Opening Pandora’s Box: A Dialogue Regarding Psychosocial Issues in Diabetes Presented By: Michael Vallis, PhD Psychologist, Halifax Lori Berard, RN CDE, Nurse, Winnipeg

Unrestricted education grant funding for this session was provided by AstraZeneca. The Canadian Diabetes Association is grateful to AstraZeneca for their contribution to diabetes in Canada.

Session Goals To increase awareness and confidence in addressing complex psychosocial issues in diabetes self-management support Specific issues to address include Emotional burden of living with diabetes Diabetes Distress, Burnout, Depression Establishing relationships that are empowering and non-judgmental Increasing patient motivation for self-care

Why the Title: “Opening Pandora’s Box” Providers are trained to stay within limits of their scope of practice However, scope of practice has changed From: mental health issues were psychopathology-based so the only issues were when and where to refer To: the ground has shifted as we understand the whole person experience of chronic disease Scope of practice now requires us to focus on outcomes we can achieve separate from outcomes achieved through the behavioural choices of the patient

Outcomes Controlled by Patient Choices Outcomes Under Our Control Outcomes Controlled by Patient Choices Diagnosis/ Assessment Description Outcomes are dependent on how good you are Prediction Treatment/ Intervention Discussion: if we support the goal of achieving the biological outcomes then Jim is a failure. If the goal is to modify his behaviour according to healthy lifestyle factors, then Jim is a success (60% of cholesterol is determined by genetics. Outcomes Choice

Interpersonal Connectedness – How We Maintain Connection Circumplex model1 People can be categorised along two independent dimensions Dominance Agreeableness/sociability Interpersonal complementarity2 Dominance evokes submission Friendliness evokes friendliness Assured–Dominant Unassured–Submissive Cold– Hearted Warm– Agreeable Dominance Warmth Markey & Markey. Assessment.2009;16:352–361 2.Markey et al. Personality and Social Psychology Bulletin,2003;29:1082–1090

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Motivational Communication Non-Judgmental Curiosity is defined as: A willingness to understand a person’s behaviour through the lens of their own experience (why do you do what you do) without a value judgment (behaviour is neither right or wrong – it is). If a person feels judged, they will become defensive. If a person feels guilt/shame, they will become avoidant. It is about how we react to what patients tell us. You will have biases, and you need to recognize and acknowledge them in order to convey NJC. This next exercise will demonstrate this…

Motivational Communication Ask Listen Summarize Invite “Understanding” This is the what you do. Exercises Listening exercise

Why Understanding First? Healthy behaviour is abnormal behaviour Pleasure principle Path of least resistance Preference for short term gain regardless of long term consequences Environment pulls for unhealthy behaviours

Low Hanging Fruit Medication adherence is one of the fundamental health behaviours of relevance to self-management and chronic disease outcomes WHO estimates nonadherence to medication at 30% - 70% of medications for chronic conditions Adherence to Long-Term Therapies: Evidence for Action. World Health organization, 2003. ISBN 92 4 1545992

Needs and Concerns Analysis Assess the patient’s view of the needs for medication Assess their concerns about the potential side-effects Concerns High Low Needs Ambivalent Accepting Sceptical Indifferent Horne R, et al. Inflamm Bowel Dis 2009;15:837–44

Decision Aid: SURE test Yes [1] No [0] Sure of myself Do you feel SURE about the best choice for you? □ Understanding information Do you know the benefits and risks of each option? Risk-benefit ratio Are you clear about which benefits and risks matter most to you? Encouragement Do you have enough support and advice to make a choice? Yes equals 1 point No equals 0 points If the total score is less than 4, the patient is experiencing decisional conflict Légaré F, et al. Can Fam Physician 2010;56:e308–14

Human Nature Patients want to be as normal as possible This means making the psychological footprint of diabetes as small as possible Clinicians want their patients to be as healthy as possible This means making the psychological footprint of diabetes large

Negative Impact of Diabetes on Aspects of Life % of people with diabetes rating impact on at least one aspect of life as slightly to very negative Type 1 (A) Type 2 (B) Aspects of life rated Physical health Emotional well-being Financial situation Leisure activities Work or studies Relationship with friends, family, peers The vast majority of people with diabetes feel that diabetes has negatively impacted at least one aspect of their life, with Type 1 significantly more likely than Type 2 to feel this way (83% vs. 72%). Niccoluci et al. Diabetic Medicine. 2013;30:767-777

From Burden to Burnout to Distress to Depression Diabetes Distress Depression

Diabetes Related Problems of Living Distress Screen for Caseness Psychopathology Well-Being Resiliency Positivism Vallis, M. 2015©

Disease-Specific Distress Diabetes Distress Scale (Polonosky et al., 2005) Emotional Burden Regimen Distress Physician Related Distress Interpersonal Distress Provider Related Distress Fisher, et al. Clinical Depression Versus Distress Among Patients With Type 2 Diabetes: Not Just a Matter of Semantics. Diabetes Care, 2007;30:542-48

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Emotions Primary Emotions Secondary Emotions Interpersonal Emotions Natural, appropriate emotional responses to live experiences Expressing and “sitting with” lead to transformation (grief) Secondary Emotions Often come from our thoughts when we review experiences Interpersonal Emotions Emotional displays that serve a purpose in terms of eliciting reactions from others

The Role of the Diabetes Care Provider It’s not your job to change the Patient:Provider role and self-efficacy Identify Educate Recommend Support Replace the function If you can understand behaviour you can negotiate choices Keep the conversation going: The 4 S’s Self-Image Self-Efficacy Social Support Stress Management (discharge, calming, expression, connection)

Why Don’t Recommendations Work? Whose idea is it to change, usually? Provider Who does the work of change? The individual Typically, how excited by the work of change is the individual Low

Collaborate and Empower Collaboration leads to change in three ways: Bond (working together in a respectful way); Task (agreeing on who does what to get to the goal); Goal (agreeing on the value of final outcome);

Determine Readiness Is the behaviour (or lack of it) a problem for you? Does the behaviour (or lack of it) cause you any distress? Are you interested in changing your behaviour? Are you ready to do something to change your behaviour now?

Getting to the Behaviour Readiness Assessment Not Ready Ready Ambivalent Expectation of change off the table Understand the behaviour Personal meaning Seriousness, personal responsibility, controllability, optimism Expanding on readiness Personal/meaningful reasons to change Willingness to work hard - connect to principles Delay of gratification Go Right to Behaviour Modification Decisional Balance

Working With the Behaviour: Behaviour Modification Goal Setting/Action Plans FIRST STEP Goals Shaping NEXT STEP goals Stimulus control Personalized healthier built environment Reinforcement Management Incentives that transfer external to internal drive