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 17, 2009

A Surprise Ending to Thesis Thursday: 20

And on the 7th day….

Oh, wait… I meant to say it’s the final installment of 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! Last week was the final juicy section, Implications for Future Research, and Proposal for a Small Scale Study. Today is the Summary and Conclusions, so I’m merely wrapping it all up in a tidy bow. Once the bow is tied though, don’t forget to check the metaphorical gift tag at the end.



Based on the information gathered in this review of the literature, it can be concluded that non-adherence to prescribed self-management treatment among type 1 diabetic adolescents is common and well documented. A general understanding of the developmental reasons for this kind of behavior is in place, as is an understanding of the negative consequences of such behavior. Research documenting the medical consequences of non-adherence has consistently shown that medical outcome is contingent on diabetes self-management behaviors. Clear and successfully researched methods to address and treat the problem of non-adherence in this population seem to be missing.

Art therapy has been proven an effective method of treatment with both adolescent populations, and medical populations other than patients with diabetes. Art therapy is especially effective with adolescents because it is developmentally appropriate, and it can be effective in overcoming the resistance typical of adolescents.

Therefore it is the assertion of this paper that art therapy has the potential to be an effective method of treatment for diabetic adolescents who do not adhere to treatment. It would allow them to express their feelings and concerns related to their illness, improve problem-solving skills, and gain greater insight into themselves. Some general guidelines for a small-scale qualitative multiple case study were outlined, with the intent that the completion of such would provide information allowing further investigation of this treatment.


Short, sweet, and to the point. Tons of thanks to everyone who kept up or at least attempted as much. I know it was dry minus the occasional snarky comment, so hopefully the snark will be back in full-force next week when I have to conjure up some content that isn’t five years old. I hope those who read it, umm, I don’t know… learned something, I guess.

On that note, I had really wanted to have this news squared away in an official kind of way before I posted it here, but I think most 4-year olds have more patience than I do, and I’ve completely exhausted what little I had. Over a year ago, I interviewed with a private practice of mental health providers, mostly art therapists, about subletting space. They really liked me, or so I was told anyway, but at the time I didn’t have my art therapist registration (ATR), and they felt it was a liability to have me there minus that credential which I totally understood. I got the credential back in February, and my friend and connection there had asked a few times since then if and when I was going to join, but for reasons that elude me now, I didn’t follow up.

I’ve finally decided to take the plunge and start art therapy groups for children with diabetes in my community. The opportunities I want don’t exist, so I’m going to create them. I’ve had some vague discussions about it with my art therapy supervisor over the last couple of years, and very recently, I picked the brain of Beth Ann Short, the art therapist who guest blogged for me back in July. She runs groups at the 100th Monkey Studio in Portland, Oregon, and she graciously shared her experience and ideas with me.

The challenge has been finding a space that’s suitable, and has the basic things I need – tables, chairs, enough room for a group to work, a space that is art making-friendly so no one will yell at me for creative breadcrumbs (paint smudges, pastel fingerprints, etc.), decent lighting, access to a sink. The space will make or break art therapy, and it’s not easy to find the right space that nicely melds a therapist’s office with an art studio set-up, especially when I’m not in a position to create it myself, and I have to work with what’s available to me. The space at the aforementioned practice is more for individual therapy, but the therapist who is offering it has done some family work, so she thinks I could accommodate 5 or 6 kids. Tonight, I’m actually going to see it and talk to her. A couple of days ago, I looked at a space in another art therapist’s office, and that space would work logistically, but it’s a lot pricier. So I’ll see how it goes tonight, and make my decision within the next few days. Having to be in someone else’s space is clumsy at best, but I have to start somewhere. Of course, it’s my hope that someday I can have very own studio space.

Once I have the location set, I’ll finish the brochure I’ve been trying to put together, and once I have those, I’ll be off to clumsily market myself to area pediatric endo and general pediatric practices. Getting clients will heavily rely on their willingness to refer kids, so that part is a little uncertain. I do have some other marketing avenues I’m going to try though, and hopefully it won’t take too long to be on my way to what I truly want to do.

In light of yesterday’s post, the obvious downside is that none of this solves my health insurance problem. I’ve been leaning more and more towards investing all of my efforts in pursuing private practice since the job search has been a perpetual bust and a drain on my self-confidence – and there’s the matter of absolutely no one anywhere wanting an art therapist to work with diabetics. Really, I think this is what the universe wants me to be doing anyway. So the health insurance issue isn’t going away, and I don’t know what’s going to happen with that. As so many of us have shared, it’s a crime that we have to choose between career goals and health insurance. I suppose if I end up being worm food sooner than I’d like, at least I’ll go down fighting the good fight, doing something meaningful that will make me feel like this tumultuous journey with diabetes, depression and an eating disorder wasn’t completely for naught.

I’m just hoping this is the right path, and the other stuff will work out somehow.

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!

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