The Diabetes Multidisciplinary Team: Psychologists in diabetes care

At least four in ten people with diabetes experience emotional or psychological problems, such as depression, anxiety and diabetes-related emotional distress (Diabetes UK, 2016). This can cause a reduction in the ability and motivation to self-manage, leading to poorer health outcomes, reduced quality of life and an estimated 50% increase in healthcare costs (Mental Health Taskforce, 2016). This article will briefly explore the emotional and psychological impact of diabetes to establish the context for the need for psychological support. The role of the psychologist within the diabetes care settings will be explored, including helping the reader to understand the training psychologists receive, the range of ways psychologists can work with practices and how primary care professionals can make the most of their expertise.
 
What does a psychologist do?
Psychologists work with people living with diabetes to:

• Support the development of helpful thinking styles and coping strategies to deal with diabetes-specific difficulties including:
  • Diabetes distress, low mood and depression.
  • Eating issues (e.g. binge eating, insulin omission for weight loss and eating distress).
  • Anxiety affecting diabetes self-care (e.g. fear of hypoglycaemic episodes and needles, and psychological barriers to insulin use).
  • Diabetes resilience, self-care, motivation and adjusting to diabetes. 
  • Recurrent diabetic ketoacidosis.
• Formulate an understanding of the role their early experiences may have in impacting their health in adulthood (including the influence of adverse childhood experiences on health-related self-esteem), the ability to implement education and motivation to self-care. 
• Increase confidence and skills in their ability to manage their diabetes.

 
The range of psychological need
Numerous factors can impact the emotional well-being of a person with diabetes. Below is a list of the type of emotional struggles that may affect people with diabetes across the course of their condition:

• Accepting the diagnosis and integrating it into their identity and existing life roles (e.g. employee or parent).
• Coping with the ongoing demands of self-management. 
• Increasing emotional resilience and developing flexible coping styles to manage the ups and downs of their condition. 
• Managing thinking styles to better manage naturally occurring anxieties (e.g. long-term complications, hypoglycaemia or needles).
• Recognising non-hunger eating and having strategies other than food to cope with emotional struggles.
• Coping with the development and progression of diabetes-related complications, including an impact on sexual function.

 Diabetes UK uses a pyramid model to depict the breadth of psychological need in our populations of people living with diabetes. These range from mild difficulties with coping, through diabetes-related emotional distress, to severe psychological and psychiatric conditions. It is important not to pathologise naturally occurring distress, which is distinct from classifiable mental health conditions, as demonstrated in the pyramid model (Figure 1).
 
A 2015 survey by Diabetes UK found that 76% of people with diabetes had not been offered emotional or psychological support when they needed it (Diabetes UK, 2015). Current service provision is not adequately meeting the psychological needs of people with diabetes. Mental and physical health services tend to be divided and disjointed, and people with diabetes lack access to appropriate emotional and psychological support (Diabetes UK, 2016). Psychologists and their equivalents can support primary care health professionals in their medical role to achieve better physical health outcomes.
 
 

Training of psychologists and their equivalents
Historically, psychologists in diabetes care settings were generally clinical psychologists based in secondary care diabetes teams, focussing on supporting people with type 1 diabetes. In the last decade, the range of psychological practitioners has expanded to include an array of practitioners, with varying backgrounds and levels of training. There is a range of different types of psychologist that may work within health care settings. It includes clinical psychologists, health psychologists and counselling psychologists. 
 
These professionals have all completed an undergraduate degree in psychology, have usually gained some practical postgraduate experience in a work place setting (often as an assistant to a qualified psychologist) and have completed a postgraduate degree, either to a master’s or, often, doctoral level. Newly qualified psychologists commence their career as band 7 health professionals within the NHS pay scales. They are registered with the Health and Care Professions Council and abide by its code of conduct, ethics and practice. They are often also registered with The British Psychological Society and other relevant professional bodies. 
 
Equivalent roles are counsellors, psychotherapists and high intensity therapists, who perform similar roles, but with slightly different routes to qualification. 
Within primary care psychology services, there is also a range of psychology staff, usually working at band 5 and 6, who have completed an undergraduate degree in psychology and can provide lower-level emotional support within a “psychological well-being practitioner” role. 
 
Primary care psychology services, often called improving access to psychological therapies (IAPT) services, were originally established to focus on supporting individuals with mild to moderate depression or anxiety and supporting people with long-term conditions, including diabetes, is becoming increasingly common. Their delivery is in a “stepped care” model, with those with mild difficulties being offered computerised cognitive behavioural therapy (cCBT), guided self-help, group interventions, individual face-to-face short-term therapeutic interventions, usually based on cognitive behavioural therapy (CBT), or interpersonal therapy (IPT).

How psychologists work with practices
The Diabetes UK Position Statement for Emotional and Psychological Support for People with Diabetes (Diabetes UK, 2016) states that commissioners and service providers are advised to work together to ensure:

• Emotional and psychological support for people with diabetes of all ages is embedded in each step of the diabetes care pathway and is not limited to people with “diagnosable/classifiable” psychological problems.
• Appropriate services are available locally to meet the varying emotional and psychological needs of people with diabetes of all ages, in line with the pyramid model. This should include timely access to IAPT interventions with specific care pathways for diabetes. 
• Healthcare professionals working in diabetes, in both primary and specialist care, have training and ongoing supervision to identify and provide proactive support for psychological and emotional problems as part of routine clinical care – including using screening tools and care planning. 
• GPs and primary care professionals have access to specialist psychological expertise (defined as mental health professionals who can deliver complex psychological interventions [i.e. clinical/counselling psychologists and equivalents, or, in some services, liaison psychiatry]).
• Mental health professionals providing emotional and psychological support for people with diabetes, such as IAPT workers, have specific training in diabetes.

 
Support offered by a psychologist to practices
The types and range of support that a psychologist can offer include:

• Training to colleagues on topics such as communication skills, using motivational interviewing skills within time-limited consultations, working with diabetes distress and burnout, supporting psychological adjustment to diabetes, and working with individuals with diabetes and severe/enduring mental health problems.
• Consultations or complex case discussions – this can also be provided by phone/virtually to reduce time/cost of travelling.
• Joint reviews with person with diabetes, GP/nurse and psychologist.
• Group interventions (e.g. Coping with Diabetes) that offer strategies drawn from cognitive behavioural therapy (CBT) approaches.
• Guided self-help and psychoeducation. 
• Individual therapy, usually offering short-term evidence-based therapies such as CBT and cognitive analytic therapy (CAT). 
• Access to online interventions (e.g. The Eating Blueprint for psychological strategies to support weight management; contact the author for further information).

How primary care professionals can utilise psychologists
Psychological support tends to be a limited resource, so the needs of the local population are likely to outstretch the resources available. The level of primary care psychological support nationally varies widely. Depending on what non-diabetes-specific psychological support is available locally, it is beneficial to discuss referral criteria and develop a support pathway that works locally, integrating with non-diabetes-specific psychological support services. Some additional suggestions for discussion locally are:

• The appropriateness of using screening tools and questionnaires, and screening measures that can be used in routine clinical practice (e.g. Problem Areas in Diabetes Scale [Joslin Diabetes Centre, 1999] and the Diabetes Distress Scale [Polonsky et al, 2005]) to flag people within your care who need support.
• The creation of a pack of local resources to support emotional health and well-being that can be offered as needed and routinely to individuals who are newly diagnosed (e.g. signposting to local resources and support, and emotional and mental health-related national and online resources).
• Making available fact sheets to guide health professionals in conversations about aspects of emotional well-being (e.g. those from the Diabetes and Emotional Health handbook; Hendrieckx et al, 2016).

 
Conclusion
This article has explored the emotional and psychological impact of diabetes and the scope of need for psychological support. The range of ways psychologists may work with practices and how primary care professionals can make the most of the often limited resource have been explored. Commissioning guidelines have, for many years now, called for the provision of psychological support for people with diabetes. However, the culture of care is slow to invest in the adoption of these recommendations. Contrasting the way people with diabetes are supported psychologically to people with a diagnosis of cancer and HIV, demonstrates how far the culture must shift in this regard.