When I was first diagnosed with diabetes in 1981, I was working at the University of Hamburg in pediatric mental health/child development. On hearing the diagnosis, I was relieved that it was not something worse. I immediately reorganized my life, kept exactly to the meal schedule, gave up sweets, and consequently felt better than before. I reacted like a good patient who does exactly as he is told, even if the recommendations were contradictory.

That is how it was in those days: the doctor told the patient what to do, and the good patient was compliant, no matter how severe the effects of these changes on quality of life. Those who did not follow the recommendations were labeled noncompliant, held to be disturbed, and devalued.

Fortunately, I soon found a self-help group. The first thing I learned there was that I did not need to take the many rules quite so seriously, and that most doctors did not understand much about diabetes anyway. The group members found it rather odd that I had done everything without contradicting, because at that time there were already opportunities available by which therapy could be adjusted in a flexible manner. Regular blood glucose monitoring and adjustment of insulin meant that times for meals and shots could be moved, and one could eat practically anything. At that time, however, there was only one diabetes center in the whole of Germany, in Düsseldorf, where this could be learned.

The Düsseldorf education program provided a qualitative leap to a higher quality of life for many people with diabetes: knowing how therapy worked, escaping from the cage, and making your own decisions, all while having improved blood glucose and less anxiety. Germans flocked to Düsseldorf and fought for the implementation of this type of therapy in their home towns.

This type of education program assumed that people with type 1 diabetes would take a self-management approach because of the resulting increased competence and quality of life and would keep to it, at least regarding self-management of blood glucose and insulin adjustment. This was the case for the large majority. It became clear in follow-up studies, however, that 20­30% of those educated had problems with this therapy.

At first, those experiencing difficulties were seen as psychosocially challenged exceptions. When I read Funnell, Anderson, and associates' first article on empowerment,¹ I realized what was missing. The therapy made no allowances for individual needs. Thus, the problematic patients became an important impetus for the individualization of therapies according to the wishes and capabilities of those who carry them out.

The philosophy of empowerment was the second qualitative leap forward for people with diabetes. Today in Germany, we have more than 100 diabetes education centers in which a self-management approach tailored to participants' wishes can be learned. It is becoming clearer that the only therapies that will be carried out long term are those about which the person concerned has made a conscious decision.

In 1987, I was given the opportunity to work as a psychologist on a team at one of the diabetes education centers. Since that time, I have been involved in counseling, therapy, and research on psychological aspects of the disease.

Today, many Germans with type 1 diabetes are in a position to carry out their therapy competently themselves and are able to lead a mostly normal life with their diabetes, while maintaining good blood glucose. This means that they have no restrictive diet, can adjust insulin doses according to the carbohydrate content of their meals, and enjoy relatively free choice of timing for their shots.

More people with type 2 diabetes are also learning self-management therapy and so have similar opportunities to decide things for themselves. The needs of people with type 2 diabetes are beginning to be taken seriously, and these individuals are increasingly less likely to be tortured with unrealistic demands to change their lifestyle.

In all of these education programs, people are taught to adjust their insulin to situations they meet in everyday life, and they are taught to avoid hypoglycemia. This may well be the reason why there has been no increase in hypoglycemia with intensified therapy in Germany.

Flexible therapy does not mean that nobody has problems with diabetes any more. It is still a demanding, strenuous therapy that only a minority carry out conscientiously. Some 20­30% still have high HbA_1c values and experience severe hypoglycemia. A greater number suffer psychologically as a result of the remaining strictures and demands. The diabetes teams need professional psychological support for psychosocial problems, and centers now in planning will have a psychologist qualified in diabetes.

The humanization of the treatment of the chronically ill, which can be seen in the empowerment movement, is under threat from the medicalization and technicalization of medicine. Doctors, patients, and society will have to decide whether they want to view health as something that includes mental and social aspects, or whether health is to be measured simply in terms of medical parameters. People with diabetes stood up for their right to evidence-based therapy. But more than this, they need honest and complete information, a listening, nonjudgmental ear, recognition of their chosen way of life, and room for informed choices. These, too, are worth fighting for.

Axel Hirsch, PhD, is a clinical psychologist at Bethanien Hospital in Hamburg, Germany.