Inez B. is a 68-year-old woman who was initially referred to a community clinic after a fainting episode that occurred during her part-time shift at Wal-Mart. Aside from modest obesity and hypertension, the clinic’s health care team discovered that Inez has Type 2 diabetes, advanced to the point where careful management of her disease, including insulin therapy, is required. In fact, Inez is already showing symptoms of peripheral vascular disease secondary to uncontrolled diabetes. Her primary care physician referred her to the clinic social worker because of significant concerns about her social situation and her ability to manage her disease effectively.

The following information was available from the limited social history in her clinic records: Inez is a naturalized citizen who emigrated from Mexico 23 years earlier along with her husband and three young children. Her command of English is limited, she is functionally illiterate, and she currently relies on her adult children to help her with complex written information. Aside from the limited income Inez brings home from her part-time job, she and her husband have only his Social Security Old Age Insurance benefits. Inez does all the housework and the cooking for her husband and herself and provides meals and day care for three of her grandchildren while their parents are at work.

The following exercise consists of three elements:

1)    Using the Typology of Chronic Disease framework shown in Table 1, identify the characteristics of Inez’s diabetes and her hypertensive disease.

[Note to instructor: Students should note that both hypertensive disease and insulin-dependent adult onset diabetes are shown on Table I to fall in the cell designated for diseases that are gradual, progressive, and associated with a shortened life span. The speed of disease progression in both adult onset diabetes and hypertension, as well as their respective effects on a shortened life span, are largely determined by how well the diabetic patient can manage their disease, which in turn is heavily influenced by access to appropriate health care and the support they receive from their family. Several of your students are likely to have someone in their family managing insulin dependent-diabetes, and it often works well to have these students describe what is entailed for the person; this then can be applied to the situation of Inez and her specific challenges.]

2)      Investigate the kinds of adaptive demands that diabetes and hypertension place on Inez and her family system. Be as specific as possible regarding each disease.

[Note to instructor: Several of your students will likely have someone in their family managing insulin-dependent diabetes, and it often works well to have these students describe to the class what is entailed for the person managing this disease (e.g., planning every meal and snack, recognizing and balancing the effects of stress and exertion on blood sugar levels and insulin dosing, rigorous and sometimes painful monitoring of blood sugar). This then can be applied to the situation of Inez and her specific challenges as described in her brief social summary. For example, diabetes educational materials are often written with at least a high school level of literacy assumed; thus, even should they be made available in Spanish, Inez ill not necessarily be able to comprehend them. Further, Inez has a very limited income with which to pay for her anti-hypertensive medications, glucose sticks, and insulin. Finally, the early onset of peripheral vascular disease signals the possibility that she will not be able to sustain demanding work that keeps her on her feet for long hours. Health insurance coverage and access to health care are also large issues. In addition, students should think about the role that Inez has fulfilled in the family as the prime caregiver for her husband and children, and the kinds of adaptive demands implied for the family should Inez be supported by her family in managing her disease effectively.]

3)      What kinds of questions or areas of exploration should the social worker pursue in the biopsychosocial assessment process?

[Note to instructor: Students should be encouraged to identify the information they have in hand, both about Inez and the nature of her disease processes. This then helps them to identify critical elements of information that they do not know—some of which might be acquired via patient/family interviews and some of which can be gathered from other sources (e.g., disease and disease management information via library resources and the internet). The most critical elements of information pertain to Inez’s experiences with and beliefs about diabetes—in particular her beliefs about disease prognosis and the capacity of the patient to influence the course of the disease. Another line of inquiry pertains to the sources of motivation and capacity that will support Inez’s adaptation to the specific demands entailed in a rigorous regime of disease management. A third line of inquiry pertains to material resources and health care system access. Also, students should be advised that a complete biopsychosocial assessment, ideally, would entail more than one interview, because the patient needs time to absorb information about the disease and the implications for her life to be a more effective informant. Some students might suggest this is unrealistic—which then could be used as a basis for a discussion on tensions between the organization of the health care system and the nature of successful behavioral interventions].

 NOTE: The Stanford Geriatric Education Center is a good resource for students to explore the impact of diabetes on mental health among diverse populations.  http://sgec.stanford.edu/diabetes_mh.html