Health Care Review: Supporting Clients With Type 1 Diabetes
By Jessica Crowe, MSW, LICSW
Social Work Today
Vol. 19 No. 4 P. 32

Does your client have an autoimmune disease such as type 1 diabetes (T1D)? It is a common mistake to assume that type 1 and type 2 diabetes are the same, but they’re not at all the same. T1D has no cure, and there is no way to prevent it. According to the Juvenile Diabetes Research Foundation (JDRF), “T1D is an autoimmune disease that occurs when a person’s pancreas stops producing insulin, the hormone that controls blood-sugar levels. T1D develops when the insulin-producing pancreatic beta cells are mistakenly destroyed by the body’s immune system.” Neither diet nor lack of exercise causes T1D. If you or someone you know has been diagnosed with T1D, it means that there is an organ within their body that is no longer working properly and will never work properly again, an organ that is needed to live—the pancreas.

Living a New Life
So how does this affect mental health treatment? Many of the symptoms an individual may experience when having high or low blood sugar levels can mimic emotional dysregulation and mood fluctuations. Symptoms of depression and/or anxiety may gradually appear or increase due to stressors and the loss of a previous life without the injection of insulin (and without the constant monitoring of carbohydrates). Once individuals are diagnosed with T1D, the stages of grief—denial, anger, bargaining, depression, and acceptance—may also be present during parts of their life, as well as parts of their family’s lives (Kessler, n.d.). An individual may also not exhibit symptoms of depression or anxiety; however, it is important to fully assess and rule out any additional or potential symptoms.

Blood sugar levels must be continually monitored throughout the day and night by a continuous glucose monitor and/or a finger prick test. These checks ensure blood sugar levels do not need to be treated (for hypo- or hyperglycemia). Although there have been strides made with technology to assist with the monitoring of blood sugar levels, it does not take away the exhaustion or make it any easier in certain aspects due to so many factors impacting blood sugar levels: mood, age, hormones, heat, exercise, and adrenaline. Dosing for insulin does not equate to the symptoms of the disease becoming nonexistent. Dosing for too much or too little insulin can be dangerous. An individual’s insulin dose and ratios are recommended by the their medical team based on the patient (JDRF, n.d.).

It is important to understand the basics of this disease and how blood sugar levels can impact an individual’s life and mood to avoid a misdiagnosis during an intake assessment or throughout a treatment period. Also, it is important for a social worker to understand how this disease can impact the individual’s family, as children and adults diagnosed with T1D may need extra support at times to avoid a hospital admission, seizures, and diabetic ketoacidosis, and to stay alive. It is crucial to believe in social work values and to understand how important it is to start where the client is—and having an understanding of the client’s chronic medical condition is a good way to start demonstrating this value.

Honeymooning
So, is your client honeymooning? Understanding what this question means is to begin to understand how an individual starts to learn and live with this 24/7 condition. According to JDRF, “right after the time of diagnosis, some people experience a ‘honeymoon phase’ during which their existing beta cells still function and the body is able to produce its own insulin.” In other words, the individual’s pancreas may still be working at certain times, but may it be inconsistent. This can impact how much insulin a person needs, and too much insulin can lead to hypoglycemia, which can become life threatening if not treated within a certain time frame. Untreated hypoglycemia can lead to seizures, a person becoming unconscious, and the use of glucagon* during emergency situations (JDRF, n.d.).

An important fact to be aware of during the honeymoon phase is that this does not mean a person has been cured. There is no cure. It is important to provide support to families throughout the honeymoon phase in order to not endorse false hope, as individuals who experience this phase will eventually come out of it and the pancreas will stop working indefinitely (JDRF, n.d.).

Potential Interventions/Techniques
Potential interventions and techniques include the following:

• individual, family, and/or group therapy; and

• a strength-based perspective, the view that a disease does not define a person.

- Identify strengths and positives.

- All individuals with T1D show ways they are brave, strong, and knowledgeable.

Resources to learn as a social worker or to offer clients and families include the following:

• American Diabetes Association diabetes camps for kids;

• Understanding Diabetes: A Handbook for People Who Are Living With Diabetes, published by the Children’s Diabetes Foundation; and

• support groups for children, adults, and legal guardians.

Coordinating Treatment With the Endocrinologist
In order to ensure you are supporting the client and family in the most responsible way, it is crucial to coordinate treatment with your client’s endocrinologist (as long as the client or legal guardian of the client is giving you permission to do so by having a release signed by the client and/or legal guardian).

The benefits of coordinating treatment with an endocrinologist may include the following:

• understanding where your client is (e.g., in honeymoon phase, past the honeymoon phase, or has not/will not ever experience the honeymoon phase);

• understanding the endocrinologist is the specialist who should be monitoring and working with your client specifically for T1D;

• understanding you should not be adjusting or suggesting ratio or insulin changes and to always have the client or family contact the endocrinologist;

• understanding insulin does not treat low blood sugar levels and doing so is dangerous; and

• understanding the stressors your client may be experiencing.

Questions that may helpful to know include the following:

• Does your client have insurance and/or the resources to obtain what is needed to safely treat T1D?

• Is your client using a continuous glucose monitor and which kind?

• Is your client using an insulin pump and which kind?

• Is your client not using an insulin pump and deciding to use multiple daily injections?

• What is your client’s A1c (a glycohemoglobin test)?

• If your client is a minor, how is the legal guardian handling this 24/7 disease?

The legal guardian may experience anxiety, depression, grief/loss, etc. and may experience lack of sleep due to monitoring the child to ensure the child is within a safe range throughout the night. It is common for legal guardians to check the child’s blood in the middle of the night and for a child to need to be treated at times throughout the night, whether blood sugar is too high or too low.

Coordinating Treatment for Minors
If your client is a minor, it is important to coordinate treatment with school personnel, as school personnel and/or the school nurse are responsible for monitoring and treating the child throughout the school day. An individualized education program or 504 plan may be necessary in order for the child to be successful within the school setting, as the child may need accommodations at times and will need to have diabetes supplies on hand at all times. It is also important to realize how completing school work or a test if the child’s blood sugar is not in a healthy range is not fair to the child. Blood sugar levels that are too high or too low can be dangerous and can impact mood, energy levels, and how the child thinks and retains information, among other symptoms (JDRF, n.d.).

Safety Concerns and Emergency Information
Potential safety concerns may include the following:

• self-injurious behaviors;

• taking too much insulin (unintentionally or intentionally overdosing on insulin);

• taking too little insulin (rationing insulin due to high costs of insulin or not having the resources to obtain prescribed amounts of insulin); and

• diarexia or diabulimia, which is “an eating disorder in a person with diabetes, typically type 1 diabetes, wherein the person purposefully restricts insulin in order to lose weight” (National Eating Disorders Association, n.d.).

* Glucagon. If a person is experiencing hypoglycemia and becomes unconscious, has a seizure, and/or is unable to swallow liquid or food to treat the low blood sugar level, glucagon can be administrated during these emergency situations. A person with T1D should always have glucagon with them, in addition to other diabetes supplies to prevent or treat hypoglycemia, as hypoglycemia can quickly become life threatening (JDRF, n.d.).

It is best practice to ensure you are informed and competent in this area as a social worker when working with someone who has been diagnosed with T1D to understand the disease, symptoms, and other potential co-occurring mental health/medical conditions in order to best support your client.

— Jessica Crowe, MSW, LICSW, is a clinical intake therapist at The Providence Center in Providence, RI.

References
Juvenile Diabetes Research Foundation. (n.d.). Type 1 diabetes facts. Retrieved May 29, 2019, from https://www.jdrf.org/t1d-resources/about/facts.

Kessler, D. (n.d.). The five stages of grief. Retrieved May 29, 2019, from http://www.grief.com.

National Eating Disorders Association. Diabulimia. (n.d.). Retrieved June 18, 2019, from https://www.nationaleatingdisorders.org/diabulimia-5.