This paper serves as a proposal for a therapeutic support group for those with type 1, type 2, and gestational diabetes in university/college environment. While a great deal is known about the medical implications of diabetes, those living with the conditions find very few opportunities in which they are able to gain psychological support to help come to terms and cope with the condition. This paper outlines a professional therapeutic diabetes support group, in which professionals would come together to learn more about diabetes and increase compliance and accountability. Over the span of the group, members will learn details about diabetes, learn ways to cope with and fight stigma, and also build rapport and develop a community from which they can obtain support in the future. The aim of the group is to have members end up with a better understanding of diabetes and develop ways to help maintain a healthier lifestyle physically and psychologically.
Keywords: diabetes, type 1, type 2, gestational diabetes, group therapy, therapeutic support group, diabetes stigma, university
University/College Therapeutic Diabetes Support Group Therapy
Diabetes is a medical condition in which your body has issues that cause blood glucose (sugar) levels to rise higher than normal (American Diabetes Association, 2015). There are two main types of diabetes: Type 1 and Type 2. In type 1 diabetes, the body, more specifically the pancreas, does not produce insulin. Insulin is a hormone that is needed to convert sugar, starches and other food into energy needed for daily life. Type 2 diabetes is the most common form of diabetes. With type 2, the body does not use insulin properly, referred to as insulin resistance. At first, the pancreas makes extra insulin to make up for it. Over time it is not able to keep up and cannot make enough insulin to keep the blood glucose at normal levels (American Diabetes Association, 2015). In addition to problems with insulin regulation, diabetes can cause complications with high blood pressure that can raise the risk for heart attack, stroke, eye problems, and kidney disease if left untreated (American Diabetes Association, 2015).
Purpose of Group
The prevalence of type 1 and type 2 diabetes has been increasing worldwide in the last few decades (Unnikrishnan, Bhatia, E., Bhatia, V., Bhadada, Sahay, Kannan, & Sanjeevi, 2008). Diabetes is a growing challenge for health care systems worldwide. Recent estimates have predicted that more than 300 million people will have the condition by the year 2025 (Gomersall, Madill, & Summers, 2011; King, Aubert, & Herman, 1998; Zimmet, Alberti, & Shaw, 2001). These numbers are shocking, and preventions and interventions for diabetes are crucial now more than ever. While the medical field is doing what it can to aid developing these interventions and preventions, assistance from the experts in psychology would help to bolster the effort even more.
While it is known that there is currently a diabetes epidemic, little attention is given to the ever growing young adult population diagnosed with diabetes (Wolpert & Anderson, 2001). Young adults with diabetes face unique challenges as they transition to self-care, and yet they fail to fit into neither pediatric nor adult medicine to help address these challenges. Because of this, they tend to be a forgotten group within the university/college population and counseling centers. University/college counseling centers, according to Gallagher (2014), typically include groups for students struggling with, anxiety disorders, crises requiring immediate response, psychiatric medication issues, clinical depression, learning disabilities, sexual assault on campus, self-injury issues, (e.g. cutting to relieve anxiety), and problems related to earlier sexual abuse.
However, there is a paucity of diabetes support groups in these counseling centers. When they are present, utilization and participation of these groups are low. Many young adults are affected by serious disorders, such as epilepsy, diabetes, or autism, and support for these groups of people on college campuses falls short. People in general tend to close their eyes and are blind to these groups. Research has shown us that these disorders, specifically diabetes, come with a number of negative implications, such as depression, anxiety, and poor self-esteem (Schabert, Browne, Mosely, & Speight, 2013). However, the research is limited in that it does nothing to provide these groups of people with the psychological support they need when dealing with diabetes. For all of these reasons, the need is greater now more than ever for a support group that targets under serviced groups.
The diabetes epidemic is much more of an issue than the public realizes (Schabert et al., 2013). While the above facts give examples of how the medical field acknowledges the severity of the disease, the ways in which the field of psychology and counseling helps to support people with diabetes are few. There is a huge stigma and misconception around diabetes (Schabert et al., 2013). People with diabetes know all too well the reality of living in a world where they are labeled and judged because they have a medical condition. Many people with diabetes experience constant worry, and many consistently face feelings of self-blame, fear, disgust, and feeling the need to fit into societal norms and avoid their disease. They also fear being judged, rejected, and discriminated against due to their condition (Schabert et al., 2013). This concept may give indication as to why compliance and accountability are huge issues with diabetes. People with the diagnosis may be in denial about their condition, where admitting that they have diabetes would mean admitting that there is something wrong with them (more than a medical condition). Because of this, they may be more likely to be noncompliant with their diabetes self-care and have little accountability over the decisions they make. The stigma has been found to cause serious issues with a person’s psychological well-being (Schabert et al., 2013). There is a great shame in people with diabetes; that somehow it is their fault that they have this medical condition. For that reason, therapeutic diabetes support groups need to be established to help people realize that they are not alone in their disease and that it is not a character fault.
The young adult period marks a critical point in a person’s life, where lifelong routines of self-care are set (Wolpert & Anderson, 2001). This presents a window of opportunity to intervene and influence habits that will help maintain good health later in life. For that reason, this paper proposes that we target this young adult group during college and as they start settling into their careers. In addition, the incidence of diabetes is so high and steadily increasing and more people are left with having to come to terms and deal with the ramifications of this condition. A therapeutic diabetes support group would aim at making the transition easier on people new to the diagnosis, as well as allowing people who have lived with the condition for many years to have much needed support. The overall purpose of the group would be two-fold: help with the medical aspects of the condition, such as education on what diabetes is, information about blood glucose/testing, and dietary/exercise information, as well as provide support and accountability to help increase compliance. The focus will be to not only provide emotional and psychological support to those with diabetes, but to help normalize the concept of diabetes and to try to help end the stigma as well.
Type of Group
The therapeutic diabetes support group plans to focus on psychoeducation, skill development, and support for emerging adults with diabetes. Research has found that self-management is the most used approach to diabetes control (Gomersall, Madill, & Summers, 2011). In this self-management approach, patients are awarded the responsibility for managing their illness, for example adopting new diets and regular exercise. To control diabetes, individuals must oversee daily behavior and long-held habits that often have to be changed (Gomersall, Madill, & Summers, 2011). Understandably, this leaves room for the client to curb or even ignore compliance to these guidelines. It has been found that for people with diabetes, adhering to these programs of self-care is often problematic (Nagelkerk, Reick, & Meengs, 2006). In addition to compliance in general, a number of other barriers have been cited to cause problems. The most frequently reported barriers were lack of knowledge of a specific diet plan, lack of understanding of the plan of care, helplessness and frustration from a lack of glycemic control, and continued disease progression despite adherence to the guidelines (Nagelkerk, Reick, & Meengs, 2006). In light of these findings, a support group that focuses on the development of skills needed for diabetic maintenance, as well as psychoeducation on the disease in general, will be the most effective approach in working with this population. The therapeutic support group will focus on developing a collaborative relationship between the facilitator and group members, maintaining a positive attitude that prompts proactive learning, and having a support person who provides encouragement and promotes accountability.
Screening criteria for the therapeutic diabetes support group will be simple but rigid. Members must have a diagnosis of type 1, type 2, or gestational diabetes. The main caveat with this group is that it will aim to be a professional diabetes group. Professionals are people with the standards of education and training that prepare members of the profession with the particular knowledge and skills necessary to perform the role of that profession. For that reason, members should be working graduate level students or professionals in emerging adulthood. Making the group a professional association works to ensure stricter compliance, accountability, attendance, and higher group rapport. The group will have a rolling admissions, and members will be able to pick up where they need. Members can be selected through a referral program or through their job place/college campus.
In addition, each member must have a blood glucose meter or a continuous blood glucose monitoring system readily available. They must have access to a computer and/or smartphone for tracking of blood sugar levels. There will be a strict attendance policy due to the fact that compliance and accountability are key components of the group. Missing a session will result in termination from the group (extenuating circumstances will be evaluated on a case by case basis). Members must agree to these conditions and sign a contract at the beginning of the initial session. Finally, research has suggested that “stage of change” may be a good predictor of attendance at diabetes prevention and intervention sessions and have implications for intervention design and assessment (Helitzer, Peterson, Sanders, & Thompson, 2007). Because of this, the group should include only people in at least the preparation stage of change. The stage of change model explains that there are five stages a person goes through when they are making a behavior. The stages include pre contemplation, contemplation, preparation, action, and maintanence (Prochaska & DiClemente, 1983). The success of the group will be based heavily on each member’s willingness to change and devotion to the rules and regulations of the group. An evaluation by the member’s therapist, doctor, and/or an interview with the group facilitators as to what stage of change the client is believed to be in will be necessary for admittance into the group. This will help ensure a higher chance that the members will attend the sessions and therefore have higher chance for success with compliance.
Role of Group Leaders and Facilitation Issues
The biggest facilitation issue will be the compliance and attendance of the group members. Because of this, the attendance policy will be very strict and groups will run weekly. The group should include a small, even number of people – preferably around six. There will be two group leaders. One should have diagnosis of diabetes themselves, and the other should be a person without diabetes who can act as a neutral, non-invested party. At least one should be therapist as well. The role of the group leaders will be to facilitate group discussions, answer questions, hold group members accountable, and provide support.
Methods and Techniques
Each session will begin with the group leaders checking in with all of the members and discussing any issues that arose from the previous week. Every session will focus on a specific topic surrounding diabetes maintenance. The group will be highly collaborative in nature, and each session topic for the following weeks will be picked by the group in the first session. Topics may include things like diets and exercise, psychoeducation on diabetes, how to maintain accountability and compliance, blood glucose meter training, and tracking of blood glucose levels. When appropriate, the group leaders will arrange a guest speaker to come into the session to discuss that week’s topic. This may include help from a dietician, for example, where every group member will be given their own personalized diet plan to follow.
In addition, medical specialists in the field of diabetes will come to educate the group on what diabetes actually is and the science behind what is going on in the body. A session will be devoted to the discussion of the psychological and emotional impacts of diabetes and how to cope with them. A nurse practitioner will attend one session to administer initial blood glucose readings (to serve as a baseline for comparison after the group has ended) and demonstrate proper use of blood glucose meters, as well as appropriate times to test blood glucose throughout the day (typically 1-2 hours after meal times). A personal trainer will attend one group to educate the members about the importance of physical activity and will help each member develop personalized exercise routines. Finally, a guest speaker will come teach the group how to track their levels in a smartphone/computer app. The members will then be able to bring their results to session every week for analysis and discussion. This will also serve as data throughout the length of the group.
Accountability will be the main component of this group. Within the group itself, everyone will be paired up with another individual. In addition to the accountability to the entire group, each member will form a therapeutic alliance with their own personal partner to further facilitate compliance. Weekly check-ins with the therapeutic partner (in addition to the actual group meeting) will be necessary. Further, members should utilize their therapeutic partners on an as needed basis throughout the week for added support. Every group member will also be given the group leaders’ contact information as a last source of support. The group leader will focus on one member every week to stay accountable to and will check in with this person daily.
Duration of Group and Expected Outcomes
Depending on the number of topics selected by the group in the first session, the group will run anywhere from 8-12 weeks. Sessions will be on a weekly basis on the assigned day and time. They will be held in the evening or on weekends to accommodate the members. After the group has ended, it is hypothesized that compliance and accountability towards their diabetes maintenance (adherence to diet, exercise, blood glucose monitoring, etc.) will increase. In addition, the members’ levels of depression, anxiety, and stress involving their diagnosis are hypothesized to decrease. Overall health and well-being (as reported in self-report form and in regards to weight loss, stamina, and overall better sense of self) is expected to increase. Finally, it is hypothesized that there will be a decrease in the overall average blood glucose levels.
Process of Evaluation
Evaluation will take place in the form of self-report, scales, and data collected throughout the span of the group. At the end of the group, the members will submit journal entries detailing their progress and how they feel the group has helped them. Depression, anxiety, and stress will be measured using pre and post scores from the Beck Depression Inventory, the Holmes-Rahe Stress Inventory, and the Health Anxiety Inventory. In addition, the data collected from each member’s smartphone/computer app will be analyzed to review the overall progress of each member and the group as a whole. The more precise blood draw taken by the nurse practitioner to measure blood glucose levels pre and post group will be used in addition to the data collected personally by the members to ensure that their true progress is calculated, and to counteract any deception by the members on their personal recording of levels. Finally, attendance and a self-report of the number of compliance days (diet, exercise, check-ins with partner, etc.) will be recorded as a final measure to check for compliance and accountability.
The aim of the therapeutic diabetes support group is to end with a better understanding of diabetes and how to best maintain a healthy lifestyle, both physically and psychologically, as well as to increase compliance and accountability. Through psychoeducation and a better medical understanding, the group members should be able to combat the stigma against them in better ways. Hopefully, they will be able to spread strength, knowledge, understanding, and positivity to help end the stigma altogether. By using a model of professionals with diabetes, the hope is that there will be more compliance and accountability. These concepts are extremely important in the initial stages as the group in general as it is just starting out. As the number of cases of diabetes continues to increase, creating a group that will help this population is critical. The proposed group will help people to come to terms with their diagnosis, get the emotional and psychological support they need, and ultimately end the stigma.
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