Family therapy.

Another major force not letting us succeed in the treatment of diabetes remains right inside the patients home, their family members. Hence, it is important to know the perception of the close family members about this simple and strong tool in diabetes, 'insulin'. The drug is nearing its century, it has not fully being accepted gracefully even in todays electronic savvy society. So, we need to strongly discover the reason for its non-acceptance, while trials are out inventing new drugs. One vital thing that can change this attitude is increasing the understanding of this drug, insulin in depth to close people around the patient, the 'family'. Underestimating family's perception about disease and treatment for diabetes is detrimental to both diseased and the doctor. This consists of a biopsychosocial model; biological, psychological and social factors. Family forms the most important part of it. The strategies in family therapy include psychodynamic, structural, strategic, and cognitive-behavioral component. Diabetes has and will continue to rise, so will be the treatment options. From the clinicians side its to fix fasting first but from patients its fix family first. Family therapy demonstrates the importance of insulin initiation and maintenance in insulin naive patients, and continuation for others. The specific needs of such patients and their impact on family life are met with family therapy. Who needs family therapy? Benefits of family therapy and a case based approach is covered.

INTRODUCTION

Despite being the densely populated nation of the world, India yet sees major hurdles in its management. These barriers have been largely discussed in relation with patient and physician since long time and have been documented including the psychological insulin resistance.[1] However, another major force not letting us succeed in the treatment of diabetes remains right inside the patients home, their family members. Family therapy holds its importance in management of substance abuse, etc.[2] however, its role and impact in the management of diabetes is not explored.

NEED FOR NEW THERAPY

The therapeutic armamentarium of diabetes is expanding enormously on a very fast pace. From insulin to incretins, conventional to analogues and daily to weekly dosing, these are showing their efficacies in management of diabetes. But, people frowning at the voice of insulin, is still common in daily practice. It's sometimes beyond the injection, the word “insulin” itself. The drug is nearing its century, it has not fully being accepted gracefully even in today's electronic savvy society. Hence, we need to strongly discover the reason for its non-acceptance while trials are out inventing new drugs. One vital thing that can change this attitude is increasing the understanding of this drug, insulin in depth to close people around the patient, the “family.” This consists a biopsychosocial model; biological, psychological and social factors. Family forms the most important part of the social component.[3] It is used not only in modern medicine, but also across alternative forms of medicine.

ROLE OF FAMILY MEMBERS

Parental fear and misperception about diabetes[4] is another difficult issue to tackle. Parents, siblings and children form the main basis of the family tree for any given individual. These members know most of the time the minute details of lifestyle that one leads. Not only from point of view of diet and exercise, but also their behavior about the disease and the treatment patient is on including oral and injectable. Insulin forms the most physiological basis for treatment of diabetes. Hence, it is important to know the perception of the close family members about this simple and strong tool in diabetes, “insulin.” Family therapy helps in the stress management of diabetes way beyond insulin therapy. In India, family therapy is more successful as there is generally a strong bond within the folks.

FAMILY THERAPY

Under estimating family's perception about the disease and treatment for diabetes is detrimental to both the diseased and the doctor. Family therapy includes the use of psychoeducation and is used in other ailments such as attention deficit hyperactivity disorder, depression and its role has expanded in the past four decades.[5] The strategies in family therapy include psychodynamic, structural, strategic and cognitive-behavioral component.

It involves calling them to clinic talking and asking the difficulties along with knowledge level of important family members. Even in study of peer group for diabetes, patients and their family members chose to be educated in the group rather than done in singular.[6] This therapy positively influences the outcomes for a diabetic patient. If neglected, it can have negative influence on the part of patients and perceptions about the disease. We need to select appropriately the problems inside patients, family and connect them in order to solve the issues related to diabetes, its treatment or complications. Also, the treating physician needs to understand symptoms of the patient are stressful not only for the patient himself or herself, but it affects the family as a whole. Family members have to bear the brunt of economical as well as social burden and mood swings of the diseased patient. And is distressing to both patients and their families. Hence, family therapy is to understand and educate the family by taking out time for the individual patient.

WHO NEEDS FAMILY THERAPY?

The case of carbuncle coercion

This gentleman of age 50 years, with swelling over his upper back and fever since 7 days, comes with fasting plasma glucose (FPG) of 300 mg/dl and preprandial glucose (PPG) of 450 mg/dl. On enquiry, history of weight loss and polyuria present. No history suggestive of any micro or macro vascular complications. Family history: Father and sister diabetic since 18 and 7 years respectively. He takes mixed diet and has a sedentary lifestyle. On examination: Pulse of 80 beats/min, blood pressure 130/80 mmHg no orthostatic hypotension, acanthosis nigricans present. 10 cm × 8 cm inflamed swelling over upper back on the right side. Patient education was done, explained about diabetes initial and present management. This officer agreed and learnt insulin technique in the clinic took the first dose of insulin by himself and was absolutely comfortable. He had glucometer at home and knows to keep a record of glucose values.

His glucose value at fasting was 220 mg/dl after two doses of insulin. He came back the next week with painful swelling after surgical excision over the same site.

His glucometer reading was 475 mg/dl this visit. He said that he was totally compliant about diet and exercise. However, he could not continue treatment at home.

On further discussion, he admitted that his family members forced him not to take any more insulin.

Benefits of family therapy

Patient education remains the cornerstone in diabetes management, but such case scenarios makes us impart it to at least the immediate family members.

Patient related

Better control of parameters

Knowing daily difficulties of the patient through family members

Better patient care in complicated case e.g., in diabetic retinopathy

Improved quality of life

No extra cost to care of diabetes.

Family related

Improved family life

Family members needing insulin may be started, improving diabetes management in the family.

Physician related

Better patient physician bonding

More helping hands to management of patient at home itself to tackle difficult situations.

WHAT HAPPENED NEXT?

Patient was counseled again and called back with family members. He started taking insulin after his family was explained the importance of insulin initiation. Dynamic form of the strategy was used with patient. It brings unconscious conflict to conscious interpretation. This was an eye opener even to his father suffering diabetes 17 years and sister 7 years. These two close family members were on oral treatment for their diabetes. The structural and strategic form of family was used to counsel patient's father and wife. The strategic form is generally solution focused. It allows reframing the whole situation into a reality and patients are explained by giving live example from reality. Or restrain from a particular act or situation. In the structural form of family therapy, we have to identify the family as a unit. Then check for the contact between family members, i.e., they have too much contact or too little contact. Also ascertain the hierarchy in the family, who heads it. Although this family had seen diabetes in generations and followed all dietary instructions carefully since long, they were curtained with myths and lack of information. After 2 weeks, our patient's FPG 140 mg/dl PPG 190 mg/dl; no osmotic symptoms healing carbuncle at the back.

CONCLUSION

Diabetes has and will continue to rise, so will be the treatment options.

From the clinicians side, it's to fix fasting first, but from patients its fix family first. Family therapy holds good promise in management of diabetes for more than one person in the family. Family therapy demonstrates the importance of insulin initiation and maintenance in insulin naive patients. The specific needs of such patients and their impact on family life are met with family therapy.