Adolescents with Poorly Controlled Type
1 Diabetes can Benefit from Coaching: A
Case Report and Discussion
Jette Ammentorp, Jane Thomsen &
Poul-Erik Kofoed
Journal of Clinical Psychology in
Medical Settings
ISSN 1068-9583
J Clin Psychol Med Settings
DOI 10.1007/s10880-013-9374-z
1 23
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1 23
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J Clin Psychol Med Settings
DOI 10.1007/s10880-013-9374-z
Adolescents with Poorly Controlled Type 1 Diabetes can Benefit
from Coaching: A Case Report and Discussion
Jette Ammentorp • Jane Thomsen
Poul-Erik Kofoed
•
Springer Science+Business Media New York 2013
Abstract Traditional interventions aimed at improving
patient self-management and at motivating the patients to
change behaviour seem to be insufficient in adolescents
with very high HbA1c. In this paper we present a case
consisting of nine adolescents with poorly controlled diabetes type 1. They had previously shown continuously high
levels of HbA1c for 2 years despite intensive follow-up and
were therefore invited to participate in a coaching program.
The coaching program was conducted by professional
certified coaches and consisted of two group and eight
individual coaching sessions. After completing the coaching sessions, HbA1c had decreased significantly in six out
of nine of the adolescents. The participants were interviewed twice following the coaching sessions. All participants reported that they found the sessions very rewarding,
and several explained that they now saw themselves differently and had gained more self-esteem and more energy.
Keywords Coaching Intervention studies Diabetes Mellitus Type 1 Adolescent Health
behaviour
J. Ammentorp P.-E. Kofoed
Health Services Research Unit, Lillebaelt Hospital/IRS
University of Southern Denmark, Kolding, Denmark
J. Ammentorp (&)
Health Services Research Unit, Vejle Hospital, Kabbeltoft 25,
Bygning S100, 7100 Vejle, Denmark
e-mail: [email protected]
J. Thomsen P.-E. Kofoed
Department of Paediatrics, Kolding Hospital, Kolding, Denmark
For many teenagers adolescence is a time with major
challenges of a social and personal nature, and for an
adolescent with type 1 diabetes, it also involves balancing
several extra components such as diet, medication and
clinical control (Lehmkuhl et al., 2009). Living with type 1
diabetes requires that the adolescent every day has to take
decisions based on conflicting interests and emotions
(Spencer, Cooper, & Milton, 2010). In order to cope adolescents need not only medical treatment and education but
also psychosocial care (Anderson, 2009).
An increase in the prevalence of diabetes type 1 has
been seen in Europe during recent years, and in Denmark,
the annual increase in childhood diabetes has been found
to be 3.4 % (Svensson, Lyngaae-Jørgensen, Carstensen,
Simonsen, & Mortensen, 2009). Type 1 diabetes is an
autoimmune disease in which the insulin producing cells in
the pancreas have been destroyed requiring the patients to
be treated with insulin. The insulin is given as basal insulin
ensuring a low level of insulin to be present continuously,
and as bolus insulin, which is needed for all meals and
whenever the blood glucose level is higher than desired.
The insulin is actively administered by the patient either
using an insulin pump or a special insulin pen. Furthermore, the patients should measure their blood glucose at
least four times a day to ensure an acceptable level and
count the carbohydrates they intake to administer a dosage
for that as well.
An estimate of the metabolic control during approximately the past six weeks can be obtained by measuring the
HbA1c level of the patients as it correlates with the blood
glucose levels during this period. Most diabetes centres aim
at an HbA1c level of less than 7.5 % in children and
adolescents, and a level of less than 7.0 % if it seems
realistic for the individual patient. The importance of a
good metabolic control is indicated by findings showing
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that, for each 0.9 % decrease in HbA1c (such as from 9.0 to
8.1 %), there is a 39 % reduction in the risk of developing
retinopathy (The writing team for the diabetes control and
complications trial, 2002).
It has been demonstrated that there is an association
between adherence to diabetes treatment regimens and
metabolic control (Hood, Peterson, Rohan, & Drotar,
2009), and that an acceptable metabolic control can be
achieved for many children and adolescents by intensive
clinical follow-up (Kofoed, Pedersen, & Thomsen, 2008;
White et al., 2001). However, for patients with very high
HbA1c levels, the effect of such interventions seems to be
insignificant (Benhamou et al., 2007; Kofoed et al., 2008,
2010). Therefore, improving patient self-management and
motivating patients to change behaviour is one of the main
challenges. Self-efficacy, defined as one‘s belief about own
capacity to manage a specific task (Bandura, 1977), contributes significantly to motivation and attainment. By
influencing the choices, goals, emotional reactions, effort
and coping of the individual person, self-efficacy has been
found to be a strong predictor for behavior (Bandura, 1977;
Gist & Michell, 1992).
Among young adults with type 1 diabetes self-efficacy
has been found to be a predictor of HbA1c and an
important factor for management of self-care practice and
physiological outcomes (Johnston-Brooks, Lewis, & Garg,
2002). Findings from a study including patients with type 2
diabetes indicate that social support and self-reliance in
living with diabetes are the main predictors for self-management (Whittemore, D’Eramo, & Grey, 2005).
Coaching
Coaching is a method that has proven to be very useful to
increase personal insight, and to shape and reinforce
desired behaviour (Peterson, 2006). In a review about
strategies for improving the outcomes of diabetic patients
coaching has been suggested as a supplemental method of
treatment (Hayes, McCahon, Panahi, Hamre, & Pohlman,
2008; Koenigsberg, Bartlett, & Cramer, 2004).
Coaching has developed from a wide range of disciplines, and is based on a broad academic knowledge
including cognitive and behavioral psychology, social
science, positive psychology, organizational change and
development. There is no precise definition of coaching,
but it has been described as a method to ‘‘unlock a person’s
potential to maximise their own performance’’ (Grant &
Stober, 2006), to encourage patients to acknowledge their
creativity, and to find their own unique solutions by
focusing on the present and by being goal-oriented
(Bluckert, 2005; Driscoll & Cooper, 2005; Quirk et al.,
2008).
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Studies that have examined the impact of coaching in
adults with type 2 diabetes, have demonstrated an
improvement in HbA1c, lipid levels and body mass index
(Bray, Turpin, Jungkind, & Heuser, 2008; Sacco, Morrison,
& Malone, 2004, Sacco, Malone, Morrison, Friedman, &
Wells, 2009; Whittemore, Chase, Mandle, & Roy, 2001,
Whittemore, Melkus, Sullivan, & Grey, 2004; Wolever
et al., 2010). After five individualized coaching sessions
and two follow up calls, Whittemore et al. showed better
self-management, less diabetes related distress and better
integration of the diabetes into daily life (Whittemore et al.,
2004). In another study where telephone coaching alone
was used, the frequency of exercise increased significantly,
diet was improved and diabetes medical symptoms and
depressive symptoms were reduced. HbA1c was numerically, but not statistical significantly reduced (Sacco et al.,
2009). Furthermore the study showed that the participants’
self-efficacy and awareness of self-care goals mediated the
effect of the coaching (Sacco et al., 2009).
In a study including both patients with type 1 and type 2
diabetes the patients who were engaged in a lifecoach
program were less likely to experience poor metabolic
control; however, only 2.6 % had type 1 diabetes (Bray
et al., 2008).
Only two studies about coaching have targeted patients
with type 1 diabetes. A pilot study investigating a brief
telephone intervention showed positive preliminary results
(Sacco et al., 2004), and a study offering coaching to 1,117
adult patients with both type 1 and type 2 diabetes showed
significant improvements in key diabetes indicators. For
example, 40 % of the patients were less likely to experience poor control as evaluated by HbA1c (Bray et al.,
2008).
Clinical Example
We present a case consisting of nine adolescents with
poorly controlled diabetes; six females and three males
between 16 and 19 years of age and with an average
duration of diabetes of 9.7 years (6–15). For the past 2
years they had had continuously high levels of HbA1c
despite intensive follow-up consisting of scheduled visits
every 6 weeks. Two years before the intervention their
mean HbA1c was 10.6 (7.7–14.0) and one year before their
mean HbA1c was 11.5 (9.8–13.9). Our aim was to reduce
the HbA1c by more than 2 % for 25 % of the adolescents
for the intervention to be considered satisfactory.
The nine adolescents were invited to participate in a
coaching program as a supplement to their usual treatment
and all of them accepted the invitation. Four attended all
coaching sessions, two attended all but one session and
three attended all but two sessions (attendance rate 91 %).
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Coaching Program
coaching process they did not communicate with the diabetes team.
The coaching sessions were conducted by three professional certified coaches. They were not a part of the health
team, but were hired specifically for the project and were
paid by project funds.
The aim of the coaching sessions was to motivate the
patients to take action, to make changes and to achieve
goals that were congruent with their life situation.
The coaching program started and ended by group
coaching sessions lasting 4 h in which the nine participants
and the three coaches participated. During the program the
adolescents were offered five individual face to face
coaching sessions lasting approximately one and a half
hours and three telephone coaching sessions. The sessions
took place outside the hospital in hired meeting facilities
suitable for the purpose.
The coaching was based on a co-active coaching model:
(Whitworth, Kimsey-House, Kimsey-House, & Sandahl,
2007). It is a model in which the coach is described as a
‘‘change agent’’ that chooses the direction and the methods
that best serve the client. The cornerstones of the co-active
coaching model are: (1) the coaching addresses the client’s
whole life; (2) the agenda is given by the client and not by
the coach and finally; (3) the coach must sense what is
important and be able to change course by shifting currents
and themes during coaching sessions (Whitworth et al.,
2007). The approach in ‘Co-active coaching’ is very similar to ‘Life Coaching’ (Williams & Davis, 2007), a method
that is also based on the assumption that the issues most
important for the client are self-identified and prioritized,
and therefore it is the client that chooses the topic, the
action, and the results that they want to achieve.
To guide the adolescents through the process, the coaches made a Pro-Active Plan for each of them. The plan
included different tools that the adolescents could use as
homework e.g. ‘‘The wheel of life’’ by which different
aspects of life can be rated, templates for writing down
barriers, resources and their values, goals, milestones and
action plans. Before the study started, the coaches were
introduced to the most common medical terms used in
diabetic care. They did not have access to any information
from the patients’ files and were not in other ways provided
with information about the adolescents. During the
Follow-Up
HbA1c was routinely measured at all visits at the diabetes
clinic. No differences were found between the mean
HbA1c level at the start of the coaching sessions and the
levels measured 24, 12, and 6 months prior to inclusion,
whereas a significant decrease was found at the end of the
intervention and 1 year after enrolment (Table 1).
From March to October 2010 (the intervention period)
three patients had a reduction in HbA1c of C2.0 %, three
patients had a reduction between 1.0 and 1.9 %, whereas
three patients had unchanged values. From March 2010 to
March 2011 the corresponding numbers were two, two, and
five patients, respectively.
One and a half years after the intervention two patients
had moved, but at the last visit they both had high HbA1c
values. Of the remaining seven patients, two maintained a
reduction in HbA1c C 2.0 % and 1 of C1.0 %, while the
last four had HbA1c values equalling the values at the
starting point.
The participants were interviewed twice to get an indepth knowledge of what it is like to be coached (Kvale,
1997). The first interview took place after three or four
coaching sessions and the last between one and three
months after having finished the coaching. The interviews
were conducted by a member of the project group not
known to the participants, and were based on a semistructured interview guide inspired by the interview guide
developed by Stelter (2010). The participants were asked to
tell, how they experienced the coaching, and to describe
any possible changes in their thoughts, their behaviour and
their feelings. At the second interview the same questions
were asked supplemented by questions about the method
and the experienced self-image before and after the
coaching. Data were tape-recorded, transcribed verbatim,
and analyzed using the meaning condensation method, as
introduced by Van Manen (1990).
All but one of the participants were interviewed twice,
and the main theme describing their experiences of the
coaching elucidated by the interviews was identified as
‘‘Seeing things from a new perspective’’. All but one
Table 1 The mean HbA1c for the nine participants measured before, during and after the coaching, which took place from March to September
2010
Mean HbA1c (%)
p value*
March 2008
March 2009
October 2009
March 2010
October 2010
March 2011
10.858
10.644
11.522
11.089
9.961
10.278
0.77
0.56
0.49
0.03
0.047
* Paired t test
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experienced that the coaching made a difference. The
experience of being seen not as a patient but as a young
human being with ‘‘normal problems’’ seemed to have
made the biggest impression on the participants.
From these experiences elucidated in the interviews the
following four sub themes were generated: ‘‘The experience of being met’’, ‘‘Looking at myself and my diabetes in
a new way’’, ‘‘More self-esteem and more energy’’ and
‘‘New tools to change routines’’.
Table 2 shows citations from the interviews according
to the four sub themes mentioned above.
In the last interview the participants were asked to
evaluate the coaching process and the different methods
used. All participants found that the group sessions were
very inspiring. In general they preferred face to face
coaching instead of telephone coaching, and most
mentioned that it was important that the coach was not one
of the health care professionals from the department. It was
experienced as refreshing and inspiring that the coaching
took place outside the hospital. Only one found it difficult
to talk with the coach and would have liked to have had
another coach, while the others were very satisfied with
their coaches.
Dialogue About the Case
Dr. Jette Ammentorp (Research Manager)
The adolescents in the current study did not previously
manage to obtain acceptable metabolic control in spite of a
good knowledge of diabetes. The results of this
Table 2 Citations from the 17 interviews divided on the four themes (N = 9)
Themes
Citations
The experience of being met
In the long run I get sick and tired of mum and dad, when they keep saying: you must, you must now…. It
is sort of negative, and then you meet such a positive attitude… and you too become more motivated in
the long run
Well he does a god job listening to me and then guides me from there, and I really like that. And then you
really present the answers yourself, and then he adds to that. And I think that that is really’ the bomb’,
and also that they are as nice as they are
To be looked at in a different way. The staff just sees me as an impossible one. It is different with the
coach… the coach makes me look at myself differently
Well, it is a whole different way of talking to people, they are sitting there following what you say, and
instead of suggesting solutions on things, they are more likely to ask you for more information by
asking different questions, so that you have to sit and think about what to do yourself like that
Looking at myself and my diabetes
in a new way
Where I used to hate it …….it now becomes more and more a part of me
For instance regarding diabetes you look at it in a different way so you just get things done instead of
thinking about how annoying it is
It has made me accept it more. For instance I found it difficult to tell people, that I had diabetes, but I feel
that it has become much easier now
Before I was in a bad mood and tired and did not have energy for anything at all. Now I look at things
more positively and bright
More self-esteem and more energy
I have learned that I am not so unusual and I have gained more self-esteem, too
I have become happier and can cope with a little more than I could before
I am not walking around being in a bad mood anymore, I am just sort of, well not happy all the time, but
kind of more fit
It gives you self-esteem… much more self-esteem…I used to walk around in my own world thinking, that
it was just me being stupid. Just me who could not manage and then nine others arrived being just as
stupid as me, if you can say it like that
I have been told by people, that I have become much happier, that I have become much nicer to look at, I
smile much more, I am more accommodating towards others after I started coaching
New tools to change routines
It is especially the fact that I have changed my routines in the mornings. Now I measure my blood glucose
and take insulin before I start working—in the dressing room
Well after a conversation like that, you are much happier and are thinking that now I will go home and try
it. It is always a sort of exiting feeling you take home with you
Before I could not take my blood glucose at school, because I felt embarrassed that I had diabetes. I do
not mind anymore. Now I just take it out in the middle of the class when that is what is needed
Before it was to punish her (the mother)… I have gained good methods to talk to her and to let her into
my heart
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intervention indicate that coaching helped a part of them to
improve the management of their diabetes. Let’s talk about
our experiences so far and the potential role of coaching in
diabetic care.
Jane Thomsen (Diabetes Specialist Nurse)
I know these adolescents quite well, and I was surprised to
see that although this is a group that has demonstrated
serious difficulties in keeping appointments and to follow
treatment plans, it proved possible to involve them and to
have them take responsibility when supplementing their
treatment with professional coaching.
Dr. Poul-Erik Kofoed (Paediatrician)
I agree. We can be encouraged by their participation and
involvement in the program, but also by the improvement
in the glycaemic control. Although they still had HbA1c
levels that were too high international research has shown
that the decrease in HbA1c could have significant impact
on their risk of developing retinopathy.
Well, 18 months after the coaching the HbA1c had
again returned to the pre-study level for three of these
patients. Nevertheless, bearing in mind that all nine had
previously shown very high levels of HbA1c for at least the
past 2 years before the coaching sessions, I consider it
clinically meaningful, that three of nine patients maintained a reduction of more than 1 % and two of these of
more than 2 % one and a half years after the sessions.
Dr. Jette Ammentorp
In addition to the improvements in HbA1c and the results
generated from the interviews, I think it could be interesting to hear if you have observed other positive effects of
the coaching.
Another girl told me that her attitude towards her mother
had become more positive giving them a much better
relationship for which she was very grateful.
In general, my impression is that several of them
became more open about their diabetes, probably due to
higher self-esteem, which made it a lot easier for them to
measure blood glucoses and take their insulin as they did
not have to find a place to do it in hiding. It also made it
easier for them to discuss issues with me that previously
seemed to be difficult.
Dr. Jette Ammentorp
From what you tell and from reading the interviews, it
sounds like the coaches have addressed dysfunctional
emotions, cognitive processes and maladaptive behaviour
by using cognitive behaviour therapy.
Jane Thomsen
Yes, I suppose that the fact that coaching is based on a
broad academic knowledge means that different approaches have been used depending of the agenda of the
patients. By listening to the experiences of the adolescents
I think I can recognize methods such as cognitive and
behavioral psychology, positive psychology and motivational interviewing. However for us who have not participated in the coaching it is still like ‘a black box’, and in
order to get the opportunity to really identify the methods
used we will have to make audio recordings of the
coaching, which will enable us to do a more proper
analysis.
Dr. Jette Ammentorp
Have you experienced any negative effect of the coaching?
Jane Thomsen
Jane Thomsen
Well—one of the girls told me what a big relief it was for
her to realise that she was not the only one who found it
difficult to cope with having diabetes. In the coaching
program she was among others who also had to have
special treatment. It was very reassuring for her to know
that she was not alone.
Another girl shared her ‘‘Wheel of life’’ with me, and we
had an opportunity to discuss expectations. She was convinced that her parents and I were disappointed with her,
because she was not well regulated. We had a discussion
where the main issue was whether she was happy with herself
or not, and it made her see that in fact she was disappointed
with herself and assumed that we were as well.
Not directly—no. But one of them didn’t think it had done
him any good. He was blaming himself, saying that he had
not worked hard enough which is a very common feeling
among adolescents with poor metabolic control. They
blame it on themselves.
Dr. Jette Ammentorp
During the coaching intervention the adolescents were
given very much time and attention. Do you think it is
possible to answer the question, whether the positive result
is a consequence of the attention and the time offered to the
adolescents, or if it is a reflection of the concrete outcomes
of the coaching intervention?
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Dr. Poul-Erik Kofoed
Dr. Jette Ammentorp
In a case study like this, the answer is: No. But it is an
interesting and important question which will require a
study designed to answer precisely that question. However,
the statements from the interviews indicate that it is not
only the time and the increased focus on the patients, but
also the coaching in itself that made a difference.
Still, to be sure that we can distinguish between the
impact of the coaching method and the impact of the time
offered, one should compare the outcome in an intervention
group with that of a control group, in which the patients,
instead of receiving coaching, are offered extra time and
attention as a supplement to the ordinary routine visits. By
this design it could be possible to demonstrate, whether the
positive effect found is due to the coaching or only an
effect of the intensified attention offered to the patients.
From a scientific point of view I can add that these findings
are in concordance with the great amount of studies about
communication in health care emphasizing the importance
of the patients’ experience of being listened to and being
taken seriously and the association with important health
outcomes.
That brings me to the next question; do you think it is
realistic to transfer the method into clinical practice if
future research can show the same positive results as found
in this case study?
Dr. Jette Ammentorp
What do you think is the main difference between the communication with the doctor or the nurse and with the coach?
Dr. Poul-Erik Kofoed
Unlike the counseling in the outpatient clinic there was no
predestined agenda during the coaching sessions, and the
adolescents could bring up whatever issue they wanted to
discuss.
In fact, they are very welcome to do that in the outpatient
clinic as well, but I think that the main difference is that they
expect the consultation to focus on their metabolic control,
and therefore many of them experience it as a kind of
examination.
Jane Thomsen
Yes, it probably has something to do with the expectations
of one another and our roles.
I am not sure that I would obtain the same positive
results as the coaches if I used the same coaching methods
simply because the adolescents expect me to be a nurse
checking the metabolic control. The fact that the coaches
were not a part of the health care professionals taking care
of the diabetes seemed to be essential.
It gave the adolescents a new opportunity to drop their
role as diabetic patients and to choose the role of a person
responsible for his/her own diabetes. I think that many of
the statements in the interview point to that.
Also ‘‘the experience of being met’’ seems to be very
important for the adolescents, and the fact that they felt they
were listened to and taken seriously was mentioned several
times during both interviews.
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Dr. Poul-Erik Kofoed
It was a relatively expensive intervention and it may be
unrealistic to translate it into clinical practice. However, it
gave us an opportunity to investigate, whether coaching
under the most optimal conditions could change the metabolic control in patients where nearly all former attempts
had been in vain.
The results from the interviews together with the
encouraging metabolic results indicate a need for more
research within this area. The next step could be to
investigate the impact of engaging a professional coach in
the department for the purpose of coaching a broader group
of diabetes patients in a randomized design.
From our experience I believe that we should aim at a
non-medical person. Both for professional health care
providers and for patients it could be difficult to distinguish
between the role as a coach and the role as a health care
professional—that is when to treat and when to coach.
Jane Thomsen
The results from our study indicate that there is a need for a
follow up on the coaching session. We do not know what it
would take to maintain the behavioural changes over time,
but we are quite sure that some kind of follow up on the
coaching is necessary. The adolescents are in a phase of
life where they are continuously facing new challenges. We
are planning a new study in which we will prolong the
coaching intervention to eighteen months. It will be a
randomised controlled trial which makes it possible for us
to do a follow-up on both the intervention group and a
control group.
Dr. Jette Ammentorp
Will you be using external coaches in your next project or
have you considered training members from the diabetes
team as coaches?
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Jane Thomsen
Yes, we have considered it. However, based on our experiences from the pilot study, we may expect that the adolescents will still see a diabetes team member as a member
of the treatment provider that is focusing on the metabolic
control. Thus it may not give the adolescents the same
chances of seeing themselves in a new perspective as they
did in this pilot study where they met a coach with no
professional knowledge of diabetes.
Dr. Jette Ammentorp
Are there types of patients for whom coaching might be
contraindicated?
Dr. Poul-Erik Kofoed
For some patients with psychiatric disorders it might not be
relevant to offer coaching, as it could be stressful for them
to be confronted with the coaching methodology in which
they themselves have to define their needs and goals.
Furthermore, these patients might often need treatment by
a psychologist or psychiatrist and it could be difficult for
the patients to focus both on this treatment and on the
coaching.
To benefit from coaching the patients have to have
reached a certain maturity. The lower age limit might be
individual, but will probably be around 12 years. And the
patients should have a near to normal psycho-social
development.
But for all it is a must that the patient is interested and
open to the coaching method—otherwise it will not work.
So even if we as healthcare professionals believe that a
young person not taking care of his diabetes should have
the opportunity to participate in a coaching program, you
should never try to force them.
Acknowledgments The authors want to thank the adolescents participating in the study, the professional coaches who performed the
coaching sessions with the adolescents and the Department of Paediatrics for their assistance with the study.
Conflicts of interest No particular conflicts of interest relevant to
this article were reported.
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