Burnout: When Managing Your Diabetes Becomes Too Much

If you have diabetes, then you know that taking care of yourself can feel like a full time job. Blood sugar levels, which becomes the central number in your health universe, can be affected by many common activities of daily living - and it can feel exhausting. Many diabetes management behaviors are in-line with recommendations we are familiar with for everyone - eat well, exercise regularly and manage your stress, are some of the main ones. But it can feel entirely unfair that while other people can sometimes eat well and at other times splurge, managing your diabetes requires one to be on their best behavior - most of the time. Falling of the wagon, like you see friends and family often do, is not an option. No wonder that burnout is a chronic risk for diabetes sufferers.

And while keeping a handle on stress levels is one of the key factors in managing diabetes, managing diabetes can itself contribute to stress. This creates a cycle that when it gets too bad can lead to depression, which leads to less effective diabetes management coping skills and so on. In fact, in a recent study conducted by the Harvard School of Public Health, it was found that women suffering from depression were 17% more likely to contract Type 2 diabetes, and that women struggling with diabetes were 28% more likely to end up with depressive symptoms.*

According to the lead researcher on the study, while BMI may account for some of the findings, the likeliest reason for this correlation has to do with stress. Cortisol, the main stress hormone found in the body, is often found at elevated levels in people with depression - and in turn it plays a negative role in blood sugar levels and insulin resistance, increasing risk factors found in diabetes. 

The feeling that one has to be on "their best behavior" all of the time when managing this illness is not limited to food and exercise. Relationships, too, take on extra importance as diabetes sufferers need to look for extra support and understanding from the important people in their lives. Those people in turn need to be supported in order to be adequate supports to you - and need to be educated to the needs of diabetes management just as you are. 

If you have diabetes, remember to ask for help when you need it. Find your supports and use them wisely. Remember that managing your illness is doable and manageable and perhaps may even be an opportunity to "do all the right things" that we are all supposed to be doing anyway. But also don't forget to give yourself a break - diabetes management is a marathon not a sprint. And while getting into a comfortable routine is crucial, so is the realization that as your life circumstances and body changes, so can your relationship to food, exercise, your medical procedures, and to friends and family. If you find yourself experiencing "burnout," which may include feelings of anger, sadness, helplessness, withdrawal from activities of everyday living, and "forgetting" to take care of your diabetes regimen, then it may be time to sit down and reexamine what has been going in your life, and most importantly, not to forget to ask for help. Diabetes is easier managed when you are not doing it alone.

* As reported in WebMd: http://www.webmd.com/depression/news/20101122/new-links-seen-between-depression-and-diabetes

I am a Licensed Psychologist. Many of my patients are older adults, and while illness is not necessarily linked to aging, some of my patients also suffer from chronic pain and other physical ailments. My office is in Conshohocken and I can be reached at (484) 534-8830 or at dan.livney@gmail.com. For more information please go to www.danlivney.com

Parenting: Soothing the Hurt of Good-byes

“It’s time to go now…” (or put your toys away, or turn off the TV, or go to sleep) Many a fight between parent and young child has begun with these words. Why are these transitions such a stress point for parent/child interactions, and how can we think about them more effectively?

 As I pointed out in my last blog posting, I like to give examples because it makes ideas easier to visualize. These can certainly be tried by others, and I am glad if they work for you, as they have for me. But my interest is really not in providing techniques. No technique would work for all children (or all parents), and none would work for any given child all of the time. I’d like to encourage the reader instead to think of the underlying message that the examples try to convey. In this post, we are going to think about the good-bye.

What is a good-bye? We usually say our good-byes when we separate from a person with whom we have spent some time, whether hours or even a minute. It’s a way of acknowledging that the time we spent together, long or short, had meaning, and because of that we find it worthwhile to give a benediction to the person from whom we are taking our leave (“good-bye” is an archaic form, originally meaning “god be with you.”). We as adults do this almost without thinking. But here it is useful to pause and give some thought to those things that seem so automatic to us, but not to our little people for whom everything in the world is new and open to question. If we allow ourselves the moments to do this, we ourselves see the world anew, as through their eyes, and find that sometimes the obvious is in fact profound.

What do children have to teach us about good-byes? What is the tension that comes up when parents try to pull their children away from an activity or a favorite grandparent, or from the quickening world into the darkened bedroom for the night? What is the reason for the screaming, the distress; why, in short, does it appear to hurt so much?

Let’s take an example where we can try to imagine ourselves as we are when we have lost something and feel helpless; to get in touch for a moment with feelings a child might have. In scene “A,” imagine you spent more than you had intended on an item at a department store. You didn’t shop around, grabbed the first item on the shelf and ended up spending $40 instead of $20. You can imagine being disappointed, but would probably find a way to forgive yourself. In scene “B,” you went to the store intending to spend $20, but the item was rung up as $40 and you didn’t notice until later (after you lost the receipt); now you have a very different set of feelings. You may feel mad at the cashier and the store, upset at the injustice of it all, disappointed in yourself for not noticing sooner. In both examples you spent $40 and got the item you wanted – in theory it should amount to the same thing, so why the strong feelings?

What is different is that in the first example you made the choice, even if you had mixed feelings about it. In the second example you found out what had happened to you was not what you had intended. As it turns out that makes all the difference in the world. Losing something is hard, but having something taken away from you can be infuriating, humiliating, and maddening. This is a difference in perspective which goes all the way back to childhood, as we are reminded each time our children react with such hurt and rage to being separated from important people, places or things; and to the realization that these partings are beyond their control.

But, you say, sometimes it’s not their choice: they need to go to sleep, they can’t watch TV for hours at a time, they can’t stay overnight playing with their friends when it’s time to go home. Of course. It’s our responsibility as parents and caregivers to make decisions for them that they can not yet make for themselves. But what we can do is to build in time to help them to say “good-bye,” and what this can do is to help turn a situation that leaves them feeling passive and helpless, into one that invites them to become active participants in the leave-taking.

Ahead are some practical examples of how this can be done. I encourage you to read them not so much as a series of methods, but as examples of how one can think about what is important to your child, and to respond in kind. When my child became infatuated with the moon at around 18 months, before going upstairs for bedtime every night we would make our rounds: “Let’s go say good night to outside. Good night, outside. Good night, moon. Good night neighbors.” Most of you are probably familiar with a children’s book that has a very similar theme. This can work in ways both large and small. When a child protests leaving a toy, ask her “do you want to say good-bye to the ball?” And then help her to really say good-bye to it. Ask her if she wants to say good-bye. Help the child remember the fun she had with the ball, and the fun that she may have again in the morning with it. Maybe say thank you to the ball for being there to be played with. Explain to the child in specific detail why it is time to leave the ball she was playing with: “It’s lunchtime, and we have to go to eat now, otherwise you will be hungry and you know how unhappy you can get when you get hungry.” Having an understanding – in their own way, even if they don’t get every detail of what you are saying, is an important part in helping them feel like they are an active participant in their life, rather than a dragged along bystander. I sometimes think that the very act of explaining with great specificity and earnestness, as I often do with children, my reasons for doing the things I do that affects them, allows them to feel that they are being taken seriously. Of course, I can’t know that for sure, they don’t tell me. But I’ve noticed it often has a calming effect.

Not unusually, my oldest child had a particularly difficult time leaving exciting spots like the zoo, the beach and so on. We would look back before getting into the car to go home, and spend a few minutes reminiscing about what we did there and how glad we were to have been there, and how much we are looking forward to coming back there one day soon. Then I would tell him to have one last look, so he could take something of the place with him by remembering it. The first time we tried this approach he needed to be strapped in screaming into his car seat to get him home, but by the second or third times the tears would stop almost as soon as we began our good-bye routine.

Giving children options is another way of helping them take their leave, of giving up something they feel is important to them, at least in the moment. Rather than “You can’t have brownie until after dinner,” try “You can’t have a brownie now, but do you want to have a brownie after dinner?” Instead of “you need to go upstairs now,” what about “would you like to walk upstairs, or would you like a piggy-back ride upstairs?” Options provide the child with a choice, giving them some level of personal influence within a situation that they can’t have full control over. And I am certainly not one to be above cajoling, gently joking, bargaining and acting silly to help along with the process.

One final example, and this is the most painful one but in some ways also the most relevant. Think for a moment how difficult it is for adults to acknowledge, to talk about, or perhaps even to think about somebody close to them dying, or having died. There is no way to take away the pain of that kind of loss, but the grieving process is really just the biggest and most final form of saying “good-bye.” Those who have had the sadness to have gone through this know how difficult it is. But many find it a help and a comfort to do many of the very same things I suggested to my child as we left the beach: saying “good-bye,” reminiscing, remembering what we are grateful for, having one last moment, and taking something along with us whether it’s something tangible like a seashell, or something less tangible, as a memory. For children, the lessons of learning to say good-bye well to everyday things: a toy, a playground, a play date, or to the last light of a fun day, are small steps towards learning the lessons of what it means to say good-bye to the bigger things in life – which happen to all of us one day. 

About me: I am a Licensed Psychologist in private practice. Among my interests is working with couples on relationship and parenting issues. My office is in Conshohocken, and I can be reached at (484) 534-8830 or at dan.livney@gmail.com. For more information, please see his website at www.danlivney.com

Parenting: The Toddler and the "No!"

“No, No, No!” If you have a toddler, you know what this sounds like. It’s frustrating, it’s aggravating, and it makes you late for work, or wastes the meal you carefully made, or causes your child to miss her bedtime. But the toddler’s “no” is also more than that, and understanding the full message allows parents and caregivers to better respond to and interact with the resistant toddler in full throttle.

There are actually two meanings contained within the toddler’s no: the action or event the toddler is resisting, and then the ability to resist, in and of itself. When the child refuses to put on his shoes as you’re desperately trying to leave the house in the morning, at issue are the shoes, and his ability to say “no” to you, the all powerful parent. Often enough in the heat of the moment, parents react to the first part of the message and put even stronger demands on the child to put her shoes on “now!” But this drowns out what is likely to be more important to the child in that moment, which is the second part, the refusal. Addressing the refusal rather than the shoes, can dramatically change the interaction, and can often (but not always) change the “no” into a “yes.” Even more importantly, understanding what is important to your toddler and forming a habit of responding to it accurately can set you and her up for improved interactions in the long-term, and provides her a model for dealing with her relationships in general. In short, thinking about what the “no” means to the toddler is an important teaching moment, for both child and parent together.

What might this look like, addressing the refusal rather than the shoes? In a moment we will look at some examples of how to do this, but building your own understanding of what it means to your child to refuse your directions, and what kinds of feelings it generates within you as she does so really involves getting to know your child better – as well as yourself. While techniques can be useful, no one way will work for all children, and none will work for any given child all of the time. It can, however, be helpful to keep some in your tool chest as options to keep in mind and try out with your own child. For example, one I’ve found helpful is making it explicit to the child that she is refusing – because as surprising as it may be – until you say it out loud – children are often unaware of the meaning of their actions, and what the impact of their actions are on others. As adults, we struggle with this, too.

Let’s say you are trying to get your child to put her shoes on by the front door, but instead of complying, the child runs out of the door barefoot. Securing the child, of course, comes first. But once you have child in hand try saying, calmly, even playfully: “you don’t want to listen to mommy/daddy right now, do you?” This names and describes the behavior to the child so that it’s out in the open; it also makes the child feel that an important need of hers has been acknowledged and heard. As an adult you know that kind of acknowledgment of real feelings, what one might call empathy, can be very powerful in your adult relationships. It should come as no surprise that it works for children as well. And ideally, empathy is never a technique. Trying this kind of approach requires spending an extra minute or two with the child as she negotiates with you this new information – something that can be hard for you to do on a busy morning. But what you get in return is a no-fuss morning with you and her still enjoying each other’s company at the end: and that, of course, is the point, while often challenging, parenting is supposed to be fun, not a chore.

Another approach is waiting out the “no.” Let’s say you are brushing your little one’s teeth, and she steadfastly closes her mouth and refuses to open. Forcing the issue runs the risk of creating more reason for her to resist in the future, while allowing her to win risks sending the message that you can be defeated if she only waits long enough. An alternative approach is to allow her a minute to refuse, while you wait, toothbrush in hand, perhaps saying something like: “ok, I see you are not ready to brush your teeth yet.” This sends the message that she has the right to participate in the process, she can get to choose to say no; but that you are not willing to give up on the eventual outcome. Again, if we emphasize the underlying meaning of this example, rather than viewing it as a simple technique, the message is that your expectations are to be respected, but that she gets to have a say too. This takes more time, but then again, may end up taking less time than the fight which can be the alternative.

The hardest part of this approach is that it requires you as the parent/caregiver to come in touch with the feelings that are generated in you. For example, the toothbrush example comes from personal experience. I wanted my child to get finished with brushing his teeth and get to bed in order for me to move on with all the other things I needed to do that evening. I felt frustration, even some anger that he wouldn’t comply: “doesn’t he know that I have other things to do?!” Of course, the answer is he does not, nor does he care. Nor can he possibly have much understanding of what my life is like aside from my caretaking responsibilities which have immediately to do with him. But children are exquisitely sensitive to emotions. If anger had crept into my voice as I tried to acknowledge his need to take over the process, he would have sensed it. That doesn’t mean I was not aware of, or denied that feeling within myself, only that I worked to keep it out of the room and out of my interaction with him.

And that is really the key: They have a need for control in their lives, much as we do, even if the specific goals and desires are obviously different. Where their need to say “no” encounters our own intentions, that is where problems happen. There is no one way, or some simple answer for how to have an effective and collaborative relationship with your child. Rather, parenting requires a careful balance between allowing them to feel that they have some control over their bodies, their lives, and over us in some ways and to some degree. But also learning how to listen to our feelings so that parenting becomes healthy compromise rather than into a battle that we need to win, or that we allow the child to win.

About me: I am a Licensed Psychologist in private practice. Among my interests is working with couples on relationship and parenting issues. My office is in Conshohocken, and I can be reached at (484) 534-8830 or at dan.livney@gmail.com. For more information, please see his website at www.danlivney.com

Chronic Pain: Treating the Whole Person

Treating the suffering of chronic pain can be one of most challenging and vexing of all health related problems. Pain is the most common reason for a physician consultation in the U.S., and it has been estimated that 30 million people experience chronic or recurrent pain conditions – defined as pain that lasts for longer than three months or after the tissue damage initially associated with the pain has healed. This perhaps is one of the places where the phenomenon of chronic pain begins its confounding stature: why should pain persist after the damage has apparently healed? While there have been a number of theories proposed at the neurological level for this, what patients experience is that if the pain persists, then treatment may become a sometimes frustrating search for a treatment that targets the symptom but not necessarily the underlying cause which may remain elusive.

Depending on the type of pain, opioids, anti-depressants, steroid injections or even surgery may be prescribed. In some cases these work well, in others repeated and even long-term treatment is the result. In either case, the toll on the patient and on the patient’s family can be tremendous. Chronic pain can result in significant physical impairment and emotional distress, loss of work, family distress, and subjective feelings of an overall diminished quality of life.

Because of this, the most recent research has shown that simply addressing symptom reduction is an inadequate goal in itself. The reality is that, sadly, the treatment of chronic pain, even in successful cases, often means an improvement in but not the full elimination of symptoms. Rather, treatment teams may focus on the physical, emotional and social aspects of a patient’s life and experience as it is impacted by chronic pain. What patients will often report is that these three areas of their life are actually found to strongly impact one another. For example, a reduction in depression that is often associated with pain also reduces the pain itself.  Improved social relationships also serve to improve mood, and through that, the experience of pain. Chronic pain takes away a person’s sense of control over their life. It makes one feel bound to their body and unable to participate in social and physical activities that a person previously enjoyed. But while it is true that in many cases there is no “cure” for chronic pain, patients can learn to retake control and to lessen the constraint that pain has on their lives.


As a psychologist, my job is to help my patients think of themselves not just as a set of pain symptoms to be treated, but as a whole person who is in pain. The change in perception between these two ways of being opens up possibilities that at first are often hidden to the person struggling and in pain. I talk to my patients about what does healing mean to them. Sometimes it may mean full remission, but even when it doesn’t, important questions remain about how a person with long-term pain lives and relates to his or her family, friends, and loved ones; how that person relates to his or her own body and emotional self; and all in all, how that person works, lives, loves and plays – in control of, not controlled by their symptoms.

I am a Licensed Psychologist. Many of my patients are older, and while illness is not necessarily linked to aging, some of my patients also suffer from chronic pain and other physical ailments. My office is in Conshohocken and I can be reached at (484) 534-8830 or at dan.livney@gmail.com. For more information please go to www.danlivney.com

Our Bodies, Not Ourselves?

The popular book on women’s reproductive health, Our Bodies, Ourselves was published quietly in 1971, and quickly became a best seller, claiming no fewer than 9 domestic and 26 foreign editions. The book sought to encourage women to get in touch with the sexual and reproductive parts of themselves; parts that in that era, and perhaps still now, are, as the book points out, often more unfamiliar to women than other parts of themselves.

The important message of this book came to my mind recently because it seems to me to raise some interesting questions about our relationships to our bodies – and when I say “our,” I speak of men and women both. Let me start with the possibly odd-sounding suggestion that our bodies are not ourselves. True, legally speaking, if you commit a crime they will take a mug shot of you. That photo is intended to identify you, the person who committed the crime, and so from a legal standpoint we and our bodies are one. On the other hand, if you think about the point of the book: that we can go through life not knowing about our own basic feelings and biologies, then perhaps we can also say that “we” – let’s for the sake of simplicity call this entity our minds – our minds are in a constant state of relationship with our bodies. We learn about them, we discover them, we enjoy them when they give us pleasure, and we lament them when they give us pain. It is also true that our minds are in a special kind of relationship with our bodies, different than the kind of relationship we have with other people – precisely because our bodies are always there. But still, just because our minds and our bodies are not one and the same, it is also possible for us to have quite complicated relationships with them.

Let me give you some examples of what I mean. When our bodies give us pain, we actually have a range of emotions and options with which we can react. We can tense up, angry that the pain is there. This often leads to more tension and therefore more pain. Or we can relax and accept, and the pain becomes more tolerable. We can make decisions about the pain: how do we know to enjoy the pain of a strenuous workout, but not the pain of a toothache? It turns out these are not simple decisions. For some people the idea of pain from a workout can be just as painful as a toothache and may be part of why it is so hard for many of us to start an exercise routine. That is also an example of our mind making a decision or a judgment about the feelings our bodies are giving us.

Now what happens when our bodies are sick? Let’s use for our example just an everyday cold. For some people that can be quite stressful, others take it in stride. What’s the difference? Maybe just in personality type, but maybe also in the difference between someone who has sick days they can enjoy (and the kind of job where taking them is minimally intrusive), while for someone else it may mean lost wages and complicated child care arrangements. In both cases what we often find is that the ways our bodies react to illness (or pain) is in part based on all of these thoughts and feelings which our minds have about what is going on with our bodies. Depending on what we think, the pain in our body can feel worse, the illness can feel more oppressive.

Most importantly, this means that our way to health, or at least improvement, is also affected by the thoughts and feelings our minds produce about the experiences of our bodies. The same kinds of injuries or illness conditions in two different people – or even in the same person under different circumstances, can have wildly different outcomes. One researcher found that back surgery done to relieve chronic lower back pain is predominantly unsuccessful for people with a history of abuse and trauma in their lives; while the exact same type of surgery is far more likely to eliminate pain in people without such a history.

Next time you are sick, or under stress, or even when you’re not, take heed of the messages your mind is having about your body. As it turns out, an important part of taking care of our bodies involves getting to know our minds, and most importantly, nourishing the relationship between them.

I am a Licensed Psychologist who works with people who suffer from medical conditions and chronic pain. My office is in Conshohocken and I can be reached at (484) 534-8830. For more information please go to www.danlivney.com

Psychology and Medical Illness

A few years ago I was at a reception held at a restaurant, and I was sitting with some friends, several of whom were also psychologists. A husband of one approached, himself an educator, and seeing all of us therapists sitting together joked: “Someone just ate some of the soup and now she’s feeling sick… is there a doctor in the house?” To which, the table's resident smart alec quipped: “Not the useful kind.”

It was a good joke, and we all laughed. Of course, what he had meant was that none of us at that table had been trained in medicine and physiology, and we were not going to the ones best able to help this hypothetical person in that moment. When someone needs to get rushed to the ER, you don’t call a psychotherapist. So what is therapy good for? Is it, as some have asked me, “just talk?” Well, it can be. For some people just talking is something that can be useful in many ways and for many of life’s problems, as some of you already no doubt know or have some personal experience with. But what about when it comes to your health? If most people will agree that talk therapy can help with all kinds of relationship and emotional difficulties, what about when we’re sick or just worried about our health, or that of a loved one? Is it “useful” then?

A great deal of research says, “yes.” Studies have shown that depression and/or anxiety often accompanies major illnesses. This may not seem so surprising. When patients come down with the debilitating effects of conditions such as diabetes, coronary artery disease, cancer or COPD, it raises all kinds of difficult questions about the quality and the length of their lives. People who have these conditions often have to make adjustments to their lifestyles and their day to day activities in response to their symptoms. Major depression can play a role in decreasing their ability to make these adaptations, which leads to further impairment, and so, cyclically, to further depression. Certain illnesses can even mimic, or cause, symptoms of depression or anxiety; for instance, hypo- and hyperthyroidism, some forms of hepatitis, Alzheimer’s and Lyme disease.

But while depression can be the result of a feared diagnosis, it can also contribute to developing various medical conditions in the first place, and in can do so in a number of ways. People who are depressed are more prone to engage in a wide range of behaviors associated with medical illness such as smoking, excessive drinking, or having sedentary lifestyles. Depression can also result in nonadherence to prescribed medication regimens, and to diminished social functioning…all of which can frequently cycle into more depression.

Finally, depression and anxiety are strongly associated with stress, in all of the many complicated ways that modern life is heir to.  Physicians call this condition, “allostatic load,” which is just a way of saying that stress, when it occurs not just in brief periods but when it’s prolonged over the long term, causes all kinds of wear and tear on the body, such as impaired immunity, atherosclerosis, obesity, bone demineralization, and atrophy of nerve cells in the brain. Lastly, data also shows that when people are matched for similar medical conditions, but one group has depressive symptoms and one group does not; the depressed group incurred significantly higher medical costs to treat the exact same condition ($4,246 vs. $2,371 per year according to one study).


Now this really can change the answer to the question “what is the use of talk therapy?”

I am a Licensed Psychologist. Many of my patients are older adults, and while illness is not necessarily linked to aging, some of my patients also suffer from chronic pain and other physical ailments. My office is in Conshohocken and I can be reached at (484) 534-8830 or at dan.livney@gmail.com. For more information please go to www.danlivney.com