Last summer, the journal Insulin published What people with diabetes want their caregivers to know: Development of the TCOYD patient concensus statement” based on the results of a workshop I ran at the 2004 Raleigh Taking Control of Your Diabetes conference. I’m going to look at three items from the patient consensus statement and show how they relate to bits of positive psychology that contribute to good health.
Before you turn the page, this topic isn’t confined to people with diabetes. The same skills and awareness that help one person live well with diabetes can help someone live with a different chronic health condition or help anyone live in ways that contribute to good health.
“When first diagnosed, we don’t know what to ask you. We are also overwhelmed by the new medications, new health dangers, and life style changes. We need help learning how to play the central role in our own care.” #1 in the Patient Consensus Statement.
The person most in charge of your medical care is you. You can’t take doctors and nurses home to help you manage the health-related choices and actions you have to make every day. So how do you gain the confidence that you can manage?
Build self-efficacy with respect to health management. Albert Bandura defines self-efficacy as “people’s beliefs about their capabilities to produce designated levels of performance that exercise influence over events that affect their lives. Self-efficacy beliefs determine how people feel, think, motivate themselves, and behave” (1997).
Bandura describes 4 ways to increase self-efficacy in decreasing order of effectiveness: have mastery experiences of your own, experience vicarious mastery by observing people like yourself achieving mastery, listen to social persuasion, and learn how to interpret physical stress symptoms constructively.
Achieving personal mastery means keeping challenges within your grasp with appropriate support. As you gain self-efficacy, the challenges you can handle get bigger and the need for support gets less. Appreciate the support, and appreciate how you need it less and less as you practice.
Vicarious mastery means finding people who are a lot like you who are achieving mastery. I remember enjoying the speech given by the diabetic who traveled to the South Pole, but it didn’t increase my own sense of mastery. But when I was a pregnant, hearing stories of women who had just gone through successful diabetic pregnancies was a big help. Find people like you to emulate.
People with high self-efficacy view symptoms of physical stress as an “energizing facilitator of performance”, while people with low self-efficacy find them debilitating. Diabetes is a never-ending balancing act between blood sugar being too high or too low. The inevitable tilts in either direction result in unpleasant physical responses. One way to increase personal confidence is to work on using these tilts as motivators for change, rather than as proofs of personal inadequacy.
A lot of good health is making good decisions. I’ve been a Type 1 diabetic myself for 29 years. Let’s assume I make at least 10 diabetes-related decisions a day, for example about what to eat and when to stop eating, whether and how to exercise, when to take medications, and whether I am in a fit state to drive or talk to clients. Over 29 years that comes to over 100,000 decisions. In the quest for good health habits, it is crucial to learn how to make decisions well.
“Because we are the ones who make the daily decisions about our own care, including what to eat, when to test, when to exercise, when and how to take medications, we need to participate in the big decisions in order to be motivated to make these daily decisions correctly.” #4 in the Patient Consensus Statement.
Understand how self-regulation works. Roy Baumeister and his colleagues have demonstrated that self-regulation works like a muscle in two ways. In any particular situation, self-regulation gets exhausted by use. The first decision to turn down an unhealthy snack is easier than the second, which is easier than the third. This supports the common sense view that it is better to avoid temptation than to struggle with it.
Self-regulation can also be strengthened through exercise, and that exercise does not have to be specific to any particular situation. So if you want to have a stronger self-regulation ‘muscle’ when it comes to refusing food, exercise it in some other low cost way, such as straightening your spine every time you detect yourself slumping.
Diabetes makes high demands on self-regulation — eating the right quantities at the right times, resisting excess, exercising regularly even when you don’t feel like it, taking medications. Think about conditioning your self-regulation.
Satisfice, don’t maximize. Satisficers make good enough choices, while maximizers hold out for the best possible choices and always fear that they have missed making them properly (Schwartz, 2004). There are so many decisions to be made with diabetes. Trying to make them all perfectly can lead to exhaustion and discouragement.
Several points in the consensus statement, including the one below, have to do with dealing effectively with bad news.
“We have deep emotions about dealing with diabetes. We are fearful of complications. We worry about being a burden to our families. We feel like failures when our individual blood sugar values and/or A1c are not good. This sense of failure sometimes makes things worse – we give up on taking medications, testing, exercising, and being careful about what we eat. We need help keeping our complications and numbers in perspective. If we are truly failing, most of us want to know. But if we are not, we need help moderating our self-blame.” #10 in the Patient Consensus Statement.
There are several resilience techniques associated with positive psychology that help people deal with the inevitable negatives of life. Here are a few.
Learn to interpret bad events as temporary and specific, rather than permanent and pervasive (Seligman, 1998). It is so easy to get a high blood sugar reading and think, “I am just no good at managing anything about my diabetes ever.” Moderate self-blame by reducing the scope of judgments like this, for example to “Oops, I forgot to take my breakfast insulin. Everybody forgets things occasionally.”
Reframe negative interpretations. When you are interpreting an event, you have many choices about the meaning you assign to it. Some choices leave you feeling powerless and weak. Others put you in a position of control. Here’s one of my examples. I used to stare at my morning medications and think, “Taking so many pills means I am a medical train wreck.” One day I tried a different interpretation. As I took each pill, I had thoughts such as “This is me bravely facing up to the fact that neither my pancreas nor my thyroid work properly,” and “This is me prudently doing what I can to prevent kidney damage.” There’s no denial of the negative here, just a different point of view that makes me feel powerful rather than diminished. There are other great ideas for resilience in Reivich and Shatte (2002).
Marshall and value positive emotions.. According to positive psychologist Barbara Fredrickson, positive emotions such as contentment, satisfaction, interest, joy, elevation, and love broaden our behaviors and build durable resources, including physical health. There’s a hitch. Positive emotions tend to be less salient than negative emotions. So it takes more of them to come out ahead – by some calculations, at least 3 to 1. So take time to celebrate small successes, seek out things to be interested in, view each positive emotion as a positive contribution to your good health. Above all, don’t take the things you do well for yourself for granted.
Let me close by taking the spotlight off of diabetes. We are so much more than our physical limitations.
Pay attention to your own happiness. According to Sonja Lyubomirsky in her new book, The How of Happiness, happier people are more resilient in the face of hardship, have stronger immune systems, and are physically healthier. Happy people even live longer.
Yes, there is a genetic element to happiness. Some people find it easier to be happy than others. But there is also a substantial part of the differences in happiness among people that is attributable to intentional activity. Happy people do things to make themselves happy. They practice gratitude, cultivate optimism, nurture social relationships, practice mindfulness, and so on. Trying out some of the activities in Sonja’s book could be one of the best things you can do for your health. The efficacy of the techniques she chose have been studied almost as much as the efficacy of the pills you take.
Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84<2), 191-215.
Baumeister, R. et al (pre-publication). Self-regulation and personality: How interventions increase regulatory success and how depetion moderates the effects of traits on behavior. Retrieved 7 March 2008 from http://www.psy.fsu.edu/~baumeistertice/baumeisteretal2006.doc
Edelman, S. & Britton, K. (2007). What people with diabetes want their caregivers to know: Development of the TCOYD patient consensus statement. Insulin, 2 (3), 146-147.
Lyubomirsky, S. (2008). The How of Happiness: A Scientific Approach to Getting the Life You Want. New York: Penguin Press. See also the PPND review. If you are worrying about the buzz right now about Eric Wilson’s book, Against happiness: In praise of melancholia, check out Sherri’s response.
Reivich, K. & Shatte, A. (2002). The Resilience Factor: 7 Keys to Finding Your Inner Strength and Overcoming Life’s Hurdles. New York: Broadway Books.
Schwartz, B. (2004). The Paradox of Choice: Why More Is Less. New York: Harper Collins.
Seligman, M.E.P. (1998). Learned Optimism: How to Change Your Mind and Your Life. New York: Free Press.
Two pieces of research that are relevant to this article.
Self regulation can be objectively measured using Heart Rate Variability.(Psychological Science, Volume 18, Issue 3, March 2007, Pages 275-281). By the way HRV is also used in psychology to measure stress resilience.
Your approaches to stress are very western. Research shows mindfulness is a powerful stress management technique. eg http://www.innate-intelligence.com.au/blog/?p=87
Thanks for your additions, Wayne, particularly the extension to mindfulness as a stress management technique. I knew I couldn’t be exhaustive, given the word limit, so I particularly appreciate people throwing in other ideas.
I appreciate your dilemma about the list of interventions for stress but their is compelling research highlighting the importance of mindfulness. By the way mindfulness boosts self regulation and both are related to HRV.
Thanks for your additions to the list.
Any pointers to the research about mindfulness and self-regulation?
Perhaps I can add them to the reference list.
HRV = Heart rate variability, right? Could you say more about its importance?
I have sent several articles through to your personal email. Read them and if you think they are worthwhile then might wish to publish the references.