An intervention based on the diabetes-specific coping skills training model I have just described has also been incorporated into the comprehensive 5 day (37 hour) outpatient education programme offered by the Johns Hopkins Diabetes Center at the Johns Hopkins Hospital in Baltimore. Over 3000 participants have completed this programme since its inception in 1984. The programme is taught by a multidisciplinary team of health care providers, including mental health professionals who offer diabetes-specific coping skills training.
As noted earlier, diabetes coping skills training is designed to help people overcome barriers to successful application of new knowledge and skills. The approach used in this programme, a cognitive-behavioural psycho-educational group intervention, focusing on beliefs and attitudes that underlie patterns of self-care, has been described in detail elsewhere37'40'41. The training is active and individualized; participants begin the process by identifying their own regimen barriers or 'sticking points'. The more specifically the problem is defined, the easier it is to solve. Even with common issues such as diet adherence, one person's sticking point might be an irrepressible sweet tooth, while another's might be an overpowering urge to 'graze', or continuously snack, after dinner.
Once a personal sticking point has been identified, a problem-solving orientation is invoked. Potential solutions are inventoried, with special attention to those the person has used successfully in the past. This process helps patients learn that certain thoughts or attitudes trigger non-constructive behaviour. The group then works together to identify thoughts or attitudes that have triggered their own pattern of response. Patients learn that the ability to achieve a positive attitude is a skill that they can develop if they practice patiently and persistently. Next, patients are taught how to implement this procedure, how to note successful and less-than-successful outcomes, and how to continuously adapt their approach based on the results.
A final element of the coping skills training intervention is relapse prevention42. Since perfect self-care is an ideal no-one can realize, people
Table 9.1. Coping skills training example
First Session (90 minutes)
• Identify specific regimen problem: 'grazing' (continuous nibbling) after dinner
• Identify 'trigger' thoughts for failure: 'I've already blown my diet (after the first nibble) so it makes no difference what I do now
• Identify 'trigger' thoughts for success (personal or generated by the group): 'I've done pretty well with my diet all day. If I stop after the first nibble I can still feel good about myself and I won't be up all night going to the toilet'
• Practice 'trigger' thoughts for success: based on a common problem, group participants visualize the problem situation and rehearse solutions
• Implement coping skills: at home, implement approaches learned in first session
• Identify successful and less-than-successful outcomes: 'I grazed less than usual, but I did not stop altogether'
Second Session (60 minutes)
• Refine coping approaches: add coping tactics, e.g. preparing acceptable snack and then not reentering kitchen for the rest of the evening, identifying non-food treats (music, social contacts) and incorporate them into evening routine
• Develop relapse prevention techniques: 'contracts for change' are completed by all participants. Contracts include cognitive elements ('Remember, everybody slips; your goal is to keep a lapse from becoming a collapse') and behaviour ('When you lapse, use your support network—family, friends, medical staff, and especially other group members'). Group participants are provided with a list of members' phone numbers and encouraged to call when in need of support must have strategies for coping with inevitable lapses and failures. Patients are helped to develop specific techniques for coping with slips when they occur, in order to prevent lapses from becoming full-blown collapses. A case example of the coping skills training process is described in Table 9.1. The first coping skills training session is held on the morning of the second day of the group education programme, and the second coping skills training session is held on the afternoon of the fourth day of the programme.
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Diabetes is a disease that affects the way your body uses food. Normally, your body converts sugars, starches and other foods into a form of sugar called glucose. Your body uses glucose for fuel. The cells receive the glucose through the bloodstream. They then use insulin a hormone made by the pancreas to absorb the glucose, convert it into energy, and either use it or store it for later use. Learn more...