Case Study 1: Dual-process model

Dr. Wendy Maltinsky, University of Sterling.

This case study explores the challenges facing people with insulin dependent diabetes and the use of behaviour change techniques to support lifestyle change.

Diabetes is a long-term condition consisting primarily of two types: type 1 diabetes (T1D) and type 2 diabetes (T2D). People living with T1D are typically diagnosed at a young age. Individuals learn to manage the condition through balancing blood glucose levels with monitoring diet, physical activity, insulin injections and checking for foot health. It is important for individuals to manage diabetes self-care behaviours to achieve good health outcomes and to minimise the risk of some of the complications of the illness. Diabetes self-care behaviour needs to commence immediately on diagnosis particularly in managing insulin and glucose balance. A high level of health literacy is required but also basic literacy and numeracy in order to calculate and balance blood glucose levels with insulin requirements. Some people with T1D report that despite their good efforts to adhere to self-care behaviours, disease complications develop and they lose confidence in how and what to do.

T2D is typically diagnosed at a later age and was previously called late-onset diabetes for this reason. Its aetiology is different from that of T1D however; instead of the body not being able to produce insulin as in T1D, in T2D, the body either stops producing sufficient insulin or the insulin produced is not effective (www.diabetes.org.uk). Normally after diagnosis, individuals are advised to manage their weight, encouraged to follow a healthy diet with lower intake of carbohydrates and to increase activity. At early stages, insulin is rarely prescribed, and if it is, it is normally taken orally in the form of a tablet. At early stages of T2D, individuals may not feel unwell or their symptoms may not be particularly noticeable. Symptoms such as going to the toilet more often, feeling more thirsty or tired may have a limited impact on their daily life. Nevertheless, despite not experiencing ill health, to avoid disease progression and to maximise health outcomes, changing lifestyle factors is important. Many who are diagnosed may be older and accustomed to living particular lifestyles making change difficult.

In both cases, understanding what to do is important. Knowledge of what to do on its own, however, is often not sufficient to lead to successful outcomes (Ahola & Groop, 2013).  While people may know what to do, they may find it difficult nevertheless to undertake the tasks required that are routine and require continual monitoring. To achieve good self-management of lifestyle factors and manage all of the diabetes self-care behaviours, it is necessary to navigate a wide range of environmental, social and/or personal barriers.

Consider the barriers to changing behaviour and how these may differ between the two conditions.

Consider the barriers to changing behaviour and how these may differ in different socioeconomic environments.

Building self-efficacy may be one approach to supporting people to change behaviour. Think about what intervention might be introduced to support self-efficacy to change one diabetes self-care behaviour.

References

Ahola, A. J., & Groop, P. H. (2013). Barriers to self‐management of diabetes. Diabetic Medicine, 30(4), 413–420.

www.diabetes.org.uk

Case Study 2

This case study considers the role of health care professionals in behaviour change with particular reference to people with type 2 diabetes (T2D).

Health professionals can act as important conduits of health behaviour change for people. In the case of diabetes care professionals, much of diabetes care management for people with T2D is undertaken in collaboration with primary care staff including GPs, podiatrists, practice nurses and dieticians (Eccles, Hrisos, Francis, Stamp, Johnston, Hawthorne ... & Hunter, 2011). Typically, diabetes health consultations consist of checking health status, but may also provide guidance on what patients should do in order to increase health and minimise risks that can be the outcome of suboptimal self-management (Hawthorne, Hrisos, Stamp, Elovainio, Francis, Grimshaw ... & Eccles, 2012).

To support behaviour change, there are different methods that health professionals can use (Swanson & Maltinsky, 2019). It is important that individuals know and understand the potential risks of disease progression and complications; however, concentrating on fear measures can be counterproductive.  Fear messages can increase anxiety, which in itself may interfere with efforts to change behaviour. Motivation to change behaviour is important but again is not in itself sufficient for behaviour change and may fluctuate widely dependent on a range of factors such as different environments, mood, cognitive load, social contexts, etc.

Behaviour change techniques (BCTs; Michie et al., 2013) are useful in helping people to change behaviour. The health behaviour change competency framework (Dixon and Johnston, 2010) has categorised behaviour change techniques according to those that help people to build motivation, those that help people to put positive action through creating plans and those BCTs that assist people to review their environment in order to build prompts and triggers that help make change more simple, therefore termed Motivation, Action and Prompt (MAP) techniques framework.

This takes account of the dual-process approach to understanding behaviour (Strack and Deutsch, 2004). The dual-process approach suggests that behaviour is influenced by our rational conscious approach to a planned approach to change. At the same time, an automatic route to the behaviour can over-ride this planned route. Habit, for example, if we have done the same thing repeatedly, may result in repeating the old behaviour and forgetting to use the new behaviour. On one hand, people who want to change behaviour can make clear and unambiguous plans to change behaviour, and, on the other hand, they need to manage the automatic routes to the behaviour by changing the environment. An example might be to place a water bottle in the fridge by the milk to act as a prompt to take it to work.

Think of examples of how a dual-process approach could support a behaviour change you have been intending to make.

What might be some of the challenges that health professionals may have in changing their behaviour to use different BCTs in practice settings?

How can a dual-process approach for behaviour change be used to help to train health professionals to change their practice?

References

Dixon and Johnston (2010) Health Behaviour Change Competency Framework. http://www.healthscotland.com/documents/4877.aspx

Hawthorne, G., Hrisos, S., Stamp, E., Elovainio, M., Francis, J. J., Grimshaw, J. M., . . . & Eccles, M. P. (2012). Diabetes care provision in UK primary care practices. PLoS One, 7(7), e41562.

Michie, S., Richardson, M., Johnston, M., Abraham, C., Francis, J., Hardeman, W., . . . & Wood, C. E. (2013). The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Annals of Behavioral medicine, 46(1), 81–95.

Strack, F., & Deutsch, R. (2004). Reflective and impulsive determinants of social behavior. Personality and social psychology review, 8(3), 220–247.

Swanson, V., & Maltinsky, W. (2019). Motivational and behaviour change approaches for improving diabetes management. Practical Diabetes, 36(4), 121–125.

Case Study 3: Diabetes/illness acceptance

Liz Whelen, University of Chester

‘Carla’ is 24 and works two jobs to make ends meet. Both are zero-hours contracts, so if she does not go to work, she will not get paid. She works in the hospitality sector, with one job being bar work and the other waitressing, and so she primarily works late shifts. She is also trying to study for a degree with the Open University to improve her prospects as she wants a more regular and daytime job.

Carla tends to eat on the run – sometimes with late night takeaways or visits to McDonalds on the way home from work, with some food grabbed from leftover food when she is waitressing. Often, she will get in and find nothing to eat in the fridge, but she is too tired to go to the shops, so she grabs something from her local shop on the way to work. In the last 9 months, she has felt more tired than usual and feels thirsty all the time, and she has also lost weight which she thinks might be due to her irregular hours and eating patterns. She is quite happy about this as she has found herself piling on the pounds in the last year. She was also suffering from what she thought was a bout of thrush, but over-the-counter medication was not helping, so she went to her GP to get some stronger medication.

After a long chat about her symptoms and lifestyle, her GP sent her for blood tests, which showed she was suffering from type 2 diabetes. This has been a real shock for Carla. She has seen the dietician and been given advice on lifestyle as well as medication, but she feels it is all overwhelming and she doesn’t totally believe her diagnosis. The suggested changes to her diet and lifestyle are also something she thinks she will struggle with alongside her work.

Discussion questions

1.   How might you use psychological approaches to help Carla accept her diagnosis?

Case Study 4

Adjustment disorder arising from conversion disorder

Dianne Perrett-Abrahams, Forensic & Health Psychologist, Victorian Occupational Support Service

This case study explores the impact of conversion disorder resulting from a workplace injury and the resulting delicate psychological condition of the patient.

Ms. P reported that she suffered a workplace injury in 2003 by way of a heavy fall, on a slippery walkway, in which she injured her spine and knee, five weeks after commencing new employment. A workers compensation claim was implemented and accepted. She reported that following her fall she spent 5½ months in hospital and stated that during her rehabilitation she lost significant motor skills, specifically in her lower limbs initially. Her rehabilitation was conducted at various facilities including a regional hospital, and city hospitals and rehabilitation facilities. Multiple and repeated tests were undertaken, which did not reveal a physical diagnosis. Ms P was ultimately diagnosed with a conversion disorder. A further diagnosis of Dupuytrens contraction was identified, affecting both hands, and in this patient’s case, likely caused from weight bearing on her hands when transferring in and out of a wheelchair and propelling herself in a wheelchair. Her condition has deteriorated to a stage where she can no longer sit up, or hold her head up and she suffers phases where she cannot speak.

She is treated by a health psychologist who has diagnosed a chronic adjustment disorder, arising from her severe and increasing conversion disorder, which has emanated from her workplace injury.

Ms P has been compelled to reside in a nursing home since 2010, as a consequence of her substantial loss of upper body strength and increasing incapacity. Such deterioration has involved loss of neck muscle strength; causing profound head instability. Her presentation is indicative of severe quadriplegia. Her upper body regression has caused added symptoms of increased and ongoing pain in her shoulders, elbows, wrists and hands with sciatic pain in her mid to lower back and buttocks. She is unable to manage without intense nursing and is now bed-ridden mostly. She requires full-time carers to assist her at all times and when she occasionally goes out of the nursing home she must be accompanied by two carers with her mobilisation in a specialised electric wheelchair. Ms P utilises a wheelchair which requires extension to almost a fully reclining position, necessitated by the patient’s inability to sit up or control her head. This wheelchair, however, is unstable and dangerous and has caused Ms P numerous falls from the chair as it is prone to tipping over.

Of psychological necessity, Ms P needs to reside in her own purpose-built home with full disability aids tailored to her needs. In her psychologist’s view, an aged care facility designed for residents until their death is inappropriate for Ms P at age 43. Further, Ms P reports that the aged facility are short staffed and she reports neglect regarding hygiene needs.

To sustain such independent care, she requires two carers during the day with a carer at night to turn her every two hours due to her inability to turn herself. This is essential to reduce pulmonary compromise and bed sores.

Ms P requires a minimum of 30 carer hours per week while she resides in the nursing home. Without carer assistance Ms P is isolated and bed 24-hour day. The impact psychologically to this patient cannot be overstated and will, in her psychologist opinion, provoke and engender significant depression and anxiety and increased psychological crisis.

Ms P reported that she is required to take an extensive array of medication to relieve her condition. She is prescribed venlafaxine for depression, with analgesics and anti-inflammatory drug therapy.

Psychological treatment intervention is comprised of CBT, cognitive reconstruction, psychotherapy and strategies to engender distraction with modalities incorporated in therapy to assist the patient in coping with a devastating disability. Ms P, in her psychologist’s opinion, suffers from a chronic and severe adjustment disorder with depression arising from a maladaptive response to the ongoing stress of having a chronic disability with such disability incorporating a chronic complex regional pain syndrome arising from a workplace injury on 14 May 2003 with ongoing sequelae diagnosed as conversion disorder in 2006.

Symptoms of conversion disorders may appear suddenly after a stressful event, or with emotional or physical trauma. Conversion disorder is still a poorly understood diagnosis in adult patients and even more so in children. The term ‘conversion disorder’ refers to the conversion of emotional stress to physical symptoms. However, these same kinds of physical and sensory problems can occur with or without known psychosocial or traumatic stressors. An adjustment disorder can arise from maladaptive ways of coping after a stressful event or events.

Discussion questions

• How significant is the stress or emotional or physical trauma in understanding conversion disorder?
• What is the relevance of an adjustment disorder in this case study and how does such a disorder impact on treatment efficacy?
• Some symptoms of conversion disorder, specifically, if not treated, can result in substantial disability and impoverished life quality, similar to chronic medical pathologies. How do health psychology interventions on adjustment disorder provide better health outcomes for such individuals?
• Are women more likely than men to develop conversion disorders?