Original Article

Yonago Acta medica 2016;59:81–88

A Qualitative Study of Confusing Experiences among Japanese Adult Patientswith Type 1 Diabetes
Ikuko Nishio, Masami Chujo and Hideyuki Kataoka

Department of Adult and Elderly Nursing, School of Health Science, Tottori University Faculty of Medicine, Yonago 683-8503, Japan

ABSTRACT

Key words confusion; experience; powerlessness; type

Background1 diabetes

Corresponding author: Ikuko Nishio
ikurin@med.tottori-u.ac.jp
Received 2015 December 18
Accepted 2016 January 22
Abbreviation: T1D, type 1 diabetes

Diabetes is a common life-long health condition. Diabetes is classified as Type 1 or Type 2. In type 1 diabetes(T1D), pancreatic beta cells are destroyed, resulting in
low insulin secretion and leading to a state of absolute
insulin deficiency. According to the Ministry of Health,
Labor and Welfare, approximately 8,000 people in Japan
currently suffer from this condition, which often develops during childhood or adolescence. T1D is characterized by deficient insulin production and requires daily
insulin administration.1 Therefore, patients with T1D
require lifelong self-care, including daily management of
their blood glucose levels, to maintain their health andprevent future complications. They also must suitably
modify their behavior after diagnosis, since it is important that they learn to self-manage their condition.
Good self-managers have been defined as individuals who have learned the skills required to cope with
their illness, knowing how to continue with their daily
activities, and being able to regulate the ever-changing
emotions related to their chronic illness.2 For patientswith T1D, self-management can be difficult because theyexperience physical, emotional, and social distress andoften need to communicate about these issues with coworkers and supporters.3 Although some T1D patients
excel in managing their distress, others struggle to do so.
This phenomenon is evident across academic, social, anddevelopmental domains. When T1D patients are facedwith difficulties, they often perceive their own lack of
power. To recover from this state of powerlessness, theymust take steps to regain their power.4 Powerlessness
was defined as the perception where one lacks the capacity or authority to act to affect the outcome of the current
situation or immediate circumstances,5 and NANDAI describes the feeling of powerlessness as “The lived
experience of lack of control over a situation, including
a perception that one’s actions do not significantly affectan outcome.”6 Gibson reported that in order for patientsto become empowered, they must understand the factors
underlying their own powerlessness.7 However, very few
studies of powerlessness have been conducted, and thepapers published to date only consider the phenomenon
from the perspective of patients’ subjective experiences

In this study, we investigated the powerlessness of patients with type 1 diabetes (T1D), anddescribed the structure of powerlessness that these individuals experienced. In order for patients to recover fromthis state, we recommend that they take steps to regain
their power.
Methods Fifteen Japanese adults with T1D participated in this study. Data were collected from all subjects
between July 2013 and March 2014 via in-depth semistructured interviews. Qualitative data analysis was
conducted according to a grounded theory approach.
Finally, the core category was identified, which allowed
us to build a new powerlessness structure for T1D.
Results The results suggested a core category, ‘Wandering a tangled path,’ comprising four categories, eightsubcategories, and twenty-six concepts. These four
categories were as follows: ‘being burdened by T1D,’‘suffering from insulin-related troubles,’ ‘being unable
to cope with difficulties in self-management,’ and ‘facing
social prejudice.’ In the state of powerlessness, negative
emotional experiences snowballed, with patients feelingmore and more depressed until they ultimately reached‘rock bottom.’Conclusion We found that as negative emotional experiences related to powerlessness increased, negative
feelings intensified until the patients reached rock bottom. Powerlessness is like ‘wandering a tangled path,’ astate in which T1D patients struggle to cope with reality
on their own when faced with both internal and external
events. ‘Wandering a tangled path’ is at the core of powerlessness. A primary characteristic of the structure of
powerlessness is suffering from confusing experiences.
To help patients cope with T1D without being crushed
by powerlessness, nurses must pay attention to signs of
powerlessness. Powerlessness is not just an emotional
state, but a combination of feelings, perceptions, andthoughts; therefore, it is important to comprehensively
understand patients’ narratives.

81

I. Nishio et al.

and do not examine the inherent nature of powerlessness.8, 9
Many studies have attempted to understand the psychology of T1D patients from the perspective of medical
professionals. However, it is also important to understand patients’ experiences from an internal perspective.
Therefore, in this study, we sought to shed light on thenature of powerlessness in the experiences of T1D patients, who lead lives with various constraints, as well as
the structure of powerlessness. This elucidation of powerlessness should be of great value in identifying effective nursing support, which empowers T1D patients andhelps them recuperate and improve their personal lives.

pants, additional recruitment relied on recommendations
from a doctor who specializes in diabetes. The detailsof the study were explained to all clinic patients, whowere then invited to participate; interested patients who
agreed to participate contacted the researchers for further information.
Data collection

Data were collected from fifteen patients with T1D
between July 2013 and March 2014 via in-depth semistructured interviews that took place in clinic waiting
rooms. One of the authors conducted all interviews. Participants were asked to share their experiences since being diagnosed with T1D, including difficulties, pain andhelplessness related to T1D in their daily lives, perception of difficulty in self-management and diabetes control issues, the significance of living with diabetes, andsupport from family and friends. The participants were
initially informed of the topics and were then asked tofreely reflect on and discuss their experiences of livingwith T1D. The researchers were careful not to ask leading questions in order to obtain particular answers.
Follow-up questions were posed to obtain more detailed descriptions or explanations. The interviews (which
each lasted for 60–75 minutes) were audio-recorded,transcribed verbatim, and stored for analysis.

SUBJECTS AND METHODS
Study aim

The purpose of this study was to elucidate the powerlessness (i.e., the state in which an individual perceives alack of personal control over certain events or situations
that affects outlook, goals, and lifestyle) of patients with
T1D, and to describe the structure of powerlessness experienced by T1D patients.
DesignTo ascertain the structure of the process underlying
powerlessness in adults with T1D, we used the groundedtheory method because it focuses on exploring processes
and understanding them in a new way based on available data.10 The process of generating grounded theory
involves systematic collection of data through field observations, interviews, meetings, and inspection of documentation where appropriate and possible.
This approach was suitable because it allowed us to
use the participants’ own words to understand the effects
of a T1D diagnosis on the meaning of powerlessness.

Ethical considerations

This study was approved by the ethics committee of
Tottori University (Record Number 2307, January 2013).
Informed consent was obtained from all patients using
the procedure approved by the ethics committee, and theconfidentiality of the participants’ information was protected. Furthermore, patients were told that they could
stop the interview at any time they wished and could
refuse to answer any unwanted questions. Pseudonyms
were allocated to all patients to ensure confidentiality,
and all data were stored securely during the research
process.

Participants

Inclusion criteria were as follows: being a Japanese
speaker, diagnosis of T1D, and age ≥ 20 years. All
participants resided in Tottori Prefecture, Japan, andwere recruited from two diabetes outpatient clinics thatspecifically serve adults with T1D. All patients wererecruited from the short-term wards of these clinics. Approximately 5% of patients who visit these wards havea diagnosis of T1D with symptoms of hypo- or hyperglycemia, and nurses in these wards provide self-caremanagement and group therapy with the ultimate goal ofdischarging the patient. We recruited 15 individuals with
T1D who were recommended by health professionals,
and whose reactions, behaviors, and facial expressions
were observed before conducting the study. Because it
was difficult to identify appropriate and willing partici-

Data analysis

The qualitative data analysis was conducted according toa grounded theory approach.10, 11 The grounded theory
approach is the way established by a qualitative study. In
each interview, the first author listened to the interview
tape several times and read the typed transcripts in their
entirety, ensuring a full understanding of the raw data.
The verbatim translations were then coded and analyzed
in the same manner as the interview transcripts.12 QSR
NVivo 10 software was used to sort and retrieve datafrom the interviews. All transcripts were translated into
English and subjected to the same coding and analysis
82

Confusing experiences with adult T1D patientsprocess as the Japanese interview transcripts; the results
did not differ from those obtained from the Japaneselanguage analysis. The next step was line-by-line in vivo
coding. The codes were then compared to identify differences and similarities, and then sorted into categories
and subcategories.13 Subsequently, we identified linkages
among these categories, subcategories, and concepts.
This process of immersion in the data is typical for
analysis of grounded theory approach, and improves thetrustworthiness of qualitative studies.
Finally, the core category was identified, whichallowed us to build a new powerlessness structure for
T1D. The structure is the connection of words to words.
In other words, the core category (i.e., the category towhich all other subcategories are related) was labeled
and used to build a conceptual framework of powerlessness in adult T1D patients. The core category was established upon completion of the 15th interview. We repeatedly compared the raw data with theoretical sampling,leading to a gradual focusing of the theory. Once thecentral category had been conceptualized, the raw data
and resultant analytical memos, codes, and categories
were re-examined to validate and explore.

Table 1. Demographic characteristic of the 15 study
participants with type 1 diabetes
Participant characteristics
GenderFemaleMale
Employment status
Full time
Part time
UnemployedAge groups (years old)
20–30
31–40
41–50
51–60
> 60
Time living with Type 1 diabetes (years)
<5
6–10
1–20
> 21
Living
Alone
Cohabiting†HbA1c (NGSP) (%)
Insulin therapy
MDI
CSII

RESULTS
Table 1 shows study participants’ basic attributes. Table
2 shows an outline of the concepts, subcategories, categories and core category. The core category, identified as‘wandering a tangled path,’ comprised four categories,
eight subcategories, and twenty-six concepts.
Hereafter, categories, subcategories and concepts
will be denoted within quotation marks. Our investigation into the phenomenon of powerlessness in T1D
patients revealed that they experienced ‘wandering atangled path.’ This powerlessness comprised four categories including ‘being burdened by T1D,’ ‘sufferingfrom insulin-related troubles,’ ‘being unable to copewith difficulties in self-management,’ and ‘facing social
prejudice’. A schematic description of the theory is presented in Figure 1. Patients find it difficult to decide theirown path, and move back and forth among these four
experiences (Fig. 1). In the state of powerlessness, negative emotional experiences snowballed, with patientsfeeling more and more depressed until they ultimately
reached ‘rock bottom.’

n
13
2
7
3
5
1
7
3
2
2
8
6
0
1
6
9
5.3–9.0 (7.1 ± 1.1)
12
3

†glycated hemoglobin.
CSII, continuous subcutaneous insulin infusion; MDI, multiple
daily injection; NGSP, National Glycohemoglobin Standardization
Program.

pointment and powerlessness, such as “I don’t feel liketrying,” “I have a negative image of T1D,” and “I can’t
accept having T1D” resulting from the need to strictly
maintain a stable blood glucose level via insulin therapy
starting from the time of diagnosis:“You know there is nothing I can do about this. It
was beyond my control (that I got T1D).” (Participant O)‘Facing the reality of T1D’ is associated with themindset that the patient will never be cured despite continuing to take insulin injections, which was expressed
as follows: “even though I need long-term care, I will
not recover before I die.” In regard to insulin injections,patients stated that “taking injections makes me realizethat I am sick” and “the pain and scars from the injections do not go away,” which forced them to face thereality that they had T1D:

Category 1: Being burdened by Type 1 diabetesThis category comprises two subcategories, ‘feeling
resistance toward T1D’ and ‘facing the reality of T1D.’‘Feeling resistance toward T1D’ is associated with sentiments such as “I can’t believe that I developed T1D” following diagnosis. These in turn trigger feelings of disap83

I. Nishio et al.
Table 2. Outline of the concepts, subcategories, categories and core category
Core category

Categories

Subcategories

Concepts

Wanderinga tangled pathI can’t believe that I developed T1D
I don’t feel like trying
Feeling resistance toward
T1D
I have a negative image of T1D
Being burdened
I can’t accept having T1D
by T1D
Even though I need long-term care, I will not recover before I die
Facing the reality of T1D
Taking injections makes me realize that I am sick
The pain and scars from the injections do not go away
I can’t openly take my injections
Being at the mercy of insulin I always have to carry my injections with me
My injections have priority over work
Suffering frominsulin-related troubles
I get hyperglycemia after forgetting to take my insulin injection
Being overconfident anddeveloping hypo- andI get hyperglycemia from overeating
hyperglycemia
I became hypoglycemic because I had no time to eat
Management is needed when the patient’s condition is poor, andmaintenance is needed when the patient’s condition is good
Being unable to cope Being unable to self-manage Unable to cope with hypoglycemia on my own
with difficulties
as expected
Poor blood glucose control continued for unknown reasonsin self-management
Efforts to self-manage are not worthwhile
Nervousness over the smallest physical changes
I cannot explain the difference with T2D to those around me
People around me refuse to
I cannot convey the hardship of hypoglycemia to those aroundunderstandme
Things do not necessarily change solely as a result of my illness
I get tired of excessive concern
Facing social
Not being treated normally
prejudice
It hurts to be considered as a sick person
Loss of employment and relationships with friends
Despite wanting employment, I am not hired because of my illNot being acknowledged
nessby society
Companies and hospitals do not guarantee a living

Fig. 1. A new powerlessness structure for Japanese adult patients with T1D: Patients find it difficult todecide their own path, and move back and forth among these four experiences.

84

Confusing experiences with adult T1D patients“The fact that I had to give myself an insulin injection made me realize that I had a disease. I used
to feel that way every time I injected insulin backthen.” (Participant D)“The (insulin) injections leave a mark; they haveeven left bruises. The (insulin) injection leaves a
noticeable mark that doesn’t go away for a while.”(Participant I)

levels. When hypoglycemia is particularly severe, somepatients stated that they are “unable to cope with hypoglycemia on my own.” Furthermore, some patients felt
‘stuck’ and ‘powerlessness’ when they were unable toself-manage as expected, such as when “poor blood glucose control continued for unknown reasons,” “efforts to
self-manage are not worthwhile,” or when they experienced “nervousness over the smallest physical changes:”“Adjusting my insulin dose according to the volume
I eat is a little stressful. The pain of injecting [insulin]hasn’t been a problem. I worry [instead] about the
numbers [blood sugar levels] and about messing up
the dose because I don’t quite know how to adjustit.” (Participant K)“My job kept me so busy that I had no time for it[the insulin injection]. I didn’t even have time to eat.
Therefore, results were always bad on my regular[clinic] visits. I couldn’t do anything about it. It
became a kind of dilemma for many years. I was
sometimes reluctant to go to the clinic knowing that
I would be told something bad [by the doctor] or get
scolded again.” (Participant J)

Category 2: Suffering from insulin-related troubles

This category consisted of two types of feelings, including ‘being at the mercy of insulin’ and ‘being overconfident and developing hypo- and hyperglycemia.’ ‘Being at the mercy of insulin’ involved a sense of being
controlled by insulin due to the constant need to findtimes and places to take insulin injections, or being insituations where injections cannot be taken due to superseding considerations. Patients were overwhelmed by asense of powerlessness and lost their confidence. Narratives included statements such as, “I can’t openly takemy injections,” “I always have to carry my injections
with me,” and “My injections have priority over work.”“I just hated the injection. I don’t like that I had totake a break from work to inject in the restroom.”(Participant B)‘Being overconfident that I would not become hypoor hyperglycemic’ resulted from overconfidence inpatients that led them to develop hyperglycemia despite
understanding that overconfidence can be a cause ofhypo- and hyperglycemia. This was expressed in statements such as “I get hyperglycemia after forgetting totake my insulin injection,” “I get hyperglycemia fromovereating,” and “I became hypoglycemic because I had
no time to eat:”“I often forgot about it [the insulin injection]. WhenI forgot the [insulin] injection, something went
wrong with me and I began feeling tired and thirsty.
I started to realize that I wasn’t doing well.”(Participant G)

Category 4: Facing social prejudiceThis category consists of three types of subcategory,including ‘people around me refuse to understand,’ ‘notbeing treated normally,’ and ‘not being acknowledged
by society.’ The sentiment that ‘people around me refuse
to understand’ resulted from the failure of other people
to distinguish T1D from type 2 diabetes (T2D), and was
described by patients as “I cannot explain the differencewith T2D to those around me” or “I cannot convey thehardship of hypoglycemia to those around me,” in part
because patients appear well despite having hypoglycemia:“I guess that I don’t look too tired to my colleagues
when I’m hypoglycemic. No one can understand thesuffering I go through unless they have the same
condition.” (Participant A)‘Not being treated normally’ arises from the drasticchange in the way people treat T1D patients; in particular, others can decrease their level of involvementwith the patient and become less familiar, resulting insentiments such as “things do not necessarily changesolely as a result of my illness,” “I get tired of excessive
concern,” “it hurts to be considered as a sick person,”and experiences such as “loss of employment and relationships with friends.” T1D patients consequently feel
distress as a result of coming out of their illness:“People built a wall around me. They treated me
like a sick person. They felt they should not invite
me out. They asked me if I could eat this and that

Category 3: Being unable to cope with difficulties
in self-management

This category consisted of a feeling of ‘being unable toself-manage as expected,’ which was further explained
as follows: “management is needed when the patient’s
condition is poor, and maintenance is needed when thepatient’s condition is good.” This concept arose frompatients’ need to constantly prepare coping methods forsituations in which their blood glucose level becomes
unstable, and to maintain their blood glucose level when
it is stable. When they develop hypoglycemia, patientsare sometimes unable to cope with their blood glucose
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I. Nishio et al.

and I would say, ‘Yes, of course!’” (Participant D)“I didn’t like it when people treated me like an invalid just because I had this condition. They said
things like ‘Don’t you have to get an [insulin] injection?’ or ‘Are you okay?’ over and over again.”(Participant E)‘Not being acknowledged by society’ was related tofinding employment and continuing to work, and included narratives such as, “Despite wanting employment, I
am not hired because of my illness,” and “Companies
and hospitals do not guarantee a living.”
T1D patients had a sense of powerlessness andperceived that they were regarded as disabled and abandoned by society, including their companies and hospitals:“I was told by my boss that I could not be a caregiver because my body required care. I basically got
fired.” (Participant B)“Even if you wanted to work, you would still havethe monthly clinic visits. That was a disadvantage.
I was completely able to work but [I believed that]companies might not want to hire me. I saw that asa disadvantage.” (Participant C)from society. We also revealed that as negative emotional experiences related to powerlessness increase,negative feelings intensify until the patients reach rockbottom.
In the first category, ‘being burdened by Type 1 diabetes,’ patients had the negative emotional experiencethat they had to accept their circumstances specificallythat they could not survive without insulin, in responseto their sudden diagnosis of T1D. Kleinman reported,“Illness is the experience of suffering, and is given
meaning through its association with the individual’s
personality and with local community such as the culture and society to which the individual belongs.” 14
Feelings such as “Why did I develop T1D?” and “I don’t
really want to take insulin” dominate patients’ consciousness, and can be expressed as strong negative feelings. Our results showed that, in this category, patients
perceived having T1D and requiring insulin as ‘debts’
because they did not fully accept T1D. This was the beginning of the gradual process of powerlessness.
In the second category, ‘suffering from insulinrelated troubles,’ patients had an emotional experience inconjunction with the start of insulin therapy. The blood
glucose level patterns of T1D patients are affected bymeal size, meal content, amount of activity, and physicalcondition, and the insulin dose varies according to these
conditions. The timing of insulin injections and insulin
dose used should therefore be considered as extremely
important regardless of the circumstances.1 Moreover;patients also take injections without letting other people
know in environments where their illness cannot bemade public. At work, patients endure situations inwhich they cannot take their injections or forget to taketheir insulin. Patients not only struggle with insulin selfregulation, but also suffer from the effects of spendingtime and energy on insulin therapy in their daily lives.
In this category, patients are at the mercy of insulin
therapy.
In the third category, ‘being unable to cope withdifficulty in self-management,’ patients sought to incorporate self-management of T1D, in the form of insulin
therapy, as a new habit in their daily lives. This study revealed that patients not only found that adjusting insulin
was a major burden, but also experienced self-denial (e.g.,shame, misery, and hardship) because they were unable
to stabilize their blood glucose level despite their best
efforts. The negative emotions leading to stronger selfdenial and increasing powerlessness were more intensethan in the previous category. Fleming et al describe themodes of service characterizing pediatric care as providing a family centered, social orientated, informal and relaxed mode, comparatively, the adult care is described as

Storyline

Patients start on insulin therapy as soon as they are
diagnosed with T1D. Daily insulin injections intensify
the patient’s awareness that they are sick, and they areconsequently weighed down by the sense that they are‘being burdened by T1D.’ Insulin therapy not only involves simple injections of insulin, but also enhances the
feeling of ‘suffering from insulin-related troubles’ dueto the constraints it places on daily life. The burden of
self-management increases in association with this feeling. Furthermore, a worsening blood glucose level andinability to self-regulate insulin despite their best efforts
result in a sense of ‘being unable to cope with difficulties in self-management.’ Because others did not understand diabetes, the patients lost jobs or were unable tofind employment. In addition, T1D patients feel that others consider them as sick people or treat them with bias,
thus they feel oppressed by society and become aware of‘facing social prejudice.’
DISCUSSION
Characteristics of powerlessness in T1D patients

This study elucidated powerlessness as revealed by the
personal experiences of patients, from the perspectiveof the onset of T1D as an important event in their lives.
Our results demonstrated that the powerlessness of T1D
patients is characterized by ‘wandering a tangled path’
resulting from a life dominated by T1D and alienation
86Confusing experiences with adult T1D patients

more individual centered, disease orientated, formal anddirect mode.15 Lundin reported the difference between
care culture in pediatric and adult diabetes care, and indicated that the patients become less ‘visible’ after beingtransferred to adult diabetes care.16 In this category ofdecreasing ‘visibility,’ patients feel unable to cope with
self-management because they come to a standstill.
In the fourth category ‘facing social prejudice,’ patients were confronted with unfair treatment in job interviews and in the workplace due to misunderstanding andprejudice from surrounding people who lacked accurate
information about T1D. Relationships with friends andfamily were distorted as a result of discrimination. Patients were distressed and hurt by the people aroundthem. Wallerstein determined that an external locus ofcontrol is a risk factor for powerlessness, and our results
were consistent with this idea.17 In this category, patients
had negative emotional experiences due to the presenceof an external locus of control. They recognized thatthey were incapable of achieving anything on their own
and could not organize their own feelings. Powerlessness
is not the result of limited individual resources or abilities, but the result of being continuously deprived of social support, resources, economic and political power.17
In this study, we also found that powerlessness arises
from both limited abilities and resources at an individual’s disposal, as well as from being socially oppressedand deprived of opportunities for self-determination.
In this category, powerlessness increases and patients
gradually fall to psychological rock bottom.
Our results demonstrated that the powerlessness ofT1D patients is characterized by ‘wandering a tangled
path’ resulting from a life dominated by T1D and alienation from society. We found that as negative emotional
experiences related to powerlessness increased, negative
feelings intensified until the patients reached rock bottom.

ness. A primary characteristic of the structure of powerlessness is suffering from confusing experiences.
Nursing practices from the perspective of powerlessness

Our results suggest three options to improve nursing
practice.
First, nurses should carefully listen to how T1D patients accept their diagnosis, and to explore the meaning
in this illness. To help patients cope with T1D without
being crushed by powerlessness, nurses must pay attention to signs of powerlessness. To avoid failing to
notice these signs, it is important for nurses to intentionally create situations in which patients can talk about
their personal history and thoughts, including lifestyle
constraints and difficulties and the volatile feelings andemotions associated with T1D, and to identify signs of
powerlessness in patients’ narratives.
Second, we identified four precautions regarding
nursing practice: i) the structure of powerlessness revealed in this study is a single model that can be utilized
as reference model; ii) patients must have opportunities
to talk about their experiences - if a patient has experienced powerlessness, it is important to wait until thepatient expresses him or herself; iii) Powerlessness is notjust an emotional state, but a combination of feelings,
perceptions, and thoughts; therefore, it is important tocomprehensively understand patients’ narratives; and iv)
when attempting to understand patients with T1D, nurses must not forget that while patients may wish to stoptreatment despite continuing insulin therapy for a longtime, they are still enduring their situation in their own
way. Their thoughts are not limited to enduring insulin
itself, but include their reactions to physical changes andthe fact that there is no understanding or cooperationfrom others. These thoughts actually bring out the emotional characteristics of T1D patients.18, 19
Third, in the fourth category, ‘facing social prejudice,’ powerlessness was associated with the experienceof a psychological rock bottom. In this case, ‘rock bottom’ signifies the worst possible state of being; thus,
after reaching rock bottom, things can only get better.
Wardian described “positive thinking” as the key toovercoming diabetes.20 Painful, distressing, and difficult experiences can provide valuable opportunities forlearning and growth that improve our internal strengthand resilience (i.e., Resilience is the human capacity todeal with overcome, learn from, or even be transformedby the inevitable adversity).21 It is therefore important for
nurses to share their feelings with patients and to thinkof ways to manage and regulate feelings in collaboration
with patients.

The definition of “powerlessness” in T1D patients

Based on the above discussion, “powerlessness” in T1D
patients can be defined as follows. Powerlessness is like‘wandering a tangled path,’ a state in which T1D patients
struggle to cope with reality on their own when facedwith both internal and external events. This wandering atangled path is not characterized by simple negative feelings, perceptions, and thoughts, but by complex combinations of the three.
The structure of powerlessness consists of four experiences: ‘being burdened by T1D,’ ‘suffering frominsulin-related effects,’ ‘being unable to cope with difficulty in self-management,’ and ‘facing social prejudice.’‘Wandering a tangled path’ is at the core of powerless87

I. Nishio et al.

As our data clearly demonstrate, T1D is not just aphysical condition, but also a profoundly social and psychological one. On this basis, we conclude that access toinsulin should probably come hand-in-hand with accessto personal, emotional, and psychological support. Indeed, it is in the context of this and other chronic physical conditions that the need for psychological attention
and intervention becomes most acute.

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Acknowledgments: We thank all patients with type 1 diabetes who
participated in this study.
The authors declare no conflict of interest.

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