Although therapies for diabetes are more efficacious and accessible than ever before, outcomes (HbAlc, weight and admissions) remain less than optimal. There are three components to this. As healthcare professionals, we can sometimes mismanage the process (Given et al, 2015), people with diabetes can experience “burnout” living with the condition (Polonsky, 1999) and some individuals have pre-diagnosis psychological or emotional difficulties that render regular and reliable self-care virtually impossible, despite high levels of diabetes education and support.
People with diabetes are 2–3 times more likely to have depression than those who do not have diabetes (Barnard et al, 2006). The global DAWN (Diabetes Attitudes, Wishes and Needs) study has shown that 41% of people with diabetes have poor well-being (Nicolucci, 2013). This article will look at how these difficulties are understood and treated in psychotherapy using cognitive analytic therapy (CAT; Ryle, 1990).
The need for psychotherapy
Jane Milton’s work (Milton, 1989) highlighted how emotional difficulties can cause mismanagement of diabetes. She stated that her patients were not psychiatrically ill in any formal sense but their emotional problems led to an inability to cope with stressful situations and affected self-care. Ryle et al (1993) presented three individuals with diabetes and commented that, despite intensive education, they were “seriously neglectful or self-sabotaging in their diabetes management”. In particular he outlined the differing emotional backgrounds that his patients displayed, including needy, angry, guilty and unconfident. He showed how these emotions led to a range of “procedures”, which led to poor self-care. Over eating and using alcohol to deal with emptiness, unhappiness and to “self sooth” was common. People also reported feeling trapped by others and their diabetes and therefore were resistant to any perceived demands the condition required.
Tilden et al (2005) presented a qualitative study of one 26-year-old woman, June, who developed diabetes in infancy. Their analysis was that her identity had been overshadowed by a “diabetic identity”, which she rejected and therefore she rejected the requirement for adherence to treatment. Attention from the family only seemed to configure around her diabetes, which June felt was not “good enough”. June wanted to be recognised and valued for herself, not just for her condition. The authors outlined the process of brief, focused psychotherapy (CAT), which showed that June was able to “transform” when she was recognised for herself and not her condition. Further work on CAT has looked at how adolescents might also use diabetes as a vehicle to rebel against parents and staff, who are perceived to be controlling and interfering, and this continues in to adulthood (Fosbury, 1996).
Why cognitive analytic therapy?
People referred for cognitive behavioural therapy (CBT) may have been diagnosed with disorders, such as anxiety, depression and obsessive compulsive disorder. It has specific, research-proven ways of working with such clients, using different techniques appropriate for their presentation. People who want to work with their therapist on actively changing their problems tend to do well here. However, some patients want to change, but have a number of obstacles to this process. In the Brighton diabetes psychotherapy (CAT) service, patients were recently audited on a range of issues. One issue was previous experience of therapy. Out of 30 individuals, 19 had previously received CBT from the local mental health trust.
CAT works more interpersonally than CBT. Although it integrates techniques and understandings from CBT, it is more psychoanalytical in nature. CAT looks at feelings, thoughts and subsequent behaviours, which are usually circular in nature and are causing harm. It is a short-term, focused therapy normally involving between 16 and 20 sessions. Patient and therapist will work on jointly identifying any problems and this will involve a clear description of the issues affecting the person using letters and diagrams. One aim is to understand the origins of the individual’s difficulties, normally located in early relationships and experiences. Another important aim is to use the relationship between the patient and therapist to reflect on how those learnt ways of being take place, both in and out of the therapy room.
As CAT combines a number of approaches, it is a complex treatment used for more complex, resistant problems. It therefore lends itself to comorbid and complex conditions where other psychological therapies have often failed, such as when the patient is uncooperative to their own self-care needs (diabetes and other health conditions) and often covertly uncooperative with the therapy (or diabetes education, for example). Understanding resistance is central to treating these cases and is central to a psychoanalytic approach to treatment.
There is an extensive evidence base for the use of CAT in people with mental health problems. With regards to the evidence base for diabetes specifically, Fosbury et al (1997) compared the use of CAT therapy to education provided by a DSN in people with poorly controlled type 1 diabetes. The study found that while there was no statistical difference between CAT and DSN education, the effects of CAT produce a more prolonged effect on glycaemic control. A further study (Shaban et al, 2008) demonstrated that CAT led to a reduction in HbA1c from screening to follow up at 2 years.
Why are people resistant?
Change involves emotional pain, so people are often resistant to it. It involves “letting go” of self-defeating behaviour, such as the comfort of over eating, or of only caring for others (which they may derive self-esteem from), but not caring for themselves. Individuals may have to let go of feelings of guilt when they look after themselves. Therefore, individuals can become unwilling and opposed to this change, even if it is what they desire. This resistance can be revealed to the psychotherapist in an number of ways – in the patient’s obvious discomfort in the room, in their silence or over talking, “did not attend” rates, and making “false promises”. In CAT we refer to these obstacles as “snags”. These are the “I want to change but…” statements. Another example of a snag is “If I look after myself then others won’t look after me”. These responses are often unconscious and need to be made conscious in the therapy through the process of interpretation. It is the unconscious mind that is the most troublesome as it is anatomically deep and primitive, where we can deny or bury our motivations. It is here we hide our responsibilities for our self-defeating acts, either towards ourselves or others. Problematic unconscious emotions that are not dealt with psychologically often reveal themselves in other ways, via medically unexplained symptoms and the epidemic of mind/body disorders (Sarno, 2006).
CAT in action
An individual’s activities, particularly regarding self-care and relationships with others, are understood as organised sequences of mental and behavioural processes (referred to as procedures) that are repetitive in nature. An example is shown in Figure 1.
The therapist needs to make links between the patient’s past and present experiences, and their persistent use of procedures that are ineffective or harmful. In people with diabetes this will include procedures that affect other aspects of their lives, not just their diabetes management. As with all psychotherapies, the therapeutic relationship provides the foundation where procedures may be re-enacted with the therapist (transference), and where they may be re-interpreted and changed within the safety of that relationship. At the end of the therapy, patient and therapist write “goodbye letters” to one another, which are discussed at the final session. These aspects are highlighted in the case of Mr P presented below.
Case study
Mr P was 40 years old when he was referred to the Brighton CAT diabetes service. He had been diagnosed with type 1 diabetes in his early 20s and had always had poor glycaemic control. On assessment he stated he wanted his life to be different but was fearful of what that may mean or involve. He suffered from binge eating disorder, anxiety and depression.
Mr P had a difficult upbringing. His father was neglectful and depriving in his interest and care for Mr P. He favoured the other children in the family and Mr P stated this was “destructive and cruel”. Being “unfavoured” led to feelings of suspicion and paranoia and as an adult Mr P began “falling out” with family members, friends and neighbours. His mother experienced her own early traumatic life events and was violent and abusive to all of her children. Mr P became self-abusive, via over eating, and was neglectful of himself. He was often abusive to others. Mr P had no model of reliable, decent care where he felt he was listened to. This had to be modelled in the therapy by his therapist as an antidote to his early experiences so that he did not feel so emotionally deprived and needy. He also began to understand the cause of his self-abuse and the way in which he became abusive to others and felt abused by them.
At the end of the therapy and in follow up, Mr P’s relationship with his wife, his mother and his diabetes began to improve. In relation to food he stated that “I don’t even fancy over eating”. He also began to remember good things about his father who had subsequently died.
The full process of Mr P’s therapy is outlined in his goodbye letter and is presented exactly as written by him (Box 1).
Conclusion
CAT works at a deep level with complex, often resistant individuals with a high level of emotional need. These people have often had long-term diabetes education input and other forms of therapy, with no change in diabetes self-care behaviour. Unfortunately, there can be no “quick fix” for these individuals. A number of diabetes centres around the UK use CAT for such difficulties and you can ask your local psychology department for details.
For more information on CAT visit: www.acat.me.uk
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