A Whole-Person Approach to Diabetes Health Education Part 2 of 4

In my last post, I presented an overview of the mind-body approach to diabetes health education. In this post I give a more in-depth examination of the psychological factors influencing blood glucose control, starting with the effects of emotional depression.

Psychology of Diabetes: How Mind Affects Health

Diabetes requires extreme changes to many people's lifestyles. They must change from a sedentary to health-conscious lifestyle. Instead of eating junk food and watching television, they have to begin eating healthy food, exercise regularly, monitor their blood sugar level multiple times a day, control their blood pressure and cholesterol, have regular eye and foot exams, stop smoking, and possibly take medications (which may include self-injection). Adopting these lifestyle changes and adhering to these self-management routines requires education and guidance, of course. Many diabetic individuals, however, need more than knowledge and instruction. The reason: Psychological obstacles interfere with their ability and willingness to make such dramatic lifestyle changes.
These psychological obstacles may include maladaptive (inappropriate, detrimental) attitudes, coping skills, and emotions. For example:

• Lack of self-confidence is enough to deter some people from even trying to change their lifestyle since they expect to fail.
• Just looking at a sugary snack can cause some people to worry about the life-threatening aspects of their disease, or feel depressed and angry that they must deprive themselves.
• Failure to keep up their exercise routine or eating poorly can also make them feel those same negative emotions. Unhealthy behavior can also make them feel guilty or ashamed for not doing what they should.

Unfortunately, instead of motivating them to control their diabetes, these attitudes and emotions can have the exact opposite effect; they may cause diabetic people to stop trying because they feel hopeless and helpless. Or equally harmful, they may deal with their painful feelings by ignoring their health through denial and self-deception. Following are some examples of the deleterious effects of these psychological obstacles on diabetic individuals.

Depression and Diabetes Management

Health Effects of Depression
Research shows that depression in diabetic people is associated with poorer diet and medication adherence, functional impairment, and higher health care costs.[1][2] This is often a vicious cycle. When the demands of diabetes care or complications of the disease lead to depression, a person feels overwhelmed, hopeless, helpless, and exhausted. These feelings, in turn, destroy one's motivation, which impairs self-management. Failure to manage one's diabetes results in greater health problems, which exacerbate the depression. And the cycle repeats.

Likewise, depressed people are unlikely to modify their behaviors to extend their lives because the prospect of living longer in chronic emotional pain shatters their willingness to change. Furthermore, depressed diabetic individuals may refuse to acknowledge that their illness can severely harm or kill them because the idea is too emotionally painful to accept. This means that the threat of serious complications or death is not a powerful motivator for some. In fact, the odds are nine to one that a person will fail to make substantial lifestyle changes, even if facing probable death!

Dealing with Depression
Fortunately, there are effective ways to help diabetic people overcome the psychological obstacle of depression. For example, compelling discoveries in the fields of cognitive science, linguistics and neuroscience are demonstrating the promise of "reframing" techniques. One useful reframing method helps depressed people develop a vision of "joy of living" rather than a "fear of dying," since joy can be a more powerful motivator than fear. Incorporating this kind of reframing approach into diabetes health education can promote positive changes in people's way of thinking, resulting in increased motivation to live more healthily.[3]

Diabetic people also need good coping strategies for dealing with depression (and other emotional disturbances). Some coping strategies attempt to reduce one's emotional distress by promoting adaptive (effective, useful) ways of thinking, feeling, and acting when trying to manage their illness (or other problems); other strategies, however, are maladaptive. Ten common strategies people use include five adaptive and five maladaptive coping methods.

The five positive, adaptive coping strategies help a person solve a problem or learn to accept it with minimal distress:

• Logical Analysis involves trying to understand what caused the health problem and different ways to handle it.
• Problem Solving involves developing specific plan of action to manage the problem, implementing it, learning from the results, and then modifying the plan and trying again if necessary.
• Social Support involves explaining the problem to other people and asking them for advice or help; this includes peer group support.
• Positive Reappraisal involves viewing the problem as helping the person change or grow in a good way, find new faith, or learn valuable lessons.
• Rational Acceptance involves accepting—without undue emotional distress and without self-defeating behaviors—that nothing can be done to cure one's illness; at the same time, it encourages the person to do what is necessary to prevent complications.
• The five negative, maladaptive coping strategies fail to resolve one's problems, do not enable healthy acceptance, and may even make the situation worse:
• Behavioral Distraction involves trying to feel better emotionally by doing enjoyable or interesting things, rather than dealing with the health problem proactively or coping with it through positive reappraisal and rational acceptance. While it may help reduce a person's emotional distress temporarily, this strategy is maladaptive because it will never improve the situation, does nothing to help one cope with it long-term, and can actually make matters worse through inaction. This strategy wastes precise time that could be better spent trying to understand and deal constructively with the problem.
• Cognitive Avoidance involves acting as if there is no problem, or trying not to think about the problem. As with behavioral distraction, the strategy may help reduce one's emotional distress temporarily, but it will never improve the situation, does nothing to help one cope with it long-term, and wastes precise time.
• Emotional Discharge involves expressing negative emotions by yelling or crying, taking it out on others, or avoiding certain situations. As with the previous two strategies, this one may help reduce one's upset temporarily, but it will never improve the situation and does nothing to help one cope with it long-term. In addition, this strategy may annoy other people who could have been helpful and push them away.
• Wishful Thinking involves hoping a miracle will somehow make things better, or that one's wishes or prayers would somehow be answered. This, too, may help reduce one's emotional distress temporarily, but it will never improve the situation, does nothing to help one cope with it long-term, and wastes precise time.
• Resignation happens when a person determines that nothing can be done to fix a problem, so he or she does nothing, while remaining in an emotionally distressed state of anxiety, depression (hopelessness and helpless), and/or anger. This, too, is obviously maladaptive.

It stands to reason, therefore, that helping depressed persons in diabetes health education programs deal with their depressions—through reframing, coping skill training [4], and other methods—will result in better outcomes (i.e., more effective control of blood glucose, blood pressure, etc.).
In my next post, I discuss how mental stress and personality factors affect diabetes management.

References:
[1] Ciechanowski PS, Katon WJ, Russo JE. Depression and diabetes: impact of depressive symptoms on adherence, function, and costs. 1: Arch Intern Med. 2000 Nov 27;160(21):3278-85. See http://www.ncbi.nlm.nih.gov/pubmed/11088090

Gonzalez JS, Safren SA, Cagliero E, Wexler DJ, Delahanty L, Wittenberg E, Blais MA, Meigs JB, Grant RW. Depression, self-care, and medication adherence in type 2 diabetes: relationships across the full range of symptom severity. 1: Diabetes Care. 2007 Sep;30(9):2222-7. See this link

[2] Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care. 2001 Jun;24(6):1069-78. See this link

[3] Deutschman, A. Change or Die. 2005 May. See this link

[4] Grey, M. Coping and Diabetes. Diabetes Spectrum. 2000 13(3),167. See this link
Grey, M. & Berry, D. Coping skills training and problem solving in diabetes. Curr Diab Rep. 2004 Apr;4 (2):126-31

Why people develop persistent maladaptive beliefs

Continuing the thread of beliefs and health, I will now examine why people develop maladaptive beliefs systems and why they’re so difficult to change.

A belief is a type of thought (cognition, attitude, assumption, theory) that emerges as one’s mind converts patterns of electro-chemical brain activity into internal dialogue (“self-talk”), images in the “mind’s eye,” emotions, and behavioral reactions. Since this occurs automatically and unconsciously, we are typically unaware of these thoughts and feelings as they happen.

 

How do these beliefs develop and persist? The kind of beliefs I’ve been discussing—attributions, appraisals and irrational beliefs—are created by our experiences and cultural teachings. These belief systems (interrelated set of beliefs) function as mental/perceptual “filters” through which we view the world, the future and ourselves, which ultimately affects the state of our physical, psychological and spiritual health.

 

There are many reasons why humans develop and maintain maladaptive beliefs, and the negative emotions and behaviors accompanying them. They include the following (adapted from Albert Ellis’ book, “Reason and Emotion in Psychotherapy” pp. 381-414):

 

• We have a prolonged period of childhood during which time we are—relative to healthy adults—vulnerable, weak, ignorant, unintelligent, incompetent, highly impressionable, and over-emotional creatures. This is poor training ground and preparation for the kind of thinking, emoting, and acting we will have to do to live sanely and healthily as adults.
• We often have difficulty unlearning something, even as we learn new things that contradict it. So, once certain beliefs are acquired, it often requires constant work and practice to change them. In other words, beliefs become habitual.
• Inertia is the tendency of an object at rest to remain at rest, and of an object in motion to remain in motion. Changing an object’s motion by starting it or stopping it, therefore, requires extra energy. The same is true for people’s tendency to think, feel and act in ways we’re accustomed. It takes extra effort to modify the thoughts, emotions and behaviors familiar to us. Unfortunately, we tend to have trouble with sustained effort (as discussed below), so once a strong beliefs are in place, our inertia makes them resistant to change.
• People tend to be short-sighted and want their desires satisfied immediately (“short-term hedonism”), even when they would be better off postponing satisfaction or living without. Examples of things momentarily desirable, but undesirable or harmful in the long run, include consumption of alcohol, drugs and too much food. This is one reason why we find it so easy to believe we need what we want when we want it, without consideration of the long-term consequences.
• People have a tendency to be over-suggestible, which makes us prone to adopting the beliefs of our families our cultures, rather than rejecting conformity in favor of independent critical thinking.
• Humans tend to be overly vigilant, cautious and misfocused, which means, for example, that we focus too intently on certain things we wrongly believe pose a threat, where in fact we’d be better off concentrating on other things that pose a more serious threat to our well-being.
• Extremism is a human tendency that makes it very easy for us to accept radical beliefs, rather than taking a middle-ground view.
• People are prone to wishful thinking, which makes it very easy for us to have self-deceiving beliefs that minimize problems and that enable us to foolishly justify inaction (e.g., “No need to bother … everything will work out on its own”).
• Humans have (a) trouble sustaining their focus effectively on what’s most important, (b) difficulty organizing many diverse elements of one’s existence into integrated wholes, and (c) problem engaging in disciplined & sustained effort, especially when frustrated. Belief change, however, requires competence and will in all these areas.
• Our culture reinforces beliefs that over-emphasize guilt and blame, and make us prone to envy and jealousy.
• We have a tendency to over-generalize, which means we apply our beliefs about particular people or things to other people and things believe are similar, but that are, in fact, really quite different. When combined with “people appraisal,” this tendency is the foundation of racial, ethnic, gender and religious prejudice.
• It is easy for humans to exist with disturbed beliefs and the maladaptive emotions and behaviors associated with them.

And here are some reasons why people have trouble refuting invalid beliefs:

• We tend to have a form of “selective attention” that makes us focus on a specific aspect of an experience while ignoring other aspects, as well as “hindsight bias” makes us recall only certain things from memory. The problem is that the things we focus on and remember tend to support our preconceived beliefs (assumptions/theories), while ignoring contradictory evidence. Belief change, however, requires just the opposite, i.e., examining situations objectively, through critical thinking, by seeking out evidence that refutes our assumptions and hypotheses.
• We also tend to be overconfident in the accuracy of our attributions and appraisals. So, rather than fully investigating contradictory evidence, we develop and maintain beliefs based on judgments supported by insufficient and misleading information.

In my next post, I will answer the questions: Why are certain belief systems so emotional? and What types of beliefs are associated with good health?

Beliefs, emotions, behaviors and health: Examining 3 categories of beliefs

Last time I discussed how people’s beliefs affect their health. This time I dissect three common categories of beliefs associated with exaggerated negative emotions and self-defeating behaviors: They are attributions, appraisals and irrational beliefs.

 

Attributions are inferences (conclusions) people draw about causality (i.e., who/what is responsibility, at fault, to blame for a problematic situation); changeability (i.e., prediction of whether a problematic situation is changeable and within you control or intractable and beyond your ability to change).

 

Negative beliefs about the attributes of causality and changeability tend to be associated with feelings and actions such as (a) angry emotions and hurtful behavior (e.g., if you believe someone in particular caused your problems and you blame them for it); (b) shame/embarrassment, avoidant behavior or self-destructive actions (e.g., if you believe your problem is your own fault); and (c) depression or sadness, low frustration tolerance, anxiety or fear (if you believe the problem will never change). Not only does this increase one’s stress levels (which would have an adverse affect on one’s health), but it prevents a person from being an effective problem-solver, which, when it comes to dealing with one’s health problems, means poorer health and quality of life.

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Positive beliefs about causality and changeability, on the other hand, tend to be associated with optimism and hope, courage, assertive/proactive problem solving, persistence in the face of frustration and disappointment, self-respect, willingness to accept help from others, effective coping strategies, etc.

 

Appraisals are judgments about the degree of benefit (or potential reward) and harm (or threat) something or someone has caused (or will cause). If, for example, a patient believes a doctor’s advice won’t provide much help for his/her condition, the patient is unlikely to comply, and visa versa.

Another form of appraisal is what I call “People-Appraisals,” which involves measuring the amount of inherent worth and goodness people possess. 

 

People who receive positive appraisals (from themselves and others) are believed to have successful, competent, powerful, valuable, superior, important, precious, worthy, noble, good, moral, virtuous, righteous, pure, respectable inner-selves. They are called successes, winners, stars, or good people, saints, heros, gems, respectable citizens. They develop a favorable opinion about who and what they are; they have a positive self-image and high self-esteem.

 

People who have negative appraisals, on the other hand, are believed to have worthless, useless, unlovable, unworthy, good-for-nothing, flawed, defective, inferior, weak, or wicked, degenerate, rotten, detestable inner-selves. They are called failures, losers, no-bodies, louses, flunkies, derelicts, bums, jerks, turds, shits, bad people, bastards, bitches, skunks, rats, swine, animals, sinners, evildoers, devils, criminals, scum of the earth, dregs of society. They develop an unfavorable opinion about who and what they are; they have a negative self-image and low self-esteem.

 

Just like attributions, appraisals affect one’s emotions and behaviors in powerful ways, including being a foundational component of racial/ethnic prejudice, the “deadly sin” of pride and deservingness, suicide and murder, and more.

 

Irrational beliefs are erroneous assumptions and perceptions, which include exaggerations, overgeneralizations, dogmatic demands, minimizations, personalizations, selective attention, polarized (dichotomous, black & white) thinking, and the elevation of wants/desires into needs.

In my next post, I discuss why people develop persistent maladaptive beliefs .

Beliefs and Physical Health

How can a person’s beliefs affect one’s physical health? A belief, after all, is a type of cognition (thought) … it’s a mental phenomenon. So, why are beliefs important when it comes to the health of one’s body?

The answer lies in the relationship between beliefs, emotions and behaviors. Being a student of cognitive-behavioral and rational-emotive psychotherapy (Aaron Beck and Albert Ellis), I was trained in techniques of belief change designed to facilitate changes in people’s emotional and behavioral responses to situations they find distressing.

People who are stressed or upset may have certain types of erroneous beliefs, which exacerbated their distress levels. These beliefs include distorted/faulty (a) attributions (e.g., assigning the cause of the problem to the wrong person or thing, or believing that one is powerless to do anything about it) and (b) appraisals (e.g., making incorrect judgments about how bad a situation is, or prejudging certain people without adequate evidence). They are often expressed as irrational beliefs that are based on dogmatic demands that certain things shouldn’t happen; that elevate wants and desires into “needs;” that relate to a sense of “deservingness” or “deservingness;” that view things as black & white (e.g., all good or all bad) rather than in shades of grey); and that over-generalize, personalize, etc. When this happens, their negative emotions tend to be exacerbated, causing them to feel dread, stressed-out, hostile, hopeless depression, debilitating guilt or shame, etc. in situations where concern, frustration, annoyance, sadness, regret, etc. would be more appropriate emotions.

Instead of logically evaluating the situation with a calm and rational mind—looking for reasonable solutions and ways to cope—people maintaining these beliefs act in a self-defeating manner by, for example:

• Being overly passive and avoid dealing with problematic situations
• Having very low frustration tolerance and giving up quickly
• Being self-deceptive
• Feeling helplessness and hopeless
• Feeling ashamed and embarrassed
• “Eating themselves up inside” with stress
• Over-reacting by, for example, attacking, blaming and ridiculing
• “Self-medicating” with drugs and alcohol, over-eating, etc. in an attempt to lessen their emotional pain.

All these maladaptive reactions are self-defeating because they typically make things worse instead of better, or do nothing to improve the situation.
So, what does this have to do with physical health? A great deal! This belief-emotion-behavior connection is function of the mind-body connection. For example, many people do not follow their doctor’s advice to change their lifestyle (e.g., to exercise and eat better) because of beliefs that:

• Exaggerate how difficult it is (“I can’t stand doing it…it’s just intolerable!”)
• Minimize their own abilities (“I’m helplessness … it’s hopeless … I just can’t do it!”)
• Focus on how unfair it is (“This shouldn’t be happening to me … I shouldn’t have to change … it’s not fair!”), rather than focusing on what they must do to improve their health
• Blame others for their problems (“It’s my mother’s fault for over-feeding me …”) and seek to punish them (“So I’ll eat myself to death to show her”)
• Result in self-loathing (“I’m worthless and don’t deserve to get healthy”).

People with belief systems such as these are unlikely to be effective in self-management of risk-factors and chronic conditions. They may have low frustration tolerance and motivation, become easily discouraged, “bury their heads in the sand” and deny the problem, become hopelessly depressed and give up, angrily lash out at others trying to help them, and some may actually want to die.

Furthermore, many people living or working in high stress conditions feel strong emotional distress related to similar kinds of beliefs, e.g., they may think “I can’t tolerate this place … They shouldn’t treat me this way … I’m trapped and there’s nothing I can do about it … “). These beliefs are erroneous because:

• They ARE tolerating the situations, even though they are, no doubt, having unpleasant experiences
• Everything that happens has causes; just because someone doesn’t like it, it doesn’t mean those things “shouldn’t” happen
• People are never “trapped” in a bad ob or marriage; there are always alternatives, although they might not be comfortable and pleasant.

Beliefs such as these are likely to exacerbate negative emotions and stress levels, and there is ample research on mind-body medicine that demonstrates a strong connection between stress, negative emotions and illness.

They would all be much better off if they changed their beliefs, so they could think rationally and act responsibly by keeping things in perspective, evaluating options objectively, getting constructive feedback from others, developing a game plan and executing it assertively.

So, can a person’s beliefs affect one’s physical health? You bet!

The topic continues here.