It’s no secret that people with diabetes are prone to depression and mental health issues, but historically these issues have been categorically ignored.
Even now in 2020, the psychosocial aspects of life with diabetes are not adequately addressed by healthcare professionals, and/or many patients don’t feel comfortable asking for help even when they need it most. Or help is just too hard to come by.
All of this is why longtime type 1 Adam Brown, well known by many in the diabetes community for his technology-focused work at diaTribe and Close Concerns over the past decade, is pivoting his career to become a mental health provider for people with diabetes.
As he pursues his new degree and licensing, Adam is staying involved in diabetes technology through part-time work with Tidepool, the nonprofit now building a next-generation automated insulin delivery system known as Tidepool Loop.
We talked with Adam recently about his experience and why he’s decided to devote himself to addressing mental health for people with diabetes.
DM: Hey Adam, let’s start with what you’ve observed about how mental health care is currently working (or not) for people with diabetes?
One thing that has surprised me is the difference in “dosage.” A standard appointment in mental health is 50 minutes long. Brief therapy might be six or 10 or 12 sessions. So if you get 50 minutes each session, that might be 10 hours of face-to-face time in “brief” therapy. But in the diabetes world, to get that amount of time with a healthcare provider might take ten years! That’s a staggering difference — even in brief therapy, clients get much more one-on-one attention compared to what we get in diabetes.
The trade off to that is access; if a therapist is meeting with people for 50 minutes at a time, they might be able to see 25 or 30 clients a week at the max. That means any one provider can’t reach too many people at one time. I’m really interested in exploring how we can scale mental health treatment in a way that maintains the personal touch, but also lets you reach more people.
Yes! Another nuance is insurance and how it often doesn’t cover mental health very well. For a healthcare provider, there is a process to getting on an insurance panel, and it may add some administrative burden to make insurance claims. For some therapists, the only way to make it work financially is to focus on cash-pay (i.e., non-insurance), which ends up meaning that a lot of people can’t afford the care. And yet, so many people could benefit from mental healthcare!
We need to figure out how to get it into their hands. In some ways, it’s a strange situation, where everyone agrees that mental health is so super important and that therapy is helpful, but not enough people have access to it. We must do better!
What does the study path look like for becoming a mental health professional?
You need to get licensed first as a clinician in your state. I’m doing a two-year master’s in counseling psychology. That allows me to get one of two licenses:
- Licensed Marriage and Family Therapist (LMFT) provides general counseling on social issues for individuals, couples or families.
- Licensed Professional Clinical Counselor (LPCC) focuses on treatment and counseling for those with mental health and substance abuse issues. This credential is actually more common outside of California.
In addition to school, you must accrue a total of 3,000 clinical hours to be licensed in California. From where I sit now — six months in — it will still be a couple years until I get licensed and can see patients on my own.
I’m also doing a weekend program — which is its own level of insanity — in part because school is expensive and it’s nice to have an income while I’m studying. It’s one night per week, and then once a month I have a class over three days stretching over 20 hours. We basically cover half a semester in one weekend. I love it but it is a full load!
Did you always aspire to become a healthcare provider?
Yes, I do think it’s always been kicking around in my mind. Working in diabetes, I’ve always been interested in behaviors and mental health. And I have always thought it would be awesome to be a healthcare provider, as it would be something I would really enjoy.
What was a real turning point for me came about 18 months ago, when I experienced and then wrote about having my appendix rupture. When I was sitting in the hospital recovering, away from the grind of everything, I found myself wondering where I wanted to be in a few years. Quickly after that, I started interviewing diabetes psychologists about their advice on going in this direction. They were all supportive and strongly encouraged me!
Is there a special credential for mental health experts focusing on diabetes?
Not specifically, but in 2017, the American Psychological Association (APA) and American Diabetes Association (ADA) teamed up to train psychologists to work effectively with people with diabetes.
These organizations underscore the critical need for more psychologists trained to treat diabetes.
Let’s back up for a moment to how you got here. Can you share your personal diabetes journey?
I was diagnosed at 12 and had a somewhat typical teenage experience. I did my best on fingersticks and injections. As the oldest of six kids, I took on most of my own care immediately.
That colors my views and comes back full circle later on how I approach diabetes. Like many teens, I maintained an A1C in the 8 to 9 percent range, only filled out my logbooks right before a doctor’s appointment, and wasn’t that diligent about data because it was so burdensome. In college, a few turning points happened:
- A roommate was a bodybuilder and intensely disciplined, so that had an impact on me becoming more methodical about exercise and nutrition.
- I took a bunch of nutrition classes in college, which I think gave me an appreciation for what a powerful diabetes tool that food can be.
- I started as an intern at diaTribe in my junior year of college, got introduced to this whole industry, began going to conferences and writing about diabetes.
- It was at a conference during my summer internship that I first heard about continuous glucose monitoring (CGM). I was so impressed, that I went to the lobby of the hotel after a panel discussion and called Dexcom to order the (then-newest) Seven Plus model. I’ve been wearing a CGM ever since. That was so transformative for me. I’m a geek about these sorts of things, because I enjoyed numbers and data and taking a more quantified self-approach to diabetes. It helped me figure out what worked for me.
Those all helped turn things around for me and made managing diabetes easier for me.
Tell us about your decade of work with Close Concerns/diaTribe?
At the time I joined as a summer intern, helping contribute to diaTribe and Close Concerns. I joined Close Concerns full-time in 2011 after graduating from college.
I was lucky to be in Close Concerns’ two-year associate’s program, and then stayed on and led diabetes technology writing through the end of 2019. What a marvelous journey it was!
My role at diaTribe grew to editing each issue, writing my own column, Adam’s Corner, and eventually publishing a book.
Do any highlights come to mind?
There are so many highlights! Some that stand out are:
- Covering all-things diabetes technology from 2010 to 2019 — moving from blood glucose meters to CGM, from manual to more automated insulin dosing, from locked-down medical devices to smartphone apps, from cables to wireless, etc.! At so many points, things seemed impossible (e.g., CGM data on a smartphone app) until they became possible and then the standard.
- Advocating at the Food and Drug Administration (FDA) to get CGM approved for insulin dosing — ultimately paving the way for Medicare coverage of CGM! People still tell me they remember the plane analogy presentation I shared.
- Accelerating the Beyond A1C movement with many presentations and articles over the past few years (e.g., here and here), along with continuously advocating at the FDA for recognition of time in range (TIR).
- Getting to meet people with diabetes at conferences like ADA, AADE, Friends for Life, the DiabetesMine Innovation forums, local JDRF events, and beyond! It has been such a joy and privilege to spend time with so many amazing people who are so committed to improving life with diabetes.
Did that work pave the way toward a career shift?
Yes, it did. I actually feel what’s underneath all of those things is mental health. Overall, what is the context of your life in terms of the tools we apply to diabetes management? Mental health is a lot about understanding context in people’s lives — everything from how you were parented growing up, to the community you live in now and what you can afford and access.
Most of the first part of my career in diabetes was understanding the tools. Now, I’m learning to understand the context behind all of that and how to apply it to life with diabetes.
How does this tie back in to all the new diabetes technology coming out?
One of the big picture views I’ve been thinking a lot about is the nuanced difference between tools and context. The diabetes field is really good about developing tools and talking about how we make them better. But because understanding the context of every person’s life takes a lot of time and is more difficult to design for, and there’s not a lot of clinical time spent trying to understand all those factors.
In the first part of my career, I got really good at going to these conferences and looking at the technology, products, and data. I also felt there was an “echo chamber” or “bubble” type of effect happening — too much focus on tools, too many opinions from the same people, and not nearly enough focus on the contextual aspects that are really important in understanding people’s lives with diabetes. Everything from race, socioeconomic class, trauma history, family, community, and so much more that we must better understand better to help people with diabetes.
Why do you think therapy has so much potential to help?
In my application to get into school, I wrote about how I’ve been lucky to reach the diabetes community at scale. Writing and presenting is an amazing way to talk to many people at once — but it’s often a one-way communication. In this next phase, I’m trying to learn best practices for helping people one-to-one or in a small group setting — and to have that flow of conversation and build a relationship between two people. I think both skill sets are important.
In the therapy world, there are a lot of tools for dealing with thought patterns, stress and strong emotions, coping with unpredictability, family communication, and beyond. So much of it applies to diabetes!
Behavior change is such a key component of mental health in the diabetes space, isn’t it?
Yes, an important piece is how you help people change, understand patterns, and get insight into ourselves.
I tend to look at CGM as a behavior change tool, probably more than many people do. It’s a decision-making aid. Mental health and psychotherapy have a lot to say about how you help people change who might be struggling. I wanted to learn more about that, and ultimately be able to be a healthcare provider in that area one day. This seemed like the best route to do so.
Have you had to dig into your own headspace much, starting out in mental health?
Yes, part of becoming a therapist is that you also have to cross into your own life and baggage, the things that have happened to you and looking at your own responses to things. My program strongly recommends that all of us be in therapy ourselves.
And a lot of the program is about understanding where you come from and what makes you uncomfortable, and working through that to help clients as much as possible.
And on the side, you’re helping develop new automated insulin delivery (AID) technology?
Yes, I am also helping Tidepool on their future Tidepool Loop project. I’m part-time there and working on Market Access, as in: How do we get Tidepool Loop into as many hands as possible?
I believe Tidepool is unique in how it’s building on the work of the DIY (do it yourself) and #WeAreNotWaiting community — let’s take this amazing thing that has helped several thousand people and get it through the FDA to help even more people. That involves working with in-warranty diabetes devices, so people can be using devices we’re familiar with and that are supported.
I have been Looping for a while myself and love it. What I love even more is this interoperable vision — all these different devices working together through one app!
Let’s not forget that you’re also an accomplished author of the popular diabetes book, ‘Bright Spots and Landmines.’ What has the reaction to that been like?
It has been powerful and moving in so many ways. I’ve heard thousands of stories through emails, reviews, and in-person conversations — they are inspiring, surprising, joyous, emotional, and (sometimes) even infuriating. We’ve heard about 1 percent to 3 percent A1C reductions, hours more time in range per day, 20+ pounds of weight loss, reductions in medication, massive improvements in stress and diabetes outlook, and more. I still cannot believe it. I’m also incredibly proud that we made the book available for free in PDF and audiobook forms, because cost should not be a barrier to learning.
To this day, I remain completely wowed when someone says, “Your book changed my life.” I often reply, “Really?! What did you find useful?” Then, I often get to hear their diabetes story with all its twists and turns. This is why I love reading emails from readers — they remind me of the impact, but they are also incredible teachers. We might share a diagnosis and benefit from similar tips, but our lives are complicated and diverse and ever-changing.
From an 18-month-old to an 86-year-old, no one diabetes is exactly the same, in my opinion. Even with the book reaching so many people, I still feel like I have a lot to learn!
Thanks so much for taking the time to chat, Adam. We are so proud of you, and excited to witness your new path. Make sure to also read Adam’s “goodbye column” over at diaTribe.