COMPASSION-FOCUSED THERAPY

Compassion-Focused Therapy in Reducing HIV Stigma and Depression

Background                    

            There is a cyclical relationship between HIV and related stigma to the affected individuals. With HIV categorized as one of the most deadly diseases with no effective cure, HIV-related stigma is invoked as a main pernicious and persistent barrier in effective responses to this disease. Ideally, this type of stigma is cited as a prominent barrier to accessing treatment and prevention services and this has led to devastating familial, economic, and social lives of the affected people (Brown et al. 2003). Moreover, regardless of the widespread incidences of the disease, for over the first two decades of the HIV epidemic, global, the community and national actors have been limited to addressing the effects of HIV stigma – a key aspect that has been adversely influenced by discrimination as a main imperative for success. For instance, a study by noted that stigma reduction among the HIV populaces are majorly given low weights when it comes to addressing HIV/AIDS related issues, and in most cases it goes without funding to support the activities by the global actor (Bos et al. 2008).

            Depending with the cultural setting the HIV individuals are residing, the response to HIV stigma becomes complex to handle since many cultures impose different levels of pervasive barriers to addressing the issue. Additionally, this complexity to handle HIV stigma has also injected a significant disagreement and difficulties on how to define this type of stigma, to an erroneous confusion between stigma and discrimination (Bos et al. 2007). However, the degree of stigma varies with the social, national, and cultural setting, as well as, other intrapersonal factors and these aspects make it difficult to identify these types of populaces. For instance, in many societies where HIV is perceived as an ill-mannered behavioral disease and criticized on basis of sexual misconduct, many of the HIV victims find it hard to expose to the society about their health status since they fear being isolated by their counterparts (Corrigan, 2004). Further, HIV victims find it hard, particularly in the developing countries, to report these cases until the issues are known at a later stage. Therefore, the social and cultural setting playing a big role in inducing the variability of HIV stigma manifestations and this has made it hard to develop effective approaches to containing this type of stigma – in terms of defining, assessing its impact, measuring and reducing it.

            In many of the developing countries, HIV stigma is conceptualized on deviance basis – indicating that a person infected with HIV has undesirable difference from the rest of the members of the society. Further, Ross and Srisaeng (2005) noted that, HIV stigmatization is a typical process of devaluation, often made to induce stress and social inequality at personal level, leading to a barrier towards seeking effective healthcare. Still, for HIV infected individuals who are under drugs, stigmatization may hamper them from proper response and adherence to the antiretroviral therapy. For instance, a bigger number would like to go unidentified that they are using the ARV drugs by their friends. An empirical study carried in Thailand revealed that stigmatized HIV patients have showed delays in accessing health care such as visiting facilities for therapies and drugs (Busza, 2001). Out of this stigma, majority end up not revealing their status to sexual partners, and this increases the chances of transmitting the disease to them – and this chain appears to be a constellation one which hinders the effective management of the spread of this disease.

            As much as, HIV stigma is reported to hamper effective healthcare access to these populaces, several studies have focused on assessing the social effects associated with this type of stigma. McDowell and Serovich (2007) argued that HIV patients that reported symptoms of HIV stigma were reported symptoms of depression and other psychological disorders that impaired their social lives. The study claimed that HIV individuals who lacked social support from their friends and the society reported high rates of depression than stigmatized HIV victims who had support from their family members. Such an aspect tells that, may be an effective approach towards reducing depression among the HIV victims, as it tries to induce some comfort of self-belonging to the society which they appear undesirable. Stigmatized individuals have reported internalized shame which linked HIV stigmatization and depression. Studies by Scheff, (2001) and Epstein, (2001) found a consistent relationship between HIV stigma and depression, where internalized shame played an intervening role.

The studies explored the social identities of depression through a multidisciplinary conceptual approach to establish the scope of depression under this context. Ideally, they found that personal alienation, psychology, poor support from the society, and shame were the key factors that led to depression among the stigmatized HIV people. Scheff (2001) reported that, depression as a mental stressor was linked to the progression of AIDS among the individuals living with HIV. Such an aspect introduces a double trouble for the HIV individuals who live in societies where mental illnesses are stigmatized – they suffer from two types of stigmas – the HIV and that of depression. Therefore, this tells that people living with HIV (PLHIV), regardless of their ethnicity and race, they stand a high chance of being diagnosed with depression of any related mental disorder – and this still poses  a barrier to healthcare seeking behaviors such as adherence to medications and poor rates of ARV  care retention, as well as, insignificant ART-related clinical outcomes.

The double burden of depression and HIV stigma may result to a number of other detrimental effects to the individual including poor quality of life and other episodic or depressive symptoms. According to Steward et al. (2015) stigmatized HIV victims with depression also reported high stress, anxiety and other post traumatic disorders. The efforts to introduce universal access of HIV therapy to PLHIV have been documented to reduce stigmatization levels. According to Wolf et al. (2008) individuals who perceived that ARV therapies are universally offered to these individuals had less negative attitudes towards the HIV community. Such an aspect tells that these universal therapies try to accommodate the HIV status as part of their society and increase the acceptability of these individuals. Further, it tells that increasing anti-HIV drugs to the public negotiate their minds to perceive HIV status as a normal illness; hence this reduces the level of stigma among the infected people.

Existing interventions for reducing HIV stigma

Wolf et al. (2008) reported that universal access of these drugs eliminates chances of discrimination and prejudice towards the HIV-positive individuals – however, the study was limited to explaining the link between the universal HIV therapies and the negative societal attitudes. Further, the study by Wolf et al. (2008) did not explain the link between stigma levels and the universal therapies and their effects on depression. Other intervention strategies have been developed, though their efficacy has still been criticized. For instance, Mahajan et al. (2008) claimed that the existing strategies aim to develop coping skills, increase the willingness to secure routine medical assistance and reduce stigma among the victims. Information-based and cognitive therapy interventions have been widely been used to increase the awareness of self-acceptance and providing more information on managing the disease well. On the other hand, there are skills-building approaches which typically consist of educating the general population and the PLHIV coping skills which may assist them in resolving potential conflicts like dealing with exclusion of these infected people.

Brown et al (2003) added that some of the skills-building approaches include learning through reframing, role-play, group desensitization and relaxing techniques. For example, in desensitization approach, the individuals are exposed progressively to the conflicting situation – now the population which the PLHIV feel stigmatized to interact with. Further, Brown et al. (2003) suggested counseling intervention tries to offer support towards behavioral change and this may be administered by a support group. However, all these interventions have their own weaknesses. Ideally, they do not provide a clear link between HIV stigmatization and depression – the few strategies used appear to offer social support through provision of information to the infected people so that they can manage the disease well (Gilbert and Proctor, 2006). Little empirical is in existence focusing on the use of behavioral intervention on reducing depression among the HIV stigmatized individuals.

 However, evidence-based findings by Brown et al. (2003) and Bos et al. (2008) suggest that strategies that aim at providing HIV-related information, as well as, promoting skills building appear more effective than interventions which only provide the victims with information. Actually, after they feed the victims with information they engage them with the rest of the population – a key aspect that brings the sense of self-belonging and acceptance to the general society- hence reducing stigma.  However, Brown and co-authors’ suggested interventions do not build on depression reduction; rather they focus on creating an opportunity for self-awareness and managing the disease well. Bos et al. (2008) proposed that through collaborative planning between the community and the PLHIV, evidence-based strategies, and context-specific needs assessment helped reducing HIV stigma effectively.  One of the major evidence-based interventions revealed to reduce HIV stigma and depression is the Compassion-Focused Therapy (CFT) developed by Paul Gilbert in 2009.               

Review of Compassion-Focused Therapy

            The CFT integrates several disciplines such as psychotherapy, Buddhist psychology, CBT, developmental psychology and social psychology which all revolve around the functionality of the human brain, development and growth. Ideally, the CFT focuses on using compassionate mind training to assist individuals suffering from psychological and social problems to work and develop the experiences of safeness, inner warmth, and soothing through self-compassion, and compassion (Gilbert, 2009). The central tenet of this approach teaches attributes and skills of compassion and soothing, as well as, transforming problematic patterns of emotions and cognition related to shame, self-criticism, anger, hypomania, anxiety and depersonalization.

Basically, the CFT approach  integrates the concept of biological evolution  in the essence that human beings have evolved  with primal abilities to regulate their emotions, seek resources  and protection, as well as, soothing system to achieve a compassionate self-acceptance. The strength of this intervention in reducing stigma among the HIV infected individuals is that it embraces both stigma and depression (Gilbert, 2010). The approach also buys its strength from the fact that it deals with directing human behavior to resolve conflicts and threats – and focuses more on individuals reportedly to have high levels of self-criticism and shame and have challenges of feeling the a high sense of belonging when interacting with others.

Aims and objectives

Based on the literature search, it is clear that many of the existing intervention approaches on reducing stigmatization do not focus on depression, which is a major mental disorder that most of the HIV-infected individuals are highly identified to be vulnerable to it. However, the CFT is suggested by Gilbert (2009) to help reduce both HIV-related stigma and eliminating levels of shame and discrimination which subject the affected individual to high levels of depression. Therefore, the study assesses the clinical effectiveness of the use of CFT in reducing stigma and depression among the individuals living with HIV.  Further, the study aims to assess if there is significant difference on the effects of CFT on the reduction of both stigma and depression among the HIV individuals – if CFT works the same for each of these two variables.

Hypothesis statement

H1: CFT reduces the levels of stigma among the HIV-infected individuals.

H2: CFT reduces the depression levels among the HIV-infected individuals

H3: There is a correlation between stigma and depression

Study description and procedures

            The study aimed to assess the effect of CFT intervention approach on reducing the depression and stigma levels among the PLHIV. Ideally, the target population includes the existing HIV individuals who have reported discrimination and stigmatization incidences. The research adopted a quantitative approach which embarked on experimental follow-up study to assess the effect of subjecting CFT on depression and stigma levels among the HIV-infected. The researcher subjected a group of participants known to be suffering from HIV stigma and have reported clinical depression for their previous period of three months. The study adopted a snowballing sampling technique to identify 30 individuals infected with HIV/AIDS and reported significant levels of depression and stigma for the previous three months. According to Cochran (2006) snowballing is used to study behavioral variables where the study participants are hard to find due to issues related to stigmatization or where the potential participants do not want to be revealed to the public such as HIV affected individuals, drug dealers or prostitutes.

 The researcher identified a HIV infected couple within the City which refereed the researcher other potential participants until a sample size of 30 individuals was achieved (n = 30). Therefore, the unit of analysis for the study was a HIV infected person. Prior to data collection, the researcher issued research consent and trained the participants on how to use the stigma self-reported scale to assess their stigma levels and depression scale to assess their levels of depression. The participants’ levels of depression and stigma levels were measured and recorded before they were subjected to the compassion-focused therapy sessions which went for eight weeks. After successful therapy sessions, the researcher made a follow-up study to assess the new levels of stigma and depression using the same measurement scales using the same sample subjects. All the study subjects responded to the follow-up study which aimed to assess if there was any significant change with the scores reported for stigma and depression by the participants. There was no monetary compensation given to the participants and it was solely voluntary.

Variable analysis and measures

            The study variables in this study include the CFT intervention, Depression and HIV-stigma. Ideally, the CFT intervention is the independent variable (IV) while the depression and HIV-stigma were the dependent variables (DV) since their scores were influenced by changes in CFT intervention. Ideally, the research hypothesized that subjecting the participants to CFT sessions reduced both reported depression and stigma. CFT intervention is a categorical variable while depression and HIV stigma are measured through ratio scale. A ratio scale permits the comparison of data scores having a fixed zero value, indicating that a comparison between two scores lead to a meaningful interpretation. Stigma was measured using self-reported scale while depression was measured using multiple-item scales such as internalize shame and perceived self-reported scale for stress (which was assumed to measure depression). A summative composite scale was developed for measuring the overall scores for depression. Data was collected before engaging the participants in the CFT sessions and after successful eight weeks of the intervention program.

Data analysis

            Data was recorded and analyzed using the SPSS statistical software. First, descriptive summary statistics were analyzed to describe the distribution of the variables and gender of the participants. Pearson correlation was used to assess if depression scores and stigma were related both pre and post-intervention. Third, a simple regression was used to assess if the level of stigma can be used to predict the depression level of the participants. Lastly, a paired sample T-test was carried out to assess if there was any significant difference for each of the scores after the intervention process. Ideally, the paired T-test assessed if there was a significant decrease in both HIV stigma and depression after the CFT intervention. Statistically, the paired sample T-test determines if the mean difference between two scores is zero and it is applicable in this study since the scores were extracted from the same participants, indicating that, if the reported mean for the post-intervention scores is lower than that of the pre-intervention scores, the study would conclude that CFT is effective.

Descriptive data analysis

Gender

Table 1: Gender descriptive statistics

gender
	Frequency	Percent	Valid Percent	Cumulative Percent
Valid	female	12	40.0	40.0	40.0
male	18	60.0	60.0	100.0
Total	30	100.0	100.0

            The study sample participants considered both female and male HIV-infected persons. The sample size was n = 30, where 40% were females and 60% were males. The visual presentation of gender is shown below in a pie chart.

Fig. 1 Pie Chart

HIV stigma count descriptive statistics

Table 2: HIV stigma pre and post score statistics

Descriptive Statistics
	N	Range	Minimum	Maximum	Sum	Mean	SD	Variance
HIVcount	30	11.00	19.00	30.00	736.00	24.5333	2.93297	8.602
HIVFollow	30	13.00	17.00	30.00	670.00	22.3333	2.94001	8.644
Valid N (listwise)	30

            From Table 2, it is clear that the pre-CFT stigma count had a mean score of 24.5333 with a SD of 2.9329. The lowest stigma score reported was 19 while the maximum score was 30.00. After subjecting the subjects to the CFT intervention, the mean reported score for the stigma as 22.333 with a SD of 2.94 with the minimum score reported as 13 while the maximum stigma score was 17. Ideally, based on the mean it is seen that the mean stigma dropped after subjecting the participants to the CFT intervention. However, this is not sufficient to conclude the intervention was successful and effective,

Depression count descriptive statistics

Table 3: Depression scores statistics

Descriptive Statistics
	N	Minimum	Maximum	Mean	Std. Deviation	Variance
DepCount	30	11.00	37.00	24.1667	7.98742	63.799
DepFollow	30	8.00	38.00	23.3333	7.88859	62.230
Valid N (listwise)	30

            The minimum depression score reported before the CFT intervention was 11 while the maximum score was 37 (M = 24.1667, SD = 7.9874). After the CFT intervention the minimum sore was reported as 8 with a maximum score of 38 (M = 23.333, SD = 7.8886). Again, there is a slight drop in the mean scores for depression after administering the CFT sessions to these HIV victims.

Quantitative data analysis

Correlation analysis

Table 4: Correlation between stigma and depression

Correlations
	HIVcount	DepCount
HIVcount	Pearson Correlation	1	.327
Sig. (2-tailed)		.078
N	30	30
DepCount	Pearson Correlation	.327	1
Sig. (2-tailed)	.078
N	30	30

There is a weak positive correlation between depression and stigma scores before the CFT intervention (R=0.327, p = 0.078). Such an aspect tells that there is no statistical relationship between the two variables – indicating that none of the variable’s scores can be used to predict the other. Therefore, this analysis rejects the hypothesis three (H3) for this study that hypothesized a correlation between the two variables. There is no significant correlation between the two variables (P > 0.05).

Table 5: Post-CFT Correlation Analysis

Correlations
	HIVFollow	DepFollow
HIVFollow	Pearson Correlation	1	-.020
Sig. (2-tailed)		.917
N	30	30
DepFollow	Pearson Correlation	-.020	1
Sig. (2-tailed)	.917
N	30	30

            On the other hand, the pre and post-depression scores have a weak negative correlation which is not statistically significant at 0.05 significance level (R = -0.02, p = 0.917). Therefore, it can be concluded that scores for pre-CFT depression cannot be used to predict the post-CFT depression scores.

Paired sample Correlations

Table 6: Pre and post scores for stigma

Correlations
	HIVcount	HIVFollow
HIVcount	Pearson Correlation	1	.646**
Sig. (2-tailed)		.000
N	30	30
HIVFollow	Pearson Correlation	.646**	1
Sig. (2-tailed)	.000
N	30	30
**. Correlation is significant at the 0.01 level (2-tailed).

There is a strong positive correlation between the pre and post-stigma scores which is statistically significant at 5% significance level (R = 0.646, p = 0.000). Such an aspect tells that pre-stigma scores may be used to predict the post-stigma scores.

Table 7: Pre and post-depression correlations

Correlations
	DepCount	DepFollow
DepCount	Pearson Correlation	1	.847**
Sig. (2-tailed)		.000
N	30	30
DepFollow	Pearson Correlation	.847**	1
Sig. (2-tailed)	.000
N	30	30
**. Correlation is significant at the 0.01 level (2-tailed).

There is a very strong correlation between the pre and post-depression scores indicating that either of the scores can be used to predict the other scores (R = 0.847, p = 0.000) at 5% significance level.

T-test analysis

Table 8: T-test results

Paired Samples Test
	Paired Differences	t	df	Sig. (2-tailed)
Mean	Std. Deviation	Std. Error Mean	95% Confidence Interval of the Difference
Lower	Upper
Pair 1	HIVcount – HIVFollow	2.20000	2.46912	.45080	1.27802	3.12198	4.880	29	.000
Pair 2	DepCount – DepFollow	.83333	4.38715	.80098	-.80486	2.47152	1.040	29	.307

            The above T-test findings aimed to identify if there was a significant reduction in the mean scores for stigma and depression scores after a successful CFT intervention. Considering, HIV stigma, the mean difference was 2.2 with the post stigma scores mean being lower than the pre-CFT scores. In other words, the study assessed if the pairwise mean was different from zero.  There was a significant reduction in stigma levels after a successful administration of CFT intervention among the HIV infected individuals (t=4.880, p = 0.000). Such statistics shows that the reduction in stigma levels did not occur by chance; rather it occurred as a result of the CFT intervention.

Based on this, the analysis supports the H1 of the study which hypothesized that CFT reduces stigmatization levels among the HIV-infected individuals. On the other hand, there was no statistically significant difference between pre and post-depression scores (t=1.040, p = 0.307). Such an aspect tells that any changes in the depression mean scores for the HIV infected individuals appeared by chance and not from the CFT effect. Therefore, this analysis rejects the H2 which hypothesized a reduction in depression following administering CFT intervention programme.

Discussion

            The study supports H1 and rejects H2 and H3. Ideally, there is evidence that the use of CFT reduces HIV stigmatization among the infected individuals. The study also found that, CFT does not reduce depression and that stigma and depression are not related for the individuals living with HIV. Ideally, the study findings on the effect of CFT on reducing stigma concurred with the studies by Gilbert (2009), Bos et al. (2008), and Gilbert and Proctor (2009) which found a significant relationship between the use of CFT and reduced stigma among the HIV-infected individuals. Ideally, the CFT approach tries to resolve the conflicts and threats within human behavior – and this tells that through-out the CFT sessions the participants went through a soothing, self-realization and acceptance period that made them alleviate the fear and shame that they had regarding their societal environment. Ideally, such soothing allows individuals resolve their mental, social and psychological conflicts as they negotiate with their health status (Gilbert, 2009).

Additionally, it tells that the CFT sessions successfully tried to elicit self-awareness of the health status of the study participants making them accommodate and avoid situations that made them angry or avoid situations that drove in anxiety, hypomania and depersonalization, while they adopted skills to eliminate shame, self-criticism, and avoid isolated areas. The study found that there is no relationship between CFT intervention and reduced depression as claimed by Gilbert and Proctor (2006). One of the main aspects that may have attributed to this difference is the scales used to measure depression – the shame and stress. According to Brown et al. (2003) this is possible because, different societies embrace stress, shame and depression differently, and this indicates that shame and stress were not appropriate scales to measure depression. A more advanced scale to measure depression stands a chance to yield different results. Also, the fact that different societies perceive HIV stigma and depression differently, it leaves a room for this discrepancy.

Further, a more standard or conventional scale for assessing depression stands a better chance to produce more meaningful results. Through these social and culture-based differences in the perception and definition of HIV stigma and depression, there was the possibility that the two scores (for the stigma and depression) were not related, contrary to what Gilbert (2009) argued. A claimed earlier by Bos et al. (2008) and McDowell and Serovich (2007), each society perceives HIV stigma from their own angle – and the fact that Gilbert (2009) found a significant relationship between stigma and depression – the discrepancies in societal perceptions can be held responsible for the discrepancies found between this study and the existing literature. On a different note, the paired correlations between the pre and post scores for stigma may be an indicator for the effectiveness of the CFT intervention. There was no inconsistency in data and outliers identified for the scores collected – and this translates that the data findings are reliable.

Theoretical and practical implications

            Theoretically, the study leaves a room for doing extra research to identify a more effective intervention strategy that can minimize both stigma and depression among the HIV stigmatized individuals. The fact that CFT has been suggested to reduce stigma and depression, this study does not support the suggestion by Gilbert (2006). Further, the study offers a good empirical literature on the use of CFT on reducing stigma levels among the vulnerable HIV infected individuals. More interventions may be focused to compare with the findings in this study. Practically, the use of CFT can be adopted as a home remedy for reducing stigma among the HIV infected individuals; it is cheap, economical, and effective as it considers the main pillars affecting human cognitive functioning to sooth and negotiates the aggression associated with discrimination. Still, the government may establish public facilities that offer CFT sessions freely to support the people living with HIV, manage their social lives well and eliminate issues related to social discrimination.

Recommendations for future research

Future research on this topic may consider increasing the sample size and re-examine the relationship between stigma, depression and CFT intervention. A larger sample size would increase the generalizability of the study findings. Also, using a probabilistic sampling approach would offer a more random and reliable study results – because this study adopted snowballing sampling. Lastly, using a stronger statistical approach such as the ANOVA method, is suggested to identify if other factors such as gender had influence on the scores reported by the participants

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