Читать книгу Transition of Care - Группа авторов - Страница 26

There are sometimes situations in which adolescence is coupled with limitations imposed by a chronic illness; such is the case with diabetes, particularly when it comes to gaining independence.

For the adolescent with type 1 diabetes, the body limits, unable to live without insulin, may be obstacles over and above the normal psychological process at this time. They think of their body in terms of health. They need time to learn about this “new body” that can lose control: low blood sugar levels, feeling faint, etc. Injections and blood sugar tests are both aggressive and intrusive procedures that reinforce the fragility of a body image undergoing change and in which confidence must be found.

Type 1 diabetes is an unseen illness rarely revealed by symptoms. The adolescent is limited to mentalizing it to justify treatment at a time in development when verbalization is inhibited. Rather, behaviour and acting out are what matter at this age. Getting up in the morning and feeling great requires a mental effort from the adolescents so that they can treat themselves. The psychological denial mechanisms are encouraged by the failure to feel symptoms. The adolescents come out of their childhood period, during which they conveyed a powerful self-image; this is represented by drawings where the child depicts him/herself as a sports champion or they show themselves in highly valued physical activities, such as a firefighter or a dancer. “Mourning” the forgotten all-powerful body requires significant psychological work. During childhood the body is looked after by one’s parents, whether in terms of nourishment or health. At this stage, the young individual puts boundaries between him/herself and another person’s body to be more possessive of it.

Conflicts sometimes arise with those around them as the adolescent has to work at gaining independence and at the same time accept the compulsory dependence on treatment. There are “limitations on their body and a hold over its psychological function” according to Jeammet [3]. To this is added the relational care dependence on the doctor. Knowledge of the illness and the doctor’s ability to treat it offer the adolescent a model to follow for involvement in their treatment, often for several years. “Medical authority” represents an additional obstacle that the adolescent has to overcome to show they are becoming independent, self-assured, and able to make decisions about themselves through their treatment. Keeping this ascendant care relationship, with its strong maternal association (more generally parental), at a distance is superimposed on the distancing effort made during this period. Emotional projection also occurs, sometimes making separation difficult; this takes the form of opposition, flight, and resistance to the treatment or forgotten appointments.

It therefore means separating oneself, but above all not feeling rejected. In adolescence, you are preparing to leave your parents, leave the family, leave school, leave some of your friends, and leave your paediatric diabetes specialist. You keep your diabetes. In this quest for freedom and independence, the “diabetes” illness requires the adolescents to keep and maintain restrictive habits that mark every day of their life and define their bodily experience [3].

Once again it is difficult for the young persons on the one hand to face up to their independence and on the other hand to accept, as is demanded of them, a typical situation of dependence: the treatment of diabetes. The daily obligation to inject oneself confirms a paradoxical act: on the one hand their dependence on medicines, and on the other their independence from their parent or care giver, since they gain the ability to treat themselves. To this effect, simultaneously with internal psychological resolutions, diabetes can help the adolescent feel all-powerful with regard to themselves and others: “I am master of my body by dosing and injecting myself with insulin, and I decide whether or not to involve the adult.”

Adolescents are aware of their diabetes but at the same time they do not want to know about it; this knowledge hinders the construction of their “ego ideal,” which in some ways is the template to which the individual is seeking to conform. They become caught up between knowing “I have diabetes” and not knowing “I don’t feel anything, I don’t feel ill, I am not ill” [4]. The lack of traditional disease symptoms in diabetes focuses and facilitates this denial. A compromise is needed between knowledge and ignorance; it is doubtless with this in mind that we should understand missed treatments (forgotten injections, incorrect blood sugar tests, etc.). Ignoring certain aspects of their treatment is a way for the adolescents to separate themselves from their condition and to maintain part of their idealized self-image. Neglecting treatment is a deceptive way of separating themselves from their illness.

While asserting their difference from another person, the adolescents need models to identify themselves with and to become a social adult. They seek out their peers and join groups similar to or unlike them. This ambivalence makes it hard for diabetics to find their place. Stigmatized as being different from others, they become a symbolic carrier of the risk of rejection. “If I am different, no one is going to love me any more.” For them it is often a case of hiding their illness and treatment so as not to feel excluded. Their self-respect is damaged although they do not shun a friend with an illness. Being different from others returns them to solitude until they find support, such as from another diabetic adolescent. This encounter, while maintaining their individuality, enables them not to be unique and therefore not to be alone.