lessons to be learned from partnerships with families: a case study

IntroductionWorking within paediatric diabetesthere are always multiple levels ofcontext (e.g. biological, physical,behavioural, familial and cultural)to consider and the multiple narra-tives of family members and profes-sionals.1,2

In order to join with and sup-port families and facilitate changewe find it most helpful to consider avariety of systemic family therapies,which value the core concepts of:circular causality, reflexive question-ing, and the importance of contextand language (see Minuchin3 andSelvini Palassoli et al.4 for moreinformation). In finding a focus forour work we aim to be thoughtfuland respectful of the young peopleand other family members abouttheir experiences of ‘living with dia-betes’ and the difficulties they

encounter, in order to promote aseamless service.5,6 We aim to facili-tate joining with the family by sus-pending judgement and being curi-ous7 to create and be sensitive to amultiplicity of views (such as thosebetween different family members).We also consider what the family’s‘relationship to help’ might be8 interms of what the family feel wouldbe most useful, what their previousexperiences of helping professionsare and what their expectations areabout coming to see us. Informedconsent is thus gained throughthorough discussions about what iswanted and how to provide this. Weare also mindful of evidenced-basedpractice in this area.9,10

Case historyThe family of a seven-year-old girlwas referred by a local team whenrelationships between themselvesand the family had deteriorated.Poor diabetes control and ‘behav-iour problems’ were the focus of the referral.

The referral was discussed at theteam’s weekly meeting to establishbest possible approaches involvingthe most relevant members of theteam. The Paediatric Diabetes Teamconsisted of a paediatric endocri-nologist, specialist nurse, clinicalpsychologist and dietitian. It wasdecided that a routine clinicappointment would provide theopportunity for an overall assess-ment including the specialist nurseand clinical psychologist.

Mrs Falerick and Maria (allnames and identifying features have been changed to protectanonymity) attended the appoint-ment. The main problems pre-sented by Mrs Falerick were fluctu-ating blood glucose levels despitechanges to insulin therapy, ‘badbehaviour’ and occasional periodsof ‘fussy eating’.

Maria was diagnosed with type 1diabetes in March 2001 at four-and-a-half years of age. This was twoyears after her brother (aged seven)was diagnosed with Asperger

Case Report

31EDN Spring 2005 Vol. 2 No. 1 Copyright © 2005 FEND. Published by John Wiley & Sons, Ltd.

AbstractThe following case study describes a therapeutic intervention with a seven-year-oldchild with diabetes and her family, at the centre of which was the partnershipbetween two professionals, and between the family and the team. The work wasinformed by systemic models of family therapy and elements of cognitivebehavioural therapy as well as best practice in working with families and youngpeople with type 1 diabetes. The collaborative nature of multidisciplinary teamswithin paediatric diabetes, facilitates best outcomes for families of young childrenwith type 1 diabetes and promotes continuity of care. The case study pays particularregard to the way in which practice is informed and evaluated by theory. Thus,relevant literature is signposted throughout the article, reflecting our use ofdocumented strategies and issues that have been discussed further (and in greaterdepth) elsewhere. Copyright © 2005 FEND.

Eur Diabetes Nursing 2005; 2(1): 31–35.

Key wordscollaboration; partnerships; multidisciplinary teams; family therapy; systemic therapy;clinical psychology

AuthorsDr Sarah Davidson, RN, BSc(Hons),ClinPsyD, CPsychol, Chartered ClinicalPsychologist, Department of ChildPsychology, Chelsea and WestminsterHospital, London; Senior Lecturer,Clinical Psychology DoctoralProgramme, University of East London,London, UKKaren Spowart, RSCN, MSc, PaediatricDiabetes Nurse Specialist, Chelsea and Westminster Hospital,London, UK

*Correspondence to: Dr SarahDavidson, Department of ChildPsychology, Chelsea and WestminsterHospital, London SW10 9NH, UK; e-mail: [email protected]

Received: 2 February 2005Accepted in revised form:4 March 2005

Lessons to be learned from partnershipswith families: a case studyS Davidson*, K Spowart

CR Davidson 5.05.qxp 22/3/05 11:21 am

Syndrome and epilepsy. At the timeof referral Maria was on twice dailyinsulin injections of Mixtard 30before breakfast and her eveningmeal. Mrs Falerick administered allthe injections and performednumerous capillary blood tests (upto eight a day). The HbA1c resultwas 10.1% (DCA 2000). The gly-caemic control was erratic with variable high (>17mmol/L) andlow (<4mmol/L) readings com-pounded by the ‘fussy eating’.

Mrs Falerick was concernedabout future diabetes related com-plications from the high readingsbut was also worried about hypogly-caemia if Maria didn’t eat enough.She became tearful, describing howworried she felt about Maria andhow overwhelming she foundMaria’s behaviour at home.

Initially it was felt unnecessary tointerfere with the current insulinregimen, since this may have pre-maturely reinforced the ‘problem’as being the diabetes and detractedfrom the context and family issues.Instead, we focused on the family toobtain a wider perspective of familydynamics, extended family supportand the professional systems withwhich they had come into contact.On an out-patient basis both par-ents and Maria were invited to, andattended, sessions.

Three clear themes emergedfrom these initial sessions:• The significant upheaval the fam-ily had experienced in the previoustwo years associated with the chil-dren’s health problems.• Mrs Falerick’s dominant role inthe caring and responsibility for thechildren and liaising with services.• The evident lack of resources inthe form of supportive family/friends nearby.

The key request at this stage fromthe parents was for us to addressMaria’s diabetes control and herbehaviour. The emerging theme

from early conversations involvedthe degree to which Mrs Falerickfelt unsupported and underminedby Mr Falerick. This seemed linkedto an escalating pattern of ‘badbehaviour’ from Maria, which wasin turn met with increasing forms ofpunishment used. This caused usconcern for Maria’s safety. The family’s local Social Services depart-ment had limited resources avail-able and so no additional supportcould be offered. Our team there-fore made the decision to admitMaria to the ward for further assess-ment and as a way of intervening inthe spiral of escalating violence.

The Child Protection concernsaltered the focus of our work. Thedemands of our professional con-text required in depth liaison withother services. At ward level we cre-ated a structure to Maria’s day withroutines such as attending the hos-pital school and having friends and family visit on the ward.Collaboration around the diabetesmanagement, control and educa-tion involved the team, parents andMaria in decision making relatingto numbers of capillary blood testsperformed per day and responsibil-ity for administering injections.

Star charts were very successfullyemployed in both these areas, as ameans of monitoring and rewardingcertain behaviours such as bloodtesting. The ‘fussy eating’ men-tioned by Mrs Falerick did notappear to be a major issue on theward and Maria was encouraged bythe ward nurses and play specialiststo socialise with other children onthe ward at mealtimes.

In discussions outside sessions,the authors wondered about thestate of the marriage and whetherthe children’s problems provided amore ‘comfortable’ focus ratherthan the more ‘uncomfortable’ areaof the parenting relationship.11

In attending to the concernsraised, the authors changed their

style slightly and adopted a morestructural approach, as advocatedby structural family therapists.3

Thus, we set out to explore theboundary between the parent andchild sub-systems, hypothesisingthat this had become weak and con-fused. To punctuate this, we heldsessions with the parents in thePsychology Department where wecould talk more openly without thechildren being present. Using circu-lar questioning we invited each parent to consider different per-spectives (e.g. ‘How would you, MrFalerick, know when Mrs Falerickneeded more support?’). We wereinterested in their perceived abilityto make decisions without beingundermined and how they exer-cised power as parents. We wantedto be as transparent as possible, let-ting them know that we consideredsome of their responses to beunhelpful and too extreme. Westrongly emphasised our need to actin Maria’s best interests and toinvolve Social Services as the leadchild protection agency. Throughthis level of openness we hoped tomaintain a facilitative relationshipwhereby we could continue workingwith Mr and Mrs Falerick in orderto identify different ways of under-standing what had happened andencourage them to consider differ-ent methods of responding.

Following further meetings withthe parents and Maria our levels ofconcern lessened. Our focus shiftedto considering how Mr and MrsFalerick managed their parentalrelationship and decision makingaround the children’s routines anddiscipline. They were both encour-aged to think about their ‘scripts’from their own experiences ofchildhood and how these influ-enced their current parentingskills.12 Their different experiencesand expectations of childhood, chil-dren and behaviour were consid-ered in the light of their cultural

Case ReportLessons to be learned from partnerships with families

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heritage: Mr Falerick from hisPolish parentage where difficultiesand conflict had been avoided, andMrs Falerick’s strict, Protestant,middle class family which valuedrespect and obedience. Both wereable to discuss their frustrations atthe lack of support they receivedfrom their families of origin and thedifficulties they experienced attain-ing the level of discipline theyaimed for in their own children.

The methods and timings oftheir communication were also dis-cussed, in terms of how much theyallowed the children to influencethem. By prescribing certain inter-ventions designed to enhance Mrand Mrs Falerick’s autonomy andeffectiveness in dealing with con-flict, we invited them to try differentmethods of parenting.13 For exam-ple, alternative methods of manag-ing the children’s behaviour wereconsidered, such as focusing moreon positives, agreeing a more col-laborative approach to parentingand being clearer about intergener-ational boundaries. Planned homeleave was set up as ‘in vivo’ experi-ments, where Mr and Mrs Falerickcould try out their new skills, butwith the back up of the hospitalward if all did not go to plan.

A key element of the interven-tion was the partnership betweenthe specialist nurse and the clinicalpsychologist. Our paediatric dia-betes team is fortunate to have dedicated sessions provided by adietitian and clinical psychologist,enabling all members of the team tomeet weekly to review families’progress and share concerns. Teammeetings and joint work facilitatecommunication and the sharing ofresponsibility – for example,around child protection issues. Asautonomous health professionalswith direct contact with the family,the specialist nurse and clinical psy-chologist were responsible forensuring that child protection

concerns were monitored andaddressed. However, the specialistnurse benefited from closer rela-tionships with the ward staff, thehospital school and the local school,and therefore became the key con-tact for these teams, while the clini-cal psychologist led on liaison withthe local mental health and socialservices teams. The specialist nursealso had greater skills and familiar-ity around treatment issues (such asdiet, glucose monitoring and con-trol) so led on these areas, whereasthe clinical psychologist was betterplaced to chair the meetings, reviewprogress and consider familydynamics. Imperative to good com-munication and engagement wasthe need to be explicit about ourareas of specialist knowledge andabout whom and what we were liais-ing with others. Thus, family meet-ings always started with the settingof an agenda, where both profes-sionals and family members couldfeed back on areas of progress sincethe last meeting and highlight areasthey wished to discuss. This is amodel the team has used for manyyears to facilitate clarity of roles andresponsibility in working in partner-ships together and with families.

Therapeutic outcomeMaria continued to have a bed onthe ward for the next eight weeksduring which planned home leavegrew progressively longer andreportedly calmer until her dis-charge which was agreed by all.

Ongoing contact and feedbackindicate a generally positive trendparticularly with regard to diabetescontrol, behaviour and diet. A morecollaborative approach to givinginsulin and blood testing existsbetween Maria and her parents.Maria decided to bring a ‘questionsnotebook’ with her to clinicappointments, which was encour-aged by her parents. Maria makesnotes of questions she wishes to ask

different team members. A particu-lar issue for Maria in the early stagefollowing discharge was the desirefor more flexibility around her dia-betes care, and a multiple injectionregimen was explained to herincluding any advantages (flexibil-ity) and disadvantages (more injec-tions). She was encouraged to thinkabout this and have discussions withher parents before coming to thenext clinic appointment twomonths later when she decided shewanted to try it. Her insulin regi-men was changed to glargineinsulin before bed and NovoRapidbefore meals. Within the nextmonth her HbA1c was 8.9% (DCA2000). Meal times are reportedlymore peaceful and Maria describedfeeling happier. Her parents havesaid how well behaved she and herbrother are.

Discussion On reflection we felt pleased withthe way this piece of work had gone,both in terms of the process andoutcome. It was useful to thinkabout the different priorities thatneeded attending to and how tointegrate different professional rolesand responsibilities. We are, how-ever, left with some thoughts con-cerning gender, our positions andthe notion of change.

Our approach is one that facili-tates change through a co-construc-tion of what is difficult and whatmight be helpful and using collabo-ration to achieve this. However,when there are many people in thesystem there are often a number ofpotentially incongruent priorities. Itis important to acknowledge themultiplicity of ideas and experiencesbrought by professionals, referrersand families that influence thework.8 These often take time to mapout and, when they are mapped out,much of the work is dependent onthe goodness of fit or matchbetween professional(s) and family.1




Both of us are white Britishwomen who have not been mothers.We were familiar with the hospitalenvironment and in working withyoung children with diabetes andtheir families. We are also familiarwith liaising with colleagues, includ-ing those in Social Services.Although the Falericks had someprevious contact with health serv-ices, they were commuting to a hos-pital, some distance from them,where they had had no previouscontact. Upon disclosing the degreeof escalating punishment they wereusing, the little control they had(i.e. relating to confidentiality andof who would be involved) was fur-ther diminished, as this informationhad to be shared in following childprotection procedures. The fit ormatch between the family and theteam at this point seemed almostthe most remote possible and there-fore risked the viability of furtherwork. We had to work hard to main-tain our alliance with the family,particularly with Mr Falerick (theonly man in the sessions) and didthis through being clear about whatwe were doing, our aims andacknowledging the gender imbal-ance in the room.

As no therapy is value free andno therapist neutral, therapists mustbe aware of their own attitudes andtheir effect on the family they areseeing.14 In intending to embrace amore neutral position we were aim-ing to draw a clearer boundarybetween ourselves and the family asprofessionals who had specificresponsibilities beyond their expec-tations. Outside of the meetings withthe family, we found it important toreflect on our own concerns andconnections to previous experiences(such as those relating to our fami-lies of origin and previous involve-ment in child protection proce-dures) as well as the hopes and fearswe had for each session. Thisallowed us to be more available to

reflect on what was said in sessionsand be more transparent with theFalericks about our roles, actionsand reflections. It was also useful towork collaboratively; as members oftwo distinct disciplines we broughtdifferent professional (and per-sonal) perspectives and were able tojoin with different members of thesystem at different times.

One concern we had was withregard to Maria’s lengthy admis-sion, which deprived her of contactwith family, friends, home andschool. We worried that Maria hadbecome subject to a different formof punishment and that, within ourintervention, she was becomingpathologised. Mindful of this, weaimed to increase her contact withas many of these systems as possible.During our individual meetingswith her, we were sensitive to herwishes and thoughtful as to how wecould bridge the gaps. We workedin partnership with her local dia-betes team and staff at her school,and invited them to write to Mariaand keep in contact with her. Sheattended the hospital school and, assoon as possible, she returned toher school. Overall, we feel thatwhile it may have been possible todischarge her home sooner, it wasimportant for Maria and for herparents to have sufficient time tolearn and try out new skills, whilsthaving the fall back of the hospitalward. In total, Maria only spent 20nights over an eight-week period onthe ward.

Although clear that as adults we(in partnership with her parents)held the responsibility ultimatelyfor her care, we were keen toempower Maria as much as possible,whilst being mindful of her developmental stage. Thus, weencouraged Maria to be part of ourprioritising process – for example,determining where and when shehad her fingers pricked (for glucosemonitoring), about which areas the

star chart recorded progress, andabout the frequency and durationof our individual meetings with her.

In adopting a ‘reflexive re-posi-tion’15 therapists are challenged torespond creatively, thoughtfully andin a timely fashion to the changingdemands of the family, the wider sys-tem and professional responsibili-ties. Different priorities dominate,making feedback critical to learningand re-positioning essential.Working collaboratively, and inpartnership, challenges us to bemindful of ever changing prioritiesand be thoughtful of multiple per-spectives and experiences.

References1. Carter B, McGoldrick M (eds). The

Expanded Family Life Cycle: Individual,Family and Social Perspectives, 3rd edn.New York: Gardner Press, 1999.

2. Pearce WB, Cronen VE.Communication, Action and Meaning:The Creation of Social Realities. NewYork: Praeger, 1980.

3. Minuchin S. Families and FamilyTherapy. Cambridge, MA: HarvardUniversity Press, 1974.

4. Selvini Palassoli MS, Boscolo L,Cecchin G, et al. Hypothesising,Circularity and Neutrality: ThreeGuidelines for the Conductor of theSession. Family Process 1980; 19(1):3–12.

5. Department of Health (2004).National Service Framework forChildren, Young People and Maternity Services. Available fromhttp://www.dh.gov.uk/PublicationsA n d S t a t i s t i c s / P u b l i c a t i o n s[Accessed 27 Oct 2004].

6. Department of Health (2001).Diabetes National Service Framework:Standards. Available at http://www.dh.gov.uk/PolicyAndGuidance/Heal thAndSocia lCareTopics/Diabetes [Accessed 29 Oct 2004].

7. Cecchin G. Hypothesizing,Circularity and Neutrality Revisited:An Invitation to Curiosity. FamilyProcess 1987; 26(4): 405–413.

8. Reder P, Fredman G. TheRelationship to Help: InteractingBeliefs about the Treatment Process.


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Clin Child Psychology Psychiatry 1996;1(3): 457–467.

9. Wolpert M, Fuggle M, Cotterell D, etal. Drawing on the Evidence! Advice forMental Health Professionals Workingwith Children and Adolescents. TheBritish Psychological SocietyDivision of Clinical Psychology.Faculty for Children & YoungPeople, 2002.

10.Anderson BJ, Brackett J, Ho J, et al.An office-based intervention to main-tain parent–adolescent teamwork in

diabetes management. Impact onparent involvement, family conflictand subsequent glycemic control.Diabetes Care 1999; 22(5): 713–721.

11.Carter B. Becoming Parents: TheFamily with Young Children. In:Carter B, McGoldrick M (eds). TheExpanded Family Life Cycle: Individual,Family and Social Perspectives, 3rd edn.New York: Gardner Press, 1999;249–273.

12.Byng Hall J. Rewriting Family Scripts.London: Guilford Press, 1995.

13.Tomm K. One Perspective on theMilan Systemic Approach: Part II.Description of Session Format,Interviewing Style and Interventions.J Marital & Family Therapy 1984;10(3): 253–271.

14.Goldenberg I, Goldenberg H. FamilyTherapy: An Overview, 4th edn. PacificGrove, CA: Brooks/Cole PublishingCompany, 1996.

15.Partridge K. A Systemic Tale ofAssessment and Formulation. ClinPsychology 2005; 46: 13–18.



European Diabetes NursingThe Editor welcomes contributions to the journal of all types, whether original research, reviews, case reports, confer-ence reports, conference notices, or comments etc. If you would like to contribute to the journal please contact theEditor or the Editorial Office at the address below for further information and a copy of the Guidelines for Authors.

Call for Papers

Sarah Hills, RGN, MScEditorEuropean Diabetes NursingResearch Co-ordinator, RISC Project, University of Pisa, ItalyE-mail: [email protected]

Or Tracey CurtisEditorial OfficeEuropean Diabetes NursingJohn Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex PO19 8SQ, UKTel: +44 (0)1243 770520Fax: +44 (0)1243 770144E-mail: [email protected]

PROUD – Professionals United by Diabetes‘DOUBLE TAKE’An official Satellite Symposium at the Diabetes UK Annual Professional Conference by and for health professionals who livewith diabetes themselves, with a display and presentation of ‘Diabetes Narratives’ by members of PROUD

Ness Room, Seminar Suite, Scottish Exhibition & Conference Centre, Glasgow, UKWednesday, 20 April 2005 (7.00–8.30pm)

PROGRAMME7.00pm Welcome and introduction to PROUD Eileen Emptage and Jeannette Josse (PROUD Steering Group)7.10pm Presentation of 1st Diabetes Narrative: Jo Butler, Diabetes Nurse Consultant

Failures in empowering our children7.25pm Presentation of 2nd Diabetes Narrative: Norma Grundy, Diabetes Specialist Nurse

The sadness of diabetes7.40pm Break for refreshments and to view a display of posters of Diabetes Narratives by members of PROUD 8.05pm Presentation of 3rd Diabetes Narrative: Stuart Bootle, General Practitioner

Diabetes, the NHS and me8.20pm Discussion of future PROUD ideas, led by Mary MacKinnon (PROUD Steering Group)8.30pm Close of Symposium

For further details please e-mail James Wroe, Hon Administrator, PROUD, at [email protected] Steering Group of PROUD would like to acknowledge the support given to this meeting by an unrestricted educational grant

by Novo Nordisk Ltd

Symposium


lessons to be learned from partnerships with families: a case study

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