*Psychotherapeutic Interventions for Type 2 Diabetes Mellitus DOI: http://dx.doi.org/10.5772/intechopen.97653*

management of the condition. Internet-based CBT protocols offer a promising and accessible psychotherapeutic intervention for T2DM patients, but more randomized controlled trials are needed to further elucidate their efficacy. It is also possible that certain patients will do better than others with web-based CBT interventions. Therefore, treatment matching trials are needed to identify the personal characteristics that best predict positive outcomes with non-traditional formats of CBT for T2DM.

#### **2.2 Motivational interviewing**

Motivational interviewing (MI) is a collaborative and goal-oriented therapy that focuses on resolving ambivalence toward change [9]. Suggestions or instructions for diabetes mellitus self-management may be met with resistance and non-compliance by patients. MI counters these responses by promoting self-efficacy. The therapist helps the patient to determine what is important to their own well-being and how to achieve that goal [10]. For example, a therapist may explore what the patient likes and does not like about their current behaviors to determine the costs and benefits of behavior change. By putting the patient in the 'driver's seat', intrinsic motivation is developed (e.g., "I will change my diet and exercise because I want to live a long and healthy life"). The therapeutic alliance is seen as fundamental to facilitating positive behavior change. From this starting point, the therapist and patient can work together to set an agenda for items they would like to change (e.g., medication, diet, exercise, and regular monitoring of blood sugar levels) and check in frequently about the patient's perceived importance and confidence regarding the target behavior [10].

Although MI has garnered a lot of research interest, the results of recent studies examining its utility in the management of T2DM have been mixed. In support of this intervention in the care of T2DM, Chee and colleagues (2017) found that patients who received MI for 6 months, in addition to diet and exercise planning, reported greater reductions in HbA1c (*p* = .006) and weight loss (*p* < .001) than a control group at 6 month follow up [11]. This study took place in Malaysia with a sample of 230 Indian (58%), Chinese (28%), and Malaysian (14%) participants, aged 30–65 years (*M* = 55, *SD* = 8). However, a number of recent studies have not found support for MI over treatment as usual. For example, patients treated by nurses trained in MI in the Netherlands and Denmark had similar HbA1c levels, diet, physical activity, and well-being as those treated by nurses trained in standard care. This pattern of results was found in both 14- and 18-month trials [12, 13]. Notably, the competency of the nurses trained in psychological skills for that study was below beginner-level proficiency and was similar to the standard-care nurses. In other words, it may require extensive training among therapists in order to demonstrate the superiority of MI over control groups.

Recent findings for MI in the management of T2DM are also mixed when MI examined in alternative delivery formats. A 12-month telephone-based delivery of MI in Germany was found to reduce patients' HbA1c levels to a greater extent than usual care (i.e., informational pamphlets; *p* = .006). It also improved to a greater extent patients' physical activity (*p* = .006), cardiovascular health (*p* = .011), psychological well-being (*p* = .044), illness burden (*p* = .069), and depression (*p* = .057) [14]. In another study from Norway, telephone-based MI was provided for 4 months in addition to an interactive mobile self-monitoring application that tracks diet, fitness, and diabetes-related goals. There were no differences in patients' HbA1c levels between app users with and without MI, or those who received usual care (i.e., no psychotherapeutic intervention) [15], suggesting that neither the app nor the MI produced a better health outcome than standard, non*Psychotherapeutic Interventions for Type 2 Diabetes Mellitus DOI: http://dx.doi.org/10.5772/intechopen.97653*

psychotherapeutic care. Similarly, a 6-month web-based counseling software delivery of MI was equivalent to standard lifestyle advice in resulting HbA1c levels among Arab participants [16]. The MI-based intervention was, however, superior to the control group at increasing short-term diabetes-related knowledge (*p* = .023) among patients and trended toward within group improvements in dietary habits (*p* = .050). The discrepancy between the findings within that study further highlight that all MI delivery formats are not equal; long-term direct therapist contact may be an essential component of MI in order to elicit sufficient behavior change that manifests in reductions in HbA1c levels. Further research would be necessary to confirm this hypothesis.

#### **2.3 Counseling**

Another category of psychological interventions for T2DM involves counseling interventions which tend to provide non-specific support for diabetes mellitus management. Counseling typically promotes self-awareness and self-determination which, in the context of diabetes mellitus, can aid in improving self-management behaviors [17]. Counseling can also provide emotional and psychological support to individuals who are dealing with the stress of living with a chronic disease. In other words, although behavior change is not the focus of counseling interventions, they may, in theory, be helpful for reducing stress and increasing adherence among patients.

RCTs of counseling interventions for T2DM are scarce [4–6], but there have been two recent studies on this modality. One study examined a culturally sensitive 12-month counseling program for T2DM patients in Qatar (i.e., using Arabic language and referencing culturally specific food habits and health beliefs). Within this program, patients were provided with information about diabetes and related complications, how to incorporate a healthy lifestyle and eating habits, the benefits of exercise, and how to use counseling techniques at home. The researchers found that this program led to significant reductions in patients' HbA1c levels (*p* = .012) and BMI (*p* < .001), as well as improved diabetes-related knowledge (*p* < .001), attitudes (*p* < .001), and practices (*p* < .001) over the standard practice of distributing informational booklets [18]. However, in another study of counseling, patients in Denmark who were offered short-term empowerment, motivation and medical adherence (EMMA) therapy, which focuses on goal setting and autonomy support, did not report improvements in HbA1c levels over and above treatment as usual. Individuals who received counseling did, however, demonstrated increases in frequency of healthy eating (*p* < .05) [19].

Based on these findings, counseling may have benefits for improving HbA1c levels in specific cultural contexts, but these therapies may have to be long-term (one year or longer) and follow a structured format to be beneficial for glycemic control.

#### **2.4 Mindfulness-based therapies**

Mindfulness-based therapies teach meditative practices and promote a nonjudgmental awareness of the present moment, including noticing thoughts, emotions, and bodily sensations. In the context of T2DM, noticing negative diabetesrelated thoughts can help promote passive observation of the experience and allow the individual to be present in their everyday life without an unhelpful behavioral reaction. For example, noticing internal hunger or satiety cues can influence dietary choices and help patients regulate blood sugar levels. Mindfulness can, in theory, help patients become better attuned to their physiological state, including blood

sugar levels. Or a patient who experiences anxiety about increasing their physical activity may learn to nonjudgmentally notice their anxious thoughts and urges to avoid exercise, but intentionally choose to exercise nonetheless. Regular mindfulness practice trains the mind to be less reactive and more intentional in one's choices and experiences.

Mindfulness interventions have increased in popularity in the past decade and there have been a number of recent RCTs that indicate the applicability of mindfulness-based therapies for the treatment of diabetes mellitus. The outcomes are mixed in regard to changes in HbA1c levels. In support of the efficacy of mindfulness programs, an 8-week mindfulness-based stress reduction program in Iran was found to improve HbA1c levels (*p* = .010), fasting blood sugar (*p* < .001), depression (*p* = .010), anxiety (*p* = .010), and overall mental health (*p* = .001) compared to a control group [20]. In another study from New Zealand, an 8-week program based in mindful self-compassion led to greater decreases in HbA1c (*p* = .050) than a waitlist control, as well as reductions in depression (*p* = .001) and diabetes-related distress (*p* = .050) [21]. Even when the 8-week program was selfdirected, mindfulness practice has been found to improve HbA1c levels (*p* = .020), stress (*p* = .030), and depression symptoms (*p* = .020) compared to a control condition in Australia [22]. Specific techniques within a mindfulness-based practice have been found to be effective. For instance, Thai patients with T2DM who engaged in mindful walking for 3 months demonstrated greater decreases in HbA1c (*p* < .050) relative to walking alone [23].

A relatively recent variation of mindfulness therapy, mindfulness-based cognitive therapy, involves training patients in both meditation and cognitive therapy (i.e., identifying and challenging cognitive distortions). A series of studies in the Netherlands were recently conducted to investigate the effects of this intervention on the care of patients with T2DM, but none showed any benefit for HbA1c levels. For instance, although van Son and colleagues [24, 25] found improvements in selfreported stress (*p* = .001), anxiety (*p* = .020), depression (*p* = .010), and improved quality of life (*p* = .010) following mindfulness-based cognitive therapy and that were maintained at 6-month follow-up, they did not find a difference on HbA1c levels when compared to usual care. Another study also did not find differences in glycemic control between mindfulness-based cognitive therapy and a control group, but did report changes in diabetes-related distress (*p* = .020) and well-being (*p* = .001) [26]. Within these studies, poor glycemic control was not an inclusion criterion, which may have resulted in a floor effect due to generally low levels among patients regardless of treatment condition. It may be that mindfulness-based cognitive therapy, which was originally developed to treat depression, is less effective at reducing HbA1c levels than traditional mindfulness training practices that do not incorporate cognitive therapy but focus instead on meditation. In other words, the cognitive therapy addition may dilute the efficacy of mindfulness training, which, at this point in time, has more support for it in the care of T2DM. Research designs that compare mindfulness-based cognitive therapy to other mindfulness interventions in patients with poor glycemic control would be necessary to confirm this hypothesis.

#### **3. Summary**

T2DM is a serious disease with significant morbidity which, if poorly managed, can lead to short- and long-term complications including cardiovascular disease, blindness, nerve damage, and loss of limbs [1]. There has been interest among researchers to examine whether psychotherapeutic interventions aimed at changing

#### *Psychotherapeutic Interventions for Type 2 Diabetes Mellitus DOI: http://dx.doi.org/10.5772/intechopen.97653*

thoughts, feelings, and/or behaviors among patients with T2DM have any significant benefit. Recent randomized controlled trials suggest that psychotherapy for T2DM may be an effective treatment option for certain outcomes, but that not all therapies have an evidence base for use with patients with T2DM.

Research from the past 8 years has provided the most support for mindfulnessbased therapies at improving health outcomes for patients with T2DM. Numerous studies with different samples have demonstrated statistically significant reductions in HbA1c levels and fasting blood sugar, as well as improvements in psychological variables such as depression, anxiety, stress, diabetes-related distress, and overall mental health. These findings were demonstrated in various geographical regions (including Iran, New Zealand, and Australia) among middle-aged (average age ranged from 23 to 59 years old) men (*n* = 67) and women (*n* = 123). Notably, however, mindfulness-based cognitive therapy was only superior to a control group for psychological outcomes, not HbA1c levels. In other words, mindfulness-based therapies that emphasize meditative practices, but not mindfulness-based cognitive therapy, have evidence to support their use in the management of T2DM. Of note, the existing studies on mindfulness-based cognitive therapy that did not show its benefit for glycemic control were conducted with middle-aged (53 to 56.5 years old) men (*n* = 118) and women (*n* = 115) from the Netherlands. As such, this form of therapy may not be effective within this relatively young sample. More research is needed to understand whether mindfulness-based cognitive therapy is as good or better than mindfulness therapy.

While research interest in traditional-delivery CBT has declined in recent years, one recent study expanded upon existing literature to demonstrate the effectiveness of CBT in a web-based format in diabetic patients from Saudi Arabia. This program improved HbA1c levels, as well as diabetes mellitus knowledge and self-efficacy, to a greater extent than the control group. The research results are more divided for MI and counseling interventions. In regard to the former, MI was typically found to be as effective as standard care on HbA1c levels and diabetes-related behaviors such as diet and physical activity in patients from Malaysia and parts of Europe (average ages 55 to 64 years old). However, when delivered in a telephone- or web-based format, MI had the added benefits of improving diabetes-related behaviors, such as dietary changes and physical activity, as well as psychological variables, including lowering depression and increasing well-being and diabetes-related knowledge. Notably, this was true in both men and women from diverse backgrounds (i.e., Arab and German). Recent findings for counseling intervention have been mixed whereby culturespecific counseling appears to be more effective at reducing HbA1c levels than informational booklets for middle-aged (*M* = 53.5 years old) Arab patients. But counseling was no more effective than usual care for diabetes mellitus self-management in older (*M* = 64.5 years old) Danish patients on improving HbA1c levels.

Commonly used psychotherapeutic interventions, such as mindfulness-based therapies and CBT, have empirical support in recent studies for use in the management of T2DM. This provides an evidence base for the widespread implementation of these treatments by healthcare professionals in their care of patients with T2DM. Training in both of these psychotherapy approaches for health professionals is widely available through professional development workshops or training manuals, and many workshops have been offered remotely during the COVID-19 pandemic. In addition, the recent promising findings from a study of self-directed mindfulness therapy suggests that healthcare professionals can recommend these programs to patients to pursue as a self-help resource, which reduces the potential obstacles of cost and geographic accessibility. Additional research is necessary to understand the efficacy of counseling and alternative-format CBT before practitioners should recommend these interventions in the management of T2DM.

This chapter reveals that psychotherapeutic interventions are an appropriate treatment modality for patients with T2DM and some have support from recent studies in improving health outcomes. These interventions extend beyond treating the physiological concerns of this disorder and can address other psychosocial variables, such as thoughts, feelings, and behaviors related to diabetes mellitus care. As such, not only did HbA1c levels improve in a number of treatments, research has supported changes in diet, physical activity, diabetes-related knowledge, and, in some cases, mood. There are no known negative effects of psychotherapeutic interventions on the health or well-being of patients with T2DM. The evidence for these interventions should be considered in regard to the sample population and size, comparison group, length of intervention, and geographic region.

There are still many gaps in the literature regarding which groups of individuals benefit the most from psychotherapy for T2DM and from which approach. Future research should continue to explore psychotherapeutic interventions especially in the areas of counseling and new delivery formats of CBT to expand treatment options. Of note, a recent RCT of Acceptance and Commitment Therapy for patients with T2DM has demonstrated preliminary success in improving HbA1c levels compared to education alone [27], but more research is needed on this intervention strategy before drawing generalized conclusions. In addition, more attention in future research studies needs to be paid to how different types of patients respond to psychotherapy and whether variables such as age, sex, and ethnicity interact with intervention type to produce different outcomes. Across all psychotherapeutic treatment modalities under investigation for use in the management of T2DM, treatment matching research is warranted to determine which patients may be able to benefit from modified, more accessible and cost-effective (self-help, web-based) formats. With that more targeted research in future research, healthcare professionals can feel even more confident implementing some therapies, such as mindfulness-based therapies, CBT, and some formats of MI, to promote better glycemic control and psychological well-being in their patients with T2DM.

#### **4. Conclusions**

Psychological interventions can lower HbA1c levels, improve psychological distress, and support healthy coping among patients with T2DM. There is recent and reliable research support for mindfulness-based therapies at improving HbA1c levels, blood sugar, and psychosocial variables. Results are promising, but more research is needed on the efficacy of longer-term culture-sensitive counseling as well as alternative delivery formats of cognitive-behavioral therapy on health outcomes among patients with T2DM.

#### **Acknowledgements**

Dr. Joel Katz is supported by a Canadian Institutes of Health Research Canada Research Chair in Health Psychology. Thank you to Susan Zahir for help with tables and revisions.

#### **Conflict of interest**

The authors have no conflicts of interest to declare.
