Clinical Model
Integrating diabetes medicine, psychiatry and psychotherapy within a single clinical formulation
Diabetes psychiatry requires more than placing mental-health treatment alongside diabetes care.
The clinical task is to understand how the person's diabetes, psychological life and circumstances interact sufficiently well to identify something that can change.
1. Start with the outcome
What needs explaining?
Recurrent DKA?
Persistent severe hyperglycaemia?
Severe hypoglycaemia?
Insulin restriction?
Another high-risk trajectory?
Start with the physical-health problem rather than assuming its psychological explanation.
2. Understand the diabetes
Know enough diabetes medicine to understand what is actually happening.
This may include insulin treatment, glucose patterns, CGM, HbA1c trajectory, DKA, hypoglycaemia, renal function, albuminuria, retinopathy, other complications and previous diabetes interventions.
Most importantly:
What does the person actually do with their diabetes treatment?
The prescribed regimen and the person's diabetes behaviour may be very different things.
3. Understand the person
Conduct a proper psychiatric assessment.
Understand mood, anxiety, trauma, eating, substances, personality functioning, neurodevelopment, cognition, self-harm and suicidality where relevant.
But diagnosis alone is rarely sufficient.
Ask:
What happens to diabetes when this person's mental state changes?
4. Understand the person psychotherapeutically
How does this person manage difficult affect?
What happens with dependency, shame, anger, loss, trust and relationships?
How do they respond when they need help?
What happens in the clinical relationship when difficult material appears?
These are not separate from diabetes care if the same processes shape insulin use, monitoring, attendance or help-seeking.
5. Understand the relationship with diabetes
People do not simply have diabetes.
They also have a relationship with it.
Useful questions include:
Who or what is diabetes to you?
Where does diabetes live?
How often do you visit it — or does it visit you?
What happens when you think about diabetes?
What does insulin mean to you?
Diabetes may be experienced as intrusive, frightening, shameful, burdensome, punitive, hated or something best kept at a distance.
The question is not whether this relationship is right or wrong.
It is:
How does this person's relationship with diabetes affect their ability to care for it?
6. HEAT
Diabetes can become emotionally too “hot” to think about. But the HEAT does not always originate in diabetes: bereavement, relationships, housing, trauma or mental illness may consume the person's capacity to manage it.
When that HEAT cannot be contained within the person, it may move into the wider system — family members become frightened, clinicians become increasingly concerned, services become reactive, and medical risk escalates.
PCMHRD asks not only “How much HEAT is there?” but “Where is the HEAT, what is generating it, and who is currently carrying it?” This helps identify the intervention — or lever — most likely to make diabetes thinkable and manageable again.
HEAT & Containment explores this idea in more depth.
7. Understand what the behaviour is doing
Do not stop at:
“They don't take their insulin.”
That describes behaviour. It does not explain it.
Insulin omission might relate to depression, hopelessness, avoidance, an eating disorder, executive dysfunction, substances, interpersonal crisis, fear, self-destruction, suicidal intent or something else entirely.
Ask:
Why is this behaviour happening, and what does it do for this person?
Self-destructive behaviour is not synonymous with suicidal behaviour.
Understanding function is part of understanding risk.
8. Integrate
Avoid parallel formulations:
Diabetes: poorly controlled
Psychiatry: depressed
Psychology: avoidant
Social: housing problems
Instead ask:
What is happening to this person, and how is it producing this diabetes outcome?
A useful formulation connects:
PERSON / SITUATION
↓
THOUGHT / AFFECT / MENTAL STATE
↓
RESPONSE
↓
CHANGE IN DIABETES BEHAVIOUR
↓
PHYSICAL-HEALTH OUTCOME
The formulation should explain the observed trajectory.
9. Find the lever
Formulation should lead to intervention.
Ask:
If I could change one thing in this system, which change would make safer diabetes care more possible?
The lever may be medical, psychiatric, psychotherapeutic, practical, relational or systemic.
It does not have to solve everything.
It needs to move something that matters.
10. Act
Sometimes the intervention is medication.
Sometimes psychotherapy.
Sometimes basal insulin.
Sometimes treatment for ADHD, depression, an eating disorder or substance use.
Sometimes CGM or regimen simplification.
Sometimes a housing letter, benefits intervention, family meeting or different crisis plan.
Sometimes the clinician needs to obtain additional specialist expertise.
Before concluding that a problem belongs elsewhere, ask:
Is there something useful I can do?
11. Stay involved
High-risk diabetes trajectories often develop over years.
Continuity provides something that repeated assessment and referral cannot: the opportunity to observe whether a formulation remains true over time.
The principle is:
Add expertise without unnecessarily transferring ownership.
12. Look for appreciable change
The immediate target does not have to be perfect diabetes management.
Look for a change that is:
small enough to be achievable
and
important enough to alter risk.
Reliable basal insulin.
Earlier help-seeking.
Using CGM.
Taking treatment for depression.
Reducing insulin restriction.
Allowing diabetes to remain in mind for longer.
Resolving a major practical problem.
13. Return to the physical-health outcome
Did DKA recur?
Did HbA1c change?
Did severe hypoglycaemia decrease?
Did emergency or hospital use change?
The physical-health outcome provides one test of the formulation.
If the expected change does not happen:
Become curious again.
The formulation may need to change.
The clinical method
Understand the diabetes.
Understand the person.
Bring the two together.
Find something that can change.
Act.
See what happens.