Learning Objectives:
1- List 5 stages of emotional adjustment to
diabetes.
2- Describe the 3 components (A-B-C’s) of
Cognitive Behavior Therapy.
3- Describe the “four pronged” approach to
diabetes care.
I. 5 Stages of Emotional Adjustment
Originally, these stages were developed to describe stages of grief, but it can be expanded to describe stages of diabetes acceptance.
Disclaimer: Not everybody goes through these stages, nor do they necessarily go through the stages in this order.
5 Stages of Emotional Adjustment
A. DENIAL (“Dia-Denial”)
Denial is when somebody doesn’t want to
acknowledge their diagnosis. A person may
feel overwhelmed with feelings of anxiety
about the future, that they cope by ignoring
the facts.
5 Stages of Emotional Adjustment
Is this your client? “Debbie Denial”
She generally ignores her diabetes.
How can “ostrich policy” help?
Sticking your head in the sand and hoping it goes
away.
5 Stages of Emotional Adjustment
B. ANGER
Anger is the direct result of a person’s thoughts,
not of the event.
“Anger is only one letter short of danger.”
Eleanor Roosevelt
5 Stages of Emotional Adjustment
Is this your client? “Angie Anger”
Asks “Why me?” and thinks “This is so unfair!”
It would be better to direct her actions toward
managing her diabetes and not being angry at
it.
5 Stages of Emotional Adjustment
C. BARGAINING
Bargaining is when a person makes a desperate
plea (usually to a higher power or to a
healthcare professional) how they will change
their life, in exchange for taking away the
diabetes.
5 Stages of Emotional Adjustment
Is this your client? “Barry Bargainer”
Makes a deal to be “good” from now on.
Help your client to focus on living as a person
who happens to have diabetes, rather than
seeing themselves as a victim of diabetes.
5 Stages of Emotional Adjustment
D. DEPRESSION/DIABETES DISTRESS
Clinical depression is defined by symptoms that
have lasted more than 2 weeks.
IF the depression is unrelated to diabetes, the
person should consider seeking professional
treatment with a licensed clinical psychologist
or clinical social worker.
5 Stages of Emotional Adjustment
Symptoms of clinical depression:
• Persistent sadness, such as feeling “empty”
• Feeling a loss of joy in your life
• Changes in appetite
• Sleep difficulties
• Feeling fatigue or loss of energy
• Feelings of worthlessness or excessive guilt
• Difficulty with attention and concentration
• Recurrent thoughts of death or suicidal thoughts
5 Stages of Emotional Adjustment
DIABETES DISTRESS
Diabetes distress arises from living with the
emotional burden of diabetes self-
management and blood sugar control.
There are 4 main areas of distress:
5 Stages of Emotional Adjustment
• Emotional burden
• Physician-related distress
• Regimen-related distress
• Interpersonal distress
Diabetes distress can be managed and reduced
using cognitive behavior therapy.
5 Stages of Emotional Adjustment
Is this your client? “Dee Dee Depression”
She cries at the mere mention of the word
“diabetes.” She feels hopeless that she will
ever be able to manage her diabetes.
Diabetes educators can teach depressed clients to
accept diabetes and how to cope with it. They
can be empowered to manage their diabetes!
5 Stages of Emotional Adjustment
“T L C Therapy: Talk, Listen, Counsel”
• Talk: the talk part is educating about diabetes
management
• Listen: the listen part is being quiet and let the
client’s feelings be heard
• Counsel: the counsel part is teaching the
coping strategies of cognitive behavior therapy
5 Stages of Emotional Adjustment
E. ACCEPTANCE
Acceptance is our goal. Helping people with
diabetes to accept their diagnosis of diabetes
and make lifestyle choices that keep them
healthy and happy.
5 Stages of Emotional Adjustment
My story of diabetes acceptance:
Living successfully with type 1 diabetes
for 42 years.
II. The A-B-C’s of Cognitive Behavior Therapy (CBT)
The basic idea of CBT is that the way a person
thinks about an event is directly related to
how a person feels about the event.
• If the thoughts are negative, the feelings will
be negative.
• If the thoughts are positive, then the feelings
will be positive.
The A-B-C’s of CBT
A. ANTECEDENTS
An antecedent is the event which is not within a
person’s control – such as having diabetes.
The A-B-C’s of CBT
B. BELIEFS
1- Irrational (unreasonable) thinking
2- Rational (reasonable) thinking
The A-B-C’s of CBT
• People with diabetes who experience denial,
anger, helplessness, and diabetes distress are
less likely to practice good self-care behaviors,
which could then negatively impact their A1C.
• When using CBT, the goal is to challenge
irrational, unreasonable thoughts so that the
patients can better manage their self-care and
improve their blood sugar management.
The A-B-C’s of CBT
Revisit your clients:
• “Debbie Denial” – an example of “Minimization”
• “Angie Anger” – an example of “Should”
statements
• “Barry Bargainer” – an example of “The
Fortune-Teller Error”
• “Dee Dee Depression – an example of “All-or-
nothing Thinking”
III Spiritual Approach
Spirituality can be defined as:
Experiencing the presence of a power or force
and experiencing a closeness to that presence.
Note: A belief in God is not a requirement to
adopt the message of empowerment
Spiritual Approach
• Current diabetes self-management guidelines,
such as those of the ADA, reflect a more
holistic style. Spirituality can be seen as part
of the journey toward becoming whole.
• Religiousness and spirituality have been
shown to improve glycemic control, as well as
lower diabetes-related morbidity and
mortality.
Spiritual Approach
A. Serenity Prayer
God, grant me the serenity
To accept the things I cannot change,
The courage to change the things I can,
And the wisdom to know the difference.
Spiritual Approach
Learning to recognize what is not within their
power to change (their diagnosis)
and to recognize what is within their power to
change (their thoughts and actions)
– and the understanding of both choices –
will result in the wisdom of your clients to accept
their diabetes.
Spiritual Approach
The Other Serenity Prayer
God, grant me the serenity to stop beating myself up for not doing things perfectly,
The courage to forgive myself because I’m working on doing better,
And the wisdom to know that You already love me just the way I am.
Eleanor Brown
Spiritual Approach
B. “Four-pronged” approach to diabetes care
1- Medication
2- Diet
3- Exercise
4- Spirituality
Spiritual Approach
• Elliott Joslin, MD (1869 – 1962) was the first
doctor in the US to specialize in diabetes and
was the founder of today’s Joslin Diabetes
Center in Boston.
• He recognized that managing tight control of
blood sugar could be achieved through diet,
exercise, and insulin and could extend one’s
life and prevent complications.
Spiritual Approach
• Joslin’s approach to diabetes management was
expressed by the “troika,” the Russian word
meaning threesome.
• He created a three-horse chariot to reflect this
philosophy of living with diabetes – the three
horse motif symbolized insulin, diet, and
exercise, which are needed to achieve
“victory” over diabetes.
Spiritual Approach
• In my men’s book MY SWEET LIFE:
Successful Men with Diabetes, one of my
contributing authors took the idea of the
triangular facets of diabetes self-care to a new
level – a square!
• In his paradigm, diabetes management has
four points: medication (insulin), diet,
exercise, and spirituality.
Spiritual Approach
Diabetes care is coming to address the 4 areas in one’s life:
1- Insulin and diabetes medicines help the body.
2- Diabetes educators teach people about blood sugar monitoring, meal plans, and exercise.
3- Ideally, the health-care team also teaches people to manage stress and maintain emotional health.
4- Recently, organized medicine has begun to address the spiritual aspect of self-care as well.
Spiritual Approach
With a positive attitude toward diabetes, your
clients can choose to feel at peace with their
diagnosis and feel empowered to manage their
diabetes self-care.
Spiritual Approach
C. Selected quotes about acceptance and attitude:
• “The primary cause of unhappiness is never
the situation but your thoughts about it.”
Eckhart Tolle
• “If you don’t like something, change it. If you
can’t change it, change your attitude.”
Maya Angelou
Spiritual Approach C. Selected quotes about acceptance and attitude:
• “Change your thoughts and you change your
world.” – Norman Vincent Peale
• “Choosing to be positive and having a grateful
attitude is going to determine how you’re
going to live your life.” – Joel Osteen
Spiritual Approach
C. Selected quotes about acceptance and attitude:
• “I cannot always control what goes on outside.
But I can always control what goes on inside.”
– Wayne Dyer
• “Remember, happiness doesn’t depend upon
who you are or what you have, it depends
solely upon what you think.” – Dale Carnegie
Spiritual Approach C. Selected quotes about acceptance and attitude:
• “Everything is an opportunity. The glass is either half empty or half full. You can choose….it’s the same glass.”
Diane von Furstenburg”
• “What has happened to me isn’t nearly as important as how I decide to respond to it. I choose to grow through adversity.”
Carl Jung
Spiritual Approach
C. Selected quotes about acceptance and attitude:
• “A bad attitude is like a flat tire – you don’t
get anywhere until you change it.” –
Anonymous
• “There is nothing good or bad, but thinking
makes it so.” – William Shakespeare”
Spiritual Approach
Conclusions – Lessons for your clients:
Encourage your clients to choose a positive
attitude. There’s a saying: “You cannot live a
positive life with a negative mind.”
“A negative thinker sees difficulty in every
opportunity. A positive thinker sees
opportunity in every difficulty.”
Spiritual Approach Conclusions – Lessons for your clients:
Diabetes can be managed, not cured. Help your clients take charge of their diabetes. The difference between try and triumph is a little UMPH.
Worrying about the future with diabetes doesn’t take away tomorrow’s troubles. It takes away today’s peace. Teach your clients to be a warrior, not a worrier.
Announcement
I will be retiring as a clinical psychologist and
Certified Diabetes Educator treating the
emotional issues of clients with diabetes……