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Diabetes Across the Lifespan: Family Centered Approaches to Assessment and Intervention
• Ruth Nutting, PhD, LCMFT, Director of Behavioral Health, Via Christi Family Medicine Residency Clinical Assistant Professor, University of Kansas School of Medicine
• John S. Rolland, MD, MPH, Professor of Psychiatry, Northwestern University Feinberg School of Medicine and Executive Co-Director, Chicago Center for Family Health
• Jennifer Harsh, PhD, LIMFT, Director of Behavioral Medicine, Internal Medicine, University of Nebraska Medical Center
Session # D2
CFHA 20th Annual ConferenceOctober 18-20, 2018 • Rochester, New York
Faculty DisclosureThe presenters of this session have NOT had any relevant
financial relationships during the past 12 months.
Conference Resources
Slides and handouts shared in advance by our Conference Presenters are available on the CFHA website at http://www.cfha.net/?page=Resources_2018
Slides and handouts are also available on the mobile app.
Learning Objectives
At the conclusion of this session, the participant will be able to:
• Recognize the prevalence of diabetes and its implications for patients and families.
• Describe systemic assessment and intervention to increase adherence.
• Identify strategies to promote positive systemic coping and resilience.
1. Centers for Disease Control and Prevention. (2017). National diabetes statistics report: Estimates of diabetes and its burden in the United States. Retrieved from https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf
2. Gonzalez, J. S., Schreck, E., Psaros, C., & Safren, S. A. (2015). Distress and type 2 diabetes-treatment adherence: A mediating role for perceived control. Health Psychology, 34, 505-5.
3. Hara, Y., Hisatomi, M., Ito, H., Nakao, M., Tsuboi, K., & Ishihara, Y. (2014). Effects of gender, age, family support, and treatment on perceived stress and coping of patients with type 2 diabetes mellitus. BioPsychoSocial Medicine, 8, 16-27.
4. Kripalani, S., Yao, X., & Haynes, R. B., (2007). Interventions to enhance medication adherence in chronic medical conditions: A systematic review, Archives of Internal Medicine, 167, 540-550.
5. Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). New York, NY: Guilford Press.
6. Osterberg, L., & Blaschke, T. (2005). Adherence to medication. The New England Journal of Medicine, 353, 487-497.
7. Prochaska, J. and DiClemente, C. (1983). Stages and processes of self-change in smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 5, 390–395.
8. Rolland, J. S. (2018.) Helping couples and families navigate illness and disability: An integrated approach. New York: Guilford Press.
9. Rolland, J.S. (2016). Chronic Illness and the Family Life Cycle. In M. McGoldrick, N. Garcai-Preto, & E. Carter (Eds.), The Expanded Family Life Cycle: Family and Social Perspectives (5th ed.) Boston, MA: Allyn & Bacon.
10. Rollnick, S., Miller, W. R., & Butler, C. C. (2008). Motivational interviewing in health care: Helping patients change behavior. New York: Guilford Publications.
11. Rubak, S., Sandaek, A., Lauritzen, T., & Christiansen, B. (2005). Motivational interviewing. A systematic review and meta-analysis. The British Journal of General Practice, 55, 305-312.
12. Safeer, R.S., & Keenan, J. (2005). Health literacy: The gap between physicians and patients. American Family Physician, 72, 463-468.
13. Satterwhite Mayberry, L., Egede, L.E., Wagner, J.A., Osborn, C.Y. (2015). Stress, depression and medication nonadherence in diabetes: Test of the exacerbating and buffering effects of family support, Journal of Behavioral Medicine, 38, 363-371.
14. Walsh, F. (2016b). Strengthening Family Resilience (3rd ed.). New York: Guilford Press
Bibliography / Reference
Learning Assessment
A learning assessment is required for CE credit.
A question and answer period will be conducted
at the end of this presentation.
Diabetes Overview
Diabetes in the U.S.o 30 million people have diabetes.• 23 million people diagnosed.• 5% estimated to have type 1 diabetes.
oPrevalence among ethnicities:• American Indians/Alaska Natives-15%
• Non-Hispanic blacks-13%
• Hispanic-12%
o Prevalence varies significantly by education level• 13% < high school education
• 10% = high school education
• 7% > high school education
Centers for Disease Control and Prevention [CDC], 2017)
Biopsychosocial StressorsNON-ADHERENCEo Emotional distress• Denial
• Lack of control
• Rigidity
o Obstructive family behaviors• Avoidance
• Nagging
o Social stressors• Low social support
• Socioeconomically disadvantaged
TREATMENT ADHERENCEo Emotional well-being• Acceptance
• Sense of control
• Flexibility
o Healthy family behaviors• Supportive
• Open communication
o Decreased social stressors• High social support
• Affordable treatment options
Gonzalez et al., 2015; Hara et al., 2014; Satterwhite Mayberry, et al., 2015)
Knowledge & ApplicationSYSTEMIC, CHRONIC ILLNESS RELATED, ASSESSMENT AND INTERVENTION SKILLS
Case Study #1 PATIENT: CHARLENE
SETTING: DIABETES CENTER
Multigenerational Developmental Perspectiveo Inquire about:• Multigenerational experiences with illness & loss, including stories of resilience• Experiences with specific condition
• Culturally-informed caregiving traditions and expectations
o Current timing and possible impact on individual and family life cycle planning
o Upcoming life cycle transition
Key Family Beliefso Multigenerational legacies about illness/loss
o Normative illness experience
o Mind body interaction
o Mastery, control, acceptance
o Cause of illness
o Course & outcome
o Ethno-cultural & spiritual beliefs
o Gender
Family-Centered Clinical & Psychoeducational Serviceso Routine screening family consultation & brief psychological screening of the patient at time of diagnosis or entry into the Diabetes Center.
o Identify & refer complex or “high risk” cases.
o Periodic family psychosocial “check-ups” & consultations:• At key illness-related transitions
• Disruptive individual and family transitions
Charlene & Familyo Presenting Issues:• 17 y.o. African-American, strong working-class family (2 younger sibs: 12 & 14). Excellent
student with strong peer network.
• Type 1 diabetes since age 9 treated at Diabetes Center
• Well-managed until 1st semester of college away from Chicago
• Neglected diet, excessive alcohol, weight concerns
• Two visits to ER in diabetic ketoacidosis
• Recently returned home to family on medical leave
o Developmental Issues/Transitions:• Diabetes: Transition to full self-care without parental oversight
• Individual: Transition to early adulthood (here leaving home)
• Family: Launching teenagers
Family History with Illness & Losso Beloved maternal aunt died two years ago from complications of diabetes-related
ESRD—poor adherence history. • Charlene saw her deterioration.
• Little family discussion about the loss and meaning.
• Mother has been very protective and involved in Charlene’s diabetes management, not wanting her daughter to repeat her own sister’s pattern and disease course/outcome.
• Charlene developed her own fears of not being able to manage her disease independently and suffering like her aunt.
• Paternal uncle, history of positive experience managing moderate-severe childhood and adult asthma.
Salient BeliefsCause: Mother secretly has felt genetically responsible for Charlene’s diabetes.
Course & Outcome: Charlene and mother fear repeat of diabetes course and suffering of mother’s sister.
Spirituality: Strong connection to church and community.
Mastery: Industrious/cohesive family. Can-do philosophy. Family stories of resilience in the face of adversity (e.g. poverty, racism).
Gender: Strong marital relationship. Father works two jobs. Mother in charge of home and communication with kids, including Charlene’s diabetes management, visits to clinic, etc. Father defers to his wife’s decision-making.
Key Case Formulation Issues1. Interaction of illness, individual, and family life cycle transitions fuel anxiety of
threatened loss.
2. Multi-generational experience with recent loss of aunt.
3. Issues of race and social class- Pressures on Charlene as first family member to get higher education, succeed, and help family reach a higher social class and move to a better neighborhood.
4. Lack of proactive communication about these issues.
5. Together these created context for medical crisis with chronic illness
Key Interventionso Decisions: stay home, secure part-time job, address key diabetes,
individual, and family issues, return to school next fall
o Processing the interaction of diabetes and life cycle transitions
o Increased involvement of father in discussions and decision-making
o Living with uncertainty and long-term threatened loss
o Gradual transition of diabetes responsibilities to Charlene
o Loss & meaning-making regarding loss of aunt
o Process protective pattern of mother – daughter relationship, including mother’s feelings of guilt related to perception of genetic transmission
o Promote connection of Charlene with her uncle as chronic illness management role model
Case Study #2PATIENT: TIFFANY
SETTING: INTEGRATED PRIMARY CARE
Structure of Encounters
Now Return
Scheduled
CollaborationCollaboration
Motivational InterviewingWhat is it?◦ A person-centered, goal-directed
counseling method for helping people to change by working through ambivalence.
(Rollnick et al., 2008)
MI and DM EvidenceEffective in brief encounters
MI led to:◦ Reductions in substance use
◦ Smoking cessation
◦ Diabetes plan management
◦ Weight-related problems
◦ Increased patient satisfaction
(Bernstein et al., 2005; Rubak et al., 2005)
SpiritWHAT IT IS:
o Collaboration
o Evocation
o Autonomy Support
o Empathic Response
WHAT IT IS NOT:
o Persuasion
oConfrontation
o Advice-giving
(Rollnick et al., 2008)
Systemic Assessment & Intervention
OARSOpen ended questions:◦ You mentioned you’d like to eat less crap.
What does that mean to each of you?
Affirmations:◦ You have a really tough time keeping your medical appointments, and you’ve made such a
big effort to come here today.
Reflections: ◦ You’re really hoping to improve your health.
Summarizing:◦ Let me see if I understand…
(Rollnick et al., 2008)
Decisional Balance
(Rollnick et al., 2008)
Scalingo On a scale from 1-10…
oWhy not less?• Assess for facilitators
oWhy not more?• Assess for barriers
(Rollnick et al., 2008)
When is MI working?o Change Talk• We really want to have better health.
• Well, I think we could do this one small thing.
o Sustain Talk• Yeah, but…
• I don’t really think that would work for us.
Q & A
Session Evaluation
Use the CFHA mobile app to complete the
evaluation for this session.
Thank you!
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