Effects of a Brief Emotion Regulation Intervention with Biofeedback in Patients with Alcohol Use Disorder: A Quasi-Experimental Study Based on Gross's Emotion Regulation Theory
Article information
Abstract
Purpose
This study assessed the impact of a brief emotion regulation program incorporating biofeedback, grounded in Gross's Emotion Regulation Theory, on psychological and physiological outcomes in patients with Alcohol Use Disorder. Key variables included abstinence self-efficacy, perceived stress, anger rumination, alexithymia, and physiological attention concentration.
Methods
Utilizing a non-equivalent control group pretest-posttest quasiexperimental design, 42 inpatients with Alcohol Use Disorder were recruited from two psychiatric hospitals and divided into an experimental group (n=21) and a control group (n=21). The intervention consisted of weekly sessions lasting 60 minutes over four weeks, combining biofeedback-based attention training with emotion regulation strategies, including situation modification, emotional awareness, cognitive reappraisal, and emotional expression. Outcome variables were assessed before and after the intervention, and data were analyzed using appropriate parametric and non-parametric tests in SPSS 27.0.
Results
Following the intervention, the experimental group exhibited significant improvements in perceived stress (z=-3.91, p<.001), anger rumination (t=-8.25, p<.001), alexithymia (t=-2.80, p=.008), and abstinence self-efficacy (t=2.73, p=.011). Additionally, physiological attention concentration showed significant enhancement (t=-2.61, p=.017).
Conclusion
This Gross theory-based program has the potential to inform effective psychiatric nursing interventions aimed at reducing relapse risk in individuals with Alcohol Use Disorder.
INTRODUCTION
1. Necessity of the Study
Alcohol use disorder is a chronic disease characterized by high relapse rates; low treatment adherence; and significant physical, psychological, and social problems, necessitating effective relapse prevention interventions. Approximately 65~90% of individuals reuse alcohol within a year post-treatment, and 46.9% are readmitted within one month, potentially leading to severe issues [1,2].
According to the 2021 Epidemiological Survey of Mental Disorders in Korea, the lifetime prevalence of alcohol use disorder in the Korea is 11.6%, with males (17.6%) showing a 3.3 times higher prevalence than females (5.4%) [2]. However, mental health services' utilization rate is only 2.6%, significantly lower than those of major depressive disorder (28.2%) and anxiety disorders (9.1%), indicating the need for early intervention and increased treatment accessibility [3].
Alcohol consumption is associated with substantial socioeconomic costs. Expenses related to alcohol-related diseases amount to approximately 6.12 trillion KRW and economic losses due to alcohol-related accidents are approximately 1.2492 trillion KRW, affecting social safety and public order [4]. Individuals with alcohol use disorder frequently exhibit liver disease, cardiovascular disease, and premature death, along with psychological problems such as low self-esteem, depression, anxiety, suicidal ideation, and maladaptive behavioral patterns [5].
Research has highlighted emotional vulnerability as a core risk factor for alcohol use disorder [6,7]. Perceived stress, alexithymia, excessive negative emotional experiences, anger rumination, and negative urgency are emotional factors that significantly increase relapse risk in individuals with alcohol use disorder [7,8]. Abstinence self-efficacy significantly reduce the risk of relapse [9]. Moreover, improvements in self-efficacy at various stages of intervention play an important role in maintaining abstinence and reducing alcohol consumption [5,9]. Therefore, enhancing abstinence self-efficacy is crucial for both recovery and relapse prevention.
Perceived stress refers to how individuals subjectively interpret situations as stressful, and it is, a significant emotional risk factor for patients with alcohol use disorder [10]. These individuals experience stress during failed attempts to control their drinking and repeated admission and discharge cycles, perceiving themselves as incompetent [11]. They use alcohol to relieve stress, reinforcing the relationship between stress and alcohol use [5], suggesting that perceived stress acts as a major emotional trigger for alcohol abuse.
Anger rumination is the cognitive tendency to dwell on situations that provoke anger [12]; it is a cognitive characteristic rather than an emotional response [8]. Individuals who ruminate on anger tend to not resolve anger-inducing events for extended periods, and their emotional responses vary, depending on their anger coping mechanisms [13]. Patients with alcohol use disorder are often angered by internal conflicts and interpersonal problems, which can trigger or be exacerbated by drinking [11]. Therefore interventions aimed at modifying anger rumination perception in individuals with alcohol use disorder are necessary [8].
Alexithymia is the inability to clearly identify or express one's emotions, including difficulty in recognizing negative emotions such as anxiety or depression, and avoiding feelings [14]. Individuals with alcohol use disorder find it more difficult to recognize and express emotions than the general population [8] consequently, they rely on alcohol to alleviate negative emotions.
Abstinence self-efficacy, a core factor in maintaining sobriety for individuals with alcohol use disorder, is crucial in predicting and reducing relapse risk [5]. This enables effective coping in high-risk situations, supports continuous abstinence, and forms a foundation for long-term recovery [9,15,16]. However, having inadequate coping strategies to address stressful situations associated with an increased likelihood of relapse and lowered self-efficacy about maintaining abstinence [17-19].
Biofeedback training is a biosignal-based attention enhancement training program used in psychophysiology to enhance emotion regulation. It promotes autonomic nervous system control through physical relaxation (e.g., breathing techniques) and attention training (e.g., improving immersion and concentration) using visual and auditory feedback that converts psychological states such as stress and anger into physiological signals [20,21].
Although established nonpharmacological treatments for alcohol use disorder include 12-step relapse prevention, Alcoholics Anonymous, motivational enhancement therapy, cognitive-behavioral therapy (CBT), narrative therapy, art therapy, exercise therapy, and digital interventions [5,22-25], few studies have explored the combination of biofeedback training and Gross's emotion regulation [20,25].
Biofeedback training is designed to increase awareness and voluntary regulation of an individual's physiological processes of bio-signals processes, thereby reducing alcohol-related craving and impulsivity, improving self-awareness, and fostering stronger beliefs in one's ability to abstain from alcohol use disorder [20,21,26,27].
Gross's theoretical process model proposes four stages for structurally regulating emotions: situation modification, attentional deployment, cognitive reappraisal, and response modulation [28]. Emotional regulation interventions are more effective when preceded by physiological relaxation and focused attention [7,20,29]; biofeedback facilitates physical relaxation and attentional training through visual and auditory feedback on autonomic nervous system responses. Consequently, it has gained attention for its effectiveness in promoting physiological relaxation and increasing attention, both of which are essential for improving emotional regulation [20,21]. Biofeedback training visualizes real-time autonomic nervous system fluctuations and, when combined with diaphragmatic breathing and relaxation exercises, facilitates sympathovagal balance restoration and strengthens cognitive reappraisal, thereby enhancing overall emotion regulation [7,20].
Emotional regulation interventions combined with biofeedback for individuals with alcohol use disorder have not been sufficiently studied. While conventional nonpharmacological interventions involve various approaches, short-term interventions focusing on emotional regulation integrating physiological, cognitive, emotional, and behavioral factors are lacking [24,25,30]. The World Health Organization (WHO) emphasizes the effectiveness of brief interventions in reducing alcohol use and as initial treatment strategy. According to official WHO guidelines, one to four sessions of brief intervention are recommended for individuals with alcohol use disorder [26,27].
2. Objectives
This study developed a short-term emotion regulation program based on Gross's process model of emotion regulation (Figure 1) with biofeedback for hospitalized patients with alcohol use disorder. It evaluated its effects on perceived stress, anger rumination, alexithymia, and abstinence self-efficacy.
The study aimed to evaluate the program's effectiveness.
• Hypothesis 1. Short-term emotion regulation intervention combined with biofeedback will result in a significant change in perceived stress.
• Hypothesis 2. Short-term emotion regulation intervention combined with biofeedback will result in a significant change in anger rumination.
• Hypothesis 3. Short-term emotion regulation intervention combined with biofeedback will result in a significant change in alexithymia.
• Hypothesis 4. Short-term emotion regulation intervention combined with biofeedback will result in a significant change in abstinence self-efficacy.
• Hypothesis 5: Short-term emotion regulation intervention combined with biofeedback will result in a significant change in physiological attention concentration.
3. Conceptual Framework of the Study
Grounded in Gross's process model of emotion regulation (Figure 2), this study integrated biofeedback-based relaxation and attentional training into each regulation stage to enhance physiological stability and autonomic balance [20]. This short-term emotion regulation program with biofeedback aims to improve perceived stress, anger rumination, alexithymia, abstinence self-efficacy, and physiological attention in patients with alcohol use disorder by applying physiological, cognitive, experimental, and behavioral strategies at each stage of Gross's model. Delivered via immersive computer-based games, this noninvasive intervention concurrently promotes physical relaxation and focused attention, supporting physiological, emotional, motivational, cognitive, and behavioral processes yielding positive outcomes [20,21].
The conceptual framework of this study.
Each session began with diaphragmatic breathing and a biofeedback-based attention game for relaxation and focus, followed by structured short-term interventions tailored to each stage.
In the situation stage, participants identified emotion-triggering events and practiced strategic modification. Hospitalization due to relapse and choosing to join the program were framed as "situation selection." Biofeedback was used for relaxation, alongside activities promoting acceptance, emotion recognition, and motivation to reduce perceived stress.
In the attention stage, biofeedback-based concentration training was followed by attentional deployment to enhance emotional awareness. Activities included distraction from negative emotions and induction of positive emotions, supporting intentional attention shifts for clearer emotion recognition.
In the appraisal stage, a cognitive reappraisal strategy was employed to reinterpret irrational thoughts and reinforce rational cognition. Specifically, participants engaged in the exploration of primary emotion-eliciting factors, identification of core emotions, recognition of automatic thoughts, and reinterpretation of cognition-emotion linkages to induce cognitive change and facilitate emotional recovery.
In the response stage, adaptive emotional responses were promoted by regulating emotional reactions. Strategies included enhancing emotional expression, communication training, reducing maladaptive responses, and learning action-based regulation. Biofeedback and activities to reduce suppression, encourage expression, and strengthen coping and self-regulation were also applied.
Patients with alcohol use disorder exhibit autonomic hyperarousal, cognitive distortions, suppression of emotional experience, and maladaptive coping behaviors that interact to elevate relapse risk [7,18,30]. The biofeedbackassisted brief emotion regulation program developed in this study integrates physiological relaxation and attentional focus, cognitive reappraisal, experiential emotional expression, and behavioral problem-solving training to concurrently address these factors, thereby strengthening emotion regulation capacity, enhancing self-efficacy and contributing to relapse prevention.
METHODS
1. Research Design
This nonequivalent control group pretest-posttest, quasi-experimental study was conducted to verify the effectiveness of the short-term emotion regulation program. The intervention comprised four successive strategies: situation selection, attentional deployment (focus and distraction), cognitive change, and response modulation. At the start of each session, participants engaged in diaphragmatic breathing to induce physiological relaxation, followed by a biofeedback-assisted attention-training exercise to enhance concentration. The experimental group received this brief, biofeedback-augmented emotion regulation program in addition to the ward's standard care, whereas the control group received only the standard care.
Intervention effects were evaluated by comparing preand post-intervention scores on perceived stress, anger rumination, alexithymia, and alcohol abstinence self-efficacy in both groups; physiological attention concentration was also assessed pre- and post-intervention in the experimental group.
2. Participants
This study was conducted after visiting two psychiatric hospitals in Y City and G City, North Gyeongsang Province, explaining the study's purpose, and obtaining approval for space and implementation. Two wards with similar settings were selected via convenience sampling. Posters were displayed in the wards, and inpatients diagnosed with alcohol use disorder who voluntarily consented after understanding the study were enrolled.
Using G*Power 3.1.9.4, the required sample size was calculated based on an effect size of 1.16 [26], ⍺=.05, and power=.95, resulting in 21 participants per group (total 42). Accounting for a 10% dropout rate, 23 participants were recruited per group. After exclusions due to early discharge, ineligibility, or posttest refusal, 21 participants per group remained. Forty-two participants were included in the final analysis.
Participants were selected based on predefined criteria: diagnosed with alcohol use disorder per the DSM-5, aged ≤65, no history of brain disease or surgery, and stabilized withdrawal symptoms after 1~2 weeks of hospitalization.
Among patients currently admitted to the alcohol treatment ward, those who had a dual diagnosis documented in their admission records, were receiving first-generation typical or second-generation atypical antipsychotic medications, had a history of cardiovascular disease, had auditory or visual impairments, or had participated in a biofeedback-based emotion regulation intervention similar to the present study within the previous three months were excluded from the study.
3. Research Instruments
1) Perceived stress
Perceived stress was measured using the Perceived Stress Scale, a short form revised by Cohen through factor analysis, based on Cohen et al.'s (1983) scale. The scale comprises 10 items, each rated on a five-point Likert scale ranging from 1 ("not at all") to 5 ("very often"). High scores indicate higher perceived stress. The Korean version translated by Park and Seo (2010) was used after obtaining prior permission from the translator [10]. Reliability Cronbach's ⍺ was .74 at development and .71 in this study.
2) Anger rumination
Anger rumination was measured using the Korean version of the Anger Rumination Scale (K-ARS), translated and validated by Cho and Lee (2007), based on the Anger Rumination Scale (ARS) developed by Sukhodolsky et al. (2001), Prior permission to use the instrument was obtained from the translator. It comprises 16 items, each rated on a four-point Likert scale ranging from 1 ("almost never") to 4 ("almost always"), with higher scores indicating a greater tendency toward the corresponding anger rumination style [12]. Cronbach's ⍺- of the instrument was .94 at development and .94 in this study.
3) Alexithymia
Alexithymia was measured using the Korean version of the scale modified and translated by Shin and Won (1997), based on Taylor et al.'s (1994) scale. Prior permission to use the instrument was obtained from the translator. It comprises 23 items, each rated on a five-point Likert scale ranging from 1 ("not at all") to 5 ("very much"). The total score was the sum of the scores of each item by a factor, with higher scores indicating a higher degree of alexithymia [6]. Cronbach's ⍺- of this scale was .86 at development and .82 in this study.
4) Alcohol abstinence self-efficacy
Alcohol abstinence self-efficacy was measured using the 20-item Korean standardized version of the Alcohol Abstinence Self-Efficacy Scale developed by Kim (1996), based on DiClemente et al.'s (1994) scale. The instrument was employed after obtaining prior permission from the developer. Each item was rated on a five-point Likert scale ranging from 0 ("very unsure") to 4 ("very sure"), with higher scores indicating higher self-efficacy for alcohol abstinence [18]. Cronbach's ⍺- of this instrument was .92 at development and .93 in this study.
5) Biofeedback training
Psychophysiological relaxation-concentration training conducted in each session comprised diaphragmatic breathing and biofeedback concentration training. For the biofeedback concentration training, Play Attention, an attention enhancement program developed by Freer Logic, Inc. (USA), was used for 20 minutes. This training comprised two programs: pure attention training to enhance pure concentration and cognitive discrimination training to induce attention and responses to stimuli, which were integrated into one biofeedback training session [20]. Concentration data for each training session were recorded in real time and automatically saved. The concentration rate (percentage of time maintained) served as the attentional indicator for the experimental group [20]. Upon session completion, the concentration score was displayed on the monitor for immediate verification.
(1) Attention Stamina Training Program
Attention Stamina training is a biofeedback-based program designed to induce and continuously maintain attention. Trainees selected one of the following characters in Play Attention at the start of the program: dolphin, orca, diver, or submarine. In the training, as the selected character gradually moves to the deep sea, gold coins can only be acquired from irregularly appearing treasure chests only when a certain level of concentration is maintained.
The red bar graph displayed in the upper-left corner of the screen represents real-time concentration. The graph is entirely filled with red when the maximum concentration is reached. Thereafter, the graph maintains this state as long as the maximum concentration is sustained. Concentration-related data were automatically saved and cumulatively recorded on a computer during the training process.
The concentration rate (%) calculated from the game statistics of the program was used for analysis. Concentration rate is the percentage of the total training time in which concentration was maintained, while sustained attention time refers to the cumulative time in which the bar graph remained fully filled [20].
(2) Discriminatory Processing Training Program
Discriminatory Processing training is an attention-enhancement program that induces selective recognition of, and responses to, target stimuli in an environment with various stimuli. A cognitive discrimination training module was used within the Play Attention system. When training begins, a stationary spaceship appears on the computer screen, moving slowly when the user's concentration level reaches a certain threshold. As the spaceship moves, various meteoroids appear on the screen, among which white and red asteroids serve as target stimuli for selective attention.
The training involves instructing participants to consider approaching white asteroids as distracting stimuli and immediately press the space bar to respond. Distinguishing and responding to target stimuli improves selective attention. The graph's display was the same as in the Attention Stamina training. Concentration-related data during the training were recorded on a computer in real time, and this information was automatically saved and accumulated.
The concentration rate (%) from the training results of the experimental group was used as pre-post comparison data. The concentration rate refers to the percentage of concentration results recorded in the in-program game statistics after the training is completed, and it was used as an objective indicator of attention ability [20].
4. Research Procedure
The program commenced on April 1, 2024, and concluded on June 30, 2024, with the study procedure comprising a pretest, the intervention, and a posttest.
1) Development phase of the short-term emotion regulation program with biofeedback for patients with alcohol use disorder
The program based on Gross's emotion regulation theory, referencing prior programs by Lee [5], Ahn [19], Kim [20], Cho [28], and Lee [29] was revised by the researcher to suit the clinical needs of patients with alcohol use disorder (Table 1).
Contents of the Brief Emotion Regulation Intervention with Biofeedback Training Program
The intervention adhered to Gross's four-stage model-situation selection, attention deployment, cognitive reappraisal, and response modulation-with each session beginning with diaphragmatic breathing and biofeedback-based attention training to promote relaxation, emotional focus, and optimize intervention effects.
Biofeedback training was conducted at the beginning of each session to maximize the effectiveness of the emotion regulation intervention. The program was an individual, short-term intervention comprising four 60-minute sessions, held once per week
• Session 1 corresponds to the "situation" stage, during which participants identified specific antecedent situations that elicited negative emotions due to prior experiences and, endeavored to modify them. Reevaluating the inpatient context arising from relapse of alcohol use disorder and choosing to participate in the program constitutes an act of situation selection. Activities targeting situation acceptance, emotion identification, and motivation enhancement were strategically implemented to facilitate changes in perceived stress.
• Session 2 addressed attention deployment and distraction, guiding participants to explore current emotions and shift focus from negative to positive experiences. They practiced directing attention away from alcohol-related negativity and reframing past experiences into positive alternatives.
• Session 3 focused on cognitive change, addressing anger rumination and restructuring negative perceptions. Participants explored irrational thoughts and practiced cognitive reappraisal.
• Session 4 focused on response modulation, teaching healthy emotional expression and communication. Assertiveness and alcohol refusal skills were practiced, along with saying "no" and writing self-letters to boost self-efficacy and evoke positive emotions. A posttest and participant feedback concluded the session.
2) Pretest
The pretest was conducted at two psychiatric hospitals that approved participant recruitment. The researcher explained the study in person and collected data using structured self-report questionnaires on general characteristics and key variables: perceived stress, anger rumination, alexithymia, and alcohol abstinence self-efficacy. To prevent treatment diffusion, the experimental and control groups were assigned to different hospitals with similar environments. Control group data were collected first, followed by the intervention and data collection for the experimental group, with pre- and post-tests administered at equivalent time points.
3) Experimental intervention
The experimental group received four weekly individual sessions (60 minutes each) from May 4 to June 30, 2024, conducted in the alcohol ward counseling room. Sessions were held on weekdays (7~9 PM) or weekends. Each session included 20 minutes of diaphragmatic breathing and biofeedback (attention stamina and cognitive discrimination training), followed by a 40-minute emotion regulation program based on Gross's theory. Program effectiveness was assessed using pre- and post-tests on perceived stress, anger rumination, alexithymia, and alcohol abstinence self-efficacy.
The intervention was delivered by a psychiatric nurse and a mental health nurse with seven years of clinical experience in an alcohol ward. A Biofeedback Certification International Association (BCIA) certified nurse (No. ****) served as co-researcher, and the program was implemented following prior training and consultation on content and methods.
4) Posttest
The posttest was conducted immediately after the four-week intervention, using the same measures as the pretest, excluding general characteristics. It was administered individually in the ward's counseling room. Along with psychological scales, physiological attention was assessed via biofeedback equipment, calculated as the real-time concentration percentage based on biosignals.
5. Data Collection
This study was conducted with inpatients diagnosed with alcohol use disorder at two psychiatric hospitals (W Hospital in G City and M Hospital in Y City, North Gyeongsang Province). Study details were explained to hospital staff, and consent for data collection was obtained. Participant recruitment was conducted via ward bulletin boards, and only those who voluntarily consented after a full explanation were included. Control group data were collected from April 3 to 29, 2024, using structured pre- and post-test questionnaires on general characteristics and key variables. The experimental group was recruited at M Hospital using the same procedure, and data were collected from April 30 to June 30, 2024. After the 4-week intervention, a posttest was conducted immediately.
6. Data Analysis
The data collected in this study were processed and analyzed using SPSS ver. 27. First, the general characteristics of the participants were described using frequencies, percentages, means, and standard deviations. Second, the homogeneity of general characteristics between groups was tested using the chi-square test (x2 test), independent samples t-test, and Fisher's exact probability test. Third, the pretest homogeneity of the study variables between the experimental and control groups was tested using the independent samples t-test and Mann-Whitney U test. Fourth, the independent samples t-test and paired t-test were applied to variables that could assume a normal distribution to verify the program's effectiveness, and the Mann-Whitney U, Friedman, and Wilcoxon signed-rank tests were performed on variables that did not satisfy normality. Fifth, the reliability of the measurement tools was confirmed by calculating Cronbach's ⍺, the internal consistency coefficient.
7. Ethical Considerations
This study was approved by the Institutional Review Board of Kyungpook University (IRB No. 2024-01-11). Participants were fully informed of the study's purpose, procedures, data collection, and their role, and only those who consented voluntarily were included. They were assured of their right to withdraw at any time without penalty and received a 30,000 KRW gift upon completion. Confidentiality and anonymity were strictly maintained, and data were used solely for research purposes and securely discarded after three years. Ethical communication was ensured throughout. After the study, the control group received the program workbook and an optional brief intervention session.
RESULTS
1. Homogeneity Testing of General Characteristics and Dependent Variables
Participants aged 50~59 years accounted for the largest proportion in both the experimental (42.9%), and in control (38.1%) groups. High school graduates were the largest group in both the experimental (47.6%) and control (57.1%) groups. Most participants in the experimental group (76.2%) had a religion, while most participants in the control group (52.4%) did not. Divorced or widowed participants were most common in the experimental group (42.9%), and single individuals in the control group (42.9%). Those without cohabitants were more frequent in both groups: 52.4% in the experimental and 76.2% control groups. Hospitalizations ranging 0~2 times were most common in the experimental group (52.4%), and 3~4 times in the control group (38.1%). Involuntary admissions were high in both groups (71.4% experimental, 61.9% control). x2 tests, Fisher's exact tests, and independent t-tests showed no significant differences in general characteristics (Table 2).
Homogeneity Test of General Characteristics and Study Variables between Two Groups in Pretest (N=42)
Independent t-tests and Mann-Whitney U tests were conducted to assess pre-intervention homogeneity of the dependent variables. No significant differences were found in perceived stress (z=-0.03, p=.980), anger rumination (t=1.31, p=.198), alexithymia (t=1.62, p=.114), or alcohol abstinence self-efficacy (t=-1.42, p=.162), confirming baseline homogeneity between groups (Table 2).
2. Hypotheses Testing
1) Hypothesis 1
The analysis of the degree of change in perceived stress showed that the experimental group's mean score significantly decreased from 3.07 before the program to 2.50 after it (z=-3.65, p<.001). Conversely, the control group showed no statistically significant change, with a pretest score of 3.18 and a posttest score of 3.12 (z=-0.72, p=.469). A comparison of the change in posttest scores between the two groups also showed that the experimental group had significantly reduced perceived stress compared to the control group (z=-3.91, p<.001). Therefore, this program was effective in reducing perceived stress, supporting Hypothesis 1 (Table 3).
Comparisons of the Dependent Variables between Two Groups (N=42)
2) Hypothesis 2
The analysis of the pre- and post-test changes in anger rumination scores showed that anger rumination significantly decreased in the experimental group from 3.01 to 1.89 after the program (t=-10.16, p<.001), while the control group showed no significant change (2.82 to 2.76; t=-0.68, p=.502). A between-group comparison revealed a greater reduction in the experimental group (t=-7.88, p<.001), supporting Hypothesis 2 (Table 3).
3) Hypothesis 3
Alexithymia scores in the experimental group significantly decreased from 3.37 to 2.79 (t=-4.66, p<.001), while the control group showed no significant change (3.08 to 3.00; t=-0.64, p=.531). A between-group comparison showed a greater reduction in the experimental group (t=-2.80, p=.008), supporting Hypothesis 3 (Table 3).
4) Hypothesis 4
Alcohol abstinence self-efficacy in the experimental group significantly increased from 1.21 to 1.79 (t=2.77, p=.010). A between-group comparison also showed a greater improvement in the experimental group (t=2.73, p=.011), supporting Hypothesis 4 (Table 3).
5) Hypothesis 5
Physiological attention in the experimental group significantly increased from 62.69 to 67.67 (t=-2.59, p=.018), supporting Hypothesis 5 (Table 3).
DISCUSSION
This study verified the effects of an emotion regulation program based on Gross's process model of emotion regulation, combined with focused biofeedback training, on perceived stress, anger rumination, alexithymia, alcohol abstinence self-efficacy, and physiological attention in hospitalized patients with alcohol use disorder. The study's main findings of follows.
The verification of Hypothesis 1 confirmed a significant difference in the change in perceived stress between the experimental and control groups, supporting this hypothesis. The experimental group exhibited a significantly greater reduction in perceived stress than the control group, indicating the program's efficacy in stress management and paralleling the effects of narrative-therapy group counseling in patients with alcohol use disorder [17]. Stress perception reflects cognitive appraisal of stimuli rather than the stimuli [10], aligning with findings that individuals with alcohol use disorder commonly resort to drinking as an avoidance strategy in stressful situations [5,10]. In the study's first session, perceived stress was reduced by applying physical relaxation therapy through biofeedback training, exploring automatic thoughts related to alcohol addiction, and applying emotion regulation strategies (situation selection) to stressful situations. To reduce stress, physical relaxation was implemented through diaphragmatic breathing before the program began [5]. Studies have reported the effectiveness of implementing biofeedback-based relaxation and concentration training in improving self-regulation skills and alleviating psychosomatic stress symptoms, such as anxiety and depression, by regulating brain homeostasis and improving attention [20]. Emotion regulation training is effective in reducing stress levels [17]. Exploring the reasons for alcohol use in stressful situations can significantly decrease perceived stress. Additionally, relaxation training using biofeedback, including the process of recognizing perceived stress situations and modifying distorted thoughts during inpatient treatment, has demonstrated significant effectiveness as an intervention to reduce relapse and aid prevention in individuals with alcohol use disorder.
The verification of Hypothesis 2 revealed a significantly greater reduction in anger rumination in the experimental group than in the control group, thus supporting the hypothesis. This suggests that anger-related cognitive patterns are modifiable through intervention. Comparable effects have been reported for cognitive defusion techniques [13], forgiveness therapy [11], and cognitive-behavioral music therapy [16]. In the third session, Gross's cognitive reappraisal strategy was employed to reinterpret irrational anger cognitions, thereby reducing rumination. Post-intervention, the experimental group exhibited a significant reduction in anger rumination, demonstrating the intervention's efficacy in modifying cognitive responses to anger- provoking events. Participants undergoing the program performed cognitive reappraisal of past anger-provoking events, thereby facilitating emotional recovery and recognizing that these events no longer exerted a direct influence on their current affective state. Post-intervention assessment using the Anger Rumination Scale demonstrated a significant reduction in ruminative thinking. These results suggest that the program can be an effective coping strategy for anger-provoking life events experienced by patients with alcohol addiction. It is consistent with previous research findings [8] regarding the need to move beyond emotion-focused approaches that simply aim to alleviate or resolve anger and instead change ruminative cognitive characteristics in relation to anger situations and stimuli. This study suggests the possibility of interventions aimed at changing the cognitive characteristics of anger rumination, going beyond anger emotion regulation traditionally emphasized by CBT [8,16]. This is a significant result suggesting that specific interventions for anger rumination can contribute to improving emotional regulation abilities and preventing relapses among patients with alcohol addiction [8]. Throughout the intervention, participants engaged in an anger reappraisal process that enabled them to express and resolve previously unaddressed emotions, which appeared to contribute positively to anger reduction [29]. This approach supports the idea that directly addressing anger, which is a significant relapse-promoting factor in patients with alcohol addiction, is an effective method [11]. If anger is not adequately resolved, the likelihood of aggressive behavior or alcohol reuse may increase, which can hinder treatment outcomes. Therefore, this study has practical significance in confirming the effectiveness of an emotion regulation program for hospitalized patients with alcohol addiction.
The verification of Hypothesis 3 demonstrated a significantly greater reduction in alexithymia in the experimental versus the control group, indicating enhanced emotional recognition and expression. The present study, along with those of Kim and Byrne et al, each comprised a four-session brief emotion regulation intervention, demonstrating significant effects even over a short timeframe [14,20]. The current study employed a biofeedback-based emotion regulation program, whereas Byrne et al. integrated mindfulness and mentalization techniques [14]. Both investigations reported significant reductions in alexithymia and achieved high participation and completion rates in forensic and inpatient settings, supporting the utility and acceptability of brief interventions across diverse clinical contexts. The meaningful effects observed with the brief four-session protocol used in this study suggest that short-term emotion regulation interventions can be sufficiently effective when combined with physiological interventions. Positive changes were achieved by improving emotional recognition and attention through diaphragmatic breathing and biofeedback, alongside training in effective emotion-expression techniques.
The verification of Hypothesis 4 revealed a significantly greater improvement in alcohol abstinence self-efficacy in the experimental versus the control group, thus supporting this hypothesis. Alcohol abstinence self-efficacy significantly increased in the experimental group, consistent with the results of non-pharmacological interventions such as abstinence programs [9], cognitive-behavioral programs [5], and group art therapy [23]. Alcohol abstinence self-efficacy is an important psychological resource for preventing relapses among patients with alcohol use disorder [25], and this program helped improve practical self-efficacy by promoting positive self-awareness through emotion regulation strategies and training in refusing alcohol through assertiveness. Abstinence self-efficacy is useful for coping with high-risk drinking situations, influences health-promoting behaviors, and plays a key role in relapse prevention [5,23]. In particular, the fourth "response modulation" phase of the program was designed to regulate previously experienced emotional responses and elicit adaptive ones. One of the strategies in this phase-effective emotion expression training-was structured to support the acquisition of practical adaptive skills, such as communication and problem-solving abilities required in interpersonal contexts [5], thereby contributing to strengthening alcohol abstinence self-efficacy. These results are congruent with studies [5,9,23] that emphasized the need to acquire practical skills to improve alcohol abstinence self-efficacy. In alcohol addiction, self-efficacy is a key internal factor that promotes motivation and the acquisition of skills necessary for change [5], and this study suggests that strengthening these internal factors provides practical help in enhancing alcohol abstinence self-efficacy.
The verification of Hypothesis 5 confirmed a significant increase in physiological attention concentration within the experimental group, supporting this hypothesis. Physiological attention also significantly improved after the short-term emotion regulation program with biofeedback, showing an increase from pretest (62.69 points) to posttest (67.67 points). This finding is consistent with the results of a biofeedback training study targeting adolescents who had experienced sexual assault [20]. It also aligns with a biofeedback study on sexually assaulted adolescents [20], in which participants reported enhanced attention shifting and anger self-control, and the researcher confirmed their sustained focus throughout the training. If concentration decreased during training, focus was induced through immediate feedback on the results provided at the end of each training game. Participants were encouraged to self-reflect on and self-assess the strategies they used to improve their attention performance or their physical and emotional states when their attention performance decreased. Biofeedback contributed to arousing interest and increasing participation through the game format. Supporting the strengthening of concentration in each session through the repetition of easy patterns. Furthermore, drawing on prior research the demonstrated diaphragmatic breathing exercises and environmental modifications effectively enhance concentration [21], the researcher identified factors impeding participants' focus during training-such as reduced physical condition, waning interest, and other distractions-and implemented the corresponding remedial strategies within the biofeedback training sessions. This approach alleviated negative psychological states during training, fostered a positive environment, and provided encouragement and support to facilitate deeper engagement in subsequent sessions.
Gross's biofeedback-enhanced emotion regulation program significantly improved emotional (perceived stress, anger rumination, alexithymia) and behavioral (abstinence self-efficacy, physiological attention) outcomes in patients with alcohol use disorder, supporting its feasibility as a practical nursing intervention to reduce relapse risk. By preceding each session with diaphragmatic breathing and biofeedback-based concentration training, participant immersion and intervention efficacy were enhanced. As the first biofeedback-integrated emotion regulation intervention for this population, this study pioneers and validates its effectiveness.
This study had some limitations. First, patients with alcohol use disorder exhibited marked variability in hospitalization duration due to frequent readmissions and discharges, which constrained participant recruitment. Individuals with shorter stays or strong preferences for early discharge were unable to enroll, potentially introducing selection bias and limiting sample homogeneity [1,4]. Second, participant selection was limited to convenience sampling at two hospitals, limiting the generalizability of the results. Third, as this study was conducted only on male patients, follow-up studies on female patients with alcohol use disorder or other addictions are needed.
The four-session brief emotion regulation intervention developed in this study was expressly designed for early implementation in individuals with alcohol use disorder at elevated risk of relapse, thereby facilitating the rapid acquisition of core emotion regulation skills and adaptive coping strategies. This early-phase approach augments initial treatment engagement and self-efficacy, while its concise session structure minimizes clinical resource utilization- including personnel, time, and equipment-and permits flexible deployment across diverse inpatient settings [1,26,27]. Moreover, by attenuating negative affect and fostering multifaceted coping strategy learning during hospitalization, the intervention proactively targets primary relapse- precipitating factors, suggesting its potential to stabilize long-term treatment trajectories. These results support the active implementation of emotion regulation interventions during the hospitalization period after detoxification to prevent repeated relapses in patients with alcohol addiction [1]. Subsequent research is recommended to track the program's long-term effects and expand the research to a continuous management model that can confirm its impact on reducing relapses after discharge.
This study employed nonpharmacological cognitive-behavioral techniques in line with previous psychosocial interventions but differs in three key respects. First, whereas prior research relied on group discussion and self-report measures, it strengthens self-regulation by delivering immediate biofeedback through real-time measurement and visualization of physiological attention. Second, instead of the conventional 8~12 session format, it demonstrates significant improvements in emotional stability and self-efficacy with only four weekly sessions, augmenting engagement via gamified tasks and session-by-session self-assessment and strategy sharing. Third, it concurrently verifies psychological scales alongside pre- and postintervention physiological indices to comprehensively elucidate psychophysiological relationships [1,25,30].
This study presents three clinical implications: First, a standardized protocol combining real-time physiological attention biofeedback with diaphragmatic breathing accelerates emotional engagement and self-regulation; second, a four-session brief intervention is feasible within typical inpatient stays and, when integrated into existing therapeutic and educational activities, maximizes resource and staffing efficiency; and third, the incorporation of gamified training tasks with session-by-session self-assessment and strategy sharing enables early detection of motivational decline and delivery of individualized nursing encouragement..
The biofeedback-enhanced brief emotion regulation program significantly improved perceived stress, anger rumination, alexithymia, alcohol abstinence self-efficacy, and physiological attention in patients with alcohol use disorder. These results indicate that integrating biofeedback-based relaxation and attention training can effectively enhance emotional awareness and expression. Consequently, this multicomponent intervention is validated as an effective physiological, experiential, cognitive, and behavioral strategy for this population.
From a nursing perspective, this study applied Gross's model-based intervention to hospitalized patients with alcohol use disorder, confirming its effectiveness. The study provides foundational data for mental health nursing interventions.
CONCLUSION
A brief, biofeedback-integrated emotion regulation program grounded in Gross's process model-uniting cognitive, behavioral, experiential, and physiological strategies-significantly reduced perceived stress, anger rumination, and alexithymia while enhancing abstinence self-efficacy and physiological attention, demonstrating its efficacy as a short-term inpatient intervention to bolster emotional regulation, psychological stability, and relapse prevention in patients with alcohol use disorder.
Notes
Park, Wanju has been an editorial board member since January 2020, but has no role in the decision to publish this article. Except for that, no potential conflict of interest relevant to this article was reported.
AUTHOR CONTRIBUTIONS
Conceptualization or/and Methodology: Hong, M-J & Park, W
Data curation or/and Analysis: Hong, M-J & Park, W
Investigation: Hong, M-J & Park, W
Project administration or/and Supervision: Park, W
Resources or/and Software: Hong, M-J
Validation: Hong, M-J & Park, W
Visualization: Hong, M-J & Park, W
Writing: original draft or/and review & editing: Hong, M-J & Park, W