Family Effects of Structural Ecosystems Therapy (SET) for HIV+

Women in Drug Recovery

Victoria Mitrani, Daniel Feaster & Brian McCabe

e, Date, 2012 State of the Science Congress on Nursing Research

Center of Excellence for Health Disparities Research

Research was supported by the National Institute on Drug Abuse (R01DA16543, R01DA15004) and the National Institutes of Health Office of Research on Women’s Health. This presentation was also supported by the National Institute of Minority Health and Health Disparities (P60MD002266). The content is solely the responsibility of the authors and does not necessarily represent the views of the National Institutes of Health.

Significance of HIV/AIDS for Women’s Health

• Treatment advances have transformed HIV/AIDS from a mortal illness into a manageable chronic condition (Cole, Hernan, Anastos, Jamieson, & Robins, 2007).

• However, HIV/AIDS remains the fifth-leading cause of death for women in the United States, and in 2004 the leading cause of death for black women aged 25-34 years (Centers for Disease Control, 2008).

Mental Health and Substance Abuse Among Women with HIV/AIDS

• Women living with HIV/AIDS experience elevated psychological distress (Bing et al., 2001; Catz, Gore-Felton, & McClure, 2002), which can have a detrimental impact on physical health (Ickovics et al., 2001; Leserman et al., 2002; Remien et al., 2006).

• Drug use is associated with poor adherence to HIV treatments (Lucas, Cheever, Chaisson, & Moore, 2001; Sherer, 1998)

• Stimulant use is associated with immune activation that hastens HIV viral replication (Carrico et al., 2008).

HIV and the Family

• Family stress and support impact medication adherence (Merenstein et al., 2009; Murphy, Greenwell, & Hoffman, 2002) and health (Jones, Beach, Forehand, & Foster, 2003) among women with HIV/AIDS.

• HIV+ women report that communication with family about illness, the family’s denial about the woman’s HIV status, their lack of knowledge about transmission, and the woman’s past drug use contribute the most stress in family relationships (Owens, 2003).

• Families dually affected by HIV/AIDS and substance abuse are vulnerable to disruptions, such as loss of child custody (Barroso & Sandelowski, 2004; Conners et al., 2004).

Family Interventions for Persons with HIV/AIDS

• Couples Interventions- – Remien et al.; 2005 - support-enhancing intervention

resulted in improved medication adherence.– El-Bassel et al., 2010 - skill-building intervention reduced

sexual risk behaviors in African American couples. • Parent/child Intervention- Rotheram-Borus et al., 2003 -

coping skills intervention for parents with AIDS and their adolescent children reduced emotional distress and problem behaviors.

• Whole-Family Intervention - Szapocznik et al., 2004 - SET for HIV+ African American women reduced psychological distress, drug use relapse (Feaster, Burns, et al., 2010) and improved medication adherence (Feaster, Brincks, et al., 2010).

Design of Parent RCT

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• 126 HIV+ women in drug recovery randomized to SET or HIV Health Group (HG)

• Assessments every 4 months for 1 year• Aim: To examine the impact of SET in reducing drug relapse

and improving medication adherence in the target women

Target Women’s Outcomes

• The results were mixed. • Women in SET did not show better drug use or

medication adherence outcomes than women in HG. • Women in SET did show better outcomes than women in

HG on: – improvement in CD4 T-cell count – starting antiretroviral treatment – accessing substance abuse services in response to

relapse – separating from drug-using household members

Reported in Feaster, D.J., Mitrani, V. B., Burns, M.J., McCabe, B.E., Brincks, A.M., Rodriguez, A.E., Asthana, D., Robbins, M.S. (2010). A randomized controlled trial of Structural Ecosystems Therapy for HIV medication adherence and substance abuse relapse prevention. Drug and Alcohol Dependence, 111(3),227-234.

AIMS of the Family Study• Examining the impact of SET in families of HIV+ women in drug recovery• Examines aggregated data of family members (>age 10) including the

woman– H1 - Family functioning– H2 - Family outcomes on psychological distress and drug abstinence– H3- Effect of changes in family functioning on family outcomes– H4- Reciprocal effects between the woman’s and family-members’

(excluding the woman) outcomes

Reported in Mitrani, V. B., McCabe, B. E., Burns, M. J., & Feaster, D. J. (2012, June 18). Family Mechanisms of Structural Ecosystems Therapy for HIV-Seropositive Women in Drug Recovery. Health Psychology. Advance online publication.

Structural Ecosystems Therapy: SET• SET is not a drug treatment intervention, but rather a post-

treatment or ancillary approach• Through conjoint sessions, SET seeks to improve relationships

within the family and between the family and outside systems (e.g., health or drug treatment providers, courts, church) to prevent drug relapse & encourage HIV medication adherence , by: – Strengthening family support (e.g., to encourage HIV self-care

and adherence)– Strengthening ties to supportive resources outside of the family– Establishing relationship boundaries (e.g., helping woman

distance herself from drug-using family members, peers) – Creating a plan for family to respond to relapse and other crises

(e.g., illness, housing loss, domestic violence)

Mitrani, V.B., Robinson, C., and Szapocznik, J. (2009). Structural Ecosystems Therapy (SET) for women with HIV/AIDS. In M. Stanton and J. Bray (Eds.), Handbook of Family Psychology (pp. 355-369). West Sussex, United Kingdom: Wiley-Blackwell.

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Treatment Parameters for SET and Health Group

• 4 months of treatment:– SET: 1 hour/week – woman and family– Health Group: 2 hours/bi-weekly – woman only

• Location of treatment:– SET: Home-based– Health Group: Office w/$ for transportation

• Manualized treatments• Therapists with master’s degrees & comparable

experience in modality

Inclusion Criteria for Women

• English or Spanish speaking• HIV+ and meets criteria for ART (viral load over

100,000 or CD4 T-cell count under 350 or any AIDS-defining illness)

• ≥18 years• Meets DSM-IV critera for abuse or dependence on an

illegal substance in the last year • ≤1 year since exit from drug treatment• Willing to disclose HIV status to at least one health

care professional• Having an eligible family member enroll in the family

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Identifying the Family• Used a flexible but standardized definition to capture the richness

and variety of family constellations (including nontraditional “kin”)• Focused on family relationships that would potentially influence,

and be influenced by, the woman’s condition

Inclusion criteria for family members:• Must meet ≥1 of the following:

– Live in the woman’s household (but not strictly as boarder)– Her children (>5 yrs) with at least monthly contact– Has a role in helping to raise her children– Is her spouse or partner– Is a major source of support to the woman

• Individuals were excluded if the woman did not want them in the study

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Analyzed (n = 59 families, n = 119 family members)Excluded from analysis (n = 0)

Analyzed (n = 67 families, n = 150 family members)Excluded from analysis (n = 0)

Analysis

Families 52 (88%) present at 4 month45 (76%) present at 8 month42 (71%) present at 12 month

Women + Family Members111 present at 4 month103 present at 8 month110 present at 12 month

SETAllocated to intervention (n = 59 families; n = 119 family members)Received allocated intervention(n = 33 families)Did not receive allocated

intervention(n = 26 families)

Families64 (96%) present at 4 month 61 (91%) present at 8 month57 (85%) present at 12 month

Women + Family Members145 present at 4 month 152 present at 8 month148 present at 12 month

Health GroupAllocated to intervention (n = 67 women; n = 150 family members)Received allocated intervention (n = 42 women)Did not receive allocated

intervention (n = 25 women)

Allocation

Follow-Up

Randomization

Family Flow in the Study

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Measurement of Family Functioning

Family Cohesion

Family Functioning

Acquiring Social Support

Reframing

Family Support

Significant Other Support

Family Environment Scale (Moos & Moos, 1994)

Multidimensional Scale of Perceived Social Support(Zimet, Dahlem, Zimet, & Farley, 1988)

Family-Crisis Oriented Evaluation Scales (F-COPES; McCubbin, Larsen, & Olsen, 1981)15

H1: Effect of SET on Family Functioning

. The GEE analysis for family functioning revealed a significant time by treatment interaction (B = -0.05, SE = 0.02, p < .01). 16

Effect of SET and Family Functioning on Family Member Outcomes

• H2: No effect of SET on family psychological distress or drug abstinence

• H3: Effect of Changes in Family Functioning on psychological distress and drug abstinence– Changes in family functioning were not related to

changes in family level drug abstinence– Changes in family functioning were related to changes

in psychological distress of family members (B = -6.26, SE = 1.49, p < .001). (see next slide)

Effect of Family Functioning on Psychological Distress

• Psychological distress was reduced in both SET and HG, so there was no direct effect of SET on distress.

• However, change in family functioning was related to change in psychological distress (B=-6.26, SE= 1.49, p< .001).

• After controlling for change in family functioning, there was a significant difference in the trajectory of psychological distress between SET and HG (B=-0.28,SE= 0.13, p<.05).• There was an indirect effect from treatment to change in

psychological distress such that when SET helped to reduce distress in the family it was acting through the mechanism of family functioning.

• There was likely some other mechanism that reduced distress among family members of women in HG and caused the two groups to look similar on distress (Shrout & Bolger, 2002; Krause et al., 2010).

H4: Reciprocal Effects Between Woman and their Family Members

• Cross-lag models were used to test reciprocal effects.• Model fit for psychological distress was not acceptable so

effect could not be tested. • Family drug abstinence significantly predicted the woman’s

drug abstinence at the next timepoint (B = 0.19, SE = 0.06, p < .001).

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Conclusions

• SET affected family functioning by preventing deterioration, which may be a risk for families with members post- drug treatment

• Prevention of deterioration in family functioning may have led to reduced psychological distress in the women and their family members.

• Reductions in drug use among family members led to abstinence in the women.

• These findings demonstrate the interdependency of family members and the impact that family can have in preventing relapse.

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