It’s Thesis Thursday once more, 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. Last week was the final section from the Literature Review Chapter on medical art therapy. This week, is a little dry in comparison, but I never promised you this was going to read like an edge-of-your-seat novel. The Methodology chapter will explain how I organized my data to support my argument that art therapy for diabetic adolescents would rock!

The design for this thesis is a literature based study. The objective of this research is to propose a theoretical model of using art therapy in order to develop a practical model for the use of art therapy with type 1 diabetic adolescents to address the psychosocial needs of this population as a means of increasing adjustment so as to improve medical outcomes.

There are no human subjects in this study.

The primary data for this study was literature. The literature that was utilized included texts and journal articles. Literature was identified through the use of library and data base sources. Data bases for journal searches included: EBSCO Online Citations, MEDLINE, Academic Search Elite, Alt Health Watch, Nursing and Allied Health Collection, The American Diabetes Association’s online journal database, and PSYCH Info. The literature was selected based on its relevance to the topic. Keywords used in the searches included:

Adherence, Adjustment, Adolescence, Adolescent art therapy, Adolescent growth and development, Art therapy, Barriers to treatment, Behavioral, Chronic illness, Diabetes, Health psychology, Intervention, Medical art therapy, Mind-body, Multi-disciplinary, Pediatric art therapy, Psychosocial, Type 1 diabetes

The literature on health psychology was first explored. The origins of this field of study were reviewed in order to better understand what it is today, and what it has to contribute to our knowledge base of health, illness and associated behavior.

Literature on adolescence was the next topic. Literature on normal adolescent development was examined in order to put information on diabetic adolescents into context. Aspects of normal adolescent physical development were looked at to increase understanding of how puberty plays a role in the complicated dynamic between adolescence and diabetes. Following that, cognitive development was outlined, specifically Piaget’s theory of cognitive development because it is one of the most widely recognized. Then Erikson’s theory of psychosocial development was outlined because it is one of the most widely recognized theory of psychosocial development.

Next, the literature on diabetes was explored. The term type 1 diabetes was defined and its etiology, pathophysiology, epidemiology, and statistics reviewed. A review of its management was then provided in order to understand what is involved in its management and self-care regimens.

The psychosocial aspects of living with type 1 diabetes were discussed in order to understand how it impacts the lives of those living with it, and to provide a more holistic view of the illness. Psychosocial aspects of adolescents living with diabetes were then examined because this is an age group that presents special challenges in the management of diabetes. The final part of this section was a review of the research to date on psychotherapeutic and behavioral interventions specifically aimed at diabetic populations. Literature on treatment interventions intended to address diabetic patients’ adherence levels was explored. Interventions that have shown some promise as well as those that have led to inconclusive results were reviewed.

Art therapy literature was explored. There was a general review of the practice of art therapy and its benefits, in order to put more specialized uses and applications of this modality into a framework. Literature on medical art therapy was examined in order to put this practice into a framework in which its use with a diabetic population can be conceptualized. Particular attention was paid to the literature on this topic that related to pediatrics and chronic illness.

Adherence: “The extent to which a person’s behavior (in terms of taking medications, following diets, or executing lifestyle changes) coincides with medical or health advice” (Rapoff, 1999 [as cited in Haynes, 1979], p. vii).

Adolescence: “[Y]oung people between 12 and 20 years old” (Snoek & Skinner, 2000, p.25).

Health Psychology: The “science, with objective researchers and practitioners who ‘uncover the truth’ about health and illness-related behaviour and help individuals adjust to the demands of health and illness” (Crossley, 2001, p.244).

Medical Art Therapy: “[T]he use of art expression and imagery with individuals who are physically ill, experiencing trauma to the body, or undergoing aggressive medical treatment such as surgery or chemotherapy” (Malchiodi, 1999, [as cited in Malchiodi, 1993], p. 13).

Multidisciplinary Diabetes Treatment Team: A group of health care professionals, working with the diabetic adolescent and his family, with the purpose of providing comprehensive care for all aspects of diabetes management. The team may include all or some combination of the following professionals: physician, preferably one with specialization in endocrinology or diabetes; nurse educator, preferably a certified diabetes educator (CDE); registered dietician; opthamologist; podiatrist; mental health professional experienced with diabetes-related concerns; exercise specialist; and a pharmacist (American Diabetes Association, 1998a; American Diabetes Association, 1999a; Plotnick & Henderson, 1998).

Psychosocial: Relating “to the psychological development of the individual in relation to his social environment” (Guralnik, 1986, p.1147).

To analyze the data, the Matrix Method was used. “The Matrix Method is both a structure and a process for systematically reviewing the literature” (Garrard, 1999). Using this method, the relevant literature was identified, collected and organized. A Review Matrix, a system of columns and rows, used to abstract selected information from each piece of literature (Garrard, 1999), was then constructed. Matrices were made to separate the literature into the following categories:

Health Psychology
Diabetes: Medical
Diabetes: Psychosocial
Adolescence
Art Therapy
Art Therapy: Medical

Within each of the aforementioned categories, subcategories were delineated, and assigned a number. Each of those numbers was allotted a column in each respective matrix. All the literature was then allotted a row in a matrix; some pieces of literature were included in more than one matrix because the information was deemed relevant to more than one matrix category. Once this structure was established, whenever information within a piece of literature related to a matrix subcategory, the page(s) were indicated on the matrix, under the assigned number of the subcategory, and on the row assigned to that particular piece of literature.

To analyze the data, trends in the literature were identified. The trends, critical ideas within each respective piece of literature in which they were identified, were extracted from the literature. The authors who supported ideas which support the assertion that art therapy is a viable psychosocial intervention worthy of clinical research were listed (Table 1). Only authors who made definitive statements regarding the identified trends were included; authors who did not make clear statements regarding each trend were excluded. While not all authors made statements which support the following ideas, there was no literature found in which statements were made that directly oppose these ideas. The ideas for which trends were identified are:

Authors Who Support that Psychosocial Issues are Important Determinants of General Well-Being and Disease Outcome

Authors Who Support that Psychosocial Research with Diabetics Has Not Resulted in Standardized, Effective Clinical Application and Integration with Medical Management

Authors Who Support that Lack of Research, Methodological Inconsistencies Between Previous Studies and Problems within Studies Have Prevented Development and Application of Effective Treatment Strategies to Address Psychosocial Issues

Authors Who Support that Subclinical and Clinical Psychiatric Symptomology Is Not Being Adequately Detected, Evaluated and Treated Successfully

Authors Who Support that Diabetes Management Is Especially Problematic with Adolescents

Authors Who Support that Normal Adolescent Developmental Tasks are Threatened Due to the Demands of a Diabetes Self-Management Regimen

Following this analysis, information on research of previously studied psychosocial interventions with diabetics was compiled (Table 2). Various types of interventions were categorized. The authors and years of the respective studies listed, and the outcomes of the respective studies summarized. The categories of interventions were:

Biofeed-back -Assisted Relaxation
Group Coping Skills Training
Diabetes Camps
Social Skills Training
Group Psycho-Education Incorporating Coping Skills Training
Cognitive Behavioral Group Training
Behavioral-Family Systems Therapy

Next, the limited number of studies on psychosocial interventions with diabetic populations having a co-morbid psychiatric disorder were listed (Table 3). A cognitive behavioral method used with depressed diabetics, and a psycho-educational method used with eating disordered diabetics were summarized

Finally, literature on medical art therapy was compiled (Table 4). The authors and years of the respective studies listed, the illness for which the treatment protocol was applied, and the conclusions of each study were summarized.

The information that was collected and analyzed will be used to support the proposal for a small scale study of art therapy with type 1 diabetic adolescents. An art therapy protocol will be developed and outlined. Methods for collecting data from the implementation of the protocol will be discussed, and then possible applications of the results will be proposed.

Just like that, Chapter 3: Methodology is done, and next week I’ll bring you Chapter 4: Results. Please note that the tables referenced in this chapter will be in the next chapter.