Welcome to Life Without Limits, the One Drop podcast that gives you the tools, inspiration, and support to challenge your limits.
Our first episode features Dr. Harpreet Nagra, a clinical psychologist and researcher, who discussed how to handle diabetes burnout during a global pandemic.
Did you know that on average, people with diabetes need to make about 180 extra decisions per day? And, that’s why burnout can be so common.
Dr. Nagra discussed how to navigate some of the emotions that accompany diabetes and all of the extra decisions that need to be made each day.
You can learn more and follow Dr. Nagra at:
Show Notes and Full Transcript
Host: This is Life Without Limits, the One Drop Podcast that gives you the tools, inspiration and support to challenge your limits. We talk with experts across all areas of health to open up more possibilities for you. Lean on us, as you step outside your comfort zone to work your way toward better overall health and a life without limits.
Kim Constantinesco: Welcome to our first episode of Life Without Limits, the One Drop Podcast where we talk with health experts to help people transform their lives and re-imagine possible. I’m your host, Kim Constantinesco, and on today’s show we have Dr. Harpreet Nagra, who is a clinical psychologist based in Portland, Oregon, and she’s here to talk with us about the twists and turns of living with diabetes during a global pandemic. Dr. Nagra has a double master’s degree in psychology, a doctorate in counselling psychology, and she has specialized in health psychology for most of her career.
She has worked as a professor and as a therapist, both in hospital and group practice settings. Specifically helping people with diabetes manage their emotional health. Currently she is working as a clinical diabetes researcher at the University of California San Francisco and as adjunct faculty at Purdue Global’s College of Social and Behavioral Sciences. Dr. Nagra, thanks so much for coming on our first show. We’re thrilled to have you here.
Harpreet Nagra: Thank you so much for having me, Kim. I’m excited to talk about diabetes. I think this is a really important topic to be starting with.
Kim Constantinesco: So tell us a little more about yourself and why you decided to specialize in diabetes psychology.
Harpreet Nagra: Yes, definitely. So I was trained as a counseling psychologist, as you said, and over the years I really developed an interest for health psychology. And along the way I was introduced to diabetes, partly from personal and professional experience. Personally I’ve had family members who have had both type one and type two. And what I learned from that personal experience is that there wasn’t a whole lot of discussion around the psychological aspects of managing diabetes.
And so when I was getting my training as a counseling psychologist and then learning about chronic illness and health factors that impact people’s mindset, I was noticing that with diabetes specifically there wasn’t a huge focus on how a person’s psychological well being could impact their biological interactions in managing their chronic illness like diabetes.
So what I wanted to do was figure out how can I incorporate more of the sort of psychological as well as social aspects of managing diabetes, along with the biology of it. So when I first started out I was still in training and working at a hospital setting. And I noticed that when I would sit down with families who were managing type one diabetes for their children, they were often being bombarded with messages about, this is the right way to take insulin. Or, this is the appropriate carb to insulin ratio that they should be working on. And all of that was very appropriate and helpful information. But there wasn’t much discussion of the emotional weight of carrying diabetes and dealing with it 24/7 for not just the kiddo who was dealing with it, but also the rest of the family.
And so I decided to focus in on that for my postdoctoral degree, fellowship at a diabetes centre. I switched over to working with young adults and adults at that point. And there I learned that diabetes impacts people throughout the life span. It’s not just something that we have to be mindful of at diagnosis. But we really need to be supporting folks throughout their journey with diabetes. So that was pretty impactful for me, and being a psychologist of color I was also noticing that diabetes impacts communities of color quite often. But people of color are much less likely to seek out emotional health resources.
And so I wanted to be another resource, another face that could be useful for communities of color. And within that I also wanted to recognize that not everybody can afford therapy regardless of socioeconomic status or race or a variety of sort of demographic factors. It’s just not something that’s easily accessible to everybody. So I really wanted to provide psycho education about diabetes and how to manage sort of the emotional side of diabetes to those who couldn’t access these types of services. So that’s a long winded answer to your initial question.
Kim Constantinesco: No, thank you for going into detail like that. And you’ve mentioned to me that there are some common emotions that people with diabetes experience, whether they are newly diagnosed or they’ve been living with the condition for many years. Can you talk about that a little bit more?
Harpreet Nagra: Yeah, so I would say there’s a spectrum of emotions that go hand in hand with managing diabetes. Diabetes is one of those illnesses where there’s multiple opportunities for self-criticism and judgment on a regular basis. So I would say a lot of folks who are newly diagnosed can recognize the sense of isolation and loneliness that they experience. But there’s also a great amount of shame around just having diabetes that tends to come on as well.
And with that shame comes a sense of regularly feeling like you’re failing at managing diabetes and potentially even a sense of failing at having the diagnosis initially. There’s been some studies that looked at what does a person living with diabetes have to contend with emotionally on a daily basis in terms of how much are they problem solving or decision making every single day? And what they found is that diabetes requires a person to make an additional 180 decisions per day.
Last weekend I was sharing this factoid with a client they said, “Well, if it’s 180 decisions per day, then it feels like it’s 180 failed pop quizzes every single day that I’m dealing with.” I mean, you can just imagine how much of an emotional toll that would take on any person to feel like they’re failing 180 times per day, day in, day out, right.
So what tends to happen is that for those folks who are living with the condition for multiple years, there’s a feeling of, of course that failing sensation. But also this idea that they should have mastered it because they’ve been living with it for so many years. They should have mastered it by year one or year ten or year twenty, whatever it may be. But because that sense of pressure is there, there tends to be a significant amount of feeling burnout around wanting to manage diabetes.
And so a lot of the diabetes psychologists – or psychologists in general, what we want to do is start taking away some of that sensation of burnout. Because what burnout does is it kind of numbs you to wanting to deal with diabetes. Which means that you may not be as likely or as interested in doing the day-to-day tasks that diabetes requires. And that fuels even more of that feeling of powerlessness or hopelessness about your future. And we all know that if we’re feeling powerless or hopeless about something, then we’re just not going to want to show up to deal with it day in, day out. So there’s a significant number and a whole spectrum of emotions, and a lot of them have to do with this overarching feeling of not feeling like we’re good enough to take this task on.
Kim Constantinesco: Yeah, absolutely. So I know loneliness and isolation are two other very common emotions that people experience when they have diabetes. And here we are in the middle of a global pandemic where more and more people are feeling isolated and lonely, what are you noticing from your experience working with clients and what you’re seeing in the diabetes community as it relates to COVID and these feelings of loneliness and isolation?
Harpreet Nagra: Yeah, there is – I would say there is a significant amount of uncertain up in the air right now. So what I’ve seen in my clinical work and even in our research work is that many folks are experiencing the stress and worry that COVID has brought on. So there’s stress and worry about resources, such as, will I have a job? Will I have insurance? How will I manage being in a high risk job where I might get exposed? Or if they are going to be losing their job or their insurance, how will they cover insulin? Not only for the person themselves, but also if their partners are losing access to some of these resources. And of course that’s going to be impactful for the lifestyle that they’ve been living. Not just in sort of downgrading, but also in just making sure that they have enough food and access to the regular doctors that they’ve been seeing to manage diabetes on an ongoing basis.
What we are also noticing is that there’s higher rates of isolation due to the quarantine. So folks who are able to work from home and still keep their jobs, they’re feeling, again, more of that loneliness coming through, which can cause a spike in mental health concerns, such as depression or anxiety. And in addition to that, if you’ve got a family at home, if you’ve got a partner at home, we’re also noticing some folks who might be experiencing higher levels of relationship conflict. If a person is experiencing higher symptoms of depression or anxiety, then that’s going to show up in their relationship. And if you don’t have any of those sources of support that you used to or moments of rest that you used to, breaks in the day where you could go out and go for a walk or go out for social activities with friends as a way to sort of distress from your relationship or whatever stress might be coming up in the household. We’re noticing some of those feelings are starting to get – they’re building up over time. And folks are responding to that in possibly higher distressed ways in terms of how they’re managing their diabetes overall.
We’re also noticing a lot of powerlessness coming through. So we know that financial distress and worry about resources is at its peak right now. With that comes this sense of, well, if I don’t have the finances to take care of myself right now, how am I going to take care of my family? And that is causing distress within familial relationships and friendships as well. But we’re also noticing powerlessness and that feeling of having to go back to work just to afford the insulin, even if a person may not feel ready to go back to work during the pandemic.
Kim Constantinesco: Yeah, there’s so much to juggle, and you mentioned the 180 decisions a day and just condition management, is really challenging, even when we’re not in a global pandemic. So can you talk a little bit about what are some things that people can do to help prevent or relieve this kind of distress?
Harpreet Nagra: Certainly. I think a lot of evidence-based strategies out there that diabetes psychologists will talk about, but I will share the three that I’ve noticed as being the most impactful in my clinical work with my clients. The first I would say is self-compassion. Self-compassion is an idea that was well researched, continues to be well researched and discussed by a psychologist by the name of Kristin Neff. She talks about it more broadly. But I would say in its relationship to diabetes, what we’ve seen is that it helps reduce that self-critical voice that is so prominent in diabetes management.
And what self-compassion refers to is really just acknowledging your humanness and the imperfections that come with managing an imperfect illness like diabetes. There is no sort of mastery to it that we could do. Really what we want to do is help you manage it and negotiate all the decisions that come with it as you practice managing every single day.
So with that is going to come errors along the way, areas of improvement as well. But what we want to do is say, things will not always go the way that you want them to, and that’s okay. And that’s a part of sort of your journey in learning how to manage diabetes. So self-compassion, what we want to say is that we want you to be speaking to yourself as if you would to a close friend or a partner or a loved one who might be feeling distressed. If you’re noticing that you would speak to them more kindly when they’re feeling distressed compared to how you’re speaking to yourself when you’re talking about your diabetes or having a low blood sugar or a high blood sugar, then that indicates some room for improvement.
With diabetes we know you’re going to always encounter frustrations and some sense of loss or a failing might come up. And you’re going to make mistakes and bump up against what your limitations might be. But what self-compassion says is that that’s all okay. Even though there might be ideal numbers that the American Diabetes Association might have set up for you, that’s totally fine. Only about 18% of folks living with diabetes actually live up to the ideal numbers that ADA has set up for them in terms of A1C blood pressure and cholesterol levels.
But the rest of us are really just kind of doing the best that we possibly can, and that’s okay. So I think as soon as folks start to recognize that their sense of self-compassion may not be where they want it to be, that ends up being a huge sense of relief for them. And the more you practice self-compassion, the easier it becomes to sort of relieve the overall pressure that diabetes can bring about.
Some additional strategies that I’ve noticed being really useful for folks it to mobilize your social support. I think during COVID especially, this is the time when we’re not seeing our family and friends, extended family and friends as much as we would otherwise. So we have to be much more mindful and intentional about reaching out for support and help. So a lot of folks, when I say that, mobilize your social support, what they end up saying in response is, well, if I tell my family or my friends that I’m not doing so well with my diabetes, then they start going to the other end of the spectrum and start nagging me about checking my blood sugars. Or making sure I have my supplies up to date, or making sure that I’m attending my appointments or whatever it might be.
So if that’s the case, then what I typically respond with is, typically when family and friends say those things to us, they’re saying it from a place of wanting to help. They’re not saying it to be nags in any way. But they care about us, and they’re wanting us to be able to take care of ourselves. And if you don’t want them to help you in one way, then give them something else to do. So if it feels annoying or frustrating or upsetting to you for them to constantly ask you, did you check your blood sugar? Did you check your blood sugar? Then give them something else to do. Have them just quietly bring your diabetes supplies from the other room over to you without saying anything. That might be one potential difference that you could integrate into your relationship. But there’s lots of different ideas and strategies in terms of how to still receive the sense of social support without it leading to more conflict or more problems within the relationship.
And then the final strategy that I’ve seen to be really effective with clients is to participate in some sense of advocacy around, whether it’s diabetes or it’s another cause that they’re passionate about. Being part of either online communities or local communities, where they can engage in a high level of advocacy for whatever is meaningful to them. My inclination is that this is effective because it gives folks a sense of purpose outside of just a day-to-day and detailed management of diabetes. It kind of forces you to keep your head out of the trees and look at the sort of larger forests that we’re all living in. And it helps to reduce some of that feeling of powerlessness that can easily be evoked when you’re living with diabetes.
Kim Constantinesco: Excellent strategies, Dr. Nagra . And I’d like to jump back to that social support piece. What if you’re a person who finds it difficult to ask for help or ask for support? What are some strategies to overcome that?
Harpreet Nagra: Yeah, that’s a great point, Kim. I think there’s a lot of folks who would say, I’m getting all this unsolicited feedback and advice from doctors, from family members about how to manage my diabetes. Why would I be reaching out to them for more help, right? This is a common occurrence, where folks feel like I don’t want to be inviting more judgment or more criticism into my life by asking for help, especially if folks don’t know how to support me.
And I would say the main strategy here is to start with yourself and really self-reflect on why this is coming up for you. Why does this feel hard for you? Are there feelings about diabetes that you might be trying to avoid? Going back to the earlier conversation we had about all the – sort of the spectrum of the emotions that diabetes brings with it. Shame is a big one. If you’re feeling embarrassed about having diabetes in the first place, then yeah, it’s going to definitely impact how often you reach out for support.
But I think through self-reflection you can start to notice what main emotion might be – and it might be multiple feelings, what main emotions are coming up for you and why they might be coming up for you. And I think in that self-reflection piece you can start to acknowledge well, is shame something that I want to carry around with me about my diabetes? Or if diabetes is going to be a part of my life from here on out, then how do I make peace with it? Or how do I develop some sort of a relationship with it so it doesn’t sort of consume me over time?
And then I mean, these are – I’m just throwing out a few strategies here. But there’s so many different directions that a person can go in when they start to engage in that self-reflection piece. But start there, and once you start noticing what’s coming back at you, see if you can respond to yourself in a more compassionate way to the hard feelings that come up for you. And see if you can allow yourself to potentially fit with whatever feelings, whether it’s isolation, shame, anger, sadness, whatever is coming up, how would you respond to a friend who might disclose that they were experiencing these types of hard feelings in relation to their medical condition? And you’ll notice that the language kind of comes out much more easily when we’re thinking about supporting and caregiving for another person versus when we’re trying to do that for ourselves.
But all of this I think starts with first by just noticing what’s coming up for you and why it’s coming up for you during that sort of deep self-reflection. And then the other strategy that I would share is that if it’s hard to ask for help, start practice seeking help in very small ways. And I’m talking tiny. It can be something as simple as, you know, if you live with somebody, asking them to hand you a fork, a spoon, whatever it might be. Just to sort of put yourself in that mindset of, what does it feel like to be vulnerable and to say, I need help or I need your support in this way, and this is how you can support me. I’m giving you a very small step that a person can take. But it can be as small as that, or it can be something slightly bigger. Like, while doing a lot of Zoom calls and video calls nowadays, asking for help in connecting to a video call, if that’s something that you’re struggling with.
But making it as small as it possibly can be, so that you still feel that sensitive feeling that comes up from being vulnerable and having to ask for help. But it doesn’t feel so overwhelming that you shy away from basically saying the words of, “I need your support this,” or, “I need help around this.” And I think within this, as you’re starting to practice seeking help in small ways, you can also start the request as more of a conversation rather than a transaction. It doesn’t have to be a situation where you say immediately right off when you walk up to somebody, “I need your help to check my blood sugar for me.” It doesn’t have to be that. It can be just a conversation. You can – about how your day’s going, build up to it, to the point where you start asking for very small sources of support rather than something that feels big or overwhelming.
Kim Constantinesco: Great point, and social support comes in so many forms, whether it’s family or friends or coworkers. And then there’s also the support that comes from working with someone like yourself, a diabetes psychologist or a therapist of some kind. And what would you say, how do people recognize that they may benefit from seeking outside counseling?
Harpreet Nagra: Yeah, I’m going to have a biased response here because I think everybody who’s living with diabetes could benefit from a diabetes psychologist support. But I know that not everybody is in a space where they feel like they want that support or could afford it or need it. So I would say there’s so many levels of distress that come up with managing diabetes. There’s a Behavioral Diabetes Institute, a lot of folks may have heard about it, that is led by psychologists who are researchers, clinicians themselves. They developed a diabetes distress scale, and the scale identifies seven sources of diabetes distress that anybody living with diabetes would typically encounter.
So it includes ideas such as eating distress. Just the day-to-day idea of carb counting. Carb counting at every single meal, that can be a source of eating distress. Or physician distress, you go to your doctor and you feel like they’re only focused on the numbers and not the human being sitting across from them and sort of the overwhelming feeling of, am I really, truly getting all the help that I could be getting in this moment from this provider? That can be a source of physician distress.
There’s about five other examples of different types of diabetes distress that can occur. And this is a free survey that anybody can take online. I believe you can just go to Diabetesdistress.org or I can send you the link and we can put it in the show notes. But it lists out all the different ways that emotional diabetes distress can show up for folks. And if you notice that any of these layers of distress are showing up for you, I think that’s a great opportunity to decide for yourself, is this a good time for me to be reaching out to a diabetes psychologist to talk more about the type of distress that’s coming up for me?
A lot of folks will notice after they complete this questionnaire that whatever comes out as being in the sort of high severity range or high level of diabetes distress for you, it’s what they end up talking about the most when they talk about their diabetes to other people. So if they’re worried about hypoglycemia, they will obviously be talking about that with their friends, coworkers, family members. But hypoglycemia distress is what will show up on the questionnaire. So it’s another way to sort of validate the type of emotional diabetes distress that’s coming up for them.
So I think that’s one way that folks can identify for themselves whether or not they’re ready to speak to a diabetes psychologist. And I also think that, I don’t know if you really need anything in particular to have happen, if you feel like you’ve been wanting to speak to a psychologist about some of the issues that are coming up. Diabetes burnout happens for every single person that’s living with diabetes. So if you feel like you have either started to give up on diabetes or you’re just going to do the day-to-day tasks without emotionally engaging with diabetes, that is a pretty good indicator that a diabetes psychologist could provide additional support.
But I think anybody, anybody who’s living with diabetes can at any point engage in seeking out support from a diabetes psychologist. Mainly because when we’re talking about diabetes, we’re always talking insulin. Insulin is a hormone, and any fluctuations in your hormones is going to impact your mood. And so any diabetes psychologist would be more than happy to support a person who’s wanting to work through the emotional weight that diabetes provides.
I would also say that diabetes psychologists are trained in habit change. So if you have prompts from your medical provider or your medical team around – and that you should be checking your blood sugar more often or that they want you to go back to syringes or there’s some sort of a needle phobia that’s coming up for you, a diabetes psychologist is a very appropriate professional who can support you through making those habit changes over time.
In addition to sort of those two examples that I gave, relationship distress, which tends to show up very commonly in terms of, how do I talk to my partner about the best way to support me? Or, how do I tell my coworkers? Should I even tell my coworkers that I have diabetes? These are great questions to work through with a diabetes psychologist.
Kim Constantinesco: Great points. And Dr. Nagra your insights and tips have been so helpful today. If the One Drop community wants to get to know you or your work better or learn more strategies around maintaining good emotional health, where can they go?
Harpreet Nagra: Yeah, so I’m currently working in a group practice called Vista Counseling. The only sort of drawback is that for psychologists, they can only see clients in the state that they’re licensed. So if you’re in the state of Oregon, I am more than happy to see you as a therapy client. If you’re not, then I would say the online resource would be Diabetesredefined.com. I decided to create Diabetes Redefined as an educational platform for educating communities about diabetes. There’s just so many emotional components to it that are not discussed nowadays. So Diabetesredefined.com is my main website. But you can also find me on Twitter and Instagram. I try to do postings, something related to the psychological aspects of managing diabetes on a daily basis on those social media platforms. And I’m more than happy to continue to talk to anybody who might be interested. So even if you want to just send me an email, that’s totally fine. I’m available at Diabetesrefined@gmail.com.
Kim Constantinesco: Excellent and Dr. Nagra, it’s been such a pleasure today, and we look forward to having you on more episodes of Life Without Limits.
Harpreet Nagra: Thank you so much for having me Kim. It’s been wonderful.
Kim Constantinesco: Stay tuned for more great episodes of Life Without Limits as we aim to help you be proactive about your health and change how you think and feel on your health journey. We’re in this together.
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