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Cognitive Behaviour Therapy:


How to Improve Diabetes
Self-Management
>>
people with diabetes find that trying
hard does not always pay off (Rubin
et al, 1990). Additionally, the health
benefits resulting from the daily
efforts to control diabetes often
remain invisible in the short term.
There is no immediate positive
feedback, other than the stated
reassurance that strict glycaemic
control now can help to reduce
health risks in the future. This lack of
direct feedback jeopardizes the
maintenance of intensive diabetes
self-management in the long run.
Diabetes is for life but, not
surprisingly, many people with
diabetes find it hard to stick to the
treatment regimen all the time.
Trust thyself and know thy
diabetes
Still, some people with diabetes find
it harder than others to live with and
actively manage their condition.
These individual differences may be
due to personal as well as situational
barriers.
Knowing what diabetes is and how
to control it is of course essential to
effective self-management. It is,
however, no guarantee for success.
Heal t h Del i ver y
Nicole van der Ven, Katie Weinger and Frank Snoek
'It doesn't matter how hard I try, I'll still get the
complications' is a typical example of how some
people with diabetes feel when faced with the
hardships of self-management and with the
difficulty in controlling the condition despite all
good intentions. It is, however, possible to escape
from these negative feelings and gain renewed
confidence in one's ability to manage diabetes,
and in the positive impact of treatment on one's
well-being, thanks to CBT Cognitive Behaviour
Therapy.
September 2002 Volume 47 Issue 3
Self-management is hard
work
People with diabetes have to face the
challenge of carrying out a range of
self-care tasks on a day-to-day basis
without compromising a 'normal'
flexible lifestyle and their sense of
well-being. Accomplishing this,
however, seems hard for mostif
not allpeople with diabetes.
Apart from the treatment regimen
being demanding and often
interfering with daily life, many
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An increase in someone's knowledge
of diabetes is not automatically
translated into improved self-care
and better glycaemic control.
Many people with
diabetes find it
hard to stick to
the treatment
regimen all the
time.
The behavioural changes needed to
ensure optimal diabetes self-
management seem to a large extent
to be determined by the feelings
people have about their diabetes, its
treatment, and themselves. People
with diabetes need to believe that
the outcome of treatment, ie
acceptable glycaemic control leading
to a lower risk of developing
diabetes complications, is
worthwhile. They have to be
confident that they are capable of
adopting adequate behaviours to
fight their condition, and that their
efforts will benefit them.
Psychological disorders (such as
eating disorders, anxiety and
depression) are signficant problems,
but fortunately represent a major
obstacle only for a few people with
diabetes.
Beliefs and negative
emotions
Given that diabetes is highly
demanding both for people with the
condition and their families, it's not
surprising to see that a substantial
number of people repeatedly fail to
keep it under control. Particularly for
those who perceive good diabetes
control as an important goal, this
'failure' can give rise to feelings of
guilt, frustration, anger and
hopelessness. Often people will think
'What have I done wrong again?'.
Other beliefs giving rise to negative
feelings are, for example, 'It doesn't
matter what I do, there is absolutely
no point in trying', or 'I always get it
wrong, I'm such a failure'.
People with
diabetes have to
be confident that
their efforts will
benefit them.
These negative feelings, resulting
from multiple experiences of
'failure', foster a pessimistic attitude
towards diabetes and oneself,
leading to a tendency of 'letting it
all go', instead of renewing the
efforts. This reinforces a negative
cycle of events that can ultimately
lead to a state of emotional
exhaustion, defined as 'diabetes
burnout' by Polonsky (2000).
Unfortunately, this emotional state
will further reinforce poor self-
management and control, resulting
in even more negative feelings (see
Figure 1).
What can be done to escape this
negative cycle? One way of dealing
with it is to try to avoid having
negative feelings, by 'pushing the
condition away', trying not to think
too much about it. Clearly this
solution is of no help, as people
with diabetes will always be
confronted with their condition,
especially in the long run. Denial is
not an acceptable option.
A more effective way of dealing
with undesirable emotions and
behaviour can be found in Cognitive
Behavioural Therapy CBT.
How does CBT work?
Central to the cognitive model is the
observation that behaviour and
emotions are in constant interaction
with cognition (understanding; see
Figure 2). A person's cognition or
beliefs may be inaccurate, leading to
excessive emotional reactions and
ineffective coping behaviour. This
notion can be found in the works of
both Aaron Beck, the founder of CBT,
and his contemporary Albert Ellis, the
originator of Rational Emotive Therapy
(RET). Originating in the sixties, both
Heal t h Del i ver y
September 2002 Volume 47 Issue 3
Figure 1: The negative cycle leading to poor diabetes management
When is CBT useful?
Since its development, CBT and
RET have been successfully applied
to a wide array of psychological
problems. People with chronic
diseases are often confronted with
additional psychological problems,
such as mood disturbances and
fatigue. They need to adopt an
active self-management approach,
establish collaborative relationships
with their healthcare providers, and
expand their repertoire of skills to
deal with their condition and its
social and emotional consequences.
The characteristics of CBT make it
particularly suited to address
precisely these challenges (White,
2001).
CBT is structured so that there is a
clear agenda for every meeting,
which is usually limited in time, and
it encourages the active
participation of patients through
homework assignments. The
principles of CBT are easy to
integrate into usual care, not only
by trained mental health specialists
but also by other healthcare
professionals.
CBT and diabetes
So far, research on the effectiveness
of CBT in diabetes care has been
scarce. Two research projects are
currently testing the usefulness of
short and structured group
meetings based on CBT principles
for people with Type 1 diabetes
who present long-term poor
glycaemic control, using a
scientifically rigorous, randomized
controlled design (Weinger et al,
2002; Snoek et al, 2001). In both
studies, the effects of group CBT
are compared to a control group
attending meetings which are
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psychotherapies were developed to
treat psychiatric disorders, such as
depression and anxiety.
Denial is not an
acceptable option
for people with
diabetes.
However, their underlying philosophy
goes back even further. The ancient
Greek philosopher Epictetus (55-135
BC) wrote: 'Men are disturbed not
by things, but by the views they take
of them'. Applied to diabetes, this
means that coping with the daily
demands of the condition is difficult,
but this does not necessarily imply
that one needs to suffer from these
demands. Much depends on the
individual's perception and attitude.
CBT posits that emotional and
behavioural problems are rooted in a
system of 'core beliefs' that are the
product of our upbringing, education
and experiences in life. When these
experiences are mainly negative,
negative thoughts are 'automatically'
generated. These thoughts contain
some form of cognitive distortion
about ourselves and/or the world
surrounding us, resulting in, for
example, 'catastrophizing' (when
negative consequences are magnified,
and even a slight disappointment is
perceived as an absolute disaster) or
overgeneralizing' (when a negative
event is perceived as a never-ending
pattern of defeat).
The aim of both CBT and RET is to
help patients modify their emotions
and improve coping behaviour by
assisting them to identify their
dysfunctional beliefs, test these
beliefs against reality, and replace
them with more appropriate or
realistic beliefs.
Figure 3 shows an example of how
this is done in RET using an 'ABC
scheme'. People are asked to
describe an Activating event, in which
they experience negative emotions
or undesirable behaviour
(Consequences). Then they describe
the Beliefs leading to these
consequences, and try to Dispute
them and replace them with more
helping beliefs, leading to the desired
Effect, namely less negative emotions
and more effective coping behaviour.
Heal t h Del i ver y
September 2002 Volume 47 Issue 3
Figure 2: The cognitive model
similar in structure and intensity to
the CBT ones, but which are not
based on CBT. The effects on
glycaemic control, self-care
behaviour, emotional well-being and
patient appreciation of the various
groups are being evaluated and
compared.
The group meetings take place 6 to
8 times a week, and are delivered to
small groups of 6 to 8 people by a
trained psychologist alone (Weinger
13
Heal t h Del i ver y
et al, 2002), or by a psychologist and
a diabetes educator (Snoek et al,
2001). The meetings have a clear
structure: the homework previously
assigned is reviewed, a new topic
(such as dealing with stress, or fear
of complications) is introduced and
discussed, exercises related to the
topic are practised, and new
homework assignments are given.
Participants highly
appreciate the CBT
programme and
the group
interactions.
These assignments consist of filling
out ABC schemes (Snoek et al,
2001), or of other cognitive and
behavioural exercises.
The experiences with these groups
are so far encouraging. Modest
improvements in glycaemic control
have been registered. Particularly
important is that participants highly
appreciate the programme and
the group interactions. The
collaboration of a psychologist and a
diabetes educator is also proving to
be successful.
Delivering CBT obviously requires
skills and knowledge, but even non-
psychologists can be trained to apply
CBT to individual and group
consultations. This opens up new
opportunities for helping people with
diabetes to cope more effectively
with the daily demands of diabetes
self-care. If we still cannot cure
diabetes, the least we can do is help
those affected to live with this
burden as well as possible.
September 2002 Volume 47 Issue 3
Figure 3: The ABC scheme
Nicole van de Ven, Katie
Weinger and Frank Snoek
Ms Nicole van der Ven is a psychologist
and researcher with the Diabetes
Research Group of the Department of
Medical Psychology at the Vrije
Universiteit Medical Centre, Amsterdam,
the Netherlands.
Dr Katie Weinger is an investigator at
the Joslin Diabetes Center and an
Instructor in Psychiatry at Harvard
Medical School, Boston, Massachusetts,
USA.
Dr Frank Snoek is Associate Professor in
Medical Psychology and Consulting
Clinical Psychologist for the diabetes
healthcare team at the Vrije Universiteit
Medical Centre, Amsterdam, the
Netherlands.
Further reading
Polonsky WH. Diabetes burnout: What
to do when you can't take it anymore.
Alexandria, VA: American Diabetes
Association, 2000.
Rubin R, Walen S, Ellis A. Living with
diabetes. J Rational-Emotive Cognitive
Behavior Therapy 1990; 8: 21-39.
Snoek FJ, van der Ven NCW, Lubach
CHC, Chatrou M, Ader HJ, Heine RJ,
Jacobson AM. Effects of cognitive
behavioral group training (CBGT) in
adult patients with poorly controlled
insulin-dependent (Type 1) diabetes: a
pilot study. Patient Education
Counseling 2001; 45: 143-148.
Weinger K, Schwartz E, Davis A,
Rodrguez M, Simonson DC, Jacobson
AM. Cognitive Behavioral Treatment in
Type 1 Diabetes: a randomized control
trial. Diabetes 2002; 1 (suppl 2): A439.
White CA. Cognitive behavioral
principles in managing chronic disease.
Western J Med 2001; 175: 338-342.

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