Summary
In 2013, a weekly psychotherapy group was developed within Betsi Cadwaladr University Health Board's locality diabetes team for diabetes patients for whom self-management was very challenging. Some were reluctant to engage at all, and those discharged were repeatedly referred back to begin the cycle of usual care once again. A group was developed with supervision of the lead psychotherapist for personality disorders, and led by the dietitian as therapist in the group. Patients leave when they are ready, based on their personal outcomes. The diabetes dietitian has supervision from the lead psychotherapist in the personality disorder service. The DSN also works "on the boundary", maintaining appropriate communication whilst ensuring the safety of the patient. To date 14 patients have been active in the group and reported outcomes and acceptability are very positive and demonstrate individual clinical improvements and reductions in weight and medications.
Results
Patients' outcomes are agreed by the patients themselves when thinking about joining the group, and the group helps patients understand their progress and whether leaving or staying in the group is most helpful. Self-measured outcomes for the patients included: subjective /objective binge eating reducing, reducing or maintaining weight and being able to monitor blood glucose appropriately. Patients who have left the group have enjoyed a variety of their desired outcomes: Funding for bariatric surgery (x1); no longer requiring bariatric surgery (x1); stopping insulin (x2); maintaining > 9% weight loss (x5); and one decided to return to work. The psychological benefits have not been directly measured but anecdotally the patients are able to relate more satisfactorily in their outside lives.
Challenge
In 2009, as part of a new locality based diabetes team (total population 50,000), the DSN and dietitian implemented a variety of interventions to support patients to self-manage their diabetes. But by 2011, a subgroup of patients still found their diabetes management and control challenging due to co-existing emotional or relational difficulties which usual care was not addressing. This meant patients were 'held' in usual care making little improvement, or discharged where their diabetes management deteriorated, and so would be referred to re-enter the usual care over again. There were some patients also reluctant to enter usual care, or those who accessed regular contact through unplanned phone or clinic visits, were reluctant to be discharged by health professionals or their self-care (eating behaviour, glucose testing, and administration of medication/ insulin) became sabotaged. Patients who were offered referral to the local CMHT would often decline (due to stigma) or dropped out of the treatment offered, and the waiting times were around 18 months for a longer therapy which would be usual when treating emotional/relational difficulties in a psychoanalytic way. This was both unsatisfactory for the patients and difficult to time manage for the diabetes professionals.
Objectives
To provide an intervention which would be accessible to patients with the full spectrum of diabetes phenotypes, when usual care was rejected, or not successful, and whose commonality would be having emotional or relational difficulties making their diabetes self-management difficult. To develop an integrated psychotherapeutic approach to treat mental and physical health concomitantly.
Solution
During 2011 and 2012 the dietitian and DSN arranged in-house training to observe and experience psychotherapists delivering group intervention based on therapeutic community and group analytic principles. They also joined a supervision group run by the lead for personality disorders services for multi-professionals within the local CMHT. In 2011, the dietitian undertook a Foundation training in group analysis (through Institute of Group analysis, IGA) and in 2013 undertook a Diploma in group work through the IGA, which involved setting up and conducting a training group to be executed under scrutiny of the IGA as well as the local supervision provided. This framework provided an opportunity for the dietitian (as therapist) to set up a therapy group for 1.5 hours a week, for up to eight patients as a pilot for 30 weeks. All patients sign a confidentiality agreement and understand the boundaries and expected commitment to the group as a whole. All patients were invited to be weighed weekly by an assistant, in order that the conductor has some understanding of the situation a patient with both type 1 and type 2 in terms of what they are working for, and also the patient can talk about the difficult feelings towards this in the group in real time.
Learnings
Fifteen patients have been part of the group in all, including the six current members and a new member who was preparing to join in June 2016. As a slow-open model, the duration of stay can vary, although a minimum of 30 sessions would be desirable. This model enables a wide spectrum of diabetes difficulties and also range of psychological, emotional or relational difficulties to be explored simultaneously.
Evaluation
This model demonstrates that an inter-disciplinary approach can be provided in a single intervention, if professionals with varying specialist knowledge and skills are prepared to work in a truly integrated way to share appropriate cross discipline skills within a safe governance framework.
