A man walks along a tree-lined pathStress is a state of physical, mental, and emotional strain or tension resulting from adverse or demanding circumstances. It can also be a reaction people experience as they encounter rather routine changes in life, if the changes are frequent and ongoing.

Stress is a normal reaction, but it can have a number of negative effects on the physical body. According to the National Institutes of Health, “long-term stress may contribute to or worsen a range of health problems including digestive disorders, headaches, sleep disorders, and other symptoms. Stress may worsen asthma and has been linked to depression, anxiety, and other mental [conditions].” In addition, stress is known to suppress the human immune system. For all these reasons, it is particularly important for people living with HIV and AIDS to manage the level of stress in their lives.

It’s important to note that the last sentence reads “manage” stress and not “eliminate” stress. For nearly all of us, experiencing a certain level of stress is a routine part of our daily lives. Stress often arises as a response to change, and change, for better or worse, is a constant in most of our lives. So rather than spend time and energy toward eliminating stress, people living with HIV/AIDS could benefit from reducing and managing their stress levels.

Decades of research has shown that both physical and emotional/mental stress suppresses the human immune system. This essay will not focus on how this happens, but it is worthwhile to note that stress reduces the production of T-cells in the body. These are cells that help fight infection. Unfortunately, it is also the class of cells that HIV attacks in infected people. An individual living with HIV/AIDS may have a lowered level of T-cells due to HIV. Ongoing physical and emotional/mental stress will only add to this deficit.

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In my years of experience working with the HIV/AIDS community, I’ve learned many individuals in this group live with additional life stressors and, thus, elevated levels of stress. A few of these stressors include:

Numerous HIV-positive people have come to me over the years, concerned that ongoing stressors in their lives are causing anxiety and depression. Many seek therapy to help support them with their stressors, but just as many are interested in learning how to relax in the hope of lessening their stress before it adversely affects their immune systems.

Fortunately, there are several easy, low-impact, and free forms of relaxation available, some of which can be taught and practiced during a therapy session. They include:

Massage and acupuncture are often considered complementary or alternative therapies. Both have been offered free of charge to HIV-positive individuals at numerous social service agencies in New York City, among other places. Many people, particularly those living with HIV/AIDS, report that therapeutic touch brings on a deep sense of relaxation and well-being. For those with relatively good physical health, moderate exercise, including walking and yoga, can be a big source of stress reduction. Many people over the years have reported that joining a gym or exercising in a park on a regular basis have helped reduce anxiety and depression symptoms.

Some individuals may find that their stress and tension has brought on anxiety that they feel unable to control despite many attempts to do so. They may seek treatment with psychotropic medications. There are numerous antianxiety psychotropic medications, many of which are widely known by the general public. They include Klonopin, Valium, and Xanax. These medications are all controlled substances and can be obtained only through a prescription.

For both mental and physical health, I have learned from experience to never underestimate the benefits of a good night’s sleep. One of the most common symptoms of stress I hear reported is insomnia. Feeling refreshed and fully awake helps make it easier to handle life’s daily stressors. Without a sufficient amount of sleep, many people experience an impaired ability to concentrate, regulate their emotions, digest food, and stay awake throughout the day.

References:

  1. Segerstrom, S. C., & Miller, G. E. (July 2004). Psychological Stress and the Human Immune System: A Meta-Analytic Study of 30 Years of Inquiry. Psychological Bulletin of the American Psychological Association, Vol. 130(4), pp. 601-630. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1361287/
  2. U.S. Department of Health & Human Services: National Institutes of Health. (n.d.). Stress. Retrieved from https://nccih.nih.gov/health/stress

therapist deep in thoughtIn my initial posting for GoodTherapy.org, I wrote about the fact self-testing for HIV is a reality in the United States. What this effectively does is change the access point for people to find out their HIV status. Prior to this, the only way to legally get tested was through a testing clinic (including health centers, testing vans, and Planned Parenthood) or through a medical provider. I say “legally” because people could buy self-tests online and have them shipped to their homes, but these were neither FDA-approved nor legal.

Since the approval, people can choose when and where they want to get tested. This has both clinical and legal implications for clinicians and clients. Future postings will explore many of the clinical issues, but as a starting point, it is important for clinicians to know some of the basics, especially the laws regarding transmission and disclosure.

Taking an HIV test does not change one’s status. It changes one’s knowledge about one’s status. The way current laws are written in most states, the concern is not as much with the former as it is with the latter. In more than 30 states, there are laws on the books regarding the transmission of HIV. These laws vary greatly, but broadly fall under two categories.

We often hear it said that “knowledge is power.” With regard to taking an HIV test, this has truth. As mentioned, the test does not change one’s status, just his or her relationship with the truth of status. However, as can be seen from the first category above, knowledge also has greater consequences. If someone has HIV and engages in sexual activity, but he or she does not know HIV status, the law may not hold the person accountable.

This sets up possible scenarios such as these: The person with HIV who does not know his or her status can have unprotected sex, spread HIV, and not be held liable, whereas the person who knows he or she has HIV, does not disclose this, uses protection, and does not spread HIV can be prosecuted. It is a flawed system that ultimately discourages doing the responsible thing (getting tested), and it is just one of many issues regarding HIV that are caught in a web of politics, prejudice, and fear. It is also a system that creates strong narratives of “victim” and “perpetrator,” holding the person who knows he or she has HIV wholly responsible while absolving the one who does not know his or her status. This victim/blame narrative is another common theme when dealing with HIV in clinical settings.

When working with clients, it is imperative that we continue to strive for higher levels of functioning than laws that blame the “perpetrator,” who, in many cases, also has been the “victim” (of cultural violence, for example). It is a deadly cycle, and one that we can help break with good foresight. From my training with the American Psychological Association’s HIV Office of Psychology Education (HOPE), we learned that the law, as intimidating as it is, is the lowest level from which we operate, often puts us in ethical binds, and we have to use our ethical dilemma models to act in the best ways we know to reduce harm and maximize benefit while documenting every step.

Back to the issue of HIV self-testing and implications for clinicians: Given that it is now possible that people can self-test (and more people will as advertising increases on places such as Facebook, MTV, and Comedy Central), it is important that clinicians become familiar with their state laws regarding transmission. This is especially the case for clinicians working with sexually active youth and young adults, and/or sexually active clients with addictions. A list of states and transmission laws, including what constitutes a felony, misdemeanor, or finable offense, can be found here.

Clinicians will also need to consider potential liability issues if he or she is the only person to whom the client has disclosed HIV status (say, in a situation where the person has self-tested and is not seeking treatment) and the person spreads HIV. Do we collude with the client and deny his or her HIV status in the absence of any other documentation? How do we document agreements with clients regarding disclosure?

As with all ethical dilemmas, there really is not clarity as to what is the right thing to do. What we can do is to make sure we have a reliable framework with which to address ethical dilemmas, colleagues with whom we can consult, and knowledge of the law in our state. Where laws exist, we should make sure the client is aware as well.

If people have questions or would like to explore any of this further, please feel free to reach out to me. We serve our profession and clients better when we are not caught off-guard, and this is one of those issues we should be considering.

“Gay and bisexual men experience numerous negative health conditions, including high rates of mental health problems,” said Beth N. Fischgrund of the Department of Psychiatry & Behavioral Sciences at Northwestern University, and lead author of a new study examining masculinity and mental health in gay and bisexual men. “Empirical studies show that a strong adherence to masculine norms is correlated with poor health outcomes, such as mental health problems and risky sexual behaviors.” National studies have shown that gay men are nearly twice as likely to suffer from depression and anxiety as heterosexual men, and that suicide rates for these men are nearly double those of other men.

The way gay and bisexual men perceive their masculinity has a significant impact on mental health. “Society’s messages about sexuality are not the only cultural attitudes that sexual minority men are confronted with; cultural attitudes also delineate what it means to be a man,” said Fischgrund. She added that some men may exhibit hyper-masculine behaviors when they feel their masculinity is being threatened. “Gay men who endorse hyper-masculine norms might then experience identity incongruence when they are presented with general society’s norms that differ and contradict their own. In these situations, the more integral the hyper-masculine norms are to a man’s identity, the more psychological distress he may experience.”

For her study, Fischgrund recruited 311 gay and bisexual men, nearly a third of which reported an HIV positive status. “Among these gay and bisexual men, those who adhered to norms that incorporate an interpersonal aspect of masculinity (i.e., conceptions of masculinity as social behavior or as sexual  behavior) endorsed higher levels of mental health distress than did men who adhered to norms that focus on the intrapersonal aspects of masculinity (i.e., conceptions of masculinity as physical appearance),” said Fischgrund. “Additionally, men who did not know their HIV status endorsed higher levels of depression.” She emphasized the importance of her findings. “Specifically, designing programs that center on altering the social and sexual masculine norms within the gay male community are needed to decrease the mental health burden of gay and bisexual men, which has been shown to be associated with HIV risky behaviors.”

Reference:
Fischgrund, B. N., Halkitis, P. N., & Carroll, R. A. (2011, October 24). Conceptions of Hypermasculinity and Mental Health States in Gay and Bisexual Men. Psychology of Men & Masculinity. Advance online publication. doi: 10.1037/a0024836

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