| Diabetes Spectrum Volume 12 Number 2, 1999, Pages These pages are best viewed with Netscape version 3.0 or higher or Internet Explorer version 3.0 or higher. When viewed with other browsers, some characters or attributes may not be rendered correctly.
Counseling Techniques for Clinicians and Educators Jill Weissberg-Benchell, PhD and James W. Pichert, PhD This article uses a challenging case to contrast the outcomes of two approaches to clinic-based, diabetes-related interviewing and counseling. As you read the following case, put yourself in the role of a clinic-based diabetes educator about to visit with Lynn Wilson and her mother. Case Description The day before their clinic visit, the mother called to tell you that last weekend Lynn was discovered passed out at a friend's house. The friend did not know how long Lynn had been that way (Mom thinks maybe the friend was drunk). However, after the friend could not rouse Lynn, she called Lynn's mother, who came to the house and checked Lynn's blood glucose, which was 32 mg/dl. Mom administered glucagon, was able to rouse Lynn, and took her home. She did not think it was necessary to "bother" the diabetes team with a phone call on a Sunday morning. Mom wants you to "talk sense" into her daughter and to find out if Lynn was also drinking. Here's what you know about the family from clinic records and previous visits: Lynn was diagnosed 10 years ago. She is currently in the 10th grade. She receives learning disability services for reading and language arts. She receives mostly C's on her report card. Lynn lives with her mother, her mother's boyfriend (who moved in about 14 months ago), and her 14-year-old sister. Her parents were never married, and she has not seen her biological father in many years. Her mother is a billing clerk. Her mother's boyfriend is an auto mechanic. Lynn and her mother have come fairly regularly to clinic (at least 3 times/year). They rarely call-in blood glucose results, and sometimes Lynn forgets to bring her records to clinic. She's been growing and gaining weight appropriately over the years and is at approximately the 50th percentile for height and weight. She is on a 3 shot/day regimen and has been running HbA1c levels of 8.5–9.0 over the past year. She was hospitalized once in diabetic ketoacidosis approximately 1 year ago because she says she wanted to know what would really happen if she skipped her shots. Two Different Interviews How would you proceed? What questions would you ask in order to complete an assessment? What information would you want to gather, and in what order? What strategies might you employ that will help Lynn (and her mother) both immediately and for the long term? Educator #1 She reassured Lynn about the confidential nature of their discussion, then asked, "What experiences have you had with alcohol, Lynn?" When Lynn responded, "Not much," #1 persisted, asking a series of nonjudgmentally worded questions punctuated by anecdotes about other patients. As a result, #1 learned that Lynn frequently drinks with her friends on the weekends and will drink as much as a six-pack of beer at a time. The incident this last weekend occurred when Lynn was at a friend's party. She'd been shopping with her friends during the day, and they were so busy she skipped lunch. Then they went to the party, where Lynn drank "a lot" of beer and "something that was sweet." She remembers feeling shaky, but that was it until she woke up back at home feeling nauseated. She told her mother that she passed out because she skipped lunch and her blood glucose got too low. She does not want her mother to know that she was drunk. The educator reiterated that the information Lynn had provided was confidential, expressed deep concern about anyone drinking to the point of passing out, and asked Lynn if she was interested in learning some principles of safe alcohol use for people with diabetes. Lynn responded that she did not want to hear a lecture, so #1 kept it brief and provided an instructional take-home brochure on alcohol and diabetes. Mom was brought back for a couple of minutes so that #1 could reinforce the importance of keeping blood glucose records and bringing them to appointments. A follow-up visit was scheduled for 34 months. The educator regretted not having more time to spend with this family. Comments on Interview #1 However, the interviewer fell into a number of common traps that limited both the information gathered and the support provided. First, the interviewer spent virtually the entire session on a single topic, alcohol use. This topic appeared to be important to Lynn's mother based on her telephone call from the day before, but binge drinking may not have been the highest priority for either Lynn or her mother. Unfortunately, Educator #1 won't know that. Second, the interviewer did not ask questions about any other aspects of living with diabetes. Third, because of the limited questioning and narrow definition of the problem, the educator arrived at a solution (providing instruction on how people with diabetes can drink alcohol safely) based on assumptions that may not be valid. Finally, no effort at collaboration was made—not in defining the topics of importance, and not in coming up with possible solutions. An alternative approach to counseling is to complete a more thorough social and behavioral assessment before initiating instruction. Examples of questions that might prove useful, assuming they are rephrased to suit both your patient and your interviewing style, are listed in Table 1. By asking these and similar questions, another educator would have learned not only the particulars of Lynn's binge drinking, but also some additional information.
Educator #2 At school, Lynn has been cutting classes, and she is in danger of failing a number of courses. When asked, Lynn says that school is boring and stupid. Although Mom is quite worried about this, she does not want to confront Lynn about it, again because Lynn becomes so irritable when the topic is raised. Educator #2 thanked Mom for her time, then asked Mom to retire to the waiting room so she could finish up by talking with Lynn alone. Educator #2 continued the discussion using more of the questions suggested in Table 1. Lynn revealed the following: Having diabetes "sucks." It gets in the way of "everything," and "nothing" in her life is the way it should be because of diabetes. She is fairly compliant with shots because she hated being in the hospital, having IVs, eating "awful" hospital food, and being unable to escape from her worried mother. She tests "most times," but usually can "just tell" what her numbers are and so takes the insulin doses she "knows" she needs. Lynn has a large group of "friends," really just acquaintances, with whom she hangs out, but no best girlfriend. When she's not at home or at school, she's usually with these friends, hanging out near the local park or at the mall. She's been dating since she was 14, and her first serious relationship ended 1 month ago when her boyfriend's family moved to another state. Lynn had met Sean through a mutual friend, and it was "love at first sight." They dated for almost 8 months, and they were sexually active. Sometimes they would use condoms, but sometimes they would "forget." Sean never knew Lynn had diabetes. In addition to learning about the binge drinking episode, Educator #2 discovered that Lynn has smoked approximately 1/2 pack of cigarettes per day since age 13. Lynn believes that her mother does not know because Mom has never said anything about it. Comments on Interview #2 Educator #2's Intervention Strategy
By the end of the session Lynn agreed that, before the next regularly scheduled clinic visit, she would identify three peers she might be willing to tell about her diabetes and return ready discuss the pros and cons of such a disclosure. To seal the agreement, Lynn even signed a performance "contract" (a note in the chart). She also agreed to do a series of "experiments" to test her ability to predict her blood glucose values. Educator #2 provided a sheet of paper on which to record both a guess and an actual blood glucose value for at least 12 times, 3 each in the morning, after school, at bedtime, and whenever Lynn felt low. Early on during the brainstorming, Lynn said that she did not want any lectures about sex or drinking. Educator #2 respected Lynn's wishes, but almost as an aside after the contract had been written, she suggested that Lynn look over a collection of brochures "and see if there are any you'd like to take home with you while I finish writing up my notes on our session." Lynn took a brochure on alcohol and stuffed it in her backpack, but she did not take any of the ones on safe sex or pregnancy and diabetes. Educator #2 made a note in the chart to ask at the next visit whether Lynn had read anything about diabetes and what questions she might have. Educator #2 also casually mentioned that Lynn may like to talk with someone who counsels teens with diabetes and who helps them learn new ways of coping with living with a disease that "sucks." Since Lynn appeared disinterested, the educator also wrote a note in the chart to remind her to broach the subject of counseling again at the next clinic visit. Mom was called back and, with Lynn's permission, was made aware of the blood glucose predicting experiment. The educator counseled Mom to stock up on supplies if it looked like her current job and insurance benefits might end. A follow-up visit was scheduled in 2 months to more closely monitor Lynn's progress and to try to see them before Mom lost insurance coverage. Mom agreed and thanked #2 for her concern. The educator regretted not having more time to spend with this family. Comments on the Self-Management Plan For Lynn
Wilson Lynn poses many problems and obstacles to adherence. In such cases, your task is not to unilaterally identify and fix all of the problems but rather, we believe, to help the patient identify one behavior and, assuming that you are working with someone who has expressed willingness to be involved, create a plan containing one or more strategies that might help the patient gain some control over that behavior. Table 3 suggests one outline for organizing your thoughts.
As described in the narrative, Educator #2 identified several risky behaviors that undermined Lynn's diabetes self management (not including Lynn's irritable behavior toward her mother whenever Mom expressed concern about Lynn's diabetes). Analysis of the most likely barriers suggested that the biggest one might be loneliness, an emotion that might be behind the risky behaviors. This formulation was endorsed by the patient. Given a choice about how to proceed, Lynn agreed to work on the blood glucose estimation experiment and think about who she might tell about her diabetes. She refused direct intervention about alcohol and sex, but given the opportunity, she took some literature on alcohol, opening up the possibility for future discussion. The self-management strategies employed by Educator #2 (see Table 3) included asking for Lynn's help in coming up with ideas and choosing what ideas to pursue. Following Lynn's lead, Educator #2 simplified the treatment plan by postponing some topics for discussion (alcohol, smoking, unprotected sex, family relationships) and concentrating on just two: insulin adjustments based on "feelings" and feelings of loneliness/isolation. A simple contract was used to gain a measure of commitment to the blood glucose estimation experiment and to build some accountability into the relationship. Despite acknowledging her loneliness and isolation, Lynn was resistant to telling any friends right away, but would agree to think about who she might eventually tell. This agreement sets the stage for an ongoing discussion about strategies for dealing with Lynn's loneliness. Conclusions Acknowledgment Jill Weissberg-Benchell, PhD, is a clinical psychologist at Children's Memorial Medical Center and an assistant professor at Northwestern University Medical Center in Chicago. James W. Pichert, PhD, is an associate professor of education in medicine at the Diabetes Research and Training Center at Vanderbilt University School of Medicine in Nashville, Tenn. Copyright © 1999 American Diabetes Association Last updated: 5/99 |