help. ‘It sounds as if you have a number of concerns about your eating and weight.
Which would you like to talk about, or shall we talk about these one by one?’ Vague solutions to vague problems will never be effective, so clarify statements; ‘You say that ‘‘it ’’, that is the diet, always makes you feel bad ’.
By drawing out these emotions and feelings it is possible to clarify exactly what the patient is trying to say.
It is important to identify their concerns about diet, health, weight and diabetes as these will influence both their behaviour and outcomes, and determine the agenda for the discussion.
Reflecting feelings is important and needs to be dealt with as they arise.
Recognising signs, verbal and non-verbal, will help with this.
Watch out for giggling, tearfulness, fidgeting, wringing of hands, crying, etc.
Feelings must be acknowledged and labelled; ‘you seem to be angry with the way events have gone’, . . . ‘I sense you’re frustrated with your diabetes’, . . . ‘it sounds like you felt let down’, . . .
Acknowledging feelings as they arise is another way of indicating that you have heard what the patient said, and are able to empathise with the feelings that a certain situation or event has caused.
It shows understanding and demonstrates active listening is taking place.
Open discussion provides valuable insight into the attitudes, beliefs and lifestyle that have influenced patients’ eating behaviour.
They may have encountered different messages, approaches and attitudes towards diabetes, weight and eating in the past.
These will have influenced their behaviour and need exploring (23).
While information-giving can improve confidence and reduce anxiety, be clear why information is being given, find out what the patient already knows, ask patients’ views before giving your own (20).
Patients need to be given the opportunity to talk and the environment should be conducive towards this.
Acknowledge the patient’s expectations and allay their anxieties.
The key to any good discussion is an understanding of the patient’s current situation.
How are they coping with the diagnosis, are they ready to make changes, and what is the level of personal responsibility for the management of their diabetes (24)?
These factors will determine the type of responses that are required, as well as the type of strategies that may be used (24,25).
In summary, to start the consultation: .
Use open questions , to establish rapport , to identify patients’ concerns , to examine patients’ beliefs, attitudes, values and understanding of diabetes, weight, eating and exercise , A typical day can help to open discussion .
Use closed questions to clarify points. .
Use silence to allow thoughts to be gathered. .
Reflect content to check understanding.
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. Acknowledge and reflect emotions as they arise. . Paraphrase and clarify points as they arise.
EXPLORING PROBLEMS WHICH PATIENTS PRESENT
Eating habits are intensely personal and are a result of nutritional, emotional and social components such as family pressures, lifestyles, beliefs about food and diet (26).
Successful management means considering all of these factors.
If only the nutritional component is taken into account, poor dietary compliance may be the result of a failure to adopt a comprehensive educational model that considers emotional and social dimensions (27, 29).
Past problems may need exploring to enable patients to examine their understanding of previous events and help them identify what was difficult about the task that they had been set and how it could have been made easier.
This is an essential step if they want to avoid similar pitfalls in the future.
We learn from our mistakes and from our own life experiences, not from other people telling us what to do.
This is probably the hardest lesson for health professionals, as we want them to get it right all the time.
Letting go can be difficult.
Concreteness can be a way of interrupting long vague stories, with clarifying questions, concrete paraphrases and reflections. ‘What happened exactly . . . what did you say . . .
How did you react . . .
Have I got this right, on the one hand you have had all these difficulties that have prevented you from doing the things that you want to do, and equally you have discovered an amazing ability to cope and get on with things?’ Emotions experienced by the patient need to be explored and expressed by the patient.
They form an important part of the picture of how the patient is coping in relation to food, weight and diabetes, and as such provide valuable insight.
They can help to explain why people eat when they are not hungry.
In practice this can prove a dilemma, as responding to emotional issues and avoiding a problem-solving approach is difficult.
Instead of providing answers we need to help patients draw from their own conclusions about how to manage or solve such issues for themselves.
Dealing with emotions can be hard, and professionals can find it upsetting, or even frightening, and may worry that they will make things worse if people shout or cry.
However, the reality is that people appreciate expressing their feelings or even simply having them labelled.
Completely ignoring emotions, or belittling them by saying ‘It’s not that bad, everyone feels that’, is not helpful but it may serve to make you feel better and safe.
Emotions have a major role to play in dietary education, and the link between emotions and eating is well established (28,30, 32).
So aim to get people thinking through their behaviour and reflecting on past experiences.
COUNSELLING IN DIABETES 39
Empowerment is a philosophy of diabetes care that uses as its base a four-step counselling approach.
Its use in diabetes care has been increasing over the last few years, and it encompasses a lot of the areas discussed in this chapter (33).
Useful questions from this work are ‘What part of your diet is the most difficult or unsatisfying for you?’, ‘How does that situation make you feel?’, ‘How would this situation have to change for you to feel better about it?’ In summary, to explore the issues raised: .
Use open questions. .
Explore the emotional aspect of issues raised. .
Aim to get people thinking through their behaviour and reflecting on past experiences. .
Clarify by paraphrasing and concreteness to check issues being addressed are the real concerns of the patient.
Agreeing goals Having clarified a patient’s concerns and focused on the emotions behind them it is now necessary to look at self-care management options available to the patient.
What self-care behaviour are they willing to make and commit to?
Remember that you are still facilitating the process and the patient should be fully instrumental in the decision process, so negotiation is vital (31).
If a patient suggests a change, they are far more likely to follow it through and to understand their responsibility for the solution and ultimate control of the diabetes lies with them.
Inflexible advice can be negative as it will lower self- esteem and make the patient more resistant to change (34).
By allowing the patient increased autonomy, on the other hand, you can identify those who are poorly motivated and find ways to increase their motivation and alter methods of care appropriately.
Rollnick et al. (21) describe two aspects to motivation or readiness to change.
These are ‘importance’ and ‘confidence’.
Importance looks at the ‘why’ aspect of change, and confidence looks at the ‘how’ and ‘what’ aspect of change (see Figure 3.2).
This can help to break down a difficult area of behaviour change by focusing on the aspect that, for the patient, is inhibiting or preventing change.
For example, the patient may understand the importance of change but lack the understanding or skills to make the practical changes required.
Alternatively, you may have a patient who is confident that they could change their diet as they have done so in the past.
They have the necessary information to do this, but they do not perceive the change as important and so action has not been taken.
Decisional balance can also help, as weighing up the pros and cons with patients can assist them to focus on the issues around change.
List factors that will support change and highlight how the proposed action will be beneficial.
40 NUTRITIONAL MANAGEMENT OF DIABETES MELLITUS
Figure 3.2 Readiness to change Reproduced from Rollnick et al. (21), p. 22.
At the end of the discussion key concerns should have been identified, summarised and key points or individual goals negotiated and written down.
A patient-centred personalised problem-solving educational process should have taken place where collaborative goals are set, and both barriers and supports in patients’ social environments are identified.
Useful empowerment questions to help this process would be: ‘Are you willing to take action to improve the situation for yourself ?’, ‘Are there some steps that you could take to bring you closer to where you want to be?’, ‘Is there one thing you will do when you leave here to improve things for yourself ?’ In summary, when agreeing goals: .
Weigh up the pros and cons of change. .
Explore the patient’s motivation, using Rollnick et al. (21). .
Allow the patient to identify and set their own goals.
FACILITATING CHANGE
EVALUATING EFFECTS OF DECISIONS AND ACTIONS When focusing on dietary management of diabetes, discussions of issues other than food will achieve a clearer picture of the events or triggers related to
COUNSELLING IN DIABETES 41
certain eating behaviours, and allow better understanding of why the patient eats in a particular way. Exploring ‘what if’ situations helps to equip the patient with more life-management skills, especially once they have a greater understanding of their own behaviour. For patients, their real concerns are being listened to and knowing they are learning to cope with their diabetes.