Helping Diabetes Management in Teens | Identifying the barriers to achieving desired A1C

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Assisting people with improved diabetes management behaviors has been a specialty of mine in my psychotherapy practice since 2009. My Wife has a been a senior research coordinator at the Barbara Davis Center for Childhood Diabetes in Denver since 2006, and through bonding with her passion to assist in this area, I have developed my own modes of intervention.

There are a number of factors which make managing A1C particularly difficult for teens including: Social pressures and responsibilities, motivation, personality, nutrition, substance use, sleep habits, brain re-structuring, defence mechanisms (such as denial and avoidance), social justice issues (oppresion – racism), diabetes education, individuation, future-oriented culture, access to health services, family structure and dynamic issues, marital conflict between parents, family and friendship conflict with teen, mental health stigma, academic pressure and responsibility, limited mindfulness and somatic awareness, spirituality (especially concerning death), an under-developed ability to conceptualize long-term cause and effect (this is developmentally normal for teens), co-parenting discrepencies, emotional inteligence, individuation, hormonal changes, the tendency for co-morbidity (people with diabetes can be more prone to additional physical and mental health diagnosis), and many other life/environmental stressors (poverty, grief etc.) .

One of the most significant impediments to proper management is the reality that often times the variables which are most disruptive to diabetes management are outside of the control of the teen. 2 examples: (1) If the teen lives in a household with domestic violence the resulting stress can impede their ability to maintain attention on their management routine. In this instance the ‘cycle of abuse’ needs to be intervened upon – assistance to the teen alone may not render significant results. (2) If for financial reasons the teen does not have access to proper nutrition, diabetes education, insulin or testing strips, the ability to manage diabetes will be near impossible (again an intervention on the teen alone would not be particularly helpful – a social intervention is necessary).

Proper diabetes management requires an unbelievably high level of self-discipline, familial and social support, consistency, mindfulness, finances, education, and organizational skills. Imagine dedicating yourself to an exercise and nutrition regiment that was conducted exactly the same way every day of your life … a routine that was never to change despite the relative influences of changing social, emotional, and environmental conditions… yet, paradoxically… the specific intervention was always to change in response to changing social, emotional, and environmental conditions. (ex. you exercised at exactly the same time every day, but the way you exercised was different and in response to a large number of variables). Wow, this is hard…

In order to best assist an individual in achieving their A1C goals, we must first help in identifying the impediments or barriers to proper management. in other words-

“What are the factors or stressors which are most disruptive to proper management?” 

The answer to this question can then dictate the most effective mode of intervention, and to be realistic, there is most often a need for multiple forms of intervention. Social, emotional, cognitive, motivational, familial, and academic interventions have been the most abundant needs in my experience.

From answering this question we can come up with a treatment plan which is holistic and individualized. Of course, this can become a financial issue as it is rare to find an interventionist who is adept at all these different modes of intervention (many of these interventions come from different theoretical orientations and it is not uncommon for a psychotherapist to specialize in one).

To address this financial reality, perhaps it is helpful to subtly change the question so as to identify the one variable which is most disruptive to diabetes management for the given individual.

“What is the one variable or stressor, once removed, that will have the most positive impact on your ability to manage your diabetes?

note: answering this question will often take a minimum of a session or two with a highly trained psychotherapist (ideally other people who know the teen will collaborate) as it is very likely that the teen is not conscious of the answer… additionally, the answer that the teen initially offers is usually what they believe to be the ‘right’ answer or an answer someone already suggested (ex. I need to try harder) as opposed to the answer which would ultimately serve them most effectively (ex. I need my house hold to be a place of respite, which means I need my parents to stop fighting so much).

I will end with a short list of specific intervention types which have been used to address the ‘most significant stressor.’

Existential and Spiritual Intervention – Stressor = fear of death and resulting apathy. The intervention focuses on increasing tolerance of the fear surrounding death so that it can be contemplated with less stress. Reducing this stress can reduce avoidance behaviors to proper management.

Family Structure Intervention – Stressor = overinvolved and under-involved parent creating inconsistent and less useful assistance to teen. In any family system, there is always going to be a parent who is more adept at motivating a teen (this is no one’s fault and mostly has to do with personalities). In many family systems, there is one parent doing all the ‘reminding’ – this reminding often increases avoidance behaviors. The goal of the intervention is to create a family structure and interaction dynamic which motivates the teen towards better management and minimizes stress and avoidance behaviors. This involves getting the parents on ‘the same team’ and intelligently deducing who engages with the teen in what way (ie. who asks about blood sugars and who reminds or collaborates in reminding to give insulin and how they do that).

Motivation and Solution-Focused Intervention – Stressor or factor = lack of willpower, habit, momentum or hope that better management will positively impact a teens life. The collaborative method focuses on identifying what the teen believes that they can realistically accomplish and to ‘cheerlead’ them when successful. The intended result is for the teen to feel empowered to engage in solutions and to be more hopeful about the positive impacts of engaging in solution-oriented behaviors. On an unconscious level this also ‘re-trains’ the mind to focus more on solutions and less on cynicism or ‘problem-focused’ thinking.

Attachment-based Intervention – Stressor = Stress from Family conflict including an inability for the family to offer a supportive and regulating home environment to assist in mediating stress, promoting resiliency, and in offering validation. helping the family in developing the emotional intelligence aptitudes necessary to interact with other family members in a way which supports: bonding, authenticity, vulnerability, and compassionate empathy. Attachment intervention serves to mitigate stress by increasing the family systems ability to offer regulation through connection. In my experience, often it is marital counseling which ends up having the most positive impact on the teen’s stress level = the intervention is with the parents and not necessarily with the teen at all.

Academic Advocacy Intervention – Stressor = Inability to meet the responsibilities of school, which result in intolerable emotions (shame, fear, anger etc) that encourage apathetic behaviors in all areas of the teen’s life – including diabetes management. In my experience, constantly fluctuating blood sugar levels appear to create symptoms similar to ADHD – this makes it extremely difficult for certain teens to use the attention and organization skills necessary to complete tasks on time and independently. Additionally, because of medical leaves of absence, Teens often fall behind in school and find themselves completely overwhelmed by the task of ‘catching up’ (often it is mathematically impossible for them to ‘catch up’). In these instances, the intervention is to advocate for the teen to have an individualized education plan which accommodates their specific needs (ex. certain homework assignment being excused, tutors, un-timed testing etc.)

Education, behavioral and strategic Intervention – Stressor = a lack of understanding of the most effective form of management along with a lacking ability to create an implementation strategy that accommodates all the nuances of the teen. For this intervention, the psychotherapist takes both an expert and a collaborative position to create an individualized behavior plan that the teen can follow to best manage their diabetes. (the plan will include: times to check blood sugar, education about carb counting and taking insulin, and a daily time for the teen to report to his parents about management updates etc. – parents need updates or else they become overwhelmed with fear – often a structural intervention is necessary for the teen to feel comfortable in offering updates.

Cognitive Intervention – Stressor or Factor – thoughts, ruminations, and/or beliefs which negatively influence the teen’s management behaviors. The intention of this intervention is to both dispute unhelpful and possibly irrational beliefs while also allowing new narratives to positively impact the teen’s life. Some examples of an unhelpful belief could be: “if I can’t do it perfectly I shouldn’t do it at all” – or – “If I don’t think about my problems they will go away.”

Mindfulness intervention – Stressor or factor = an inability to observe physiological indicators which could help to inform the teen about current blood sugar levels or an inability to focus attention on the present moment so as to reduce anxiety and increase felt happiness. Mindfulness is the ability to keep your attention in the present moment as opposed to the future or the past. Body awareness mindfulness exercises help a teen to observe the sensations of the body in the present moment. I have found that teens with this ability are far superior at managing their diabetes as they take management action long before they are way ‘too- high’ or ‘too-low” This intervention generally also necessitate one of the above intervention as mindfulness facilitates increased ‘awareness’ and other interventions are often helpful in encouraging responsive action.

 

 

 

 

 

 

 

 

 

 

 

William Hambleton Bishop is a practicing therapist in Steamboat Springs Colorado.

Double Binded Communication

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Often we send ‘mixed messages’ to people. It can be a source of dis-ease in a relationship when a partner or loved one is giving you two opposing messages at the same time. This creates a double-bind as there is not an effective way to respond correctly to the communication.

Most commonly the opposing messages are coming from two different forms of communication – verbal and non-verbal.

A person can, therefore, say two things at the same time which are in conflict or contradict each other.

Example. If I were to say to you (verbally) “I am so happy to see you – come towards me!” While I started walking away from you with a disinterested facial expression. I am telling you two things at the same time “I am happy to see you and I want to connect (verbally) … and I am indifferent about you and don’t want to be around you (non-verbally).

This dissonance tends to cause anxiety in the receiver.

Often the non-verbal communication is being transmitted emotionally – so we can ‘sense’ a discrepancy in what is being said and what is being emoted (for example, people often will respond to “how are you doing?” with an answer such as “really great” when the person is emotionally far from feeling ‘great’.

 

It is important for us humans to be able to correctly deduce communication so that we have continual feedback concerning the nature of our relationship – we need reassurance that everything is ‘ok’, that we are effectively understanding the other person, and that we are reading the needs of the other person accurately.

Double binded communication removes the congruent feedback mechanism – we, therefore, do not have an effective means of deducing the state of our relationship with the other person. Additionally, we do not have a way to respond effectively to double binded communication (ex. if some who is emoting ‘sadness’ reports that they are ‘happy’… do you respond to ‘sad’ or to ‘happy’… do we respond as if they are ‘fine’ or ‘in need of assistance’? The resulting emotions range anywhere from annoyance to terror.

Children are exceptionally susceptible to double binded communication as it impedes their ability trust their intuition, to develop an ability to effectively empathize, and to trust that people mean what they say.

Adults use double binded communication frequently as a means of appearing professional, being polite, and avoiding conflict etc.

Much double binded communication is unconscious – Every human on the planet has automatic emotional reactions that flash upon our faces called in response to the environment (micro-expressions). a micro expression cannot be controlled – so if you verbalize an opinion that contradicts your emotional reaction to a stimulus, you will be engaging in a form of double binded communication.

For example – let us pretend you are visiting a different culture that has cuisines that you have been implicitly programmed to have a disgust reaction to… If your host says,” we are so happy to have you – and we have good news – we have a fresh selection of the areas finest insects for us to eat tonight.” likely your micro expression would be a combination of fear and disgust… if you then said, “thank you, I am so happy to enjoy the cuisine of your culture.” you would be sending out double binded communication = you say that you are happy, but you are emoting disgust and fear. The solution is difficult in this example as you likely have the goal of not being offensive or impolite = Saying “wow I am disgusted by insects and am fearful about eating them” would likely no go over too well…

There are many other instances where congruence is the best option (meaning what you say), but this can be difficult in a culture that places less value on vulnerability and honesty … and perhaps more value on professionalism, being polite, and avoiding conflict.

to avoid double binded communication we need to develop self-awareness of our emotional state – and increase our courage to communicate messages which reflect our emotional reality accurately.

 

 

 

 

 

 

 

William Hambleton Bishop is a practicing therapist in Steamboat Springs Colorado.

Fear, Competence, Values and Anger in Parenting Rambunctious Children

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This post will investigate how our perceived parenting competence impacts our fear and resulting emotional and behavioral reactions. We will focus on how fear can lead us into parenting interventions that are not consistent with our parenting values.

I was offering a parenting coaching intervention in a couples context the other week and I arrived at an interesting finding.

The couple has one very creative, sensitive, expressive, intuitive, and impulsive child that needed parental intervention to ensure the relative safety of various environments and people in those environments (the child needed help not playing to rough and chaotically). The parents needed help as their intervention methods were very different, and the fathers more authoritative method made the mom uncomfortable.

Values -I started the intervention by assessing values… in order to do so my goal is always to create as much felt safety as possible by genuinely entering into a place of significant curiosity and acceptance. My hypothesis was that there was a bit of value, belief, and ethical dissonance between the couple which resulting in differing parenting schemas (it is very hard to have a united parenting front when there are two widely different sets of beliefs as to how to parent a child). … as we deconstructed the parenting values and beliefs to there foundations we arrived at a welcome conclusion – the couple had essentially the same parenting values and same desires for how they would ideally re-direct misbehaving children.

Family of Origin – We then looked into family of origin themes to isolate how the two partners were parented themselves as children. This part promoted greater bonding and understanding between the couple, but still did not explain the intervention style of the husband… this intervention did however elicit some emotions for the father as the process uncovered his deep dissatisfaction with his intervention style.

Emotions – Next step was Somatics (body’s reaction) and Emotions – and we arrived at the answer. I oriented the clients into a more mindful place by directing them to differentiate from the parenting story I was going to have them recall. I told them that we all have a tendency to become enmeshed with our emotions while retelling a difficult story, but for this exercise we would be a curios mindful observer of our emotional and physiological states while retelling the story – we were going to observe with as little judgement, explaining or defending as possible.

The story was one that all of us with young children have experienced many many times. The young boy gets over excited at the playground… he misinterprets the non-verbal signals from a child he is playing with – he plays too rough and there is a worry that the other child might get hurt. Dad swoops in quickly and assertively to separate the children then relays to his child how dangerous he was playing. Dad appeared very angry while educating the child.

The emotion that the couple first identified were anger. Anger was what the couple believed to be the problem.

I share this next sequence of deconstructed emotions to normalize for all of us what it is like to parent in these difficult instances.

The emotional experience of the Dad (‘kind of’ in order)

Anxious or nervous: That he is in a situation were there is a high probability that his son will need a parenting intervention that he believes he is not competent enough to enact.

Embarrassed: that his child is more frequently the rambunctious one.

Fear: that the other child will get hurt

Fear: that he will not be able to successfully intervene with his son.

Fear: that his wife will think poorly of him

Sad and Shameful: That he is intervening in a way that is incongruent with his values (his parents were very patient, calm, and compassionate)

Terrified: that his wife (his primary connection) is non-verbally displaying disappointment and fear related to his authoritative parenting intervention.

Hopeless, Confused, and Flooded: that he does not have the confidence in his ability to regulate his son and thereby improve the probability of more empathetic play.

Angry: because his fight or flight system has been activated. His system is terrified as he feels disconnected from his attachments figures. (Quick note: social threat impacts our brains (and the fight or flight system) the exact same way as a physical threat. So the fear of being rejected by your partner impacts us the same way as the fear of being attacked by a tiger.

 

During this time both myself and his partner offered deep warmth and compassion.

Next we moved on to the solution

Solution Focused: We then switched to a solutions focused’ish’ intervention to identify unique outcomes = when the above story-line happened but there was a different result. The couple relayed numerous examples of successful outcomes and commented on how dramatically better things have gotten with the parenting now that they are more securely connected to each other (emotionally vulnerable and supportive… attuned… compassionate… present etc.)

Now if you look at the chain of emotions above you may be able to identify the ideal place of intervention… Anxious and Nervous.

The cascade into anger started long before the child started playing too rough… it started when they arrived at the park and the father started feeling anxious do to his self-perception of his parenting competence.

Unique outcome: In instances where the couple was successful the Dad was self-aware of his emotional state (mindful), vulnerable enough to turn towards his wife for reassurance (brave), and the wife was able to give him very quick regulation through validating their connection to each other (bonded).

yes it is sometimes that simple… we just need the courage to tell our partner we are emotionally overwhelmed. And our partners need the courage to trust that offering love and connection is sometimes all we need in order to be able to utilize an effective parenting intervention.

Yes, sometimes parents need help with behavioral strategies, but more often then not they simply need emotional support so that they can be regulated enough to intentionally and effectively utilize the parenting intervention that they already know (they just don’t have access to those methods when they are overwhelmed and dis-regulated by a sea of emotions.)

During an intervention such as this I tend to use a lot of self disclosure – I have two very rambunctious and passionate boys – I can related very much to wanting to over control their behavior to ward off the possibility of them getting so chaotic that I fear i wont be able to successfully intervene. in these times I Don’t need academics or education of strategy… I simply need to be loved and a hug works really really well for me. I am expansively grateful that I am married to a really good hugger that knows me very well.

 

 

 

 

 

William Hambleton Bishop is a practicing therapist in Steamboat Springs Colorado.

Parenting and Rowboats

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There is more than one way to skin a cat they say…

and there is more than one way to row a boat, but if there are two people rowing that boat you better find a common way.

and so it is with parenting, guiding, directing, and mentoring our young ones.

family systems can and perhaps should parent their young ones with different methods than other family systems, but as with the boat, you are unlikely to guide a child in a meaningful way if the older generations is offering inconsistent or contradicting guidance to that kid.

So now we arrive at the rowboat metaphor – what will happen to the boat if two rowers are engaging in different strategies that essentially ignore the methods of the other person?

the answer is that the boat isn’t going to go in a meaningful direction despite the best interests and intentions of the rowers.

We mostly get the above metaphor, but there is another piece to this that entices us to use this dysfunctional method. We love love love love to be right! Which is so very ironic as in our efforts to be right we are often doing something indisputably wrong (that comment was also ironic).

Now what is the best rowing strategy? – to row from back to front … or from front to back? Is it best to have the advantage of greater core power by having your back face the direction you are moving … or is it better to have the advantage of better sight by facing the direction you are moving?

the obvious point here is that the answer is mostly subjective and the best choice would be to have both rowers using the same strategy…. the best strategy is the same strategy = the best strategy is not to debate on the boat about which of the two differing methods is best.

In the above metaphor the boat is the kid and the different guidance from the two rowers (parents) has a very concrete impact on the direction of the boat (kid)… now lets complicate this metaphor a bit more by giving our boat the consciousness of a kid as well… what are the more abstract impacts of not using a common rowing (parenting) strategy?

Judging is a natural and normal activity for us social humans… we use judgements as a way of isolating and sharing our own belief systems so as to find commonality with people that we are in relationships with.

When we judge someone else’s parenting with our partner (or other family members) we are kinda saying, “Hey I don’t (or do) want to do that with our kids… do you agree?”

These conversations must happen in some form in order to collaborate around a set game plan for intervening with the children.

But what is the impact of having these conversations in front of the kids? or worse yet, what is the impact of completely disregarding the parenting directions of your partner in front of the children?

If we are going to use the rowboat again we will end up with two consequence.

the concrete consequence is that the boat will not travel in a useful direction.

the abstract consequences are that the boat: will not know which rower to trust, will not have hope or security that the rowers can successfully offer guidance, and the boat may be encouraged to believe that it doesn’t have to listen to or take influence from one (or both) of the rowers.

When the rowers can’t collaborate in using a consistent methodology the boat is lost in a unpredictable anxiety provoking ocean of chaos… in such instances the child is very likely to become emotionally overwhelmed and will probably engage in ‘difficult’ behaviors”

So what is the solution?

Unite around a common rowing strategy… and if you think that you and your partner can advance towards a better rowing strategy, then have an open-minded conversation without the kids present.

just remember – With two kind and well intentioned adults it is better to row the boat with the same (though less effective) rowing style than to row the boat with two different rowing styles.

Doing so models to your children the importance of kindness, open-mindedness, collaboration, the ability to take positive influence, respect and love… and these things can be more beneficial than rowing strategies.

 

William Hambleton Bishop is a practicing therapist in Steamboat Springs Colorado.

Respecting Elders in a Society of Rugged Individualism

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My intention is to stir up a conversation as to a possible answer to why there seems to be a decreasing degree of ‘respecting your elders’ in the United Stated and other individual focused cultures (as opposed to collectivist cultures).

In my times of contemplating the subject of decreasing respect I came to an interesting observation…

Generally speaking there is a dramatic difference between what ‘respecting your elders’ means in a collectivist culture as compared to what that means in an individualistic culture.

Respecting your elders in a collectivist culture could mean that one respects the customs, rituals, and traditions that are followed with great consistency by the group.  As all individuals are unconsciously motivated to meet the needs of the group it stands to reason that the elders have great insight into what the collective needs are… therefor when you are respecting your elders you are respecting the collective need and fulfilling the collective intention. In this way when you respect your elders in a collectivist culture there is a clarity and a consistency in regards to what the younger generations are respecting.

Respecting your elders in an individual focused culture may not have the clarity or the consistency in regards to what variables are to be respected. If the Elders of such a culture are unconsciously motivated primarily to meet their own needs then respecting those elders calls for one younger individuals to respect the subjective desires of one older individual. This means that respecting your elders calls for the younger generation to respect an infinite amount of variables related to each differing older person… those variables to be respected may prove to be truly difficult to isolate and respecting one elder often causes the youth to disrespect another elder. Respecting an older person’s independently created beliefs could unfortunately be going directly against what the young individual was conditioned to do… the culture conditions the young ones to be motivated by their own desires and not by the subjective desires of an older person.

The short of it is that perhaps respecting elders truly has very little to do with age… instead this principle is more likely to succeed when the elders are representatives of the collective needs. Therefor respecting elders is synonymous with respecting the collective over the individual.

In an individual focused culture respecting your elders means that you are arbitrarily respecting an older individuals subjectively created needs simply because that individual in chronologically older than you are… respecting that older individual very often means that you will not be meeting the needs of yourself as an individual (which is the primary unconscious motivator) or the cultural or collective needs.

I am from and individualist culture… it makes sense to me that if I wanted the youth to respect me it would be best if I allowed myself to make decisions which were in the best interest of the collective. If I am to ask for respect simply because I am older I worry that I might be asking the youth to enable my vanity.

I am a lover of balance, and though this post seems to favor collectivism I would like to clarify that it is likely a balance which harvests the greatest harmony.

In relation to the variable of respecting our elders I am simply suggesting that we are so far away from that place of balance that a more radical collectivist intention may be needed to bring us to center.

Quick oversimplified definition of terms –

  • When I say an Individualist culture I am talking about a culture in which the individual is primarily motivated by independent ambition. A person of this group is very motivated to fulfill individual goals which are perceived to be largely separate form collective goals or separate from the goals of the system which encompasses that individual.

 

  • When I say collectivist culture I am referring to a culture in which the individuals are primarily motivated by collective ambitions. A person of this group is very motivated to fulfill the collective goals of all the people that are in the same system as that person. This person would authentically prefer to do that which was in the best interest of the group despite whether it was in their own individual best interest.

The environment that we grow up within affects the ways in which we experience rewards and therefor effects how we are unconsciously motivated. A person who grows up in a culture of individualism can choose to put the needs of the group before them; the difference is that the choice is motivated by expressing the freedom to make an independent choice. They feel internally rewarded by meeting their need to express their individualism… which guided towards meeting the collective need.

It is argued that a person from a collectivist culture would not feel as though serving the group was truly an independent choice… they are unconsciously motivated to do so… they feel internally rewarded by meeting the needs of the group.

Of course these are gross over generalizations and there are infinite differences within individual focused and collective focused cultures.

If we tell a youth to respect their elders in the United States what variables are we asking them to respect? (Ex. Conservatism, liberalism, alcoholism, perfectionism, racism, volunteerism, Buddhism, athleticism, compassion, capitalism, individualism, collectivism… etc.)

 

 

William Hambleton Bishop is a practicing therapist in Steamboat Springs Colorado.