Therapy helps beat diabetes
A recent diabetes pilot shows how value and belief therapy can help beat the now rampant disease.
Clinical psychologist Steve Malcolm talks to Sally Webster about his recent involvement in a diabetic trial and how value and belief work is vital in beating the now rampant disease.
Once Steve Malcolm has waved a client goodbye after a therapy session, he usually goes back to his desk and emails them their homework – basically, the resolutions they made during their hour together.
No more welcome has this practice been than with a diabetic client he started seeing over the last year. They first met as part of a pilot programme that The Ministry of Health will unveil to media, hopefully in September. One of its main points of difference is that for the first time, psychotherapy has been slotted into the medical, fitness and dietary interventions in an attempt to reign in a costly, rampantly spreading disease.
“This gentleman had worked out in therapy that as part of his exercise plan he needed to be social otherwise he wouldn’t stick to it. Just as importantly, he needed to be accountable to someone for carrying out the plan, and emailing resolutions satisfies that and offers a little support beyond the actual session” says Malcolm, also an occupational therapist and Co-Director of Auckland based Lifespan.
The client is finally losing weight and managing his diet and hence, blood glucose. One could say the therapeutic intervention in what most people mistake for a purely physical condition is saving his life.
At first glance though, it appears ridiculously simple; why do you need a shrink like Malcolm to help you work out that you like doing stuff socially? Because it is actually part of a technique to drill down to clients’ core beliefs and peg health changes onto them. This way they stick.
The Choose Change pilot tag line suggests that the only sustainable change is one that resonates with beliefs floating round in the Freudian unconscious – beliefs that often surface under a therapeutic question line. Malcolm explains how he’s dealt with about 200 clients in the pilot.
“So I first ask: ‘Why are you in the programme?’ They answer, and I say ‘Ok, but why?’ and we repeat the process again and again. I go through this until we’ve drilled down to a value. Reasons align with values. And change is based on values not fear, as is commonly thought.”
The other aspect that needs to be explored is a person’s barriers to change. Malcolm questions people on their barriers not to adhere to change.
“They might call themselves ‘lazy’ which actually has negative connotations and this leads to other problems. Their finances might also be an issue. But what is deeper here is the clients’ barrier in their belief to change. This is not the ability to change but the belief in that ability.”
Culture can play a part here too. One commonality participants shared was that food is an important part of their culture. Traditional gender roles also contributed; for women in some families there was a lot of taking care of everyone else, leaving little time for themselves.
“Belief is influenced by many things. If we get to run the program again we would like to look more deeply into how ethics and group beliefs affect change.”
Self-belief and an ability to think positively are severely quashed if people are suffering from depression and anxiety – traits quite commonly identified in the pilot.
Endocrineweb.com, a site that contains a trove of professional information on the source of diabetes, the endocrine system, states that not only are diabetics likely to suffer depression, but that depressives are likely to develop diabetes.
They suggest that even though ‘primary care physicians have a limited amount of time to spend with a patient during a visit…screening for depression in patients with diabetes is necessary.’ Malcolm agrees that more screening is vital to beat-back the growth of the disease.
“Diabetics are twice as likely to have depression and anxiety as non-diabetics. The depressed will feel hopeless and not see the worth in activities – they have no energy. Behaviours leading to thoughts leading to emotions: this is the cycle of depression. If you can change behaviours then the cycle can be broken.”
Malcolm’s contribution to Choose Change has seen him sit down with about three participant intakes for two sessions each over the last 18 months. These accounted for about three quarters of the 240 participants who volunteered for the programme via four Regional Sports Trusts (RSTs) – Counties Manukau Sport, Sport Auckland, Harbour Sport and Sport Waitakere – with Type 2 Diabetes and Pre-Diabetes.
Diabetes New Zealand estimate only 10% of diabetics have Type 1 Diabetes, the condition where the body attacks insulin-making beta cells in the pancreas, thus stripping away the ability to make insulin. It is a permanent condition and not able to be manipulated.
On the other hand Type 2 diabetes is the result of a low production of, or the body’s failure to recognise, insulin. The high levels of blood glucose can be managed in a pilot like Choose Change and in some cases prevented, by dramatically healthier diet and exercise choices. Its precursor is Pre-Diabetes, when symptoms of high blood glucose don’t rate as diabetes but offer a strong warning.
When broken down into District Health Boards rather than RST’s the figures loom large: in December 2014 Auckland DHB estimated it catered to 27,537 diabetics from a 2013 Census pool of 525,555 people; Counties Manukau had 40,523 diabetics out of the Census’s 469,293 total; and Waitemata had 30,784 diabetics out of 436,341 people. An average 7% of Aucklanders now have diabetes.
While MOH’s latest figures on what diabetes costs New Zealand are not being made available yet, older statistics suggest that Type 2 Diabetes will cost the best part of $2 billion in six years. The New Zealand /Australian publication known as Fight the Obesity Epidemic quoted in 2007 that diabetes would ‘consume an estimated 15% of the government’s health budget, up from 3% of the current health budget. The …actual prevalence of diabetes in 2006 is 19 percent higher than the Ministry of Health predicted it would be back in 2001.’
America faces the same problems, but exponentially. In 2010 the monthly American journal Health Affairs published a study called The Economic Burden of Diabetes. New research, said the authors, revealed a United States price tag of $218 billion in 2007. Timothy Dall and team stated that, ‘This estimate includes $153 billion in higher medical costs and $65 billion in reduced productivity.’
The World Health Organisation doesn’t pull any punches with their online statistics either: ‘A diabetes epidemic is underway. An estimated 30 million people world-wide had diabetes in 1985. By 1995, this number had shot up to 135 million. The latest WHO estimate [for the year 2000] is 177 million. This will increase to at least 300 million by 2025. The number of deaths attributed to diabetes…is considerably underestimated. [It] is likely to be around 4 million deaths per year related to the presence of the disorder. This is about 9% of the global total. Many of these diabetes related deaths are from cardiovascular complications.’
It makes sense then that New Zealand’s MOH wants something else in its arsenal besides goals and good intentions– there is no point getting people to do exercise and diet programmes like Green Prescription if the results are not lasting. According to a hint of results from Choose Change, psychological intervention answers that call, making sure participants don’t set themselves up to fail by trying to reach too high a target.
“One area that needs work in these interventions is ‘getting rid of the perfectionism trait.’ We have to ask: where is it ok to make mistakes? There is a danger in setting too big-a-goal and trying to be perfect. This is when people start slipping and give up – because the goals were unrealistic in the first place, not their aspirations” says Malcolm. “We do need to have a plan and consistency is an important part of this.”
“People also need to understand that when one part of a plan isn’t working, it does not mean the whole thing is not working. There is a bigger picture than that and we can slowly build up to it. This way it is sustainable. “
Results of the full Choose Change report and other relevant diabetes information will be available soon.
Photo credits: livinghistory.med.utoronto.ca ‘Insulin bottles from Connaught Laboratories, Toronto’