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

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

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

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.

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.

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.

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.

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!

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.

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.

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.

What? It’s already 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? Indeed, it is! Last week was Chapter 4: Results, data tables and all. This week, we’re getting to the really good stuff. I’ve presented my data, explained how I collected it and organized it, etc., and now we’re moving ahead towards the very point of all of this – why and how art therapy would be so awesome with diabetics. So get ready because I’m gettin’ all researchy on yo a**, right, Chris?

The information collected and analyzed will be used to explore possible treatment recommendations and clinical applications into the use of art therapy as a treatment method for diabetic adolescents who do not adhere to their prescribed self-managed treatment regimen. Because no data on such pre-existing research was found, it is impossible at this juncture to determine the practical feasibility of such treatment. Thus, a small scale, qualitative research study will be proposed, the results of which may be applied to a larger scale study, and eventually practical application in a clinical environment by qualified art therapists.

The major findings of this study are that adolescents with type 1 diabetes mellitus face the same developmental tasks as their non-diabetic peers, however these tasks can be amplified and complicated due to the added complexities of managing diabetes. Having diabetes can present psychosocial stressors that are not necessarily experienced by non-diabetic adolescents, and this has the potential to impede emotional development, which can in turn limit the diabetic adolescent’s ability to cope with their illness. An impaired ability to cope with this illness has the potential to lead to severe health consequences, long term complications from diabetes. There is also significant evidence that diabetics are more prone to develop both sub-clinical and clinical psychiatric conditions such as depression and eating disorders, which further jeopardize the diabetic individual’s health outcome.

The evidence that psychosocial issues are an integral part of the overall presentation of a non-adherent diabetic adolescent is clear. Both medical professionals and a growing number of behavioral health professionals recognize this and are seeking to address it, through both multidisciplinary healthcare teams and consultations. The literature supports that the problems exist, however guidelines and methods for psychosocial interventions are limited, and guidelines and methods of treatment for art therapy interventions are unavailable.

When an adolescent’s glycemic control seems to be declining or fluctuating, it is common to return to the educational model as an intervention approach. The patient is often given information about the diabetic complications that he is making himself vulnerable to by neglecting diabetes self-management. Often, this approach is interpreted by the adolescent as “scare tactics” intended to motivate him to better care for himself, which is not necessarily well-received and might be perceived as a threat to the adolescent’s need to exert control.

Doctors and other medical clinicians, with little background in the social sciences can become frustrated and lose hope, wondering why an adolescent will not do what he is supposed to do. Well-meaning medical professionals educate their patients about the long-term consequences of poor diabetes management. Retinopathy, the leading cause of blindness, neuropathy, which can result in sensory loss in the extremities and amputations as well as internal systemic damage, and nephropathy, the leading cause of end-stage renal failure, are explained. The patient has the cognitive capacity to process this information, but mediating factors, including self-perceived invincibility, do not necessarily result in self-preserving behaviors. An adolescent looking for immediate self-gratification is simply not able to thoroughly process the consequences of their actions (Blos, 1964; Cerreto & Travis, 1984).

An examination of the developmental phenomena characteristic of adolescence clearly shows why this educational approach is potentially counterproductive. The drive for instant gratification, reflected in impulsivity, increased alcohol and drug experimentation, and sexual experimentation, become factors in following through on fundamental diabetes-related tasks, such as taking injections, blood glucose monitoring, and dietary management. The consequences of deviations from a management regimen that might not become manifest for years have no impact on the here-and-now feelings of gratification and social acceptance sought by adolescents. The well-intentioned educational approach automatically assumes that the diabetic adolescent, as opposed to a non-diabetic peer, is more mature in setting priorities, considering consequences, utilizing advanced social skills, and decision-making (Anderson & Rubin, 1996; Skinner, Channon, Howells & McEvilly, 2000). Additionally, the didactic educational approach might be perceived as an infringement on the adolescent’s independence and decision-making capabilities. An adolescent who feels these are being threatened, might rebel against the advice of the educator, an adult in an authoritative position, and make choices that are not conducive to good diabetes control.

With an illness such as diabetes that must be managed continuously and for the duration of one’s life, it is inevitable that its impact permeates most, if not all aspects of life. This can be a difficult prospect for diabetic adolescents, who like non-diabetic adolescents, look to their peers to define identity. The diabetic adolescent, who needs to be cognizant of food intake and activity level, of taking insulin and checking blood glucose levels, can feel his emerging freedom impended upon, and resentment for age-mates who don’t have these same perpetual concerns. Adolescents do not want to be singled out or feel different, thus the impact on psychological development.

The task of identity formation in the diabetic adolescent, who must incorporate this aspect of life and self into his identity, can be compromised. If the adolescent is to develop into an adult who will strive to live as a healthy diabetic, the integration of his diabetes into his identity should occur in such a way that it is accepted and ego-syntonic. The challenge presented, is that diabetic adolescents will primarily have peer groups comprised of non-diabetics. The diabetic adolescent, looking to identify with peers, and thus define his own identity, is unable to fully identify with others, who do not have the same lifestyle. The ideally structured diabetic lifestyle, and adolescence, a time of characteristic rebellion against imposed structure, are not necessarily compatible.

This population seems to have particular psychosocial issues that are not being effectively addressed in most clinical settings in which these patients are seen (Kovacs, Obrosky, Goldston, & Drash, 1997). Diabetes education does not adequately address these issues, nor does it necessarily translate into higher compliance rates (Cox, Gonder-Frederick, Pohl & Pennebaker, 1986; Plotnick & Henderson, 1998).

Thus far, the results of studies of psychosocial interventions with diabetics have been mixed overall. The studies of biofeedback-assisted relaxation therapy have shown varied results. While McGrady, Bailey and Good (as cited in Rubin, 2000), and Rosenbaum and Tannenberg (as cited in Rubin, 2000) reported improved glycemic control in type 1 diabetic patients, Bradley, Moses, Gamnsu, et al. (as cited in Rubin, 2000), Landis, Jovanovic, Landis, et al. (as cited in Rubin, 2000), and Surwit and Feinglos (as cited in Rubin, 2000) found no benefit. Feinglos, Hastedt and Surwit (as cited in Rubin, 2000) concluded that biofeedback-assisted relaxation did not result in improved glycemic control, however they suggest that it might be useful with a subpopulation of type 1 diabetics who have a hyperglycemic response to stress.

Group coping skills training techniques proved to have better results than biofeedback assisted relaxation techniques. Many of these studies reported improved emotional wellbeing and enhanced coping skills. Results were mixed on changes in glycemic control, with some studies concluding that it improved (Shalom & Ryan [as cited in Rubin, 2000]; Warren-Boulton, Anderson, Schwartz, et al. [as cited in Rubin, 2000]; Dupuis [as cited in Rubin, 2000]), and others showing no improvement (Boardway, Delameter & Tomakowsky [as cited in Rubin, 2000]; Mendez & Melendez [as cited in Rubin, 2000]; Aveline, McCulloch & Tattersall [as cited in Rubin, 2000]). Sample sizes were small (<20), and the researchers recommend further investigation. It appears that a group format has great potential as a tool to improve both medical and psychosocial outcomes for diabetics.

Rubin (2000) cites the results of studies done on diabetes camps as a method for psychosocial intervention. He reports that studies by Sandor, Lipets, and Moffatt and Pless showed an improvement in internal locus of control. However, studies cited by Scharf, Leach and Adams, and McCraw and Travis demonstrated short-lived results with no difference between campers and non-campers. Based on this group of findings, it is difficult to determine the effectiveness of diabetes camps.

Eiser (1990) identifies studies of social skills training that showed mixed results. Gross, Johnson, Wildman and Mullett reported increased assertiveness in social situations, but the sample size was 4, and they did not assess effects on diabetes management behaviors. Kaplan, Chadwick and Schimmel reported improved glycemic control, but no distinction in other measurements with the comparison group. Follansbee, LaGreca and Citrin reported increased assertiveness in social situations, but no differences in improved treatment adherence with the comparison group.

Studies cited by Rubin (2000) on group psycho-education incorporating coping skills training demonstrate promising results. Three separate studies by Rubin, Peyrot and Saudek consistently showed improvements in emotional well-being, treatment adherence and glycemic control. Another group intervention, cognitive behavioral group training, researched by van der Ven, Chatrou and Snoek (2000) resulted in improved glycemic control and reduced diabetes-related distress, but showed inconsistent improvement in diabetes-related self-care behaviors.

An intervention targeted at diabetic patients and their families, behavioral-family systems therapy, was studied by Wysocki, Greco, Harris, Bubb and White (2001). The primary improvement was in the parent-adolescent relationships. There was a delayed improvement in treatment adherence, but no measurable effect on adjustment to diabetes or diabetic control.

It can be concluded from the results of research on psychosocial interventions that some techniques have proven more effective than others, while many techniques have resulted in mixed and inconsistent results. It appears that group interventions can be effective. Studies of individual interventions were limited however, and should not be disregarded without further research into their effectiveness. There are no clearly effective psychosocial interventions, but elements such as a group format with a focus on interpersonal skills, psychoeducation and coping skills show promise. It is suggested that these elements can be integrated into an art therapy intervention, so that the recipients of the intervention would benefit from the elements that have shown some success and medical art therapy which shows theoretical validity.

Based on this information, it seems that a new approach for addressing psychosocial concerns is worth consideration. Art therapy is a developmentally appropriate treatment approach for adolescents (Linesch, 1988), and may serve as a means to explore the feelings, thoughts and responses to living with diabetes.

Next week, the Discussion chapter will continue, so check back for more because you won’t want to miss it.