are 

responsive and effective in meeting the multiple, complex 

needs of people living with or affected by HIV. 

A collaborative network is a series of formal or informal relationships between and among individuals and organizations designed 

to further programmatic goals and objectives. While it is difficult 

to establish high-quality and effective services independent of 

existing services, collaborative networks allow providers and 

administrators to benefit from the experience of other 

organizations in the community that share a commitment to serving people living with or affected by HIV. Most importantly, collaborative networks can dramatically enhance the range and 

accessibility of services available to clients. 
30 CREATING PROGRAMS Chapter 2: Collaborative Networks 

What Types 

of Service 

Organizations 

Can Benefit 

From Collaborative 

Networks? 

• primary medical 

care organizations 

• AIDS service 

organizations 

• academic institutions 

• cultural and ethnic 

service organizations 

• hospitals 

• dental clinics 

• food banks 

• religious 

organizations 

• job placement 

agencies 

• city, state, 

and federal agencies 

The biggest winner in the network 

approach is the client. New programs also 

can benefit from collaborative networks. 

For example, involvement in collaborative networks can: 

• increase client access to care 

• eliminate barriers to care by providing a 

broader range of supports for clients, such 

as transportation, child care, medical services, housing, education, and food 

• facilitate the sharing of information, knowledge, experience, and resources between 

individuals and organizations 

• improve the coordination of multiple services across multiple systems 

• prevent duplication of services 

• reduce or eliminate service gaps 

• create new opportunities for funding 

• improve communication between frontline staff, service providers, and representatives of different agencies 

• increase opportunities among service 

providers for referrals 

• promote a strong sense of “community” 

among providers 

• reduce competition between and among 

service agencies 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
CREATING PROGRAMS Chapter 2: Collaborative Networks 31 

WHAT A COLLABORATIVE NETWORK 

MAY LOOK LIKE 

Networks often begin between individual 

service providers who share a client. 

These networks can develop into teams 

that evaluate treatment on an ongoing 

basis. It is important to maintain a client 

focus in these teams and to come to an 

agreement about who does what. It also is 

imperative to identify confidentiality 

standards and appropriate boundaries. 

Most importantly, since the most disenfranchised clients will be the first to get 

lost between service providers, special 

care must be taken to ensure that these 

clients do not fall between the cracks. 

Collaborative networks can become more 

formalized through letters of agreement 

between two or more organizations, such 

as when an HIV/mental health program 

contracts with a local group to do street 

outreach. These letters should identify 

the specific services, information, and 

resources to be shared between the organizations. 

What is a 

Collaborative 

Network 

Worth? 

In Los Angeles and 

Atlanta, local funding 

is determined by a 

program’s ability to 

demonstrate linkages 

and networks with 

other service providers 

in the community. 

Some collaborative 

networks seek funding as a single source 

to fund their various 

programs. 

Federal Resource Contact Information 

CDC National AIDS/HIV Hotline 800.342.AIDS 

CDC National AIDS Clearinghouse 800.458.5231 

Center for Mental Health Services http://www.mentalhealth.org/ 

Substance Abuse and 

Mental Health Services Administration http://www.samhsa.gov/ 

Health Resources and Services Administration http://www.hrsa.dhhs.gov/ 

National Institute of Mental Health http://www.nimh.nih.gov/ 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
32 CREATING PROGRAMS Chapter 2: Collaborative Networks 

...planning, 

funding, 

and information-sharing 

structures... 

How to Find Local 

Planning Councils 

Local Ryan White 

planning councils can 

be an excellent 

resource for establishing collaborative networks. Information 

about local planning 

councils can be found 

on the Internet at 

www.hrsa.dhhs.gov/hab 

or by calling the 

Health Resources 

and Services 

Administration, Office 

of the Director, at 

301.443.1993. 

Many communities already have formal 

networks in place. It is important for new 

programs to be aware of existing networks 

in the community and the resources they 

can offer. For example, on a local level, 

Ryan White CARE Act money is distributed through planning councils. New programs may want to build relationships 

with representatives on the council or 

seek representation on the council— 

either of which can help foster program 

sustainability. Both the Los Angeles and 

Chicago programs have been able to continue to offer services directly as a result of 

networking efforts with their local planning councils. In Atlanta, the collaborative network formalized into the Ryan 

White Mental Health Task Force to guide 

HIV-related mental health funding. 

Hierarchically, there also are existing 

structures at the state and federal level. 

These planning, funding, and information-sharing structures serve as valuable 

resources in initiating and developing 

service programs and collaborative networks, as well as providing education and 

prevention materials. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
CREATING PROGRAMS Chapter 2: Collaborative Networks 33 

ISSUE 

POSSIBLE 

SOLUTION 

Common Issues That Arose When Demonstration Projects 

Created Collaborative Networks 

Identifying participants 

Seek a blend of different administrative and functional levels (e.g., a mixture of line staff, clients, administrators, 

and evaluators). They must all share one characteristic—they are key people to disseminate information within 

their own constituent groups and return to the table with feedback. 

Selecting the meeting location 

Select the easiest and most accessible site for most members. Consider rotating locations. 

Addressing turf issues (funding, clients) 

Openly discuss instances when members are going to be competitive and cooperative, especially around seeking Ryan White funding and providing client services. 

Maintaining interest and participation 

Find members who will take their participation seriously. Rotate responsibility for sustaining the network. Orient 

new members (especially clients) to the value of networks and how they work. 

Making participation worth the members’ time 

Clarify the purpose of the network and what members can “get” from their participation. Consider holding topiccentered meetings or workshops (e.g., on shelter resources) so that members can know in advance what they 

are going to do and gain. The purpose and content of the meeting should justify the network. 

Maintaining confidentiality 

Privacy of personal information of participants and/or shared clients must be respected. Consider establishing 

“ground rules” that deal with this issue, as well as other issues of respect and privacy. 

Addressing tension between members about the mission of the network and service 

provision issues 

Allow members with differing missions and ideas about service provision to offer training to other members as a 

way of outlining their points of view. Invite other members to their respective places of work to show their missions in action. Agree to disagree in some instances. 

Responding to change in leadership in the network or within member organizations 

The importance of maintaining the network supercedes changes in leadership. If the leader leaves or becomes 

de-funded, some other agency/representative needs to take the initiative to guarantee the ongoing vitality of the 

network. When leadership changes within organizations, seek the support of new administrators and leaders to 

allow staff time to participate in networks. Ask the predecessor to underscore the value of the network to his/her 

successor. 

Dealing with disagreements about individual client care in formalized client centered 

networks (case conferencing, etc.) 

Maintain an open dialogue about various approaches to care. Agree early on to discuss differences. Members of 

the team who clearly understand the importance of confidentiality and boundaries in the therapeutic relationship can educate other members about maintaining these boundaries. Agree to disagree. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
34 CREATING PROGRAMS Chapter 2: Collaborative Networks 

DEVELOPING, MAINTAINING, 

AND EVALUATING NETWORKS 

Although formal networks may already 

exist in a community, some programs may 

find it necessary to forge new networks to 

meet service goals for their population. For 

example, a program may discover that its 

mechanism for referring clients to primary 

medical care, substance abuse treatment, 

housing programs, and case management 

needs to be strengthened. To address this 

need, a program director could convene a 

meeting of local service providers in these 

areas to create a mutually beneficial referral network, to address and decrease barriers to services, and to prevent duplication 

among partner organizations. Ultimately, 

these meetings may lay the foundation for 

an ongoing network that continues to 

meet regularly, working in close partnership for many years to come. 

When establishing networks, it is important to carefully consider the composition of the network. It has been the 

experience of some of the Demonstration 

projects, however, that the membership 

may simply come down to those who 

keep showing up. This process can be 

viewed as natural selection. The members who return are those who are most 

vital to the continuation of the network. 

Evaluating a collaborative network can 

provide valuable information about program and client outcomes. For instance, 

an evaluator can help collaborative networks better understand the value of forming networks and their effectiveness in 

increasing standards of care, how the network addresses service gaps, how the network strengthens ongoing inter-organizational relationships, and how the network 

affects client outcomes. The processes for 

evaluating a network are similar to those 

for evaluating a program. (See Chapter 14 

on Program Evaluation.) 

As noted throughout this Practical Guide, 

HIV infection is a dynamic illness, so 

individuals and organizations must be 

flexible in adapting to the changing needs 

of clients. Collaborative networks can 

serve as a vehicle to stay current and provide appropriate responses to change. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
35 

CHAPTER 3: 

Staffing 

Staffing a program to serve the mental health needs of 

HIV-infected and -affected individuals can be a 

lengthy and time consuming process. Program directors need 

to do the most they can up front to hire or train the “right” 

staff to address the multiple issues confronting persons living 

with HIV. Before undertaking such an endeavor, it is crucial 

to have certain organizational and program elements in 

place. (See Chapter 1 on Establishing Services.) The most 

significant factors to examine and act upon when hiring or 

re-assigning staff for an HIV-specific mental health program 

are found in this chapter. 
36 CREATING PROGRAMS Chapter 3: Staffing 

STAFF COMPOSITION 

The staff composition of the 11 

Demonstration projects included social 

service case managers, social workers, 

psychologists, psychiatrists, psychiatric 

nurses, substance abuse treatment counselors, medical doctors, medical case managers, nurse practitioners, physician 

assistants, outreach workers, pastoral care 

providers, HIV-positive peer providers, and 

other paraprofessionals. A program's staff 

composition depended on the program's 

focus, and the needs and service utilization 

patterns of the target population. (See 

Chapter 1 on Establishing Services.) 

STAFF CHARACTERISTICS 

Certain staff characteristics are highly 

desirable when it comes to meeting the 

mental health, substance abuse, and case 

management needs of people living with 

or affected by HIV. Some key traits to look 

for include those identified below. 

Commitment to the program's mission, 

vision, and philosophy. It is important to 

get a sense of how staff see themselves 

applying the program's mission, vision, 

and philosophy in client interactions. For 

instance, several Demonstration sites 

experienced difficulty in finding staff who 

not only understood their program's philosophy and model but also knew how to 

operationalize its concepts. For the sites 

who overcame these difficulties, staff 

adapted and integrated their professional 

training and field experiences and/or their 

personal recovery strategies in order to 

fully carry out the mission, vision, and 

philosophy of their programs. 

Cross-cutting competencies and skills. It is 

important to have the following knowledge 

and skills represented in a program’s staff: 

• Mental health treatment practices and 

modalities, such as individual, group, family, and peer-led therapy and counseling, 

as well as neuropsychiatric and psychiatric 

services and neuropsychological testing 

• Substance abuse treatment practices, such 

as harm reduction and 12-step programs 

• Biomedical practices in the ever-changing 

treatment of HIV, such as the evolution of 

the virus itself, new medications, their side 

effects, and new opportunistic infections 

• Holistic approaches to treating the complications of HIV, such as aromatherapy, 

acupuncture, or herbal therapies 

• Awareness of the service system and its 

political context 

• Knowledge of local resources 

• Experience in using evaluation tools to 

measure client outcomes 

Diversity. Staff need to be demographically similar or relate easily to the target 

population in terms of ethnicity, age, gender, class, sexual orientation, language, 

culture, life experiences, and HIV status. 

However, demographic matching is not 

always possible, nor does it necessarily 

guarantee the best "fit" between staff, 

clients, and the program's mission. 

Program planners also need to look for 

providers who share similar values and 

beliefs with clients, as well as providers 

who have the most appropriate skills to 

meet the client’s needs. Demographic 

matching, value matching, and skill 

matching are equally important. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
CREATING PROGRAMS Chapter 3: Staffing 37 

Flexibility with clients. Since people living with or affected by HIV 

present with multiple and dynamic 

needs, staff may need to adapt traditional ways of working to meet 

clients “where they are.” For example, some clients will benefit from 

after-hours appointments or make 

unscheduled visits. Within the 

therapeutic relationship, staff likely 

will be called upon to change their 

approach from time to time. 

Whether it be assuming case management responsibilities or altering 

the format and goals of treatment 

so that they are more relevant and 

appropriate for the unique needs of 

each client, flexibility is an essential characteristic for service 

providers. 

Sensitivity. Clients often present 

with values, beliefs, and behaviors 

that conflict with the worker’s values, beliefs, and behaviors. Staff 

must have the capacity to remain 

nonjudgmental and avoid any hint 

of “moral superiority.” 

Empathy. Living with HIV and its 

accompanying uncertainties, 

stigma, demanding medication regimens, and emotional stressors is a 

challenge, especially when HIV 

occurs in tandem with mental 

health, substance abuse, and other 

physical disorders. Staff who are 

able to understand these issues from 

the client’s perspective are better 

equipped to engage and retain 

clients in treatment. 

HIV-Specific Mental Health Training 

Opportunities 

The Mental Health Care Provider Education 

In HIV/AIDS Program II, funded by the 

Center for Mental Health Services, is an interdisciplinary program that promotes training 

opportunities for the full cadre of mental 

health care providers who serve people 

affected by HIV, including traditional mental 

health care providers, such as psychiatrists, 

psychologists, nurses, social workers, counselors, marriage and family counselors; 

other front-line providers of mental health 

services, such as medical students and primary care physicians; and nontraditional 

providers, such as clergy, other spiritual 

providers, and alternative health care workers. The program supports seven grants to 

universities across the nation that provide 

HIV/mental health-specific training opportunities to professionals in their communities. 

In addition, the American Psychiatric 

Association, the American Psychological 

Association, and the National Association of 

Social Workers provide training and education opportunities for mental health professionals who are members of, or affiliated 

with, these three national organizations. 

For more information about possible training 

opportunities, call 1-800-789-CMHS (2647) or 

go to http://www.mentalhealth.org/ on the 

Internet. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
38 CREATING PROGRAMS Chapter 3: Staffing 

In-Vivo Training at the Los 

Angeles Project 

At the Los Angeles project, social work 

interns observe staff clinicians as they 

conduct psychosocial intakes (with the 

client's prior permission). Interns then 

complete the next round of intakes 

with a staff clinician observing and 

intervening when necessary. Since 

direct observation of individual therapy sessions often is impossible (unless 

a facility is equipped with two-way mirrors), process recordings can be an 

effective way of teaching clinicians 

how a session should be conducted. 

(See Appendix B for the form that the 

Los Angeles project uses for process 

recordings.) In addition, the use of 

audio recordings provides instant feedback for clinicians and supervisors. 

Comfort with difficult issues. Addressing 

death and dying issues—both in the 

abstract and on a personal level—is 

extremely important. Comfort with sexual 

issues on several levels, including being 

comfortable with one’s own sexual identity, thoughts, and behaviors; accepting 

differences in clients around sexual 

promiscuity, experimentation, and expression; and being comfortable talking about 

sex, sexual abuse, incest, and death issues 

concurrently with clients also is important. 

Determination. Staff likely will face barriers from clients, co-workers, systems, 

and other service providers. After fighting many such battles, staff may become 

discouraged. With support from supervisors, staff must persevere and seek help 

when they experience low morale and 

burnout. (Burnout issues are discussed 

later in this chapter.) 

Ability to be a team player. To meet the 

diverse needs of clients, staff need to work 

closely and cooperatively with other service providers. Learning from one another, 

sharing responsibility, and reaching consensus are key staff attributes. 

Ability to adapt to the changing 

nature of the epidemic. As the epidemic changes and as new research and 

treatment approaches continue to 

emerge, staff need to continually adapt 

their thinking and approach to how 

services are delivered. If staff do not 

have the knowledge or skills required to 

provide HIV-specific mental health 

treatment, it is important that they are 

open to learning about these areas so 

they can become better equipped to 

serve the target population. 

Perseverance. With some clients, it takes 

a lot of energy and patience on the part of 

staff to initiate, stabilize, and maintain 

relationships and keep clients engaged in 

services. While the client may relapse or 

want to discontinue services, staff need to 

reach out and press onward so that clients 

can accept the help they need. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
CREATING PROGRAMS Chapter 3: Staffing 39 

Sheila’s Story 

In addition to mood swings stemming from her bipolar disorder, Sheila was 

naturally drawn to dramatic and attention-seeking behaviors that got her into 

trouble. Monitoring the lithium adherence, the crack abstinence, and the natural 

peaks and valleys of Sheila’s volatile relationships kept Dottie in a state of 

concerned vigilance. Over a three-year period, Dottie provided a wide range of 

case management services, including reinstating Sheila’s Social Security disability 

check, helping her find progressively independent housing, securing emergency 

financial assistance, counseling and coaching her for court appearances and job 

interviews, and accompanying her during painful gynecological procedures. 

The order was predictable. Sheila would skip her lithium, develop manic 

symptoms, relapse into crack use, and then re-enter detoxification—a cycle she 

repeated three times. The precipitant would be an upsetting event—a physical 

assault by her boyfriend, an appearance in court as a witness to a shooting, 

the incarceration of a younger brother, or a sharp drop in her T-cell count. 

Much of Dottie’s energy was spent calming and reasoning, taking Sheila step 

by step through the consequences of her threatened actions. 

Sheila handed Dottie her walking papers on many an occasion. Threats of suicide and 

homicide (toward a boyfriend) required at least one psychiatric hospitalization. Dottie 

remained steadfast, tenacious, available, non-judgmental, and persistent. When Dottie 

returned to the office, out of breath after a high-heeled chase through an alley to the 

crack house, even her supervisor cautioned against “excessive pursuit.” 

From their first meeting at the jail, through a shelter placement, a residential 

group home, and finally Sheila’s own place and a part-time job, Dottie 

demonstrated the intensive case management, outreach, careful monitoring of 

medication adherence, and consistent follow-through necessary for Sheila to 

come to grips with her triple diagnoses. Above all, Dottie made evident 

through her actions her unflagging belief in Sheila’s worth and her ability to 

significantly improve the quality of her life. 

Dottie, a psychiatric nurse, demonstrated some of the staff characteristics put to 

effective use in working with Sheila, a triply diagnosed client. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
40 CREATING PROGRAMS Chapter 3: Staffing 

STAFF TRAINING 

Staff training should be driven by a program's staff composition, the services 

offered, and the needs of the target population. Ideally, staff training should incorporate the following elements. 

Orientation to the organization, the program, the work, and the clients. All staff 

should receive training about the organization's and program’s mission and vision, 

as well as its functions and operations. 

Staff also need to know where they "fit" in 

the program and the roles and responsibilities expected of them. 

Continuous and ongoing training opportunities. Training should be updated to 

reflect changes at the macro-level (e.g., 

changes in the epidemic, psychotropic 

medications, and local resources) and the 

field's response to such changes. In addition, staff need to be trained when these 

changes affect day-to-day program operations and procedures. 

Experiential and didactic formats. 

Training has the best effects when it is 

both experiential and didactic. If possible, conducting direct observations of 

staff as they perform their jobs can be an 

important part of training and quality 

assurance. 

Multidisciplinary training conducted by 

other staff. Training curricula can be 

developed and delivered by staff from different backgrounds and orientations— 

including staff from other agencies and 

...training from 

multiple 

perspectives... 

programs. Training from multiple perspectives helps staff better understand the 

role of different providers in the service 

delivery process. It also can provide staff 

with ideas on how to work with other 

providers. 

Match the needs of staff to changes in the 

epidemic. Training opportunities can 

address individual staff and team needs, as 

well as areas of weakness. A training needs 

assessment, conducted with the input of 

staff, can be an effective way to identify 

training needs and areas of weakness. 

Another way to assess training needs is to 

interview clinical supervisors. Individual 

staff training may be necessary for individuals who have greater needs or areas of 

weaknesses. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
CREATING PROGRAMS Chapter 3: Staffing 41 

TRAINING INITIATIVES CONDUCTED BY 

DEMONSTRATION PROJECTS 

Throughout the Demonstration 

Program, the 11 projects implemented 

a broad range of training initiatives 

related to HIV, mental health, substance 

abuse, and case management. (See 

Figure 6.) The projects also conducted 

trainings on many other topics, including the following areas. 

Desirable staff characteristics. Not every 

staff member can possess the characteristics described previously in this chapter. 

Training should be provided to ensure that 

these characteristics and skills are discussed and conveyed to staff as being vital 

to their work with clients. 

Group interventions. For programs that 

offer group treatment, the following staff 

training topics were found to be useful by 

the Demonstration sites: 

• Learning about group facilitation 

and skills (e.g., role plays) 

• Understanding clients’ informationprocessing styles 

• Learning about the different ways to 

educate clients 

• Understanding the issues that may 

arise from integrating clients with 

different life experiences (i.e., social, 

class, and cultural differences) in 

group situations 

• Understanding the issues that may 

arise when clients with varying 

degrees of mental health problems 

participate in the same group 

Safety issues. Clinics that provide HIVspecific mental health services should have 

a viable safety plan in place if a client 

becomes aggressive or loses control. This 

plan can be communicated to each 

employee through a series of trainings. 

Local county departments of mental health 

often provide Management of Assaultive 

Behavior training, and every staff member 

should be trained under such a program. 

Special populations. Specialized training 

may be required to increase staff awareness 

of and sensitivity to issues predominant in 

special populations (e.g., HIV-positive 

women and their children; people who are 

transgendered; and ethnic and cultural 

minorities). Training can help staff recognize multicultural nuances of service 

delivery and provide a framework for 

working effectively with these special 

populations. 

Legal issues. There are many legal issues 

associated with providing services to people living with or affected by HIV. For 

example, there may be restrictions on the 

kinds of services a program may offer (e.g., 

needle exchange programs) or on service 

providers themselves (e.g., duty to warn or 

confidentiality laws). In addition, staff 

need to know about a client’s legal rights, 

such as his/her eligibility for entitlements. 

Specific training on these issues can help 

ensure that programs operate within the 

confines of the law and assist staff in providing high-quality services, including 

access to HIV-specific legal assistance. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
42 CREATING PROGRAMS Chapter 3: Staffing 

Figure 6 

Examples of Training Topics Used in the Demonstration Program 

Substance Abuse Issues: 

• Different theories and interventions, including harm reduction vs. abstinence orientation 

• Relationship between substance abuse and HIV 

• Interaction between legal and illegal psychoactive substances and medication 

• Similarities between marinol and marijuana, and cocaine and anti-depressants 

Mental Health Issues: 

• Categories of mental illnesses, especially those associated with HIV 

• Current psychotropic medications and treatment modalities 

• How to incorporate HIV-specific and primary medical needs into the clinical 


assessment of clients
 

• Working with clinicians from multiple disciplines, including medical care providers 

• Exploring death and dying issues 

• Addressing ambivalence associated with sexual expression 

• Integrating HIV as a chronic illness into assessment and psychotherapy 

• Interactions of psychotropic medications with HIV medications 

Primary Care Issues: 

• Basic training on HIV and how it attacks the immune system 

• Current medication and treatment regimens 

• Basic information on HIV and opportunistic infections 

• How to help clients adhere to medical regimens 

• New developments in HIV and its effect on medication and treatment 

Case Management Issues: 

• The existing service delivery environment and the contacts within each system 

• Existing linkages (informal, or formal) between the organization and other 


service providers
 

• How clients and/or the program can access federal, state, and local services 


and entitlements
 

• Ways to empower clients so they can navigate numerous systems effectively 

• Confidentiality issues, such as state reporting requirements and partner notification standards 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
CREATING PROGRAMS Chapter 3: Staffing 43 

supervision... 

an important 

component 

SUPERVISION 

Staff supervision is an important component of programs delivering HIV-specific 

mental health services. The goal of 

supervision is to train, lead, motivate, and 

support staff around clinical and 

programmatic issues. Supervision also 

helps ensure that clinical services reflect 

the program’s commitment to quality 

assurance. Areas of focus for supervision 

may include the supervisee’s: 

• therapeutic relationships with clients 

• professional relationships with the 

supervisor and other staff 

• fidelity to the program’s mission and 

philosophy 

• application of desirable characteristics in 

his/her work with and on behalf of clients 

Desirable Characteristics 

in a Supervisor 

The 11 Demonstration 

projects identified the 

following qualities beneficial 

in a good supervisor: 

• sound clinical judgment 

• unflappability 

• creative problem-solving 

• knowing when and how to 

lay down the law 

• ability to contain anxiety 

• a therapeutic approach
 

grounded in research and
 

experience
 

• a fair, even-handed
 

approach to the work
 

• willingness to include staff
 

in decision-making
 

• motivation and the ability to 

motivate others 

• a sense of humor 

• a non-shaming and non-


blaming approach to
 

his/her work
 

• sensitivity to burnout and 

the emotional toll associated 

with serving people with 

HIV 

• a capacity for nurturing that 

fosters independence 

• good listening skills 

• a willingness to consider 

and try new approaches to 

service delivery 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
44 CREATING PROGRAMS Chapter 3: Staffing 

SPECIAL STAFFING ISSUES 

health services. Countertransference refers 

Transference and countertransference. 

Transference and countertransference are 

concepts from psychoanalytic theory that 

are used broadly by mental health practitioners and are particularly useful to 

understand when providing mental health 

services to people living with or affected 

by HIV. Basically, transference is the phenomenon of the client projecting his/her 

feelings, thoughts, and wishes onto the 

therapist who has come to represent 

someone from the client's past. 

Transference may be either positive or 

negative (e.g., the client overvalues or 

undervalues the therapist without basis in 

reality). In working with HIV-positive 

persons, some clients will re-experience 

unresolved past issues. It is therefore helpful for therapists to be aware of transference and the particularly rich frame it 

provides for therapeutic work. 

Some client concerns that led to transference reactions at the Demonstration projects were: 

• past experiences with helping 

professionals 

• thoughts and feelings toward illness 

and dependency 

• past experience in intimate and familial 

relationships 

• thoughts and feelings about HIV 

• beliefs about sexuality, homosexuality, 

and substance abuse 

It also is important for therapists to be aware 

of countertransference and how it may arise 

in the provision of HIV-specific mental 

to the phenomenon of the therapist projecting past feelings and wishes onto the 

patient who has come to represent someone 

from the therapist's past. Because this is an 

unconscious phenomenon, therapists must 

be alert to what is occurring in the therapeutic process. Often, supervision is helpful 

in identifying countertransference issues. If 

countertransference continues unrecognized, it can obstruct a clinician's understanding of the client’s situation or needs 

and may have a detrimental effect on the 

success of treatment. 

Some therapist concerns that led to countertransference reactions at the 

Demonstration projects were: 

• fear about "being contaminated" 

by the virus 

• values, beliefs, and judgments about sexuality and homosexuality 

• thoughts and feelings about meeting 

dependency needs of others 

• relief in not being HIV-positive 

• past experiences in intimate and familial 

relationships 

Burnout. When staff have difficulty balancing their commitment and motivation 

with the stresses in their work, the result 

may sometimes be an onset of symptoms 

suggestive of burnout. The word "burnout" 

refers broadly to an individual's response 

to work-related stressors that have not 

been successfully managed or resolved 

(Macks & Abrams, 1992). 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
CREATING PROGRAMS Chapter 3: Staffing 45 

The process of burnout for HIV-specific 

mental health providers operates within a 

multi-layered context of adverse sociocultural issues (e.g., discrimination, fear, and 

stigma), harsh medical realities (e.g., multiple course of HIV and the lack of a 

cure), and difficult psychological circumstances (e.g., continued confrontation 

with hopelessness and helplessness, 

death, and dying). An understanding of 

this context and its influence on staff 

burnout will help program directors 

respond better to staff who begin to show 

signs of burnout (McDaniel et al, 1996). 

Burnout may be manifested in a variety of 

ways, including: 

• Physical symptoms, such as chronic 

fatigue, changes in appetite, gastrointestinal 

problems, tension headaches, and sleep 

disturbance 

• 	Psychological symptoms, such as alienation, depression, anxiety, irritability, loss of 

concern, negativism about self and others, 

and anger toward clients 

• Behavioral symptoms, such as avoiding 

responsibilities, decreased productivity, 

under/overeating, lethargy, and increased 

alcohol or drug use 

In some instances of burnout, program 

directors may be forced to accept the fact 

that some staff simply do not belong in an 

HIV service delivery setting. Perhaps they 

do not have the necessary coping skills, 

have worked too long and too hard to 

remain in this line of work, or HIV has 

taken its toll in their personal lives as well. 

Staff may need to take a respite from the 

work until they have restored balance in 

their lives. 

Ways to Prevent Staff 

Burnout 

The 11 Demonstration projects found 

the following efforts to be helpful in 

preventing staff burnout: 

• Providing ongoing staff support 

• Helping staff learn new skills and 

techniques so they remain interested 

in their work 

• Revamping or eliminating cumbersome or unnecessary procedures, 

such as paperwork and reporting 

requirements 

• Using different strategies to 

motivate staff 

• Promoting team building by doing 

activities together, such as holding 

staff retreats 

• Balancing caseloads 

• Delegating authority so that staff 

feel a greater sense of control 

over their work 

• Supporting and nurturing staff 

members’ special interests 

• Frequently acknowledging and 

rewarding staff contributions 

• Giving staff “mental health days” off 

• Asking staff to assume a variety 

of assignments so they are not 

dealing with the same difficult tasks 

every day 

• Assisting staff in developing 

positive and healthy coping skills 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
46 CREATING PROGRAMS Chapter 3: Staffing 

Turnover. Any HIV-specific mental 

health program inevitably will 

encounter the challenge of managing 

staff turnover. Staff turnover is not 

necessarily a negative event. However, 

clients and staff may experience it as an 

additional loss. The following issues contributed to staff turnover at the 11 

Demonstration projects: 

• The pressures inherent in work with HIVinfected and -affected clients 

• The emotional ramifications that can 

emerge when trying to help a client who 

does not want to be helped 

• Experiencing the death of clients 

• Inflexibility on the part of program directors 

to help staff meet the changing needs of 

HIV-positive clients 

• Poor matching of staff with clients 

• An historic and persistent shortage of 

resources to serve clients effectively 

• Neglectful leadership 

• Poorly operationalized program goals 

• Ignoring the “red flags” that often lead 

to burnout 

• Inadequate and non-responsive 

supervision 

• Low pay and the lack of promotional 

opportunities 

How a program intends to prevent high 

staff turnover should be articulated 

when the program is being established. 

In addition, organizational leaders must 

pay constant attention to the “warning 

signs” identified above. Otherwise, the 

program’s ability to serve clients 

effectively and consistently may be 

severely jeopardized. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
DELIVERING SERVICES 

49 

CHAPTER 4: 

Mental 

Health
 Services

People living with or affected by HIV need access to a 

broad range of mental health services. Some services may 

be more widely available, particularly traditional mental 

health services, while others have been developed in response 

to the unique needs of persons affected by HIV. This section 

of the Practical Guide describes the range of mental health 

services offered by the Demonstration sites in response to the 

ever-changing impact of HIV infection on the biomedical, 

psychological, social, cultural, and spiritual dimensions of 

each client’s life and experience. 
50 DELIVERING SERVICES Chapter 4: Mental Health Services 

...a flexible approach to 


engaging clients. 


ENTERING THE MENTAL HEALTH SYSTEM 

People living with HIV may enter the 

mental health system through a variety 

of means: 

• Referrals from medical and allied health 

staff of hospitals, both from general 

medical units and from inpatient 

psychiatric units 

• Community-based public health clinics, 

including Sexually Transmitted Disease/HIV 

testing programs 

• Non-governmental organizations providing community-based HIV-related services 

• Public and private providers of substance 

abuse treatment 

• Various levels of the legal and court system, including prison/jail discharge planners, parole and probation offices, community-based ex-offenders’ groups, and 

child protective services 

• Peer-led HIV service and support 

organizations 

• “Word of mouth” referrals 

• Social services staff at local government 

levels 

• Community-based providers of services to 

people who are homeless 

• General mental health service systems, 

both publicly and privately based, that do 

not possess the capacity to provide HIVspecific mental health care 

Clients with HIV infection who enter the 

mental health service system may have 

long-standing mental and/or addictive 

disorders that were present prior to HIV 

infection. Some may develop symptoms of 

a mental disorder—such as a mood or 

adjustment disorder—in response to 

learning of their HIV status, while others 

may develop more serious symptoms of 

psychosis or mania due to the progression 

of HIV infection itself. Regardless of the 

severity or duration of mental and/or substance abuse problems, some people living 

with HIV experience powerful feelings of 

loss, shame, and guilt related to HIV 

infection and may cope through deeply 

held denial or avoidance. 

Clients can benefit from a broad range of 

HIV-specific mental health interventions. 

However, for some, it may be very difficult 

to acknowledge a personal need for mental 

health services. The mental health service 

system needs to take a flexible approach to 

engaging clients. For example, a client may 

not attend one or several scheduled intake 

appointments. Service providers need to 

accept this and be willing to reach out to 

and engage the client. A section discussing 

approaches to enhance the engagement of 

clients follows the overview of services 

described below. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
DELIVERING SERVICES Chapter 4: Mental Health Services 51 

SERVICES OFFERED 

The following services, either alone or in 

combination, comprise the foundation of 

mental health treatment offered by the 

Demonstration projects. Some of these services will be described in more detail later in 

this chapter. Determining the package of 

services that will be clinically useful involves 

an accurate and comprehensive assessment 

of clients’ functioning so that the link to 

appropriate treatment and services can be 

made successfully. For instance, a client 

recently released from prison who had been 

receiving psychotropic treatment for bipolar 

disorder and recently began Highly 

Advanced Anti-retroviral Treatment 

(HAART) to slow the progression of HIV 

will need a formal biopsychosocial assessment that may prompt linkages to case management, psychiatric evaluation, medication 

management, psychotherapy, residential 

services, or psychosocial rehabilitation, 

when indicated. 

As a component of each service, it is 

important to incorporate a discussion of 

risk reduction strategies, specifically ways 

for clients to promote safer sexual behavior and safer drug use for those clients who 

use drugs. As more advanced medications 

become available to prevent the progression of HIV, it is critical that mental 

health clinicians use their unique perspectives to assist clients in adhering to complex medication regimens. Becoming 

aware of the psychological and social barriers that may inhibit client adherence to 

such life-extending medications needs to 

be addressed in the helping relationship 

between clinician and client. 

Psychotherapy and counseling . 

Sometimes referred to as “the talking 

cure,” psychotherapy or counseling with a 

person with HIV infection can occur at 

many levels, through diverse modalities, 

and from different theoretical perspectives. Some clients are only interested in 

looking at their immediate situation, 

resolving issues that may cause present 

pain, ongoing relationship struggles, coping with HIV infection, or sorting out job 

options. Others may move toward a 

deeper examination of their past and the 

early childhood alliances and formative 

experiences that may have shaped their 

sense of self, their current relationships, or 

their functioning. 

Clients with a history of sexual abuse 

often discover that working through 

aspects of childhood trauma can be both 

a liberating and necessary step in moving 

toward a commitment to self-care and 

risk reduction. Psychotherapy can help 

clients develop greater self-awareness, 

stronger coping skills, and greater motivation to engage in meaningful and productive activities. Clients with a history 

of substance use often discover and begin 

to heal—through counseling or psychotherapy—the underlying pain against 

which they have long sought to medicate 

themselves. (See Chapter 8 on 

Psychotherapy and Counseling for a discussion of psychotherapy treatment 

modalities and theoretical approaches 

used by the 11 Demonstration projects. 

See Chapter 9 for more information on 

counseling themes.) 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
52 DELIVERING SERVICES Chapter 4: Mental Health Services 

Case management. Past experience in 

serving people with serious and persistent 

mental illness in community mental 

health centers led to the development of 

case management as a supportive 

approach that provides clients with case 

managers who link and refer clients to 

needed services—such as additional mental health treatment, entitlements, housing, clothing, and financial assistance— 

and advocate on behalf of the client to 

other agencies and organizations. As trust 

develops, case managers may be able to 

introduce more traditional mental health 

services. Seeking change in a supportive 

case management relationship in which 

there are mutually identified service goals 

may lead to greater empowerment for 

clients. Ultimately, clients may gain skill 

and comfort seeking additional services 

for themselves. (See Chapter 7 on Case 

Management.) 

Psychiatric evaluation. Completed as 

part of a formal and comprehensive 

biopsychosocial assessment, the psychiatric evaluation involves assessing clients’ 

presenting mental health symptoms, past 

psychiatric treatment, current mental 

health status, and the appropriateness of a 

psychotropic medication evaluation. 

Psychiatric evaluations also may be helpful in obtaining a consultation related to 

diagnoses or further evaluation of neuropsychiatric symptoms. Clients with a 

history of psychotic mental illness or those 

with past or current diagnoses of mood 

disorders (e.g., depression and bipolar disorder) and anxiety disorders may benefit 

from taking medications that alleviate 

their symptoms. 

Medication management. Once medications have been provided by the prescribing clinician, follow-up is required to 

ensure that clients understand medication 

dosing and side effects, to monitor medication effectiveness and adherence, and 

to watch for possible adverse effects. 

There is a heightened need for sensitivity 

regarding adverse drug effects when working with those with HIV due to possible 

interactions between psychotropic drugs 

prescribed simultaneously with HIVrelated medications. In addition, close 

monitoring of organ functioning and 

blood levels is needed, given the presence 

of HIV infection and other chronic medical complications. 

Inpatient psychiatric hospitalization. 

Stabilizing a client’s psychiatric symptoms 

may not always be possible in an outpatient setting. Staff often will recommend 

inpatient psychiatric hospitalization. 

Clients may voluntarily agree to such hospitalization, recognizing the need for 

greater structure and supervision. 

However, there may be a need for involuntary commitment and detention to an 

inpatient psychiatric setting for those 

whose threats of harm to self or others 

have been assessed as acutely dangerous 

and whose symptoms or behaviors interfere with accepting help. Psychiatric hospitalization involves a thorough biomedical and psychiatric assessment that may 

lead to changes or improvements in psychotropic treatments. These efforts are 

supplemented with group treatment, 

occupational therapies, and multidisciplinary inpatient care. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
DELIVERING SERVICES Chapter 4: Mental Health Services 53 

Emergency services. Working with persons who have mental disorders requires 

the availability of emergency and crisis 

intervention/stabilization services, as 

well as the programmatic flexibility to 

accommodate “drop-in” visits when 

needed. The re-emergence of psychotic 

symptoms, or decompensation, requires 

immediate assessment and intervention. 

Similarly, threats of suicide and/or 

homicide must be assessed to determine 

a client’s intent, history, plan, and 

means to act. The stress of living with 

HIV may require heightened monitoring of those most at risk for harming 

themselves or others. 

Psychosocial rehabilitation, partial hospitalization, and psychiatric day treatment. For those with serious and persistent mental illness, psychosocial 

rehabilitation programs offer day support 

to enhance self-care and social functioning, and to stimulate a sense of self that 

incorporates and internalizes the ability to 

manage oneself (See Chapter 13 on 

Psychosocial Rehabilitation). Partial hospitalization programs provide more intensive outpatient treatment for those whose 

mental health symptoms seem too deeply 

entrenched to be alleviated by outpatient 

psychotherapy. These approaches include 

more frequent, often daily, monitoring of 

medication adherence and greater support, including the use of group work. 

Partial hospitalization and psychiatric day 

treatment may be a short-term intervention during times of intensified symptomatic distress and risk. 

Residential services and treatment. For 

those for whom independent living may 

be too unstructured, residential services 

may offer placements with varying levels 

of staff support that seek to maximize 

medication adherence, social living 

skills, and self-care, and to introduce 

tasks of independent living in a consciously stepped fashion so that clients 

may find success in their efforts toward 

greater independence. A more structured 

environment, specifically as it relates to 

medication adherence, may improve 

medical and physical outcomes for persons with HIV infection who have lived 

in more chaotic circumstances, those 

who have cognitive impairments, and 

those who have not successfully adhered 

to their medication regimen. Residential 

treatment also is often a long-term and 

intensive intervention that may prove 

successful in helping clients maintain 

sobriety. 

Expressive therapies. Art, music, dance, 

psychodrama, bibliotherapy, and other 

expressive therapies can provide a means 

to access and express emotional 

experiences that otherwise may not arise 

in talk-driven psychotherapy. Frequently, 

for those living with HIV, certain defense 

mechanisms, like denial and sublimation, 

serve to protect clients from overwhelming anxiety and fear related to HIV 

infection and its progression. Expressive 

therapies seek to uncover such distress in a 

non-threatening and non-confrontational 

manner so that the client may gain 

mastery over it. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
54 DELIVERING SERVICES Chapter 4: Mental Health Services 

COMPLEMENTARY TREATMENTS 

Several emerging therapies may be used in 

combination with traditional mental health 

services to expand the choices available to 

clients participating in the development of 

their own treatment plans. In addition to 

the sense of empowerment that stems from 

having choices and assuming greater control in dealing with one’s illness, complementary treatments may offer other means 

of generating psychological, emotional, and 

spiritual support. They also may offer relief 

from pain associated with neuropathy 

linked to antiretroviral therapies. Service 

programs may seek partnerships with a 

diverse range of clinicians who have expertise in these treatments and a clinical understanding of HIV and mental health issues, 

as well as an openness to collaborative and 

integrated care. 

Herbal therapies. There is a growing interest in herbal therapies for the treatment of 

psychiatric symptoms such as depressed 

mood, anxiety, insomnia, cognitive slowing, 

and memory loss. Surveys of research literature have shown that St. John’s Wort 

(hypericum perforatum) seems helpful in 

the treatment of mild to moderate depression (Linde et al, 1996). Similarly, Ginkgo 

Biloba has shown some efficacy and benefit 

for persons with moderate to severe memory 

impairment (LeBars et al, 1997). Other 

herbal therapies have not yet been found to 

be demonstrably effective for other mental 

health symptoms. 

Acupuncture . A component of 

traditional Chinese medicine that dates 

back many centuries, acupuncture seeks to 

enhance energy flow with the use of 

needles or pressure (commonly called 

acupressure or shiatsu) at certain points 

along the body’s network of meridians 

that conduct chi (energy) through the 

body. Recently published findings indicate 

that acupuncture seems helpful for HIV 

and other medical conditions (Shlay et al, 

1998). Though promising, research 

involving acupuncture’s treatment for 

psychiatric purposes is not yet definitive. 

Exercise. The physical benefits of exercise 

are well known and also may benefit 

clients with emotional distress. For example, involvement in some form of exercise 

seems to promote a decrease in symptoms 

related to mild to moderate depression. 

Additionally, for persons with HIV, exercise appears to reduce other emotional distress and enhance immune functioning 

(Perna et al, 1998). It is important to 

ascertain whether clients have previously 

been involved in exercise and their willingness to resume physical activity. 

Stress reduction and relaxation techniques. Relaxation techniques seem to 

show promise in helping persons cope 

with anxiety and other distress. Guided 

imagery, progressive relaxation, meditation, visualization, and hypnotherapy 

have been shown to reduce emotional distress and promote well-being. 

Other nontraditional therapies. 

Approaches such as massage therapy and 

body work have been found to be beneficial 

in reducing tension and alleviating some 

physical manifestations associated with 

HIV infection. Some believe that these 

approaches are useful as adjunctive measures in treating some mental disorders. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
DELIVERING SERVICES Chapter 4: Mental Health Services 55 

ENGAGING CLIENTS 

THROUGH OUTREACH 

Many of the 11 Demonstration projects used 

outreach as a means to engage and retain 

clients who may not acknowledge a need for 

mental health care. In addition, many clients 

served by the Demonstration Program experienced numerous barriers (e.g., lack of transportation or child care, and psychological distress) that prevented them from keeping 

appointments or continuing to receive services. Service providers can engage individuals 

in the service delivery process by making 

repeated telephone calls, finding clients on 

the street, or making home visits. Outreach 

contributes to ongoing clinical service delivery by offering supportive telephone counseling and psychotherapy to persons who are 

unable to travel to the service site. Outreach 

can be performed by clinicians or paraprofessionals with sensitivity to individuals in alienated subcultures. 

Treatment or services offered outside of 

the treatment facility. Clients in detention 

facilities, hospitals, shelters, long-term care 

facilities, and those who require home-based 

services often lack access to treatment and 

support services. By meeting clients where 

they are, clinical staff can successfully reach 

people with disabilities, those with debilitating medical complications, those who cannot afford transportation, and parents whose 

child care responsibilities interfere with 

treatment. Off-site service delivery can be 

negotiated and reassessed periodically 

between clients and clinicians so that clients 

do not become unnecessarily dependent on 

clinicians or other program staff and can 

begin to receive or resume services at the 

agency setting when able or feasible. 

...outreach 

contributes 

to ongoing 

clinical 


service
 

delivery... 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
56 DELIVERING SERVICES Chapter 4: Mental Health Services 

COORDINATION OF CARE 

Conducting joint assessments with primary 

medical staff. Offering joint assessments 

may decrease the need for multiple intakes 

for clients, reduce the administrative burden 

for clinicians, and lay the foundation for a 

team approach to treatment. Involving the 

client’s primary medical providers in the 

assessment and delivery of mental health 

services enables providers and clinicians 

across disciplines to have a more comprehensive understanding of the client’s primary medical and mental health needs. This 

step also fosters a treatment approach 

informed by a biopsychosocial perspective. 

Facilitating the development of provider 

teams also may reduce duplication of services and avoid damaging impediments to the 

therapeutic process, such as “splitting” 

or triangulation. 

Offering interdisciplinary “prescription” 

team meetings with clients. When a client 

is receiving many services at the same time, 

such as medical care, case management, 

mental health, and substance abuse treatment, coordination of care among providers 

becomes essential for several reasons. First, 

duplication or gaps in service can be problematic. Second, clients with personality 

disorders sometimes pit one provider 

against another. And third, a client may 

present a particular display of symptoms to 

one provider and quite a different diagnostic picture to another. 

By periodically bringing all players, 

including the client, to the treatment 

planning table, such obstacles can be 

addressed and clarified. The Alexandria 

project makes frequent use of such prescription team meetings throughout the 

client’s treatment. While, at first glance, 

coordinating and scheduling such a meeting may seem cumbersome and time-consuming, staff have uniformly found these 

meetings to be helpful in preventing confusion, misunderstandings, and wasted 

effort during the course of treatment. The 

sharing of information from different disciplines also enriches the knowledge, 

skills, and abilities among providers. 

Such meetings can be useful at different 

phases of treatment. Sometimes, one 

provider through such a meeting can effectively link a reluctant or hesitant client to 

an historically stigmatized service such as 

mental health. In working with mothers 

who are connected to the Child Protective 

Service system, close coordination usually is 

essential. During times of crisis, when the 

client’s situation needs to be stabilized or 

reassessed, or when an intervention needs to 

be initiated, the prescription team meeting 

can be a powerful coordination tool. 

Expansion of the traditional mental health 

role. It was the experience of the 

Demonstration projects that clinicians benefited from being actively involved in case 

management activities and serving as a consultant to or liaison with the primary medical provider. In addition, clinicians were 

effective advocates in linking clients to 

other service providers as they sought access 

to entitlements and support services, such 

as legal advice. Once case management 

needs are identified, clinicians were able to 

determine the client’s capacity to follow 

through with potential referrals. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
57 

CHAPTER 5: 

Clinical 


Assessment 

Working with persons with HIV infection in the mental health arena requires a comprehensive approach 

to the clinical assessment and treatment planning process 

that fully incorporates the biopsychosocial complexity of living with HIV. For many clients triply diagnosed with HIV, a 

mental disorder, and a substance abuse disorder, the clinical 

assessment will be a multi-dimensional and dynamic process. 

Clinicians will meet with clients over several sessions to gather 

factual and perceptual information, draw hypotheses about what 

clients are revealing about themselves and their behaviors, and 

integrate what is learned into a diagnosis. Clinical assessments can 

then be used to develop client-specific treatment objectives that 

incorporate the client’s history and current struggles, as well as 

his/her strengths and resources. This process requires thoroughness 

and sound clinical thinking, but is a critical step toward ensuring 

that each client’s unique needs are addressed appropriately—and 

in a timely fashion. 

Lessons learned from the Demonstration Program include the kinds 

of questions to ask, the value of informal and formal assessment, and 

issues to consider when conducting a clinical assessment. 
58 DELIVERING SERVICES Chapter 5: Clinical Assessment 

AREAS TO BE COVERED 

IN THE CLINICAL ASSESSMENT 

It was the experience of the 11 

Demonstration sites that clinical assessments need to be tailored to a program’s 

populations, its settings, and the purpose 

of its interventions. When clinicians have 

the opportunity to develop a more comprehensive clinical assessment, it is important to consider the complex biological 

and social needs of people living with or 

affected by HIV. This can be accomplished by adding HIV-specific questions 

to an existing clinical assessment that 

covers the following areas: 

• demographics 

• presenting problem 

• psychiatric history 

• mental status exam 

• social history 

• medical history 

• alcohol and other drug use history 

• risk level, including sexual risk-taking and 

intravenous drug use 

• social support 

• coping skills 

• strengths 

• financial and other resources 

• employment history 

• educational background 

• religious and spiritual practices 

Relating the Clinical Assessment 

to Program Issues 

The following examples demonstrate how 

the questions asked in a clinical assessment 

are related to the program’s populations, 

setting, and purpose. 

• If a client comes into a community 

mental health center in a highly agitated state and is suicidal, then the 

assessment should focus on stabilizing 

the client and making sure appropriate 

safeguards are in place. More detailed 

information can be gathered after the 

client's crisis has stabilized. 

• If a client is assessed for mental health 

issues as part of his/her medical services, then staff will likely conduct a 

screening rather than a comprehensive assessment. The outcome of the 

screening may include recommendations for further assessment, individual 

or group treatment, follow-up with 

clients during medical visits, or no 

treatment at this time. (See Appendix C 

for a copy of the screening tool used 

by the Chicago Project.) 

• If a client comes into a psychosocial 

rehabilitation program for the first time, 

staff and other clients probably will 

want to begin by welcoming the client 

and introducing him/her to the program gradually. After building rapport, 

the following areas can be assessed: 

daily living activities; reading and education level; independent living skills; 

and leisure skills. 

• If an HIV-positive custodial parent is 

bedridden and very sick, staff will 

likely conduct an assessment of the 

client's most urgent and immediate 

needs—putting off the assessment of 

permanency planning issues until the 

crisis is stabilized. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
DELIVERING SERVICES Chapter 5: Clinical Assessment 59 

...a 

multidimensional 

and dynamic process... 

Whether the program is an HIVspecific stand alone program (see 

Appendix D for a copy of the assessment 

tool used by the Los Angeles project) or 

one that offers HIV-specific mental health 

services within a larger mental health 

organization (see Appendix E for a copies 

of the assessment tools used by the 

Alexandria project), a comprehensive 

clinical assessment needs to incorporate 

information from all these areas. This will 

allow an accurate understanding of the 

issues that are contributing to the client's 

presenting symptoms and/or complaints, 

as well as how a client's symptoms and/or 

complaints contribute to other areas of 

functioning (e.g., how depression may 

affect a client’s success in getting social 

support). Examples of how to incorporate 

HIV-specific issues into a clinical assessment are provided below. For each area, 

sample questions are included to keep in 

mind when gathering information during 

the clinical assessment. The areas are not 

presented in any specific order, and the 

sample questions are not intended to be 

asked in the manner presented. 

Social Support. In addition to informing 

staff about the quality of interpersonal 

relationships and the client's reliance 

upon others, social support questions can 

be used to ascertain to whom the client has 

disclosed his/her HIV status. Information 

about a client’s social support may be 

gained using established clinical tools— 

like genograms, which graphically depict a 

person’s social support network—or by 

asking direct questions. 

Types of Questions That May Be Helpful in 

Assessing the Client’s Social Supports 

• Have you disclosed your HIV status 

to anyone? 

• Is there anyone who knows about 

your status and helps you with 

day-to-day needs? 

• How often do you have contact 

with that person? 

• Is your contact with that person 

limited, or is it ongoing? 

• How is this person similar to 

you in age, gender, ethnicity, 

HIV status, and risk factors? 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
60 DELIVERING SERVICES Chapter 5: Clinical Assessment 

Coping Skills. These questions can help 

staff get a sense of how the client has historically and recently approached problems in his/her life, as well as how the 

client is coping with being HIV-positive. 

Staff will want to better understand the 

client’s strengths (e.g., strong will to 

live), adaptive skills (e.g., problem-solving, information-gathering, talking to 

and getting support from others), and 

maladaptive behaviors (e.g., self-isolation, taking part in potentially selfdestructive activities, avoidance, denial, 

or poor self-care). 

Types of Questions That May Be Helpful in 

Assessing the Client’s Coping Skills 

• In the past, when you’ve had to face challenges, how did you respond? How did 

you cope? What personal strengths did 

you bring to the situation? 

• How did you react when you first found 

out you were HIV-positive? How do you 

deal with it differently today than when 

you first found out? 

• What do you do to make yourself feel 

better? 

• What would make things more manageable for you? What has worked in the 

past? What hasn't worked as well? 

Medical Care. There are many reasons for 

including questions about a client’s past 

and current medical experiences. For 

example, many people living with HIV 

have multiple health problems, so gaining 

a picture of their HIV medical care and a 

complete medical history of other acute 

and chronic illnesses is crucial. In addition, adherence to medical treatment and 

recommendations is so vitally important 

that a clinician can benefit from knowing 

how clients interact with their medical 

providers. As medical care serves as a vital 

service to those with HIV infection, it is 

critical to understand how it affects their 

psychological well-being. The following 

sample questions are provided as a guideline to get a better understanding of the 

client’s perspective and can be woven into 

the clinical assessment. 

Types of Questions that May Be Helpful in 

Assessing the Client’s Medical Care 

• When you feel sick, do you go to the 

emergency room, call your medical 

provider, or call someone else? 

• Have you recently received medical care? 

What was that experience like? 

• Are you currently receiving HIV-specific 

medical care? What has that been like? 

• Has treatment helped, or has it not 

proved helpful? 

• How comfortable do you feel talking to 

your medical providers? 

• How well do your medical providers 

explain your treatment options? 

• Do you think your medical providers are 

sensitive to your pain (e.g., mental, emotional, physical, and spiritual pain)? 

• What is your CD4 count? Has this 

changed in the past 3 months? What is 

your current viral load? Has this changed 

in the past 3 months? 

• Do you have any other chronic medical 

conditions, such as diabetes, asthma, high 

blood pressure, liver problems, or kidney 

problems? 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
DELIVERING SERVICES Chapter 5: Clinical Assessment 61 

• Are you taking any medications for these 

conditions? What are you taking? How 

much are you supposed to take? Do you 

take these medications as prescribed? 

What are the circumstances when you do 

not take them as prescribed? 

• Are there any side effects with these medications? How do you cope with these 

side effects? 

• How often do you see your medical 

provider for your other medical conditions? How often do you keep these 

appointments? 

Current Service Utilization. To gain a 

better understanding of a client’s service 

needs and to help a client maneuver 

through the service system effectively, it 

may be important for clinicians to inquire 

about all the other systems (e.g., community-based agencies that offer HIV support 

services, AIDS service organizations, and 

community-based agencies that offer relevant services) to which he/she is already 

connected. 

Types of Questions that May Be Helpful in 

Assessing the Client’s Current 

Use of Services 

• Can you tell me about other services 

you use? 

• What has it been like to use these services, now and in the past? 

• How have these services benefited you? 

• Do you have a case manager? How has 

he/she helped you? 

Quality of Life. Given that HIV has 

become a chronic illness for many individuals, quality of life issues have become 

more salient for assessment and treatment. In addition to conducting a clinical assessment of specific symptoms and 

diagnoses, quality of life issues should be 

assessed because many clients respond 

more quickly to treatment when these 

issues are more readily understood and 

dealt with. One of the benefits of asking 

quality of life questions is that the clinician is less likely to impose his/her version of quality of life onto the client, and 

the client’s idea of quality of life is better 

understood. 

Types of Questions that May Be Helpful in 

Assessing the Client’s Quality of Life 

• When did you find out that you are HIVpositive? 

• How did you spend your time before you 

became HIV-positive? What was your typical day like back then? Who did you 

spend time with? 

• Back then, how satisfied were you with 

your life? 

• How do you spend your time now? What 

is your typical day like? Who do you 

spend time with? 

• How satisfied are you with your life? 

• How do you see yourself spending time 

in the future? What do you want a typical 

day to be like? Who do you want to 

spend time with? Are there people you 

would like to get to know better? 

• How would you like to live your life differently in the following areas: job/career, 

education/training, social/recreation, spiritual, and volunteer work/advocacy? 

Would these things give you a greater 

sense of purpose in life? Would they bring 

you pleasure? 

• If you were able to accomplish those 

goals, how satisfied would you be with 

your life? 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
62 DELIVERING SERVICES Chapter 5: Clinical Assessment 

CONDUCTING THE CLINICAL ASSESSMENT 

After program planners and clinicians at 

each of the 11 Demonstration sites 

selected areas to assess, it was then necessary to attend to the administration of the 

clinical assessment. This section describes 

the three key elements of a clinical assessment: preparing staff to conduct the 

assessment; preparing clients to participate in the assessment; and conducting 

the assessment. 

Preparing staff to conduct the assessment. Given the complexity of physical 

and mental health circumstances for persons seeking HIV-specific mental health 

services, clinicians should prepare themselves for the following: 

• Potentially uncomfortable and sensitive 

issues that may arise during the initial 

assessment meetings. These issues include 

death and dying issues; sexuality and sexual practices; different life experiences 

(e.g., substance abuse, class differences, 

sexual orientation); and explicit descriptions of physical symptoms. Through 

supervision and training, clinicians may 

learn to be sensitive to and comfortable 

with these and other issues before they 

actually conduct assessments with clients. 

• Alternative terms and slang. Clients may 

use alternative terms and/or slang to 

describe their experiences. To enhance a 

clinician's ability to connect with clients, it is 

important to familiarize themselves with 

alternative terms and slang by asking clients 

or other people who are familiar with the 

culture to explain unfamiliar words. 

• Local jurisdictional laws and regulations 

regarding confidentiality and safety. When 

working with HIV-infected clients, clinicians need to be aware of state and local 

liability and disclosure laws—and appropriate ways to respond. This relates to 

knowing about duty to warn, the emergent risks related to suicidality and homicidality, and the potential risk to children or 

vulnerable adults. State and local departments of mental health can provide some 

guidance in these matters. 

Preparing clients to participate in the 

assessment. Many HIV-infected individuals have had negative experiences with 

human service systems. With that in 

mind, it is important to make the clinical assessment process as favorable as 

possible. The collective experience of 

the 11 Demonstration sites has shown 

that the following practices can increase 

the likelihood of a successful assessment 

experience: 

• Explain the purpose of the assessment. A 

client needs to know why clinicians need 

to understand their story and how this 

process will benefit them in the long run. 

• Explain the assessment procedures. A 

client should be told up front what to 

expect and how long the assessment 

may take. 

• Establish trust. Take time to allow the client 

to become familiar with the assessment 

procedure. 

• Describe the limits of confidentiality. It may 

also be helpful to discuss the difference 

between confidentiality and keeping 

secrets. 

• Recognize that the process for 

seeking mental health services may 

be intimidating. 

• Recognize that the client or someone in 

his/her support network may have told 

the client that he/she is "crazy" for seeking 

mental health services. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
DELIVERING SERVICES Chapter 5: Clinical Assessment 63 

• Acknowledge that a client may be too sick 

to participate in an assessment and that 

information may need to be sought from 

other caregivers or staff who have had 

previous contact with the client. 

• Acknowledge potential discomfort. It is difficult for many clients to discuss their sexual 

practices, their illness, and other information of a private and intimate nature. 

• Inform the client that his/her disclosure of 

information is completely voluntary. 

During the clinical assessment, it is essential 

to maintain the level of respect and trust 

initiated with clients prior to conducting 

the assessment. To demonstrate empathy 

with the client’s situation, some client perspectives to keep in mind when conducting 

the clinical assessment are: 

• Respect a client's endurance. Allow water, 

coffee, and bathroom breaks. 

• Be sensitive to the client's circumstances. 

Do not begin the clinical assessment by 

asking the client how he/she contracted 

the virus. 

• Stay client-centered (e.g., Are you doing 

okay? Are you getting a chance to tell me 

what would be helpful for you? Is there 

something you'd like to tell me that I 

haven't asked?). 

• Pay attention to the pace of the assessment. Clients might not be ready to give 

you all the information all at once. 

• Remember that denial and avoidance are 

adaptive strategies—not necessarily signs 

of resistance—and that these strategies 

give client's control in divulging sensitive 

material. 

• Recognize the client's strengths and 

resources. For many triply diagnosed 

clients, HIV is an additional burden to a 

long list of burdens with which they have 

managed to live. 

CONNECTING THE CLINICAL ASSESSMENT 

WITH THE TREATMENT PLAN 

A comprehensive clinical assessment 

leads naturally to an effective treatment 

plan. An accurate and client-focused clinical assessment can ensure that treatment 

goals reflect client goals and priorities, 

that the client feels a strong sense of 

“ownership” over his/her treatment plan, 

and that clients are motivated to engage 

and remain in treatment. 

With those objectives in mind, it might be 

helpful for clinicians to ask clients the following questions: What are some of the 

issues you would like to work on in your 

life? What would you like to improve? 

And how would you like your life to be 

different after treatment has successfully 

been completed? 

To ensure that the client has ownership of 

the treatment goals, the following actions 

also may be helpful: 

• Emphasize client-driven goals in the treatment plan. 

• Negotiate treatment goals within the 

framework of which services and interventions are offered by the program and 

what the client wants. 

• Give clients an opportunity to consent to 

treatment, to review and revise their service and treatment goals, and to sign the 

plan when it is finalized. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
64 DELIVERING SERVICES Chapter 5: Clinical Assessment 

ADDITIONAL CLINICAL 

ASSESSMENT TOOLS 

Standardized Measures. Many of the 

Demonstration sites used standardized 

assessment instruments as an adjunct to 

their clinical assessment. Standardized 

measures were used for different reasons. 

Some sites used standardized measures as 

a means of describing their populations, 

while other sites used standardized measures to obtain clinical information in a 

more uniform manner. It is important for 

program planners and clinicians to agree 

on the use of standardized measures 

before introducing them into the clinical assessment. Some standardized measures used by Demonstration sites are 

listed in Figure 7. As shown in Figure 8, 

there are advantages and disadvantages 

to using standardized measures as an 

adjunct to the clinical assessment. 

Psychological and Neuropsychological 

Testing. Gathering information on 

thoughts, feelings, motivations, behavior 

patterns, personality type, relational style, 

and cognitive capacities fall within the 

domain of psychological testing. Assessing 

the presence of specific cognitive impairments, or HIV-associated dementia, and 

the status of general cognitive functioning 

is the domain of neuropsychological testing. Performed by clinical psychologists or 

neuropsychologists, such testing or screening relies on various tests and instruments 

to assess intellectual functioning; reading 

and math skills; speed of mental processing 

or problem-solving; and status of memory 

and recall. 

Figure 7 

Standardized Clinical Assessment Tools Used By Demonstration Sites 

Domain Standardized Measure Site 

Alcohol and ASI (alcohol & drug sections) All sites 

Drug Abuse Addiction Problem Survey Richmond 

CAGE Atlanta, Alexandria 

Anxiety Beck Anxiety Inventory San Juan 

State Trait Anxiety Inventory Atlanta 

Demoralization PERI Demoralization Scale New York, Elizabeth 

Depression	 CES-D New York, Elizabeth 

Hamilton Depression Rating Scale Atlanta 

Beck Depression Inventory Elizabeth, San Juan, 

San Francisco, Alexandria 

Neuropsychological Trail Making Test (Parts A & B) Richmond 

Disfunction Dementia Rating Scale Richmond 

Bender Gestalt	 Richmond, San Juan 

Psychiatric Distress Brief Symptom Inventory Atlanta 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
DELIVERING SERVICES Chapter 5: Clinical Assessment 65 

Figure 8 

Pros and Cons of Using Standardized Measures 

PROS 

• May give clinicians information that they cannot get any other way 

• All clinicians use the same procedures to obtain information about 

specific areas 

• There is a greater probability that the data can be quantified 


and analyzed
 

• The program will have the capacity to compare types of clients served 

with other programs that are using the same assessment tools 

• May give clinicians another perspective on the client 

• Have established validity 

• May have greater generalizability 

• May provide greater confidence in the findings 

CONS 

• The norms may not be pertinent to the program's target population 

• Can take longer to administer and score than administering non-standardized tools 

• Can require formal training of the interviewers 

• The information may not be meaningful or clinically relevant 

• Getting the information in a timely fashion may not be possible 

• Can be an obstacle for treatment, especially when a program's 

"unspoken rule" prioritizes assessment requirements over helping 

clients with presenting problems 

• Can be an "unfriendly" approach to getting information from clients 

• Can be expensive to purchase, administer, and score 


standardized measures
 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
66 DELIVERING SERVICES Chapter 5: Clinical Assessment 

Because HIV can affect the brain in 

numerous ways, it is highly desirable for clinicians to use neuropsychological testing as 

an adjunct to their clinical assessments. 

While many programs will not have these 

services available on-site, it is strongly recommended that program planners and clinicians access neuropsychological testing 

services from other sources because testing 

can provide a valuable and clinically rich 

contribution to the assessment and treatment planning process. 

Neuropsychological testing can give clinicians a better understanding of the 

impact of HIV on the brain itself, including functioning associated with tasks 

related to memory, attention, concentration, planning, and prioritizing. Problems 

in these areas of functioning may be 

directly affected by HIV infection—even 

during its early stages. Clients who complain of forgetfulness, who become lost 

while traveling, or who have difficulty 

adhering to scheduled appointments 

and/or medication dosing may be displaying some signs of the cognitive impairment commonly associated with HIV. 

Since these symptoms may not be readily 

identified by the medical provider, it is 

important to acknowledge, inquire about, 

and assess these troubling instances when 

they occur. 

Such impairment may not only be related 

to HIV but may result from other mental 

or substance abuse disorders, such as 

depression or substance-induced dementia, as well as from medical diseases, such 

as poorly controlled diabetes and/or liver 

disease. Frequently, there are clients who 

are triply diagnosed, whose symptoms and 

disorders related to HIV, mental health, 

and substance use disorders further complicate and contribute to a decline in cognitive functioning. 

Once interpreted, both psychological and 

neuropsychological test findings can 

prove valuable in determining a diagnosis—even when the clinical symptomatology may be complex. They also may 

provide an accurate assessment of previous and current capabilities related to 

memory, attention, problem-solving, and 

concentration, and identify specifically 

how a client’s ability to plan, organize, 

and prioritize life concerns may be 

impaired. Due to the progressive nature of 

HIV and its biomedical and psychiatric 

impact, it is important to monitor cognitive capabilities over time, either informally through observation of a client’s 

behavior and comments or more formally 

through repeated psychological or neuropsychological screening or testing. For 

clients, testing results can help demystify 

troubling and intrusive symptoms, as well 

as assist with differential diagnosis; support treatment planning; help educate 

clients about the implications of cognitive impairment in daily living; lead to 

strategies clients can use to compensate 

for cognitive changes; support a client's 

disability claims; inform providers about 

client strengths; and provide information 

about client support networks. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
67 

CHAPTER 6: 

Psychiatric & Neurologic Conditions

There are several neuropsychiatric complications 

associated with HIV infection. These complications 

have numerous etiologies. Awareness of them will assist 

clinicians in appropriate client assessment, referral, and 

treatment. In almost all cases, access to a clinician with skills 

in neuropsychiatric assessment and treatment is essential. 

Neuropsychiatric conditions are rarely isolated occurrences. 

Instead, they generally occur in conjunction with other 

medical, mental health, and substance abuse problems. These 

complications, particularly when left untreated, are associated 

with increased morbidity and mortality, impaired quality of life, 

and numerous psychosocial challenges, such as nonadherence 

with the treatment regimen. The complexity of these 

conditions should encourage all mental health clinicians to 

incorporate multidisciplinary approaches to client-centered care. 
68 DELIVERING SERVICES Chapter 6: Psychiatric & Neurologic Conditions 

For the purposes of this Practical Guide, neuropsychiatric 

complications are categorized as follows: 

• Disorders attributed to HIV in the brain 

• Disorders due to medical complications of HIV infection 

• Psychiatric disorders 

• Serious mental illness 

For each of these conditions, comprehensive management 

strategies require skilled interventions that utilize psychotropic 

medication management, medical treatment, behavioral 

management, and psychosocial care. 

Estimated Prevalence (Past 12 Months) of Selected Psychiatric and 

Substance Use Disorders Among 1,837 Clients Served in the Demonstration Program 

MOOD AND ANXIETY DISORDERS (%) SUBSTANCE USE DISORDERS (%) 

Major Panic Alcohol Drug

Depression Dysthymia GAD Agoraphobia Attack Dependence Dependence 

58.8 22.4 25.5 14.3 24.7 22.1 47.6
 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
DELIVERING SERVICES Chapter 6: Psychiatric & Neurologic Conditions 69 

DISORDERS ATTRIBUTED TO HIV 

IN THE BRAIN 

HIV-Associated Dementia (HAD). 

Clients who develop HAD generally will 

experience abnormalities in their cognitive 

and motor abilities that significantly impair 

their ability to function effectively. HAD 

signals progression to AIDS for those HIVpositive persons not yet meeting AIDSdefining criteria. Generally, HAD occurs in 

later stages of HIV infection, and debilitating symptoms may progress over time. 

Pharmacological treatments include antiretroviral therapies and psychotropic medications. This condition cannot be 

diagnosed when a client is simultaneously 

experiencing delirium (see below). 

Screening instruments that may be helpful 

in diagnosing HAD include the MiniMental State Examination (Folstein et al, 

1975) and the HIV Dementia Scale 

(Power et al, 1995). 

Minor Motor-Cognitive Disorder 

(MMCD). Clients who develop MMCD 

will experience mild and sometimes subtle decrements in their motor or cognitive 

functioning. Examples include clients 

who have slight difficulty coordinating 

finger or hand movements, but not to the 

extent that use of their fingers or hands is 

severely limited. Similarly, clients may 

develop mild impairments in memory, but 

not to the extent that their impairment is 

noticeable by others. MMCD does not 

necessarily progress to HAD. 

Delirium. This neuropsychiatric disorder 

is characterized by a disturbance of consciousness (i.e., reduced clarity or awareness of one’s environment) with reduced 

ability to sustain attention. Delirium is 

accompanied by memory problems and 

perceptual disturbances, such as illusions 

(e.g., misinterpreting objects or persons as 

something else). The condition develops 

over hours to days and fluctuates throughout the day. Delirium is the most common 

neuropsychiatric complication in hospitalized persons with HIV who are severely 

ill. A screening instrument helpful in 

diagnosing delirium is the Mini-Mental 

State Examination (Folstein et al, 1975). 

Treatment. Primary treatment for these 

conditions attributed to HIV in the 

brain consists of medical management 

(e.g., psychotropic and antiretroviral 

agents) in combination with psychotherapeutic and support services. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
70 DELIVERING SERVICES Chapter 6: Psychiatric & Neurologic Conditions 

DISORDERS DUE TO MEDICAL 

COMPLICATIONS OF HIV INFECTION 

The course of HIV infection may include 

medical complications that create 

changes in one’s mental status that mimic 

more common psychiatric conditions, 

such as depression, mania, anxiety, and 

psychosis. The most critical feature of 

treatment is accurate diagnosis and treatment of the medical causes. Although 

psychotropic medications often are warranted for symptom relief, at least temporarily, overall management should 

focus on treating the underlying medical 

complication(s). When these conditions 

occur, coordinated care with medical 

providers is absolutely essential. 

These complications highlight the need 

for clinicians to be aware of and knowledgeable about clients’ medications and 

substance use patterns and to be suspicious of major changes in mental status, 

particularly among clients with more 

advanced illness or those on many 

medications. 

Treatment. Primary treatment for these 

conditions due to complications of HIV 

infection relies on treatment of the underlying medical etiology. 

Medical 

Complication 

Possible 

Causes 

Possible Underlying 

Causes of Common 

Medical Complications 

Associated with HIV 

Opportunistic brain infections 

Toxoplasmosis 

Cryptococcal meningitis 

Cytomegalovirus infection 

Tuberculosis 

Progressive multifocal leukoencephalopathy 

Opportunistic cancers 

Lymphoma 

Kaposi’s sarcoma 

Metabolic complications 

Fever, 

Anemia 

Blood infections 

Hypoxia 

Drug-to-drug toxic interactions 

Corticosteroids 

Alpha-interferon 

Protease inhibitors 

Psychoactive substance 

use complications 

Recreational 

Cocaine 

Alcohol 

Methamphetamine 

Hallucinogens 

Nitrate inhalant 

Opiates 

Prescribed 

Sedative hypnotics 

Opiates 

Psychostimulants 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
Psychiatric Conditions Examples of Symptoms 

Mood Disorders 

• Depression Pervasive sadness, apathy, fatigue, suicidal ideation, 

hopelessness, appetite and sleep changes 

• Mania (Bipolar Disorder) Increased energy, decreased need for sleep, 

racing thoughts, grandiosity 

Psychotic Disorders 

• Schizophrenia Auditory hallucinations, delusions, thought disorders 

Anxiety Disorders 

• Generalized anxiety disorder, Nervousness, heightened arousal, panic attacks, 

panic disorder, obsessive-compulsive intrusive anxiety-provoking thoughts, 

disorder, post-traumatic stress disorder obsessions/rituals, flash backs 

Adjustment disorders Depression and/or anxiety of less severity and 

directly related to an identifiable stressor 

Personality disorders Persistent, maladaptive life behaviors that 

interfere with interpersonal relationships 

Sleep disorders Difficulty initiating and/or maintaining sleep 

Sexual functioning disorders Diminished libido, difficulty having an orgasm, 

difficulty obtaining or maintaining an erection 

Constitutional problems 

• Chronic fatigue Chronic lack of energy 

• Wasting syndrome Chronic muscle wasting 

• Pain Chronic pain from such conditions as neuropathy 

DELIVERING SERVICES Chapter 6: Psychiatric & Neurologic Conditions 71 

PSYCHIATRIC DISORDERS 

Numerous psychiatric disorders have been identified among people with HIV infection. 

Some of these disorders may have existed prior to the HIV diagnosis, while others may 

have developed during the course of living with HIV. Some of the more common conditions are listed below. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
72 DELIVERING SERVICES Chapter 6: Psychiatric & Neurologic Conditions 

Psychotropic Medications 

Psychotropic medications, such as those 

agents used to treat depression, anxiety, 

psychosis, and other conditions, are 

well tolerated and clearly efficacious for 

persons living with HIV infection. 

Psychiatric disorders should be treated 

aggressively with these medications 

when warranted, especially since 

untreated disorders can impair one’s 

quality of life and may be linked to 

increases in HIV transmission risk behaviors (e.g., unsafe sex and drug use practices). Psychotropic agents should be 

used judiciously in persons on antiretroviral and other HIV-related medications. 

In most cases, psychiatrists should manage these medical regimens. The combined use of psychotropic agents and 

protease inhibitors requires careful attention to routes of metabolism of each of 

these medications. Because the medications can alter the metabolism of each 

other, they are best prescribed and 

monitored by clinicians with an understanding of potential drug-to-drug interactions, side effects, and routes of 

metabolism. These medications can be 

used safely and effectively when combined. However, informed treatment 

and close monitoring is essential. 

...client-centered,
 

individualized, and 

comprehensive...
 

Treatment. Mental health treatment of 

psychiatric disorders should be client-centered, individualized, and comprehensive 

to encompass the full spectrum of biopsychosocial needs. In most cases, due to the 

complexity of these conditions, no single 

modality of treatment will suffice. 

Clinicians should consider a full range of 

treatments, including psychopharmacology; cognitive-behavioral, interpersonal, 

psychodynamic, and other psychotherapies aimed at individuals, groups, families, 

and couples; intensive case management; 

psychosocial rehabilitation; partial hospitalization; day treatment programs; substance abuse counseling; and others. 

For persons with serious mental illness, 

treatment may need to be uniquely tailored 

to strengthen diminishing social support 

systems. To promote stability and treatment adherence, consideration must be 

given to supportive housing, living arrangements, vocational rehabilitation, outreach, 

and strong linkages with other community 

resources. Persons with serious mental illness who are not engaged in mental health 

care are less likely to be engaged in HIV 

primary medical care (Cournos & 

McKinnon, 1997). Moreover, they are at 

higher risk of being lost in the system due 

to homelessness, incarceration, rehospitalization, and substance abuse relapse. For all 

of these reasons, diagnosis or identification 

of mental illness, including HIV-related 

neuropsychiatric complications, requires 

aggressive treatment and is a critical component to the overall health care of HIV 

positive clients. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
DELIVERING SERVICES Chapter 6: Psychiatric & Neurologic Conditions 73 

Caroline’s Story 

Caroline was an attractive woman in her mid-30s with a pleasant disposition 

and a ready smile. Diagnosed with schizophrenia and HIV-associated dementia, 

Caroline’s situation was further complicated by volatile and poorly controlled 

diabetes. While her schizophrenia was stabilized through regular intramuscular 

injections of Haldol Decanoate, her short-term memory was impaired by HIVassociated dementia, ruling out the possibility that she could adequately adhere 

to the range of medical treatments she required on her own. 

Neuropsychiatric testing revealed that, in addition to short-term memory loss, 

Caroline had difficulty concentrating, planning, or solving problems. These cognitive deficits prevented her from being able to check her glucose levels (which 

had soared to as high as 410), determine if she needed insulin, and inject the 

proper amount. Although her HIV infection was not yet advanced, adherence 

to needed HIV medications also was problematic. 

Her psychological counselor quickly realized that a series of external supports 

were needed to ensure Caroline’s survival. The counselor enrolled her in a psychosocial support day program and arranged for a Medicaid waiver that provided for a nurse to go into the home twice a day to administer Caroline’s 

insulin. She was then placed in a group home in which overnight staff could 

ensure that she didn’t eat middle-of-the-night snacks that would elevate her 

blood sugar levels or light up cigarettes she might forget to put out. The counselor involved Caroline’s family in treatment planning and educated them about 

her medical condition and her cognitive limitations. Close coordination with the 

public health nurses, the residential counselor, and Caroline’s family members 

has resulted in a safe and supportive environment where Caroline retains some 

freedom and self-direction, but where her biopsychosocial needs are met. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
74 DELIVERING SERVICES Chapter 6: Psychiatric & Neurologic Conditions 

SERIOUS MENTAL ILLNESS 

Serious mental illnesses (SMI), particularly those illnesses which cause persons to 

experience severely distorted thinking or 

cognitive impairment, pose unique challenges in HIV treatment. Serious mental 

illnesses may be conditions that are 

directly attributed to HIV infection, such 

as the neurocognitive disorders previously 

described (e.g., HAD), or conditions that 

existed before a person becomes HIV-positive, such as schizophrenia, bipolar disorder, and severe personality disorders. 

These conditions create numerous challenges for clients and providers alike, 

including increased likelihood of the 

client engaging in high-risk behaviors and 

other maladaptive health behaviors, such 

as substance abuse and treatment nonadherence. 

Persons with SMI often experience high 

rates of unemployment, poverty, and 

homelessness. For these reasons, persons 

with SMI typically lack access to health 

care, substance abuse treatment, HIV primary medical care, and new antiretroviral 

therapies. As a result, persons with SMI 

are likely to have shortened HIV-related 

survival, severely impaired quality of life, 

and more complications from HIV and 

other medical problems that disproportionately affect persons who are marginalized in health care systems. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
75 

CHAPTER 7: 

Case 

Management 

Case management, as an accepted mental health 

treatment modality, developed largely in response to 

deinstitutionalization—the release of large numbers of persons 

with serious mental disorders from state hospitals in the 1980s. 

Community mental health centers were charged with 

developing methods for effectively treating and maintaining 

those who were released back to the community. In order to 

prevent frequent re-hospitalizations, it was often necessary to 

put in place a wide range of services to support the client in 

meeting basic human needs. While the resources—such as 

food, shelter, medical care, financial assistance—were often 

already in place in the community, staff with an 

understanding of serious mental illness and local resources 

were needed to link clients to services and to monitor treatment adherence and general functioning. 
76 DELIVERING SERVICES Chapter 7: Case Management 

...a 

service plan 

based 

on needs... 

Due to the many concrete service needs of 

those living with HIV infection, case management has long been a cornerstone of 

HIV care. The Ryan White CARE Act has 

recognized the importance of case management and allocates a significant amount of 

its funding for case management. Today, as 

HIV increasingly moves into communities 

of poverty, a disproportionate number of 

persons who are homeless, have mental 

and addictive disorders, lack experience in 

accessing services, and/or who are in jails 

and prisons are affected. Given these 

trends, the need for case management 

becomes even more profound. 

As the HIV/AIDS Mental Health Services 

Demonstration Program progressed, many of 

the 11 projects found themselves allocating 

more and more resources for case management, underscoring the growing need and 

demand for this function in assisting people 

living with HIV who also have mental 

and/or addictive disorders. This chapter 

describes the Demonstration sites’ experiences in providing case management services to people living with HIV. 

CASE MANAGEMENT ACTIVITIES 

Assessing the client’s needs. With input 

from the client, the case manager assesses 

the client’s comprehensive biopsychosocial needs. The case manager’s assessment 

will complement the clinical assessment 

referred to in Chapter 5, which needs to be 

comprehensive and thorough and take the 

needs of the whole person into account. In 

cases where the needs are immediate or 

urgent, the case manager must possess the 

judgment and skills necessary to make an 

emergency referral for food, shelter, psychiatric hospitalization, detoxification, or 

emergency room care. 

Developing a service plan. Together, the 

client and the case manager develop a 

service plan based on the needs identified 

in the case manager’s assessment. 

Encouraging the client to prioritize his/her 

own needs helps to establish trust between 

the client and the case manager. It also 

reinforces the client’s sense of self-determination. The case manager needs to honor 

what the client sees as the priority. For 

example, the case manager may believe 

getting medical care for HIV infection is 

first on the list, while the client may be 

more worried about paying next month’s 

rent. A written service plan—jointly 

agreed to and signed by the client and the 

case manager—is a useful instrument in 

establishing trust and setting service priorities. The agreement can serve as a valuable reference tool for reflecting back upon 

what has been accomplished and planning 

for goals not yet met. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
DELIVERING SERVICES Chapter 7: Case Management 77 

Linking the client to services. Clients with 

HIV often need a broad range of services. 

These may include primary medical care, 

mental health and substance abuse treatment, financial assistance, housing, food, 

financial entitlements, clothing, transportation, child care, dental care, and legal 

services. Many clients need help in obtaining resources and/or connecting with 

services. The process of coordinating a 

broad range of health care and support 

services requires a case manager with creativity, negotiation skills, political savvy, 

and a knowledge of community resources. 

In cases where the client is capable of 

accessing services, simply giving him/her a 

phone number may be sufficient help. If, 

on the other hand, the client has a serious 

mental illness, HIV-associated dementia, 

poor communication skills, or is unfamiliar 

with the service delivery system, the case 

manager may need to schedule appointments and accompany the client to the 

appointment. The case manager often 

serves as a “go-between” with the service 

provider when long and difficult forms 

must be filled out or when the client 

becomes tired or frustrated and unable to 

go through the cumbersome steps required 

to obtain the needed service. Case managers can make productive use of this time 

spent transporting or waiting with the 

client to build a positive therapeutic relationship and to engage him/her in mental 

health treatment. At the same time, the 

opportunity can be seized to nurture working relationships with other service 

providers to facilitate future referrals and 

collaboration. 

Monitoring the client’s progress. Since the 

client’s biopsychosocial needs are dynamic 

and ever-changing, it is important for the 

case manager to regularly monitor the 

client’s level of functioning and his/her 

progress. This monitoring includes assessing medication adherence and relapse prevention, reviewing the client’s service 

needs, and refining the treatment plan. 

Since many clients’ lives are dominated by 

chaos related to substance abuse, poverty, 

and the progression of HIV infection, the 

case manager’s aggressive follow-up, outreach, and re-engagement efforts can be 

key to the client’s length and quality of life. 

...coordinating 

a broad range of 

health care and 

support 

services... 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
78 DELIVERING SERVICES Chapter 7: Case Management 

Advocating on behalf of the client. 

Persons with HIV face a broad range of 

stigmatizing attitudes and actions, stemming from society’s response to the person’s 

mental illness, substance use, HIV status, 

race, sexual practices, socioeconomic status, cognitive deficits, homelessness, and/or 

criminal record. When a door is shut, an 

opportunity is denied, or a right is violated, 

feelings of helplessness, hopelessness, and 

rage can take over. While the goal is to 

empower the client to advocate for himself/herself, the case manager has a responsibility to intervene when the client is 

unable to do so. 

Examples of discrimination in emergency 

rooms, housing opportunities, and employment situations abound—as do examples of 

effective advocacy. While advocacy on an 

individual level is the immediate task, the 

dedicated case manager also keeps in mind 

his/her responsibility to advocate for 

change on a systems level so that institutionalized prejudice and discrimination 

against persons with HIV, mental illness, 

substance abuse, or members of a minority 

race, minority sexual orientation, or minority religion can be addressed. Effective 

advocacy on an individual and systemic 

level can positively affect the whole climate of future service delivery. 

CASE MANAGEMENT 

TREATMENT PHASES 

Case managers at the Alexandria project 

identified five phases of treatment in 

working with persons who are homeless 

and dually diagnosed with mental and 

substance abuse disorders (Alexandria 

Community Services Board, 1994). 

• The acute stabilization phase may 

require detoxification or hospitalization to stabilize acute medical or psychiatric symptoms. 

• The engagement phase is the time 

during which the helping relationship 

is developed and basic services, such 

as food and shelter, may be provided. 

• The persuasion phase occurs when 

the case manager encourages the 

“engaged” client to recognize and 

accept the need for treatment. 

• The active treatment phase is the 

stage during which the client develops the attitudes, behaviors, skills, and 

determination to accept treatment 

and does so. 

• The relapse prevention or rehabilitation phase is when the client develops a greater sense of mastery over 

his/her disorder(s) and exhibits 

greater competence in functional and 

social capabilities. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
DELIVERING SERVICES Chapter 7: Case Management 79 

Elijah’s Story 

In recovery from a crack cocaine habit for almost three years and climbing 

steadily up from a major depression, Elijah faced eviction from the small apartment where he lived with his teenage son. Savings from occasional jobs had 

supplemented his meager veteran’s disability pension, but now a rent increase 

forced him to look for subsidized housing. His mental health worker had identified an apartment in a well-kept building in a safe neighborhood where another 

of her clients lived. She had dealt with the landlady before and set up an 

appointment to look at the apartment. 

The moment the white landlady laid eyes on the dark-complected Elijah, she 

began to make excuses. “Someone in the building has just asked if he could move 

to a two-bedroom, so I have promised it to him. I’m sorry, but the apartment is no 

longer available.” Elijah immediately became agitated. A sensitivity born of countless encounters with subtle—and not-so-subtle—race discrimination left no doubt 

in his mind about the motivation of the woman standing before him. “I’ll never get 

this apartment,” Elijah mumbled to his worker. “Let’s get out of here.” Herself 

Hispanic and a woman of color, the worker also picked up the vibes. Returning to 

the office in anger, she spoke with her supervisor and colleagues, relating the 

experience and its impact on Elijah. 

The HIV team immediately took action. A team member called to inquire about the 

apartment’s availability and was told she could come to see it in the morning, providing sufficient evidence to call the Housing Authority to register a discrimination 

complaint. “We’ll investigate right away.” The mental health worker, realizing she 

might need to deal with the landlady in the future, called her and diplomatically 

expressed her puzzlement and dismay at Elijah’s being turned down and hinting 

at discrimination. The landlady vehemently denied she had been discriminating, 

but lo and behold, the upstairs neighbor had changed his mind about moving into 

a two-bedroom apartment. Elijah and his son got their clean, new apartment. 

In this true case of discrimination, successful advocacy had a beneficial impact on 

both the individual and the system. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
80 DELIVERING SERVICES Chapter 7: Case Management 

CASE MANAGEMENT 

PROVIDERS AND SETTINGS 

Because the need to link persons with HIV 

to a spectrum of resources and services is 

readily apparent, a range of disciplines and 

persons with varying levels of education 

and skill have felt called upon to provide 

case management when necessary—from 

psychiatrists and psychologists to social 

workers, counselors, case aides, and peer 

providers. With the need for case management increasingly being recognized by 

many health fields, specialized forms of case 

management have developed in mental 

health, public health nursing, social services, and substance abuse. 

The level of training, education, and 

skill required to be an effective case 

manager often is underestimated. To 

work effectively with clients who are 

triply diagnosed with HIV, mental illness, and a substance use disorder, a master’s degree in a human services field is 

highly desirable. An effective case manager brings a broad range and high level 

of skills and/or natural ability to his/her 

work, including an ability to establish 

rapport, to understand the client’s 

biopsychosocial needs, and to know the 

resources that are available in the community. He/she must possess determination, persistence, advocacy skills, 

empathy, and tact. In the field of behavioral sciences, increased recognition and 

credit is being given to case managers 

and the important work they do. 

With many case managers working in mental health centers, medical clinics, substance abuse programs, and AIDS service 

organizations, service duplication and gaps 

can become problematic. Coordination of 

services among providers through establishing clear, individual responsibilities is necessary to make the most efficient use of 

limited resources. Designating a “primary 

case manager” and holding periodic “prescription team” meetings in which all 

providers and the client are present is useful 

in providing quality care. (See Chapter 4 on 

Mental Health Services.) 

Case management can be provided with 

varying degrees of intensity. Working with 

persons who are triply diagnosed and also 

homeless or recently incarcerated requires a 

high level of assistance or intensity—and a 

correspondingly smaller caseload. A highfunctioning client may need assistance in 

accessing HIV or mental health resources 

from time to time but is generally capable of 

navigating the system on his/her own with 

little outside help. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
DELIVERING SERVICES Chapter 7: Case Management 81 

...targeted, strategic approaches...
 

BUILDING A STRONG 

HELPING RELATIONSHIP 

At the heart of effective case management 

is a strong, trusting, and collaborative helping relationship. Working with an HIVaffected population that is increasingly 

disenfranchised, stigmatized, and alienated 

from society requires special skills and a 

special attitude on the part of the case 

manager. Efforts to engage and retain the 

client in service often require targeted, 

strategic approaches. Meeting the client on 

his/her own turf and hiring culturally sensitive and street-wise outreach workers who 

establish contact and serve as a bridge 

between the client and the provider can 

significantly improve engagement and 

retention rates. Many clients feel degraded 

by their present circumstances and have 

felt rejection from their family, their 

church, and their peers. Experiences in 

dealing with “the system,” including the 

criminal justice system and recovery programs often have been negative and disempowering. At times suspicious of others, 

disorganized in their thoughts, and/or in 

denial about their HIV status or substance 

abuse, many view the case manager reaching out to help with profound distrust. 

In developing rapport and trust with the 

client, the Demonstration sites found the 

following approaches effective: 

• Focus efforts on the person’s skills, 

strengths, and potential, as well as 

his/her capacity to change or improve 

his/her quality of life. 

• Solicit and encourage client selfdetermination in setting priorities 

for obtaining services. 

• Remain consistent, flexible, 

nonjudgmental, positive, and helpful. 

• Accept the person for who he/she is. 

• Be patient in all interactions with the 

client. Be readily accessible when 

needed by the client. Avoid demanding too much too soon. 

• Respect the person’s need and right 

to decide when and how he/she 

will accept help. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
82 DELIVERING SERVICES Chapter 7: Case Management 

BARRIERS TO EFFECTIVE 

CASE MANAGEMENT 

Barriers to obtaining needed services, 

treatment, and interventions exist for 

both the client and the provider. The 

effective case manager is presented with 

the challenge of using ingenuity, creativity, and people and problem-solving skills 

to overcome these barriers with and on 

behalf of the client. In the course of their 

work, the 11 Demonstration projects 

encountered, identified, and overcame 

many such barriers at both individual and 

systemic levels. Possible ways to address 

and minimize these barriers are discussed 

throughout this Guide. 

Barriers Faced By The Case Manager 

• Personality or value conflicts among 

service providers 

• Ethical issues related to disclosure and 

“duty-to-warn” 

• Difficulty maintaining professional 

boundaries with clients 

• Lack of adequate resources to meet 

client needs 

• Restrictions on the number of 

days allowed for hospitalization 

or treatment 

• Bureaucratic red tape preventing 

quick responses 

• Discrimination against client 

population 

• Client expectations and demands that 

are unrealistic or cannot be met 

Barriers Faced By The Client 

• Distance from needed services 

and providers 

• Unduly cumbersome application and 

referral processes 

• Lack of transportation to and from 

appointments 

• Lack of child care while keeping 

appointments 

• Distrust of the service system 

• Fear of confidentiality violations 

• Social stigma and discrimination 

• Cultural insensitivity and 

language barriers 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
83 

CHAPTER 8: 

Psychotherapy &Counseling 

Therapists make decisions about psychotherapy and counseling 

approaches based on their education, training, supervision, and 

personal experience. The 11 sites in the Demonstration Program 

found that client need was the most important factor in selecting the 

approach. Traditional approaches required modification to meet new 

and complicated problems associated with living with HIV. 

Psychotherapeutic and counseling approaches used by the Demonstration 

projects included: 

• Cognitive/behavioral therapy 

• Supportive psychotherapy 

• Pastoral counseling 

• Crisis intervention/therapy 

• Brief psychotherapy 

• Educational counseling 

• Psychoanalytic psychotherapy 

• Existential psychotherapy 
84 DELIVERING SERVICES Chapter 8: Psychotherapy & Counseling 

PROFESSIONAL INTERVENTIONS 

Psychotherapy and many types of counseling are primarily provided by trained 

professionals who are prepared to facilitate behavioral and cognitive change. A 

mental health professional must consider 

how the intervention can be shaped to 

incorporate the many psychosocial complications of HIV infection. 

It is helpful for service providers to be 

mindful that "traditional" service patterns 

often have to be reconsidered in order to 

provide adequate services. The 11 

Demonstration projects found the concept of "bending the frame" to be a helpful way of doing this (Winiarski, 1991). 

For example, through the process of dealing with HIV infection, many service 

providers have found themselves visiting 

clients at their homes or at hospitals— 

something that is not usually considered a 

common procedure of more traditional 

mental health service approaches. 

Additionally, the crisis of HIV infection 

brings many individuals into mental 

health treatment who have no previous 

experience or familiarity with the process. 

For example, some traditional psychotherapists elect not to call their clients if they 

miss a psychotherapy appointment. 

However, the 11 Demonstration projects 

found themselves spending a great deal of 

time focusing on retention efforts, such as 

calling clients to remind them of appointments and making follow-up calls. Such 

calls seemed to help Demonstration 

Program clients understand that the therapeutic process was taken seriously by the 

program staff. In time, many clients began 

to take ownership and responsibility for 

their own treatment, which may have 

never occurred without the retention 

efforts put forth early on in the process. 

Other examples of “bending the frame” 

included harm reduction approaches to 

substance abuse treatment, in-home services, telephone sessions, and intensive 

case management coupled with 

psychotherapy. 

Another important facet of the process 

was to develop and/or maintain a “community” in which Demonstration Program 

clients felt comfortable seeking help. This 

was accomplished in a variety of ways— 

from peer interaction to group interventions to a structured community in a 

psychosocial rehabilitation program. 

Individual interventions. For persons 

with HIV who seek mental health services, individual counseling or psychotherapy sessions are generally a first step in the 

treatment process. Client concerns about 

confidentiality, substance use, sexual orientation, and sexual practices may initially make one-to-one interventions the 

most comfortable modality. Counseling 

generally refers to explorations and problem-solving interventions relating to current concerns and issues, such as adjusting 

to the HIV diagnosis, managing relationships, and job and workplace issues. 

Psychotherapy explores feelings, motivations, behavioral patterns, interpersonal 

relationships, and patterns of thinking 

over time. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
DELIVERING SERVICES Chapter 8: Psychotherapy & Counseling 85 

In the experience of the 11 

Demonstration projects, a significant 

number of clients with HIV had histories 

of early sexual abuse and boundary violations. For those clients, working through 

aspects of the childhood trauma can be 

both a liberating and necessary step in 

moving toward a commitment to selfcare and a reduction of risk-taking 

behaviors. Psychotherapy can help 

clients develop greater self-awareness, 

stronger coping skills, and greater motivation to engage in meaningful and productive activities. Through counseling 

or psychotherapy, clients in recovery 

from substance abuse often discover and 

begin to heal underlying psychological 

wounds they attempted to mask through 

substance use. 

Length of treatment varies by case. For 

some Demonstration projects, treatment 

lasted as long as clients kept returning 

for their appointments. Since most 

Demonstration Program clients had complex psychosocial needs, treatment was 

oftentimes long-term, with mental health 

professionals constantly re-evaluating 

their treatment plans to ensure they were 

realistic and client-centered. 

Group interventions. All of the 

Demonstration projects used group interventions to some degree. Some used 

group therapy on an occasional basis, 

while other Demonstration projects were 

exclusively focused on group interventions. Group interventions can be a very 

powerful way of facilitating change or 

managing mental health issues associated 

with HIV infection. Group interventions can often be modified to better 

address the specific needs of the group 

and its members. 

Groups can be led by either professionals, 

peers, or a combination of both. Mental 

health professionals may be better suited 

to serve as facilitators in groups designed 

to deal with mental health issues, such as 

psychotherapy groups. Peers, on the other 

hand, may be better suited to lead support 

groups and group discussions relevant to 

the experience of living with and adapting 

to HIV. However, both professionals and 

peers, depending on their personal experience and training, may be qualified to 

address either of these concerns. 

The 11 Demonstration projects found the 

following issues important when creating 

a “safe” group: 

• Consider issues relating to inclusion/ 

exclusion criteria. 

• Have individual selection interviews in 

which group processes and rules are 

reviewed and agreed upon. 

• Create a "confidentiality agreement" that 

all clients read, agree to, and sign before 

ever coming to the group. 

• Establish clear rules for the group process, 

including rules on how to address others, 

accepted behavior in the group, maintaining a safe environment, outside visitors to 

the group, schedule and meeting place, 

and interactions outside the group. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
86 DELIVERING SERVICES Chapter 8: Psychotherapy & Counseling 

GROUP INTERVENTIONS 

Support groups are organized meetings in 

which participants exchange information on 

life situations to develop new ways to manage, 

adapt, or change the situation. Support 

groups have been the mainstay of psychosocial 

support within HIV-affected communities 

since the beginning of the epidemic. 

Particularly for people living with HIV, support groups offer a venue for sharing information and experiences. For example, disclosure 

of status with family and friends, reaction to 

d their side effects, disappointments regarding medical setbacks, and issues around 

re-entering the job market 

are common themes one

may encounter in an HIV 

support group. A major goal 

of support groups is to 

increase the social support 

networks of its members. 

One of the benefits is the

creation of friendships

among participants that may

last beyond the group 

process. Outside interaction 

is sometimes promoted. 

medications an

g several 

hile incarnew comfamily. His 

onely and 

unity supral friended that, in 

d diabetes 

Derrick’s Story 

Derrick had been released after servin

years in prison. He had stayed sober w

cerated and continued to do so in the 

munity in which he had settled with his 

HIV course had improved, but he felt l

isolated. He became involved in a comm

port group where he developed seve

ships. This proved necessary as he learn

addition to his HIV infection, he also ha

and advanced liver disease. Months later, a friend 

from the group was hospitalized with the same 

diagnoses and died soon after. Derrick became 

consumed with the idea of his own death and 

physical status. He focused his energy on weight 

loss and appetite. He had linked progressive wasting with death. The support group helped Derrick 

confront this irrational belief and refocus his energies toward self-care. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
DELIVERING SERVICES Chapter 8: Psychotherapy & Counseling 87 

Psychoeducational groups 

are directed at obtaining and 

processing new information. 

They usually have a limited 

scope and duration. Many 

use "invited" speakers in 

addition to the group facilitator. "Teaching" by the 

facilitator or invited guests 

can be part of the group 

process but other interactional processes also can 

serve as a powerful way of 

"learning" (Freire, 1993). 

Examples of psychoeducational group topics from the 

11 Demonstration projects 

included recognizing depression, managing cognitive impairment, 

HIV medication adherence, understanding psychotropic medications, disclosure 

of status, and returning to work. 

Couple and family interventions provide 

the opportunity for the client’s significant 

other and/or loved ones to join the treatment process. The diagnosis of HIV not 

only affects the infected person but 

his/her entire “family.” For example, disclosure of status, safer sex negotiations 

with a partner, permanency planning, 

sero-discordant couples, and unresolved 

fear and anger are issues that may be 

encountered by treating a family or couple. Additionally, HIV may bring additional stresses to families already made 

vulnerable by substance abuse or poverty. 

Andy and Phillip’s Story 

Andy had been living with HIV for 10 years when 

he met Philip, a younger, HIV-negative gay man. 

Though initially they expressed comfort with their 

sero-discordant status, several years into their relationship Philip seemed less interested in a sexual 

interaction with Andy and both seemed to struggle with communicating with each other. Couples’ 

counseling sessions over several weeks brought 

them to a point of trust that they were able to discuss their fears—Philip’s concerns about HIV infection and his worry about the impact of HIV on 

Andy’s health. 

Psychosocial Programming Groups 

involve creative expression, skill-building, 

insight development, and socialization. 

These groups are very interactive, often 

involving doing a task rather than verbal 

discussion alone. (See Chapter 13 on 

Psychosocial Rehabilitation.) 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
88 DELIVERING SERVICES Chapter 8: Psychotherapy & Counseling 

PEER COUNSELING 

Peer counseling involves the provision of 

services by individuals who are members 

of the treatment population. At some of 

the Demonstration sites, peer counselors 

shared a number of characteristics, usually 

including HIV status and/or ethnic and 

cultural membership. Peer counseling, 

like professional psychotherapy, can be 

done in several modalities (individual, 

couples, families, and groups). While traditional professional psychotherapy may 

focus on psychological change, peer counseling typically focuses its intervention on 

support and education. 

Peer counseling may be a less stigmatizing 

experience than traditional mental 

health treatment, increase a sense of trust 

and empathy between the counselor and 

the client, allow for a more open discussion of treatment adherence and negotiating the service system, and promote the 

development of “community” among 

clients. It also may be a cost-effective 

way to serve clients. 

Training is a crucial component of peer 

counseling. Peer counselors need specific 

guidance on when to refer clients to professionals and may need training to 

improve their listening and assessment 

skills. Supervision by a professional mental health clinician is critical to safeguard 

the quality of services and to 

help ensure that clients who 

need professional psychotherapeutic help are getting it. There are also 

ethical considerations to be 

addressed to ensure that 

appropriate counselor/client 

boundaries are observed.

Again, supervision is critical.

How One Program Used Peer Counselors	 

“Our peer counselors have done outreach in medical clinics, provided individual and group support, 

led educational forums, and directed peer-based 

substance abuse groups. Those clients whose 

needs were greater or expressed interest or readiness for professional psychotherapeutic treatment 

were referred to the mental health team. Many 

clients have come to mental health treatment 

through the normalization of the counseling experience by peers. This program is supervised by a 

licensed mental health clinician in order to ensure 

appropriate triage.” 

-- Phil Meyer, LCSW 

Los Angeles Project 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
89 

CHAPTER 9: 

Counseling Themes & Clinical 


Considerations 

“Will I lose my dignity / Will someone care / 

Will I wake tomorrow / From this nightmare?” 

These lines from RENT, the Pulitzer prize winning musical 

by Jonathan Larson, evoke the emotional turbulence often 

accompanying a diagnosis of HIV disease. 

Counseling and psychotherapy sessions may include poignant, 

harrowing stories filled with anger, sadness, shame, and rejection. 

During these same sessions, however, people living with HIV can 

find hope, survival, acceptance, and redemption. When working 

with HIV-infected persons, it is essential to be present with such 

pain and hope, whether it is verbalized or not. 

It was the experience of the 11 Demonstration projects that certain counseling themes and clinical considerations emerged 

among all sites. While not an exhaustive list, this chapter highlights the common themes and considerations encountered in the 

Demonstration projects. 
90 DELIVERING SERVICES Chapter 9: Counseling Themes & Clinical Considerations 

Louis’ Story 

Louis was in his early forties when he learned of 

his HIV infection. He had survived a traumatic 

childhood and adolescence in which he was a victim of family incest that was tolerated since the 

perpetrator brought money into the family. 

Multiple oppressions had strangled his self-esteem. 

He is African American, and he questioned 

whether his darker complexion was the reason 

that his mother and grandmother did not love and 

protect him. Aware of his same-sex sexual attractions, he was confused and troubled following the 

sexual assaults by his uncle and chose a path of 

pansexuality and prostitution during which he felt 

hypervigilant, empty, and vacant. Impoverished, 

he recalls holidays and birthdays without gifts 

while watching other children play. Such victimization and lack of nurturance thwarted his ability to 

trust. Nearing his 45th birthday, he stopped using 

alcohol and drugs, an addiction since his teens, 

and began intensive outpatient substance abuse 

treatment accompanied by psychotherapy—resulting in full-time employment, securing his own 

apartment, and several years of sobriety. 

What arises as the important core issues for clients 

will vary, depending on 

their specific life circumstances. For example, 

clients living with families 

who are fearful and uninformed about HIV transmission may describe how 

family members demand 

that they use only 

disposable plates and 

utensils—to “protect” others. Lacking knowledge, 

the family contributes to a 

conclusion for the person 

with HIV that he/she is 

unclean, thereby promoting isolation and stigma. 

The 11 Demonstration projects identified the following 

counseling themes and clinical considerations common 

in the provision of mental 

health services to people 

living with or affected by 

HIV: sense of self and self 

esteem; parenting; fear; disclosure; sexual orientation; 

loss of loved ones; adherence; Lazarus Syndrome; 

and spirituality. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
DELIVERING SERVICES Chapter 9: Counseling Themes & Clinical Considerations 91 

SENSE OF SELF AND 

SELF-ESTEEM 

Clients whose sense of self and self-esteem 

are not strong or fully developed may be 

especially vulnerable to stigma by family 

members and friends. For all clients, the 

sense of stigma and shame related to 

infection may foster feelings of guilt, 

anxiety, and self-loathing. They also may 

contribute to symptoms of depression. For 

women, there are particularly subversive 

effects. They may perceive that HIV will 

mark them as sexually undesirable, cause 

their partners to leave them, or result in 

abuse. For those who have 

survived sexual abuse and 

assault, infection with HIV 

further complicates the healing of one’s shattered self. 

PARENTING 

Specifically for parents, 

complex personal struggles 

will naturally involve guilt 

over having become 

infected, having shortened 

time with their children, 

and/or leaving orphaned 

children—all of which may 

generate a permissive parenting style that impedes 

setting limits and discipline. 

As a result, parents may too 

readily gratify their children’s wants in an effort to 

assuage their guilt. When 

HIV-infected parents 

become ill, it may be more
 

difficult for them to actively 

parent—to discipline and provide caretaking. In such a situation, children may 

develop parentified behaviors and assume 

a caregiver role toward both the parent 

and younger siblings. When a parent 

recovers or ultimately dies, a child may 

find it difficult to relinquish such a role 

and return to a developmental stage suited 

to his/her age. 

Maria’s Story 

Maria, a 22-year-old Latina, lost custody of her 

daughter, due to neglect relating to Maria’s addiction to crack cocaine. Maria did not appear to

understand the responsibilities of being a parent, 

but she was intent upon regaining custody of her 

daughter—even though her worker from Child 

Protective Services (CPS) thought this highly 

unlikely. Over the course of three years, Maria, 

with the help of her therapist, worked diligently on

parenting skills, communication with her family, 

her relationship with CPS, and her substance 

abuse problem—in both individual and family therapy sessions. Several months ago, Maria was 

given custody of her daughter, and her CPS case 

was closed. Maria remains in treatment and currently is working on setting clear and consistent 

limits with her daughter, as well as issues around 

returning to school to get her GED.
 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
92 DELIVERING SERVICES Chapter 9: Counseling Themes & Clinical Considerations 

FEAR 

Fear is a reasonable and expected reaction to HIV. Clients may fear the infection and its progression. They also may 

fear rejection from friends, family, or 

co-workers when they disclose their status. As a result, they may choose not to 

disclose their infection, preferring to 

keep this a secret. This becomes especially complex for families and their 

children as noted above. A parent may 

choose to keep his/her children and the 

family removed from interacting with 

others in the extended family or in the 

community to protect this secret and to 

delay or avoid disclosing his/her status. 

Parents also may decide to disclose 

HIV-related information selectively— 

but only after determining criteria 

about who will be told. 

Families that fear repercussions related 

to stigma may develop a boundary 

around the family and limit contact with 

extended family or the community. 

Such insularity may deplete the parent 

as he/she serves as the sole emotional 

link for the children and limits other 

potentially supportive contacts for the 

children. Older children may sense that 

a secret exists and may become suspicious regarding the nature and reason for 

the secret—a suspicion that the parent is 

unwell and has HIV. 

...a reasonable 

and 

expected 

reaction... 

DISCLOSURE 

Disclosure can present its own turbulent 

struggle. Disclosing one’s HIV status may 

contribute to strong feelings of rejection 

and isolation, or it may facilitate finding 

support and lessening one’s burden. The 

risk and complexity of disclosing one’s 

status is especially weighty for those in 

intimate relationships or those attempting 

to establish such a connection. 

For many, disclosure becomes a complicated dilemma that may best be handled 

through discussion in counseling sessions. 

Therapists can encourage clients to discuss their own emotional responses to 

HIV and their beliefs about reactions from 

others. This will assist clients in determining if disclosure needs to occur at all. 

For clients whose boundaries in relationships frequently blur and may become 

enmeshed with others, there may be benefits if clients can learn to protect their 

privacy and limit disclosure to prevent 

emotional upset. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
 a 

th 

nd 

ed 

om 

lion 

 or

SEXUAL ORIENTATION 

Gay, lesbian, or bisexual clients may 

feel guilt or shame as a result of society’s negative and distorted beliefs 

about homosexuality. Some may even 

believe that their infection is a “punishment” for being gay. Many people 

remember when HIV was initially 

identified as gay-related immunodeficiency disease (GRID), and for some, 

disclosure of one’s HIV-positive status 

is complicated by whether 

ed 

ard

en 

rs,

till

cihis 

 a

he 

tuesothers will automatically 

assume they are gay. Many 

heterosexual individuals 

do not want to risk what 

they view as a societal 

stigma, and many gay individuals are not prepared to 

publicly acknowledge their 

sexual orientation. Such 

reactions may damage the 

client’s sense of self and 

lead to low self-esteem and 

isolation. Therapeutic 

work with issues of sexual 

orientation requires specific knowledge, sensitivity, an appreciation of the 

effects of homophobia, and 

an affirming attitude. 

LOSS OF LOVED ONES 

In communities where there have been

great number of deaths associated wi

AIDS, such as in the gay community a

now more commonly in impoverish

communities of color, there is a toll fr

the trauma of multiple deaths that comp

cates grieving. Multiple losses is a comm

theme for many people living with

affected by HIV. For clients not infect

with HIV who belong to communities h

hit by HIV’s impact, such as older gay m

and long-standing injection drug use

there may be survivor guilt merely from s

being alive while close friends and asso

ates have died from AIDS. Work in t

area involves an acknowledgment of

client’s loss. For HIV-infected persons, t

reactions to multiple deaths may be na

rally compounded by fear of HIV’s progr

sion for themselves.

Alan’s Story 

Alan had cared for his partner, Jerome, for a year 

after symptoms of HIV-associated dementia

appeared and created drastic changes in Jerome’s 

personality. Alan speaks of how he tenderly cared 

for Jerome until his death. When faced only a 

month later with his father’s death, he describes 

how he felt numb and disconnected. Further complicating his grieving was the earlier death of a

family member and several deaths of friends.

Alan’s therapist helped him reflect on his relationship with Jerome and strive for reconciliation. His 

coping capacity was enhanced after grief work 

was incorporated into several counseling sessions. 

DELIVERING SERVICES Chapter 9: Counseling Themes & Clinical Considerations 93 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
94 DELIVERING SERVICES Chapter 9: Counseling Themes & Clinical Considerations 

adherence 

and health 

are critically linked 

ADHERENCE 

The interplay between adherence to medication and treatment regimes, clients’ 

psychological and emotional state, and 

their health is critically linked. The 

greater use of protease inhibitor treatment, for example, has contributed to 

renewed health for some with advanced 

HIV infection and a longer period without disease progression for those with 

asymptomatic HIV infection. Managing 

the doses and administration of these 

drugs requires a significant level of commitment from providers and clients as 

there are risks when medications are not 

taken properly. Realistic fears about 

adverse effects, reluctance to acknowledge 

one’s need for medications, and avoidance 

of HIV itself may affect one’s emotional 

reaction to initiating protease inhibitor 

treatment. For many to cope, HIV itself 

needs to be put out of their minds as they 

continue to live from day-to-day. 

However, beginning protease inhibitor 

therapy becomes a frequent reminder of 

their HIV infection. 

LAZARUS SYNDROME 

A central psychological theme that 

accompanies protease inhibitor therapy 

is the emergence of the “Lazarus 

Syndrome,” in which persons with 

advanced HIV infection notice a significant improvement in the medical indicators of immune system function and 

HIV viral load. With improved health, 

they may experience varying degrees of 

increased energy and fewer immobilizing 

symptoms. For many, this is a relief and 

becomes a welcome opportunity to 

reconstruct their lives. For others, there 

may be a sense of existential angst and 

the development of symptoms of depression, such as lethargy, isolation, and sadness, because they already had prepared 

to die. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
DELIVERING SERVICES Chapter 9: Counseling Themes & Clinical Considerations 95 

Edward’s Story 

Edward had begun treatment with protease inhibitors in May of the previous 

year. His response to the medications 

was excellent, as his viral load became 

undetectable and his T-cells increased. 

Edward had survived the deaths of practically everyone else he knew who had 

been infected with HIV. When he considered his survival, he was consumed with 

the question, “Why me?” Diagnosed with 

an AIDS-defining illness in the 1980s, 

Edward expected a trend of deterioration 

and death. However, protease inhibitor 

treatment revised that assumption. 

Edward was called upon to confront the 

task of life reconstruction complicated by 

survivor guilt and the developmental 

dysynchrony that comes from not progressing to the next stage he was expecting. Edward seemed ashamed that he 

was not happier and more pleased by his 

improved health. Treatment, consisting 

of both an increase in an anti-depressant 

medication and insight-oriented psychotherapy with a focus on loss, helped 

Edward to re-invest himself in life and 

make a trial return to work. 

SPIRITUALITY 

Attending to the spiritual aspect of 

clients’ coping may prove helpful in 

stimulating resources for living, as well as 

assisting clients to extract and integrate 

meaning into their experiences of living 

with HIV. Provider insensitivity to the 

client’s spiritual background and belief 

system can erect an insurmountable barrier to treatment. 

Mental health providers may need to 

increase their own comfort with religious 

traditions and spiritual practices as clients 

may not wish to meet with a separate pastoral counselor. Counselors and therapists 

may consider integrating spiritual issues 

into their counseling work by exploring 

the meaning of faith, as it relates to the 

client, and the purpose it serves in the 

client’s life. Linked to this is the need for 

providers to remain open to clients’ belief 

systems—especially when clients’ beliefs 

are not reflective of their own religious 

traditions (specifically for individuals 

among recent immigrant groups and communities of color) and utilize the client as 

a resource. 

By incorporating concepts of faith, 

strength, and redemption (as determined 

and described by the client) into the 

therapeutic process, mental health 

providers may find that this approach 

offers comfort and solace to clients, especially those experiencing increasing 

health complications or those facing 

death. By being willing to explore the 

topic of spirituality or faith, mental 

health providers can begin to discuss 

ways to help clients integrate their spirituality and HIV status into their lives 

more effectively. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
97 

CHAPTER 10: 

Substance Abuse 

Treatment 

There has been a long-standing relationship between HIV 

infection and substance use disorders. The correlation 

between injection drug use and HIV infection is well known 

and documented. There also exists a relationship between 

non-injection drug use and HIV infection. Individuals are at 

greater risk for HIV transmission while under the influence of 

alcohol or other drugs due to impaired decision-making 

processes. Continued alcohol or other drug use can further 

suppress the immune system. It also has potentially damaging psychological effects that may interfere with well being 

and functioning. 

The experience of the 11 Demonstration projects confirms the high 

correlation of HIV infection and substance abuse. Demonstration 

data show that approximately 25 percent of clients served in the 11 

sites had a diagnosis of alcohol dependence, while approximately 50 

percent of clients met criteria for drug dependence. 
98 DELIVERING SERVICES Chapter 10: Substance Abuse Treatment 

A diagnosis of HIV can be overwhelming, 

and a common response of the newly diagnosed is to self-medicate with alcohol or 

other drugs. HIV-specific substance abuse 

treatment must incorporate treatment 

approaches that are sensitive and responsive to the presence of multiple diagnoses. 

In addition, service providers need to be 

better informed of the broad range of substance use disorders and better equipped 

to make accurate substance use diagnoses. 

To make sound and clinically responsible 

choices about the proper approach to substance abuse treatment and the selection 

of the appropriate treatment modality, 

service providers can look to the assessment process as the best place to start the 

treatment regimen. This is especially true 

when a client meets criteria for substance 

abuse and/or dependence. (See Chapter 5 

on Clinical Assessment.) 

TREATMENT APPROACHES 

Increasingly, persons infected with HIV 

are from indigent, marginalized populations. It is essential that they be linked 

with some type of substance abuse treatment programming if they are dependent 

on alcohol or other drugs. 

Abstinence. The historical approach to 

substance abuse treatment has been to 

promote abstinence from non-prescribed 

substances. This approach has been, and 

continues to be, supported by involvement in 12-step programs (Alcoholics 

Anonymous, Narcotics Anonymous, and 

Cocaine Anonymous). Abstinencebased programs are generally appropriate 

for individuals who are diagnosed as 

substance dependent, self-identified as 

addicted, or who want to abstain regardless of diagnosis. Some professionals 

working within the 12-step framework 

believe that the prescribed use of 

psychotropic and/or pain medications is 

not appropriate. However, adherence to 

this belief has declined significantly in 

recent years. 

Harm reduction. The harm reduction 

model has become increasingly popular, 

partially in response to the HIV pandemic. 

It recognizes that some people will not or 

do not need to abstain from all substance 

use. In light of this recognition, the harm 

reduction model focuses on the need to 

decrease the potentially damaging effects of 

alcohol or substance use and on reducing 

the risk of HIV transmission. Persons with 

HIV who use alcohol and illicit drugs are 

vulnerable to engaging in high-risk behavior. Furthermore, these individuals may 

have failed abstinence-based substance 

abuse treatment programs in the past. 

They may, however, benefit from 

approaches that emphasize health and well 

being, rather than total abstinence from 

substances. Harm reduction is applicable 

to a range of self-destructive behaviors, 

including high-risk sexual activities. Types 

of harm reduction programming include 

methadone maintenance, needle 

exchange, and programs that teach persons 

to use alcohol and other drugs in ways that 

are less harmful. Frequently, individuals 

are referred to abstinence-based programs 

from harm reduction programs. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
DELIVERING SERVICES Chapter 10: Substance Abuse Treatment 99 

TREATMENT MODALITIES 

A number of substance abuse treatment 

modalities were used by Demonstration 

projects in working with people with HIV 

who also had a substance use disorder. In 

sites where substance abuse treatment 

services were not provided, existing community resources were critical. These 

modalities are described below. 

Medical detoxification may be required for 

the individual with a long history of substance use/dependence—particularly those 

using alcohol or heroin. Medical detoxification includes a brief period of hospitalization (approximately 3 to 7 days) and the 

administration of medication to alleviate 

withdrawal symptoms. Medical detoxification also may be considered when beginning substance abuse treatment for those 

with chronic medical diseases to control the 

impact of withdrawal on the client’s medical condition. Mental health services 

offered in conjunction with detoxification 

services may be effective in encouraging 

participants to access more structured care 

following the detoxification experience. 

Social detoxification occurs in either a 

hospital or non-hospital setting and usually does not include medication to treat 

withdrawal symptoms. The length of stay 

varies from 7 to 21 days, depending on the 

client and his/her available financial 

resources. Social detoxification provides 

the individual with an opportunity to quit 

using substances without medication 

while under constant supervision. 

Inpatient treatment programs provide a 24­

hour-a-day structure for clients in substance 

abuse treatment. These programs are 

located within hospitals, psychiatric institutions, or as separate, stand-alone facilities. 

The length of inpatient treatment varies, 

depending on program rules, ability to pay 

for services, and other concerns. Clients 

may receive more personal attention than 

in other substance abuse treatment settings, 

as well as a higher number of service contacts in a shorter period of time. This 

approach does not work for some clients— 

largely because they are placed in a setting 

that is dramatically different and more 

structured than their usual environment. In 

addition, they are not exposed to situations 

that may jeopardize their recovery. One 

cautionary note is that this may create a 

false sense of success. Also, inpatient treatment programs often are short-term interventions that may not provide ongoing support services. Fewer insurance companies 

reimburse for inpatient treatment than in 

the past, and many others have decreased 

the number of days that they will cover for 

such services. 

Residential treatment can occur in a setting 

that provides constant structure and substantial client supervision. Residential 

treatment programs vary both in the length 

and the intensity level of treatment. Some 

programs are as short as 30 days, while others may provide residential treatment for 

more than a year. These programs may 

include treatment groups, individual sessions, vocational rehabilitation services, and 

other support to clients. While some residential treatment programs may provide 

housing and require the client to attend 12­

step group meetings, other residential treatment programs provide little additional support, structure, or supervision. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
100 DELIVERING SERVICES Chapter 10: Substance Abuse Treatment 

...a 

continuum 

of care 

Partial hospitalization programs (PHPs), 

also known as day treatment programs, 

often are affiliated with inpatient treatment and are part of the continuum of 

care offered by such entities. PHPs offer 

group and individual sessions during daytime hours to clients who require some 

supportive structure in their lives but do 

not require 24-hour monitoring. The 

comprehensiveness of such programs 

depends on the needs of the client and 

varies from one agency to another. Some 

clients participating in a PHP attend a few 

hours a day, while others attend one or 

two days a week, depending on whatever 

is deemed appropriate and necessary for 

the client. This option is particularly necessary for addicted single parents with 

children who are unable to move into a 

residential treatment program without 

losing their dependents. 

Methadone maintenance is useful for 

some persons with a long history of 

heroin use. Methadone is used in place 

of heroin and is itself addictive. 

Methadone maintenance requires medical supervision. Clients usually are 

required to submit urinalysis or blood 

toxicology screens to determine if they 

have used other substances while on 

methadone. If these screens are positive, 

there may be appropriate repercussions 

related to their treatment eligibility. 

Some treatment difficulties may include 

individuals selling methadone on the 

street or exchanging it for heroin. Since 

methadone is addictive and is a replacement drug, some programs implement 

tapering procedures. Tapering is a 

process to lower the dose in small 

amounts over a period of time, leading to 

eventual abstinence from this substance. 

The use of methadone in combination 

with antiretroviral drugs, such as protease 

inhibitors, requires close monitoring of 

drug interactions. 

Outpatient treatment allows clients to 

maintain their daily routine while receiving substance abuse treatment. These programs may provide services during evening 

hours, daytime hours, or on weekends so 

participants do not have to take time away 

from work to attend appointments. Clients 

receive services and support through group 

or individual sessions, or both if indicated. 

This approach allows the client to apply 

what he/she is learning in treatment to real 

life situations outside of the substance 

abuse treatment setting. A major downfall 

of this approach is that clients may have 

difficulty stabilizing since they remain in 

their daily routines and encounter their 

earlier temptations. A significant adjunct 

to traditional outpatient substance abuse 

treatment is participation in 12-step programs. There are HIV-specific 12-step programs in many cities across the U.S. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
DELIVERING SERVICES Chapter 10: Substance Abuse Treatment 101 

RELAPSE PREVENTION 

Relapse prevention acknowledges that 

addiction is a chronically relapsing condition, but that relapse can be avoided. 

Relapse prevention is essential for HIVinfected populations, because relapse with 

alcohol and other drugs is frequently associated with other high-risk behaviors. 

Successful relapse prevention treatment 

often focuses on both behavior modification and restructuring internal processes. 

Relapse prevention planning services are 

provided at two levels: 

• Relapse prevention counseling focuses on 

identifying high-risk situations and developing plans to decrease any potential for 

resuming alcohol and other drug use. This 

is achieved through either individual or 

group sessions for a specific period of 

time—usually eight to twelve sessions. 

• Relapse prevention therapy helps the client 

identify core psychological and emotional 

issues that may lead the client to placing 

himself/herself in high-risk situations. 

Individuals work with professionals to identify those changes necessary to prevent 

them from putting themselves at risk. This 

often involves a thorough examination of 

the individual's system of core values and 

beliefs. This process occurs once a client 

has stabilized, has maintained abstinence 

for an appropriate period of time, and has 

demonstrated the necessary behavioral 

changes. The length of the process varies 

with the client's history and level of commitment to change. 

The Realities of Relapse 

Relapse is often a normal part of 

the recovery process and should 

not be considered a treatment failure. Substance abuse is an underlying behavioral symptom of dysfunctional coping skills. Relapse to 

substance abuse generally begins 

with internal dysfunction that is 

either psychological, emotional, or 

mental in nature. Resuming substance use often is the last in a 

series of steps that lead to alcohol 

and other drug use. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
102 DELIVERING SERVICES Chapter 10: Substance Abuse Treatment 

CLINICAL CONCERNS 

Comorbidity. Individuals diagnosed with a 

substance use disorder, a mental disorder, 

and HIV infection are commonly referred 

to as triply-diagnosed. These clients require 

a broad range of comprehensive and individually tailored services. Such services 

may be offered within one agency or 

through the collaboration of several agencies. In the latter case, meeting the client’s 

needs requires a great deal of coordination 

by a case manager or another service 

provider. Often, responsibility for helping 

the client to access available services falls 

on the service provider. Failure to assist 

clients in obtaining services for such needs 

can negatively affect treatment adherence 

and may lead to treatment failure. 

Self-medication. Many individuals with 

pre-existing psychological problems 

begin alcohol or other drug use to medicate themselves in order to cope with 

such problems. To promote and support 

successful outcomes, clients need to be 

assessed for any mental disorder and provided services as needed. This may 

include the need for psychotropic medications to treat any identified mental 

disorder. 

Prescription medications. Clients living 

with HIV infection eventually will be 

prescribed medications to help manage 

the progression of the illness. The client 

may be required to take multiple pills at 

numerous points during the day. Taking 

the many medications necessary to manage HIV infection can cause drug interactions, and any one of these medications may cause severe side effects. The 

service provider can be an important 

resource for the client by providing information and support that helps the client 

adhere to his/her medication regimen. If 

clients are reluctant to take certain prescribed medications, the service provider 

can discuss various treatment options 

with the client and help him/her make a 

clinically appropriate and informed decision. In particular, clients who have a 

history of drug use—especially those currently in recovery—may be reluctant to 

take certain psychotropic or pain medications. Conversely, clients accustomed 

to abusing alcohol and other drugs may 

manipulate service providers to secure 

more medication than is necessary. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
DELIVERING SERVICES Chapter 10: Substance Abuse Treatment 103 

Medicinal marijuana. Currently, the federal government does not deem the use of 

medicinal marijuana appropriate or legal. 

However, some jurisdictions have passed 

legislation legalizing the use of marijuana 

for medical purposes. People living with 

HIV may use marijuana to deal with the 

side effects of certain medications or to 

increase their appetite. For example, 

some clients with persistent nausea or a 

poor appetite may try tetrahydrocannabinol, an active metabolite of marijuana, in 

pill form (e.g., Marinol, by prescription). 

However, delineating use and abuse of 

marijuana in the setting of HIV infection 

is important. Program staff must be fully 

informed of state and local laws related to 

the medicinal use of marijuana. 

Adherence. Successful substance abuse 

treatment can play a major role in helping 

clients adhere to recommended services 

and prescribed medications. Individuals 

can become more willing and able to take 

HIV-related and psychotropic medications as prescribed, thus impeding the progression of HIV infection and improving 

the client’s mental and emotional well 

being. There is a strong correlation 

between HIV medication adherence and 

longevity, and it is common for many individuals actively using drugs and/or alcohol 

to not adhere to their HIV medications. 

Risk reduction. Risk reduction refers to 

the impact substance abuse treatment may 

have on decreasing HIV-related risk 

behaviors. Due to decreased inhibitions 

while under the influence of drugs and/or 

alcohol, clients may participate in unsafe 

sexual activity or use injection drugs. 

Individuals participating in substance 

abuse treatment should be encouraged to 

reduce or eliminate behaviors that put 

them or others at risk for HIV 

transmission. Risk reduction efforts can 

be further strengthened by relapse prevention planning, mental health services, 

abstinence, or harm-reduction 

approaches. (See Chapter 11 on Risk 

Reduction.) 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
104 DELIVERING SERVICES Chapter 10: Substance Abuse Treatment 

PROGRAMMATIC CHALLENGES 

Outreach. Since a large number of clients 

may not access mental health and substance abuse treatment through traditional 

avenues, it is important for programs to 

include outreach as a key programmatic 

activity. Outreach helps agencies reach a 

greater number of potential clients and 

establish and maintain important relationships. It also can increase public awareness 

of the service program and its efforts. 

Here are examples of activities that make 

for successful outreach: 

• Going to the places where clients use 

alcohol and other drugs. This means 

traveling into the neighborhoods where 

drug use is prevalent and meeting clients 

in a diverse range of areas, such as 

where the sex trade is prevalent, shooting 

galleries, crack houses, neighborhood 

bars, street corners, and parks. Safety 

training is important for workers going 

into dangerous areas. 

• Providing tangible items to potential 

clients. These may include “safer sex kits” 

that include condoms and lubricants or 

“safer drug use kits” that offer clean needles and/or bleach. 

• Using peers. Outreach efforts can be 

enhanced and more effective when peers 

or clients are part of the outreach effort. 

These individuals may be able to relate to 

potential clients more effectively because 

they know the drug “lingo;” understand 

the subcultures of drug use, the sex trade, 

and formerly incarcerated individuals; and 

are better equipped (because of their personal experience with the program) to 

establish trust with potential clients. Such 

individuals may be able to educate clinical 

staff in such issues. 

• Persistence. Outreach activities should 

go beyond an initial contact. Additional 

outreach efforts and multiple contacts 

with clients may be necessary to engage 

and retain them in the service delivery 

process. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
DELIVERING SERVICES Chapter 10: Substance Abuse Treatment 105 

Engagement. This concept involves being 

able to identify and encourage individuals 

to accept and receive treatment and support services. Genuine engagement is an 

ongoing process that only starts by getting 

a client involved in service delivery. 

The following elements are key components of a sound approach to engagement: 

• Ability to provide immediate services. 

Clients may request substance abuse treatment when in crisis. It is essential that 

services be available at that time. 

• Provide clinically and socially appropriate services that are based on a thorough assessment. Assessing the client’s 

substance use history—including past 

involvement in treatment, types of treatment attempted, previous periods of 

recovery, and relapse history—will generate a treatment plan that matches the 

client’s current needs. Agencies frequently 

offer limited substance abuse treatment 

options, such as outpatient group therapy 

or short-term inpatient treatment. These 

limited approaches may not be sufficient 

for some clients. 

• Cultural competence. This concept 

encompasses taking a multicultural 

approach to client engagement. As 

clients are engaged, service providers and 

other staff must be sensitive to the client’s 

race/ethnicity, sexual orientation, personal 

and professional experience, and other 

factors. Although staffing patterns do not 

have to specifically match the client base, 

program managers should take whatever 

steps are necessary (e.g., sensitivity or 

cross-cultural training for staff) to ensure 

that staff are prepared to take a multicultural approach to client outreach and 

engagement. 

The Demonstration projects 

tried a variety of creative 

approaches to engaging 

substance abusing clients: 

• Holding raffles and offering prizes to 

people at sessions 

• Offering gift certificates 

• Holding holiday parties for clients and 

their families 

• Giving away fast food coupons 

• Providing child care, transportation, 

refreshments, and other benefits 

that make it easy and desirable to visit 

the program 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
106 DELIVERING SERVICES Chapter 10: Substance Abuse Treatment 

it is essential that 

treatment remain 

accessible 

BARRIERS 

The Demonstration projects found that 

numerous barriers to substance abuse 

treatment can arise. For example: 

• Potential clients may view substance abuse 

treatment programs as part of the legal system and therefore want to avoid it. This 

perception may be based on an individual’s 

previous, court-ordered experience in treatment programs. 

• There is high potential for relapse—especially among clients who have not stabilized or made a solid connection with the 

treatment program. Extra efforts may be 

needed to pursue these clients. 

• Language itself can be a barrier to substance abuse treatment. Clients may use 

street or drug culture language, and this 

“lingo” may differ from one geographical 

location to another. Service providers must 

be able to work through this barrier by 

learning the language or at least asking 

clients to explain terms that are not immediately clear to the provider. 

• Lack of support is another barrier that 

may prohibit individuals from accessing 

substance abuse treatment. Potential 

clients may not have the encouragement 

from family, friends, or service providers 

to enter or re-enter substance abuse 

treatment. 

• Finally, substance abuse treatment should 

be offered to anyone requesting such services, including those individuals who 

remain under the influence of alcohol 

and/or drugs. It is essential that treatment 

remain accessible to HIV-infected populations even if they have not previously benefited from a treatment episode. 

These are just a few of the barriers that 

may occur. Programs need to be aware of 

these and other barriers to ensure that 

services are available and accessible to the 

target population, and appropriate for 

their needs. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
107 

CHAPTER 11: 

Risk 

Reduction 

Risk reduction activities cover a range of educational, 

cognitive-behavioral, and skills-building interventions. 

The Demonstration Program considered risk reduction as an 

intervention designed to diminish maladaptive behaviors and 

promote a healthy lifestyle. Risk reduction activities can be 

delivered via both individual and group modalities at any 

time during the intervention process. Risk reduction interventions may be implemented in locations where persons 

with HIV are served. 
108 DELIVERING SERVICES Chapter 11: Risk Reduction 

FACTORS AND BEHAVIORS 

The 11 Demonstration projects identified 

several factors and behaviors that may 

negatively affect the health and well being 

of people living with HIV. For example: 

• Engaging in unprotected sex. Re-infection often results in the introduction of new 

strains of HIV. Persons are especially vulnerable to other sexually transmitted diseases and hepatitis. 

• Use of alcohol and other drugs. The use 

of alcohol and drugs reduces inhibitions 

and increases the likelihood of engaging in 

unsafe sexual activities. Their use can further impair the immune system and can 

adversely interact with HIV medications. 

Sharing of hypodermic needles can reinfect and spread HIV as well. 

• 	Lack of medication adherence. HIV 

medications must be taken as prescribed 

to have maximum benefit. The lack of 

strict adherence to antiretroviral medications can lead to ineffective treatment and 

the potential to produce drug-resistant 

strains of HIV. Although medication regimens often are difficult to follow, clients 

need to understand the importance of 

observing a strict dietary routine and medication schedule—largely because treatment adherence is strongly associated 

with survival. Other medications, including psychotropic drugs, often are essential 

in helping persons adhere to HIV medication regimens. 

• Poor nutrition. It is important that persons 

with HIV pay close attention to nutritional 

guidelines. Optimum absorption of HIV 

medications depends upon following these 

guidelines. Proper nutrition is necessary to 

avoid HIV-related wasting syndrome and to 

enhance one's ability to cope with a compromised immune system. 

• Untreated medical conditions. Persons 

with HIV frequently have co-occurring 

medical conditions. Chronic illnesses, such 

as diabetes, liver and renal disease, and 

cancers must be treated aggressively, and 

adherence with medical regimens must be 

monitored. 

• Untreated emotional distress. A range of 

psychological or emotional disorders frequently interfere with an individual’s ability 

to actively manage HIV. It can interfere 

with medication adherence, the client’s 

ability to keep appointments, the client’s 

judgement, and one’s ability to assume 

responsibility for his/her behavior. 

• Homelessness. Without stable housing, all 

other therapies and treatment interventions 

can be seriously compromised. Lack of 

housing can exacerbate co-occurring disorders or other problems with mental health, 

substance abuse, and HIV infection. 

• 	Lack of a strong sense of self worth. 

Poor self-image can be one of the greatest 

barriers to the cultivation of healthier 

habits. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
DELIVERING SERVICES Chapter 11: Risk Reduction 109 

promoting healthier behaviors
 

IMPLEMENTING RISK REDUCTION 

ACTIVITIES 

Clinicians can employ a range of techniques to teach persons with HIV risk 

reduction practices. The process of immunizing clients against high-risk behaviors 

can be woven into the treatment process 

by providing information, teaching skillbuilding techniques, and offering selfesteem enhancing activities. 

First and foremost, persons with HIV must 

be made aware of high-risk activities and 

how certain behaviors can jeopardize one’s 

health. This can be accomplished 

through didactic seminars, written materials, and individual and group therapy sessions. It is essential that a curriculum be 

developed that covers behaviors associated with increasing or decreasing risk. 

Information by itself, however, is not sufficient. Clients may not have the motivation or self-esteem to engage in preventive 

activities. Skill enhancement concerning 

assertive behaviors can be taught effectively. Insisting on condom use, negotiating other safe sex practices, and saying no 

to drugs and alcohol under peer pressure 

can all be taught in skill-building or 

assertiveness training workshops. 

Methods of promoting healthier behaviors 

and improving physical, emotional, and 

spiritual health include: 

• Involvement in support groups focused 

on HIV-related medical conditions 

• Close monitoring of people with 

advanced HIV infection 

• Access to prenatal care 

• Tools to enhance medication adherence 

• Taking a more active role in one’s 

health care 

• Linkage with medical treatment advocates 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
110 DELIVERING SERVICES Chapter 11: Risk Reduction 

OTHER CONSIDERATIONS 

Many service providers may need education and training to increase their knowledge and understanding of risk reduction 

activities and the potential benefits for 

the clients they serve. In addition, an 

awareness of cultural practices is necessary 

to help negotiate risk reduction behaviors. 

For example, women of different cultures 

and socioeconomic groups have varying 

degrees of power in heterosexual relationships, which may affect their ability to 

insist upon safer sexual practices. It also 

helps to know how different cultural 

groups manage and interpret different 

social contexts. For example, poor, gay 

Latino immigrants sometimes use class 

markers (e.g., how well someone is 

dressed, what kind of job someone has) as 

part of their decision-making around sexual risk-taking (Ayala & Diaz, 1997). 

Knowledge of the specific dynamics of 

relationships among various cultural 

groups and the kinds of attributions individuals may make regarding class, race, 

and power can assist clinicians in their 

efforts to assist clients in adopting healthier behaviors. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
111 

CHAPTER 12: 

Permanency Planning 

One of the 11 sites participating in the HIV/AIDS 

Mental Health Services Demonstration Program 

devoted its treatment approach to permanency planning. 

This chapter reflects the lessons learned from the Kinship 

Connection Program in Elizabeth, New Jersey—as well as the 

collective experience of the other 10 projects. 

Permanency planning is the process by which custodial parents 

living with HIV develop a viable plan for the future care of their 

minor children in the event of their own death. For the purposes 

of this chapter, the term “caregiver” refers to the person selected 

by the parent to take responsibility for the future care of the children. Permanency planning can be done by any individual who 

has legal custody of minor children—whether he/she is the biological parent, an adoptive parent, a grandparent, an aunt, an 

uncle, or another individual. 
Planning for the future care of the child is 

a very emotional and difficult task for the 

parent. Acknowledgement of the need for 

permanency planning does not necessarily 

mean that the custodial parent is ready to 

take the necessary steps to start working 

on permanency plan. Engaging the client, 

building trust, and assessing the client’s 

readiness is crucial to completing the permanency planning process. Likewise, it is 

in the best interests of the parents and the 

children to face the decision about who 

will be the future caregiver of the children 

after the parent dies. It is very important 

that this decision be made while the parent is still capable of making an informed 

and competent decision. 

Unquestionably, permanency planning is 

difficult. It involves thinking about the 

illness and one’s potential death. Many 

parents facing death intend to leave 

their children with relatives in some 

kind of informal adoption, not realizing 

the importance of planning, discussing 

it, and making a “legal plan” ahead of 

time. Parents can make the most appropriate decision for their children if they 

are well-informed of all available legal 

options. Many parents with HIV fear 

the many legal mazes that they must go 

through to secure a safe and viable family for their children. They also may fear 

Child Protective Services, the possibility 

of losing their parental rights, or having 

their children removed 

from their home before 

it is necessary. 

Permanency planning 

also is difficult because 

some clients may feel that 

completing a permanency 

plan and “taking care of 

business” equals giving 

up—not knowing that 

developing a permanency

plan may also bring peace

of mind. 

Facts About HIV, Women, 

and Their Children 

Women—especially those in their child-bearing or childrearing years—continue to become the fastest growing 

segment of the population to be infected with HIV or 

diagnosed with AIDS. Consequently, there is a corresponding increase in the number of children who are directly 

affected by HIV. For example, it is estimated that, by 

2000, between 72,000 and 125,000 children and 

teenagers in the U.S. will have lost their mothers to HIV. 

An additional 60,000 young adults (18 and older) also 

will have lost their mothers (Levine & Stein, 1994). 

112 DELIVERING SERVICES Chapter 12: Permanency Planning 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
DELIVERING SERVICES Chapter 12: Permanency Planning 113 

Charlotte’s Story 

Charlotte was referred to treatment after she was diagnosed with 

advanced HIV infection. Charlotte had three children—two boys ages 6 

and 12, and a girl age 14. Charlotte lived alone with her children. She 

also had a history of drug use. 

After becoming engaged in the permanency planning process, Charlotte 

identified her mother, as the potential guardian for her children. But she 

soon changed her mind and identified her sister Karen as the preferred 

future caregiver, with her other sister as a back-up potential guardian. 

Steps to complete the permanency planning process were taken. Case 

workers met with both of Charlotte’s sisters to determine if each sister 

would be able to carry out the plan. Regular meetings between both 

of Charlotte’s sisters and her children were held. An attorney made the 

plan legal. 

Then Charlotte’s health rapidly began to deteriorate. Because of HIVassociated dementia, Charlotte was unable to care for her children. At 

one point, Charlotte called her lawyer and ordered that her will and custody plan be changed so that a hospital employee would get custody of 

her children. Charlotte’s sisters went to court, and the court gave custody of Charlotte’s children to Karen, based on Charlotte’s previous permanency plan. Charlotte went into hospice care. She died soon after. 

Karen had a difficult time with her niece and nephews. They were not 

accustomed to having rules. They exhibited behavioral problems—both 

at home and at school—and they consistently received D’s and F’s in 

school. Program staff, however, continued to provide mental health and 

case management services, including bereavement counseling and a 

range of other services. 

Today, Charlotte’s children are earning A’s and B’s in school. Their behavior has improved, and they have adjusted to their new home. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
114 DELIVERING SERVICES Chapter 12: Permanency Planning 

The 12 Steps of Permanency Planning 

1. Assist the parent in feeling comfortable 


with the idea.
 

2. Determine whether or not the parent has 


discussed his/her illness with the potential
 

caregiver.
 

3. Talk to potential future caregiver(s). 

4. Identify and address potential legal and 


non-legal barriers to the custody plan.
 

5. Find out who lives with the future caregiver
 

or who visits frequently so that the child’s
 

physical, emotional, and sexual safety is 


protected. 


6. Assess the future caregiver’s readiness 


and availability to care for the children 


(e.g., health status, financial status, and
 

housing situation). 


7. Get the children involved at the 


appropriate time.
 

8. Try to keep siblings together. 	If this is not
 

possible, help future caregivers understand
 

and plan the need for frequent contact
 

between siblings in the future.
 

9. Assist in planning and easing transitions into
 

new schools, when necessary.
 

10. Determine when it is an appropriate time
 

for the child and the future caregiver to
 

start spending more time together. 


11. Obtain legal approval of the custody plan. 

12. Provide ongoing counseling and case 


management, as needed. 


WHY PERMANENCY 

PLANNING IS IMPORTANT 

Permanency planning is important for many reasons: 

• If there is no custody plan, individuals other than the custodial 

parent will have to make several 

important decisions when the 

parent becomes too ill or after 

the parent’s death. These decisions will be necessary at a time 

when the children and the possible caregiver will be grieving. 

• The informal caregiver, even if 

he/she is a close relative, has 

no legal authority to make decisions on the child’s behalf, such 

as enrolling the child in school, 

obtaining health insurance coverage or affordable health care, 

or securing other services the 

child may need. 

• Child Protective Services may be 

required to intervene by placing 

children in foster homes, which 

may result in separating siblings. 

• Final decisions may be made by 

the court, without hearing the 

parent’s wishes, and the court’s 

decision may not be what the 

parent wanted. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
DELIVERING SERVICES Chapter 12: Permanency Planning 115 

parents, children, future caregivers, attorneys,
 

case managers, family therapists, 


other family 


members
 

THE PARTIES INVOLVED IN 

PERMANENCY PLANNING 

Depending on the situation, permanency 

planning can involve several individuals 

who share an interest in carrying out the 

parent’s wishes and protecting the children and their future. For example: 

• The parent explains his/her wishes and 

makes decisions about the future care of 

the children. 

• The children identify their preferences and 

dislikes, provide reactions to different 

options, and prepare to adjust to new living arrangements. 

• The future caregiver expresses his/her availability, willingness, and readiness to 

assume new responsibilities for the children. At the same time, program staff can 

assess the caregiver’s ability to care for the 

children and make arrangements for additional services and support systems. 

• The attorney advises the client on his/her 

legal options, remaining sensitive and 

responsive to the client’s unique legal 

needs. 

• The case manager coordinates the full 

range of services that are needed to support the parent, the children, and the caregiver; ensures continuity of care; and advocates on behalf of the client and the 

reconfigured family. 

• The family therapist 	assists the client, the 

child, and the future caregiver in dealing 

with the parent’s illness—including issues 

associated with denial, stigma, isolation, 

disclosure to the caregiver and/or child, 

and coping with HIV and its effect on the 

family. The therapist also facilitates the permanency planning process from beginning 

to end by maintaining contact with the 

child and the future caregiver after the parent’s death to ensure continuity of therapy 

and permanency of the plan. 

• Other family members and friends can be 

active participants in developing and implementing the permanency plan and in supporting the identified caregiver. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
116 DELIVERING SERVICES Chapter 12: Permanency Planning 

BENEFITS OF INVOLVING FAMILIES 

The benefits of involving families in the 

permanency planning process include the 

following: 

• It is empowering and can help the custodial parents retain a sense of control. 

• Permanency planning minimizes disruptions in the child’s life. For example, the 

child will not be bounced from one family 

member to another and will have an 

opportunity to gradually spend time with 

the potential caregiver as a way to ease 

transition into the caregiver’s family. The 

ultimate goal is to meet the child’s need 

for continuity, familiarity, and stability. 

• It can ease the transition for the parent, the 

child, and the caregiver by addressing 

needs, fears, and concerns prior to and during the transition into the caregiver’s family. 

• Decisions can be made that may help keep 

all siblings together. If that is not possible, 

arrangements can be made for siblings to 

get together during special occasions, such 

as birthdays, anniversaries, holidays, etc. 

• Parent, child, and caregiver family needs 

can be identified so that all needed support services are put in place to ensure 

the viability of the plan. 

• The parent, the children, and the caregiver are afforded an opportunity to discuss concerns and/or potential problems 

with the potential permanency plan. 

• Involving the concerned parties in this 

process helps to minimize the potential for 

future legal custody battles once the permanency plan is implemented. 

• When an infected parent is using alcohol 

or other drugs and refuses to discuss permanency planning, program staff may be 

able to work with the individual who 

supervises the client’s children, a family 

member, or someone else close to the 

client who is interested in protecting the 

children in the future. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
DELIVERING SERVICES Chapter 12: Permanency Planning 117 

Whenever possible,

children should be 

active 

participants 

WHEN TO GET FAMILIES INVOLVED 

The sooner custodial parents begin to confront permanency planning the better. 

Many parents agree to work on permanency planning issues, but they may not be 

ready to do it when it is brought up for the 

first time. Permanency plans take time to 

develop and the amount of legal paperwork may be daunting, especially in cases 

where there is the potential for custody 

battles. In spite of these challenges, clients 

should be encouraged to begin permanency planning as soon as they are willing 

and able to make these decisions. 

While there is no easy time to bring up the 

need for permanency planning, some times 

may be better than others. For example, if 

a parent is hospitalized and has not yet 

developed a permanency plan, he/she may 

be more prepared to discuss the possibility 

when hospitalized. Clinicians can use this 

opportunity to discuss the options and 

resources available to the client. 

HIV-affected children also require a careful approach to engagement. Program 

staff can encourage parents to allow their 

children to be engaged at an appropriate 

point in the permanency planning 

process. Whenever possible, children 

should be active participants in permanency planning so they can begin to identify preferences. In fact, if a custody plan 

is reviewed by the court, many judges will 

ask older children to indicate their preferences for a potential caregiver. 

Future caregivers also play an important 

role in permanency planning. Identifying 

the future caregiver early in the process 

ensures that he/she is aware of and in 

agreement with the plan itself. This provides an opportunity to assess the caregiver’s ability to carry out the permanency 

plan and to determine what services may 

be necessary to help him/her care for the 

children, such as support systems, appropriate housing, financial resources, insurance coverage, and other potential services. This also provides an opportunity for 

the future caregiver to spend time with 

the children (e.g., staying overnight), 

which can help ease the transition for all 

parties involved. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
118 DELIVERING SERVICES Chapter 12: Permanency Planning 

LEGAL OPTIONS AVAILABLE TO PARENTS 

It is important to educate and empower 

parents regarding the different permanency planning and guardianship options 

available. The following brief descriptions of current legal options available to 

families are provided for educational purposes only. Before any actions are taken, 

one should consult an attorney in the 

state of residence. 

A will is a legal document used to record 

a person’s wishes upon his/her death. It 

may include a nomination of a caregiver 

who will serve as the child’s future 

guardian. Drafting a will is relatively simple and allows a parent to retain full legal 

custody of the children until death. 

However, a will does not guarantee placement with the parent’s chosen guardian. 

Following the death of the parent, the 

chosen guardian must petition the court. 

The court then determines what it 

believes to be in the best interest of the 

child. If there is a surviving biological 

parent, he/she will have to consent to the 

chosen guardian. A biological parent will 

most likely be successful in gaining full 

custody if he/she wishes to seek custody 

after the parent’s death. A will is only a 

method to indicate a “preference” and is 

not binding as a final determination. 

Adoption is the most permanent form of 

placement. In an adoption, the parental 

rights are “terminated” and transferred to 

the adoptive parent(s). To initiate adoption, an application or petition must be 

filed with the court. The petition requires 

a signed document from both parents giving up their rights over the child. A hearing is then scheduled and the judge makes 

a final determination. The process may 

take a year or more. Because of its time 

and permanency, adoption is impractical 

and not emotionally feasible for some parents with advanced HIV infection. 

Guardianship is a less permanent placement than adoption and usually is a more 

plausible choice for parents. 

Guardianship involves a process in which 

a parent’s rights are suspended, allowing 

the designated guardian to serve as the 

primary caregiver. A petition must be 

filed in court, and a judge makes a final 

ruling after a hearing several weeks later. 

In the interim, a court-appointed social 

worker will visit and assess the prospective 

guardian’s home. If there is a surviving 

biological parent, he/she must consent to 

the placement, legally abandon the child, 

or waive his/her rights for placement to 

proceed. Surviving parents who challenge 

the appointment may succeed, unless 

demonstrated to be unfit parents. Once 

guardianship papers are signed, all 

parental rights are suspended. The new 

guardian has legal authority and will not 

have to take any steps following the parent’s death. Although this fairly simple 

process allows the parent to complete the 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
DELIVERING SERVICES Chapter 12: Permanency Planning 119 

process of finding a home for the child 

before his/her death or disability, the parent must give up his/her parental rights 

and decision-making authority over the 

child. In some cases, the parent may be 

required to give up physical custody of the 

child as well. 

Stand-by Guardianship allows a parent to 

complete a process to designate a secondary individual as a stand-by guardian to be 

empowered to assume the parental role 

immediately on the death or adjudication 

of incapacity of the last surviving natural 

parent or adoptive parent of the child. 

Typically, the statute requires the triggering event to be either the parent’s physical 

debilitation, mental incapacity, or death. 

Stand-by Guardianship allows parents to 

care for their children and retain parental 

rights. However, upon parental death or 

declared incapacity, the legal authority 

automatically goes to the stand-by 

guardian. Under Stand-by Guardianship, 

a parent can make legal arrangements 

while still in good health, be involved 

with these arrangements throughout the 

court process to insure his/her wishes will 

be carried out, and retain parental rights 

until death or incapacity. Stand-by 

Guardianship is not an appropriate option 

for every parent. When there are two natural parents, both parents have an equal 

right to custody of a child. Stand-by 

Guardianship cannot be established if the 

other parent desires custody and is able to 

care for the child. Even when the other 

parent has been absent from the child’s 

life or has abandoned the child, the custodial parent must always attempt to notify 

the non-custodial parent of the intent to 

name a stand-by guardian. The custodial 

parent must show that the other parent 

has no intent or desire to seek custody or 

that the other parent did not respond to 

the notification. Some states also will 

allow the custodial parent to show evidence that the non-custodial parent is not 

a suitable custodian for the child. 

Joint Guardianship is a permanency 

planning option available in only a few 

states. The primary purpose of Joint 

Guardianship is to allow a parent to complete the guardianship process while still 

healthy, without relinquishing or suspending all parental rights. This option 

allows the parent to choose the legal 

guardian and allows the child to become 

familiar with the guardian. However, 

since Joint Guardianship requires a parent to give up some control of the children by sharing decision making responsibility with the chosen guardian, this may 

not be a perfect solution for some parents. 

In those cases, Stand-by Guardianship 

may be more suitable. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
120 DELIVERING SERVICES Chapter 12: Permanency Planning 

permanency planning 

offers 

numerous 

therapeutic
 

opportunities
 

Foster care/adoption becomes the option 

of last resort when parents living with 

HIV do not have family members or 

friends to take care of their children or 

when permanency plans are not in place. 

Once families are involved in the foster 

care system, options are limited. In most 

states, regulations give parents 18 months 

to correct or make needed changes in 

their life to regain custody of their children. If the children do not return to their 

biological parents, the next step is to put 

them up for adoption. Given that most 

foster care systems already are overburdened, this process may lead children to a 

series of placements and risk the possibility that siblings may be separated prior to 

and/or after adoption. 

Because of the psychological implications 

associated with the permanency planning 

process, there are numerous therapeutic 

opportunities. The roles of the worker 

and mental health clinician are important. (See Chapter 4 on Mental Health 

Services, Chapter 8 on Psychotherapy and 

Counseling, and Chapter 9 on Counseling 

Themes and Clinical Considerations.) 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
121 

CHAPTER 13: 

Psychosocial Rehabilitation 

One of the 11 Demonstration projects—the Community 

Living Room in Philadelphia—used the psychosocial 

rehabilitation (PSR) model exclusively in serving an innercity population living with HIV. PSR has a long history in 

providing services to persons with mental illness. Its adaptation to clients who have mental health issues and who are 

HIV-positive has particularly proven effective with a population that is difficult to engage, traditionally does not seek 

services, and has often been marginalized to the outer fringes 

of society. Numerous PSR models exist, but most PSR models share specific characteristics that are integral to engaging 

and meeting the needs of the individual who has both HIV 

and a mental disorder. 
122 DELIVERING SERVICES Chapter 13: Psychosocial Rehabilitation 

PSYCHOSOCIAL REHABILITATION 

PRINCIPLES 

By highlighting what PSR emphasizes in 

comparison to what it does not emphasize, some key principles of PSR can be 

illustrated in the following list: 

Emphasizes 

Strengths 

Wellness 

Hope 

How-to 

Goal planning 

Working with 

the client 

Small steps 

“Here and now” 

orientation 

Clients as active 

decision-makers 

De-emphasizes 

Deficits 

Illness 

Pity 

Why 

Treatment planning 

Providing services to the 

client 

Leaps 

Past 

Clients as passive 

recipients 

PSR 

has a 

long

history... 

STAFF/CLIENT THERAPEUTIC 

RELATIONSHIP GOALS 

PSR program staff must be firm believers 

in, and supporters of, PSR values and 

principles, which places total emphasis on 

engaging and involving the client as an 

equal partner in the therapeutic relationship. Relationships between staff and 

clients are non-hierarchical and must be 

environmentally generalized (e.g., occur 

in several different everyday milieus). 

Clients are treated in a PSR program not 

as “unfortunate people with a deadly 

virus.” Instead, they are viewed as functioning human beings with dreams, capabilities, skills, creativity, and aspirations—as people in possession of a life to 

still be lived. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
DELIVERING SERVICES Chapter 13: Psychosocial Rehabilitation 123 

...proven effective 

with a population that is difficult to engage, 

traditionally does not seek services, and has 

often been marginalized to the 

outer fringes of society 

PROGRAM OBJECTIVES 

Philadelphia’s Community Living Room 

Program centered its objectives around 

three change agents that functioned as the 

foundation upon which program services 

and activities were built. 

• 	Meaningful social and support networks. The primary goal of the PSR clubhouse model is that enjoyable and supportive relationships in the program setting 

are the catalysts for the formation of a 

working therapeutic community. The therapeutic community then serves as a 

molder of behaviors, a marketplace for 

ideas, and an incubator for growth. 

• Achievement. Helping clients to achieve 

success has long been the central catalytic 

change agent of expectancy model psychosocial programming. This approach is 

driven by the belief that achievement—no 

matter how small—is a stepping stone 

toward greater achievement (“successive 

successes”). Confidence in exerting more 

control on the present and exploring the 

possibilities of the future results from the 

intrinsic and extrinsic rewards that come 

with achievement. 

• Client empowerment. PSR programs provide a nourishing milieu for client empowerment. Becoming empowered can be a 

compelling change agent in anyone’s life. 

To aid clients in empowering themselves, 

this specifically means that the program 

must provide education on mental health 

and HIV, teach and build skills so that 

clients are able to access that knowledge, 

and help motivate clients to use their skills 

and knowledge in day-to-day living. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
124 DELIVERING SERVICES Chapter 13: Psychosocial Rehabilitation 

In PSR programs, clients are considered 

“members” and are instrumental in formulating rules, facilitating community meetings, helping to determine services 

offered, giving support to one another, and 

in performing many of the tasks needed 

for the daily operation of the program. 

They also are integral to the process of 

outreach and engaging new members, as 

well as providing support and direction to 

other members as they navigate their own 

life transitions. The cohesive partnership 

between members and staff ensures that 

the therapeutic community becomes a 

viable village in which everyone has a 

vital role to perform in helping all inhabitants thrive and be properly sustained. 

For many clients with HIV and a mental 

disorder, being a member of a PSR program may present the first opportunity in 

years where input and contributions are 

not only valued, but also are expected and 

deemed necessary. A visitor to a successful PSR program should be struck by activity, enthusiasm, and a profound sense of 

ownership of the therapeutic community. 

doing is 

as important 

as talking 

The program’s services, which emanate 

from the program objectives, are many 

and varied. However, the range of services almost always includes groups, 

workshops, activities, and counseling. 

At the Community Living Room, 

groups and workshops are divided into 

six categories: 

• Mental health and HIV education concerning issues such as illness management, risk prevention, medications, 

and nutrition 

• Skill enhancement in such areas as vocational training, activities of daily living, 

communication, and leisure time 

• Creativity and self-expression through 

such venues as art, music, writing, and 

drama 

• Insight development involving areas 

such as relationships, sexuality, goal-setting, and decision-making 

• Complementary and holistic therapies, 

such as yoga, herbalism, and meditation 

• Support groups, such as Alcoholics 

Anonymous, Narcotics Anonymous, 

Triple Trouble, and other groups such as 

those focusing on male- and female-specific issues 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
DELIVERING SERVICES Chapter 13: Psychosocial Rehabilitation 125 

The structure of groups and workshops is 

varied so that doing is as important as 

talking. Task, recreation, and interactive 

exercise groups have equal weight in 

importance as process groups. 

Activities are an integral part of any PSR 

program. They are planned as enjoyable 

ventures in which members can interact 

with other members and staff in normalizing milieus. Excursions to museums or 

theatres, boat cruises or historic walks, 

outside lunches or retreats in the country 

emphasize that programming is a mission 

that exists beyond its four walls. Internal 

program activities, such as seasonal 

celebrations, birthday parties, dances, or 

talent shows celebrate client and staff 

milestones and collaborative capabilities. 

An especially meaningful activity of a 

PSR program may be lunch time, when 

staff and members eat together as a family. 

Counseling in PSR can also be varied in 

its modality and style but is primarily 

directed by members and staff working 

together to develop achievable, clientcentered goals and to support their 

attainment. Intervening life issues and 

crises can also be shared and addressed in 

group settings, as well as in one-on-one 

counseling. 

The program space and environment 

should be warm, stimulating, aesthetically 

pleasing, and functional. 

Comfortable furniture, plants, and artwork should fill the large spaces and 

corners of the facility. The physical 

environment should support the program’s groups and activities and not 

detract from them. For example, a theatre group will need a space where it can 

spread out, while a support group needs a 

space where it can be close together. 

Likewise, an art group will need a space it 

can mess up, and an education group will 

need a space where it can easily focus and 

not be distracted by clutter. 

The amenities of programs are varied 

from site to site but are always present to 

complement and augment services offered 

and to further enrich the PSR environment. At the Community Living Room, 

coffee and tea are provided throughout 

the day. Showers and laundry facilities 

are on site for members who do not have 

suitable living arrangements. Member 

lockers are available for storage. Purified 

water and public phones are centrally 

located. Pamphlets and bulletin boards 

supply information on mental health and 

HIV issues and resources, as well as leisure 

time opportunities. A piano, electronic 

keyboard, games, and books are readily 

accessible to members, as are lounges and 

spaces for quiet conversation. A computer room is open for members to learn 

and perfect skills, as well as play interactive games, write résumés, or surf the 

Internet. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
126 DELIVERING SERVICES Chapter 13: Psychosocial Rehabilitation 

POTENTIAL BARRIERS 

Though an HIV-specific PSR program 

may seem on the surface rather easy to 

develop, there are actually many obstacles 

that must be overcome. 

• The first major hurdle is finding a flexible 

funding source which recognizes that 

many of the nontraditional psychiatric 

aspects of a PSR program are indeed therapeutic. 

• Hiring staff who can thrive in an egalitarian, client-centered environment and 

remain firmly committed to the PSR model 

is a challenging endeavor. In many cases, 

a person may have to adapt previous professional experience or education that did 

not include PSR principles. Since the therapeutic community is a living organism, staff 

need to be flexible to constant change in 

their roles and responsibilities. 

• A PSR program must often operate in a 

larger system in which most workers may 

not understand its principles and operations. It is often thought of as an adjunctive therapy or kind of “play time” rather 

than a complete treatment modality. 

Therefore, to be a vital cog in a wider system, a PSR program must strive to communicate with other components of the 

organization and to interact with other 

interventions that may be vastly different in 

style and not appreciative of the uniqueness of the PSR approach. 

A PSR model program is only one of several possibilities for providing ongoing 

services to the client living with HIV and 

a mental disorder. The Community Living 

Room has proven especially effective with 

the client who does not easily participate 

in the traditional programs of group and 

individual psychotherapy or cannot effectively deal with hierarchical systems. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
EVALUATING SERVICES &PROGRAMS

129 

CHAPTER 14: 

ProgramEvaluation 

Program evaluation was a requirement of the 

HIV/AIDS Mental Health Services 

Demonstration Program and a critical component of 

developing and providing services at each of the 11 

Demonstration sites. This chapter describes some of 

the issues to consider when developing and implementing a program evaluation of HIV-specific mental health services. 
130 EVALUATING SERVICES & PROGRAMS Chapter 14: Program Evaluation 

DEFINITION OF PROGRAM EVALUATION 

Program evaluation means different
 

things to different people. A utilization-


focused approach to evaluation was found
 

by some members of the Demonstration
 

Program to be a comprehensive and practical way to conceptualize and evaluate
 

HIV-specific mental health programs.
 

According to Patton (1989), program
 

evaluation is:
 

"the systematic collection of information 

about the activities, characteristics, and 

outcomes of programs for use by specific people to reduce uncertainties, 

improve effectiveness, and make decisions with regard to what those programs are doing and affecting (p. 14)." 

Using this definition, program evaluation 

is focused on gathering data with the purpose of improving programs and decisionmaking. For the purposes of this Practical 

Guide, the remainder of this chapter, 

incorporating the lessons learned from 

the 11 Demonstration projects, follows 

Patton’s utilization-focused approach to 

evaluation. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
EVALUATING SERVICES & PROGRAMS Chapter 14: Program Evaluation 131 

REASONS TO EVALUATE THE PROGRAM 

Because evaluation can be a time- and 

effort-consuming process, it is important 

for program administrators and directors 

to ask themselves: “Why should we evaluate our program?" There are a variety of 

answers to that question, including: 

• To get a better idea of what the program is doing. Conducting an evaluation 

can provide information about the program’s activities and the extent to which 

the program is being implemented as 

intended. 

• To assess the effects on clients. An evaluation can provide information on how 

well a program is accomplishing its goals 

and objectives. It also can help administrators and the public better understand how 

a program is helping clients. 

• 	To improve the program's services. 

Evaluation findings can be used to make 

informed decisions about the program, 

including where to make improvements, 

where to cut back on or add resources, 

and how to bolster weaknesses or 

enhance successes. 

• 	To obtain future funding. Given current 

federal and state funding priorities and 

strong emphasis on measuring outcomes, 

evaluation findings can assist an organization in obtaining funding for the program. 

For example, sharing evaluation findings 

with local or state HIV policymakers can 

lead to increased funding for a program. 

• 	To disseminate information. Evaluation 

findings can be disseminated to service 

providers, program developers and evaluators, funders, and researchers so that others 

can benefit from past experiences and 

avoid making similar mistakes. 

• To meet requirements. More and more 

HIV-specific programs are required to evaluate their services and outcomes as part of 

receiving federal, state, and local dollars. 

The most forward-looking programs see 

this requirement as an opportunity rather 

than a burden. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
Potential 

Stakeholders 

What Do They 

Want to Know? 

Figure 9 

Clients 

• How will mental health services help me? 

• Are services consistent with my cultural beliefs and expectations? 

Community-Based Organizations (CBOs) and AIDS Service Organizations (ASOs) 

• Will mental health services help our clients? 

• Will services improve treatment adherence? 

Staff 

• Does the work I do really help people? 

• What can we do better? 

Federal, state, and local funding entities 

• Are our funds being well-spent? 

• Are future requests for funding justified? 

The public 

• Will this program benefit our community? 

• How does this program help people? 

132 EVALUATING SERVICES & PROGRAMS Chapter 14: Program Evaluation 

IDENTIFYING THE PRIMARY USERS OF 

THE EVALUATION 

The Demonstration projects found that, 

prior to conducting a program evaluation, 

it was important to identify their stakeholders. Program planners can identify 

key stakeholders by determining who will 

benefit most from knowing about the 

evaluation findings. Stakeholders may 

include an organization's CEO, clinical 

director, clinicians, case managers, clients, 

peers, HIV medical providers, Ryan 

White planning council members, community leaders, or members of a collaborative network. Stakeholders usually have a 

lot of influence over the program, the 

overall organization, and the system of 

care for people living with HIV. 

Examples of different stakeholders in the 

Demonstration Program and the kinds of 

questions they asked are presented in 

Figure 9. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
EVALUATING SERVICES & PROGRAMS Chapter 14: Program Evaluation 133 

There may be a multitude of stakeholders 

who have a multitude of questions about 

the program. Often, it is a good idea to 

start with a small list of stakeholders who 

have the most investment in the program. These primary stakeholders should 

be committed to the evaluation process 

from its initiation through implementation. At any point in the evaluation 

process, additional stakeholders can be 

added when: 

• There is decreased anxiety around conducting the evaluation 

• The scope of questions to be addressed 

expands to include other people who are 

invested in the answers 

• There is increased confidence regarding 

the group decision-making process 

DOING AN EVALUABILITY ASSESSMENT 

OF THE PROGRAM 

An important "first step" for the program 

and its key stakeholders is to figure out if 

the program is ready to be evaluated and 

who should lead these efforts. One way to 

accomplish this is to convene stakeholders 

for a series of meetings to discuss critical 

areas of the program's functioning. Prior 

to these meetings, one of the stakeholders 

should be elected to lead the discussions, 

to be responsible for providing written 

feedback to the group, and to develop a 

written description of the group's 

responses at the end of the meetings. In 

the Demonstration Program, it was useful 

to address questions in each of the following areas: 

• The program's target population. Who 

does the program serve? Be specific and 

exhaustive in the description. If, for example, the target population is "families 

affected by HIV," how are they affected? 

Does an adult family member have to be 

infected? Does the target population 

include children who are HIV-negative 

who have lost a caregiver to HIV? What 

are the demographics, characteristics, and 

trends (e.g., many more women are presenting with depression at intake) of the 

target population? 

• The program's mission and philosophy. 

What is the program's mission and philosophy? Does it adequately describe the 

problem that the program is trying to 

solve? Does it need to be updated to better reflect the services provided? Is the program’s mission and philosophy responsive 

to the needs of the target population? 

How is the larger organization's mission 

and philosophy connected to the program's mission and philosophy? 

• The program's goals. What are the major 

goals related to achieving the program's 

mission? What changes are necessary 

among the target population? What must 

the program accomplish in terms of its role 

in the larger community in such areas as 

community relations, advocacy, education, etc.? Do all of the program's goals 

have end results, rather than processes or 

steps leading to results? 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
134 EVALUATING SERVICES & PROGRAMS Chapter 14: Program Evaluation 

• The program's objectives. What are the 

program's objectives? Are they measurable? Are they achievable? Is there a timeframe for accomplishing each objective? 

Are program objectives really activities, or 

are they stated with end results? Do the 

objectives naturally lead to accomplishing 

program goals? 

• The program's interventions. For each 

program objective, what are the services 

and activities provided by the program 

that will lead to the accomplishment of 

the objective? How much of a service or 

what type of activity is needed? What are 

the resources needed (e.g., staff, funding, and equipment) to achieve the 

objectives? 

If the stakeholders adequately address 

each of these areas and develop a written 

document that describes the group's combined response to each area, the program 

has made the first step in preparing to be 

evaluated. 

FINDING A PROGRAM EVALUATOR 

At this juncture, stakeholders need to 

determine if the evaluation will require 

the services of an outside, professionally 

trained evaluator or if an individual from 

within the program or group of stakeholders can serve in this capacity. In the 

Demonstration Program, all 11 sites hired 

professionally trained evaluators or 

researchers. Because evaluation is such a 

critical component of most HIV programs, it is highly recommended that program administrators and directors seek 

and utilize the professional services of 

trained evaluators. 

Finding an evaluator who is a “good fit” 

with a program and its stakeholders can be 

a fairly involved process. This section is 

devoted to addressing issues that may arise 

in achieving this goal. Project Directors 

in the Demonstration Program found 

evaluators by: 

• Asking colleagues if they knew of any 

evaluation support in the area 

• Contacting Departments of Public Health, 

Social Work, Epidemiology, Sociology, 

Psychology, and Health Administration at 

local universities or community colleges 

• Asking local ASOs and CBOs about evaluation support in the area 

• Contacting the American Evaluation 

Association (AEA) for a list of evaluators 

located in the area 

• Referring to the literature on HIV and 

mental health and identifying researchers 

whose work they respected and admired 

When a list of potential evaluators is 

obtained, the next step involves contacting 

individuals to find out about their experience, availability, and interests. Don’t be 

intimidated by this process. There are 

many evaluators who would welcome the 

opportunity to expand their experience in 

the field of HIV. Figure 10 describes some 

tips on how to choose an evaluator. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
EVALUATING SERVICES & PROGRAMS Chapter 14: Program Evaluation 135 

Figure 10 

Choose the Evaluator Wisely 

From the collective experience of the 11 Demonstration projects, the programs with the 

most compatible program director/evaluator relationships fared much better in terms of 

developing and implementing an evaluation that was satisfactory for all parties 

involved. Some tips on how to choose an evaluator include: 

• Know communication preferences in advance (in person, in writing, on the phone, 

via e-mail or faxes, on a regular basis, or on an as needed basis) and how program 

staff and stakeholders like to learn (through reading, lecture, back-and-forth 

discussions, or combination of approaches). 

• Interview multiple individuals. Don’t "settle" for the first one that comes along. 

• Make sure he/she is committed to helping stakeholders frame and answer the 

evaluation questions rather than promoting his/her pet theories or methodologies. 

• Ask about the evaluator’s methodological preferences (e.g., quantitative vs. 

qualitative). This issue is discussed in more detail later in this chapter. 

• If the candidate is not experienced and knowledgeable about the focus of the 

program or the target population, make sure he/she is interested in becoming more 

experienced and knowledgeable. 

• Check references. 	Ask about the candidate’s communication style and listening skills. 

Find out if he/she is a naturally collaborative and flexible person. 

• Don’t be overly impressed by the candidates curriculum vitae or résumé. 	Talk about 

the candidate’s beliefs and values about clients, his/her approach to the work, and 

experiences with other programs. 

• Ask if the candidate has helped other programs write evaluation sections of grants 

and whether that has been done “pro bono” or for a fee. 

• Ask if the candidate has experience disseminating knowledge and information. 

Find out if he/she is familiar with publishing articles in peer-reviewed journals. 

• Ask about the candidate’s availability to participate with the program. Also, find out 

if the candidate uses less-experienced staff to take over their responsibilities once 

program evaluations are up and running. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
136 EVALUATING SERVICES & PROGRAMS Chapter 14: Program Evaluation 

Before launching the search for an evaluator, it is important for program 

administrators to allocate a portion of their program's budget to evaluation. 

This will help in the negotiation process when the subject of fees arises. 

While most human service programs are tight for extra dollars, there are creative measures that program administrators can take to pay an evaluator. 

The end of the fiscal year may be an ideal 

time to locate resources for this purpose. If 

none are available, stakeholders can be 

asked to contribute to the cost of hiring an 

evaluator. Stakeholders may be more willing to do so if they are a part of the interview process. It may be possible to convince program leaders, administrators, or 

the Board of Directors that a program evaluation can help the organization generate 

more revenue to expand programs that 

serve clients well. Figure 11 describes 

some incentives that may be useful in 

obtaining the services of an evaluator. 

Once the services of an evaluator are 

secured, it is recommended that an informal contract be developed that outlines 

his/her roles and responsibilities in 

designing and implementing the program 

evaluation (see Appendix F for an example). When an agreement is reached, it 

is time to bring together the evaluator 

and stakeholders with the goal of further 

defining and describing the program's 

target population, mission and philosophy, goals and objectives, and interventions. The evaluator needs to be a key 

figure in guiding this process, ensuring 

that there is consensus in each area and 

that this consensus is clearly written 

down and communicated to key stakeholders. The next step of designing the 

program evaluation involves focusing on 

the questions it will seek to answer. 

Figure 11 

Other Incentives 

to Obtain the 

Services of an Evaluator 

• Offer access to client and program 

data that may be used for publishable research. 

• Offer access to client and program 

data for dissertation or master's 

thesis research. 

• Ensure that program staff will assist 

the evaluator with data collection, 

relieving him/her from the burden 

of having to assign extra staff to 

collect data. 

• Discuss ways to collaborate on 

future projects. 

• Discuss ways to collaborate on 

future grant proposals. 

• Offer the potential evaluator an 

opportunity to analyze results of a 

randomized experiment that might 

be done at the program. 

• Sell this as an opportunity to 

expand the potential evaluator's 

HIV expertise. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
EVALUATING SERVICES & PROGRAMS Chapter 14: Program Evaluation 137 

IDENTIFYING AND FRAMING 

EVALUATION QUESTIONS 

The worst thing that could possibly happen when a program evaluation is completed is for stakeholders to express the 

following sentiment: 

"The evaluation did not tell us what we 

really wanted to know." 

To keep this from happening, it is imperative that the “right” questions are chosen 

to be evaluated and that the “right” people are part of the process in choosing 

these questions. Important questions to 

ask when identifying and framing evaluation questions are: 

• What is the purpose of the evaluation? 

• How will the information be used? 

• What will be understood after the evaluation is completed that is not known now? 

While the answers to these questions may 

seem straightforward, connecting them to 

the evaluation questions frequently 

involves disagreement among the stakeholders as to which evaluation questions 

need to be asked to satisfy all parties 

involved. One way to work through this 

kind of disagreement is to utilize a logic 

model. 

Using a Logic Model. To help stakeholders frame relevant evaluation questions, 

several evaluators in the Demonstration 

Program used logic models (See Appendix 

G for the Chicago Project's logic model). 

This approach gives stakeholders a way of 

tying program results or achievements to 

program inputs or resources. It stresses the 

importance of making sure a logical relationship exists between a program's goals 

and what it wants to accomplish. (See 

Resources for more information on logic 

models). 

Developing a logic model for a program 

evaluation takes time and effort on the 

part of both the evaluator and stakeholders. The following guidelines are recommended when undertaking such an 

endeavor: 

• Educate stakeholders about logic models 

before one is developed for the program. 

• Provide examples of other logic models. 

• Have the evaluator develop a first draft of 

the program's logic model based on 

his/her perceptions during the initial meetings. This step will make it easier for the 

stakeholders to respond to an incorrect 

logic model versus a blank logic model. 

• Encourage input and questions about a 

program's logic model from stakeholders. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
138 EVALUATING SERVICES & PROGRAMS Chapter 14: Program Evaluation 

Selecting the type of evaluation to conduct. Using the logic model, the next step 

is to select the type of evaluation that 

should be conducted. The choice will 

depend on the purpose of the evaluation 

and the type and extent of programmatic 

and client information desired. Two types 

of evaluation are: 

• Process Evaluation. If the stakeholders 

are interested in the extent to which the 

program is being implemented as planned, 

then a process evaluation would be conducted. Process evaluation requires that 

the evaluator work closely with the stakeholders to determine how they view program implementation versus how program 

implementation is described in a grant or 

other program document. Examples of 

process evaluation questions are: 

• How many intakes were conducted with 

newly diagnosed HIV-seropositive clients 

during the first quarter? 

• How well did the mental health clinicians 

coordinate their treatment planning efforts 

with primary care providers? 

• How many HIV-infected and -affected 

clients attended at least 80 percent of 

the treatment adherence groups? 

• Outcome Evaluation. If the stakeholders are interested in knowing how well the 

program is doing in meeting its goals, then 

an outcome evaluation would be conducted. Examples of outcome evaluation 

questions are: 

• Before your HIV-specific mental health 

program began, how many HIV-seropositive clients kept at least 75 percent of 

their medical appointments? After your 

HIV-specific mental health program 

began, how many HIV-seropositive 

clients kept at least 75 percent of their 

medical appointments? 

• How do high service utilizers differ in 

their quality of life compared to low 

service utilizers? 

• In comparison to other clinics where mental health and substance abuse treatment 

services are provided, what percentage of 

HIV-infected clients remain drug-free? 

Once the evaluator and stakeholders 

select the type of evaluation to conduct, 

it is time to refocus on identifying and 

framing the evaluation questions. Which 

program processes should be evaluated? 

Which outcome would be the most interesting to measure? Needless to say, much 

confusion may arise at this juncture 

because of the seemingly endless choices 

of questions to ask and evaluate. It is the 

evaluator's responsibility to remind stakeholders to think clearly about the 

intended uses of the evaluation and to 

choose only those questions that fit those 

criteria. (See box for Atlanta's site 

experience). 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
EVALUATING SERVICES & PROGRAMS Chapter 14: Program Evaluation 139 

After the evaluator and stakeholders have 

selected the specific process and/or outcome questions to address, it is time to 

select the evaluation methodology. 

Deciding on the methodology. When 

making evaluation methodology decisions, the goal is to get the best possible 

data, given available resources and time, 

to adequately answer stakeholders' questions. The essence of utilization-focused 

evaluation is to decide on the measures, 

samples, and comparisons that are most 

appropriate and credible to address the 

program's evaluation questions. 

It is important for stakeholders to have 

some information about quantitative and 

qualitative methodologies because evaluators tend to lean toward one or the 

other. The dominant paradigm espouses 

the use of quantitative methods (i.e., 

using statistical methods under experimental conditions, "hard data"). Most of 

their proponents believe that this scientific method is superior to the use of qualitative methods (i.e., systematically 

describing differences in a phenomenon 

by considering the context and its development, "soft data"). Both methods 

reflect particular world views. 

In actuality, there are strengths and weaknesses in relying solely on either quantitative or qualitative methodologies in an 

evaluation. What is required is flexibility 

in attitude and thinking, and creativity in 

using the most appropriate approaches for 

the questions at-hand. In addition, the 

evaluator should be honest about his/her 

methodological prejudices. More than 

“At our site, all of the coalition 

members were given an opportunity to provide input into the evaluation plan. A preliminary plan 

was developed by Steve McDaniel, 

the Project Director; Peter 

Campos, the Project Coordinator; 

and me; but this was significantly 

revised as a function of input from 

other members. In addition, the 

other members suggested consumer focus groups, which we 

conducted, that were used to help 

develop the intervention itself. All 

forms were also reviewed by the 

group, and the evaluation team 

reported on our progress at 

monthly coalition meetings.” 

-- James Emshoff, Ph.D. 

Chief Evaluator 

Atlanta Project 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
140 EVALUATING SERVICES & PROGRAMS Chapter 14: Program Evaluation 

likely, the program's methodology will be 

a combination of quantitative and qualitative methods because this strategy often 

produces the most worthwhile findings. 

To further ensure that a program is getting 

the most use of evaluation findings, the 

evaluator and stakeholders also should 

consider the following issues when selecting the evaluation methodology: 

• What will the findings look like? Imagine 

what the evaluation findings will look like 

and how to interpret them. Design a 

mock-up report or visual representation of 

the findings, and guide stakeholders 

through an exercise on how they might 

actually use the findings. 

“We had to streamline our originally planned local evaluation to 

meet the needs of our population, 

who needed to receive services as 

soon as possible rather than participate in lengthy evaluations. So 

the lesson for us was that, unlike 

other dually diagnosed groups, 

HIV-positive patients seeking substance abuse and mental health 

services require abbreviated evaluations and rapid entry into treatment for physical and psychological reasons.” 

-- Karen Ingersoll, Ph.D. 

Chief Evaluator 

Richmond Project 

• Is it okay to start with a simple evaluation? Yes, especially if evaluation is a new 

experience. Start with process evaluation 

questions. That will give stakeholders an 

idea of the state of the program's recordkeeping system (see the next bullet). Be successful first with a small endeavor, then 

expand the scope with additional successes. 

• How good is the program's recordkeeping? Evaluation relies on the program's 

recordkeeping system. It is important to 

know when, how well, and by whom 

records are kept. The four basic types of 

records that a program's process evaluation may access are resource expenditures; 

administrative activities; client intake/assessment information; and service delivery 

activities. 

• How good is the program's management 

information system (MIS)? Another concern is whether any or all of these records 

are entered into, stored, and easily accessed 

through a computerized MIS. If so, are there 

staff who can help the evaluator access and 

transfer this information? Numerous questions regarding a program's MIS capacity will 

need to be addressed as it affects the evaluation methodology in terms of costs, effort, 

and time. 

• Will program administrators thwart the 

evaluation? Because the burden of conducting a program evaluation often falls 

upon the program administrator, he/she 

must be the one to commit to the evaluation. If program administrators are unwilling to do so, it is unlikely that a good evaluation will take place, even though he/she 

may pay "lip service" to it. 

• 	Will program staff thwart the evaluation? Because many evaluations rely on 

staff to administer evaluation tools and/or 

document services in new ways, their fears 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
EVALUATING SERVICES & PROGRAMS Chapter 14: Program Evaluation 141 

and discomfort must be acknowledged 

and attended to in a firm, respectful manner. There will be less resistance if the evaluation questions are clinically relevant, if 

staff feel that the evaluator respects and values their work, and if staff perceive the findings as being beneficial to themselves and 

their clients. Resistance from staff also may 

be addressed by including them in the 

group of stakeholders so their points of 

view are considered. 

• 	How will the program's intervention 

affect the methodology? If the program's 

intervention is too difficult to define, then it 

will be very difficult to measure. If treatment changes with each client, then the 

evaluation will need to be flexible to measure these differences. If there is not 

enough of an intervention (dosage), then 

it may not be worth measuring—but it 

may be worth describing. 

• How will the program's target population 

affect the methodology? Developing the 

evaluation methodology depends directly 

on the program's target population. Will the 

measures require clients to read? If so, at 

what level? Are the measures culturally and 

linguistically sensitive? When is it ideal to 

administer pre- and post-test instruments? 

How intrusive will certain measures be to the 

engagement process? Will clients need to 

be paid to participate? Again, having a 

member of your target population or an HIVpositive peer participate in your group of 

stakeholders may be one way of understanding and managing these issues. 

Deciding what information and how 

much data to gather in an evaluation 

involves difficult decisions and tradeoffs. For example, stakeholders may 

decide to conduct qualitative interviews 

only with clients who successfully complete treatment. The trade-off is not 

knowing how and why the program 

failed to work with clients who dropped 

out of treatment. In general, collecting 

more data costs more and takes more 

effort and time, but getting less data may 

reduce confidence in your findings. 

Issues of reliability and validity need to 

be addressed by the evaluator and stakeholders, as well as threats to using the 

evaluation findings. 

Unfortunately, there is no evaluation template that will help stakeholders make 

these methodology decisions, and there 

are no magical strategies to offer other 

than revisiting the question: "Is the 

methodology focused on providing 

intended users with information they can 

use?" There are steps, however, that the 

evaluator can take to help stakeholders 

better understand the program in order to 

make informed suggestions related to the 

evaluation methodology decisions: 

• Assess the points in the program's intervention where evaluation would be the least 

intrusive and where conducting the evaluation would be most clinically relevant. 

• Assess the feasibility of using existing staff as 

data collectors. 

• Identify alternative data collectors (e.g., 

receptionists, research assistants). 

• Assess the feasibility of using existing administrative and clinical records as data 

sources. 

• Develop and/or locate alternative data 

sources (e.g., standardized instruments). 

Having a better sense of the program's 

flexibility and its readiness to be evaluated 

will lead to a clearer picture of what needs 

to be incorporated into the evaluation 

methodology. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
142 EVALUATING SERVICES & PROGRAMS Chapter 14: Program Evaluation 

IMPLEMENTING THE EVALUATION 

When it is time to implement the evaluation, various stakeholders may have different ideas about how to proceed. The evaluator may be excited and anxious to start 

collecting data. Program administrators 

may be distracted by new mandates or the 

every day crises that arise in doing HIVrelated work. Staff may be nervous and 

unsure about what evaluation will mean 

to their day-to-day work life and their 

treatment approach with clients. Other 

stakeholders may be tired from the process 

and/or exhibit a combination of these 

feelings. Before the group embarks on this 

next stage of the evaluation, it is important to recognize all the hard work that 

has gone into the evaluation process so 

far. It is truly a milestone. After that is 

acknowledged, it is time to implement the 

evaluation. What follows are action steps 

taken by many of the evaluators and program administrators within the 11 

Demonstration projects that helped make 

implementation more successful. 

At the end of the pilot period, convene a 

meeting with program administrators, 

staff, and data collectors to discuss 

problems and solutions related to implementation. The evaluator must be ready 

to listen with an open mind and a nondefensive approach because there will be 

issues to work through. It helps to 

reframe these "problem-solving" meetings 

as "relationship building" meetings 

because it promotes continued enthusiasm and support for all members of the 

evaluation and clinical teams. If decisions have been made about the changes 

to the evaluation procedures and 

processes, incorporate them into both 

written and visual materials. 

The evaluator and stakeholders need to be 

flexible, creative, and understanding of 

the many issues that may arise during the 

implementation phase. These include 

changes in the organization and program, 

changes in the epidemic, and tension 

between clinical and evaluation needs. 

Part of the evaluation may involve tracking these changes, noting occurrences of 

tension, and integrating observations with 

changes in client and program outcomes. 

Part of the evaluation may also involve 

giving stakeholders feedback on a regular 

basis about the effect of these changes and 

issues on client and program outcomes. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
EVALUATING SERVICES & PROGRAMS Chapter 14: Program Evaluation 143 

Evaluation, Implementation, Action Steps 

• Conduct a series of staff trainings related to implementing the evaluation. 	Encourage 

participants to raise potential obstacles and solutions. Acknowledge fears and discomfort around changing the staff's routine. Reassure staff that, for most of them, it 

will become natural to blend evaluation into their clinical work over time. 

• Conceptualize the evaluation for clinicians in such a way that it can provide valuable 

feedback for the treatment of their clients. 

• Develop confidentiality procedures. 	Create the consent form for clients to sign before 

participating in the evaluation. Develop procedures for storing and accessing data onsite and off-site. Develop and/or utilize existing client identification system. 

• Devise written procedures for staff around administering instruments, entering or storing 

data, and sending data to the evaluator (see Appendix H for an example of written procedures for the Chicago Project’s service encounter record). While this task may take a 

long time to accomplish, staff appreciate having a written reference. 

• Pilot the evaluation over a four-to-six week period—or longer if the evaluation is more 

involved. During this period, give program administrators and staff permission to 

make mistakes. Reinforce that there is a learning curve involved in implementing new 

processes and procedures. Encourage staff to document any problems, solutions 

tried, and results as they occur in order to present it accurately in future problem-solving sessions. 

• Establish expectations. 	Give administrators and staff expectations of how the evaluator is going to maintain communication. Ask staff for best ways and times to communicate. Provide staff with information about who to contact (and their back-up contacts) should problems arise. 

• Establish timetables that clarify when staff will be interviewed, when record abstractions 

will be conducted, and when written and verbal feedback will be provided. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
144 EVALUATING SERVICES & PROGRAMS Chapter 14: Program Evaluation 

Important Steps to Take 

With Stakeholders 

During the Analysis Phase 

• The evaluator is responsible for analyzing the data first, 

explaining how this was accomplished, and sharing the 

findings with stakeholders. Findings should be presented 

in multiple ways (e.g., written, orally, and visually) so that 

each stakeholder has an opportunity to understand them 

and respond. 

• Stakeholders should have the first stab at interpreting the 

evaluation results. The evaluator should facilitate a discussion with stakeholders and insert his/her own interpretations and recommendations as the discussion progresses. 

• Stay focused on the findings that will be the most useful for 

intended users. It may be tempting to discuss all the findings at the same intensity, but stakeholders will lose interest 

if too much information is presented and discussed. 

• Recommendations need to be carefully developed and 

clearly connected to the evaluation findings. Too many 

programs fail to do this because stakeholders want to 

present the “news” or a grant proposal or program 

report would benefit from have the evaluation findings 

included. Work through the recommendations until 

they are mutually satisfying. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
EVALUATING SERVICES & PROGRAMS Chapter 14: Program Evaluation 145 

ANALYZING AND 

INTERPRETING THE DATA 

The data analysis and interpretation 

phase occurs when the evaluator and 

stakeholders convene to look at the data 

and determine what it means. There is a 

difference between analyzing and interpreting data. Data analysis involves 

organizing the data in a systematic way 

(i.e., constructing statistical tables if 

quantitative data is being collected) and 

arranging the data in an orderly and easily understood format. Interpretation 

involves deciding what the data mean, 

providing reasons for the findings, and 

assigning importance to the findings. 

The procedures that the program uses to 

analyze data will be defined mostly by the 

evaluation questions and design. A 

description of the different ways to analyze quantitative and qualitative data is 

beyond the scope of this chapter. There 

are several issues that may influence the 

analysis of the data, including: 

Stay focused on 

the findings 

that will be 

most useful 

• Competing projects for the evaluator. 

The evaluator likely will be involved in 

other projects. The evaluator should be 

encouraged to be up front about his/her 

situation so that negotiations can be 

made to possibly make the analysis a 

higher priority. 

• Qualitative versus quantitative analysis. It takes much longer—and usually 

costs more—to perform a qualitative 

analysis than a quantitative analysis 

because it takes more effort to develop 

and utilize a systematic framework for 

organizing and extracting qualitative 

data into meaningful units of analysis; 

qualitative data is frequently converted 

(i.e., transcribed from audiotaped interviews or archival records) before it is analyzed; and there are many statistical 

packages that allow for quicker quantitative analysis. 

• 	Accuracy of the data. In circumstances where the completion of forms 

or instruments has gone unchecked 

for any period of time, there may be 

problems with the accuracy of the 

data. Examples include periods of 

time during which client services were 

not tracked because of staff turnover; 

a failure to train new staff on how to 

complete instruments as intended; 

and a natural tendency for trained staff 

to forget how to complete instruments. When situations such as these 

arise after the fact, it may stall data 

analysis if the evaluator and stakeholders decide to somehow retrieve and 

enter the data. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
146 EVALUATING SERVICES & PROGRAMS Chapter 14: Program Evaluation 

DISSEMINATING THE 

EVALUATION FINDINGS 

As experienced in the Demonstration 

Program, the dissemination of evaluation 

findings varied greatly from site to site. 

Some sites disseminated findings internally to program staff, while other sites 

disseminated findings to professional audiences. The nature of dissemination is a 

matter for negotiation between the evaluator and stakeholders. Not everybody is 

going to be as excited as the evaluator and 

stakeholders are about the findings and 

recommendations. The reality is that 

most evaluation reports end up on a funder's shelf or under a pile of other unread 

reports. It is the joint responsibility of the 

evaluator and stakeholders to ensure that 

this does not happen. Some ways to 

accomplish this are: 

• Know the audience. Different audiences 

will be interested in different types of information. For example, a presentation of the 

findings at a local coalition meeting probably will be less formal, require some handouts, and involve questions from the audience that are more specific to sharing of 

similar experiences or "gut instincts" from the 

audience. On the other hand, a presentation of the findings to the local Ryan White 

council may be more formal, require more 

visual rather than written materials, and 

involve questions from the audience that 

may be more specific to the target population's response to the evaluation. 

• Take on a marketing stance. In order to 

disseminate the findings, the evaluator 

and stakeholders may need to reframe 

their thinking and roles. They have to 

think like marketing agents and get the 

message out. The character of the message is critical. Evaluation findings will 

need to be translated into whatever languages are spoken by the target audiences. If this stance seems beyond the 

evaluator's and/or stakeholders' skills and 

abilities, a marketing consultant can be 

hired to do the job. 

• Use multiple strategies to reach multiple audiences. Multiple strategies (e.g., 

written vs. verbal, executive summary vs. 

complete description, slides vs. handouts) 

will need to be devised to present the findings and recommendations for multiple 

audiences. It also is important to have different combinations of the evaluator and 

stakeholder group (e.g., clinician and evaluator; client, funder, and evaluator) present the findings. 

• 	Have these discussions during the 

development of the evaluation. 

Although it may seem odd to have a discussion about how, to whom, and where 

to present the evaluation findings and 

recommendations during the development of the evaluation, these discussions 

will help the evaluator and stakeholders 

focus their methodology and questions 

on how the information will be gathered 

and how it will be used. 

People who participate in successful program evaluations from its development 

through implementation and dissemination usually look forward to the next 

opportunity to do so again. Because it is 

so critical to conserve time, dollars, and 

effort in finding ways to help people with 

HIV live better lives, program evaluations need to be done completely and 

effectively so that the most useful information can be shared with stakeholders 

and others who share the program’s mission and vision. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
147 

References &Suggested Reading 

INTRODUCTION 

Centers for Disease Control and Prevention, Update: Trends in AIDS incidence, deaths, 

and prevalence—United States, 1996. Morbidity and Mortality Weekly Report, 46:861­

867, 1997. 

CDC Update, CDC releases 1997 data on the HIV epidemic: Data from 25 states suggest 

that HIV infection has increasing impact among women and minorities. Centers for Disease 

Control and Prevention, Atlanta, GA. April 23, 1998 news release. 

Webster’s New Riverside University Dictionary, 2nd Edition, Riverside Publishing 

Company, 1988. 

CREATING PROGRAMS 

Establishing Services 

Collins BE & Reed GM, Ten principles proposed as policy guidelines for mental health 

intervention research and mental health services among persons living with HIV/AIDS. 

Psychosocial Rehabilitation Journal, 17(1):83-95. 1993. 

Feingold A & Slammon WR, A model integrating mental health and primary care services for 

families with HIV. General Hospital Psychiatry, 15(5):290-300. 1993. 

Harris K & Williams LD, Communities of caring: Integrating mental health and medical 

care for HIV-infected women. Focus: A Guide to AIDS Research and Counseling, 

10(12):1-4. 1995. 

Linn JG et al, Stage of illness, level of HIV symptoms, sense of coherence and psychological 

functioning in clients of community -based AIDS counseling centers. Journal of the 

Association of Nurses in AIDS Care, 4(2):24-32. 1993. 

Sarwer DB & Crawford I, Therapeutic considerations for work with persons with HIV disease. 

Psychotherapy, 31:262-269. 1994. 

Voelker R, Rural communities struggle with AIDS. Journal of the American Medical 

Association, 279(1):5-6. 1998. 
148 REFERENCES & SUGGESTED READING 

Collaborative Networks 

Ridgely MS et al, Interagency collaboration in services for people with co-occurring mental 

illness and substance use disorder. Psychiatric Services, 49(2):236-238. 1998. 

Rosenes R et al, Providing for the mental health needs of staff in AIDS service organizations: 

Collaborating with the private sector. International Conference on AIDS. 1996. 

Vancouver. 

Staffing 

Bennett L & Kelaher M, Longitudinal predictors of burnout in HIV/AIDS health 

professionals. Australian Journal of Public Health, September; 18(3):334-336. 

Elia N, Grief and loss in HIV/AIDS work, in HIV mental health for the 21st century, 

Winiarski MG, Editor. 1997, New York: New York University Press. 67-81. 

Knox MD et al, Training HIV specialists for community mental health. Community Mental 

Health Journal, 30(4):405-413. 1994. 

Macks JA & Abrams DI, Burnout among HIV/AIDS health care providers in AIDS Clinical 

Review. Feldman DA & Johnson TM, eds. New York: Praeger. 283-299. 1992. 

McDaniel JS et al, Caregivers working with AIDS: Avoiding burnout, in American 

Psychiatric Press Textbook of Homosexuality and Mental Health, Cabaj RP & Stein TS, 

Editors. 1996, Washington, DC: American Psychiatric Press, Inc. 839-858. 

Rudd RE, et al, HIV-related training programs for health care professionals: Findings from a 

collaborative assessment. AIDS Education and Prevention, 6(4):283-295. 1994. 

Silverman DC, Psychosocial impact of HIV-related caregiving on health providers: A review 

and recommendations for the role of psychiatry. American Journal of Psychiatry, 150:705­

712. 1993. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
REFERENCES & SUGGESTED READING 149 

DELIVERING SERVICES 

Mental Health Services 

Braithwaite RL et al, Prisons and AIDS: A public health challenge. 1996, San Francisco: 

Jossey-Bass Publishers, Inc. 

Conforti P, Spirituality, in HIV mental health for the 21st century, Winiarski MG, editor. 

1997, New York: New York University Press. 52-66. 

Ernst E et al, Complementary therapies for depression. Archives of General Psychiatry, 

55:1026-1032. 1998. 

Kalichman S & Sikkema K. Psychological sequelae of HIV infection: Review of empirical 

findings. Clinical Psychology Review, 1994. 

Kalichman SC, Understanding AIDS: A guide for mental health professionals. 1995, 

Washington, DC: American Psychological Association. 

LeBars, P.L., Katz, M.M., Berman, N., Itil, T.M., Freedman, A.M., and Schatzberg, A.F. 

(1997) A placebo-controlled, double-blind, randomized trial of an extract of Ginkgo biloba for 

dementia. North American EGb Study Group. Journal of the American Medical 

Association. October 22-29; 278 (16): 1327-32. 

Linde, K., Ramirez, G., Mulrow, C.D., Pauls, A., Weidenhammer, W. and Melchart, D. 

(1996) St. John's wort for depression - an overview and meta-analysis of randomised clinical 

trials. British Medical Journal, 313, 253-258. 

MacIntyre RC & Holzemer WL, Complementary and alternative medicine and HIV/AIDS. 

Part II: Selected literature review. Journal of the Association of Nurses in AIDS Care, 

March-April; 8(2):25-38. 1997. 

Martin JL & Dean L, Bereavement following death from AIDS: Unique problems, reactions, 

and special needs, in Handbook of bereavement: Theory, research, and intervention, Stroebe 

MS, Stroebe W & Hansson RO, Editors. 1996, New York: Cambridge University Press. 

O’Conner MF, ed., Treating the psychological consequences of HIV. The Jossey-Bass library 

of current clinical technique, ed. I.D. Yalom. 1997, San Francisco: Jossey-Bass Publishers. 

Odets W & Shernoff M., eds., The second decade of AIDS: A mental health practice 

handbook. 1995, New York: Hatherleigh Press. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
150 REFERENCES & SUGGESTED READING 

Pace JC & Stables JL, Correlates of spiritual well-being in terminally ill persons with AIDS 

and terminally ill persons with cancer. Journal of the Association of Nurses in AIDS Care, 

8(6):31-42. 1997. 

Perna FM et al, Cognitive-behavioral intervention effects on mood and cortisol during exercise 

training. Annals of Behavioral Medicine, Spring; 20(2):92-98, 1998. 

Shelby RD, People with HIV and those who help them. 1995, New York: Haworth Press, 

Inc. 

Shlay et al, Acupuncture and amitriptyline for pain due to HIV-related neuropathy: A 

randomized controlled trial. Terry Beirn Community Programs for Clinical Research in AIDS. 

Journal of the American Medical Association, 11;280(18):1590-1595. 1998. 

Stoff DM, HIV infection in people with severe mental illnesses. NAMI Advocate. 20(2):25­

26. October/November 1998. 

Wheatley, D. (1998) Hypericum Extract: Potential in the treatment of depression. CNS 

Drugs, June: 9 (6): 432-440. 

Winiarski MG, ed. HIV mental health for the 21st century. 1997, New York: New York 

University Press. 

Wong A et al. Herbal remedies in psychiatric practice. Archives of General Psychiatry, 

55:1033-1044. 1998. 

Clinical Assessment 

Abidin RR, Parenting Stress Index Manual. Second Edition. Charlottesville, VA: 

Pediatric Psychology Press. 1986. 

Batki SL, Drug abuse, psychiatric disorders, and AIDS. Dual and triple diagnosis. Western 

Journal of Medicine, 152(5):547-552. 1990. 

Baumann SL, Mental health assessment of persons with HIV. Journal of the Association of 

Nurses in AIDS Care, 4(4):36-44. 1993. 

Butters N et al, Assessment of AIDS-related cognitive changes: Recommendations of the 

NIMH Workshop on Neuropsychological Assessment Approaches. Journal of Clinical and 

Experimental Neuropsychology, 12(6):963-978. 1990. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
REFERENCES & SUGGESTED READING 151 

DeJong P & Miller SD, How to interview for client strengths. Social Work, 40(6):729-736. 

1985. 

McLellan AT et al, An improved diagnostic evaluation instrument for substance abusing 

patients: The Addiction Severity Index. Journal of Nervous and Mental Disease, 168:26­

33. 1980. 

Radloff LS, The CES-D Scale: A self-report depression scale for research in the general 

population. Applied Psychological Measurement, 1:385-401. 1977. 

Scofield EC, A model of preventive psychosocial care for people with HIV disease. Health 

and Social Work, 20(2):102-109. 1995. 

Psychiatric and Neurologic Conditions 

Atkinson JH et al, Prevalence of psychiatric disorders among men infected with human 

immunodeficiency virus. Archives of General Psychiatry, 45:859-864. 1988. 

Berger JR, Levy RM, eds. AIDS and the nervous system. 2nd ed. 1997, Philadelphia: 

Lippincott-Raven Publishers. 

Carey MP et al, Risk for human immunodeficiency virus (HIV) infection among persons with 

severe mental illness. Clinical Psychology Review, 17:271-291. 1997. 

Carmen E & Brady SM, AIDS risk and prevention for the chronic mentally ill. Hospital and 

Community Psychiatry, 41(6):652-657. 1990. 

Cournos F & Nicholas B, eds, AIDS and people with severe mental illness. 1996, New 

Haven: Yale University Press. 

Cournos F & McKinnon K, Substance use and HIV risk among people with severe mental 

illness. Research Monograph Series. Rockville, MD: National Institute on Drug Abuse. 

172:110-129. 1997. 

Deeks SG et al, HIV-1 protease inhibitors: A review for clinicians. Journal of the American 

Medical Association, 277:145-153. 1997. 

Folstein MF et al, Mini-mental state: A practical method for grading the cognitive state of 

patients for the clinician. Journal of Psychiatric Research, 12:189-198, 1975. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
152 REFERENCES & SUGGESTED READING 

Goodkin K et al, HIV-related neuropsychiatry complications and treatments. AIDS and 

HIV Disease - A Mental Health Perspective: APA Training Curriculum. 1996, 

Washington D.C.: American Psychiatric Association. 

Grant I & Martina A, eds. Neuropsychology of HIV infection. 1994, New York: Oxford 

University Press. 

Kalichman SC et al, Human immunodeficiency virus risk among the seriously mentally ill. 

Clinical Psychology: Science and Practice. 1996. 

Maj M et al, World Health Organization Neuropsychiatric AIDS study, cross-sectional Phase 

I: Study design and psychiatric findings. Archives of General Psychiatry, 51:51-61. 1994a. 

Maj M et al, World Health Organization Neuropsychiatric AIDS study, cross-sectional phase 

II: Neuropsychological and neurological findings. Archives of General Psychiatry, 51:39-49. 

1994b. 

McArthur JC, Neurological and neuropathological manifestations of HIV infection, in 

Neuropsychology of HIV infection, Grant I & Martin A, Editors. 1994, New York: Oxford 

University Press. 56-107. 

McArthur JC et al, Dementia in AIDS patients: Incidence and risk factors. Neurology, 

23:S34-37. 1993. 

McDaniel JS et al, An assessment of rates of psychiatric morbidity and functioning in HIV 

disease. General Hospital Psychiatry, 17:346-352. 1995. 

McDaniel JS & Purcell DW, Neuropsychiatric disorders in HIV and AIDS, in Medicine for 

the practicing physician. Hurst JW, editor. 1996, Norwalk, Connecticut: Appleton and 

Lange. 60-63. 

McDaniel JS et al, Severe mental illness and HIV-related medical and neuropsychiatric 

sequelae. Clinical Psychology Review, 17(3):311-325. 1997. 

Perry SW, Organic mental disorders caused by HIV: Update on early diagnosis and 

treatment. American Journal of Psychiatry, 147:696-710. 1990. 

Peterson J et al, Stress, coping, HIV status, psychosocial resources, and depressive mood in 

African American gay, bisexual, and heterosexual men. American Journal of Community 

Psychology, 24:461-486. 1996. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
REFERENCES & SUGGESTED READING 153 

Power C et al, The HIV Dementia Scale: A rapid screening test. Journal of AIDS, 68:261­

264, 1995. 

Preston SL & Stein DS, Drug interactions and adverse drug reactions with protease 

inhibitors. Primary Psychiatry, (July):64-69. 1996. 

Rabkin JG et al, Treatment of depression in HIV+ men: Literature review and report of an 

ongoing study of testosterone replacement therapy. Annals of Behavioral Medicine, 18:24­

29. 1996. 

Satz P, et al, Depression, substance use, and sexual orientation as cofactors in HIV-1 infected 

men: Cross-cultural comparisons. Treatment of Drug-Dependent Individuals with 

Comorbid Mental Disorders: National Institute on Drug Abuse Research Monograph 

Series, 172:130-155. 1997. 

Sewell DD et al, HIV-associated psychosis: A study of 20 cases. American Journal of 

Psychiatry, 151:237-242. 1994. 

Stober DR et al, Depression and HIV disease: Prevalence, correlates and treatment. 

Psychiatric Annals, 27(5):372-377. 1997. 

Case Management 

Albrecht GL & Peters KE, Peer intervention in case management practice. Journal of Case 

Management, 6(2):43-50. 1997. 

Alexandria Community Services Board, Breaking the cycle: An intensive case management 

model to engage homeless people with co-occurring mental illness and substance abuse 

disorders. 1994. 

Indyk D et al, A community-based approach to HIV case management: Systematizing the 

unmanageable. Social Work, 38(4):380-387. 1993. 

Riley TA, HIV-infected client care: Case management and the HIV team. Clinical Nurse 

Specialist, 6(3):136-141. 1992. 

Schwartz B et al, Case management of substance abusers with HIV disease. Journal of Case 

Management, 3(4):173-178. 1994. 

Snyder CM et al, An interdisciplinary, interagency, primary care approach to case 

management of the dually diagnosed patient with HIV disease. Journal of the Association of 

Nurses in AIDS Care, 7(5):72-82. 1996. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
154 REFERENCES & SUGGESTED READING 

Sowell RL, Community-based HIV case management: Challenges and opportunities. Journal 

of the Association of Nurses in AIDS Care, 6(2):33-40. 1995. 

Sowell RL & Meadows TM, An integrated case management model: Developing standards, 

evaluation, and outcome criteria. Nursing Administration Quarterly, 18(2):53-64. 1994. 

Ulmer C et al, Categorical funding to seamless systems of care: The challenge for communitybased primary care providers. Journal of Case Management, 6(3):96-103. 1997. 

Psychotherapy and Counseling 

Barouch G, Support groups: The human face of the HIV/AIDS epidemic. Long Island 

Association for AIDS Care, Inc., 1992. 

Caldwell SA et al, eds. Therapists on the frontline: Psychotherapy in with gay men in the age 

of AIDS. Washington DC: American Psychiatric Press, Inc., 1994. 

Dworkin SH & Pincu L, Counseling in the era of AIDS. Journal of Counseling and 

Development, 71:275-281. 1996. 

Farber EW, Psychotherapy with HIV and AIDS patients: The phenomenon of helplessness in 

therapists. Psychotherapy, 31:715-724. 1994. 

Farber EW & Schwartz JAJ, Changing conceptions of self and world through the spectrum of 

HIV disease: Implications for psychotherapy. Journal of Psychotherapy Practice and 

Research, 6:36-44. 1997. 

Freire P, Pedagogy of the oppressed (Translation by Myra Bergman Ramos). New York: 

Continuum Publishing Company, 1993. 

Getzel GS, Survival modes for people with AIDS in groups. Social Work, 36(1):7-11. 1991. 

Kelly J & Sykes P, Helping the helpers: A support group for family members of persons with 

AIDS. Social Work, 34(5):239-242. 1989. 

Kennedy E & Charles S, A Basic Guide for Nonprofessional Counselors. 1996, New York: 

Crossroad Press. 

Markowitz JC et al, Individual psychotherapies for depressed HIV-positive patients. 

American Journal of Psychiatry, 152:1504-1509. 1995. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
REFERENCES & SUGGESTED READING 155 

Posey EC, Confidentiality in an AIDS support group. Journal of Counseling and 

Development, 66(5):226-227. 1988. 

Rabkin JG et al, Maintenance of hope in HIV-spectrum homosexual men. American Journal 

of Psychiatry, 147:1322-1326. 1990. 

Rounds KA et al, Linking people with AIDS in rural communities: The telephone group. 

Social Work, 36(1):13-18. 1991. 

Somlai AM et al, An empirical investigation of the relationship between spirituality, coping, 

and emotional distress in people living with HIV infection and AIDS. Journal of Pastoral 

Counseling, 50:171-179. 1996. 

Thomason G et al, Cognitive behavioral interventions with persons affected by HIV/AIDS. 

Cognitive and Behavioral Practice, 3:417-442. 1996. 

Vincent E et al, Peer counseling skills, ethics and perspectives. 1996, Palo Alto: Science & 

Behavior Books. 

Vinogradov S & Yalom ID, Concise guide to group psychotherapy. Washington, DC: 

Concise Guides/American Psychiatric Press. 1989. 

Walker G. In the Midst of Winter: Systemic therapy with families, couples, and individuals 

with AIDS infection. 1991, New York: W. W. Norton & Co. 

Winiarski MG, AIDS-related psychotherapy. 1991, New York: Pergamon Press, Inc. (Now 

distributed by Allyn & Bacon.) 

Winiarski MG, HIV mental health for the 21st Century. New York: New York University 

Press. 1997. 

Counseling Themes and Clinical Considerations 

Benevedes JM, The protease inhibitors and the therapist. Focus: A Guide to AIDS 

Research and Counseling, 12(16):5-6. 1997. 

Besch, CL, Compliance in clinical trials. AIDS, 9(1):1-10. 1995. 

Crespo-Fierro M, Compliance/adherence and care management in HIV disease. Journal of 

the Association of Nurses in AIDS Care, 8(4):43-54. 1997. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
156 REFERENCES & SUGGESTED READING 

Ferrando SJ et al, Psychiatric morbidity, illicit drug use and adherence to zidovudine among 

injection drug users with HIV disease. American Journal of Drug and Alcohol Abuse, 

22(4):475-487. 1996. 

Frank E, Enhancing patient outcomes: Treatment adherence. Journal of Clinical Psychiatry,
 

58(suppl 1):11-14. 1997.
 

Herek GM & Glunt EK, An epidemic of stigma: Public reactions to AIDS. American
 

Psychologist, 43:886-891. 1988.
 

Hogg RS et al, Improved survival among HIV-infected individuals following initiation of
 

antiretroviral therapy. Journal of the American Medical Association, 279(6):450-454.
 

1998. 


Kissinger P et al, Compliance with public sector HIV medical care. Journal of the National
 

Medical Association, 87(1):19-24. 1995.
 

Singh N et al, Determinants of compliance with antiretroviral therapy in patients with human 

immunodeficiency virus: Prospective assessment with implications for enhancing compliance. 

AIDS Care, 8:261-269. 1996. 

Stall R et al, Decisions to get tested and to accept antiretroviral therapies among gay/bisexual 

men: Implications for secondary prevention efforts. Journal of Acquired Immunodeficiency 

and Human Retrovirology, 11:151-160. 1996. 

Stokes JP & Peterson JL, Homophobia, self-esteem, and risk for HIV among African 

American men who have sex with men. AIDS Education and Prevention, In Press. 

Substance Abuse Treatment 

Barth RP et al, eds., Families living with drugs and HIV: Intervention and treatment 

strategies. 1993, New York: The Guilford Press 

Brooner RK et al, Antisocial personality disorder and HIV infection among intravenous drug 

abusers. American Journal of Psychiatry, 150:53-58. 1993. 

Freeman RC et al, Compliance with AZT treatment regimen of HIV-seropositive injection 

drug users: A neglected issue. AIDS Education and Prevention, 8(1):58-71. 1996. 

McCarty D et al, Substance abuse treatment and HIV services: Massachusetts’ policies and 

programs. Journal of Substance Abuse Treatment, 13(5):429-438. 1996. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
REFERENCES & SUGGESTED READING 157 

Merzger DS et al, HIV conversion among in and out-of-treatment intravenous drug users in 

Philadelphia. Journal of AIDS, 6(9):1049-1056. 1993. 

O’Conner PG et al, Medical care for injection-drug users with Human Immunodeficiency 

Virus infection. New England Journal of Medicine, 331(7):450-459. 1994. 

Shernoff M, ed., Counseling chemically dependent people with HIV illness. 1991, New 

York: Haworth Press. 

Sobell MB & Sobell LC, Problem drinkers: Guided self-change treatment. New York: 

Guilford Press. 1993. 

Wells EA et al, Retention in methadone maintenance is associated with reductions in different 

HIV risk behaviors for men and women. American Journal of Drug and Alcohol Abuse, 

22(4):509-521. 1996. 

Risk Reduction 

Ayala G & Diaz R, Racism, poverty, and other truths about sex: Race, class, and HIV risk 

among Latino gay men. Workshop presentation at the 10th Annual National AIDS 

Update Conference, San Francisco, CA. 

Brook DW et al, Psychosocial risk factors for HIV transmission in female drug abusers. 

American Journal of Addiction, 6(2):124-134. 1997. 

Cochran SD, Applying social psychological models to predicting HIV-related sexual risk 

behaviors among African Americans. Journal of Black Psychology, 19(2):142-154. 1993. 

Cournos F et al, AIDS prevention for people with severe mental illness. Journal of Practical 

Psychiatry and Behavioral Health (September):285-292. 1997. 

DiClemente RJ & Peterson JL, eds. Preventing AIDS: Theories and methods of behavioral 

interventions. 1994, New York: Plenum Press. 

Doll LS et al, Bisexuality and HIV risk: The Canadian and U.S. experience. Annual 

Review of Sex Research. In Press. 

Jemmott LS et al, African American women and HIV-risk reduction issues, in Women at 

risk: Issues in the primary prevention of AIDS. AIDS prevention and mental health, O’Leary 

A & Jemmott LS, editors. 1995, New York: Plenum Press, 131-157. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
158 REFERENCES & SUGGESTED READING 

Kalichman S et al, Fatalism, future outlook, current life satisfaction, and risk for human 

immunodeficiency virus infection among gay and bisexual men. Journal of Consulting and 

Clinical Psychology, 65:542-546. 1997. 

Kalichman S et al, Prevention of human immunodeficiency virus infection among chronic 

mentally ill adults: Effects of a brief behavioral skills intervention. Psychiatric Services, 46. 

1995. 

Kelly JA, Changing HIV risk behavior: Practical strategies. 1995, New York: Guilford 

Press. 

Kelly JA et al, Psychological interventions are urgently needed to prevent HIV infection: New 

priorities for behavioral research in the second decade of AIDS. American Psychologist, 

48:1023-1034. 1993. 

Marin G, AIDS prevention among Hispanics: Needs, risk behaviors, and cultural values. 

Public Health Reports, 104(5):411-415. 1989. 

Meyer IH & Dean L, Patterns of sexual behavior and risk taking among young New York 

City gay men. AIDS Education and Prevention, 7(Suppl 5):13-23. 1995. 

Peterson J & Carballo-Dieguez A, HIV prevention among minority men who have sex with 

men, in DiClemente RJ, Peterson JL, editor. In Press, New York: Plenum Press. 

Stephens TT et al, Perceptions of vulnerability to AIDS among African American men: 

Considerations for primary preventive counseling for undergraduates. Social Behavior and 

Personality, 25(1):77-91. 1997. 

Thomas S & Quinn S, The Tuskegee Syphilis Study 1932-1972: Implications for HIV 

education and AIDS risk reduction programs in the Black community. American Journal of 

Public Health, 81(11):92-95. 1991. 

Thomas S & Quinn S, The burdens of race and history shaping Black American attitudes 

toward needle exchange policy to prevent HIV infection. Journal of Public Health Policy, 

14(3):320-347. 1996. 

Tortu S et al, Factors associated with needle exchange use in East Harlem. Journal of Drug 

Issues, 26(4):735-749. 1997. 

Strathdee SA et al, Needle exchange is not enough: Lessons from the Vancouver injecting 

drug study. AIDS, 11(8):59-65. 1997. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
REFERENCES & SUGGESTED READING 159 

Woody GE et al, Psychiatric symptoms, risky behavior, and HIV infection in National 

Institute on Drug Abuse Research Monograph Series: Treatment of Drug-Dependent 

Individuals with Comorbid Mental Disorders, Onken LS., et al., eds. Rockville, MD: 

National Institute on Drug Abuse. 156-169. 1997. 

Permanency Planning 

Boyd-Frankin N et al, Children, families, and therapeutic issues. New York-London: 

Guilford Press. 1995. 

Feyler N et al, Building bridges: How social service providers can help parents with 

HIV/AIDS make appropriate custodial decisions about their children. Philadelphia, PA: MCP 

& Hammer University Department of Community Health. 1995. 

Geballe S et al, The forgotten children of the AIDS epidemic. New Haven and London: 

Yale University Press. 1995. 

Grollman E, Talking about death. Boston: Beacon Press. 1976. 

Heim MD &Digeronimo T, AIDS: Trading fears for facts: A guide for young people. 

Yonkers, N.Y. (3rd Ed): Consumer Reports Books. 1989. 

Kubler-Ross E. On children and death. New York: Collier Books/Macmillan Publishing 

Co. 1983. 

Levine C & Stein GL, Orphans of the HIV Epidemic Unmet Needs in Six U.S. Cities. 

1994. 

McNaught D, The gift of good-bye: A workbook for children who love someone with AIDS. 

New York: Delta/Dell Publishing Group, Inc. 1993. 

Tasker M, How can I tell you? Secrecy and disclosure with children when a family member 

has AIDS. Bethesda: Association for the Care of Children’s Health. 1992. 

Psychosocial Rehabilitation 

Anthony WA & Liberman RP, The practice of psychiatric rehabilitation: Historical, 

conceptual, and research base. Schizophrenia Bulletin. 12:542-559. 1986. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
160 REFERENCES & SUGGESTED READING 

Beard JH, The Fountain House model of psychiatric rehabilitation. Psychosocial 

Rehabilitation Journal. 5(1). 1982. 

Breier A & Strauss JS, Social relationships in the recovery from psychotic disorders. 

American Journal of Psychiatry. 141:949-955. 1984. 

Cnaan RA, Psychosocial rehabilitation: Toward a definition. Psychosocial Rehabilitation 

Journal. 11(4). 1988. 

Cnaan RA, Expert’s assessment of psychosocial rehabilitation principles. Psychosocial 

Rehabilitation Journal. 13(3). 1990. 

Hatfield A, Serving the unserved in community rehabilitation programs. Psychosocial 

Rehabilitation Journal. 13(2). 1989. 

Weinberg RB, Recognizing the social in psychosocial competence: The importance of social 

network interventions. Psychosocial Rehabilitation Journal. 6(4). 1983. 

EVALUATING SERVICES AND PROGRAMS 

Program Evaluation 

Beigel A & Levenson AI, Program evaluation on a shoestring budget in Evaluation of 

human service programs. Attkisson CC, Hargreaves WA & Horowitz MJ, eds. New York: 

Academic Press. 1978. 

Depoy E et al, Training trainers: Evaluating services provided to children with HIV and their 

families. Research on Social Work Practice, 2(1):39-55. 1992. 

Patton MQ, Utilization-focused evaluation. Newbury Park CA: Sage. 1989. 

Strauss A & Corbin J, Basics of qualitative research. Newbury Park, CA: Sage. 1990. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
196 APPENDIX 

Andrea Ronhovde, L.C.S.W. 

Alexandria Mental Health Center 

Alexandria Community Services Board 

720 North Saint Asaph Street 

Alexandria, VA 22314 

T 703.838.6400 

F 703.838.5062 

aronhovde@aol.com 

Martha Saldarriaga, L.C.S.W. 

Elizabeth General Medical Center 

Kinship Connection Program 

655 East Jersey Street 

Elizabeth, NJ 07206 

T 908.965.7460 

F 908.965.7127 

Mickey J.W. Smith, M.S.W., C.A.C. 

1315 T Street, N.W., #1 

Washington, DC 20009 

T 202.462.7756 

dcmickey@mindspring.com 

Doug Wagner, Ph.D. 

Charles Drew Health Center 

2915 Grant Street 

Omaha, NE 68111 

T 402.453.1433 

F 402.453.1970 

FEDERAL PARTICIPANTS 

This manual was written and edited by 

individuals from the Demonstration's study 

sites. Two of the authors of the manual are 

representatives of the U.S. Department of 

Health and Human Services that contributed 

in their private capacity. No official support or 

endorsement by the Department of Health 

and Human Services is intended or should be 

inferred. 

Catherine Acuff, Ph.D. 

Office of the Associate Director for 

Medical Affairs 

Center for Mental Health Services 

Substance Abuse and Mental Health 

Services Administration 

5600 Fishers Lane, Room 15C-87 

Rockville, MD 20857 

T 301.443.0688 

F 301.443.0737 

cacuff@samhsa.gov 

David Stoff, Ph.D. 

Office on AIDS Research 

National Institute of Mental Health 

National Institutes of Health 

6001 Executive Boulevard, Room 6209, 

MSC 9619 

Bethesda, MD 20892-9619 

T 301.443.4625 

F 301.443.9719 

dstoff@nih.gov 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
159 

Appendices 


APPENDIX A 

THE 11 HIV/AIDS MENTAL HEALTH SERVICES DEMONSTRATION PROGRAM SITES 

Alexandria Mental Health HIV/AIDS Project
 

Alexandria Community Services Board
 

720 North Saint Asaph Street
 

Alexandria, VA 22314
 

Center for AIDS/HIV Mental Health Services
 

Emory University
 

Grady Health System Infectious Disease Program
 

341 Ponce de Leon Avenue
 

Atlanta, GA 30308
 

Chicago HIV Health and Psychological Support Project 

Cook County HIV Primary Care Center and Chicago Department of Health 

1900 West Polk 

Chicago, IL 60612 

Kinship Connection
 

Department of Psychiatry/Elizabeth General Medical Center
 

655 East Jersey Street
 

Elizabeth, NJ 07206
 

SPECTRUM Community Services and Research 

(Services for HIV Prevention, Education, Care, Treatment, 


and Research for Underserved Minorities)
 

Drew University of Medicine and Science
 

1774 East 118th Street, Building K
 

Los Angeles, CA 90059
 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
160 APPENDIX 

APPENDIX A (Continued) 

The Special Needs Clinic 

Presbyterian Hospital 

622 West 168th Street 

New York, NY 10032 

Harambee 

Charles R. Drew Health Center, Inc. 

2915 Grant Street 

Omaha, NE 68111 

The Community Living Room 

COMHAR, Inc., and Philadelphia Office of Mental Health 

207 North Broad Street, 5th Floor 

Philadelphia, PA 19107 

Mini Mental Health Center 

Virginia Commonwealth University/Medical College of Virginia 

P.O. Box 980109 

Richmond, VA 23298 

Walden House Planetree Assessment and Treatment Services 

Walden House, Inc. 

520 Townsend Street 

San Francisco, CA 94103 

Puerto Rico HIV/AIDS Mental Health Services Demonstration Project 

Puerto Rico Department of Health 

P.O. Box 70139 

San Juan, PR 00936 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
PROCESS RECORDING OUTLINE 

Student’s Name:____________________ Client’s Name:____________________ Interview Date:___/___/__

 Date Submitted:___/___/___ Date D

1. PURPOSE OF THE SESSION: (Statement of the purpose that is concise, clear and specific. Show relatedness between this sessio2. CONTENT: (Using the recording form below, record one significant exchange in the beginning, in the middle, and at the end of the int

INTERVIEW CONTENT 

(I said, she said) 

CLIENT'S 

FEELINGS/AFFECT 

STUDENT'S 

FEELINGS/AFFECT SUPERVISORY 

Use feeling words to describe your own feelings from the session (see attached). 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
INTERVIEW CONTENT 

(I said, she said) 

CLIENT'S 

FEELINGS/AFFECT 

STUDENT'S 

FEELINGS/AFFECT SUPERVISORY C

Use feeling words to describe your own feelings from the session (see attached). 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
3. IMPRESSIONS/ASSESSMENT: A) How did the client present her/himself – appearance, behavior and affect

observe throughout the session – behavior and affect; C) Was the behavior/affect appropriate, explain; and D) Hobehavior/affect fit with what you know about the client’s past behavior affect? 4. IDENTIFY THE MAJOR THEMES/ISSUES THAT EMERGED: 5. INTERVENTIONS: Choose two significant interventions you made: A) Identify/describe; B) What was your effectiveness; and C) What would you change? 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV

/AIDS: A PRACTICAL GUIDE 
6. PROFESSIONAL USE OF SELF: A) Body language/use of space/voice; B) Worker’s own feelings/values – h

hinder the process; and C) How worker dealt or is dealing with own feelings. 7. PLAN: (Brief statement of your plans for the next session, long range goals, short range goals that are relevan8. ISSUES, QUESTIONS OR PROBLEMS: (To explore in supervisory sessions. Areas to explore in your supervincluding issues of diversity, value dilemmas, counter-transference, etc.) 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV

/AIDS: A PRACTICAL GUIDE 
APPENDIX 165
 

APPENDIX C 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
166 APPENDIX 

APPENDIX C (Continued) 

GUIDE TO COMPLETING THE PSYCHOSOCIAL ASSESSMENT 

In an attempt to provide greater uniformity in completing our psychosocial assessments. We 

thought providing some general guidelines on completing the various components would be 

helpful. 

For each section we ask that you indicate in writing at minimum the following domains: 

1) Appearance: Please comment on: a) age; b) ethnicity; c) gender d) build/height; e) dress; 

f) hygiene; g) Sexual orientation and risk factor if patient is forthcoming. 

2) Mental Status: This section aims to provide a brief mental status of the patient at assessment. 

Please comment on the following areas: a) intelligence; b) judgment; c) memory (STM & 

LTM); d) thought disorder; e) delusions/hallucinations; and f) mood/emotional state. 

For example: pt is oriented x3, displays above average intelligence, memory appears intact, 

judgment intact, no indication of thought disorder or delusions/hallucinations and mood 

seems to be sad. 

3) Suicide/homicide: If patient denies suicidal ideation at present, check denies and move on. If 

patient reports suicide or homicidal potential, elaborate with focus on ideation vs gestures vs 

attempts. 

For example: “pt reports having suicidal ideation w/o plan”; or “pt. has made suicidal gesture 

(took larger amount of meds than needed) but denies being suicidal at present”; or “pt. 

reports being suicidal has plan (slit wrists) and means 

4) Psychiatric history: In this section, we would like to get an indication current and past psych. 

Tx. Indicate whether pt. is currently in tx by marking yes or no. If yes, indicate type 

frequency and duration (e.g. pt. is being seen at ISPI’s output. program on a weekly basis x 

2yrs. or “Pt. Has recently been released from Read where he was hospitalized for 2 weeks for 

Suicide attempt”) If patient is aware of his diagnosis it may be helpful to indicate. 

5) Substance Use: This section should provide a snapshot of pt. Drug use and indicate whether 

it is a factor in psychological functioning AT INTAKE. Specifically, indicate pt.’s primary 

drug of choice and attempt to get as accurate of an assessment of onset, frequency, and 

attempts to stop. The past use section should cover past substance abuse patterns and 

previous tx. For substance use. Below are a few examples of varying degrees of specificity: 

POOR: Pt. reports using various drugs on an intermittent basis. Past: pt reports have heroin 

prob. In past. 
APPENDIX 167 

APPENDIX C (Continued) 

BETTER: Pt. drinks alcohol and smokes marijuana occasionally. He does not identify 

substance use as a concern. Past: blank 

BEST: Pt. indicates that he drinks (beer x3day/wk, 1 sixpack per day) Pt. uses cocaine (snorts 

lgm x 1/month). He reports onset of alcohol use at age 18 and cocaine use at age 27. No 

other drug use at present. Past: Pt. Has entered 3 detox programs (88, 94 & 95) never 

successfully completed drug tx. Program 

6) Social support: This section has provided in the past a great deal of variability. It would be 

best to indicate social support along two domains (practical/financial and emotional). 

Practical support which would include assistance with daily living activities. Emotional 

support refers to who the person talks with to receive emotional support around living with 

HIV. Also, may want to assess level of HIV disclosure (to who and why and reasons not 

disclosed to others) 

For example: “pt reports living w/ family who provide food, and transportation to medical 

appointments. Family not supported around emotional needs w/ family not telling other 

family member of pt’s health status. Pt. Reports not talking to anyone about living with HIV” 

6) Vocational: please indicate whether pt works full, pt, unemployed or unable to work at 

present. Indicate nature of work. (e.g. fast food or administration). For past, indicate primary 

job or job hx. (e.g. pt. Worked for gas company for 9yrs. or pt. held numerous part time jobs) 

You may want to comment on whether Pt. has concerns about HIV impacting work situation. 

7) Initial Impressions: This section is the section where the most variability has existed. It may 

be best to conceptualize this section in the following way: 1) Consider the audience other 

health and social service staff; 2) “What would be helpful for them to know about the 

patient’s psychological functioning?” and “what’s your impression of this client’s psychological 

management of his HIV diagnosis?” I would write very clearly (try to keep psychological 

jargon to a minimum) and provide concrete examples to substantiate your impressions. 

Providing an initial diagnosis is optional at present. Below is an example: 

“Pt. is a 35 y/o gay AA male dx. HIV+ in 6/95. Pt. Appears to have cognitive impairments 

particularly in memory superimposed with active substance use, and failing health. Etiology 

for memory impairment is unclear but may be due to seizures, HIV, underlying psychosis (as 

evidenced by possible delusions) or a personality disorder. Preliminary diagnosis: Cocaine 

Abuse, R/O psychotic disorder, NOS. Pt. Does appear to respond well to structure and this 

should be factored in to tx. Planning. 

8) Recommendations: self explanatory. Use “other” section for a more detailed discussion 

of tx. Rec. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
The Mental Health SPECTRUM 

Clinical Diagnostic Assessment 

Date: 

Clinician: 

Patient Name: 

Patient ID#: 

ID (Gender, Race, Ethnicity, Age, D.O.B., HIV Status and Stage, Living Environment)

Source

Presenting Problem

Current Stressors

168 APPENDIX 

APPENDIX D 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
Psychiatric Hx

Hospitalizations, where, reason 

Family Hx 

Medications 

Previous Dx 

ETOH/Drug Hx

Current Use (Substance, how much per day, how ingested) 

Past Hx 

Hospitalizations for SA 

Treatment: current and past (counseling, groups, day treatment, 12 step) 

Arrests, accidents, financial losses secondary to SA 

Medical Hx

Past status 

Current status 

APPENDIX 169
 

APPENDIX D (Continued) 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
Diagnosis 

Medications 

Surgeries 

Social Development/Family Hx

Sexual Behavior & Orientation

Coping skills

Religious and/or Spiritual

Employment and Education

Legal

Financial

170 APPENDIX 

APPENDIX D (Continued) 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
Services Needed

Transportation

voucher

dis bus pass

taxi ability card

Disability

Social Security

Food Services

Psychosocial Needs

12 Step Program

Case Management

Child care

Group(s)

Housing

Psychiatric Evaluation

Medication Evaluation

Neuropsych Consult

Psychological Testing

Individual Psychotherapy

Couples Counseling

Family Counseling

Detox/Sober Living

Domestic Violence

Mental Status Exam

 Attitude, appearance and motor activity 

 Mood 

Depressed 

Euphoric 

Labile 

Dysphoric 

Angry/Hostile 

Brief Description: 

APPENDIX 171
 

APPENDIX D (Continued) 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
Affect 

Flat 

Broad 

Bright 

Blunted 

Inappropriate 

Brief Description: 

Structure of thought and speech 

rapid speech slurred speech within normal limits incoherent 

perseveration flight of ideas circumstantiability blocking 

neologisms tangentiality loose associations distractibility 

clang/associations/rhyming/punning 

Brief Explanation: 

Content of thought and speech 

preoccupation/rumination somatic concerns/hypochondriasis 

derealization/depersonalization compulsions/obsessions grandiosity 

dreams and fantasies ideas of reference/influence excessive religiosity 

delusions: types and content_________________________ 

Brief Explanation: 

Perception: hallucinations (types and content) and illusions 

Sensorium and Cognition 

Potential for destructiveness 

172 APPENDIX 

APPENDIX D (Continued) 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
Suicidal attempts, thoughts and ideation 

Insight and motivation 

Summary

DSMIV DX

Axis 1 

Axis 2 

Axis 3 

Axis 4 

Axis 5 

Problems

1. 

2. 

3. 

Treatment Plan

1. 

2. 

3. 

Signature Title Date 

APPENDIX 173
 

APPENDIX D (Continued) 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
DEPARTMENT OF MENTAL HEALTH, MENTAL RETARDATION AND SUBSTANCE ABUSE 

ADMISSION/CRISIS INTERVENTION RECORD 

 

CLIENT NUMBER: CLIENT NAME: 

STAFF CODE: STAFF NAME: 

PROGRAM CODE: PROGRAM NAME: 

DATE OF REPORT: SVC: MINUTES: LOCATION: 

 

1. Identifying Information: 

2. Chief Complaint: 

3. Presenting Problems with Precipitating Events: 

4. Relevant History of Treatments (include psychiatric, substance abuse, medical, criminal involvement, 

family relationships): 

--PSYCHIATRIC TREATMENT OR HISTORY: 

--SUBSTANCE ABUSE HISTORY: 

--MEDICAL: 

--CRIMINAL HISTORY: 

--FAMILY RELATIONSHIPS: 

Service Location: AS= St. Asaph JA = Jail MI = Mill Road CO = Community HO = Hospital/Training Center 

PA = Patrick Street CL = Client Home CH = Charles Houston HE = PIE CO= Colvin Stree

174 APPENDIX 

APPENDIX E 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
APPENDIX 175
 

APPENDIX E (Continued) 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 

CLIENT NAME: CLIENT NUMBER: 

 

5. Mental Status Examination (include current appearance, behavior, speech, affect, mood, content and 

process of thought, memory, orientation, abstraction, suicidal/homicidal ideation, potential for acting out, 

judgment and insight):

6. Risk Assessment: Describe below and rate the level of risk. (Consider especially a recent history, 

such as the last two weeks, of plans to commit suicide, violent or assaultive behaviors, threats of violence or 

fear inducing behaviors such as throwing objects. Be particularly concerned with acute states of psychosis 

or substance abuse intoxication/withdrawal associated with potentially violent or self-destructive behaviors, 

and also note the degree of mental disorganization. Mention any remote history of suicide attempts or 

violent behaviors. Discuss involvement of recent losses, stressors, threatened or identified victims, 

availability of weapons/lethality of means, support system available, and demonstrated adaptive coping 

skills. Do not necessarily limit yourself to these factors.)

RISK LEVEL: Circle one. 

 A. 

Elevated Risk: Current and/or recent history of 

suicidal plans or behaviors, violence, threats or 

similar acting-out behavior which may be 

associated WITH a disorganized mental state or 

substance abuse. 

 B. 

Concern of Risk: No recent history of the elevated risk 

factors, yet does have a history of suicide attempts, 

violence, or threats which may be associated WITH 

psychosis or substance abuse, and/or moderate risk 

factors in current presentation. 

 C. 

Low Risk: No past history of suicide attempts or 

violence, but clinical presentation contains some 

factors which raise concern. 

 D. 

No Concern of Risk: No risk factors present in client's 

history. 

7. Diagnostic Impression: DIAGNOSIS 

AXIS I: 

AXIS II: 

AXIS III: 

AXIS IV: 

AXIS V (GAF): 
CLIENT NAME: CLIENT NUMBER: 

8. Initial Service Plan: (Include immediate action required and taken, and follow-up plans; purpose; who, 

what, by when, and indication for hospitalization when appropriate.) 

I have participated in the development of this service plan, have read the goals and objectives, and agree to 

its implementation. 

CLIENT SIGNATURE: ______________________________________ DATE: ____________________ 

SIGNATURE OF QMHP, QMRP, OR QSAP: ________________________ DATE: ____________________

176 APPENDIX 

APPENDIX E (Continued) 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
DEPARTMENT OF MENTAL HEALTH, MENTAL RETARDATION AND SUBSTANCE ABUSE 

CONSUMER ASSESSMENT 

CONSUMER NUMBER: CONSUMER NAME: 

STAFF CODE: STAFF NAME: 

PROGRAM CODE: PROGRAM NAME: 

DATE OF ASSESSMENT: LOCATION: 

PURPOSE OF ASSESSMENT (check one): Initial ___ Follow-up ___ Crisis Intervention ___ Other (specify): __________

1. Identifying Information: 

2. Reason for Contact: 

3. Presenting Problems with Precipitating Events: 

4. Relevant History:

Institutionalizations (Date/Place): 

Hospitalizations (Date/Place): 

Past Services (Date/Place): 

Medications (Type/Amount): 

Educational History: 

Employment History: 

Substance Abuse History: 

Criminal Involvement/History: 

Medical Problems: 

Service Location: AS= St. Asaph JA = Jail MI = Mill Road CO = Community HO = Hospital/Training Center 

PA = Patrick Street CL = Client Home CH = Charles Houston HE = PIE CO= Colvin Street

APPENDIX 177
 

APPENDIX E (Continued) 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
CONSUMER NAME: CONSUMER NUMBER: 

 

Family History/Support:

5. Mental Status (complete all sections): 

Current appearance: 

Behavior: 

Speech: 

Affect: 

Mood: 

Content process of thought: 

Memory: 

Orientation: 

Abstraction: 

Suicidal/homicidal ideation: 

Potential for acting out: 

Judgment: 

Insight: 

6. Risk Assessment (Describe below rate the level of risk). 

Recent history (such as the last two weeks) plans or attempts to commit suicide, violent or assaultive 

behaviors, threats of violence or fear-inducing behaviors such as throwing objects: 

Acute state of psychosis or substance abuse intoxication/withdrawal associated with potentially 

violent or self-destructive behaviors, also note the degree of mental disorganization: 

Any remote history of suicide attempts or violent behaviors (include dates): 

178 APPENDIX 

APPENDIX E (Continued) 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
CONSUMER NAME: CONSUMER NUMBER: 

Describe involvement in recent losses, stressors, threatened or identified victims, availability of 

weapons/lethality of means, support system available, demonstrated adaptive coping skills (do not 

necessarily limit yourself to these factors): 

 FACTORS INCREASING RISK (CHECK ALL THAT APPLY) STRENGTHS REDUCING RISKS 

Aggressive Behavior – 

Past Denial of Mental Illness Compliant with Treatment 

Aggressive Behavior – 

Recent Access to Weapons Compliant with Medications 

Fear Inducing Behaviors Head Injury/Organic Brain 

Syndrome Adaptive Coping Skills 

Fear Inducing Behavior 

Toward Property 

Sexual Excitation Through 

Inappropriate/Aggressive 

Means 

Has/Uses Strategies to Cope 

with Command Hallucinations 

Threats of Aggression Intellectual Impairment Social/Peer Support 

Aggressive Ideation Suicide Attempts No History of Violence 

Criminal 

History/Psycopathy Suicide Ideation No Current Substance Abuse 

Anger or Repressed 

Hostility Suicide Plans Family (Significant Other) Suppor

Homicidal Ideation Suicide Attempts by Family 

Members Acceptance of Mental Illness 

Impulsiveness by History Non-Compliant with 

Medications Insight into Mental Illness 

Paranoid Delusions Non-Compliant with Treatment 

Plans 

Sadistic Tendencies Lack of Social Support 

Command Hallucinations Current Substance Abuse 

RISK LEVEL: Circle one. 

A. Elevated Risk: Current or recent history of suicidal plans or behaviors, violence, threats, or 

similar acting out behavior which may be associated with a disorganized mental state or 

substance abuse. 

B. Concern of Risk: No recent history of elevated risk factors, yet does have a history of suicide 

attempts, violence, or threats which may be associated with psychosis or substance abuse, or 

moderate risk factors in current presentation. 

C. Low Risk: No past history of suicide attempts or violence, but clinical presentation contains some 

factors which raise concern. 

APPENDIX 179
 

APPENDIX E (Continued) 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
CONSUMER NAME: CONSUMER NUMBER: 

 

7. Diagnostic Summary of Assessment:

DIAGNOSIS 

AXIS I: 

AXIS I: 

AXIS II: 

AXIS II: 

AXIS III: 

AXIS IV: 

AXIS V (GAF): 

8. Initial Service Plan: 

Immediate action required/taken: 

Follow-up plans (include purpose, by whom, by when, indication for hospitalization when 

appropriate): 

I have participated in the development of this service plan, have read the goals and objectives, and agree to 

its implementation. 

CONSUMER SIGNATURE: ____________________________________ DATE:_______________________ 

SIGNATURE OF QMHP, QMRP, OR QSAP: ______________________ DATE: ______________________

180 APPENDIX 

APPENDIX E (Continued) 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
DEPARTMENT OF MENTAL HEALTH, MENTAL RETARDATION AND SUBSTANCE ABUSE 

DIAGNOSTIC STUDY OF THE CLIENT

 

CLIENT NUMBER: CLIENT NAME: 

STAFF CODE: STAFF NAME: 

PROGRAM CODE: 

DATE OF REPORT: 

1. REFERRAL INFORMATION (include source and reason): 

2. HISTORY OF PRESENT CONDITION, ILLNESS, AND/OR SUBSTANCE ABUSE: 

3. SOCIAL HISTORY: 

A. Developmental Background: 

B. Family Structure and Relationships: 

C. Significant Milestones in Childhood or Adult Development: 

D. Critical Incidents in Childhood or Adult Life (include trauma, victimization): 

E. Employment/Vocational/Educational History (including current employment and military history, if any): 

4. HISTORY OF AGGRESSIVE/CRIMINAL BEHAVIOR AND CURRENT CRIMINAL JUSTICE STATUS: NONE 

5. SUBSTANCE ABUSE HISTORY: CLT REPORTS OCCASIONAL CANNABIS USE; TO EXPLORE FURTHER.

Substances Age at Onset of Method of Frequency Quantity Last Time Used Used Use Administration 

A. CURRENT: 

 

B. PAST: 

 

Is use sufficient to warrant further exploration? (Yes or No. If yes, complete C through M. If no, skip to 6). 

C. Are/were substances used in either combination or sequentially? 

APPENDIX 181
 

APPENDIX E (Continued) 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
182 APPENDIX 

APPENDIX E (Continued) 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 

CLIENT NAME: CLIENT NUMBER: Page 2 

 

D. Client’s reason for starting substance use: 

E. What purpose(s) does client believe that these substances have served? 

F. Have any family members or significant others complained about the client’s alcohol or drug use? 

G. Has client ever done anything while intoxicated that s/he has regretted? 

H. Has substance abuse caused any trouble in the client’s life (e.g., keeping family, child care or work 

responsibilities, financial or social obligations, or problems with physical or psychological well-being)? 

I. Does substance use recur in situations that are physically dangerous? 

J. Has the client ever committed any violent acts towards self or others while intoxicated? 

K. How long has the client attempted to maintain a Presently attending AA/NA? 

drug-free lifestyle? AA or NA Sponsor? 

L. Do characteristic withdrawal symptoms occur if use of the substance is discontinued? 

6. FAMILY HISTORY OF PSYCHIATRIC ILLNESS, SUBSTANCE ABUSE, SEXUAL/PHYSICAL ABUSE 

(by whom/against whom): 

7. FAMILY HISTORY OF SELF-DESTRUCTIVE, SUICIDAL OR HOMICIDAL BEHAVIOR (by whom, 

against whom, circumstances): 

8. RESULTS OF INDIVIDUAL PSYCHOLOGICAL, PSYCHIATRIC AND NEUROLOGICAL 

EXAMINATIONS, IF APPLICABLE: 

9. PREVIOUS MENTAL HEALTH AND/OR ALCOHOL/DRUG TREATMENT (include psychiatric 

hospitalizations): 

10. MEDICAL HISTORY: 

A. Serious illnesses and chronic conditions of family members: 

B. Recent physical complaints/conditions; changes in Date of last physical: 

or concerns about eating/sleeping patterns: 

C. Past serious illnesses, infectious diseases, HIV testing, serious injuries, head trauma, hospitalizations: 

D. Physician/Dentist contact information: 

Physician Name, Address and Phone: 

Dentist Name, Address and Phone: 

11. MEDICATION USE: 

A. History of prescription and/or non-prescription drug use: 

B. Drug allergies, idiosyncratic and/or adverse drug reactions: 

C. Ineffective medication therapy: 
CLIENT NAME: CLIENT NUMBER: Page 3 

 

12. MENTAL STATUS EXAMINATION (include current appearance, behavior, speech, affect, mood, 

content and process of thought, memory, orientation, abstraction, suicidal/homicidal ideation, potential for 

acting out, judgment and insight):

13. RISK ASSESSMENT: Describe below and rate the level of risk. (Consider especially a recent history, 

such as the last two weeks, of plans or attempts to commit suicide, violent or assaultive behaviors, threats of 

violence or fear inducing behaviors such as throwing objects. Be particularly concerned with acute states of 

psychosis or substance abuse intoxication/withdrawal associated with potentially violent or self-destructive 

behaviors, and also note the degree of mental disorganization. Mention any remote history of suicide 

attempts or violent behaviors. Discuss involvement of recent losses, stressors, threatened or identified 

victims, availability of weapons/lethality of means, support system available, and demonstrated adaptive 

coping skills. Do not necessarily limit yourself to these factors.)

RISK LEVEL: Circle one. 

 A. B. 

Elevated Risk: Current and/or recent history of Concern of Risk: No recent history of the elevated risk 

suicidal plans or behaviors, violence, threats or factors, yet does have a history of suicide attempts, 

similar acting-out behavior which may be violence, or threats which may be associated WITH 

associated WITH a disorganized mental state or psychosis or substance abuse, and/or moderate risk 

substance abuse. factors in current presentation. 

 C. D. 

Low Risk: No past history of suicide attempts or No Concern of Risk: No risk factors present in client's violence, but clinical presentation contains some history. factors which raise concern. 

14. CLINICAL IMPRESSION: (include diagnosis, maintenance of current psychological and/or substance 

abuse problem, ego strengths and weaknesses, pathological personality traits, patterns of interpersonal 

relationships, impulsive and/or aggressive tendencies, responsiveness to previous interventions/medication, 

motivation for change.) 

AXIS I 

AXIS II 

AXIS III 

AXIS IV 

AXIS V 

APPENDIX 183
 

APPENDIX E (Continued) 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
CLIENT NAME: CLIENT NUMBER: Page 4 

 

PSYCHOSOCIAL ASSESSMENT 

15. Behavioral/Emotional Symptoms, Strengths, Service Need: 

Needs: Barriers to Service: 

Plan for Service Linkage: 

16. Substance Abuse Needs: Service Need: 

Barriers to Service: 

Plan for Service Linkage: 

17. Health Strengths, Needs: Service Need: 

Barriers to Service: 

Plan for Service Linkage: 

18. Familial/interpersonal Relationships Service Need: 

Strengths, Needs: 

Barriers to Service: 

Plan for Service Linkage: 

19. Current Living Situation Strengths, Needs: Service Need: 

Barriers to Service: 

Plan for Service Linkage: 

20. Vocational, Educational Strengths, Needs: Service Need: 

Barriers to Service: 

Plan for Service Linkage: 

21. Social, Recreational Strengths, Needs: Service Need: 

Barriers to Service: 

Plan for Service Linkage: 

22. Communication Strengths, Needs: Service Need: 

Barriers to Service: 

Plan for Service Linkage: 

23. Transportation Strengths, Needs: Service Need: 

Barriers to Service: 

Plan for Service Linkage: 

24. Financial Assistance, Needs: Service Need: 

Barriers to Service: 

Plan for Service Linkage: 

184 APPENDIX 

APPENDIX E (Continued) 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
CLIENT NAME: CLIENT NUMBER: Page 5 

 

PSYCHOSOCIAL ASSESSMENT 

25. Legal Assistance Needs: Service Need: 

Barriers to Service: 

Plan for Service Linkage: 

26. High Risk Behavior Management Needs Service Need: 

(high-risk behaviors which currently pose an Barriers to Service: elevated risk to client or others, as described in 

# 13). Plan for Service Linkage: 

I have participated in the development of this service plan, have read the goals and objectives, and agree to 

its implementation. 

CLIENT SIGNATURE: _______________________________________ DATE: _______________________ 

SIGNATURE OF QMHP, QMRP, OR QSAP: _____________________ DATE: _______________________ 

APPENDIX 185
 

APPENDIX E (Continued) 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
DEPARTMENT OF MENTAL HEALTH, MENTAL RETARDATION AND SUBSTANCE ABUSE 

MASTER INDIVIDUAL SERVICE PLAN 

 

CONSUMER NUMBER: CONSUMER NAME: 

UNIT/SUBUNIT: PROGRAM NAME: 

CASE MANAGER STAFF CODE: CASE MANAGER NAME: 

DATE FORM COMPLETED: Estimated length of consumer’s need for 

service: 

Objectives and strategies must include desired outcomes, how (modality), who (responsible person) and frequency of planned service. 

QUARTER CONSUMER PROBLEM/NEED: TARGET 

DATE CODE/ CODE/ CODE/ CODE/ ANNUAL DATE DATE DATE DATE 

GOAL OF SERVICE: 

OBJECTIVES AND STRATEGIES: 

 

BARRIERS TO SERVICE: 

QUARTER CONSUMER PROBLEM/NEED: TARGET 

DATES CODE/ CODE/ CODE/ CODE/ ANNUAL DATE DATE DATE DATE 

 GOAL OF SERVICE: 

 OBJECTIVES AND STRATEGIES: 

 

 

 

 

BARRIERS TO SERVICE: 

I have participated in the development of this treatment plan and agree with it. 

__________________________________________ ______________________ 

Consumer Signature Date 

CODES: C = Continue OM = Objective Met MS = Modify Strategy AR = Annual Review 

 D = Discontinue MO = Modify Objective N = New Objective Added

186 APPENDIX 

APPENDIX E (Continued) 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
APPENDIX 187 

APPENDIX F 

Contract Agreement for Services 

(Name of Evaluator) 

THIS AGREEMENT, made and entered into by and between (Name of Evaluator), 

hereinafter referred to as “Evaluator,” and (Name of Agency), a not-for-profit corporation 

duly organized and existing under the laws of the State of (Name of State), with a place 

of business at (Address of Agency), stipulates: 

1. (Name of Agency) and Evaluator agree to enter into a relationship as described in 

this Contract, and to be bound by the terms of this Contract. 

2. This Contract shall commence on (Start date), and shall continue until (End date). 

3. Evaluator agrees to conduct a (Scope of work) with (target group). 	 Such a (Scope 

of work) will include: (list of specific things that will be done). 

4. (Name of agency) agrees to assist in these efforts by providing the following: 	 (List 

of specific things the agency will provide). 

5. Evaluator agrees to perform the services described in this Contract for (amount ­

hourly or payment for entire service). Evaluator will submit invoices and 

description of activities to (Name of Agency) on a ________ basis before receiving 

payments. 

6. At their discretion, (Name of agency) shall compensate Evaluator for expenses 

incurred while conducting (scope of work), including: (list of expenses). 

7. Evaluator acknowledges that all information received as a result of this agreement 

shall be deemed confidential, and Evaluator shall not release or reveal such 

information without the express, prior, written agreement of (Name of Agency). 

Evaluator understands that only aggregate data is sought, and to that effect, the 

confidentiality of individual participants in the individual and focus group 

interviews will be maintained. Evaluator agrees to take extensive notes during 

interviews, but will use audio or videotape equipment to record responses. If 

particular themes emerge, Evaluator may use non-identified quotes in the final 

report to further illustrate such themes. Because of the size of (Name of Agency) 

and the composition of the focus groups and individual interviews, it may be 

inferred from the final report whose perceptions are being presented. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
___________________________________ 

___________________________________ 

188 APPENDIX 

APPENDIX F (Continued) 

8. Evaluator acknowledges that in receiving, storing or otherwise dealing with any 

client information that they are bound by the requirements of 42 CFR part 2 

and/or the Mental Health and Developmental Disabilities Confidentiality Act. 

Evaluator agrees to institute appropriate procedures for safeguarding information 

and to resist in judicial proceedings or other efforts to obtain access to any client 

information. 

9. (Name of Agency) and Evaluator agree that any and all collected data will be the 

property of the (Identify who will own the data), and that the final report will be 

the property of (Name of Agency). Evaluator agrees that in any reference to the 

(Name of Agency) experience, the identity of (Name of Agency), its location, the 

identity of (Name of Agency) staff and community members, and the identity of 

any and all interviewees will remain confidential. 

10. Evaluator acknowledges and understands that he/she is an 	 independent 

contractor, and shall not be considered to be an employee of (Name of Agency) 

for any purpose. 

11. (Name of Agency) acknowledges and understands that any services provided by 

the Evaluator beyond the scope of this CONTRACT will involve different fees for 

service and requires the development of a separate Contract agreement. 

12. (Name of Agency) and Evaluator agree that this Contract agreement may be 

terminated by either party, with or without cause at any time, on sixty (60) days 

written notice. 

In witness whereof, each party to this agreement has caused it to be executed at (Address 

of agency), on the date indicated below. 

(Name of Agency):	 Evaluator: 

BY ITS EXECUTIVE DIRECTOR	 (Name of Evaluator) 

DATE	 DATE 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
Process Domain

1.

Medical Providers 

conduct medical 

intake and provide 

outpatient medical 

treatment to HIV+ 

clients

2.

Medical Providers 

assess mental 

health status of 

clients and refer to 

Mental Health 

Specialists (MHS)

4.

MHSs conduct 

psychosocial 

assessment and 

make recs. to 

client

5.

MHSs diagnose 

mental health 

status and develop 

mental health 

treatment plan

6.

MHSs provide a 

variety of mental 

health services

8.

Appropriateness of m.h. care is ensured thru initial training at CCH HIV PCC. Ongoing formal training, and 

supervision from preceptors and on site supervisors

9.

Continuity of 

Mental Health/

Medical Care 

Improved

12.

Increased Medical 

Compliance

15.

Improved Quality 

of Life

10.

Increased 

Acceptance to 

Being HIV+

13.

Increased 

Capacity to 

Manage Stress

16.

Sustained Medical 

Treatment

7.

MHSs consult with 

medical and other 

human service 

providers

3.

On-site human 

service providers 

consult with MHS 

about clients and 

refer for mental 

health care

11.

Increase in 

knowledge of 

effects of HIV/

AIDS on mind and 

body

14.

Enhanced Mental 

Health Status

CHHAPS Project: Logic Model of Integrated Care for Persons Living with HIV 

(Level II)

Outcome Domain

Short-Term Effects Intermediate Effects Long-Term Effects

APPENDIX 189
 

APPENDIX G 
CHHAPS PROJECT 

SERVICE ENCOUNTER RECORD 

 

I. Client’s First Initial and Last Name: __________________________________________________ 

II. Staff ID: 

III. Date(s) of Service Encounter(s): see table below 

IV. Category of Provider Agency: 

V. Service Provided (more than one may be recorded for each date of service): 

III. 

Date of 

Service 

A. 

Service Type(s) 

B. 

Comp 

Status 

C. 

Treatment 

Mode/Form 

D. 

Duration 

E. 

Location 

of Service 

1. 08 

2. 08 

3. 08 

4. 08 

5. 08 

6. 08 

7. 08 

8. 08 

9. 08 

10. 08 

11. 08 

12. 08 

13. 08 

14. 08 

 

Office Use Only 

Date Submitted to Data Coordinator or Administrative Assistant: ______________________ 

Date Entered into Computer: _____________________ 

 

190 APPENDIX 

APPENDIX H 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
APPENDIX 191 

APPENDIX H (Continued) 

CHHAPS DCQC Manual; 12/1/96 

SERVICE ENCOUNTER RECORD 

PURPOSE OF THE FORM 

The purpose of the multi-site Service Encounter Record (SER) is to uniformly collect 

information about the services provided and activities conducted by demonstrationfunded staff across all eleven project sites. 

DEVELOPMENT OF THE FORM 

The SER was collaboratively developed by interested members of the Steering 

Committee, Coordinating Center, and Local Evaluators. It has gone through a 

minimum of three iterations. The final SER was developed on August 1, 1996, and 

approved by the Steering Committee in mid-August. It is available in hard copy and in 

English. In the future, it may also be available in a computerized version and in 

Spanish. 

Although the general outline of the SER is used across all sites involved in the 

Demonstration Project, there are individual variations in the forms and data 

specifications (e.g., definitions of each of the service categories used in the SER) used 

at sites around the country. These variations are due to differences in the target 

populations and type of services delivered at each site. For example, the Local 

Evaluator and Data Coordinator of the CHHAPS Project developed the CHHAPS 

SER in order to better fit the needs of the CHHAPS Project. Without compromising 

the intent of the multi-site SER, the following steps were taken in the development of 

the CHHAPS SER: 

• The Local Evaluator and Data Coordinator compared and contrasted drafts of the 

final SER with the crosswalk that was developed for the previous iteration of the 

SER and the current service tracking form - 1009 - utilized by the Mental Health 

Specialists at Englewood and Lakeview. The fields which CHAAPS staff utilize on 

the final SER were highlighted by the four Mental Health Specialists and 

communicated to the Data Coordinator. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
192 APPENDIX 

APPENDIX H (Continued) 

• The Local Evaluator and Data Coordinator developed the CHHAPS SER, which 

encompasses the fields highlighted by the Mental Health Specialists and the intent 

of the multi-site SER. 

• In mid-August, the Data Coordinator showed the Mental Health Specialists the first 

iteration of the CHHAPS SER. During the group training of the CHHAPS SER, 

suggestions were made by the Project Director and Mental Health Specialists 

regarding additional modifications to the data specifications and form. 

• The CHHAPS SER was finalized by the Local Evaluator and Data Coordinator in 

late August, 1996. A copy of the CHHAPS SER data specifications and form was 

submitted to RTI in late August, 1996, for review and comment. 

TRAINING ON THE FORM 

The Mental Health Specialists were trained in late August, 1996, on the intent and use 

of the CHHAPS SER. The following protocol was used: 

• The Data Coordinator provided a group didactic presentation of the CHHAPS SER 

at the August local evaluation meeting to the Mental Health Specialists, Local 

Evaluator, and Project Director. This involved going through the entire CHHAPS 

customized data specifications document, item by item, discussing the application of 

each code, and comparing 1009 codes to SER codes. 

• The Data Coordinator met individually with Mental Health Specialists to answer site 

specific questions related to the CHHAPS SER. He documented the questions and 

his answers. 

• At the September and October local evaluation meetings, the Data Coordinator led a 

discussion on “common errors” and resolutions. There is a standardization in 

definitions and use of the CHHAPS SER across all four Mental Health Specialists. 

ADMINISTRATION OF THE FORM 

During the didactic training on the CHHAPS SER, it became evident that there was a 

lot of redundancy between the CHHAPS SER and the 1009s. It was also noted, 

however, that the 1009s tracked services in a more “broad brush stroke” way compared 

to the CHHAPS SER. In order to avoid having the Lakeview Mental Health Specialist 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
APPENDIX 193 

APPENDIX H (Continued) 

spend too much time doing paperwork AND in order to assure that the original intent 

of the multi-site SER is not compromised, the following procedures have been put in 

place: 

• The Lakeview Mental Health Specialist adds the appropriate Service Type and 

Treatment Mode/Form codes at the end of each entry on their 1009s. 

• If a referral is made during a case management activity, the Lakeview Mental Health 

Specialist adds the appropriate Service Type code at the end of their 1009 entry, 

asterisk (*) this code, and, under the “Staff Notes” section, writes the SER referral 

code and the agency to which the case management referral was made. 

The Mental Health Specialists at the Cook County Hospital, Englewood, and 

Woodlawn sites are responsible to complete the CHHAPS SER as originally intended. 

There are two periods of time at which all four Mental Health Specialists may decide 

to complete the CHHAPS SER or 1009s for each of their clients. The forms may be 

completed directly after the service/s are provided, or Mental Health Specialists may 

opt to complete the forms at the end of each week. Use of the CHHAPS SERs and 

new way to complete 1009s began on September 1, 1996. 

DATA COORDINATION OF THE FORM 

Because the original administration plan of the CHHAPS SER was modified at one site 

in order to lessen the paperwork time spent by the Mental Health Specialist (see 

previous section), the role of the Data Coordinator has expanded to include more 

intensive quality control procedures. In order to manage his expanding role related to 

the multisite evaluation, the Project Director and Local Evaluator are enlisting the 

efforts of the Administrative Assistant regarding: a) data transfer from the 1009s to the 

multisite SER, b) data transfer from the CHHAPS SER to the multisite SER; and c) 

data entry of the SERs. 

The majority of SER data entry is conducted by the Data Coordinator. During October, 

1996, the Data Coordinator trained the Administrative Assistant on SER data entry. 

Regarding the specific procedures for data entry, the Data Coordinator organizes hard 

copies of “to be entered” SERs by site in separate manilla folders. After an SER has 

been entered either into the Administrative Assistant’s computer or the main computer 

in the Project Director’s office, the hard copy of the SER is stamped with the date of 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
194 APPENDIX 

APPENDIX H (Continued) 

entry, paperclipped with other “entered” SERs, and placed back in the folder. The Data 

Coordinator then files the “entered” SERs by date of entry into the computer. If the 

Administrative Assistant’s computer is used to enter SERs, the Data Coordinator 

downloads the latest SER data entries from this computer and uploads this information 

into the Project Director’s computer before the weekly polling to the Coordinating 

Center takes place. 

QUALITY CONTROL PROCEDURES 

There are several quality control procedures in place to ensure that the SERs and 

1009s are completed, transferred, and entered as intended: 

• On a monthly basis, the Data Coordinator copies the SERs and 1009s, and files them 

along with the other information collected on each client (i.e., Participant Log, 

Interviewer Tracking Form) in a locked file cabinet in the central office at Cook 

County Hospital. Mental Health Specialists keep the originals in locked file cabinets 

at their respective sites. 

• On a monthly basis, the Data Coordinator and the Mental Health Specialists review 

the forms to assure that standardized definitions are used by each of them and to 

assess the need for more multisite SER service type categories. This review of the 

form is also an opportunity for Mental Health Specialists to provide feedback 

regarding use of the forms. 

On a quarterly basis, during local evaluation meetings, the Data Coordinator randomly 

selects forms, and asks Mental Health Specialists how they use certain codes (e.g., crisis 

intervention vs. psychotherapy/counseling focused on HIV testing). Discussion is 

encouraged. 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE 
APPENDIX 195 

APPENDIX I 

LIST OF AUTHORS 

DEMONSTRATION PARTICIPANTS 

John Archambeault 

Alexandria Mental Health Center 

Alexandria Community Services Board 

720 North Saint Asaph Street 

Alexandria, VA 22314 

T 703.838.6400 

F 703.838.5062 

Brian Greenberg, Ph.D. 

Walden House 

520 Townsend Street 

San Francisco, CA 94103 

T 415.554.1100, x103 

F 415.554.1122 

bgreenb488@aol.com 

Jeff Hoeltzel, M.Sc. 

The Community Living Room 

207 North Broad Street, 5th Floor 

Philadelphia, PA 19107 

T 215.569.8414 

F 215.569.4855 

J. Stephen McDaniel, M.D. 

Grady Health System Infectious Disease 

Program 

341 Ponce de Leon Avenue 

Atlanta, GA 30308 

T 404.616.6310 or 6612 

F 404.616.1010 

jmcdani@emory.edu 

Phil Meyer, L.C.S.W. 

SPECTRUM Community Services and 

Research 

Charles R. Drew University of Medicine 

and Science 

1774 East 118th Street, Building K 

Los Angeles, CA 90059 

T 323.563.4939 

F 323.563.9333 

Philmdrew@aol.com 

Craig Packer 

Craig Packer & Associates 

20081 Sweetwater Road 

Dry Run, PA 17220 

T 717.349.0085 

F 717.349.0095 

cpacker@innernet.net 

Francisco Javier Parga, Ph.D. 

Program for AIDS Affairs and 

Transmissible Diseases 

P.O. Box 70139 

San Juan, PR 00936 

T 787.274.5601 

F 787.274.5503 

javierparga@compuserve.com 

Michelle Beaulieu Pillen, Ph.D. 

2504 Lowman Drive 

Bloomington, IL 61704 

T 309.662.3510 

F same 

voice4many@aol.com 

MENTAL HEALTH CARE FOR PEOPLE LIVING WITH OR AFFECTED BY HIV/AIDS: A PRACTICAL GUIDE