The ineffectiveness of current approaches on educating the severely mentally ill about sexual health and a proposal for change – Ivy Zang
Few formal sexual health programs exist for the mentally ill. While much research has been done to demonstrate the need for such programs, little research has been done to determine the proper way to construct and deliver a program. The approaches documented in literature rely upon traditional public health models, which erroneously assume the individual to be rational and impervious to outside forces. The studied interventions also fail to discuss the unique needs of the mentally ill. An ecological approach incorporating predictable irrationality is necessary to minimize risky sexual behaviors among mentally ill adults.
Evidence of need for intervention.
Severe and persistent mentally ill (SPMI) adults experience major functional disabilities and undergo recurrent relapses requiring periodic stabilization and hospitalization (1). Since 1955, SPMI individuals have been deinstitutionalized from state hospitals into the community. This change in treatment has yielded a need to develop and improve sexual education programs for the mentally ill (2).
Historically, the SPMI were viewed as asexual, a view that stemmed from forced sterilizations and institutionalization. However, in a recent study of 400 SPMI adult patients of a outpatient clinic, 94% reported engaging in sexual intercourse (3). In addition to being sexually active, mentally ill adults often engage in high risk-sexual behaviors. Ten percent of the sexually active SPMI individuals in the study reported exchanging sex for housing, drugs, or money. More than half reported not using a condom in any of their last five sexual acts (3). Women with SPMI have more lifetime sexual partners than women without mental illness (4). Schizophrenic women have the same number of pregnancies as women without mental illness, but a greater percentage of them are unplanned and unwanted. Despite not wanting to become pregnant, sexually active women with schizophrenia often do not use birth control and lack basic knowledge of contraception (5). In a study of males with SPMI, nearly one-third reported engaging in sexual intercourse with a partner that they knew for less than twenty-four hours (6). HIV rates in the mentally ill are estimated between 5% and 7%, in contrast to 0.6% in the rest of the population, and 30% to 60% of SPMI individuals are at elevated risk for contracting HIV (7).
Critique 1.
The public health community fails to address the issue of high risk sexual behaviors among the mentally ill as sexual education programs targeting this population are few and far between. The Royal College of Nurses describes the sexual health care and education of people with SPMI as “inconsistent and inadequate” (8). This may be due to concerns about confidentiality, competency, and treatment responsibility (9). Only 38% of psychiatric hospitals have policies regarding sex relations. Only 58% of those policies include statements about contraception or sex education (10). Many facilities are opposed to offering sexual education programs, anticipating a resulting increase in sexually inappropriate behaviors on the unit, even though literature shows that most clients can tolerate exposure to sexually charged material without de-compensation or acting-out sexually (11).
This resistance to sexual health education stems from a “lack of knowledge about sexuality, conservative attitudes, and anxiety when discussing sexual issues” among mental health providers (12). In a study of British mental health home care nurses, the nurses felt that 41% of their patients would be comfortable discussing sexual issues with them, while only 50% of nurses felt comfortable discussing sexual issues with their patients (13). Although most mental health professionals believe that their patients will present the subject if necessary, most SPMI individual are not prepared to defy social and professional norms to bring up sexual health issues (14). Most adults with SPMI want to be informed about the social and environmental effects of illness on their sexuality and they want their providers to initiate this discussion (12).
Critique 2.
Where formal sexual education programs do exist, they are based on the framework of traditional public health models, most notably the Health Belief Model (HBM) and the Theory of Planned Behavior (TBP), which also predominate sex education programs for the non-mentally ill. Most sexual education programs investigated in the literature attempt to educate while promoting behavioral change. Most of the studies use small group interventions that rely on cognitive factors, behavioral skill factors, and external consequences in an attempt to change behaviors (15). Although some of the studies show reductions in risk behaviors, these effects are time-limited and repetition is necessary to maintain even short-term behavioral gains. Only a few studies examine actual behavioral change at the end of the intervention and even fewer follow-up with patients to determine the long term gains. As participation in the studies was voluntary, the examined samples were comprised of highly-motivated volunteers (7).
A study of 35 group home residents involved three l-hour educational sessions, focusing on AIDS, risk behaviors, risk reduction, and condom use. Pre and post-intervention questionnaires assessed knowledge and did not reveal a change (16).
A three-session invention at an outpatient mental health clinic in Boston focused on sexual education, AIDS information, and condom use training. The study showed increased knowledge amongst participants, but did not assess behavioral change (17).
A study of 52 participants of a community support program in Milwaukee involved four 90-minute sessions focusing on HIV education, sexual assertiveness, negotiation skills, condom use, risk reduction and problem-solving. At a one-month follow-up, the rates of unprotected intercourse declined by 50% and the proportion of condom protected intercourse occasions increased from 18% to 53%. However, long-term changes were not assessed (18).
In a study of patients at a mental illness community center, six biweekly sessions focused on the transmission of STDs, HIV/AIDs myths, perceptions of the threat of infection, risky behaviors proposed by partners, screening sexual partners, and barrier contraception. Participants’ HIV information scores increased from 66% of questions correct during pre-intervention to 75% correct at post-intervention and remained at 75% correct at 1 month follow up. However, there was no significant change in participants’ attitudes towards condom use and the participants appraised their risk of infection as relatively low both before and after the intervention (19).
A study of 189 SPMI individuals at an outpatient clinic involved a 7-session small group intervention that focused on risk reduction, condom use, handling personal triggers for risky sexual situations, problem-solving, personalized plans to implement personal behavior change, communication, negotiation, and assertiveness. Men who attended the intervention only showed improvement in knowledge, while female participants changed their attitudes toward sexual behavior and increased their percentage of condom-protected vaginal intercourse occasions from 20% to 47%. This gain amongst females decreased substantially at the 12-month follow-up (20).
In a study of 97 chronically psychotic men with co-existing substance disorders living in New York City homeless shelters, subjects were randomly assigned to either a brief AIDS education or a 15-session risk reduction intervention incorporating condom use, communication skills, and risk management of situations known to be encountered by homeless men, including casual sexual contacts, sexual behavior while intoxicated, and same-sex contacts. Outcome analyses revealed greater reductions in unprotected intercourse and increases in condom use among participants in the intervention than the control group. Behavior changes remained observable through a 15-month follow-up, but weakened over time (21). Although this 15-session program proved effective, programs of this length are often not economically and logistically feasible.
In addition to the limited ability of the interventions noted above to elicit substantial behavior change, the health promotion literature has suggested many limitations to the traditional health care models. Many studies testing HBM and TPB-based interventions yield results that are inconsistent with the models’ constructs (22). Both models focus on individual decisions and do not address the multi-level ecological causes of behavior addressed in the next section of this paper. The basic assumption behind the models is that the individual has the ability to make rational and cognitive-based decisions; however, this inability is inherent in the diagnosis of mental illness (23). These models assume that health behaviors are simply based on attitudes and beliefs, failing to address the many other factors that influence health decisions (24). Psychosis and delusional thought amongst the SPMI may alter perception of real world events, but the mentally ill do not live in a vacuum. Even subtle changes in context and environment can drastically influence an individual’s health behavior decisions. For instance, the increase in motivation to have sex produced by sexual arousal is proven to decrease the relative importance of protecting oneself from unwanted pregnancy and STDs (25). An individual who has strong intentions to always wear condoms when engaging in intercourse with a new partner may spontaneously engage in unprotected sex if he is sexually aroused and condoms are not readily available. In addition, an individual with bipolar disorder may typically lead a monogamous lifestyle, but may engage in unprotected sexual encounters with multiple partners during an acute manic episode. By assuming that behavior is static, the models do not take into account the spontaneous actions that characterize most of human behavior (24). Lastly, these models assume that people value health highly (24). Health is a value that has a specific place in each individual’s value system, therefore the relative importance of health and its degree of influence on behavior varies among persons (26). Based on a randomly distributed survey of core values and preventative health behaviors, researchers determined happiness, pleasure, salvation, and a comfortable life to be the strongest core values for individuals who do not engage in preventative health behaviors. Those who do not engage health preventative behaviors rank health as a lesser core value than world piece and inner harmony (27).
Despite the obvious flaws with the models, health care practitioners continue to apply them to interventions. As these traditional health models serve as the basis for nursing and public health education, mental health professionals often rely upon these models when planning interventions (28).
Critique 3.
Sexual health interventions present in the current literature are based on generic cognitive-behavioral intervention models and have not been “specifically tailored to the special needs, risk situational circumstances, and change barriers likely to be encountered by the severely mentally ill” (7). The mentally ill face unique issues inherent in their diagnoses, their treatment, and the social and political consequences of their disease. The SPMI are unable to weigh costs against benefits when multiple ecological forces are in fact driving their decisions.
Although SPMI individuals are less sexually active than the rest of the population, those who are sexually active often engage in higher risk sexual behaviors. These high risk behaviors may be derived from poor interpersonal functioning, impaired psychosocial development, cognitive deficits, poor judgment, impaired decision making, labile mood, and impulsiveness leading to high levels of sexual vulnerability. Information processing deficits related to severe mental illness may inhibit people with SPMI from benefiting from preventive interventions that are based on traditional behavioral change principles (29). Hyper-sexuality, aggression, deep dependency needs, efforts to compensate for feelings of inferiority, response to auditory hallucinations, loneliness, and boredom may also be motivating factors for high risk sexual behaviors (30). The SPMI often have difficulty forming and sustaining stable sexual and social relationships. Sexual encounters amongst the mentally ill usually occur within casual relationships and some are “characterized by naiveté, abuse, and exploitation” (7).
Individuals with SPMI often have low levels of sexual health information, lack basic vocabulary of sexual terms, and have many misconceptions about sexual anatomy and physiology (5). In a focus group of rural women with SPMI, many held false beliefs, knew little about contraception and general women’s health, and did not receive regular gynecologic examinations (31).
The SPMI tend to be unemployed, impoverished, and overrepresented among the homeless, the incarcerated, and other disadvantaged groups at higher risk for STDs (9). Due to socioeconomic disadvantages, the mentally ill may also have tenuous and transient living arrangements and are often disproportionately concentrated in inner-city neighborhoods with higher rates of drug use, STDs, and HIV infections (7). Fifty percent of the mentally ill suffer from a dual diagnosis of chemical dependency which has synergistic implications for increased high risk sexual practices. Patterns of exchanging sex for drugs, lodging, and basic survival needs are not uncommon (7). Many SPMI individuals lack resources to purchase condoms and oral contraceptives (9).
The general population often stigmatizes the SPMI, attributing mental illness to sin or lack of character or willpower (33). The media transmits multiple misconceptions about the mentally ill, including that they are homicidal maniacs or rebellious free spirits. This stigmatization decreases their self-esteem and hinders their ability to make friends and sustain social relationships, which may augment risky sexual behaviors (34). The SPMI lack political power and strong advocates, inhibiting change on community and governmental levels (9). Although organizations like the National Alliance of Mental Illness (NAMI) serve as powerful community resources, their legislative lobbying efforts are limited due to insufficient monetary funds (35).
Intervention.
Since multiple causes contribute to high risk sexual behaviors among individuals with SPMI, including the illness itself, an ecological approach is essential. Enhanced prevention strategies must extend beyond individually focused cognitive-behavioral interventions and address the broader psychosocial context in which risk behaviors occur (36). As behavior is affected by multiple levels of influence, interventions must be planned at an intrapersonal, organizational, community, and public policy levels (37).
The ecological model encourages educational programs, support groups, and counseling at the intrapersonal level (37). However, at the intrapersonal level, the ecological model does support the use of the traditional health promotion models determined earlier in this paper to be incapable of changing complex human behavior. This is an evident limitation of the ecological model; however, this level of the ecological model can be adapted with theories of predictable irrationality, most notably framing and ownership. Successful public health programs utilize “potentially effective combinations of established theory (38).
At the intrapersonal level, a sexual health program should be provided to patients during inpatient hospitalizations as most SPMI individuals have multiple hospitalizations over a lifetime, allowing for a broad target audience and multiple reinforcement sessions. On the inpatient units, staff nurses or mental health workers should lead a sexual health group multiple times during the week for the patients nearing discharge, as the ability to process information resumes when the acute phase of illness subsides (11). Groups should be informal with the ultimate goal of empowering the patients, not reprimanding or frightening them (39). To account for the cognitive impairment of many SPMI individuals, the group must start with a concrete discussion of sexuality, including reproductive anatomy and physiology, the transmission of disease, and contraception (15). During the educational session, instead of framing AIDS and STDs as severe and detrimental and trying to evoke fear as would be encouraged by the HBM, educators should reframe them as diseases preventable and controllable through communication with partners and avoidance of sexual risk (15).
Practicing condom use is a vital component of this intervention (11). When marketing condoms to male patients, the educators should, in addition to advertising the safe-sex benefits, reframe the action as a gain or a positive experience by reinforcing that condoms extend sexual performance and postpone ejaculation. By presenting the message as sex-positive and making condoms fun and erotic, the educator can reframe an individual’s perception, easing the process of seceding ownership of the high risk sexual behavior and increasing the likelihood of condoms use. When educating female patients on how to deal with male partners who refuse to wear condoms, the educator should describe the female condom as a tool capable of empowering women. The educator should reinforce the idea that the female condom is just as effective as the male condom, taking away the man’s power in the sexual relationship. When the female condom is reframed as a gain—a symbol of empowerment—safer sexual practices may emerge. Patients should be instructed to carry condoms with them at all times in the community, as people often underestimate their likelihood of having sex when in non-aroused states and will not make an effort to find condoms in an aroused state (25). Masturbation should also be discussed as a safe alternative to sexual intercourse. Traditionally, psychiatric units have had strict “no masturbation” policies and punish patients caught masturbating. This brings shame and embarrassment to the act. Masturbation should be reframed as a gain: a safe outlet for channeling normal sexual drives when done privately (30).
Additionally at the intrapersonal level, psychiatric facilities should employ women’s health nurse practitioners to counsel female patients of childbearing age about contraceptive options before discharge as SPMI women often have difficulties using community facilities for family planning (41). Mental health facilities are also more informed than family planning clinics as to how mental illness affects informed consent for family planning (42). On the day prior to discharge, the nurse practitioner should discuss the available contraceptive options. Injectable hormonal contraception, depo-provera, is the most appropriate contraceptive choice for use in this population. It lasts for three months and does not have significant clinical interactions with any anti-psychotic medications (5). Similar to the framing of the female condom, the nurse practitioner should frame the injectable contraceptive as a gain. It can be framed in terms of freedom and power: freedom from pill taking and a newfound power in the sexual relationship. The majority of patients who receive family planning counseling and are started on contraceptives in psychiatric hospitals continue contraception use after discharge and follow up with providers (5). As the SPMI often have difficulty utilizing community resources for contraception, have insufficient funds to purchase contraception, and underestimate their need to have contraception readily available, nurses should give condoms to both male and female patients at every discharge along with the discharge medication list.
Psychiatric facilities can utilize changes in organizational characteristics to support the behavioral changes of its patients. This includes changes in institutional commitment, policy and procedures, actions of staff members, and learning opportunities (37). As long as mental health professionals do not feel comfortable discussing sexual issues with their patients, the diffusion of comprehensive sexual health programs across psychiatric facilities will be unsuccessful (13), (14). In order to increase the comfort of mental health professionals, psychiatric facilities should provide continuing education programs that encourage providers to introspectively examine their attitudes and sensitivities to various aspects of sexuality in order to become more comfortable sexual issues (42), (43).
For program diffusion to be successful and behavioral change among SPMI individuals to be possible, the policies and corporate culture of psychiatric facilities must change. Policies must not rely on the personal judgment of staff, but should be sensible, sensitive, and validate the sexual rights of the mentally ill. Formal guidelines for sexual education, birth control, and capacity to consent must be devised (44). Organizational attitudes towards sexual practices must change along with new policies; staff members must not allow personal biases, fears, moral beliefs, and stereotypical beliefs to obstruct the implementation of new policies (45).
Community level interventions use existing social networks as mediating structures to influence community awareness (37). Depression and Bipolar Support Alliance (DBSA) is the leading patient-directed national organization for individuals with SPMI and has a strong social network (46). Through a system of peer-run support groups, DBSA educates SPMI individuals on the impact and management of mental illness. The organization has been a success, as 86% of its members remain compliant with their psychiatric medications (46). This existing social network can be used to increase sexual knowledge amongst the mentally ill and encourage members in engage in protective health behaviors. As DBSA relies on peer-to-peer communication, the sexual health message delivered would be one of considerate concern from a friend, instead of a provider’s paternalistic educational message. DBSA creates a community of trust, reciprocal support, and positive self identity where healthy behavioral changes can occur (47). Peer-mediated sexual health interventions have proven to effectively reduce risky sexual behaviors in other high-risk populations and may serve as an effective tool in eliciting behavioral change amongst the mentally ill .
Regulatory policies are essential in protecting the health of the community (37).
Local departments of mental health (DMH) should develop policies to control many of the external factors that lead to impulsive sexual behaviors amongst the mentally ill. Local DMHs should increase their funding of intensive case management services, which have proven to positively affect functional level and quality of life, while preventing exacerbation of illness (48). With an increase of funding, more case managers could be hired and individual case managers could spend more time with their clients ensuring medication compliance, temperance, and stable living situations to decrease likelihood of risky sexual practices. Case managers can work with the local Social Security offices to appropriately budget their clients’ finances and prevent the exchange of sex for lodging and food. DMH should allocate increased funds for supportive housing. Supportive housing gives SPMI individuals that are particularly prone to sexual exploitation or risky sexual practices a unique opportunity to learn about and to practice safer sexual activities in a supportive context (49). DMH should expand substance abuse services for the mentally ill as substance use is the strongest correlate of high risk sexual practices in this population (50).
Defense of Intervention 1.
The ecological model is an appropriate basis for the development of a sexual health intervention for the mentally ill as it encompasses the multiple physical and social factors that influence the healthfulness of a situation and the well being of its participants. Based on the model, efforts to promote health should emphasize the advantages of multilevel interventions that combine behavioral and environmental components, like facilitating psycho-educational group interventions while changing the professional culture of psychiatric units (51). The ecological model focuses on population-level prevention and includes individual level interventions aimed at persons with certain risk factors, interventions mediated through important organizational channels, and public policy interventions that redirect societal counter forces (52). The proposed intervention operates on all of those levels. Effective interventions create therapeutic micro-environments that facilitate and reinforce desired health behaviors, instead “arm[ing] patients with behavioral control strategies and then send[ing] them off into society to maintain their treatment gains, leaving them at the mercy of a social system that encourages, rewards, and profits from high risk behaviors” (52). This is done by beginning the intervention in the hospital with groups and reproductive counseling and continuing the intervention in the community with case management and supportive living services. Extensive research has been done using the ecological model as a framework for understanding behaviors and despite the fact that current evidence supports multi-level interventions, only a relative few number of studies involving the ecological model as a framework for intervention are published in the health promotion literature (53), (54). Many published papers discuss successful interventions that utilize the ecological model, but do not test the intervention in a formal study (55), (56). Despite this dearth of research, a multi-level intervention will yield greater benefit to SPMI individuals than a sole intrapersonal level intervention.
Defense of Intervention 2.
Frames are an effective way of promoting protective sexual behaviors at the intrapersonal level, as health care promoters can manipulate frames to alter the judgments and opinions of the targeted population. A frame is a way of packaging and positioning an issue to convey a certain meaning. By packaging an issue in a more desirable way, health care promoters can change attitudes towards health behaviors and the likelihood of behavioral change (57). A meta-analysis of framing experiments in relation to health promotion proved framing to be a successful tool for interventions that involving safer sex (58). People are sensitive to whether an intervention is framed in terms of its associated costs (loss frame) or in terms of its associated benefits (gain frame), even when the two frames describe the same situation (59). Gain frame interventions are more persuasive than fear-inducing frames when it comes to implementing preventative behaviors, like condom use (60), (61). Threat or fear appeals advocated by traditional health models are ineffective in sexual health interventions as many people fear STDs or HIV without feeling that they are personally vulnerable and will downplay their own personal risk in comparison to risks of others (62).
Messages that are framed in unexpected ways or do not match participants’ experiences or concerns can be more effective as they lead to greater message processing (63). Instead of presenting a message of sexually transmitted disease and health effects, the proposed intervention delivers an unexpected sex positive message of freedom and empowerment. By changing the definition of the problem, it is thus possible to change the response. Although health is a core value for some, successful public health interventions must utilize frames that appeal to the same compelling core values being tapped into by the opposition (57). In a state of arousal, sexual pleasure is a much more compelling core value than health. By reframing condom use as a way to improve sexual activity, instead of a way to prevent disease, a more compelling core value is utilized.
Defense of Intervention 3.
As individuals quickly come to own their health behaviors, behavioral change is dependent upon their ability to give those behaviors up. When a health promoter is able to offer the individual a new behavior coupled with a compelling core value, behavioral change may be possible. Psychological ownership is the state in which individuals feel that a target of ownership is theirs. A target of ownership may be an object or a non-physical entity, such as ideas, words, or behaviors. The cognitive state of ownership is tied with emotional and physical sensations, including the rise of pleasure, efficacy, and self-identity. This leads to an intimate relationship between self and possessions; the entity may become part of the extended self (64). People tend to place a larger value on an entity when it is in their possession and resist to part with their possessions as they allow people to keep to the status quo. Over time, individuals come to own their health behaviors, thus their health behaviors become an extended part of themselves and are difficult to give up (65). As duration of ownership increases, the owned behavior increases in value (66). Despite the unattractiveness of risky sexual behaviors, owners still see parting with them as a loss (65). As people are “more reluctant to give up an attainment than they are eager to acquire it,” they must be persuaded with something that they value even more (66). As discussed earlier, pleasure has shown to be the most valuable of possessions for those who do not engage in preventative health behaviors, so for a person to give up risky practices, he or she must be offered pleasure in return (27). For men to give up sex without a condom, they must be given the pleasure of improved sexual performance. For women to give up passivity in sexual interactions, they must be given pleasure of empowerment.
Conclusion.
“Sexual activity among the [mentally ill] is a reality and one with which we must deal and not put our heads in the sand” (10). The mentally ill are sexually active and do engage in high risk sexual activities due to lack of education, the complexities of mental illness, and social and behavioral factors. Due to attitudes and beliefs of health care professionals, the sexual practices of the mentally ill have long been unaddressed. High-risk sexual activities are a reality that traditional models of health promotion cannot change. An ecological approach along with the principles of framing and ownership could serve as an effective way of dealing with sexual activity amongst this vulnerable population.
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Evidence of need for intervention.
Severe and persistent mentally ill (SPMI) adults experience major functional disabilities and undergo recurrent relapses requiring periodic stabilization and hospitalization (1). Since 1955, SPMI individuals have been deinstitutionalized from state hospitals into the community. This change in treatment has yielded a need to develop and improve sexual education programs for the mentally ill (2).
Historically, the SPMI were viewed as asexual, a view that stemmed from forced sterilizations and institutionalization. However, in a recent study of 400 SPMI adult patients of a outpatient clinic, 94% reported engaging in sexual intercourse (3). In addition to being sexually active, mentally ill adults often engage in high risk-sexual behaviors. Ten percent of the sexually active SPMI individuals in the study reported exchanging sex for housing, drugs, or money. More than half reported not using a condom in any of their last five sexual acts (3). Women with SPMI have more lifetime sexual partners than women without mental illness (4). Schizophrenic women have the same number of pregnancies as women without mental illness, but a greater percentage of them are unplanned and unwanted. Despite not wanting to become pregnant, sexually active women with schizophrenia often do not use birth control and lack basic knowledge of contraception (5). In a study of males with SPMI, nearly one-third reported engaging in sexual intercourse with a partner that they knew for less than twenty-four hours (6). HIV rates in the mentally ill are estimated between 5% and 7%, in contrast to 0.6% in the rest of the population, and 30% to 60% of SPMI individuals are at elevated risk for contracting HIV (7).
Critique 1.
The public health community fails to address the issue of high risk sexual behaviors among the mentally ill as sexual education programs targeting this population are few and far between. The Royal College of Nurses describes the sexual health care and education of people with SPMI as “inconsistent and inadequate” (8). This may be due to concerns about confidentiality, competency, and treatment responsibility (9). Only 38% of psychiatric hospitals have policies regarding sex relations. Only 58% of those policies include statements about contraception or sex education (10). Many facilities are opposed to offering sexual education programs, anticipating a resulting increase in sexually inappropriate behaviors on the unit, even though literature shows that most clients can tolerate exposure to sexually charged material without de-compensation or acting-out sexually (11).
This resistance to sexual health education stems from a “lack of knowledge about sexuality, conservative attitudes, and anxiety when discussing sexual issues” among mental health providers (12). In a study of British mental health home care nurses, the nurses felt that 41% of their patients would be comfortable discussing sexual issues with them, while only 50% of nurses felt comfortable discussing sexual issues with their patients (13). Although most mental health professionals believe that their patients will present the subject if necessary, most SPMI individual are not prepared to defy social and professional norms to bring up sexual health issues (14). Most adults with SPMI want to be informed about the social and environmental effects of illness on their sexuality and they want their providers to initiate this discussion (12).
Critique 2.
Where formal sexual education programs do exist, they are based on the framework of traditional public health models, most notably the Health Belief Model (HBM) and the Theory of Planned Behavior (TBP), which also predominate sex education programs for the non-mentally ill. Most sexual education programs investigated in the literature attempt to educate while promoting behavioral change. Most of the studies use small group interventions that rely on cognitive factors, behavioral skill factors, and external consequences in an attempt to change behaviors (15). Although some of the studies show reductions in risk behaviors, these effects are time-limited and repetition is necessary to maintain even short-term behavioral gains. Only a few studies examine actual behavioral change at the end of the intervention and even fewer follow-up with patients to determine the long term gains. As participation in the studies was voluntary, the examined samples were comprised of highly-motivated volunteers (7).
A study of 35 group home residents involved three l-hour educational sessions, focusing on AIDS, risk behaviors, risk reduction, and condom use. Pre and post-intervention questionnaires assessed knowledge and did not reveal a change (16).
A three-session invention at an outpatient mental health clinic in Boston focused on sexual education, AIDS information, and condom use training. The study showed increased knowledge amongst participants, but did not assess behavioral change (17).
A study of 52 participants of a community support program in Milwaukee involved four 90-minute sessions focusing on HIV education, sexual assertiveness, negotiation skills, condom use, risk reduction and problem-solving. At a one-month follow-up, the rates of unprotected intercourse declined by 50% and the proportion of condom protected intercourse occasions increased from 18% to 53%. However, long-term changes were not assessed (18).
In a study of patients at a mental illness community center, six biweekly sessions focused on the transmission of STDs, HIV/AIDs myths, perceptions of the threat of infection, risky behaviors proposed by partners, screening sexual partners, and barrier contraception. Participants’ HIV information scores increased from 66% of questions correct during pre-intervention to 75% correct at post-intervention and remained at 75% correct at 1 month follow up. However, there was no significant change in participants’ attitudes towards condom use and the participants appraised their risk of infection as relatively low both before and after the intervention (19).
A study of 189 SPMI individuals at an outpatient clinic involved a 7-session small group intervention that focused on risk reduction, condom use, handling personal triggers for risky sexual situations, problem-solving, personalized plans to implement personal behavior change, communication, negotiation, and assertiveness. Men who attended the intervention only showed improvement in knowledge, while female participants changed their attitudes toward sexual behavior and increased their percentage of condom-protected vaginal intercourse occasions from 20% to 47%. This gain amongst females decreased substantially at the 12-month follow-up (20).
In a study of 97 chronically psychotic men with co-existing substance disorders living in New York City homeless shelters, subjects were randomly assigned to either a brief AIDS education or a 15-session risk reduction intervention incorporating condom use, communication skills, and risk management of situations known to be encountered by homeless men, including casual sexual contacts, sexual behavior while intoxicated, and same-sex contacts. Outcome analyses revealed greater reductions in unprotected intercourse and increases in condom use among participants in the intervention than the control group. Behavior changes remained observable through a 15-month follow-up, but weakened over time (21). Although this 15-session program proved effective, programs of this length are often not economically and logistically feasible.
In addition to the limited ability of the interventions noted above to elicit substantial behavior change, the health promotion literature has suggested many limitations to the traditional health care models. Many studies testing HBM and TPB-based interventions yield results that are inconsistent with the models’ constructs (22). Both models focus on individual decisions and do not address the multi-level ecological causes of behavior addressed in the next section of this paper. The basic assumption behind the models is that the individual has the ability to make rational and cognitive-based decisions; however, this inability is inherent in the diagnosis of mental illness (23). These models assume that health behaviors are simply based on attitudes and beliefs, failing to address the many other factors that influence health decisions (24). Psychosis and delusional thought amongst the SPMI may alter perception of real world events, but the mentally ill do not live in a vacuum. Even subtle changes in context and environment can drastically influence an individual’s health behavior decisions. For instance, the increase in motivation to have sex produced by sexual arousal is proven to decrease the relative importance of protecting oneself from unwanted pregnancy and STDs (25). An individual who has strong intentions to always wear condoms when engaging in intercourse with a new partner may spontaneously engage in unprotected sex if he is sexually aroused and condoms are not readily available. In addition, an individual with bipolar disorder may typically lead a monogamous lifestyle, but may engage in unprotected sexual encounters with multiple partners during an acute manic episode. By assuming that behavior is static, the models do not take into account the spontaneous actions that characterize most of human behavior (24). Lastly, these models assume that people value health highly (24). Health is a value that has a specific place in each individual’s value system, therefore the relative importance of health and its degree of influence on behavior varies among persons (26). Based on a randomly distributed survey of core values and preventative health behaviors, researchers determined happiness, pleasure, salvation, and a comfortable life to be the strongest core values for individuals who do not engage in preventative health behaviors. Those who do not engage health preventative behaviors rank health as a lesser core value than world piece and inner harmony (27).
Despite the obvious flaws with the models, health care practitioners continue to apply them to interventions. As these traditional health models serve as the basis for nursing and public health education, mental health professionals often rely upon these models when planning interventions (28).
Critique 3.
Sexual health interventions present in the current literature are based on generic cognitive-behavioral intervention models and have not been “specifically tailored to the special needs, risk situational circumstances, and change barriers likely to be encountered by the severely mentally ill” (7). The mentally ill face unique issues inherent in their diagnoses, their treatment, and the social and political consequences of their disease. The SPMI are unable to weigh costs against benefits when multiple ecological forces are in fact driving their decisions.
Although SPMI individuals are less sexually active than the rest of the population, those who are sexually active often engage in higher risk sexual behaviors. These high risk behaviors may be derived from poor interpersonal functioning, impaired psychosocial development, cognitive deficits, poor judgment, impaired decision making, labile mood, and impulsiveness leading to high levels of sexual vulnerability. Information processing deficits related to severe mental illness may inhibit people with SPMI from benefiting from preventive interventions that are based on traditional behavioral change principles (29). Hyper-sexuality, aggression, deep dependency needs, efforts to compensate for feelings of inferiority, response to auditory hallucinations, loneliness, and boredom may also be motivating factors for high risk sexual behaviors (30). The SPMI often have difficulty forming and sustaining stable sexual and social relationships. Sexual encounters amongst the mentally ill usually occur within casual relationships and some are “characterized by naiveté, abuse, and exploitation” (7).
Individuals with SPMI often have low levels of sexual health information, lack basic vocabulary of sexual terms, and have many misconceptions about sexual anatomy and physiology (5). In a focus group of rural women with SPMI, many held false beliefs, knew little about contraception and general women’s health, and did not receive regular gynecologic examinations (31).
The SPMI tend to be unemployed, impoverished, and overrepresented among the homeless, the incarcerated, and other disadvantaged groups at higher risk for STDs (9). Due to socioeconomic disadvantages, the mentally ill may also have tenuous and transient living arrangements and are often disproportionately concentrated in inner-city neighborhoods with higher rates of drug use, STDs, and HIV infections (7). Fifty percent of the mentally ill suffer from a dual diagnosis of chemical dependency which has synergistic implications for increased high risk sexual practices. Patterns of exchanging sex for drugs, lodging, and basic survival needs are not uncommon (7). Many SPMI individuals lack resources to purchase condoms and oral contraceptives (9).
The general population often stigmatizes the SPMI, attributing mental illness to sin or lack of character or willpower (33). The media transmits multiple misconceptions about the mentally ill, including that they are homicidal maniacs or rebellious free spirits. This stigmatization decreases their self-esteem and hinders their ability to make friends and sustain social relationships, which may augment risky sexual behaviors (34). The SPMI lack political power and strong advocates, inhibiting change on community and governmental levels (9). Although organizations like the National Alliance of Mental Illness (NAMI) serve as powerful community resources, their legislative lobbying efforts are limited due to insufficient monetary funds (35).
Intervention.
Since multiple causes contribute to high risk sexual behaviors among individuals with SPMI, including the illness itself, an ecological approach is essential. Enhanced prevention strategies must extend beyond individually focused cognitive-behavioral interventions and address the broader psychosocial context in which risk behaviors occur (36). As behavior is affected by multiple levels of influence, interventions must be planned at an intrapersonal, organizational, community, and public policy levels (37).
The ecological model encourages educational programs, support groups, and counseling at the intrapersonal level (37). However, at the intrapersonal level, the ecological model does support the use of the traditional health promotion models determined earlier in this paper to be incapable of changing complex human behavior. This is an evident limitation of the ecological model; however, this level of the ecological model can be adapted with theories of predictable irrationality, most notably framing and ownership. Successful public health programs utilize “potentially effective combinations of established theory (38).
At the intrapersonal level, a sexual health program should be provided to patients during inpatient hospitalizations as most SPMI individuals have multiple hospitalizations over a lifetime, allowing for a broad target audience and multiple reinforcement sessions. On the inpatient units, staff nurses or mental health workers should lead a sexual health group multiple times during the week for the patients nearing discharge, as the ability to process information resumes when the acute phase of illness subsides (11). Groups should be informal with the ultimate goal of empowering the patients, not reprimanding or frightening them (39). To account for the cognitive impairment of many SPMI individuals, the group must start with a concrete discussion of sexuality, including reproductive anatomy and physiology, the transmission of disease, and contraception (15). During the educational session, instead of framing AIDS and STDs as severe and detrimental and trying to evoke fear as would be encouraged by the HBM, educators should reframe them as diseases preventable and controllable through communication with partners and avoidance of sexual risk (15).
Practicing condom use is a vital component of this intervention (11). When marketing condoms to male patients, the educators should, in addition to advertising the safe-sex benefits, reframe the action as a gain or a positive experience by reinforcing that condoms extend sexual performance and postpone ejaculation. By presenting the message as sex-positive and making condoms fun and erotic, the educator can reframe an individual’s perception, easing the process of seceding ownership of the high risk sexual behavior and increasing the likelihood of condoms use. When educating female patients on how to deal with male partners who refuse to wear condoms, the educator should describe the female condom as a tool capable of empowering women. The educator should reinforce the idea that the female condom is just as effective as the male condom, taking away the man’s power in the sexual relationship. When the female condom is reframed as a gain—a symbol of empowerment—safer sexual practices may emerge. Patients should be instructed to carry condoms with them at all times in the community, as people often underestimate their likelihood of having sex when in non-aroused states and will not make an effort to find condoms in an aroused state (25). Masturbation should also be discussed as a safe alternative to sexual intercourse. Traditionally, psychiatric units have had strict “no masturbation” policies and punish patients caught masturbating. This brings shame and embarrassment to the act. Masturbation should be reframed as a gain: a safe outlet for channeling normal sexual drives when done privately (30).
Additionally at the intrapersonal level, psychiatric facilities should employ women’s health nurse practitioners to counsel female patients of childbearing age about contraceptive options before discharge as SPMI women often have difficulties using community facilities for family planning (41). Mental health facilities are also more informed than family planning clinics as to how mental illness affects informed consent for family planning (42). On the day prior to discharge, the nurse practitioner should discuss the available contraceptive options. Injectable hormonal contraception, depo-provera, is the most appropriate contraceptive choice for use in this population. It lasts for three months and does not have significant clinical interactions with any anti-psychotic medications (5). Similar to the framing of the female condom, the nurse practitioner should frame the injectable contraceptive as a gain. It can be framed in terms of freedom and power: freedom from pill taking and a newfound power in the sexual relationship. The majority of patients who receive family planning counseling and are started on contraceptives in psychiatric hospitals continue contraception use after discharge and follow up with providers (5). As the SPMI often have difficulty utilizing community resources for contraception, have insufficient funds to purchase contraception, and underestimate their need to have contraception readily available, nurses should give condoms to both male and female patients at every discharge along with the discharge medication list.
Psychiatric facilities can utilize changes in organizational characteristics to support the behavioral changes of its patients. This includes changes in institutional commitment, policy and procedures, actions of staff members, and learning opportunities (37). As long as mental health professionals do not feel comfortable discussing sexual issues with their patients, the diffusion of comprehensive sexual health programs across psychiatric facilities will be unsuccessful (13), (14). In order to increase the comfort of mental health professionals, psychiatric facilities should provide continuing education programs that encourage providers to introspectively examine their attitudes and sensitivities to various aspects of sexuality in order to become more comfortable sexual issues (42), (43).
For program diffusion to be successful and behavioral change among SPMI individuals to be possible, the policies and corporate culture of psychiatric facilities must change. Policies must not rely on the personal judgment of staff, but should be sensible, sensitive, and validate the sexual rights of the mentally ill. Formal guidelines for sexual education, birth control, and capacity to consent must be devised (44). Organizational attitudes towards sexual practices must change along with new policies; staff members must not allow personal biases, fears, moral beliefs, and stereotypical beliefs to obstruct the implementation of new policies (45).
Community level interventions use existing social networks as mediating structures to influence community awareness (37). Depression and Bipolar Support Alliance (DBSA) is the leading patient-directed national organization for individuals with SPMI and has a strong social network (46). Through a system of peer-run support groups, DBSA educates SPMI individuals on the impact and management of mental illness. The organization has been a success, as 86% of its members remain compliant with their psychiatric medications (46). This existing social network can be used to increase sexual knowledge amongst the mentally ill and encourage members in engage in protective health behaviors. As DBSA relies on peer-to-peer communication, the sexual health message delivered would be one of considerate concern from a friend, instead of a provider’s paternalistic educational message. DBSA creates a community of trust, reciprocal support, and positive self identity where healthy behavioral changes can occur (47). Peer-mediated sexual health interventions have proven to effectively reduce risky sexual behaviors in other high-risk populations and may serve as an effective tool in eliciting behavioral change amongst the mentally ill .
Regulatory policies are essential in protecting the health of the community (37).
Local departments of mental health (DMH) should develop policies to control many of the external factors that lead to impulsive sexual behaviors amongst the mentally ill. Local DMHs should increase their funding of intensive case management services, which have proven to positively affect functional level and quality of life, while preventing exacerbation of illness (48). With an increase of funding, more case managers could be hired and individual case managers could spend more time with their clients ensuring medication compliance, temperance, and stable living situations to decrease likelihood of risky sexual practices. Case managers can work with the local Social Security offices to appropriately budget their clients’ finances and prevent the exchange of sex for lodging and food. DMH should allocate increased funds for supportive housing. Supportive housing gives SPMI individuals that are particularly prone to sexual exploitation or risky sexual practices a unique opportunity to learn about and to practice safer sexual activities in a supportive context (49). DMH should expand substance abuse services for the mentally ill as substance use is the strongest correlate of high risk sexual practices in this population (50).
Defense of Intervention 1.
The ecological model is an appropriate basis for the development of a sexual health intervention for the mentally ill as it encompasses the multiple physical and social factors that influence the healthfulness of a situation and the well being of its participants. Based on the model, efforts to promote health should emphasize the advantages of multilevel interventions that combine behavioral and environmental components, like facilitating psycho-educational group interventions while changing the professional culture of psychiatric units (51). The ecological model focuses on population-level prevention and includes individual level interventions aimed at persons with certain risk factors, interventions mediated through important organizational channels, and public policy interventions that redirect societal counter forces (52). The proposed intervention operates on all of those levels. Effective interventions create therapeutic micro-environments that facilitate and reinforce desired health behaviors, instead “arm[ing] patients with behavioral control strategies and then send[ing] them off into society to maintain their treatment gains, leaving them at the mercy of a social system that encourages, rewards, and profits from high risk behaviors” (52). This is done by beginning the intervention in the hospital with groups and reproductive counseling and continuing the intervention in the community with case management and supportive living services. Extensive research has been done using the ecological model as a framework for understanding behaviors and despite the fact that current evidence supports multi-level interventions, only a relative few number of studies involving the ecological model as a framework for intervention are published in the health promotion literature (53), (54). Many published papers discuss successful interventions that utilize the ecological model, but do not test the intervention in a formal study (55), (56). Despite this dearth of research, a multi-level intervention will yield greater benefit to SPMI individuals than a sole intrapersonal level intervention.
Defense of Intervention 2.
Frames are an effective way of promoting protective sexual behaviors at the intrapersonal level, as health care promoters can manipulate frames to alter the judgments and opinions of the targeted population. A frame is a way of packaging and positioning an issue to convey a certain meaning. By packaging an issue in a more desirable way, health care promoters can change attitudes towards health behaviors and the likelihood of behavioral change (57). A meta-analysis of framing experiments in relation to health promotion proved framing to be a successful tool for interventions that involving safer sex (58). People are sensitive to whether an intervention is framed in terms of its associated costs (loss frame) or in terms of its associated benefits (gain frame), even when the two frames describe the same situation (59). Gain frame interventions are more persuasive than fear-inducing frames when it comes to implementing preventative behaviors, like condom use (60), (61). Threat or fear appeals advocated by traditional health models are ineffective in sexual health interventions as many people fear STDs or HIV without feeling that they are personally vulnerable and will downplay their own personal risk in comparison to risks of others (62).
Messages that are framed in unexpected ways or do not match participants’ experiences or concerns can be more effective as they lead to greater message processing (63). Instead of presenting a message of sexually transmitted disease and health effects, the proposed intervention delivers an unexpected sex positive message of freedom and empowerment. By changing the definition of the problem, it is thus possible to change the response. Although health is a core value for some, successful public health interventions must utilize frames that appeal to the same compelling core values being tapped into by the opposition (57). In a state of arousal, sexual pleasure is a much more compelling core value than health. By reframing condom use as a way to improve sexual activity, instead of a way to prevent disease, a more compelling core value is utilized.
Defense of Intervention 3.
As individuals quickly come to own their health behaviors, behavioral change is dependent upon their ability to give those behaviors up. When a health promoter is able to offer the individual a new behavior coupled with a compelling core value, behavioral change may be possible. Psychological ownership is the state in which individuals feel that a target of ownership is theirs. A target of ownership may be an object or a non-physical entity, such as ideas, words, or behaviors. The cognitive state of ownership is tied with emotional and physical sensations, including the rise of pleasure, efficacy, and self-identity. This leads to an intimate relationship between self and possessions; the entity may become part of the extended self (64). People tend to place a larger value on an entity when it is in their possession and resist to part with their possessions as they allow people to keep to the status quo. Over time, individuals come to own their health behaviors, thus their health behaviors become an extended part of themselves and are difficult to give up (65). As duration of ownership increases, the owned behavior increases in value (66). Despite the unattractiveness of risky sexual behaviors, owners still see parting with them as a loss (65). As people are “more reluctant to give up an attainment than they are eager to acquire it,” they must be persuaded with something that they value even more (66). As discussed earlier, pleasure has shown to be the most valuable of possessions for those who do not engage in preventative health behaviors, so for a person to give up risky practices, he or she must be offered pleasure in return (27). For men to give up sex without a condom, they must be given the pleasure of improved sexual performance. For women to give up passivity in sexual interactions, they must be given pleasure of empowerment.
Conclusion.
“Sexual activity among the [mentally ill] is a reality and one with which we must deal and not put our heads in the sand” (10). The mentally ill are sexually active and do engage in high risk sexual activities due to lack of education, the complexities of mental illness, and social and behavioral factors. Due to attitudes and beliefs of health care professionals, the sexual practices of the mentally ill have long been unaddressed. High-risk sexual activities are a reality that traditional models of health promotion cannot change. An ecological approach along with the principles of framing and ownership could serve as an effective way of dealing with sexual activity amongst this vulnerable population.
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