Be kind to yourself


Living with a chronic condition is demanding and new research shows that ‘diabetes distress’ can have a big impact on emotional and physiological well-being. Auckland health psychologist and researcher Anna Friis explains.


Living with diabetes can be tough – there are no days off from the routines essential for good glycaemic control, and 24-hour vigilance is often required. Unsurprisingly many people at times feel distressed by the demands of healthy selfcare. Emotional difficulties can add a further complication to diabetes management, making healthy blood glucose control more elusive, and providing a target for further self-criticism.

Emerging research suggests that the emotional difficulties frequently experienced in diabetes – and often mistaken for depression – are in fact signs of distress specifically related to the experience of life with diabetes. So-called ‘diabetes distress’ appears to be surprisingly prevalent and often goes undetected in patients – yet in itself is linked to many of the same problems associated with depression, such as lack of motivation and poorer adherence to medication and lifestyle prescriptions.

What is diabetes distress?

Diabetes distress refers to one’s emotional responses and reactions to life with diabetes. This compares to the more generalised experience of depression, characterised by feelings of sadness and hopelessness, as well as physical and cognitive symptoms.

A recent study by myself and colleagues among patients at Waitemata District Health Board’s Diabetes Clinic at North Shore Hospital, showed that more than half of the 110 patients included in the study had clinically significant levels of diabetes-specific distress, ascertained by asking just two brief screening questions (see below).

Do I have diabetes distress?

A brief screening tool called Diabetes Distress Scale -2 is used to screen for clinically significant signs of distress by asking just two questions:

(1) “How distressing has it been to feel overwhelmed by the demands of living with diabetes?”

(2) “How distressing has it been to feel that you often fail with your diabetes regime?”

Respondents answer on a six-point scale ranging from 1 –‘ not at all distressing’, through to 6 ‘very distressing’.

If you are scoring a 3 or above on either of these questions, maybe talk to your doctor or health provider.

Of interest in this study was that it was diabetes distress, and not depression, that better predicted HbA1c results. Results showed that the higher people’s perceived distress, the more poorly controlled was their diabetes as indicated by HbA1c measurements. These findings are supported by a growing number of published studies in the diabetes literature indicating that high levels of distress among people with diabetes correlated with poorer metabolic outcomes.

One explanation for the finding may be that diabetes distress is related to the specific behaviours that likely impact on metabolic control, such as difficulty adhering to medication, diet or exercise prescriptions. On the other hand, depression may be related to more of a generalized low mood, which likely affects a broader range of behaviours and functioning over and above those that are diabetes-related.

 The importance of self compassion

Of particular interest with this study was that while higher distress was associated with higher HbA1c, this finding was only true for people who scored low on a scale designed to measure their general level of self-compassion (being kind to yourself). People who were higher in self-compassion, on the other hand, appeared to be protected against the effects of this distress on their HbA1c, suggesting the capacity to treat oneself more kindly when things feel tough, reduced the body’s responses to that distress.

Self-compassion in the context of the scale measured one’s tendency to be kind to oneself in the face of difficulties, to recognise that difficulties are part of being human, and to avoid being absorbed by negative thinking or rumination. Although our investigation was the first of this nature, and needs replicating with further studies, my colleagues and I suggested three possible interpretations for this effect: first, when people who are high in self-compassion experience distress about their diabetes self-management, they may be less likely to engage in self-criticism and unhelpful behaviours such as isolating and getting stuck in negative thinking. A degree of self-compassion may help patients avoid getting caught in a ‘downward spiral’ of thoughts and behavior that makes it even harder to take care of themselves. Studies have shown that self-compassion leads to increased self-improvement motivation, possibly because people who are higher in self-compassion are less likely to beat themselves up with self-criticism if they don’t quite achieve the goals they have set.

Second, people high in self-compassion have been found to take greater responsibility for their problems and be less overwhelmed by difficulties, suggesting they are more likely to take care of themselves when ill. For diabetes patients, it may be that ‘taking care’ of the self includes behaviours associated with good metabolic control such as maintaining regular physical activity, appropriate dietary choices, and regular self-monitoring of blood glucose. Finally, it may be that people who are kinder to themselves are less physiologically aroused or physically ‘stressed’ by feelings of distress. Potentially, therefore, the practice of self-compassion might provide a kind of buffer on the physical processes by which distress impacts on HbA1c.

Practising self-compassion

According to Dr Kristin Neff, the author of the ground-breaking book Self-compassion: Stop Beating yourself Up and Leave Insecurity Behind, self-compassion “provides emotional strength and resilience, allowing us to admit our shortcomings, motivate ourselves with kindness, forgive ourselves when needed, relate wholeheartedly to others, and be more authentically ourselves, qualities that would be helpful in living with diabetes”. 

Self-compassion is essentially the opposite of self-criticism and beating yourself up – common practices among diabetes patients who are encouraged to achieve ‘near normal’ glucose control and who have daily opportunities for self criticism (I’m too high, I’m too low, I’m not testing, not eating properly, not exercising… the list goes on). Interestingly, the research shows that self-criticism is associated with less motivation whereas self-compassion predicts more motivation, possibly because we are less afraid of our own negative self-talk if we don’t quite meet our goals, and are therefore more likely to keep trying to achieve these. 

In a nutshell, while it is very normal to struggle with difficult feelings at times, if these are starting to feel overwhelming, consider if you are making it worse by harsh criticism of yourself, or getting caught up in a spiral of negative thinking. Maybe it’s time to consider treating yourself more kindly when things feel particularly tough. This might entail doing for yourself the very things you would suggest to someone you dearly care about who had come to you with the same difficulties. See some suggestions below.

Tips for practising self-compassion

The simplest way to manifest self-compassion in daily life is to discover how you already care for yourself, and then remember to do these things when life becomes difficult. When these actions are taken with the intention to comfort and meet our needs, they are a form of self-compassion.

Physical – soften the body

How do you care for yourself physically? For example exercise, massage, warm bath, cup of tea. Make time for these when things get tough.

Mental – reduce agitation

How do you care for your mind, especially when you’re under stress?

For example, meditate, watch a funny movie, read an inspiring book.

• Emotional – soothe and comfort yourself

How do you care for yourself emotionally? For example, pet the dog, write a journal, cook.

Relationships – connect with others

How or when do you relate to others in a way that brings you genuine happiness? For example, meet with friends, send a birthday card, play a game.

Spiritual – commit to your values

What do you do to care for yourself spiritually? For example, pray, walk in the bush or on a beach, help others.

 *For further information on the study referred to in this article, see Friis, A, Johnson, M, Cutfield, R, & Consedine, N. (in press). Does Kindness Matter? Self-compassion buffers the negative impact of diabetes-distress on HbA1c. Diabetic Medicine.

**This article first appeared in the Autumn 2015 issue of Diabetes Wellness magazine. Subscribe to Diabetes NZ today to receive your copy.

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Jo Chapman