HEAT and Containment

High-risk diabetes often makes more sense when we ask not only what a person is doing with their diabetes, but what is happening to the emotional and relational system around it.

We use HEAT as a way of thinking about this.

Diabetes can itself become emotionally hot

For some people, bringing diabetes into mind evokes powerful feelings: fear, shame, anger, grief, frustration, helplessness or resentment. The demands of diabetes may simply become too difficult to think about.

One way of reducing this affective HEAT is to put diabetes out of mind: not checking glucose, avoiding appointments, taking insulin intermittently, or trying not to think about what might happen.

This may reduce emotional pressure in the short term. But the diabetes itself becomes more dangerous.

The heat may be somewhere else

Sometimes diabetes is not the hottest thing in the person's life.

Bereavement, relationships, housing, trauma, depression, substance use, financial difficulties or conflict with services may generate much greater immediate emotional pressure.

As more of the person's capacity is required to manage this other problem, there may be less capacity available for diabetes.

Diabetes can then deteriorate almost in the background.

The hottest problem in the system may not be diabetes, but diabetes may be where the system eventually boils over.

Heat can move

When increasing emotional and medical risk can no longer be contained by the person, the HEAT often moves outwards.

A parent becomes frightened. The diabetes team starts chasing appointments. Emergency departments repeatedly rescue someone from DKA or severe hypoglycaemia. Different services become increasingly worried. Clinicians may disagree about responsibility or about how much risk can safely be tolerated.

The problem is no longer located simply within an individual. The whole person–diabetes–care system has become hot.

This is one reason why high-risk diabetes requires more than simply telling someone what they need to do differently.

Containing HEAT

An important function of diabetes psychiatry is to help make diabetes thinkable and manageable again.

Sometimes this means helping someone understand and tolerate their feelings about diabetes. Sometimes it means treating depression, psychosis, trauma or an eating disorder. Sometimes the immediate intervention is practical: housing, benefits, family work, changing an appointment, or going to someone's home.

And sometimes the psychiatrist or wider diabetes team temporarily needs to carry more of the thinking and responsibility for diabetes while the person is unable to do so themselves.

At the most severe end, the question may become whether someone currently has the capacity to make a particular decision about their treatment, whether medical risk can continue to be managed outside hospital, or whether mental health legislation needs to be considered.

These are not separate from the psychotherapeutic model. They are different levels of containment within the same clinical system.

Finding the lever

HEAT therefore gives us a practical set of questions:

Where is the HEAT?

What is generating it?

Who is currently carrying it?

What is it doing to the person's diabetes?

What could change the current situation?

That final question leads to what we call the lever: the specific psychological, medical, relational, practical or systemic intervention most likely to shift the person's current equilibrium.

The lever may be small. But if it is the right lever, it can make diabetes sufficiently tolerable to think about again — and create the possibility of appreciable change in diabetes behaviour and physical health.