The Effect of a Mind–Body Intervention on Mental Health and Coping Self-Efficacy in HIV-Infected Individuals: A Feasibility Study

Abstract

Objectives:

Human immunodeficiency virus (HIV) infection is a stressful disease, and depression is the most common form of psychologic distress experienced by those infected. The aim of this study was to further develop and validate a mind–body intervention to improve coping self-efficacy strategies and increase mental health.

Design:

Feasibility study, a randomized trial. Participants were assigned into two blocks (female/male) and simple randomization in a 1:1 ratio was performed within each block to one of two arms (1) intervention group, (2) control group who received usual care.

Setting/Location and Subjects:

The authors enrolled 30 HIV-infected individuals (10 women and 20 men) who had psychologic challenges and were motivated for working with personal development at the Department of Infectious Diseases at Aarhus University Hospital, Denmark.

Intervention:

The intervention was a group intervention facilitated by an educated coach. The framework was a 3-day residential course plus two single-day/8-h follow-up events. The intervention was based primarily on a Native American philosophy of life and its understanding of how changes affect human beings and create imbalance.

Outcome measures:

Primary outcomes were change in risk of depression and level of coping self-efficacy. Secondary outcomes were change in levels of stress and personal growth.

Results:

Significant improvement between the intervention group and control group was seen in risk of depression and personal growth mean values from baseline to 6-month follow-up. Significant improvements were shown within the intervention group in mean values of risk of depression, coping self-efficacy, stress, and personal growth. There were no significant improvements within the control group.

Conclusions:

The authors suggest that interventions designed to increase resilience through enhancing coping self-efficacy be used in conjunction with HIV medication to make this approach and especially the “whole-person” commitment a fully integrated aspect of HIV care.

Background

Depression is the most common form of psychologic distress experienced by people living with human immunodeficiency virus (HIV).¹ In a Danish setting, the authors found that 26% had symptoms of major depression.^2,3 Disclosure of HIV status was a continuous challenge and a potential stressor, and disclosing may accordingly constitute a social stressor. Furthermore, lack of coping self-efficacy may increase the likelihood of nondisclosure and depression.⁴ Studies show that higher resilience is associated with lower psychologic distress and higher perceived quality of life in physical and mental health among HIV-infected individuals.⁵ Given that HIV-infected individuals are faced with internal and external challenges, the stress–response system is constantly activated, attempting to adapt to these challenges. Mind–body medicine approaches (e.g., relaxation techniques, yoga, meditation, cognitive behavioral therapy)⁶ and mindfulness-based stress reduction (MBSR)⁷ have shown to be effective in reducing and managing the clinical manifestations of stress, reducing anxiety, and increasing patients' resilience in a wide variety of illnesses. This study seeks to further develop and validate a mind–body intervention based on a Native American philosophy and had positive results in a previous pilot study,⁸ to increase resilience through enhancing coping self-efficacy, and to improve mental health among HIV infected.

Methods

Study design

The authors used the U.K. Medical Research Council's (MRCs) model for developing complex interventions.⁹ Stratified randomization: after all participants were included, they were assigned into two blocks (female/male) and simple randomization in a 1:1 ratio was performed within each block to one of two arms (1) intervention group, (2) control group who received usual care. Inclusion criteria were as follows: age 18 years or older, understanding and speaking Danish, psychologic problems (e.g., depression, anxiety, stress, loneliness), and motivated for working on personal challenges. Exclusion criteria: nontreated mental illness. Thirty HIV-infected individuals (10 women and 20 men) were enrolled in the study. Before inclusion, all patients confirmed their motivation for working on personal challenges and provided written informed consent. The participants were not compensated for their participation. The study was approved by the Aarhus Health Human Research Ethics Committee and the Danish Data Protection Agency.

Study intervention

The overall focus of the intervention was to improve each person's balance in life (a stable mental or psychologic state, emotional stability), making each person conscious about his or her own behavior and activating their own resources. It was a group intervention facilitated by an educated coach. The framework was a 3-day residential course plus two single-day/8-h follow-up events (4 days less than the pilot study),⁸ and the total length was 3 months.

The mind–body approach in the intervention took into account the effect of the mind on physical processes, including the effects of psychosocial stressors and conditioning. The intervention was based primarily on a Native American philosophy of life and its understanding of how changes affect human beings and create imbalance¹⁰ combined with other mind–body approaches.

The following components were addressed: (1) warrior/victim behavior, (2) personal limits and boundaries, and (3) techniques to address fear/stress management. The intervention offered the participants a variety of techniques and then chose what works best individually. They were not obliged to work with all techniques to gain an effect. The main framework and content of the intervention are shown in Table 1.

Table 1.

Framework and Content of the Intervention

Approach	Schedule	Components	Tools and techniques
Creating the setting The coach first of all ensured a safe environment of trust and respect, which is crucial and the main condition to be able to open up and work with private challenges	Module 1 Three-day residential course Anonymous place outside the hospital Homework Train skills, mediation Buddy talk Exercises of own choice	1. Warrior/victim behavior	Various tools and principles that focus on whether a person chooses a warrior or victim behavior when facing challenges in his/her daily life
The circle The participants were seated in a circle The circle is the pattern of harmony, according to the native Indians	Module 2 One day (8 h) Anonymous place outside the hospital Homework Train skills, mediation Buddy talk Exercises of own choice	2. Personal limits and boundaries	Mix of teaching/reflection within the group, two and two, individual Reflective discussion to develop emotional intelligence and accurate thinking
Talking stick This was how all gatherings started Initially a talking stick was sent from one person to the next in the circle and the person with the talking stick had the right to speak and the rest were obliged to listen	Module 3 One day (8 h) Anonymous place outside the hospital	3. Techniques to address fear/stress management	Breath awareness Mindfull awareness Guided meditation Imagery Body Scan Grounding Self-awareness Physical exercises: walk in the nature, yoga
Attitude Welcome with all that is you No specific plan—You make the plan, we serve you

In this mind–body Native American intervention, a framework is provided whereby the way in which people deal with challenges determines whether, in a given situation, he or she assumes the stance of warrior or victim. The source of the warrior behavior is love and courage, while the source of the victim behavior is fear. Once the person becomes more conscious of how he or she reacts in stressful situations, the development of a new ability to act arises. When you become aware of your fear behavior, you can use strategies/techniques to switch from the stress response to the relaxation response to gain balance.¹¹

The outcome of the components: Self-care: taking responsibility for one's own health and well-being. To do so, each individual has to understand that he or she has to judge what is right and acknowledge one's own decisions about how to live one's life. Beyond just focusing on health and well-being, self-care incorporates self-management. Self-management means people drawing on their strengths and abilities to manage or minimize how a condition may limit their life, and what they can do to feel happy and fulfilled.¹² Personal Growth: to grow in areas that are important for a person, both cognitive and behavioral aspects of growth such as self-efficacy, spirituality, appreciation for life, and the ability to relate to others.¹³ Resilience: the capacity and dynamic process of adaptively overcoming stress and adversity while maintaining normal psychologic and physical functioning. It is the ability to adapt successfully in the face of stress and adversity.¹⁴ They practiced exercises at home by own choice, listening to audio files (the same as they were introduced to during the intervention) that contained instructions for the following techniques: (1) breathing awareness; (2) mindfulness awareness; (3) body scan; and (4) imagery.

Study outcomes

Participants filled out a self-reported standardized questionnaire, as used in the previous study,⁸ at baseline and 3, 6, and 9 months after the intervention was completed.

Results

All available data were included in calculating the descriptive statistics of the measures. Mean disease duration in the control group was 8.3 years (range: 2–33 years) and 13.3 years (range: 2–29 years) in the intervention group. The completion rate at the three follow-up times was 100%, 87%, and 87% for the intervention group and 73%, 66%, and 60% for the control group (Table 2).

Table 2.

Mean Values Within the Control Group and the Intervention Group at Baseline and 3-, 6-, and 9-Month Follow-Up

	Baseline		3 months			6 months			9 months
	Control n = 14	Intervention n = 15	Control n = 11	Intervention n = 15	p 0 months vs. 3 months	Control n = 10	Intervention n = 13	p 0 months vs. 6 months	Control n = 9	Intervention n = 13	p 0 months vs. 9 months
The Beck Depression Inventory II	11.45	16.33	11.09	10.93^a	0.13	11.1	10.07^a	0.04^b	7.44	10^a	0.13
The Coping Self-Efficacy Scale	154.72	113.8	170.18	155.86^a	0.18	158	154.53^a	0.16	164.22	156.23^a	0.18
The Personal Growth Scale	13.36	15.93	17.45	16.93	0.13	15.1	18.53	0.04^b	15	20^a	0.13
The Perceived Stress Scale	27.54	30.06	24	21.66^a	0.07	26.2	23.46^a	0.11	24.11	20.23^a	0.17

Reasons for dropping out and not completing follow-up times: control group: psychological problems (4), travelling (1), brain hemorrhage (1). Intervention group: did not think that it was the right way (1), difficult to work in a group (1).

Significant change within the group.

Significant change between groups.

A significant improvement was seen in the Beck Depression Inventory II (BDI-II)¹⁵ and Personal Growth Scale (PGS)¹⁶ mean values between the intervention group and the control group from baseline to 6-month follow-up (Table 2). Significant improvements were shown within the intervention group in mean values of BDI-II, Coping Self-Efficacy Scale (CSE),¹⁷ and Perceived Stress Scale (PSS).¹⁸ Significant improvements in PGS were seen at the 9-month follow-up. The improvements in outcome measures in the intervention group sustained with a mean value BDI-II change from 16.33 to 10 (p = 0.02), a mean value CSE change from 113.8 to 156.23 (p = 0.05), a PSG change from 15.93 to 20 (p = 0.02) and a PSS change from 30.06 to 20.23 (p < 0.01) at the 9-month follow-up. There were no significant improvements within the control group. Overall, there was an improvement in risk of depression in the intervention group from baseline to the 9-month follow-up. The intervention was shortened with four single days versus the previous study; thus, the effect maintained and confirmed the previous results.⁸

Discussion

According to the MRC model for evaluating complex interventions, there are several interacting components⁹ and the key questions are whether they are effective in everyday practice, what the active ingredients are, and how they are exerting their effects. Significant improvements were shown within the intervention group in mean values of risk of depression, coping self-efficacy, stress, and personal growth. Overall, the participants gained a consciousness about their reactions and enhanced tools and techniques to act in a different and more healthy and balanced way—they incorporated a new mind-set. Despite the physical and psychologic changes that arise with a diagnosis of HIV infection, results from this intervention suggest that persons may build resilience over time. This is an individual process, which this intervention accommodated. The intervention was individualized, as it was designed as a multiskill approach to different individuals who respond to and adopt skills that they find useful. It is vital that each individual works at one's own pace and to understand that he or she is the one to judge what is right for them and acknowledge own decisions about how to live one's life. An important facilitator was the context. First, the intervention took place outside the hospital, which implied that focus was moved from focusing on the disease to the healthy part of the person. Next, in creating the setting, the coach ensured a safe environment of trust and respect, which is crucial for the ability to open up and work with private challenges. Third, the participants were motivated for working on personal challenges. Fourth, the intervention was a group intervention promoting vicarious learning from others, knowing and being comforted by the fact that others share one's difficulties, and practicing in a safe environment. Being part of a group, being understood by and understanding others, and being able to give and receive help strengthen the sense of belonging and enhance emotional well-being. The authors speculate that the effects can be considered as a causation chain starting with (1) motivation to learn new practices, tools, and techniques, thus (2) building up both an inner bodily awareness and a consciousness about one's reactions, and then (3) by practicing techniques that work, slowly changing habits according to the new awareness. This leads to (4) a more conscious behavior with increased self-care, less stress, and increased resilience. Resilience might mediate the associations between stress and physical and physiologic well-being.⁵

Limitations

The small size of the study and lack of adherence filling in the questionnaires in the control group decrease the statistical power of the analysis and increase the likelihood of bias. The results nevertheless correspond with the findings in the initial pilot study.

Conclusion

Further research in the area of the effect of mind–body medicine in reducing risk of depression in HIV-infected individuals is needed. The authors suggest that interventions designed to increase resilience through enhancing coping self-efficacy be combined with HIV medication treatment to improve mental health and to make this approach and especially the “whole-person” commitment a fully integrated aspect of HIV care.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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