Diabetes and the Process of Behavioral Change
In 1983, Prochaska et. al published "Stages and Processes of Self-Change of Smoking: Toward an Integrative Model of Change" in the Journal of Consulting and Clinical Psychology, Volume 51, No. 3, 390-395. Although the paper targeted smoking cessation, this change model has been applied and is appropriate in many clinical situations. The ability to manage diabetes is not a static process. There are periods in the lives of those with diabetes in which management may not be the number one priority. These periods may include major life events (both happy and sad) and, particularly in my diabetes practice, changes in growth and development. As children mature from toddlers through school age and finally adolescence, it is clear that both physical and emotional changes result, thus making diabetes care a continued challenge.
Prochaska defined the following stages in the Process of Change:
The above process has been the basis for much of the psychosocial therapy for those that wish to make behavioral change. The key to understanding this table is that to change behavior, one must move from pre-contemplation to contemplation to action and then maintain the behavior. Movement through the steps is a process and maintenance is often difficult with frequent missteps. A practical illustration of the process is in order.
A 14-year-old teen with a 10-year history of type 1 diabetes presents to the diabetes team for the first time after moving from another city. Her hb A1c is 12 and her downloaded meter indicates one blood glucose check per day. Of course the family and diabetes team know that for the young lady to improve her glycemic status she must increase the frequency of testing and administer the appropriate amount of insulin. The parents cannot make the child do these self-care tasks (often we ask the family to assume more responsibility of the child/teen is unable). Our healthcare team becomes involved to try to move the child/teen from one stage to the next.
Teen: "There is no way I am going to check my blood sugar more than once a day."
Healthcare Team: "Why not?"
Teen: "I have more important things to do in my life then to check blood sugars. Besides, I don't want anyone to know I have diabetes."
Healthcare Team: "So, no point to try to explain why you need to check?"
At this juncture, it is probably not going to be a productive conversation to try to convince the teen of the importance of SBGM. The goal is to try to move them to the next stage "contemplation" wherein the teen is beginning to wonder if checking blood sugars might make them feel better and perhaps improve track times or grades in school. The healthcare team may then begin to start work with the teen to move them towards making changes. Once the teen acts to increase SBGM, the key is to maintain that behavior. This is hard and relapse often occurs.
Frank Snoek and T. Chase Skinner in Psychology in Diabetes Care, discuss the process of change in the chapter "Diabetes in Adolescents." The authors stress that diabetes programs use approaches that are designed to enhance the self-efficacy (confidence that the desired task can be successfully completed) of children and teens. He states that the key to success is to understand that health professionals must understand that "self-efficacy is the key to productive working relationships with adolescents and young people with diabetes." So, how does the caregiver move the child or adolescent through Prochaska's stages of change?
I believe that Drs. Snoek and Skinner provide a very realistic means to achieve the path towards positive self-care behavior. He states that the "techniques that develop self-efficacy (mastery experience, modeling, verbal persuasion and emotion regulation) are not enough to facilitate change." To have successful psychosocial interventions using these or other techniques, healthcare professionals must adopt the appropriate attitudes as well as have certain qualities. These qualities would include:
1. Acceptance of the child/teens' behavior and beliefs
2. Respect for each individual's decision
3. Curiosity to understand the world in which these children/teens live so that the professional may understand what drives their decision-making
4. Honesty from the healthcare provider so that the child/teen can understand what drives the professional's beliefs.
The premise by Dr's Snoek and Skinner is that for a therapeutic relationship to be successful, these attitudes and qualities may even be more important than the particular techniques or strategies employed by the healthcare professional.
The take-home message is that for positive change to occur, it is my belief that there must be a positive therapeutic relationship with the healthcare team. Change is difficult and there must be unqualified support from both the family caregivers and the healthcare team even at times when it appears most difficult. Also, keep in mind, that family caregivers and healthcare professionals cannot always be perfect in terms of the best approach with a particularly challenging child/teen and that relapses occur for them as well.
We must do our best and keep trying.