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.