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Please Sign into Poll EverywherePresentation to join:◦ PollEv.com/ruthnutting756 or Text RUTHNUTTING756 to 37607
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Diabetes Across the Lifespan: Family Centered Approaches to Assessment and Intervention
• Ruth Nutting, PhD, LCMFT, Director of Behavioral Health, Via Christi Family Medicine Residency Clinical Assistant Professor, University of Kansas School of Medicine
• John S. Rolland, MD, MPH, Professor of Psychiatry, Northwestern University Feinberg School of Medicine and Executive Co-Director, Chicago Center for Family Health
• Jennifer Harsh, PhD, LIMFT, Director of Behavioral Medicine, Internal Medicine, University of Nebraska Medical Center
Session # D2
CFHA 20th Annual ConferenceOctober 18-20, 2018 • Rochester, New York
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Faculty DisclosureThe presenters of this session have NOT had any relevant
financial relationships during the past 12 months.
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Conference Resources
Slides and handouts shared in advance by our Conference Presenters are available on the CFHA website at http://www.cfha.net/?page=Resources_2018
Slides and handouts are also available on the mobile app.
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Learning Objectives
At the conclusion of this session, the participant will be able to:
• Recognize the prevalence of diabetes and its implications for patients and families.
• Describe systemic assessment and intervention to increase adherence.
• Identify strategies to promote positive systemic coping and resilience.
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1. Centers for Disease Control and Prevention. (2017). National diabetes statistics report: Estimates of diabetes and its burden in the United States. Retrieved from https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf
2. Gonzalez, J. S., Schreck, E., Psaros, C., & Safren, S. A. (2015). Distress and type 2 diabetes-treatment adherence: A mediating role for perceived control. Health Psychology, 34, 505-5.
3. Hara, Y., Hisatomi, M., Ito, H., Nakao, M., Tsuboi, K., & Ishihara, Y. (2014). Effects of gender, age, family support, and treatment on perceived stress and coping of patients with type 2 diabetes mellitus. BioPsychoSocial Medicine, 8, 16-27.
4. Kripalani, S., Yao, X., & Haynes, R. B., (2007). Interventions to enhance medication adherence in chronic medical conditions: A systematic review, Archives of Internal Medicine, 167, 540-550.
5. Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). New York, NY: Guilford Press.
6. Osterberg, L., & Blaschke, T. (2005). Adherence to medication. The New England Journal of Medicine, 353, 487-497.
7. Prochaska, J. and DiClemente, C. (1983). Stages and processes of self-change in smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 5, 390–395.
8. Rolland, J. S. (2018.) Helping couples and families navigate illness and disability: An integrated approach. New York: Guilford Press.
9. Rolland, J.S. (2016). Chronic Illness and the Family Life Cycle. In M. McGoldrick, N. Garcai-Preto, & E. Carter (Eds.), The Expanded Family Life Cycle: Family and Social Perspectives (5th ed.) Boston, MA: Allyn & Bacon.
10. Rollnick, S., Miller, W. R., & Butler, C. C. (2008). Motivational interviewing in health care: Helping patients change behavior. New York: Guilford Publications.
11. Rubak, S., Sandaek, A., Lauritzen, T., & Christiansen, B. (2005). Motivational interviewing. A systematic review and meta-analysis. The British Journal of General Practice, 55, 305-312.
12. Safeer, R.S., & Keenan, J. (2005). Health literacy: The gap between physicians and patients. American Family Physician, 72, 463-468.
13. Satterwhite Mayberry, L., Egede, L.E., Wagner, J.A., Osborn, C.Y. (2015). Stress, depression and medication nonadherence in diabetes: Test of the exacerbating and buffering effects of family support, Journal of Behavioral Medicine, 38, 363-371.
14. Walsh, F. (2016b). Strengthening Family Resilience (3rd ed.). New York: Guilford Press
Bibliography / Reference
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Learning Assessment
A learning assessment is required for CE credit.
A question and answer period will be conducted
at the end of this presentation.
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Diabetes Overview
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Diabetes in the U.S.o 30 million people have diabetes.• 23 million people diagnosed.• 5% estimated to have type 1 diabetes.
oPrevalence among ethnicities:• American Indians/Alaska Natives-15%
• Non-Hispanic blacks-13%
• Hispanic-12%
o Prevalence varies significantly by education level• 13% < high school education
• 10% = high school education
• 7% > high school education
Centers for Disease Control and Prevention [CDC], 2017)
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Biopsychosocial StressorsNON-ADHERENCEo Emotional distress• Denial
• Lack of control
• Rigidity
o Obstructive family behaviors• Avoidance
• Nagging
o Social stressors• Low social support
• Socioeconomically disadvantaged
TREATMENT ADHERENCEo Emotional well-being• Acceptance
• Sense of control
• Flexibility
o Healthy family behaviors• Supportive
• Open communication
o Decreased social stressors• High social support
• Affordable treatment options
Gonzalez et al., 2015; Hara et al., 2014; Satterwhite Mayberry, et al., 2015)
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Knowledge & ApplicationSYSTEMIC, CHRONIC ILLNESS RELATED, ASSESSMENT AND INTERVENTION SKILLS
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Case Study #1 PATIENT: CHARLENE
SETTING: DIABETES CENTER
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Multigenerational Developmental Perspectiveo Inquire about:• Multigenerational experiences with illness & loss, including stories of resilience• Experiences with specific condition
• Culturally-informed caregiving traditions and expectations
o Current timing and possible impact on individual and family life cycle planning
o Upcoming life cycle transition
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Key Family Beliefso Multigenerational legacies about illness/loss
o Normative illness experience
o Mind body interaction
o Mastery, control, acceptance
o Cause of illness
o Course & outcome
o Ethno-cultural & spiritual beliefs
o Gender
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Family-Centered Clinical & Psychoeducational Serviceso Routine screening family consultation & brief psychological screening of the patient at time of diagnosis or entry into the Diabetes Center.
o Identify & refer complex or “high risk” cases.
o Periodic family psychosocial “check-ups” & consultations:• At key illness-related transitions
• Disruptive individual and family transitions
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Charlene & Familyo Presenting Issues:• 17 y.o. African-American, strong working-class family (2 younger sibs: 12 & 14). Excellent
student with strong peer network.
• Type 1 diabetes since age 9 treated at Diabetes Center
• Well-managed until 1st semester of college away from Chicago
• Neglected diet, excessive alcohol, weight concerns
• Two visits to ER in diabetic ketoacidosis
• Recently returned home to family on medical leave
o Developmental Issues/Transitions:• Diabetes: Transition to full self-care without parental oversight
• Individual: Transition to early adulthood (here leaving home)
• Family: Launching teenagers
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Family History with Illness & Losso Beloved maternal aunt died two years ago from complications of diabetes-related
ESRD—poor adherence history. • Charlene saw her deterioration.
• Little family discussion about the loss and meaning.
• Mother has been very protective and involved in Charlene’s diabetes management, not wanting her daughter to repeat her own sister’s pattern and disease course/outcome.
• Charlene developed her own fears of not being able to manage her disease independently and suffering like her aunt.
• Paternal uncle, history of positive experience managing moderate-severe childhood and adult asthma.
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Salient BeliefsCause: Mother secretly has felt genetically responsible for Charlene’s diabetes.
Course & Outcome: Charlene and mother fear repeat of diabetes course and suffering of mother’s sister.
Spirituality: Strong connection to church and community.
Mastery: Industrious/cohesive family. Can-do philosophy. Family stories of resilience in the face of adversity (e.g. poverty, racism).
Gender: Strong marital relationship. Father works two jobs. Mother in charge of home and communication with kids, including Charlene’s diabetes management, visits to clinic, etc. Father defers to his wife’s decision-making.
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Key Case Formulation Issues1. Interaction of illness, individual, and family life cycle transitions fuel anxiety of
threatened loss.
2. Multi-generational experience with recent loss of aunt.
3. Issues of race and social class- Pressures on Charlene as first family member to get higher education, succeed, and help family reach a higher social class and move to a better neighborhood.
4. Lack of proactive communication about these issues.
5. Together these created context for medical crisis with chronic illness
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Key Interventionso Decisions: stay home, secure part-time job, address key diabetes,
individual, and family issues, return to school next fall
o Processing the interaction of diabetes and life cycle transitions
o Increased involvement of father in discussions and decision-making
o Living with uncertainty and long-term threatened loss
o Gradual transition of diabetes responsibilities to Charlene
o Loss & meaning-making regarding loss of aunt
o Process protective pattern of mother – daughter relationship, including mother’s feelings of guilt related to perception of genetic transmission
o Promote connection of Charlene with her uncle as chronic illness management role model
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Case Study #2PATIENT: TIFFANY
SETTING: INTEGRATED PRIMARY CARE
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Structure of Encounters
Now Return
Scheduled
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CollaborationCollaboration
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Motivational InterviewingWhat is it?◦ A person-centered, goal-directed
counseling method for helping people to change by working through ambivalence.
(Rollnick et al., 2008)
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MI and DM EvidenceEffective in brief encounters
MI led to:◦ Reductions in substance use
◦ Smoking cessation
◦ Diabetes plan management
◦ Weight-related problems
◦ Increased patient satisfaction
(Bernstein et al., 2005; Rubak et al., 2005)
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SpiritWHAT IT IS:
o Collaboration
o Evocation
o Autonomy Support
o Empathic Response
WHAT IT IS NOT:
o Persuasion
oConfrontation
o Advice-giving
(Rollnick et al., 2008)
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Systemic Assessment & Intervention
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OARSOpen ended questions:◦ You mentioned you’d like to eat less crap.
What does that mean to each of you?
Affirmations:◦ You have a really tough time keeping your medical appointments, and you’ve made such a
big effort to come here today.
Reflections: ◦ You’re really hoping to improve your health.
Summarizing:◦ Let me see if I understand…
(Rollnick et al., 2008)
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Decisional Balance
(Rollnick et al., 2008)
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Scalingo On a scale from 1-10…
oWhy not less?• Assess for facilitators
oWhy not more?• Assess for barriers
(Rollnick et al., 2008)
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When is MI working?o Change Talk• We really want to have better health.
• Well, I think we could do this one small thing.
o Sustain Talk• Yeah, but…
• I don’t really think that would work for us.
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Q & A
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Session Evaluation
Use the CFHA mobile app to complete the
evaluation for this session.
Thank you!