1- List 5 stages of emotional adjustment to diabetes. 2- Describe the 3 components (A-B-C s) of Cognitive Behavior Therapy.

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2 Learning Objectives: 1- List 5 stages of emotional adjustment to diabetes. 2- Describe the 3 components (A-B-C s) of Cognitive Behavior Therapy. 3- Describe the four pronged approach to diabetes care.

3 I. 5 Stages of Emotional Adjustment Originally, these stages were developed to describe stages of grief, but it can be expanded to describe stages of diabetes acceptance. Disclaimer: Not everybody goes through these stages, nor do they necessarily go through the stages in this order.

4 5 Stages of Emotional Adjustment A. DENIAL ( Dia-Denial ) Denial is when somebody doesn t want to acknowledge their diagnosis. A person may feel overwhelmed with feelings of anxiety about the future, that they cope by ignoring the facts.

5 5 Stages of Emotional Adjustment Is this your client? Debbie Denial She generally ignores her diabetes. How can ostrich policy help? Sticking your head in the sand and hoping it goes away.

6 5 Stages of Emotional Adjustment B. ANGER Anger is the direct result of a person s thoughts, not of the event. Anger is only one letter short of danger. Eleanor Roosevelt

7 5 Stages of Emotional Adjustment Is this your client? Angie Anger Asks Why me? and thinks This is so unfair! It would be better to direct her actions toward managing her diabetes and not being angry at it.

8 5 Stages of Emotional Adjustment C. BARGAINING Bargaining is when a person makes a desperate plea (usually to a higher power or to a healthcare professional) how they will change their life, in exchange for taking away the diabetes.

9 5 Stages of Emotional Adjustment Is this your client? Barry Bargainer Makes a deal to be good from now on. Help your client to focus on living as a person who happens to have diabetes, rather than seeing themselves as a victim of diabetes.

10 5 Stages of Emotional Adjustment D. DEPRESSION/DIABETES DISTRESS Clinical depression is defined by symptoms that have lasted more than 2 weeks. IF the depression is unrelated to diabetes, the person should consider seeking professional treatment with a licensed clinical psychologist or clinical social worker.

11 5 Stages of Emotional Adjustment Symptoms of clinical depression: Persistent sadness, such as feeling empty Feeling a loss of joy in your life Changes in appetite Sleep difficulties Feeling fatigue or loss of energy Feelings of worthlessness or excessive guilt Difficulty with attention and concentration Recurrent thoughts of death or suicidal thoughts

12 5 Stages of Emotional Adjustment DIABETES DISTRESS Diabetes distress arises from living with the emotional burden of diabetes selfmanagement and blood sugar control. There are 4 main areas of distress:

13 5 Stages of Emotional Adjustment Emotional burden Physician-related distress Regimen-related distress Interpersonal distress Diabetes distress can be managed and reduced using cognitive behavior therapy.

14 5 Stages of Emotional Adjustment Is this your client? Dee Dee Depression She cries at the mere mention of the word diabetes. She feels hopeless that she will ever be able to manage her diabetes. Diabetes educators can teach depressed clients to accept diabetes and how to cope with it. They can be empowered to manage their diabetes!

15 5 Stages of Emotional Adjustment T L C Therapy: Talk, Listen, Counsel Talk: the talk part is educating about diabetes management Listen: the listen part is being quiet and let the client s feelings be heard Counsel: the counsel part is teaching the coping strategies of cognitive behavior therapy

16 5 Stages of Emotional Adjustment E. ACCEPTANCE Acceptance is our goal. Helping people with diabetes to accept their diagnosis of diabetes and make lifestyle choices that keep them healthy and happy.

17 5 Stages of Emotional Adjustment My story of diabetes acceptance: Living successfully with type 1 diabetes for 42 years.

18 II. The A-B-C s of Cognitive Behavior Therapy (CBT) The basic idea of CBT is that the way a person thinks about an event is directly related to how a person feels about the event. If the thoughts are negative, the feelings will be negative. If the thoughts are positive, then the feelings will be positive.

19 The A-B-C s of CBT A. ANTECEDENTS An antecedent is the event which is not within a person s control such as having diabetes.

20 The A-B-C s of CBT B. BELIEFS 1- Irrational (unreasonable) thinking 2- Rational (reasonable) thinking

21 The A-B-C s of CBT C. CONSEQUENCES 1- Negative feelings 2- Positive feelings

22 The A-B-C s of CBT People with diabetes who experience denial, anger, helplessness, and diabetes distress are less likely to practice good self-care behaviors, which could then negatively impact their A1C. When using CBT, the goal is to challenge irrational, unreasonable thoughts so that the patients can better manage their self-care and improve their blood sugar management.

23 The A-B-C s of CBT Revisit your clients: Debbie Denial an example of Minimization Angie Anger an example of Should statements Barry Bargainer an example of The Fortune-Teller Error Dee Dee Depression an example of All-ornothing Thinking

24 III Spiritual Approach Spirituality can be defined as: Experiencing the presence of a power or force and experiencing a closeness to that presence. Note: A belief in God is not a requirement to adopt the message of empowerment

25 Spiritual Approach Current diabetes self-management guidelines, such as those of the ADA, reflect a more holistic style. Spirituality can be seen as part of the journey toward becoming whole. Religiousness and spirituality have been shown to improve glycemic control, as well as lower diabetes-related morbidity and mortality.

26 Spiritual Approach A. Serenity Prayer God, grant me the serenity To accept the things I cannot change, The courage to change the things I can, And the wisdom to know the difference.

27 Spiritual Approach Learning to recognize what is not within their power to change (their diagnosis) and to recognize what is within their power to change (their thoughts and actions) and the understanding of both choices will result in the wisdom of your clients to accept their diabetes.

28 Spiritual Approach The Other Serenity Prayer God, grant me the serenity to stop beating myself up for not doing things perfectly, The courage to forgive myself because I m working on doing better, And the wisdom to know that You already love me just the way I am. Eleanor Brown

29 Spiritual Approach B. Four-pronged approach to diabetes care 1- Medication 2- Diet 3- Exercise 4- Spirituality

30 Spiritual Approach Elliott Joslin, MD ( ) was the first doctor in the US to specialize in diabetes and was the founder of today s Joslin Diabetes Center in Boston. He recognized that managing tight control of blood sugar could be achieved through diet, exercise, and insulin and could extend one s life and prevent complications.

31 Spiritual Approach Joslin s approach to diabetes management was expressed by the troika, the Russian word meaning threesome. He created a three-horse chariot to reflect this philosophy of living with diabetes the three horse motif symbolized insulin, diet, and exercise, which are needed to achieve victory over diabetes.

32 Spiritual Approach In my men s book MY SWEET LIFE: Successful Men with Diabetes, one of my contributing authors took the idea of the triangular facets of diabetes self-care to a new level a square! In his paradigm, diabetes management has four points: medication (insulin), diet, exercise, and spirituality.

33 Spiritual Approach Diabetes care is coming to address the 4 areas in one s life: 1- Insulin and diabetes medicines help the body. 2- Diabetes educators teach people about blood sugar monitoring, meal plans, and exercise. 3- Ideally, the health-care team also teaches people to manage stress and maintain emotional health. 4- Recently, organized medicine has begun to address the spiritual aspect of self-care as well.

34 Spiritual Approach With a positive attitude toward diabetes, your clients can choose to feel at peace with their diagnosis and feel empowered to manage their diabetes self-care.

35 Spiritual Approach C. Selected quotes about acceptance and attitude: The primary cause of unhappiness is never the situation but your thoughts about it. Eckhart Tolle If you don t like something, change it. If you can t change it, change your attitude. Maya Angelou

36 Spiritual Approach C. Selected quotes about acceptance and attitude: Change your thoughts and you change your world. Norman Vincent Peale Choosing to be positive and having a grateful attitude is going to determine how you re going to live your life. Joel Osteen

37 Spiritual Approach C. Selected quotes about acceptance and attitude: I cannot always control what goes on outside. But I can always control what goes on inside. Wayne Dyer Remember, happiness doesn t depend upon who you are or what you have, it depends solely upon what you think. Dale Carnegie

38 Spiritual Approach C. Selected quotes about acceptance and attitude: Everything is an opportunity. The glass is either half empty or half full. You can choose.it s the same glass. Diane von Furstenburg What has happened to me isn t nearly as important as how I decide to respond to it. I choose to grow through adversity. Carl Jung

39 Spiritual Approach C. Selected quotes about acceptance and attitude: A bad attitude is like a flat tire you don t get anywhere until you change it. Anonymous There is nothing good or bad, but thinking makes it so. William Shakespeare

40 Spiritual Approach Conclusions Lessons for your clients: Encourage your clients to choose a positive attitude. There s a saying: You cannot live a positive life with a negative mind. A negative thinker sees difficulty in every opportunity. A positive thinker sees opportunity in every difficulty.

41 Spiritual Approach Conclusions Lessons for your clients: Diabetes can be managed, not cured. Help your clients take charge of their diabetes. The difference between try and triumph is a little UMPH. Worrying about the future with diabetes doesn t take away tomorrow s troubles. It takes away today s peace. Teach your clients to be a warrior, not a worrier.

42 Announcement I will be retiring as a clinical psychologist and Certified Diabetes Educator treating the emotional issues of clients with diabetes

43 .Just as soon as they find a cure for diabetes!! Thank You!