The present study examines Therapeutic Processes of 2-year Conjunctive Group Therapy Model of adult type I diabetes mellitus patient in parallel with medical treatment at a Greek state hospital. The study focuses on the patient’s changes in thoughts, emotions, behaviors and metabolic control after termination of the intervention, through group dynamics. Qualitative data was collected from focused interviews and group sessions, before and after the intervention and thematic analysis was performed. Blood samples were collected for the measurement of glucose levels. Findings showed that by termination of the group therapy, the patient improved blood glucose regulation and she integrated all aspects of the disease, the psychology of her needs, the idiosyncratic personality traits and the quality of her life. The effectiveness of the two-year therapeutic model confirms the need for a holistic approach towards type 1 Diabetes Mellitus treatment.

Type 1 diabetes mellitus, Patient, Group therapy, Conjunctive group therapy, Therapeutic processes of the group, Therapist, Group members.

The present study examines Therapeutic Processes of 2-year Conjunctive Group Therapy Model of adult type I diabetes mellitus patient in parallel with medical treatment at a Greek state hospital. The study focuses on the patient’s changes in thoughts, emotions, behaviors and metabolic control after termination of the intervention, through group dynamics. Qualitative data was collected from focused interviews and group sessions, before and after the intervention and thematic analysis was performed. Blood samples were collected for the measurement of glucose levels. Findings showed that by termination of the group therapy, the patient improved blood glucose regulation and she integrated all aspects of the disease, the psychology of her needs, the idiosyncratic personality traits and the quality of her life. The effectiveness of the two-year therapeutic model confirms the need for a holistic approach towards type 1 Diabetes Mellitus treatment.

Type 1 diabetes mellitus, Patient, Group therapy, Conjunctive group therapy, Therapeutic processes of the group, Therapist, Group members.

Type 1 Diabetes Mellitus (T1DM) is an important public health problem, as diabetes complications are responsible for high morbidity [1-3]. In Greece, it is estimated that there are around 800,000 Diabetes Mellitus (DM) patients (8% of the population) of which 10% (80,000) suffer from T1DM, according to the Hellenic Diabetes Association [4]. T1DM develops early in life and insulin injection is an integral part of medical treatment of the disease. As a chronic disease T1DM brings patients up against complicated psychological challenges as changes induced by its onset may be detected at a biological as well as an emotional level [5,6]. It is noticed that Greek T1DM patients often address their medical problem exclusively to endocrinologists and usually have problems with regimen compliance, and thus metabolic control, such as the present case report. Thus, the present study argues that therapy of T1DM patient should focus not only on the organic-medical aspects, but also on the psychological factors that contribute to the course of the disease. The 2-year Group Psychological Intervention in Patients with T1DM used in the present study is based on the principles of Conjunctive Group Therapy (CGT) model [7-10]. This model attempts to explore and therapeutically address the intermediate psychosomatic variables that affect the course of adjustment and, finally, the acceptance of the disease, substantially determining the diabetes regimen compliance and the therapeutic outcome, i.e. the achievement of glycemic control. The course of adjustment to the T1DM, is long and often damaging, with potential complications, not only at an organic, but also at a psychosomatic level. The CGT model, aims at regulating blood glucose levels by helping to shorten the adjustment time and finally to the acceptance of T1DM. CGT for adult T1DM patients is a Group Psychological Intervention for T1DM that combines principles and techniques from various psychotherapeutic models including the Strategic School of Family Therapy [11,12], focused on the Strategic School [13], Systems-Centered Therapy for Groups [14] and Supportive Psychotherapy for people suffering from physical disease [15-17]. The basic target of the model is improvement of metabolic control through the group processes and following mechanisms:

Diabetes education (psychoeducation) is an integral part of Conjunctive Group Therapy. Also, the Model includes, focused interviews of the outpatients before and after the participation in 2-year group sessions and measurement of the biological index of glycosylated hemoglobin HbA1c (%), before and after the application of group intervention, as well. The purpose of this article is to present the case of T1DM adult patient who participated in a 2-year CGT [7,18] voluntary, while receiving parallel medical treatment for T1DM. It is focus on a patient with Brittle Diabetes (BD), manifesting severe fluctuations of glucose levels. Unbalanced glycemic control with severe fluctuations of low and high glucose of a multifaceted etiology constitutes the definition of BD. The metabolic instability accompanied by often and severe episodes of hypo and/or hyperglycemia (ketoacidosis) occurs suddenly and uncontrollably [19-26]. This condition is observed often in patients with T1DM, especially young adults and women [26-30], while it is rare in patients with Type 2 diabetes mellitus [31]. Response to treatment does not always follow glycemic control [32]. This model is recommended as an integral part of the treatment of T1DM because it combines medicine that is the realistic aspect of the illness- with the psychology of the individualized patient needs.

A 29-year-old woman outpatient attended 2-year group intervention in parallel with medical treatment for DM1 at Greek state hospital (Diabetes Clinic of Evaggelismos General Hospital/Department of Endocrinology, Diabetes and Metabolism) in Athens. The patient’s demographic and clinical characteristics are presented in table 1. She was diagnosed with DM1 at the age of 18 and had followed intensive medical treatment with the use of injection since then. Group Therapy started in the beginning of 2014 and ended in the beginning of 2016 and was based on the principles of CGT [7,10,18,33,34]. Group involved eight members including the patient and the meetings took place at “Evaggelismos” hospital. Each session lasted two hours and the group met twice per month. The patient’s participation in the group was based on referral from the endocrinologist and her own consent and personal request for a psychotherapeutic intervention. The patient also was informed:

The members common request was the achievement of metabolic control. For practical reasons, four different groups of patients were formed. The Therapist was a Psychologist specialized in Clinical and Health Psychology and received external supervision by a mental health expert specialized in Liaison Psychiatry. Research data was obtained with the use of focused interview by Merton RK, et al. [35] at two different times (before and after the intervention) and the patient’s answers were content-analyzed using Grounded Theory methodology [36-38]. Grounded theory seeks to derive thematic categories from initial data. The basic thematic categories that emerged were: expectations from the group, psychological adjustment to T1DM, self-care, everyday life, stress, quality of life and depressive symptoms, family and friends, redefinition of T1DM and metabolic control. The process was reiterated several times in order to examine emerging thematic categories. Validation of the approach was considered to have been achieved when repeated data analysis revealed no new thematic categories [38]. The same analysis was followed for focused interview before and after the group intervention, and for the therapeutic processes of the group. Data concerning metabolic control was collected by glycosylated Haemoglobin measurements (HbA1c%). HbA1c% is a biological index, which indicates the average plasma glucose concentration over prolonged periods of time. The index is produced using High Performance Liquid Chromatography method and a high percentage value of HbA1c% indicates poor DM regulation during the last weeks (good regulation: 6.5% to 7%, marginal regulation: 7% to 7.5% and poor regulation: >7.5%) [35]. Blood samples for HbA1c% measurement was collected prior to, and after the termination of the therapeutic intervention. The results of the therapeutic processes of the group are presented in table 2. The first column contains the therapeutic processes that develop in the group dynamics. The second and third column contain the patient’s emotional state, beliefs and attitudes through the aforementioned processes and her own characteristic phrases, before her participation in the group and after termination of the group, respectively. The results of HbA1c% measurements are presented in table 3. The patient’s HbA1c% measurement before the intervention was 12.4% and after the intervention HbA1c% value was 11.4%. The patient gave an oral ethical clearance for this case study. Her basic demographic characteristics have been altered, for confidentiality purposes.

The patient’s participation in the group was voluntary; psychological aspect of diabetes was the only motive of participation in the group. At the beginning of the process, she displayed strong resistance to disclose. The typical difficulty of somatic patients to express their emotions [37], which rate them as a sign of weakness of their ego, is the fundamental belief of the Therapist of these patients (Table 4). Her dominant resistances consist of:

Gradually, as the intervention progressed, she realized that the group taught her alternative and more effective approaches for the disease through the suggestions of members or through therapeutic interventions. The strengthening of modeling, through the therapist and members (psychological mirroring), emit new healthy traits of personality through imitation [15] and learning as an emergent property, resulting from the interactions among members [41]. The previous negative or even hostile attitude towards the disease that may function as a self-destructive behavior [42] was eliminated. And she recognized her personal responsibility, regarding the longterm dysregulation. She also regained contact with friends and improved some aspects of her social activity through the process of developing social skills that enhance wellbeing, mood satisfaction from her daily routine and, as a result, the motive of self-care [43,44]. The processing in the group contributed to realize that the power/help she offered to her mother was at the same time deprived from her (Table 2). She learned how to set personal boundaries and became more autonomous because she deserves it. Finally, she realized that various stressful situations were accused for glucose fluctuations, inhibiting the “motivation” of her self-care. She redefines the role of diabetes in her life as a part of herself. The group operates as a social and familial microcosm, where she could, not only freely express disease management obstacles and behaviors but also thoughts and emotions regarding the self. These changes regarding motives, mechanisms, roles, emotions, behaviors and disease outcome that the patient displays are in line with the principles of CGT, as the intervention addresses both the psychological and biological aspects of T1DM [7,18,33,45- 50]. All these insights require the long-term duration of the group (2 years) and the use of combined techniques, for the achievement not only of functional behaviors, but also of stable changes. Moreover, she activated healthy elements, such as: schedule, strong will to control glucose which no longer is an enemy but part of the “unified self’” [7], responsibility for self-care (patient-centered style) as a necessity in life [51]. So, she becomes aware of the effect of stress on blood glucose fluctuations, recognizes the early sighs of hypoglycaemia and she was able to distinguish them from those of stress [52] and she took the responsibility for her difficulties in managing the diabetes even for its deterioration (Brittle Diabetes, unstable diabetes). More specifically, as shown by the results in table 2 prior to intervention, her expectations of diabetes treatment were observed to be concerned about psychological issues instead of medical ones. This means that she was concerned with the factors that mediate regulation or dysregulation of glucose, thus suggesting the multifactorial aetiology of metabolic control. Gradually, she perceived that experiences diabetes as a continuous struggle and a constant sense of threat with intense and prolonged stress, caused by her family of origin. Regarding T1DM management the support from the family is especially important for the patient’s empowerment and their adherence to self-care [18,53]. Furthermore, studies refer that family interactions may be stressful triggers (due to judgmental comments expressed) that lead to inadequate metabolic control [54-56] in contrast to positive emotion, which leads to optimal metabolic control through the processes of hormonal mechanisms [55]. It is also likely that family’s perception of the disease (disability/stigma) influences patient’s regulation of metabolism [57]. Thus, for many years she had poor metabolic control, as shown by HbA1c% value in table 3. The areas where Therapist Diabetes Care focused were:

The atmosphere of the group has a dual role: supportive and therapeutic. This means that patient interacts and reflects thoughts, feelings, share decisions and help with problem-solving, by undertaking an active role, not only in their own reality, but also in the reality of other members. The perception and understanding of different thoughts, emotions and behaviors, and hence the various types of disease management, contributes to the reduction of disparities. Strengthening of the views of members, suffering from the same disease has a strong therapeutic potential. This is because, due to common emerging emotions, their views act as a primary corrective emotional experience of adjustment and finally acceptance of the disease, before reintegration to the healthy society [18]. Patients that participate in CGT are expected to develop their self through the system of the group. Thus, they obtain deeper self-awareness and this leads to eventually redefinition of diabetes. This means that pain caused by the disease is regarded as an opportunity for personal development. Thus, the Therapist is assumed to contain and listen to all the needs of group members and the painful feelings generated by the disease, acting as a helper for pain generated by the disease [61-63]. The aforementioned therapeutic targets of CGT focus on the person who suffers from T1DM, rather than the patient. Cure is being replaced by Care, which is oriented towards the individual as a unique personality [7,18]. The examination of one patient who participated in group therapeutic intervention for T1DM does not allow generalizations about the use of CGT in T1DM treatment and does not account for treatment outcomes for other T1DM patients. The focus was to emphasize on the changes that took place in the patient, through the therapeutic processes of the group and explores the T1DM treatment as a process that requires a holistic approach for the effective coping that combines medical monitoring, regimen compliance and psychological intervention. Further research is required in order to examine the causes of change that addresses both the physical and psychological aspects of diabetes.