As a chronic condition Diabetes Mellitus type 1 induces various changes in patients’ lives, which can be detected both on a biological and a psychological level. Due to the early onset of the condition, the diagnosis of diabetes may cause a family crisis, which in turn may lead to complications for the patient, the family environment and the course of the condition itself. For the above reasons, the need to address both the biological and the psychological aspects of diabetes in combination becomes imperative. The present article presents and recommends Conjunctive Group Therapy Model for adult type 1 diabetes mellitus patients as a therapeutic approach for disease treatment, in parallel to medical treatment. The 2-year therapeutic model combines various types of psychological interventions, supports person-centered care in medical practice and combines all aspects of the disease, namely biological, psychological and psychosomatic. The effectiveness of the intervention confirms the need for a holistic approach towards type 1 Diabetes Mellitus treatment.
**Key Words: ** Type 1 Diabetes Mellitus, Conjunctive Group Therapy, Family Crisis
INTRODUCTION – THEORETICAL ISSUES
Diabetes Mellitus (DM) is a chronic condition and a severe public health issue, as its complications are responsible for high morbidity as well as high premature mortality rates (Atkinson and Maclaren, 1994; Jörgens et al, 2002; Mygdalis, 2000). It is estimated that 8% of the Greek population suffers from DM, of which 10% suffers from type 1 DM (T1DM) (http://www.hndc.gr).
Due to the chronic nature of diabetes, T1DM patients are faced with multiple psychological challenges, as T1DM onset affects the person both on a biological and an emotional level (Cox and Gonder, 1992). Diabetes is characterized as a psychosomatic condition because it has an effect on, and at the same time is influenced by, the individual’s functionality, social relationships, professional life and family interactions (Clay, 1992).
When a child or an adolescent is diagnosed with T1DM the result is disequilibrium in family life, because the threat of the disease cannot be treated with common practices; therefore, T1DM diagnosis is related to a family crisis (Siousioura, 2014). Diabetes onset triggers stress responses among family members. Stress in its turn creates difficulties in disease management, impedes treatment compliance, and hinders metabolic control achievement. Family plays a crucial role in disease management, and family support is very important in the empowerment of the patient and their adherence to diabetes care. Family support involves empathy, provision of advice, open communication, encouragement, and plan of action. Simultaneous medical and psychological intervention, combined with family support, constitute fundamental actions towards T1DM treatment.
Minuchin (2000) and Tsiouli et al. (2013) emphasize the fact that stress experienced by family members contributes to difficulties in disease management, and metabolic control achievement, and also to patient’s treatment non-compliance. Minuchin (2000) describes the family as an interactive system where each member responds to stress caused by other members and contributes to the other members experiencing stress. More specifically, family support and absence of conflicts creates an atmosphere where patient’s autonomy and security are encouraged; these two factors are especially important for effective T1DM treatment.
Greek T1DM patients are often seen to address their medical issue exclusively to endocrinologists, and also to have important difficulties in treatment compliance and achievement of metabolic control. The present article supports that diabetes treatment should focus not only on the biological/medical aspect of the condition, but also on the psychological and psychosomatic factors that play a role in the course of diabetes (holistic approach to diabetes treatment). The Conjunctive Group Therapy presented below is based on the Conjunctive Model (Grotjahn et al., 1983; Stone et al., 1991; Yannitsi, 1997). In general, group therapy is broadly implemented in clinical practice and is based on the biopsychosocial model (Scheidlinger, 1994; Yalom, 2006).
Conjunctive Group Therapy consists of a number of psychotherapeutic models, including: Strategic School of Family Therapy (Minuchin, 1974; 2000); Focused on the Strategic School of Family Therapy «FDST» (Mc Lendon et al, 2005); Systems-centered Therapy for Groups (Agazarian, 1997); and Supportive Psychotherapy for people suffering from physical conditions (Sifneos, 1975; Yalom, 2006). Conjunctive Therapy intervenes both in the psychological and biological aspects of T1DM and is oriented towards whole-person care (Shillitoe, 1988), psychosomatic wholeness (Karush et al., 1969), and the unified self.
CONJUNCTIVE GROUP THERAPY
The members of Conjunctive Group Therapy were 32 adult T1DM patients who attended the Outpatient Clinic of “Evangelismos” General Hospital of Athens (Department of Endocrinology, Diabetes and Metabolism), as well as the 3rd Clinic of Brief Hospitalisation of “IKA” in Athens, for medical monitoring. In parallel, a second group of T1DM patients was studied, consisting of individuals who received only medical treatment for the condition and did not participate in any kind of psychological intervention for T1DM. This group was considered the control group.
Before and after group participation patients went through Focused Interviews (Cohen and Manion, 1994) and HbA1c% measurements (Analysis method: HPLC). The group sessions followed a free and non-directive agenda, the group was closed-type and the criteria for group participation were the following: a. glucose dysregulation, b. referral by endocrinologists and/or diabetologists and c. priority order. The members’ common request was the achievement of metabolic control. The intervention lasted for two years, and the group meetings took place twice a month for a two-hour session. For practical reasons, four different groups of patients were formed, consisting of seven to eight members each. The group leader was a Psychologist specialized in Clinical and Health Psychology and received external supervision by a mental health expert specialized in Liaison Psychiatry. In parallel, there was participative observation of the group processes by an Endocrinologist/Diabetologist of the Hospitals. Patients consented to exploration of the psychological aspects of diabetes during group process. In cases when medical or nutritional issues arose, the groups would schedule an inline meeting with a practitioner or a nutritionist for psychoeducational purposes. Before group participation, patients were informed about the rules of group functioning such as: stable presence, confidentiality, trust, open expression, and non-directive agenda.
The therapeutic targets of Conjunctive Group Therapy focus on the intermediate psychological and psychosomatic factors, which not only mediate but may also optimize the therapeutic outcome, i.e. metabolic control. More specifically, the basic targets are the following:
**A. ** Psychoeducation, which comprises of individual responsibility undertaking and modification of previous dysfunctional behaviours. Specifically:
Enhancement of pre-diabetic behaviours
Communication skills learning
Provision of medical information
Metabolic control achievement
**B. ** Psychological support, which aims at diabetes acceptance and is influenced by mediating factors such as the following:
The effect of negative emotions on metabolic control
Quality of life enhancement
Family and social network dynamics
The therapeutic techniques applied in Conjunctive Group Therapy aim at inducing modifications on an intellectual, emotional and behavioural level that will in turn cause alterations on a biological level (metabolic control), in accordance with the multifactorial nature of T1DM (Siousioura, 2012; Trisjburg et al., 1992). The techniques are the following:
Free associations (Kleinetal., 1986).
Clarification of members’ needs (Govaerts, 1991).
Encouragement of the patient’s active role in diabetes (and life-) management (Betcher and Zinberg, 1988).
Encouragement of expression of negative emotions (Johnson and Grand, 1998) and traumatic experiences (Schwartz, 2001).
Focusing (Anderson et al., 1995; Miller et al., 2000; Yalom, 2006).
Role-playing (Hoyt et al., 2003).
Reconstruction and rational explanation (Whiteand Epston, 1990)
Self-transcendence (Yalom, 2006).
Fighting spirit (Greer and Moorey, 1997).
Table  shows the characteristics of Conjunctive Group Therapy leader.
Conjunctive Group Therapy effectiveness was measured by two criteria (Siousioura, 2010): a. patients’ responsed in focused interviews ( Cohenand Manion, 1994; Glaser, 1978; Glaser and Strauss, 1967; Merton and Kendall, 1946) that took place before and after the intervention, and b. ΗbΑ1c (%) levels measurements before and after the intervention, and comparison with ΗbΑ1c (%) levels measurements of the control group. Group patients’ ΗbΑ1c (%) measurements showed metabolic control achievement after termination of the group processes.
The findings indicate that there is a statistically significant difference between patients’ ΗbΑ1c (%) values before and after the intervention. The mean value of patients’ ΗbΑ1c (%) measurement is reduced after the intervention, and more specifically by one unit, a fact that draws attention. This result shows that most of the patients achieved ΗbΑ1c (%) values that are closer to the mean value and more acceptable by international guidelines concerning ΗbΑ1c (%) measurements rates. The result is of great importance for T1DM, as it highlights the psychosomatic connections that exist in the condition, and confirms that Conjunctive Group Therapy has a positive impact on ΗbΑ1c (%).
Patients’ initial request was the achievement of metabolic control, which clearly constitutes a medical issue. Nevertheless, during group process patients were observed to be concerned about psychological issues instead of medical ones. This means that patients were concerned with the factors that mediate regulation or dysregulation of glucose, thus suggesting a multifactorial aetiology of metabolic control. Therefore, while during the first year of the group intervention patients referred more to diabetes-related general issues of everyday life, during the second year of the group intervention they focused more on the psychological and emotional aspects of diabetes, as if they subconsciously talked about the factors that cause dysregulation. Moreover, while patients talked about the impact of the family on diabetes in the beginning of the intervention, their focus moved towards their self as the group progressed, a fact that is noteworthy enough.
Additionally, during the first year the patient’s prevailing emotion was negative, such as diabetes denial, announcement denial, avoidance of intimate relationships, whereas during the second year the emotion transformed into positive, e.g. emotional expression and autonomy, diabetes redefinition and acceptance, expectation for childbearing and quality of life enhancement.
Another important issue is patient-practitioner relationship. During the first year patients seemed to rely on the relationship with their practitioners, and considered it as a factor that facilitates glucose regulation, whereas at the same time their measurements showed poor metabolic control. This phenomenon is a general positive view of what constitutes a good patient-practitioner relationship, although it is ineffective in terms of treatment. During the second year, patients formed their own opinion as to what kind of patient-practitioner relationship would be effective for them, and made their own suggestions to improve this relationship, while they had already improved metabolic control. Patients’ emotional autonomy seems to have led to their undertaking individual responsibility towards diabetes and their life—a fact that influenced the formation of a patient-practitioner relationship as well as metabolic control.
Furthermore, inferiority feelings and diabetes stigma were also significant issues for the patients. Both contributed to their denying or avoiding announcing diabetes, something that was clearly evident during the first year of the intervention. This means that patients processed diabetes as something “foreign” and “hostile” towards their unified self. The discussions during the second year of therapy showed that diabetes stigma had been transformed to: diabetes redefinition, developing process of diabetes acceptance, self-awareness and quality of life.
According to the above, it is recommended that practitioners and health experts, namely endocrinologists and nutritionists, refer T1DM patients to psychiatrists and psychologists (specialized in clinical or health psychology), when they display the following: excessive stress responses that lead to loss of control, negative emotions as response to stressful conditions, diabetes-related stress that leads to avoidance of self-care, and fear of hypoglycaemia that leads to them choosing to maintain high blood sugar levels in order to prevent it. It should be noted that high stress levels are usually hard to discriminate from hypoglycaemia symptoms (irritability, tremor, dizziness, high pulse rate, headache, exhaustion, perspiration, feeling of hunger, inability to concentrate, mood swings, aggressiveness, confusion, feeling of fainting, spasms, loss of muscular control); moreover, negative experiences of hypoglycaemia constitute prognostic factors for the development of fear of hypoglycaemia, hyperglycaemia and depression (Polonsky et al., 1992).
Diagnostic criteria for depression (American Psychiatric Association, 1994) and psychological symptoms of hyperglycaemia (such as fatigue, sleep disturbances, changes in body weight, appetite, etc.) are common. However, depression is not considered as a T1DM complication (Peyrot and Rubin, 1997); yet depression contributes to long-term dysregulation and the establishment of brittle diabetes (Clark, 2001; Dutour et al., 1996; Gill et al., 1985; Pickup, 1992; Schade et al., 1985a; Schade, et al., 1985b; Τattersall, 1997; Tattersall, et al., 1985). The need for treatment of depression, which is the most common mental disorder among T1DM patients, is imperative as it helps patients improve their mood, quality of life and metabolic control. T1DM and depression comorbidity may lead to relapse of depressive episodes in the future, which has a negative impact on diabetes management (Lustman and Clouse, 2002), increases the possibility of complications (Peyrot and Rubin, 1997; The DCCT Research Group, 1993), and frequently causes family dysfunctionality.
Within the family environment it is important to evaluate the interaction that takes place between the T1DM patient and the other members, and understand the connection of family interactions to a. metabolic control, and b. treatment compliance. The interactions are significant as family members often share the responsibility of treatment compliance and it is possible for them either to facilitate or to hinder it.
Regarding T1DM management, family support is especially important for the patient’s empowerment and their adherence to self-care (Siousioura, 2012; Siousioura, 2014), as there is even a direct impact of support on stress hormones levels (Chrousos and Gold, 1992). There is a positive correlation between stress and blood glucose levels, explained by neuroendocrinological dysfunctions and stress hormones (catecholamines) secretion, which cause hyperglycaemia, block the activity of insulin and further stimulate glucose production by the liver (Tsiouli et al., 2014).
Numerous studies have found a positive correlation between self-care adherence and family support, given that there is no such thing as a good or a bad treatment complier (Glasgow, 1991). More specifically, a supportive and conflict-free family environment creates an atmosphere of flexibility, encouragement and support, which are very important for T1DM patients (Edelstein, 1985). This environment is a good prognosis for the achievement of metabolic control, through the encouragement and development of self respect on the part of the patient. The supportive family teaches that self-care is part of one’s individual responsibility and ability to control diabetes and build mastery. At the same time the supportive family helps the patient tolerate pain and obtain optimal mental health and effective emotional management.
Furthermore, studies report that family interactions may be stress triggers (due to judgmental comments expressed) that lead to inadequate metabolic control (Brown, 1985; Lustman, and Clouse, 2005; Peyrot et al., 1988; Rubin and Peyrot, 1992), in contrast to positive emotion, which leads to optimal metabolic control through the processes of hormonal mechanisms (Lustman and Clouse, 2005).
In addition, patients’ emotional attachment to their family accounts to a great extent for difficulties in diabetes adjustment and dysregulation. The young/adolescent patient has not yet accomplished the formation of their personality. Parents’ possible negative interpretations of diabetes may hinder its treatment. Patients internalize these interpretations, a fact that affects the future course of diabetes.
Moreover, diabetes unpredictability may serve as an alibi for patients to be influenced by the family and the social environment, and maintain a certain level of vulnerability. After all, the social environment provides patients with security as it functions as a balance against the uncertainty caused by diabetes. The impact of such a form of attachment is negative, as it reinforces lack of self confidence, impedes emotional autonomy, prolongs living with family of origin, reduces friendly relationships, weakens the patient’s efforts to search for alternative supportive networks, reinforces feelings of inferiority and eliminates the expectation of creating a family of their own.
Based on the outcome of the intervention, Conjunctive Group Therapy (Tsamparli and Siousioura, 2009a; Tsamparli and Siousioura, 2009b; Siousioura, 2012) for T1DM patients is recommended for application in parallel to medical monitoring for diabetes, as a holistic approach to diabetes treatment. This type of therapy addresses both the psychological and the biological aspects of diabetes and focuses on the person who suffers from T1DM, rather than the patient . Cure is replaced by care , which is oriented towards the individual as a unified self and a unique personality (Siousioura, 2012; 2014).
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**Table  ** . The characteristics of Conjunctive Group Therapy leader
Characteristics of the Leader
Considers each patient as a unique individual with psychosomatic needs.
Contributes to a therapeutic relationship based on support instead of interpretations.
Listens actively to the patient’s needs and wishes that relate not only to diabetes but also to life in general.
Performs therapeutic connections among emotions, life events, experiences and diabetes symptoms (hypo- and hyperglycaemias and complications).
Reinforces the expression of diabetes experiences, as well as the verbalization of negative emotions, to which the patient resists.
Reinforces understanding of resistance, so that the patient is enabled to make connections among diabetes, the self and the others.
Encourages deep understanding of diabetes and of the self, as this contributes to reality testing instead of idealizations.
Explores brittle diabetes on an individual level.
Explores the correlation of diabetes-related stress with inadequate self-care.
Reinforces individualized responsibility, not only towards diabetes, but also towards the patient’s everyday life.
Explores phobia of hypoglycaemia and its medical and social impact on patients’ life.
Explores the impact of family dysfunctionality and diabetes social stigma on glucose dysregulation.
Reinforces diabetes announcement as a process of self-awareness and diabetes acceptance.
Reinforces patients’ search for supportive social network.
Connects, separately for each patient, diabetes adjustment, with acceptance and final metabolic control.