F A Guide toOAIDSCResearch andU Counseling Volume 11 Number 4 March 1996S

study of services for gay men, the fact Returning with AIDS: that rural communities “are more conser- vative, ingrown, traditional, religious and Supporting Rural Emigrants less tolerant of diversity.”5 Finally, long Michael Shernoff, MSW distances to medical facilities and the reluctance of medical personnel to pro- vide HIV-related services are significant The majority of the 22,800 people with barriers to care in rural areas.3,4,5 (Several AIDS who live outside of urban areas in researchers are evaluating a model linking the are men who have sex rural satellite health care clinics with with men, some of whom identify as gay, urban facilities, whereby physicians expe- although there are increasing numbers of rienced in HIV-related treatment would people who have contracted HIV in other 3 1,2 train and consult with local providers. ways. Many of these men are emigrants Confidentiality is a particularly trouble- returning from urban lives to their rural some barrier to care in rural areas. Patricia families of origin. Gunter states: “Confidentiality is a diffi- An informal survey of 12 therapists who cult issue within the rural environment. work with large numbers of people with Because of the limited geographic bound- HIV disease in seven cities in different aries and ‘incestuous’ nature of the sys- parts of the U.S. revealed that all but one tems, personal associations, work and have treated gay men who returned to leisure time activities, and work patterns small towns or rural areas near the end of are usually well-known to all in the com- their lives. But most rural communities, munity. The high level of visibility places cocooned from the epidemic thus far, have the individual in jeopardy, particularly had little chance to develop social services when receiving health and welfare ser- for people with HIV disease and their vices.”5 Gunter also states that due to families, and as prevalence increases, HIV- funding problems in rural communities, 3 related stigma is on the rise. This article many agencies use paraprofessionals and details the research on this topic and volunteers as staff members and that, “For suggests approaches for urban providers some reason, paraprofessionals, volun- with clients returning to rural homes. teers and nonprofessional workers in rural communities appear not to feel bound by Barriers the rules of confidentiality.” In tight-knit There is little research on HIV-related rural communities, entire families may be services in rural areas. Among the barriers stigmatized by association to an HIV- to care cited in a 1996 study are the lack infected family member, effectively of adequately trained medical specialists; depriving people with HIV disease of geographical distances and isolation from much needed support.4 sources of social support; insufficient or Ironically, people with HIV disease and unreliable sources of transportation; and their families have been able to access a the lack of a cohesive support community variety of social services through informal for infected gay men and women.4 systems already functioning in rural Additional barriers include the lack of areas. Comprised of family, friends, neigh- information and resources and responsive bors, fraternal and civic organizations, educational, health care, and social ser- and religious institutions, these systems vice systems, and according to another deliver services ranging from crisis inter- are in physical decline. Isolation Editorial: Rural Support is common and distance from Robert Marks, Editor medical services requires coop- eration from friends, family, and neighbors. Rural areas have not After 15 years, it’s hard to with family in the final stages of had the time to develop the know what “wave” of the epi- illness. By providing counseling same community commitment to demic is engulfing us now, but to both parties before the move the care and comfort of people whether it’s the second or the and continuing after the move, with HIV disease that now exists third, it is clear that the “city” Shernoff facilitates reconcilia- in some urban centers. epidemic is comfortably tion when necessary, educates ensconced in the “country.” For a families about HIV disease, The Power of Rural Communities number of reasons, HIV-specific helps identify local medical and Health and mental health services are not as well-estab- emotional support resources, practitioners face these same lished in rural areas as they are and supports clients in adjusting difficulties engaging the good in U.S. cities. In particular, sup- to their new surroundings and will and services of people in port services for both people conflicts. rural communities who might with HIV disease and their fami- Tartaglia rattles off some help provide support. But the lies remain underdeveloped. impressive statistics about the return for this effort can be role of religious institutions in substantial: rural communities Basic Human Relations frontline counseling throughout and rural congregations are In this issue of FOCUS, the United States. He suggests traditionally tightly knit and Michael Shernoff and Alexander that an institution so prominent when their energies are mar- Tartaglia outline two approaches in the lives of rural residents shaled, they can be a powerful to providing emotional support can play a central role in provid- force. To muster these in rural areas. Shernoff, a decid- ing support to people with HIV resources, not only must these edly urban pioneer in HIV coun- disease—both natives and immi- communities and congregations seling from New York, may at grants—and their families. put aside ignorance and fear, but first appear a strange commen- In both of these cases, people also clinicians must put aside tator on this subject, but he with HIV disease face basic prejudices about the abilities suggests that support in the challenges of human relations: and willingness of rural institu- country can begin in the city. finding acceptance in situations tions to provide support. Shernoff observes that many rife with ignorance, stigma, Applying education, patience, people with AIDS in rural areas prejudice, and fear. The stakes and clarity has worked to create begin their acquaintance with are higher than usual, because committed community support HIV infection in the city and many people with HIV disease in the city; this same approach migrate to the country to be move to rural areas when they can work in the country.

vention, child care, and emotional and When clients raise the possibility of financial support to in-home health care. returning to live with parents, it is gener- When these informal systems resist homo- ally a good idea to thoroughly explore phobia and fear of AIDS, they can provide other options, for example, an assisted a type of care that draws numbers of living residence for people with HIV dis- people with HIV disease to return to the ease or the home of a friend or family communities in which they were raised. member living in the city. Considering Addressing rural HIV disease requires these options is especially important if strengthening and supplementing these the client expresses any ambivalence informal networks as well as formalizing about moving to his or her parent’s home. HIV-specific services. If finances are the major factor in decid- ing to move, the therapist should explore Moving from Urban to Rural America with the client what resources may be It is never too early for people with HIV available including financial support from disease to begin considering contingency families and from non-profit organiza- plans for living with a progressive and tions. For example, the Actor’s Fund of debilitating illness. As illness progresses, America’s AIDS Initiative Program offers therapists should seek appropriate financial assistance to people with AIDS moments to ask clients to discuss the who have been theater professionals any- plans they are considering to ensure their where in the country. care. Urging clients to face this issue early Clients should also consider whether on can help avoid future crises. their new home is appropriate for a dis- 2 FOCUS March 1996 abled person. Is it well-heated? Is it acces- clients express fears of being infantilized sible? Is it served by home health care by their parents since they are critically agencies and an AIDS service organiza- ill, in need of a great deal of assistance, tion? Do they drive, and will there be a car and are returning to live in their parents’ available for their use? How do local enti- home. For parents, it may be difficult to tlements and other respect the adulthood and autonomy of a benefits compare grown child who is in reality once again to current ones? physically, emotionally, and possibly Individuals who decide Are there compe- financially dependent. In such situations, tent health and the lack of alternatives to returning to the to return to a rural mental health care family of origin may leave some clients providers in rea- feeling as if their lives were bankrupt. In community often feel sonable proximity? addition to the ordinary anger about hav- that they no longer Answers to these ing AIDS and weathering loss, the client questions will may feel anger about being trapped into have any other options clarify for the returning home to parents with whom he client the benefits or she may have an ambivalent relation- for maintaining a and drawbacks of ship. For some, the return invalidates his or her future their lives as adults who have lived an reasonable quality of home. They will unapologetic and openly gay life. also suggest life and adequate care. actions the client Maintaining Contact and Providing Support This recognition is often and his or her It may be useful, prior to the return, to family might take arrange telephone conference calls that accompanied by intense prior to the move. will include the client, his or her family, In almost all and the therapist to raise and address anger and sadness. cases, individuals some of these issues. These calls can also who decide to help to prepare the family for the practi- return to a rural cal and emotional realities of caring for a community feel loved one in the final stages of HIV dis- that they no longer have any other ease. Once the client has returned home, options for maintaining a reasonable these telephone sessions can continue and quality of life and adequate care. This may remain the only source of emotional recognition is often accompanied by support for the client and the family. intense anger and sadness; therapy can be One case exemplifies the usefulness of critical for helping the client manage telephone contact for both emotional and these feelings. Some individuals who practical support: “John Miller” (not his return to small towns are the last surviv- real name), a 31-year-old gay man, decid- ing members of an entire friendship net- ed to return to his parents’ home in rural work devastated by AIDS, and there is Georgia three months before he died. He simply no one left other than paid atten- and his therapist decided to maintain dants to care for them. When an individu- telephone contact during this process. Mr. al does not have large financial resources and Mrs. Miller had not told anyone about References or government entitlements to maintain their son’s diagnosis. In a telephone ses- 1. Centers for Disease care, there may literally be no one who sion with John and Mrs. Miller before John Control and can provide practical support and trans- left New York, the therapist suggested that Prevention. HIV/AIDS portation. Mrs. Miller prepare a support system by Surveillance Report. 1994; 6(2): 8-9. Once a client decides to return, the telling her husband’s parents and her central therapeutic objective is to help him minister about John’s illness and immi- 2. Lam NS, Liu K. or her explore emotional responses to nent return. Two weeks later, Mrs. Miller Spread of AIDS in rural leaving. This process is likely to be diffi- joyously reported that these contacts had America, 1982-1990. Journal of Acquired cult for both the client and therapist as gone well and were crucial in her feeling Immune Deficiency they confront a history of multiple loss and confident of her ability to manage whatev- Syndromes. 1994; loss of control. Therapists must be alert to er lay ahead. Mrs. Miller’s in-laws had 7(5): 485-490. understandable countertransference feel- been shocked and devastated, but offered 3. Heckman T, Somlai ings about prematurely losing the client to do everything they could to help. Mrs. A, Kelly J, et al. Rural not only to death, but also to the move. Miller’s minister was solicitous and had persons living with When a family has accepted a son’s preached a sermon the following Sunday HIV/AIDS: Reducing and AIDS diagnosis, return- about the need for Christian compassion barriers to care and ing provides the opportunity for final for all people with AIDS. He assured Mrs. improving quality of life. AIDS Patient familial reconciliation and healing of old Miller of his continuing availability as a Care. In press. wounds. Even when this is the case, many friend, pastoral counselor, and spiritual 3 FOCUS March 1996 advisor. These telephone sessions, in turn, she is and that the Johnsons had never reassured John of a welcoming environ- respected Paul’s choices to live his life in ment, decreasing his fears about moving accordance with his feelings. Paul also felt 4. Heckman T, Somlai back to south Georgia. badly for causing his parents so much A, Otto O, Salaj L. Telephone contact may also maintain upset by being gay and now by being Community-based the counseling relationship between thera- dependent upon them. Paul’s therapist organizations’ percep- tions of quality of life pist and client, providing both individual saw this as regression, since early on in among rural people emotional support and practical problem- the therapeutic relationship he tended to living with HIV/AIDS. solving help. This may be particularly blame himself for other people’s negative American Journal of important when families are not as wel- reactions. Eventually Paul realized that it Community Psychology. coming as the Millers were. In another was too terrifying for him to tell his fami- Unpublished case, “Paul Johnson” (not his real name) ly his true feelings about their demands manuscript. returned to his fundamentalist Christian because he feared they would withdraw family for care. Paul’s family had used his their offer of a place to live. 5. Gunter P. Rural gay men and : In return as a way of blackmailing Paul into To supplement his weekly telephone need of services and repenting for a life they characterized as therapy, Paul’s therapist suggested that understanding. In sinful, and had sought promises from him Paul consider the AIDS and gay/ Shernoff M, Scott W, to become born again in return for care. In chat rooms on the Internet. Subsequently, eds. The Sourcebook on Lesbian/Gay this situation, Paul experienced feelings of Paul had a telephone line installed. He Health Care. 2nd guilt, internalized homophobia, worthless- said the time he spent on the Internet edition. Washington ness, powerlessness, and rage. literally saved his sanity and resulted in DC: The National Before he left, Paul expressed his feel- his meeting gay men and lesbians and Lesbian/Gay Health Foundation, 1988. ings in the following way: “Originally, I people with AIDS who lived close enough thought I was returning to my parents to visit. Authors home so I could die with dignity. [But Michael Shernoff, now] I really have to wrestle with the Conclusion MSW, a therapist in question: is the physical comfort worth Facing the reality that living indepen- New York, is adjunct the emotional toll it will take on my self- dently has become unmanageable puts lecturer at Graduate esteem to pretend that I regret having significant stress on both a person with School of Social Work lived the life that was so meaningful and HIV disease and his or her counselor. The and is active in the joyous for 15 years?” feelings that arise in response will be National Social Work Due to the intrusive and controlling intense; the necessity to relocate becomes and AIDS Network. He is the co-editor (with nature of Paul’s family, Paul scheduled a metaphor for the myriad losses that HIV Walt Odets) of The telephone sessions with his therapist only disease forces clients to face. To be of Second Decade of when he knew for certain that he would be maximum assistance to clients, therapists AIDS: A Mental Health alone in the house. The sessions initially need to be prepared to be flexible in terms Practice Handbook (Hatherleigh Press, centered on validating his rage. of the form and role of therapy. 1995) and the editor Sometimes, Paul believed that he needed Therapists should seek out professional of Counseling to recognize his family’s pressure as an or peer supervision to help them weather Chemically Dependent expression of love and concern. But Paul’s the countertransference feelings that will People With HIV Illness (Haworth Press, therapist reminded Paul that uncondition- arise, feelings that may be as intense as 1991). al love means accepting a person as he or those of the client’s.

in a rural community. Ethiopian Medical Clearinghouse: Rural AIDS Journal. 1995; 33(1): 1-6. Lal P, Kumar A, Ingle GK, et al. Knowledge and attitudes of university Nursing. 1995; 12(5): 324-334. References students regarding HIV/AIDS: An Brownlee K. Responding to client- Horner RD, Kolasa KM, Irons TG, et al. urban-rural difference. Journal of therapist relationships in rural areas: Racial differences in rural adults’ Communicable Diseases. 1994; 26(4): The suitability of constructivist family attitudes toward issues of adolescent 186-191. therapy. Family Therapy. 1994; 21(1): sexuality. American Journal of Public 11-23. Health. 1994; 84(3): 456-458. Lam NS, Liu KB. Spread of AIDS in rural America, 1982-1990. Journal of Farmer P. AIDS-talk and the constitu- Howland RH. The treatment of persons Acquired Immune Deficiency Syndromes. tion of cultural models. Social Science with dual diagnosis in a rural commu- 1994; 7(5): 485-490. and Medicine. 1994; 38(6): 801-809. nity. Psychiatric Quarterly. 1995; 66(1): 33-49. Lockman-Samkowiak J. Care of patients Highriter ME, Tessaro I, Randall-David with acquired immune deficiency E, et al. HIV-related concerns and Ismail S, H/Giorgis F, Legesse D, et al. syndrome in rural areas. Journal of educational needs of public health Knowledge, attitude, and practice on Intravenous Nursing. 1994; 17(4): 206- nurses in a rural state. Public Health high risk factors pertaining to HIV/AIDS 209.

4 FOCUS March 1996 congregations may behave like families, AIDS and the Rural Church displaying regressive tendencies in the Alexander Tartaglia, DMin face of crisis. These include avoidance behavior, blaming behavior that leads to The migration of HIV disease from scapegoating, and double-bind messages. predominantly urban to rural areas has These tendencies have contributed to challenged the traditional approach of withholding ministry for fear of being centralized delivery of comprehensive perceived as condoning “sinful” behavior, medical and mental health services. offering ministry only under the pressure Decentralization requires creativity to to convert, and invoking rhetoric such as overcome inadequate experience, educa- separating “innocent from guilty victims.” tion, and funding.1 It also demands a It may be surprising to some that clergy willingness to move beyond the comprise the most common group of front- limitations of the single-system line counselors. More than four in 10 provider-client model and toward Americans go to clergy when seeking emo- It may be increased collaboration among tional help, and this figure increases to professionals and with natural more than 50 percent for people who support systems.2 Local religious attend religious services at least once a surprising to 3 communities are potentially month. Evidence suggests that these fig- some that important allies in this effort, ures are higher in rural areas and within because they are historically and the African-American community. clergy functionally among the most Nonetheless, there is no consistent pattern influential of rural institutions. of collaboration between clergy and health comprise the care professionals. The clergy referral rate most common AIDS and Religious Congregations to mental health professionals is less than The traditional Christian con- 10 percent, while the referral rate by physi- group of ception of sin and the problematic cians and counselors to clergy is negligible. relationship between health The nature of this gap is complex. A lack frontline providers and clergy inhibit the of perceived or actual values in common great potential of religious congre- between clergy and health professionals counselors. gations to respond to the needs of contributes to suspicion and avoidance. families affected by HIV disease. The attitude toward religion in psychiatric As voluntary organizations that literature has been largely negative, and tend to reflect the prevailing ethos medicine continues to accept the mecha- of a community, rural congregations often nistic-reductionistic treatment model that hold conservative or biblically literal per- overlooks the role played by spirituality as spectives on social issues. When faced with a component of health.4 Clergy often lack HIV-infection, rural congregations experi- diagnostic skills necessary for adequate ence the by-products of fear—judgment, referral. Few physicians and therapists are prejudice, and apathy—and often impose a trained in spirituality or religion. moral response that characterizes AIDS as To respond to this gap, clergy and health a “sinner’s disease.” Small in size, rural professionals must take steps toward each

Mainous AG 3rd, Neill RA, Matheny SC. with depression. Archives of Family information, contact Donna Yutzy, 926 J Frequency of human immunodeficien- Medicine. 1994; 3(5): 409-414. Street, Suite 522, Sacramento, CA 95814, cy virus testing among rural U.S. 916-444-0424, (fax: 916-444-3059). residents and why it is done. Archives Thomas SB, Quinn SC, Billingsley A, et of Family Medicine. 1995; 4(1): 41-45. al. The characteristics of northern black churches with community health Contacts Qiu F, Lu S. Guardianship networks for outreach programs. American Journal Timothy G. Heckman, PhD, Department rural psychiatric patients: A non- of Public Health. 1994; 84(4): 575-579. of Psychiatry and Behavioral Medicine, professional support system in Jinshan 8701 Watertown Plank Road, Milwaukee, County, Shanghai. British Journal of Conferences WI 53226, 414-287-4680. Psychiatry. 1994; 165(Supp 24): 114-120. Taking Care of Our Own: HIV/AIDS Care Michael Shernoff, MSW, 80 Eighth Rohland BM. A survey of utilization of and Prevention in Rural America, October Avenue, Suite 1305, New York, NY psychiatrists in community health 22-24, 1996. For information, contact 10011, 212-675-9563. centers in Iowa. Psychiatric Services. Missouri Department of Health, Bureau of 1995; 46(1): 81-83. STD/HIV Prevention, PO Box 570, Alexander Tartaglia, DMin, Lowcountry Jefferson City, MO 65102, 314-751-6139. Counseling Center, 105 Holiday Drive, Rost K, Humphrey J, Kelleher K. Summerville, SC 29483, 803-851-1806. Physician management preferences The LIFE Institute offers training for rural and barriers to care for rural patients AIDS case managers in California. For See also references cited in articles in this issue.

5 FOCUS March 1996 other. Discussion groups and case confer- of God and the religious tradition, clergy References ences can help counselors, physicians, and can model unconditional affirmation of 1. Eberle S. Beyond clergy share their strengths and perspec- each person as a child of God. the Urban Epidemic. FOCUS: A Guide to tives, as well as decrease emotional dis- Since the need to reconnect with a per- AIDS Research and tance, increase trust, and facilitate son’s historical religious tradition parallels Counseling. 1992; cooperation. Health care professionals can reconciliation with family of origin, it is a 7(5): 1-4. teach clergy clinical assessment skills fundamental task for clergy and congrega- 2. Landau-Stanton J, needed to recognize severe emotional tions to offer support to HIV-infected indi- Clements CD, Griepp disorders, substance abuse, and high-risk viduals and their families—both blood and AZ, et al. Identifying behaviors. Clergy can offer therapists surrogate—who seek to reenter the faith the systems impacted insights into the communities they serve, community. To accomplish this, congrega- by AIDS. In Landau- Stanton J, ed. AIDS, teaching spiritual assessment skills as well tions need to reestablish trust with those Health, and Mental as how racial, ethnic, and religious values who have experienced alienation and still Health. New York: influence attitudes and behaviors. fear rejection. Inclusion of people with HIV Brunner/Mazel, 1993. disease in the sacraments and rites of tradi- Contributing to a Supportive Environment 3. Weaver AJ. Has tion can symbolize public acceptance. there been a failure to To support people dealing with HIV dis- Clergy and congregations, because of prepare and support ease, clergy can implement educational and their influence in rural communities, have parish based clergy in service-related interventions for the com- the capacity to shape the direction of ethical their role as frontline 5,6 community mental munity, the congregation, and families. and moral discourse. HIV challenges the health workers? A Congregational sponsorship of educational church to promote a communal attitude of Review Journal of programs can differentiate fact from myth healing over the temptations to fuel fear Pastoral Care. 1995; while addressing emotional issues. and ignite controversy. Strong and positive 49(2): 129-147. Multidisciplinary leadership in trainings can leadership can limit dysfunctional family 4. McKee DD, Chappel model cooperation, and using local trainers and organizational tendencies by coaching JN. Spirituality and can diffuse the resistance of rural communi- and supporting congregants who voice hope medical practice. The ties to perceptions of urban imposition. By and reconciliation in the face of uncertainty, Journal of Family sponsoring 12-step programs and support fear, and judgment. The pulpit is a critical Practice. 1992; 35(2): 201-208. groups, congregations can send a message locus for providing such direction, especial- of inclusiveness to the community. ly at the funeral of someone who has died. 5. Landau-Stanton J. Clergy are in a unique position to know Clements CD, Tartaglia the private struggles of individuals and Conclusion AF. Spiritual, cultural, and community sys- families who may secretly carry the burden The capacity of religious communities tems. In Landau- of HIV disease. They can, with permission, to respond constructively to HIV disease Stanton J, ed. AIDS, connect congregants who live in isolation depends on two strategies. Clergy and Health, and Mental and who experience fear, guilt, and grief. congregations must witness and demon- Health. New York: Brunner/Mazel, 1993. They can also help individuals and families strate through action that HIV disease is address difficult medical decisions. not God’s judgment on human behavior, 6. Shelp EE, DuBose As part of the natural support network, but rather an opportunity for people of ER, Sunderland RH. congregations can function as extended faith to carry out their historical mission The infrastructure of religious communi- families in crisis situations. They can of redemption and human service. ties: A neglected maximize independence for the ill by Religious and secular institutions must set resource for care of undertaking meal preparation, housekeep- aside artificially created barriers in order people with AIDS. ing, and transportation. Congregations to collaborate in the face of a disease that American Journal of Public Health. 1990; can also provide financial or legal aid and no single system can tackle alone. 80(8): 970-972. respite for caregivers. Clergy can offer family members and other caregivers Authors living with ambivalence and guilt permis- Alexander Tartaglia, sion to enjoy life. Finally, communal Comments and Submissions DMin, an ordained prayer, offered in a non-judgmental, car- We invite readers to send letters minister and clinical ing manner, is a powerful intervention. pastoral education responding to articles published in supervisor, is a thera- FOCUS or dealing with current AIDS Contributing to a Redemptive Environment pist in a pastoral research and counseling issues. We counseling center. He The church is charged with the funda- also encourage readers to submit arti- has been a training mental task of facilitating human redemp- chaplain and a faculty cle proposals, including a summary of member at the Medical tion. Clergy are in the position to actively the idea and a detailed outline of the University of South pursue reconciliation among family mem- article. Send correspondence to: Carolina and the bers who experience actual or perceived University of Rochester, “cut off” relationships. Using intentional Editor, FOCUS where he served in the mediation and a non-blaming approach, UCSF AIDS Health Project, Box 0884 Division of Family Programs’ AIDS clergy can facilitate listening and encour- San Francisco, CA 94143-0884 Training Program. age mutual acceptance. As representatives 6 FOCUS March 1996 ed to North Carolina for social support Recent Reports and 65 percent had moved to be near family. More than 50 percent of respon- HIV Infection and Migration Trends dents said they moved back for either health or “work/education” reasons. Cohn SE, Klein JD, Mohr JE, et al. The geography of AIDS: Patterns of urban and rural migration. Injection drug users were more likely to Southern Medical Journal. 1994; 87(6): 599-606. immigrate for health and “lifestyle” rea- (University of Rochester Medical Center; and sons, while men who had sex with men University of North Carolina at Chapel Hill.) were more likely to move for “work/edu- A North Carolina study of 325 people cation” or health reasons. with HIV disease found that 20 percent had been infected while living in a rural Training for Rural AIDS Providers area and 56 percent currently lived in a Aruffo JF, Thompson RG, Gottlieb AA, et al. An AIDS rural area. While only 22 percent of the training program for rural mental health providers. Psychiatric Services. 1995; 46(1): 79-81. (University sample had migrated between urban and of Arkansas for Medical Sciences, Little Rock.) rural areas after infection, a larger percent- age migrated from urban to rural areas (17 Rural mental health providers may be percent) than from rural to urban areas (5 knowledgeable about HIV transmission, percent). but often fail to assess clients’ HIV-related Researchers surveyed the migration risks and so underestimate the number patterns of HIV-infected patients at who may be in danger of infection. A trial University of North Carolina hospitals, intervention in Arkansas found that train- identifying 390 consecutive patients in ing programs for rural providers can help the summer of 1990 and surveying 325 of them identify people at risk and address these. Eighty-seven percent of the sub- the specific psychosocial needs of people jects were men, and 62 with HIV infection. percent were White. Participants in the training included 194 Nonwhites were dispropor- mental health care providers primarily tionately represented from rural areas and small communities. While rural mental among women (72 per- Eighty-eight percent had received less than cent), injection drug users five hours of AIDS training in the past health providers (71 percent), and people year; 35 percent had received no previous may be with heterosexually training. Subjects responded to a question- acquired HIV infection (66 naire before and after the four-hour train- knowledgeable percent). Men who had ing, which consisted of a lecture and a contracted HIV through slide and video presentation. The training about HIV sex with men constituted focused on basic transmission and preven- 51 percent of the group; tion, risk assessment, neuropsychiatric transmission, people infected through manifestations of HIV disease, and charac- injection drug use consti- teristics of special populations including they often fail tuted 10 percent; and minorities, gay men and lesbians, and to assess people who may have been people with mental illness. exposed through either Before the training, 22 percent of the HIV-related risks. route constituted 9 per- providers reported having no clients at cent. Fifteen percent of the risk for HIV infection, and 28 percent sample contracted HIV reported having no more than 10 percent through contaminated of their clients at risk. However, 32 per- blood, and 12 percent through heterosex- cent of the providers had never assessed ual sex. Most of the patients were severely their clients’ drug and alcohol history, 52 immunocompromised: 49 percent had T- percent had never taken a sexual history, helper cell counts of less than 200, 42 and 84 percent had never undertaken a percent had T-helper cell counts between formal HIV risk assessment. 200 and 499, and only 9 percent had T- The most crucial gap in knowledge helper cell counts of more than 500. regarded clients with mental illness. Sixty percent of respondents had Before the training, only 28 percent of migrated to North Carolina from another participants could distinguish symptoms state; nearly two-thirds of these were of HIV infection from symptoms of mental North Carolina natives returning home to illness and only 28 percent knew that seek health care services in “low preva- psychostimulant medication might lence” areas. Of respondents who had improve cognitive abilities among HIV- lived out of state, 88 percent had migrat- infected patients. 7 FOCUS March 1996 Issues for a Rural Support Group Rural psychiatric practice involves Anderson DB, Shaw SL. Starting a support group for certain limitations, including professional families and partners of people with HIV/AIDS in a isolation, little opportunity for continuing rural setting. Social Work. 1994; 39(1): 135-138. education, and barriers to clients’ use of (Monadnock Family Services; and The Woodward: services, including poverty and distrust of F A Retirement Home, Keene, New Hampshire.) professionals. Compounded by the A Guide toOCUAIDS Research and CounselingS An effective support group for people absence of the familiar environment of a Executive Editor; Director, affected by HIV disease in rural communi- medical center, these issues proved to be AIDS Health Project overwhelming for second-year students, James W. Dilley, MD ties should ensure privacy and include who were still struggling with basic con- Editor people from different generations and Robert Marks stages of grief, according to a commentary cepts of diagnosis and therapeutics. In the Staff Writer on how one bereavement group helped first year, one resident left and others John Tighe family members and partners of people reported anxiety and dissatisfaction. Founding Editor; Advisor with AIDS counter isolation in the small, The program trained residents at three Michael Helquist conservative community of Keene, New agencies: a four-county mental health, Medical Advisor Hampshire. developmental disabilities, and substance Stephen Follansbee, MD In a small town where family identity abuse program; a medical school depart- Marketing and prestige are paramount, disclosure of Michal Longfelder ment of psychiatry; and a state agency HIV infection can result in stigmatization supporting medical education. The train- Design Saul Rosenfield and social isolation. Accordingly, the ing resolved students’ problems by pro- Production primary concern of this rural support viding a more structured work day Jennifer Cohen group was to avoid public exposure. consisting of four hours of patient care Kelly Van Noord Meetings were not advertised and new and three hours of education, including Circulation members were initially screened by the one hour of professional supervision. Sandra Kriletich group’s founder. Also, the program developed a more elab- Interns The group received crucial support Julie Balovich orate orientation to introduce students to Shirley Gibson from a local AIDS service organization, a broader range of professionals and however, group members accepted help support staff at the community site. FOCUS is a monthly pub- from the agency only when they felt Students found that they learned more by lication of the AIDS secure about confidentiality. The agency working with the professionals who prac- Health Project, affiliated provided referrals and support, and ticed in the rural setting than they did by with the University of California San Francisco. assisted in the recruitment of a trained studying the specific issues of working in therapist who was skilled in issues of Twelve issues of FOCUS a rural environment. are $36 for U.S. residents, family, bereavement, and stigmatized $24 for those with limited populations. The involvement of the agen- incomes, $48 for individu- cy enabled the group to meet without als in other countries, $90 for U.S. institutions, and charging fees, a potential barrier to a Next Month $110 for institutions in stressed rural economy and grassroots Safer sex negotiation is at the crux other countries. Make support. checks payable to “UC of all AIDS prevention efforts. But talk- Group members had relatives in all Regents.” Address sub- ing about sex, particularly with one’s stages of HIV infection, and the members scription requests and cor- partners, is one of the greatest obsta- respondence to: FOCUS, represented different generations ranging cles to implementing safer sex prac- UCSF AIDS Health from 25 years old to 75 years old. This Project, Box 0884, San tices. But partner negotiation is a multigenerational and multi-stage group Francisco, CA 94143- highly formalized ritual in the “kinky 0884. Back issues are $3 set the stage for a unique forum in the community,” that is, among “people each: for a list, write to the rural setting where members could openly above address or call who participate in leather, sado- support, comfort, and learn from each (415) 476-6430. masochistic, and fetish styles of erotic other. To ensure uninterrupted expression.” In the April issue of delivery, send your new FOCUS, Guy Baldwin, MS, a Los address four weeks before Role Models for Rural Psychiatric Residents Angeles therapist, offers lessons from you move. Bridges D. A public-academic partnership to train Printed on recycled paper. psychiatric residents in a rural mental health pro- the kinky community about safer sex ©1996 UC Regents: gram. Hospital and Community Psychiatry. 1994; negotiation, in particular the use of All rights reserved. 45(1): 66-69. (University of North Carolina at “safe words” and the power of com- ISSN 1047-0719 Chapel Hill.) munity to encourage safety. Also in the April issue, Dan Bigg of An evaluation of a rural psychiatric the Chicago Recovery Alliance discusses residency training program found that the relationship between safer sex and providing positive role models and creat- drug use and the challenges of sexual ing a supportive environment were more negotiation in couples where one or effective than instituting a specialized more of the partners uses drugs. curriculum that focused on the problems of rural practice. 8 FOCUS March 1996 searchable archive FREE DID YOU KNOW?

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ABOUT UCSF AIDS Health Project Publications The AIDS Health Project produces periodicals and books that blend research and practice to help front-line mental health and health care providers deliver the highest quality HIV-related counseling and mental health care. For more information about this program, visit http://ucsf-ahp.org/ HTML2/services_providers_publications.html.