Why have a psychologist in a diabetic foot clinic?
In a presentation at this month’s Diabetes UK Professional Conference, a psychologist working within a diabetic foot clinic outlined her role and why all clinics should have one. Lisa Buckingham reports.
‘I often joke that medics look at the feet and psychologists look at the person attached to the feet,’ said Catherine Bewsey, chartered counselling psychologist and Diabetes UK Clinical Champion. She works in the diabetic foot clinic at St George’s University Hospital in London and set up its psychology provision from scratch.
Psychologists working within diabetes look at the interaction between a person’s mental health and their diabetes. If distress is picked up sooner, said Catherine, a person can be better supported to self-manage. Her role is an integral part of the multi-disciplinary team (MDT), and she works with both inpatients and outpatients, as well as being part of the amputation pathway. Along with addressing issues such as depression and anxiety, she also helps patients make informed decisions about surgery and works with their families/carers.
In her presentation at the Diabetes UK conference, she first discussed the kinds of clients that might be seen by her and reminded the audience that diabetes is like a full-time job with no breaks or holidays. Patients have much to deal with on a daily basis such as medication, diet, monitoring and testing blood sugars and keeping a positive mindset. On top of that come the demands of the diabetic foot, such as reduced mobility, managing ulcers, medical appointments and neuropathy. Emotionally, patients may feel shame for not having managed their diabetes sooner and guilt for the burden of care on their loved ones.
Therefore, psychological issues in the diabetic foot patient need our attention. For example, if someone is depressed, they may not feel motivated to self-manage. Many of the patients Catherine sees have issues with eating, whether that’s overeating, poor diet or making themselves sick after eating. Social anxiety is also seen and that can result in a delay to seeking treatment. Patients also have the means to self-harm with so much medication available to them.
She sees many patients who have had adverse childhood experiences, such as being brought up in care, and have enduring life stressors. Others have psychological, neurodevelopmental, cognitive and social issues such learning difficulties and substance misuse. Co-morbidity is common, such as sight loss and renal failure.
Regarding amputation, Catherine outlined the issues she encounters with these patients before and after surgery, such as loss and adjustment, trauma, coping with job loss or role change, body image issues, self-neglect and sabotaging rehab.
Her work with these patients involves assessments undertaken jointly with the medical team on their suitability for amputation, normalising fear and grief, involving them in support groups, helping patients communicate with family and friends about their amputation, and helping to build resilience and self-compassion.
Next, she flagged up the important issue of health inequalities. Her experience of the patients they see in the diabetic foot clinic is that they are commonly older, mainly single males who are often manual workers who work on their feet such as chefs, security guards and cleaners. There is financial poverty and limited sick pay, digital poverty resulting in difficulty engaging with medical services, high levels of medical non-adherence, social issues such as housing problems, and difficulty navigating postcode lotteries when it comes to services.
Here, she posed three questions. Why are these patients not being picked up earlier? Why are the barriers they face not being recognised? Why are they slipping through the net and ending up with diabetic foot complications? Sadly, she said, she doesn’t have the answers.
Going into more detail about her role within the MDT, she provides training and case consultation, helps staff to reflect on their practice and she introduced routine screening.
The team in a diabetic foot clinic has a very tough patient group, she said. The work is often crisis driven, with patients arriving with emergency symptoms or from A&E, and the focus is very much on the foot. Part of her role is to get everyone to think about the whole person.
She supports the clinic to ask the difficult questions around a patient’s wellbeing. This is difficult if you don’t have a screening process in place, she said, as staff may be reluctant to open ‘Pandora’s box’; they’re worried about stigmatising/alienating a patient and wellbeing is sometimes at the end of their checklist. In her clinic, all new patients now complete a brief diabetic distress screening measure (embedded alongside medical questions).
There are also high emotional and psychological demands on the staff as it’s not easy to work with human suffering and complex patients, so their welfare needs looking after too. The pandemic has meant facing high death rates among patients, with some of whom the staff will have had longstanding relationships, and they need strategies to protect against burnout.
Another area of her work is the language used in clinic, particularly the delivery of bad news. The wrong words or a rushed consultation can make patients feel like a failure, she said, and so her recommendations are that this is done in a private space, their options are written down as they may be too stressed to remember them, support numbers should be given, the offer of family/friends to listen in should be offered, as well as the chance to ask questions later on.
In answer to the question ‘can non-psychologists offer patients emotional support?’, Catherine said the answer is yes. There are resources such as training courses to support brief interventions and all members of staff can and do listen to their patients. However, having a psychologist on the team helps support staff members with their listening skills and reflect upon their cases.
She referred to the Too Often Missing report, which found that emotional and psychological support must be an integral part of all diabetes care and that there needs to be greater access to specialist diabetic mental health support. There aren’t enough psychologists working in diabetes and certainly not enough in foot clinics. General mental health teams often have limited knowledge of diabetes.
In summary, she said, emotional distress impacts on self-management and we need to embed psychologists into diabetic teams; screening picks diabetic distress sooner and the role of the psychologist is to build a psychologically informed service.
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Any opinions expressed in this article are the responsibility of the EASD e-Learning Programme Director, Dr Eleanor D Kennedy.