Dispositional Mindfulness in People with HIV: Associations with Psychological and Physical Health.

We used a Stress and Coping model to examine the association of dispositional mindfulness, defined as the tendency to intentionally bring nonjudgmental attention and awareness to one's experience in the present moment, with psychological and physical health in adults with HIV. Data were collected at baseline of a randomized controlled trial of Mindfulness-Based Stress Reduction (MBSR). Four facets of mindfulness (acting with attention/awareness, nonjudging of inner experience, observing, and describing) were examined as correlates of appraisal, positive and negative affect, coping, and indicators of psychological well-being and physical health. We found that mindfulness was inversely related to depression, stress appraisal, and negative affect, and positively related to positive affect. Mindfulness was also inversely related to escape/avoidance and self-blame forms of coping. Mediational analyses indicate that perceived stress and negative affect were the most consistent mediators of the association of mindfulness and psychological well-being. The findings from this paper contribute to a growing understanding of the potential adaptive role of mindfulness in people living with the stress of serious illness.

Do house officers learn from their mistakes?

Mistakes are inevitable in medicine. To learn how medical mistakes relate to subsequent changes in practice, we surveyed 254 internal medicine house officers. One hundred and fourteen house officers (45%) completed an anonymous questionnaire describing their most significant mistake and their response to it. Mistakes included errors in diagnosis (33%), prescribing (29%), evaluation (21%), and communication (5%) and procedural complications (11%). Patients had serious adverse outcomes in 90% of the cases, including death in 31% of cases. Only 54% of house officers discussed the mistake with their attending physicians, and only 24% told the patients or families. House officers who accepted responsibility for the mistake and discussed it were more likely to report constructive changes in practice. Residents were less likely to make constructive changes if they attributed the mistake to job overload. They were more likely to report defensive changes if they felt the institution was judgmental. Decreasing the work load and closer supervision may help prevent mistakes. To promote learning, faculty should encourage house officers to accept responsibility and to discuss their mistakes.

Appraisals of controllability and coping in caregivers and HIV+ men: testing the goodness-of-fit hypothesis.

The authors examined goodness of fit between controllability appraisals and coping in 82 HIV+ and 162 HIV-gay men experiencing the chronic stress of caregiving and 61 HIV+ gay men who were not caregiving. Multiple assessments of each individual over a 2-year period allowed replication of prior cross-sectional research examining goodness of fit, as well as the creation of intraindividual goodness-of-fit scores that were then used to examine within-person fluctuations in goodness of fit over time and goodness of fit as an individual difference variable related to adjustment. Results indicate that the importance of goodness of fit varies for different kinds of coping: The concept was supported for problem-focused coping and, to a lesser extent, for emotion-focused coping but not for meaning-focused coping. Within-subject variation in goodness of fit was related to within-subject variation in depressed mood, but between-subjects variation (individual differences) in fit was not associated with depressed mood, suggesting that goodness of fit is better understood as a transactional variable than as a personality or "coping style" variable.

Tacit definitions of informal caregiving.

AIMS OF THE STUDY: This study describes three tacit definitions of informal caregiving and explores the extent to which differences in these tacit definitions explain variation in caregivers' negative mood over time. BACKGROUND/RATIONALE: There is a growing need to understand the sources of stress and gratification for informal caregivers. Tacit definitions of informal caregiving refer to caregivers' understanding of what caregiving entails. These definitions are tacit because they arise from caregivers' taken-for-granted understanding rather than formally articulated positions concerning caregiving. DESIGN/METHODS: A random sample of 60 men, all of whom were caregiving partners of men with acquired immunodeficiency syndrome (AIDS), was drawn from a larger cohort of 253 participants in the University of California San Francisco (UCSF) Coping Project (1990-1997). The caregivers were assessed bimonthly for 2 years with procedures that included a semi-structured interview focusing on a recent stressful event involving caregiving, and quantitative measures of well-being. RESULTS/FINDINGS: Interpretive phenomenological case studies of the narrative accounts of the 60 caregivers produced three tacit definitions of caregiving - engagement, conflict and distance. These three tacit definitions were distinguished by differences in learning about caregiving, involvement in health care decisions, caregiving activities and reported sources of stress. The three groups differed on measures of dyadic adjustment, depression, anger and anxiety. CONCLUSIONS: Better understanding of caregivers' tacit definitions can facilitate and enhance effective support and interventions for caregivers.

Coping and physical health during caregiving: the roles of positive and negative affect.

The associations among coping, mood, and health variables were examined prospectively over 2 years in 86 HIV positive (HIV+) and 167 HIV negative (HIV-) gay men undergoing the stress of AIDS-related caregiving. Path models suggested that including both positive and negative mood and the men's associated coping strategies increases understanding of why some people suffer adverse health effects during times of stress. Among the HIV- caregivers, higher levels of social coping predicted increases in positive affect, which in turn resulted in lower levels of physical symptoms. In contrast, higher levels of cognitive avoidance predicted increases in negative affect, which in turn resulted in higher levels of physical symptoms. Self-injurious forms of avoidance coping predicted higher levels of physical symptoms independent of mood among the HIV+ caregivers.

Positive affect and the other side of coping.

Although research on coping over the past 30 years has produced convergent evidence about the functions of coping and the factors that influence it, psychologists still have a great deal to learn about how coping mechanisms affect diverse outcomes. One of the reasons more progress has not been made is the almost exclusive focus on negative outcomes in the stress process. Coping theory and research need to consider positive outcomes as well. The authors focus on one such outcome, positive affect, and review findings about the co-occurrence of positive affect with negative affect during chronic stress, the adaptive functions of positive affect during chronic stress, and a special class of meaning-based coping processes that support positive affect during chronic stress.

Promoting psychological well-being in the face of serious illness: when theory, research and practice inform each other.

This article describes the interplay among theory, research and practice regarding the maintenance of psychological well-being during serious illness. The ideas emerged from two independent lines of work, one that evolved through clinical practice within the medical model, the other that evolved through theory and field research within a behavioral science model. Each of these lines of work independently points to the importance of focusing on psychological well-being and the coping processes that support it, as a complement to the traditional focus in both the medical and behavioral sciences on psychiatric symptoms. This article describes a theoretical framework for the discussion of psychological well-being during serious illness. Then, this framework is used to define variables that research indicates contribute specifically to psychological well-being during serious illness, and finally, based on theory and research, a therapeutic program is described for patients with serious illness. The goal of this paper is to encourage researchers and clinicians to give as much attention to the development and maintenance of psychological well-being in the face of serious illness as they do to the etiology and treatment of psychiatric symptoms.

Depressive symptomatology in three Latino groups.

The purpose of this study was to examine depressive symptomatology in three Latino groups: Mexicans living in Mexico City, Latino immigrants living in the South Bay area of San Francisco, and Puerto Ricans living on the island of Puerto Rico. The Spanish version of the Center for Epidemiological Studies Depression Scale (CES-D) was used as part of a larger study on stress and coping. The levels of depressive symptomatology in all three Latino groups were significantly higher than those reported in other Latino samples and in White Americans. Mexican immigrants reported the highest levels of depressive symptomatology.

Spiritual aspects of loss among partners of men with AIDS: postbereavement follow-up.

This article is a follow-up study of bereaved caregiving male partners of men with AIDS (T.A. Richards & S. Folkman, 1997). The earlier study examined spiritual beliefs, experiences, and practices reported in interviews with 125 caregivers conducted 2 and 4 weeks following bereavement. This follow-up study reports qualitative and quantitative data from 70 members of the earlier cohort, collected 3 to 4 years later, regarding the presence of spiritual phenomena. Spirituality increased or deepened in 77% of the entire cohort. An ongoing relationship with the deceased partner was reported by 70% of the cohort. The use of spirituality as coping appeared to decline as the bereaved moved further in time from the loss. Instead, spirituality was identified as a personal governing influence that provided value and direction to the individual. In general, relationships between the expression of spirituality and mood, coping, and physical health symptoms were not statistically significant owing to small samples, but there were medium effect sizes.

HIV sexual risk behavior following bereavement in gay men.

The present study followed a group of 100 gay men up to 1 year before and 1 year after losing a partner to AIDS (University of California, San Francisco Coping Project). Following bereavement, participants were at increased risk for engaging in unprotected anal intercourse: at 4 to 6 months for HIV-negative men and at 8 to 12 months for HIV-positive men. Sociodemographic variables, HIV serostatus, substance use, depression, prebereavement relationship quality, and social support did not explain sexual risk-taking in this sample. However, men who engaged in unprotected anal intercourse were twice as likely to be involved in a new primary relationship as those who did not. The authors concluded that risk varies over time by HIV status and may involve engagement in new relationships.

Informal caregivers and the intention to hasten AIDS-related death.

OBJECTIVES: To determine the extent to which homosexual men dying of the acquired immunodeficiency syndrome (AIDS) receive medication intended to hasten death. To assess the impact on caregivers of administering medications intended to hasten death. METHODS: In a prospective study of caregiving partners of men with AIDS (n = 140), characteristics of the ill partner, the caregiver, and the relationship were assessed at baseline and 1 month before the ill partner's death. Three months after the death, caregivers were asked if they had increased their partner's narcotic and/or sedative-hypnotic medication dose and if so, what had been the objective of the increase, and their comfort with their medication decisions. RESULTS: Of 140 ill partners who died of AIDS, 17 (12.1%) received an increase in the use of medications immediately before death intended to hasten death. Diagnoses and care needs of ill partners who received increases in the use of medications to hasten death did not differ from those of ill partners receiving medication for symptoms. Fourteen increases (10%) in use of medications were administered by caregivers. These caregivers did not differ from those administering medication for symptom control in level of distress, caregiving burden, relationship characteristics, or comfort with the medication decision, but they reported more social support and positive meaning in caregiving. CONCLUSION: The decision to hasten death is not a rare event in this group of men. There is no evidence that it is the result of caregiver distress, poor relationship quality, or intolerable caregiving burden; and it does not cause excessive discomfort in the surviving partner. This study, although small, has implications for the policy debate on assisted suicide.

Positive psychological states and coping with severe stress.

Providing care to a spouse or partner who is dying and then losing that person are among the most stressful of human experiences. A longitudinal study of the caregiving partners of men with AIDS showed that in addition to intense negative psychological states, these men also experienced positive psychological state states throughout caregiving and bereavement. The co-occurrence of positive and negative psychological states in the midst of enduring and profoundly stressful circumstances has important implications for our understanding of the coping process. Coping theory had traditionally focused on the management of distress. This article describes coping processes that are associated with positive psychological states in the context of intense distress and discusses the theoretical implications of positive psychological states in the coping process.

Spiritual aspects of loss at the time of a partner's death from AIDS.

Spiritual phenomena were spontaneously reported in interviews of 68 of 125 recently bereaved HIV-positive and HIV-negative partners of men who died from AIDS. Spiritual schemas involving beliefs, experiences, rituals, social support, and roles were used to help assimilate the fact of death and were appraised as sources of solace and meaning. The relationship between spirituality and coping, mood, and physical health was examined. Those reporting spiritual phenomena showed higher levels of depression and anxiety and lower levels of positive states of mind, used more adaptive coping strategies, and reported more physical health symptoms than those who did not report spiritual phenomena.

Suicidal ideation, bereavement, HIV serostatus and psychosocial variables in partners of men with AIDS.

This prospective 2-year study examines suicidal ideation in 86 HIV-positive and 167 HIV-negative caregiving partners of men with AIDS. One hundred and fifty-six of the caregivers became bereaved during the course of the study. The study focuses on the relationship between suicidal ideation and bereavement status (bereaved vs non-bereaved), HIV serostatus (HIV-positive vs HIV-negative), and psycho-social factors (caregiving burdens, social support, coping, and optimism). Bereavement was related to suicidal ideation, but HIV serostatus was not. High suicidal ideators were characterized by feeling burdened by caregiving, perceiving low levels of social support and subjective social integration, and the use of behavioural escape-avoidance coping. Those who reported never having suicidal ideation were characterized by higher levels of optimism. Clinical implications are discussed.

Stability and change in psychosocial resources during caregiving and bereavement in partners of men with AIDS.

This study examines the effects of caregiving and bereavement on psychosocial resources in HIV+ and HIV- caregivers of men with AIDS. We explored three hypotheses regarding these effects: the "wear and tear" hypothesis, which asserts that the chronic stress of caregiving and bereavement diminishes resources; the "enhancement" hypothesis, which asserts that caregiver resources may increase in response to increased demands; and the "personality" hypothesis, which asserts that psychosocial resources reflect stable personality characteristics. We addressed four questions: (a) What are the effects of caregiving on resources? (b) How do these resources vary by the imminence of the partner's death? (c) What is the effect of the partner's death on these resources? and (d) How does the caregivers' HIV serostatus influence the effects of caregiving and bereavement on resources? Support for the personality hypothesis predominated, with some support for the wear and tear hypothesis, depending on the resource in question. In general, HIV seropositivity did not put people at additional risk for resource depletion.

Introduction to the special section: use of bereavement narratives to predict well-being in gay men whose partners died of AIDS--four theoretical perspectives.

Four teams of investigators, representing distinct theoretical perspectives, independently analyzed the same bereavement narratives of 30 men whose partners had died of AIDS within the previous month. The data came from a longitudinal study of the caregiving partners of men with AIDS. Caregivers were interviewed with an open-ended format 2 weeks and 4 weeks following their partner's death. Positive and negative psychological mood was assessed at the time of the bereavement interviews and again 12 months later. Scores derived from the qualitative analyses were used to explain mood at the time of the bereavement interviews and 12 months later. The Rashomon format of the 4 studies provided an unusual opportunity to see overlaps and distinctions among theoretical approaches, resulted in thorough exploration of bereavement processes, and illustrated four different methods of analyzing qualitative data.

Appraisal and goal processes as predictors of psychological well-being in bereaved caregivers.

Narratives of 30 caregivers were scored for appraisals and coping responses following the death of their partners from AIDS. Appraisals were identified as valenced beliefs, emotions, and goal outcomes, whereas coping responses included goals and plans of action. The proportion of positive appraisals predicted long-term goals and plans and psychological well-being at both bereavement and 12 months later. Positive appraisals were correlated with positive moral and positive states of mind. The latter were negatively correlated with partner-centered, short-term plans. Positive appraisals were negatively correlated with depressive mood. Caregivers, who reported proportionately more positive appraisals during caregiving and after the loss of their partner, were more likely to have future- and self-oriented goals and plans and to demonstrate positive well-being at bereavement and better recovery 12 months later than were those who reported more negative appraisals.