Edited by Frank J. Snoek and T. Chas Skinner
Diabetes in Adolescents
2.3 Individual Interventions (Part 2 of 2)
Diabetes poses considerable demands on the young person’s coping, self-esteem, mood and quality of life.
Once a decision has been taken to change, then implementing the desired behavior depends on several factors. A taxonomy of conflicting goals will be occurring in the young person’s social circle, thinking and behaviors. Although a young person may shrug off the complexities of, for example, increasing the frequency of injecting insulin from twice daily to four times daily, complex intra- and inter-personal processes will be guiding the young person in adopting novel behaviors.
One strategy that has been used and received very positively by adolescents was voicing commitment to change, by discussing ‘the journey of change’. It is a genuine attempt at understanding how the young person adapts to and copes with change in all different areas of their life, e.g. learning a new sport or musical instrument, coping with exams, etc…. This hopefully enables them to reflect on their strengths and previous successes and failures. Again, the aim is to put diabetes in the context of other aspects of their life in a constructive way.
This strategy attempts to examine the underlying ‘how’ of the change trajectory based on the idea, formulated by Bandura,124 that people cannot influence their motivation and actions very well if they do not pay adequate attention to their own performances, the conditions under which they occur and the immediate and distal effects they produce. The strategy taps into the self-regulatory notion of volition or trying 125,126 by unpacking the processes of goal progress monitoring and efficacy coping, to understand how the young person overcomes implementation problems such as putting goals into practice. It is an attempt to understand and reflect on the young persons’ ‘how’ of adapting to change, compared with the ‘what’ they are going to change. In making these processes tangible, the young persons are able to examine their own barriers to change, successes they have experienced and how they maintain their patterns of behavior and also prevent relapse.
Part of the discussion of previous experiences of change will include the role that other people have played in facilitating or impeding the process. Discussing their preference for a ‘coach’, ‘teacher’ or ‘parent’ alongside them will help them think about what they need to help them move on and specifically the nature of the relationship with the counselor. This collaborative strategy needs to be implemented when trust and rapport have become established, and when the young person is voicing commitment to change. It can facilitate problem solving and goal planning, and build on confidence.
Importance, confidence and readiness
A core strategy of MI incorporates the concepts of importance, confidence and readiness.127 The assessments of these values are presented on linear scales of gradations between 0 to 10 (with 10 being the highest value). Miller and Rollnick108 suggest that the importance or personal valence of changing must be explored against the ability or confidence to change. The underlying principles tap into self-regulatory theories such as Bandura’s 128,129 self-efficacy model, and the theory of reasoned action of Ajzen and Fishbein.130 The health action process model of Schwarzer and Fuch126 offers health cognitions analogous to these dimensions (with importance paralleling outcome expectancies and confidence paralleling efficacy beliefs).129 The distinctions between the three constructs are useful heuristics and have practical applicability in consultations. Rollnick et al.127 argue that having established a numerical value for the person’s values, this sets the stage for the person thinking hard about change. It also helps the counselor consider with the client the nature and focus of their involvement. If a professional asks a young person how important it is to them to make a particular change and how confident he or she is (using a 0–10 scale) then this can be used to inform how to take things forward. For example, a score of nine on importance and three on confidence should lead to a discussion that will be focused on building confidence. If the scores are reversed, then motivation to change is low so exploring the pros and cons of change might be the way forward, or it may be best to concentrate on other areas of change first.
Once change has been decided upon, the next step is to slowly and constructively develop a plan for change. The counselor steers the process with maximal patient autonomy. It is beneficial to draw on the experiences of change plans from other adolescents in the study and what has/has not worked for them. This allows social comparison with peers and assessment of their own beliefs and sense of efficacy. It requires careful thought on the part of the adolescent as any goals set should be realistic, achievable within a short time span, measurable and evaluative. Thus, a certain degree of help is required in negotiating a suitable and workable plan. The young persons may still have some conflicting feelings about change, and it is important to respect their wishes and difficulties, working at their own pace. Working with teenagers will occasionally bring the counselor into consideration of risk behaviors, particularly as part of the teenager’s social interaction, which brings with it its own ethical dilemmas.
Over the last decade there has been a trend in the adolescent literature to focus more on intervention studies. Furthermore, these studies seem to have responded to the criticisms in the published reviews, with most articulating a clear theoretical rationale for their intervention methods, and predominantly using randomized trial designs. The value of supporting parents and adolescents to negotiate their way through issues around the transfer of diabetes care responsibility continues to receive support. This work can be done in small groups, or with individual families, and positive results have now been demonstrated by two independent research teams. Interventions with individual adolescents have also continued to develop. Where the intervention has targeted the specific needs of a specific population, those starting on intensive insulin regimens, the results have been very positive. However, generic approaches continue to produce results that show trends toward positive effects, but the studies would appear to be underpowered. Clearly there is a need for more multi-centre working on these generic approaches, if large enough samples are to be secured to generate robust results. The one thing that does continue to be consistent throughout this literature is that many of the programs, either explicitly or implicitly, use approaches that are designed to enhance self-efficacy. Therefore, for health care professionals, understanding the role of self-efficacy or confidence and how to support it seems to be one key to productive working relationships with adolescents and young people with diabetes. However, it is important to remember that the techniques to develop self-efficacy (mastery experience, modeling, verbal persuasion and emotion regulation) are not sufficient to facilitate change. For these techniques, or any other psychological educational intervention, to work, they must be accompanied by appropriate attitudes and qualities from the professional. The simplest way to summarize these qualities is acceptance (of the person, regardless of their behavior and beliefs), respect (for each individual’s decision; everyone makes the best decision they can to optimize their quality of life, given their perception of their situation), curiosity (to genuinely understand the world the young persons live in, their thoughts and feelings, which drive their decisions) and honesty (about what you as a professional think and feel, and why you hold the beliefs you do). In many if not all therapeutic relationships these qualities are more important than particular techniques or strategies used by the professional, and these should be a priority for professional development.
Next Week: 3.0 Psychological Issues in the Management of Diabetes and Pregnancy
124. Bandura A. Self-efficacy. The Exercise of Control. New York: Freeman, 1997.
125. Bagozzi RP, Edwards EA. Goal setting and goal pursuit in the regulation of body weight. Psychol Health 1998; 13 (4): 593–621.
126. Schwarzer R, Fuchs R. Changing risk behaviors and adopting health behaviors: the role of self-efficacy beliefs. In Bandura A (ed.), Self-Efficacy in Changing Societies. New York: Cambridge University Press, 1995, pp. 259–288.
127. Rollnick S, Mason P, Butler C. Health Behavior Change: A Guide for Practitioners. London: Churchill Livingstone, 1999.
128. Bandura A. The explanatory and predictive scope of self-efficacy theory. J Soc Clin Psychol 1986; 4 (3): 359–373.
129. Bandura A. Exercise of personal agency through the self-efficacy mechanism. In Schwarzer R (ed.), Self-Efficacy: Thought Control of Action. Washington, DC: Hemisphere, 1992, pp 3–38.
130. Ajzen I, Fishbein M. Understanding the Attitudes and Predicting Social Behavior. Englewood Cliffs, NJ: Prentice-Hall, 1980.
For more information on this book, just follow this link to Amazon.com, Psychology in Diabetes Care (Practical Diabetes).
Copyright © 2005 by John Wiley & Sons, Ltd.