Adherence Strategies

Therapy for family, patient improves adherence

Intervention designed to reduce drug abuse relapse

Investigators have found that an intensive one-on-one therapy that involves HIV patients and their families holds promise as an effective adherence intervention.

"Structural ecosystems therapy is a systemic family therapy that targets the way families are grouped and interact," says Daniel J. Feaster, PhD, an associate professor of biostatistics at the Stempel School of Public Health, Florida International University in Miami.

Families are defined broadly, and the goal is for the therapist, typically a master’s level social worker, to gain the family’s trust and observe how the members relate to one another, Feaster explains.

Initially, a study using this technique was aimed at improving patients’ adjustment to HIV infection, but it was modified to measure HIV adherence, as well, he notes.

Therapists receive extensive training of up to five months, depending on their level of experience in systemic work, Feaster says.

The therapists’ meetings with patients and their families primarily take place in person, although some crisis intervention could be conducted by telephone, Feaster says.

"The overriding theme is building support," Feaster says. "As much as possible we try to get the family in at the first session with the therapist," Feaster says. "It really is a matter of dropping in and getting to know the family, feeling out what they think of the therapist."

A key component is to create an atmosphere of trust in which the patient does not feel as though she is being judged or given orders.

Therapists might let the patient and family tell their stories in the beginning, Feaster explains.

"That’s an important period because the therapist is joining with the family and is supportive and understands their issues," he says.

Therapists encourage family members to assist patients in creating a plan for what will happen if the woman relapses into drug abuse, Feaster says.

"We break the barriers to talk about the issue and to try to make the woman understand that if she slips up, it’s not forever and she need not be afraid to draw on her family support," Feaster says.

"In some families there are huge issues, but in others there are other issues that may prevent the family from adequately supporting the woman," Feaster says. "The whole basis of this theory is that as groups we get into repetitive interactions, and everyone has a way of pushing buttons, and so sometimes you have to change the way you interact to keep those buttons from being pushed and from triggering a relapse."

Each session may last up to an hour, and it’s typically conducted inside the patient’s home. For purposes of the research study, the sessions were videotaped, but they were reviewed only for providing feedback to the therapists, Feaster says.

The therapist supervisor might provide feedback to the therapist about how she over-supported a particular person in the family group and did not make all of the family members feel as though their issues were as well acknowledged, he says.

Each weekly sessions builds on the establishment of rapport, and they may last for up to four months, Feaster says.

"It is fairly intensive, and for some families there may not be a need for it to continue that long," he says.

The initial study found that women in the intervention arm had significantly better adherence than did the control arms, Feaster says.

"So we’re testing a modification of that original therapy, involving mostly African American women who have just received drug abuse treatment," Feaster says. "We’re focusing on drug abuse relapse, HIV medication adherence, and sexual risk behaviors."

Investigators felt the intervention should focus on sexual risk behaviors so that women could prevent themselves from being exposed to sexually transmitted infections, which are difficult to treat in the HIV population, Feaster says.

The second study will eventually enroll about 150 women, including both English and Spanish-speaking women, he says.

The first study, which enrolled 209 African American women of whom about 60% had a history of drug abuse, found that the women who were in the therapy intervention had significant declines in distress relative to the community control group and to a group of women who had a person-centered therapy, Feaster notes.

"We saw a significant decline in family hassles," Feaster says. "Since we did look at medication adherence outcomes, we saw improved medication adherence relative to the person-centered group."

Also, the intervention group receiving structural ecosystems therapy had a lower rate of drug abuse relapse than those in the person-centered therapy, Feaster says.

"We feel this program is a good relapse prevention type of therapy and after care," Feaster notes. "So if people have drug problems, we feel they could go through an extensive drug therapy and then we’d help to reintegrate them with their families."

This integration is time-consuming because their family-oriented relationships may have been strained in the past, he says.

The reason this type of intervention is ideal also for the medication adherence among an HIV population with a drug abuse history is because this group often are not prescribed HIV antiretroviral medications if physicians fear they are active drug users, Feaster says.

Through the intervention, involving the patients’ families, investigators have shown that antiretroviral drug adherence can be improved, and so there is no reason to be afraid of prescribing to this population, Feaster says.

If the second study’s results are similarly positive, investigators are hopeful the model will be used by others. It could be adapted for different populations, as well, Feaster notes.

"We’re also testing an adaptation of this model among HIV-infected prisoners in California," Feaster says. "In that model the sexual risk behaviors has more prominence because they’re just getting out of prison."

Once the model has been proven in studies, it is possible it could be extended to work with other ecosystems and family sessions, Feaster says.