Acceptance And Commitment Therapy For Diabetes Self
Acceptance and Commitment Therapyfor Diabetes Self-ManagementTherapist ManualJennifer GreggSan Jose State UniversitySteven C. Hayes, Ph.D.University of Nevada, RenoGlenn M. Callaghan, Ph.D.San Jose State University
Diabetes ACT Manual – Therapist2Overview of TreatmentBackgroundMany diabetics are given information about how to manage their diabetes,and are sent off to take care of their diabetes on their own. This strategydisregards the large number of research studies demonstrating that simplyproviding individuals with diabetes with education is a necessary, but notsufficient, component of their ability to manage their diabetes successfully.Obviously not every diabetic needs more than education in order tosuccessfully manage their diabetes, but this manual is designed for the vastmajority of individuals with diabetes, who do.This manual has two purposes. The first is to lay out a treatment approachthat integrates education and acceptance of thoughts, feelings, and bodilystates to make a distinction between areas of living that are within anindividual with diabetes’ ability to control and those that are not. The secondpurpose of this manual is to describe how to deliver this treatment inmultiple different modalities, in order to fit the treatment to the needs andrequirements of a given health care clinic or system. This treatmentMany individuals with diabetes wish that they did not have diabetes. Oftenthey have first- or second-degree relatives who have had complications ordied from diabetes-related illnesses. For these people, and many others, thediagnosis of diabetes can be overwhelming. In addition, individuals who arediagnosed with diabetes have many things they need to do, keep track of,and worry about that they never had to address previously. Some examplesof lifestyle changes required by diabetes are:1)2)3)Carefully watch one’s diet in order to eat meals low incalories, sugar, carbohydrates, fat, sodium, cholesterol, andlow in protein if kidney disease has developedDaily monitor blood glucose levels in order to determineeffects of food, exercise, and other daily activities.Exercise regularly in order to continuously stimulate thebody’s ability to produce and utilize insulin.These changes can be difficult to make, particularly for individuals with type2 diabetes, who often developed diabetes due to obesity, eating too muchsugar, and being relatively sedentary.Making the lifestyle changes required for good adherence to medicalrecommendations in diabetes is difficult to do. It is difficult for individualswithout diabetes to eat low-calorie, low-fat, and low-carbohydrate meals andexercise consistently. Another dimension of difficulty is added for manypatients when not engaging in these behaviors has dire health consequencesthat can include death. Many diabetes patients report that they would ratherthink about anything else than think about having diabetes, what that meansabout them in terms of their health, their weight, and the changes that arerequired for them to live a long, healthful life.
Diabetes ACT Manual – Therapist3The avoidance of thoughts or feelings related to diabetes makes sense withina larger context of avoidance present in the culture, and particularly in theway individuals in this culture cope with difficult problems. Obesity is anepidemic in our culture, largely because when life feels overwhelming oruncertain, it is not at all uncommon for people to turn to food to cope withthese difficulties. In addition, the food which people often use to cope withdifficult life events is what is commonly called, “comfort food.” This istypically food that is high in carbohydrates, fat, and sugar – all three ofwhich should be limited in a strict diabetic diet.Given the emotional reaction many individuals with diabetes experience whenfinding out they have diabetes, the difficulty of strict adherence to themedical recommendations, and the propensity of individuals in our culture tocope with difficult thoughts, feelings, and bodily sensations through the useof food, it is not surprising that as many as 93% of diabetes are not adherentto medical recommendations. In addition to these factors, in order to remainadherent, individuals with diabetes must remain vigilant about their diabetesall day every day in order to stay in good glycemic control. This vigilanceencompasses watching which foods they eat in which combinations, oftencounting carbohydrates, fat, and sodium consumed throughout the day, andpricking oneself with a lancet sometimes multiple times each day in order totest current blood glucose levels.The combination of these factors creates a specific situation in the lives ofindividuals with diabetes: In order to avoid, deny, numb or dissociateoneself from the worries and fears about having diabetes, it is increasinglydifficult to adhere to the medical regimen due to the number of remindersabout one’s diabetes therein.Said another way, if an individual withdiabetes wants to try to “forget” that they have diabetes, that individual maybe less likely to eat a “diabetic meal,” exercise consistently, and, importantly,test his or her blood glucose throughout the day to determine whetherpharmacological treatment should be altered. This is the situation manyindividuals with diabetes find themselves in.Components of the TreatmentAcross problems in living, ACT is a treatment that is difficult to deliver withintegrity. The application of ACT to diabetes is no different, and containsspecific challenges as well. The goal of the treatment is to compassionatelyassist patients in dealing with any thoughts, feelings, worries, anxieties, orfears they may have related to their disease and its maintenance in order tohelp them live their life in a valued direction related to their diabetes.A key first step in this holistic approach to diabetes self-management is toprovide adequate information about how to care for one’s diabetes in orderto address the specific motivational and acceptance pieces laid out in thetreatment. Thus, the first half of the treatment provides specific informationregarding the management of diabetes and the second half of the treatment
Diabetes ACT Manual – Therapist4addresses motivational and acceptance issues related to engaging in selfmanagement behaviors.The treatment is divided into 5 main modules:Module I:Education and InformationModule II: Food, Diabetes, and Your HealthModule III: Exercise and DiabetesModule IV: Coping and Stress ManagementModule V: Acceptance and ActionThese modules correspond to the organization of the patient handbook, inorder for patients to have a way to reference the material after treatment.This is an important component of the treatment, given the large amount offactual information disseminated in the treatment.In the first three modules, patients are given broad information aboutdiabetes and its complications, and are given specific information about theeffects of high and low glucose on one’s body. In the second module, thisinformation is tied specifically to the intake of food and information isprovided about how to eat in order to prevent surges and dips in bloodglucose. In the third module, information is provided about the impact ofexercise on blood glucose, and setting up an exercise routine.Once the broad and specific information on diabetes is given, the second halfof the treatment addresses more psychological and motivational barriers toeffective self-management. The fourth module addresses avoidance copingas it relates to diabetes, and particularly addresses avoidance of negativelyevaluated thoughts and feelings in diabetes, and how they may interfere witheffective self-management. The fifth module integrates the didactic andacceptance elements of the treatment and focuses patients on moving in thedirection of their values.In addition to being specifically addressed in the fifth module, values aretargeted throughout the treatment and are a major component of theintervention. Specifically, directing patients toward values-directed behaviorchange in diabetes self-management is the overall task of the treatment,with diabetes-related information and information about acceptingnegatively-evaluated thoughts and feelingsGroup StructureGroups are designed to be implemented into a variety of settings, and areparticularly designed for use with primary care patients, who may not beseeking a psychological intervention.In order to do this, groups arepromoted as “classes” and are broken down into modules that can beimplemented as a weekly class or delivered back-to-back as a full-day class.The latter mode of delivery is becoming increasingly common withinmanaged care organizations in the U.S.
Diabetes ACT Manual – Therapist5The issue of where to deliver the treatment depends largely on the resourcesand needs of the organization. Classroom settings, or large rooms in whichpatients can form a circle so that everybody is visible are optimal but maynot be available in some settings. It is recommended that the treatment bedelivered within the primary care setting if the patients are primary carepatients, in order to increase the continuity of care and decrease thedistinction between this treatment and medical components of diabetes care.Group Leader CharacteristicsDelivering this treatment requires of knowledge in two separate areas forclinicians. First, it requires a good working knowledge of Acceptance andCommitment Therapy, and the principles and mechanisms espoused by ACT.This is important because a main focus of the treatment is helping individualsuntangle their thoughts and feelings about having diabetes from theirbehavior relating to the management of their diabetes. This is a difficult taskto do with integrity, and traditional methods of training in ACT, such asworkshop attendance and ongoing support/supervision from another ACTtherapist is crucial to maintaining a sense of how to remain consistent in this“untangling”.In addition to information and experience with ACT, it is also necessary forclinicians delivering this treatment to have a degree of knowledge aboutdiabetes and its processes, complications, and treatments. While a medicaldegree is not necessary to deliver this intervention, many questionsregarding medical management tend to come up over the course oftreatment, and an easy-to-understand language and way of answering thesequestions lend credibility with patients who, again, may not be seeking apsychological intervention.Along with knowledge about ACT and diabetes, clinicians who deliver thistreatment also should maintain a value of being empathic and warm with asometimes challenging population. The experience of having a potentiallyfatal disease that requires a great deal of management every day of the sortthat none of us like to do is one that should not be underestimated. Inaddition, many individuals with diabetes, particularly obese patients, mayhave received poor care from medical staff who may believe that they are “atfault” for their health problems. Assisting individuals with diabetes to copewith all of the feelings connected to this experience and move forward intheir life is the purpose of this treatment.This ManualThis manual is laid out to provide both content and process information ofthe delivery of this treatment. The text provided in regular font is the sametext provided in the patient workbook and gives a sense of the content to becovered. Information provided in shaded boxes in italics provides specific
Diabetes ACT Manual – Therapist6information for the group leader, and will be accompanied by the symbol tothe left. This will allow group leaders to know which content isincluded in the patient manual. This does not, mean, however,that group leaders should bring this manual into group, particularlyin the final two modules where having a manual to focus on mayprevent the group leader from attending to process.
Diabetes ACT Manual – TherapistIntroductionBefore any of the modules are started, it is important to lay outsome of the key introductory and safety information. Thisincludes a general introduction of all the members of the group,including the facilitator and any trainees present. When doingintroductions, we typically ask patients to state the followinginformation:1.2.3.4.NameWhere they are fromHow long they have known they have diabetesWhat is most important to themThis exercise serves multiple purposes. First, it provides every patientthe chance to reveal a little about themselves in order to activate themto do more over the course of the group. Second, it gives individuals thechance to see similarities between themselves and other groupmembers. Third, and perhaps most importantly, it sets the tone for thefocus of the treatment – an emphasis on what the individual personallyvalues and how that fits with their diabetes care. Typically patientsreport that what is important to them is family or other closerelationships in their life, and this information is used as a focusthroughout the group.In addition to introductions, another important feature of theIntroduction is to provide information about what patients should do in amedical emergency. Most patients know that they should call “911” ifthey are experiencing an acute emergency, but they may not know whatthey should do if they need non-emergency medical attention right away.It is a good idea to cover these issues at the beginning of the treatment.WHAT TO DO IN AN EMERGENCY1. Call Your Doctor If your emergency occurs during regular business hours or doesn’tneed immediate attention, call your doctor first and have your doctortell you what to do next.2. Call 911 If your emergency is immediate happens after hours (after yourdoctor’s office has closed), or if you are unable to talk to your doctor,dial 911 immediately.7
Diabetes ACT Manual – Therapist8Activity #1Assess Your Own Diabetes CareOn page 3 in the patient manual, there is an exercise entitled,“Assess your own Diabetes Care”. This exercise is a good placeto start the treatment because it provides patients with a clearsense of what their own diabetes care is. Patients should beencouraged to discuss their current level of care, things theywould like to do less or more of, and the barriers to doing thatwith other group members.Activity #1Assess Your Own Diabetes Care1. Rate your current level of taking care of your diabetes, if “0” wasthe worst possible care and “100” was the best possible care2. What do you think you would have to do more of to better takecare of your diabetes?3. What do you think you would have to do less of to better takecare of your diabetes?4. What stops you from being able to take care of your diabetes aswell as you should?
Diabetes ACT Manual – TherapistMODULE IEDUCATION AND INFORMATIONI.II.III.IV.What is diabetes?What does insulin have to do with Diabetes?How did I get Diabetes?What are type 1 and type 2 diabetes? How do I know which typeI have?V.How do I check my blood sugar levels?VI.What are the right blood sugar levels?VII. Do I need to take insulin?VIII. Is there a cure for diabetes?IX.Taking Control of Your DiabetesX.Medical Identification TagOne of the most important things you can get from this workshop is somebasic information about diabetes! This section will provide you with somebasic education and information.I.What is diabetes?Diabetes means that your body has problems with keeping the rightlevels of blood sugar (called glucose). Your blood always has someglucose in it because the body needs this glucose for energy to keepyou going, but too much glucose in your blood is not good for yourhealth. Diabetes keeps your body from turning the food you eat intoenergy, making it so that there is too much glucose just sittingaround. Maintaining the right levels of blood glucose is very, veryimportant for your body.DiabetesWhen describing the mechanisms of insulin to patients, it is agood idea to use examples to elucidate the key features andparticularly how the patients’ own self-management plays amajor role. For example:I like to think of insulin as a key that opens a lock on theoutside of your cells. The food that you eat provides yourbody and each individual cell, energy to continuefunction. When your insulin is not working, as in the caseof folks with diabetes, the cells are not “unlocked”properly.This leads to two problems: 1) the cells do not receive the energythey need, which can lead to fatigue, and 2) the energy, in theform of blood sugar, does not get released into the cells and thusremains in the bloodstream. This creates a higher concentration ofglucose in the blood.9
Diabetes ACT Manual – TherapistII.10What does insulin have to do with Diabetes?Without glucose and insulin, your body will stop running.III.How did I get Diabetes?Diabetes develops when there is a problem with your body’s insulin. (Anorgan called the pancreas produces Insulin). Problems with your insulin canbe: Your pancreas does not make any insulin. (This happens with type 1diabetes)Your pancreas does not make enough insulin. (This happens with type2 diabetes)The insulin your pancreas makes is unable to let glucose enter yourcells. (This happens with type 2 diabetes)IV.What are type 1 and type 2 diabetes? How do I know whichtype I have?Your doctor should have told you what type of diabetes you have. Takingshots of insulin once or twice a day can be part of the treatment of both type1 and type 2 diabetes. With type 1 diabetes your pancreas stops making insulin. Type Idiabetes sometimes starts before you turn 20.With type 2 diabetes, your pancreas either does not make enoughinsulin or it makes the wrong kind of insulin. Type 2 diabetes oftenstarts later in life.For this class and in using this Workbook, you need to know what type ofdiabetes you have been diagnosed with because there are certain thingspeople with each type needs to do in order to better manage their diabetes.VII.Do I need to take insulin?There are two types of medication for diabetes: Pills and insulin injections. Ifyour doctor has prescribed pills for you to take, then you are not takinginsulin directly. These pills help your pancreas make more insulin.If your pancreas is unable to make enough insulin, your doctor may prescribethat you take insulin injections. Type I diabetics are required to take insulininjections. Type II may also be required to take insulin injections.If you are taking insulin injections, your doctor or nurse should have taughtyou how to give yourself the injections. If are not sure how to do this, or
Diabetes ACT Manual – Therapist11you do not know how to do give yourself an insulin injection, please tell yourdoctor right away.InsulinIt is important to have a sense of who in the group is takinginsulin, as there are special issues with this population.Specifically, it is important to talk with these members aboutthe importance of testing blood glucose before injectinginsulin, in order to prevent seriously low glucose levels. In addition, it isimportant to talk with these individuals about whether they have goalsto stop taking insulin (if type 2) and whether they have discussed thisoption with their doctor.Information on Insulin InjectionOver the years, a number of different types and brands of insulin have beendeveloped to meet different needs. Most of those in use today are synthetichuman insulins produced by recombinant technology.Human insulinsgenerally have a more rapid onset and shorter duration of activity than porkderived insulins.Because people don’t respond to individual types of insulin the same way,you will need to work with your doctor to find the right insulin or combinationthat works best for you. Your insulin choice should dovetail with your eatingand exercise patterns, so it’s important for you to plan your insulin intakewith your doctor or diabetes educator.Types of Insulin Very fast acting- The fastest acting insulins are called lispro(Humalog) and insulin aspart (Novolog). They should be injected underthe skin within 15 minutes before you eat. You have to remember toeat within 15 minutes after you take a shot. These insulins startworking in five to 15 minutes and lower your blood sugar most in 45 to90 minutes. They finish working in three to four hours. With regularinsulin you have to wait 30 to 45 minutes before eating. Manu peoplelike using lispro because it’s easier to coordinate eating with this typeof insulin. Fast acting- The fast acting insulin is called regular insulin. It lowersblood sugar most in two to five hours and finishes its work in five toeight hours. Intermediated acting- NPH (N) or Lente (L) insulin starts working inone to three hours, lowers your blood sugar most in six to 12 hours infive to eight hours. Long acting- Ultralente insulin prolongs the entry of insulin into theblood for four to six hours and remains active for 28 hours.
Diabetes ACT Manual – Therapist 12Ultra-long-acting- A new type of insulin, glargine, is injected once aday. Its activity begins in just over an hour and is sustained at arelatively constant rate for 24 hours, without any peaks.Insulin mixtures-There may be advantages of using insulin mixturesand these should be discussed with your doctor. These are usedprimarily by people with type 2 diabetes.
Diabetes ACT Manual – TherapistTypeBrand NameVery fast ingtoOnsetPeak5-1545-903-4Human: Theminuteshoursacting insulin5-8 hoursHuman oftenminutesHumulin R30 minutes 2-5 hoursNovolin R-1 hourDurationCommentsbefore mealsVelosulinfor theHumanfrom foodIntermediateacting13compensatesugar intakeIletin IIRegular30 minutes-2 hours3-4 hours4-6 hoursPork-basedHumulin LHumalin NNovolin LNovolin N1-3 hours6-12 hours20-14hoursHuman16-20hoursPork-based28 hoursHuman:II aL cure4-68-14 hoursVIII. IletinIs thereforhoursdiabetes?Iletin II NPOTENTIAL COMPLICATIONS ARE HIGHLY PREVENTABLE.LongHumulin U4-6 hours 18-28 hoursUsually used in Blindness (see discussion below)acting Foot problems (see discussion below)w/ a faster Finger, toe, and limb amputation combinationacting insulinDeathto provideproper controlatmealtimesUltraLantusInjected oncelong1.1hoursNo peakConstantHuman:concentrationdaily at
Diabetes ACT Manual – Therapist14ChoicesChoice is an important component of this treatment, andplenty of time should be spent on it at this point. First of all,it is important to make a distinction between choices anddecisions, as defined in ACT. A good way to elucidate this iswith the following exercise:For this class, we are going to make distinction betweenchoices and decisions which may help how you think abouttaking care of your diabetes. For our purposes, decisions aremade for reasons, and choices are made with or withoutreasons, but not for or because of them. So for example, youmay decide to go to a movie because you like the actors, wantto get out of the heat, etc, but you could choose to go to themovies whether or not you like the actors and whether or notyou want to escape the heat; really for “no reason” at all.Okay, so understand? Great. Can I get a volunteer? Okay,now all I want you to do is play a little game with me. Say Ihave a can of Coke in this hand and a can of diet Coke in theother (the use of diet and sugary Coke for this example helpsaddress some of the difficulties inherent in these choices fordiabetes, where food rules may be particularly salient), andyour job is to choose one or the other. (Patient selects one orthe other). Great, now why did you choose that? (Patientreplies, typically with a reason). Oops, I said “choose” one orthe other. Try again, do you choose diet Coke or Coke? (Thiscontinues on until patient does not provide a reason or repliesthat they chose for no reason. This is then directly discussedin terms of diet and regular soda, and how patients may“decide” between one or the other for many reasons, but thatthe goal here is to choose with or without reasons and move inthe direction of their values).Another important aspect of choice is the distinction that is madethroughout this treatment between choosing what you do versuschoosing what you feel. Many of these patients may provide detailedreasons why they cannot take care of their diabetes, and the emphasisis consistently placed back on what they can do to improve their health.YOU HAVE A CHOICE!You are in charge of your health, and you get to choose what actions youtake to take care of your diabetes.We aren’t telling you the bad things that can happen to scare you into doingsomething you don’t want to do. We know that won’t work.
Diabetes ACT Manual – Therapist15We also know a few other things: We know we can’t follow you around andmake you do things you don’t want to do.That’s why we want you to choose the health you want to have. By comingto this Workshop and using this Workbook, you are choosing a life withbetter health, instead of ignoring your diabetes and having potentialcomplications.KNOW YOUR BODYWhen you have diabetes you have to keep your blood glucose level inbalance. Your doctor will tell you what these levels are and how you shouldtest to check your levels.Each person with diabetes will have different symptoms when their bloodlevels are out of balance. One of the hardest things about having diabetescan be when a person doesn’t know what is happening to his or her body.There may be things happening to your body even though you don’t know it.This condition is called being asymptomatic. You don’t know want to waituntil you show signs of problem to take charge and make changes.It is important to know how your blood level balance affects you. Here issome important information that will tell you what different levels of glucosefeels like for many people, and what you should do if those levels are toohigh or too low.You must check your blood sugar before attempting to decrease orincrease your levels because some symptoms of blood sugar problems can besimilar. That is, problems with very high or very low blood sugar levels canlook the same, but the treatment of these would be very different. DON’Tassume that you have very high or very low levels – DO check before youadjust!V.How do I check my blood sugarlevel?After you have pricked your finger, squeeze a small drop of blood onto thetest strip. This test strip is inserted into a blood sugar meter, or you cancompare the color of the strip to a color chart to figure out your blood sugarlevel.
Diabetes ACT Manual – TherapistRemember that not all blood sugar measuring devices are the same. Makesure that you read the instruction carefully before you prick your finger. Ifyou are having difficulties setting the device ask your family, friends, ordoctor to assist you with the device.Blood TestingTesting blood sugar is an important aspect of good diabetescare. It is important to create a space where patients feelcomfortable admitting whether or not they test their blood,because often patients do not test because of fear of the painof testing. This is a wonderful opportunity for in-vivoexposure. Depending on how the class is structured, it maybe helpful to have folks bring their testing kit to class andprovide a demonstration. Another thing that is helpful foryou, the class leader, to also have a kit and test with thepatients if you ask them to do it in class. This not only givesthe opportunity to show continuum on which blood glucoseproblems are situated, but it is often seen by the patients asvery supportive.Remember these tips on blood sugar testing: VI. Get instruction on how to test your blood sugar levels from yourphysicianWash your hands and dry them well before doing the test.Pay attention to expiration dates for test strips.Use a big enough drop of blood.Be sure your meter is set right.Keep your meter clean.Check the batteries of your meter.Follow the instructions for the test carefully.Write down the results and show them to your doctor.Use a spring-loaded device that pricks your finger when you press itagainst your skin. This makes it much easier!Some fingers tend to be easier that other. Find the ones easiest foryouRunning warm water on your finger can help you easily access toflowing blood.What are the right blood sugar levels?Talk with your doctor about what range of blood sugar levels is bestfor you.A good goal is:o 90-120 before mealso 115 to 140 after mealsNot everyone with diabetes can get their blood sugar levels this low16
Diabetes ACT Manual – Therapist17Be sure to talk with your doctor about what to do if your blood sugar levelisn't within the range that's best for you.What is Hemoglobin A1c?Hemoglobin A1c measures the average blood sugar levels over 2-3 months of90-day period. High levels of Hb A1c increase the chances of a individuals tobe at risk for kidney disease, blindness, and or amputations. Research asshown that well monitored diabetes shows a lower incidence of complicationsin diabetics. It is important to have your blood drawn every three to fourmonths to have your Hb A1c evaluated. The red bloods live about 120 daysand this blood examination measures the percentage of red blood cells thatare coated with glucose over 3 –4 months of the cells life.If you change your diet and exercise, you would see a change after 90 days.Consistently high values means you are consistently having high sugar,which can cause damage to your eyes, blood vessels, feet etc. The ideallevel of Hb A1c is between 5 to 6, which reflects a blood sugar between 80 to120.What is glucose?Glucose is your current blood sugar. It is like a Polaroid snapshot of thatmoment. Glucose is a product of the body’s assimilation of sugars and asource of energy. Carbohydrates (sugars) are present in the form of glycogenin your body. The end product is glucose, which is formed during digestionof foods and absorbed from the intestines into the blood stream via portalvein.HbA1c vs. Blood GlucoseIt is important to make clear the distinction between BloodGl
Commitment Therapy, and the principles and mechanisms espoused by ACT. This is important because a main focus of the treatment is helping individuals untangle their thoughts and feelings about having diabetes from their behavior relating to t
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Acceptance and Commitment Therapy (ACT) is a mindfulness-based, values-directed behavioural therapy. There are six core processes in ACT: The Essence of ACT: 2 major goals Acceptance of unwanted private experiences which are out of personal control
