This article is more than 5 years old. Information may no longer be current.
Reduce resistance to help patients adopt good diabetes self-management practices
Click Here to Manage Email Alerts
Medical providers often view a patient’s resistance to diabetes self-management as a deliberate refusal to follow the provider’s prescribed course of action. Whether the directive is to change one’s diet or to take medication, the outcome of resistance is usually the same: The patient’s diabetes worsens, and the provider becomes increasingly frustrated.
The inherent problem with this perspective is that the provider tends to blame the patient, and many patients blame themselves for not following the doctor’s recommendations. Many times, this sets up the patient for failure. Resistance is a symptom of a larger problem and must be understood from the patient’s point of view.
Recognizing resistance
Ambivalence is a large part of a patient’s resistance. The patient is conflicted about choosing between the status quo and change. Resistance is the anti-change side of ambivalence, and both provider and patient play a role.
Typically, the provider will argue for change while taking the stance of the expert — hurrying, lecturing, criticizing, labeling and blaming the patient — which increases patient resistance.
Patient resistance tends to present in four ways: arguing — challenging the accuracy of information, discounting the provider’s experience or being hostile; interrupting — defensively breaking the conversation; negating — expressing unwillingness to take advice; and ignoring — not paying attention or sidetracking the discussion.
Finding the source of resistance
The provider should assess and address any possible causes for resistance as soon as they occur. External causes may stem from the patient’s home environment or peer group and include domestic violence, lower socioeconomic status, family dietary norms, erratic employment or sleep schedule, and unsupportive family members, among others.
Internal causes can range from developmental issues to the cognitive impact of high blood glucose levels and may include difficulties with reading, writing, vision, hearing, language, mental capacity, learning disabilities or mental health disorders. The provider may be able to remedy some of these, and some will require referrals.
Some resistance can be attributed to a patient’s priorities — the perceived need to change may be lower than other perceived needs.
The perceived importance of change
Resistance in the context of diabetes self-management is a state of ambivalence between the status quo and lifestyle change. Resistance is not a deliberate act, but an internal conflict.
Miller and Rollnick discuss four types of ambivalence that can be helpful for addressing a patient’s resistance: approach-approach, approach-avoidance, avoidance-avoidance and double approach-avoidance. With approach-approach, both choices are equally attractive, both sides of ambivalence are positive choices, such as choosing between two ice cream flavors. In avoidance-avoidance, both status quo and change are equally unattractive or difficult; the patient may say, “I am between a rock and a hard place.” Approach-avoidance describes a choice with both attractive and unattractive outcomes, such as when an addict is sickened at the thought of using a drug but also can’t wait to use again.
The hardest ambivalence to resolve — and the most common cause of resistance for patients with diabetes making lifestyle changes — is double approach-avoidance, in which both the status quo and change have benefits and costs.
Facilitating change, resolving resistance
Some patients will not be resistant to change. However, resistance can pop up midstream, so providers must be vigilant.
Medical professionals have a proclivity to set things right for their patients, but for lifestyle changes to stick, patients need to set things right for themselves. Diabetes education should be personalized to the individual’s needs. The goal is to facilitate change guided by the patient instead of imposing a generic management plan.
When a provider accepts the patient’s choice as theirs to make, it creates a supportive relationship that builds the patient’s self-esteem and increases change. When the provider does not accept the patient’s choice, it reinforces the status quo. Acceptance is not necessarily agreeing or approving of a patient’s behavior.
A patient who is ambivalent about change is likely to argue for the status quo. The provider should avoid arguing for change, but instead agree with the patient’s need to maintain the status quo and let the patient disclose the reasons for the change. If the patient wants to continue with an unhealthy diet, agree that he shouldn’t change his diet. If his resistance is due to ambivalence, he will give you reasons that he should change his diet.
The provider should help the patient explore the discrepancies between current behaviors and goals and values. Hopefully, the patient has a substantial increase in both reasons to change and to avoid the status quo. Simultaneously, the reasons to maintain the status quo and to avoid change should diminish. The greater the gap between the need to keep the status quo, compared with the need to change, the greater likelihood of change.
Lastly, the provider should roll with resistance when facilitating change. Resistance is a normal and natural part of change. The provider should not impose new goals, but invite the patient to consider new information and new perspectives and turn questions back to the patient. This creates active involvement in problem solving.
The health care provider must partner with the patient, recognize the patient’s right to make choices and the patient’s expertise on his own perspectives. If the patient feels heard and respected, the provider can draw on the patient’s perceptions, goals and values to resolve resistance and promote change.
- References:
- Corey G. Theory and Practice of Counseling and Psychotherapy, 8th ed. Belmont, California: Brooks/Cole; 2008.
- Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change. New York: Guilford Press; 2012.
- For more information:
- Eliot LeBow, LCSW, CDE, is a diabetes-focused psychotherapist, presenter, author and founder of DiabeticTalks and Diabetes-Focused Psychotherapy. His private practice is in New York City and is also available via Skype. LeBow, who has been living with type 1 diabetes since 1977, treats the many diverse cognitive, behavioral and emotional needs of people living with diabetes. He can be reached at: eliot.lebow@gmail.com. He reports no relevant financial disclosures.