Abstract
Alcohol dependence (AD) syndrome refers to a strong addiction to alcohol and high tolerance physiologically or psychologically, due to the repeated consumption of alcohol-based substances. This study aimed to examine the efficacy of group cognitive behavioral therapy (GCBT) on patients with AD. A total of 128 patients with AD were randomly assigned to the GCBT or control group. Patients in the GCBT group underwent an 8-week GCBT in addition to conventional treatment, and patients in the control group only received conventional treatment. The insight and treatment attitude questionnaire (ITAQ) score, chronic disease self-cognition evaluation score (CDSCES), treatment adherence, and relapse rate at 6 and 12 months were compared among the 2 groups. The ITAQ scores of the GCBT group, after treatment, increased significantly compared to those of the control group (19.69% vs 13.26%, P < .001). The CDSCES in the GCBT group increased significantly compared to those in the control group after treatment (3.98 vs 2.18, P = .001 for problem-solving ability; 8.08 vs 5.08, P = .001 for self-management efficacy; 4.29 vs 3.30, P = .005 for a positive response, and 4.84 vs 3.44, P = .008 for a social function, respectively). After treatment, the percentage of patients with AD with full compliance in the GCBT group was much higher than in the control group (93.8% vs 65.6%, P < .001). Contrastingly, the percentage of patients with AD with partial compliance in the GCBT group was much lower than that in the control group (3.2% vs 34.4%, P < .001). The relapse rate (%) of drinking in patients with AD in the GCBT group was much lower than that in the control group (1.56% vs 21.8%, P = .001 for 6 months and 4.7% vs 51.6%, P < .001 for 12 months). The results suggest that GCBT for 8 weeks is an effective approach for patients with AD, improving problem-solving ability, self-management efficacy, positive response, and social function, leading to increase in treatment compliance, and reducing relapse rate.
Keywords: alcohol dependence, chronic disease self-cognition score, group cognitive behavioral therapy, insight and treatment attitude questionnaire score, relapse rate, treatment adherence
1. Introduction
Alcohol dependence (AD) syndrome refers to the strong addiction and tolerance of the body or mind due to the repeated use of alcohol-based substances. Further, these are often prioritized over other essential activities, resulting in mental, physical, and social impairment of individuals.[1] AD has a high recurrence rate without an effective treatment.[2] However, targeted interventions can play a positive role in preventing relapse based on the investigation and analysis of high-risk factors that cause patients with AD to relapse.[3] AD treatment includes routine treatment and psychological rehabilitation. Psychological rehabilitation treatment mainly includes health education and psychological counseling. Although the incidence of AD is high, the number of psychotherapists in China is insufficient. Therefore, meeting the needs of most patients is challenging. Cognitive behavioral therapy (CBT) is an evidence-based psychotherapy that can cause cognitive changes (such as correcting a patient’s thoughts and belief systems) through multiple methods, resulting in changes in mood and behavior.[4] As the most commonly used psychotherapy method, CBT can effectively improve the mood and quality of life of patients with mental illnesses.[5,6] Based on CBT theory, group cognitive behavioral therapy (GCBT) adopts the form of group psychotherapy and combines the advantages of CBT and group therapy to improve group members’ cognition, emotion, and behavior. The final goal of the GCBT is the harmonious unity of knowledge, emotion, and intention. Compared to individual CBT, GCBT has the same or an even better therapeutic effect[4] and can be less time-consuming and more cost-effective for patients.
Many studies have demonstrated the effectiveness of GCBT in the treatment of social, mental, and psychological problems. Some of these studies included crimination among HIV-positive Latino sexual minority men[7]; individuals with anxiety, depression, and suicide reattempts[8,9]; women diagnosed with bipolar disorder; major depressive disorder spectrum seeking help for menopausal symptoms[10]; women with AD[11]; and Chinese patients with anorexia nervosa.[12] The present study was designed to investigate the efficacy of GCBT in male Chinese patients with AD to provide an effective approach for patients with AD.
2. Method
2.1. Participants
Participants were recruited from the inpatient department of the Third Hospital of Lanzhou City between January and December 2020. The prospective participants were informed of the risks and benefits of study participation and they provided written informed consent. Further, this study was approved by the Ethics Review Committee of the Third Hospital of Lanzhou City, China. The inclusion criteria met the diagnostic criteria of AD according to the International Statistical Classification of Diseases and Health-Related Problems 10th Revision.[13] The other requirement was that the participants were willing to participate in the program. Further, they had a strong desire to recover from AD. They got the agreement and support from their families and agreed to enroll and signed the informed consent form. The exclusion criteria included severe mental disorders (such as schizophrenia). In total, 128 men with AD were enrolled in this study. The participants completed an insight and treatment attitude questionnaire (ITAQ) and a chronic disease self-cognition evaluation scale (CDSCES) at each point of time. The researchers would assess treatment adherence for every participant in the first and last weeks of the study. Moreover, re-drinking and relapse was followed up 6 and 12 months after discharge.
2.2. Groups and intervention
Participants were assigned to the control and GCBT groups. Patients in the control group were given psychoeducation, psychological support, and medical management of abstinence with, for example, the use of disulfiram or anticraving medication.[14] Besides the treatment in the control group, patients in the GCBT group received an 8-week GCBT. GCBT treatment was performed 8 times during the test, once a week. The duration of each treatment was 60 minutes, and the number of members in each treatment group was 6 to 8 people. Additionally, participants who were absent more than 3 times were considered to exit the research. The GCBT used in this study was based on past literature.[15] The formulation and implementation of the GCBT program were based on CBT, a literature analysis, and preliminary interviews with patients with AD. We designed 8 plans for group psychotherapy during the study period (Table 1). In this study, the team members of GCBT included a group mentor with long-term practical experience related to GCBT who is considered an expert in clinical psychology and a national second-class psychological counselor. One assistant has rich, relevant experience in GCBT and is an expert in clinical psychology. Further, 2 supervisors have rich clinical research experience and are the chief physicians of the psychology and psychiatry departments. One supervisor was a nationally registered psychotherapist who had received CBT training in a Sino-Germany class.
Table 1.
The 8 plans of group cognitive behavioral therapy.
| Week | Theme | The main content |
|---|---|---|
| First | To form a group and set goals for the group | Self-introduction of group members and the group’s initial formation; introduce the GCBT; establish goals for GCBT treatment. |
| Second | To understand the dangers and treatment of AD | Analyze the physical, psychological, family, and social problems caused by AD; Know how to treat AD; Establish confidence and hope in curing AD. |
| Third | To identify automatic thinking and behavior training | Establish an automated thought process (the effect of automatic thinking on the emotion of AD); establish catastrophic thinking of withdrawal symptoms; guide the record of the automatic thinking; activate behaviour (daily activities and arrangements); conduct behavioral relaxation training (gradual muscle relaxation). |
| Fourth | Against distorted cognition and functional behavior | Understand the distorted cognition of AD; learn common ways of thinking against distorting cognition; instruct patients to record confrontational thinking; instruct patients to practice beneficial behaviors. |
| Fifth | Change attribution style and decompose the task | Share attribution style and deal with patients’ self-blame; guide the skills of task decomposition; Record training practice and build positive thinking flash card; do breathing training. |
| Sixth | Discover core beliefs and positive intentions | Discover the motto of positive thinking; point out patients’ core beliefs about AD; guide the skills of solving problems; practice the skills of behavior relaxation. |
| Seventh | Look for social support and development strategy | Guide patients to seek social support around them to deal with difficulties; help patients to develop strategies to deal with practical difficulties; continue to relax behavior; do homework. |
| Eighth | Review, plan, and prevent a recurrence | Review the ways to overcome AD; deal with setbacks; prevent a recurrence; handle the separation of group members. |
AD = alcohol dependence, GCBT = group cognitive behavioral therapy.
2.3. Insight and treatment attitude questionnaire
The ITAQ can reflect a patient’s cognition of mental illness and treatment, assessing their treatment attitudes and self-awareness.[14,16] It includes 11 items, each divided into 3 levels (0 points = no cognition, 1 point = partial cognition, 2 points = all cognition; the score range is 0–2 points).
2.4. Chronic disease self-cognition evaluation scale
The CDSCES[5] assesses the efficacy of self-cognition, social function, positive response to problems, and the problem-solving abilities of patients. It uses Likert scoring, in which the efficacy of self-cognition has 10 levels, where the higher the score, the higher the confidence. The social function has 5 levels; the higher the score, the better the social function. The positive response to problems has 4 levels; the higher the score, the more positive the coping behavior for problems. The problem-solving ability has 4 levels; the higher the score, the stronger the ability to solve problems.
2.5. Treatment compliance
The treatment compliance of hospitalized patients was assessed in the first and last weeks of the study. The assessment content included 3 parts: full compliance (active medication and long-term maintenance medication according to the doctor’s advice), partial compliance (passive medication and inability to maintain medication consciously according to the doctor’s advice), and no compliance (often refusing medication or refusing to maintain medication).
2.6. The relapse rate of drinking
Re-drinking (relapse) was followed up at 6 and 12 months after discharge.
2.7. Statistical analyses
Descriptive and inferential statistics were analyzed using SPSS 25.0. Data are reported as the mean ± standard deviation (SD), unless otherwise indicated, with a significance level set at P < .05. Sample size calculations were conducted using the PASS software (PASS 11. NCSS, LLC. Kaysville, UT).
3. Results
3.1. Demographic characteristics between 2 groups
A total of 128 patients with AD were randomly divided into control and GCBT groups, with 64 patients in each group (Table 2). Their age ranged from 18 to 74 years, with a mean ± SD of 48.7 ± 16.8 years in the control group and from 18 to 69 years, with a mean ± SD of 49.5 ± 15.2 years in the GCBT group, respectively (P = .235). Their addiction duration was 9.75 ± 2.26 years in the control group and 10.25 ± 2.65 years in the GCBT group, respectively (P = .325). No significant differences were found in marital status, hospitalization time, or drinking time between the 2 groups.
Table 2.
Demographic characteristics.
| Characteristic | Control (n = 64) | GCBT (n = 64) | P |
|---|---|---|---|
| Age (years) | .235 | ||
| Mean ± SD | 48.7 ± 16.8 | 49.5 ± 15.2 | |
| Range | 18–74 | 16–75 | |
| Addiction time (years) | 9.75 ± 2.26 | 10.25 ± 2.65 | .325 |
| Marital status | .474 | ||
| Married | 52 (81.3%) | 48 (75.0%) | |
| Single | 10 (15.6%) | 15 (23.4%) | |
| Divorced | 2 (3.1%) | 1 (1.6%) | |
| Hospitalized times | 4.01 ± 1.26 | 3.96 ± 1.43 | .235 |
| Drinking time | 18.1 ± 4.97 | 17.26 ± 5.31 | .481 |
The data were expressed as mean ± SD or number (%).
GCBT = group cognitive behavioral therapy, SD = standard deviation.
3.2. Insight and treatment attitude questionnaire score between 2 groups
The ITAQ reflects patients’ cognition of mental illness and assesses their treatment attitudes and self-awareness. Therefore, the ITAQ was used to assess the effects of GCBT before and after treatment, in both groups. As shown in Table 3, the ITAQ scores were comparable between the control and GCBT groups before treatment (8.20% vs 8.12%, P = .385). However, the ITAQ scores in the GCBT group after treatment increased significantly compared to those of the control group (19.69% vs 13.26%, P < .001). These results suggest that GCBT for 8 weeks is an effective approach for patients with AD.
Table 3.
ITAQ score.
| Variable | Before treatment | After treatment | ||||
|---|---|---|---|---|---|---|
| Control | GCBT | # P | Control | GCBT | # P | |
| ITAQ score | 8.20 ± 2.59 | 8.12 ± 2.68 | 0.385 | 13.26 ± 3.45 | 19.69 ± 3.28 | <.001 |
The data were expressed as mean ± SD.
ITAQ = insight and treatment attitude questionnaire, GCBT = group cognitive behavioral therapy.
P < .05 compared to control group before and after treatment, respectively.
3.3. Chronic disease self-cognition evaluation scores between 2 groups
As shown in Table 4, the CDSCES were comparable between the 2 groups before treatment. However, these scores in the GCBT group increased significantly compared to those in the control group after treatment (3.98 vs 2.18, P = .001, problem-solving ability; 8.08 vs 5.08, P = .001, for self-management efficacy; 4.29 vs 3.30, P = .005, for a positive response, and 4.84 vs 3.44, P = .008, for social function, respectively). These results suggest that GCBT for 8 weeks significantly improves problem-solving ability, self-management efficacy, positive response, and social function in patients with AD.
Table 4.
Chronic disease self-cognition evaluation scores.
| Variable | Before treatment | After treatment | ||||
|---|---|---|---|---|---|---|
| Control | GCBT | # P | Control | GCBT | # P | |
| Problem-solving ability | 1.49 ± 0.63 | 1.58 ± 0.52 | .325 | 2.16 ± 0.71 | 3.98 ± 0.68 | .001 |
| Self-cognition efficacy | 3.90 ± 1.62 | 3.98 ± 1.46 | .285 | 5.08 ± 1.32 | 8.08 ± 1.28 | .001 |
| Positive response | 2.47 ± 0.72 | 2.67 ± 0.48 | .315 | 3.30 ± 0.38 | 4.29 ± 0.52 | .005 |
| Social function | 2.60 ± 0.88 | 2.96 ± 1.02 | .385 | 3.44 ± 1.08 | 4.84 ± 0.79 | .008 |
The data were expressed as mean ± SD.
GCBT = group cognitive behavioral therapy.
P < .05 compared to control group before and after treatment, respectively.
3.4. Treatment compliance between 2 groups
No difference in treatment compliance was found between the 2 groups before treatment (Table 5, P = .375). After treatment, the percentage of patients with AD with full compliance in the GCBT group was much higher than that in the control group (93.8% vs 65.6%, P < .001). Contrastingly, the percentage of patients with AD with partial compliance in the GCBT group was much lower than that in the control group (3.2% vs 34.4%, P < .001). These results suggest that GCBT for 8 weeks significantly improves treatment compliance in patients with AD.
Table 5.
Treatment compliance.
| Before treatment | After treatment | |||||
|---|---|---|---|---|---|---|
| Control | GCBT | *P | Control | GCBT | *P | |
| Compliance | .375 | <.001 | ||||
| Full | 38 (59.4%) | 32 (50.0%) | 42 (65.6%) | 62 (96.8%) | ||
| Partial | 26 (40.6%) | 32 (50.0%) | 22 (34.4%) | 2 (3.2%) | ||
The data were expressed as number (%).
GCBT = group cognitive behavioral therapy.
*P < .05 compared to control group before and after treatment respectively.
3.5. The relapse rate of drinking between 2 groups
As shown in Table 6, 6 months after treatment, the relapse rate (%) of drinking for patients with AD in the GCBT group was much lower than that in the control group (1.56% vs 21.8%, P = .001). Twelve months after treatment, the relapse rate (%) of drinking in the GCBT group was significantly lower than that in the control group (4.7% vs 51.6%, P < .001). These results suggest that GCBT for 8 weeks significantly reduces the relapse rate of drinking in patients with AD even after 6 to 12 months after treatment.
Table 6.
The relapse rate of drinking.
| Variable | 6 months after treatment | 12 months after treatment | ||||
|---|---|---|---|---|---|---|
| Control | GCBT | *P | Control | GCBT | *P | |
| The relapse rate of drinking | 14 (21.8%) | 1 (1.56%) | .001 | 33 (51.6%) | 3 (4.7%) | <.001 |
The data were expressed as number (%).
GCBT = group cognitive behavioral therapy.
*P < .05 compared to control group 6 and 12 months after treatment, respectively.
4. Discussion
The present study found that GCBT is an effective approach for patients with AD, improving problem-solving ability, self-efficacy, positive response, and social function, along with increasing treatment compliance, and reducing relapse rate.
AD remains a major health concern in China. To date, efforts to treat AD have been only partially successful. It is clearly demonstrated that many people will relapse to drinking following the treatment.[1] A study showed that more than 80% of patients with AD also experience other mental illnesses, such as anxiety, depression, and antisocial personality disorder.[17] After a period of treatment, if patients with AD drink again, all symptoms of withdrawal syndrome will reappear quickly.[18] Therefore, it is necessary to provide an effective treatment for patients with AD.
Based on CBT theory, GCBT uses the form of group psychotherapy and combines the advantages of group therapy to improve group members’ cognition, emotion, and behavior. The ultimate goal of GCBT is to achieve a harmonious unity of knowledge, emotion, and intention. This study used a GCBT model, and each group had therapists and assistants, including psychiatrists, who provided psychological counseling to patients. Throughout 8 sessions of GCBT, patients with AD gained a new perspective on multiple aspects of their life, ranging from emotional, physical, psychological, and social factors. Their responsibility to their family and society improved, and they learned the meaning of life again. Finally, GCBT improved treatment compliance, consciously corrected dependent behavior, and helped patients gradually move toward rehabilitation. Many studies have consistently revealed the effectiveness of GCBT in treating social, mental, and psychological problems. Bogart et al developed a 9-session, community-based GCBT intervention to address coping with discrimination among HIV-positive Latino sexual minority men. They found that the intervention holds promise for reducing disparities by empowering Latino sexual minority men to leverage innate resilience resources to improve their health, while facing discrimination.[7] Bautista et al reported that GCBT delivered in an intensive weekend format might positively impact individuals with anxiety, including a reduction in symptoms of anxiety and depression and improved overall functioning.[8] Conklin et al reported that GCBT is beneficial for women diagnosed with bipolar disorder and major depressive disorder seeking help for menopause symptoms.[10] Epstein et al tested GCBT in women with AD, and positive outcomes were found for drinking, mood, coping skills, self-confidence, interpersonal functioning, and self-care.[11] Gu et al explored the feasibility and efficacy of GCBT in Chinese patients with anorexia nervosa. GCBT showed significant improvement in eating pathology and associated psychopathology throughout treatment.[12] Moreover, Lin et al investigated the effectiveness of GCBT on depression and suicide reattempt and emotion regulation strategies among those with borderline personality disorder. They showed that GCBT effectively decreased depression and suicide reattempt in Borderline Personality Disorder college students, probably through increasing adaptive antecedent-focused or response-focused strategies of emotion regulation, respectively.[9]
A study has shown that the psychological desire of patients with AD can last 2 to 3 years after abstinence. Further, 50% of them would likely drink again within 1 year after abstinence.[19] The social functioning of patients with AD is worsening because they are repeatedly hospitalized, which places a tremendous burden on their families and society. Therefore, reducing the relapse rate of alcohol consumption is vital to successful abstinence. The follow-up results of the present study, 6 and 12 months after discharge, showed that the relapse rate of drinking in the GBCT group was significantly lower than that in the control group. However, whether it has a long-term (>12 months) impact on the relapse rate of drinking requires further follow-up. Therefore, the development of health education and consolidation of the effects of in-hospital treatment will be the focus of future research.
The present study had several limitations. First, only male patients with AD were enrolled in this study because most patients with AD in China are men who were violent toward family members. Second, the sample size was relatively small. Third, the study was conducted at a single center. Finally, the follow-up time (6 and 12 months after discharge) was relatively short. These limitations will be addressed in the future by enrolling female patients with AD, increasing the sample size, expanding to multicenter investigations, and increasing the follow-up time.
5. Conclusion
The results suggest that GCBT is an effective approach for patients with AD, improving problem-solving ability, self-management efficacy, positive response, and social function, increasing treatment compliance and reducing relapse rate.
Author contributions
Conceptualization: Wanxiu Peng, Hui Zhang.
Data curation: Wanxiu Peng, Jinmei Yang, Junan Wang, Jianying Kang.
Formal analysis: Wanxiu Peng, Hui Zhang, Rui Zhu, Wei Pan.
Investigation: Wanxiu Peng, Hui Zhang, Jinmei Yang, Junan Wang.
Methodology: Wanxiu Peng, Hui Zhang.
Software: Wei Pan, Bing Xu.
Supervision: Hui Zhang.
Writing – original draft: Wanxiu Peng.
Writing – review & editing: Hui Zhang.
Abbreviations:
- AD =
- alcohol dependence
- CBT =
- cognitive behavioral therapy
- CDSCES =
- chronic disease self-cognition evaluation score
- GCBT =
- group cognitive behavioral therapy
- ITAQ =
- insight and treatment attitude questionnaire
- SD =
- standard deviation
This study was supported by Lankeyanzi (No. 189).
The authors have no conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
How to cite this article: Peng W, Zhang H, Yang J, Wang J, Kang J, Zhu R, Pan W, Xu B. Group cognitive behavioral therapy as an effective approach for patients with alcohol dependence: A perspective study. Medicine 2022;101:36(e30459).
Contributor Information
Wanxiu Peng, Email: 936751802@qq.com.
Jinmei Yang, Email: 297086068@qq.com.
Junan Wang, Email: 1063016790@qq.com.
Jianying Kang, Email: 1837113968@qq.com.
Rui Zhu, Email: 1101094164@qq.com.
Wei Pan, Email: 1061055629@qq.com.
Bing Xu, Email: 1006932860@qq.com.
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