Conclusions and Future Directions 209the psychologist and others on the medical team. When such
an arrangement is not possible, consultation and referral to
outside health psychologists is another option.
A role for health psychology is clearly justi“ed by several
factors. First, the prevalence of psychological problems (e.g.,
major depression) in patients with diabetes suggests that
health psychology could have a prominent role with these
patients. The experience of multiple losses may be character-
istic of a chronic illness such as diabetes. Patients face not
only the loss of their previously healthy body, but also poten-
tial losses of function, self-esteem, and freedom as diabetic
complications develop. Second, the literature has demon-
strated that the majority of patients “nd it dif “cult to follow
the recommendations for self-care. The diabetes treatment
regimen clearly presents multiple, ongoing challenges and
demands. Adherence problems appear to be most dif“cult
for those components of the diabetes regimen that require
lifestyle changes (e.g., diet, exercise), which all patients with
diabetes are prescribed. Health psychologists are well-suited
to assess and treat these dif“culties and to facilitate the be-
havioral changes needed for optimal outcomes. In addition,
health psychologists as researchers have a role in advancing
our understanding of psychosocial factors associated with
adjustment to, and coping with, diabetes, the link between
physiological and psychosocial factors in diabetes, and inter-
ventions to address the psychosocial challenges inherent in a
chronic disease such as diabetes.
Assessment of diabetes patients should occur on an ongo-
ing basis, starting at the time of diagnosis. Throughout the
natural history of diabetes, there will be times that present
challenges to both emotional and physical well-being. For
example, at diagnosis, patients are faced with issues of loss
while attempting to assimilate a large amount of novel infor-
mation and new skills for disease management. However,
the need for health psychologists is not limited to this early
contact. Other times of need may be when complications de-
velop, physical status worsens, or the treatment regimen
changes. By having the psychologist readily available and
familiar, patients may be more apt to avail themselves of
needed psychological services. In the clinical setting, health
psychologists are likely to use a combination of clinical in-
terviewing, along with self-report questionnaires, in a com-
prehensive assessment. Varieties of diabetes-speci“c, as well
as general assessment, instruments have been reviewed
brie”y. Assessment of diabetes patients should be dictated by
the referral question or presenting problem. However, com-
mon targets of assessment include affect (e.g., depression,
anxiety), current and past stressors, coping styles, resources
available to the person (e.g., social support from natural sup-
port network as well as medical team), and levels of self-care.
By adopting an empathetic, nonjudgmental stance, health
psychologists may build rapport with patients, delineate the
nature of the presenting problem, and jointly determine treat-
ment goals with the patients.
The goal of psychological treatment with diabetes patients
is to maximize psychological well-being as well as glycemic
control. The provision of psychological services can also
positively affect the use of medical services (e.g., distressed
patients will use more medical services; psychological inter-
ventions can reduce medical utilization). Treatment may
occur in a variety of modalities (e.g., group, individual,
marital, and family therapy) according to the needs and de-
sires of the patient. As part of a multidisciplinary treatment
team, the health psychologist can work together with other
professionals (e.g., diabetes educators, nutritionists) to
achieve treatment goals with patients and their families.
Clinician researchers have begun to establish an empirical
foundation for particular interventions with diabetes patients.
Behavioral treatment appears to be particularly well-suited
for many of the presenting problems (e.g., adherence, stress
management). As described next, research is needed to fur-
ther delineate effective treatments that can be individualized
for particular patients• needs.CONCLUSIONS AND FUTURE DIRECTIONSGiven the recent landmark “ndings of the DCCT (1993) and
UKDPS (1998), there has been increased emphasis on
achieving optimal management of diabetes mellitus. Persons
with diabetes are faced with a rigorous treatment regimen,
which relies heavily on self-management to attain the tight
glycemic control that was fundamental to the decreases in
complications found in these clinical trials. Thus, research
into factors that either facilitate or suppress optimal disease
management is even more crucial at this time. Studies have
indicated the dif“culties that diabetes patients have in
following treatment recommendations, even when these rec-
ommendations are not as complex or demanding as the man-
agement strategies that are typically recommended today.
The preceding review has highlighted empirical “ndings on
the relationship between several psychosocial factors and
both adherence levels and physiological outcomes. Impor-
tantly, behavioral researchers have begun to develop and
evaluate the ef“cacy of various treatment programs designed
to modify these psychosocial variables and thereby enhance
patients• psychosocial and physical outcomes.
Rubin and Peyrot (1992) have reviewed the need for im-
provements in the intervention work being conducted. These
authors note that, historically, intervention studies have used