A Whole-Person Approach to Diabetes Health Education Part 3 of 4

In my last post, I began an in-depth examination of the psychological factors influencing blood glucose control, starting with the effects of emotional depression and effectiveness of one's coping skills. In this post I focus on the effect of mental stress and personality characteristics.

Mental Stress and Diabetes Management

Health Effects of Stress
Prolonged mental (emotional, psychological) stress can cause persistent high blood glucose levels. Mental stress can be caused by many different things, including problems in one's marriage, job, health, or finances. When people are anxious, angry, guilty or ashamed about such problems, their mental stress triggers the "fight-or-flight response" in their bodies. This automatic response prepares their bodies to take action to deal with a perceived danger by fleeing from it or attacking it, even if those problems pose no real physical threat.

In preparation for the threat, various hormones (including adrenalin, noradrenalin and cortisol) surge through the body. This biological process raises blood glucose levels in order to increase one's energy level to help handle the threat. Since diabetic people have insufficient or ineffective insulin, the glucose piles up in the blood and can result in persistent hyperglycemia. This rise in blood sugar under mental stress almost always happens to people with Type 2 diabetes, although it may be mixed in Type 1 diabetics (i.e., blood glucose levels rise for some and drop for others). Physical stress (such as illness or injury), on the other hand, causes higher blood glucose levels in people with either type of diabetes.

Another way mental stress can raise blood glucose levels is by interfering with one's self-care. For example, any diabetic person (Type 1 or 2) who is under mental stress may drink more alcohol, use illicit drugs, exercise less, forget (or not have time) to check one's blood glucose, fail to plan proper meals, etc.

Mental Stress Reduction Methods
Learning to control one's mental stress is therefore very important. Some people find relaxation therapy helpful. Relaxation techniques may include breathing exercises, progressive relaxation, exercise, and positive thinking. Another way to reduce mental stress is to develop more effective coping skills. And still another is to change some of the things in one's life that are creating stress.
Stress reduction methods can be learned by reading self-help books and listening to recording, meditating, receiving psychological counseling, obtaining assertiveness training, joining a support group, etc. The benefits of stress reduction on lowering blood glucose are clearest with Type 2 diabetes since stress blocks the body from releasing insulin. But even those with Type 1 diabetes can benefit from reducing their stress levels because it can help them take better care of themselves.[1]
Helping people deal with their mental stress in diabetes health education programs is, therefore, another way to improve outcomes.

Personality Characteristics and Diabetes Management

How well a person manages his or her health, including diabetes and other chronic conditions, can be understood in terms of four health personality types: Activists, Wannabes, Inactives and Ignorers/Deniers. Each personality type has its own set of attitudes, beliefs, emotions, motivations, and behaviors.

Activists
Activists' attitudes about managing their health can be expressed by the attitude: "I believe I can do whatever must be done, and I'm willing to do it!" This positive, adaptive way of thinking reflects a joy of living and a willingness to manage one's health competently.
In terms of their character traits, Activists tend to be confident, motivated, aware, rational, and assertive. They seek knowledge about their health status and risks to help them make wise decisions and take responsible action. They try to understand how to avoid health problems and self-manage chronic conditions by using their knowledge to live healthily. Activists, therefore, are rational people who manage their physical and mental health using positive, proactive coping strategies, such as:

• Trying to understand what caused the problems and thinking of different ways to handle it.
• Determining what has to be done to manage their condition and then adhering to an effective plan of care.
• Talking to people about what they are going through and seeking advice or help.
• Viewing their health problem as something that helps them change or grow in a good way.
• Rationally accepting that their condition cannot be cured, which minimizes their emotional distress while motivating them to do what is necessary to avoid complications.

The more a diabetic person's character traits resemble an Activist, the more likely he or she is to manage the condition effectively.

Wannabes
A second group of individuals is the "Wannabes" (want-to-be). Wannabes think and talk about improving their health and wellbeing, and are willing to learn about healthy living, but they never seem to act on it, or do so half-heartedly. This is because they tend to have attitudes and beliefs such as:

• "I may be able to do what's required to improve my health, but I'd rather not deal with it right now."
• "I'm not sure what to do."
• "I'm just not ready."

As a result, Wannabes tend to be aware—or are willing to be aware—of their health problems and risks, but they lack the self-confidence and motivation they need to actually do something about it. Their self-doubt and lack of drive may come from the belief that they may not be able to do things the way they should. This uncertainty, in turn, may cause them to avoid making decisions and changing their behaviors for fear of failure; they don't want to be ashamed or embarrassed if they try, but do not succeed.

Wannabes, therefore, tend to cope with their doubts and fears through avoidance. For example, they may:

• Try to feel better by doing enjoyable or interesting things, rather than focus on managing the health problem.
• Act as if there is no problem, or try not to think about it.
• Express negative emotions by yelling or crying, taking it out on others, or avoiding certain people, rather than doing something constructive.
• Hope a miracle will somehow make things better or that one's wishes or prayers would be answered, rather than gaining knowledge and self-managing their health problem.
• Resign themselves that nothing can be done, even though this is an erroneous assumption.

While some of these coping strategies may alleviate their emotional distress temporarily, it is a maladaptive in the long-term since it fosters procrastination. Their inaction, in turn, allows their health to deteriorate. Nevertheless, there are several positive aspects of the Wannabe personality.
Since Wannabes think and talk about improving their health and wellbeing, they may be willing to participate in a whole-person diabetes health education programs that help them gain knowledge about their health problems and risks, as well as help them understand how to manage their diabetes. And they may be agreeable to wellness coaching and counseling offered through the program, which focuses on overcoming their self-defeating psychological obstacles and developing more adaptive coping strategies. Useful health information technologies would also help them gain the knowledge and skills they need. The goal is to help them become more like the Activists, so they will be motivated, capable, and psychologically prepared to manage their diabetes.

Inactives
A third personality type is the "Inactives." They think about their health on occasion, but do not believe they should or can do anything to manage their diabetes. This is because they tend to have attitudes and beliefs such as:

• "I doubt I'll be able to do what's required to improve my health and prevent complications, so why even bother."
• "I don't deserve to be sick…it's not my fault…so why should I have to be the one to do anything about it"—or—"I do deserve to be sick…Illness is my punishment…I'm just getting what I deserve."

Inactives, therefore, doubt that they can deal effectively with their health risks and problems. Some of them also believe they do not deserve what has happened to them, which makes them feel resentful and angry. The mental stress this causes not only distracts them from focusing on constructive health improvement activities, but it can actually raise their blood glucose levels as discussed earlier. Some Inactives, on the other hand, may believe they deserve to be sick due to self-loathing, or there is no hope and they are doomed.

The result is that the Inactives, like the Wannabes, lack the self-confidence and motivation they need to improve their health and manage their diabetes. What makes Inactives less likely to change their unhealthy lifestyles is that:

• Their self-doubt is stronger because it comes from the belief that they are not able (rather than may not be able) to do what is necessary to manage their health effectively.
• Their inertia (inaction) may be exacerbated by (a) fear that they will be shamed if they try to manage their health but fail, (b) the belief that there is no good way to manage their health, and (c) despair related to the belief they deserve to be ill.

The end result is poor management of their diabetes.

The way Inactives attempt to cope with their pessimism, fear, anger, resentment, and despair is similar to the negative avoidance strategies the Wannabes use. And, as with the Wannabes, the maladaptive coping strategies of the Inactives may alleviate their emotional distress temporarily, but hurt them in the long-term since their inaction allows their health problems to worsen.
Nevertheless, since Inactives think about their health and wellbeing on occasion, it is possible for them to become more focused and motivated through the help of wellness coaching, counseling, and useful health information technologies. They may, for example, be willing to gain greater knowledge about their problems and learn constructive strategies for dealing with them. And they may be willing to get help to use the knowledge they gain to self-manage their diabetes by helping them:

• Overcome their inertia, changing their self-defeating psychological obstacles (including self-doubt, fear, anger and shame)
• Replace their negative avoidance-based coping strategies with the positive strategies of the Activists.

Ignorers/Deniers
"Ignorers/Deniers" just don't focus on their health. These people "close their eyes and ears" to information about healthy living. They refuse to acknowledge or accept they have health problems or risk factors; or they refuse to do anything about it. These maladaptive behaviors are a consequence of a self-destructive mindset that includes attitudes and beliefs such as:

• "I do not accept there's a problem with my health" – despite convincing evidence to the contrary.
• "I'm fine the way I am … It doesn't matter what others say" – even though their health is deteriorating, relationships are crumbling, and overall quality of life is suffering.
• "I'm different … I'm special … I'm not like those other people … Nothing's going to happen to me!" – false sense of security and invincibility.
• "I don't trust doctors" – an attitude based on gross overgeneralization.
• "Getting help is a sign of weakness ... A strong person handles one's own problems" – an irrational belief driven by pride and based on distorted measure of self-worth.

Ignorers/Deniers, therefore, differ from the other personality types in important ways. Following are some examples:

• The three other types of individuals think about their health and, when confronted with a health problem, many question whether they are able to do what is necessary to improve things, which may make them feel anxious due to self-doubt. Nevertheless, they may be willing to learn and act responsibly despite their anxiety and doubt. Many Ignorers/Deniers, however, are so terrified by the notion that their diabetes may lead to serious complications that they avoid thinking about their health—preferring, instead, to pretend everything is all right. As a result, Ignorers/Deniers may refuse to accept the reality of their situation, even when confronted with the threat that they are likely to die from their health problems, because such possibilities are just too painful to consider. Although this denial and self-deception may keep their fear in check for a while, their inaction and ignorance makes them very vulnerable to worsening health.
• If Ignorers/Deniers did think about their health, many would feel hopeless and helpless, believing they are incapable of managing their illness effectively. And those who portray an air of invincibility are likely covering up great self-doubt and fear; or they may even be delusional.
• Some Ignorers/Deniers may also be so distrustful of the healthcare profession that they won't even consider seeing a doctor, often until it's too late.
• While health problems may cause other personality types to become sad, or even depressed, for a time, they are able to get themselves motivated and begin to take constructive action because they want to live and be happy. Ignorers/Deniers, on the other hand, may be so lonely and depressed that they believe they have nothing for which to live. For them, the prospect of living longer in chronic emotional pain isn't motivating. This prevents them from having the drive and focus needed for constructive action.
• While other individuals are willing to get help when they need it, Ignorers/Deniers may have been so influenced by their cultures that they believe seeking assistance for personal problems is a sign of weakness.
• Unlike the other personality types, Ignorers/Deniers may have physical addictions or powerful psychological compulsions that prevent them from focusing on healthy living until they reach "rock bottom," which, unfortunately, may be too late.

What this means is that Ignorers/Deniers rely on some of the same maladaptive coping strategies as the Wannabes and Inactives.
Because these thoughts, feelings and reactions are so deeply ingrained in their personalities, getting through to Ignorers/Deniers is very difficult. However, all is not lost! Through wellness coaching, counseling, innovative self-help software, they may be influenced by the "reframing" methods discussed earlier.

Dealing with a person's lack of trust may require intervention by a wellness coach or counselor who takes the time to establish a close, positive relationship with the Ignorer/Denier, and who has the knowledge and experience to gain the person's confidence.
As for Ignorers/Deniers with addictions or compulsions, lengthy psychotherapy (and possible medications) may be needed before they acknowledge their problems and are willing to deal with them.

In diabetes health education courses, wellness coaches and counselor should begin by focusing on helping Ignorers/Deniers understand and reframe their maladaptive beliefs and attitudes. This will enable them to be more open to gaining knowledge and awareness of their diabetes. Innovative health information technologies that help focus and entice them to break through their negative mindsets and resistance would also be helpful. Once Ignorers/Deniers stop deceiving themselves, have a stronger desire to live and enjoy life, gain trust, are more aware and open to receiving help, and are no longer controlled by their addictions/compulsions, they can be treated as Inactives or Wannabes as appropriate.

In my next post, I discuss the role of health information technology supporting innovative diabetes health education programs.

References
American Diabetes Association. Stress. See http://www.diabetes.org/type-1-diabetes/stress.jsp
Patrick Ober, M.D. How Does Stress Affect Diabetes And How Can I Better Manage Stress? See http://abcnews.go.com/Health/DiabetesLivingWith/story?id=3845034