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Why Striving is a Distraction from Lasting Change.
Healthcare providers live in a world of measurable metrics where the idea of non-striving appears incompatible. Learn how this apparent paradox is driving racial and weight stigma.
Sitting in the Buddhist Center, I listened to the presenter explain the concept of non-striving. This thin young man talked about why focusing on the future distracts us from the present moment. He explained that basing our self-worth and identity on these temporary outcomes erodes our empathy and self-compassion.
There was a deeper truth swirling around the room that felt like an electric charge flowing through all of us. As a dietitian and diabetes educator, I wanted to share what I was learning with my clients. Healthcare providers live in a world of measurable metrics where the idea of non-striving appears incompatible. Yet, is it? How does striving feel different with the internet so prevalent in our lives? Does striving magnify other forms of stigma, including diabetes, weight, and racial stigma? What are possible solutions for people with diabetes who want to get off the treadmill of striving?
Fast forward to 2023, where I have been working in the field of diabetes for just under 30 years. In the last 25 years, I have been able to find words, research, and training to introduce the idea of non-striving as part of diabetes care, despite my requirement to create SMART Goals. The mnemonic represents Specific, Measurable, Achievable, Relevant, and Time-Bound (SMART), which are required parts of diabetes care.
I have experienced the disconnection of SMART goals when introduced, as required at the end of an appointment because they force clients to commit when the relationship hasn’t established sufficient trust. In short, clients feel controlled and manipulated.
Yet, when my client comes to a session, my intention isn’t for them to create a goal. It is for them to have the necessary space and grace to sort out their thoughts and feelings. This lack of a goal is the non-striving I learned about 25 years ago. It is different from trying to promote weight loss or to get a person with diabetes to eat less or more of anything, which is coercive.
The way I see it is my clients have a wealth of information at their fingertips but lack understanding, which fuels the sense of overwhelm. A former boss liked to remind me of this truth, “knowing what to do and doing it are two different things.” This truth is echoed by my clients, who share, “I know what to do, but I don’t know why.”
Knowing but not understanding creates a second problem: stigma. The stigma of ignorance is painful, and it is connected to isolation. Being ‘smart’ is viewed as a virtue, and if the internet has all the information, the sting of ignorance is even more painful. Adding to it is the way in which ignorance intersects with diabetes stigma. The CDC defines diabetes stigma as negative attitudes, judgment, discrimination, or prejudice against someone because of their diabetes, which comes from the false idea that those with diabetes made unhealthy food and lifestyle choices and doing so resulted in their diagnosis.
These two stigmas create feeling overwhelmed, resulting in most people pulling back and self-isolating. Why would clients go to a support group if they can learn about diabetes from a website? Why would they attend a diabetes class if an app would tell them what to do?
The book Together, by Surgeon General Vivek Murthy, MD, explains in detail the mental, physical, and societal problems isolation and loneliness cause. A CIGNA study found individuals with co-existing health issues are 50 percent more likely to experience feelings of loneliness. Loneliness goes hand-in-hand with other physical and mental health challenges. The same study estimates the cost to employers is more than $154 billion dollars due to absenteeism.
Frustration and Anger Aren’t Always Bad
Creating the space for reflection opens the door for doubt, frustration, and anger to enter. These strong emotions are hard to hold and can be offloaded during a session when clients share their fear by doubting their diagnosis or by being frustrated at their medical care, providers, or research. Their distress can exponentially increase when receiving the diagnosis of diabetes and then being asked to go online for additional instructions. To quote a client, “I sat there, incredulous, as my provider nonchalantly told me to be patient for three months until my labs were repeated!”
Patient interactions are dynamic and can’t be scripted. However, some problems also shouldn’t be ignored. If my White-bodied client is frustrated, what about my marginalized clients? Marginalized clients are holding a lot more than their diagnoses. They are also holding their feelings about the many systems supporting oppression. Medically, this term is called “Weathering.” In the book of the same name, Dr. Arline Geronimus explains racial stress physically impacts marginalized bodies, increasing the risk of diabetes, hypertension, and heart disease.
Bob’s smile was big and white, and he walked with a contagious joy. As we talked, his facial expression never changed, and it was my cue that Bob, a young Black man from the South, was masking his true feelings to get ‘better care.’ Racial masking refers to how marginalized folks hide their true feelings to keep white bodies emotionally regulated. Bob had learned that white-bodies typically don’t have the emotional strength to hear him fully.
At a recent training, Resmaa Menakem, LCSW, reminded participants, “The charge enters the room before the words do.” My two years attending Resmaa’s program exposed me to how racism impacts diabetes care. I can better see that strong emotions are hard to come alongside if the assumption is these emotions are ‘bad’ instead of present. I also see how feelings come from many places, including Bob’s past experiences. They are not required to be paced, ordered, or logical. In fact, PWD (people with diabetes) may offload their most painful feelings and deepest wishes simultaneously. Feelings, desires, and possible actions are mixed together in a tumble.
Striving for Balance
Clients are reluctant to tell their stories because they have learned masking their feelings about diabetes, health, societal weight, and racial oppression are required to receive good medical care. Trust allows clients to be honest and to let their fears be seen. It isn’t something given; it is something earned. This is why it is helpful to have space and grace for clients to create their own learning needs assessment. At a session, I will typically point to the poster of The Four Factors of Diabetes Care and ask open-ended questions to learn what levers can be adjusted to find a greater sense of balance.
As trust increases in a session, many clients have shared that 'unless' they lose weight, their efforts to improve their health are devalued. It is clear that their personal story of self-worth is connected to weight. When our clients stop focusing on what they weigh (which is striving) and instead look for balance in their lives - WITH DIABETES, the pressure of expectation decreases. They aren’t trying to please their provider or be ‘good.’
In mindfulness, there is an intention shift from striving for achievement to awareness of the present moment. It isn’t to say having a goal is wrong. It is saying without an assessment of what is present, we can’t create an effective goal. Craving is a human experience, and it is normal to want things (good diabetes care, diet, health, or a specific weight) to be different. Unfortunately, craving has become the tool to pole vault over the only place change can happen – the present moment.
So, what can healthcare professionals become aware of? It must be the charge Resmaa spoke of that entered the room before words or understanding did. Striving creates an emotional bypass that allows clients to ignore their feelings. Yet, the more this charge is ignored, the bigger their feelings become, and the more out of balance our clients feel. Striving is a future-focused thought that pulls us away from the present moment.
A person recently diagnosed with diabetes is likely already distracted by the flood of emotions upon hearing the news. They are navigating past decisions, efforts, and perceived failures. If a healthcare professional lacks the capacity to be present with the emotional charge that proceeds to our client, it makes sense to focus on goal formation.
Focusing on goals (i.e., what a client is expected to do) completely ignores the pain the person before us is experiencing. This reality forces the counseling session to no longer focus on the person with diabetes; it is NOW centered on the expectations of that person.
If the PWD is overwhelmed, they are now required to mask emotionally. If a PWD can’t mask any longer, the flood of charged and painful feelings can be easily misinterpreted, fueling white-thin-bodied fears and reinforcing racial/sized-based stereotypes.
When diabetes education lacks holding space and grace during our appointments, no one will experience a sense of balance. Emotionally overwhelmed clients will offload their feelings, creating emotionally overwhelmed professionals. This ineffective cycle drives isolation at every level of healthcare, which, as stated, is estimated to cost over 154 billion in lost productivity.