Health Psychology: Evaluation of the Benefits of CBT - Case Study Example

Health Psychology Background to the problem Diabetes is one of the most prevalent diseases afflicting the general population. It is the more common type of diabetes and it is one of the most persistent issues in health care. It is a chronic disease characterised by high levels of glucose in the blood. It has various causes, and one of these causes is obesity which is in turn caused by limited activity and unhealthy eating habits. This is the case of Andrea, a 35 year old project manager from Glasgow who was recently diagnosed with Type 2 diabetes mellitus. She is overweight, which is likely to be the contributing factor to her obesity. She is being regularly seen by her GP for monitoring. Her GP has recommended a change of diet and an increase in activity in order to manage her diabetes without being overly dependent on insulin injections. No improvements in Andrea’s condition were however seen. The GP suspects that she is not complying with his advice. Andrea however claims that she has changed her eating habits and has resorted to walking instead of taking the bus to work every day. Historical and conceptual background of the problem The issue of diabetes was first seen about 1550BC when an Egyptian papyrus described a disease which can cause a person to rapidly lose weight and to urinate frequently (Diabetes.uk, 2011). More references to this disease were seen in other ancient societies, including the Greeks, where they speak of a disease which manifests with excessive thirst, excessive urination, and loss of weight. Aretaeus, a Greek physician, named the disease “diabetes,” a word which means “flowing through” (Diabetes.uk, 2011). During the 19th century, more tests were developed which made it possible to test the presence of excess sugar in the urine. Attempts at treating this disease were attempted but were initially unsuccessful. During the Franco-Prussian War, a treatment which primarily involved a restricted diet was implemented and this diet seemed to be effective in managing the disease (Diabetes.uk, 2011). Microscopic studies by Philip Langerhans around this time also helped identify the tiny cell islands in the pancreas. Barron, in the 1920s related Langerhan’s cells to diabetes. Insulin was also identified and linked with the pancreas and diabetes. The treatment of this disease has improved significantly since then (Diabetes.uk, 2011). However, it remains one of the most difficult and delicate diseases to manage in health care. It has been known to cause various health complications, including organ damage and heart disease. Diet is said to be one of the major contributors to the rising rates of diabetes in the population. This diet is largely based on a high fat, high cholesterol, and high carbohydrate diet found in the foods currently consumed by the general population. Unhealthy diets often cause the increase of glucose in the blood—more than what the insulin can carry and bring to the pancreas for processing (Leslie and Robbins, 1995). Moreover, researchers have also established the condition known as endoplasmic reticulum stress triggered by a high fat diet. This stress causes the increased production of glucose in the liver which is a crucial step towards insulin resistance (Salk Institute, 2009). A major concern in the food industry and in health is the fact that more and more people prefer to eat in fast foods. These fast food chains sell foods which are high in fat, in sodium, and in carbohydrate content, thereby increasing the prevalence of obesity in the general population (VOA News, 2005). Many working professionals who are too busy to go home and cook home cooked and healthy meals are also opting for fast foods. Andrea is no doubt one of these individuals who have been drawn into this type of diet. She occupies a managerial position which likely leaves room for healthy eating which also implies her indulgence in fast foods for her regular meals. The diabetes issue in Andrea’s case is an issue which is very much related to Andrea’s lifestyle and her environment. There is a need to address her eating habits and her general lifestyle in order to resolve and manage her diabetes. Diabetes is an endocrine and metabolic disorder which is caused by the way the body utilizes insulin (Eckman, 2010). Insulin is important in transporting glucose into the cells and out of the blood to be stored and used later for energy. In type 2 diabetes, the body is not properly responding to insulin; in other words, there is insulin resistance. This means that fat, liver, and muscle cells are not responding normally to insulin (Nakayama, et.al., 2005). In effect, the blood becomes saturated with glucose causing hyperglycaemia. With high level of blood sugar, the pancreas is triggered to release more insulin. However, this is sometimes insufficient in managing the blood sugar. Those who are overweight or obese have a higher likelihood of developing insulin resistance because fat interferes with their body’s use of insulin (Mokdad, et.al., 2003). Type 2 is a disease which gradually develops over time and many of those who are first diagnosed with type 2 diabetes are overweight at the time of diagnosis. However, it may also be seen among thin individuals. A person’s obesity, along with his low activity level, unhealthy diet, and extra body weight are risk factors for the development of the disease (Eckman, 2010). This lends more credence to the fact that Andrea’s obesity is a major cause for her diabetes. Interventions for her illness must therefore be based on the management of her weight, including her eating habits, as well as her activity levels. In relation to other factors, like age, race, and gender, the older a person gets, the more prone he is to experience different diseases like type 2 diabetes, heart diseases, and osteoarthritis (American Diabetes Association, 2011). Andrea is at an age where different possible manifestations of diseases would be seen. Based on an accumulated lifestyle of unhealthy eating habits and a minimally active lifestyle, she is vulnerable to the risks of different diseases, including diabetes, heart disease, and stroke. In terms of gender, women reaching the age of menopause are more vulnerable than their male counterparts to diabetes and heart diseases (American Diabetes Association, 2011). Andrea is not menopausal, hence, this consideration does not apply, as yet, to her. However, if the pattern of her behaviour persists in her later years – into her menopause years, she would also be likely to develop heart diseases and increase her risk for strokes. Design of intervention Since the nature of Andrea’s problem is founded on her unhealthy eating habits and lifestyle, the intervention to be applied is on the establishment of a healthy diet and an exercise regimen. The cognitive behaviour therapy may be employed in order to assist in her compliance with her diet and exercise regimen. Cognitive behavioural therapy (CBT) is a type of therapy which can help a person change how he thinks (cognitive) and what he does (behaviour). It is a therapy which focuses on dealing with a person’s current issues and difficulties (Timms, 2010). CBT is based on the concept that a person’s thoughts and feelings have an important role in affecting a person’s behaviour. For example, “a person who spends a lot of time thinking about plane crashes, runway accidents, and other air disasters may find themselves avoiding air travel” (Cherry, 2011). CBT is meant to instruct patients that even as they cannot manage the different things going on around them, they can manage and control their interpretation and dealings with the environment (Cherry, 2011). Since Andrea is exposed to different factors which prompt her to violate her commitment to diet and exercise, the CBT is a means by which she can be taught to manage her thoughts and behaviour and to control her environment in order to ensure her compliance with her treatment regimen (Hazlett-Stevens and Craske, 2002). This type of intervention is justified because Andrea’s issue is more of a behavioural problem – with her eating and exercise habits. Such behaviour needs to be addressed and managed in order to help manage her obesity and her diabetes. Her disease does not appear to be genetic. It is based on a behavioural issue – her unhealthy eating habits. Therefore, the intervention for her must also address her behavioural problems—to help her change such behaviour with the end result of managing her diabetes and obesity. “A comprehensive behavioural weight control program, comprising components of improved eating habits, lifestyle change, and increased exercise, is widely viewed as the treatment of choice for overweight and moderately obese individuals” (Devlin, 2000, p. 854). Behavioural therapy has also been known to reduce depression and body image dissatisfaction among obese individuals; they have also been known to increase self esteem and interpersonal relations (Arehart-Treichel, 2007). Once the core emotional issues of the person are addressed, she would be a more willing participant to her diet and exercise regimen. At one point in the treatment, she would also likely have a reduced need for the CBT; she would be able to manage her diet and exercise on her own. The term “cognition” means to conceptualize and to recognize (Karthik, 2010). It is therefore a mental process which involves grasping the knowledge, remembering it, and then applying it. Cognitive behavioural therapy is therefore based on the theory that cognition or the conceptualization of a subject matter has a crucial role in understanding the behavioural issues of a person (Karthik, 2010). Using the cognitive behavioural theory to support the cognitive behavioural therapy helps to ensure a clear understanding of the CBT. The cognitive behavioural theory evaluates people’s personalities. This theory sets forth that all people have a unique personality. These traits are influenced and shaped by a person’s environment, lifestyle, and culture (Karthik, 2010). Psychiatrists point out that the cognitive behaviour of individuals is greatly impacted by their emotional quotient. This emotional quotient is gradually built over time after observations have been made and after their perceptions and thoughts have been retained over time (Karthik, 2010). In understanding one’s emotional quotient – the behaviour, attitudes, and perceptions he has accrued over time – it is possible to implement a therapeutic treatment which is meant to revise his perception and cognition of a subject matter and of the things which are happening to him. Using the cognitive behavioural theory to understand CBT is also advantageous because the theory specifies different personalities or types of temperaments which can be used to categorize people and how best to manage their behaviour (Littauer, 1992). These temperaments include the: optimistic (those types associated with liquid blood); phlegmatic (types who are lethargic and lackadaisical); melancholy (those who are sad and depressed); and the choleric (aggressive crowd). These four temperaments help define the personalities of individuals and the differences in these temperaments help determine the direction of the therapy to be adapted for the client. Cognitive behavioural theory is justified because it helps CBT in identifying personality disorders and to manage such disorders after proper remedies are implemented by the therapist. In using the cognitive behavioural theory to evaluate CBT, the disadvantages of CBT also apply to the theory. For one, there is a need to commit oneself to the therapy in order for the process to work well. The theory will apply only if a person is committed to the process of change (NHS, 2010). Since this theory is structured, it may sometimes not be applicable to individuals who have complex mental health issues and problems. Since the theory only seeks to discuss the current issues of the client, the underlying causes or issues of a client which may have a bearing on his behaviour and issues, may be ignored. Finally, this theory only focuses on an individual and his capacity of changing himself (NHS, 2010). It does not cover his deeper issues, like that of his family, his childhood, or his past experiences. And yet these issues may actually have an impact on his current health issue. The cognitive behavioural theory is appropriate in providing support for CBT because it is based on the same assumptions and concepts. The theory is based on the assumption that people build their own reality. In other words, “it is within the realm of processing information that people assess and make judgments that fit into their cognitive schema” (Hepworth, 2009, p. 391). The basic foundations of the theory include the facets covered by CBT. These foundations include: thinking, cognition, and behavioural change. Thinking is the main determinant of behaviour and it involves the statements and generalizations people make about themselves. Thinking that “my husband is cheating on me” or “I think my neighbours do not like me” are just some of these thoughts which people come up with. Another tenet is that of cognition. Cognition impacts on behaviour and is seen in behavioural responses (Dobson, 2009). These responses are based on how the cognitive responses are also processed or retained. The last tenet of this theory is behavioural change. This involves clients assisting the therapist in making the constructive changes in their lives while focusing on the misconceptions and how these impact on behaviour (Dobson, 2009). Based on the above tenets, the application of this theory to CBT is justified. There is sufficient support in explaining CBT and these explanations can further assist in the management of the client’s affliction. In the utilization of cognitive behavioural therapy for Andrea, there are various psychological factors which have to be taken into consideration. For one, stress usually affects a person’s metabolism – directly or indirectly. There may be no outward manifestations indicating that Andrea is stressed by her illness and/or by her job as a manager, however, in most cases, stress and anxiety are common among managers and among obese individuals (Fisher, et.al., 1982). This stress may impact on the efficacy of the CBT and make the process more difficult to implement. It is therefore important for the therapist to come up with ways to manage Andrea’s stress along with her obesity and her diabetes health issue. There is also a need to address Andrea’s motivation to change (Reever, 2009). Although she says she is dieting and exercising, she has not lost weight. This is an indication of evasiveness on her part and/or a lack of willpower to implement some changes in her eating habits and in her lifestyle. The lack of motivation to change would greatly impact on the efficacy of the therapy and of the management of her disease. Intervention: CBT for diabetes (weight management) CBT is an effective means of managing obesity and consequently, of managing Andrea’s diabetes. It consists of three stages: changing eating behaviours, challenging the psychological patterns which interfere with healthy eating, and long-term maintenance of weight (Thompson, 2009). In the first stage, Andrea would learn to recognize her destructive eating patterns. In Andrea’s case, she is fond of eating fast foods, especially high fatty and high sodium foods. She often does not have time to cook home cooked meals and this often prompts her to buy and eat in convenient fast food stores. Due to the demands of her job, she also misses meals and to assuage her hunger, she often snacks with sugary sweets, like candies, chocolate bars, and on similar foods. She also often takes in more than her recommended daily allowance of carbohydrates, mostly through white breads and pasta. She also does not have time to exercise due to her hectic schedule. There is a need for Andrea to recognize that she needs to change her eating habits from the high fat, high sodium, and high carbohydrate diet, to a healthier and well balanced diet. There is a need for Andrea to make more efforts towards healthier food choices – including cooking ahead of time to ensure that she has healthy foods available; bringing fruits with her to work to snack on; and ordering food from stores which offer healthier food choices. There is also a need to change Andrea’s daily routine to include atleast 30 minutes to 1 hour of exercise. If she prefers to consider walking as her exercise, she needs to be more religious about it and to be disciplined in regularly carrying it out. In the second phase, it is important to manage stress better in order to prevent overeating as a coping mechanism (Thompson 2009). Because of a poor body image and because of stress, Andrea sometimes copes by overeating. The more she eats however, the more she feels bad about herself. And on the cycle is repeated. This second phase shall teach Andrea to find other coping mechanisms for her poor self image and for her stress. Stress-relieving mechanisms like deep breathing, playing music, and similar methods can be taught to Andrea in order to help manage her stress (Mitra, 2008). Supplementing and encouraging her to express and explore her strengths as a person can help build her self-image. On the third phase, Andrea and the therapist can establish an individualized weight management plan (Thompson, 2009). This plan can involve a - per minute or per hour detail of her daily activities, her meals, and her work. This plan can start with her waking up at 6 am in the morning to start her day. This plan can be built with Andrea and her therapist, working out acceptable and doable changes in her life. With her active participation in the plan, she would likely be more engaged in it (World Health Organization, 2000). As her lifestyle habits begin to change, she is also more likely to lose weight and to better manage her blood sugar levels. A study Fowler (2007) sets forth the importance of lifestyle changes in the management of diabetes. The author first points out that unhealthy habits propagate majority of diabetes cases. As was already mentioned, this is likely the case for Andrea. Various studies indicate that there is a strong relationship between excess weight and diabetes and therefore, the management of diabetes largely stems from the implementation of lifestyle changes on clients. Fowler (2007) also emphasizes that lifestyle modification is an important part of diabetes management. It is actually considered the primary means of preventing diabetes, and in this case, it is now the primary means of managing the disease. The lifestyle consideration in this intervention is based on the management of glucose intake and on the increase of physical activity to maintain one’s weight. Expected outcomes of the intervention include a marked decrease in Andrea’s weight through the improved eating habits and increased levels of activity. These outcomes are expected because they are based on evidence. In a study by Brownell and O’Neil, 1993, the authors pointed out that obesity can be managed with CBT after 16-20 sessions. Another study by Agras, et.al., (1990) set forth that moderately overweight women can be managed through CBT after five sessions. These favourable results were also seen even with follow-ups at one year. Another research also manifested that after two computer therapy treatments with four group sessions weight reduction was seen (Taylor, et.al., 1991). Still, another study pointed out improved outcomes for obese participants to a computer-assisted CBT manifested with weight reduction and outcomes (Burnett, et.al., 1992). With these studies, there is a clear support for the use of CBT in the management of Andrea’s weight, and eventually, in the management of her diabetes. Problems in the application One of the problems which would likely be seen in the management of Andrea’s diabetes is her insufficient willpower to comply with the treatment regimen and therapy. On some level, obesity can be considered a product of addiction – to food – as it were. For many addicts, they often find it hard to lick their habit because they have a weak willpower (Barry, Clarke and Petry, 2009). This weak willpower can also be seen in Andrea; and this is exacerbated by her poor self-image. This would be a major issue in Andrea’s treatment because it would impact on the success (or lack thereof) of her CBT. The fact that Andrea does live a very busy and highly stressful job as a project manager will also likely make the implementation of lifestyle changes difficult. Unless there is someone who can prepare the healthy meals for her or who can ensure that she gets her meals on time, the treatment regimen would be difficult to implement. For Andrea, what could be done next may be seen with the potential conceptualization of a plan for the maintenance of her diet and her blood sugar levels. This would include a regimen for regular blood sugar checks, regular blood pressure checks, regular blood chemistry check, etc (Del Prato, et.al., 2005). These are a part of her monitoring process – to help evaluate the progress of her weight loss and how such weight loss has assisted in decreasing her blood sugar levels. The steps which would help complement the CBT for Andrea is the regular assessment and monitoring implemented on her behalf. Monitoring is an important part of diabetes management because the speedy implementation of remedies would help prevent extremes in blood sugar levels (Del Prato, et.al., 2005). Too high and too low levels of blood sugar can prove fatal to diabetes patients. Andrea must be advised to have herself be regularly checked by her GP and to have her blood sugar and blood pressure be regularly monitored. She must learn to recognise her danger levels as a patient and the symptoms which might prompt immediate medical attention. In evaluating the benefits of CBT, it is important to note that the basis of Andrea’s diabetes treatment is her weight management. In this case, her weight management is being sought with the application of the CBT. CBT is a difficult process to implement because it would call for the process of undoing years of ingrained behaviour on a client. It would also demand a significant amount of will-power from the client. However, the benefits which are likely to accrue for Andrea are very encouraging because the CBT would address the core of her health issue which is her lifestyle – to recognize the issues giving rise to her obesity and to change it. In other words, the intervention is based on a more permanent remedy for her weight issue and in the end, her diabetes issue as well. Works Cited Agras,W., Taylor, C., Feldman, D., Losch, M., & Burnett, K. (1990). Developing computer- assisted therapy for the treatment of obesity. Behavior Therapy, volume 21, pp. 99–109. American Diabetes Association (2011). Age, Race, Gender & Family History. Retrieved 05 May 2011 from http://www.diabetes.org/diabetes-basics/prevention/checkup-america/nonmodifiables.html Arehart-Treichel, J. (2007). CBT Teaches Obese People How to Think Thin. Psychiatric News, volume 42(15), p. 18 Barry, D., Clarke, M., Petry, N. (2009). Obesity and Its Relationship to Addictions: Is Overeating a Form of Addictive Behavior? Am J Addict., volume 18(6): pp. 439–451. Brownell, K., & O’Neil, P. (1993). Obesity. In D.H. Barlow (Ed.), Clinical handbook of psychological disorders (2nd ed., pp. 318–361). New York: Guilford Press. Burnett, K., Taylor, C., & Agras,W. (1992). Ambulatory computer-assisted behavior therapy for obesity: An empirical model for examining behavioral correlates of treatment outcome. Computers in Human Behavior, volume 8, pp. 239–248. Cherry, K. (2011). What Is Cognitive Behavior Therapy? About.com. Retrieved 05 May 2011 from http://psychology.about.com/od/psychotherapy/a/cbt.htm Del Prato, S., Felton, A., Munro, N., Nesto, R., & Zimmet, P. (2005). Improving glucose management: Ten steps to get more patients with type 2 diabetes to glycaemic goal. International Journal of Clinical Practice, volume59(11), pp. 1345–1355 Devlin, M., Yanovski, S., Wilson, G. (2000). Obesity: What Mental Health Professionals Need to Know. Am J Psychiatry, volume 157: pp. 854-866 Diabetes.uk. (2011). Diabetes History. Retrieved 05 May 2011 from http://www.diabetes.co.uk/diabetes-history.html Dobson, K. (2009). Handbook of cognitive-behavioral therapies. London: Guilford Press Eckman, A. (2010). Type 2 diabetes. Medline Plus. Retrieved 05 May 2011 from http://www.nlm.nih.gov/medlineplus/ency/article/000313.htm Fisher, E., Delamater, A., Bertelson, A., & Kirkley, B. (1982). Psychological factors in diabetes and its treatment. Journal of Consulting and Clinical Psychology, volume 50(6), pp. 993-1003. Fowler, M. (2007). Diabetes Treatment, Part 1: Diet and Exercise. Clinical Diabetes, volume 25(3), pp. 105-109 Karthik, N. (2010). Cognitive Behavioral Theory. Buzzle.com. Retrieved 05 May 2011 from http://www.buzzle.com/articles/cognitive-behavioral-theory.html Hazlett-Stevens, H. & Craske, M. (2002). Brief Cognitive-Behavioral Therapy: Definition and Scientific Foundations. London: John Wiley & Sons Hepworth, D., Rooney, R., Rooney, G. (2009). Direct Social Work Practice: Theory and Skills. London: Cengage Learning Leslie, R. & Robbins, D. (1995). Diabetes: clinical science in practice. Cambridge: Cambridge University Press Littauer, F. (1992). Personality Plus. London: Revell Publishing House Mitra, A. (2008). Diabetes and Stress: A Review. Ethno-Med., volume 2(2): pp. 131-135 Mokdad, A., Ford, E., Bowman, B., Dietz, W., Vinicor, F., Bales, V., & Marks, J. (2003). Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. JAMA, volume 289, pp. 76-79. Nakayama, M., Abiru, N., Moriyama, H., Babaya, N., Liu, E., Dongmei, M., Liping, Y., & Wegmann, D. (2005). Prime role for an insulin epitope in the development of type 1 diabetes in NOD mice. Nature, volume 435(7039): pp. 220–223. National Health Services (2010). Cognitive behavioural therapy – Considerations. Retrieved 05 May 2011 from http://www.nhs.uk/Conditions/Cognitive-behavioural-therapy/Pages/Advantages.aspx Reever, M. (2008). Cognitive-Behavioral Interventions for Obesity. Northeast Florida Medicine, volume 59(3), pp. 37-40 Salk Institute (2009, June 22). How Obesity Increases The Risk For Diabetes. ScienceDaily. Retrieved 05 May, 2011, from http://www.sciencedaily.com/releases/2009/06/090621143236.htm Taylor, C., Agras,W., Losch, M., Plante, T., & Burnett, K. (1991). Improving the effectiveness of computer-assisted weight loss. Behavior Therapy, volume 22, pp. 229–236. Thompson, L. (2009). Obesity: An Overview. Eating Disorder Resources. Retrieved 05 May 2011 from http://www.eating-disorder-resources.com/eating-disorder-articles/eating-disorders/obesity-overview/ Timms, P. (2010). Cognitive Behavioural Therapy (CBT). Royal College of Psychiatrists. Retrieved 05 May 2011 from http://www.rcpsych.ac.uk/mentalhealthinfoforall/treatments/cbt.aspx VOA News. (2005). Scientists Say Fast Food Heightens Risk of Diabetes. Retrieved 05 May 2011 from http://www.voanews.com/english/news/a-13-2005-01-03-voa3-67510292.html World Health Organization. (2000). Obesity: preventing and managing the global epidemic. Switzerland: World Health Organization Read More