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3».

 

NSTATE UN

41526

                                 

 

 

 

 

 

 

 

Q

       

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This is to certify that the
dissertation entitled

A Program of Self-Advocacy and Social Support
for Diabetic People

presented by
Thereasa A. Cronan

has been accepted towards fulfillment
of the requirements for

degree in Wjfi ‘W 617

 

George w. Fairweather

 

MSUi- nn Arr—mun. . - r1 .A

n, ' ' "‘ " 0-1277!

 

 

 

 

 

 

)V1531_J RETURNING MATERIALS:
Place in book drop to
LIBRARIES remove this checkout from
your record. FINES will

 

 

 

 

be charged if book is
returned after the date
stamped below.

 

 

 

 

 

A PROGRAM OF SELF—ADVOCACY AND SOCIAL SUPPORT
FOR DIABETIC PEOPLE

By

Thereasa A. Cronan

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY
Department of Psychology

1985

ABSTRACT
A PROGRAM OF SELF-ADVOCACY AND SOCIAL SUPPORT
FOR DIABETIC PEOPLE

By

Thereasa A. Cronan

The purpose of the present study was to compare the
efficacy of two interventions for people with diabetes.
The first intervention taught self—advocacy and social
networking. The second program provided the same
information; however, the information was presented in a
manual. People who had received some educational
instruction about diabetes were eligible to participate in
the study. They were randomly assigned to one of the two
conditions. All subjects participated in assessments at
their entry into the study (pre-assessment), at the end of
the intervention (post assessment), and approximately
three months later (follow-up).

The outcome measures included body weights,
glyco—hemoglobin assays, blood pressure, health beliefs,
amount of reported compliance in following medication,
diet, exercise regimes, general health practices,
assertiveness or general advocacy, health locus of

control, cohesiveness, and satisfaction with the program.

Thereasa A. Cronan

Both comparative and associative analyses were
performed on the data from the three groups (two
experimental groups and the manual group). The results
from the comparative analyses revealed no significant
differences between groups or over time for body weights,
health beliefs, reported compliance in medication, diet,
exercise, general health practices, or health locus of
control. Significant differences were found for
glyco—hemoglobin levels, blood pressure, cohesiveness, and
satisfaction with the program. Glyco—hemoglobin levels
increased over time for both the experimental groups and

the manual group. Blood pressure decreased for the three

groups by the follow—up assessment. People in the
experimental groups were more cohesive than people
assigned to the manual group. People in one of the

experimental groups rated the program lower than the
people in the other experimental group or people in the
manual condition.

The associative analysis (cluster analysis) indicated
that people who scored high on the specific advocacy
dimension more often had a medication change between the
post and follow-up assessments. The general advocacy
dimension was not related to any measures of behavior
change. These findings support the need for focused and

specific training in advocacy.

Thereasa A. Cronan

The O—Types analysis identified ten O-Types. Only
two of the types consisted of over six people; because
of this only these two types were used in the additional
comparisons. The first O—Type contained ten people,
five males and five females; all were from the manual
condition. Half of them had juvenile onset diabetes.
These people scored high-average on the blood and
physical condition clusters, and very low on the
cohesiveness cluster (necessarily, since they were in
the manual group). Nine people made up the second
O—Type. All of them were from the experimental groups;
four of the nine people were females. These people
scored lower on the blood cluster, lower on the physical
condition cluster, and higher on the cohesiveness
cluster than the people who made up the first type.

The experimental hypotheses may have received
minimal verification because of weaknesses in the
measures of the dependent variables, in experimental
manipulations, or in the specificity of the training.
Arguments are presented for the latter interpretation.
Future research should include more specific
interventions, and early and frequent consultation with
subjects in helping to decide on what goals should be
pursued, and how success in reaching those goals should

be measured.

 

TO AL HILLIX

MY PARTNER IN LIFE

ii

ACKNOWLEDGMENTS

I would like to thank my chairperson, G. W.
Fairweather, and my other committee members, Esther
Fergus, William Davidson, and M. Ray Denny, for being
both my teachers and my friends. All gave freely of
their time and expertise, and, when it was needed, of
their personal support.

A very special thanks is due all of the
participants in the study. Without them there could
have been no study. I am also deeply indebted to
Shannon Groters, Barbara Horner, Gail Skinner, and Laura
Wallace for their dedicated help with the day—to—day
activities which kept the project going. Each of them
willingly contributed a tremendous amount of time and
energy to this project. Bets Simon went far beyond the
call of duty to help before, during, and after the
period of this study, and I owe her a special thanks.

My dear friend Leah Gensheimer gave generously of
her support and expertise. She had prepared a manual
for teaching assertiveness training, and she unselfishly
gave me all of her materials as a basis for the
assertiveness training manual used in this study. She
also took care of a multitude of details which demanded
attention after the study was completed and I had left

the area. For these things, and others too numerous to

mention, I owe her more than she can ever collect.

Brain Mavis and Marilyn Monda both consulted with
me on the statistical portions of this project. Brain
was my pipeline to the cluster analysis (the notorious
"BC Try"), and Marilyn helped me with data
transformations.

Donna Jacobs helped to get the project started. I
appreciate her as a fine patient educator and eager
worker and associate. She encouraged several of my
first patients to participate, encouraged me throughout,
and was still there at the end to meet and talk to the
participants when the study was finished.

I am very grateful to John Beasley, Director of the
Chronic Disease Division of the Michigan Department of
Public Health. He took a chance on funding a
dissertation, and thereby made it possible for this
project to be done in its present form.

My husband, Al Hillix, was also an important part
of this project. He helped in ways that ranged from
taking telephone calls from potential participants to
proof reading this manuscript. Finally, I would like to
thank Rebecca Bryson for her long—standing support and
confidence in me throughout my graduate education, and
my family and other friends for their support throughout

this project.

iv

TABLE OF CONTENTS

List of Tables......................................viii
List of Figures.....................................x
Introduction........................................l
Definition.....................................1
Physiology.....................................1
Insulin's Relationship to Diabetes........l
Hyperglycemia and Hypoglycemia............2
Diagnosis......................................4
Types of Diabetes..............................8
Incidence......................................lO
Complications of Diabetes......................10
Eye Problems..............................ll
Circulatory Problems......................ll
Kidney Disease............................12
Nerve Changes.............................13
Pregnancy.................................13
Correlates of Diabetes.........................14
Heredity..................................l4
Obesity...................................16
Age.......................................16
Sex.......................................l6
Stress....................................17
Benefits of Compliance.........................l8
Components of Medical Regimes..................20
Diet......................................20
Exercise..................................23
Stress Reduction..........................25
Good General Health Practices.............28
Medication................................28
Degree of Compliance to Medical Regimes........28
Factors Related to Compliance..................30
Educational Approaches to Increasing
Compliance.....................................34
A Comparison of Alternative Strategies.........38
Suggestions for Future Studies.................41
Assertiveness Training in Behavior
Modification Programs.....................41
Social Support............................42
Types and Sources of Social Support..42

General Research Findings in
Social Support.......................43
Social Support and Adherence to
Medical Regimes......................45
Social Support and Diabetes..........48
Problems in Doing Research on
Social Support.......................49
Group Process.............................50
Cohesiveness.........................51
Group Goals..........................53
Conclusion.....................................54
Proposed Study.................................56
Hypotheses.....................................57
Hypothesis One............................57
Hypothesis Two............................57
Hypothesis Three..........................57
Hypothesis Four...........................57
Hypothesis Five...........................57
Hypothesis Six............................58
Hypothesis Seven..........................58
Hypothesis Eight..........................58
Hypothesis Nine...........................59

Method..............................................60
Subjects.......................................60
Recruitment...............................6O
Demographic Characteristics...............62
Measuring Instruments..........................63
Historical Questionnaire..................63
Physiological Measures....................64
Height and Weight....................64
Glyco-hemoglobin assays..............65
Blood Pressure.......................68
Health Beliefs Scale......................68
Indicators of Health Behaviors............72
Rathus Assertiveness Scale................74
Health Locus of Control Scale.............75
Sociometric Questionnaire.................77
Log Books.................................78
Knowledge Questionnaire...................82
Program Evaluation........................82
Tape Recordings...........................84
Procedures.....................................85
Interviewing Procedures...................85
Experimental Setting......................86
Self—advocacy and Social Networking Group.86
Manual Group..............................
Design.........................................88

vi

Results.0-00..cocoo...attoto00loccoooooooooooooooolosg

Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis

of
of
of
of
of
of
of
of
of

Hypothesis
Hypothesis
Hypothesis
Hypothesis
Hypothesis
Hypothesis
Hypothesis
Hypothesis
Hypothesis

One.....................89
Two.....................9O
Three...................97
Four....................101
Five....................105
Six.....................105
Seven...................106
Eight...................126
Eight...................128

Method of Associative Analysis.................136
Results of the Cluster Analysis................136
Blood.....................................137
Beliefs and Reported Compliance...........142
Physicial Condition.......................142
Cohesiveness..............................143
Juvenile Diabetes.........................144
Compulsivity..............................144
General Advocacy..........................l44
Specific Advocacy.........................145
Medication Compliance.....................145
External Health Control...................145
Medical Histories.........................146

Health
Typological
O-Type
O—Type

Practice Concern...................l46
Analysis..C....I'..............'...l47

on000000.00...oooococuoooooc000000148

2'00onoonno0'09000.0000000000'00000149

Discussion..........................................151
Failure to Confirm Experimental Hypotheses.....151
Reliability of Measures...................151
Weaknesses in the Experimental Manipulations...153
Type of Social Support....................153

Lack of Situational Specificity

of Treatment...

0.0.0.00...one-000.00.000.0154

Content of the Intervention...............157
Duration and Timing of the Intervention...159
Experimenter Effects......................1 O
Cluster Analysis...............................l6l
General Observations...........................166
Suggestions for Future Research................17l

Appendix A..........................................l75
Appendix B..........................................178
Appendix C..........................................194
List of References..................................298

 

10.

ll.

13.
14.

15.
l6.

17.
18.

LIST OF TABLES

Factors Affecting Compliance to Medical
Regimes.......................................31
Repeated Measures Analysis of Variance of
Quetelet's Index..............................91
Three Means of Quetelet's Index for
Conditions....................................91
Repeated Measures Analysis of Variance of
Glyco—hemoglobins.............................92
Two Means for Pre and Post Glyco—hemoglobin
Readings......................................92
Repeated Measures Analysis of Variance of
Reported Compliance to Medication Regime......93
Mean T Scores for Reported Compliance to
Medication Regimes............................93
Repeated Measures Analysis of Variance of
Reported Compliance to Diet...................94
Mean T Scores for Reported Compliance to Diet.94
Repeated Measures Analysis of Variance of
Reported Compliance to Exercise...............95
Mean T Scores for Reported Compliance to
Exercise......................................95
Repeated Measures Analysis of Variance of
Reported Compliance to General Health
Practices.....................................96
Mean T Scores for Reported Compliance to

General Health Practices......................96
Repeated Measures Analysis of Variance of

Right Mean Arterial Blood Pressure............99
Means of Right Mean Arterial Blood Pressure...99
Repeated Measures Analysis of Variance of

Left Mean Arterial Blood Pressure.............100
Means of Left Mean Arterial Blood Pressure....100
Repeated Measures Analysis of Variance of
Beliefs About the Consequences of Diabetes....102
Mean T Scores for Beliefs About the
Consequences of Diabetes......................102

viii

20.

21.

22.

23.
24.

25.
26.

27.
28.

29.
30.
31.
32.
33.
34.
35.
36.

37.
38.

39'
40.

41.
42.

43.
44.

45.

47.

Repeated Measures Analysis of Variance of

Beliefs About the Consequences of Health
Practices.....................................103
Mean T Scores for Beliefs About the

Consequences of Health Practices..............103
Repeated Measures Analysis of Variance of

Beliefs About the Ability to Follow Health
Practices.....................................lO4
Mean T Scores for Beliefs About Ability to

Follow Health Practices.......................104
Repeated Measures Analysis of Variance of

Rathus Assertiveness Scores...................108
Mean Rathus Assertiveness Scores Over Time....lO8
Repeated Measures Analysis of Variance of

Health Locus of Control Scores................109
Mean Health Locus of Control Scores Over Time.109
Repeated Measures Analysis of Variance of

Chooser Scores for the Three Conditions.......110
Mean Chooser Scores for the Three Conditions

Over Time.....................................llO
Repeated Measures Analysis of Variance of
Popularity Scores for the Three Conditions....lll
Mean Popularity Scores for the Three

Conditions Over Time..........................1ll
Repeated Measures Analysis of Variance of

Log Book Completeness Scores for Medications..129
Mean Log Book Completeness Scores for
Medications...................................129
Repeated Measures Analysis of Variance of

Log Book Precision Scores for Medications.....l30
Mean Log Book Precision Scores for
Medications...................................130
Repeated Measures Analysis of Variance of

Log Book Completeness Scores for Diet.........131
Mean Log Book Completeness Scores for Diet....l3l
Repeated Measures Analysis of Variance of

Log Book Precision Scores for Diet............132
Mean Log Book Precition Scores for Diet.......l32
Repeated Measures Analysis of Variance of

Log Book Positive Advocacy Scores.............133
Mean Positive Advocacy Scores.................133
Repeated Measures Analysis of Variance of

Log Book Negative Advocacy Scores.............134
Mean Negative Advocacy Scores.................134
Repeated Measures Analysis of Variance of

Program Rating................................135
Mean Overall Ratings of the Program...........135
The Twelve Pre—set Clusters...................138
Correlations Between the Oblique Cluster
Domains.......................................l41

ix

Figure

l.
2.

LIST OF FIGURES

Blood Glucose Tolerance Test Results..........7
Model of Effects of Sympathetic Nervous
System........................................26
Number of Problems Raised per Session for

Each Group....................................1l3
Number of Solutions Suggested per Session by
Members of Each Group.........................ll4
Time Spent Discussing Group Tasks per Session

for Each Group................................115
Time spent in Silence per Session for Each
Group................. ........................116
Amount of Time One Person Talking per Session

for Each Group................................117
Amount of Time More than One Talking per

Session for Each Group........................1l8
Time Discussing Overall Study per Session

for Each Group................................ll9
Number of Positive Statements per Session

for Each Group................................120
Number of Negative Statements per Session

for Each Group................................121
Number of Offers of Help per Session for

Each Group....................................122
Number of Self—disclosures per Session for

Each Group....................................123
Number of People Attending Each Session for

Each Group....................................124
Total Group Support Time per Session for

Each Group....................................125
Scale Values for Cohesive and Noncohesive
O-types.......................................150

INTRODUCTION

Definition
The word "diabetes" comes from the Greek. It means
"to run through a siphon." Mellitus is a Latin word
which means honey. According to Surwit, Feinglos, and
Scovern (1983), the word was first used in 200 CE. No
doubt it was easy to detect by a rough kind of
urinanalysis (taste), since the high level of glucose in
the blood results in the excretion of sugar in the
urine.
Physiology
In order to understand the behaviors required of
diabetics, and the information available to guide that
behavior, it is necessary to understand the basic
physiological events of diabetes and how those events
are controlled and monitored.
Insulin's Relationship to Diabetes
Diabetes is related to the function of the
pancreas, a 3—4 inch gland located behind the stomach.
Insulin is a hormone produced by the pancreas. It is

the key that opens the cells for the entry of glucose,

 

which then nourishes the cell and furnishes it with
energy.

In diabetes the body is unable to use glucose
normally. Sometimes the body makes either too little
insulin for its needs, or too much. In other cases the
body makes sufficient, but ineffective, insulin. Unused
glucose remains in the bloodstream, and some of the
excess is eventually passed by the kidneys and
eliminated with the urine. This process is often
referred to as "spilling sugar," and gives diabetes its
name. When glucose cannot be used properly, fat cells
start breaking down to be used for energy by the body.
The by—products of this fat breakdown are called
ketones. Acetone is the most abundant ketone. Ketones
are poisons made when the body cells burn fat for
energy. This occurs when there is not enough insulin,
and the resulting condition is referred to as
ketoacidosis.

Hyperglycemia and Hypoglycemia

People are considered to be within the normal range
if their blood glucose level is within the 70—160 mg
range. Two conditions can result when insulin is not
produced or used by the body. One is hyperglycemia,
which is a high level of blood glucose (160 or over).

Hyperglycemia may result in ketoacidosis, which is also

called diabetic acidosis, and may result in a diabetic
coma. This occurs when insulin decreases to a very low
level, and glucose cannot be used for energy by the
cells. Thus hyperglycemia may produce ketoacidosis via
the substitution of fat for sugar as an energy source.

Ketoacidosis is more likely to occur when a
diabetic eats too much, doesn't take enough insulin (or
forgets to take it), is less active but eats the same
amount of food, or experiences too much stress.
Ketoacidosis is relatively rare in a non-insulin-
dependent diabetic.

Another type of hyperglycemia is nonketotic

hyperosmolar hyperglycemia. This usually occurs in
persons over the age of 50 who have mild,
non—insulin—dependent diabetes. More than half of the

diabetics who develop this complication do so following
another disease or event such as heart attack, stroke or
burn. This happens because there is enough insulin
present to prevent fat breakdown, but not enough to
control sugar.

The second general condition that diabetics may
have is hypoglycemia. This is low blood glucose (70 or
below). It is also referred to as hypoglycemic
reaction, insulin reaction, or insulin shock. Low blood

glucose levels can occur if a diabetic eats too little

food or delays a meal, takes too much insulin or oral
medication for his or her body's needs, or increases
physical activity without increasing food intake or
insulin dose.

W

There are several glucose tests used for detecting
and treating diabetes. They include urinanalysis, a
simple blood-glucose test, the fasting blood—glucose,
two-hour post—prandial glucose tolerance test, and
hemoglobin Alc (glyco-hemoglobin). These tests are
important for practitioners of behavioral medicine to
understand, in part because the patient must use a test
to monitor his or her own condition. The urine test,
although only an indirect measure of blood glucose, is
usually preferred by patients because it is painless and
relatively simple. Unfortunately, the more complex and
difficult the test of blood sugar level, the more
reliable it tends to be.

A simple blood—glucose is a determination of a
patient's blood sugar. It is often identified by the
timing of its administration. This test provides
immediate feedback on the current level of glucose in
the bloodstream. A fasting blood glucose measures blood
sugar after a period of fasting (usually overnight, with

the test before breakfast). A two hour post—prandial

 

test is taken two hours after breakfast or a meal. If
any of these test results deviate grossly from normal
(elevated), they may be used by a physician, along with
a patient's medical history and symptoms, in making a
diagnosis of diabetes.

In a known diabetic patient a blood—glucose
provides the doctor or patient with information on the
effectiveness of short-term therapy (whether type,
amount or timing of administration of insulin or other
diabetic medication needs to be altered). If a
blood—glucose is done while a patient is experiencing
symptoms of hypoglycemia (low blood sugar), an objective
evaluation cannot be made (symptoms of hypoglycemia and
hyperglycemia are similar and may be confused).

A glucose tolerance test consists of measures of
blood glucose made at several intervals: fasting, 1/2
hour and 1, 2, or 3, hours after the patient drinks or
is given a shot of glucose (the dose is determined by
the patient's height and weight). This test is given to
people with a family history of diabetes, to pregnant
women, and to people suspected of having functional
hypoglycemia. Cooper (1980) reported that the glucose
tolerance test is especially useful in gestational
diabetes, so that if the results are abnormal

appropriate treatment may be instituted. Figure 1 shows

responses to a glucose tolerance test by three
individuals: one normal, one with impaired glucose
tolerance, and another with diabetes.

A relatively new test, the glyco—hemoglobin assay,
measures a type of hemoglobin found in the red blood
cells. In poorly controlled diabetes the amount of
glyco—hemoglobin present may be two to three times
normal. The test results reflect the average blood
sugar level over an extended period of time
(approximately 2-3 months before the test). A major
advantage of this test is that it is only slightly and
slowly affected by recent diet, exercise, or recently
administered insulin or oral medications (these factors
influence a regular blood-glucose test dramatically).
Thus the glyco-hemoglobin test results allow for a
long—term evaluation of therapy, but are useless as
measures of current blood sugar level.

In summary, the blood glucose, fasting blood sugar,
and post-prandial tests are used in making a diagnosis
of diabetes and in evaluating short—term therapy. The
glucose tolerance test is often used to detect impaired
glucose tolerance and diabetes which develops during
pregnancy. The glyco—hemoglobin assay reflects blood
sugar levels over an extended period of time. The

relatively simple and painless urinanalysis test,

§

The three people represented on this
graph each had 100 grams of glucose
administered by mouth. One person (A-
Normal) is nondiabetic. One person (B-
IO T) has impaired glucose tolerance.
And the other person ( C -DM ) is diabetic.
either insulin-dependent or non-insulin-
dependent. You can see that the
nondiabetic's body has removed most of
the glucose from circulation within two
hours. In the diabetic. whose glucose
levels were already too high. the glucose
level shot even higher than at first. and
three hours later. the levels had not yet
A-NORMAL begun to drop. The person with impaired
glucose tolerance has a curve similar to
that of the nondiabetic, except that it is
somewhat higher. Also, at the end of two
hours. this person's glucose level had
dropped only slightly. whereas the
nondiabetic's blood-glucose level had
returned to normal.

    

N
&
O

C-OIABETES

§§8§§§£§

.. PLASMA venous GLUCOSE (MG PER 100 ML.)
8

o w v 2 ,I‘ 3
Tine after administration of glucou (Hans)

Figure 1. Blood Glucose Tolerance Test Results.

although it is subject to error, is usually used by
patients to monitor their own condition. A simple,
painless, reliable, valid, and inexpensive test would be
a boon both to diabetics and to their physicians
(financial considerations aside, in the case of the
physicians).
Types of Diabetes

There are two basic types of diabetes mellitus, not
very informatively named Type I and Type II. Type I and
Type II diabetics are differentiated on the basis of
insulin dependence. Type I diabetics need to take
insulin in order to survive, and hence are referred to
as insulin-dependent diabetics. Type II diabetics are
referred to as insulin independent, because they do not
need insulin to survive. Type I diabetics are also
referred to as juvenile diabetics, and they account for
15% to 20% of the diabetic population. They usually are
diagnosed as children who make very little insulin,
although a person may be diagnosed as a Type I diabetic

at any age. Most Type I diabetics are thin.

In Western societies, 60 to 90 percent of
non-insulin—dependent diabetic patients are obese
(National Diabetes Data Group, 1979). This is

significantly more than in the general adult population;

the United States Public Health Service estimates that

25-45% of the American population over the age of 30 is
more than 20% overweight. Typically people who are
heavy have plenty of insulin; in fact they have more
than they need. It just doesn't work. Type II
diabetics usually become diabetic between the ages of 30
and 50. New evidence (Speckart, personal communication)
suggests that insulin works by fitting into receptor
sites on cells and "firing" them. Each cell has
hundreds of receptors, and under certain conditions
receptors close down. The evidence suggests that
exercise and body weight can affect the number of
receptors. Infections decrease the number of insulin
receptors.

In some Type II diabetics, their own antibodies
attack their insulin receptor sites. Like, et al.,
(1982) found that performing thymectomies reduced the
frequency of spontaneous diabetes mellitus in selected
rats from 27% to 3 %. Incomplete thymectomies reduced
diabetes to 9%. Since the thymus produces antibody
cells, these findings are consistent with the hypothesis

that Type II diabetes is caused by a defect in the

autoimmune system. They also account for the
relationship between infection and receptor site
decrease, since more antibodies are produced to combat

infections, and these antibodies might attack receptor

 

10

sites. An immediate implication of this finding is that
an important goal of behavioral interventions should be
to teach the diabetic to avoid and control infections.
In the long run, Type II diabetes may be curable through
making specific antibodies to attack the antibodies
attacking the insulin receptor sites, using hybridoma
techniques.
Incidence

Diabetes Mellitus and its complications are the
third leading cause of death in the United States, after
heart disease and cancer. Classical diabetes occurs in
3—5% of all adults, or nearly one in twenty in the
general population. Diabetes is a chronic condition
that can be controlled, but not cured, at the present
time.

Surwit, Feinglos, and Scovern (1983) attribute
300,000 deaths per year to diabetes, and estimate that
there are one million insulin—dependent diabetics, four
million non—insulin-dependent diabetics, and five
million undiagnosed diabetics.

Complications of Diabetes

Complications arise when blood glucose is not
controlled. These complications shorten 80% of
diabetics' life spans. Diabetics are 25 times as likely

to be blind, 20 times as likely to have gangrene, 17

11

times as likely to have kidney disease, and twice as
likely to have heart disease or stroke, as the normal
population (Davidson, 1981). Although the complications
of diabetes are severe, they are slow to appear. Thus
the diabetic may not see clearly the link between his or
her own behavior and its disastrous consequences.
Bringing about behavioral changes in diabetics has
something in common with producing changes in smokers,
obese persons, and alcoholics. In all these cases, the
undesirable behaviors have immediate payoffs, while the
payoffs for desirable behaviors are remote and
intangible.
Eye Problems

Diabetes is the major cause of blindness in the
world. High blood sugar causes the vision to be
blurred. Sugar accumulates in the lens, and diabetics
have an early appearance of cataracts. Changes in the
retina also occur because the vessels weaken and
hemorrhaging may occur. If hemorrhaging does occur, a
whole section may lose sight when the retina is
damaged.
Circulatory Problems

Diabetics are at a greater risk of heart disease
and hypertension. Adults with diabetes have a greater

chance of developing nerve problems and poor circulation

12

in their lower legs and feet. Poor circulation and
increased glucose (sugar) in the tissues also increase
the possibility of infection and slow down the healing
process. Atherosclerosis (hardening of the arteries) is

a major cause of heart disease and poor circulation in

the legs. Although this condition occurs more
frequently in diabetics than in non-diabetics,
scientists are unsure why. Gonen et al. (1982)
discovered that glucose attaches to low—density

lipoprotein (LDL), which carries cholesterol through the
blood, and that the cholesterol in glucose—laden LDL was
not efficiently used by body cells. They suggest that
this may cause cholesterol levels in the blood to
increase dangerously and lead to complications.

Panzram and Zabel-Langhenning (1981) gathered the
records of all newly—diagnosed diabetics who had been
registered in the Erfurt district in 1966. They studied
this population for a ten year period. Out of 2560
diabetics, 1054 had died during the 10-year follow—up
period. Cardiovascular causes accounted for 63% of the
deaths. Excess mortality was present in most age
classes and was evident within the first year after
diagnosis.

Kidney Disease

Diabetics are prone to kidney disease. Kidney

13

diseases usually develop over a period of years, and are
more common in Type I diabetics than in Type II
diabetics. Kidney disease in a diabetic is characterized
by progressive thickening of the glomerular and tubular
basement membranes. The function of the glomeruli is to
separate waste materials from the blood. These waste
materials are passed out as urine. When the membranes
of the glomeruli are thickened, the filtering function
is impaired. Studies have indicated that diabetics tend
to have higher concentrations of albumin in their
kidneys (Michael and Brown, 1981). Why diabetics are
more prone to kidney diseases, and whether or not there
is an interaction of albumin and glucose, is not known
at the present time.
Nerve Changes

Nerve problems may decrease a diabetic's ability to

feel pain from blisters, bad fitting shoes, small cuts,

or splinters. If the injury goes unnoticed, a serious
infection or ulcer can occur. Gangrene may follow
(Crofford, 1976), and for this and other reasons

amputations are 20 times more frequent in diabetics than
in the general population.
Effects 22 Pregnancy

Out of 100 pregnant insulin—requiring, Type I,

diabetics, 40 will have a miscarriage, as compared with

14

4% for the normal population. Out of 100 diabetic women
that carry the full term, 15—20% can expect to have dead
babies, and 40% of those left will have babies with some
disease (Speckart, personal communication). Although
this evidence seems very frightening, with very strict
monitoring of diet and control of her diabetes, 90-95%
of pregnant diabetic women can go home with healthy
babies.
Correlates of Diabetes

Although the exact cause(s) of diabetes are not
known, there are several factors that are known to be
correlated with the development of diabetes. A
knowledge of these correlates helps the medical
psychologist to describe the population of interest, and
thus to tailor behavioral interventions to the
population of interest. For example, it will become
apparent that a majority of diabetics are female and
above the population median in age.
Heredity

The incidence of diabetes is higher if other family
members have diabetes. The closer the genetic
relationship, the more likely it is that the relative of
the diabetic will also have diabetes; this is as it
should be if heredity plays a part in diabetes.

Barnett et a1. (1981) studied 53 pairs of

 

 

15

non—insulin—dependent diabetic (NIDD) twins. The twins
were recruited from a variety of sources, some from the
authors' own clinic, some from other physicians and
hospitals, and some through advertisements on radio and
television. They found that in 48 pairs both twins
developed diabetes, and the interval between diagnosis
in NIDD co—twins was short. In 35 of the 48 pairs (73%)
the second twin became diabetic within five years of the
first. 0f the remaining 13 pairs, 11 pairs had both
developed diabetes within ten years, and the remaining
two pairs became concordant 11 and 12 years after the
diagnosis in the first twin. In the five cases
remaining from the original 53, the affected twin had
been diagnosed only within the last three years, and all
of the remaining twins showed early metabolic changes
characteristic of diabetes.

Other observations that could indicate a hereditary
component are: women are twice as likely as men to have
Type II diabetes, and in one particular group of females
(Pima Indians over 40), the incidence of diabetes is 50%
(Bennett, 1982). Of course none of these observations
demonstrate conclusively that heredity is the dominant
factor in diabetes, since environmental differences are
confounded with hereditary differences in every case.

It does seem likely that genetic factors are important,

 

16

but it is also certain that environment is important, as
we see in the case of obesity.
Obesity

As mentioned previously, 60 to 90 percent of
non—insulin-dependent diabetic patients are obese
(National Diabetes Data Group, 1979). Obesity causes
continuous stress to the body because of the increased

demand on the pancreas to produce more insulin.

13

Most new cases of Type I diabetes occur before the
age of 20 (Kaplan and Atkins, 1985). For Type II
diabetes, the proportion of new cases, as identified in
population surveys, increases with age for both adult
men and women (Barett—Connor, 1980).

Sex

 

After age 45, diabetes occurs twice as often in
women. In a recently reported study (Kissebah, 1982),
women between 20 and 40 years old were tested for cases
of diabetes that had not been previously diagnosed. It
was found that obese women whose fat was concentrated on
the upper body were 30 times likelier than other women
to have undiagnosed diabetes. Obesity from the waist up
tends to involve enlarged individual fat cells; these
enlarged cells are less able to process glucose, so

diabetes is more likely. Obesity below the waist is

l7

typically caused by too many regular—sized fat cells.
Type of obesity, like diabetes itself, may be related
both to heredity and to environment. It is thought that
overeating while young leads to an increased number of
fat cells, while overeating later leads to the
enlargement of individual cells.
Stress

Increasing evidence (Sanders, Mills, Mattin and De
La Horne, 1975; Grant, Kyle, Teichman and Menchels,
1974) indicates that lingering stress may cause or
worsen the development of many illnesses; included in
these illnesses is diabetes (Danowski, 1963). This is
of great interest in the present context because stress
is presumably amenable to reduction through behavioral
manipulations. Physical stress ranging from illness,
such as a heart attack, through drugs such as steroids,
to pregnancy may cause a temporary state of diabetes.
When the stresses are removed, these individuals recover
their normal glucose tolerance, but are subject to the
same dangers of hyperglycemia and hypoglycemia as
chronic diabetics during their diabetic episodes.

Grant, Kyle, Teichman, and Mendels (1974)
investigated whether or not a relationship could be
demonstrated between life events — many of which are

stressful — and the course of illness in a group of

 

18

diabetic patients. Patients filled out Schedules of
Recent Events so that an evaluation of both positive and
negative life changes could be made. Scores on this
schedule were correlated with a "Global Rating" of the
patients' physical well—beings. There was no significant
overall correlation between life events and well—being;
however, 26 of 37 individual correlations were positive,
and 24 individuals had positive correlations between
negative life events and their diabetic condition.

Unfortunately, the study was beset with
methodological and statistical errors, so it provides
only the weakest of support for the contention that
stressful life events correlate directly with diabetic
condition. It is possible that a subjective evaluation
of the degree to which the diabetic is stressed would
correlate better with condition. There is, in any case,
adequate reason to believe that stress and diabetes are
related, and more of this evidence will be presented
later.

Benefits of Compliance

A major study begun in the} early 60's helped to
increase interest in behavioral manipulations for
diabetic patients. The study was conducted by the
University Group Diabetes Project from 1961 to 1971.

The study involved 823 patients in twelve clinical

19

centers. They were instructed in a diet intended to
achieve or to maintain normal body weight. Then they
were randomly assigned to one of four groups. Two
groups received insulin, one on a regular dosage
schedule and one on a variable dosage schedule. Another
group received tolbutamide, and yet another group
received a placebo that they believed was an oral
medication. Patients were monitored for eight years and
10 months. Then the life—death status of 818 of the
original patients was determined. The results indicated
that patients that received tolbutamide had a higher
probability of dying due to cardiovascular diseases than
the control group. The groups receiving insulin did not
differ from the control group. The authors concluded
that tolbutamide and diet were less effective in
controlling Type II diabetes than was diet alone (plus
placebo pills).

The UGDP has been criticized for several reasons.
The main criticisms have centered on the clinical design
and the statistical analyses. Feinstein (1979) has
pointed out that 95 of the patients in the study did not
fulfill the minimum standards of glucose intolerance
that had been established as a diagnostic criterion for
diabetes mellitus. These patients were included because

of poor communication between the collaborators in the

20

study.

Some investigators have charged that the
randomization failed to allocate to the treatment groups
patients who were generally comparable with respect to
baseline risk factors. This criticism seems justified,
since the excess mortality was confined to only a few of
the twelve clinics. In defense of the UGDP, the
Biometric Society upheld the statistical analyses of the
original UGDP report, and rejected a number of widely
publicized arguments against its conclusions (Sussman
and Metz, 1975). Although this study was controversial,
it has inspired the reexamination of methods of
controlling diabetes. At the very least, it provides
evidence that behavioral manipulations alone are often
g2 worse than medication (in this case, tolbutamide).

Cgmponents pf Medical Regimes
21.22

Since 1970, poor dietary habits and lowered
physical activity are often cited as contributory to
maturity—onset diabetes. It is possible that social
behaviors and habits are partially responsible for an
increased incidence of diabetes (Saltin et a1. 1979). A
ten-year follow—up study recently published reports that
people with impaired glucose tolerance can prevent

diabetes with tolbutamide and diet regulation. Sartor et

21

al. (1980) assigned 267 men who had impaired tolerance
to oral glucose, but did not have manifest diabetes, to
one of five groups. One group received diet regulation
and 0.5g tolbutamide, another group received diet
regulation and one placebo tablet. The third group
received diet regulation only, and the fourth group
received no treatment. These four groups all received
an annual oral glucose tolerance test (OGTT). The fifth
group did not receive any treatment; only a pre— and
post— (after ten years) OGTT were taken . At the ten
year follow-up, 29% of those without diet regulation and
medication had developed diabetes. Of those that
received diet regulation, but without active medication,
13% had diabetes. None of the men that received

tolbutamide and diet regulation had developed diabetes.

Further, no individual with initially normal OGTT
developed either diabetes or an abnormal OGTT. Sartor
et al. suggest that people with impaired glucose

tolerance may be prevented from, or may postpone,‘
developing diabetes by treatment with the combination of
diet regulation and tolbutamide. While the results of
this study are impressive, they do not by themselves
tell us whether or not the tolbutamide alone can produce
the results, since there was no group that received

tolbutamide alone. Sartor's results are thus somewhat

22

at odds with the findings of the UGDP study discussed
above, in which the evidence seemed to indicate that
tolbutamide was not helpful to diabetics. Perhaps it
helps to prevent diabetes, but does little once the
disease has developed.

Other research has focused on changing and varying
the eating habits of diabetics. Fibre has been found to
improve carbohydrate tolerance, which is an important
factor to be considered in the dietary management of
non-insulin-dependent diabetics. One such study (Kay et
al., 1981) examined the influence of low and high fibre
diets on carbohydrate tolerance in five maturity-onset,
non—insulin—dependent diabetics. Subjects were put on a
diet rich in natural fibre for a 14—day period, and then
they were put on a low fibre diet for 14 days. The
results indicated that subjects' carbohydrate tolerance
improved when they were put on the diet rich in natural
fibre.

De Bont et a1. (1981) were interested in comparing
the effects of low—fat diets in the management of
diabetic women to the effects of conventional low
carbohydrate, high fat, diets. They found that patients
in the low—fat group had reduced their fat intake from
41% to 31% of total energy, while the carbohydrate

percentage of total energy intake increased from 38% to

23

46%. Body weight fell for all groups. Mean plasma
total cholesterol fell in the low—fat group compared
with the controls. Adherence to the low-fat diets
occurred without any worsening of the diabetes and with
benefit for weight and total cholesterol.

It should also be noted that methods found useful
in bringing about weight loss in a general obese
population would also be applicable to diabetics, since
the problems with weight control in the two cases are
very similar. Diabetics would be expected to have
somewhat more motivation to lose weight.

Exercise

As mentioned earlier, physical activity has been
found to augment insulin sensitivity associated with
enhanced insulin binding to receptors (Cahill, 1971).
For these reasons, many studies have attempted to
increase the amount of exercise a diabetic receives.
Since approximately 60 to 90% of non—insulin-dependent
diabetics are obese when they are diagnosed, it is
obvious why compliance to exercise programs is
essential. Most studies that have attempted to increase
the amount of exercise a diabetic receives have also
included diet as part of the manipulation. Since most
diabetics are obese, the goal has been to achieve and/or

maintain ideal body weight through both diet and

24

exercise.

Some researchers have investigated whether blood
glucose levels improve more when information is given on
diet, exercise or both. The question is whether it is
more important to stress diet or exercise, or whether
they are both equally important. Saltin et al. (1979)
randomly assigned men between the ages of 47 and 49 that
had had two consecutive pathological OGTTs to one of
three groups. One group of men received dietary advice,
one received physical training, and the other received
physical training plus dietary advice. Improvement on
the OGTT was greatest for the group receiving both
physical training and dietary advice. However, the
OGTTs improved for all three groups.

Physicians sometimes hand an exercise program to a
patient and tell them that exercise is important and

that they should follow the program. Rice (1981) felt

that greater involvement and compliance could be
achieved if priority were given to the clinical
characteristics of the patient population when
developing an exercise. She designed an exercise

program emphasizing general flexibility, conditioning
and toning activities, along with walking. She had
diabetic patients participate in a six-part program: 1)

exercise videotape; 2) illustrated take-home booklet; 3)

25

individual sessions with a dietitian; 4) individual goal
contracting; 5) reinforcement phone calls; 6)
post—program evaluation. Patients preferred the other
exercises to walking, and believed that the program was
hbeneficial. Sixty—five percent of the exercise goals
were accomplished, and 95% of the patients continued
exercise at the end of their programs. Hence both
greater involvement and greater compliance were
accomplished. While the results seem impressive, the
dependent variables did not include glucose tolerance
tests or other variables demonstrating that the exercise
improved the diabetics' pathological condition.
Stress Reduction

Surwit, Feinglos, and Scovern (1983) emphasize the
benefits of stress reduction for diabetics. Figure 2
reproduces their simplified model of the effects of the
sympathetic nervous system on glucose metabolism. If
stress overactivates the sympathetic nervous system, and
is thus responsible for exacerbation of the diabetic
condition, there is a priori reason to believe that
stress reduction would help the diabetic.

A number of studies have indicated that this a
priori promise can be realized empirically. Daniels
(1939) reported that Bauch in 1935—1936 had used

relaxation techniques to cut patients' exogenous insulin

..._____’— ___—

26

E“"5""Cl'Symtadmk:Norman-SysrmmnGlace-oMet-matte»!

CNS

"numeric moo: svs'rtn
ac'nvmr ‘

    

 

 

 

 

 

 

 

 

o...-
” urn-c i m u
ml.“- nun-unu- W
e“ n ‘

 

 

 

 

 

Figure 2. Model of Effects of Sympathetic Nervous System
on Glucose Metabolism.

 

 

 

 

27

requirements by 10 to 60 units. Several case studies
have reported similar results, and Surwit and Feinglos
(1983) showed in a controlled trial conducted in a
hospital that six patients given progressive relaxation
training improved their glucose tolerance, while six
patients not given the training actually deteriorated
during the same 9—day period.

Kaplan and Atkins (1985) point out that the
apparently exciting Surwit and Feinglos results must be
interpreted with caution. Despite random assignment of
patients to treatment and control groups, it turned out
that half of the treatment group had fasting plasma
glucose values less than 140 mg/dl prior to the
intervention. Only one control was below the 140 mg/dl
criterion. Further, the treatment group had greater
glucose-stimulated insulin secretion prior to
treatment.

These results are useful as an indication of the
possible promise of behavioral techniques with
hospitalized diabetics, but relaxation techniques may
not apply so well to the stresses encountered in the
diabetic's everyday life outside the hospital. It will
be suggested in a later section of this paper that
techniques like assertiveness training may be more

effective in helping patients to relieve everyday

28

stresses.
Good General Health Practices

It seems indisputable that the diabetic will
benefit from following a program of good health habits.
Because of the possible complications listed above,
diabetics should be unusually conscientious about daily
foot care, preventive mouth care, and protection and
care of the skin. They should have adequate rest and
avoid high stresses of all kinds. They should have
regular examinations by doctors (eye doctors in
particular) and dentists.

Medication

Even with good programs of diet and exercise, some
diabetics will need medication; Type I diabetics all
need exogenous insulin, and many Type II diabetics also
take insulin and/or other medications. It is essential
that medications be taken as prescribed.

The behavioral requirements for the
insulin—dependent diabetic are quite stringent. Careful
regulation of caloric intake and exercise in relation to
insulin dosage is necessary in order to maintain the
delicate balance between hyperglycemia and hypoglycemia
(Karam, 1981).

Degree of Compliance to Medical Regimes

The proportion of patients who fail to adhere to

29

physicians' orders was estimated by Davis (1966) as
ranging from 15 to 94%, and by Gillum and Barsky (1974)
as ranging from 33% to 50%. Different studies have used
different criteria for compliance, but it seems to be
clear that the problem of noncompliance is a serious
one. However, Davis reports that most doctors claimed
that all of their patients complied. It seems that
physicians are unrealistic in estimating the amount of
compliance.

Perhaps because of its chronic nature and the long
latency of its serious complications, conformity with
diabetic regimens seems to be particularly poor.
Watkins, Williams, Martin, Hogan, and Anderson (1967)
said that 75% of diabetic patients fail to follow their
diets, and that 45% perform urine tests incorrectly.
Hulka, Cassel, Kupper, and Burdette (1976) found that
80% of those they studied made errors in insulin
administration. Cerkoney and Hart (1980) reported that
33% of patients with insulin-dependent diabetes failed
to conform to all aspects of their program.

Skyler (1981) points to serious problems with the
very concept of compliance, which may account in part
for the "unsatisfactory" degree of compliance observed.
He says:

Compliance implies that a patient behaves according

30

to a physician's prescription, regardless of the
relevance, understanding, or practicality of that
prescription. Rather, it seems that the patient,
family, and health providers must negotiate an
acceptable, pragmatic plan. The definition of such
plans and the implementation of such negotiations
seem worthy areas of study. The providers may need
as much study and intervention as the patients (p.
657).
Factors Related to Cgmpliance

Table 1, taken from Janis (1983), who adapted it
from Kirscht and Rosenstock (1979), presents a very
useful summary of the variables which are, or might be,
related to compliance to medical regimes. Checking the
nature of diabetes and the characteristics of the
diabetic population against the relationships portrayed
in this table helps us to see why compliance presents
such a severe problem for diabetics.

On the negative side, we find every applicable
factor under situational demands. That is, symptoms,
which are positively related to conformity, are
typically missing in the early stages of diabetes;
remember that it is estimated that half of the diabetics
in this country aren't even diagnosed! Factors which

are negatively related to conformity are all present in

31

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Table l. Facrors Affecting Compliance to Medical Regimes.

32

diabetes; the actions demanded are often complex,
certainly have a long duration, and do interfere with
other actions (like being lazy, and eating all one
wants).

Alogna (1980) performed one of the studies designed
to find what specific characteristics of individual
diabetics might be related to conformity. Fifty
non-insulin—dependent diabetics were classified as
compliant or non—compliant. They were considered
compliant if they had lost 20 to 50 pounds in one year,
and had lost 10% of their initial weight each year for
up to three years, and had a plasma glucose level less
than 195 mg/dl. Patients in the noncompliant group had
lost less than 10% of their initial weight for the
period of up to three years (or showed a weight gain),
and had a plasma glucose level of 250 mg/dl or greater.‘

The only demographic variable which distinguished
the‘ two groups was age, with the compliant group
significantly older. Compliant subjects viewed their
illness as significantly more severe than did the
noncompliant subjects. There was a trend in the
direction of more internality on the health locus of
control scale by the compliant subjects, but the
observed difference was not statistically significant.

The author concluded that patient education programs

33

should increase their emphasis on the seriousness of the
disease.

Hayes (1976), in a review of the compliance
literature, noted that there is an inverse relationship
between the amount of behavioral change required by a
medical regimen and the extent to which patients comply
to the regimen. One possible implication of this finding
is that educational programs and behavioral approaches
should try to achieve goals gradually so that the
patient will never have cause to be either discouraged
or rebellious. Of course there is a question of balance
involved; it may be impractical to break up a total set
of behavioral objectives into too many subsets, making
patients rebellious because, every time they achieve a
goal, they are presented with an additional goal which
is more difficult to achieve. Experimentation may be
needed to determine the balance between making goals
easier by breaking them into steps, versus having too
many steps. There is the further problem that the
optimal step size probably depends on the individual
patient.

~.

Shelton and Levy (1981) summarized the reasons for
noncompliance under three headings. First, the
client/patient may lack the necessary skills and

knowledge to complete some or all of the tasks in the

 

 

34

assignment. Second, the client/patient may have
cognitions that interfere with completion of the
assignment. Third, the client/patient's environment may
elicit noncompliance. The Shelton and Levy formulation
fits neatly with the proposition that a training program
for diabetics should include behavior modification
approaches, perhaps including assertiveness training and
social networking as aids, in addition to the
traditional educational component.

On the positive side, we do find some
characteristics of the diabetic population; that is, the
majority are female and older, factors which are related
positively to conformity. Diabetics do not differ
clearly from the general population of those dealing
with "health experts" with respect to the remaining
relevant factors.

Educational Approaches £2 Increasing Compliance

Many hospitals are aware of the research indicating
that education increases compliance, and these hospitals
feel a responsibility to inform their patients.
Typically they teach newly diagnosed patients about
their disease as quickly as they can. Unfortuately,
many patients who are newly diagnosed are traumatized by
the disease, and later report that they were not well

informed on how to care for their diabetes. In response

35

to this problem, some hospitals offer new classes every
few months. Usually family members are encouraged to
attend the classes with the diabetic person. In many
cases the materials used for the classes are furnished
by the American Diabetes Association.

The American Diabetes Association (ADA) stresses
four major areas for any educational program: diet,
medication, activity/exercise, and good general health
practices. The ADA assumes that a normal, active life
is usually possible for people with diabetes, if the
four areas emphasized in the educational program are
handled adequately.

In a special report, the ADA (1979) stated that the
education of a diabetic person is the key to achieving
an effective diet. This involves a continuing process.
The report states that "pre—printed handout" meal plans
will not achieve the desired objectives, and they are
strongly discouraged. Appropriate family members should
understand, and be able to implement, the diabetic's
daily meal plans, should that be necessary. Every
effort should be made to work with family members so
that meal plans do not create conflicts within the
family or disrupt the usual family activities. Education
is, therefore, a family matter.

The concerns of the ADA about the nature of the

36

educational process seem to be very well founded. A
National Health Survey of a respresentative sample of
diabetics living in the United States found that 22% of
them "...stated that they were never given a diet for
their diabetes;" another 25%"... had received a diet but
said they didn't follow it;" and 53% indicated that they
did follow a prescribed diet (Holland, 1968). Even when
an optimistic interpretation is put on these data, it is
clear that more effective programs of education and/or
behavior modification are badly needed.

Green (1979), in a review of educational strategies
for increasing health care compliance, stated that
methods which provide social support in both the clinic
and the home environments should be most effective in
maintaining health behaviors over long periods of time,
as is necessary in the case of diabetes. Cohen (1982)
developed a community—based program following this
suggestion. Unfortunately, a fatal error in the design
of Cohen's study makes it impossible to draw any
conclusions from it. Cohen‘s experimental group
consisted of 10 patients who had been attending the
clinic for at least five months, and were still
attending. The control group had attended for at least
five months, but had stopped. Thus the experimental

manipulation was completely confounded with whatever

37

factors determined group membership. Was the
experimental group more motivated? Was their diabetes
less well controlled? Had they learned the lessons of
the clinic less well, so that they needed to continue in
attendance? This is a small sample of the possible
sources of confounding, and none of them can be either
accepted or rejected.

Even if the confounding could be ignored, the
results were unimpressive, to say the least. The
"control" group, which was completely inactive during
the twelve weeks that the experimental group was being
treated, actually did better on portion sizes and
general knowledge. The experimental group was better on
foot care, and the groups did not differ on many other
measures (performing urinanalysis or identifying proper
foods). There were no significant differences in weight
loss. Whatever the results had been, the study can tell
us nothing about the effects of adding social supports
to a program of education.

Sulway (1980) made another attempt to improve
patient education, adding individualized instruction,
family involvement, support groups, and group projects.
Although patients reported high satisfaction with the
program, no data were reported showing any connections

with the diabetics' health.

38

As these studies illustrate, the attempts to
increase compliance rates in diabetics through education
have met with mixed, limited, or uninterpretable results
(Hayes & Sackett, 1976). It could be that one reason
that results are not more encouraging is that those who
seek out and participate in such programs tend to be
those whose disease is most out of control. Certainly
if patients are taken "as they come" no conclusions are
possible. Even if available subjects are randomly
assigned to experimental and control conditions, the
results may apply only to those with less controlled
diabetes, rather than to the total population.

In summary, it is clear that the evidence that
educating patients alone will increase compliance rates
is extremely weak. The educational approach must, at
the least, be supplemented with other approaches. In
the next section behavioral approaches will be
reviewed. Little of the research on the use of
behavioral approaches to increase compliance has been
done with diabetics. Thus research with a variety of
populations will be included in order to increase the
coverage of types of intervention.

A Comparison of Alternative Strategies
Dunbar, Marshall, and Hovell (1979) distinghished

between three types of interventions for increasing

 

39

compliance: (1) Educational interventions, which rely
most heavily on transmission of information and
instructions as a means of changing behavior, (2)
Organizational interventions, which focus primarily on
clinic and regimen convenience, and (3) Interventions
which focus on behavioral techniques. Heitzmann,
Kaplan, Wilson, and Sandler (1985) recently completed a
study which concentrates on the third type of
intervention. They compared the effectiveness of
cognitive and behavioral interventions for training
patients to cope with diet and exercise programs. They
randomly assigned Type II diabetics to one of four
groups: behavior modification, cognitive modification,
cognitive—behavior modification, and a control
condition. Participants met with the experimenter for 7
sessions. The experimental groups also received home
visits.

The behavior modification group concentrated on
self—control procedures and participants were asked to
keep a log book of their weight, food consumed,
exercise, and events surrounding eating and exercising.
The cognitive modification group discussed the important
role that cognition play in developing control over
behaviors and the making of positive and negative

self—statements. Subjects in this group also kept a log

40

book; however, they recorded their self-statements
during eating and exercise. People in the
cognitive-behavior modification group were asked to
monitor their diet and exercise behavior, in addition to
their self—statments. The control group was exposed to
progressive muscle relaxation training to help them cope
with stress. All three of the experimental groups were
given dietary advice and a prescribed exercise regimen.

Follow—ups were conducted at three, six, twelve,
and eighteen months following the onset of the
projects. They found that subjects in the behavior
modification group lost significantly more weight than
subjects in the cognitive—behavior modification and
control groups. However, people in this group also
weighed the most when they entered the study. An
analysis of percent body fat, controlling for initial
body fat showed the same effect as for weight. However,
when relative weight was controlled for, using The
Quetelet Index, there were no significant differences
between groups.

Interestingly, men in the behavior modification
group lost 29 pounds and maintained a weight loss of
nine pounds over 18 months. No differences were found
in the glyco—hemoglobin assay, nor were differences in

the expected direction during the first year. However,

41

at the eighteen-month follow up subjects in the behavior
modification group (those that had the greatest weight
loss) had the highest decrease in their
glyco—hemoglobins, followed by the control, the
cognitive-behavior, and the cognitive modification
groups.

Suggestions for future studies

Assertiveness Training in Behavior Modification Programs

Assertiveness training is a behavioral technique
that has been used to reduce anxiety in a variety of
populations. The training includes any therapeutic
procedure aimed at increasing the client's ability to
engage in assertive responding. Behavioral goals
include an enhanced ability to express negative feelings
(anger, resentment) and positive feelings (joy, love,
praise) (Rimm and Masters, 1979). As Wolpe has pointed
out, one benefit to assertiveness is its ability to
inhibit anxiety reciprocally. He assumes that assertive
responding is very similar to deep muscle relaxation
(Rimm and Masters, 1979). Another benefit of assertive
behavior is that an assertive person will be able to
communicate openly and honestly and will be rewarded by
others for this behavior. Although assertiveness
training has not been used with diabetics, it has been

used in a wide variety of situations with diverse

42

populations as a stress reduction technique, for example
with alcoholics (Hirsch, 1975), those in marital
counseling (Alberti and Emmons, 1978), blacks (Cheek,
1976), and phobics (Hardy, 1978).

McMillian (1977) reports that assertiveness
training can be a powerful adjunct in any weight control
program, regardless of the treatment modality used. The
ultimate task in weight control can be regarded as
learning to say "no" to oneself and others when there is
a temptation to consume excess food.

Social Support

For the past two decades there has been
considerable interest in social support for patients
with chronic problems. However, no definition of
support has been agreed upon in the literature. Further,
different studies of social support have used different
criteria for determining the effectiveness of the
support.

Iypgg Egg Sources pf Social Support. Social
supports may be divided into three classes determined by
the source of the support: family, friends and existing
social groups, and special groups of people sharing the
same problem. It is likely that different sources of
support play different roles in ameliorating or

exacerbating problems.

43

The type of support received is even more variable

than the source. Included are feedback about behavior,

encouragement, cueing, modeling of appropriate
behaviors, financial support, education, love and
affection, group activities, ‘ attention, and many

others. With respect to an individual's problem, these
types of support may affect the yglggg the person puts
on his or her health and continuing existence, hence the
individual's intentions with respect to carrying out
behaviors relevant to the problem, and finally the
individual's Epiligigg to carry out the behaviors.

Since the source of support and the type of support
received are so variable, it is difficult to reach
intelligible general conclusions about the effectiveness
of something so global as "social support." The
difficulty is increased by the fact that so many studies
have been correlational, so that it is not possible to
reach firm conclusions about the probable efficacy of
interventions intended to supply the social support
that, for other people, occurs naturally.

General Research Findings ip_ Spglgl Spppggg.
Despite these caveats, it should be noted that social
support, as variously defined by several authors, has
’been reported to be important with many populations. It

reduced the perceived severity of psychological and

‘1!

44

health-related problems that accompany unemployment
(Core, 1978) and the stress connnected with graduate
school (Goplerud, 1980); it assisted with post—divorce
adjustment (Raschke, 1977).

Stout, Morrow, Brandt, and Wolfe (1964) observed an
unusually low rate of death from myocardial infarction
in a close-knit Italian—American community in
Pennsylvania. The community was characterized by
unusually warm social support. Most of the incidents of
infarction that did occur were in people who were
marginal, or who had left the area. Correlational
studies such‘ as this were precursors to the recent
interest in developing support networks to improve
health status.

Nuckolis, Cassel, & Kaplan (1972) examined the
effects of social support on women experiencing many
life changes before and during pregnancy. Fewer
complications were reported for women with high levels
of social support. Social support has also been shown
to aid in the coping process and in factors related to
self—esteem for women who have undergone mastectomies
(Bloom, 1979).

Since most of these studies have been naturalistic
rather than experimental, they cannot answer questions

like "Can experimental efforts to increase social

45

support improve the adjustment of diabetic patients?" It
could be that (to give one example of possible
confounding) the personal and/or demographic
characteristics of certain persons lead both to higher
levels of social support and to better adjustment.

Nevertheless, there are many indications that
social support has a significant effect on patients
suffering from chronic illnesses. For example, Goodman
and Labianca (1981) gathered data from the medical and
social records of 73 patients with non—insulin—dependent
diabetes mellitus. The data included information on:
(1) the temporal pattern of hospitalization, (2) changes
in marital, residential, and employment status, and (3)
the social service department's rating of available
social support. Those diabetics rated as having weak
supports had 80% more readmissions than did those with
strong supports. Further, when social changes decreased
social supports, readmissions increased; but when social
changes did not involve decreased social supports, there
were no effects on health.

Social Su ort and Adherence £2 Medical Regimes.

 

Some studies have attempted to manipulate social support
to increase compliance or adherence to medical regimes.
Such studies are critical if it is to be demonstrated

that active interventions, in contrast to

46

naturally—occurring differences in support, will affect
medical problems. Some studies have used home visits in
an attempt to increase support and compliance in
hypertensive patients (Earp & Ory, 1979; Levine, Green,
Deeds, Chualow, Russell, and Finaly, 1979). Other
studies have focused on educating the spouse or
"significant other" in an attempt to produce increased
understanding and support (Caplan, 1976). Some studies
have trained the partners of patients in various
reinforcement techniques (Pearce, LeBow, & Orchard, in
press; O'Neill, Currey, Hirsch, Riddle, Taylor, Malcolm
& Sexauer, 1979; Weisz & Bucher, 1979). These studies
have produced mixed results. A major problem with these
studies (Levy, 1983) is that "no data are presented on

how (or if) these support manipulations were conducted"

(p. 1332). Some studies of compliance incorporated
other, non-support, manipulations to increase
compliance; in these studies the possibility of

confounding cannot be ruled out. Thus the studies have
varied as to the source of support studied (family or
"friends"), and neither the manipulations nor the type
of support received has been well described.

Other techniques for increasing social support
(again, with the nature of the support not well

specified) have been used by groups such as Alcoholics

47

Anonymous, Weight Watchers, and Gamblers Anonymous.
These organizations have helped to spark an interest in
the effects of getting people with similar problems
together (our third category under "sources of
support"). Such groups try to get people with similar
problems to support each other on a daily basis, as well
as to get people to discuss problems and generate
solutions to the problems that are proposed. While such
groups report great success in getting their members to
refrain from specific behaviors, these claims must be
evaluated with caution. Colletti and Kopel (1979) have
pointed out, with respect to one such group, that "there
are two reasons why it is difficult to interpret
reported weight losses from these groups: nearly all
information has been collected from questionnaires, and
attrition from these groups is very high" (p.36).

Ziesat (1978) has examined the effects of such
special group support on a hypertensive population. He
assigned patients to receive regular medical treatment
or to a group designed to increase interaction. He
found that systolic blood pressure decreased
significantly more for the patients that were assigned
to the group interaction condition than for those that
received regular medical treatment.

Other investigators have obtained similar results

48

with arthritic patients. Kaplan & Kosin (1981) examined
the effect of group counseling and education on a group
of patients with rheumatoid arthritis. Patients were
randomly assigned to groups (1) receiving education plus
group counseling or (2) just education. Patients that
received education plus group counseling showed
increases in their self—concept scores, as well as
improvements in knowledge scores.

Social Support app Diabetes. Few studies have
investigated social support with people that had
diabetes. One was the Goodman and Labianca (1981) study
mentioned previously, and another was a recently
completed study (Heitzmann, 1983) that investigated the
effects of social support on weight and glycosylated
hemoglobins (both of which are affected by conformity to
medical regimes) in Type II diabetic adults. Half the
subjects were female, and half used insulin. Each
subject was given the Social Support Questionnaire (SSQ)
mentioned above. Each subject was randomly assigned
either to a behavior therapy regimen designed to enhance
diabetic control and weight loss, or to a control
group. Experimental subjects lost significantly more
weight than control subjects.

The effects of social support interacted with the

sex of the subject. Male subjects who had strong social

49

supports were less in control of their diabetes, as
measured by the glyco-hemoglobin assay, than were
females with high levels of support.

While the results of this study are interesting,
conclusions must be drawn with caution. The subjects
making up the experimental and control groups were not
matched on social support before being randomly assigned
because of the demands of a larger study of which this
one was a part (the Heitzmann et. a1. study mentioned
above). Further, subjects merely reported on their
social support; no intervention was used to change
degree of social support, so we are again faced with a
correlational study.

Problems 13 Doing Research 23 Social Support. A
major problem in the studies that have investigated the
effect of support groups is the method of evaluating
support. Studies have used outcome measures such as
blood pressure and assumed that any differences that are
observed can be attributed to the intervention (support
group). Only one of the studies reported in a recent
review of the social support and compliance literature
reported group process measures (Levy, 1983). As Levy
points out "several assumptions of group processes . .
. are made without any data to back them up." That is,

we cannot know what aspects of the supposed social

50

support produced the observed results unless these
aspects are measured.
___eGrou 11993.5.

Whenever practitioners conduct an intervention
involving groups, it is important to measure group
processes. This consideration applies to the proposed
intervention. Before proceeding, however, it is
necessary to distinguish between two aspects of group
processes. The first aspect is the "surface" side of
the group process; that is, what activities does the
group engage in, especially with respect to the problems
of the individual members? The second is the "deeper"
side of the group process. This can be expressed as
three questions: (1) How cohesive is the group? (2)
What degree of agreement exists as to its goals? (3)
How much mutual support is derived from the group? To
clarify what is meant by this distinction, imagine that
there are two groups of alcoholics, equal on the
"deeper" side; that is, they are equally cohesive,
supportive, and in agreement about goals. On the
surface side, however, the first group's activities
involve acquiring alcohol, arranging parties, and
getting inebriated as often and as long as possible.
The second group's activities are all designed to insure

abstinence and to substitute non—alcohol—related

51

activities for drinking.

Thus what we have described as the deep side or
group process refers to properties of the group per se,
what we might also characterize as the structural
properties of the group, while what has been described
as the surface side refers to the content of group
activities. It is clear that it is important to
manipulate and measure both aspects of group process if
the nature and usefulness of group support is ever to be
fully understood. It is particularly important to
measure the deep features of group process when groups
are to be used for victims of chronic disease, for
groups, if they are to be maximally effective, must last
as long as the disease with which group members must
cope. Let us examine the three aspects of deep group
processes as they relate to group effectiveness and
longevity.

Cohesiveness. Cohesiveness is generally described

 

as the degree to which group members are attracted to
each other, or the extent to which members "hang
together" (Shaw, 1976). It seems reasonable that some
degree of cohesiveness must be present for individuals
to function as a group. Researchers have found: a
relationship between cohesiveness and communication

(Lott & Lott, 1961); that cohesiveness facilitates

 

 

52

verbal interaction (Moran, 1966); and that organized
groups are more cohesive than unorganized groups
(French, 1941). In addition, group cohesiveness is
related to social influence in the group. When group
members are attracted to the group (they want to belong)
they are more likely to go along with decisions that
promote or prolong the group's functioning (Festinger,
Schachter, and Back, 1950).

Researchers have also shown that group members who
are attracted to the group will work harder to achieve
group goals. Van Zelst (1952) found a relationship
between the amount of cohesiveness and productivity in a
group of carpenters and bricklayers. In the first
study, carpenters and bricklayers were asked to list
three choices of teammates. Men that were allowed to
work with the teammates they preferred showed a five
percent savings in total production costs. In a second
study, sociometrically constructed work groups were
compared with control groups during' a three-month
period. Van Zelst found that the sociometrically
constructed work groups were superior to the control
groups on turnover rates, on an index of labor cost, and
on an index of materials cost.

In summary, research evidence has indicated that

the cohesiveness of a group may affect a number of

53

outcomes. Cohesiveness should be fostered and measured
when any intervention involves a group. The most common
measure of cohesiveness is a sociometric questionnaire;
one will be constructed for the present study.

Group Goals. In a "typical" group there is at
least one goal that is accepted by the majority of
members. Shaw (1976) defines a group goal as "an end
state desired by a majority of the group members"
(p.297). It can be identified by observing the
activities of group members or, usually, by asking the
members of the group to specify it. Shaw states that
the activities of group members are directly related to
immediate goals, but only indirectly related to
long-range goals.

Zander & Newcomb (1967) demonstrated that when
group members accept group goals they are more likely to
initiate activities that they think will achieve group
goals. In the present study, we will try to insure that
group goals include fostering good individual
health—related behaviors. Agreement about goals is no
doubt an important determinant of the length of time a
group is maintained after an "official" intervention is
terminated. Group cohesiveness, group goals, and group
support are not independent factors; they are dependent

on one another. Group goals affect group cohesiveness.

54

Support is affected by group cohesiveness and group
goals. In the present study, scores on a sociometric
scale, and the length of time the group members stay in
contact with each other, will be dependent measures.

In conclusion, it must be said that the bulk of the
evidence indicates that the global variable, "social

' is important in many contexts, including the

support,’
context of chronic disease. There is insufficient
research to indicate whether the most effective place to
intervene is at the level of family, friends and
existing social networks, or special groups. There is
even less research analytic enough to indicate what
aspects of social support deserve the most stress, and
there are certainly many features of such support,
ranging from education through increased feelings that
life is worthwhile. Finally, it is clear that the
effectiveness of groups is related to properties of
groups per se, regardless of context.

Conclusions

 

Diabetes is a severe and widespread health problem,

affecting nearly one person in twenty. Older obese
women are particularly at risk. One risk factor is
clearly genetic. A complete or partial cure may

eventually be found for diabetes, since it is a disease

of the metabolic system. Meanwhile, however, the best

55

hope for the diabetic is careful compliance to a regime
of diet, exercise, and, where necessary, drugs.
Cognitive and behavioral methods may help in achieving
both the necessary compliance to medical regimes and the
independence needed to resist social pressures not to
comply.

Patients in short-term therapy sometimes comply
well. On the other hand, many techniques intended to
increase compliance have been tried with patients
suffering from chronic diseases, without notable
success. Thus a major question in the area of compliance
research remains unanswered, to wit "How do you get
patients to comply with medical programs over long
periods of time?"

Some techniques have showed promise in some areas
of compliance. Possibly the integration of advocacy
training with educational materials will help diabetics
to apply their knowledge better in their daily lives,
and may help them to reduce both objective sources of
stress and their subjective reactions to those that are
unavoidable. In particular, advocacy training may help
participants to interact more effectively with their
physicians. The doctor may then be better informed
about the effects of medications; the patient may demand

better understanding of the treatment regimen by asking

56

more questions, and may be better able to demand better
or more practical alternative treatment regimens when a
current regimen is not working.
Proposed Study

The purpose of the present study was to compare the
efficacy of two different interventions that were
designed for diabetic patients. The first intervention
was intended to teach patients self-advocacy and social
networking. The second program provided subjects with
the same information; however, the information was

presented in a manual. Diabetics who had received some

educational instruction about their disease were
eligible to participate in the study. Patients were
randomly assigned to one of the two experimental

conditions. All subjects were required to participate
in assessments at their entry into the study
(pre-assessment), at the end of the intervention
(post—assessment), and at a later follow-up.

An additional objective of the present study was to
consider other variables that might be important
mediating variables affecting the following of a medical
regime. These variables include duration of disease,
number of complications experienced, health beliefs,
internal '1ocus of control, group cohesion, and

participant satisfaction. Hence, this research project

57

measured multiple outcomes and process dimensions.

Hypotheses
WEE

Patients that participate in the self—advocacy and
social networking group will have significantly more
weight loss than patients assigned to the manual
condition. This hypothesis will be assessed by
comparing the weight changes at all measurement times.
was

Patients who participate in the self—advocacy and
social networking group will have higher compliance
rates than those assigned to the manual condition.
Compliance will be assessed directly via verbal reports
(the health indicator scale) and indirectly by the
glyco-hemgoblin assays.

Hypothesis lgpgg

People assigned to the experimental group will have
lower blood pressure at post and follow up assessments
than people assigned to the manual group.

Hypothesis Egg;

People in the experimental group will have higher
scores on the health belief scale at post measurement
periods.

Hypothesis Fly;

Diabetics in the self—advocacy and social

58

networking group will be better self—advocates, at all
post measurement periods, than those in the manual
condition. This hypothesis will be assessed via the
patients' Rathus Assertivenss scores.

Mattias—13%

People who participate in the self—advocacy and
social networking group will become more internally
controlled by the post measurement periods. The measure
of participants' degree of internal—external control
will be the Health Locus of Control Scale.
11mm

Participants in the self—advocacy and social
networking group will be more cohesive than those in the
manual condition. This cohesiveness will be maintained
in follow-up measures. Differences between conditions in
amount of cohesiveness will be assessed by chooser and
popularity scores derived from a sociometric
questionnaire.

Hypothesis Elgpg

People in the self—advocacy and social networking
group will be more thorough in keeping their log books
than people in the manual group. Differences between
the two groups in the amount of thoroughness will be
assessed by completeness and precision scores derived

from the log books.

59

Hypothesis Nine

Participants in the experimental group will
evaluate the program more favorably than will those in

the manual condition.

60

METHOD

This study employed the Experimental Social
Innovation (ESI) approach to experimentation created by
Fairweather (1967). The ESI approach requires examining
the relationships between outcomes, participants and the
social situation. In the present study two approaches
were examined. The first was the traditional approach,
which involved educating people with diabetes by giving
them reading materials. The second was a more
innovative approach; people with diabetes were given
information, but also were given special training in
self-advocacy, and the opportunity to meet similar
people and to develop a support group. In this chapter
the details of the programs, the subjects, the

instruments, and the procedures are presented.

Subjects
Recruitment
Recruiting was started at Lansing General
Hospital. When patients showed up for their first

educational class, they were told about the study. 0n
the last day of class each person was asked if he or she
would be interested in participating in the study.

After 3 weeks only five subjects from the hospital had

61

volunteered. It was clearly necessary to try other
recruiting methods, so the study was publicized. Local
newspapers were contacted and sent a summary of the
study. The following papers published a story about the

study: The Lansing State Journal; a free local

 

community newspaper called 2E2 Towne Courier; and 132
Detroit Ngyg. In addition, community service
announcements were aired on several local television and
radio stations. It was not possible to monitor all such
announcements, and thus the identity of all stations
making the announcement is unknown. Display ads were
placed in the Lansing State Journal four times, and in
two free papers once (the Wheeler Dealer and the
Shopping Guide). Forty—nine subjects were recruited
from these advertisements, announcements, and newspaper
articles, and three additional patients were recruited
from the local hospital, for a total of 57 subjects. A
copy of the display ad and two of the newspaper stories
are presented in Appendix A.

After a subject agreed to participate in the study,
an appointment was made to conduct the pre—assessment.
The subject was given the choice of having an
interviewer come to his or her home or office, or to
meet an interviewer at one of the three local

laboratories that were doing the blood tests.

62

Demographic Characteristics

The subjects were 57 diabetics; 33 were diagnosed
as type II, 13 as type I, and 11 "did not know."
Twenty-seven were men and 30 were women. The sample had
the following characteristics:

1. The age range was from 20 to 77 years; the mean
age was 50.21.

2. The educational level ranged from four to 19
years, with a mean of 14.12, equivalent to 2 years of
college.

3. The duration of diabetes ranged from one month to
376 months, with a mean of 119.26 months, or 9.94
years.

4. Seven of the subjects controlled their diabetes
by diet only; 11 controlled their diabetes by taking
oral agents; 39 were insulin dependent.

5. Thirty—two participants had a family history of
diabetes.

6. Forty participants had a medical condition
besides diabetes, which included one stroke, six cases
of heart disease, two eye problems, two kidney problems,
23 cases with high blood pressure, seven with arthritis,
one case of colitis, and five cases with allergies.

7. Thirty-eight participants had experienced some

complication from their diabetes. Nineteen had

 

63

experienced hyperglycemia, hypoglycemia, or insulin
reactions; 11 had experienced acidosis; 19 had
circulatory problems; 18 had eye problems; 7 had heart
problems; 4 had kidney problems; and 15 had experienced
impotence from their diabetes.

Measuring Instruments

Several paper and pencil measures, together with
medical measures and content analyses of tape recordings
and self—report measures, were used to assess the
effects of the interventions. Assessments were
conducted three times. The paper and pencil measures
are in Appendix B.

Historical Questionnaire

The historical questionnaire was used for gathering
demographic information on each participant. The
questionnaire was administered by a person on the
research team as soon as the administrative agreement
was signed.

The items chosen were based on three sources of
information. The first emphasizes participant variables
that may affect the outcomes of experimental social
innovations (Fairweather and Tornatzky, 1977). The
second emphasizes variables that have been shown to
affect conformity to medical advice (Janis, 1983). The

third involves information related to the conditions of

64

the study, or normally collected by hospitals and
physicians because it is related directly to the
patients' diabetic condition. Representative items
included details of the participants' personal history,
diagnosis, condition, and medical history.

Before a potential participant was interviewed, he
or she was told as much as possible about the details of
the present program. This information concentrated on
the requirements for the participants, and it was
clearly explained that the study was not medically based
in the sense of manipulating a patient's medical
regime. If the individual showed an understanding of
the requirements, agreed to participate, and signed an
administrative agreement, he or she progressed to the
interview proper. The questionnaire was administered
individually to participants so that ambiguous responses
could be clarified.

During the post— and follow-up assessments medical
history information was updated. This included: new
medical conditions, new complications, hospitalizations,
and any changes in a participant's medical regime.
Physiological Measures

Height and Weight. All subjects were measured with

 

a measuring tape; height in inches was recorded by one

of the interviewers. Heights were taken only at the

65

first assessment. Height was taken so that a
weight/height ratio could be calculated. Subjects were
weighed at each measurement period. A standard spring
scale, calibrated against a physician's balance scale,
was used. Weight was recorded in pounds. Weights were
an important measure in the present study, since most
type II diabetics are obese, and it has been shown that
some patients' diabetes is weight dependent. Weight
loss is a recommended component of treatment for nearly
all type II diabetics.

Quetelet's index (weight divided by the square of
height) was calculated for each participant. This ratio
has been found to correlate best with skinfold thickness
for all age—race-sex groups (Killeen, Vanderburg, and
Harlan, 1978).

Glyco-hemoglobin assays. This assay measures a
type of hemoglobin found in the red blood cells, and
reflects the average blood sugar level over an extended
period of time (approximately three months before the
test). One advantage of this test is that the results
are not determined solely by recent diet and exercise;
it is thus a very stable measure. The patient can
neither obtain a good result by conforming for a brief
period, nor lie effectively about his or her average

conformity level.

66

Trivelli (1971) found that adult diabetics (n = 75)
had a mean reading of 11.1%, with a standard deviation
of 2.9. Juvenile diabetics (n = 25) had a mean reading
of 12.4%, with a standard deviation of 3.1; normals (n =
20) had a mean of 6.5, with a standard deviation of
1.5. Although attention has focused on the ranges of
different groups, reliability studies on the test itself
have been rare, if not non—existent.

The pre—intervention readings for the diabetic
subjects were surprisingly low. The researchers
inquired about the values and were assured that they
were accurate. The mean glycohemoglobin reading was
7.86 (the normal range was considered between 4 and 8%
by the labortatory used.) When the second
glycohemoglobin readings were taken about 17 weeks
later, the average readings were substantially higher
for both experimental and control groups. The first
post-test readings were on the average three percentage
points higher, with a few four percentage points higher,
than the pre—test readings. This was true for all
groups. This led the researchers to question the
reliability of the test in more depth. No reliability
studies could be found.

While exploring the nature of the assay, we found

that it is a very complex test. The test requires at

67

least ten distinct steps. The following sample of steps
shows how complex the test is: The blood must be
centrifuged; washed in 5 volumes of 0.9 per cent sodium
chloride; luped in two volumes of distilled water and
saturated with carbon monoxide; then hemoglobins ‘Ala,
Alb, Alc, and A are separated by column chromatography.
These are just a few of the steps. Some of the steps
require that graphs be read by human technicians. With
such a complex test one should not assume high
reliability.

To test how reliable the glycohemoglobin test could
be, forty—three of the post—test glycohemoglobin tests
were duplicated so that the reliability on the measure
could be assessed. (Not all of the blood samples from
participants could be recovered.) The Pearson
correlation coefficient between two evaluations of the
forty—three blood samples was 0.90. This involved two
different tests of the ggpg blood sample for the
forty—three individuals. It is not known whether or not
the second test was done "b1ind;" that is, the
technicians may have known the first score when they
produced the second.

Even assuming that the correlation of 0.90 was
obtained in a completely legitimate manner, problems

remain. There were nine cases in which there were

68

extreme differences between pre and post samples, and no
satisfactory explanation could be given. For these
samples the test was replicated four, five, or six
times. In four of the nine cases the standard deviation
was greater than one. For example, one sample was
replicated six times; the values were 11.2, 7.8, 8.3,
9.1, 9.3 and 11.7; the mean was 9.57 with a standard
deviation of 1.56. It should also be noted that these
measures were made on the same sample of blood, and
probably with the same reagents and by the same
technicians. Changes in any of these factors would be
expected to decrease reliablility. It is also possible
that reliability would be lower if the measures were
made under unalerted conditions.

Blood Pressure. Blood pressure was taken on both
arms at all three measurement times. This measure was
relevant because many of our participants were
hypertensive. An aneroid sphygmomanometer, placed on
the left upper arm, and a stethoscope were used to
determine each subject's blood pressure.

Health Beliefs Scale

This scale was designed to assess participants'
beliefs about the consequences of diabetes, about the
probable effects of different health practices, and

about the ability of the participant to carry out

69

effective health practices. Past research has shown
that patients comply better to medical regimes when they
believe that the consequences of their condition are
serious. The health belief model (a special case of the
self-efficacy model) has as its two components patients'
beliefs about (1) the effects of health—related
behaviors and (2) their ability to carry out the
behaviors. If the patient believes that a health plan
will be effective in ameliorating the consequences of
the disease, and that he/she can carry out the health
plan, then it is more likely that the patient will
comply to an effective plan.

The goal of the two experimental programs was to
provide the participants with support and with
confidence in themselves. It was necessary to find out
whether or not patients' expectancies change over time
as a function of the type of intervention. Therefore
this measurement of expectancy was administered at each
measurement time.

Most items were rationally derived after reviewing
the diabetes literature and trying to decide what
beliefs about following good health practices might be
most important. The whole scale consists of 25 items,
of which three are related to beliefs about the

consequences of diabetes (Part I), six to beliefs about

7O

consequences of health practices (Part II), and 16 to
the patient's ability to follow good health practices
(Part III). The subjects were asked to fill in
percentages that would best describe their beliefs or
behaviors. High percentages indicate more favorable and
hopeful expectancies about diabetes and the possibility
of controlling it through individual action. Low scores
thus have their natural meaning for this scale; that is,
they indicate less favorable and hopeful expectancies
about diabetes and the possibility of controlling it
through individual action.

To assess the reliability of this scale it was
administered to 20 diabetic people twice. All the
diabetics that filled out the scale were members of the
American Diabetes Association in two chapters, Kalamazoo
and Jackson. The people that filled out the scale had
the following characteristics:

1. Nine were males and 11 were females.

2. The age range was from 21 to 76 years old, with a
mean of 49.94.

3. Three people were single, 15 were married and 3
were widows or widowers.

4. All twenty people were white.

5. The educational background ranged from 10 years

to 18 years, with a mean of 13.82.

71

6. Five of the twenty individuals were covered by
Medicare or Medicaid.

7. The duration of diabetes ranged from 2 months to
240 months. with a mean duration of 116.9 months, or
9.74 years.

8. There were 5 Type I diabetics, 9 Type II
diabetics and 6 people who did not know what Type they
were.

9. Two people took no medication; four were taking
oral agents and the remaining 6 people were on insulin.

10. The following complications were described:

a. Six had experienced eye problems.

b. Two had experienced circulatory problems.
c. One person had experienced kidney problems.
d. One person had experienced slow healing.

11. Twelve people had at least one other medical

condition besides diabetes. These included:

a. Five people had heart disease.

b. One person had eye problems that were not a
result of diabetes.

c. One person had kidney problems that were not
a result of diabetes.

d. Five people had high blood pressure.

e. One person had scoliosis.

f. Three people had arthritis.

 

72

g. There were six other problems.
12. Eleven people had a family history of diabetes.

Test-retest reliability for the first of the three
subscales was 0.65, indicating moderate reliability.
The second subscale also showed moderate reliability,
with a coefficient of 0.61. The coefficient for the
third subscale was only 0.22.

One possible reason for the low reliability of the
third subscale was that there was considerable missing
data. One example was given for each dimension;
participants were asked to estimate the amount of
ability, time, money, and will power they had available
to carry out good medical care, diet, exercise, and good
health practices. Possibly the directions were unclear,
because many of the participants only filled in four of
the sixteen blanks. However, in an attempt to clarify
any ambiguities, all of the scales were read to people
participating in the present study.

Indicators pf Health Behaviors

This health behavior indicator scale was designed
to assess any changes that occur in participants'
behaviors in carrying out their medical regimes.
Assessing these behaviors is important in part because
changes in attitudes may lead to changes in behavior,

and in part because the relationships between attitudes

73

and behavior may also vary as a function of the type of
intervention. For example, the patients in the active
group may be better able than those in the manual group
to implement the behaviors that should follow from their
attitudes.

The items for this scale were rationally derived
after reviewing the literature on diabetes, attending
classes on diabetes with diabetics at Mercy Hospital in
San Diego, and interviewing a physician who specializes
in the treatment of diabetics.

The scale consists of 12 items. There are four
sub—scales of three items. The four sub—scales examine
health behaviors in the following areas: medications,
diet, exercise, and general. The subject is asked to
report the percent of time that he or she performs the
behaviors that are stated.

Low numerical scores on each of the four sub-scales
constitute operational definitions of poor adherence to
a medical regime. Conversely, the higher the numerical
score, the higher the compliance rate. Items on each of
the four scales were selected so that information about
different aspects of the regime could be assessed.

Instructions to respondents are given at the top of
the scale, and were designed and pilot—tested to

minimize the need for verbal supplementation by anyone

74

administering the scale. However, the directions and
items were read to each participant.

Test-retest reliability of this scale was
determined by administering the scale to the same group
of diabetics used to test the reliability of the health
beliefs scale, described immediately above.

Test—retest reliability of the first subscale,
which was intended to tap compliance to medication
regimes, was 0.93. The reliability for the second,
diet, subscale was unsatisfactory, 0.12. The third
subscale, which was concerned with compliance to the
patient's exercise regime, was moderately reliable (r =
0.74). The fourth and final subscale had a reliability
of 0.89; the items on this subscale were constructed to
tap a patients' adherence to generally good health
practices.

Rathus Assertiveness Scale

The Rathus Assertiveness Scale is a self—report
measure designed to assess an individual's level of
assertiveness (Rathus, 1973). The device consists of 30
statments, e.g., "I have avoided asking questions for

' Test-retest reliability over a

fear of sounding stupid.’
two—month period in one study was 0.78. Odd-even
reliability in another study was nearly the same (r =

0.77). In one validity study, the Rathus score

75

correlated 0.70 with the mean of two judges' ratings of
the assertiveness of 47 women's responses to interview
questions about what they would do in situations wherein
assertive reponses could be used with profit. The
Rathus has also been shown to correlate negatively with

' and to correlate with Semantic

ratings of "niceness,'
Differential ratings of assertiveness.

Although the reliability of the Rathus is not
particularly impressive, and the validity studies less
than completely convincing, its ease of administration
is such that it is a cost—effective component of an
evaluation program. This scale was administered at all
three assessment periods.

Health Locus pf Control (gpp) Scale

The health locus of control concept is derived from
social learning theory and seeks to measure a person's
belief that his or her health is or is not determined by
his or her behavior (Wallston, Wallston, & DeVellis,
1978). Individuals who believe that their health is
determined by their personal .traits or behavior
(self-determined) are termed "health—internals." Those
who believe that health is determined by external
factors, such as chance, fate, luck, or powerful others,
are termed "health-externals." The HLC further divides

the "health external" group into "chance-externals" and

76

"powerful-other externals" (Wallston, Wallston, Kaplan,
& Maides, 1976).
The scale consists of 11 items in Likert-type

' (scored as one)

format, ranging from "Strongly Disagree'
to "Strongly Agree" (scored as six), for the externally
worded items and reverse scored for the internally
worded items. The scale score can range from 11 to 66.

The validity and reliability of the HLC scales have
been documented (Wallston et al., 1976). Alpha
reliabilities ranged from 0.40 to 0.54. The expected
correlations with other meaures of HLC were found, and
predictive validity was demonstrated.

In theory, health locus of control may predict
health-related behaviors. A number of studies have
suggested that health locus of control measures are
correlated with health behavior and outcomes; these are
reviewed by Wallston et al., (1978). Furthermore, these
authors have found that health locus of control beliefs
can be changed by psychosocial interventions. The
relationship of health locus of control beliefs, using
the HLC scales, to the outcomes of patients with
diabetes was examined to determine whether or not the
advocacy training and social support interventions alter

the HLC.

77

Sociometric Questionnaire

The sociometric questionnaire was used to determine
the cohesiveness of the experimental group.
Cohesiveness may be related to the effectiveness of a
program, especially as reflected in the diabetics'
feelings of well being and overall health. This measure
was of special interest because both of the
interventions emphasize social networking.

The items used to make up the sociometric scale
were intended to sample a range of intimacy, and thus
should indicate a range of tendencies of individuals to
share with and support each other. The statements range
from "To whom would you say hello if you saw them
outside of class?" to "Whom would you consider a close
friend?" The questions in this scale were independently
ranked by two judges from least intimate to most
intimate, which was intended to produce a Guttman—like
scale.

All participants in the study were given a list of
the names of all members of their group at both post and
follow—up assessments. They were asked to list in order
the names of the people with whom they would feel
comfortable in the various activities listed. No
minimum number of choices was required, so the number of

choices made was the measure of group cohesivenss.

 

78

Two scores for each individual were computed at
each measurement time. First, a "chooser" score was
computed by dividing the number of people the person
chose by the number of people he or she could have
chosen. Second, a "popularity" score was calculated by
dividing the number of times the participant was chosen
by the number of times the person could have been chosen
by others. These scores operationally define the roles
of individuals as "preferrers" and as social objects
(Fairweather, 1964).

Egg Books

Each participant in the study was asked to keep a
log book. Patients were asked to record: medication
taken, all food consumed, physician visits, hospital
visits, daily urine test results, and any contacts they
had with other members of the group. In addition,
participants were asked to record the details of
situations in which they thought that they should have
been a self—advocate and were not, and each situation in

which they were a self-advocate.

 

The log book was shown to each participant, and
instructions on how to fill out the log book were
given. Two log books were given to each participant.
One was given when the subject entered the study. It

was collected at the post—assessment interview. At the

 

79

post—assessment interview the second log book was given
to the participant. It was collected at the follow-up
assessment.

Not all of the data collected in the log books
could be used. Very few people recorded each time that
they spoke to another member of their group. In
addition, few of the people who participated in the
study saw a physician during the period in which they
were in the study; and not all of those who did see a
physician recorded the visit. Fewer than five people
were hospitalized during the study. For that reason,
these data were not used. People in the study used many

different methods of measuring their blood and urine

results, and the methods that were used are not
standardized. In addition, some people used several
different methods, which makes comparisons between

groups and over time impossible.

However, six scores for each subject were derived
from the log books. These included: a score for
.completeness for meds and diet; a score for precision
for meds and diet; and a positive and negative advocacy
score. A description of how each score was obtained is
in the next section.

Each time a participant filled out his/her log book

for meds, he or she was given three points. The

80

completeness score for meds was then calculated by
dividing the number of days the participant filled out
the log book, times three, by the total number of days
patients should have filled out their log book, times
three. A mean precision score was also calculated for
each participant. If a participant only listed the name
of the medication he/she was taking, a value of one was
given for that day. If the exact quantity of the
medication was listed, a value of three was assigned for
that day. To calculate a precision score for
medications, the total number of precision points was
divided by the number of days the patient filled out the
log book, times three.

A completenss score for diet was calculated for

each participant at post— and follow—up assessments.
One point was given for each meal a participant
recorded. A completeness score was then calculated by

adding all the completeness points and dividing them by
the total number of days the patient should have filled
out the log book, times three.

A precision score was also given for filling out
the diet section of the log book. A score of one was
given when something was recorded for the meal, but it
was vague. A score of two was assigned when

quantitative terms were used (e.g. small or large). A

81

score of three was assigned when numbers were recorded
for the food items (e.g. 3 ounces of chicken, 1 apple).
Mention of singular items was not interpreted as
implying a clear quantity, and was rated as one (e.g.,
"sandwich"). If the person specified a number for one
item, full credit was given for the meal (i.e. 4 Oz.
orange juice, bacon, & eggs was given a score of
three). Precision points for diet were given for each
day the patient filled out the log book. If the patient
filled out three meals and was assigned a score of three
for each meal, a precision score of three was given for
that day. If a patient filled out one meal and the
precision score was three, the score for the day was
still three. To derive a precision score for diet the
total precision points were added together and divided
by the total number of days the patient filled out the
log for diet, times three.

A positive advocacy score was given to each
participant. One point was given for each day the
patient filled out something in the section "Situation
in which you were a good self advocate." The positive
advocacy score was generated by dividing the number of
positive advocacy points by the number of days the
patient was supposed to fill out the log book.

A negative advocacy score was also calculated for

 

82

each participant. One point was given for each day the
patient filled out something in the.section "Situation
in which you were not a good self advocate." The score
was calculated in the same way that the positive
advocacy score was calculated.
Knowledge Questionnaire

This scale contained ten items which were designed
to test the participants' knowledge of the materials
presented on advocacy training in sessions they
attended, or that were presented in a manual that was
given to them. One true—false question was constructed
from material presented in each session. These
questions were administered to all participants during
the post assessment. The participant could score
between 0 and 10, depending on how many of the questions
were answered correctly.
Program Evaluation

This questionnaire was designed to measure the
participants' satisfaction with the program. It was
administered during the post—assessment period. The
items for this questionnaire were rationally derived
after relevant literature was reviewed.

The questionnaire had a total of 14 questions, with
three of the questions having multiple parts. The

participants were asked: the number of sessions

 

83

attended, to rate the program on a five—point Likert
scale, to rate the purposes and goals (unclear to very
clear), the length of time for each meeting (too short
to too long), the number of group sessions (too few to
too many), the pace of each program (too slow to too
fast), the discussions and materials presented (not
useful to relevant and useful), the opportunity to
participate and contribute in the program (poor to
excellent), the practicality of applying the information
learned (not helpful to very helpful), and the ease of
using techniques taught (not easily to very easily).
Another question had the participant rate the handouts,
discussions, exercises, and role playing on a five-point
scale (not useful to very helpful). Another question
had the participant rate the organization, clarity, and
interest of the program on a five—point scale (not at
all to very much). Participants were asked the
probability of recommending this program to a friend
(not likely to very likely), and their rating of the
program (poor to excellent). The last three questions
were open—ended. The participants were asked what they
liked most, least, and what they most recommended.

Since manual participants did not attend sessions,
some of the questions were not relevant for them;

participants were asked to omit these questions.

 

84

Participants were given the questionnaire and asked to
fill it out on their own. In a few cases participants
asked for an interviewer to read the questions, and the
request was granted.

Since the participants in the manual group did not
answer some of the questions, comparisons between the
groups were not possible for these questions. Responses
from the questions: what did you like most, what did you
like least, and what would you recommend to improve this
program, were content analyzed.

Tgpg Recordings

The experimental groups were tape recorded during
the second (support section) part of the group
meetings. After the self—advocacy section of the
program ended, the tape recorder was started. A member
of the group was asked to change the tape, if necessary,
and to shut off the tape when the group was finished and
to give it to the experimenter.

The total amount of time the group met was recorded
by a research team member. Tapes were later coded by
members of the research team. They were scored on the
following dimensions: the number of problems discussed
by the group, the number of solutions discussed by the
group, the time the group spent discussing group tasks,

time Spent in silence, amount of time with one person

85

talking, amount of time with more than one person
talking, amount of time spent discussing topic presented
in part 1, time spent discussing the overall study,
number of positive statements about the study, number of
negative statments about the study, number of offers of
help, number of arguments, number of self-disclosures,
number of people attending, and the total support group
time.

Sections of different tapes were used to train
members of the team in scoring of the tapes. Thirty-two
tapes were scored, twenty from the first experimental
group's sessions, and twelve from the second group's
sessions.

Procedures
Interviewing Procedures

Four undergraduate females assisted with the
project for course credit. One was a nurse. Each
student was required to accompany the experimenter and
observe assessments until the student felt prepared to
do her own assessments, at which time the experimenter
conducted a reliability check by recording a complete
assessment jointly with the student. If the percent
agreement was 90 percent or above, the student was
allowed to do assessments on her own. After three or

four additional assessments, another joint assessment

 

86

was conducted to insure continued reliabilty. All
reliability checks on all measures produced a percent
agreement of 90 or above. Twenty—seven of the
assessments were conducted by the writer alone, ten
interviews were joint interviews, and twenty were
conducted by the undergraduate interviewers alone.
Experimental Setting

The self-advocacy and social networking group met
in a conference room in the Psychology Research Building
at Michigan State University. The manual group had no
meetings. Assessments were sometimes carried out in
participants' homes and sometimes at a laboratory of
clinical medicine. Several post assessments, for
experimental group members only, were conducted in the
Psychology Research Building.

Sglf—advocacy 321 Social Networking Group

Each meeting was broken into two periods. During
the first period of each meeting material on
self—advocacy was presented. This material is included
in a trainer's manual (Appendix C).

In the second period of each meeting, which was
devoted to the development of social support, no
experimenter was present; only the diabetics
participated. Before each social support session was

started, the group was given a list of tasks to be

 

87

completed. These tasks are included in the training
manual.

This group was an open group which could be joined
at any time by new participants. The materials were
prepared in the form of modules which could be used
repeatedly, so that members who missed a particular
module could pick it up when the same materials were
again presented when the lesson was repeated. This
method of presentation made it practical for patients to
enter the group at will.

Patients were asked to attend ten consecutive
sessions which lasted approximately two hours a night,
twice a week. Once patients completed their sessions,
they were free to discontinue the group meetings.
However, if a patient wanted to continue participating
in the group he/she was free to do so.

Two groups were run. One group which eventually
involved 14 members met on Monday and Wednesday
evenings. This group was the first group to start.
Since recruitment in the beginning was slow, twenty
group sessions were held in order to give the group time
to build to a viable size. The second group, which had
15 members, was held on Tuesday and Thursday evenings

for a total of twelve sessions.

 

88

Manual Group

Subjects in this condition were not asked to meet.
They were given a manual that included all of the
information presented in the previous condition. This
manual was a modified version of the trainers' manual
used for the experimental group and presented in
Appendix C, and is available upon request. Participants
in the manual group were asked to read the materials and
to participate in all of the assessment periods. The
subjects assigned to this condition received a list of
members who were in the same group. They were given the
same social support instructions and told that they were
free to contact other members of their group.

Design

The experimental design for the study was a two by
three repeated measures design. The between variable,
with two levels, was the group to which a participant
was assigned: (a) the advocacy and social networking
group condition, and (b) the manual condition. The
within variable, with three levels, was the time at
which the assessment was made: (a) when the participant
entered the study, (b) when the manipulation ended,
about five weeks after the beginning of the study, and
(c) approximately twelve weeks after the second

assessment was conducted.

 

89

RESULTS

Both comparative and associative analyses were
performed. The comparative analyses were primarily time
trend analyses of variance, and the associative were
cluster analyses. Comparative analyses were performed
for each of the nine major hypotheses in the study. The
alpha level was set at 0.05 for the tests of
significance. The comparative analyses are discussed
first.

Since the two manual groups had received identical
treatments, they were combined for the analyses. Thus
three groups were compared, the manual group and the two
experimental groups.

Analysis pf Hyppthesis Opp

Hypothesis one stated that patients who
participated in the self-advocacy and social networking
group would have significantly more weight loss than
patients assigned to the manual condition. A three
(group) by three (time) repeated measures analysis was
performed on the mean Quetelet's index. There were no
significant differences as a function of groups, time,
or their interaction. Table 2 shows the results of this
analysis. Table 3 shows the mean Quetelet's index over

the three time periods for each of the three groups.

 

90

Analysis pf Hypothesis Two

 

Hypothesis two was that patients who participated
in the self-advocacy and social networking groups would
have higher compliance rates than those assigned to the
manual condition. The glycohemoglobin level scores
presumably constitute an indirect measure of compliance,
since greater compliance should lead to lower scores.
The three (group) by two (time) repeated measures
analysis of variance of these scores revealed a
significant time effect, as shown in Table 4.
Glyco—hemoglobin levels increased for all three groups
for the follow—up test. No main effect for group, or
interaction between group and time, was found. Table 5
shows the means for the three groups over time.

The health indicator scale scores are a more
direct, although less objective, indicator of
compliance. In order to standardize these scores and to
eliminate negative scores, raw scores were converted to
T scores before analysis. There were four subscales in
this instrument. Each of the four subscales was
analyzed individually. A 3 (group) by 3 (time) repeated
measures analysis of variance was performed on each of
the four subscales. The results of these analyses are
shown in Tables 6, 8, 10, and 12. No significant

differences were found for any of the subscales.

 

91

Table 2: Repeated Measures Analysis of Variance of
Quetelet's Index

 

 

 

Source DF MS F Prob
Condition 2 0.00010 0.32 0.7279
Error 46 0.0031

Time 2 0.0000 0.30 0.7403
Condition by

Time 4 0.0000 0.79 0.5159
Error 92 0.0000

 

 

 

Table 3: Three Means of Quetelet's Index for Conditions

T1me Manual Group Group Mean of

1 Means
Pre 0.04 0.04 0 04 0.04
Post 0.04 0.04 0.04 0.04
Follow up 0.04 0.04 0.04 0.04
Mean

of Means 0.04 0.04 0.04 0.04

 

 

92

 

 

 

 

 

 

 

 

Table 4: Repeated Meaures Analysis of Variance
of Glyco-hemoglobins
Source DF MS F Prob
Condition 2 776.83 1.03 0.3663
Error 47 757.16
Time 1 2409.6 5.20 0.0272
Condition by Time 2 489.6 1.06 0.3558
Error 47 463.5
Table 5: Two Means for Pre and Post
Glyco—hemoglobin Readings
Time Manual Group Group Mean of
1 2 Means
Pre 7.49 7.53 7.88 7.60
Follow up 7.75 9.28 8.95 8.46
Mean of
Means 7.62 8.40 8.41 8.03

 

Table 6: Repeated Meaures Analysis of Variance of
Reported Compliance to Medication Regime

 

 

 

 

 

 

Source DF MS F Prob

Condition 2 2300.895 0.44 0.6451

Error 47 5200.932

Time 2 655.017 2.33 0.1024

Condition by

Time 4 65.511 0.23 0.9189

Error 94 280.543

Table 7: Mean T Scores for Reported Compliance to

Medication Regime

Time Manual Group Group Mean of
1 2 Means

Pre 140.76 136.69 126.33 132.78

Post 144.68 143.74 136.69 140.60

Follow up 145.46 143.89 131.66 138.43

Mean

of Means 143.63 141.44 131.56 137.27

 

 

94

Table 8: Repeated Meaures Analysis of Variance of
Reported Compliance to Diet

 

 

 

 

 

 

Source DF MS F Prob
Condition 2 1349.640 1.14 0.3270
Error 47 1178.795
Time 2 26.614 0.13 0.8781
Condition
by Time 4 179.040 0.88 0.4816
Error 94 204.432
Table 9: Mean T Scores for Reported Compliance to Diet
Time Manual Group Group Mean of
1 2 Means
Pre 140.97 149.82 153.03 149.06
Post 145.62 145.86 154.23 149.81
Follow up 141.69 154.74 151.94 150.00
Mean of

Means 142.76 150.14 153.06 149.62

 

 

 

 

 

 

 

 

Table 10: Repeated Meaures Analysis of Variance of
Reported Compliance to Exercise

Source DF MS F Prob

Condition 2 1923.541 1.67 0.1998

Error 47 1153.782

Time 2 13.731 0.07 0.9366

Condition

by Time 4 108.185 0.52 0.7237

Error 94 209.445

Table 11: Mean T Scores for Reported Compliance to
Exercise

Time Manual Group Group Mean of

l 2 Means

Pre 143.73 151.31 150.24 148.82

Post 138.16 156.73 152.64 149.94

Follow up 141.87 154.77 151.82 150.00

Mean of

Means 141.25 154.27 151.57 149.59

 

 

96

 

 

 

 

 

 

 

Table 12: Repeated Meaures Analysis of Variance of
Reported Compliance to General Health Practices

Source DF MS F Prob

Condition 2 818.514 1.29 0.2854

Error 47 635.567

Time 2 2.738 0.02 0.9773

Condition by

Time 4 83.241 0.70 0.5951

Error 94 119.213

Table 13: Mean T Scores for Reported Compliance to
General Health Practices

Time Manual Group Group Mean of

l 2 Means

Pre 149.54 156.15 146.05 149.58

Post 154.56 151.91 146.72 150.11

Follow up 150.08 155.13 147.17 150.00

Mean of

Means 151.39 154.40 146.65 149.90

 

 

 

97

Tables 7, 9, 11, and 13 show the means for each subscale
for each of the three groups at each assessment period.
Hypothesis two thus receives no support.
Analysis pf Hypothesis Three

The third hypothesis was that people who were
assigned to the experimental group would have a lower
blood pressure at post— and follow—up assessments than
those assigned to the manual group. Blood pressure was
taken on both arms, except for one man who had impaired
circulation resulting from a stroke. His blood pressure
was taken only from his unaffected left arm. Mean
arterial pressure was used for statistical analysis; it
is defined as systolic pressure plus diastolic pressure
divided by two. Two three (group) by three (time)
repeated measures analyses of variances thus were
performed on the data, one for each arm. For the
right—arm mean arterial pressure there was a significant

main effect for group and for time. No group by time

interaction was found. Table 14 shows these
differences. Examination of the means indicated that
blood pressure decreased over time for all three
groups. The pre— blood pressure for Experimental Group

1 was 8 points higher than for either of the other
groups. Blood pressure was lowest at the follow—up

reading for all three groups. These means are shown in

 

98

Table 15. The Fisher LSD post hoc comparison revealed a
significant difference between the pre blood pressure
readings and the follow—up blood pressure readings (p <
0.05), but no significant difference was found for
groups. Kirk (1982) points out that this apparently
anomalous situation, with the F test showing a
significant overall effect, and the Fisher LSD
indicating no specific group differences, is not either
unusual or unreasonable. However, the difference
between one of the experimental groups and the other two
groups narrowly missed being significant according to
the Fisher LSD.

The left mean arterial blood pressure differed as a
function of group, time, and group by time, as shown in

Table 16. Again, blood pressure decreased over time for

all three groups. Experimental group one's blood
pressure increased for the second assessment, but
decreased for the third or follow—up assessment.

Experimental group two's blood pressure decreased by the
second assessment, and stayed very near that level for
the follow—up assessment. The left arterial blood
pressure decreased for the manual group over time.
Table 17 shows the left mean arterial blood pressure
readings for the three groups at each assessment

period. The Fisher LSD test yielded a significant

 

99

 

 

 

 

 

 

Table 14: Repeated Meaures Analysis of Variance of
Right Mean Arterial Blood Pressure

Source DF MS F Prob

Condition 2 1626.66 3.54 0.0371

Error 46 459.09

Time 2 501.38 5.39 0.0061

Condition

by Time 4 102.59 1.10 0.3604

Error 92 93.08

Table 15: Means of Right Mean Arterial Blood Pressure

Time Manual Group Group Mean of

Means

Pre 110.00 118.46 109.19 111.86

Post 106.08 120.79 102.81 108.82

Follow up 104.96 111.17 101.54 105.57

Mean of

Means 107.01 116.81 104.51 108.75

 

 

Table 16:

 

100

Repeated Meaures Analysis of Variance of
Left Mean Arterial Blood Pressure

 

 

 

 

 

Source DF MS F Prob

Condition 2 2871.52 6.73 0.0027

Error 47 426.72

Time 2 354.42 4.73 0.0111

Condition

by Time 4 274.98 3.67 0.0123

Error 94 74.97

Table 17: Means of Left Mean Arterial Blood Pressure

Time Manual Group Group Mean of
l 2 Means

Pre 108.33 118.54 107.27 110.71

Post 102.15 124.35 100.85 107.58

Follow up 104.04 112.00 101.54 105.46

Mean of

Means 104.84 118.30 103.22 107.92

 

 

101

difference between the pre blood pressure readings and
the follow-up blood pressure readings (p < 0.05).
Again, the Fisher LSD test did not indicate a
significant difference between groups, but, when applied
to the interaction, showed that there was a significant
difference between group 1's pre-, post—, and follow-up
readings and the manual and group 2's post and follow—up
readings.
Hypothesis £233

Hypothesis four was that patients who were in the
experimental groups would have higher scores on the
health belief scale at post measurement periods. The
health belief scores were converted to T scores to

standardize them and eliminate negative scores. Each of

the three subscales was analyzed separately. The
subscales were designed to tap differences in a
participant's beliefs about the consequences of

diabetes, the consequences of health practices, and
ability to follow health practices. A 3 (group) by 3
(time) repeated measures analysis of variance was
performed on each of the three subscales. The results
of the three analyses are shown in Tables 18, 20, and
22. No significant differences were found as a function
of groups, time, or groups by time in any of the

subscales. Tables 19, 21, and 23 show the mean t scores

 

102

 

 

 

 

 

 

 

Table 18: Repeated Meaures Analysis of Variance of
Beliefs About the Consequences of Diabetes
Source DF MS F Prob
Condition 2 339.144 0.45 0.6413
Error 47 756.107
Time 2 4.735 0.02 0.9809
Condition
by Time 4 98.768 0.40 0.8068
Error 94 245.678
Table 19: Mean T Scores for Beliefs About the
Consequences of Diabetes
Time Manual Group Group Mean of
1 2 Means
Pre 150.25 147.48 149.75 149.29
Post 147.48 146.53 153.30 150.03
Follow up 153.16 144.79 151.11 150.00
Mean of
Means 150.30 146.27 151.39 149.77

 

 

103

 

 

 

 

 

 

Table 20: Repeated Meaures Analysis of Variance of Beliefs
About the Consequences of Health Practices

Source DF MS F Prob

Condition 2 1459.608 1.07 0.3526

Error 47 1369.373

Time 2 192.347 0.29 0.7514

Condition

by Time 4 413.171 0.62 0.6524

Error 94 671.029

Table 21: Mean T Scores for Beliefs About the
Consequences of Health Practices

Time Manual Group Group Mean of

1 2 Means

Pre 298.51 293.74 301.58 298.74

Post 297.58 283.48 302.82 296.43

Follow up 304.72 293.62 296.73 298.00

Mean

of Means 300.27 290.28 300.38 297.72

 

 

104

 

 

 

 

 

 

Table 22: Repeated Meaures Analysis of Variance of Beliefs
About the Ability to Follow Health Practices
Source DF MS F Prob
Condition 2 16582.73 0.94 0.3975
Error 47 17626.36
Time 2 1102.90 0.30 0.7422
Condition
by Time 4 2256.46 0.61 0.6552
Error 94 3688.22
Table 23: Mean T Scores for Beliefs About Ability
to Follow Health Practices
Time Manual Group Group Mean of
2 Means
Pre 767.93 801.32 805.00 794.40
Post 772.60 799.60 810.38 797.76
Follow up 777.37 828.75 796.69 800.00
Mean of
Means 772.63 809.89 804.02 797.39

 

105

for each of the scales for each group at each of the
three measurement times.
Analysis pf Hypothesis Fiyg

Hypothesis five was that diabetics who participated
in the self—advocacy and social networking groups would
be better self-advocates, at all post measurment
periods, than patients in the manual condition. A 3
(group) by 3 (time) repeated measures analysis of
variance was performed on the total Rathus Scores. The
results are shown in Table 24. There were no
signifificant effects. Table 25 shows the means of each

group at each time.

Analysis pf Hypothesis Six

 

The sixth experimental hypothesis was that people
who participated in the self-advocacy and social
networking groups would come to believe that their
health is determined by their personal traits or
behavior (self—determined), by the post measurement
periods. The three (group) by three (time) repeated
measures analysis. of variance again indicated no
significant differences. Table 26 shows the results of
the analysis, and Table 27 shows the means of each group

at each of the time periods.

 

106

Analysis pg Hypothesis Seven

Hypothesis seven was that diabetics who

participated in the self-advocacy and social networking

groups would be more cohesive than those who
participated in the manual condition. This support
would be maintained in follow-up measures. These

differences in cohesiveness were to be assessed by
chooser and popularity scores derived from the
sociometric questionnaire. The chooser score was
derived by dividing the number of people that were
chosen by the number of people who could have been
chosen. A three (group) by two (time) repeated measures
analysis of variance was performed on these scores.
There was a significant main effect for group, and a
significant main effect for time. No group by time
interaction was found, as shown in Table 28.
Participants in both experimental groups had much higher
chooser scores at both post— and follow—up assessments.
All three groups had lower chooser scores at the
follow—up assessment than at the post-assessment. The
Fisher LSD Test revealed a significant difference
between the manual group and each of the experimental
groups (p < 0.05). The experimental groups did not

differ significantly. There was also a significant

 

107

difference between the post— and follow-up scores (p <
0.05).

The popularity scores were calculated by dividing
the number of times the participant was chosen by the
number of times the person could have been chosen by
others. The analysis indicated a significant main
effect for group and a significant main effect for time;
these results are shown in Table 30. The interaction
was not significant. Again, people in the experimental
groups were chosen significantly more often than those
in the manual group. In all three groups the number of
times that a person was chosen decreased at the
follow—up assessment. Table 29 shows the mean chooser
scores for each group at each time period, and Table 31
shows the mean popularity scores. The Fisher LSD test
again revealed a significant differences between the
manual group and the experimental groups (p < 0.05), and
again there was no difference between the experimental
groups. The difference between the post and follow—up
scores was again significant (p < 0.05).

Analyses of the tape recordings of the social
support section of the group were performed to examine
group process variables. The dimensions that were
scored included: the number of problems discussed by the

group, the number of solutions discussed by the group,

 

108

Table 24: Repeated Meaures Analysis of Variance of
Rathus Assertiveness Scores

 

 

 

 

 

 

Source DF MS F Prob
Condition 2 2336.866 0.92 0.4068
Error 47 2548.521
Time 2 1156.708 0.98 0.3802
Condition by
Time 4 668.811 0.56 0.5840
Error 94 1183.742
Table 25: Mean Rathus Assertiveness Scores Over Time
Time Manual Group Group Mean of
1 2 Means
Pre 108.29 97.62 107.00 105.18
Post 110.04 106.69 110.85 109.38
Follow up 127.75 101.00 114.23 117.28
Mean of

Means 115.36 101.77 110.69 110.61

 

 

109

Table 26: Repeated Meaures Analysis of Variance of
Health Locus of Control Scores

 

 

 

 

 

 

Source DF MS F Prob
Condition 2 1.876 0.02 0.9809
Error 47 97.283
Time 2 4.716 0.20 0.8162
Condition by
Time 4 28.256 1.22 0.3078
Error 94 23.172
Table 27: Mean Health Locus of Control Scores Over Time
Time Manual Group Group Mean of

l 2 Means
Pre 32.29 35.39 34.08 33.56
Post 34.92 33.77 34.92 34.62
Follow up 34.79 33.31 34.15 34.24
Mean of

Means 34.00 34.15 34.39 34.14

 

 

110

Table 28: Repeated Meaures Analysis of Variance of
Chooser Scores for the Three Conditions

 

 

 

 

 

 

Source DF MS F Prob

Condition 2 4185.841 13.33 0.0001

Error 46 314.069

Time 1 1305.892 15.13 0.0003

Condition by

Time 2 9.756 0.11 0.8934

Error 46 86.299

Table 29: Mean Chooser Scores for the Three Conditions

Over Time

Time Manual Group Group Mean of
Means

Post 16.88 30.31 37.50 25.49

Follow up 8.25 22.39 31.08 17.59

Mean of

Means 12.56 26.35 34.29 21.54

 

 

111

Table 30: Repeated Meaures Analysis of Variance of
Popularity Scores for the Three Conditions

 

 

 

Source DF MS F Prob

Condition 2 3267.341 30.02 0.0001
Error 46 108.828

Time 1 1186.633 86.66 0.0001
Condition by

Time 2 22.467 1.64 0.2050
Error 46 13.692

 

Table 31: Mean Popularity Scores for the Three
Conditions Over Time

 

 

Time Manual Group Group Mean of

l 2 Means
Post 14.63 30.31 31.83 23.00
Follow up 7.63 21.00 26.25 15.74
Mean of

Means 11.13 25.65 29.04 19.37

 

 

112

the time the group spent discussing group tasks, the
time spent in silence, the amount of time one person was
talking, the amount of time more than one person was
talking, the amount of time spent discussing the topic
presented in the self—advocacy section, the time spent
discussing the overall study, the number of positive
statements about the study, the number of negative
statements about the study, the number of arguments, the
number of self-disclosures, the number of people
attending, and the total support group time. Neither
group spent enough time discussing the topic that was
presented in the self—advocacy section of the group, nor
enough time in arguing, to allow this data to be
analyzed, so all discussion of these variables is
omitted.

Since the unit of analysis for the tape data was
the group (no individual data were scored from the
tape), and because each group had a different number of
sessions, the data was analyzed separately for the two
experimental groups. The Cox—Stuart Test for Trend was
performed on the remaiping thirteen different dimensions
for each group. No significant trends were found on any
of the dimensions. These trends can be seen in Figure 3

through 15.

 

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126

Analysis 2: Hypothesis Eight

The eighth hypothesis was that diabetics who
participated in the self—advocacy and social networking
groups would be more thorough in keeping their log books
than people who were assigned to the manual group. Six 3
(group) by 2 (time) repeated measures analyses of
variance were performed on information collected in the
log book. The first analysis was performed on the mean
completeness scores for meds for each of the three
groups at both post- and follow—up assessments. Only
time produced a significant effect; the results of this
analysis are shown in Table 32. Not surprisingly, the
completeness scores decreased at the follow-up
assessment. Thus participants filled out their
medication records more completely between the pre— and
post-assessments than between the post— and follow—up
assessments. The mean completeness scores for each of
the three groups at each of the three assessment periods
are shown in Table 33.

The results from the analysis of variance performed
on the mean precision scores, reflecting the exactitude
of what patients wrote in their log books, indicated
that the only significant effect was for time. Table 34
shows the results from the analysis of variance. As

shown in Table 35, participants were more precise in

 

127

describing their medication regimes during the first
part of the study.

Results from the analysis on the mean completeness
score for diet indicated, again, that there were no
significant differences between groups. The only
significant difference was over time; this is shown in
Table 36. Table 37 shows that participants gave less
complete descriptions of their eating behaviors during
the last part of the study.

The results of the analysis of variance on the
precision scores for diet indicated only a main effect
for time. Precision scores for diet decreased over
time. The results of the analysis are shown in Table
38; Table 39 shows the mean log book precision scores
for diet.

Analysis of the positive advocacy scores revealed
no significant differences between groups; the only
significant difference was between post— and follow-up
assessments. The results are shown in Table 40. As
shown in Table 41, more situations were recorded between
the pre and post asssessments then between the post— and
follow—up assessments. As shown in Table 42, analysis
of the negative advocacy scores indicated only a
significant time effect. Again, participants recorded

fewer situations between the post— and follow-up periods

 

128

than between the pre— and post-assessement periods, as
shown in Table 43.

In summary, all of the data from the log books
indicated no significant differences between groups. In
each case only a significant time effect was found,
indicating that people are less apt to record various
events over a period of time, despite interventions
intended to affect such recording.

Analysis of Hypothesis King

The final hypothesis was that patients in the
experimental groups would evaluate the program more
favorably than patients in the manual condition. A
one-way between—subjects analysis of variance was
performed on the mean program ratings for the three
groups. As shown in Table 44, the analysis of variance
indicated that there were significant differences among
the means. The means for the three groups are shown in
Table 45. A Newman-Keuls specific comparison test was
performed to determine where the significant differences
could be found. Experimental group 2 evaluated the
program significantly lower than either experimental

group 1 or the manual group (p < 0.05 in each case).

 

Table 32: Repeated Meaures Analysis of Variance of
Log Book Completeness Scores for Medications

 

 

 

Source DF MS F Prob
Condition 2 3718.178 1.63 0.2073
Error 43 2277.698

Time 1 25528.297 29.92 0.0001
Condition by

Time 2 1271.813 1.49 0.2366
Error 43 853.173

 

Table 33: Mean Log Book Completeness Scores for Medication

 

 

Time Manual Group Group Mean of
l 2 Means

Post .48.59 64.83 73.58 59.35

Follow up 24.77 15.50 42.67 27.02

Mean of

Means 36.68 40.17 58.13 43.19

 

 

 

130

Table 34: Repeated Meaures Analysis of Variance of
Log Book Precision Scores for Medications

 

 

 

Source DF MS F Prob
Condition 2 3890.800 1.53 0.2270
Error 43 2534.791

Time 1 14866.516 12.22 0.0011
Condition by

Time 2 978.457 0.80 0.4541
Error 43 1216.902

 

Table 35: Mean Log Book Precision Scores for Medication

 

 

Time Manual Group Group Mean of
1 2 Means

Post 69.73 86.08 81.75 77.13

Follow up 38.73 50.00 69.42 49.67

Mean of

Means 54.23 68.04 75.58 63.40

 

 

131

 

 

 

 

 

 

Table 36: Repeated Meaures Analysis of Variance of
Log Book Completeness Scores for Diet

Source DF MS F Prob

Condition 2 5105.886 2.43 0.0993

Error 47 2103.862

Time 1 24878.516 39.06 0.0001

Condition by

Time 2 686.308 1.08 0.3487

Error 47 636.971

Table 37: Mean Log Book Completeness Scores for Diet

Time Manual Group Group Mean of
1 2 Means

Post 50.96 57.92 75.08 59.04

Follow up 25.25 14.49 45.69 27.74

Mean of

Means 38.10 36.15 60.39 43.39

 

 

132

Table 38: Repeated Meaures Analysis of Variance of
Log Book Precision Scores for Diet

 

 

 

 

 

 

Source DF MS F Prob

Condition 2 4410.009 2.09 0.1347

Error 47 2107.057

Time 1 7852.814 11.94 0.0012

Condition by

Time 2 400.641 0.61 0.5481

Error 47 657.786

Table 39: Mean Log Book Precision Scores for Diet

Time Manual Group Group Mean of
1 2 Means

Post 54.67 62.08 76.69 62.32

Follow up 40.79 35.08 62.15 44.86

Mean of

Means 47.73 48.58 69.42 53.59

 

 

Table 40: Repeated Meaures Analysis of Variance of

Log Book Positive Advocacy Scores

 

 

 

 

 

 

Source DF MS F Prob

Condition 2 42.943 0.28 0.7585

Error 47 154.476

Time 1 1359.270 9.70 0.0031

Condition by

Time 2 36.640 0.26 0.7711

Error 47 140.153

Table 41: Mean Postive Advocacy Scores

Time Manual Group Group Mean of
2 Means

Post 9.83 9.77 5.77 8.76

Follow up 0.63 1.08 0.62 0.74

Mean of

Means 5.23 5.42 3.19 4.75

 

 

134

Table 42: Repeated Meaures Analysis of Variance of
Log Book Negative Advocacy Scores

 

 

 

 

 

 

Source DF MS F Prob
Condition 2.946 0.09 0.9150
Error 47 33.101
Time 1 269.862 9.08 0.0042
Condition by
Time 2 3.149 0.11 0.8997
Error 47 29.721
Table 43: Mean Negative Advocacy Scores
Time Manual Group Group Mean of

1 2 Means
Post 4.25 3.08 3.85 3.84
Follow up 0.21 0.23 0.46 0.28
Mean of
Means 2.23 1.65 2.15 2.06

 

135

 

 

 

 

 

 

Table 44: Between-Subjects Analysis of Variance of
Program Rating

Source DF MS F Prob

Condition 2 3.1227 3.856 0.0278

Error 49 0.8097

Table 45: Mean Overall Ratings of The Program
Manual Group 1 Group 2

4.12 4.21 3.33
Number
of cases 26 14 12

 

 

136

Method of Associative Analysis

Cluster Analysis (Tryon, 1939) is a statistical
technique which groups together variables on the basis
of their correlations. This type of analysis allows
researchers to determine what associative relationships
exist among multiple variables.

In the present study over 100 measures were taken.
The number of variables was reduced to a manageable
number by using a combination of rational and empirical
processes. Variables in which there was little or no
variance were eliminated. This reduced the number of
variables to 81. A V—analysis (cluster analysis of-
variables) was performed on these 81 variables. Eleven
clusters resulted from the first analysis. Variables
with factor loadings less than 0.40 were eliminated.
Since the glyco—hemoglobin assays were considered the
most important outcome measure, it was then pre—set for
cluster 1 and a pre—set cluster analysis was performed.

Results of the Cluster Analysis

 

The pre—set analysis identified twelve empirical
dimensions that characterized the data set. These
clusters were:

I. Blood
II. Beliefs and Reported Compliance

III. Physical Condition

137

IV. Cohesiveness

V. Insulin Dependent Diabetes (IDD)
VI. Compulsivity

VII. General Advocacy

VIII. Specific Advocacy

IX. Medication Compliance

X. External Health Control

XI. Medical Histories

XII. Health Practice Concern

The variables that made up each of the pre—set
clusters are presented in Table 46. The correlations
between the oblique clusters are presented in Table 47.
Each of the twelve clusters is described below.
131—om <1)

This cluster was named blood because the follow up
glyco-hemoglobin was pre—set as the primary variable in
cluster I to see which variables would cluster with it.
This cluster correlated most (0.26) with cluster 5, the
insulin dependent diabetes (IDD) cluster. Participants
with high glyco-hemoglobin assays readings tended to be
IDDs. This makes sense since, as reported earlier, IDDs
tend to have higher glyco—hemoglobin readings than do
adult onset diabetics. This cluster did not correlate

highly with any other clusters.

 

138

Table 46: The Twelve Pre—set Clusters

 

 

 

Cluster Loading
Cluster 1: Blood
1. Reported compliance to good health
practices, T1 .70
2. Glyco—hemoglobin assay, T1 .49
3. Glyco—hemoglobin assay, T3 (D) .49
4. Kidney Problems .43
5. Occupation —.41
Cluster 2: Beliefs and Reported Compliance
1. Reported compliance to good health
practice, T3 1.00
2. Reported exercise compliance, T3 .93
3. Beliefs about the ability to follow
health practices, T2 .92
4. Beliefs about the ability to follow
health practices, T3 .92
5. Beliefs about the consequences of
following health practices, T3 .91
6. Reported diet compliance, T3 .87
7. Beliefs about the consequences
of diabetes, T3 .86
8. Reported compliance to good
health practice, T2 .81
9. Reported diet compliance, T2 .73
10. Beliefs about the consequences of
following health practices, T2 .73
11. Reported exercise compliance, T2 .73
12. Knowledge about advocacy .72
13. Beliefs about consequences of
diabetes, T2 .57
Cluster 3: Physical Condition
1. Left mean arterial pressure, T2 .91
2. Left mean arterial pressure, T1 .85
3. Right mean arterial pressure, T2 .83
4. Right mean arterial pressure, T1 .81
5. Left mean arterial pressure, T3 .81
6. Quetelet's index, T2 .76
7. Quetelet's index, T1 .70
8. Right mean arterial pressure, T3 .69
9. Quetelet's index, T3 .67
10. Has high blood pressure .53

 

139

Table 46 (cont'd)

11.
12.

Cluster

\IONU'IJ-‘th—t
O 0 O O O .-

oo
o

Cluster

«>me
‘0

Has medical condition besides diabetes
Group 1

4: Cohesiveness

Manual

Chooser Score, T3

Popularity Score, T3

Popularity Score, T2

Group 2

Chooser Score, T2

Recommended- would like to have group
meetings

Liked social support section of the
program

5: Insulin Dependent Diabetes (IDD)

0n insulin

Has experienced hyper or hypoglycemia
Number of times hospitalized for diabetes
Total number of diabetic complications
experienced

Duration of diabetes

0n oral medication

Beliefs about the consequences of
diabetes, T1

Has experienced acidosis

6: Compulsivity

Log book completeness score for diet, T3
Log book completeness score for meds, T3
Log book precision score for diet, T3
Log book precision score for meds, T3
Log book completeness score for diet, T2
Log book completeness score for meds, T2

7: General Advocacy

Rathus assertiveness score, T1
Rathus assertiveness score, T2

.44
.43

-085
.82
.81

.65
.64

_-61

.53

.88
.82
.64

.54
.51
—.49

.49
.46

.88
.85
.77
.74
.73
.68

.88
.64

 

140

Table 46 (cont'd)

Cluster 8: Specific Advocacy

1. Negative advocacy, T2 .93
2. Positive advocacy, T2 .75
3. Completeness score for meds, T2 .63
4. 0n the same medication as time 2, T3 -.52

Cluster 9: Medication Compliance

1. Reported medication compliance, T2 .91
2. Reported medication compliance, T3 .79
3. Diabetes controlled by diet —.75
4. Reported medication compliance, T1 .62
5. 0n the same medication as time 1, T2 .53

Cluster 10: External Health Control

1. Health locus of control score, T1 .83
2. Health locus of control score, T3 .77
3. Health locus of control score, T2 .70
4. Education -.53
5. Sex .45

Cluster 11: Medical Histories

1. Total number of complications

experienced from diabetes .76
2. Heart problems - diabetes related .73
3. Eye Problems .61
4. Has heart problems - not necessarily diabetes

diabetes related .
5. Family Income -.52
6. Circulatory problems .49
7. Has been hospitalized since Time 1, T2 .46

Cluster 12: Health Practice Concern

1. Log book precision score for

medication, T2 .84
2. Reported compliance to good health

practices, T2 .78
3. Log book precision score for diet, T2 .66
4. Has been hospitalized since time 1, T2 —.51
5. Reported exercise compliance, T1 .50

 

141

Table 47: Correlations Between the Oblique
Cluster Domains

_——.——- ———_—————-——_—-———-——_

 

 

 

 

 

 

 

 

CLUSTER
1 2 5 6

CLUSTER

1 —-- 09 .03 .07 .26 .02
2 —-— —.16 .09 .07 -.02
3 -—- ~.12 -.14 —.11
4 ——— .09 .27
5 ——- —.03
6 __..
7

8

9

10

11

12

CLUSTER
7 8 11 12

1 .01 .05 .04 .04 .05 .12
2 -.17 .25 .33 .08 -.13 .35
3 —.06 —.10 .04 .07 .22 -.10
4 .05 .15 .14 — 11 —.15 .15
5 04 34 .08 -.15 16 .04
6 .05 .33 .24 .08 —.30 .27
7 ——- 01 .03 -.44 -.07 —.07
8 --— .04 .04 —.07 .31
9 —-— —.08 -.03 .05
10 —-— .08 —.01
11 ——— —.38

 

142

Beliefs and Reported Compliance (1;)

This cluster was named beliefs and reported
compliance because of the large number of belief and
compliance variables that made up the cluster. It
appears that recent experience during the study affects
beliefs and compliance. The belief and compliance
variables that make up this cluster were measured at the
post— and follow—up assessments. This cluster
correlated most (0.33) with Clusters 9 (medication
compliance), 12 (Health Practice Concern, 0.35), and 8
(Specific Advocacy, 0.25). Both clusters 9 and 12 have
reported compliance variables in them; cluster 8 is made
up of measures of care in keeping a log book. It is to
be expected that people who were compliant in following
their diet and exercise regimes would also be compliant
with their medications. In addition, people who are
compliant with a medical regime would probably be more
compliant with a request to keep a log book. This
cluster did not correlate highly with the blood cluster
(cluster 1).

Physical Condition (I;_)

This domain was termed physical condition because
it is primarily made up of physiological measurements.
The variables that make up this cluster, blood pressure

and weight, have repeatedly been reported to be highly

 

143

correlated. This cluster negatively correlates with
seven of the twelve clusters. It correlates best (0.22)
with imedical histories (cluster 11). Although this is
not a high correlation, it tends to confirm the
reasonable expectation that physical condition would
correlate with medical histories.

Cohesiveness (I!)

This cluster was named cohesiveness because most of
the variables in this cluster are the measures that were
constructed to measure cohesiveness. Being in the
manual condition negatively correlated with the
cohesiveness measure. Since manual members did not tend
to interact with other manual members, they showed lower
cohesiveness. In addition, the recommendation "would
like to have group meetings," also negatively loaded on
this cluster. This recommendation was made only by
participants in the manual group. "Liked the social

' positively loaded, was

support section of the program,’
a comment made only by group members. Being in
experimental group 2 positively loaded in this cluster.
This is consistent with the finding that experimental

group 2 had higher cohesiveness than experimental group

1 at both measurement periods.

 

144

Insulin Dependent Diabetes (1)

This domain was termed insulin dependent diabetes
because the factors in this cluster were characteristic
of people with Type I diabetes (juvenile onset
diabetes). As previously mentioned, this cluster
postively correlated with the "blood" cluster. This
cluster correlated highest (0.34) with the Specific
Advocacy cluster; hence, people with IDD diabetes tend
to be more concerned with getting proper medication
through the use of advocacy skills.

Compulsivity (1;)

This dimension was termed compulsivity because the
variables that loaded on this domain were scores that
participants received for filling out their log books.
This cluster correlated highest (0.27) with the
cohesiveness cluster. People who are "compulsive"
tended to be peOple in the experimental groups. Thus,
although the analysis of variance did not reveal a
significant group effect for any of the log book
variables taken singly, there does seem to have been
some effect of group membership on keeping a log book.
General Advocacy (ill)

This domain was termed general advocacy because the
variables that make up this cluster are scores on the

Rathus Assertiveness Scale, which was designed to

 

145

measure assertiveness in a variety of situations. This
cluster negatively correlated (-0.44) with the external
health control cluster.

Specific Advocacy (Xlll)

This domain was termed Specific Advocacy because
the variables that loaded on this cluster involved
advocacy and a change in medications between the post—
and follow—up assessments. This cluster correlated most
strongly (0.25) with the Belief and Reported Compliance
cluster, with the Compulsivity cluster (0.24), and with
the Health Practice Concern (0.31).

Medication Compliance (ll)

 

This domain was termed Medication Compliance
because the variables that loaded the highest were the
participants' reported compliance to medication. The
more compliant a person reported being with medications,
the less likely he/she was to change medications between
the first and second assessments. This cluster
positively correlated with beliefs and reported
compliance (0.33).

External Health Control (l)

This domain was termed External Health Control
because the three health locus of control measures
correlated positively. Education negatively correlated

with this domain, with less educated people reporting

 

 

146

that they had less control over their health. Also
females reported that they had less control than males.
General advocacy negatively correlated (—0.44) with this
cluster. This makes rational sense; people who feel that
they have less control over their health are less
assertive.

Medical Histories (ll)

This domain was termed medical histories because
the variables that make up this cluster are items that
have to do with a person's medical history. Family
income correlates negatively with this domain. People
with a lower income would be less likely to concern
themselves with preventive health care. This cluster
negatively correlates with the Health Practices cluster
(-0.38).

Health Practice Concern (lll)

This dimension was termed Health Practice Concern
because the variables that make up this cluster indicate
concern about one's health. The variable "has been
hospitalized since the pre—assessment" negatively loaded
on this cluster. This cluster correlated positively with
clusters 2 (0.35) and 8 (0.31), and correlated

negatively with cluster 11 (-0.38).

 

147

Typological Analysis

 

The typological analysis (Tryon & Bailey, 1970) is
a statistical method whereby objects or persons can be
grouped into clusters on the basis of their similarities
or differences. The similarities or differences are
based on scores on the defining variables from a pre-set
analysis. This procedure provides a way in which
typologies or "types" based on similar profile scores on
a given set of variables or dimensions can be
constructed.

For the final O—Type analysis presented below, only
three clusters were used. The reason is that there were
only forty—nine people that had complete data on all
measures. If the original twelve clusters that resulted
from the pre—set analysis were used for the O—Type
analysis, the number of people within any type would
have been very small.

This is illustrated by the first O—Type analysis
attempted, which used five of the twelve clusters:
blood, health beliefs and reported compliance, physical
condition, cohesiveness, and general advocacy. This
analysis produced thirteen O-Types. Only one of the
resulting types had more than five people, and it had
only six. Since the O-Types did not vary as a function

of health beliefs and reported compliance, nor as a

 

148

function of general_ advocacy, these variables were
dropped and another O-Type analysis was performed using
the blood, physical condition, and cohesiveness
clusters. This analysis produced 10 typologies for the
forty-nine people. However, eight of these ten O—Types
were dropped from further analysis because they
contained five or fewer individuals. With five or fewer
indivudals within a type, it is difficult to determine
the underlying characteristics of the group. The two
remaining types accounted for 19 of the 49 individuals.
The resulting O—types are presented graphically in
Figure 16.
g—im l

This type of diabetic person scored average on the
assays reading, average on the physical condition
dimension, and low on the cohesiveness dimension. When
individuals in this O-type are examined, it turns out
that every one of them was in the manual group. Thus
the cluster analysis has simply isolated a subset of
people in ,the manual condition who have similar
characteristics, and their chief distinguishing
characteristic is simply that they had low cohesiveness
- which is to say that they were average members of the

manual group.

 

149

97% 3

This type of diabetic person scored lowest on the
blood dimension, average on physical condition and
highest on cohesiveness. These are people in the
experimental groups, three from group 1 and six from
group 2, who became highest in cohesiveness, and whose
blood level and physical condition were improved
somewhat. It is possible that these people are
precisely those who benefit most from associating with
other diabetics. Group membership may reinforce them
for whatever they have been doing to keep in shape, and
encourage them to engage in additional health-related

activities.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

00000000
mmmmmmm

\\\\\\\w

 

151

DISCUSSION

The fundamental issue to be approached is the
minimal verification of the experimental hypotheses.
Only the most inevitable of the predicted consequences,
that subjects in the experimental group would develop
higher cohesiveness, received clear confirmation. This
leaves two primary subordinate issues. First, how can
one account for the apparent failure of the study to
verify its hypotheses? Second, does the study give any
clear indications of how future interventions might be
designed so as to increase their probability of
success? The results do seem to be highly suggestive
with respect to both of these interrelated subordinate
issues.

Failure to Confirm Experimental Hypotheses

Reliability pl Measures

One possible explanation of the failure of the
study's predictions is that the reliability of the
instruments employed was not great enough to detect
differences that occurred as a result of the
intervention. It has become a truism that experimental
and statistical tests have to be much more powerful if
effects are to be detected with measurements of low
reliability. This point has been made specifically with

respect to the kinds of variables involved in the

 

152

present study. Heitzmann & Kaplan (1983) pointed out
that it may be difficult to detect relationships between
social support and health outcomes with measures having
low reliability. For example, these authors show in one
of their simulations that, if the true correlation
between a scale and an outcome measure were 0.5, the
observed correlation would be only 0.28 if the
test-retest reliability of one scale were 0.32 and that
of the other were 0.97.

Thus it is possible that, in the present study,
changes did occur but were not detected because the
instruments used to measure the differences were not
reliable enough. The methods and results sections have
already detailed various questions about the reliability
of the measures; clearly the outcome measure which
seemed most promising at the outset of the study, the
glyco—hemoglobin assay, does not have a reliability
approaching 0.97! '

However, a consideration of the overall pattern of
results, including the cluster analysis, indicates that
low reliability is unlikely to be the primary reason for
failures to reject the null hypothesis. The measures
used intercorrelated consistently and in accord with
reasonable expectations. They simply did not differ

significantly as a function of membership in an

   

153

experimental versus the manual group. There were
several significant differences as a function of time;
if the primary problem had been unreliability of the
measures, 33 significant differences should have
appeared. Thus low reliability could have contributed
in some cases to the failure of a hypothesis, but could
not account for the general failure to find
differences.

Weaknesses lg the Experimental Manipulations

A more likely "meta-hypothesis" is that the
experimental manipulations were lacking in one or more
respects. The dependent variables measured did not show
a broad range of beneficial effects. Thus either the
wrong dependent variables were being measured, or the
independent variable(s) manipulated had weak effects.
Probably both of these things contributed to some
extent. The independent variable side will be discussed
first.
lypg 2i Social Support

Only one type of social support was provided in
this study. As pointed out in the introduction, sources
of social support can be divided into three classes:
family, friends and existing social groups, and special
groups of people sharing the same problem. It seems

likely that different sources of support play different

 

 

 

 

154

roles in ameliorating or exacerbating problems. It may
be necessary to manipulate all the types of support,
rather than relying exclusively on adding one new
special type of support.

Targeting one type of support may actually create
problems with the other support systems. One woman in
the study illustrated this possibility. She was an
obese women of about 50 who had never worked outside the
home. She started attending the groups and seemed to
enjoy them and to perceive some need for self-advocacy
training. However, attending the group in the evening
took time away from her husband and family. After a few
weeks, her husband made her drop out of the study; he
did not like the idea of his wife getting involved with
other people.

Possibly if family and friends were included in the
support group a more effective total support system
could be developed. People involved in the support
system could see the benefits and problems with each
component of the system. Any problems among and between
the people in the support system could be addressed and
minimized.
lggk gf Situational Specificity gl Treatment

A problem that researchers in the field of learning

have been addressing for decades has been the problem of

 

155

transfer of training. Researchers typically train
subjects in some limited range of skills and assume that
other behaviors or attitudes will also change. However,
this seldom happens. Fairweather, Moran, and Morton
(1956) found that attitudes, fantasies, and behaviors
are only marginally related. Further, Fairweather
(1964) found that patients' perceptions of themselves,
of their treatment programs, and of others are
relatively unrelated to their behaviors in the
community.

In the field of diabetes the problem has been how

one gets people to transfer their knowledge about

diabetes into practice. The present study was
successful in creating cohesiveness among group
members. People participating in the experimental

groups were more cohesive than people who were assigned
to a manual group. However, the hoped—for results of
increasing cohesiveness did not occur. That is, people
who were cohesive did not show changes in their
physiological measures, beliefs, feelings of control, or
assertiveness. Hence, the hypothesis that cohesivenss
would affect these measures was not substantiated.
Another example of this problem was the indication
that there was no time effect for general advocacy.

That is, participants did not report becoming generally

 

156

more assertive after they received training. However,
the cluster analysis revealed that there was a more
specific effect for advocacy. People who recorded more
positive and negative advocacy situations had a greater
probability of having a medication change between the
post and follow—up assessments. This finding did
indicate that there was a specific advocacy effect in
one area. Examples of diabetics who were having
difficulties with physicians or with their medications
were used in the group as well as in the manual. This
may have encouraged participants to demand a change in
medication. Thus it may be necessary to target specific
behaviors to be changed and to specify particular
methods to change the behaviors, rather than relying on
the teaching of general skills.

A further indication that this might be a desirable
change was that, when participants were asked for
recommendations, several people recommended that the
advocacy training be more closely tied to the problems
one might experience as a diabetic.

The practical question of how one bridges the gap
between providing social support and changing behaviors
remains. One possibility may be to incorporate support
groups into the educational classes. The focus could be

on how one can use the educational information for

 

 

157

changing one's maladaptive behaviors. Another focus
could be on how those in a support system can help to
change behaviors.

Content pl Egg Intervention

The question of optimizing the content of support
meetings also must be addressed. The results indicated
that the process, or lpgm of the support manipulation
was effective. People in the experimental groups were
more cohesive than those in the manual group. The
groups continued to meet after the study was completed.
Some of the control group subjects joined in the
meetings. Thus it seemed clear from simple observation
that the study had achieved some of its goals, even
though this did not show up in the form of traditional
hypothesis evaluation.

It is much less clear that advocacy training was
the best content, or vehicle, for furthering the goals
of the study or the goals of the groups. Many
participants expressed a preference for studying
medical, rather than psychological, information. One
man dropped out of the study two hours after he was
assigned to the manual group. He finished the
assessment and went home and started to read the manual
he was given. He called up the experimenter and said he

wanted medical information, and if the manual was all

 

 

158

that he was getting, he wanted to drop out of the
study.

A major problem with diabetics seems to be that
they are not aware of the limitations of purely medical
solutions. People are always looking for the easy way
out. This was quite apparent in the experimental group
meetings. Both groups were very interested in getting
medical people to speak to them about their disease;
they were especially interested in the latest research
findings. They seem to believe that there is something
magical about the medical profession, that with time
there will be a cure. Why put a lot of effort into
counteracting the effects of diabetes now, when there
may be a cure tomorrow? This problem is not limited to
people with diabetes; it seems to be a problem with most
chronic diseases. It appears that educators, physicians,
and researchers need to dispute the beliefs that people
have about the magic of medicine. It may be that any
social support manipulation is doomed to failure unless
it first disposes of this issue. This may require
continuing the educational training over a much longer
period of time while incorporating existing support
systems with new social supports. After people
incorporated the limitations of medical solutions into

their belief systems, they might be more open to more

 

hr...-

159

realistic — although more effortful — approaches.
Duration 23d Timing pl Egg Intervention

The duration of the intervention may have been
insufficient to bring about the desired effects. The
mean duration of diabetes for the participants in the
study was over nine years. It may have been
overoptimistic to believe that a five-week program could
have a major impact on behaviors formed over a decade.
Participants had been living with diabetes continuously
for about 500 weeks, and this study was trying to
overcome the inertia developed over that period with 20
hours of contact. That may be too much to ask.

A brief manipulation might have more chance of
success if it were begun soon after diagnosis. Then the
patients' "diabetic life styles" would not yet be set,
and more adaptive habits might be possible. But any
intervention begun at that time should be continued,
ideally for as long as the person lived. It has already
been said that patients require some time to adapt to
diabetes, and presumably to other chronic diseases, and
may not be receptive to some ideas right after
diagnosis. Thus it appears that intervention should
begin immediately after diagnosis, and should be as

chronic as the disease itself.

 

160

Experimenter Effects

The characteristics of the experimenter and the
other students working on the project were an important
part of the intervention. All of them were young
females. Almost half of the participants in the study
were males. Several of the males in the study protested
because they were being taught advocacy. They claimed
that they did not have any problems in advocating for
themselves, and that this was a problem that females
had, not males. Their views may have been affected by
the fact that they were in a group being facilitated by
a female.

The contention that experimenter characteristics
may have been important is supported by the observation
that some males made sexist remarks involving the
experimenter and/or the students working on the
project. These remarks were not directed toward aspects
of the study, but toward personal characteristics of the
people working on the project. One man offered to have
sex with the experimenter "so that she could experience
sex with a diabetic who had had a penis implant." It is
not possible to determine what effect(s) the
experimenter had on the outcomes of the study. However,
these effects cannot be ruled out as contributing

factors, particularly when it is well known in social

 

161

psychology that experimenter characteristics like
prestige may be powerful variables.
MM

In this section the cluster analysis will be
discussed in more detail, both as it relates to the
experimental hypothesis and as it sheds light on the
relationships between the dependent variables. The
reasonableness and consistency of the outcomes of the
cluster analysis are striking. For example, the cluster
of glyco-hemoglobin readings correlates positively with
reported good health practices, and negatively with
kidney problems; the whole cluster correlates with the
"insulin dependent diabetes" cluster, and the pattern
indicates that those with juvenile diabetes are prone to
have kidney problems, to have been conforming better at
the beginning of the study, and to have high
glyco-hemoglobin readings. It should be noted that this
is discouraging in the sense that better initial
conformity was not related to lower blood readings, nor
did reported conformity at any stage cluster with these
readings. They seem to have been related exclusively to
disease type.

The cluster analysis gives some comfort to
advocates of the health belief model, but it is a cold

type of comfort. Measures of health beliefs and

 

162

reported compliance to medication, diet, and exercise
regimens were in the same cluster. This supports the
prediction from the health belief model that beliefs
should affect compliance. However, all of these
measures were verbal, and had no relationship to
glyco—hemoglobin levels or other measures of physical
condition. In fact, beliefs and reported compliance
correlated negatively with the following clusters:
physical condition, compulsivity, general advocacy, and
medical histories.

It thus appears that beliefs about the seriousness
of one's disease can affect a number of variables, but
none are positively related to health status. It could
be hypothesized that the direction of causation is the
opposite of what might be implied by the health belief
model; that is, serious medical problems lead to belief
in the seriousness of the consequences of diabetes, and,
perhaps through rationalization, to the belief that good
health practices can be followed and will be effective.
However, the present study does not support the belief
that better reported compliance leads to better physical
condition.

Janis (1983) reported that people who do not
believe that their medical condition is serious, or do

not believe that they can do much about it behaviorally,

 

163

are not very likely to follow a prescribed regimen or
take any preventive measures. It may be that the
doubters are realistic. Future research needs to
examine very carefully the cost/benefit ratios involved
in following a medical regime. If those ratios are
extremely high, noncompliance is an optimal strategy.
The insulin dependent diabetes cluster correlated
with the specific advocacy cluster, and, as pointed out
in the previous section, people with higher scores on
the specific advocacy dimension were more apt to have

medication changes. This relationship lends support to

the assertion that the advocacy manipulation was
somewhat effective. In addition, it appears that some
people wanted to learn advocacy skills. Since the

insulin dependent diabetes cluster correlated with the
specific advocacy cluster, it is likely that people who
felt uncomfortable with their medical regimes decided to
try out the advocacy techniques after reading examples
of their usefulness. It is also interesting that the
specific advocacy cluster correlated with the health
practice concern cluster. This again indicates that
those who scored highest on the specific advocacy
cluster were those who were most concerned about their

health.

164

The External Health Control cluster also contained
a reasonable combination of five variables; three were
the health locus of control scores (at the three
measurement times), one was education and one was sex.
This cluster correlated with the General Advocacy
cluster, indicating that differences in external locus
of control and assertiveness may be a result of
differential socialization of males and females, as well
as dependent upon education. Males seem to be more
confident of their ability to control their health and
be assertive.

The O—Types analysis lent some credence to the
hypothesis that high cohesiveness could affect
physiological outcome measures. All people making up
the first O—Type were in the manual group. Half of them
had juvenile onset diabetes. They were very interested
in meeting other juvenile onset diabetics. Some had
been diabetic for years and did not know anyone else who
had diabetes. The other five people in this O—type were
adult onset diabetics; all were either currently
overweight or had been overweight in the past. The ten
people in this O—type were half males and half females.
They were all interested in starting a support group.
Two of the people that made up this cluster had tried to

get a support group going; one was a juvenile diabetic

165

and the other was an adult onset diabetic. Both were
women. All of them were disappointed that they were not
assigned to the experimental groups. They rated the
overall program slightly above "somewhat good" (above
four on a five point scale). These people scored
high—average on the blood and physical condition
clusters, and very low on the cohesiveness cluster
(necessarily, since they were in the manual group).
People comprising the second O—Type had been in the
experimental groups.‘ Six of the nine people were from
the second experimental group. Four of the nine people
were females. They had been active in their groups.
All attended at least 8 of their sessions (the mean
number of sessions attended was 9.67). Two of these
people had juvenile onset diabetes; the other seven had
adult onset diabetes. These people on the average were
heavier than the people that made up the first type.
Although these people were very active within the
"official" groups, and continued after the "official"
groups were terminated, they rated the overall program
just slightly over average. They scored lower on the
blood cluster, lower on the physical condition cluster,
and higher on the cohesiveness cluster than the people

who made up the first type.

 

166

To summarize, the cluster analysis produced
impressively reasonable results. The dependent
variables clustered in ways that seemed rational in
terms of a priori theoretical considerations, or post
hoc analysis, or even both. Although the results of the
experimental component of the study were discouraging,
those of the "naturalistic" component are interpretable,
suggestive, and perhaps encouraging for future
interventions.

General Observations

Perhaps some of the more interesting findings were
not those obtained through the use of traditional
experimental methodology. For instance, two people in
the study (both from the same group) met through the
study, and by the follow-up assessment had developed an
intimate relationship. The female was obese, so much so
that we were not able to weigh her at any of the
assessment periods. The male was bulimic. Both of the
people said that they thought the relationship was a
"good" thing for them.

One woman who was very involved in developing the
group dropped out. Before the "official" group ended,
participants who were interested in recruiting new
members were asked to check with potential members to be

sure that they were not already participating in the

 

167

study. The woman who dropped out was very upset by this
request. She thought that it was unethical to limit
their group. She thought that her group would be a
"life—saving activity" too important to limit. She
decided that the experimenter was unethical and refused
to participate in the post— and follow—up assessments.
She continued to be very active in the group. She found
a meeting place for her group, designed flyers to
advertise the group, and started new activites for group
members.

Both of the incidents that were reported above took
place in the same group (group 2), which had only twelve
sessions. Members of this group also shut off their
tape recorder at various times. They did not like the
idea of being tape recorded; they thought that they had
the right to shut off the tape whenever they wished.
This group also decided that they wanted more "medical"
information. They asked a dietician to come to a
meeting and give a talk on nutrition. The group invited
her to come and speak during the time that was scheduled
for their support group. They also asked one of the
participants, who worked in the library and who knew a
lot about diabetes, to give a presentation on research

that had been done on diabetes.

 

168

By the time of the follow—up assessment, group 2
had started a swim night, an aerobics night, had
picnics, and scheduled several speakers. They had a
meeting place, held group meetings twice a month, and
had recruited new members. None of these events were
assessed via the formal dependent variables of the
"official" study.

Group 1 was also interesting. It started with
three members. It was not until the beginning of the
third week that new members were recruited. New members
came into the group until the eleventh session. Some
members had finished their commitment to the study when
new members started. This group was much more low—keyed
than the other group. However, they did rebel. They
wanted more medical information. They were told that
the group was theirs and they could do anything they
wanted, provided that the decision was made by the group
as a whole, rather than by one or a few individuals.
The group then asked the experimenter to try to get a
physician to come and give a presentation on the
glyco—hemoglobin assay. They wanted to know more about
the test that they were having done as part of the
study. The sessions were typically two hours long. The
group elected to have the physician come after half an

hour, so that they could still have half of the advocacy

 

169

presentation, have the physician speak for an hour, and
then have a half hour to ask questions.

Then a few members of the group decided that it
would be more interesting and more informative for them
to schedule speakers than to have more information on
advocacy training presented. The group members were
again told that it would be fine as long as the group
(not an individual) made the decision. The group never
made a decision on this matter. A few of the members
enjoyed the presentations on advocacy and would not
agree to give up the presentations. This group, which
had twenty "official" meetings, was continuing when the
follow-up assessments were conducted.

All participants in the study were told about
mid—way through the study that when the study was over a
pot-luck dinner would be organized. The pot-luck dinner
would give all the people in the study a chance to meet
others who had participated, as well as giving people in
the manual group a chance to get involved in an ongoing
group, if there were one. Group 1 spent a lot of time
helping to get ready for the pot—luck. They got
permission to have the pot-luck at the church where they
were holding their meetings. By the time of the
pot—luck dinner they had a flyer made up and had

retained a speaker for their next meeting.

 

170

Each group had flyers for the pot—luck dinner.
Each member brought a dish that people with diabetes
could eat; they were also asked to bring the recipe.
Family and friends were also invited. About 45 people
attended, few of whom were from the manual group. Each
group elected a member of their group to give a short
presentation about their group and their future plans.
Members of both groups spoke to each other about their
experience in the study.

There is thus evidence that this study succeeded in
ways not reflected in statistical analyses. The
participants were empowered, as demonstrated by their
rebellions. They formed cohesive groups, as
demonstrated by the continuation of the groups after the
study was finished. There were few dropouts from the
study, with 49 of the original 57 completing all of the
study; we have seen that one dropped out as an ultimate
rebellion, and another dropped out because of pressure
from her husband. Thus the rather mediocre verbal
evaluations of the intervention may be compromised by
rebellion, and at any rate are probably comparable with
much higher ratings by studies with ‘the usual high
dropout rates. Our general observations, then, suggest
that part of the apparent failure to confirm that the

intervention was effective is related to an

 

 

171

inappropriate, or at least incomplete, choice of
dependent variables.

Suggestions for Future Research

 

The present study suggests several directions for
future research. One important direction is having
people with diabetes decide on the independent and
dependent variables that should be manipulated and
measured. In the present study some of the important
findings were not "measured," but directly observed.
The people involved are the subject of interest, and
they will affect the findings of research and be
affected by the changes that occur. Possibly more
changes will occur if the people who are the object of
the research decide what variables are important to
measure.

The word conformity becomes important here.
Conformity implies that the patient is following the
advice of a physician or other health care provider.
Researchers then measure the degree to which the patient
follows this advice. From the physician or health care
provider's perspective the patient is simply told what
to do. Choice is not an option. In working from this
medical perspective, variables such as
glyco-hemoglobins, weight, blood pressure, and health

beliefs are important. These variables may indeed be

 

172

important in sustaining life. But from a patient's
point of view the most important variable may be his/her
quality of life. Patients may not be interested in
physiological measures. The choice of the focus of
change or treatment is not one that should be made by
the physician or health care provider, but one that
should be made by the person affected. If the patients
are allowed to define the goals, and possibly even the
methods to reach the goals, more satisfaction and
progress are likely. For example, a physician may
decide that a patient is too heavy, that his or her
glyco—hemoglobin readings are too high. The patient
makes no contact with glyco-hemoglobin readings, and may
not care much about either variable. The patient may be
more interested in whether or not he or she can drink
beer on Friday night. Maybe drinking beer on Friday
night is worth dying sooner for. In summary,
researchers need to consider the goals of patients as
well as those of physicians. The key word may then
become cooperation between the experimenter and the
subjects, rather than conformity to the wishes of
medical personnel. Such an approach may make the
experimental manipulations appear to be much more

powerful than is now the case.

 

173

Social support appeared to be an important
variable. However, it seems clear that if support
systems are going to make a difference in the lives of
people with diabetes, research needs to include all
types of support, as described above.

Educational information for a person with diabetes
is a must. It seems important for the process to begin
soon after a person is diagnosed. If they are begun
early, before the "diabetic life styles" are set, it is
more likely that they will be effective. It is clear

that these educational classes need to be extended over

a longer period of time. An important component of
these classes should be the discussion of the
limitations of medical solutions. This may motivate

people to make changes in their lives.

It also seems important for these classes to target
specific behaviors that are to be changed. The
educational classes need to be more action—oriented,
making the support group activities less intellectual
and social and more oriented toward bringing about
changes in appropriate behaviors.

Chronic disease research also needs to be
longitudinal in nature. Since the topic of the research
is long-term, researchers in the field need to set up

long term research programs that are able to measure

 

174

long term effects of different interventions. For
example, Wilson, Kaplan, Heitzmann, & Sandler (1985)
conducted a study of weight loss programs with
diabetics. they found that, although weight changes did
occur during the study, the glyco-hemoglobin assay did
not show changes until the 18 month follow—up period.
This supports the need for more long—term research.
Finally, future research needs to be based on a
careful distinction between the two types of diabetes.
The two types are medically different, and the present
study provides some evidence that the two types of
diabetic people may respond differently to psychological
interventions, as well; the cluster analysis showed a
relationship between specific advocacy and insulin
dependent diabetes. Proposed interventions should
consider the different needs and goals of the two kinds

of diabetic people.

 

 

APPENDIX A

 

 

 

175

APPENDIX A

designed to help you deal with the prob-
lems of your disease.
CALL TERRY CRONAN
~ at 332-6342
for further information

 

 

LANSING STATEJouaNAL Sunday, July 1, 1984 38

 

Metro Roundup

176

 

 

Disabled vets installed

The Lansing chapter of Disabled
American Veterans, and its Auxili-
ary chapter have installed new of.
fleet: for the m year.

Elected by' the D.A.V. Capital
City Chapter #8 were James W10-

commander; Richard
Casler, senior vice commander;
Wmston Morgan, junior vice com-
mander; Nicholas Corey, chap-
lain- William Hi ' 7 '

officers are: Patricia
commander; Phyllis
Rowlee, senior vice co :
Beverly Rowlee. junior vice com-
mande ; eve

lain: Shirley Casler. W; and
Lucille Masher, adjutant.

Nancy greets Kiwanis
Two Lansing Kiwanis Club mem-
bers were among the 1541!) Club
leaders gird Fgusts who Nwere
greeted ust Lady ancy
Reagan at~the m annual conven-
tion of Kiwanis International in

Lansing Kiwanis president Rich-
ard Hacker and lst vice precedent
Howard 1.. Canon Jr. represented
one of the 8.1“) C ubs from
lions around the world at the con—
vention. which was held June 24 to
27

The Club's agenda included com-
munity service reports for the past

 

emeaaencv ,
H OTIJ N83
Housing: 487-6091" .
(O out-l pat).
Housing: 484-7481."
(EV-vines. maid-ti ’
Food: 372-6330
_ (I anal pan. Men-F10 ‘
Energy: 1-800-292-5650

Outreach: 678-1065-
. (14......quer -

 

 

 

tioml officers. Kiwanis boasts of
having 311,01!) members. its high-
est membership count in its his-
tory. ‘

Study needs diabetics

Terry Cronan, a Michigan State
University doctoral student. is
seeking people interested in partic-
ipating in her to improve
health-related beha on of diabet-
ics.

Cronan would like to enlist at
Ieast'eo adult volunteers who have
received some educational instruc-
tion about diabetes. The study has
been approved by the human nib
jects committees at MSU, Minster:
General Howital and Ingham M
ical Center.

She has a grant from the Michi-
gan. Department of Public Health
to help finance the study. Anyone
interested may phone Cronan at

m ,

year and the election of intema- 332

 

1’77

TheDetroltNews 3;;
Comics / Celebrities / “(leather/L
Thursday, July 19, 1.984 .
Scicn‘ce 222.2300. _ ' p 55‘:

 

 

 

 

 

sci ./TECH

O

i . A .-
BRIEFING

l-ICINB .

Diabetic research

A doctoral student atMichigan State Univer-
sity is seeking 60 diabetics willing to participate
in a research project that will evaluate education
programs for those who suffer from the disease.
The volunteers must be from the Lansing area
and must have previously had some education
about their disorder. The program will provide
educational materials to all participants. Some
will also attend meetings for five weeks, when
they will have access to counseling and a support

 

 

 

 

 

 

group.

Student Terry Cronan’s research is supported
by the university, Lansing General Hospital and
Ingham Medical Center. It is financed partly by
the Michigan Department of Public Health.

Participants will receive free blood sugar»
teats. Those interested can call Ms. Cronan at
517/332-6342. ‘ '

 

APPENDIX B

 

 

1’78

APPENDIX B

Self-Advocacy and Social Support for the Diabetic

Dear Potential Participant,

I as a researcher froa Michigan State University.
studying progress that night isprove health behaviors in people who,
like you, have diabetes. He would like to find out whether or not
sore training will help you cope with your disease better. This
training is not further educational information about diabetes. The
training is intended to help you to 233 the information and to help
you deal with your diabetes on a daily basis.

H are trying to get people to participate in this study. The
study will last five weeks. If you agree to participate in the
study, he will assign you to one of two different programs.

If you are assigned to one group. we will ask you to meet twice
a week for a total of five weeks. The classes will be held from
TO . The classes will

 

be two hours per evening.

are assigned to the second group. you will be given
information intended to help you cope with the problems associated
with diabetes. but you will at be asked to attend classes.
However, you will be asked to provide the same information to
that is provided by the other group. He will be asking you
questions three tines during the study: once before you start.
after five weeks, and again three months after the five week period
ends. If you are not assigned to attend the classes. we will give
your nase and phone to other people that are assigned to the same
group. You will also receive t e names 0 the people in your

 

179

Participant Agreement

We will be asking all participants to:

a. agree to be randoaly assigned to one of the‘two progress.

b. complete the program to which you are assigned: however.
participants may withdraw at any time without penalty.

c. participate in a follow-up evaluation.

d. keep daily log books on your daily activitis

allow prograa staff access to your medical records. The

inforu tion we will get from the records includes: number

of hospitalizations. complications. blood tests results.

other medical problems, which will include: psychological

or social service records. substance abuse. treatment

records. date of diagnosis of diabetes. and any other

relevant medical information about your diabetes.

I agree to:

a. keep all of your information anonymous in al
discussions or reports and confidential at all times.

b. provide instructions

c. provide information about the results upon completion of
the program

d. pay for blood work which will be done for the purpose of
this research project.

Signed Date

 

Participant

 

__________________.
Project Director
._____._.__________...._

 

Witness

 

 

180

Code No.

Historical Questionnaire

Name

 

Address

 

Telephone number ' -

 

 

 

 

Sex Male Female Date of Birth

Marital status: single _ married __ widow or widower
_ separated _ divorced _ remarried

Ethnic origin: __ White _ American Indian _ Black
__ Arabic Asian _ Hispanic

Other (please specify) ___—___

A an“

 

Number of hours worked per week

 

Education. highest grade completed:

 

Do you have health insurance? No Yes

 

If yes, please specify the name of the company.

 

Date of diabetic diagnosis

Lilood glucose level at diagnosis __

Diagnosed Type II (non-insulin-dependent. adult) No Yes
Your blood glucose level at last examination was

Are you taking any medication? No Yes

 

if so, what is it? How much are you taking?

 

 

When did you begin taking it? Date

 

181

Have you ever received any educational instructions on diabetes? it so,

please specify:

Where ‘ When

 

 

Total number of hours of instruction

What was included in the instruction? Please describe briefly.

 

 

Have you ever been hospitalized? If so, please list the reason and duto(s

 

 

 

 

Have you experienced any complications from your diabetes? IE yes, please
specify. when the complication occurred and whether you are experiencing
any symptoms presently.

 

 

Do you have any medical condition besides diabetes? LL so, please :peclky:

 

 

HLease spectfy the relationship to you of any member of your family who

have d |ubOLuHI

 

homily income:

below )lU,UUU $20,001 - $25,000
)lU.UUU — $15,000 $25,001 - $30,000 ____
>lS.00L - n10.000 above $30,000

 

PhySLcian's Name

Weight lbs. Height inches

 

blood Pressure: Left: Right:

 

182

Code Number

Health Belief Scale

For nth statement below. write in the blank space on the left the
number that you think best fits the statseent.

For esespls:

_m_ I believe thst I as responsible for
own sedicsl csre.

percent of my

 

The person who tilled in the ststssent believed that he or she was
responsible {or 801 of his or her own medical care.

Part 1. Beliefs shout consequences.

‘1. I believe that the lite expectancy of the average
person with UNTREATED diabetes would be shortened
by

II.

 

 

__ 2. The quality of. life of the average person with
UNTREATZD diehetee would be reduced to _______
percent of whet it would be without diabetes.

3. There are chencee out of 100 that the
average person with UNTREATBD diabetes would
heve serious complications (like eye problems.
circulatory problems..end kidney problems).

Part 2. Beliefs about the consequences of health practices.

6. The average person with diebetes who got good
medical treatment would gain back _ years
of life expectancy fro- the treatment alone.

_______ 5. The average person with diabetes who followed
good health practices would gain beck an
additional yours of lifie expectancy.

6. The quality of life oi the average pore
with diabetes who got good medical treatment
would be percent oi who t it would be
it they did not have disbetes.

7. The quality of life of the average person with
diubetes who got good medical treatment and
followed good health practices would be
percent of what it would be ii they did not have
diabetes.

3. The average person with diabetes who got good
medical treatment would decrease the chances
of serious complications to out of 100.

 

LL

 

183

'9. The everege person with diebetes who got good
sedicsl trestsent and followed good health
practices would decrease the probability of
serious cosplicstions to chencee out of lOO.

Part 3. Beliefs about Ability to Follow Heelth Practices. In order
to follow the health practices needed to counter. the effects of
diabetes. you have to have the necessary ability. and be willing to
spend ties. soney. end will power. Plsese estinete below whet
percentage of perfection you think you can achieve in each case.
et's loo et en exesple in each of the {our arses covered in the
table below.

1. In the eree of nedicsl care, a person with 1001 of the ideal
ability would know Just how to find the best medical care
sveileble. They would heve the ability to find the best doctors.
phsrssciets. hospitals. and other heelth care professionals as
needed.‘ It you felt that you had three-fourths as much ab li as
the ideal in that eree. you would write 75 (for 75 per cents in
top left blank in the table.

2. In the eras of diet. the "ideal patient" would be able to spend
as such tine es necessary to plan and prepare perfect diabetic
seels. If you can only afford belt as such tine as the ideal. you
would write a 50 in the second blenk down. second blank over.

3. In the arse of exercise. it might be desirable to purchase
equip-eat, club sesberships. or professional help to insure that you
get the ideal esouat of exercise. If you can afford as much of this
as the idesl, you would write "loo" in the third blank down. third
bleak over.

A- Finally. if you have only a quarter of the will power necessary
t engsge in ideal health practices. you would write a 25 in the
bottos right blank.

w go ahead and fill in your best guess at the percentage
the ideal that you think you can bring to caring for your diabetes.
Fill in oil Lg blanks below with your best estimete.

m 3 ___Eu"
Ability Time Money Hill Power

Medical Cars

 

Diet

Exercise

Good Heslth
Practices

 

184.

Indicators of Health Behaviors

For each stetenent below. please indicate the percent of the time
that you pertorn the behavior described in the statement.

For exeaple. it you were on insulin you night answer as tollows:
_L I take ny insulin

You ould Just put the percentage of tine you take your insulin in
the let: blank

percent of the time.

 

It are not on sedicstion do 53; answer the medicntion
questions. Go to the diet questions.
flllifiliiflll

l. I follow ay nedication progras percent

0! the tile.
2. I take ny1:edication within 30 minutes at the
correct pa cent of the tin

3. I as percent sure that I always take
the correct eaount ot medication.
_Lu.

6. _______ percent 0! the tood I eat is on my
diet plan.

5. I eat percent more food than I should.

6. I eat percent oi my food at regular
neal tines.

7. 0n the average I exercise days a week.
_______ 8.. 0n the average I exercise for minutes a day.

9. When I exercise, I work percent as hard
as I should.

10. I test my urine daily percent oi the time.
ll. I check my feet daily percent of the time.

12. I consult my physician on the average every

days. —

 

F

185

“8551!“; “SW BEHAVIOR

mt. '

 

 

 

Directions: Indicate how characteristic or descriptive each at the following
ststeneots is or you by usint the code given bel .

”H
as

U-

u-

..
Douay
04.n-

.—
U

. u
e s

.—
u
a

.-
O

,..
0
e

salsa“
Ne—
. .

Noll.“
n e e s e

N
(I
e

n
0
s

+3 very characteristic oi as. sstrensly descriptive

#3 rather characteristic o! as. quite deecripti

+1 sonewhet characteristic o: as. aliphtly descript

-l suswhat uncharacteristic“ no. lll'htly eondescriptive
-2 rather uncharacteristic or as. ts nondescr

-3 very ushersctsristic at us. astr-ely- aondssoriptive

host peeplsss. sects be are aggressive and assertive than I an.
I have hesitated to sets or accept dates because at "shyness."
months teed served at s restaurant is not done to a1 satistsction.
I oo-lein about it to the waiter er waitress.
I-carerulto aflidhurtiosothsrpeeplesselinss.svenwhsnI
tool that I have be. .
I! s sale-an has tons to considerable trouble to show no cheodise
which is not quite suitable. I have s dinicult tins in ssyins "Ne."
WeenIsnssked todo sonsthins. Iineistuponuknowincwhy.
MentineewhenIleeetorspod.viporo “sense
I strive to set ahead as well on nest people in or position.
To behoaest. people ort- tshs sdvaatass ores
I enjoy startinse snversations with new acquaintances and strsnssre.
I otten don't knew what to say to sttrsstive persons 0! the opposite can...
will hesitate to lake phone calls: to business establishneots and
institutions.
stuld rather apply tor a Job or tor sdnissieas to o tollsoe by
writinsa let tars than by going thrcush with pereoeslin
I (ind its-barrassinu to return nnrchsodise.
It a close ad respected relative were eonoyins no, I would mther
nyteelinns rather than enpross ey annoyan
I have avoided askinsq ueetions for fear or. soundins stup id.
Derinssa mt I an soastines strain that Iwill set so upset that
Iwill shake all over
I! a (seed and respected lecturer ashes s statusnt which I think is
incorrect. I will havetns audience hear ay point at views swell.
Isvoid srsuint over prices with clerhs and salesnen
uh. I have done sons chins iaportant or worthwhile. I senses to let
others how tti
Ian encode and frank about oy toolinns
I! seasons has been spreading (a ice and bad stories about as. I see
bin (her) as soon as possible to "have a talk" about it.
I often have a herd tine sayia
I tend to bottle up ny sections rather then nade a scene.
I mlsin sbout poor service in a restaurant and elsewhere.
When I an siven a conplinent, I sonetines just don't know what to say.
I! a couple near as in a theatre or at a lecture were conversion
"“1" loudly. I would ask than to be quiet or to take their conver-
setioo elsewhere.
Anyon- Icusstia. to push ahead or no in a lins 1.6 u: (or . good battle.
I an quick to curses an opinion
There are tines when I Just can't say snythino.

H

 

186

Code hunter

Health Locus of Control Scale

Please eveluate on a 6 point scale the extent to which you believe
each of-ths following state-eats. The scale values are as follows.

Strongly Disagree Sonewhat Soaewhat Agree Strongly
Diazgrse 2 Disagree A':.. 5 Agree

1. I! I take care of nyaelf. I can avoid illness.

2. Whenever I get sick it is because of sosething
I've done or not done.

3. Good health is largely a letter of good fortune.

b. No natter what I do. if I an going to get sick
I will get sick.

5. Most people do not realize the extent to which their
illnesses are controlled by accidental happenings.

6. I can only do what my doctor tells no to do.

7. There are so neny strange diseases around that you
can never know how or when you night pick one up.

8. When I feel ill. I know it is because I have not
been getting the proper exercise or eating right.

9. People who never get sick are just plain lucky.
10. People’s ill health results tron their own carelessness.

ll. I an directly responsible for my health.

 

187

Code No.

Date
Post Assessment Medical History Questions

 

Nana

Address
Street City State Zip

Telephone nunber

 

Date of Birth

Your blood glucose level at last examination was

 

Yes

 

 

Are you taking the seas nedicntion? No

How much are you taking?

 

If new. what is it?

 

 

When did you begin taking it? Date

 

Have you been hospitalized in the past couple of months? If so, please
(

list the reason and date

 

 

Have you experienced any new complications from your diabetes?
If yes. please specify, when the complication octurred and whether
or not you are experiencing any symptoms presently.

 

 

Do you have any new medical condition besides diabetes?
If so. please specify:

 

 

Physician's Name

 

Weight lbs. Height inches

 

Blood Pressure: Left: Right:

 

 

188

Code Number

Date
Sociometric Questionnaire

0n the attached sheet you will find the names of all of your group
members. For each of the activities listed below. please fill in the
names of the people from your group with whom you would feel
comfortable: arrange the names in order of preference. from left to
right, and write as many names as you-wish on each line (you may use
initials to save time and space).

1. To whom would you say "hello" if you saw them outside of class?

 

2. With whom would you carpool to group meetings?

 

3. Who- would you invite to share in a social activity?

 

A. With whom would you discuss you medical program?

 

S. If you were experiencing problems with your diabetes.
whom would you call?

6. Hhom would you invite to a party you were giving?

 

7. Uhom would you call for a chat?

 

3. If you were experiencing marital or family problems.
with whom would you discuss them?

 

9. Whom would you consider a close friend?

 

 

 

Code Number

Date

,5

Pi

H

189

Questions about the Manual

Assertiveness means to stand up for your own
rights. to express your anger, to reach out to
others, to express your affection. to be more
direct.

An aggressive person violates his/her own rights
by failing to express honest feelings. thoughts.
and beliefs. and consequently permits others to
violate him/her

Empathic assertions involve clearly describing
how the other person's words contradict his/her
deeds

Progressive relaxation is designed to increa

a person's awareness of the internal sensations
associated with tension or anxiety and at the same
time to provide an active coping skill Eor relaxing
away such reactions.

when setting goals you need to define your goals.
concentrate on :subgoals, write them down.
seek out mode

Internal dialogues are the ways you talk to other
people.

Negative self—statements are self-defeating.
Social tears help people respond assertively.

Uhen dealing with difficult Situations
nonasaertion creates an angry behavior cycle.

People never respond negatively when you
respond assertively.

 

190

Code Number Date

 

Evaluation

The following questionnaire is designed to assist in the evaluation
of this program. Please respond to the following items based upon
your feelings and perceptions about the program. Your comments will
be helpful in the planning of future programs.

1. How many sessions did you attend?

 

2. The purpose and goals of the program were:

1 2 3 A 5
never little somewhat explained Fully explained
explained explanation explained pretty well (very clear)
(unclear) (not very (somewhat (clear)
r) c ear

3. The length of time for each meeting was:

1 2 3 A 5
too short somewhat satisfactory somewhat too long
too short too long

A. The number of group sessions was:

1 2 3 A 5
too few somewhat satisfactory somewhat too many
few too long

5. The pace of each program was:

1 2 3 a 5
too slow somewhat Just right somewhat too fast
too slow too fast

0. The discussions and materials presented in this program were:

l 2 3 a 3
not useful somewhat neither somewhat relevant and
for me unuseful useful or useful useful for me
not useful
7. The opportunlLy to participate and contribute in the program was:
1 2 J A 3
poor not very neither pretty excellent
good poor nor good

good

 

191

2 PROGRAM EVALUATION

8. Do you think that applying what you learned in this program to
your daily life can be:

1 2 3 A 5
not helpful not very neither pretty very helpful
at all helpful helpful nor helpful to me
to me unhelpful

9. Do you think that you could make use of the techniques used/taught
in this program in the future?

1 3 a 5
not easily somewhat maybe pretty very easily
uneasy easy

10. 0a a scale of 1 through 5. please evaluate the following:

Not Somewhat Neither Pretty Very
useful unuseful useful or helpful helpful
unuseful
a. Handouts l 2 3 A 5
b. Discussion 1 2 3 A S
c. Exercises 1 2 3 a S
d. Role Playing l 2 3 A 5
11. Has the program:
a. Organized in presenting material?
1 2 3 A 5
Not at all not very somewhat pretty much Very much
b. .Clear in conveying Lnlurmation?
2 3 A 5
Not at all not very somewhat pretty much Very much
d. interesting?
2 3 a 5
Not at all net very somewhat pretty much Very much
[2. would you recommend this program to a Lriund?
l 2 3 4
not likely somewhat somewhat pretty likely very likely

unlikely
13. How would you rate this program overall?
1 ' 5

poor somewhat average somewhat excellent
P0 good

 

192

3 FROG

RAM EVALUATION

Please include any comments which may help in the future

 

 

 

 

 

1A.
planning of this program.

a. What did you like most about the program?

b. What did you like least?

c. What would you recommend to improve this program?

 

 

THANK YOU!

 

 

\
APPENDIX c
l

 

193

APPENDIX C

SELF-ADVOCACY AND SOCIAL SUPPORT FOR THE DIABETIC

By

Leah K. Gensheimer and Terry Cronan

 

copy r guote from
permission f

this
the authors.

 

 

 

manual without the

"lh 4

 

194

SELF-ADVOCACY AND SOCIAL SUPPORT
FOR PEOPLE WITH DIABETES
Preface

This manual is a guide for group leaders who wish
to help diabetic people become more assertive and
develop social support. It was not designed to be a
"cookbook" which one could follow in detail to
guaranteed successful outcomes. Such a product probably
cannot be written. This manual is offered in the hope
that it will be of some help to diabetic people who
would like to become more assertive and to develop the
social support that they may need.

Much of the material which follows was taken from
three primary sources: 123; Perfect Bight (Alberti &

Emmons, 1982), Don't Say Yes When You Want t2 Say N2

 

(Fensterheim & Baer, 1975), and Responsible Assertive
Behavior (Lange & Jakubowski, 1976). Concepts,
philosophies, exercises, etc., originated by these
experts in the area of assertion training, were read,
sorted, and organized to produce an introductory manual
for diabetic people. An attempt was made to identify
specific sources, to give appropriate credit and to
provide the user of this manual direction on where to

locate further information/details.

 

 

195

Session 1: Introduction
Objectives
1. Establish rapport between self and participants.

2. "Break-the—ice" and have group members introduce
themselves.

3. Provide participants with a clear understanding of

the goals of the group. Define the way the group will
be run.

Self—advocacy Training

1. Increase participants' awareness of what is meant by
assertive behavior, highlight major obstacles which
interfere with appropriately asserting oneself, and
discuss society's impact on one's behavior. Emphasize
the learning process involved in any form of behavior.
2. Begin to develop in members an assertive belief
system. Help participants identify and accept their own
personal rights as well as the rights of others.

3. Discuss with the participants how the second part of
the group will be structured.

Social Support Section

1. Get the group started. Give the participants the
first set of tasks to be completed.

Handouts:
ACTIVELY BECOMING MORE ASSERTIVE
MYTHS

BASIC HUMAN RIGHTS

 

196

Means £2 Objectives
Introduction
1. Rapport Building

a. Greet group members as they enter the room.
Introduce yourself and ask members their names as they
arrive. Make small talk if time permits.

b. Provide a formal introduction. This should include
the purpose of the group and what is expected of the
group members.

2. Breaking—the—Ice: Introduction

Have group members introduce themselves in a manner that
will demonstrate the facilitative processes which will
later be used in the group (covert rehearsal, modeling,
behavior rehearsal).

Instruct members to close their eyes and think of two or
three statments they will use as a means of
introduction. Tell them that they are to state their
names and four words which they feel best describe
themselves. Allow one or two minutes for group members
to think of their responses (covert rehearsal). Then
begin by stating your name and four words you've chosen
as characteristic of yourself. In this manner, the
facilitator serves as a model, demonstrating the type of
response requested, and assisting those group members
who may not have been clear on what was expected of
them. This is also intended to ease anxiety or tension
among those who may be apprehensive about speaking out.

Continue around the group until all members have
introduced themselves. This provides behavioral
rehearsal of those statments previously rehearsed in the
trainees' minds).

Note: This exercise may facilitate spontaneous
discussion among group members, who may question one
another on their choice of words to describe

themselves. Welcome such spontaneity, especially since
the nonassertive individual is often reluctant to talk
out among new individuals or within a group setting.
Care, however, whould be taken to prevent some members
from feeling excluded or becoming bored.

 

 

3.

197

Procedures and goals of the grOup

All the sessions will be tape recorded. Only members
of the research team will be allowed to listen to the
tapes. The reason that we will be recording the
sessions is that we want to follow what is happening
in the group. This might help us in future groups.

The sessions will be divided into two parts.

The first part of the session will be more
directive. The purpose is to learn self-advocacy
skills. I will present materials each meeting on

ways to become a self—advocate. We can discuss as a
group the materials that are presented. We have asked
each one of you to keep a log book. One of the
things we have asked all of you to record in the log
book is situations in your life in which you were an
effective self—advocate and events in which you were
not an effective advocate for yourself, but would
like to have been. In the first part of each meeting
we will discuss these events. We hope that such
discussions will help you as well as other group
members.

The Goals of the Group

The goals of this group are:

1. To teach you the distinction between
nonassertive, assertive, and agressive responses to
specific situations.

2. To help you develop an assertive belief
system which involves sincere concern for individual
rights by assisting you in identifying and accepting
your own personal rights, as well as the rights of
others.

3. To reduce existing cognitive (thought)
and/or affective (emotional) obstacles that may keep
you from acting assertively.

4. To suggest ways for you to find different
resources that are available in your community.

5. To suggest ways for you to meet other people
who are similar to you.

Goal number three should be clarified by
providing examples of cognitive and affective
obstacles which may inhibit assertive responding;
e.g. irrational thinking, excessive anxiety, feeling
of guilt and/or anger. Briefly explain the behavior
cycle involved which facilitates assertive
responding:

 

198

The less anxious one is,

the more confident one becomes
in situations that require assertive behavior;

the more confident one is,
the more likely one is to engage in the behavior;

the more practice one gets,
the more successful outcomes there will be.

In clarifying goal number 4, stress the fact
that becoming more assertive is an "active" learning
process which will require motivation and effort on
the part of the person trying to change his/her
behavior. Explain how the previous introduction
exercise (thinking of what one will say, listening to
others introduce themselves, and then actually
introducing oneself) was an "active practice method,"
which will be one technique used in the classes.

Tell the group that assertion training is not
intended to teach people how to manipulate others,
nor is it a miraculous cure—all for everyone's
problems or difficulties. Rather, it is a way to
increase one's ability to express one's feelings,
beliefs, and rights openly and honestly, as well as a
way to help one consider the rights of others. It
increases one's confidence and self-esteem. The
extent to which a person will benefit from these
classes will depend on how much effort he or she
takes in practicing the skills and techniques
taught.

Self—advocacy Training

1. "Assertiveness" — What Is It?

a. Question group on what "assertiveness" means
to them. Shape their responses to coincide with the
definition presented on their handout, ACTIVELY
BECOMING MORE ASSERTIVE. List key elements on the
board. Stress how engaging in assertive behavior is

 

 

'[I‘ ‘III

199

one way to become the person they want to be, and
thus to come to feel good about themselves and
increase their confidence and self—respect, as well
as their respect for others.

Point to those items outlined on the board and
comment on how "great" being assertive sounds. With
this, pose the question: "Why, then, are some people
nonassertive?"

b. In response to the above question, comment
on the three significant barriers to self-assertion
identified by Alberti & Emmons (1982):

Many people do not believe that they have
the right to be assertive.

("Do I have the right to tell my boss I
can't work later tonight?")

2. Many people are highly anxious or fearful
about being assertive.
("I know how to do it, but I'm afraid!")

3. Many people lack the social skills for
effective self- -expression.
("But I don't know how to start a

conversation with those I don't
know well.")

c. Discuss how these barriers to personal power
and healthy relationships stem from the influence of
society on one's behavior.

Distribute MYTHS handout and allow members to comment
on the assumptions set forth. Tie discussions and
comments together by stating that these and similar
beliefs tend to be perpetuated by our own social
structures.

To help demonstrate how nonassertive behavior has
been instilled in us by our culture (and the learning
process involved), conduct a brief lecture on how the
basic structures of the family, educational,
business, political, and religious systems squelch
assertive behavior and reinforce nonassertiveness.
The following outline was derived from material
presented by Alberti and Emmons (1982, p. 5—11,
14—15) and is presented here to provide some ideas to
guide lecture or discussion.

 

200

The Civil Rights Movement:

 

—Women, children and members of ethnic minorities
have often been taught that assertive behavior is the
province of the white male adult. This also makes
things difficult for the nonassertive, white male.

—The women's movement: The ratification of the Equal
Rights Amendment has met great resistance from
various special interest groups, legislators, and the
President. Further, women's new efforts at
self—assertion have faced opposition from employers,
husbands and, in some instances, from women
themselves.

I_ the Family:

 

—The individual (typically the child or adolescent)
who states his/her thoughts, beliefs or feelings, or
decides to speak up for his/her own rights is often
ignored or promptly censured. Wives or husbands may
sometimes be treated in the same way.

—Examples:
—"Don't you dare talk to me that way."
—"Children should be seen and not heard."
—"Never let me hear you say that again."
—"Why don't you grow up?"

I the Educational System:

 

 

—The quiet, well—behaved child who does not ask
excessive questions and passively obeys the teacher
is looked upon favorably. Those who complain, raise
questions, and "buck the system" are usually dealt
with via disciplinary action.

n Business:

-One learns not to "rock the boat" in an
organization, and that becoming a "company man" means
maintaining things as they are and not questioning
the system.

-The boss is "above" and others are "below" in some
hierarchical order, and those below are obliged to go
along with whatever is expected of them by those
above, even if such expectations are clearly
inappropriate.

 

201

l_ t e Church:
—The teachings seem to imply that being assertive is
not the "Christian" thing to do.

—Emphasis is placed on fostering such qualities as
humility, self—denial, and self—sacrifice, even at
the expense of personal gains or satisfaction.

All of these behaviors are learned somewhere along the
line. They can also be unlearned; new, more effective
and self—enhancing means of responding can be learned to
take the place of previously self—defeating or stifling
behaviors.

2. Building an Assertive Belief System:

Begin to develop in members an assertive belief system.
The purpose here is to merely introduce the group to
basic rights every human being is entitled to.
Throughout the course of the workshop, this belief
system will be further developed.

a. Distribute BASIC HUMAN RIGHTS handout. Read
sheet aloud, clarify and discuss the materials
presented.

b. To demonstrate how these abstract statements
relate to their everyday lives, instruct group members
to brainstorm all possible personal rights they can
think of, stemming from those outlined on the handout.
List their responses on the board.

Examples:

—The right to get what you paid for.

—The right to ask about prescriptions we're taking.

-The right to make mistakes.

-The right to dislike your relatives.

-The right to ask "Why?"

—The right to ask for help.

—The right not to laugh at jokes.

—The right to ask questions about our health.

—The right to refuse food or drink that we
should not have.

—The right to take a nap.

-The right to question our medical treatment.

 

202

3. Discuss with the participants how the group meetings

will be structured.
The second part of the session will be structured to
encourage cooperation among group members. People
define groups differently, but overall we can say
that a group is made up of people that work together,
that people want to be a part of the group and the
group wants them to be a part of it. When people are
put together a group can form, but there is no
guarantee that this will occur. One reason that
groups form is that they allow people to meet other
people who have common interests and concerns. In
this group all members have something in common; all
of you have diabetes. Some of your interests and
concerns are probably similar.

People who have worked with groups in the past have
found that, when an outside person was present, the
group was very different than when no outsider was
present. The reasons for this are not completely
clear. What we do know is that if group members work
together without having an outside group leader from
the onset, the group seems to last longer. Also,
many people report that they are more satisfied with
the group. So, for the second part of each session I
won't be here. I will be available if you would like
to consult with me on an occasional basis.

Before you begin the second part of each
session, I will give you a list of tasks or questions
that I would like the group to discuss and make some
decisions about. I would like you as a group to
write down your decisions. When you are finished,
before you go home, I would like you to give me a
copy of what you decided to do.

 

203

SOCIAL SUPPORT SECTION

Give the group participants the following tasks.
Make sure members have the necessary recording
materials.

1. Elect a chairperson and a secretary of the
group.

2 . Discuss what these people should do.
Certainly the secretary will need to keep minutes of
the meetings.

3. Since there will be new members coming into
the group each week, you need to decide on a way to
allow new members to feel welcome. The way to do
this is by forming a welcoming committee:

a. Decide who will be on the committee.

b. Decide what they will do.

c. Ask the committee to establish a
procedure for welcoming new members.

4. Decide on a temporary method that will allow
people to get in touch with other members of this
group should they need to do so.

 

20A,

ACTIVELY BECOMING MORE ASSERTIVE

 

Group Leader: Tine:

 

 

Location:

What Is Assertiveness?

 

"It is a means to stand up for your own rights. to express your
anger, to reach out to others. to express your affection. to be
more direct. Most importantly, it is one means to become the per-
son you nnt to be, to feel good about yourself and to demonstrate
your respect for the rights of others

(Alberti 6 Emmons, 1978)

What are the Overall Goals of This Workshop?
The goals of the workshop are:

1. To teach you the distinction between nonassertive. assertive.
and aggressive responses to specific situations.

2. To help you develop an assertive belief system which ha
positive regard for one' 9 rights by assisting you in identifying
and accepting your own personal rights as well as the rights of
the rs.

H

To reduce existing cognitive (thoughts) and/or affective (emotional)
obstacles thet may inhibit yOu from acting assertively.

‘c

To develop in each one of you a wider repertoire of effective and
appropriate assertive skills through active practice methods.

 

205

MYTHS

Society often evaluates human beings on scales which make some people
"better" than others.

1. Adults are better than children.
_ 2. Bosses are better than employees.
3. Man are better than women.
4. Physicians are better than plumbers.
5. Teachers are better than students.
6. Government officers are better than voters.
7. Generals are better than privates.

8. Winners are better than losers.

Taken from: Alberti. R. E. and Emmons, M. L. A guide to assertive living,
Your Perfect Right. San Luis Obispo. California: Impact
Publishers. 1982, p 4.

 

 

 

206

BASIC HUMAN RIGHTS

WI

"Eve eryone is entitled to act assertively and to express honest
thoughts. feelings. and beliefs

Basic Assertive Rights:
1. We all have the right to respect from other people.

2. We all have the right to have needs and to have these needs
be as lmporrtant as other people’ s needs. Moreover; we have
the right to ask (not demand) that other people respond to
our needs and to decide whether we will take care or other
Ipeople's needs.

3. We all have the right to have feelings- - and to expressn these
feelings in ways which do not violate the dignity ofo
people (e.g.. th 0 right to feel tired. happy, depressed.. sexy,
angry, lonesome, silly).

9. We all have the right to decide whether we will meet other
people's expectations or whether we will act in ways which {it
us. as long as we act in ways which do not violate other people' 5
ri 'ghts. H

5. We all have the right to form our own opinions and to express
these opinion

 

Taken from: Lange. A.J. and Jakubowski. P. Res onsible Assertive
Behavior: QognitivegaehsvioraI Procedures for Trainers.
Champaign, Ill nois, Research Press, 197 , p. 5 .

 

207

Session 2: Discussing Problems and Solutions

Objectives

Introduction

1. "Break the ice" and have group members introduce
themselves. Include any welcoming procedures decided on
by the committee on the previous week.

2. Provide participants with a clear understanding of
the goals of the workshop. Define procedures which will
be employed.

3. Briefly review the materials covered previously.

Self—advocacy Training

1. Teach participants the distinction between
nonassertive, assertive, and aggressive responses,
including verbal and nonverbal behavior associated with
each.

2. Provide a rationale for homework assignments
(self—monitoring procedures) and demonstrate the
recording of assertive situations.

Social Support Session

1. Have each member of the group discuss some of the
problems that he/she faces. Have group members generate
solutions to each member's problems.

Handouts:

DEFINITIONS

A COMPARISON OF NONASSERTIVE, ASSERTIVE AND AGGRESSIVE
VERBAL BEHAVIORS

ASSERTION EXERCISE

A COMPARISON OF NONASSERTIVE, ASSERTIVE AND AGGRESSIVE
NONVERBAL BEHAVIORS

 

208

Means pg Objectives

Introduction

 

l. Breaking-the—Ice-: Introductions

 

Turn the meeting over to the welcoming committee, which
will take over introductions from this point on.

2. Group Goals and Procedures:
Review the materials presented in session 1.
3. Recap Previous Session:

a. Briefly review major topics discussed during
last session. Specifically highlight: what is meant by
assertiveness; how everyone has the right to appropriate
expression of feelings, beliefs, and thoughts as well as
the right to stand up for their own personal rights.

b. Review the log books. Question participants as
to whether thy have used any of the assertion techniques
discussed in the previous sessions. If so, what were
the results? You may suggest role-playing recorded
situations in which a member(s) indicated dicontent in
how s/he responded. Allow other group members to offer
corrective feedback and suggest alternative means of
handling the situation.

Self—Advocacy

l. The Distinction Between Nonassertive, Assertive, and
Aggressive Behavior:

 

a. The Basic Components

Distribute DEFINITION handout, read and discuss.

Elaborate on the definitions by adding the
following comment obtained from Lange and Jakubowski
(1976, p. 7—10).

Nonassertive:

-Person violates his/her own rights by failing to
express honest feelings, thoughts, and beliefs and
consequently permits others to violate him/her.

-Expressing one's thoughts and feelings in an
apologetic, timid manner causing other to disregard them
easily.

 

209

—The Basic Message communicated:

"I don't count, you can take advantage of me."

"My feelings don't matter — only yours do."

"My thoughts aren't important — yours are the only
ones

worth listening to."

"I'm nothing, you're superior."

A nonassertive person shows lack of respect for his
or her own needs. We can summarize the goal of
nonassertion as the desire to appease others and to
avoid conflict at any personal cost.

Aggressive

-Involves directly standing up for one's rights and
expressing thoughts, feelings, and beliefs in a way that
is often dishonest, usually inappropriate, and that
always violates the rights of others.

—The goals of an aggressive person are domination
and winning, forcing the other person to lose.

~Winning is insured by humiliating, degrading,
belittling or overpowering other people so that they
become weaker and less able to express and defend their
needs and rights.

—The basic message communicated is:

"This is what I think — you're stupid for
believing

otherwise."

"This is the way it is — forget your way."

"This is what I want - what you want isn't
important."

"This is how I feel — your feelings don't count."

Assertive:
—Involves "respect" for oneself and for others.

-Involves standing up for personal rights and
expressing thoughts, feelings, and beliefs in direct,
honest, and appropriate ways which do not violate
another person's right.

The basic message communicated is:
"This is what I think."
"This is what I feel."
"This is how I see the situation."

 

 

210

Compare these behaviors in terms of:

-Characteristics of the behavior.

—Your feelings when you engage in this behavior.

—The other person's feelings about him/herself when
you engage in this behavior.

Distribute a COMPARISON OF NONASSERTIVE, ASSERTIVE
AND AGGRESSIVE BEHAVIOR handout. This will help
facilitate the discussion.

b. Nonverbal Components

Distribute ASSERTION EXERCISE sheet. Allow several
minutes for group members to complete the form. Go over
and discuss.

Under the nonverbal behaviors we have "shaking a
fist in someone's face." This is a pretty aggressive
behavior. Looking at the floor while talking to someone
is a nonassertive behavior. A relaxed, non—slouched
body position is an assertive nonverbal behavior.
Number 4 is nonassertive, number 5 is aggressive, number
6 is assertive, numbers 7 and 8 are aggressive, number 9
is nonassertive, numbers 10 and 11 are aggressive, and
number 12 is nonassertive.

Under the verbal behaviors numbers 1, 5, 8, and 10
are assertive behaviors. Numbers 2, 4, 7, 9, and 12 are
aggressive behaviors. Numbers 3, 6, and 11 are
nonassertive behaviors. If you missed any of these, go
back over them and try to decide why the behaviors would

be classified as they are. If you are unsure after
re—reading the behaviors, go back over them when you are
through reading this manual. The answers should be

clear then.

Have group members fill in A COMPARISON OF NONASSERTIVE,
ASSERTIVE AND AGGRESSIVE NONVERBAL BEHAVIOR sheet.
Point out the role of nonverbal behaviors and the impact
of such actions (body language) on statments being
made.

c. Explain reason for filling out log books.

When you agreed to participate in these classes we
gave you a log book; the reason for this was that we
wanted you to keep a self—assertion log. The reason we
asked you to do this was that keeping a log of your
assertive behaviors will increase your understanding of
the behavior; the log provides a more objective view of
how you behave in real—life situations; it is a way for

 

. ‘-'-'—"-h‘nrue_._— ——§—==

211

you to see whether or not you are becoming more
assertive. It also helps to identify common patterns or
problem areas that you may want to work on. Lastly, it
is a record of your progress and personal growth and it
may motivate you to continue your efforts at changing
your behavior. Please don't forget to fill out the log
sheets.

Social Support

Present the group with the following:

Groups like Alcoholics Anonymous have found that
their members need to find out just what kinds of
problems each individual member faces, and how members
meet and conquer their problems. Diabetics, like
everyone else, are bound to have problems and to have
found ways to solve them. Tonight the group has learned
the distinction between assertive, nonassertive, and
aggressive behavior and responses. When you discuss
each member's problems, try to generate assertive
responses. After each solution is suggested, members
'should ask themselves whether the situation is one in
which the person should be advocating for themselves,
and whether the response is assertive, not aggressive.
The group should try to come to a majority agreement on
a decision.

In order to decide what this group can do, you need to
identify these problems and solutions. Therefore,
tonight the group should:

1. Have each individual member of the group state some
problem that has been presented in his or her life by
diabetes. The secretary should record very carefully
each different problem. Repeat problems need not, of
course, be recorded separately.

2. After each member has had a chance to state a
problem, each member should state a solution, if one has
been found, to a problem. It might be the person's own
problem, or a problem presented by someone else. The
group should get a consensus on each members' problem.
Again, the secretary should record each solution so that
no suggestion will left out.

 

212

3. For example, a problem might be:

Linda has received several dinner invitations, which
she would like to accept. The problem is that most
of the invitations for dinner are for late meals.
Linda needs to have her dinner fairly early. On one
hand, Linda feels upset because she would like to
accept the invitations; on the other hand Linda is
afraid of what might happen.

People in the group might suggest a solution such as:

Eat your snack at dinner time and this might get you
through until dinner. Or, ask the person extending
the invitation to make the dinner earlier and explain
why.

 

 

 

213

DEFINITIONS

Nonassertive — That type of interpersonal behavior which
enables an individual's rights to be
violated in one of two ways: (a) the
person violates her/his own rights
when s/he permits her/him to ignore
personal rights which are actually
very important to her/him or (b) the
person permits others to infringe on
her/his rights. Involves letting
someone else take away your rights.

Assertive — That type of interpersonal behavior

in which an individual stands up for
her/his legitimate rights in such

a way that the rights of another are
not violated. Assertive behavior is
a direct, honest, and appropriate
experssion of one's feelings,
opinions, and beliefs. High quality
assertion also includes an empathic
component which shows consideration
and respect for the other person.

Aggressive - That type of interpersonal behavior
in which an individual stands up
for her/his rights in such a way that
the rights of another person are
violated. The purpose of aggressive
behavior is to dominate, humiliate,
or "put the other person down"
rather than to simply express one's
honest emotions or thoughts.
Involves demanding your rights without
respecting the rights or others.

 

 

214

 

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use Oman-o: »~aauu«seum:=
.ucusucoeeu

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€3.35... :5...

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ssuu ecu ue »uoue«ueueeo
.nouwsasa .esoeun-«n

.ewocuo no success can

on oauuo edeou ae>uacu<
.euesuo no smeuse>ea aux-H
.euesuo no soanun eaueaou>
.uueuqa ace ueeeoc »-e
Icoquoso »~aus«waooaaeeu

 

.
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nou>ecun e>uouono< augueco no:

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us ucuuaeoueuuuee .uoesuuoou

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as» use engage eao euouooum
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»-eeo«uooe »~uoauoaonaa<

 

nou>ecuu u>uunomm<

 

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uoq>ecsn usuuuunmecoz

 

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az< dankmmmme

 

.anee_euh sou euusuuuonm
.m .«aesoassan ace .n .< .euees “Iowa penance

.uo«>eaea ease
sq ensues so» can:
so» user eucudeeu
a.coewed uecuo e:H

.uo«>ecua aucu ea
sue-cs so» coca wane
Ines usoaa eucuuoeu
e.noaoea necuo och

.uou>s:ea
saga cu eunuco so»
coca eucuaeeu use»

.wou>a:oa ago no
equueunuuuaweau

 

ASSERTION EXEECISE

—-———

Identify the following as either nonassertive (NA), assertive (A),
or aggressive (AG).

1:
2.
3.
‘0

5.
6.
7.
8.
9.

10.
ll.

llHlHl-Hl

12.

l.

2.

3.

NONVERBAL
Shaking fist in someone's face.
Looking at the floor while talking to someone.
Relaxed, non-slouched body position.

Inaudible voice (extras-1y quiet; cannot hear what's
being said).

Loud shouting.

Direct eye contact.

Standing very close to someone while telling them off.
Giving someone the finger.

Sitting sideways, looking out the window while talking‘
to your professor.

Staring fixedly or squinting.
Excessive clearing of throat.

Covering mouth when speaking.

VERBAL

 

”I'm sorry I can’t do that, I have too much to do."
'Get the hell out of here.“
"I'm sorry I brought the idea up, your idea is better.“

"Don't give me any stuff. Just do it the way you're
told!"

 

216

Assertion Exercise

age
5.

6.

7.

B.

9.

10.

ll.

12.

‘I need your opinion on this if you have the time."
'It's hard for me to tell you how I feel.'

'You are totally unreliable and I will never lend
you anything agein.‘

“I‘m really sorry to interrupt, but do oyou think
it uld be at all possible for you tm your
stereo down a little? I'm having difficulty
reading next door.‘

'I won't wait a minute. You're going to listen to
no NOWI'

'I know what I did was wrong, but could you please
let me tell my side of the story?‘

I'Oh, well, um, huh, I guess I could stay late to
complete the project. No, it won't be any problem.
I'll phone and tell my husband to cancel our reser-
vations.

"You made three typing errors on this form: Next
time be more caretull'

 

 

217

 

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Icoc uuusuocxeoue— aeuneqe an:

edge acqoa e.uu;:

euuaesgmau tee acuruueuuue

.euuomaee see oueeeuo nebuo>
ecu cow: ucueuueou —ebuo>=o=

1.1m added u.ueo: Handgun
new are eouevoe uo«>erub «enue>coz
ucoeeueuuenunee .ucuveume
. .aueunce .eeucxee: e>u>=ou

acoucou

 

m uguoocu ueosuaa
oueuvullu .0>«e~:me« .uuuelou=<

aeronau-
urueotu :neoce he» .eeeocebcodm

enuu era mo uequuu: nauseous”
ueOuAU use no neg-souu unearunm
eoecsd guy: amuuuu ace henna-u:
-c«3b-e:e aceuvoum

9.1.:

 

m couueeuus ecu
uqu u.:eoov uesu euuo> ucuvuuuu
” econ ucuaeuueeoceu no uuueeueem

some: a0; ee sou-us euneresu
eogueeuue on 930— uneueuudouao<

73:53.3 do. 2.25
.coeuueom

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douuuo~ueu .ucohv
ouuo>

 

m rheo- 1emau~|uauuu scenes

Ache ..u.eueuuuv emu“:
euouaexe can no med-and
oval—nun: .215..—

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Aug-ac. or“ e=¢>uuc

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see ace: euequdeund<

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can: rad: gueol ecuuo>ou
uuruo eau
ou uoou ace Iona urn—u: euuuurm
ucuauoqu acuueeqae.au—oaen
.ugl neuuoxcuu.u.e.euu:ueuu eeo>uo=

eoueueou

 

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soeauou ncueeea
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. wouaeuueeu ucuob
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eves eu Juneau e>uuueeee

ee eoeuoo loan unusuauen ennum
condone-cu

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uoeucou eae e>uee>u

 

 

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ea—huuuv<zcz no

nou>sgon Aubnu>coz

 

 

218

 

 

acoucou

 

9:5

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mood-enuexm ueuusm

 

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neu>e£uo uebue>coz

 

219

D S .N l

W

The following sel:—eheek discrimination exercise consists or
60 interpersonal situations. The responses to these situations
are sive. assertive, or nonassertive. Twenty Judges rated
each or these responses reaching 90 percent to 100 percent agree-
ment on classifying each situation.

Care! read each situation and classify each responae as
either assert ve (e). aggressive (-). or nonassertive N .

Examples:

 

Situation gggpgngg

1. Husband gets silent. instead I guess you are uncomfortable talk-
of eayin; what's on his mind. in; about what's bothering you.. I
You say. think we can work it out if you tel

me what's irritating you.

2. A friend has asked you for Youfre taking advantage of me and
the second time this week to I won't stand for it! It is your
babysit her child while ehe reeponsibility to look after your
runs errands. You have no own child.

children of your own and
you' reapond.

 

 

 

Situation

3M etendantatspudmmh.
“Wine-slap _r
leleounetlatM-mem.
Watemltendyeu-y,

4. Vul‘d like a raise I‘ll say,

LSemeeneaelulwandenmutdlxuup
m‘mvfl‘nmmuew
Mandatedrltweilltalteyouuto!
wwaouny.

‘Ml «lento. Dealer's date and
an

thrush-lemony... mutt-mu
”*“demuatnemu
lhool. The pianist hut-tot been curled
mYouuy,

220

Retro-V.

Otedyedwlteefueottoommypaomtonll

:. you-u wily m. . u... .u..
:‘fivfilfi‘jr "'3
"”- rm-fio .-n.

olfifiu-mmmmummmmm

Masonite!

lmnufortlowtedeystdanukeywtoamvm-

lettbtusteeJutlm'tbeabletooheyeuhm

Yul make the menial interesting. I like the way you teach

If.“

I that“: we tweed last Tuetday that you would have a
on: with M allouthev behavior at school. So far there't
be. matinnonyouroen. l ttill think you thouid talk to

h" 1°”- ” older tometlme tonlm.

 

 

,

unduly. When awed shout the the. you
my.

9.le a mm. a mat «ideally tsyt.
Whatdeyouwowllibeenmtiny-

HLYu‘ve been talking in a while with a
friend on the telephone. You would like to
.d the mien and you lay,

ILA married men pettitu h ultine you out
la a date. tsyln; “Come on honey. what
hmnanltdotogotolunch withmeiua
this mu?" You retool-Id.

12./u a meeting one person olten interrupts
you when you're touting. You say.

13. You are in I hard-tell camera store. and you

been pressured to novel-late an iten.
You HY,

 

Well i p- It't-OK'. PM not seine to be able to attend very

M but It lite mom elte't Wale.

Fsimll and eetnllty.

I'm unlbly sorry but my wooer's burning and l have to

get of! the ohm. I hoot you don't mind.

i like our relationthio the way it is. i wouldn't feel con-lion-
tole with any kind of dstln; relztlonthip-end that include:

Iunth.

Escute me. I would like to finish my tutement.

Well, OK, I [met that't pretty much what I was looting for.

Yes. 1 wood“ I'll get it.

.H; -'-‘-'v'v".':

 

Sitar-tree

14.Abflndeelueme¢ultduktyoute
mundane“.

15.7w It-eedtodela-tey.Aedte
child out handy In the edit, went
“YI-

ItYouhaeehn "alumni
weekhya‘enoh-Mwledto
reflyoummealleeeeetaeuyou
ruin elm hmmquheoreoetldon.
You-v.

11.xumhaemalthgalotefnflYou
bangtstdtedluetdyell,

lLMaeetnh-eehuaehdtohenowyeur
al‘uthemYouew,

19. Wile tell: “and the'd like to return to
Mil-hut'tmtheetodemltand
aye.

flmmnh-aletdmhtah-le
“You-y,

2LI-lutbuwleseeetedlreterennelewhenlte
arrive: horse Ire. wot and no an”
WilbnudienbnmedlatelyJIouny,

21You'vetak-asrltlothedemenmatyou
plantoeeulo‘aeorniqtoeelaioeulon.
WhenyouptoolehItueJlllflndtnet
there'uhele'et it You tsy.

23.Youarehseq‘ troubleevltlngaouerlnd
don‘tkmweaaedywltatfurthwinl‘m
tianyouneed.Yousay,_

24.noornmate toutto leave for wort tells
you Ihatalrbndofhleneedearidethat
allernom and he ha volunteered your
unknYou-y,

25.A Inend‘ pruned' to come to a soeuai‘
partyandthotfsiiedtothowuo.Youeall
andalteraleemlnutetoftoeiaioarm
Ila-tawny.

 
 

221

mat—Ha“
Yeueeoele'm"dtatltnbetetnyou‘re blind, people
ltseete.trt'ry.nrl!truyeu.Well.l'meemlnlynotgoing

:utfmiflopwmmhunymoumthe
MtMIYeuluetneoerdodthgulghu
Thislsdtethiedtlmel‘eebeendhorrbedandeaehtimel've
toldyoutlltl'mnetlntereetedinaroeeriblngtoanyrnaga-
mlfyouallagaioJl timolyltevetoreoortthittothe
led-marlin.

HeyyoulKneekoll'theneieel

ldon't know“ . Well. it‘s not wonhgettingintoafuu
shortltYeueuhenowlt. butlthouldwunyoumat
l'hbeerlhsrirtgtrouelewidtdwlnlret

Why mid you I'll to do that? You know you're not
eaoableertouduohandletheestnworlrload.

 

.. $8»)

2 wi‘ll‘t‘mw‘o

lhwwmlllmtlredan and hung-y utdwouldliketohaye
dinner Immediately.~llut l have belt doing tome tculoting
Mkmtbmlwlllhayedlnnerrudytoon.

I planned to wear that tonldtt. Aren't you people retoomi-
bleenoudnodeeomethhgebeutlt

lreally mutt be dtlnh but I don't lutowwnere to begin on
truism.

You’ve got your nerve committing me without aelting firm
The“ no way I'm going to the airport today. Let him take
a cab iilte everybody elee does.

I undentoed that you were coming to my party but you
didn't come. I feel bad about not having you there. . . .
What happened to you

 

 

Sim

nnmrmuumuutmmae
Wyn-tyortomdlesoeetlu
nth-IMVIoudon‘tw-tttodoltwldsay.
27.Yule.etarseetlngofsevenmwtlldose
wtsnwthhebeflwiIgefthereeedng,
dam-tryoutobedse-oetary.
Yeurematd.
nYwneawualtthyeu‘redoingall
the planning, teeming. int-reeling ltd
evehuthsardwtuYouay,
nThebusIsaowhdwidthldtsthoolstu-
mam-earthwommvu
witttoptollbutnooneoaysattmtlm
“may“Ootple-a'finelly,you
av.
nsmumlasetoebforthethbd
dreaTeaherr-oont.

 

 

 

31.Manasltsyoul’oradate.You'vedatedhlm
onoebeloreandyou‘renothtsrestedln
datinghirnaaabuvumwl.
3211a Ioeal llbrwy sells and asks you to
return a book which you never chested
ouLYouresoond.
.YouareutalineulhemSorneone
behindytsrhasonelternandasltstoptln
frontolyotnYousay,

. Parent-ls talking with amarleddrild on the
telephone and would lllte the ehild to come
for a visit When "to child politely refuses.
the parent says.

. Employer sends a memorandum stating that
there should be no more toll business calls
made withurl first getting prior permission.
One employee responds,

3&erhusbandespetu dlrwteronmetable

when he arrives borne from work and gets
angry when It Is not there Immediately.

You respond,

222

up,lelusthndeat1w-rywiubernadatmelfl
ray}, 'Heaeys l‘malwaysgettlnginvoivedintoomany
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l‘mlhunltwtsnanln

.
3153130"; . '...-

    

We'rearootnedto lswnteaohir'andyetlseethatlarn
doitgallmew'tl'dllhetotalkaboutdtangingthia

Mutlsdtemauerwithyou kids? I'm-apposed tog-toll
atthenestoornwl

“yahoothmeatthebeglmingolrnylecuthave
tone-Imel'rnyleeutremdmattalteseatnolassume.
lhmuthwedbyyourwdlnem.

 

on, I'm really so busy this week that I don't think I will
haeetlrnetoseeyou thisSalurdaynight.

What be your talking about! You people better get your
reeords straight—I never had that book and don't you try to
matte me pay for It.

I rediae that you don't want to wait in line, but I was here
first andl really would like to 'l out ol here.

You‘re never salable when I needyou. All youever think
about Is your-sell.

You're talting away my prolestionai iudgrnent. It‘s Insulting
to me.

I feel awful about dinner. I know you're tired and
hungry. . . It‘t all my fault. I'm lust a terrible wife.

 

m

31M to nation touther re abruptly
chanpdbyfriendandrnertedtoyraren
thephertefluueqend.

“herniaMIhedtfldfltt-hn

”Yumhwuallyleae-lheroore
amYutey.

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neonW.Therelss-rtethlngeleethat
yeu'dllketoeeteh. Yttusav,

41.?lentisutnoyedthaudtoolootnseiorh-
not donelmhing abs-rt son‘s eertfllet with
ateaeherJaentr-Iys.

41ml- iust berated you in you
recent.

'w..'. hair'-

223

1:." .'_N-‘.

reaIIy'tak-rnrybyurprise. I'd like toeall
yter' berm-I've had same time to dlgut what's
Ml :I\-'__“€.'1: '

Venibi r's‘sI-titeimtues in on whole um lfl m
qumwbilhmh,Ieuudm
hasehadarykidtatull

You'rea'reeasltdoutroernlsarnees

Well,ah.honey.poaheadmderatdtthegwne.igueul
cottlddouutelrunlne.

l have asked the school to investigate thetituation in my
tat‘smandltooneernsmethatnothinghasbeen
Mimmmmumuimelm.

lethkteeteelyourattleluruareanutlmldhave

wk. You

llkedyutrbdtgl-persondahutttelllngmeaboutmy
m

 

‘3. Your terr-year-old childhasinterruptedyou
_three tlrnes with something that is not
org-it. You'eeaseeniyelyaaketlhunotlo
interruptyetuThechlldhasr-ovaaalnln-
terruptedyotLYousay.

«.ltisyourturntooleutheaotunmt.
which you have nedecud to do several
tirneainthelastrnonomnaeeryalrntone
olvoieeyourtoornrnateaakayoutoelean
uptlteaoannsatLYoutav.

4S.You‘retheatlyminayoupolmm
anoyou'reashdtobethetecretaryofthe
meetingLYourespond.

uAfwwmdmsolestegetwtof
doinghisturnofteatnteaohingandasks
youagaintotakehistumvousay,

47.Artaequaintanuhasalsod to borroeryout
car for the evening You say,

48. Loud stereo upstairs is disturbing you. Ym
telephone and say,

 

Ican’tlistantoyouandtalkmmephmatthesarne
tlrne.l'llbeonthephoneafeerntorernimtesandthen
ere'lltalk.

Would ya getol'frny Ml

I'm willing to do my share and take the notes this time. In
luture meetings, I'd like us to share the load.

Well... I was that'dbeOKeven ifldohaveatplitting
headathe.

Are you cmyl I don't lend my car to anyone.

Hello, I live downstairs. Your stereo is loud and is bothering
me. Would you please turn it down.

 

i

Sutton-

4!. You havetetaslde4zwtostmlw thin.
youeuturuedtodoiomeoneasksto
ueyottattltattlmeYutuy.

muf'flflthdafl'ma.‘
hermintYouny, .

SI'W “mwmmh
frontdyurlriendsYureay,

52.41“ olten mmllflmggd
”Humanitarian-use.
““wfwamflmmyurd
mmu‘vehar.Y¢laay,

”'Amhlmmwmm
Wm we. The last um,“
leWltensheasbdloritauh,m

I

224

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W“. U“, 'I we eu- , “‘ ‘ I... u o‘
M “my“ ‘II! “III {c ya”

, then.

Huerta-.mug'tnm treatment. Would ‘
ltktl
wltltoutltlsoneel, _,' lYOIHo
L'really teal luneh-ryouerlticlaantyappearancein front
odterpewle. ll'youluvesontethingtosay.pleatebring
ltupathemebetueueieavel

lonlyltaveenouflttneneytopayformyoeniunch today.

i‘m sorry. btnldon’teranttoloan
my sweeper anymore.
Thelaettlrne lloanedlttoyouitwaareturned broken.

 

“Awbbeutghtervieeredloralobdn
the process of which the interviewer looks
atherleer-indyandsayt. "Yuceruinly
look like you have all the qualifications (or
the lots.” She responds.

55.er mate waste to go out {or a late night
snack. You‘re too tired to go out and say.

56. You're walking to the copy machine when a
ielloer employee. who always asks you to
do his copying. nks you where you‘re
going. You respond.

51. Parent is talking with a married child on the
telephone and would like child to come for
a visit. The parent says,

58. Your best friend has recently divorced. She
confides that site is currently sleeping with
several men and is not happy with this
situation. She says that she's not tun hour
to handle It. You respond.

   
   

‘ m4...

I‘rnosrelarntealteeaoableoldolngtheworkhere.

i really don't (eel like going out tonight. I‘m too tired. But
I'll go with you and watch you eat.

l'm going to the Celtics ball game. . . Where does it look like
i‘rn golngi

I had a funny dream last night. I dreamt that the grand-
children carne to visit me.

Well, i press it's true about what they say about divorcees
being an easy mark.

 

 

59.‘Each night your touttrnate consistently
slams the bathrocn and bed‘oom doors.
eiflter keeping you avake u out if you're
not Mill]. ltnoying you. You say.
.fiLYou ueauud b one «ta-amumuae
You respond,

Taken from: Lange. A.J.
. Behovi :-

 

  

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225

Pleasedon'tslln “doors-it's mnoylngtohearthatlate
irtotertiutolteraketnteupandian'tgetbacktosleep. _—

l'ot story. I'm

mnhmuhbaeuneormucummau. ..___

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and Jakuboneki. P. Ree

 
  
     

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oneible Assertive
T rocedure: Tor

   
  

Reaearch Preae.

 

226

Session 3: Evaluating Solutions

Objectives
Introduction
1. Have welcoming committee conduct introductions.
2. Provide participants with a clear understanding of
the goals of the workshop. Define procedures which will
be employed.
3. Briefly review the materials covered‘previously.
§g1£-advocacy Training

1. Introduce the various assertion techniques: basic,
empathic, escalating, confrontative, and I—language.

2. Provide an opportunity for members to practice the
techniques through role playing. Explain what role
playing is, and the procedures involved.

Social Support Session

1. Have group members evaluate the previous solutions.
Present members with the tasks to be completed during
this session.

Handouts:

TYPES OF ASSERTION

HOW TO GIVE FEEDBACK

 

227

Means to Objectives:
Introduction.

1. Greet members as they enter. Make small talk.
Turn the meeting over to the welcoming committee.

2. See session 1 for explanations of the goals of
the group,'and the definiton of procedures that will be
used in the group.

3. Recap Previous Session:

a. Briefly review major topics discussed during
last session. Specifically highlight: what is meant by
assertiveness; how everyone has the right to express
their feelings, beliefs, and thoughts appropriately, as
well as to stand up for their own personal rights; and
the distinction (verbal and nonverbal) between
nonassertive, assertive, and aggressive behaviors.

This last point can be covered conveniently by quickly
reviewing the DISCRIMINATION EXERCISE ON ASSERTIVE,
AGGRESSIVE, AND NONASSERTIVE BEHAVIOR assigned as
homework last session.

b. Review the log books. Question participants as

to whether they have used any of the assertion
techniques discussed in the previous sessions. If so,
what were the results? You may suggest role—playing

recorded situations in which a member(s) indicated
discontent with how s/he responded. Allow other group
members to offer corrective feedback and suggest
alternative means of handling the situation.

Self-Advocacy Training

1. Assertion Technique:

Distribute TYPES OF ASSERTION handout. Inform
participants that there are many different ways to act
assertively, and these are just some techniques designed
to help them assert their rights in an appropriate and
effective manner. Stress that the information provided
on the handout is merely intended to serve as a guide,
suggesting alternative ways to respond, from which one
can select (and also modify) the method most appropriate
to the situation at hand.

Read handout over with participants, elaborating and

228

clarifying the techniques outlined.
Skill Practice:

Provide an opportunity for participants to practice
the various assertion techniques by having them role
play personal examples.

2. Role Play Introduction

Ensure that the group clearly understands the role play
technique. Ask participants if they have ever
role-played before, or if they know what is meant by the
term. Explain what role play is:

A learning method in which an individual is asked to
take a "role" of another person or him/herself, and
enact (act out) the situation at hand as if they were
that character. Through role play, one can observe
and receive feedback on the effect of his/her
behavior and can practice new ways of responding.

Inform participants that role—play procedures will be
employed throughout the course of the workshop in order
to provide a chance to practice the techniques and
skills taught, to receive feedback from the trainer and
other group members on their behaviors, ane to observe
others role play and provide them with constructive
feedback.

Outline the basic role playing procedures that will be
followed. (Write key words on board).

1. A situation requiring an assertive response
will be described by either the participants or by the
group leader.

2. Group members will be asked to volunteer to act
out the roles involved.

3. Those role playing the situation are to apply
the skills and techniques they have learned in training,
while the remaining group members observe.

4. Following the enactment, each member of the
group will provide feedback on what s/he observed.
Comments are to be directed at the actor's behavior,
taking into account the actor's application of skills
and techniques. Corrective feedback should be provided,
if applicable, along with praise and approval for

229

appropriate and effective responses.

(At this point, it would be appropriate to distribute
and read over the FEEDBACK handout to provide trainees
with a clear set of guidelines for giving useful
feedback).

5. Following feedback, the person receiving the
feedback should rephrase the feedback to ensure accurate
understanding. The receiver may then replay the

situation (behavior rehearsal), applying suggestions
made during feedback, or may request another group
member to role play and model a more effective
response.

NOTE: The above is designed only to serve as a
guide. Often variations in these procedures are called
for. This is left to the discretion and expertise of
the trainer, who should base specific procedures on the
needs of the participants. Role reversal procedures may
also be effective in certain situations.

Role Play Assertion Techniques

Attempt to diminish trainees' possible reluctance
to participate by stating that at first they may feel a
bit silly or awkward. However, the more they do it and
the more they put themselves in the role (by adding
personal touches which represent their individual
style), the more realistic the situation will be, and
the less awkward they will feel.

Start by giving an example. With the help of an
assistant, or an eager volunteer, role play the
appropriate application of an assertion technique
described in the handout.

Have members role play the various assertion techniques,
suggesting. that they select an incident recorded in
their logbooks. If no one volunteers, or the group

overall appears reluctant to engage in such
self—disclosure at this time, employ hypothetical
situations. These descriptive situations should be

prepared prior to the session, and their content should
reflect assertive situations of common concern to the
particular training group.

 

230

Social Support Session

During this meeting each member of the group should
discuss the problem(s) that were brought up in the last
meeting. This should be an open session. Every member
should be free to offer both problems and solutions. If
you disagree with a solution that is offered, tell
everyone why you disagree. This should be a good time

to practice your self—advocacy skills. Every member
should resent his or her problem and discuss the
solution(s) tried. Attached is a list of the problems

and solutions that were discussed in the last meeting.

Present the group with the following questions?
1. Discuss the solutions that were suggested by
members last week.

a. Were the solutions that were discussed last
meeting tried out? Was(were) the solution(s)
effective? Did any members use any of the assertion
techniques discussed earlier?

b. What solutions were not effective? Discuss
possible reasons.

2. What new solutions can be offered for unsolved
problems? Could the various assertion techniques be
used?

3. Write down solutions for each problem that is
presented.

 

231

Types of Advocacy

1. Basic Assertion:

There are many different ways to act assertively.
A basic assertion involves standing up for one's r1ghts,

beliefs, feelings, or opinions.
Examples:

When being interrupted:
"Excuse me, I'd like to finish what I'm saying."

When being asked an important question for which you
are unprepared:
"I' d like to have a few minutes to think that over."

When returning an item to a store:
"I'd like to have my money back on this dress."

When refusing a request:
"No, this afternoon is not a good time for
you to come and visit."

When you would like something re— explained:
"I' m sorry I do not understand what you are staying;
would you please explain it in simpler terms?"

Basic assertion also involves expressing affection
and appreciation toward others.

Examples:

"Thank you for picking up the papers."

"I like you."

"I feel better after having discussed this
matter with you."

"You're truly special to me."

"I really appreciate what you did."

2. Empathic Assertion:

There are also empathic assertions. Empathic
assertions involve making a statment that shows you have
listened to the other person and recognize that person's
situation or feelings. This is followed by another
statment which stands up for your rights.

 

 

232

Examples:

When two people are chatting loudly while a meeting
is going on: "You may not realize it, but your
talking is starting to make it hard for me to hear
what's going on in the meeting. Would you please
keep it down?

When having some furniture delivered: "I know it's
hard to say exactly when the truck will arrive, but
I'd like a ball park estimate of the arrival time."

When you don't understand the directions for taking
your medication: "I realize that you are very busy,
and that there are other people waiting to see you;
however, I do not understand how to give myself these
injections. I would like you to give me a little
more time, so that when I have to give them myself,
I'll feel more comfortable."

Empathic assertions are particularly good when dealing
with angry or upset individuals and/or superiors.

Example:

When telling a parent you don't want advice: "I know
that you give me advice because you don't want me to
get hurt by mistakes I might make. However, at this
point in my life, I need to learn how to make
decisions on my own even if I do make some mistakes.
I appreciate the help you've given me in the past and
now you can help me by not giving me advice."

3. Escalating Assertion:

Another assertion technique is called escalating
assertions. They involve increasing the assertiveness
of a response in order to obtain a desired goal. First
you start with a minimal assertive response, intended to
accomplish your goal with a minimum amount of effort and
negative emotion and a small possibility of a negative
consequence. If the other person fails to respond to
the minimal assertion and continues to violate your
rights, you gradually escalate the assertive response,
becoming increasingly firm without becoming aggressive.
If the other person continues to violate your rights and
fails to respond appropriately, you can offer a contract
option. This involves presenting your original demand
in an "IF" - "THEN" statement, clearly identifying the

 

 

233

consequence for noncompliance.

Example:

The speaker is in a theater sitting where it is
clearly marked "N0 SMOKING" next to an individual who
is smoking a cigarette.

Minimal Assertive Response: "Would you please put

 

out your cigarette? This area is designated as no
smoking."
Escalating Assertion: "I asked if you would put out

 

your cigarette."

Contract Option: "If you do not put out your
cigarette, I will bring the matter to the attention
of the manager."

4. Confrontative Assertion

It is to be used when the other person's words
contradict his/her deeds. Confrontative assertion
involves clearly describing what the other person said
s/he will do, and what s/he actually did, after which
you express what you want. Your statments should be
made in a "matter—of—fact," nonevaluative way.

Examples:

"I said it was O.K. for you to drink some of my diet
cola as long as you checked it out with me first.
Now, I see you drinking the cola without having asked
me. I'd like to know why you did that?"

"Last week we decided we'd discuss and arrive at a
mutual agreement before giving the children
permission to stay out late on certain occasions.
Earlier today, Joshua informed me that you have
allowed him to go to that concert Friday night. Next
time, I want to discuss such matters beforehand, as
we had agreed. If there is a problem in doing this,
then let's discuss it now."

5. IfLanguage Assertion
This is a useful technique when asserting or expressing

difficult negative feelings. It is helpful in bringing
about an empathic reaction.

 

234

Use the following formula:

When you ....(clearly describe the other person's
behavior)

The effects are ....(describe how the other person's
behavior affects your life or feelings)

I feel ....(describe your feelings)
I'd prefer ....(describe what you want)
Examples:

"When ygp borrow my things without telling me, I don't
know whether or not I've misplaced them, lost them, or
whether someone stole them. I start to feel upset and
angry. I'd prefer that you ask me before you borrow my
stuff."

 

"When ygp don't call to tell me you'll be late for
dinner, the food either gets cold or gets overcooked. I
feel annoyed and mad. I'd prefer you call and tell me
if you are going to be late, so I can plan accordingly."

 

 

Information taken from: Lange, A. J. and Jakubowski, P.
Responsible Assertive Behavior, Cognitive/Behavioral
Procedures for Trainers.

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3. Avoid outing "how I would do it." Give ‘ ‘ ‘
By doine thie. you allow the trninee to make the choice9 on who: to do.
or {eedbeek in {or the benefit of the receiver, not the giver.

4. Give feedbeok an after behevior.

5. Per-on getting leedbeok should try to rephraee the feedback to clarity
the an:

 

236

Session 4: The Role of Anxiety

Objectives

1. Turn over meeting to welcoming committee for
introductions.

2. Provide participants with a clear understanding of
the goals of the workshop. Define procedures which will
be employed.

3. Briefly review the materials covered previously.

Self—Advocacy Training

1. Continue to help members develop an assertive belief
system.

2. Help participants recognize how anxiety serves as a
barrier to self-assertiveness.

3. Provide participants with a way to overcome anxiety
through relaxation training. Include a rationale behind
using relaxation, and describe the procedures involved
in progressive deep muscle relaxation.

Social Support Session

In this session participants should discuss whether

or not anxiety is a barrier to their
self—assertiveness. Each member should discuss the
degree to which he/she feels anxiety. In what
situations does each person experience the most
anxiety? These situations .may not be specific to
diabetes; they could be situations at work, with family
members, with friends, with physicians, etc. Present

group with the tasks to be completed.
Handouts:
TENETS OF AN ASSERTIVE PHILOSOPHY

HOW SOCIALIZATION MESSAGES MAY NEGATIVELY AFFECT
ASSERTION

PROGRESSIVE RELAXATION OUTLINE (and CARTOON)

237

Means pg Objectives: Introduction

1. Greet members as they enter. Make small talk.
Turn the meeting over to the welcoming committee.

2. See session 1 for a description of the goals
and procedures of the group.

3. Recap Previous Session:

a. Briefly, review gala; Egpigg discussed during
last session. Specifically the distinctions (for verbal
and nonverbal cases) between nonassertive, assertive,
and aggressive behaviors.

b. Review the log books. Question participants as

to whether they have used any of the assertion
techniques discussed in the previous sessions. If so,
what were the results? You may suggest role playing

recorded situations in which a member(s) was not content
with how s/he responded. Allow other group members to
offer corrective feedback and suggest different ways to
handle the situation.

Self—Advocacy Training

1. Building a3 Assertive Belief System: (The Basic
Philosphy of Assertiveness Training)

a. Continue to help group members develop positive
beliefs about assertion.

Distribute TENETS OF AN ASSERTIVE PHILOSOPHY HANDOUT.
Read aloud and discuss the handout briefly.

b. Help group members to accept their assertive
rights by challenging typical internal messages which
deny them their just rights and, in turn, inhibit their
assertive responding.

Distribute HOW SOCIALIZATION MESSAGES MAY NEGATIVELY
AFFECT ASSERTION handout. Read over and discuss
briefly.

2. The Role 2f Anxiety

 

Discuss how some people become so anxious when they
think about a certain situation that they, in effect,
become paralyzed, unable to respond in the most
effective manner, even when they know what to do. Fear
or anxiety may inhibit the application of assertion

 

238

skills or techniques. To prevent the unpleasant
feelings associated with anxiety, people often avoid
such anxiety-provoking situations and rarely or never
engage in assertive behavior; thus, they continue to
deny themselves their just rights. For example, a
person may be entitled to a raise but, because he/she is
so anxious around the boss, s/he never asks for the
raise. Other people feel very anxious around their
doctors. They have questions that they really want or
need to ask, but because of the anxiety they don't ask.
Other people have side effects or symptoms they are
concerned about, but do not tell the physician what the
symptoms are. You are paying a physician or any other
health provider for his or her service; you are entitled
to ask questions. By asking the physicians or other
health care provider questions or telling them your
symptoms, you are also helping them. If you can tell a
physician your symptoms, he or she may be able to change
the medication or another part of the treatment
program. If the symptoms are normal, you can put your
mind at ease.

Give an example of what can happen if you aren't
assertive enough to ask questions, for instance:

A woman about 40 years old was diagnosed as diabetic;
this was a very tramatic experience for the woman.
Shortly after she was diagnosed, while she was still
in the hospital, she was given an exchange list and a
sample diet. She read over the diet, and while doing
so she wondered if she could ever eat anything that
was not on the list. She never bothered to ask the
nurses or dieticians. Six months later I saw her in
a class for diabetics. After about three classes she
asked if she was ever going to be able to eat
anything besides what was on the sheet. If she had
been more assertive, she would not have had to eat
the same things for six months! She later said the
reason she hadn't asked before was that she was
nervous and didn't want anyone to think she was
dumb.

Ask if anyone can identify a situation in which
anxiety acts as an obstacle, inhibiting them from
asserting themselves. If no one responds, provide a
personal example to facilitate disclosure.

Learning to be more assertive can help reduce anxiety;
however, sometimes a person's anxiety is so great that
it is necessary to deal with it directly. One such way

 

239

is through relaxation training. It is very difficult to
accomplish a task when you are in a state of arousal or
under stress (e.g., have you ever tried to thread a
needle after you just noticed a split seam in your pants
and you see the headlights of your ride coming up the
driveway?)

When your body and mind are in a relaxed, unaroused
state you are better able to focus on the situation at
hand. You can increase your ability to select an
appropriate and effective course of action. You are
also more likely to dispel irrational beliefs or fears
which may inhibit more appropriate means of responding,
and that in turn increases the likelihood that you will
engage in assertive behavior, and achieve more
satisfying results.

3. Progressive Relaxation

a. Present Rationale is designed to increase a
person's awareness of the internal sensations associated
with tension or anxiety, and at the same time to provide
an active coping skill for relaxing away such reactions.

Inform participants that by placing their bodies and
minds in a relaxed, unaroused state they:
-are better able to focus on the situation at hand
—increase their abilities in selecting an appropriate
and effective course of action.
-dispel irrational beliefs/fears which may inhibit
more appropriate means of responding and, in turn,
—increase the likelihood that they will engage in
assertive behavior, which is likely to produce more
satisfying results.

b. Introduce Progressive Relaxation Technique
Inform participants that this procedure is designed to
increase their awareness of the internal sensations
associated with tension or anxiety and at the same time
to provide an active coping skill for relaxing away such
reactions.

Provide participants with PROGRESSIVE RELAXATION OUTLINE
(and CARTOON), and request that they follow along while
you explain the procedure and model the appropriate
behavior. Make sure trainees know where each muscle
group is.

Provide participants with a means of self—assessing
their levels of anxiety. Describe and explain the "SUDS
Scale," which is simply rating one's physical feelings

 

 

240
of anxiety on a scale of O to 100. "SUDS" is an acronym
for "Subjective Units of Disturbances."

Draw the following diagram on the board to further
clarify this scale:

 

0 25 50 ‘7‘? 100

no tension very very extremely
completely relaxed tense tense
relaxed (maximum level)
Carry out relaxation exercise. Have participants

evaluate their level of tension before and after the
exercise, both subjectively (by employing the "SUDS
Scale") and objectively (pulse rate). Following
exercise, obtain feedback on how participants felt about
the exercise.

—"Did you enjoy the exercise?"

-"How did you feel?"

-"What physiological reactions did you notice?"

Encourage group members to practice the relaxation
exercise at home. Stress the importance of practice.
For relaxation to become an effective coping skill, it
needs to be practiced so that it can become as automatic
as those reactions associated with tension or fear,
which are often induced by an anxiety- provoking
situation.

Make an analogy: with learning any new skill, practice
is required; e.g., driving a car, dancing, playing
tennis.

Homework

Distribute SELF—ASSERTION DATA SHEET, instructing
the group to continue to self-monitor their
nonassertive, assertive, and aggressive behaviors.
Request that they begin to identify particular obstacles
which tend to interfere with their asserting themselves.
Some examples of obstacles are anxiety, wrong beliefs,
lack of skills, or resistance from significant others.

Instruct participants to practice relaxation at home and
to practice using the different types of assertion
techniques discussed in the beginning of the session,
whenever the opportunity avails itself.

 

241

Social Support Session

In this session participants should discuss whether
or not anxiety is a barrier to their
self—assertiveness. Each member should discuss the
degree to which he/she feels anxiety. In what
situations does each person experience the most
anxiety? These situations may not be specific to
diabetes; they could be situations at work, with family
members, with friends, with physicians, etc.

Present the group with the following questions:

1. Discuss the situations that produce anxiety for
each member in the group. The secretary should write
down each anxiety-producing situation. Are there
situations that are anxiety—producing for several
members of the group?

2. Discuss how anxiety relates to being assertive
for each member.

3. How can the anxiety be reduced for each person
in the group? Can progressive muscle relaxation be used
for some of these situations? What other solutions
might be effective? The secretary should write down all
anxiety—producing situations and the solutions that are
suggested for each member. Make sure that each member
contributes to both the problem identification and the
solution. Each member's anxiety-producing situations
should be addressed.

 

MI

242

TENETS 0? AN ASSERTIVE PHILOSOPHY

 

ertion - rather than manipulation, submission, or hostility -

enriches life and ultimately leads to more satisfying personal
relationships with people.

Beliefs:

By standing up for ourselves and letting ourselves be known
o others, we gain selforespect and respect from other people.

By trying to live our lives in such a way that we never hurt
an one under an circumstances. we end up hurting ourselves
other peope

 

When we stand up for ourselves and express our honest feelings
and thoughts in direct and appropriate ways, everyone usually
benefits in the long run. Likewise, when we demean other
people, we also demean ourselves and everyone involved usually
loses in the process.

By scarificing our integrity and denyin ng our personal feelings,
relationships are usually damage ed or prevented from developing.
Likewise, personal relationship are hurt when we try to control
others through hostility, intimidation, or guilt.

Personal relationships become more authentic and satisfying
when we shar our honest reactions with other people and do
not block others' sharing their reactions with us.

Not letting others know what we think and feel is just as self~
1sh as not attending to other people's thoughts and feelings.

When we frequently sacrifice our r1ghts, we teach other people
to take advantage of us.

By being assertive andtelling other people how their hehav1or
affects us, we are giving them an opportunity to change their
behavior, and we are showing respect for their right to know
where they stand with us.

Taken from: Lange, A. J. and Jakubowski, P. Res onsible Assertive
Behavior, Co nitive/Behavioral Procedures 2

.or
Tra1ners. Champaign. IIIinOise: Research Press,

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ante us being i;-
nored. you have 1 rid“ Lo mats de-

manda.

 

 

 

Said/lotion Men‘s Eliot! on Rldm

Islenu'dveloomer lhawenorl'lnodo

people': feeling. anylhln; which

Don't hun och. midi: hurt xomoone

people. she‘s feeling or do-
flale Iomeone else'l
In.

Reproduced from: Lange, A.

244

Eric: on Ass-1M Bel-var

lwillnotuywhulnallyolhlnu
roam-mummmm
mdnlwillhhlbllmyaoonulo-

{wumldon‘lhouldvdyey
m

thaw-“worldly

Mamet-looked:

J.

and Jakubowski

Hldllly MM

II is unduirahle to dellboralely try to
hurt others. However, i: i: imoonlble
a well as undesirable lo try to govern
your llfo :o as to m hurl anyona
You have a right to express your
mum and feeling even if moons
she's fallen pl occasionally nun. To
do otherwise would result in your
bales phoney and in denying olher
people m opportunity to learn how lo

the
P. sen
Res nsible Assertive Behavior, om.“ an mes: rum :9 manipulate
Co n1t1ve7§ehav1oraI 3

Proce “3'93 you. I! you accidentally hurt metric

for Trainers. Chain amap lgn,

III1n o1s: Research Press, 1976.:-

leerlaue wllh modes lmMcmugm.r.a. [ma
De 0. Caner e L Ila-«nu “‘5.me wall wen-e

 

mm
mulsmcfhemaadnenu.

also, you can morally repair the darn-

evs me tllnltal modems of woman.

 

245

PROGRESSIVE RELAXATIQN OUTLINE

A. General Guidelines

 

1'

2.
3.
h.
5.

Find a location with minimal distractions. (Optm
conditions: quiet room. alone. easy chair, dim light)

Sit in a comfortable position.

Close eyes.

Tense only one muscle.group at a time.

Tense muscle to 705-805 capacity. (905-1005 capacity may
or b

cause muscles to cm

too much tension.)

of
mam-4114011

ody to tr emble, an indication

It you experience pain while tensing.

Tense each major muscle group for 5-8 seconds.

When you hear the word

‘NOW' immediately release

"RELAX or
the tension in that muscle. -(Say these words to yourself. )

Wait 10—15 seconds. focusing your attention on the sensa-
tions associatedw ith the relaxed state, e.g.. looseness.
warmth, heaviness. tingling in the muscle.

Breathing pattern should coincide with tense/release cycle.
Inhale upon tonsing and deeply exhale during release stage.

Progress systematically throughout the major muscle groups.
Take care not to tense muscle previously relaxed.

Repeat tense/release cycle twice for each muscle group.

Once all muscles have been relaxed. sit quietly for a minute
or two. remaining with your eyes closed focusing on th
pleasant sensation of being totally relaxed.

Come back to normal condition by counting backward. from
10-0} becoming more and more aware or your surroundings
and body as you approach zero.

Evaluate your physical state.
a. Rate level of tension/relaxation before and after exerc-

Use a ten point sea
1 2

Extremely relaxed

Melting away)

5 5 6 7 8 9
Highly te
LUptignt

b. Take pulse rate before and after exercise and compare

differences.

‘0

 

21.6

Progressive Relaxation Outline

3. Order of Muscle Groups

1.
2.
3.

\I
0

Make a fist with right hand (hand and lower forearm).
Make a fist with left hand (hand and lower.forearm).

 

Tense biceps muscles or right arm.

Tense biceps muscles of left arm.

 

Raise forehead muscles up toward ceiling (forehead, scalp).
Frown (forehead. scalp).
Squint eyes together (upper face muscles).

Clench teeth together (jaw. lower face muscles).

 

Pull chin downward toward chest while preventing it from
touchim the chest (neck muscle s).

Pull back shoulder blades attempting to make them touch.
fling a deep breath and holding it as you do so. (chest.
shoulders and upper back).

Tighten stomach muscles as if in anticipation of a punch
to the stomach (abdominal muscles).

Pull right toes toward head (calf and lower leg).

 

Pull left toes toward head (calf and lower leg).
Push down with right tees to arch foot (foot). 1

 

Push down with left toss to arch foot (foot).

 

247

 

I‘m sorry he css'l corn to (lie (these right no- . . . lu'x prurient; bis mulch "-
Ieseu‘es umiml '

 

248

Session 5: Obstacles to Self Development
Objectives
Introduction

1. Introduce welcoming committee and have them welcome
new members.

2. Provide participants with a clear understanding of
the goals of the workshop. Define procedures which will
be employed.

3. Briefly review the materials covered previously.

Self-advocacypTraining

1. Provide participants with a set of basic
goal-setting procedures.

Social Support Session

Have each individual in the group think about specific
goals they would like to achieve. Have members discuss
obstacles which prevent them achieving the goals they
would like to. Present members with specific tasks to
be completed.

Handouts:

WHY GOALS ARE IMPORTANT

SETTING GOALS

GUIDELINES FOR ASSERTIVE GOAL SETTING

 

249

Means to Objectives
Introduction

1. Greet members as they enter. Make small talk.
Turn the meeting over to the welcoming committee.

2. See session 1 for a description of the goals
and procedures of the group.

3. Recap Previous Session:

a. Briefly review major topigs discussed during
last session, especially how anxiety serves as a barrier
to self-assertiveness. In addition, review progressive
deep muscle relaxation.

b. Review the log books. Question participants as

to whether they have used any of the assertion
techniques discussed in the previous sessions. If so,
what were the results? You may suggest role-playing

recorded situations of which a member(s) indicates
discontent in how s/he responded. Allow other group
members to offer corrective feedback and suggest
alternative means of handling the situation.

Self—Advocacy Training

1. Goal Setting

3. Stress the need for individuals to develop specific
goals if one is to become more assertive.

Distribute WHY GOALS ARE IMPORTANT handout. Read aloud
and briefly discuss.

b. Teach participants the basic procedures involved in
goalsetting (either long or short—term goals), and have
them begin to consider personal goals they would like to
work toward as these relate to assertive behavior.

Distribute SETTING GOALS and GUIDELINE FOR ASSERTIVE
GOALSETTING handouts. Read aloud and discuss,
clarifying the procedures involved.

Comment on several additional points:

—Initial attempts at being assertive should have a
high likelihood of success. (You want the
individual's successful outcome to serve as
reinforcement for assertive behavior.)

 

250

-Goals are not absolute. As often as one implements
strategies working toward initial goals, situations
change and it becomes necessary to reevaluate the
situation and modify or set new goals.

-Remember that there will always be some failure in
one's striving to be more assertive. One cannot
realistically expect 100% sucess; however, the more
attempts are made at being assertive, the greater the
number of successes one can expect.

Social Support:

Give the group members the topics to be covered
tonight along with the appropriate recording
materials.

1. Each person in the group should be asked to
write a list of things that keep them from doing what
they would like to do. When these lists are
finished, every person in the group should be given a
chance to point out these obstacles in the group
itself, in the family, or in interactions outside the
family.

2. When these items have been discussed,
arrange to have someone assemble the items and omit
those that overlap.

3. Have a group discussion of what can be done
to remove these obstacles.
a. Analyze goals that are being
frustrated. Were the procedures for setting goals
appropriately considered in choosing these goals?

c. In the case of each goal for which
difficulties have been encountered, would it be
better to reconsider the goal or persist in removing
obstacles to reaching the goal?

d. What obstacles can group members help to
remove? For instance, if transportation or finances
are a problem for some people, can members of the
group do anything to help each other out? If anxiety
is a problem, can principles of self—advocacy be used
to remove obstacles? The secretary should keep
records of suggested solutions for future reference.

 

251

WHY GOALS ARE IMPORTANT
\

To be assertive, you must develop goals.

- Goals direct. Without them, you lack a sense of purpose
in Iife.

-%usmuuu. wmtutmmusmnmmwhamu,we
closer they get to a goal. the faster they hasten toward
it. When you.take a trip, you become more impatient as
you near your destination. It you set a goal, as you
approach it. you gain greeter motivation to succeed.

- Goals reinforce self-esteem. Achievement of goals strength-
ens your aesire to ICELIVQ other goals. As a result. you
attain a feeling or movement through life and a higher
sense of self-worth.

Taken from: Fensterheim, H. and Beer, J. Don't Say Yes When You
Want To Sa No. New York: Dell Pub ishing Co.,
Inc., I§75 p. 56.

I

252

§§TTIN§ QOAL§

l) QE:IE§_XQ§3_§QA§§I reads this ask ygyzgglz some ageggigns.

u)

S)

a) What are your goals?
b) How can you“accomplish them?
c) How do you deal with obstacles?
e.g. You want to move up the ladder at work. the next
logical position requires some knowlege of market?
in; which you new lack. Can you learn this on your
present job? Should you take a course? How can you
get help!
CO C P O A : Ask yourself what do.I-want~out ofllife?
Then divide your 11:. into sub goals. That means. what do I want to
accomplish today?
neg; I: EASIAg gn XQHESELE' Once you have formulated your goals.
a) Write them down. i
b) Make the list concrete and specric.
g::&_gg1_mgp§;§x Talk with friends who have managed to achieve goals
you want and see how they have handled problems you anticpate that
prevent you from even attempting the goals. .
Dgfl'x LE! 01fl§3§ 5:: XQQR QOAL§: There are many people who love to tell
you how to run your life .. when to leave a party; what school to choose
for your children. what to serve at a party. who to invite.‘what:you
should or shouldn't eat , just to name a few examples. Réfiber it's your

life.

 

Lam":

W
(Be specific 5)

Describe the behavior you want to change.

Identify any obstacles which may intertere with achieving your zoels
(e.g.. anxiety, cognitions. lack of skill/knowledge. another person)

Check your goal to make sure it is:
-reslistic
«uurable
-csn be broken down into smaller subgoels

U
a

A. List your subgoels:

Specify strategies for achieving each subgoel listed above:

5.

 

254

6. Set up s time schedule for cmleting subgoals:

7. How will you evaluate/determine success?

8. flow will you reward yourself for achieving goals? What will you do if
goals aren't achieved?

 

 

 

255

Session 6: Buddying Up

Objectives
Introduction
1. Ask welcoming committee to do introductions.
2. Provide participants with a clear understanding of
the goals of the workshop. Define procedures which will
be employed.
3. Briefly review the materials covered previously.
Self-advocacy Training
1. Discuss how one's cognitions (thoughts) can act as a
barrier to self—assertiveness. Identify the role of

cognitions and their impact on one's behavior.

2. Introduce participants to cognitive restructuring as
a way to challenge their irrational beliefs.

Social Support Session

1. Have members choose other group members that they
would like to interact with. Determine convenient times
for conversations to take place, and useful topics to be
discussed.

Handouts:

TEN IRRATIONAL IDEAS

A—B-C THEORY OF EMOTIONAL DISTURBANCE

 

256

Means £2 Objectives

Introduction

1. Turn the meeting over to the welcoming
committee.

2. See session 1 for a description of the goals
and procedures of the group.

3. Recap Previous Session:

a. Briefly review major topics discussed during
last session. Specifically highlight goal-setting
procedures. ,

b. Review the log books. Ask participants whether
they have used the assertion techniques discussed in the
previous sessions. If so, what happened? You may
suggest role playing situations in which members were
not pleased with how they responded. Allow other group
members to offer corrective feedback and suggest
alternative means of handling the situation.

Self—Advocacy Training

 

 

l. The Role pf Cognitions:

Briefly discuss how one's beliefs, attitudes, and
feelings influence one's behavior. Emphasize how one's
cognitions (thoughts) can inhibit, direct, guide, and
facilitate actions.

Discuss with the participants the need to:
recognize faulty internal dialogues which often lead to
debilitating effects on one's behavior; develop

effective coping skills for handling faulty think; and
practice such skills in order to gain mastery of their
use and maximize their effectiveness in real—life
situations.

2. Rational Emotive Procedures (Cognitive
Restructuring):

Provide group members with a means of challenging
some of their irrational beliefs that may be the root
factors contributing to their nonassertive behavior.

257

a. Distribute TEN IRRATIONAL IDEAS handout. Read
each irrational belief aloud, discuss how such thoughts
can contribute to unassertive behaviors, and discuss
various rational alternative cognitions intended to
foster an assertive belief system. (The group leader is
directed to Lange and Jakubowski (1976) p. 127—140 for
further details which will help guide group
discussions.

b. The A—B-Q Paradigm

 

Distribute A-B-C THEORY OF EMOTIONAL DISTURBANCE
handout. Describe Ellis' approach to the relationship
between thinking, feeling, and behavior (Activating
experience > Belief about the experience > emotionally
upsetting Consequence). Extend the theory to points D
(Determining the irrational beliefs involved and then
Disputing or challenging them) and E (substitute
irrational beliefs with new more adaptive emotional
consequences or Enjoy new emotions). Use handout to
help clarify the theory and process involved.

Provide group with several specific situations
(Activating experiences) and have a volunteer go through
Ellis' process; Egg/g; have volunteer/s share personal
Activating egperiences about which they have formulated
irrational beliefs. Have them restructure their
cognitions by applying the extended A—B-C approach.
Provide feedback and invite other group members to do
the same.

 

Social Support

The trainer should give the group the following
information:

So far in this group we have not suggested that you
interact with other group members outside of the
session. Group members may enjoy this and it may be
very beneficial for some.

1. Many people have said that they could benefit from
having daily support from other diabetics. Since the
problems of diabetics are often similar, it would be
beneficial to communicate with other group members on a
day—to—day basis.

a. Divide the group into sets of two to four
people, each of whom will agree to contact each other on
a daily basis.

 

258

b. Work out a way and a time that each member of a
set can contact other members as near to every day as
possible. Discuss each other's schedules and available
times.

c. Discuss what members of each set might do
together that would be fun and help the other person or
persons. Examine the possibility of practicing
self-advocacy skills and methods of reducing anxiety.
Write down what you decide so that it can be shared with
other members of the total group.

d. About what problems (one or more) would you like
consultation from other group members. Each person in
the group should discuss their problem, including a
history of the when the problem(s) started. This could
be a specific problem such as dieting, or it could be a
more general topic such as practicing advocacy skills,
or just chatting. Each member should decide what type
of interaction he or she could benefit most from; write
each person's choices down.

e. After everyone has had a chance, gather the
whole group together and share what was discussed in the
smaller groups. This might allow people to feel less
inhibited or shy in the future.

f. Finish planning a permanent directory
arrangement so that all members of the group can contact
each other if necessary. Decide how new members will be
included in small sets and have their information
included in the directory.

 

 

259

TEN IRRATIONAL IDEAS

 

1. You must - yes, must- have sincere love and approval almost
all the time from all the people you find significant

2. You must prove yourself thoroughly competent, adequate,
and achieving, or you must at least have real competence
or talent at something important.

3. You have to view life as awful, terrible, horrible,
catastrophic when things do not go the way you would like

4. People who harm you or commit misdeeds rate as generally
bad, wicked. or villainous individuals and you should
severely blame. damn, and punish them for their sins.

S. If something seems dangerous or fearsome, you must become
terribly occupied with and upset about it

6. People and things should turn out better than they do and
- you have to view it as awful and horrible if you do not
quickly find good solutions to life's hassles.

7. Emotional misery comes from external pressures and you have
little ability to control your feelings or rid yourself of
depression and hostility.

You will find it easier to avoid facing many of life's
difficulties and self-responsibilities than to undertake
more rewarding forms of self-discipline.

9. Your past remains all-important and because something once
strongly influenced your life, it has to keep determining
your feelings and behavior today.

lo. You can achieve happiness by inertia and inaction or by
passively and uncommitedly "enjoying yourself.II

Taken from: Lange, A. J. and Jakubowski. P. Res onsible Assertive
Behavior, Co nitive/Behavioral Procedures for
Trainers. Champaign,IIIln013: Research Press,

1976, p. 127-140.

 

 

l.

260

W

" AS A .
gmbat this irrational idea by saying to yourself:

A. If I assert myself. people may or may not get angry. They may
feel closer to me
like that I asserted myself
have more.respect for me
help me to solve the probl-

3. If I assert myself and they do get angry, this .
does 39; mean that I will fall apart :
does 395 mean that the relationship is necessarily destroyed
does 55 mean that 1 am a bad person
does not meen‘tbat I am responsible for the other's anger

I! I'M rmmrorm‘s mm“

gabet this irradonal idea by saying to yourself:

A. If I assert myself. others may or may not feel hurt.

B. If they are hurt. I am not responsible for their feelings.

C. If they are hurt. they are usually not so fragile that they
will fall apart.

D. If they are hurt. it does not necessarily mean that the
relationship is over forever and ever.

A SA 'NO“ TO A L '1' '1'
3 'M B SELF P OP ‘4'! TB '1!
am

Combat this irrational idea by saying to yourself:

 

A. my needs are as legitimate as the other‘s requests and I
\ have the right to assert than.

B. It is okay for me to sanetimes put my needs before those
of others.

c. People will not necessarily think I'm a terrible person for
asserting myself. If they do. that may be their problem.

0- I can only maintain control over my own life by not trying
to please all the people all the time.

 

261

Session 7: Group Project
Objectives
Introduction
1. Have the welcoming committee do introductions.
2. Provide participants with a clear understanding of
the goals of the workshop. Define procedures which will

be employed.

3. Briefly review the materials covered previously.

Self-advocacy Training

1. Provide participants with a set of effective
cognitive-behavioral intervention procedures to help
facilitate assertive responding, specifically:
self-induced relaxation, thought stopping,

self-statements, and reality testing.

Social Support Session

1. Members of the group should think about all of the
resources they might have. The group should combine all
of the. groups resources, and decide on most efficient
way to put the materials together for other diabetics.
Present the group with the specific tasks.

Handouts:

COPING SKILLS

EXAMPLES OF SELF-STATEMENTS

 

262

Means to Objectives:

Introduction

 

l. Greet members as they enter. Make small talk.
Turn the meeting over to the welcoming committee.

2. See session 1 for a description of the goals
and procedures of the group.

3. Recap Previous Session:

a. Briefly review major topics discussed during the
last session. Cover how thoughts can act as a barrier to
self assertiveness and how cognitive restructuring can
be used to challenge their irrational beliefs.

b. Ask participants whether they have used any of
the assertion techniques discussed last session and, if
so, what were the results of their use. You may suggest
role playing recorded situations in which a member(s)
was not content with how s/he responded. Allow other
group members to offer corrective feeback and suggest
alternative means of handling the situations.

Self—Advocacy Training

1. Cognitive—Behavioral Intervention Procedures:

Demonstrate and teach participants several
cognitive-behavioral techniques designed to halp
facilitate assertive behavior. Explain how these
techniques are classified as "coping skills" and are

designed to help one handle maladaptive thoughts and
anxiety which may inhibit assertive responding.

Distribute COPING SKILLS handout and explain the
techniques outlined.

a. Self—Induced Relaxation (Brief Relaxation
Technigues):

Brief relaxation techniques are useful in handling
anxiety or stress, or the physiological reactions
associated with these states. One of the best
indicators of increasing stress is your body reaction.
When most people are under stress their heart rate
increases; they start perspiring; some people feel
shaky. To help cope with this increased stress you

 

263

might use deep muscle relaxation training. Through
practice you could learn how to identify signs of
negative arousal and learn how to relax these responses
away. During an anxious or stressful situation,
however, it may be impossible or impractical to tense
and relax each muscle group. In such instances, brief
relaxation techniques are useful. These techniques are
based upon remembering the sensations and feelings
associated with the state of total relaxation.

Techniques:
1. Deep Breathing:

Have group members close their eyes as you read the
following script in a slow, smooth tone:

"See yourself taking a slow deep breath, slowly
filling your chest cavity. Good. Now exhale
slowly. As you see yourself exhaling, note the
feeling of relaxation and control you have been able
to bring forth. Next you simply stop the image and
just relax. (Gambrill, 1977).

Obtain feedback on how participants felt.

2. Imagery:

This technique also requires closing your eyes.
Once you have closed your eyes, picture the sensations
associated with total relaxation - for example, floating
on a calm sea under the warm sun, melting into the
chair.

Tell participants that merely by visualizing a soothing,
calm, pleasant scene they will be able to combat the
physiological reactions associated with the anxious or
aroused state.

3. Conditioned Relaxation:

Remember the progressive relaxation technique we
discussed a few sessions ago. This was when you tensed
and relaxed each muscle group. What cue word did you
use for releasing tension? Well, "conditioned
relaxation" refers to the pairing of a word (for
example, relax, calm, release) with the relaxed state.
Through repeated practice, the word becomes a cue for
relaxation. It simply involves remembering what you
felt before, so that after a while just saying the word
brings on the relaxed state.

 

264

Remember that with practice the application of any of
the above techniques will help to reduce levels of
anxiety, and return your body to a calmer, more relaxed
state, and thus enable to to gather your thoughts and
respond in the most effective and appropriate manner.

a. Thought Stopping

Have group members close their eyes and silently
think about some disturbing experience or thoughts they
would like to extinguish. Make several general comments
or statments to help participants imagine the arousing
situation. After one or two 7minutes, abruptly shout
"STOP" and question members as to what became of their
thoughts.

The participants should report that their thoughts
abruptly ended. Discuss with the participants how one
can gain control over his/her thoughts in a similar
way. After the negative thoughts have left, you should
immediately substitute pleasant thoughts. Or you could
use any of the previously described brief relaxation
techniques to replace the disturbing, unwanted
thoughts. You may not want to shout "STOP" aloud
because this may prove to be embarrassing when you are
in public; however, you can do so silently, in your
head, and obtain the same results. Again, emphasize
that this technique also requires practice. With
repeated application every time the thoughts occur, the
time between reoccurring thoughts will become longer and
longer, and the duration will become less and less,
until they no longer exist.

c. Self—Statements:
1. Negative Self-Statements:

Many individuals engage in self—defeating, negative
self—statments.

Examples: "No one will be interested in what I have 33
ll

say. ___ _——— _— _——-————-—'—_I_—- — ___—
"I'm not absolutely sure if I'm right."

"My opinion isn't important anyway.

Such thoughts help convince us not to take action or to
respond assertively. These thoughts are merely
self—defeating, and it is necessary to change these
negative self—statements into positive ones that will

 

265

help convince us to be assertive and to take action,
rather than sit back and remain fearful of standing up
for our rights.

Positive Self—Statements:

A positive self-statement procedure involves
developing complimentary statements about yourself that
you memorize and repeat regularly. The purpose is to
build self—confidence. Read over the following examples
(Alberti & Emmons, 1982, p. 57).

Examples:

I am respected and admired by my friends. I am a

kind and loving person. I have a job. I handle

anger well. I got through school successfully.
(Alberti & Emmons, 1982, p. 57)

Suggest to the group that they generate their own
personal list of positive self-statements and place the
list where it will be readily available, reminding them
of their importance and value ( e.g. on the refrigerator
door, on a mirror, in wallet).

Demonstrate how positive self—statments can be used in
conjunction with the thought—stopping procedure
previously described. Once you have abruptly stopped
those undesired thoughts, positive self—statements can
be immediately susbstituted. With practice, the
positive self-statments can replace the undesirable
ones. Discuss with the participants how once they have
practiced the positive self—statement procedure for a
while, you should then begin to take definite steps
toward acting in a manner which is consistent with your
thoughts.

Provide an example

Example:

You initially feel that your statements and opinions
are unimportant. You begin by reminding yourself that
your opinion is important. After practicing the
self-statement: "My opinion ig important" to the
point where you are comfortable with it and believe
it to be true, you then take steps to begin to act as
you think. If you are at a group meeting, and the
floor is open for opinions or comments, you may start

 

266

off by agreeing with what another speaker has stated
and, as your confidence increases, gradually work up
to stating your own opinion because you now know that
"my opinion ii important!"

2. Coping Self—Statements

 

Comment on the use of other types of
self-statments that can be used whenever thoughts or
feelings interfere with one's effectively or
appropriately handling a given situation. Coping
self—statements are such self—statements.
Self-statments can be used to help guide and direct
behavior before, during, and after a situation. Using

such a procedure can help:
—rationally focus on the particular situation at hand
—challenge irrational/self—defeating cognitions.
—reduce levels of anxiety.
—consider appropriate courses of action.
-assist in evaluating our behavior.

Distribute EXAMPLES OF SELF—STATEMENTS handout. State
that coping self-statments can be generated and employed
for handling any type of situation such as anger,
stress, anxiety, etc. Invite group members to comment
on situations in which they would like to employ this
technique. Have group generate a list of applicable
self—statements for the situations mentioned.

d. Reality Testing:

This technique is very similar to the procedures
involved in cognitive restructuring that we talked about
earlier. It. is important to assess the reality of a
given situation by challenging irrational thoughts.
Provide an example.

Example:

"Just because my boss asked to see me after work
doesn't necessarily mean I'm going to be fired.
There are a number of alternative reasons...."

 

267

Social Support Session

Present the group with the following questions:

1. Decide what resources each person in the
group has access to, or that he or she could use
personally. In this process define "resources" and

list examples of types of resources including medical
services, services, food sources, financial aids,
exercise facilities, and transportation. Also
include suggestions for Egghpigpgg g; Epppgppg each
person has found effective in dealing with diabetes.

2. Decide on a way of putting together all of
the different resources so that other new diabetics
in this group or other members of this group could
have a permanent catalog.

3. Elect a committee to put together all the
materials.

4. Set forth the procedures that will be
necessary to complete the task.

5. How could you give other diabetics access to
this information?

 

268

Session 8: Evaluating the Network

Objectives
Introduction
1. Have welcoming committee conduct introductions.
2. Provide participants with a clear understanding of
the goals of the workshop. Define procedures which will
be employed.
3. Briefly review the materials covered previously.
Sglf—advocacy Training
1. Identify some common fears which inhibit assertive
responding. Help participants to develop basic
communication skills.

Social Support Session

1. Members should work out any problems that have come
up regarding the resource project.

2. Review the materials for the resource project. Is
the information correct? Are there any new resources
that should be added?

3. Finalize the plans for putting the resources
together.

4. Each member should evaluate the network that is
developing.

w:
COMMON SOCIAL FEARS

BASIC COMMUNICATION SKILLS

269

Means £2 Objectives:
Introduction

1. Greet members as they enter. Make small talk.
Turn the meeting over to the welcoming committee.

2. See session 1 for a description of the goals
and procedures of the group.

3. Recap Previous Session:

a. Briefly review major topics discussed during
last session. Specifically highlight the coping skills
of self—induced . relaxation, thought—stopping,

self-statement and reality testing.

b. Question participants on their use of the
various assertion techniques and the coping skills
taught up to this point. Probe to discover outcomes of
their applications and resolve any problems which
members may have encountered in their use.

Have group members role play recorded
situations, allowing other members to offer corrective

feedback and suggest alternative means of handling the
situation.

Self—Advocacy Training
1- ___LsDevelo in _Basic W M:
A. Common Social Fears:

Comment on two important facts of social life identified
by Fensterheim and Baer (1975):

B. Basic Communication Skills:

a. Discuss the importance pf "small talk," which
functions as a finding—out process. It helps to explore
common grounds and areas of interest for further
conversations.

 

 

b. Things don'; just happen. Interesting people,
activities or occasions don't just happen to appear
suddenly out of the blue. To be interesting, a good
friendship, a funny occasion, etc., requires skills and
active involvement on your part.

 

 

27O

Distribute COMMON SOCIAL FEARS handout. Read aloud and
obtain participants' reactions.

2. Basic Communication Skills:

Comment on how many nonassertive individuals avoid,

or experience difficulties in, carrying on a
conversation because they lack the basic communication
skills involved. These skills can help reduce the

anxiety that many people experience in a variety of
situations.

Distribute BASIC COMMUNICATION SKILLS handout. Describe
and demonstrate the three basic skills involved in
initiating and maintaining a social conversation as
identifigd and explained by Lange and Jakubowski (1976,
p. 77-80 :

a. Ask o en—ended Questions.

This maximizes the other person's opportunity to respond
more fully. The responsibility of carrying on the
conversation is not left to any one individual. Such
questions equalize the flow of the conversation and
increase the likelihood of receiving more free
information to which one can further respond.

 

b. Responding £3 free information elicited by
open—ended questions. Respond to free information with
your own opinions, disclosures and knowledge to
facilitate further discussions (maintain the

conversation).

c. Paraphrase to continue a conversation when you don't
know anything to add. This technique allows you to
continue a conversation when you don't have anything to
say in response to someone else's free information.
This shows that you are listening, interested, and would
like to hear more.

Each of these techniques can be used in any
situation. They are very helpful when you just meet
someone and would like to get to know the person.

 

271

Social Support

Present the group with the following tasks:

1. Have the committee selected the previous week
report on progress up to this time. Work out any
problems that have come up with respect to reproducing
materials. Decide how reproduction and distribution are
to be carried out and paid for.

2. Have the resource list and description read
aloud to the group. Each person should make sure that
the information is accurate, especially the information
he or she has provided. Everyone should make sure that
the information is complete enough so that the resource
could be used without any information besides what is
present in the resource list. Necessary changes should
be recorded by the secretary and by the committee
chair.

3. Any additional resources that have come up
should be added to the list. Everyone will have to be
careful not to add resources of limited use that might
make the list too long.

4. Plans should be finalized to complete and copy
the resource list before the next meeting. People with
access to word processors or copy machines should not
hesitate to come forward! Plans should include some
extra copies for future group members.

5. Group members should look at the network that
is developing among group members. Evaluate the
network. Each member should have a chance to say what
they think.

a. Who called who?
How often did you talk to one another?

b. What topics did you talk about?

The secretary should record all of the information.

 

2’72

COMMON SOCIAL FEARS

People have a whole set of social fears which tend to inhibit
assertive respondin

Honestly ask yourself - Do you fear:

- People will think you're stupid, so you avoid talking.

- Lookin foolish. You don't say anything that is different
or inHiViaual, so your conversation becomes stuffy and
conventional. Often you bore yourself.

- Rejection. You tend to stick to people you know andw th
you feel relatively safe. Then you complain you're

inarut.

- closeness. Yo ou keep everything at a small- talk level on a
superficial basis. You don't follow up with new people
or allow new personal relationships to develop.

Fears identified by: Fensterheim, H. and Beer, J. Don_ tSay

Yes When You WunL To Se No. New Vein:
Dell Publishing Co., Inc., 1975. p. 100.

 

273

Open-ended vs. Closed Questioning:
Cloped Questioning:

Janet: Hi. are you a patient here?
Mark:

Janet: Are you a diabetic patient?
Hark:

Janet: How long have you been a diabetic?
Mark: One year.

Pause.....

Janet: Do you live around here.
Hark: No.

Janet: Do you live close to Lake Michigan?
Mark: No.

Janet: Would you like to live closer to Lake Michigan?
Mark: Yes.

Open-ended Questioning:

Janet: What are you doing here?
Mark: I'm waiting for my regular check-up.

 

Janet: How do you Like your doctor?

Mark: I have only been seeing her for three months. but
so Let L thluk she's really good. She takes time to
explain things to me.

Janet: What did you think of the diabetic classes here?
Mark: 1 think they were really informative. The mOSL
surprising thing that I Learned was ....(and so on).

 

2'74

fisgggggigg to Information in an Open-ended Question.

 

Take advantage ol your opportunity to respond to information with
your own opinione. disclosures. and knowledge to maintain the
conversation.

Exaegle.

Janet: What do you do for a living?

Mark: I work at Fisher auto body. I an responsible for
ordering different products we need. I also
supervise a few people in the office

Janet: Oh. I work for the phone coupeny. I install
telephones in holes and in businesses. I've
worked for the coepeny for 15 years. I'm
hoping to get a pronotion to a supervisor in
few months. I won't meet as many people. but
I'll be making more honey.

 

 

 

Paraphrase to Continue a Conversation Hhen You Don' i Know Anything

to Add.

This technique allows to continue a conversation when you don't have
anything to say in response to soeeone else's free information.

This shows that you are listening, interested and would like to hear
more.

Example:
Janet: What do you do for a living?
Mark: I work at Fisher auto body. I am responsible for

ordering different products we need. I also
superv1se a few people in the office.

Janet: So you do ordering and supervise people too?

Hark: Yeah, it gets to be quite a job. You wouldn't
think it would involve so much keeping track of
Lhutgs, buL IL does I like .3 Challenge, Lhough.

Janet: So what is it that you like about challenges?

 

275

Session 9: Examining the Group's Relationship to Other
Groups .

Objectives
1. Have welcoming committee conduct introductions.
2. Provide participants with a clear understanding of
the goals of the workshop. Define procedures which will
be employed.
3. Briefly review the materials covered previously.
Self-advocacy Irglnigg

1. Provide participants with ways to handle difficult
situations, specifically: dealing with anger, dealing

 

with putdowns, and saying "no."

2. Help participants recognize the importance of
expressing warm feelings — an often overlooked mode of
assertive responding.

Social Support Session

1. Members should decide as a group whether or not the

group should establish relationships with other groups.
members feel that the group should relate to other

groups, how will this be done? Present the group with

their tasks for the evening.

Handouts:

DEALING WITH ANGER

PUT—DOWNS

EXERCISE IN SAYING NO

DIRECT OBSERVATION OF ROLE PLAY SITUATIONS

SOFT ASSERTION

276

Means £3 Objectives:
Introduction

1. Greet members as they enter. Make small talk. Turn
the meeting over to the welcoming committee.

2. See session 1 for a description of the goals and
procedures of the group.

3. Recap Previous Session

a. Briefly review major topics discussed during
last session. Specifically highlight: common fears which
inhibit assertive yresponding; basic communication
skills.

b. Question participants on their use of the
various assertion techniques and the coping skills
taught up to this point. Probe to discover outcomes of
their applications and resolve any problems which
members may have encountered in their use.

Have group members role-play recorded situations,
allowing other members to offer corrective feedback, and
suggest alternative ways to handle the situation.

Self-Advocacy Training

1. Handling Difficult Situations:

a. Dealing with Anger:

Distribute DEALING WITH ANGER handout. Comment on
the fact that there are bound to be instances in all of
our lives when we will be forced to deal with another
person's anger or aggression. It is important to
maintain an assertive position. Mention the likely
consequences of nonassertion and aggression in response
to an aggressor.

Nonassertion - reinforces the other person's
aggression.

Aggression — creates an angry behavior cycle.

 

 

277

Inform participants that the handout they have
received outlines some assertion techniques designed to
help them maintain an assertive position while
confronted with another's anger. Stress that the
information provided on the handout is merely intended
to serve as a guide, providing alternative ways to
handle such situations other than resorting to being
nonassertive or aggressive.

Read handout over with participants, elaborating
and clarifying the techniques outlined. Invite group
members to provide further examples. Based on group's
need/common level of interest, model and role play
appropriate use of the techniques outlined.

b. Dealing with Put-downs:

Make some general comment regarding put-downs as a
means of an introduction to this session. Obtain
information on how various group members respond to
put—downs (Do they passively accept them? Do they
beocme ag ressive? Do they feel hurt? Do they feel
resentful.§

Distribute PUT-DOWNS handout. Read aloud and
discuss. Have group members provide futher examples.
Based on group's need/common level of interest, model
and role play further examples.

 

c. "Don't Say Yes When You Want £2 Say N2" (Fensterheim
& Beer, 1976, p. 12—12).

Comment on how people will always make requests or
place demands on others. Some people find it very
difficult to say "no" to these requests. If you are like
these people, you could spend your life doing things
that others request. This is not to say that it is not
right or good to do things for other people. The point
to be made here is to say "no" when you do not want to
do something. Invite participants to share situations
in which this is true for them.

Stress the importance of being able to stand up for
oneself and say "no" when you want to. Identify some
negative consequences of being unable to say "no." Ask
group for contributions and list consequences on the
board. Include:

—It leads you into activities you don't respect
yourself for doing.

 

278

—It distracts you from what you really want to
accomplish.

—Because you allow other people to exploit you
continually, the resentments build up and,
sometimes after years of the "yes" rountine, you
lose your temper in an inappropriate outburst.

—It produces a lack of communication between you
and others."

(Fensterheim & Baer, 1976)

State the basic principles one should follow in
saying "no." (Write on the board):

1) be specific

2) be clear

3) be firm

4) be honest

5) Answers should be short, to the point and
start with the word "no" to prevent
ambiguities.

Distribute EXERCISE IN SAYING NO (Fensterheim & Baer,
1976). Read Situations aloud and model appropriate
responses.

Provide participants with an opportunity to practice
saying no. Have them role play the situtions on the
handout and/or have them role play personal
situations in which they have difficulty saying "no."

Have group members provide feedback.

Optional: Distribute DIRECT OBSERVATION OF
ROLE PLAY SITUATION and have group members complete
the sheet to assist them in providing important
feedback. Note: this sheet, or a modification of
it, may be useful whenever feedback procedures are
employed to help guide given responses.)

 

2. Soft Assertion:
(Alberti & Emmons, 1982, Chapter 11)

Comment on the difficulty experienced by many
aggressive as well as non—assertive individuals in
expressing positive, caring feelings. Question
members as to why expressions of warmth, concern and
caring are often inhibited by adults in our society
(e.g., embarrassment, fear of rejection, ridicule,
the irrational belief that being emotional is a sign
of weakness).

 

279

Expressing positive, warm feelings is a highly
assertive act. Generally, it is difficult to express
warm feelings because it is considered to be a high
risk act and because of the feelings of embarrassment
often attached.

Comment on how people often assume that the other
person fully understands your feelings toward them
(e. g., "She knows I love her"). Emphasize the fact
that we all need to know that someone cares, and we
need and want to hear this.

Distribute SOFT ASSERTION handout. Have group
members read it and allow for comments.

Social Support Session
Present the group with the following questions:

1. Discuss how the group should relate to:
physicans, hospitals, health insurance groups, and
other diabetic organizations.

a. Discuss whether or not the group should
develop formal relationships with hospitals. Discuss
whether or not the group should find a physician who
would be willing to be a co—director of the group.

b. Discuss how the group would become an
affiliate of the American Diabetes Association.

c. Write down the groups feelings and
attitudes on these topic areas.

2. What ideas‘ can this group use from other
groups?

3. What ideas can the group give to other
groups?

280

DEALING wxra ANGER
mm:

Reflection involves simply reflecting back what the aggressor
is saying or feeling. This helps the aggressor to realize that s
or her message hes been received. Usually this causes the aggressor
to start calming down, after which each person can react to what has
been heard and can state a personal position.

Exes e

"l kngw thgg Eggm your pgint a; view i;'; completely unfair that
ou'v received 1 small gala: this 1335. Ideally, I would have
i e to give you a large rsiae._but right now the company has

severely limited raises. We're in financial trouble, and the

only way I could give a larger raise to you ~ and to the other
people who'd like larger raises — wou d be to let some employees

3 The at' a unacceptable to the company and to me, too."

 

 

 

 

 

 

ngtign : kg care n95 to give the impression that yo u
are agreeing with the unwarranted aggressive
criticisms

 

 

fissssssi Assetsis_:

Involves repeating the basic assertive message while taking
into consideration any legitimate points which were made by the
aggressor. The assortor should ignore all uunreluvaht issues and
provoking statements. This technique is appropriate when the other

rson overreacts, ignores. or discounts the asserter's thoughts.
feelings. opinions, and wants. Do not caunterreact by justifying
personal feelings, opinions. etc.

Example:

A student social worker disagreed with the stout pnystClun ubuut
the disposition of a client's case, and wanted to have a second
eveluat on given before a final decision was made about the kind
of therapy the client would receive. The physician was sarcastic
and refused to respond to the student's initial suggestion. Thu

lal worker again said. ”I'd like a second opinion on this
case," and finally the third time responded. "I realize that your
decision is the final one. and I‘m willing to abide by that, but
I'd sti l like to have a Setuud evaluation made of this client."
The physician finally decided to act on the suggestion.

Note: Repeated assertion L; not simply exact repetition.

 

281

Brgksn figggrg:

This technique involves repeating the same message (assertive
response) in a calm, monotonous tone of voice. This is useful when
the other person is extremely aggressive, disruptive, distractive,
manipulative. or unieeling.

hauls:

"Please stay calm." (5 second pause)

"Please stay tale." (5 second pause)

"Please stay calm." (5 second pause)

_ggg: You are not to increase the tone or loudness of your voice or
make any threatening gesture.

Efliflilnl Eli lflll$£$£ (lgglfigg) Agegmgtions:

Pointing .out implicit assumptions requires that the person
carefully listen to what the aggressor is saying, hearing the
implicit assumptions‘ of the extreme position being taken. pointing
out these assumptions. waiting for the aggrasaor's response, and
then expressing one's own point of view. This technique helps to
diffuse the aggression present and makes it easier to communicate.

Example:

A man was aggressively attacked by his wife for disagreeing with
her on a minor issue. The husband responded. "The message I'm
getting is that under no circumstances - regardless of
think or feel - should I disagree with you. It's like 1 have no
rights except to agree with you." The wife essentially agreed
with this ridiculousness and continued her attack. After a short
time. the man interrupted: "The way I see Lt. as long es'l don't
put you down, I have a right to express my opinion. Just because
have a different opinion than you doesn't mean that I think
you're stupid. Hy opinions are my own, Just as yours are. We
can't always think the same way. I don't expect you always to
agree with me or to have the seas opinion I do. and I don't think
it's fair for you to impose your opinions on me either."

uBSClOflln :

The question technique simply involves questioning the
aggressor on the reason behind his or her anger. This helps the
aggressor to become aware of the unwarranted reaction.

Example

When asked to wrap a package, the clerk said nothing but looked
extremely irritated and muttered almost lnaudibly as he wrapped
the package. The customer responded In a puzzled, nonsarcastlc
tone of voice, "You got mad because I asked you to wrap the
package "

 

282

This is a useful technique when you are being provoked by another
person. It involves diffusing the other person's aggression
confusing him or her with agreement. Yo ou are not actually agreeing
with the person. but rather you decide to turn things into a

3min
Provoker: "You're a stupid jerk." Response: "You're right, I
an." (turns around and walks away)

Note: You must be extreaely careful when using this technique.

Your response one: case across assertively no; aggressively

(Inforastion taken from: Lange & Jakubowski. l976.)

 

283

Dealing with Put-Downs:

Most people have a difficult time dealing with put-downs. The
manner in which a put-down is handled can have an effect on future
interactions with the person; it will also have an effect on how you
feel about yourself. Here are four common types of put-downs and
suggestions on how to handle them.

1. Th: Qilgg; Verbal P t—down:
§£££2L3=
As you walk down a crowded staircase. you accidentally push

someone as you pass by. That person immediately responds in a
hostile manner:

"Damn it! Why don't you watch where you‘re goingl You idiot,
you could have hurt me if I had fallen!"

__th £9. is=
-Allow the person vent her/his feelings until s/he calms down a little.
-Admit it when you are wrong (even in the face of an insult).
—Acknowledge the other person's feelings.
-Assert yourself about the way s/he is reacting.
-G we a s ort statement to bring the encounter to an end.

Example:
"I apologize for pushing you. It was unintentional. You're

obviously upset. but I do not like being called names or being
yelled at. I can get your point without that."

2. The Ingirecg Verbal Pug-down:
Example:

 

In response to your inquiry about your new outfit. a friend
states: "You look nice. It fits you. You always wear something
a bit weird."

What to do:

-Ask for more information to hel clarify the person's true
intent. -Yeur next response will depend on the other person's
answer to your question. Your objective is to teach the other
person to be more straightforward with you.

Examplg:

You: "What do you mean by that?"

Friend: "Oh. I think it looks really good. I like it.”

 

284

You: "O.K.. thank you. I was a bit confused by your first comment.
If youldon' t like my style in clothes, I hope you can to all
direct

3. The Nonverbal P t-down:

 

3. Th: Aggigggivg Ngnverbsl Pgt-dgwn:
Examples:

-obecene gesture

odirty

-pouting

~silly grins
-sm rks

22:; £2 £2:
-Attempt to get the person to clarify her/his agesture with
rds (Be) prepared for a verbal put- -down nd spond
accordingly

Examples:

"I have trouble understanding what you're feeling unless you tell
me directly."

"Could you interpret that look for me?"
b. The Nonssgertive Nonverbal Put-down:
Example:

As you make a request of someone. s/he begins to stare off into
space or inappropriately grins

What 33 do:
Attempt to get the nonverbal response out in the open to clarify
its meaning (if an y Ask the person to explain.

Examples:

"I don‘ t understand your exprossion."
"Did I do something you didn‘ t like?"

 

 

285

h.
The Self-Pu -ggwn.
Examples:

Could be verbal and/or internal thoughts:

"My opinion isn't worth much."
"I m a bore."
“I'm not smart enough to go back to school."

your own behavior.
ive.)
e in such self-defeating behavior

_th =_°. is:

~Be a fair judge of

(Be objective not subject
-Catch yourself when you engag

and substitute positive self—statements.

-3e assertive with yourseifl

mule—v

“My opinion does count."

"I as important."

"I can do anthing I set my‘mind out to do."
Alberti & Emmons. 1982).

(Taken from:

 

286

EXERCISE IN SAYING N0

 

Situation One:

 

Co-worker asks to borrow some coins for the coffee machine.
Somehow he always does this and never repays the change.
Co-worker says, "I have no silver. Would you lend me thirty-
five cents for the machine?

How would you say 'No'?

Situation Two: ‘ ”

A friend had asked you to go with him ”sometime soon" to select
a new hi-fi set. You had assented. On the Saturday morning
when you had been planning to catch up with house chores, he
calls and says, '"(on promised to help me pick out that hi-fi
set. Can you come with me this morning?" You really want to
sort your bookshelves.

How would you say "No“?

Situation Three:

 

You have been working on the planning committee for a local or-
ganization's upcoming fund-raising event. You' we already put
in more time than anyone else. Now the president makes another
demand. asking, ”Joan. you're such a terriffic worker.

count on you to collect tickets at the door

How would you say 'No'?

Taken from: Fensterheim. H. and Beer, J. Don't Say Yes When

You Want To Say No. New York: Dell Publishing
Co., Inc., 1975, p. 79.

 

287

SOFT ASSERTION

When was the last time you've told someone you care tor:

'Thank you.‘

'You're greatl'

'I really understand what you mean.“
. “I like what you did.‘

Give a warm smile.

'i'm here.‘

Give extended eye contact.

"I believe you."

'I trust you.“

'I love you.‘

"I believe in you."

"I'm glad to see you.“

'You've been on my mind."

List of warm statements taken from:
Alberti, R.E. end Emmons, M.L. A Guide to

Assertive Livin Your Perfect ii ht.
Eah L is 551390, EaIiEornia: Impact

u
Publishers, 1982, p. 90.

 

 

288

Session 10: Making Plans to Continue the Group
Objectives

Introduction

1. Have the welcoming committee perform introductions.

2. Provide participants with a clear understanding of
the goals of the workshop. Define the procedures.

3. Briefly review the materials covered previously.

Self—advocacy Training

1. Caution participants on possible adverse reactions
to their assertiveness, and offer suggestions on how to
handle such reactions.

2. Provide participants with some suggestions on what
to do when they assert themselves and end up being
wrong.

3. Provide group members with some points to consider
in deciding whether or not they should be assertive.

Social Support Session

1. Members should consider how they would like to deal
with members that will be completing their committment
to the project. A committee should be formed so that

this area of concern can be taken care of at each
meeting.

Handout:

WHEN TO BE ASSERTIVE

 

289

Means £2 Objectives: Introduction

1. Greet members as they enter. Make small talk.
Turn the meeting over to the welcoming committee.

2. See session 1 for a description of the goals
and procedures of the group.

3. Recap Previous Session:

a. Briefly review major topics discussed during
last session. Specifically highlight: dealing with
anger, dealing with put—downs, saying "no," and the act
of expressing (asserting) warm positive feelings.

b. Question participants on their use of the
various assertion techniques and the coping skills
taught up to this point. Probe to discover outcomes of
their applications and resolve any problems which
members may have encountered in their use.

Have group members role—play recorded situations.
Self—Advqgagerraining
1. Potential Adverse Reactions

Caution participants on possible adverse reactions
by others to their assertiveness. Inform them that even
when an individual appropriately asserts him/herself,
there is no guarantee that one's honest, open, and
direct expressions will be taken positively by others.
At times, others may respond unpleasantly.

Identify some such reactions, provide examples, and
offer suggestions for dealing with the reactions. The
following outline is based on materials presentd by
Alberti & Emmons (1982) pp. 124—125.

Write key words on the board and allow for discussion.

a. Backbiting - disgruntled, childish behavior, often
involves indirect actions.

Example:

-Someone cuts in front of you in a line. You assert
yourself, after which the individual goes to the back
of the line but grumbles while passing you, "Big

 

290

 

-Ignore the behavior.
b. Aggression - hostile actions taken toward asserter.

Examples:

-Yelling or screaming —Cursing -Obscene gestures
—Physical actions (e.g., bumping, shoving, hitting)

What to do:

 

-Employ appropriate assertion techniques for dealing

with anger discussed earlier (e.g., reflection,
questions, etc.). Stress that it is important that
one maintain an assertive position to avoid

reinforcing the aggression or generating an angry
behavior cycle.

c. Temper Tantrums —often occur when you assert
yourself with someone who has had his/her way for a long
time.

Examples:

—Individual may react by looking hurt —Cry, "You
don't like me!" —Attempt to elicit pity from others
-Attempt to make asserter feel guilty

What pg do:

 

—Ignore the behavior.

d. Psychosomatic Reaction ~actual physical illness
experienced by some individuals.

Examples:

-Abdominal pains -Headaches —Feeling faint

 

What t_ _c_i_
-Be firm in the assertion. -Be consistent whenever
the same situation reoccurs with the
same individual. —Recognize the fact that the other

person will eventually adjust
to the new situation,

 

 

TO
M3
5.:

e. Overapologizing —extremely apologetic or humble to
the asserter.

What to d

 

-Point out that such behavior is unnecessary.
f. 3212333 —may occur if there is a continuing
relationship with someone you have asserted yourself
with.

What 0 d :

 

-Immediately take steps to squelch the person's
actions. -Directly confront the individual about
his/her behavior.

 

 

2. S2 You Make 3 Mistake:

Comment on how, especially during early attempts at
assertions, they may discover that they have interpreted
the situation incorrectly, poorly or incorrectly applied
a technique, or offended another person. Instruct group
members on how to handle such situations. Include:

—Be willing and honest enough to admit, and say to
the person

involved, that you were wrong. -Avoid getting
carried away with apologies and becoming
overapologetic. -Do not be apprehensive about

future assertions if and when
the situation calls for it.

3. a. When Not pg pg_Assertive:

Make group members aware of the fact that there are
some potential negative consequences inherent in
assertiveness, aside from those adverse reactions
identified previously.

Give an example.

Comment that, because of this, it is necessary for
one always to consider the possible consequences of
one's assertive acts. In some instances, the value of
avoiding the negative consequences to an assertion will
outweigh the benefits of engaging in the assertive
ramrbhfie, in which case common sense should rule against

L . .
"_J

lg cesertive.

 

292

Identify some circumstances in which one may choose
nonassertion over assertiveness. Include and discuss
the following, as explained in more detail by Alberti
and Emmons (1982), p. 126—127:

Overly sensitive individuals

-those who are genuinely unable to accept even the
slightest assertion.

Redundancy

—when a person who has taken advantage of your rights
remedies the situation in an appropriate manner
before one gets the chance to assert him/herself. In
such instances, it is not appropriate for one to
assert him/herself.

Being Understanding

-there may be extenuating circumstances causing an
individual to have difficulties, in which case one
may choose to overlook things that may be going wrong
or postpone confrontation to a more productive time.

Manipulators and Incorrigible People

—those people who are just plain difficult, or are so
unpleasant that it is simply not worth confronting
them. The reactions of these individuals may be so
negative that they outweigh the worth of asserting
oneself.

b. When t b Assertive:

 

Distribute WHEN TO BE ASSERTIVE handout. Tell the group
that these are just some questions they could ask
themselves to help deterimine what actions they should
take. Read questions aloud and provide a personal
example to help clarify and model appropriate cognitions
involved in this self-assessment procedure. Discuss.

Social Support Session

After tonight's meeting there will be members who have
completed their committement to this project. The group
needs to make some plans for these members. In the
first session a welcoming committee was formed. It seems
appropriate to form a committee for members that may be

 

293

leaving. There might be members that would like to
continue in the group; there may also be members that
might not want to continue with the group on a regular
basis. Tonight's group should focus on these issues.

Have the group deal with the following problems:

1. Last week you discussed how the group would
relate to other groups. In this meeting you should
review and decide an actual course of action. In other
words, what exactly are you as a good going to do?

2. What will happen to members completing ten
sessions?

a. Form a committee to deal with this and
select members. .

b. Decide what they will do.

c. Ask the committee to establish a procedure
for members that are leaving.

d. Determine whether members who are leaving
wish to keep in touch with the group. If so, how? How
will the experimenter_ be able to keep track of these
people so that their progress can be followed up later?

3. Since some members will be leaving and might
want to attend on an irregular basis, members need to
address the following issues.

a. Make plans for continuing the group after a
self—advocacy trainer is no longer involved.

b. Make plans for securing a meeting place.

4. Set a time for the committee to report back to
other members.

5. Decide whether the assertiveness training could
be done by a member of the group or would require
finding a new person.

6. Select two people in the group that you will

continue to have regular contact with. Call these
people once a week. Select two additional people to
contact in case you need other opinions or more

support.

 

WHEN TO 32 ASSERTIVE

 

Following are some questions to help you determine when to
response assertively. (Salt-assessment

1. How important is the situation to me?

2. Hw I likely to feeln afterwards if I don‘ t assert
myself in this situatio

3. How much will it cost me to assert myself in this
situation? What are the potential consequences?

REMEMBER: You have the indiVidual choice to decide if,
when, and how to be assertive.
This is your personal right!

 

Questions obtained from:

Lange, A.J. and Jakubowski, P. ResponSible Assertive
BehaVior, Co nitive/BehaVioral Procedures for
C ampaiqn, Illinoise: Research Press, 1976, p. 64.

         

 

Potential Advegse Reactions

 

 

Even when an individual appropriately asserts him/herself.
there is no guarantee that one's honest, open, and direct
expressions will be taken positively by others. At times, others
may respond unpleasantly. The following are some possible negative
reactions and suggestions on how to handle them.

Beckbiting - disgruntled. childish behavior, often involves indirect
ions.

Example:

-Soseone cuts in front of you in a line. You assert yourself.
after which the individual goes to the back of the line but
gruehles while passing you, "Big deal," or "Who does he think he
is anyway?’

What to do:

 

~[gnore the behavior.
Aggression - hostile actions taken toward asserter.

549M:

-Yelling or screening ~Curse -Obscene gestures -Physical actions
(e.g.. bumping, shoving, hitting)

__“hac Lo 6.0:

-Employ appropriate assertion techniques for dealing with anger
discussed (e.g., reflection, questions, uLL.). Stress LhuL AL is
important that one maintain an assertive position to avoid
reinlorcing the aggression or generating an angry behavior
cycle.

lamps; Tantrums -often occur when you assert yourself with sumconu
who has had his/her way for a long time.

 

Examples:

-£ndividual may react by looking hurt —Cry. "You don't like me!"
—Attempt to elicit pity from others -Attempt to make asserter
feel guilty

What to do:

 

-Ignore the behavior.

 

 

LL—

 

2%

Psychosomatic Reaction -actual physical illness experienced by some
individuals.

 

Examples:

-Ahdo-inal pains -Headachas -Feeling faint

What a 4.0

 

-8e firm in the assertion. -Be consistent whenever the same
situation reoccurs with the same individual. -Recognize the fact
that the other person will eventually adjust to the new situation
in a short time.
Overagologizing -extremely apologetic or humble to the asserter.
£52; £2 12

-Point out that such behavior is unnecessary.

Revenge
-may occur if there is a continuing relationship with the person
with whom you have been assertive.
Hut—04.“
—lmmediately take steps to squelch the person's actions.

-Directly confront the LndiV‘dual on his/her uehaVior.

5 You Make a Mistake:

 

 

Especially during early attempts at assertions, you may
discover that you have interpreted the SituuLion incorrectly,
poorly or incorrectly applied a technique. or offended another
person. Possibilities Lor handling these Situations include:

-Be willing and honest enough to admit. and say to the person
involved. that you were wrong. —Avoid getting carried away with
apologies and becoming overapologetic. -Do not be apprehensive
about future assertions if and when the situation calls for it.

When Not to be Assertive:

There are some potential negative consequences that may come
with being assertive. aside from these negative reactions identified
preVLously. n some instances, the value of avoiding the negative
consequence to an assertion will outweigh the results of engaging in
the assertive response, in which case common sense should rule
against being assertive. Examples of some of these situations
follow. (Alberti & Emmons, 1982).

 

Overly sensitive individuals -those who are genuinely unable to

 

 

297

accept even the slightest assertion.

.

Redundancy -when a person who has taken advantage of your rights
remedies the situation in an appropriate manner before one gets
the chance to assert him/herself. In such instances. it is not
appropriate for one to assert him/herself.

Being Understanding -there maybe extenuating circumstances
causing an individual to have difficulties. in whicn case one may
choose to overlook things that may be going wrong or postpone
confrontation to a more productive time.

Manipulators and Incorrigible People -those people who are Just
plain difficult. or are so unpleasant that it is Simply not worth
confronting them. The reactions of these individuals may e so
negative that they outweigh the worth of asserting oneself.

Some questions you might wantr to ask yourself to help you determine
when to response assertively

L. How important is the situation to me?

2. flow am I likely to feel afterward if I don't assert myself in
this Situation.

J. How much will it cost me to assert myself in this Situation'
What are the potential consequences?

Remember that {0 u have the individual choice to l:decide Li- when. and

how to be assertive. This is your personal ign

 

 

 

 

LI ST OF REFERENCES

 

298

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