Doing diabetes differently: An overview of solution-focused approaches in paediatric diabetes care

A key component of effectively managing a chronic condition in children and young people (CYP) is an approach that establishes and maintains motivation to enable CYP to achieve the complex juggling act required to manage their condition (Christie, 2012). It is known that CYP have difficulty achieving and maintaining target glycaemic control due to a number of factors. These can include heightened concerns about social context and peers, a premature shift in responsibility for management from parents to teens, developmental inclination towards risk-taking, incomplete knowledge and understanding of treatment regimens and future health risks, fatigue from care of a chronic illness and physiological changes that lead to greater insulin resistance during puberty (Borus and Laffel, 2010).

Education is widely thought to be an important tool in the diabetes clinicians’ armoury in supporting CYP to self-manage and maintain good glycaemic control (Gardiner et al, 2018). However, generic education classes that focus on the development of knowledge and skills were found to have only ‘small to medium beneficial effects on various diabetes management outcomes’ (Hampson et al, 2002; Murphy et al, 2006). Christie et al (2014) found that of those CYP who took part in structured, intensive education that aimed to maximise engagement, motivation and long-term change, there were no improvements in HbA_1c at 12 or 24 months, although there were some initial improvements. Adherence can potentially become harder as healthcare professionals (HCPs) intensify regimens to improve glycaemic control for better outcomes, with the inadvertent result of increasing burden and reducing health-promoting behaviours. If the response to complications with CYP’s management of their diabetes is the delivery of care in a generic ‘one size fits all’ prescriptive advisory approach, there is a risk that the aims of person-centred care, as discussed in the NHS Long Term Plan, may not be implemented.

In both the short and long term, uncontrolled type 1 diabetes has serious physical and psychological consequences for CYP and their families (Christie and Katun, 2012; Knecht et al, 2015; Copenhaver and Hoffman, 2017). Traditionally, the response of HCPs to these potential or actual consequences – whether working within multidisciplinary teams or not – has arguably been to default to the medical or pathological model of treatment. That is, to seek to promote the health of (or indeed limit the damage to) the child/young person by appealing to his/her own or his/her parents’ compliance to ‘doctors’ orders’ or, failing that, by referring to the dire consequences of noncompliance, essentially by instilling fear. This may work for some CYP in the short term (Simpson, 2017). However, the longer-term impacts of this approach have not been established.

A solution-focused approach (SFA) offers an alternative to a ‘fix it’ or advice-driven approach. This easy-to-learn approach is derived from a psychological talking model and can be applied in practice by HCPs in order to enhance engagement with patients (Simm and Saunders, 2017), including CYP with diabetes (Christie, 2008). This article provides a description of SFA, discusses how it may be applied to diabetes care through the use of conversations from clinical practice, and reflects on how the potential of SFA might be better realised in paediatric diabetes settings. The reader may be interested in further descriptions of SFA in paediatric diabetes care settings, in particular Christie and Martin (2013).

Evidence base, uses and underpinning
Motivational interviewing and behavioural family systems therapy are two psychological approaches that can help clinicians to support CYP and their families to manage their diabetes effectively (Wysocki et al, 2000; 2001; Suarez and Mullins, 2008). SFA derives from solution-focused brief therapy, which was pioneered through the family therapy work of Steve de Shazer and colleagues in America (de Shazer et al, 1986). Bavelas (2012) stated that the approach ‘has a special affinity with language and communication’. The guiding principle is that clients are the experts in their condition and not the HCP they engage with.

Solution-focused brief therapy is based on over 20 years of theoretical development, clinical practice and empirical research (De Shazer et al, 1986; Berg and Miller, 1992; Berg, 1994; De Jong and Berg, 2002; Gingerich and Peterson, 2013). It is a resource-based model that differs from other psychological talking therapy approaches, such as cognitive behavioural therapy, and traditional medical models that are predominantly deficit-driven and based on a premise of diagnosis followed by expert-led treatment (eg advice, therapy, ‘fixing’). SFAs, in contrast, are grounded in a resource-based model where conversations amplify previous and present successes, no matter how small, and minimise emphasis on past failings and problems. Next steps are shaped by the client. Throughout its use, the model assumes that the solutions required to solve the problem already exist within the child’s/young person’s skill set and knowledge about his/her condition and life. A SFA advocates working with the person rather than the problem; listening to and working with patient priorities, hopes and expertise to develop meaningful goals; noticing exceptions to problems and even the smallest signs of success, as defined by the person (Simm and Barker, 2018).

There is strong evidence that SFAs have positive outcomes for CYP in relation to externalising behavioural problems, such as aggression, cooperation and truancy (Flethcer-Campbell, 2001). SFAs have positive outcomes for internalising problems too, such as shyness, anxiety, depression, low self-esteem and self-efficacy (Daki and Savage, 2010). Fisher et al (2009) and Polonsky et al (2005) describe these experiences as diabetes-related distress. Furthermore, working with CYP requires support to be given to the wider systems around the family. For example, SFAs have been found to work well in schools (Christie, 2008). The approach is very diverse and can enable multidisciplinary teams to consider collaborative ways in which to think about managing any issues CYP might present with, eg feelings of sadness or anger, difficulties with finger pricking or eating.

SFAs are applicable for use by a range of HCPs with little previous knowledge of psychology or therapy. For example, using SFAs led to satisfying outcomes for both medical registrar and patient in many situations encountered during an on-call shift (Blayney et al, 2014) and were favoured among occupational therapists working with stroke patients (Simm, 2013) and by a community pain service’s multidisciplinary team (Simm and Barker, 2018). They are thought to be particularly helpful when supporting people to live with long-term conditions that cannot be fixed (Bray, 2009).

Use in paediatric diabetes care
The Paediatric Diabetes Team at Southport and Ormskirk NHS Hospital Trust has been using a SFA since around 2015. The following anonymised excerpts from conversations are composites of the approach and experiences that showcase the principles of a SFA and how it can work in diabetes care to enhance wellbeing. The practice points and outcomes are genuine. ‘HCP’ in this instance refers to any member of the team who has interacted with the child/young person on his/her journey to better wellbeing and diabetes management.

Problem-free talk
The beginning of any conversation utilising a SFA requires the HCP to focus on the person rather than the condition – a strategy known as ‘problem-free talk’. The difference between social chit chat and problem free-talk has been described by Sharry et al (2001). During the latter, the HCP is specifically on the look out for strengths and resources that might be helpful in resolving the problem.

For example, 11-year-old John enters his appointment at midday; the HCP notices John is wearing his school uniform and opens with a question about normal activities, see Conversation 1. The HCP has identified strengths in John that would likely be missed in a conversation beginning with ‘How is the diabetes management going?’. There has been no mention of diabetes in this first conversation. John has an active interest in football and has had a leadership role within his team since the teacher spotted qualities in him. John also has an ability to spot changes he has made, as he has noticed he is scoring more goals. Furthermore there is detail in life away from diabetes, as John describes good moments occurring with his dad when watching football and practicing with his brother. It appears John also learns new things visually (by watching YouTube) and is aware of his limitations (not trying new things until he has practiced a lot). All of these skills/strategies were identified within a 2-minute conversation and might well be of use with regards diabetes self-management! All of this content is a celebration of resources and of what John has, rather than what he does not have. Blayney et al (2014) describe this as ‘noticing the doughnut and not just the hole’, ie paying attention to what is there rather than what is missing. You will notice the SFA is about constructive listening, as the majority of the spoken conversation comes from the CYP rather than the HCP.

Hoped-for outcomes: The ‘preferred future’
A SFA conversation might move onto what the client would like from the appointment with his/her HCP, and indeed from his/her life. Establishing clear, client-centred hopes is essential. Burns (2016) stated that ‘clients need to say in their own words what they want to work on, and it is sometimes surprising how different their perceptions are from those who referred them’ (p 6).

A young person called Amanda discusses her best hopes in Conversation 2. Notice here that the first question is not ‘What’s wrong?’ or ‘How can I help today?’. An open-ended question is used to allow Amanda to focus on her needs, rather than the expectations of anybody else. Getting Amanda to measure her expectation for the conversation allows the HCP to understand there is a clear focus within the allotted time, which will allow Amanda to notice when what she wanted to change has changed or that steps have been taken to do so. De Jong and Berg (2002) reflect that it is questions like this that ‘begin to send a message to clients that they are competent to decide what is best for themselves’.

The second SFA question ‘What would be different in the morning?’ is an invitation to describe the difference it would make if the problem was solved. Research suggests that thinking about the future can motivate us to take the steps necessary to reach our goals (Gardner et al, 2018). To show this in action, in Conversation 2 Amanda is asked what difference it would make if she was getting to sleep quicker and the HCP utilises ‘What else?’ to gather further detail. Notice that the detail gathered here follows the concerns raised about sleep. Problem-free talk is used throughout and the difference it would make if the best hope of the conversation was realised is imagined in significant detail.

Aspects of active listening are demonstrated too, through showing an understanding of best hopes by repeating them back. There is also a circular link to an earlier problem-free talk that opened the conversation, as the HCP picked up on Amanda’s passion for her dog and is able to bring him into the scene too. In the conversation, specific attention is paid to what the child/young person wants; when using a SFA the HCP does not gather detailed information about the problem.

Progress made towards solving the problem
Scaling questions are used within SFAs to elicit detail about best hopes, identify and amplify existing progress, and to discover what the child/young person would find helpful in moving towards their preferred future. To see scaling in practice, consider Conversation 3a and Conversation 3b with 15-year-old Saff. His best hopes for the conversation were to manage his diabetes better. He imagines a future where he is checking his blood glucose more often and shares that this would make a difference as he would be better able to go to the cinema, driving range and tennis club with friends. In addition, his parents would not be asking him all the time about his diabetes management (instead they would hardly be mentioning it) and he would be happier in school as his absence would improve. Furthermore, he would feel confident to do well in his exams to further reach his goal of becoming a diabetes nurse.

Throughout the conversation, the HCP has been able to identify what has been working, utilising effective open-ended questions to elicit strengths and exceptions. Saff’s attention has been brought to solutions that he has already utilised and they have been amplified to be utilised in the future. The smallest sign of change is talked about in rich detail. Notice, too, how the HCP takes a ‘not knowing’ stance – advice is not given – and there is a trust within the conversation that Saff knows something about what works for him. Alternative questions can also be posed around ‘When are you at your best?’ and ‘When do you manage diabetes well?’.

Further signs of progress
The HCP may be curious about what further signs of the preferred future happening might look like and might invite the patient to notice any moments of this happening as he or she goes away from the appointment. Also, in common with many person-centred approaches, it is important to use the child’s/young person’s own words and phrases to enhance engagement and co-construct the conversation in a language that is meaningful to him/her.

Henna is a 6-year-old who has struggled historically with needles. She has noticed that when she is relaxed with her panda teddy (called Bamboo, who is also very brave!) she is able to do finger pricks. Henna thinks that the next step for her is taking Bamboo into school, which she thinks will help to further relax her, meaning more finger pricks and greater control might be possible, see Conversation 4. Here, the HCP invites Henna to notice moments where her preferred future is being lived, but in no way sets ‘homework’. Observations are invited simply to notice further improvements up the scale. In Henna’s case, utilising something she has worked out herself and transferring the solution from the family home to school is doing just that. Furthermore, Henna is invited to notice broader moments of ‘bravery’ (as her one of her goals was ‘to be braver’), so that the HCP can amplify those moments at the next appointment. At a follow-up appointment the HCP might enquire when the finger pricks have been better, how she is performing them, what difference it makes when those moments occur, what else she is doing at those times, who she is talking to, what is being said that is helpful, etc. This will allow the HCP to amplify these moments to stimulate further use of Henna’s skills.

The difference SFA makes in the ‘real world’ to patients and staff
Reflective practice sessions were held with the multidisciplinary Paediatric Diabetes Team at Southport and Ormskirk NHS Hospital Trust. The team identified that using a SFA has helped them to become more effective, efficient and helpful to CYP and their families. They reported a renewed sense of wellbeing and energy. Positive feedback was consistently received from CYP and their families with regards to the friendly, affirming approach to communication used in the clinic via collaborative goal setting. Compared to national figures, the clinic’s biomedical markers and attendance rates are excellent. The main author plans to further detail these findings and the relationship with SFA in an additional paper (Guyers and Ziemba, 2019) to further explain how SFAs can work alongside the existing medical model.

Conclusion
This paper has given a flavour of the ‘real world’ application of SFA in a busy clinical setting. It suggests that SFA principles and questions can be ‘sprinkled’ into a myriad of health conversations to maximise patient–clinician interactions and promote collaborative thinking around outcomes and skills.