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Psychological Reactions to Insulin Infusion Pumps
Symposium on Diabetes Mellitus
Psychological Reactions to Insulin I nfusion Pumps Chris Stein, M.Div. *
Although more study is needed before firm conclusions can be drawn about patient reactions to insulin pumps, this article is offered to stimulate thought and to summarize current thinking about psychological adaption to the use of pumps. Our acceptance of technology does not always match the fast growth and capabilities of technology, especially those developments that become part of our bodies or are life support devices. Such technology can be viewed as intrusive rather than life-supporting by a patient who must use it. In the unique symbiotic relationship between a person and a machine, a mechanical device such as the insulin infusion pump becomes a part of the individual. Rather than viewing this new technology-the pump-as a control or a threat, patients have the opportunity to accept it. Without acceptance by the patient, infusion therapy will not work. Before infusion therapy, the diabetic patient could choose whether or not to tell others about the illness and could control the number of people who knew. Wearing a pump is a declaration that something about the person is different; it stimulates the curiosity of others, who may ask questions about the pump. This may be a source of anxiety for the patient. Wearing the pump can become a declaration of being less than whole, less than totally healthy; on the other hand, it can lead to a more complete selfimage. The patient who wears a pump is more conscious of having diabetes because no matter how cleverly the pump is hidden or disguised, it is present and creates the opportunity for awareness not only of the disease, but also of other people's reactions to it. Furthermore, the diabetic patient becomes involved in a time-consuming daily regimen for his or her own health. The patient selection process, patient/physician communication, and *Personnel Representative, Cardiac Pacemakers, Inc., St. Paul, Minnesota
Medical Clinics of North America -Vo!. 66, No. 6, November 1982
1285
1286
CHRIS STEIN
patient compliance and motivation are important factors in analyzing the psychological reactions to insulin infusion pumps. In addition, patient reactions appear to follow a consistent pattern before and during infusion therapy. It may be helpful for clinicians to be aware of the patterns that others have observed.
PATIENT SELECTION Psychological tests have not yet been developed to assure appropriate patient selection for pump therapy from a psychological perspective. A number of attempts have been made to determine an appropriate patient profile for screening candidates who will have a high probability of success with infusion pump therapy. To date, no findings are conclusive. However, according to a study done by Bleicher et aI., a constellation of psychological factors are inherent in diabetic patients who successfully manage their disease (Table 1).3 Some of these factors also must be present in the diabetic patient who can successfully manage infusion pump therapy. In addition to this psychological constellation, a spiritual constellation of factors exists (Table 2). The term spirtual here refers to a belief in a power greater than the person. This spiritual constellation meshes with the psychological constellation. These concepts must all be considered in an open and trusting physician! patient relationship, and both parties must understand the factors that will make pump therapy successful. Successful diabetic patients do not live out their lives alone and that is also true for patients on pump therapy. A strong, supportive family that is not intimidated by diabetes and allows the diabetic patient freedom within the family affords the best environment for the diabetic patient.
COMMUNICATION Infusion therapy is a new challenge to the physician/patient relationship. Because diabetes is a chronic illness, the patient may have had a long-term relationship with the physician prior to initiation of infusion therapy. Relationships, communication patterns, and emotional attachments have been set. If authoritarian or manipulative relationships have been established, they will be challenged by the new situation. It is the responsibility of the physician to create an atmosphere of working together. According to Benarde and Mayerson, "It is essential that the diabetic be made to believe that he is an independent, worthy person entitled to the most clearly stated information possible."2 Pump therapy must be initiated in an atmosphere of mutual respect. The initial success of pump therapy rests on the physician's perception of the therapy. If he is positive about it, the patient will reflect this attitude. If he considers it an inconvenience, so will the patient. If he conveys openness, the patient will reflect that-and enter into infusion therapy energetically to make it work. However, patients also bring to the adaptation process their own set of emotions and issues related to self-image.
PSYCHOLOGICAL REACTIONS TO INSULIN INFUSION PUMPS
1287
Psychological Factors Present in Diabetic Patients Who Successfully Manage Their Illness*
Table 1.
FACTOR
DEFINITION
Dominance
To To To To To To
argue for my point of view be a leader in a group persuade and influence others do what I want direct the actions of others settle arguments
Compulsion
To develop and adhere to set patterns To respond to an irresistible urge To find security in set patterns To find satisfaction in the outcome of the prescribed task
Autonomy
To To To To To
be able to come and go as desired say what I think about things be independent in decision making do things that are unconventional be able to differentiate myself from others
Affiliation
To To To To To To
be loyal to friends participate in friendly groups form new friendships share with friends do activities with friends rather than alone form strong attachments
Freedom from Depressiont
To To To To To
be aware of ,mood swings be able to communicate highs and lows allow others to help realize that low mood swings will be shortlived be sensitive to emotional stirrings
Reality Testing
To feel impending consequences of uncontrolled diabetes To be able to defend against complications To explore information on new techniques of therapy To consider protection as an asset
*From Bleicher, S. J., Temes, R., and Wright, L.: Long-term compliance with a program of blood glucose self-monitoring and intensive insulin therapy (SMITT) in type I diabetes mellitus. Unpublished, 1980. tFrom Edwards Personal Preferem;e Schedule. New York, Psychological Corporation, 1959.
1288
CHRIS STEIN
Table 2.
Spiritual Factors That May Help Diabetic Patients Successfully Manage Their Illness
FACTOR
DEFINITION
Hope/Faith
To To To To
be able to welcome tomorrow feel that what I do makes sense know that there are powers beyond me trust
Grace
To realize that I am not complete To have a sense of humor about myself and the world To live with gentleness To accept my place in the world
Forgiveness
To To To To
absolve myself from guilt fall and pick myself up accept the shortcomings of others not expect perfection
"Pump patients do not passively absorb the intentions or hopes of their physicians, but interpret what they see in light of their own hopes, dreams, and fears."l They ask, "Does this pump mean that I am no longer diabetic? "Is this pump a badge or a cross?" "Does this technology control me or do I control it?" These questions form the parameters of successful pump therapy. The self-image of the patient is at stake: how patients see themselves determines what they think, how they feel, and what they do. The diabetes health care team also has a stake in the success of pump therapy. Judy Joynes, Patient Care Coordinator of the Diabetes Education Center at the St. Louis Park Medical Center in Minneapolis, has noted the importance of open communications between the client on pump therapy and the staff. After the pump is introduced, a close clientlstaffbond is made through many clinic visits and phone calls. "When problems occur with the pump, it is important for clients on pump therapy to be able to talk with a health professional and receive support and direction in solving the problem. This policy of the open phone call is a critical aspect of the ongoing education program directed toward the client becoming independent in making decisions about infusion pump therapy."4 A close relationship between the client and the health care team is essential for success. This initial codependence tends to change into interdependence 2 to 3 months after pump therapy begins.
PATIENT COMPLIANCE Human behavior has a greater effect on patient compliance than do medical factors. The physician as well as the patient must cope with the anxieties of compliance. Compliance begins when the physician is aware of the individual as a person as well as a patient. The patient also must bring certain ingredients to the compliant relationship (Table 3). Compliance is always negotiable and is never perfect because we are
PSYCHOLOGICAL REACTIONS TO INSULIN INFUSION PUMPS
Table 3.
1289
Psychological Factors That May Enhance Compliance FACTOR
DEFINITION
Ego Involvement
To be able to cope with inner conflict To differentiate myself from others To be able to come and go in relationships
Emotional Intimacy
To be able to communicate feelings To be able to be drawn to someone rather than to pull back To be sensitive to the subtleties of relationships To be able to love and to touch
Awareness of Anxieties
To understand that I did not cause the disease To be able to cope with unresolved grief To trust the judgment of another
human. For mature persons, compliance is a statement about themselves, how they view their disease, and how they feel about the pump. "Patients can become compliant through negotiation, if they understand all the ramifications."2 Therefore, the physician must use repetitive communications or rephrasing to promote understanding. If this does not create the desired change in behavior, the patient should be asked directly what he or she needs to become compliant. Remember, communication is not linear; it is a circular and continuous process. Negotiated compliance will fall within a range. The physician begins with a preconceived goal of what compliance means to him. The patient, at first, might not even know what the word means, but through the process of give and take-negotiation-a set of behaviors is established. These become the ground rules for compliance. If five parts equal total compliance, four parts will become operative, and in this imperfect world, we might call this success. Contracts may be useful at this point. Clf;)ar objectives set the parameters for compliance and allow for deviations to be talked through rather than hidden. Joseph Shipp, M.D., of the University of Nebraska Medical Center has devised a contract for his patients on pump therapy and has found this to be very effective in establishing a mutual treatment agreement. "Compromise is not physician versus patient. It is the meeting ground of the relationship. Once the patient feels he is understood and is given latitude as an adult, the level and longevity of compliance may increase. Disrupt the pattern and compliance diminishes."1 Compliance will follow if patients can rid themselves of the belief that fate has dealt them a raw deal, that they deserve to be punished by the illness. They must believe that they can control their lives and become responsible for themselves. The patient who negotiates, has information, and knows that he or she is supported and cared for becomes compliant.
PATIENT MOTIVATION Patients are motivated to try pump therapy by an adventurous, pioneer spirit or because no other therapy has given them strict enough control of
1290
CHRIS STEIN
the diabetes. These motivations come from within. The overriding factor of motivation is that one person cannot motivate another. Motivation must come from the patient, and the role of health care professionals is to remove as many obstacles as possible so that the motivation of the patient is not hindered. Infusion therapy is a new treatment method. To motivate a patient, infusion therapy should be described as a part of a whole regimen and not as an add-on device. The best way to do this is by education. The task is not only to teach the technical operation of the device, but to develop a self-regulated diabetic patient. Education for users of pump therapy includes the individual and the family. Motivation is fostered when the members of the diabetes health care team participate equally in the treatment because the broad range of their expertise, background, and expectations challenges the wearers of the pump. The user of the pump eventually becomes part of the team. Behaviorists have learned certain tricks to sustain motivation. A number of these may be appropriate to enhance patient motivation, for example, setting up a personal reward system. The more we learn, the more we want to learn, and users of infusion pumps are no exception. To sustain long-term motivation, patients on pump therapy should be encouraged to keep a journal. This can be important for people who want to record the major experiences in their lives. A journal is a daily diary for recording good memories, the anxiety the first time the battery sounds an alarm, or the inquisitive stare of a passerby. The journal becomes something to share and to reflect upon and is an excellent motivator. It becomes a personal history that gives a purpose and perspective to the total health of the person.
EMOTIONAL STAGES IN INFUSION PUMP THERAPY Discussions with diabetes educators, especially Bonnie Jacobson, R.N., of United Hospital, St. Paul, Minnesota and Steven Leichter, M.D., of the University of Kentucky, Lexington, reveal that some rather consistent themes are observed before and during infusion therapy. These themes, or stages, are amorphous and fluctuating, but they do occur. Prospective and present wearers of pumps should be aware of the stages and should have the opportunity to communicate their feelings during the stages. Stage I. Anticipation of a significant event. This occurs when other methods have not provided strict control of blood glucose for the diabetic patient, and the physician raises the issue of pump therapy. Prior to using a pump, these people have expended a great deal of emotional effort in striving for tight control. They have worked hard at exercise, diet, urine testing, home monitoring, multiple injections, and they may have experienced complications of diabetes. These people interpret pump therapy as very significant, and the initiation of this therapy is special to them and their families. During this period, they may experience a feeling of resignation that appears to be negative anticipation. This anticipation lasts several weeks.
1291 State lI. Anger. Rather than displacing anger at the pump onto the family, job, or disease, the patient must discover that his or her anger is at the pump or the reason for needing the pump. Recognizing this anger is a necessary part of learning to accept the pump. The more opportunities the patient has to discuss this anger with health professionals or other individuals on pump therapy, the easier is the transition to acceptance of the pump. During this period of anger, the patient should experience tighter control of the disease verified by the results of blood glucose measurements, and this should help him or her through the stage. Stage Ill. Period of doubt. Even though the wearer of the pump is excited, doubt occurs during the adjustment period of learning where to wear it, how to talk about it, and how to keep from banging it on the table or dropping it off the counter. The individual will experience sadness during this period as the reality of having a chronic illness is reinforced by the constant presence of the pump. Before the individual begins to feel better, he or she has constant questions. Feelings of doubt fluctuate. The more feelings that can be shared with the health care provider, the less traumatic the doubts will be. If levels of blood glucose are regulated quickly, this period of doubt is shortened. Stage IV. Acceptance. The last stage is the acceptance period in which the patient finally can say, "The pump is now part of me and my illness." A true symbiotic relationship develops in which the mechanical device becomes part of the patient's life style or self-image. It usually takes 6 months or more before a patient can accept the pump. After this occurs, the number of visits to the physician falls off dramatically. This should not be construed as poor compliance. More initiative from the health care team is needed to retain regular contact. It can also be expected that a fairly independent person will take control of his or her disease. The stages-anticipation, anger, periods of doubt, and acceptancefollow a predictable pattern that can be successfully negotiated between caring persons. A successful infusion pump program should include dedicated health care providers who are willing to accompany the patient from the initial stage of anticipation of the pump to acceptance of the pump. Patients who know that they will receive support have a strong foundation for successful infusion pump therapy. Infusion pump clubs offer an opportunity for communication, technical updates, physician/patient contact, and relationships with others who use pumps. Patients can discuss feelings and share hints for daily living with pumps. Each member attends meetings to give and to receive support. Pump clubs allow wearers of pumps to teach others about infusion therapy. This allows patient motivation to last longer and keeps compliance at the negotiated level. Encouraging patients to become experts gives them a sense of mission and enhances their self-image. It also allows new patients to learn about infusion therapy from those who have experienced it. Persons considering pump therapy may attend club meetings to test the waters. Certainly this can only add to the support of the diabetes program and minimize demands on the time of the health care team. Helping the individual adjust to wearing a medical device requires PSYCHOLOGICAL REACTIONS TO INSULIN INFUSION PUMPS
1292
CURlS STEIN
attention to the patient's psychological adaptation process. The patient and the health care team can benefit from an awareness of these influences on the therapeutic outcome.
REFERENCES 1. Barnlund, D. c.: The mystification of meaning: Doctor-patient encounters. J. Med. Ed., 51 :716--725, 1976. 2. Benarde, M. A., and Mayerson, E. W.: Patient-physician negotiation. J.A.M.A., 239:14131415, 1978. 3. Bleicher, S. J., Temes, R., and Wright, L.: Long-term compliance with a program of blood glucose self-monitoring and intensive insulin therapy (SMITT) in type I diabetes mellitus. Unpublished, 1980. 4. Joynes, J.: Personal communication to CPI. July, 1982. Cardiac Pacemakers, Inc. 40100 North Hamline Ave. P.O. Box 43079 St. Paul, Minnesota 55164
Psychological Reactions to Insulin I nfusion Pumps Chris Stein, M.Div. *
Although more study is needed before firm conclusions can be drawn about patient reactions to insulin pumps, this article is offered to stimulate thought and to summarize current thinking about psychological adaption to the use of pumps. Our acceptance of technology does not always match the fast growth and capabilities of technology, especially those developments that become part of our bodies or are life support devices. Such technology can be viewed as intrusive rather than life-supporting by a patient who must use it. In the unique symbiotic relationship between a person and a machine, a mechanical device such as the insulin infusion pump becomes a part of the individual. Rather than viewing this new technology-the pump-as a control or a threat, patients have the opportunity to accept it. Without acceptance by the patient, infusion therapy will not work. Before infusion therapy, the diabetic patient could choose whether or not to tell others about the illness and could control the number of people who knew. Wearing a pump is a declaration that something about the person is different; it stimulates the curiosity of others, who may ask questions about the pump. This may be a source of anxiety for the patient. Wearing the pump can become a declaration of being less than whole, less than totally healthy; on the other hand, it can lead to a more complete selfimage. The patient who wears a pump is more conscious of having diabetes because no matter how cleverly the pump is hidden or disguised, it is present and creates the opportunity for awareness not only of the disease, but also of other people's reactions to it. Furthermore, the diabetic patient becomes involved in a time-consuming daily regimen for his or her own health. The patient selection process, patient/physician communication, and *Personnel Representative, Cardiac Pacemakers, Inc., St. Paul, Minnesota
Medical Clinics of North America -Vo!. 66, No. 6, November 1982
1285
1286
CHRIS STEIN
patient compliance and motivation are important factors in analyzing the psychological reactions to insulin infusion pumps. In addition, patient reactions appear to follow a consistent pattern before and during infusion therapy. It may be helpful for clinicians to be aware of the patterns that others have observed.
PATIENT SELECTION Psychological tests have not yet been developed to assure appropriate patient selection for pump therapy from a psychological perspective. A number of attempts have been made to determine an appropriate patient profile for screening candidates who will have a high probability of success with infusion pump therapy. To date, no findings are conclusive. However, according to a study done by Bleicher et aI., a constellation of psychological factors are inherent in diabetic patients who successfully manage their disease (Table 1).3 Some of these factors also must be present in the diabetic patient who can successfully manage infusion pump therapy. In addition to this psychological constellation, a spiritual constellation of factors exists (Table 2). The term spirtual here refers to a belief in a power greater than the person. This spiritual constellation meshes with the psychological constellation. These concepts must all be considered in an open and trusting physician! patient relationship, and both parties must understand the factors that will make pump therapy successful. Successful diabetic patients do not live out their lives alone and that is also true for patients on pump therapy. A strong, supportive family that is not intimidated by diabetes and allows the diabetic patient freedom within the family affords the best environment for the diabetic patient.
COMMUNICATION Infusion therapy is a new challenge to the physician/patient relationship. Because diabetes is a chronic illness, the patient may have had a long-term relationship with the physician prior to initiation of infusion therapy. Relationships, communication patterns, and emotional attachments have been set. If authoritarian or manipulative relationships have been established, they will be challenged by the new situation. It is the responsibility of the physician to create an atmosphere of working together. According to Benarde and Mayerson, "It is essential that the diabetic be made to believe that he is an independent, worthy person entitled to the most clearly stated information possible."2 Pump therapy must be initiated in an atmosphere of mutual respect. The initial success of pump therapy rests on the physician's perception of the therapy. If he is positive about it, the patient will reflect this attitude. If he considers it an inconvenience, so will the patient. If he conveys openness, the patient will reflect that-and enter into infusion therapy energetically to make it work. However, patients also bring to the adaptation process their own set of emotions and issues related to self-image.
PSYCHOLOGICAL REACTIONS TO INSULIN INFUSION PUMPS
1287
Psychological Factors Present in Diabetic Patients Who Successfully Manage Their Illness*
Table 1.
FACTOR
DEFINITION
Dominance
To To To To To To
argue for my point of view be a leader in a group persuade and influence others do what I want direct the actions of others settle arguments
Compulsion
To develop and adhere to set patterns To respond to an irresistible urge To find security in set patterns To find satisfaction in the outcome of the prescribed task
Autonomy
To To To To To
be able to come and go as desired say what I think about things be independent in decision making do things that are unconventional be able to differentiate myself from others
Affiliation
To To To To To To
be loyal to friends participate in friendly groups form new friendships share with friends do activities with friends rather than alone form strong attachments
Freedom from Depressiont
To To To To To
be aware of ,mood swings be able to communicate highs and lows allow others to help realize that low mood swings will be shortlived be sensitive to emotional stirrings
Reality Testing
To feel impending consequences of uncontrolled diabetes To be able to defend against complications To explore information on new techniques of therapy To consider protection as an asset
*From Bleicher, S. J., Temes, R., and Wright, L.: Long-term compliance with a program of blood glucose self-monitoring and intensive insulin therapy (SMITT) in type I diabetes mellitus. Unpublished, 1980. tFrom Edwards Personal Preferem;e Schedule. New York, Psychological Corporation, 1959.
1288
CHRIS STEIN
Table 2.
Spiritual Factors That May Help Diabetic Patients Successfully Manage Their Illness
FACTOR
DEFINITION
Hope/Faith
To To To To
be able to welcome tomorrow feel that what I do makes sense know that there are powers beyond me trust
Grace
To realize that I am not complete To have a sense of humor about myself and the world To live with gentleness To accept my place in the world
Forgiveness
To To To To
absolve myself from guilt fall and pick myself up accept the shortcomings of others not expect perfection
"Pump patients do not passively absorb the intentions or hopes of their physicians, but interpret what they see in light of their own hopes, dreams, and fears."l They ask, "Does this pump mean that I am no longer diabetic? "Is this pump a badge or a cross?" "Does this technology control me or do I control it?" These questions form the parameters of successful pump therapy. The self-image of the patient is at stake: how patients see themselves determines what they think, how they feel, and what they do. The diabetes health care team also has a stake in the success of pump therapy. Judy Joynes, Patient Care Coordinator of the Diabetes Education Center at the St. Louis Park Medical Center in Minneapolis, has noted the importance of open communications between the client on pump therapy and the staff. After the pump is introduced, a close clientlstaffbond is made through many clinic visits and phone calls. "When problems occur with the pump, it is important for clients on pump therapy to be able to talk with a health professional and receive support and direction in solving the problem. This policy of the open phone call is a critical aspect of the ongoing education program directed toward the client becoming independent in making decisions about infusion pump therapy."4 A close relationship between the client and the health care team is essential for success. This initial codependence tends to change into interdependence 2 to 3 months after pump therapy begins.
PATIENT COMPLIANCE Human behavior has a greater effect on patient compliance than do medical factors. The physician as well as the patient must cope with the anxieties of compliance. Compliance begins when the physician is aware of the individual as a person as well as a patient. The patient also must bring certain ingredients to the compliant relationship (Table 3). Compliance is always negotiable and is never perfect because we are
PSYCHOLOGICAL REACTIONS TO INSULIN INFUSION PUMPS
Table 3.
1289
Psychological Factors That May Enhance Compliance FACTOR
DEFINITION
Ego Involvement
To be able to cope with inner conflict To differentiate myself from others To be able to come and go in relationships
Emotional Intimacy
To be able to communicate feelings To be able to be drawn to someone rather than to pull back To be sensitive to the subtleties of relationships To be able to love and to touch
Awareness of Anxieties
To understand that I did not cause the disease To be able to cope with unresolved grief To trust the judgment of another
human. For mature persons, compliance is a statement about themselves, how they view their disease, and how they feel about the pump. "Patients can become compliant through negotiation, if they understand all the ramifications."2 Therefore, the physician must use repetitive communications or rephrasing to promote understanding. If this does not create the desired change in behavior, the patient should be asked directly what he or she needs to become compliant. Remember, communication is not linear; it is a circular and continuous process. Negotiated compliance will fall within a range. The physician begins with a preconceived goal of what compliance means to him. The patient, at first, might not even know what the word means, but through the process of give and take-negotiation-a set of behaviors is established. These become the ground rules for compliance. If five parts equal total compliance, four parts will become operative, and in this imperfect world, we might call this success. Contracts may be useful at this point. Clf;)ar objectives set the parameters for compliance and allow for deviations to be talked through rather than hidden. Joseph Shipp, M.D., of the University of Nebraska Medical Center has devised a contract for his patients on pump therapy and has found this to be very effective in establishing a mutual treatment agreement. "Compromise is not physician versus patient. It is the meeting ground of the relationship. Once the patient feels he is understood and is given latitude as an adult, the level and longevity of compliance may increase. Disrupt the pattern and compliance diminishes."1 Compliance will follow if patients can rid themselves of the belief that fate has dealt them a raw deal, that they deserve to be punished by the illness. They must believe that they can control their lives and become responsible for themselves. The patient who negotiates, has information, and knows that he or she is supported and cared for becomes compliant.
PATIENT MOTIVATION Patients are motivated to try pump therapy by an adventurous, pioneer spirit or because no other therapy has given them strict enough control of
1290
CHRIS STEIN
the diabetes. These motivations come from within. The overriding factor of motivation is that one person cannot motivate another. Motivation must come from the patient, and the role of health care professionals is to remove as many obstacles as possible so that the motivation of the patient is not hindered. Infusion therapy is a new treatment method. To motivate a patient, infusion therapy should be described as a part of a whole regimen and not as an add-on device. The best way to do this is by education. The task is not only to teach the technical operation of the device, but to develop a self-regulated diabetic patient. Education for users of pump therapy includes the individual and the family. Motivation is fostered when the members of the diabetes health care team participate equally in the treatment because the broad range of their expertise, background, and expectations challenges the wearers of the pump. The user of the pump eventually becomes part of the team. Behaviorists have learned certain tricks to sustain motivation. A number of these may be appropriate to enhance patient motivation, for example, setting up a personal reward system. The more we learn, the more we want to learn, and users of infusion pumps are no exception. To sustain long-term motivation, patients on pump therapy should be encouraged to keep a journal. This can be important for people who want to record the major experiences in their lives. A journal is a daily diary for recording good memories, the anxiety the first time the battery sounds an alarm, or the inquisitive stare of a passerby. The journal becomes something to share and to reflect upon and is an excellent motivator. It becomes a personal history that gives a purpose and perspective to the total health of the person.
EMOTIONAL STAGES IN INFUSION PUMP THERAPY Discussions with diabetes educators, especially Bonnie Jacobson, R.N., of United Hospital, St. Paul, Minnesota and Steven Leichter, M.D., of the University of Kentucky, Lexington, reveal that some rather consistent themes are observed before and during infusion therapy. These themes, or stages, are amorphous and fluctuating, but they do occur. Prospective and present wearers of pumps should be aware of the stages and should have the opportunity to communicate their feelings during the stages. Stage I. Anticipation of a significant event. This occurs when other methods have not provided strict control of blood glucose for the diabetic patient, and the physician raises the issue of pump therapy. Prior to using a pump, these people have expended a great deal of emotional effort in striving for tight control. They have worked hard at exercise, diet, urine testing, home monitoring, multiple injections, and they may have experienced complications of diabetes. These people interpret pump therapy as very significant, and the initiation of this therapy is special to them and their families. During this period, they may experience a feeling of resignation that appears to be negative anticipation. This anticipation lasts several weeks.
1291 State lI. Anger. Rather than displacing anger at the pump onto the family, job, or disease, the patient must discover that his or her anger is at the pump or the reason for needing the pump. Recognizing this anger is a necessary part of learning to accept the pump. The more opportunities the patient has to discuss this anger with health professionals or other individuals on pump therapy, the easier is the transition to acceptance of the pump. During this period of anger, the patient should experience tighter control of the disease verified by the results of blood glucose measurements, and this should help him or her through the stage. Stage Ill. Period of doubt. Even though the wearer of the pump is excited, doubt occurs during the adjustment period of learning where to wear it, how to talk about it, and how to keep from banging it on the table or dropping it off the counter. The individual will experience sadness during this period as the reality of having a chronic illness is reinforced by the constant presence of the pump. Before the individual begins to feel better, he or she has constant questions. Feelings of doubt fluctuate. The more feelings that can be shared with the health care provider, the less traumatic the doubts will be. If levels of blood glucose are regulated quickly, this period of doubt is shortened. Stage IV. Acceptance. The last stage is the acceptance period in which the patient finally can say, "The pump is now part of me and my illness." A true symbiotic relationship develops in which the mechanical device becomes part of the patient's life style or self-image. It usually takes 6 months or more before a patient can accept the pump. After this occurs, the number of visits to the physician falls off dramatically. This should not be construed as poor compliance. More initiative from the health care team is needed to retain regular contact. It can also be expected that a fairly independent person will take control of his or her disease. The stages-anticipation, anger, periods of doubt, and acceptancefollow a predictable pattern that can be successfully negotiated between caring persons. A successful infusion pump program should include dedicated health care providers who are willing to accompany the patient from the initial stage of anticipation of the pump to acceptance of the pump. Patients who know that they will receive support have a strong foundation for successful infusion pump therapy. Infusion pump clubs offer an opportunity for communication, technical updates, physician/patient contact, and relationships with others who use pumps. Patients can discuss feelings and share hints for daily living with pumps. Each member attends meetings to give and to receive support. Pump clubs allow wearers of pumps to teach others about infusion therapy. This allows patient motivation to last longer and keeps compliance at the negotiated level. Encouraging patients to become experts gives them a sense of mission and enhances their self-image. It also allows new patients to learn about infusion therapy from those who have experienced it. Persons considering pump therapy may attend club meetings to test the waters. Certainly this can only add to the support of the diabetes program and minimize demands on the time of the health care team. Helping the individual adjust to wearing a medical device requires PSYCHOLOGICAL REACTIONS TO INSULIN INFUSION PUMPS
1292
CURlS STEIN
attention to the patient's psychological adaptation process. The patient and the health care team can benefit from an awareness of these influences on the therapeutic outcome.
REFERENCES 1. Barnlund, D. c.: The mystification of meaning: Doctor-patient encounters. J. Med. Ed., 51 :716--725, 1976. 2. Benarde, M. A., and Mayerson, E. W.: Patient-physician negotiation. J.A.M.A., 239:14131415, 1978. 3. Bleicher, S. J., Temes, R., and Wright, L.: Long-term compliance with a program of blood glucose self-monitoring and intensive insulin therapy (SMITT) in type I diabetes mellitus. Unpublished, 1980. 4. Joynes, J.: Personal communication to CPI. July, 1982. Cardiac Pacemakers, Inc. 40100 North Hamline Ave. P.O. Box 43079 St. Paul, Minnesota 55164