Where are the diabetes psychologists?

Medications only work if we take them… devices only work if we use them.

Dr Mary de Groot

In her presidential address at this year’s ADA virtual conference Dr Mary de Groot outlined once again the need for diabetes services to recognise the impact of psychological processes in diabetes management. This is not a new statement to make. The ADA, along with diabetes charities have been advocating for psychological support for people with diabetes for years; however despite high-profile addresses, consensus statements and campaigns, diabetes psychology is still overwhelmingly missing.

While the list could go on and on, here are five reasons why there aren’t more diabetes psychologists in the UK

1. There aren’t enough posts – there’s a serious chicken and egg problem in diabetes psychology, and it underpins everything. In the UK (and probably further) diabetes psychology posts are extremely rare outside of paediatric services. Where posts are commissioned they are often as part of a general ‘health psychology’ remit, and budgetary restrictions mean that posts are often provided either at, or below the bare minimum level required for the population. As a result services quickly become swamped, and practitioners are forced to spend their time fire fighting waiting lists, rather than being able to work on service development or innovation. Not having enough posts means that there aren’t enough people with expertise available to demonstrate what diabetes psychology can do, and to advocate for diabetes psychology where it matters, so it doesn’t get ‘seen’, which means it gets forgotten.
2. The guideline gap – One of the factors contributing to increased paeds diabetes psychology posts in the UK is that the ISPAD guidelines explicitly outline the need for diabetes psychology and stipulate that posts should be included in service planning and peer review. It’s not the same for adult services. The current NICE diabetes guidelines for adults recommend that diabetes healthcare professionals know how to identify anxiety and depression, and that appropriate signposting is provided once issues are identified, but no mention is made of diabetes specific issues like diabetes distress or repeated DKA admissions. Unsurprisingly, diabetes psychologists were not involved in the development of these guidelines. The NICE guidelines are currently under review by a panel of experts that now (after considerable pressure) includes a psychologist, so things may improve in the future, however NICE guidelines can only support practices with significant evidence…
3. The research gap – when cases are made for comissioning diabetes psychology posts, they are consistently required to produce evidence that diabetes psychology will have a significant impact on reducing costs and HbA1c. While this seems reasonable (nobody in an under resourced NHS should be gambling tax payers’ money), the kind of large-scale RCT studies that make the case for other aspects of diabetes care simply don’t exist in this field. There are a number of reasons for this: firstly, in order to run an RCT participants need to have the same therapy every time. Some therapies like CBT lend themselves to this as they are manualised, and this is the reason that CBT has become so prevalent in NHS services despite being deeply unpopular and perceived as outdated by most psychological practitioners. The vast majority of diabetes psychologists will not use CBT and will instead tailor their approach to the needs of their clients; this does not lend itself to RCT evaluation. Secondly, when research does happen, it’s often being run by people with no or very little experience in diabetes psychology, so as a result it’s often of poor quality and unlikely to get good results (see the recent reviews of impact of talking therapy in diabetes outcomes). Third, we’re back to point number 1 – where posts have insufficient capacity to meet their clinical remit, research will never be a priority. But it’s not all bad news: in research things seem to be progressing in terms of shifting towards more meaningful measurements like time in range; it’s hoped that in the future that more holistic measures like quality of life, which would strongly support diabetes psychology, can be given as much weight as biological markers.
4. The training gap – while most practitioners working in diabetes psychology will have received extensive training on therapeutic models that can be applied to people with long-term physical health conditions, very few will have received specific training on the biology of diabetes and the daily management tasks involved. Similarly, those training in traditional diabetes care (e.g. as diabetologists or diabetes specialist nurses), will tend to receive little if any training on psychological issues in diabetes, and will often have no concept of the potential benefits of working with a diabetes psychologist. As a result of these training gaps professionals often work in silos, and significant opportunities to increase potential gains from integrating basic psychological concepts into routine diabetes care (e.g. in patient communication) get missed.
5. The representation gap – as there’s no specified route into working in diabetes psychology, those currently in the field come from a range of professional backgrounds including psychotherapy, clinical psychology, health psychology and psychiatry. While each group has very different approaches to training, skills, and overarching ethos, those outside of mental health fields are (unsurprisingly) often confused by the differences between these groups and what each can be expected to provide. Not only does this confusion make it difficult for non-psychology specialists to understand us, there is an additional layer of difficulty in that each of these groups has a different professional body. This makes it all the harder for organisations to include diabetes psychology representatives in planning and development, thereby continuing the cycle of absent psychological support.

The entire diabetes community must recognise that the behavioural study is a fundamental need in diabetes research and embrace the idea that behaviour is an equal partner to medical innovations

Dr Mary de Groot

If we’re going to improve psychological well-being for people with diabetes things need to change considerably. But there is hope- if services play an active role in growing diabetes psychology by ensuring psychology voices are represented and that psychological outcomes are truly valued, we stand to make significant gains. Surely in an age where it is accepted that the mind and body cannot be treated as separate entities, it is time for services to start truly working together?