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 11 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 12 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.