April 30, 2020 Diabetes Management in the Age of COVID: How Do We Help People Maintain Focus on Self-Management

Grace Leeder: Okay, so. Hi, everyone. Thanks for joining us for another webinar in our COVID-19 and Diabetes webinar series brought to you by Diabetes Canada. My name is Grace Leeder. I'll be your host for today. Today's Webinar, very exciting topic on diabetes management in the age of COVID-19: How do we help people maintain focus on self management presented by Dr. Michael Vallis.

First, I would like to thank our sponsor. Today's webinar is presented by and in support of Medtronic. Just having a little bit of trouble with my slides. Okay, so hopefully you can all still see that yeah so that's represented by by Medtronic. So the first thing we're going to do is we have some polling questions we're going to do just to get a sense of who's joining us today. It looks like we have a good amount of folks on the… on the call today. So the first question, we're just going to ask is what is your profession. So I'm going to launch the poll and you should be able to answer. We’ll give about 30 seconds and then we will take a look at our results. Okay so mostly registered dietitians say making up almost 50% of our audience registered nurses making about 30%. We have some nurse practitioners and pharmacists endocrinologist family physicians researchers scientists and about 10% other which we meant to put student on here. That's the one thing we were wondering if that might be the other. So a good cross section of folks. So, and then our second question, we're just going to ask where you are watching from today. And we'll give that about 30 seconds. Okay, so again, almost 50% of our audience are coming from Ontario, but we have representation from almost every province. Actually do have representation from every province across the country. So that's really nice to see. So that ends our polling questions. So again, just today's presentation diabetes management needs of Kobe 19 and I'll pass it over to Dr. Vallis.

Michael Vallis: Okay, I'm just going to share my screen. And I am hoping that you can see my slides, I'll just put it into presentation mode. Okay. So thanks everybody for dialing in. My name is Michael Vallis. I'm a, I'm a health psychologist from Dalhousie University and I've been involved in diabetes self management support for a number of decades. And I'd like to make a presentation to you today that really tries to help us in the age of the current pandemic that we're experiencing, how we can keep the diabetes back on track. So it is very easy for people to lose focus on disease management at this time because of the number of issues that they're experiencing. And so what I'd like to do is is kind of empower you to to really help our patients navigate to stay on on track. I'll begin by just my disclosures and you'll see that I have involvement with a number of industries, although nothing that would be necessary to talk about in terms of this presentation.

So what am I going to talk about. And I'd like to really touch on a couple of things. First, what is the context for understanding the emotional responses to a pandemic requiring isolation. We all recognize the importance of understanding the psychosocial aspects of diabetes management. This is something that we're really very familiar with. Until we kind of know that you can and I sometimes you see expression, you know, you can run but you can't hide. And what I mean by that is that if our patients are experiencing a psychological issue that's interfering with their disease and it's management, well, we can't really ignore that right even if we're sort of not comfortable with it. It's there we somehow have to face it. And any of you who know my work with sort of recognize that that's been the main purpose of my work as a as a diabetes professional which is to really help us all better manage the psychosocial aspects of our patients lives. But guess what, COVID is getting in the way of everything right now. And so what what if we can understand that we can work with it. And so the one thing that I think it's really important about behavior. And self management of diabetes is obviously a strong behavioral challenge. What we want to understand is that if you can understand behavior, you can work with it. So my first purpose will to give you, give you a context so you can understand what your patient what your patients, families, what your family even what you're going through. How do we make sense of it. And then, importantly, what are some of the evidence based coping strategies to mitigate stress induced non adherence. And so this is actually also quite important in terms of how do we keep the stress level under control sufficiently such that we can get our self management tasks back on the agenda. And then how do we keep the patients' focused on diabetes because right now we see that concerns over medical treatment have gone up as people have tried to navigate a COVID situation.

Let me present a general kind of concept for you in terms of the psychological understanding of how people manage crises or disasters and this is really a kind of a representation of what you can kind of expect it's quite important because it sort of shows that there are stages or phases to help people go through. And so I say these because you can be aware of it and that might help you to navigate. And importantly, move through the stages. So you can see that there's kind of a pre disaster stage where there's sort of some credit some warning, think about what we went through in January when we started to hear about things that were happening in other continents. And we had a sense that they were going to come and then as they got closer and closer the warning became threatening. Then we have the impact. And then notice that there's usually a strong sort of coping response and so you know, we heard a lot of, you know, the sort of this this sort of heroic stage and then that sort of coast for a while, but then people get tired and you know, for instance, people I think are all of us are starting to get tired, especially as the weather starts to improve and we start to see the trees blossom and the flowers grow and we're stuck inside. That, you know it can be really challenging. And then there's a reconstruction now where and we're starting to recognize this right. Will we get back to normal. Well, I don't know what normal actually is. And it's probably not going to be the normal that we knew. And so we need to really support that. What is the new norm and there will be some challenges around that but also potentially some benefits right so in the age of now telemedicine. What can we keep? That may be really helpful to us because there may be some things about telemedicine that actually make our job and our patients ability to support their disease outcomes even easier.

So let's kind of circle around and go back to the context, what do we know about this situation that we're facing. It’s stressful. Humans are creatures of habit. We have preferred lifestyles. We operate in a certain way. As we go through life we figure out how our life works best. And so as we get to a certain point and things get sort of stable, then you can expect that things will be routine. The human brain needs routine. You cannot pay attention to all of the information that's coming at you at any point in time. Selective attention is necessary. And so that our attentional span is like the spotlight of a lifetime that kind of circled around and around. And so in order for us to keep our focus on what's important, we have to put things into automatic pilot. And that's why we love routine. When routine is disturbed, then it becomes a problem and that’s stress and virtually all of our routines are currently disturbed. And this diagram that you see on the sort of bottom right of the slide kind of shows classic what we call inverted-U description of how does anxiety or stress impact behavior. And you will see that when you have no stress whatsoever. Then, you know, you sort of like just coast and you don't really pay much attention to anything because there's not a problem. So there's nothing to deal with. And then a stress starts to build your attentional focus comes in on and it's actually healthy you actually kind of work harder, you increase your efficiency, and you know, we all know that you know this. Just look at your deadlines. Right. You know, the closer you get to a deadline, the actual more efficiently you work. But then you can hit a point, if that stress gets too high, where it actually goes down or interferes. And so we really need to be cautious of this pivot point and be aware of that many of our patients this pivot point could be happening right now, given the interruption to their lives. Because we know that there's a tremendous amount of stress. And one thing that I think is really important to understand that because stress is such a demand on the system and we need to focus on it, it's actually an instinctual response that we have as stress goes up, self care goes down. And that's true for you. That's true for me. That's true for all of our patients. So if our patients are living with the disease that requires high levels of self care and their stress goes up, guess what you can expect that to have an impact. And we think about the stress of COVID, then we can see that it has a strong social impact and almost all of us would experience an impact on our work, our work isn't the same. Is it going to go back to being the same our leisure. We're are we able to continue to do what we do in my family. One of us is a is a runner and the other is a swimmer. So guess what the runner is actually getting off kind of okay because he can get up in the morning and go for a run and still be able to maintain social distance. Unfortunately, the swimmer, she cannot get to the pool so that leisure activity is strongly interrupted. And so you see this and then relationships parenting. All of these major domains. How much of your day is filled with work, leisure, relationships and parenting and all of a sudden you're thinking and almost every minute that I'm awake. And so all of those have a new plan needed because of COVID.

And so the stress has some potential psychological impact, something that we should all be really aware of that what impact does that have on mood, what impact does it have on substance use, what impact does that have on relationships. And you can see that this is some of the risk factors that we're experiencing. And there is the potential for relationship conflict for potential, potential for violence with potential for substance increases. And also for mood dysfunction. So just looking at the risk that we experience. Now that sort of universal stress response. There's sort of four basic strategies that people engage in for stress or for in reaction to stress. So, you know, you might ask yourself, which of these categories fits you which fits your patient. And those four categories are the sort of fight response where you tried to aggressively approach the, the stress and try to change it in some way to resolve it to overcome it. There's the flight response where you basically trying to get away from it. There's a tend response where you try to take care of your needs and then a befriend response where you take care of your needs and other people's needs as well. And so this is pretty important and it's useful to think about this because we can encourage people sometimes you know people that are oriented in particular to fight or flight responses. It's like, I can't do anything. I have to get away. If we can encourage those people perhaps to take more of a social focus. It can be important to notice that one of the things that's making it easier for people to tolerate isolation is to couch social isolation in the heroic metaphor. And you've heard this right people saying like, you know, the people that are isolating themselves right now are like the soldiers that were in the war there like the, you know, Rosie the Riveter in the Second World War, who was in the factories building the plane. And you know the heroic activities that they did to kind of keep their country safe during the actual physical war and notice that that's a very common metaphor. And that's because that seems to be what's helpful if people have this kind of sense of tending into friending.

Here's some of the impact. So last week there was a poll that was done in the United States. And you can see that the impact that this has on eating behavior. I'm really glad to see that there's a lot of dietitians that at the talk. Right. And here you can hear you can see 40% of the people say they're eating or snack foods. That at the same time most, two thirds, people are actually taking more time to make food and make homemade food. So there's both positive and negative. You can see there's more screen time, so health behavior looks like it's getting completely disrupted and so of stresses going up self care is going down, if our behaviors are getting interrupted, then it's really important for us to think about how we can help people navigate that especially living with diabetes. This was released by Statistics Canada and it's a survey between March 29 and April 3 and you can see that it's just kind of looking at the experience that Canadians report. A lot of feelings of concern and worry around the overloading health system or the health of a family member. Issues around family stress. And you can see that there's you know quite a bit of, you know, distracting time, right, because we're all kind of focused on how to get through the days. There was just three days ago now, I guess four, it’s the 30^th. Angus Reid did a survey of Canadians looking at their mental health and so they surveyed around 2000 Canadians and some of the highlights here just illustrate that you know we are really being disturbed by this. When asked the question, thinking about the last couple of weeks of your life, which words best describe how you’ve been feeling. You can see the top words are worried, anxious, but also grateful, bored, optimistic, depressed. So a lot of mixed emotions, but a lot of emotions so you can really what we're learning here is that there's an emotional component to this virus and its management that needs to be addressed the mental health and physical well being. You can see that's kind of scary numbers that 50% of people are saying that their mental health is worse than it was before. And that their physical well being, is also worse than it was before. On the bottom here you see the impact on relationships and it's kind of reassuring that inside of your household, it looks like more people that are reporting an improvement in their relationship and a deterioration only 14% say it's the deterioration 24 saying it's actually better, But there does seem to be a hit made on regard to the friends and family outside of the house, which again makes sense. So here we're seeing an impact.

Here's an interesting scale that I'd like to show you just to put a context. And I just want you to be aware of this with our patients. This is scale called the impact of event scale. And this is the scale that in essence assesses post traumatic stress. And so with trauma, the impact of traumas are really three fold. They have an intrusive aspect to them, they promote a lot of avoidance behavior and they’re associated with hyper arousal and you can see this is a scale that really taps into that I'm suggesting that you use the scale, but I am suggesting that we need to be mindful that they're can in fact be, in a context like this, a traumatic like effect. And I really would want to make this point strongly today because in Nova Scotia, not only are we dealing with the disruption of COVID but we had a rampage in our province, a week ago that has just left a huge, huge impact on citizens of our province and it has this effect. And it's actually scientifically, it's called aloe static load. But what this simply means is the straw that breaks the camel's back that if you have too many big stress events that hit you, then you can kind of go from being really stressed to having a traumatic stress. And so I just like us to be aware of that, because it's a risk factor that we experienced.

This is a paper based on COVID looking at the, what we call the vicarious traumatization. So not necessarily being the person who was impacted or the loved one of the person that was impacted. Perhaps associated and what this really demonstrates in this paper is the importance of what we call the ripple effect. Which is you the impact of traumatic events kind of occurs, like a ripple in the pond and even though you might be further out, you're still impacted and this is something that we kind of see very commonly and just last week there was a publication and the first COVID related suicide. Or earlier this week we heard of this doctor, Dr. Greene from New York who apparently took her life because of the stress that she was experience. She was the Medical Director of the emergency department at the New York Presbyterian  Allan Hospital in Manhattan and apparently developed COVID herself, but then after returning to work really was unable to function and actually took her life.

So again, put the context around where, where these risk factors are. Now the important thing that we need to understand for our patients. And the importance of understanding the experience is so that we can help people prevent the stress response from getting to the point where you develop flagrant psychiatric symptoms or even sort of, you know, and suicidal type of issues. And so what we know about stress and what we know about emotions is really demonstrated on this slide. And then is that when somebody is distressed. You can't assume that that there's something wrong because the distress, in fact, might be normal. The distress me fit the situation and all I will ask you to do is think about grief. Where grief is clearly a situation where the emotion is appropriate and nobody goes around telling people who just lost a loved one, “Don't feel sad. It's okay. You'll find somebody else.” Nobody would ever do that because you recognize it, that's completely normal. So with that kind of in mind. What we know is that if you're in a situation where you perceive threat: uncertainty, risk, you know, no real time frame, then that's going to lead to naturally to the feeling of anxiety. If you have the perception of loss, it will naturally lead to feeling of sadness. And if you have the perception of injustice or intrusion, then it will naturally lead to this anger. And remember that that sort of diagram and looking at the stages of setting the response to a disaster from a mental health point of view because it may be that we will go through these stages and I still can remember quite vividly the first time I went into a grocery store during the COVID. And so this was that first time now I live in Halifax, Maritimers are generally quite friendly and social so if you were to walk by somebody, you'd probably not at the moon or smile at them, or say hi. If you were in the grocery store and somebody you know drop something you'd probably reach down to pick it up, that's just kind of the social way that people in the Maritimes tend to operate. I can still remember going into the grocery store and seeing somebody and thinking, get away from me. It's like, whoa, I have no idea you're infectious or not. And so, you know, obviously, perceiving threat right away. Perception of loss, sadness. And so are you experiencing any threat. Our patients experiencing any threat and I have a friend who owns several restaurants in Halifax and I often think oh my, what's this poor person going to be what's going to be left at the end of all of this in terms of the restaurant industry in terms of where that is. So the threat of loss and then intrusion where in the United States, you can really understand why they're protesting so much because they're a culture, unlike Canada who has a strong sort of social orientation. So Canadians generally very much believe in a social system. We believe in universal education and we believe in universal health care and so we sort of have a sense to which we trust the government because there were kind of monitoring and promoting this in the United States. They don't in the United States, it's much more of an individual based society. And so when they experienced the lockdown, they don't experience as much threat or loss as much as they experienced this injustice or intrusion and that makes perfect sense when you think about what they're kind of collective psychology is. But the important point here is that these are normal feelings. And what that allows us to do is then figure out, okay, what are the strategies that we can do to mitigate this okay. So if this is normal, then we can't just expect it to go away. We somehow have to help our patients manage when it comes to coping.

I'm going to make a few comments and then really talk about some strategies that we can use in essentially here what we're talking about. COVID comes along, it makes diabetes harder. It makes diabetes harder because our stress has gone up, self care goes down, our routines are disturbed and we are preoccupied with this crisis and the crisis has a number of layers from occupational to relational to financial. And so in some way. We need to manage that stress. Now, when you think about how people manage stress, it's important to understand that not everyone responds in the same way. So different strokes for different folks. You see I've got this image of a radio dial and the important piece with this is that people generally fall into two categories in terms of how they kind of manage the stress that comes in. Some people's coping style naturally is to turn the volume down a lot of academics, a lot of achievement oriented people lot of intellectually oriented people are the kind of people that kind of try to minimize stress. They suck it up. They push on, they just tried to get on. We call those people repressors. They turn the volume down people that do that often are very effective copers. That from a behavior point of view, not necessarily from an emotional point of view. So the people that are tend to be the repressors tend to be at risk of substance use, because it's kind of a way of helping to block or get away and also to potential for irritability or anger and conflicts we resolve. The second kind of general coping style that people tend to present are the sensitizers. People to turn the volume up. These are the people that sort of focus on the stress, they may start to become preoccupied with the stress and sensitizers of course are at risk of more emotional disorders, you know, obsessiveness anxiety. And it also interferes with relationships because you know if you're a sensitizer, then sometimes people get tired. Either people kinda like, oh, you know, can you stop talking about it. It's not so bad. Let's just move on. And so the relationship conflict can happen through that.

Now what do you do about feelings, your feelings are normal and everyone has their style. Then from a company point of view, I just wanted to emphasize two aspects and psychologists we categorize emotional experiences into two categories, generally, primary emotions secondary emotions. What's the difference? A primary emotion is, think back to grief, that's really a normal emotion. It's kind of healthy and matches that objective situation. I'm really worried because, you know, you find you find a lump in your armpit. You can go to your doctor. Doctor, I don't like this at all. I'm going to take a biopsy of this is really concern to concern to me. I'll tell you what's going on in a week. Now tell me you're not going to be anxious. Tell me you're not going to be occupied by what if, what if, oh, no, no. And that would be completely appropriate because it's really matching the threat in the situation. And so when you see this threat: anxious, loss, intrusion, anger and we kind of see, oh, that makes perfect sense. It fits the circumstance, the coping strategy is really very much around helping the person not bottle up their feelings but express their feelings and not feel alone. And again, I use the grief as the best example of a primary emotion. If you're supporting somebody who's grieving, you're actually, what do you do, you're just there. You do whatever, it doesn't matter. You make tea, cook a casserole, you wash the dishes you just sit beside the person. And that's what's helpful for the person and they give him the opportunity to express themselves.

Now secondary emotions are when they tend to get a bit out of proportion. They get a bit difficult. And this is when they become obsessed, excessive rather and really unhealthy and they seem to be start to in what do you look for disturbed sleep, unreactive mood, you know, interference with functioning and this is where you know active coping strategies can be helpful. And I'd like to kind of go through what those coping strategies are so when it comes to cope and what can we advise people to do and it's really interesting because, you know, if you think about coping strategies and look at the little guy on the bottom right, you know, this is kind of the scenario, imagine doing that balloon on top of the pile of pins. Now, you know, how do you get this off, what are the stress reducing strategies. I'd like it to just reflect that coping skills when it comes to managing strength. First of all, the one size does not fit all. It's important to recognize that there are a number of evidence based coping strategies and they all work and they are additive. If you do two, it's better than doing one. If you do three, it's better than doing four. If you have one that you can do in three minutes and one that you can do in 25 minutes, then that's great. And they’re additive because what that does is allow you to kind of, you know, this didn't work so now I have another, this didn't work so now I have another. What's your plan B. What's your plan C. And so the ones that are really effective actually match the individual. And so often when it comes to coping strategies, it's really valuable if you say try this and see if it works. Be creative. Figure out how you might be able to use these strategies. And so there are in fact five very evidence based coping strategies.

The first one is what we call physical common. So the stress response involves quite a strong stress hormonal response that activates the body so you become really hyper aroused. That's why, by the way, hyper arousal is one of the main sort of domains of the post traumatic stress response. And so, physical calming is really, really helpful. And this may take the form of deep breathing. It may take the form of progressive muscle relaxation. It may take the form of yoga, Tai Chi, meditation, prayer, having a cup of tea and reading a book, patting a cat, tending a plant and note, you can kind of get where I'm coming from here. It really anything that allows the person to say okay, just let go and let yourself kind of bring that arousal level down because that's really important. And as you, as you focus or as you live through a stress response, it's even more important to find these calm reflective moment and we're kind of in this for the long run. We don't have a sense that that you know being back to normal is going to be certainly something that happens next week or next month, or even next season. And so you can't hold your breath that long. And so these physical coping strategies can be really, really effective.

On top of that are what we call physical discharge. And so these are activities that help you burn off the energy. And so they're equally important. And any sort of physical activity that would kind of give you a sense of kind of getting it out of your system. So a physical exercise is actually very useful here. And some people almost become you know we sometimes they go to becoming addicted to physical activity, you know, kind of runners are like that. And and it's because it's really healthy. It really works right in terms of that can be discharged, but it could be dancing. It could be, you know, putting on rock and roll music and vacuuming. It could be walking up and down the stairs. It could be whatever it gives you this sense of physical discharge, it could be working, you know, building something in the garage. So it's important for us as clinicians when we recommend coping strategies that we actually don't tell people what to do but we actually sort of educate them to the type of strategy and then collaborating with them to help them find something that is actually consistent with their personality and that actually is something that they can use.

Third on top of those physical calming if it's good discharge, we know that social connection is such an important aspect. Thank goodness for Zoom, for FaceTime or Skype. Could you imagine going to code in the year 2005 or the year 2000 when we didn't have cell phones in the way we did. We couldn't look at people. We couldn't do you know visit, etc, etc, we'd be in a very difficult situation. Those of you who have I remember in Nova Scotia that we went to a hurricane, 12-13 years ago was called Hurricane Juan and it was the worst thing that happened to Halifax neighborhoods because it destroyed about 70% of the trees in Halifax. Could you imagine. 70% of the trees were destroyed, but it was the best thing that happened to Halifax neighborliness in the post Juan period. People really banded together socially and it became really very, very useful. And so natural response to stress is social connection, so encouraging people especially people who may pull away from stress. Think about the fight or flight response. If your dominant response to stress is like, I gotta do something, I got to, you know, pull you pull away, then this may be a really helpful strategy.

In addition is emotional expression. We know that this is really important to manage stress that if you bottle up your feelings then this is really very, very dangerous in terms of what impact it can have on people functioning. Now when I kind of an emotional expression. I'm not saying that. Oh, we have to go on Oprah Winfrey and spend an hour just talking talking, right, it's whatever fits the person and a lot of art is very much around emotional expression. In Nova Scotia last Friday we kind of had a seven o'clock we had kind of like a memorial for the province online. People sort of logged into this online area and kind of had the equivalent of sort of a wake. You know, around the rampage, and how much if you were if you were there, most of it was surrounded by music. So music was an essential aspect of the emotional process.

And then the final coping strategy is really that strategy that we would call mindfulness or acceptance and it's kind of like, you know, the wise mind, right. Which would be, you know, one of the things that you can control. And then what you do to control them. And then what are the things that you can't control. Those are the things that you have to accept. And you know so acceptance is kind of a and sometimes I think of acceptance as surrender to win. And you know, I see this a lot in diabetes management with a person is. I don't want to take more insulin. I don't want to take her medication. I'm tired of doing all this work. I don't want to give in to this disease. And it's like, well actually just surrender to the task, in fact, you will actually be better off right and we all know that a real success story, and diabetes management is the person with type two diabetes and says to you, I've never been healthier since I've been sick. In other words, it was the diagnosis of type two diabetes that lead to self management that actually improve the person's function and quality of life.

So again, you know, these are the coping strategies and I would encourage you to think about how you can educate and then support your patient in a collaborative way.

Final comment, I'll make here is it also, I find it very interesting that we talk a lot about hand hygiene but I also think that as we're navigating and the isolation in particular it's important for us to encourage your patients to maintain what I would call a lifestyle hygiene. Trying to make sure you structure your day. Humans like a routine. And so we tend to get into a pattern and it kind of works. So try to find this way and some for some people they they kind of replicate their typical day. So they might get up at the same time to make it dressed in their work clothes. I know some people will even say like, I will leave my house at the same time I normally do and I just go in a walk, you know, five minutes around the block. Just so I have this idea that it can starting my work day they end at the end of the day they try to make a pattern. They keep the weekdays separate from the weekend. And so they kind of have this routine. So you can kind of adapt to it as opposed to an unstructured time which can really let people kind of that attempt, make people drift. It's very important that we encourage the normalization of sleep because sleep is something that is really risky when it comes to self management. Good diabetes care requires your frontal lobes to be pretty active. That is that part of your brain, that's, you know, analyzes things that makes decisions which is the best for me now that's able to problem solve that delay is capable of delay of gratification. And those frontal lobes are really where a lot of that to good self management comes from. And the more your sneakers interfered with the more difficult it is to access the frontal lobes. The frontal lobes are like a muscle, they they tire out and and when they're tired that's when you will drift. So we know that sleep is really, really important and also from a lifestyle point of view, physical exercise is really helpful for both mood. But also, importantly, because individuals living with diabetes have some risk that increased if they contract the virus, that exercise is good at boosting the immune system.

And so I just to sort of finish this part and get right to the diabetes piece by talking about how we can support our patients who are struggling using the basic of cognitive restructuring and so this is the essence of any cognitive behavioral therapy and it's actually not that difficult. And so cognitive restructuring, kind of, you can see it in three steps. The first thing that you do is you validate the patient, which is very familiar to us. So, you ask the person, you know, what are your thoughts. What are you thinking, what is going through your mind. What is your perspective, your beliefs here, your assumptions, your thoughts and you capture those thoughts in the patient's own words with the emotional way. Just use the patient experience. Once those feelings have been identified, then you kind of talk about them. So you first of all, said that makes perfect sense. But if you believe that you're at incredibly high risk because you have diabetes, because you're 67 years old, because you know, live in a high density apartment building, you... We don't kind of tell people that their thoughts are right or wrong. We're not there to judge. What we do is we understand their thoughts and we try to help them say, okay, what I see what I hear you telling me, I get it. This is what you think, and then you link that that how they think to their beliefs and their behaviors. So you kind of introduce what we call this thought affect behavior link. Your thoughts impact your feelings which determine your behavior. I can't worry about my diabetes right now because I'm worried about my father, who's 81 years old and he's sick. And so I've got to take care of him because, because if something happened to me, really, really bad. And there's no way I can even think about my diabetes right now. And then we introduce the thought affect behavior link and then introduced the idea of change. So I'll just show you how this looks. This is a resource from the Canadian Psychological Association around COVID. And it was produced by the traumatic stress section. And you can kind of see, right, the sort of various thoughts which kind of illustrate certain thinking styles like overestimating the threat, jumping to the conclusion or predicting the future, all or nothing thinking, discounting coping skills, when people get distressed these are very, very common things that they do. And then you can see how this can be really dealt with and so we sort of help people kind of rationalize and sort of think through.

Just want to make you aware as we sort of go through this, from our perspective is that what some of the resources available. First is the Canadian Psychological Association has kind of come together to identify a number of frontline, number of psychologists who will be available for frontline workers. And so if you access the site, you can see that, you know, there are a number of people. I just pulled up from Nova Scotia, New Brunswick, Newfoundland, Prince Edward Island, my area of the country, you know, these would be people who are available to help first, you know, people that are on the front lines. Every other province has this as well. And this can be accessed pro bono. If you go into the CPA (Canadian Psychological Association) website there's number of fact sheets that you can download. These are good for you and your patients. Psychological impact of coronavirus, working from home with or without children, emotional, psychological challenges faced by frontline healthcare providers. And again, this is the traumatic stress section and you see this resource has a number of tools that we can we can refer to. So this would be useful for instance in how do I manage the stress, we make general recommendations and then we can encourage our patients to access these sites.

Alright, so let's now get back to the issue of, okay, what about the getting the patient focused on diabetes management. And how can we sort of make sure that we do that. And the first thing that I want to, to sort of help you with this is really the issue of how do you screen for non adherence. And this is from a very validated tool called the needs and concerns analysis. And so I'll just quickly show you this because it's very useful. Some of you may already be familiar with. And if you are great because now's a great time to raise it because the impact of COVID is such that it's going to increase people's concerns and worries and that may make it more difficult. And so, you know, new treatments, increasing treatment intensity, etc may be challenging during this COVID. And so it really involves and this is useful around medications. But even with any other form of treatment, you basically just ask the patient two questions. To what extent do you think you need this to benefit your health and you listen to the response. You do not elaborate. It's what we call a structured interview. in a structured interview, it means you ask a question, you listen to the answer, you receive the answer, but you don't get into a conversation about the answer. So if you said to the patient, can I ask you two questions. Sure. Question one. To what extent do you think you need this treatment and the patient. Well, I thought I did. But I'm not so sure anymore. When you're doing the structure interview, you say okay. My next question is to what extent do you have concerns.

If you didn't acknowledge the answer and then immediately go to the next question, if you instead said, Well, what do you mean you tell me more about this, then in fact you lose the structure to the interviewing and lose the ability to guide the person and so structured interviewing is part of what we call guided discovery. So to what extent do you need, to what extent you have concerns and then look at the table, the person who presents with a high perceived need and low concern will be accepting of whatever that treatment is. The person with high perceived concern is interested in treatment. But if I'm sorry high perceived need is interested in treatment, but if they have high perceived concerns they may become ambivalent. This is what's happening with COVID. I don't want to take any new because I'm not sure if that what effect that will have on my immune system. If you have low perceived, needs low perceived concerns, that’s indifferent. Low perceived need, high concern, that skeptical. Now, given that COVID would have an impact on concerns that would tell us all that ambivalence and skepticism are things that we should be on the lookout for and that when you see your patient struggling, be aware that this may be a way of opening the door and kind of getting to the next step with the patient.

I'd also show you this tool which is called the SURE test. And it's really about shared decision making and the purpose of this test is to uncover ambivalence. So uncover any concerns that the person has because remember in our contact we interact with our patients, we make recommendations we try to help problem solve, which I support them and we hang up. And then they're on their own. And what's really important is what they think when they're on their own, not what they think or say when they're interacting with us. Because that's an encounter that's a bit of an artificial encounter and in the moment of their of that consult with you, they might be quite interested in the thing that you guys are talking about, but the question is what happens to the phone and the link is cut. And so again, do you feel sure about the best choice. Do you know the benefits and risks. Are you clear about which benefits and risks matter most in and do you have enough support and advice to make a choice. And the idea really is to is to find out where the patient is so you can help them through the next step.

Now one of the things that you can expect to happen with increased concerns, right, is that they will have distress. So this is the human brain and there are two behavioral control systems. On the bottom left, you can see what's the limbic system, the emotional brain. This is the instinctive emotional part of the brain. This is where fight, flight comes from this is and this is very powerful. It's very rooted in primitive functioning. And then in the frontal lobes, the upper right, we have our rational ability and diabetes management really lives up there. The problem is the limbic system is much stronger than the frontal lobes. And so if our patients have an increased distress and we need to help them and stress management, as I've gone through, is really about trying to lower that level of overall stress so that the limbic system calms down but importantly around diabetes management, especially when it comes to what people will say, well, I'm just not ready, I'm not motivated, because you're concerned. And so the important thing here is communication allows limbic discharge which helps access frontal lobe functioning. So let me say that again. Patient provider relationship, if you rather than ignoring the emotions and trying to appeal to the logic. So the person says I'm worried about COVID, you said, well, actually, if your sugars are lower your risk of the of anything bad happening actually goes down. So, so, you know, there's some evidence that maybe if you're hyperglycaemic that things could be worse. But if we're lucky, if that person is distressed I don't, I don't want to do anything. I'm just really nervous. I'm really worried, then they're only going to hear your information which is accurate, but they have to have a calm or level. And so this is where the communication skills becomes so important because they allow the person to be heard. They allow the person to kind of, get to that point where they go, okay, thank you. Now I get it now I'm ready to listen to you.

And so this is really where we kind of see the importance of distinguishing medical management, where it's really very much about our competencies and in our ability to diagnose and develop the treatments and dimension, the outcome which is not the same as clinical management because clinical management is really about self management support. It's more important for me to hear the reasons why you do not want to do something than it is for me to tell you the reasons why you should be doing it. From a medical point of view, we would focus, on no, no, no, my job is to make sure the patient knows what to do. Well, in fact, I'm a clinical manager and my job is to know if the patient has actually interested in listening to anything to say. And so clinical management is about description, understanding the patient is about predictions about sitting there with the patient side by side and helping them realize okay, what's the direction you're going in, given your choices now, which I'm not judging I'm understanding, this seems to be and are you okay with that. So can we introduced to some medical and clinical a kind of a different and as we balance this between the need for the medical management of a chronic disease such as diabetes to the importance of clinical management in terms of helping the person become ready to do the work of change, it's really important.

And so this is where the collaboration really comes in, which is really about the bond which you're good at. But notice the challenges with telemedicine. How are you feeling about maintaining the bond with your patient during COVID. During zooms. What happens when the audio signal gets interfered with? What happens if the picture freezes. How do you know the patient is really paying attention, or are they kind of look over the screen at their child that's about to pull something off the shelf. It's a… we need to be mindful of how this is going. And I would encourage you to discuss this openly with the patient and then the task alliance, the agreement on who does what. And the goal alliance. What is the purpose, where is this actually going. And so this is a really this is the kind of evidence based approach to managing the behavioral challenges and it's all rooted in communication. And so this is the essence of motivational communication, which is ask, listen, summarize. So notice that that's not about you. That's about the patient. And we ask so that we kind of understand the experience. We have to listen to the person, which is a little more challenging than it sounds. Because it's sometimes really difficult to listen to somebody when they're saying things that you do not believe or you know are not really true. The only way that a patient knows that you're listening is if you summarize it back to them. And that's actually critically important that the communicate piece. Okay, so I've asked you about how you're making with your diabetes and what you told me that you can't even think about diabetes right now because your kid. You don't think is learning anything because you don't think you're very good at homeschooling. You're a bit worried about your alcohol intake at night because you are drinking as a way of kind of, you know, managing the difficult days that you're having. And you're a little bit nervous that you and your life partner are starting to have a bit of conflict. So diabetes doesn't fit on that screen at all. Thank you. You know, that's really, I can really understand that. Would it be okay… and that’s the invitation and somehow it's around in that invitation. That we can help the person so well. Do you have any concerns about how your diabetes going out of control while you're under these conditions. And, you know, most people will say, Well, I don't have time for diabetes, but I actually don't want my diabetes to get worse. So this is what we call ambivalence. And if they have ambivalence, you can actually work with them.

And so, especially around the readiness concept and so if you've heard me present before you know that I'm pretty big on readiness, because I think self management requires commitment from the patient. It really does require them to step up and do something. And not just do the lip service but you know it can be challenging to manage you know sugars over time. And so the readiness concept is nice. And again, what I like about the readiness concept is that it gives people permission to not be ready. That when we ask these questions to understand how ready. A person is we're not expecting that they're ready, we're actually interested in knowing where they are, because then we can help them no matter where they are. So I've kind of recreated a readiness assessment. With the scenario, being that someone with diabetes has kind of drifted away from self management because of the COVID and they're in a perhaps a bit preoccupied with the risk of COVID. And so the readiness assessment could look like this. If you were to continue to focus on the COVID risk and not your disease management. So if you continue to sort of prioritize the COVID and the disease fades away, would that be a problem. That's your frontal lobes. Do you recognize that even though you're going to distress diabetes is still an issue. So wouldn't be okay, or are you not. Would it not be a problem. Would it distress you. That's your limbic system so that you can sort of help that person figure out, okay, at the end of the day, are you really okay with this not happening. And so you know, if you think about relationship issues. I don't want to speak to my partner about this issue because I'm worried that they're going to get really, really upset. And then you say but if you don't talk about them, and they kind of fester, would htat really distress you. Yeah, absolutely, it would distress me. It's… okay, so, because you know they've got the distress than that keeps the conversation going. Are you interested in focusing on your diabetes as well. This is now a time that you can do this and what we do with that is we just assess the person to where they are and if they're ready, then we go right into behavior modification. If they're not sure if part of them says yes. And part of them says no, we touch on the behavioral piece we get action plan on the table. We talk about it but we try to understand what's, what are the personal meaningful reasons to change. And if they're not ready, then we don't send them away. We don't stop the conversation and we keep the conversation going. By understanding their experience and giving the opportunity to really be heard and I find interestingly, that red light category often makes us clinicians uncomfortable when we encounter it because, like, oh no, they don't want to hear anything we say. But when you actually start to park that right. Can I tell you a little bit of a how to manage your, your disease. No, I don't want to hear any of that. Holy cow. Know what am I supposed to say. Well, you know, if it doesn't shut us down. If we say okay that's thank you for telling me that, so I'm not going to tell you anything about this, but I'm curious why you reacted pretty strongly when I asked for your permission. I'm curious, what can you tell me a little bit more about that and you start to in a non judgmental way explore it. And what you often find is really good reasons that the person is not ready. And this is where support and education become so helpful.

Okay, so I have four minutes before the hour. And I'm hoping that you found this useful. Now, if there are any comments or questions they're going to try to go up and see if there is a couple of question. Okay, so nothing really to answer. So if people want to make comments or questions now, I'd be happy to take them. And I'm also happy to share the slides. So if you can see my email there or and I don't know if CDA makes the slides kind of available.

Grace Leeder: Just gonna jump in there, yeah, Michael, if you wouldn't mind sendning me the slides, we’ll post them on TimedRight, which is where folks were sort of registering. This will make a discussion group and we will share the slides in that group.

Michael Vallis: Perfect. Okay so Alice has a question that all kind of make a few comments if it's okay. I'm just checking out. I've got three minutes. So if it's okay, I'll just talk for another couple minutes. But Alice says you know how to best help our reppressor and I think that one is really, really useful because what you want to do is sort of not threaten a person and say, oh, you know, that's not a good way of coping. But what I find is to describe it to the person to sort of ask them, you know, are you aware of how you cope and that's why I had that visual of the radio, you know, turning it up, turning it down. Because if you simply give that feedback to people, because most of us are our repressors. And we tend to just kind of push it in and move on. And so I think one of the things that you could think about with a repressor is to sort of talk about coping from the perspective of could we talk about how let's say your husband, he's in this situation, let's say your wife was in the situation. Let's say your best friend was in the situation. Then we could sort of approach the coping skills, not as though we're talking about, maybe you should do this, but what if you're if you know you know who you closest to. Okay so Alice you telling me that your husband is really, really important to you. Okay, well, if your nose was struggling and it was under a lot of stress. You know what, what do you think you would be, you know, kind of wanting to encourage and coping strategies and then. You can you can you can then sort of go that way. I did a session about a week and a half ago for the Atlantic dermatologist. And it wasn't about their clinical management, there was a two part thing I did with them in the first part of it was about them. And I and because most of those people are reactive copers I found that I couldn't, I couldn't directly, talk to them. So what I got them to do was I got them to talk about their family. So when I talked about, you know, threat. Does anyone in your family feel threatened by this when I talked about… so so you kind of do this kind of parallel. I hope that that useful business.

One other comment I’ll pull and I'll talk very quickly about it. Sorry. Make up but but I don't want to ignore it and then is what about saboteurs. Really important question because we're all kind of see question now in a very, very small cage and what if you have people who who make it difficult for you. And then there's two things that you might find helpful. One is, is this communication. Find the most polite, fewest words to express how you're feeling and what you would like and then try to repeat that endlessly. So just stay calm and just repeat it. And the second is, you really try to sort of do a physical separation. And so, you know, how do you stay away or maybe kind of, protect yourself from being around those times. So let's say if your husband brings potato chips into the living room while you're watching TV. You know, you might say, you know what, like that's a trigger for me. I'm going to go watch the show by myself upstairs in the bedroom, you know, you can have… To kind of physically separated and this is where the relationship tension really comes in, you know, hopefully the partners are saying, okay, you know what, I'll also do it on my own, or whatever. But sometimes the relationship tension kind of increases, which is a bit of a risk.

Okay, I'm out of time. I thank everybody for attending and I hope that it's useful.

Grace Leeder: I just wanted to jump in. So just before we finish, I just want to thank Michael for giving the presentation. I think it was, based on some of the questions that we got, they weren't exactly questions, they were just complimenting the presentation. So I think that's great to see.

I would like to thank Medtronic for their support in helping us put on today's presentation and I would like to invite folks to join us next Friday on May 8 and the Friday after that May 15 for our next. It's a two part series on avoiding hospital visits. So, Catherine Yu and Susie Jin will be presenting next Friday and Alice Cheng will be presenting on May 15 so I'd invite you to join you can register on TimedRight. So again, thank you, Dr. Vallis, for presenting today. I think that was a very important and wonderful presentation.

Michael Vallis: Thank you very much.

Grace Leeder: All right, bye.