Family Support

This class was developed by Dr. Albert Marston, behavioral consultant to the DPP center in Los Angeles.  The class has a strong behavioral focus and participants may bring up challenging personal issues during the sessions, so the leader should be the behavioral consultant at your center or a senior Lifestyle Coach with extensive group experience.   

If desired, any of the handouts from this class may also be given to a participant during an In-Person visit if the Coach is comfortable with the topic and tailors it to the participant.  

Be sure to review Section 6 in the Manual for Contacts After Core:  Guidelines for Conducting Lifestyle Classes after Core, before conducting this or other after-core classes.

Note:  All after-core classes should be considered a time for participants to “restart” (resume behavior changes toward their weight loss and physical activity goals).  To accomplish this, all classes should include weigh-ins, encouragement to self-monitor, and collection and review of self-monitoring records.  At Session 1, participants should set goals for fat grams/calories, exercise, and weight loss to achieve during the course.

Class Overview

In this four-session class, participants will discuss and practice specific ways in which their family can support their efforts to lose weight and exercise more.  (Note:  Family members will be invited to Session 3 only.  This will allow participants to speak more freely during the other sessions about challenging family issues.)

Session 1:  Family Help   Participants will discuss ways their family members have helped and not helped them in their efforts toward lifestyle change.  Topics will include ways for the family to help and how to ask for help.

Session 2: Praise and Nagging  Participants will discuss how to give and receive praise and how to handle nagging.

Session 3: A Family Event  Family members will be invited to this session.  The basics of the DPP (study design, lifestyle goals, rationale for the lifestyle goals, how the study is doing) will be presented as well as some ideas for how the family can help the DPP participants succeed.  Having a family talk about ways the family can help will be recommended as homework before the next session.  Refreshments and time for socializing will be included.

Session 4: Review of the Family Talk  Participants will discuss their family talks and problem-solve/role play any problems that arose.  Participants will be encouraged to carry out plans reached at their family talks and reward themselves and their family for successful change. 

Session 1: Family Help

Objectives:	Participants will discuss ways their family members have helped and not helped them in their efforts toward lifestyle change.  Topics will include ways for the family to help and how to ask for help.  Family members will not be invited to this session.
Handouts:		Ways for Your Family to Help, Keeping Track booklets, invitations to the Family Event (Session 3)

1.	Introductions.

2.	Purpose of class:: to further develop participants’ skills for meeting and maintaining the DPP lifestyle goals, especially with greater support from their family members.  Emphasize that many participants have had support from one or more family members and this course is designed to increase that support.  Announce that Session 3 will be a Family Event to which all family members are warmly invited (distribute invitations).  The basics of the DPP (study design, impact of diabetes, lifestyle goals, rationale for the lifestyle goals, how the study is doing) will be presented at that session as well as some ideas for how the family can help the DPP participants succeed.  Refreshments and time for socializing will be included.

3.	Ask each participant to describe his or her household (names, relationship, ages, whether they are currently overweight and whether they are currently physically active;  also ask if any family members in the household have diabetes.)  It's a good idea for the group leader, who may not know these participants very well, to take notes and attempt to become familiar with the family situation of the participants in the group.

4.	Ask each paticipant to name some helpful and not helpful things that their family has done with regard to their efforts to lose weight and be more active.   To illustrate, give one or two examples of each (examples of not helpful things: spouse brings home sweets, family member demands favorite high fat foods be on the dinner menu, spouse hasn't noticed when the participant lost weight, spouse isn't interested in taking walks with the participant, or teenagers only want to eat at fast food places when the family goes out for dinner; examples of helpful things: spouse brings home fresh fruit, family member compliments a new low-fat recipe you’ve tried, spouse praises you when you go for a walk, teenagers are willing to try a new restaurant where you have more low-fat options).  

Reassure participants that they can pass if they aren’t comfortable sharing.   List the participants’ responses in two columns, headed “Helpful” and “Not Helpful,” on a blackboard or flipchart. 

Make the point that the items in the “not helpful” column must be addressed and you will be discussing some of them in detail, but it’s important to remember that in many cases, they are habits that the family has developed over time, and just as with other habits, it takes time to change.  One of the best ways to begin to change these habits, and to support the changes as they develop, is to find new, positive ways for the family to help you and then praise your family whenever they do these things.  Over time, the positive, helpful behaviors can gradually replace the “not helpful” ones.  This session will focus on ways the family can help and the next session will focus on praise.
 
5.	Review the handout, Ways for Your Family to Help.  Go over each item and ask the participants for their opinions and experiences.  Make sure each item is fully understood.  Some participants may express resistance or make strong comments arguing against some of the items (such as, “I think it’s completely unfair to ask my husband to watch the baby so I can walk”).  If so, acknowledge the comment and ask if other group members have a different perspective or experience (such as, “You know, my husband watches my kids while I go to the gym, and it works out really well”).  

Encourage participants to select one type of help to ask for.  Recommend that they select an area in which they feel there will be little (or less) resistance (then later they can try to ask for help in more difficult areas). Urge resistant participants to at least try to ask for help in one area.

Give participants time to complete the handout.  Ask them to check those items on page one that they would like their family to do or do more often.  Ask them to fill in the blanks on the second page.  When they finish, ask for comments and questions.     

Have volunteers role play with you how they would ask a family member for a specific form of help (when would you ask?  what words would you use?).  Ask for comments and input from the group.  

6.	Summarize.  Assign homework:
C	Discuss one or more ideas from the handout, Ways for Your Family to Help, with a family member.

Session 2: Praise and Nagging

Objectives:	Participants will discuss how to give and receive praise and how to handle nagging and sabotage.  Family members will not be invited to this session.
Handouts:		Praise, Solving the Problem of Nagging, Keeping Track booklets, invitations to the Family Event (Session 3)

1.	Briefly review the main points of the last session.  Ask participants to comment on their discussions with family members about ways for the family to help.  

2.	Introduce purpose of session: two goals--to discuss how you and your family can 1) use praise (one of the most helpful behaviors) and 2) stop nagging and sabotage (two of the most un-helpful behaviors).

3.	Discuss the importance of praise.  Make the point that one of the most helpful things your family can do for you is praise you, and praise is also one of the best ways for you to encourage your family’s support.  However, many of us do not give or receive praise very often and may be uncomfortable with it.  Distribute the worksheet, Praise.  Ask participants to take a few minutes to answer the first three questions on the worksheet and then discuss their responses as a group:
C	How do you feel about getting praised?  
C	When might praise not feel good?  (Ask for examples, such as:  when you don’t trust the sincerity of the person giving the praise, when the praise is more intense than the behavior seems to warrant, when criticism follows praise or if it has in the past (e.g., You did a really good job, but...”), when you think the person will have unrealistic expectations of you in the future.)
C	Is it okay to ask for praise?  

During the discussion, stress that it’s important to have specific, positive, and realistic goals for yourself and clear and reasonable standards for your own performance.  This will make it possible for you to tell family members exactly what your goals are and that you would be delighted if they praised you when you reach a goal.  You can also tell them how you’d like to be praised, exactly what to say, or just to smile and give you a hug or a pat on the shoulder or back.  You can also praise yourself when you meet a goal and give yourself a reward (not food!). 

Ask participants to take a few minutes to complete the rest of the worksheet on getting and giving praise.  Discuss the responses as a group.  Ask for volunteers to role-play some examples of giving and getting praise, and ask for comments and suggestions from the group.  Encourage participants to respond with appreciation when praised.

4.	Discuss how to respond to nagging.  Nagging is a particularly unhelpful behavior.  Distribute and review the handout, Solving the Problem of Nagging.  Stress the importance of being patient with the nagger, of praising him or her if he stops nagging, and of praising him or her for any positive alternatives he tries.  Discuss the fact that nagging is a tough habit to kick because a) the nagger usually believes he or she is helping and b) there is usually a kernel of truth in the content of the nagging (e.g., you plan to avoid taking second helpings at a buffet, but go ahead and take second helpings, then your husband nags you about it later).  Above all, the participant needs to demonstrate that he or she is taking responsibility for the process of behavior change, including slips along the way. 

Ask one participant to volunteer to role play nagging and ask another participant how he or she would respond.  Ask the group to suggest alternative responses, and then ask the volunteer who played the role of responding to role play an alternative response.  

Discuss alternatives to nagging.  Ask the group if there are any ways that a family member could respond to a participant’s mistake (e.g., taking second helpings at a buffet) without nagging.  Examples:
C	You might be comfortable if you can agree with a family member in advance to signal you privately (for example, with a touch) when you do something you want to avoid (for example, taking a second helping at a buffet).  If it's a private signal and no more is said, you might not feel nagged and find the feedback useful.  If you agree to such a system, be sure to praise your partner later for helping you, and agree that he/she should praise you next time the signal seems to work (again, in some private way, like with a touch or smile).
C	Another alternative to nagging is for a family member to ask you how you are feeling at a time when he or she might typically have nagged, especially if you seem tired or upset (for example, when you seemed to have forgotten your after-dinner walk).  This shows concern for your feelings and is a positive alternative to nagging. 

5.	Discuss how to handle sabotage.  Begin with an example, such as, “Sometimes a friend or relative will bring a high-calorie sweet home as a gift despite the fact that you have specifically asked him or her not to do so.”  Explain that this is an example of what is called “sabotage.”  Emphasize that in most instances this is not done with “ill will” but is simply an example of family habits.

Ask participants if they have experienced this and if they would be willing to share any examples (be aware that this may be a particularly sensitive topic for some participants).  Discuss the fact that there may be various reasons for sabotage.  For example, a spouse or roommate may be threatened in some way by the participant becoming slimmer and physically more attractive or the family member may simply be missing the shared rituals with their favorite “eating buddy.”  [Note: Be aware of related cultural issues that may be important for your participants, such as men in certain cultures tending to prefer overweight women.  You may need to help participants reframe some of these issues.  For example, stress that the Lifestyle Balance program is designed to help prevent diabetes rather than produce a certain type of physical appearance.]

Regardless of the possible reasons for sabotage, it can be quite difficult to respond to effectively.  It’s important to give a clear message that you don’t want the behavior (e.g., bringing candy home as a gift) to continue, while at the same time showing the spouse or friend that you know they mean well.  Also, suggest something else that they can to do help.  The key is to be both firm and gentle.  For example, you might say, “Thank you for thinking of me, but candy is just too tempting.  I really love gifts that aren’t food.  Could we go out to a movie to celebrate instead?”  Be sure to give plenty of praise when the person does what you suggested would be helpful.

6.	Summarize.  Assign homework:
C	Practice praising, receiving praise, and asking for praise. 
C	Invite your family members to the family event (next session).  [Describe the event and give participants invitations.]

Session 3: A Family Event

Objectives:	Family members will be invited to this session.  The basics of the DPP (study design, impact of diabetes, lifestyle goals, rationale for the lifestyle goals, how the study is doing) will be presented as well as some ideas for how the family can help the DPP participants succeed.  Having a family talk about ways the family can help will be recommended as homework before the next session.  Refreshments and time for socializing will be included.
Handouts:		Ways for Your Family to Help (page 1 only), How My Family Can Help
Slides or overheads (optional):	How Is the DPP Doing? graphs (see Tool Box)

Note:  If possible, include a group walk with the family members before or after the session.

1.	Introductions.

2.	Describe the purpose of the session:  to provide an update for participants and their families on the DPP study, to recognize the hard work and progress of the DPP participants, and to thank family members for all they do to help the DPP participants succeed.  

3.	Present the basics of the DPP (study design, impact of diabetes, lifestyle goals, rationale for the lifestyle goals, how the study is doing nationally and locally).  Keep this brief and simple.  Emphasize the importance of the study and the progress and hard work of the participants.  If possible, have the Principal Investigator do this.  Depending on the data at your center, you may want to present the How Is the DPP Doing? graphs (see Tool Box) as slides or overheads.

4.	State that another reason for inviting participants and family members to this gathering is to thank the families for all they do to help the DPP participants succeed.  Ask the group to name some ways in which the families have helped the participants so far.  Praise the families, and emphasize that these forms of day-to-day support are crucial to the success of the study and to our efforts to prevent diabetes.  Also emphasize that their efforts contribute to the health of the entire family.  Distribute page 1 of the handout, Ways for Your Family to Help, and review any items not already mentioned as examples of additional ways to help.  

5.	State that some DPP families have found it very helpful to sit down together and talk about how the family is already helping and to think about some additional things they could do to help.  Distribute handout, How My Family Can Help.  Explain that you are giving the families some “homework” for the next session.  They are to complete the worksheet together and the participant is to bring it to the next session.  Recommend that the family pick a time that’s convenient for everyone (they may need 30-40 minutes) and a quiet place.  They are to talk about each of the topic areas listed (skipping ones that don’t apply to them), and write down what’s going well in each area, what some of the problems are, what would help, what changes you would like to make in that area, and then come up with a plan together.  Recommend that children be included in the family talk if possible.  (Warn participants not to underestimate their kids.  Many young children understand their parents’ needs and are delighted to be asked to help.  For example, young children in the DPP and other studies have helped their parents complete self-monitoring booklets like Keeping Track.  Others have agreed not to have candy in the house while Mom is in the DPP.)

Work through an example to illustrate the process, such as the following: 
In the food shopping area, 
C	What is going well:	We are buying more fruits and vegetables that help me stay under my fat gram goal. 
C	Problems: 			We buy cartons of ice cream for the kids which is tempting to me when I see it in the freezer. 
C	What would help/what change would you like: 
Try buying ice cream sandwiches, popsicles, or other single serving frozen desserts because I can better control the amount I eat of them, or maybe we could stop buying ice cream at the grocery store and only buy it for the kids when we go out.
C	Our plans: 			Try some different types of low-fat frozen desserts that come in single servings at the grocery store (popsicles, frozen fruit juice bars, frozen yogurt bars) to find one that we all like.

Stress that the talk is to be positive.  Every single thing you do as a family to help the DPP participant and to help each other stay healthy is a reason to feel proud.  The DPP can’t thank you enough for all that you are doing.

6. 	Thank participants and family members for coming.  Allow time for refreshments and to socialize.  (One option would be coffee and a low-fat dessert.)

Session 4: Review of the Family Talk

Objectives:	Participants will discuss their family talks and problem-solve/role play some of the problems or issues that arose.  Participants will be encouraged to carry out the plans made at their family talks and to reward themselves and their family for successful change.  Family members will not be invited to this session.
Handouts:  	How My Family Can Help (2-3 copies per participant), Keeping Track booklets

Spend most of the session discussing how the participants’ family talks went.  Ask for comments and questions.  If needed, use the following questions to stimulate discussion:
C	Were their families receptive to having the talk?
C	How did family members respond to a discussion of what things are going well?  To a discussion of problems and desired changes?
C	Did family members come up with suggestions for change?
C	Were participants able to communicate the changes they’d like?
C	Did the families arrive at any plans?  Ask participants to share some specific examples.
C	Did the families have a chance to begin to carry out any of their plans?
C	If some participants did not have a family talk, what got in the way?  What would be some approaches for handling those difficulties?

Ask volunteers to role play with you some alternative responses to resistance from family members or other difficulties related to their family talk.

Encourage participants to carry out their plans and to reward themselves and their families for successful change.  Ask the group to brainstorm some ideas for family rewards.

Distribute fresh copies of the worksheet, How My Family Can Help, for participants who want them for additional talks.