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Diabetes care for couples requires both support, respect for autonomy
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Incorporating couples in diabetes care has traditionally consisted only of including a patient’s partner in medical visits. However, diabetes education that focuses on good, nonjudgmental communication between partners can reinforce relationships and improve diabetes self-management, according to researchers.
“The partner relationship is unique — it’s not the same as the one we have with our parents or our children or our best friend,” Paula M. Trief, PhD, distinguished service professor at the department of psychiatry and behavioral sciences, SUNY Upstate Medical University, said in June during a presentation at the American Diabetes Association Scientific Sessions in Orlando, Florida. “The partner relationship is emotionally intense. It’s an intimate relationship where you can let down your defenses and share your thoughts and feelings. Partners also have a shared social reality. My partner’s expectations and values affect me, and my expectations and values affect my partner. That’s why some of us have decided to pursue partner intervention.”
Trief described a model of “communal coping, or dyadic coping,” which follows from interdependence theory.
“It’s not just the presence of the partner that matters, it’s how they participate,” Trief said.
Communal coping involves working together, communicating effectively and recognizing the effect of diabetes on both partners, not just the patient. Dyadic coping is an approach between couples that involves partners sharing cognitive appraisals, sources of stress, emotions and coping behaviors.
Diabetes Support Project
The realization that partners can play an important role in diabetes management led Trief and colleagues to undertake a randomized controlled trial of 268 couples (mean age, 56.8 years; mean relationship duration, 25.5 years) in which one partner had type 2 diabetes and HbA1c at least 7.5% (mean HbA1c, 9.1%). The couples were randomly assigned to three intervention strategies conducted over the telephone: diabetes education for the partner with diabetes (two sessions); the two diabetes education sessions plus an individual intervention for the partner with diabetes (12 sessions total); or the two diabetes education sessions plus a couples’ intervention (12 sessions total).
All participants with diabetes began with diabetes education phone calls (mean length, 75 minutes). The couples and individual participants then had 10 additional phone sessions focused on behavioral changes, but the couples’ calls included both partners and also addressed relationship building, problem-solving techniques and mutual support (mean length, 57 minutes).
The couples practiced the speaker-listener technique.
“The speaker-listener technique ... involves one partner talking about a concern and the other one just paraphrasing it until the speaker feels ‘heard,’ and then they switch,” Trief told Endocrine Today. “It helps people let down their defensive walls, so they don’t focus on rebutting and thus dismissing the concern, but instead focus on really hearing what their partner is saying and feeling.”
Participants in the couples’ arm also had a session on conflict resolution. Additionally, several “homework” activities were assigned to these participants, including keeping food and exercise logs, developing action plans, identifying barriers to change, and conducting “experiments” to see how lifestyle (eg, exercise, stress) affects blood glucose.
“Within those sessions in the couples’ intervention, the partner was intimately involved in all of that,” Trief said. “It wasn’t just the patient setting up their homework and the partner listening. It was the partner saying, ‘Here’s something you might consider,’ or ‘This is how I can help you accomplish that goal,’ or ‘This is how that plan will affect me.’ They were consistently talking about the impact of all of this work and all of these plans on both of them.”
The researchers found that all three interventions yielded statistically significant change in HbA1c among those with very high baseline values (HbA1c > 9.2%). But only the couples’ intervention achieved a significant reduction in HbA1c in those with values between 8.2% and 9.2%, which was superior to the individual and the diabetes education interventions.
“This was important because it showed that the partner really mattered,” Trief said.
Advice for partners
In the presentation, Trief discussed the many ways in which partners can provide support to their loved one with diabetes, for example, learning about diabetes, buying healthy food, exercising together, reminding the partner with diabetes about medications, being sensitive to the patient’s emotions, modeling healthy behaviors and change, and supporting the patients’ autonomy by acknowledging their perspective and agency.
“What I tell patients is that partners don’t want to become the ‘diabetes police,’ and it’s really easy for somebody else looking in to be critical,” Donna Rice, MBA, RN, CDE, FAADE, senior medical director for Sanofi US Diabetes, told Endocrine Today. “I always say the best way is for both partners to have the information and to understand the impact of lifestyle on diabetes and things you can do. Then, if someone decides not to follow that plan, that’s their decision.”
Rice said it is important to keep a positive attitude when interacting with a partner who has diabetes. She said rather than focusing on what partners have failed to do, it is more constructive to notice what they have done.
“Start looking for the positive,” she said. “Talk to them about what they did do well. You could say, ‘Hey, it’s great, you’re checking your blood sugar. I’m glad to see it.’”
Rice noted that if a partner with diabetes makes a questionable decision, criticism will only worsen the situation.
“People make their own decisions, and I think you’ve got to respect that from an adult perspective,” she said. “If they have a piece of cake at a party, so be it. Don’t criticize them for it. Respect that decision.”
Trief also said she believes in acknowledging and respecting a partner with diabetes’ autonomy.
“Make sure to listen to the patient’s concerns — express to them that you understand that this is their disease, not yours,” Trief said. “It’s certainly OK to point out, however, that their disease affects you too. This means not protecting your partner from knowing that you’re worried or angry.”
Janis Roszler, LMFT , RD, LDN, CDE, marriage and family therapist and manager of Diabetes Directions LLC in Miami, recommends against trying to micromanage a partner’s self-care.
“Unless your loved one asks for help, there is no way to ensure that they take their medications,” Roszler said. “Their health is their own responsibility. It’s painful to watch someone ignore their health, but adults make decisions and must deal with the consequences. If your loved one’s inability to care for their health is hard for you to live with, reach out to a mental health professional who can help you feel more comfortable with this situation.” – by Jennifer Byrne
Reference:
Trief PM, et al. Diabetes Care. 2016;doi:10.2337/dc16-0035.
For more information:
Donna Rice, MBA, RN, CDE, FAADE, can be reached donna.rice@sanofi.com.
Janis Roszler , LMFT , RD, LDN, CDE can be reached at Jewish Community Services, 333 W. 41st St., Suite 208-210, Miami Beach, FL 33140; email: dearjanis123@gmail.com.
Paula M. Trief, PhD can be reached at SUNY Upstate Medical Center, 750 E. Adams St. Syracuse, NY 13210; email: triefp@upstate.edu.
Disclosures: Rice reports she is an employee of Sanofi US Diabetes. Roszler reports she is a consultant for Boston Scientific. Trief reports she has received research funding from NIH.