National Standards for Diabetes Self-Management Education

Response to Shiu

Thank you for the opportunity to respond to the article (1) by Shiu. We have never referred to empowerment as a theory because we view it as more holistic and more fundamental than most behavioral theories. The empowerment approach is more holistic because it takes into account the fact that clinician-patient interactions are dynamic. Therefore, the empowerment approach also focuses on the important role of the purposes, values, and interpersonal skills of the diabetes educator in achieving a therapeutic alliance as well as on the behavior of patients (2). It was established some time ago in psychotherapy and education research literature that the interpersonal skills of the counselor or educator affected outcomes more than the theoretical approach they used (3,4). Clinicians can feel and express compassion, empathy, and warmth. They can establish relationships with patients that are characterized by trust, respect, and acceptance. Such therapeutic alliances facilitate high levels of patient candor and self-disclosure, laying the groundwork for growth and behavior change (3). Most current behavior change theories focus solely on the behavior of patients, as if diabetes educators/clinicians are interchangeable cogs in a wheel. Empowerment is more fundamental than theory because we have observed that the goal of the clinician applying a theory affects in significant ways how it will be applied and the outcomes it will produce. The goal of the traditional approach to behavior change is to “get” patients to comply with the clinician’s recommendations (5). The goal of the empowerment approach is to enable patients to make informed decisions that are consistent with their priorities and health goals (2).

If an educator’s/clinician’s purpose is to help patients make informed decisions, a variety of behavioral theories can be used to achieve that goal. This fact is nicely illustrated by Shiu’s letter. In our empowerment research, we use the autonomy motivation/self-determination theory as the conceptual basis of our interventions because it is consistent with our patient empowerment approach (6). Further research is needed to determine if one particular theory will prove superior for operationalizing the empowerment philosophy. Evidence-based theories are necessary and useful tools in diabetes education. However, the interpersonal skills and purposes of the person using those tools to facilitate behavior will have a significant impact on the outcomes produced (7).