I have given up trying to improve my diabetes

I have not been able to keep the change going

Scoring key: The first three items would suggest the individual was precontemplative. Items four and five refer to contemplation, six and seven determination and eight suggests early action. Nine and ten would indicate attempts at maintenance with eleven and twelve indicating relapse.

Scoring key: The first three items would suggest the individual was precontemplative. Items four and five refer to contemplation, six and seven determination and eight suggests early action. Nine and ten would indicate attempts at maintenance with eleven and twelve indicating relapse.

Figure 5.6. A method to aid assessment of stage of change for diabetes self-management

Figure 5.7. An assessment method using stage-specific pictures and statements for a specific behaviour

How do you feel about Smoking ?

Figure 5.8. An assessment method employing behaviour change cycle with pictures

attempts to adapt these for diabetes services.58 Diabetes-specific statements have been developed from the 'Readiness to Change' Questionnaire (Figure 5.6) but the transfer of this method into diabetes care is yet to be tested. This was viewed to be necessary before assessing the stage of change for a specific behaviour, such as physical activity or smoking. If individuals are precon-templative for their overall diabetes self-management, this would need to be addressed before moving on to specific behaviours. Similar tools can be employed to assess stage of change (Figure 5.7) for a specific behaviour, and visual images alongside stage-specific statements enable concurrent validity to be tested94. Alternatively, the behaviour change cycle can be described using illustrations, and the patients asked to indicate which representation applies to them (Figure 5.8). Ultimately, the practitioner can use clinical judgement. The measures illustrated are in their infancy, but an initial pilot suggests some validity to this approach95. Using the tool shown (Figure 5.7) in a small sample (n = 11), the level of reported physical activity matched closely the individual's stage of change. Furthermore, progression around the cycle was in accordance with increases in the self-reported frequency of physical activity. Much more work is needed to further test the validity and reliability of this tool.

PRECONTEMPLATION Overcoming the emotions

In diabetes, adjustment to the condition itself is a problem96'97. The diagnosis implies future losses and there is a need to acknowledge the life-long adjustments needed to accommodate and manage the process from the beginning84. In a sample of 1159 people with diabetes, 60.4% experienced strong emotional reactions at the time of diagnosis and 23% would have liked more emotional support75. Poor adjustment, as with other conditions, can be related to the way the individual was informed of the diagnoisis98, poor social support99, rigid belief structures100 or a poor range of coping strategies39. Bereavement counselling models can be used to facilitate adjustment101. People are encouraged to talk through the loss and the negative impact in a way that leads to emotional catharsis41 and emotional habituation. This requires the use of open questions that direct attention to the emotional feelings associated with loss; open questions that encourage discussion and reflections that demonstrate understanding.

A second source of negative emotion is the fear of complications77 perhaps made worse by the vicarious experience of older relatives or hospital visits. Clinicians can help by providing appropriate information and allowing individuals to question their catastrophic thinking about vulnerability, seriousness or the extent to which complications can be avoided (e.g. medical advances in screening and treatment). Maximal motivation will occur with moderate amounts of fear. If this is not achieved by informational care alone, then allowing people to talk about complications and fears in the right environment (as shown in Table 5.2) can lead to some emotional calming. Graded exposure helps individuals with diabetes-related phobias or obsessions, and needs to be conducted or supervised by an appropriately qualified practitioner.

Severe hypoglycaemia fits the diagnostic criteria for a traumatic event as it involves a threat to life in association with feelings of helplessness102. Following a traumatic event, strong and often distorted memories are stored which can be very emotionally distressing when recalled103. In order to manage this distress, individuals may avoid recalling the event and also avoid potentially similar situations. This may explain why some individuals maintain elevated blood sugar levels, although phobic fear of hypoglycaemia can develop without a traumatic event79. However, in the case of trauma, problems can be identified by asking the person to recall the distressing events to see whether he/she can still be upset by recalling them. Simple therapeutic interventions include encouraging people to repeatedly recall these experiences and elicit their beliefs about the experience until they became desensitized by repetition104. However, this must be done with caution. An individual should never be forced into this dialogue, as unresolved distress can cause further trauma. More severe cases should be referred for psychological help.

If people sense that they are being pushed into something that they do not own, they react with resistance59. In the diabetes clinic, this is likely to be covert and demonstrated by continued poor self-management. Resistance is a reflection of the person's experience and not a personality trait50. It may have accumulated from previous hospital or GP visits, especially if in the past the approach has been authoritarian, overly critical and negative. Resistance is an obstacle to increased awareness of the problem and the benefits of behavioural change. To overcome this barrier, it helps to encourage deliberate expression of resistance by asking open questions. The most valuable technique is rolling with resistance50, in which the health care professional does not necessarily agree with the person's comments but nevertheless reflects them back to demonstrate listening and empathy. This approach is likely to assist the patients to move on in their thinking and explore their own needs, rather than justifying their behaviour to the staff member. A sophisticated version of rolling with resistance is the double-

Table 5.6. Rolling with resistance

Patient comment

Staff 'role'

Examples of rolling with resistance No I don't think that the amount I drink does me any harm Smoking, that's the catch-all of the medical profession. I think my main problem is stress

Well, I suppose I could if you think it would help

I just can't take my BMs. I'm too busy at work and I forget, and once I've finished work, by the time I've picked up the kids and got home, I don't have time Examples of double-sided rolling with resistance I don't think I can do anything

Don't tell me I should lose weight, it's how I've always been

So, you really can't believe that you could be doing any harm to yourself All everybody seems to talk to you about is smoking when really you believe all your problems are related to stress Perhaps you know what we want, but you're not so sure yourself Its hard to find time to do your BMs. At work you are too busy and at home you can't find the time

So you can't do much but you have been worried about your eyes So you get a bit cross when losing weight is suggested but you don't want to go on insulin sided reflection, where the beliefs of the patient are fed back, highlighting the patient's ambivalence by including the positive aspects of change (Table 5.6).

Addressing misconceptions

Leventhal and colleagues105 established that people's beliefs about physical illness are first accumulated via past life experience, media influences and the information gained from family or friends106. They are then ordered into personally unique illness representations which are used to make sense of subsequent information. This means that people do not passively receive the information they are given during education programmes. It is filtered through an illness representation where errors occur as information is distorted to fit with existing 'knowledge'. Misconceptions are therefore to be expected.

Each individual's illness representations has five constructs. In diabetes these would be: (a) identity—the symptoms associated with the patients' diabetes and the type of diabetes they have; (b) timeline—the individuals' perception of how long their diabetes will last; (c) consequences—beliefs regarding the impact the diabetes will have upon their functioning and quality of life; (d) control/cure—whether the diabetes can be cured or controlled; and finally (e) cause—whether the diabetes is caused by stress, a virus, genetics or some other factor. Inaccurate beliefs can be one of the reasons why individuals are not considering change. For example, they may believe they have 'mild diabetes' and that they do not need to try too hard to reduce their blood sugars; or that diabetes medication is addictive, or insulin has side effects, and so miss the occasional injection or tablet. They may be unable to make the connection between blood glucose levels and serious complications, perhaps believing that no symptoms means no damage.

These misconceptions can be hard to detect, as they may have been developed over time. The individuals will assume their belief is correct and does not need to be checked out. The practitioner's counselling skills can help to elicit misconceptions by using open questions, such as, 'What do you think is the most important thing to do for your diabetes control?'. It is crucial to check the individuals' beliefs before giving information, as they will tend to select the information that fits best with their own belief system. Informational care must start with the patients' models and also check subsequent understanding. If a misconception is identified, the practitioner can provide information but must also discuss the evidence the individual is using to support that belief. This is most effective when carried out within the core style using the counselling skills presented previously, as too many questions may feel like interrogation and precipitate resistance. Table 5.7 includes some strategies that can help individuals to question their beliefs.

Table 5.7. Strategies to help question misconceptions

1. Ask the person to identify and question the evidence of his/her belief

2. Ask him/her to consider his/her response if a good friend made this suggestion

3. Test out the reality of his/her belief. This process can be enhanced by asking the individual to attend to or collect information on the subject, such as all articles in the newspapers that report the benefits and risks of the target behaviour, e.g. cigar smoking. This can also prevent 'selective attention', i.e. only noting information that fits with one's own beliefs (e.g. cigar smoking prevents Alzheimer's disease)

4. Rather than seeing something as either black or white, ask the person to consider seeing it in shades of grey

Establishing salience

There are many distractions in everyday life. They cannot all be processed, so only a fraction are given our limited attention10 . If thoughts about diabetes self-management are to be chosen, there has to be sufficient relevance or salience for the individual. Human beings are agreed to be rational processors of information calculating how they can personally achieve the most advantageous outcome106. Their needs include self-esteem, control, comfortable emotions, relationships, and a sense of achievement. Health issues may have low salience in comparison, especially when the advantageous outcome is the potential avoidance of complications in the distant future!

Thus, movement out of precontemplation involves 'hooking' someone into thinking about self-management, and so information needs to emphasize gains that are personally relevant. This means identifying the person's major needs and anticipating the way these would be threatened by poor self-management or enhanced by improved control. Table 5.8 provides some illustrations as to how health care professionals can tailor general information about diabetes to the person in a way that makes it relevant. For example, a person who values his/her fitness and enjoys competitive sports

Table 5.8. Examples of personally relevant information

Patient: 'Losing weight, it's so hard, I can't see how it will help anyway, it's not what I eat. The thing that bothers me the most at the minute is those pains in my knees' Helper: 'So it would be hard for you to lose weight (reflection). Did you know that losing weight would lesson the pressure on your knees and that would help with the pain? You might even be able to get around more easily' Patient: 'Stopping smoking and my diabetes, that's all everyone talks about. I don't want to stop smoking. It's this breathlessness that bothers me' Helper: 'So you don't want to think about stopping smoking (reflection), but it actually might help with your breathlessness and means you could walk further without stopping' Patient: 'I really hate blood monitoring—it hurts, it's messy and embarrassing, especially at work. I want someone to help me with these hypos I keep getting, they are really starting to get me down'

Helper: 'So, blood monitoring is really not for you (reflection) but it could help with your hypos. Getting a handle on your blood sugars really helps to determine how much insulin you need'

could be motivated by maintaining his/her performance for Sunday football by sustaining good control, whereas an individual who enjoys needlework could be motivated by the gains of preserving his/her eyesight.

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