The Treatment of Comorbid Anxiety in a Male With Poorly Controlled Diabetes in a Very Remote Primary Health Care Service

Abstract

Rural Australians are shown to have poorer health and mental-health outcomes compared with their metropolitan counterparts, particularly for diabetes. Individuals with diabetes often meet criteria for comorbid mental-health conditions, such as anxiety and depression. Psychological treatment, as an adjunct to medical care, for individuals with diabetes is shown to improve overall health and wellbeing. This article describes a 38-year-old male who was referred to a very remote primary health care service by his diabetes educator for strategies to reduce work-related stress and improve his diabetes mismanagement. Mindfulness-based cognitive behavior therapy techniques were used, over six sessions, in the context of a rural and very remote community. Pre- and post-intervention measures showed a reduction in anxiety, distress, and improvement in his perception of his quality of life. Clinical implications for psychological treatment of diabetes and comorbid mental-health issues in rural and remote communities are discussed.

Keywords

diabetes rural and remote health psychology

1 Theoretical and Research Basis for Treatment

Nearly two thirds (69%) of Australians live in major cities, whereas 1 in 40 (2.3%) Australians live in rural and remote, or very remote, areas (Australian Institute of Family Studies [AIFS], 2011). Australia is economically, culturally, and sociologically different to metropolitan Australia; however, defining what constitutes rural and remoteness is a difficult conceptual task (Barboupoulos & Clark, 2003; Bourke et al., 2004). Rural generally refers to population characteristics, such as nonurban groups; however, remote is defined as the extent to which Australian people can access goods, services, and social interactions outside metropolitan areas (Department of Health and Ageing [DoHA], 2001). The Accessibility and Remoteness Index of Australia (ARIA), a commonly used measure of remoteness, ranges from relatively unrestricted (Highly Accessible) to very restricted (Remote) to very little (Very Remote) access to goods, services, and social interactions (DoHA, 2001). The ability to access health care services in rural and remote Australia tends to drop with increasing remoteness (DoHA, 2013). For example, 75% of allied health services are delivered in inner regional cities compared with only 9% in very remote locations (DoHA, 2013).

Australians who live in rural and remote locations are shown to have poorer health outcomes, compared with Australians who live in major cities (Bourke et al., 2004). The well-reported rural-health disadvantage is shown to be a consequence of the social conditions specific to life in rural and remote communities including, but not limited to, geographical isolation, difficulty in accessing health care, shortage of health care providers and health services, greater exposure to injury, lower road quality, small and sparsely distributed populations, and indigenous health needs (Australian Institute of Health and Welfare [AIHW], 1998, 2008). There is now evidence for a “double deprivation” effect in rural and remote communities, that is, lower levels of income combined with higher basic living costs (Vines, 2011). For example, the cost of basic food is at least 10% higher in rural and remote communities than metropolitan areas (Vines, 2011). There are significant barriers to help seeking in rural and remote locations, such as the rural and remote attitude of self-sufficiency, self-reliance, and stoicism, as well as strict boundaries on self-disclosure and limited anonymity (Vines, 2011). Therefore, individuals who reside in rural and remote locations are subject to stress and illness not experienced by their metropolitan counterparts (Fisher et al., 2009; Greenfield, Gilles, Porter, Shaw, & Willis, 2011; Paul et al., 2013).

The rural health disadvantage is further exacerbated for men as health research shows men have poorer health outcomes than women for cancers, diabetes mellitus (diabetes), cardiovascular disease, chronic obstructive pulmonary disease (COPD), and injuries, including suicide (AIHW, 2010). Specifically, individuals who reside in rural locations have higher levels of lifestyle-related risk factors for diabetes (National Rural Health Alliance [NRHA], 2011). The gender effect is thought to be due to poorer working habits, longer working hours, lower levels of physical activity, higher alcohol and cigarette use and being overweight or obese, as well as specific barriers accessing services including isolation, discomfort in the waiting room, privacy issues, seasonal work requirements, community infrastructure, and lack of health-promoting infrastructure, such as sporting clubs (AIHW, 2010; Murray et al., 2004). Taken together, there is now evidence for a “double disadvantage” of health for men who reside in rural and remote locations (AIHW, 2010).

Diabetes is a chronic metabolic condition, affecting approximately 4.1% of Australians, with higher prevalence rates in rural and remote locations (Australian Bureau of Statistics [ABS], 2012; AIHW, 2009; Reddy, Ford, & Dunbar, 2010; Reddy et al., 2011). Australians who reside in rural and remote areas have higher rates of diabetes consultations than those who reside in major cities (ABS, 2011; Paul et al., 2013). Rates of diabetes-related hospitalization and diabetes-related death rates are shown to grow with increasing remoteness (Paul et al., 2013). Type 1 diabetes mellitus (T1DM) occurs when the pancreas does not produce insulin at all, and type 2 diabetes mellitus (T2DM) occurs when the pancreas does not produce enough insulin required to maintain healthy organ functioning and/or the body’s cells become resistant to the insulin produced by the pancreas (Martin, Southhall, Liveley, Shea, & Whitehead, 2009; Renn, Feliciano, & Segal, 2011; Singh et al., 2008). Diabetes is officially diagnosed when blood-test results reveal that glycohemoglobin (HbA1c) concentrations are greater than 6.5%, a fasting plasma glucose (FPG) test is greater than 7.0 millimoles per liter (mmol/L), and/or an oral glucose tolerance test (OGTT) is greater than 200 milligrams per deciliter (mg/dL; Diabetes Australia, 2012). Lifestyle factors, such as insufficient physical activity and poor diet, can contribute to the onset, and severity, of diabetes (Diabetes Australia, 2012).

The primary treatment goal for individuals with diabetes is good glycemic control; however, psychological distress and comorbid mental-health conditions are shown to influence compliance with diabetes-management regimes (Martin et al., 2009; Rosenzweig et al., 2007). For example, the relationship between diabetes and mental health is assumed to be bidirectional; that is, living with a chronic disease is a stressor that can negatively impact psychological wellbeing, and premorbid mental-health symptoms are a risk factor for the onset of T2DM (Adriaanse, Pouwer, Dekker, Njipels, & Stenhouwer, 2008; Goetsch, Abel, & Pope, 1994; Markowitz, Friedman, & Arent, 2008; Renn et al., 2011; Skaff et al., 2009). The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR; American Psychiatric Association [APA], 2000); the recent fifth edition (DSM-5; APA, 2013); and the International Classification of Mental and Behavioral Disorders, Tenth Edition (ICD-10; World Health Organization [WHO], 1992) all recognize the bidirectional relationship between mental-and physical-health states Approximately 40% of individuals with diabetes experience depressive symptoms, 14% experience anxiety symptoms, and 18% to 35% experience diabetes-related distress (ABS, 2012; AIHW, 2009; Reddy et al., 2010; Reddy et al., 2011). Diabetes distress (DD) is defined as emotional distress that stems from concerns and worries associated with diabetes and its management (Chaoyang et al., 2010; Fisher, Hessler, Mullan, & Polonsky, 2012; Rosenzweig et al., 2007; Simmons, Bourke, Yau, & Hoodless, 2007). Negative life events and non-disease-related chronic stress, such as personal stress, family stress, and workplace bullying, can influence diabetes management and directly influence diabetes-specific factors, such as HbA1c levels, up to 18 months post-diagnosis (Adriaanse et al., 2008; Fisher et al., 2012; Fisher, Mullan, Arean, Glasgow, & Hessler, 2010; Halberg & Strandmark, 2006; MacIntosh, 2005).

Individuals in rural and remote locations and metropolitan areas experience similar rates of mental-health disorders; however, the expression and language associated with the conditions are shown to be different (ABS, 2011; Madden, Barnard, & Owen, 2013). For example, depression experienced by men living in rural and remote locations and the language to describe their experience (e.g., “internal compound being kept within the boundary face,” “blowing up,” “nearing the edge,” and “fixing it”) was inconsistent with the language used in current assessment tools for depression in men and women living in major cities, such as the Depression, Anxiety and Stress Scale (DASS; Lovibond & Lovibond, 1995; Patterson-Kane & Quirk, 2013). Diabetes-intervention programs for individuals who reside in rural and remote locations need to understand, and respect, broader context issues specific to rural and remote locations including the use of appropriate language (Murray et al., 2004).

Meta-analyses indicate that evidence-based psychological interventions, such as cognitive behavioral therapy (CBT), interpersonal therapy, and mindfulness-based stress-reduction techniques, are effective in reducing HbA1c levels, mitigating the physiological stress response and improving adherence to diabetes management regimes (Hartmann et al., 2012; Kreitzer, O’Connor, & Whiteboard, 2009; Markowitz, Gonzalez, Wilkinson, & Safren, 2011). CBT for diabetes-management interventions focuses on increasing pleasurable social and physical activities, teaching problem-focused and emotion-focused solving procedures, and teaching cognitive techniques to identify and modify cognitive distortions maintaining diabetes mismanagement (Lustman, Griffith, & Freedland, 1999; Sridhar, 2007).

Recent modifications to diabetes-management interventions have shown promising outcomes (Brown et al., 2010; Poulsen & Pachana, 2012). For example, interventions that target diabetes-specific quality of life factors (i.e., the subjective perception of physical, emotional, and social wellbeing and how this impacts their day-to-day functioning) are shown to be critical to good diabetes management, and are often stronger predictors of medical outcomes than diabetes-specific physiological and metabolic measures (Dehalanty et al., 2007; Petrak & Herpertz, 2009; Staley & Lawyer, 2010). In other words, better glycemic control is associated with a perception of better quality of life (Rubin & Peyrot, 1999; Thoolen, de Ridder, Bensing, Gorter, & Rutten, 2006). Adjunct motivational components that focus on increasing self-efficacy in managing diet, exercise, and medication are shown to be more successful in recent diabetes-management interventions (Brown et al., 2010). Particularly, in rural and remote locations, a multidisciplinary team approach to diabetes management, including endocrinologists, nurses, dieticians, podiatrists, and diabetes educators, is shown to reduce distress and the severity of mental-health conditions affecting diabetes management (Brown et al., 2010; Poulsen & Pachana, 2012).

The present case describes a psychological treatment approach, as an adjunct to medical treatment, to assist an adult male with his anxiety and distress symptoms and the role of this in precipitating, and perpetuating, management of his diabetes in a very remote primary health care service.

2 Case Introduction

Mr. Simon Anderson (a pseudonym to protect the client’s confidentiality), a 38-year-old adult male, was referred to the provisional psychologist within a multidisciplinary primary health care service by his treating diabetes educator for strategies to assist with his health-related and work-related stress. He lived in a very rural and remote community with a population of less than 500 people. Mr. Anderson has a diagnosis of T2DM and currently sees a number of health professionals including the (fly-in fly-out) endocrinologist, podiatrist, dietician, and diabetes educator at the primary health care service to assist with his diabetes management. He is also under the care of the nephrology department (renal medicine and renal transplantation) at a metropolitan hospital after a renal transplant in 2008 for immunoglobulin (IgA) nephropathy. He has to travel thousands of kilometers every couple of months for ongoing medical review with this treating renal team. Mr. Anderson also sees a local general practitioner (GP) for ongoing medical care and review. He has to travel to the nearest town to visit his medical and allied health team on regular basis. On initial assessment, his body mass index (BMI) was 31, his HbA1c level was 9.2% (increased from 8.8% the previous week due to work-related stress), and his FPG was 7.6 mmol/L. His vision was stable, and he did not have any foot infections or parasthesia. He did not have any cardiac or respiratory symptoms.

3 Presenting Complaints

Mr. Anderson’s presenting complaint was recent work-related bullying, which was having a detrimental impact on his physical and psychological health. Specifically, he reported low mood and motivation to comply with his health regime. His management of his diabetes had always been relatively poor; however, his HbA1c levels had increased recently due to work-related stress. Mr. Anderson said that he was very disappointed with his body (i.e., “my body has let me down”) and expressed frustration with changing his lifestyle to meet his health demands. He also said that he felt a lack of confidence in being able to manage his diabetes on a day-to-day basis. Mr. Anderson said that he felt powerlessness in managing his work-related stress and “did not understand how talking about a problem in a room would help deal with the actual problem.” Currently, his treating medical team identified that their major concerns were around Mr. Anderson’s poor control of his diabetes, and this was starting to comprise his recent renal transplant with a risk of nephropathy. He reported good sleep habits. However, he had started to experience nocturnal panic attacks, approximately twice per week on average, after he had a conflict with one of his work colleagues. He also reported anxiety symptoms (i.e., “I sweat all the time!”), frustration (i.e., “I am so sick of my body and I just cannot be bothered with all of this anymore”), and low energy (“my partner and children really want me to get better with my diabetes but I just have no energy anymore”), which were interfering with his work life, family life, and health regime.

4 History

Mr. Anderson was born in Australia and has one older sister. He was raised within the faith of the Evangelical church. He completed Year 8 to Year 10 on the road while his family was driving around Australia to rural and remote communities to preach the Evangelical faith. Mr. Anderson left school after Year 10 and obtained employment in various manual labor and apprenticeship jobs. He met his ex-wife while he was working as a slaughter man at an abattoir, and they had two daughters. Mr. Anderson said that within the same week, approximately 4 years prior, his kidneys started to fail, his wife and two daughters left him, he lost his employment, and his dog died. Consequently, he ceased eating for a period of 10 days and was admitted into an adult acute-mental-health inpatient unit. He commenced on 20 milligrams (mg) of Citalopram on admission, which he still continues at present. He denies having had physical or mental-health issues prior to this. Currently, Mr. Anderson resides with his biological father and mother, as well as his partner and his eldest daughter from his marriage. He says that he has a good relationship with both of his parents. His youngest daughter resides with his ex-wife in another town. Mr. Anderson reported that he had a strained relationship with his ex-wife and both daughters and has infrequent contact with his ex-wife and youngest daughter.

Mr. Anderson has an extensive medical history. He was diagnosed with IgA nephropathy in or around 2005 and received dialysis for this. In 2008, he underwent a renal transplant and, consequently, developed T2DM as a consequence of the renal anti-rejection therapy. His current control of his diabetes is very poor, and his renal transplant is at risk of nephropathy. His blood glucose level (BGL) readings generally fall between 10 mmol/L and 18 mmol/L; however, given his renal transplant, his target diabetic-control-target value is between 4.0 mmol/L and 12.0 mmol/L (ABS, 2012). He does not have secondary diabetes complications at present. His recent foot assessment in October, 2011, indicated no foot or joint abnormalities and no signs of peripheral neuropathy. He did have a low to medium risk of decline in foot-health status and risk of developing foot complications. Mr. Anderson has seen a dietician, sporadically, since his renal transplant. His nutrition care plan in September 2011 and July 2012 indicated that he did not consume breakfast or regular meals over the course of the day. At the time, his diet goals included regular breakfast meals, monitoring of his BGLs at least three times per day, reduction of salt intake, and increase in his activity levels. Prior to the current treatment, Mr. Anderson had not complied with any of the diet goals. He does smoke intermittently and is prescribed a number of medications to assist with his diabetes management and renal function.

5 Assessment

A clinical interview was conducted with Mr. Anderson at the primary health care service. He had to travel to the nearest town to attend the assessment as there are no services available in his town. He completed the DASS (Lovibond & Lovibond, 1995), the Diabetes Distress Scale (DDS; Polonsky et al., 2005), and the brief version of the World Health Organization Quality of Life measure (WHOQOL-BREF; Murphy, Herman, Hawthorne, Pinzone, & Evert, 2000). The DASS and DDS were used as measures of his emotional state as no specific emotional state measures exist for individuals who reside in rural and remote communities at present. The DASS is a reliable and valid screening measure of depression, anxiety, and stress (Lovibond & Lovibond, 1995). DASS reliability coefficients range from .84 (anxiety) to .90 (stress) to .91 (depression) for internal consistency (Lovibond & Lovibond, 1995). Mr. Anderson’s anxiety score fell within the mild range (8); however, his depression (0) and stress (4) scores fell within the normal range. He said, “I hate my body and feel like it has betrayed me and no matter what I do, I am getting sicker and sicker and it makes me so angry and tired.”

The DDS is a measure of four pre-established domains of diabetes-related distress: emotional burden (EB), physician-related distress (PD), regime-related distress (RD), and interpersonal distress (ID; Polonsky et al., 2005). DDS reliability coefficients range from .88 (EB, PD, ID) to .90 (RD) and .93 (total DDS score) for internal consistency, and display construct validity with measures of depression (i.e., the Centre for Epidemiological Studies Depression Scale [CES-D]; Radloff, 1997, as cited in Polonsky et al., 2005), diabetes-management regimes (i.e., meal planning, exercise, and total cholesterol levels), and other DD measures (i.e., the Problem Areas in Diabetes [PAID]; Snoek, Pouwer, Welch, & Polonsky, 2000). Mr. Anderson’s EB score was 3.6 (where mean scores greater than 3 indicate distress worthy of clinical attention) indicating that his diabetes-regime requirements were a serious difficulty for him. He reported that infrequent testing of his blood sugars was a very serious problem for him, and sticking to a good meal plan was a slight problem for him. He also reported that he was failing with his diabetes routine, was not feeling confident in his day-to-day ability to manage his diabetes, and was not feeling motivated to keep up with his diabetes self-management. Mr. Anderson’s DDS scores were consistent with his self-reported low motivation to comply with his diabetes-management regime during the clinical interview. He said that he believed that his diabetes had “complete control” over him.

The WHOQOL-BREF is a measure of wellbeing and quality of life and measures the impact of disease and impairment on daily activities and behavior (Murphy et al., 2000). The WHOQOL-BREF comprises six scores: one overall perception of quality of life (Question 1), one overall perception of health (Question 2), and four domain scores of the individual’s perception of their quality of life in physical health, psychological health, social relationships, and the environment (Murphy et al., 2000). Higher scores on the WHOQOL-BREF indicate higher quality of life (Murphy et al., 2000). The WHOQOL-BREF has excellent psychometric properties (Murphy et al., 2000). Reliability ranges from .68 (social relationships) to .80 (environment) to .81 (psychological) and .82 (physical health) for internal consistency (Murphy et al., 2000). Construct validity coefficients range from .46 for the physical-health domain against the social-relationship domain (Skevington, Lofty, & O’Connell, 2004). Construct validity coefficients also range from .67 for the physical-health domain against the psychological-health domain (Skevington et al., 2004). Mr. Anderson’s overall perception of his overall quality of life was good. He also said that he was neither satisfied nor dissatisfied with his current health status. Overall, his perception of his quality of life in his psychological health (81), social relationships (81), and environment (81) domains were higher than his quality of life in his physical health (63) domain, which is consistent with his self-reported frustration with his current health status.

Mr. Anderson’s assessment results were generally consistent; that is, his mild anxiety scores on the DASS and RD scales on the DSS were consistent with his lower perception of his quality of life in physical health. His psychometric assessments results were consistent with his reported work-related stress. At the time of assessment, Mr. Anderson appeared to have very little insight into the relationship between his physical-health conditions and his mental health. Taken together, at the time of assessment, which was in or around August, 2012, Mr. Anderson’s DSM-IV-TR (APA, 2000) multiaxial assessment was as follows:

Axis I	309.24 Adjustment disorder with anxiety
Axis II	V71.09 No diagnosis
Axis III	N02.8 Immunoglobulin A (IgA) nephropathy (1989); Peritoneal dialysis (2004); Z94.0 Renal transplant (2008); 250.00 Diabetes mellitus, type II/non-insulin dependent (2011); R80.9 Proteinuria (2011)
Axis IV	Ex-partner relational problem; Occupational problems; Health problems
Axis V	GAF = 51 (on assessment)

Mr. Anderson was given a diagnosis of adjustment disorder with anxiety as he had endorsed anxiety symptoms, as a result of workplace stress and health stress, which were impacting his ability to manage his diabetes and creating diabetes-related distress. Mr. Anderson did experience a major depressive episode in the past (requiring hospitalization); however, his depression symptoms were not clinically significant at the time of assessment.

6 Case Conceptualization

Mr. Anderson’s presenting issues of work stress, mild anxiety, and diabetes regime–related distress were conceptualized within a cognitive-behavioral framework (Staley & Lawyer, 2010). His presenting complaints were most likely precipitated and perpetuated by his current health status and the rural health disadvantage; that is, living in a rural and remote location is shown to be associated with poorer health due to barriers to accessing services, shortage of professionals, and the requirement to travel to all appointments. His current stress levels, due to the high demands on his health and the restricted health care services in his community, directly affected his diabetes management and vice versa. Specifically, his anxiety symptoms might result in diminished appetite, resulting in irregular and unhealthy meals, which negatively affects control of his diabetes, resulting in reduced self-efficacy in managing his diabetes (Staley & Lawyer, 2010). He also displayed a tendency to pay attention to negative events in his life and interpret the events in a negative and unhelpful manner. For example, he said, “They always pick on me at work,” “I am never good enough for my family or my work,” “why can’t everyone just be nice to me!,” and “I am just the poor, whipping boy.”

Mr. Anderson reported that he struggled to make friends due to the constant traveling with his parents. He might have developed a withdrawal or avoidant type of coping style to manage this (Thoolen et al., 2006). He also reported feeling a sense of powerlessness in addressing the current bullying at work and a tendency to cognitively distort the events at work. He would catastrophize, jump to conclusions, and engage in “should and must” thinking. For example, he said, “they always pick on me,” “my work is never good enough,” “no one believes me there, they are all mates and they are all out to get me,” and “they should just be nice to me.” The tendency to pay attention to negative events in his life, and the tendency to interpret events in his life in a negative way, perpetuated his current health and mental-health concerns. Despite this, Mr. Anderson had a number of protective factors including being a deeply religious man, having a good social network with members of his bible-study group, and being a well-liked and popular member of his community.

At the time of assessment, the following treatment goals and plans were decided on collaboratively with Mr. Anderson: (1) to use stress-management techniques to reduce his current anxiety levels and reduce the impact of this on his health status, (2) to build his self-efficacy and confidence in managing his diabetes, and (3) to use his faith to assist him to achieve positive life change. CBT is recommended as the treatment of choice for individuals with diabetes to identify the psychological and behavioral barriers to effective diabetes self-management and decision making; that is, to assess, address, and challenge thoughts maintaining diabetes management (Phillips & Wright, 2009; Turner, 2010). Furthermore, motivational interviewing (MI) techniques and mindfulness techniques have been shown to enhance individuals understanding of diabetes care, and this has been shown to improve glycemic control and mental-health state (Adriaanse et al., 2008; Fisher et al., 2009; Lustman, Griffith, Freedland, Kissel, & Clouse, 1998; Schumman, Sutherland, Majid, & Hill-Briggs, 2011; Staley & Lawyer, 2010; Thoolen et al., 2006). MI and mindfulness-based CBT techniques were used to achieve treatment goals.

7 Course of Treatment and Assessment of Progress

The course of treatment involved one comprehensive assessment session and five individual psychotherapy sessions over 4 months. The sessions were spaced approximately 3 weeks apart due to Mr. Anderson’s requirement to travel to the sessions. Session 1 focused on building therapeutic rapport, building motivation for change and psychoeducational discussions of anxiety, panic, and the effect of this on his diabetes management (Shigaki et al., 2010). He agreed that he was frustrated with his current health status. Despite this, he was reluctant to discuss his diabetes, which might be a coping strategy to alleviate distress associated with low self-efficacy (Thoolen et al., 2006). He was taught a mindfulness breathing exercise to use with his panic symptoms at the end of Session 1. Problem-solving strategies around the workplace bullying were discussed. Mr. Anderson was uncertain about how conversations around managing workplace stress would be beneficial to decreasing his workplace stress. Time was also spent discussing psychological treatment and how psychology might be useful for Mr. Anderson’s current physical and emotional state. Psychoeducation of the relationship between his physical and mental health were discussed with Mr. Anderson. However, particular attention and care was taken in the language used to ensure that the information was provided in a supportive and non-confrontational manner.

Between Session 1 and Session 2, Mr. Anderson changed positions within his current workplace to a less stressful position and did not work with a particular colleague who was creating the majority of workplace stress. Following this change in positions, Mr. Anderson reported that he did not experience any further nocturnal panic attacks. Mr. Anderson had little insight into the relationship between his physical and mental health as he said that he was not aware of the role of his mental health in precipitating physical-health symptoms. He started to consume breakfast, but his control of his diabetes remained poor. Session 2 focused on continuing to build rapport with Mr. Anderson, as well as create healthier routines in his day-to-day life and support his self-efficacy in managing his diabetes. We explored the advantages and disadvantages of change and described a typical day of managing his diabetes.

Between Session 2 and Session 3, he changed jobs and was now employed in a different organization. He returned his completed psychometric assessment at this session. He also went on a holiday during this time and, consequently, his depression, anxiety, and stress scores were better than expected based on his previous reports of stress in Session 1. He reported that he was also surprised by the low level of severity in his DASS scores and reported that the scores would have been much higher if he completed the DASS in or around Session 1. He reported that he enjoyed his new position in Session 3. He still felt like an “outsider” and “whipping boy” at work. This unhelpful thinking style about being an “outsider” and the “whipping boy” was identified and explored in terms of the impact of this thinking style on his work, his relationships, and his health status. Mindfulness skills (i.e., mindful breathing) and cognitive disputation skills were explored to challenge, and replace, his unhelpful thinking style and to also assist with his goal of “letting things go” (Schumman et al., 2011). The sessions also focused on continually building Mr. Anderson’s awareness between his anxiety and his current management of his diabetes; that is, psychoeducation about this link, identifying triggers, and exploring alternative coping behaviors.

Between Sessions 4 and 5, Mr. Anderson tested his BGLs four times per day. He started to skip breakfast again. He said that he was “giving up hope” with being able to manage his diabetes. Session 4 focused on his recent increase in testing his levels. Mr. Anderson was unable to identify the exact reason for this. He did identify core beliefs around not being good enough. For example, “I have never put myself first in my life” and “I think my poor control over my diabetes is because I am always putting other people first.” He discussed his guilt about his faith. Cognitive disputation strategies, using Mr. Anderson’s relationship with God, were incorporated to target his physical health.

Between Sessions 5 and 6, Mr. Anderson completed his psychometric assessment. Sessions 5 and 6 focused on relapse prevention and supported him to continue his diabetes management, challenge his previously identified cognitive distortions, and develop a coping plan for addressing any setbacks in the future. He reported that he had better control of his stress levels and confidence in managing his diabetes. The provisional psychologist had finished her placement and was unable to provide further treatment to Mr. Anderson. He agreed to a referral to a local mental-health service for ongoing treatment and to also discuss recent relationship difficulties with his eldest daughter.

Over the course of treatment, the provisional psychologist met with the multidisciplinary members of Mr. Anderson’s treating team, where possible, given the restrictions of clinical practice in rural and remote locations. For example, the provisional psychologist met with Mr. Anderson’s treating diabetes educator, podiatrist, and dietician on four occasions and his treating general practitioner and endocrinologist on one occasion. The multidisciplinary team members primarily communicated over email due to high client caseloads and busy traveling schedules. In rural and remote practice, health care practitioners frequently travel out to rural and remote communities to deliver health care, and the practitioners can be absent from the office for days to weeks at a time, depending on caseloads, weather, and transport reliability. However, flexibility and adaptability in delivering health care is a necessity of rural and remote clinical practice. Flexibility around language use, and conscious awareness of the language used to describe experiences and issues, is also a required adaptation of rural and remote clinical practice (Fraser et al., 2002; Patterson-Kane & Quirk, 2013). For example, metaphors were used to describe Mr. Anderson’s physical health, mental health, and the relationship between the two (e.g., “weight on my shoulders,” “whipping boy,” etc) that are specific to life in rural and remote communities to ensure that Mr. Anderson remained heard, motivated, and engaged in psychological treatment.

Mr. Anderson’s pre-and post-intervention results showed a decrease in his anxiety (DASS) and RD (DDS), and increase in his diabetes-specific quality of life (WHOQOL-BREF). However, a 1-point increase in his DASS depression score might be explained by relationship tensions with his adolescent daughter at that time. At treatment completion, in or around November, 2012, Mr. Anderson’s DSM-IV-TR (APA, 2000) multiaxial assessment was as follows:

Axis I	V71.09 No conditions
Axis II	V71.09 No diagnosis
Axis III	N02.8 Immunoglobulin A (IgA) nephropathy (1989); Peritoneal dialysis (2004); Z94.0 Renal transplant (2008); 250.00 Diabetes mellitus, type II/non-insulin dependent (2011); R80.9 Proteinuria (2011)
Axis IV	Ex-partner and daughter relational problems; Health problems
Axis V	GAF = 61 (at treatment completion)

Mr. Anderson’s reduction in his mental-health symptoms, and better management of his diabetes, was primarily due to his change in his workplace, resulting in reduction of his stress levels. The development of insight into the relationship between physical- and mental-health issues allowed Mr. Anderson to achieve better management of his diabetes, which also positively impacted his mental-health state. Mr. Anderson also had better management of his diabetes and health status, which also positively impacted his mental-health state. Mr. Anderson’s anxiety and stress decreased once he changed positions, and he was able to mindfully and cognitively challenge his cognitive processes that were perpetuating his anxiety symptoms.

8 Complicating Factors

The difficulty in engaging Mr. Anderson in the therapeutic process complicated treatment. For example, he did not see the benefit of discussing events and was reluctant, at times, to discuss his health status and diabetes-management regime. He reported a sense of powerlessness over his current health status and did not express a desire to better manage his diabetes at times throughout the treatment. Specifically, during the first session, he refused to discuss his diabetes at all and wished to discuss his current work-related stress. Over the course of treatment, he disclosed his frustration with his health concerns, and the realization that he does not put his needs first was a turning point in treatment. Therefore, Mr. Anderson’s initial reluctance to discuss his health concerns might have been a withdrawal or avoidant type strategy to alleviate his diabetes-related distress and anxiety. Therefore, motivational interviewing techniques were used to address Mr. Anderson’s reluctance to discuss his health concerns, and this maximized his therapeutic gains. Another complicating factor was the difficulty in balancing the client’s demands with the medical team’s demands. For example, Mr. Anderson’s control of his diabetes fluctuated throughout treatment, and he was initially reluctant to discuss his diabetes at all. Mr. Anderson would often change topics when the treating provisional psychologist enquired about his health demands, which complicated the treating team’s overall communication at times throughout treatment. The rural and remote location was also a complicating factor. Individuals who live in rural and remote locations have poorer adherence to treatment, and this was reflected in Mr. Anderson’s previous noncompliance with his medical and allied health-treatment plans (Greenfield et al., 2011). The requirement of travel and the irregular sessions, which are regular practice in rural and remote communities, was a complicating factor for his initial adherence to the treatment plan (Greenfield et al., 2011).

9 Access and Barriers to Care

There were a number of barriers to care and wellbeing specific to health care treatment in rural and remote communities (DoHA, 2013). First, Mr. Anderson had to travel a considerable distance to attend his appointments. Second, perceived lack of confidentiality in rural and remote communities is a major barrier to care. Mr. Anderson was conscious of this and asked psychological appointments to be scheduled after his other allied health appointments (as this occurred in the same building) to ensure that confidentiality was maintained. Third, Mr. Anderson’s hesitation in disclosing his concerns about his health status to the treating provisional psychologist at first might be due to his previous encounter with the mental-health system, which resulted in an involuntary admission. Consequently, Mr. Anderson’s initial reluctance was a barrier to psychological treatment at first. Fourth, Mr. Anderson’s initial uncertainty about how to use psychological treatment was also a barrier to treatment.

10 Follow-Up

At treatment completion, Mr. Anderson agreed to a referral to a local mental-health service for ongoing treatment as the treating provisional psychologist’s placement had ended. He did not attend one session at the local mental-health service. Despite this, at 8 weeks post-treatment, he had good control of his diabetes and achieved within his target control range between 4.0 mmol/L and 12.0 mmol/L (ABS, 2012). Specifically, his levels were 7.0 mmol/L, and he received much praise (and a metaphorical “gold star”) from his treating medical team. Mr. Anderson continues to have good control of his diabetes and does not wish to engage in further mental-health treatment at this stage. Mr. Anderson’s difficulty in managing his diabetes might have been stress-related, and change in his workplace would have positively impacted his ability to better manage his health status. The development of insight into the relationship between his physical and mental health was pivotal in the success of the intervention.

11 Treatment Implications of the Case

This case highlights the benefit of psychological treatment as an adjunct treatment to medical treatment, particularly when the individual has comorbid-health and mental-health conditions. This case also highlights the benefit of using psychometric measures in chronic health diseases to provide clinically relevant information about the thoughts, feelings, and beliefs maintaining current health-management practices. This case also highlights the benefits of working collaboratively with other disciplines, such as dietetics, podiatry, diabetes education, and medicine to improve overall patient care. The case shows that treatment can be successful when the clinician incorporates strategies specific to individuals who live in rural and remote communities including having knowledge of rural and remote communities, being flexible in the treatment approach, and building relationships with the treating medical and allied health professionals (Greenfield et al., 2011). On reflection, the treatment could have been improved if Mr. Anderson’s reluctance to treatment was identified, addressed, and worked-through in the initial session. As rural and remote clinical practice can be very time-limited, it is important to be respectfully assertive with clients in terms of delivering psychological treatment. Mr. Anderson might have achieved better control of his diabetes earlier had his resistance been addressed. Consequently, treatment might have incorporated further mindfulness and CBT techniques, such as behavioral experiments to challenge his core beliefs that were precipitating and perpetuating his health and mental state at that time.

12 Recommendations to Clinicians and Students

Clinicians and students need to consider the benefits of working collaboratively with other disciplines, in the treatment of medical problems, and the role of psychology in supporting medical-treatment programs (Martin et al., 2009). Clinicians and students need to incorporate community profiles in clinical practice. For example, rural and remote communities have higher burden of diabetes disease and fewer resources to manage this (Reddy et al., 2011; Rugh, 2011). Clinicians and students need to be flexible in their approach and use relationship-building skills with their clients, their colleagues, the multidisciplinary team members, and the community as a whole to achieve good clinical outcomes.

Footnotes

Acknowledgements

The authors would like to thank Dr Gavin Clark for his comments on an earlier version of this manuscript and associate professor Tanya Hanstock for her editing and proofreading on a recent version.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Julia M. Caldwell is a psychologist who completed her masters in clinical psychology at the University of New England (UNE) in 2012. Her interests include child and adolescent psychology and health psychology.

Lisa Patterson-Kane is a clinical psychologist with a strong clinical and research interest in rural and remote mental health. She is the clinic coordinator of the UNE Psychology Clinic and senior lecturer in the UNE Clinical Psychology Program.

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