Transcript Why the Title: “Opening Pandora`s Box”

Opening Pandora’s Box:
A Dialogue Regarding
Psychosocial Issues in Diabetes
Presented By:
Michael Vallis, PhD Psychologist, Halifax
Lori Berard, RN CDE, Nurse, Winnipeg
diabetes.ca | 1-800-BANTING (226-8464)
Unrestricted education grant funding for this session
was provided by AstraZeneca.
The Canadian Diabetes Association is grateful to
AstraZeneca for their contribution to diabetes in
Canada.
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Session Goals
•
To increase awareness and confidence in addressing
complex psychosocial issues in diabetes selfmanagement support
•
Specific issues to address include
–
–
–
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Emotional burden of living with diabetes
• Diabetes Distress, Burnout, Depression
Establishing relationships that are empowering and
non-judgemental
Increasing patient motivation for self-care
Why the Title: “Opening Pandora’s Box”
•
Providers are trained to stay within limits of their scope
of practice
–
•
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However, scope of practice has changed
•
From: mental health issues were psychopathology-based so
the only issues were when and where to refer
•
To: the ground has shifted as we understand the whole
person experience of chronic disease
Scope of practice now requires us to focus on outcomes
we can achieve separate from outcomes achieved
through the behavioural choices of the patient
Outcomes Under
Our Control
Outcomes Controlled
by Patient Choices
Diagnosis/
Assessment
Description
Treatment/
Intervention
Outcomes
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Outcomes
are
dependent
on
how good
you are
Prediction
Choice
Interpersonal Connectedness –
How We Maintain Connection
Assured–Dominant
Dominance
Agreeableness/sociability
Dominance
Circumplex model1
People can be categorised along two
independent dimensions
Cold–
Hearted
Warmth
Interpersonal complementarity2
Dominance evokes submission
Friendliness evokes friendliness
Unassured–Submissive
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1.Markey & Markey. Assessment.2009;16:352–361
2.Markey et al. Personality and Social Psychology Bulletin,2003;29:1082–
1090
Warm–
Agreeable
Video
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Motivational Communication
•
Non-Judgmental Curiosity is defined as: A willingness to
understand a person’s behaviour through the lens of their own
experience (why do you do what you do) without a value judgment
(behaviour is neither right or wrong – it is).
•
If a person feels judged, they will become defensive. If a person
feels guilt/shame, they will become avoidant.
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Motivational Communication
Ask
Listen
Summarize
Invite
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“Understanding”
Why Understanding First?
•
Healthy behaviour is abnormal
behaviour
•
Pleasure principle
•
Path of least resistance
•
Preference for short
term gain regardless of long term
consequences
•
Environment pulls for unhealthy
behaviours
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Low Hanging Fruit
•
•
Medication adherence is one of the fundamental
health behaviours of relevance to self-management
and chronic disease outcomes
WHO estimates nonadherence to medication at 30% 70% of medications for chronic conditions
Adherence to Long-Term Therapies: Evidence for Action. World Health organization, 2003. ISBN 92 4
1545992
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Needs and Concerns Analysis
•
•
Assess the patient’s view of the needs for medication
Assess their concerns about the potential side-effects
Concerns
Needs
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High
Low
High
Ambivalent
Accepting
Low
Sceptical
Indifferent
Horne R, et al. Inflamm Bowel Dis 2009;15:837–44
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Decision Aid: SURE test
Yes equals 1 point
No equals 0 points
If the total score is less than 4,
the patient is experiencing decisional conflict
Yes No
[1] [0]
Sure of myself
Do you feel SURE about the best choice for you?
□ □
Understanding
Do you know the benefits and risks of each
option?
□ □
Are you clear about which benefits and risks
matter most to you?
□ □
Do you have enough support and advice to make
a choice?
□ □
information
Risk-benefit
ratio
Encouragement
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Légaré F, et al. Can Fam Physician 2010;56:e308–14
Human Nature
•
Patients want to be as normal as possible
–
•
Clinicians want their patients to be as healthy as
possible
–
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This means making the psychological footprint of diabetes as
small as possible
This means making the psychological footprint of diabetes
large
Negative Impact of Diabetes on
Aspects of Life
% of people with diabetes rating impact on at least one aspect of life
as slightly to very negative
Type 1
(A)
Type 2
(B)
Aspects of life rated
• Physical health
• Emotional well-being
• Financial situation
• Leisure activities
• Work or studies
• Relationship with friends,
family, peers
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Niccoluci et al. Diabetic Medicine. 2013;30:767-777
From Burden to Burnout
to Distress to Depression
Burden
Burnout
Diabetes Distress
Depression
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diabetes.ca | 1-800-BANTING (226-8464)
Vallis, M. 2015©
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Disease-Specific Distress
•
Diabetes Distress Scale (Polonosky et al., 2005)
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Emotional Burden
Regimen Distress
Physician Related Distress
Interpersonal Distress
Provider Related
Distress
Fisher, et al. Clinical Depression Versus Distress Among Patients
With Type 2 Diabetes: Not Just a Matter of Semantics. Diabetes
Care, 2007;30:542-48
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Video
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Emotions
•
Primary Emotions
Natural, appropriate emotional responses to live
experiences
– Expressing and “sitting with” lead to transformation
(grief)
–
•
Secondary Emotions
–
•
Interpersonal Emotions
–
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Often come from our thoughts when we review
experiences
Emotional displays that serve a purpose in terms of
eliciting reactions from others
The Role of the Diabetes Care Provider
•
It’s not your job to change the Patient:Provider role and
self-efficacy
•
•
•
•
•
Replace the function
–
•
If you can understand behaviour you can negotiate choices
Keep the conversation going: The 4 S’s
•
•
•
•
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Identify
Educate
Recommend
Support
Self-Image
Self-Efficacy
Social Support
Stress Management (discharge, calming, expression,
connection)
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Why Don’t Recommendations Work?
•
•
•
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Whose idea is it to change, usually?
» Provider
Who does the work of change?
» The individual
Typically, how excited by the work of change is the
individual
» Low
Collaborate and Empower
Collaboration leads to change in three ways:
1)
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Bond (working together in a respectful way);
2) Task
(agreeing on who does what to get to the goal);
3) Goal
(agreeing on the value of final outcome);
Determine Readiness
Is the behaviour (or lack of it) a problem for you?
• Does the behaviour (or lack of it) cause you any
distress?
• Are you interested in changing your behaviour?
• Are you ready to do something to change your
behaviour now?
•
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Getting to the Behaviour
Readiness Assessment
Not Ready
Expectation of
change off the
table
Understand the
behaviour
Ready
Go Right
to Behaviour
Modification
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Expanding on
readiness
Personal/meaningful
reasons to change
Willingness to work
hard - connect to
principles
Personal
meaning
Seriousness,
personal
responsibility,
controllability,
optimism
Ambivalent
Delay of gratification
Decisional Balance
Working With the Behaviour:
Behaviour Modification
•
Goal Setting/Action Plans
–
•
Shaping
–
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Personalized healthier built environment
Reinforcement Management
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NEXT STEP goals
Stimulus control
–
•
FIRST STEP Goals
Incentives that transfer external to internal drive