January 7, 2013

Type 1 Diabetes + Food & Body Issues + Social Media + Creativity = VIAL Project

I’m 18 months into my doctoral program, and so far so good. It still feels like an eternity until I’ll be done… hoping for 2015, but more likely, I’m guessing 2016. Either way, I’m trying to not focus too much on when I’ll be done with the program, and looking more short-term at completing each assignment and project as they’re due. The big project I will tackle beginning in the fall is my dissertation, but before that, I have to complete a smaller research project, a pilot study, which will be the foundation for my dissertation.

When I decided to return to school, I knew I wanted to study diabetes and art therapy, but was unclear about what direction to go until last spring when I committed to researching diabetes and eating disorders. As someone who is recovered, I have years of experience attesting to lack of knowledge, awareness and sensitivity, insufficient treatment options, and what I have often perceived as an utter disregard among too many healthcare providers for just how easy it is to get all screwed up over food and body image when you have diabetes. I now feel a moral, ethical, personal, and professional obligation to address those problems I experienced as a patient, problems that too many other people with diabetes have also experienced, problems that are preventing many people from overcoming the food and body issues that plague them.

VIAL Project

That brings me to my pilot research project: VIAL Project.

VIAL is an acronym for Voice ~ Insulin ~ Art ~ Life, and VIAL Project combines some of the building blocks of my diabetes advocacy work – social media, creative self-expression, and food and body issues – into a social networking website for people with type 1 diabetes, and food and body issues to share original, arts-based work (art, photography, creative writing, video, etc.), and connect with each other online. Because this is a research project, I will be collecting and analyzing user-submitted content, including all creative expression, posts and comments, to identify themes that emerge. My objective is to increase understanding of website users’ experience: having type 1 diabetes and food and body issues; creating and sharing arts-based work on the website; and using a social media platform to connect with others who have type 1 diabetes and food and body issues.

For the sake of this project, food and body issues cover a range of behaviors and experiences, including: overeating; stress eating; eating to avoid hypoglycemia; insulin omission or manipulation; restricting food; feelings of dissatisfaction, anxiety, anger or depression about one’s body; anxiety about food; binging; purging; use of medications such as diuretics, laxatives or weight loss supplements (not approved by a healthcare provider). Food and body issues can be mild to severe, including: behaviors and feelings connected to food and body image, causing mild to moderate psychological distress, with minimal interference with one’s daily functioning, possibly affecting diabetes management; disordered eating that is more significant, causing some disruption to daily functioning, affecting diabetes management, and posing some health risks; clinical eating disorders, diagnosed by a mental health professional.

If the results of this pilot research are promising, it is my goal to develop my dissertation research based on the results, and continue using the website as a platform for conducting research. The research on diabetes and eating disorders has grown over the years, but there is so much room for new understanding, and a great need for investigation into how to help people.

It is also imperative that more is learned about how to reach and engage people with type 1 and food and body issues because the shame and distress they experience can lead them to isolate themselves, avoid healthcare providers, and be secretive about unhealthy food and diabetes management practices. This is actually one of the primary reasons I wanted to create a website for my research, as opposed to doing more traditional clinical research with participants in person. I hope those people who might be reluctant to participate in research in person, might be more willing to participate online. I hope my research will offer new insight into these areas of need, in addition to shedding light on the qualitative experience of individuals with type 1 who struggle to make peace with their body and food.

Since my data will consist of user-submitted content, without content, I have no data. Without data, I have no research, and without research, I will have to shift the direction of my doctoral work. I am very passionate and invested in studying this topic, and I believe there is great potential for this research to not only help people in the long term through development of interventions, but more immediately, I think a dynamic community that encourages and promotes the use of creativity to cope with the difficulties of having type 1 diabetes and food and body issues could potentially benefit users of the VIAL Project website.

The success of this project depends on people registering and participating on the website, so I’m looking for the DOC’s support and help with their wildly effective viral power. First, if you have type 1, you are at least 13 years old, and you have any food and body issues, as described above, I hope you will register as a user, and participate on the website. If this doesn’t describe you, but you know someone who might be qualified, I hope you will share the project information with them. Lastly, regardless of whether or not you feel like the site might be helpful for you, I hope you will share the information because maybe one of your FB friends, twitter followers, blog readers, or other DOC connections are struggling to some degree, and this is a resource they can use. In addition to the actual project website, VIAL Project also has a presence on Facebook and twitter, which isn’t much to see yet, but in time, I hope they’ll be a reflection of the activity on the website.

I have until late spring to collect my data, which isn’t a generous time frame to build a social network, so I’m reaching out to anyone and everyone I know to put this on the fast track. The more people that register and use the site by late spring, the more data I will have to support my more in-depth dissertation research. The getting-started, getting-people-interacting, and getting-people-making-and-posting-creative-work parts of this project are going to take a big push, but I hope that if you join me in promoting this research, the website will come to life, my research will come to life, and in time, each person who is struggling with type 1 and food and body issues can create the healthful life they deserve.

VIAL Project

VIAL Project: Voice Insulin Art Life

Informed Consent

Like all research, the protection of participants is my priority. If you are interested in joining the site and participating in the project, you are strongly encouraged to carefully review the Terms of Service on the website, which include Informed Consent. By joining the site, you are agreeing to the Terms of Service and providing Informed Consent. By agreeing to the Terms of Service, participants understand that:

• I am volunteering to register and participate on a social media website with a focus on creative expression for people with type 1 diabetes who have disordered eating behavior.

• I will be submitting original, creative works that reflects my experience with diabetes and/or food and body-related issues.

• I am responsible for protecting my identity when submitting public content on the website, including, but not limited to profile photo and username, to the extent that I want to remain anonymous.

• User-submitted content, including posts, comments, profile information, visual artwork, creative writing, audiovisual materials will be used anonymously for purposes of supervision, presentation and/or publication.

• Participating on the website may bring up feelings, thoughts, memories, and physical sensations, either comforting or uncomfortable. I can participate on the website to whatever degree I am comfortable. If I experience significant emotional distress, I know that I can refrain from using the website. If my emotional distress is severe and I feel I am in danger, I have been advised to contact local emergency services in my community.

• This study may or may not benefit me. I may experience increased self-knowledge and personal insight that I may be able to use in my daily life. The results of the study may also help to increase public and professional awareness of the needs and experiences of people with type 1 diabetes who have disordered eating.

• All confidential information collected at registration that is not public will be kept on a password protected computer in the researcher’s possession for possible future use. However, this information will not be used in any future study without communication from the researcher and my electronically submitted consent.

• The researcher/therapist is ethically bound to report, to the appropriate party, any criminal intent or potential harm to self.

• I may choose to withdraw from the study at any time with no negative consequences.

July 22, 2010

Shoe Obsession

Filed under: Complications,Health Care,Research,Wellness — Tags: , , , — Lee Ann @ 7:55 pm
One in black, one in brown

One in black, one in brown

There’s this stereotype about women and shoes, and I’m pretty sure it exists because stereotypes exist for a reason. I’ve known women who would proudly offer to be the shoe whore, pardon the expression, poster child, given the chance. If TV and movies have taught me anything – and to be honest, I’ve gotten many life lessons via the big screen and the boobtube – it’s that these women who have a ‘thing’ for shoes, have closets lined with footwear, in every color of the rainbow, in every imaginable material from leather to fabric to plastic to reptile skin *gasp cry*. Ballerina flats, boots, clogs, espadrilles, huaraches, mules, pumps, stilettos, t-straps, wedges, you-name-it.

I am not one of these women. I have diabetes, and it was been drilled into my head from at least as far back as the time I was 6 years old that I should take meticulous care of my feet, and as part of that mission, stick to practical shoes. I have not always done the best job. I have purchased shoes because they were cute, not because they were comfortable. I got a pedicure before my wedding, although that was the first and the last one I ever got. I have gone barefoot, although I do it infrequently, even in my house. Taking care of my feet in the interest of not losing my most favorite dancing partners has certainly informed my foot care choices and my footwear purchases as long as I can remember, but more so as I’ve gotten older.

Now that I’m, well, older than I used to be, I have some kind of weird foot issue that I didn’t used to have, something about the connective tissue between the bones that keeps my feet from flexing all the way, more so in my right foot than my left. So in addition to diabetes, I have to take this flexing quirk into consideration too because I now have difficulty keeping some kinds of slip-on shoes securely on my feet, especially when I’m doing a lot of walking. Most of the sandals I own are slip-on, so as I prepared to go to Florida back in June, knowing I’d be doing quite a bit of walking, I decided I needed to find some sandals that would stay on my feet more securely than those that I already have.

I found some brown sandals in the spring that might as well have been custom-made for me, Doc Marten’s with that nice thick supportive flat sole that is characteristic of Docs, the ankle strap I sought, as well-constructed as a shoe can get, and very foot-friendly. Except for running shoes, which I should note, I don’t actually use to run, I’m very particular about having both a black version and a brown version of the shoes I buy. I won’t necessarily get the exact pair in both colors, but I try to find similar styles, one in each color because one or the other will match just about anything I might wear. I’m a little neurotic in this respect, but I’m OK with that.

Brown sandals that make me happy

Brown sandals that make me happy

Since I found the casual pair of ankle-strapped brown sandals I loved, I figured how hard could it be to find a black sandal with similar characteristics? I’m pretty sure black is the most popular sandal color, and surely, in a shoe store, a department store, or online, I would find the black sandal sister of my new brown sandals.

It was not to be though. One of the main problems I encountered was that the “in” style this summer has been gladiator sandals, and no offense to those who like and wear them, but I can’t stand them. It seems that a characteristic of gladiator style sandals is a very thin sole, and I don’t do thin soles. They’re not comfortable, even a little bit, they aren’t good for your feet, and by default your legs and back, because there’s no support. Also, thin soles mean your feet are less protected from the things on the ground that could be hazardous to your feet, such as rocks or sharp objects. Besides the issues I have with the soles, I dislike how the straps creep all the way up the foot. While I was in search of a sandal with an ankle strap, I am not a fan of these weird sandals with straps that go up the leg, or those ones with ankle cuffs which are atrociously hideous in my opinion. The ubiquitous flip-flop wasn’t an option for me either. I have a pair that I keep by the backdoor in case I need to step outside, but I know they’re crappy footwear, so I wouldn’t wear them more than that. I like what I like, and I don’t like those sandals, which unfortunately meant I had a rather limited selection from which to choose.

In June, I went for my regular podiatrist appointment. Because of the aforementioned problem with the range of motion when I flex my foot, I get an obnoxious callus on my right big toe. I try to doctor it up between visits, especially in the summer when my feet are visible, but having gotten myself into quite the pickle when I doctored up my feet in the past, I’m very conservative in my actions, leaving the real doctoring to the doctor.

One in brown, one in black

One in brown, one in black

I know quite a few diabetics get pedicures to remedy unsightly problems like calluses or other dead skin, and swear that their pedicurist’s instruments are sterilized and the salon is clean, etc., but except for that single visit I made before my wedding, for which I had considerable misgivings given that I knew better, I steer clear of pedicurists. I know a woman, not diabetic, who got one at a nice, new salon a few months ago, and ended up with such a nasty infection for which she ultimately needed surgery. Leading up to that she had to see several doctors, one of whom suggested she might have to kiss her toe goodbye due to a possible bone infection. I had become pretty adamant in my anti-pedicure position before, but after hearing about that pedicure-gone-wrong, now I’m that much more opposed to them, but that’s just me, and my personal, obviously conservative approach to diabetic foot care.

So my podiatrist and I were chatting, and knowing she would sympathize and understand my footwear dilemma, I told her how unhappy I was with this season’s selection. She exclaimed, “Oh, I know!” and I felt validated, having found someone who shared my shoe shopping pain. She told me how she ended up spending over $100 on a pair of sandals, far more than she would normally spend, because she too hadn’t been able to find a decent pair. I told her how I have a couple of pairs of Skechers slip-on sandals that I love, and I had hoped Skechers might offer something similar with an ankle strap, but this year their sandals aren’t to my liking at all, except for one pair that was from their Shape-Ups line that more or less met my admittedly unspecific criteria for the perfect sandal.

Now, if you aren’t familiar with Shape-Ups, they’re a line of mostly sneakers, but also some sandals, and they have a sole that’s rounded so when you wear them, you’re never quite planted firmly on the ground. Skechers asserts that you’ll get a better workout wearing these shoes because you’ll “burn more calories, firm muscles, and reduce joint stress”. When I first saw them in sneaker form, I didn’t think much of them aesthetically, and I couldn’t help but raise an eyebrow at the claims because, c’mon, they’re sneakers, not a personal trainer hovering over you while you workout!

OK not great black sandals

OK not great black sandals

My podiatrist, who I absolutely adore because she takes wonderful care of my precious feet, scoffed, and told me to stay away from Shape-Ups. She said that of the patients she had seen who were experiencing foot problems that seemed to be related to wearing Shape-Ups, all of them were diabetic. Most of her patients are older, as you might imagine, and I think it’s a fair assumption that most of her diabetic patients are type 2, so they’re more susceptible to foot problems than the typical younger people with type 1 for whom peripheral neuropathy isn’t a pressing issue, but regardless, I thought it was telling anecdotal evidence that Shape-Ups aren’t all Skechers would like consumers to think they are. As it turns out, the American Council on Exercise did a some research, and it doesn’t think much of Shape-Ups or comparable lines of footwear either.

While the Sketchers sandals I had eyed were the closest I had seen to meeting my structural and aesthetic requirements, minus the Shape-Up sole, my doctor’s recommendation knocked them off the list of contending sandals. That left me with no sandal candidates though, so it was back to searching.

Jason, who is an eternally good sport, accompanied me on several shopping trips to find a pair of sandals I liked, and as if channeling Goldilocks, not a single pair was quite right. He’d point or pick a shoe off a shelf, holding it for me to inspect, and he’d get, “Too dressy, too dainty, the sole’s too thin, the straps are too thin, the heel is too high, the toe is too narrow, too enclosed, too 1983, I don’t like that metallic decorative thing, too shiny.” I had a reason for dismissing every pair. Eventually, he gave up trying to help me, although we did find a new pair of sneakers for him.

The day before I left for Florida, I schlepped back to the mall, determined to get a pair, even if that meant getting sandals that didn’t quite meet my apparently impossible expectations. Having reached defeat by the stylistas who decided ugly sandals should be the rage this season, I settled on a pair that I like for the most part. They’re not as sporty or casual as I was hoping to find, and sole isn’t as thick as I would like, but I’ve been wearing them on occasion nonetheless, and will continue to do so until next season when I dearly hope cute sandals are in style again.

June 10, 2010

Nourishing a Good Cause

As many of you are well aware, there are a few issues that are near and dear to my heart, and of those, eating disorder awareness hovers close to the top of my list, especially as this serious condition relates to people with diabetes. I know it’s not a global area of concern to the diabetes community, no more than it’s a global area of concern in the eating disorder treatment and advocacy community, but I think we should all be concerned that an estimated third of girls and women with type 1 diabetes have manipulated their insulin, a practice that has been shown to lead to increased risks of developing retinopathy and neuropathy.

There was a tsunami of media attention when insulin omission or diabulimia became the health topic du jour a few years ago, but the tidal wave has gradually become but a trickle, and now it’s little more than yesterday’s news. If it doesn’t affect you on a personal level in some way or another, it might not feel like there’s any more to say, write, or read about it, but it’s a serious problem that deserves ongoing attention because, media attention or not, it persists among diabetes patients. While the TV cameras and journalists have moved on to other subject matter, people with diabetes continue to manipulate their insulin to control their weight, and exhibit unhealthy behaviors related to food, body-image and diabetes self-management, behaviors that range from mildly concerning to downright pathological and potentially lethal.

Just as many of us would go out of our way to help another diabetic (or caregiver) who might be in need of supplies, advice on diabetes gizmos and gadgets, or any of the countless ways that we help and are helped by the DOC, once someone becomes entrenched in the behaviors and belief system that both characterize and fuel diabulimia, we all have a role we can play in their recovery.

We can offer kind words and support if they reach out in one of the many diabetes communities to which most of us belong. We can share our own experiences with trying to find balance with a disease that by nature, seems to sabotage the most earnest of efforts to live harmoniously and intuitively with food, and can leave you with the sense that your body has a mind of its own. We can offer links to helpful websites or treatment resources. We can also support research that will eventually lead to treatment and prevention because too many of our own are suffering, and too many treatment providers have just dismissed them as non-compliant or brittle, a term that makes me roll my eyes every time, because they don’t recognize the problem for what it is or don’t know how to treat it.

While there is not a ton of research being done in this special area, Dr. Ann Goebel-Fabbri, a psychologist with Joslin Diabetes Center in Boston and professor of psychiatry at Harvard University, has been studying insulin omission amongst type 1 diabetics for years now. While there is room for improving the level of awareness, without her work, the awareness about eating disorders and diabetes wouldn’t be what it is today.

There is so much more to understand though, so towards that goal, Dr. Goebel-Fabbri will be running in this year’s Litchfield Hills Road Race, on June 13th in Litchfield, CT to raise funds for Joslin’s Women’s Behavioral Health Fund. So far, the Women’s Behavioral Fund enabled her to travel to the ADA conference in New Orleans last summer to present on the topic of diabetes and eating disorders, a problem that continues to befuddle most medical teams who almost inevitably encounter patients practicing insulin omission. The fund went towards the purchase of academic books on eating disorders to train a Joslin dietician on treatment of eating disorders. That dietitian now has a portion of her time dedicated to the Joslin eating disorders team. The funds have provided for the allotment of time for providers to discuss difficult situations and receive treatment suggestions from the eating disorders team. Additionally, it’s allowed Dr. Goebel-Fabbri to analyze more data on her 11 year follow-up study to create a manuscript that will be submitted for publication soon. This manuscript looks at women who recover from insulin restriction and women in whom the problem emerged in that 11 year period – a naturalistic follow-up to track new onset and recovery.

Dr. Goebel-Fabbri also shared some of the projects she is hoping to pursue in the future as the funding becomes available. She would like to do qualitative research on both women and men with type 1 who have recovered from insulin restriction and an eating disorder. Garnering an understanding of the factors that led to recovery would provide insight into how to tailor treatment for others battling this problem. She would also like to report on the effectiveness of new treatment strategies being used by patients to recover from eating disorders. Longer term, Dr. Goebel-Fabbri is hoping to compile the research into a book that includes real stories of recovery, a resource that is sorely needed by doctors and diabetes clinicians for whom there are few resources to help them understand and treat this serious condition.

The run is this Sunday, but please note, she will be fundraising through the summer to help build the Women’s Behavioral Health fund. Please consider contributing whatever you’re able to give. Her work will help so many individuals with diabetes struggling to overcome food and body issues, and when those people find their respective paths to recovery, the entire DOC and global diabetes community will be that much stronger and our voice will be that much louder.

September 10, 2009

Thesis Thursday: 19

Thesis Thursday, a weekly series of consecutive sections from my master’s thesis, Art Therapy with Type 1 Diabetic Adolescents, Non-Adherent to Treatment: A Literature Based Study, will be coming to a close next week. Last week, I presented Clinical Applications from Chapter 5: Discussion. The follow-up and final section of Chapter 5 includes Implications for Future Research and Proposal for a Small-Scale Study.



Implications for Future Research

It is proposed that research into the use of art therapy with type 1 diabetic adolescents be implemented, as a new means of addressing a persistent problem that is the source of frustration for clinicians who work with this population, and who are frequently left scratching their heads in search of an effective approach.

Because art therapy with diabetic adolescents has not been researched, small-scale studies exploring the relationships between this treatment modality, the self-management behaviors of this population, and health outcomes could be developed and implemented. The results of such studies could then be examined for trends and larger scale studies could be developed. Both quantitative and qualitative methods have potential application. The synthesis of the results of multiple studies would allow researchers and clinicians to develop and implement effective treatment strategies using art therapy with non-adherent type 1 diabetic adolescents.

Proposal for a Small-Scale Study

A qualitative multiple case study is proposed to assess the general response to the method of treatment, art therapy, from both the adolescents’ and the art therapist’s perspective. One reason for choosing this type of research format is that “evidence from multiple cases is often considered more compelling” (Yin, 1994, p. 45) than a single case study format. Verhoef, Casebeer and Hilsden (2002) identify purposes for using qualitative research methods: (1) “gaining an understanding of an intervention by identifying the meaning of the intervention for the participants” (p. 276); (2) “understanding the particular (natural) context within which the participants act, and the influence that this context has on their actions”, an important part of which is “identifying the role of the patient-provider interaction in the intervention” (p. 276); (3) “understanding the process by which events and actions take place” (p. 276); and (4) “assessing how perspectives of reality of different stakeholders (patients, practitioners, and researchers) on interventions differ” (p. 277).

While the benefits of a group therapy format have been reviewed, because there have been no studies on the application of art therapy with diabetic adolescents, it is recommended that the preliminary study be conducted individually. The reasoning is that it is important to garner a more thorough comprehension of the variety of issues each individual might have. To construct a potentially effective group art therapy protocol, there should be an understanding of the type of individuals and the range of issues each might contribute to a group. It is thought that an adolescent might be more disclosing on an individual basis once a therapeutic alliance begins to take form. With the knowledge of the more personal aspects, fears and concerns that a diabetic adolescent might be experiencing, an art therapist conducting group art therapy can more effectively present tasks and negotiate the dynamics of a group.

Four to six adolescents, who have been identified by their healthcare providers as non-adherent to self-management tasks, would be recruited from a larger urban medical center offering specialized multi-disciplinary pediatric endocrinologic services. It is suggested that a short treatment course of ten individual sessions be implemented. Ten sessions would provide more time for the adolescent and therapist to establish a therapeutic alliance, essential if the adolescent is to trust the therapist and feel comfortable with self-disclosure. Additionally, the number of sessions would allow the therapist and adolescent the opportunity to execute and process as many art therapy tasks. The number of sessions would be limited to ten because the lengthier the study, the higher the risk of drop-out by the participants. Each session would involve the presentation and completion of a task that addresses some aspect of diabetes or has a diabetes-related theme. A selection of materials would be offered for most sessions in order to give the adolescent choice and an increased feeling of control. Tasks for inclusion are:

  • Session One: Draw what it feels like to have diabetes. Materials provided would be a range of drawing materials, structured to less structured, including pencil, colored pencils, markers and pastels. The purpose of the task is to gain some understanding of how the adolescent feels about his diabetes. The artwork serves as a vehicle for verbalizing these feelings as well as an outlet for expressing these feelings in a non-verbal format. The therapist has the opportunity to begin to establish a therapeutic alliance by being accepting of the artwork and the associated feelings, and empathizing with the adolescent.
  • Session Two: Draw yourself managing your diabetes. Materials provided would be a range of drawing materials, structured to less structured, including pencil, colored pencils, markers and pastels. In addition to further establishing a therapeutic alliance by showing an interest in and an understanding of the work involved with managing diabetes, the therapist gains insight into the adolescent’s investment in and understanding of self-management. The artwork can serve as a springboard for discussing the particular aspects of self-management that the adolescent finds most troublesome.
  • Session Three: Draw yourself and your family doing something related to your diabetes management. Materials provided would be a range of drawing materials, structured to less structured, including pencil, colored pencils, markers and pastels. The therapist gains insight into the relationship between the adolescent and her family, both in a general sense, and also how diabetes plays a role in the relationship. The adolescent has the opportunity to consider and discuss the role her family plays in the management of her diabetes.
  • Session Four: Draw how your diabetes affects your social life. Materials provided would be a range of drawing materials, structured to less structured, including pencil, colored pencils, markers and pastels. The adolescent can consider and discuss the impact diabetes has on social relationships and activities, and express associated feelings, as well as identify solutions to perceived problems. The therapist gains insight into how the adolescent sees himself in a social context, and how diabetes relates to this, and she can assist the adolescent in identifying conflicts and possible solutions.
  • Session Five: Draw any fears or concerns you have about your diabetes. Materials provided would be a range of drawing materials, structured to less structured, including pencil, colored pencils, markers and pastels. Now that the adolescent and therapist have a more established therapeutic alliance, this more sensitive topic can be explored. Fears associated with diabetes and both the present and the future can be examined together. The therapist can validate the fears, then assist the adolescent in reality-testing those fears and concerns. Methods for coping with those fears can be considered.
  • Session Six: Using clay, represent yourself in relation to your diabetes. Using a concrete material to represent an abstraction, the adolescent can create a sculpture, which will allow him to objectify this relationship. The therapist can help the adolescent to identify unconscious feelings that might ultimately be interfering in his ability to have a ‘healthy relationship’ with his diabetes.
  • Session Seven: Create a collage of life with diabetes and life without diabetes as you recall it or as you imagine it. Materials provided would be magazines about diabetes with advertisements for diabetes-related products, and magazines of interest to adolescents, scissors, glue-stick, and a selection of more structured drawing materials (pencil, colored pencils, markers) to offer the adolescent the option of adding their own personal content to augment the magazine images. This task can serve as an expression of loss for the life the adolescent no longer has or cannot have without diabetes. The therapist can help the participant process feelings of sadness and anger associated with this loss. Magazine collage allows the adolescent to project onto the imagery, and the highly structured materials are conducive to maintaining defenses when dealing with potentially sensitive ideas and feelings.
  • Session Eight: Draw the pros and cons of mismanaging your diabetes. Materials provided would be a range of drawing materials, structured to less structured, including pencil, colored pencils, markers and pastels. This task lets the adolescent visually weigh the advantages and disadvantages of mismanagement. Objectifying the consequences of mismanagement can make the risks seem more personally relevant, and thus worth more in depth consideration. The therapist can assist the adolescent in processing feelings about the pros and cons, and in identifying solutions.
  • Session Nine: Draw the pros and cons of managing your diabetes. Materials provided would be a range of drawing materials, structured to less structured, including pencil, colored pencils, markers and pastels. Similar to session eight, the goal is to look at the adolescent’s management behaviors, but from a more positive, solution and future-oriented angle. Also, the therapist can help the adolescent focus on positive possibilities that can serve as motivating factors to properly managing diabetes.
  • Session Ten: Draw a positive experience you have had that was a result of your diabetes. Materials provided would be a range of drawing materials, structured to less structured, including pencil, colored pencils, markers and pastels. The final session is intended to end the therapeutic relationship on a positive future-oriented note. The adolescent must re-frame his experience with diabetes in order to find the benefits it has brought him. The therapist can assist the adolescent in using this art experience as a model for living with diabetes with a more positive state of mind. This task also allows the opportunity to look back on the therapy sessions, identify how it has been a positive experience associated with diabetes, and bring closure to the therapeutic experience.
  • Following completion of the task, the client and therapist would process the artwork. After the therapeutic portion of a session, the adolescent could be asked to complete a structured feedback form, and write a more impressionistic response to the session. Once the course of treatment is complete, the adolescent would again be asked to complete a structured form and write a free response, accounting her overall response to the therapy, whether or not she found it helpful, and identifying insight gained, if any. Each adolescent participant would be asked to evaluate the tasks proposed for inclusion in the study for their perceived effectiveness and relevance, and they would be asked to identify the factors of treatment which were most helpful. Additionally, the adolescents would be asked if there was anything that should have been different about the therapy protocol which might have made it more effective or helpful.

    The therapist would also need to record her impressions of the sessions and her perceived evaluation of the adolescent’s receptiveness and response to tasks and feedback, both within and across sessions. Working within a multi-disciplinary pediatric endocrinologic clinical setting, the therapist would have the opportunity to discuss cases with other care providers, including the participant’s endocrinologist, diabetes nurse educator and dietician. Information gathered from the art therapy sessions could be used to make recommendations on how best to approach a patient about their treatment regimen and self-management behaviors. Realistic diabetes-related treatment goals could be more clearly negotiated and delineated with the adolescent. With a clearer understanding of underlying issues contributing to non-adherent behavior, those issues can be taken into account and their resolution integrated with medical treatment goals.

    The qualitative information gathered from this process would include:
    1. Structured feedback form completed by the adolescent at the conclusion of each session.
    2. Impressionistic response written by the adolescent at the conclusion of each session.
    3. Structured feedback form completed by the adolescent at the end of the treatment protocol.
    4. Impressionistic response written by the adolescent at the end of the treatment protocol.
    5. Written response of the therapist completed at the conclusion of each session.
    6. Written response of the therapist completed at the end of the treatment protocol.
    7. The artwork completed by the adolescent.

    The data would be analyzed for trends in the content and nature of both the adolescent and therapist’s responses to the therapeutic process, the tasks, the therapeutic alliance, and any suggested changes in protocol. The collected data could then be used to more clearly outline a treatment protocol which could be tested on a larger scale, the ultimate goal of which would be to determine whether or not art therapy might be beneficial in the treatment of non-adherent diabetic adolescents.


    Since all of the people I know who have been reading aren’t art therapists, I’m definitely interested in your thoughts and impressions. Next week I’ll tie everything into a neat package by posting the Summary and Conclusions. Thanks for reading!

    September 3, 2009

    Thesis Thursday: 18

    It’s Thesis Thursday, a weekly series of consecutive sections from my master’s thesis, Art Therapy with Type 1 Diabetic Adolescents, Non-Adherent to Treatment: A Literature Based Study. We’re picking up where we left off last week at the first part of Chapter 5: Discussion with the next part of the chapter, Limitations of the Study, and Clinical Application.


    Chapter 5: DISCUSSION

    Limitations of the Study

    The study was limited to available and relevant literature in English. Due to the scope of this study, it was not feasible to analyze every piece of literature. A sample of the literature was selected based on availability and perceived degree of relevance from a variety of sources. Some of the literature was not based on quantitative research, but was more qualitative and anecdotal in nature.

    Clinical Applications

    Eiser (1990) cites a study by McNabb, Wilson-Pessano and Jacobs (1986) of children with asthma, another chronic medical condition whose outcome is dependent on patient and family’s capacity to adapt. Management behaviors were defined as ‘effective’ or ‘ineffective’, and then placed into categories. The four areas of competency were prevention, intervention, compensatory behaviors, and external controlling. The researchers concluded that these competencies should be integrated in programming designed to improve self-care in asthmatic children.

    Extrapolating these results when examining effective methods of helping diabetic children adapt to and manage their diabetes shows inadequacies in the educationally oriented approach. Prevention and intervention behaviors are based on knowledge (Eiser, 1990). Does the child check their blood glucose level prior to exercising in order to prevent hypoglycemia? Does the child intervene with additional insulin when their blood glucose level is elevated, as defined by their healthcare professionals? While the information on which to base these actions would be part of a comprehensive educational approach, the other two competency areas, compensatory behaviors and external controlling, which mediate following through with intervention and prevention tasks, are left insufficiently covered.

    The American Diabetes Association standards point out the need for healthcare providers to be able to evaluate the “behavioral, emotional, and psychosocial” issues pertinent to children and adolescents, but specific recommendations and techniques to assess or actively address such issues do not exist. To date, the majority of research has been directed towards establishing that the need for psychosocial and behavioral intervention even exists. There have been some studies on the application of psychosocial interventions with diabetic children and adolescents, and although some results have been promising, they have not been validated or implemented on a broad scale (Jacobson, 1996). Children are especially vulnerable, due to developmental issues, which can lead to maladaptive use of defense mechanisms, compromised ego functioning, and regression to earlier developmental stages (Erikson, 1963). The issues regarding adjustment to the external milieus of family, school, and peer interactions present themselves as more urgent, displacing the child’s internal adjustment and interpretation of both the initial diagnosis and the chronic nature of type 1 diabetes (Anderson & Laffel, 1997; Plotnick & Henderson, 1998).

    Art therapy has been successfully utilized with many different populations, including adolescents and medical populations. Adolescents benefit from art therapy because they are characteristically more resistant and less accepting of help from adults due to their developmental tasks of forming identity and separating from parents, caregivers, and authority. The art making process serves as a buffer between the adolescent and the therapist, allowing the adolescent to better tolerate the client-therapist relationship. Adolescents typically also have an affinity for art making and the creative process in general, so they are more willing to engage in the therapeutic process of art therapy as opposed to a standard talk therapy approach to treatment.

    Golden (1998) identifies “critical tasks of adolescence and young adulthood, including the development of a comfortable identity, the capacity to enjoy intimate relationships, the ability to preserve previously developed senses of autonomy and productivity, and the acquisition of more mature defenses against adversity”. He states that these “are complex developmental tasks that are generally outside of conscious awareness.” Because art therapy surpasses many defense mechanisms, allowing a glimpse into that which is beyond consciousness, it has the potential to foster these developmental processes.

    Medical art therapy has been steadily growing, and practitioners continue to find new approaches and applications. It has been shown to be beneficial to patients who have medical diagnoses other than diabetes, including several chronic illnesses. Children use art to cope with stress, and children who are sick experience trauma and stress that can be detrimental to their mental health and emotional development if not provided the opportunity to resolve some of the inner conflict associated with the stress of illness. Art making provides a chance to assert control under circumstances and in environments in which someone has limited control, which is often the case with medical treatment. Diabetic adolescents, who are dealing with the normal developmental task of assuming control for themselves and their futures, can get into a battle of control with the aspects of their medical care. Such a battle can result in the adolescent asserting his control by not doing the diabetes self-management tasks prescribed by his healthcare team and reinforced by parents. When diabetes becomes the center of a control conflict and the patient does not care for himself properly, negative health consequences are often the result. By exerting control through the art therapy process, it is possible that there will be less conflict around diabetes management responsibilities.

    Fears and concerns about diabetes can be explored through the artwork, as can anger related to the tasks and chronic nature associated with diabetes. The art making process affords a less destructive outlet for expressing and acknowledging negative feelings that might otherwise be acted out through non-adherence to diabetes self-management. Furthermore, art therapy can be used to help the adolescent diabetic integrate his illness into his identity in a healthy way that will result in a more positive attitude towards self-care and the future.

    Based on the previously done research on psychosocial interventions with diabetics, it seems that a group art therapy format might generate positive results. Adolescents would benefit from peer support, both giving and receiving. Adolescents who ordinarily feel alienated and different from family and non-diabetic peers, would have a normalizing experience in which they are just like everyone else, in which they will not feel as if they must choose between ignoring their diabetes care and ultimately compromising their health, or following their treatment but standing out in the crowd. The advantages of sharing common experiences, feelings and fears can be validating and reassuring to adolescents unsure of how to simultaneously be a normal person and a diabetic. Offering support to peers could make an adolescent recognize the benefits of past diabetes-related experiences that had otherwise been perceived as negative and burdensome.

    An additional benefit of presenting art therapy within a group context, is that the anxiety and threat of being in an alliance with an adult would diffuse in the presence of age-mates. Whereas an adolescent might be more hesitant to engage in the art making process in individual therapy, it might feel safer and socially acceptable to do so with a group of peers. Once the challenge of getting them engaged is met, the next challenge is keeping them engaged and returning for subsequent sessions. An additional advantage to group art therapy is that the adolescents would establish relationships with each other which would enhance their engagement in and commitment to the therapeutic process.

    Even though the research on individual psychosocial interventions does not compare to the research on group interventions, and there are many advantages to group interventions with adolescents, individual art therapy holds promise too. The obstacle of establishing a therapeutic alliance with an adolescent who is already wary of adults in authoritative positions can be overcome by a skilled art therapist. The art materials are a mediating factor which diffuses the intensity of being one-to-one with a therapist, an inherent advantage of art therapy with adolescents. The therapist can use this and the art materials themselves to engage the adolescent who is less receptive to such an intervention. Actually engaging in art making can help draw the adolescent into the therapeutic alliance. If the therapist is experimenting with art materials, the adolescent will feel less self-conscious, and will in turn be more open to interacting with the materials and the therapist. A skilled art therapist will also use the art materials to her advantage if the adolescent is angry or hostile. Those negative feelings can be funneled into the art making process, expelling feelings and energy

    Through the imagery of art therapy, false beliefs and misconceptions about diabetes and its implications can be explored as a means of increasing understanding. Ideas about and aspects of diabetes from which the adolescent is avoidant are objectified through imagery, and can be examined, processed, and eventually integrated within the safety of the therapeutic alliance. Adherence is fostered through increased understanding and integration, and displacement of negative feelings through the art therapy process. Compensatory behaviors and external controlling, aspects of self-care based on the study cited by Eiser (1990), could be integrated through art therapy, to complement and reinforce the aspects of prevention and intervention, creating a treatment strategy reflecting the aforementioned self-care model proposed for implementation with asthmatic children.

    The materials and techniques used within the art therapy session are important elements that should be considered for their potential in facilitating the therapeutic process. Art therapy tasks could incorporate diabetes-specific imagery such as pictures from magazines directed toward diabetics, and medical supplies such as syringes, lancets, blood glucose testing strips, and insulin pump tubing and infusion sets. Magazine pictures can be used to create collages, and medical supplies can be used to create sculpture, and can even be used as tools for creating art. Syringes used as paint applicators would mimic the activities of daily self-care that are ultimately the underlying focus of the therapy. Supplies could also be used as tools to manipulate and shape clay. Negative feelings can be displaced by puncturing with syringes, lancets and infusers, and knotting and constricting with tubing. Using medical supplies in new, unintended ways for a fun activity separate from self-care might generate a positive association to items that are otherwise perceived as intrusive and burdensome.

    Art therapy can also be used as a diagnostic tool for possible sub-clinical and clinical psychiatric disorders. Because these have been linked to poor compliance and negative health outcomes, it is best to detect and address psychiatric issues as early as possible. Art therapy can bypass some defense mechanisms, thus allowing for earlier detection. An effective therapeutic alliance between art therapist and diabetic adolescent will promote trust and facilitate disclosure of issues and concerns, which might otherwise be left unspoken. Such disclosure will further assist the therapist in evaluating the overall psychiatric status of a client, and allow the therapist to intervene if necessary.

    Art therapy with adolescents has been shown to be an effective psychological treatment approach for a wide array of mental health issues and interpersonal problems (Riley, 1999; Greenspoon, 1988). As adolescents seek to define their own identity and assert themselves as independent, self-sufficient individuals, they become less inclined to turn to the adults in their lives in times of need. While this is characteristic of normal adolescent development, it sets up obstacles between the adolescent who needs help and the adult who tries to give it. Once in a position to offer help to the adolescent who needs it, the adult encounters strong ambivalence and often rejection. While art therapy does not provide guarantees against these challenges, it can facilitate a helping relationship and communication through the intermediary role of both the art materials and art-making process. Art therapy not only provides information to the therapist about the adolescent’s conscious and unconscious thought processes, but it can serve as a bridge to the most difficult to reach teenager.

    The use of art therapy as a psychosocial intervention with diabetic adolescents has not been the subject of clinical research. However, art therapy in medical settings is becoming an area of increasing interest in the art therapy community. It has been shown to be an effective method of treating the psychosocial issues of physical illnesses other than type 1 diabetes by providing a vehicle for the expression of negative feelings and exertion of control, promoting creative problem-solving, promoting future-orientation, and providing a positive, success-oriented experience within a therapeutic relationship.

    If an art therapy treatment protocol were developed in the clinical environment, type 1 diabetic adolescents would have the opportunity to process their feelings about having diabetes and the impact, past, present and future, both real and perceived, diabetes has on their lives. Art therapy would provide a safe environment with a non-judgmental therapist, in which the patient could release and explore feelings such as sadness, anger, and guilt.

    Defense mechanisms such as denial, an impediment to following an optimal self-management regimen, could be identified and confronted, with the goal of replacing maladaptive defenses and coping mechanisms with healthier ones. The advantages and disadvantages of behaviors could be examined more objectively through artwork produced in the art therapy session. Alternative coping skills and new ways to solve old problems and issues could be identified and explored within the safety of the therapeutic relationship.

    The diabetic adolescent who does not adequately manage their illness could gain insight, potentially leading to behavior change. The goal of behavior change leading to improved self-management of their diabetes could be hastened and facilitated. With adherence to their prescribed treatment regimen resulting in improved glycemic control, the risk of both short-term and long-term complications of diabetes would decrease.


    Come back next week for the last part of Chapter 5: Discussion, Implications for Future Research and Proposal for a Small Scale-Study.

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