Beverly S. Adler, PhD, CDE uses her "TLC Therapy" to help people with their diabetes management needs as well as address the psychological aspects of the disease, including diabetes-specific distress, in order to help them work through their issues and get them on track to make better lifestyle choices.

By: John Parkinson, Clinical Content Coordinator, DiabetesCare.net

Beverly-AdlerBeverly S. Adler understands diabetes, specifically type 1, from a perspective very few can. As a person with type 1 for nearly 40 years, a practicing psychologist, and a certified diabetes educator, she can treat people with diabetes (PWD) holistically in a way that encompasses the mind and body with a clinical perspective and deeper understanding than those who might not have diabetes.  

Adler does this through her Talk, Listen, Counsel (TLC) Therapy, which is a hybrid treatment combining the AADE 7 Self-Care Behaviors framework with a therapist’s expertise. Adler is helping people take away the blinders of negative thinking and helping them adapt to living with diabetes so they can be happier and accepting of their condition.

DiabetesCare.net spoke to Adler about the various components of TLC therapy, why it is important to address the emotional component of diabetes, the difference between clinical depression and diabetes-specific distress, and when it is time to refer a patient to a therapist.

DiabetesCare.net: Can you provide an overview of the TLC Therapy?

Adler: What I did was pull together what it is that diabetes educators and that therapists do separately, except I formally organized it into a three-part therapy specifically for people with diabetes. The three parts are “T,” which is talking; the “L” is listening; and the “C” is counseling. The talking portion applies to both newly diagnosed patients, or people who have had diabetes for a long time and never got an explanation or forgotten a lot of things, so that portion is talking to them. The diabetes education field has expanded so for diabetes veterans it is about learning all the newer nuances of diabetes self-management. It is based on the framework of the AADE 7.  

The "L" or listening portion is hearing patients and supporting their concerns and feelings; and the "C" part is counseling, which uses cognitive behavior therapy to empower patients. My biggest goal withTLC Therapy is to have my patients accept their diagnosis and feel empowered. They don’t believe in themselves when they come in, so we take everything in baby steps.

DiabetesCare.net: What was your thought process in developing the TLC Therapy?

Adler: It’s something that I had been doing, but it didn’t have a name. I am educating my patients, listening to them, and counseling them. I haven’t invented anything; I just gave it a name. Putting it out as TLC Therapy was a way to help other diabetes educators with something they may want to look at as an approach for their patients.

DiabetesCare.net: You use the term healthy coping when talking about TLC Therapy. Can you explain what that is?

Adler: Healthy coping is the seventh of the AADE 7 Self-Care Behaviors. The problem is there is a lot of unhealthy coping for people with diabetes. There are a lot of negative attitudes, and to get to healthy coping is a long process. Part of getting to that healthy coping is to listen to the patient—carrying out the “L” portion of TLC—so I can know what it is I can help them with in terms of their unhealthy thoughts about the disease. People may have misconceptions or false information and that can lead them to very negative emotional reactions.  

As a behavioral therapist, I challenge them and their thoughts. Challenge does not mean that I’m disagreeing with them, but I’m trying to challenge them to look at it differently.

The way cognitive behavior works is that an event occurs,  such as being diagnosed with diabetes, and it’s an event that happens outside our control. The negative emotions are based off of the negative thoughts that we have about this event that we cannot change. If we can change our thinking, we can change our feelings.

Once people are feeling better, this can transition into healthy coping, and then they can manage their diabetes more effectively.

DiabetesCare.net: Why is addressing the emotional aspects of diabetes so important?

Adler: The problem is that with someone who is not happy with their diabetes they are likely not taking good care of themselves, and are thereby not having good control. My goal is to get them to feel better and make better choices so that their diabetes can be better controlled.  The two goals I’m looking to achieve with TLC Therapy are for clients to accept their diabetes and to feel empowered to manage it.

If somebody doesn’t believe he or she can manage their diabetes, they are giving up before they even start. The idea of what I do is to help them not give up, and do better so that they can have long-term good health.

DiabetesCare.net: One of the things we are hearing about more frequently is the connection between depression and diabetes or the term you heard and are using diabetes-specific distress. What is the difference in these terms and when is it time for people with diabetes to consider seeing a psychologist?

Adler: Depression is often associated with diabetes, and that is what is getting the most attention; however, there is a difference between clinical depression and diabetes-specific distress. Clinical depression can be remedied with anti-depressant medication. It has to do with neurotransmitter chemicals in the brain, and not just life events; whereas, diabetes-specific distress cannot be cured with anti-depressants. This is a condition that results from the demands of living with diabetes.

It is important to note that you can be both clinically depressed and have diabetes-specific distress. However, if it is just the latter condition, people can work on the stressors that are related to disease management.

Diabetes-specific distress is not my term, but a term coined by William Polonsky, PhD, CDE of Behavioral Diabetes Institute. He is a pioneer in the field, and I have respect for what he has done in treating emotional coping. He wrote a book called Diabetes Burnout: What to Do When You Can't Take It Anymore, and I believe he was the first one to discuss emotional issues related to diabetes.

There are four different areas of living with diabetes that can trigger this emotional distress. The first area Dr. Polonsky refers to is emotional burden. Those are feelings of anger and sadness. The second is regimen distress, which include feelings of failure, burnout, and inadequacy about diabetes management routine. The third area is interpersonal distress and that is conflict with family or friends regarding your diabetes care. And the fourth one is physician-related distress and that has to do with difficult relations with healthcare providers.

When a therapist, diabetes educator, or healthcare provider can identify what is the distress, then he or she can work on changing the thoughts and actions to relieve the distress. You can’t do that with clinical depression.

DiabetesCare.net: Clinical depression and diabetes-specific distress sound very different but when folks have either of these conditions do they still need to see a mental health provider? When do you think it is a good time to recommend or refer seeing a therapist?  

Adler: I don’t think a person with diabetes naturally resolves their diabetes-specific distress by themselves so they do need professional help. You need an objective, non-judgmental, professional therapist help you through the process.

I feel if I have a patient who has a lot of questions about food and eating, and they are beyond the basics, I have to recommend they see a registered dietitian, because it is out of my field of expertise. This is why I think it is important that medical providers refer patients and clients who exhibit signs and symptoms of clinical depression or diabetes-specific distress.

DiabetesCare.net: Is it simply having diabetes educators ask patients how they are feeling? How can they gauge where their patients are emotionally?

Adler: If they get to the point where they hear from their patients that they are feeling overwhelmed about their diabetes, or angry with having diabetes, or guilty when they are off-track with diabetes management or stressing about the future and complications--those are signs of distress. Additionally, if a patient is experiencing feelings of loneliness or burnout, then he or she is above and beyond the average person coping with diabetes, and needs to be referred to a mental health provider.  

The thing about diabetes is that it weaves a thread throughout our lives, and if a person is having interpersonal problems with their friends and family, diabetes is only making the situation more difficult. You can explain to somebody that maybe they need to speak to an objective person who can help them deal with their challenges and issues with their relationships, as well as help them better manage their diabetes.

Adler is the author of two books: My Sweet Life: Successful Women with Diabetes, which can be purchased here, and My Sweet Life: Successful Men with Diabetes book, which can be purchased here.