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

2. 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.

3. 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

4. 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

5. 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

6. 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

7. Video

8. 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…

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

10. 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

11. 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, ISBN

12. 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

13. 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

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

15. 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:

16. From Burden to Burnout to Distress to Depression
Diabetes Distress
Depression

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

18. 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

19. Video

20. 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

21. 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)

24. 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

25. 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);

26. 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?

27. 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

28. 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