Finding common ground with people who have diabetes Dr Jess Brown Senior Clinical Psychologist Department of Psychological Medicine York Community Diabetes Team
Aims for today Why common ground? What might we notice? What might be influencing that behaviour? What is the impact on us? How can we move things forward?
Before we start Being aware of ourselves and each other
Why common ground? An agreed basis, accepted by both or all parties, for identifying issues in an argument Collins Dictionary Shared interests, beliefs, or opinions between two people or groups of people who disagree about most other subjects Cambridge Dictionaries Online
What might we notice? BG that doesn t fit the history Not following advice Not coming to appointments Anger Tearfulness
What is the impact on us? Worry Frustration Irritation Feeling like can t do anything NHS context Self-harm literature?
What might be influencing what we see? Low mood Understanding Fear Relationship with food Shame, embarrassment
What might be influencing what we see? An estimated 41% of people living with diabetes have poor psychological wellbeing Depression is twice as common as in the general population There are higher rates of anxiety and eating disorders than the general population 85% of people with diabetes in the UK have either no defined access to psychological support and care, or at best access to a local generic mental health service only. e.g. Diabetes UK, 2007; Diabetes UK/NHS Diabetes, 2010
Depression At least 1/3 of people living with diabetes are at risk of depression Numbers are thought to be much higher for those living with lower-level depressive symptoms Particular risk factors are adjustment, grief and loss (e.g. of identity, healthy self); The reality of a demanding self-care regime; Burnout
Depression What is it? A cluster of feelings and behaviours that last over several weeks and which impact in core areas of a person s life Persistent low mood with feelings of hopelessness, tearfulness and guilt. Loss of interest in things that were enjoyable before. Changes in a person s sleeping, appetite, energy and sex drive. Avoiding activities and social interactions Negative (and painful) thoughts about ones self, the world and the future
Depression It s a bleak condition to be living with The hopelessness is so big I can t see Nothing will help I hate diabetes and I always will, you can t change that so. I m sorry, I waste your time. You must think I m so stupid..
Depression How might this influence a consultation and diabetes generally?
Anxiety What is it? Nature s power-up : A primitive (old brain) response built for survival: fight-flight-freeze Physical Cognitive Emotional Behavioural
Anxiety In diabetes we need to think particularly about: Fear of the diagnosis and all that comes with it (fear of hypoglycaemia and hyperglycaemia) Social anxieties Fear of the future Needle phobia (less common?) Fear of anxiety itself
Anxiety What happens when you re feeling anxious? Physical e.g. sweaty, beating heart, shaky Cognitive, e.g. hyperfocus, rumination, cognitive bias Emotional, e.g. terror, fear Behavioural e.g. avoiding
Anxiety How might this affect a consultation and diabetes generally?
Relationships with food Nice says: Members of multi-disciplinary professional teams should be alert to the possibility of bulimia nervosa, anorexia nervosa and insulin dose manipulation in adults with type 1 diabetes with: Over-concern with body shape and weight Low body mass index Poor overall blood glucose control
Relationship with food How might this affect a consultation and diabetes generally?
To recap Awareness of the difficult internal events that people with diabetes may be experiencing
Working with distress People may have different levels of need at different times in their lives; ideally within services we can recognise this and be flexible..
The pyramid model (from Trigwell et al; 2008). Severe, complex mental illness requiring specialist psychiatric intervention(s) More severe psychological problems that are diagnosable and require biological treatments, medication and specialist psychological interventions Mild moderate (diagnosable) psychological problems which can be treated solely through psychological interventions More severe difficulties with coping, causing significant anxiety or lowered mood, with impaired ability to care for self as result General and common difficulties coping with diabetes and the perceived consequences of this for the person s lifestyle etc.
Working with distress Most important is empathy, compassion and helping someone to feel psychologically safe with you Individual Avoid assumptions (about experience, priorities) Open questions and reflective listening
Working with distress Trying to understand and convey that understanding. Using our own words to reflect and summarise, and check whether we are getting it e.g. How has this all fitted in the rest of your life? Can I just check that I m understanding you OK? It sounds as though you re feeling more overwhelmed by your diabetes care lately and that you ve noticed you re not sleeping; is that right?
Working with distress Being aware of the language that we (and others) use in relation to diabetes What meaning do people give to the words that we use? How do we set goals? I m on the naughty step again I m such a bad diabetes patient I just feel like an idiot
Working with distress E.g. How have you been feeling over the past few days? Over the past couple of weeks? Right now talking to me? Who/what helps to make a difference?
Working with distress If you re worried.. Screening measures Can be helpful for some to communicate their distress without having to find the words A range are available; some are specific to diabetes, e.g.deps, others for more general experiences of depression or anxiety e.g. PHQ 2 or 9, PHQ SADS.
If you re worried Improving access to psychological therapies CMHT Online information and resources http://www.valeofyorkccg.nhs.uk/rss/index.php?id=mental-health Diabetes Psychology Is the struggle relating to diabetes specifically? What could be helpful?
Working with distress Foundation level communication skills training such as Sage and Thyme, or advanced level communication skills training Training in specific models, such as motivational interviewing.
References and resources Emotional and Psychological Support and Care in Diabetes: Report from the emotional and psychological support working group of NHS Diabetes and Diabetes UK (published in 2010). Speight, J. (2013) Managing diabetes and preventing complications: What makes the difference? Medical Journal of Australia 198 (1), 16-17 Trigwell et al (2008) Minding the Gap: The Provision of psychological support and care for people with diabetes. A Report from Diabetes U.K. NICE Guidance for depression, anxiety, eating disorders. Self-Help Resources: Nash, J. (2013) Diabetes and Wellbeing: Managing the Psychological and Emotional Challenges of Diabetes Types 1 and 2, Wiley-Blackwell. Gregg, Callaghan and Hayes, (2007) The Diabetes Lifestyle Book, New Harbinger Publications.
Bullet points People living with diabetes may be experiencing distressing internal events that may not be obvious Trying to manage these difficult experiences can influence behaviour and relationships with services and treatment The language that we use can convey things that we don t expect or mean to say We can try to understand and show this understanding through open questions and reflective listening Further reading / training in working with distress can support this process