TUGAS KEPERAWATAN KELUARGA

LAPORAN ANALISIS FILM KELUARGA “STEEL

MAGNOLIAR”

oleh
Kelompok 4
Kelas B 2016

KEMENTERIAN RISET, TEKNOLOGI DAN PENDIDIKAN TINGGI

FAKULTAS KEPERAWATAN
UNIVERSITAS JEMBER
2018
 TUGAS KEPERAWATAN KELUARGA

LAPORAN ANALISIS FILM KELUARGA “STEEL MAGNOLIAR”

Disusun untuk memenuhi tugas mata kuliah Keperawatan Keluarga

Dosen pengampu : Ns. Latifa Aini S. S.Kep., M.kep, Sp. Kom

Oleh
Kelompok 4, Kelas B 2016
Nurul Amilia Oktivana NIM 162310101063
Siti Nurhaliza Farisia NIM 162310101065
Fitri Eka Sari NIM 162310101078
Roihana Jannatil F. NIM 162310101079
Ikhwan Abbiyu NIM 162310101085
Novia Paramitha NIM 162310101088

KEMENTERIAN RISET, TEKNOLOGI DAN PENDIDIKAN TINGGI

FAKULTAS KEPERAWATAN
UNIVERSITAS JEMBER
2018
A. KEHADIRAN KELUARGA
1. Gambaran singkat tentang film (sebutkan anggota keluarga
dalam film dan deskripsikan khusus anggota keluarga yang
akan menjadi pasien anda.
Anggota keluarga :
a. Drum Eatenton : Ayah
b. M’Lynn Eatenton : Ibu
c. Shelby Eatenton : Anak Pertama
d. Jonathan Eatenton : Saudara laki- laki Shelby
e. Tommy Eatenton : Saudara laki- laki Shelby
f. Jackson Latcheris : Suami Shelby
g. Jackson Latcheris JR : Anak dari Jackson
dan Shelby
Shelby Eatenton adalah seorang perawat disalah satu rumah
sakit di tempat tinggalnya. Shelby merupakan putri pertama
dari pasangan Drum Eatenton dan M’Lynn Eatenton. Shelby
dan keluarganya tinggal di Amerika bersama kedua adiknya.
Adik Shelby bernama Jonathan Eatenton dan Tommy
Eatenton. Shelby Eatenton di diagnosis Diabetes tipe 1 pada
usia muda. Sejak usia muda Shelby sering mengalami kejang
jika kadar gula darah di dalam tubuhnya menurun. Shelby
memiliki kekasih sekaligus calon suaminya yang bernama
Jackson Latcheris. Jackson ingin menikah dengan Shelby dan
menerima segala kekurangannya. Jackson menginginkan jika
dia dan Shelby menikah, mereka akan memilih mengadopsi
seorang anak di dalam keluarga kecilnya, karena mengingat
akan penyakit yang dialami Shelby (Diabetes tipe 1). Suatu
hari ketika keluaga Eatenton mepersiapkan pernikahan
putrinya, yaitu Shelby dan Jackson. Keluarga Eatenton beserta
kerabat dekat datang da mebantu mempersiapkan acara
pernikahan. Semua keluarga dan kerabat mendukung Shelby
 menikah dengan Jackso karena jackso merupakan lelaki yang
baik untuk shelby. Dalam mempersiapkan acara pernikahan
Shelby semua keluarga terlihat antusias dan bahagia.

Suatu ketika ketika Selby berada di salon untuk

mempersiapkan acara pernikahannya, Shelby mengalami
kejang akibat kekurangan kadar gula darang di dalam
tubuhnya atau Hipoglikemia. Ibu dan kerabat keluarganya
dengan cepat dan tanggal dalam menangani masalah kesehatan
Shelby tersebut. Setelah resmi menjadi istri Jackson, ibu
Shelby tidak ingin Shelby hamil, karena dapat mengganggu
kesehatannya namun setelah beberapa lama menikah Shelby
memberitahu ibunya bahwa ia hamil. M’lLynn tidak senang
akan kabar yang Shelby dari putrinya. Namun Shelby tetap
kuat akan pendiriannya bahwa dia ingin memiliki anak
meskipun hanya dalam waktu 30 menit. Akhirnya Shelby
melahirkan anak laki – laki yang bernama Jackson Latcheris
JR. Suatu ketika saat Shelby dan putranya bermain, Shelby
mengalami hipoglikemi dan menyababkan dirinya tak
sadarkan diri. Kemudian saat Jackson pulang melihat anaknya
menagis dan istrinya tak sadarkan diri, Jackson langsung
membawa Shelby kerumah sakit. Shelby mengalami koma,
setelah keluarganya berusaha dengan optimal, keluarga shelby
pun menyerah dan memutuskan untuk melakukan Euthanasia
kepada putrinya Shelby.
2. Gambaran ecomap keluarga tersebut
 Keterangan :

Wanita :

Pria :

Meninggal :

Pasien :

Interaksi Sosial :

3. Analisis ecomap secara spesifik terkait hubungan keluarga dan lingkungan

sekitar
Didalam film Steel Magnolias ini, menceritakan seorang wanita yang bernama
Shelby terdiagnosa penyakit Diabetes tipe 1 di usia muda. Shelby putri dari
pasangan Drum Eatenton dan M’Lynn Etenten yang bernama Shelby Aetenton.
Shelby memiliki 2 adik laki – laki yang bernama Jonathan Eatenton dan Tommy
Eatenton. Shelby memiliki kekasih yang bernama Jackson Latcheris dan akhirnya
menikah. Pernikahan Shelby dan Jackson dilaksanakan di rumah Shelby,
pernikahan yang meriah dan disambut dengan antusias oleh keluarga serta kerabat
dekat keluarga Shelby. Setelah menikah Shelby dan Jackson memiliki seorang
anak laki laki yang bernama Jackson Latcheris JR.

B. PENILAIN KELUARGA DAN PRIORITAS KEBUTUHAN

1. KONDISI FISIK DAN PSIKOSOSIAL

Shelby dan keluarga dapat dikatakan kondisi fisik yang
cukup baik, dalam hal aspek fisik dan psikososial. Shelby dan
keluarga hidup dalam keadaan yang bercukupan tidak memiliki
 kendala dalam hal fisik dan psikososial. Dalam hal psikososial di
dalam film tidak dijelaskan mengenai hal tersebut tetapi terdapat
beberapa keadaan Ibu Shalby terbebani oleh beberapa pikiran
yang menjadi konflik dalam keluarga.
2. FAKTOR LINGKUNGAN DAN SOSIOKULTURAL: NILAI,
KEYAKINAN, RITUAL
Shelby dan keluarga tinggal di Amerika, Agama yang
dianut oleh Shelby dan keluarga adalah agama Kristen. Namun
aktivitas keagamaan yang dilakukan oleh Shelb dan keluarga
tidak dijelaskan dalam film. Hanya saja dalam film dijelaskan
Shelby dengan Jackson melaksanakan pernikannya di Gereja
Presbiterian.
3. STATUS GIZI DAN OBAT-OBATAN
Status gizi didalam film tidak di perlihatkan, dan Shelby
dan keluarga tidak mengkonsumsi obat-obatan. Hanya saja
dijelaskan sejak Shelby penderita penyakit Diabetes. Shelby
rutin mengkonsumsi insulin yang disuntikkan pada tubuhnya
sendiri sehingga mengakibatkan Shelby terlalu banyak
mengkonsumsi insulin, karena Shelby sulit untuk mengkontrol
penggunaan insulin untuk tubuhnya.
4. PENGGUNAAN SUMBER PERAWATAN KESEHAN ATAU
PENGOBATAN ALTERNATIF
Saat Shelby sakit dan koma Shelby dirawat dirumah sakit.
Shelby pernah berkonsultasi dengan Dr. Mitchell terkait
penyakit Diabetes yang diderita. Hanya saja tidak dijelaskan
pengobatan alternatif yang di gunakan Shelby dan keluarga.
5. DIAGNOSA MEDIS
Shelby didiagnosa terkena penyakit Diabetes
6. BAGAIMANA KONDISI KLIEN MEMPENGARUHI
KELUARGA DAN REAKSI MEREKA.
Kondisi klien sangat mempengaruhi keluarga besarnya.
M’Lynn Ibu dari Shelby awalnya sangat menolak saat mengetahui
bahwa Shelby sedang mengandung/ hamil. Ibu Shelby sangat
 menyangi Shelby dan takut kehilangan Shelby apabila Shelby tetap
melanjutkan kehamilannya. Namun Shelby tetap bersikukuh untuk
melanjutkan kehamilannya dan dia berusaha meyakinkan ibunya.
Seluruh keluarganya kemudian tetap mendukung segala keputusan
yang diambil oleh Shelby, seperti keputusannya saat melanjutkan
kehamilan hingga melahirkan bayi Jack jr, memotong rambutnya
menjadi pendek,dan saat Shelby akan melakukan transplantasi
Ginjal.
7. PERSEPSI KELUARGA TENTANG KESEHATAN
Keluarganya sangat menjaga kesehatan Shelby terutama ibu
Shelby M’Lynn. Hal itu dibuktikan dengan ibu Shelby yang
menginginkan bahwa setelah Shelby menikah tidak
menginginkan Shelby untuk bekerja. Selain itu, ibu Shelby yang
selalu mengetahui bagaimana keadaan yang dialami Shelby dan
juga menyetujui saat Shelby menginginkan transplantasi Ginjal
disaat ayahnya, Drum gelisah saat mengetahui hal tersebut.
Namun ayah Shelby tetap mendukung keputusan dari Shelby.
8. KEKUATAN KELUARGA
Keluarga tersebut memiliki hubungan yang sangat harmonis.
Bahkan dengan tetangga mereka terlihat seperti saudara. Mereka juga
saling mendukung satu sama lain. Namun ada beberapa adegan yang
menunjukkan perbedaan pendapat antara Shelby dengan ibunya disaat
Shelby memberikan kabar ke ibunya bahwa saat ini dia sedang
mengandung. M’Lynn yang awalnya menentang, akhirnya luluh
setelah dibujuk oleh teman-teman yang sekaligus menjadi tetangganya
yaitu Ny. Truvy, Nn. Annelle, Ny. Clairee, dan Nn. Ouiser.
 C. IDENTIFIKASI PERMASALAHAN KELUARGA

DATA MALADAPTIF DIAGNOSA RENCANA KEPERAWATAN TINDAKAN JURNAL RUJUKAN

KEPERAWATAN KEPERAWATA
N / TERAPI
KELUARGA
- Mylin kesusahan 1. Domain 7. 1. Dukungan Pengasuhan 1. Dukungan
dalam mengatur Kelas 1. 7040 Pemberi
anak – anaknya Risiko Ketegangan  Mengkaji tingkat Asuhan
dan keluarga. Pemberi Asuhan pengetahuan pemberi 2. Pemeliharaan
Anak laki laki Definisi: asuhan Proses Keluarga
Mylin yang selalu
Rentan terhadap  Mengkaji tingkat 3. Dukungan
membuat masalah penerimaan pemberi asuhan Pengambilan
ataupun kesulitan dalam Keputusan
terkait dengan perannya
melakukan peran
mengganggu  Mendukung upaya
Mylin dengan pemberian asuhan, bertanggung jawab pemberi
memasukkan es harapan dan atau asuhan, sesuai dengan
batu ke dalam perilaku untuk keluarga kebutuhan
baju Mylin. atau orang terdekat,
Suami Mylin, 2. Pemeliharaan Proses
yang dapat
Drum membuat Keluarga
mengganggu kesehatan.
kondisi semakin  Tentukan proses keluarga
terganggu saat yang khas
mengusir burung  Tentukan gangguan khas
burung di pada proses keluarga
halaman  Identifikasi efek perubahan
rumahnya. peran terhadap proses
- Mylin khawatir
keluarga
 dengan pernikahan  Dukung untuk tetap kontak
Shelby dan saat dengan anggota keluarga
Sehlby ingin
memiliki anak. Dan 3. Dukungan Pengambilan
Shelby berkata
Keputusan 5250
“Mama kamu
terlalu khawatir  Bantu pasien untuk
- Shelby saat mengklarifikasi nilai dan
memiliki anak harapan yang mungkin akan
mengatakan, ‘’ aku membantu dalam membuat
sangat memiliki pilihan yang penting dalam
tekanan saat hidupnya
merawat Jr.  Bantu pasien
Jackson’’ mengidentifikasi
keuntungan dan kerugian
dari setiap alternative
pilihan
 Hormati hak-hak pasien
untuk menerima atau tidak
menerima informasi.
Mylin khawatir saat 2. Domain 9. 1. Pengurangan Kecemasan 1. Pengurangan
Shelby ingin memiliki Kelas 2. Ketakutan 5820 Kecemasan
anak, dan disaat Definisi :  Gunakan pendekatan yang 2. Peningkatan
tenang dan meyakinkan Koping
perayaan kehamilan Respon terhadap
persepsi ancaman yang  Jelaskan semua prosedur 3. Fasilitasi
Shelby, Mylin Kehadiran
termasuk sensasi yang akan
mengatakan “Kata secara sadar dikenali dirasakan yang mungkin Keluarga
sebagai sebuah bahaya.
dokter seharusnya akan dialamai klien selama 4. Dukungan
mereka (Shelby dan prosedur (dilakukan) Spiritual
Jackson) tidak beranak.  Dorong keluarga untuk
mendampingi klien dengan
 cara yang tepat

2. Peningkatan Koping 5230

 Bantu klien identifikasi
tujuan
 Bantu klien memeriksa
sumber tersedia untuk
memenuhi tujuan
 Dukung hubungan pasien
 Bantu klien menyelesaikan
masalah secara konstruktif

3. Fasilitasi Kehadiran
Keluarga 7170
 Perkenalkan diri anda
kepada staf yang menangani
klien dan keluarga
 Tentukan kesesuaian
lingkungan untuk
mengahdirkan keluarga
 Bantu mengembangkan
harapan yang realistis

4. Dukungan Spiritual 5420

 Gunakan komunikasi
terapeutik untuk menjalin
hubungan saling percaya
 Dorong individu meninjau
ulang masa lalu dan
berfokus pada kejadian dan
 hubungan yang
memberikan dukungan dan
kekuatan spiritual
 Berikan privasi dan waktu
yang tenang untuk klien
D. TERAPI KELUARGA
Judul film : Steel Magnolias.
Masalah keluarga : Salah satu anggota keluarga terdiagnosis penyakit
kronis yaitu Diabetes.
Terapi keluarga : Terapi Keluarga Multisistemik (MST).
Pengertian terapi keluarga : Terapi keluarga Multisistemik (MST) adalah salah
satu strategi intervensi berbasis keluarga yang lebih memfokuskan sasarannya
pada kerjasama keluarga yang memiliki masalah pengobatan manajemen diri yang
buruk pada anggota keluarga dengan penyakit kronis termasuk diabetes.
Intervensi terapi keluarga Multisistemik berakar dari manajemen orang tua, dan
teori sistem keluarga. MST membahas faktor risiko individual untuk
ketidakpatuhan mengatasi penyakitnya dan juga menerapkan intervensi untuk
menargetkan individu, keluarga, teman sebaya, dan faktor lingkungan sosial.
Indikasi Terapi Keluarga : Pada keluarga dengan anggota keluarga remaja,
dewasa awal yang mengalami masalah penyakit kronis, gangguan mental,
gangguan psikis yang melibatkan keluarga, teman sebaya, tetangga dan sistem
sosial lainnya.
Kontra indikasi : Tidak ada kontra indikasi mengenai intervensi
terapi dukungan keluarga, karena pada dasarnya terapi ini melibatkan aspek-aspek
yang menyeluruh pada lingkungan keluarga.
Persiapan terapi keluarga : Kontrak waktu, tempat dan anggota keluarga yang
mengikuti terapi, menyediakan alat-alat jika diperlukan untuk membantu terapi
keluarga MST (Multisitemik Therapy)
Prosedur terapi keluarga :
1. Pra interaksi
a. Cek catatan keperawatan atau medis klien (jika ada)
b. Menyiapkan alat yang akan digunakan untuk terapi (jika diperlukan)
c. Identifikasi faktor/ kondisi yang menyebabkan kontra indikasi
2. Tahap Orientasi
a. Beri salam dan memperkenalkan diri.
b. Kontak waktu serta tempat untuk intervensi.
c. Jelaskan maksud dan tujuan intervensi.
3. Tahap Kerja
a. Berikan kesempatan kepada pasien untuk mengungkapkan perasaan,
pikiran tentang pengalamannya, keluarga dan terapis mendengarkan
secara aktif.
b. Terapis membantu keluarga bersiap untuk membuat daftar pertanyaan
dan kekhawatiran mereka sebagai bahan topik yang ingin didiskusikan
bersama therapis.
c. Penilaian perilaku masalah serta kekuatan dan kelemahan anggota
keluarga terutama yang terdiagnosa diabetes.
d. Mengidentifikasi serta mengatasi perilaku bermasalah dalam anggota
keluarga (seperti pengobatan diabetes yang tidak terkontrol dengan
baik) maka perlunya terapis untuk melakukan intervensi psikoedukasi
untuk meningkatkan keterampilan yang terkait dengan perawatan
diabetes.
e. Pelatihan orang tua untuk mengurangi pelepasan orang tua dari
rejimen diabetes, misalnya, meningkatkan pengetahuan orang tua
tentang perawatan diabetes, keterampilan mengasuh anak (seperti
meningkatkan pemantauan sistematis, dan sistem disiplin untuk
meningkatkan pengawasan orang tua dari rejimen perawatan diabetes).
f. Memberikan konseling untuk meningkatkan motivasi penyelesaian
perawatan diabetes, atau perawatan kesehatan mental seperti terapi
untuk mengobati depresi.
g. Mengajarkan strategi untuk meningkatkan rutinitas organisasi keluarga
dalam hal mendukung perawatan diabetes pada remaja.
h. Mendemonstrasikan perilaku terapi sistem keluarga untuk mengatasi
konflik sehari-hari seputar perawatan diabetes dan meningkatkan
komunikasi pengasuh satu sama lain tentang perawatan diabetes
remaja.
i. Menarik dukungan sosial dari teman atau anggota keluarga yang dapat
membantu perawatan diabetes termasuk dukungan aktif teman sebaya
atau jika klien diabetes sudah menikah dapat melalui pasangannya
mengenai kepatuhan rejimen dan mendorong pengungkapan status
 diabetes pada pasangan.
j. Selama setiap kunjungan terapis secara rutin meninjau hasil tes
diabetes dan memberi keluarga informasi tertulis tentang rencana
perkembangan dan perawatan remaja.
4. Tahap Terminasi
a. Fasilitasi klien dan keluarga jika ada yang ingin ditanyakan.
b. Berikan reinforcement positif kepada klien dan keluarga.
c. Evaluasi perasaan dan pengetahuan klien dan keluarga.
d. Kontrak tempat dan waktu untuk pertemuan selanjutnya.
e. Akhiri terapi dengan berpamitan kepada klien dan keluarga.

Evaluasi terapi keluarga : Klien dan keluarga mulai memahami dan

menerapkan terapi Multisistemik Therapy (MST) dalam kehidupan sehari-hari
sehingga menjadikan klien dan keluarga semakin erat dalam hubungan sosial
ataupun komunikasi dan kolaborasi antar keluarga untuk meningkatkan
keterampilan terkait mengatasi dan menangani perilaku anggota keluarga yang
terdiagnosa diabetes.
Sumber referensi :
Almasitoh, Ummu Hany. 2012. Model Terapi Dalam Keluarga. Klaten: Magistra
No. 80 Th. XXIV.
Carcone A.I, Ellis D.A, Chen X, Naar S, Cunningham P.B, Moltz K. 2015.
Multisystemic Therapy Improves the Patient-Provider Relationship in Families of
Adolescents with Poorly Controlled Insulin Dependent Diabetes. New York: J
Clin Psychol Med Settings.
E. CRITICAL APPRAISAL
1. Judul Multisystemic Therapy Improves the Patient-Provider
Relationship in Families of Adolescents with Poorly
Controlled Insulin Dependent Diabetes
2. Penerbitan / Tahun 2015/ Springer Science+Business Media New
terbitan York
3. Authors - April Idalski Carcone
- Deborah A. Ellis
- Xinguang Chen
- Sylvie Naar
- Phillippe B. Cunningham
- Kathleen Moltz4
4. Sumber Jurnal Doi: 10.1007/s10880-015-9422-y.
5. Abstrak Tujuan dari penelitian ini adalah untuk menentukan
apakah terapi multisistemik (MST), perawatan keluarga
intensif, di rumah dan berbasis masyarakat, secara
signifikan meningkatkan hubungan pasien-provider
dalam keluarga di mana remaja memiliki kontrol
glikemik kronis yang buruk. Seratus empat puluh enam
remaja dengan diabetes tipe 1 atau 2 dengan kontrol
glikemik kronis yang buruk (HbA1c C8%) dan pengasuh
utama mereka secara acak ditugaskan untuk MST atau
kondisi dengan dukungan telepon. Persepsi pengasuh
tentang hubungan mereka dengan tim medis multidisiplin
diabetes dinilai pada awal dan penghentian pengobatan
dengan Ukur Proses Perawatan-20. Pada penghentian
pengobatan, keluarga MST melaporkan peningkatan yang
signifikan pada skala Perawatan yang Terkoordinasi dan
Komprehensif dan sedikit peningkatan signifikan pada
skala Perawatan Respektif dan Dukungan. Perbaikan pada
perizinan Kemitraan dan Menyediakan skala Informasi
Spesifik yang tidak signifikan. Hasil menunjukkan MST
 meningkatkan kemampuan keluarga dan penyedia
pengobatan diabetes untuk bekerja sama.
6. Introduction Karena orang tua memainkan peran penting dalam
mendukung perawatan diabetes, bahkan selama masa
remaja (Silverstein et al., 2005), menumbuhkan hubungan
yang efektif antara orang tua dan provider adalah penting.
Ini mungkin benar terutama ketika diabetes tidak
terkontrol dengan baik, karena komunikasi yang buruk
mengenai hambatan untuk manajemen diabetes di rumah
dapat menyebabkan provider hanya meningkatkan dosis
insulin dari pada membantu keluarga mengatasi hambatan
penting untuk perawatan. Namun, sampai saat ini, ada
intervensi terbatas yang dikembangkan yang efektif untuk
meningkatkan hubungan pasien-provider (Nobile &
Drotar, 2003) dan tidak ada yang berfokus pada remaja
dengan diabetes yang tidak terkontrol.
Karena sifat komprehensif intervensi MST dan fokus
pada intervensi dalam berbagai sistem yang berkontribusi
pada kontrol metabolik yang buruk, hubungan antara
keluarga dan tim perawatan medis menjadi titik kritis
untuk intervensi. Dengan meningkatkan hubungan antara
keluarga dan penyedia pengobatan, terapis MST mencoba
untuk memaksimalkan kemungkinan bahwa setiap
perbaikan dalam manajemen diabetes akan dipertahankan
setelah perawatan disimpulkan. MST telah terbukti
meningkatkan titik akhir terkait diabetes yang relevan
seperti kontrol glikemik (Ellis et al., 2012), perilaku
manajemen penyakit (Ellis et al., 2005b) serta hasil
penting lainnya seperti stres diabetes remaja (Ellis, Frey ,
Naar-King, Templin, Cunningham, et al., 2005a) dan
keterlibatan orang tua dalam perawatan diabetes (Ellis,
Yopp, et al., 2006; Naar-King, Ellis, Idalski, Frey, &
 Cunningham, 2007), tetapi, sampai saat ini, dampaknya
pada hubungan pasien-penyedia, belum diperiksa.
7. Tujuan Tujuan dari penelitian ini adalah untuk menguji
efektivitas MST dalam meningkatkan hubungan pasien-
provider dibandingkan dengan kondisi kontrol perhatian.
Mengingat fokus MST pada peningkatan kolaborasi dan
pembagian informasi antara keluarga dan tim perawatan
kesehatan, kami memperkirakan bahwa keluarga yang
menerima MST akan melaporkan peningkatan yang
signifikan dalam hubungan pasien-provider mereka pada
akhir pengobatan, dibandingkan dengan kondisi kontrol.
8. Metode Data yang dilaporkan dalam penelitian ini merupakan
titik akhir sekunder dari uji coba klinis acak yang lebih
besar di mana titik akhir primernya adalah manajemen
diabetes dan kontrol metabolik. Penjelasan rinci tentang
metode percobaan dan hasil utama telah dilaporkan di
tempat lain (lihat Ellis et al., 2012).
9 Subyek Remaja dengan kontrol glikemik kronis yang buruk
direkrut dari klinik endokrinologi pediatrik yang
berafiliasi dengan universitas di rumah sakit anak-anak
perawatan tersier yang terletak di wilayah metropolitan
utama Midwestern antara 2006 dan 2010. Kelayakan
termasuk diagnosis diabetes tipe 1 atau 2 selama
setidaknya 1 tahun yang memerlukan terapi insulin,
HbA1c C8% pada kunjungan klinik sebelum pendaftaran
dan lebih dari tahun sebelumnya dan usia 10–17 tahun.
HbA1c awal dua remaja adalah \ 8,0%; Namun, mereka
dinyatakan memenuhi kriteria untuk pendaftaran studi
dan, oleh karena itu, terdaftar dalam persidangan. Kriteria
eksklusi adalah kerusakan kognitif sedang berat (dinilai
melalui laporan pengasuh dari ketidakmampuan belajar
yang didiagnosis sebelumnya, penempatan pendidikan
 khusus, dan / atau ketidakmampuan untuk menyelesaikan
penilaian penelitian secara independen), psikosis, atau
non-bahasa Inggris.
10. Protocol Diagram aliran CONSORT, Gambar. 1, merangkum
proses perekrutan dan pendaftaran peserta. Staf penelitian
menyaring 513 keluarga untuk partisipasi, dimana 238
tidak memenuhi syarat dan 36 tidak dapat dihubungi. Dari
239 yang tersisa, 52 menolak partisipasi dan 10
mengundurkan diri sebelum pengacakan menghasilkan
tingkat partisipasi 74%. 146 remaja dan pengasuh utama
mereka terdaftar secara acak ditugaskan untuk 6 bulan
MST (n = 74) atau dukungan telepon (TS; n = 72).
Pengobatan dimulai dalam 1 bulan dari awal (M = 27,9
hari, SD = 17,5). Durasi rata-rata pengobatan untuk
peserta MST adalah 5,6 bulan (SD = 1,2) dan 4,9 bulan
(SD = 1,6) di TS. Dua belas keluarga MST (16%) dan 14
keluarga dukungan telepon (19%) gagal menyelesaikan
seluruh perawatan. Hanya dua keluarga MST dan satu
keluarga dukungan telepon yang menolak untuk
melengkapi pengumpulan data tindak lanjut setelah
pengobatan putus sekolah (98% tingkat retensi). Semua
peserta dimasukkan dalam analisis intent-to-treat.
11. Measurements Karakteristik demografi pasien dikumpulkan pada awal
menggunakan penyidik yang dikembangkan, kuesioner
laporan diri. Ukuran Proses Perawatan-20 (MPOC-20;
King, King, & Rosenbaum, 2004) dirancang untuk
menilai persepsi orang tua terhadap layanan medis yang
diterima anak-anak mereka, termasuk komponen interaksi
perawatan dan keberpusatan keluarga dari hubungan
pasien-provider.
12. Hasil Karakteristik demografis ditunjukkan pada Tabel 1.
Konsisten dengan populasi yang dilayani oleh institusi di
mana peserta direkrut, sampel terdiri terutama dari remaja
Afrika Amerika (77%). Seperti yang diharapkan,
pengukuran dasar kontrol glikemik menyarankan kontrol
glikemik yang buruk secara keseluruhan (M = 11,7%, SD
= 2,5). Sebagian besar pengasuh adalah orang tua tunggal
(59%) orang tua biologis (93%). Tidak ada perbedaan
yang signifikan secara statistik antara kelompok MST dan
TS pada awal pada demografi atau kontrol glikemik (Ellis
et al., 2012) (Tabel 1).
Pengaruh MST relatif terhadap keluarga yang terdaftar
dalam TS pada setiap skala MPOC dievaluasi
menggunakan empat model regresi linier dengan semua
variabel yang dimasukkan secara bersamaan. Meskipun
tugas acak pada awal, keluarga MST melaporkan
hubungan pasien-provider yang lebih positif pada tiga
skala relatif terhadap keluarga yang terdaftar kondisi
kontrol: EP (MMST = 5,61, SDMST = 1,32 vs MTS =
5,03, SDTS = 1,49), PSI (MMST = 6.15, SDMST = 0.98
vs MTS = 5.54, SDTS = 1.40), dan RSC (MMST = 5.67,
SDMST = 1.30 vs MTS = 5.21, SDTS = 1.36). Oleh
karena itu, pengukuran dasar hubungan pasien-provider.
Hasil dari analisis regresi, disajikan pada Tabel 3,
 menunjukkan efek pengobatan yang signifikan dalam
skala CCC pada akhir pengobatan (b = 0,45, 95% CI
[0,06, 0,84] p \ 0,05). Efek yang sedikit signifikan diamati
dalam skala RSC (b = 0. 36, 95% CI [-0.01, 0.73] p \ .10),
tetapi peningkatan pada skala EP dan PSI tidak signifikan
secara statistik. (Tabel 3)
13. Diskusi Penelitian ini dibatasi oleh penggunaan data laporan diri
dari perspektif pengasuh saja. Menilai perspektif tim
remaja dan perawatan medis akan memberikan gambaran
yang lebih komprehensif tentang hubungan pasien-
provider. Sangat penting untuk mempertimbangkan
perspektif remaja. Baik pengasuh keluarga dan provider
perawatan kesehatan mengharapkan remaja untuk
menjadi semakin terlibat dalam proses pengambilan
keputusan perawatan kesehatan. Namun, penelitian
menunjukkan bahwa pengasuh keluarga dan dokter
cenderung mendominasi pertemuan klinis (Tates &
Meeuwesen, 2000; van Dulmen, 1998), yang dapat
menyebabkan remaja merasa terpinggirkan dan tidak puas
(Young, Dixon-Woods, Windridge, & Heney, 2003). ),
perasaan yang mungkin diterjemahkan ke hasil penyakit
yang lebih buruk. Juga, harus dicatat bahwa karena
terapis MST biasanya menemani keluarga ke kunjungan
klinik, staf klinik tidak dibutakan untuk partisipasi
keluarga dalam MST.
Meskipun keterbatasan ini, penelitian ini memberikan
wawasan langsung diterjemahkan ke praktek klinis.
Karena sebagian besar perawatan diabetes remaja terjadi
di luar pengaturan medis, kemampuan keluarga dan tim
perawatan medis untuk bekerja sama untuk menetapkan
dan menerapkan tujuan manajemen diabetes sangat
penting. Keluarga remaja dengan kontrol glikemik kronis
yang buruk cenderung memiliki hubungan yang
terganggu dengan tim perawatan medis diabetes mereka.
Hubungan pasien-provider yang terganggu cenderung
berdampak pada bagaimana keluarga mengelola diabetes
membuat peningkatan hubungan pasien-provider sangat
penting untuk manajemen diabetes yang efektif.
Intervensi berbasis keluarga yang komprehensif,
ditargetkan, dan berbasis (seperti MST) memiliki potensi
untuk meningkatkan hubungan antara keluarga dan tim
medis diabetes, di samping untuk meningkatkan perilaku
manajemen penyakit dan kontrol glikemik, yang dapat
meningkatkan kemungkinan bahwa perawatan diabetes
dan kesehatan yang optimal bertahan dari waktu ke
waktu.
J Clin Psychol Med Settings (2015) 22:169–178
DOI 10.1007/s10880-015-9422-y
Multisystemic Therapy Improves the Patient-Provider
Relationship in Families of Adolescents with Poorly Controlled
Insulin Dependent Diabetes
April Idalski Carcone1 • Deborah A. Ellis1 • Xinguang Chen2 • Sylvie Naar1
Phillippe B. Cunningham3 • Kathleen Moltz4
Published online: 5 May 2015
 Springer Science+Business Media New York 2015
Abstract The purpose of this study was to determine if
multisystemic therapy (MST), an intensive, home and
community-based family treatment, significantly improved
patient-provider relationships in families where youth had
chronic poor glycemic control. One hundred forty-six
adolescents with type 1 or 2 diabetes in chronic poor gly-
cemic control (HbA1c C8 %) and their primary caregivers
were randomly assigned to MST or a telephone support
condition. Caregiver perceptions of their relationship with
the diabetes multidisciplinary medical team were assessed
at baseline and treatment termination with the Measure of
Process of Care-20. At treatment termination, MST
families reported significant improvement on the Coordi-
nated and Comprehensive Care scale and marginally sig-
nificant improvement on the Respectful and Supportive
Care scale. Improvements on the Enabling and Partnership
and Providing Specific Information scales were not sig-
nificant. Results suggest MST improves the ability of the
families and the diabetes treatment providers to work
together.
& April Idalski Carcone
acarcone@med.wayne.edu
1
Prevention Research Center, Department of Pediatrics,
Wayne State University School of Medicine, Detroit, MI,
USA
2
Department of Epidemiology, College of Public Health &
Health Professions and College of Medicine, University of
Florida, Gainesville, FL, USA
3
Department of Psychiatry and Behavioral Sciences, Medical
University of South Carolina, Charleston, SC, USA
4
Division of Endocrinology, Department of Pediatrics, Wayne
State University School of Medicine, Detroit, MI, USA
•
Keywords Family therapy  Health care services 
Diabetes  Randomized controlled trial
The importance of an effective patient-provider relationship
for optimal pediatric diabetes management is well-established
(Anderson, 2003; La Greca, Bearman, & Roberts, 2003).
Upon diagnosis, families and diabetes care providers initiate a
reciprocal relationship that relies upon effective communi-
cation and collaboration. Providers rely upon the family to
provide them with accurate information about the patient’s
diabetes management and health status in order to make ap-
propriate adjustments in the prescribed diabetes regimen,
whereas patients and families rely upon the provider’s ex-
pertise in medical decision-making and encouragement of
good diabetes care. Empirical research has linked both ado-
lescent and caregiver perceptions of the patient-provider re-
lationship to critical diabetes outcomes (Hanson, Henggeler,
Harris, Mitchell, Carle, & Burghen, 1988; La Greca et al.,
2003). Empirical research suggests a poorer patient-provider
relationship is associated with poorer illness management
behavior (Hanson et al., 1988) and may be related to poorer
glycemic control and increased hospitalizations.
Because parents play a critical role in supporting dia-
betes care, even during adolescence (Silverstein et al.,
2005), cultivating an effective relationship between parents
and providers is important. This may be particularly true
when diabetes is poorly controlled, as poor communication
regarding barriers to diabetes management in the home can
lead providers to simply increase insulin dosage rather than
helping families address critical barriers to care. However,
to date, there have been limited interventions developed
that are effective at improving the patient-provider rela-
tionship (Nobile & Drotar, 2003) and none focusing on
adolescents with poorly controlled diabetes.
123
170
Multisystemic therapy (MST) is an intensive, home- and
community-based intervention that has been adapted to ad-
dress the multiple factors that contribute to poorly controlled
diabetes (Ellis, Frey, Naar-King, Templin, Cunningham,
et al., 2005b; Ellis et al., 2012; Ellis et al., 2007). Youths
with poor metabolic control and their families are charac-
terized by high rates of psychiatric co-morbidity (Kovacs,
Goldston, Obrosky, & Iyengar, 1992), family psy-
chopathology (Liss, Waller, Kennard, McIntire, Capra,
Stephens, 1998) and poor follow up with health care pro-
viders (Jacobson, Hauser, Willett, Wolfsdorf, & Herman,
1997; Kaufman, Halvorson, & Carpenter, 1999; Urbach,
LaFranchi, Lambert, Lapidus, Daneman & Becker, 2005).
The MST treatment approach is an excellent fit with the
known etiology of poor metabolic control, because the scope
of MST interventions encompasses the individual youth, the
family system and the broader community systems within
which the family operates (e.g. school, health care system).
A major addition to MST adapted for adolescents with
poorly controlled diabetes has been intervening in the rela-
tionship between the family and the medical care team.
Because of the comprehensive nature of the MST inter-
vention and the focus upon intervening within multiple
systems that contribute to poor metabolic control, the rela-
tionship between the family and the medical care team be-
comes a critical point for intervention. By enhancing the
relationship between families and treatment providers, the
MST therapist tries to maximize the likelihood that any
improvements in diabetes management will be maintained
once treatment is concluded. MST has been shown to im-
prove relevant diabetes-related endpoints such as glycemic
control (Ellis et al., 2012), illness management behavior
(Ellis et al., 2005b) as well as other important outcomes such
as adolescent diabetes stress (Ellis, Frey, Naar-King, Tem-
plin, Cunningham, et al., 2005a) and parental involvement in
diabetes care (Ellis, Yopp, et al., 2006; Naar-King, Ellis,
Idalski, Frey, & Cunningham, 2007), but, to date, its impact
on the patient-provider relationship, has not been examined.
The objective of this study was to test the efficacy of
MST in improving the patient-provider relationship as
compared to an attention control condition. Given MST’s
focus on improving collaboration and information sharing
between the family and health care team, we predicted that
families receiving MST would report significant improve-
ments in their patient-provider relationship at the end of
treatment, as compared to the control condition.
Methods
The data reported in the present study represent secondary
endpoints from a larger randomized clinical trial for which
the primary endpoints were diabetes management and
123
J Clin Psychol Med Settings (2015) 22:169–178
metabolic control. A detailed description of trial methods
and primary outcomes has been reported elsewhere (see
Ellis et al., 2012).
Subjects
Adolescents with chronic poor glycemic control were re-
cruited from university-affiliated pediatric endocrinology
clinics within a tertiary care children’s hospital located in a
major Midwestern metropolitan area between 2006 and
2010. Eligibility included diagnosis of type 1 or 2 diabetes
for at least 1 year requiring insulin therapy, HbA1c C8 % at
the clinic visit prior to enrollment and over the previous
year and 10–17 years of age. Two adolescents’ baseline
HbA1c was \8.0 %; however, they otherwise met the cri-
teria for study enrollment and, therefore, were enrolled in
the trial. Exclusion criteria were moderate-severe cognitive
impairment (assessed via caregiver-report of a previously
diagnosed learning disability, special education placement,
and/or inability to independently complete research
assessments), psychosis, or non-English speaking.
Protocol
The study was a randomized controlled trial in which
participants were blocked based on HbA1c and BMI. A
permuted block algorithm was used to randomly assign
participants to four strata: Stratum 1 included adolescents
with a low HbA1c (B10.5 % but C8 %) and a low BMI
(B85th percentile). Stratum 2 included adolescents with a
low HbA1c (B10.5 % but C 8 %) and a high BMI (C85th
percentile). Stratum 3 included adolescents with a high
HbA1c ([10.5 %) and a low BMI (B85th percentile).
Stratum 4 included adolescents with a high HbA1c
([10.5 %) and a high BMI (C85th percentile). The project
statistician generated the randomization sequence and
participants were notified of their randomization status by
the project manager to maintain research assistants’
blindness to treatment assignment.
Potential participants were approached by medical staff
during routine clinic appointments or hospitalizations re-
garding their interest in participating. Research assistants
not affiliated with the clinical care site followed up by
phone to explain the study, including details of the two
study interventions, and the random assignment and data
collection processes. Research assistants obtained informed
consent and assent via home-based consent procedures. A
trained research assistant collected data at baseline and
7 months later (1 month post-treatment) in participants’
homes. Baseline data collection occurred prior to ran-
domization and research assistants completing the 7-month
follow up data collection were blind to study conditions.
Families received $50 for each completed data collection.
J Clin Psychol Med Settings (2015) 22:169–178
Prior to the initiation of recruitment, informed consent and
data collection activities, all research assistants were
trained to administer the study assessments using stan-
dardized scripts and a professional demeanor to ensure
consistency across participants. The university-affiliated
Human Investigation Committee approved the research
protocol which was in accordance with the Declaration of
Helsinki. The trial was registered in ClinicalTrials.gov
(NCT00372814).
The CONSORT flow diagram, Fig. 1, summarizes the
process of participant recruitment and enrollment. Study
staff screened 513 families for participation, of which 238
were ineligible and 36 could not be contacted. Of the re-
maining 239, 52 declined participation and 10 withdrew
prior to randomization resulting in a 74 % participation
rate. The 146 adolescents and their primary caregivers
enrolled were randomly assigned to either 6 months of
MST (n = 74) or telephone support (TS; n = 72). Treat-
ment was initiated within 1 month of baseline
(M = 27.9 days, SD = 17.5). The mean duration of treat-
ment for MST participants was 5.6 months (SD = 1.2) and
4.9 months (SD = 1.6) in TS. Twelve MST families
(16 %) and 14 telephone support families (19 %) failed to
complete the full course of treatment. Only two MST
families and one telephone support family refused to
complete follow-up data collection subsequent to treatment
dropout (98 % retention rate). All participants were in-
cluded in the intent-to-treat analyses.
Fig. 1 CONSORT diagram
showing flow of participants
through the study for the
multisystemic (MST) and
telephone support (TS) groups
171
MST is an empirically supported, intensive, family-
centered, community-based treatment originally designed
for use with adolescents presenting with serious antisocial
behavior (Henggeler, Schoenwald, Borduin, Rowland, &
Cunningham, 2009). Our group has extensively adapted
MST to the treatment of poor self-management in adoles-
cents with chronic illnesses including diabetes (Ellis, Frey,
Naar-King, Templin, Cunningham, et al., 2005c), HIV in-
fection (Ellis, Naar-King, Cunningham, & Secord, 2006),
and asthma (Naar-King, Ellis, Kolmodin, Cunningham, &
Secord, 2009). MST is not a typical standardized ‘‘one size
fits all’’ psychotherapy approach where the therapist im-
plements a set of pre-arranged interventions in a prescribed
sequence. Rather, MST involves an initial multisystemic
assessment of the problem behavior and the strengths and
weaknesses of family members. Based on this assessment,
the MST therapist develops a comprehensive treatment
plan utilizing empirically supported interventions indi-
vidually tailored for each family to best treat the identified
problem behavior. Treatment delivery is guided by the
following key features. (1) Interventions are individualized
to comprehensively target the adolescent’s unique risk
factors that support the problem behavior within the ado-
lescent’s social ecology, including the individual, family,
peer, school, and community social systems within which
the adolescent is embedded. (2) Interventions integrate
empirically supported clinical treatments at each level of
the adolescent’s social ecology. (3) Interventions focus on
123
172
promoting behavioral changes in the adolescent’s natural
ecology by empowering caregivers with parenting skills
and resources and empowering adolescents to cope with
family, school, and neighborhood problems. (4) Services
are delivered via a community-based model in home,
school, and/or neighborhood settings at times convenient to
the family, which facilitates high engagement and low
dropout. (5) MST requires an intensive quality assurance
surveillance that aims to optimize adolescent outcomes by
supporting therapist fidelity to MST treatment protocols
(Henggeler, Halliday-Boykins, Cunningham, Randall,
Shapiro, Chapman, 2006).
As adapted for the treatment of poorly controlled dia-
betes, individual interventions with the adolescent included
psychoeducation to improve skills related to diabetes care,
counseling to enhance motivation for diabetes care com-
pletion, or mental health treatment such as cognitive-be-
havioral therapy to treat depression. Family interventions
included: (1) parent training to decrease parental disen-
gagement from the diabetes regimen, e.g., improving par-
ental knowledge regarding diabetes care, developing
parenting skills (such as increasing systematic monitoring,
reward, and discipline systems) to increase parental su-
pervision of the diabetes care regimen; (2) teaching
strategies for and improving family organizational routines
to support the adolescent’s diabetes care; (3) behavioral
family systems therapy to address day-to-day conflicts
around diabetes care and improve caregivers’ communi-
cation with each other about the adolescent’s diabetes care;
and (4) engaging social support from friends or extended
family members who could assist with diabetes care. Peer
interventions included enlisting the active support of peers
regarding regimen adherence and encouraging disclosure
of diabetic status to peers. At the community level, inter-
ventions included developing strategies to monitor and
promote the youth’s diabetes care while in school or other
community settings (i.e., extracurricular activities or
visiting extended family members). To illustrate, school
interventions included improving family–school commu-
nication about the adolescent’s diabetes care needs and
adherence behaviors (such as having school personnel
provide weekly reports to parents about blood glucose
readings completed during the school) and working with
school personnel to monitor and support the adolescent’s
regimen completion (e.g., finding a private place to test
blood glucose). Healthcare system interventions involved
fostering information sharing between families and dia-
betes care providers by: (1) helping parents to utilize clinic
resources between regular office visits, e.g., encouraging
parents to report results of blood glucose tests to obtain
insulin dose adjustments and encouraging parents to come
to educational sessions or support group meetings; (2)
helping the family to resolve barriers to keeping
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J Clin Psychol Med Settings (2015) 22:169–178
appointments; (3) helping caregivers and adolescents im-
prove communication skills by assisting them to prepare
for clinic visits by generating lists of questions and con-
cerns they wanted to discuss during the clinic visit, by
actually accompanying families to medical appointments
during which the therapist served as a role model who
demonstrated appropriate communication skills, and who
also supported the family during the clinic visit. Therapists
also, with the family’s permission, worked with the dia-
betes care providers to promote a positive working rela-
tionship by meeting independently with the providers
outside of diabetes clinic appointments to exchange infor-
mation about the child’s specific diabetes treatment needs,
facilitate communication between clinic appointments and
better coordinate the youth’s diabetes care. These biweekly
meetings with the therapist provided the diabetes care team
with greater knowledge of the family and the child’s dia-
betes care, thus enabling them to provide better informa-
tion to the family during clinic visits that is specific to the
child’s diabetes illness experience and to develop a stron-
ger, more responsive relationship with the family. MST
therapists met families twice weekly; the initial visit was
60 min and the second a briefer (30 min) follow up
session.
Adolescents assigned to the TS condition received
weekly 30-min phone calls focusing on support for diabetes
care using a client-centered, non-directive counseling ap-
proach using the Rogerian counseling techniques of re-
flective listening and providing empathetic support
(Cheung, 2014; Patterson, 1979). The purpose of the calls
was to provide emotional support regarding the adoles-
cent’s diabetes, to assess adherence to the prescribed
regimen and to help the adolescent brainstorm solutions to
any barriers they identify to completion of diabetes care.
Non-diabetes related problems such as peer, school, or
family relationship problems were also addressed during
calls at the discretion of the adolescent. The telephone
support condition did not include elements specific to MST
such as cognitive-behavioral intervention content or family
intervention. In both conditions, standard medical care was
provided at 3–4 months intervals per American Diabetes
Association recommendations (Silverstein et al., 2005) by
a multidisciplinary team including a pediatric endocri-
nologist, nurse educator, dietician, social worker, and
psychologist.
Measurements
Patient demographic characteristics were collected at
baseline using an investigator developed, self-report
questionnaire.
The Measure of Process of Care-20 (MPOC-20; King,
King, & Rosenbaum, 2004) is designed to assess parents’
J Clin Psychol Med Settings (2015) 22:169–178
perceptions of the medical services their children receive,
including the interactional components of care and the
family-centeredness of the patient-provider relationship. It
was developed for use with parents of children with
chronic health conditions. At baseline and follow up, the
primary caregiver, the person who typically accompanied
the adolescent to their diabetes clinic visits and assisted
with diabetes care independently completed the pencil-and-
paper measure. Caregivers rated their relationship with
their diabetes providers using a 7-point Likert scale
(1 = not at all, 7 = to a very great extent). Four summary
scales assessing the caregivers’ relationship with medical
providers are formed from 15 items beginning with the
stem ‘‘to what extent do the people who work with your
teen…’’. Summary scales are constructed by calculating
the mean response to the scale’s items; thus, the range of
possible scores on each scale is 1 to 7. Higher scale scores
reflect a more positive patient-provider relationship. The
Enabling and Partnership (EP) scale is the mean of three
items, including ‘‘provide opportunities for you to make
decisions about treatment?’’ and ‘‘fully explain treatment
choices to you?’’ Providing Specific Information (PSI) is
the mean of three items, including ‘‘provide you with
written information about your child’s treatment?’’ and
‘‘tell you about the results from tests?’’ Coordinated and
Comprehensive Care (CCC) is the mean of four items,
including ‘‘make sure that at least one clinic staff is
someone who works with you and your family over a long
period of time?’’ and ‘‘look at the needs of your child (e.g.,
at mental, emotional, and social needs) instead of just at
physical needs?’’ Respectful and Supportive Care (RSC) is
the mean of five items, including ‘‘treat you as an equal
rather than just as the parent of a patient?’’ and ‘‘help you
to feel competent as a parent?’’ A fifth scale, Providing
General Information, is formed from five items using the
stem ‘‘to what extent does the organization where you re-
ceive services…’’ and reflects interactions with the insti-
tution as a whole (e.g. the clinic or hospital). This scale was
not included in this study because the broader institution
was not a target of the MST intervention. Reliability and
validity of the measure has been established (King et al.,
2004; Moore, Mah, & Trute, 2009). At baseline, each of the
four scales examined demonstrated good internal consis-
tency, as assessed using Cronbach’s alpha EP = .751,
PSI = .771, CCC = .781 and RSC = .872.
Statistical Analyses
The intent-to-treat approach was used to assess the inter-
vention effect from MST. In the intent-to-treat analysis, all
randomized families were included in the analysis regard-
less of their withdrawal from treatment or other protocol
deviations (Gupta, 2011). Three families (2 %) were
173
excluded because of incomplete MPOC-20 data. The ef-
fects of MST on the patient-provider relationship were
evaluated using multiple linear regression modeling based
on the following prediction equation:
Y1 ¼ a þ b1 ðY0 Þ þ b2 ðinterventionÞ þ b3 ðCov1Þ
þ b4 ðCov2Þ þ . . .
Y1 represented the outcome variable (in four regression
models testing the four domains of the patient-provider re-
lationship assessed by the MPOC-20) measured at follow-up
(7 months post-baseline). a and bs were regression coeffi-
cients. b1 represents the baseline outcome variable mea-
surements. A significant and positive b2 (the net increases in
the outcome variable in response to the MST intervention
relative to the telephone support intervention) was used as
evidence to support intervention effect after adjusting for
baseline differences and the effects of covariates. Covariates
included were adolescent age, adolescent race (dummy
coded, non-African American race as the reference catego-
ry), and family type (dummy coded, two-parent family as
the reference category) due to the fact that these demo-
graphic variables were related to the primary study out-
comes (Ellis et al., 2012). In these models, a b2 falling
within a 95 % confidence interval not including zero is
equivalent to p \ .05 and, therefore, supports the effect of
MST. Statistical analyses were conducted using the software
SAS version 9.3 (SAS Institute Inc., Cary, NC, USA).
Results
Demographic characteristics are shown in Table 1. Con-
sistent with the population served by the institution where
participants were recruited, the sample was comprised
primarily of African American (77 %) adolescents. As
expected, baseline measures of glycemic control suggested
poor glycemic control overall (M = 11.7 %, SD = 2.5).
Most caregivers were single-parenting (59 %) biological
parents (93 %). There were no statistically significant dif-
ferences between MST and TS groups at baseline on de-
mographics or glycemic control (Ellis et al., 2012)
(Table 1).
The effect of MST relative to families enrolled in TS on
each MPOC scale was evaluated using four linear regres-
sion models with all variables entered simultaneously.
Despite random assignment at baseline, MST families re-
ported a more positive patient-provider relationship on
three scales relative to families enrolled the control con-
dition: EP (MMST = 5.61, SDMST = 1.32 vs MTS = 5.03,
SDTS = 1.49), PSI (MMST = 6.15, SDMST = 0.98 vs
MTS = 5.54, SDTS = 1.40), and RSC (MMST = 5.67,
SDMST = 1.30 vs MTS = 5.21, SDTS = 1.36). Therefore,
the patient-provider relationship baseline measurements
123
174 J Clin Psychol Med Settings (2015) 22:169–178

Table 1 Baseline
MST (n = 74) TS (n = 72)
characteristics of adolescents
and their families by treatment Adolescent Race
condition: multisystemic
treatment (MST) and telephone African American 60 (81 %) 53 (74 %)
support (TS) White 13 (18 %) 16 (22 %)
Other 1 (1 %) 3 (4 %)
Adolescent gender
Male 32 (43 %) 32 (44 %)
Female 42 (57 %) 40 (56 %)
Adolescent age (years) 14.2 (2.2) 14.1 (2.4)
Adolescent BMI percentile 71.9 (27.2) 77.0 (22.2)
Caregiver race
African American 60 (81 %) 53 (74 %)
White 14 (19 %) 18 (25 %)
Other 0 (0 %) 1 (1 %)
Caregiver age (years) 40.3 (6.9) 42.6 (8.7)
Caregiver gender
Female 68 (92 %) 65 (90 %)
Male 6 (8 %) 7 (10 %)
Relationship to adolescent
Biological parent 71 (96 %) 65 (90 %)
Other (e.g., step, foster) 3 (4 %) 7 (10 %)
Parenting status
Single parent 43 (58 %) 43 (60 %)
Two parents 31 (42 %) 29 (40 %)
Duration of diabetes (years) 4.7 (3.2) 4.6 (2.9)
Type of diabetes
Type 1 65 (88 %) 66 (92 %)
Type 2 9 (12 %) 6 (8 %)
Insulin Regimena
Conventional 21 (28 %) 18 (25 %)
Intensive injections 39 (53 %) 44 (61 %)
Insulin pump 10 (14 %) 9 (13 %)
Basal insulin only 4 (5 %) 1 (1 %)
Metabolic control, HbA1c 11.6 (2.5) 11.8 (2.6)
Patient-provider relationship
Enabling and Partnership 5.61 (1.32) 5.03 (1.49)*
Providing Specific Information 6.15 (0.98) 5.54 (1.40)**
Coordinated and Comprehensive Care 5.52 (1.29) 5.19 (1.38)
Respectful and Supportive Care 5.67 (1.30) 5.21 (1.36)*
* p \ .05, ** p \ .01
a
‘‘Conventional’’ insulin regimen refers to the prescription of two–three daily injections of intermediate-
acting and short-acting insulin. ‘‘Intensive injections’’ refers to the insulin regimen characterized by one
daily injection of a long-acting (basal) insulin and the administration of short-acting insulin boluses
whenever carbohydrates are consumed. ‘‘Insulin pump’’ refers to the insulin regimen where only short-
acting insulin is administered using an insulin infusion pump; the patient receives a continuous infusion of
short-acting insulin and additional boluses whenever carbohydrates are consumed. ‘‘Basal insulin only’’
refers to the insulin regimen where only basal insulin is administered, by daily injections

were entered to control for these initial differences in ad- Results from the regression analyses, presented in
dition to adolescent age, race, and family type. Table 2 Table 3, indicated a significant treatment effect in the CCC
presents the correlation matrix for all variables entered into scale at the end of treatment (b = 0.45, 95 % CI [0.06,
the regression analyses. (Table 2) 0.84] p \ .05). A marginally significant effect was

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J Clin Psychol Med Settings (2015) 22:169–178 175

observed in the RSC scale (b = 0. 36, 95 % CI [-0.01,
0.73] p \ .10), but improvements on the EP and PSI scales
were not statistically significant. (Table 3)
Discussion
Although previous research has found the families of youth
with poorly controlled diabetes to have ineffective rela-
tionships with diabetes care providers (Hanson et al.,
1988), few intervention studies have examined whether
patient-provider relationships can be improved among the
families of youth with poorly controlled diabetes, a group
known to have ineffective relationships with diabetes care
providers (Hanson et al., 1988). This study found that MST
improved caregivers’ perceptions of their family’s rela-
tionship with diabetes care providers in a multidisciplinary
diabetes specialty clinic as compared to caregivers in an
attention control condition. Over the course of treatment,
caregivers’ perceptions of the patient-provider relationship
significantly improved in the area of CCC and marginally
improved in the RSC domain.
This finding adds to the empirical literature supporting
the efficacy of MST as an intervention impacting the
multiple determinants of poor diabetes control. Throughout
treatment, MST therapists engage in multiple activities to
enhance the patient-provider relationship. Specifically,
therapists facilitate CCC by helping families arrive at their
diabetes clinic appointments better prepared to obtain the
information they need to effectively manage the adoles-
cent’s diabetes. For example, the therapist helped families
prepare for clinic by generating lists of questions and con-
cerns they wanted to discuss. This helped families to better
convey relevant information to providers and to more ef-
fectively articulate any additional medical, emotional or
social needs of their child. Therapists also met with the
heath care provider outside of diabetes clinic appointments
for guidance on the child’s specific diabetes treatment needs
and to facilitate communication between clinic appoint-
ments. These activities also may have contributed to the
trend observed in the RSC domain. Health care providers
may have interacted in a more supportive and responsive
manner when they were better informed about patient and
caregiver efforts to improve diabetes management, family
barriers to adherence and better understood their specific
treatment needs. Therapists may have also contributed to
this domain by role-modeling appropriate communication
during diabetes clinic appointments to help shape patients’

Table 2 Correlation matrix of study variables

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Treatment
groupa

2. Adolescent age, in years at study -.023

entry
3. Adolescent raceb .089 -.067
4. Single versus two-parent homec -.016 -.146 .214**
5. Enabling & Partnership scale, at -.203* -.029 -.024 -.041
baseline
6. Enabling & Partnership sub- -.243** -.014 -.099 -.006 .443***
scale, at 7 months
7. Providing Specific Information -.250** -.185* -.078 -.027 .632*** .361***
sub-scale, at baseline
8. Providing Specific Information -.232** -.084 -.177* .009 .406*** .758*** .474***
sub-scale, at 7 months
9. Coordinated & Comprehensive -.122 -.132 .003 .100 .721*** .431*** .718*** .438***
Care scale, at baseline
10. Coordinated & Comprehensive -.234** -.068 -.054 .124 .490*** .837*** .392*** .739*** .557***
Care scale, at 7 months
11. Respectful & Supportive Care -.172* -.075 -.006 -.007 .755*** .411*** .731*** .357*** .775*** .468***
scale, at baseline
12. Respectful & Supportive Care -.290** -.078 -.065 .061 .493*** .841*** .411*** .738*** .478*** .857*** .504***
scale, at 7 months
* p \ .05, ** p \ .01
*** p \ .001
a
TS is the reference group
b
African American is the reference group
c
Single parent is the reference group

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176 J Clin Psychol Med Settings (2015) 22:169–178

Table 3 Effects of
Effect (regression analysis)
Multisystemic Therapy (MST)
versus Telephone Support (TS) b (SE) 95 % CI
on the Patient-Provider
Relationship Lower limit Upper limit

Model 1: Enabling and Partnership

Treatment condition 0.33 (0.23) -0.12 0.78
Baseline .41 (0.08)** 0.25 0.57
Age (in years) -0.02 (0.05) -0.12 0.08
Race (if black) 0.26 (0.27) -0.27 0.79
Family type (if single parent) -0.09 (0.23) -0.54 0.36
Model fit: Adjusted R2 0.19
Model 2: Providing Specific Information
Treatment condition 0.23 (0.20) -0.16 0.62
Baseline .46 (0.08)** 0.30 0.62
Age (in years) -0.01 (0.04) -0.09 0.07
Race (if black) 0.44 (0.24)  -0.03 0.91
Family type (if single parent) -0.01 (0.21) -0.40 0.42
Model fit: R2 0.23
Model 3: Coordinated and Comprehensive Care
Treatment condition .45 (0.20)* 0.06 0.84
Baseline .46 (0.07)** 0.32 0.60
Age (in years) -0.04 (0.04) -0.12 0.04
Race (if black) 0.19 (0.24) -0.28 0.66
Family type (if single parent) -0.03 (0.21) -0.38 0.44
Model fit: R2 0.26
Model 4: Respectful and Supportive Care
Treatment condition 0.36 (0.19)  -0.01 0.73
Baseline .55 (0.08)** 0.39 0.71
Age (in years) -0.01 (0.04) -0.09 0.07
Race (if black) -0.17 (0.24) -0.30 0.64
Family type (if single parent) -0.06 (0.21) -0.35 0.47
Model fit: R2 0.31
Program effect was assessed using four multiple regression models with simultaneous entry controlling for
baseline status and demographic variables
* p \ .05, ** p \ .01,   p \ .10

and caregivers’ interactions with health care providers.
While these activities map onto the MPOC-20 constructs,
additional research is needed to determine which, if any, of
these therapist behaviors were directly responsible for any
improvement in the patient-provider relationship. Future
research is also needed to examine the sustainability of the
improvements in the patient-provider relationship once
treatment has ended and the MST therapist is no longer
facilitating these relationships. Should the patient-provider
relationship deteriorate post-intervention, this might suggest
that high risk patients, those with chronically poor illness
management, might benefit from the assistance of a patient
advocate during medical care visits.
Contrary to the study hypothesis, findings for the EP and
PSI scales were not statistically significant. Ratings on
these scales were already high at baseline, leaving limited
room for improvement. One explanation for the lack of
significant change on these scales might be the clinical care
practices of the study recruitment site. All families seen in
the clinic received formal diabetes education from a dia-
betes educator at the time of diagnosis and on an ongoing
basis during routine clinic visits. In addition, families ex-
periencing difficulty managing their child’s illness as
indicated by poor glycemic control were routinely re-re-
ferred to diabetes education programs outside of standard
office visits. During every diabetes clinic visit, providers
routinely reviewed test results (e.g., point of service
HbA1c) and gave families written information about the
adolescent’s progress and treatment plan. Thus, families
were likely already well educated in the various tasks

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necessary to manage their child’s diabetes, their child’s
current disease status as well as their treatment options
prior to the MST intervention. Consequently, the exchange
of diabetes-specific information was already high (e.g. as
assessed by the PSI scale; mean score at baseline
(M = 6.15 out of 7).
The nonsignificant finding on the EP scale might suggest
that the MST therapist assumed too much of a leadership
role or functioned as a liaison between the family and
health care providers during clinical interactions rather
than encouraging the caregiver to work with the medical
team directly. Alternatively, health care providers may
have already been utilizing a high level of partnership in
their interactions with this high risk population of adoles-
cents with chronically poor illness management. In sum,
the study results suggest that the most significant impact
the MST intervention had on the patient-provider rela-
tionship in these adolescents with poorly controlled dia-
betes was to better address all the adolescents’ needs and
enhance the continuity of care across providers and pos-
sibly settings (i.e., home, school, etc.).
This research was limited by the use of self-report data
from the caregivers’ perspective only. Assessing the ado-
lescents’ and medical care teams’ perspective would pro-
vide a more comprehensive picture of the patient-provider
relationship. It is particularly important to consider the
adolescents’ perspective. Both family caregivers and health
care providers expect adolescents to become increasingly
involved in the health care decision-making process.
However, research suggests that family caregivers and
physicians tend to dominate the clinical encounter (Tates &
Meeuwesen, 2000; van Dulmen, 1998), which may lead to
adolescents feeling marginalized and dissatisfied (Young,
Dixon-Woods, Windridge, & Heney, 2003), feelings that
might translate to poorer illness outcomes. Also, it should
be noted that since MST therapists typically accompanied
families to clinic visits, clinic staff were not blinded to
family participation in MST. Therefore, the possibility that
providers changed their behavior in response to therapist
presence rather than the content of the therapeutic inter-
vention itself cannot be ruled out. In addition, although
prior studies have shown that the MST intervention im-
proved diabetes management and HbA1c, the study was
not adequately powered to directly test the mediating effect
of improvements in patient provider relationships on dia-
betes health outcomes. Additional research is needed to test
the mediator hypothesis and to also clarify the mechanisms
responsible for improved relationships. Finally, it is im-
portant to acknowledge the high costs of delivery of home
and community-based interventions such as MST, where
therapists must be available to intervene in a variety of
systems, including patient-provider relationships during
medical clinic visits. However, prior work by our group
177
suggests that the high cost of the intervention may be offset
by associated decreases in costs of medical care, such as
unnecessary hospitalizations due to insulin non-compliance
(Ellis et al., 2008).
Despite these limitations, this research provides insights
directly translatable to clinical practice. Because the ma-
jority of adolescent diabetes care occurs outside of the
medical setting, the ability of the family and medical care
team to work together to set and implement diabetes
management goals is critically important. Families of
adolescents with chronic poor glycemic control are likely
to have an impaired relationship with their diabetes med-
ical care team. An impaired patient-provider relationship is
likely to impact how families manage diabetes making
improving the patient-provider relationship of critical im-
portance for the effective management of diabetes. Com-
prehensive, targeted, family-based interventions (like
MST) have the potential to improve the relationship be-
tween the family and diabetes medical team, in addition to
improving illness management behavior and glycemic
control, which may increase the likelihood that optimal
diabetes care and health outcomes persist over time.
Acknowledgments The authors would like to acknowledge the
National Institute of Diabetes, Digestive, and Kidney Diseases’ sup-
port of this research (Grant Number R01 DK59067, Deborah Ellis, PI)
and Yuanjing Ren for her assistance with preparation of data for use
in the analyses.
Conflict of interest Author Phillippe B, Cunningham is a board
member of Evidence Based Services, which has a licensing agreement
with MST Services, LLC, for dissemination of Multisystemic Ther-
apy treatment technology. Authors April Idalski Carcone, Xinguang
Chen, Deborah A. Ellis, Sylvie Naar and Kathleen Moltz declare that
they have no conflict of interest.
Human and Animal Rights and Informed Consent State-
ment All procedures performed with human participants were in
accordance with the ethical standards of the institutional and/or na-
tional research committee and with the 1964 Helsinki declaration and
its later amendments or comparable ethical standards. Research as-
sistants obtained informed consent and assent via home-based consent
procedures.
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