The Lever

Finding what can change the system

People living with high-risk diabetes often have many problems.

The challenge is not simply identifying all of them.

It is identifying what can be changed that might actually alter the person's current trajectory.

We call this finding the lever.

Not every problem is the lever

A conventional assessment may generate a long list: depression, diabetes distress, missed insulin, housing difficulties, family conflict, substance use, financial problems, trauma, difficulties attending appointments.

All may be true.

But treating everything simultaneously is rarely possible, and the most obvious problem is not necessarily the one that is maintaining the current situation.

We therefore suggest a different question:

“What could we change that would make other change possible?”

That is the lever.

Levers can be psychological — but they do not have to be

Sometimes the lever is recognisably psychiatric: treating depression, addressing an eating disorder, reducing substance use, understanding trauma, or helping someone regulate overwhelming affect.

Sometimes it is directly related to diabetes: establishing reliable basal insulin, simplifying a regimen, introducing appropriate technology or helping someone tolerate looking at their glucose again.

But sometimes the lever is practical or relational.

It may be resolving a housing problem.

Helping someone obtain appropriate benefits.

Repairing communication between services.

Changing who attends an appointment.

Working with a family member.

Making a home visit.

Or simply establishing a sufficiently reliable relationship with one clinician that the person begins to return.

These are not peripheral activities surrounding the “real” psychological treatment.

If changing them alters the system maintaining dangerous diabetes, they are part of the treatment.

The lever may change

High-risk diabetes is dynamic.

An intervention that matters at the beginning of treatment may become less important six months later. A new relationship, bereavement, admission to hospital, deterioration in physical health or change in housing can alter the person's equilibrium.

We are therefore repeatedly asking:

What is maintaining the situation now?

and:

Where is there currently enough movement available to make a difference?

This makes treatment iterative rather than protocol-driven.

Small changes can have large effects

A lever does not necessarily produce dramatic transformation.

Someone experiencing recurrent DKA may begin taking long-acting insulin more reliably.

Someone with extreme hyperglycaemia may start looking at their glucose once each day.

Someone who repeatedly disappears from services may begin attending one appointment each month.

These changes can appear modest when compared with ideal diabetes management.

But in a person at very high risk, a strategically important change can produce a disproportionate improvement in physical health.

The aim is therefore not immediate perfection.

It is to identify the smallest meaningful change capable of shifting the current equilibrium.

Once the system moves, another lever may become available.

And this leads to an important principle of Diabetes Psychiatry:

Treatment should be judged not only by whether somebody reaches an ideal outcome, but by whether we have achieved appreciable change.