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 ID: 753537
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Slide1
Opening Pandora’s Box:A Dialogue Regarding Psychosocial Issues in Diabetes
Presented By:
Michael Vallis, PhD Psychologist, Halifax
Lori Berard, RN CDE, Nurse, WinnipegSlide2
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.Slide3
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-careSlide4
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 patientSlide5
Choice
Prediction
Description
Diagnosis/
Assessment
Treatment/
Intervention
Outcomes
Outcomes are
dependent on
how good
you are
Outcomes Under
Our Control
Outcomes Controlled by Patient ChoicesSlide6
Interpersonal Connectedness
–
How We Maintain Connection
Circumplex model
1
People can be categorised along two independent dimensions
Dominance
Agreeableness/sociability
Interpersonal complementarity
2
Dominance evokes submission
Friendliness evokes friendliness
Markey & Markey.
Assessment
.2009;16:352–361
2.Markey et al. Personality and Social Psychology Bulletin
,2003;29:1082–1090
Assured–Dominant
Unassured–Submissive
Cold–
Hearted
Warm–
Agreeable
Dominance
WarmthSlide7
VideoSlide8
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. Slide9
Motivational Communication
Ask
Listen
Summarize
Invite
“Understanding” Slide10
Why Understanding First
?
Healthy behaviour is abnormal behaviour
Pleasure principle
P
ath of least resistance
Preference for short
term gain regardless of long term consequences
Environment pulls for un
healthy behavioursSlide11
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 1545992Slide12
12
Needs and Concerns Analysis
Assess the patient’s view of the needs for medication
Assess their concerns about the potential side-effects
Horne R,
et al.
Inflamm
Bowel
D
is 2009;15:837–44
Concerns
High
Low
Needs
High
Ambivalent
Accepting
Low
Sceptical
IndifferentSlide13
Decision Aid: SURE test
Légaré
F,
et al. Can
Fam
Physician
2010;56:e308–14
Yes
[1]
No
[0]
S
ure of myself
Do you feel SURE about the best choice for you?
□
□
U
nderstanding information
Do you know the benefits and risks of each option?
□
□
R
isk-benefit ratio
Are you
clear about which benefits and risks matter most to you?
□
□
E
ncouragement
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 conflictSlide14
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 largeSlide15
Negative Impact of D
iabetes 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
Niccoluci
et al. Diabetic Medicine. 2013;30:767-777Slide16
From Burden to Burnout to Distress to Depression
Burden
Burnout
Diabetes Distress
DepressionSlide17
17
Vallis, M. 2015
©Slide18
Disease-Specific Distress
Diabetes Distress Scale (
Polonosky
et al., 2005)
Emotional Burden
Regimen Distress
Physician Related Distress
Interpersonal 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
Provider Related DistressSlide19
VideoSlide20
Emotions
Primary 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 othersSlide21
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 choicesKeep the conversation going: The 4 S’sSelf-ImageSelf-Efficacy
Social SupportStress Management (discharge, calming, expression, connection)Slide22
22Slide23Slide24
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
LowSlide25
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); Slide26
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?Slide27
Getting to the Behaviour
Readiness Assessment
Not Ready
Ready
Go Right
to Behaviour
Modification
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
Decisional BalanceSlide28
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