Abstract #347  -  Developing a cognitive behavioural therapy model to assist women
Authors:   Presenting Author:   Mr Jan Tshabalala - University of Pretoria
Additional Authors:  Prof Maretha Visser,
Aim: The aim of the research was to develop an understanding of HIV-positive women’s experience of HIV and the related stigma so as to enable the development of a cognitive behavioural therapeutic intervention to assist them in dealing with internalised and enacted stigma.
Method / Issue: The research was conducted in two phases. Phase 1: Development of the intervention model The following sources of information were used to gain understanding of women’s experiences and the cognitive processes underlying these experiences to be used in the development of the intervention model. Focus group discussions with practising psychologists. Interviews with HIV-positive women In-depth interviews were conducted with five HIV-positive women using an interview schedule to develop an understanding of how they experience HIV, people’s reaction towards them and how they cope with stigma. A purposive sampling technique was used where particular cases are chosen because of their relevance for the study (Strydom & Venter, 2002). The nurses of the Wellness Clinic at the Witbank Hospital referred to the researcher five HIV-positive African women who were receiving treatment from the clinic and who experienced difficulties in dealing with stigma. The women were in their early to middle adulthood (aged 22 to 40), had been living with HIV for at least three months since diagnosis, had at least passed Grade 10 and were coming from a poor to average socio-economic background. A focus group discussion was held with five clinical psychologists who have had experience of working with HIV-positive women for more than seven years and were willing to participate in this study. Phase 2: Implementation and evaluation of the intervention model A sample of twenty black South African women living with HIV/AIDS, who received ARV treatment from the Witbank Hospital and who experienced difficulties in dealing with stigma, were referred to the research. Selection criteria involved having lived with HIV for at least three months and having passed Grade 10. The women agreed to voluntarily participate in the research and were randomly assigned to the experimental and control group. The experimental group participated in eight weekly individual CBT sessions and the control group formed a waiting list group. An experimental design consisting of a pre-test/post-test control group was used to evaluate the intervention. Data-gathering instruments Both qualitative and quantitative methods were used. All the therapy sessions with the 10 participants were tape-recorded and transcribed in order to identify the reactions of participants to specific techniques used. The therapist’s process notes of each session with each woman were used as participative observation notes of the progress in therapy. Five psychometric instruments were administered pre-and-post therapy to assess possible change.
Results / Comments: The pre- and post-test scores of the psychometric scales were analysed using Mann-Whitney tests. Before the intervention, no significant differences were found on the five scales between the experimental and control group. The two groups can therefore be considered similar. To determine the effect of the intervention, change scores were calculated before and after the intervention for each individual. The Mann-Whitney test was used to determine whether the experimental group’s scores had changed significantly more than those of the control group. After the intervention, significant differences were found in the change scores of the two groups for four of the five scales. This means that the women in the experimental group reported less negative ways of coping (p<0.05), lower depression (p<0.001) and internalised stigma (p<0.05), as well as more positive ways of coping (p<0.05) and higher levels of self-esteem (p<0.01) than the control group. There was no change in the enacted stigma scores in both groups. It can therefore be concluded that, compared to the control group, women in the intervention group showed more positive change. The qualitative evaluation focused on the reactions of women in therapy. Change in thought patterns and behaviour was observed in all of the women. They grasped that HIV will not cause their immediate death and that they can still live a healthy life. This was the start of the change process for seven of the women. Their self-perception changed and the way they interpreted others’ perception of them. Women regained control over their lives through the realisation that although they cannot change the diagnosis, they have control over their thoughts, feelings and behaviour. While HIV was seen as the centre of their lives before therapy, they could carry on with their lives after therapy. One woman said: “…I came to realise that I am not a failure in life. I am not different from other people. My life goes on as I wish it to …” Once the women accepted their status, they started exchanging their personal experience with others and teaching them about HIV. Five of the women disclosed their status to partners or family, despite expectations of being stigmatised. This played a pivotal role in their lives, since it helped them to reappraise their situation and to find alternative ways of coping. One woman said: “I want to live and accomplish my goals by taking care of myself and educating others about the disease.” At the end of the sessions nine of the women rediscovered their meaning in life. One woman pointed out: “I wanted to die, because I am useless due to the disease. However, I have come to realise that my life, my children and the family are important.”
Discussion: Of specific importance is the qualitative evaluation, which allowed conclusions about the value of specific CBT techniques in an African context. Positive cognitive reframing and decatastrophising (cognitive techniques), and training in coping and assertiveness skills (behavioural techniques) were effective in facilitating change. Complex cognitive techniques such as identifying underlying automatic thoughts were not effective with all the women. Some of the women were able to change negative thought patterns when the therapist highlighted these patterns. Clients were therefore not equipped with the ability to manage their own negative thought patterns outside the therapy situation (Basco & Rush, 2007), since it may require more time to incorporate these techniques as part of one’s cognitive repertoire.
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