1. Counselling for diabetes
Kate Smith
Abertay University
Tayside Centre for Counselling

2. Overview What is diabetes? What does it have to do with counselling?
The research study

3. Diabetes Type I: Aka ‘Insulin-controlled’ and ‘early-onset’ Type 2:
Monitoring blood sugar, food intake, activities/exercise, injecting insulin
Type 2:
Aka ‘Late-onset’ and ‘mild’
Initially managed by food intake, exercise, sometimes medication

4. Long-term consequences of high blood sugar
Damage to vascular system
Damage to nervous system
Weight-loss, tissue and organ damage
Let’s think about these in a bit more detail

5. Best-case scenarios Life expectancy reduced by average 10 years
Complications minimised by adherence to diet, exercise and medication (Livingstone, et al, 2015)
Early diagnosis
Effective engagement with healthcare
Stick with the programme

6. Worst-case scenarios Stroke, heart attack Liver and kidney disease
Sight-loss (Glaucoma, diabetic retinopathy)
Limb-loss
Dementia

7. Not just a physical experience
Emotional and Psychological well-being in Diabetes:
Depression
Anxiety
Eating disorders
Phobias
‘Diabetes burn-out’
Physiological and psychological factors interact
Many psychological needs without formal diagnosis (Diabetes UK, 2012)
41%

8. Minding the Gap
In 2008 Diabetes UK published a comprehensive survey of psychological support and access to services for people with diabetes:
< a third of services had mental health care
Staff were unable to respond to complex issues
>80% had no referral systems in place
Around 90% of psychological services offered CBT and MI
Can counselling help?

9. Research study
Aim: To explore the experiences of people with diabetes, practitioners working with people with diabetes, and counselling clients.
Objective: development of a model for effective support for people with diabetes. A ‘treatment manual’.

10. Controlling the uncontrollable (1)
Healthcare providers
Semi-structured interviews
How emotional experience perceived
How emotional experience managed
Impact of emotional problems for patients
Role for counselling?
17 Interviews (6 podiatrists, 3 dieticians, 8 diabetes nurses)
Transcribed, thematic analysis

11. Thematic analysis:
Emotional impact on patients
Stages of disease
Types of diabetes
Engagement of patient
Relationship with patients
Empathy…..
‘If it was me, I would do it, I’d stop my insulin for a couple of days, drop a stone…I would’

12. Thematic analysis: Difficulties depends on individuals
Individual differences
Effort required (by practitioners)
When it hits home
‘…so she’s been coming since she was about 9 years old, always bad, she’s got proteinuria, and she’s tiny, but then she got pregnant and her kidneys failed, and now she’s coming back and saying we didn’t warn her – well of course we did’

13. Thematic analysis: Professional role
Behaviour change and MI
Referring on
Lack of psychological services
Frustration and resignation
‘You know there’s a six month waiting list for psychological services, and they don’t like us sending people really, we used to have a health psychologist but the funding ran out’

14. Take home message from NHS professionals:
NHS services are limited
Adults are not ‘chased’
Communication is problematic
Varied levels of understanding for ‘problem patients’

15. Controlling the uncontrollable (2)
People with diabetes
Range of individuals
Age
Status (type I/II)
Medical complications
Ability to manage
Semi-structured interviews
Story of diabetes
Emotional and psychological needs
Role for counselling?

16. Results Ways of being now and historic
The diagnosis and ‘the honeymoon period’
The ways it was ignored
Coping with the effects
‘they got to the bottom of it and said, “You are terminal”, you know. But then if you manage your liver, I mean it’s unlikely but I could live a few more years I think’

17. Results Theme: How I manage my diabetes Day to day
Things that are difficult
Interactions with healthcare teams
‘I didn’t think about it in my day to day life, sometimes I just go the diabetes clinic and just cry.’

18. Results Emotional impact Motivation to be ‘good’ Guilt at being ‘bad’
Living with regret
Ignoring it means no emotional impact

19. Counselling Didn’t know why I was there Getting the time right
There’s people much worse off
‘when I was referred up to XXX I went maybe twice because I felt like, not being funny, all those people up there have serious issues, but I was sent for not taking my injections…’

20. Take home message from people with diabetes:
Getting on the wagon and falling off
You can pretend it’s fine for years
You need a good (honest) relationship with healthcare
If you need support it should be available and explained

21. Case-study Single counselling case for diabetic client
Pluralistic therapy
Female, 29 yrs, MODY diet-controlled, medication.

22. Case-study Issue on assessment Outcome Ignoring diabetes
Not taking medication
Not watching diet
Felt ignored by diabetes health professionals, ‘they don’t give a shit’
Outcome
Recognised reactions which impact on self-care
Changed behaviour (meds/exercise/diet)
Accept being diabetic, get on with it…..
Having a choice, ‘frame of mind’

23. The Ward Method
Comprehensive case-book: transcripts of eight sessions, plus assessment and follow-up interviews
Collaborative consensus-building
Four cycles of analysis and meetings
Research questions:
What are the goals, tasks, and methods used in this case?
What evidence is there of pluralistic collaboration?

24. Results: Goals Stated goals vs. implicit/interpreted goals
Stated problems ‘I need…’:
Face-up to diabetes
Need to care
Need to Act, be proactive, move forward with care

25. Results: Client tasks Face up to diabetes Be honest about situation
Maintain private world without family interference
Process difficult emotions – ‘not fair’, ‘I’m just angry’
Self-image, being in control of how she is seen
Tension with healthcare providers
Future impact

26. Results: Client tasks Need to care Find motivation (get the facts)
Engage in adult ego-state (family dynamics)
Focus on herself

27. Results: Client tasks Need to act Take medication
Engage in healthy eating and activities
Undo self-criticism

28. Results: Therapeutic tasks
Coming to terms with diabetes
Assimilation and acceptance
Fear for the future
Relationships with health/identity
Removing the barriers to self-care
Challenge and explore ways of being
Understanding why self-care is not happening
Changing behaviour
In ways that work for the person
Strengths and cultural resources
Stages of change...

29. Results: The collaborative relationship
Counsellor as comrade:
Perceived as equal
Remains in adult
Asking permission
Counsellor as mentor:
Gives information which client did not have
Counsellor as collaborator:
Practical strategies
Defining and reviewing goals and plans
Counsellor as crucible:
Holding and allowing parts of self
Holding and allowing emotional expression

30. How can we triangulate this data?
Professionals informed by people with diabetes
Gaps need to be addressed:
Imperative to have a (positive) point of contact
Recognise denial, and address
Information dosage
Points of impact – often physical
Complexities of helpful family and friends
Having diabetes is hard, both physically and emotionally

31. Three tiers? Tier 1 – staff are unprepared and under-resourced
Tier 2 – some provision but little specialisation
Tier 3 – specialist care for diagnosed mental health problems

32. Future directions Tier 1: Increase competencies
Tier 2: Treatment manual
Key areas of need
Possible therapeutic tasks
Methods for addressing tasks
Tier 3: Raise awareness of link between emotional well-being and diabetes outcomes

33. Thank-you for listening