Cognitive-Behavioural group training (CBGT) is a psycho-educational intervention developed by Snoek and colleagues87 at the Vrije Universiteit Hospital, Amsterdam, in collaboration with Jacobson and associates at the Joslin Diabetes Center, Boston. CBGT was designed to be delivered in an outpatient setting, by a team of a diabetes nurse specialist and a psychologist. The overall goal of CBGT is to help patients to cope more effectively with their diabetes regimen, in order to improve glycaemic control, without compromising, and possibly enhancing, psychological well-being. CBGT is based on principles from cognitive-behavioural therapy (CBT) and rational emotive therapy (RET). Several cognitive and behavioural techniques (cognitive restructuring, stress-management, cueing) are used to help patients to diminish diabetes-related distress, to reduce perceived barriers to various aspects of self-management and to enhance coping skills. This should result in improved self-care behaviour and consequently in improved glycaemic control.

Rubin, Walen and Ellis88 describe that in diabetes, apart from the regimen being demanding, unpleasant and having negative side-effects, a major reason for low adherence is the pessimistic belief that 'trying hard does not work'. Multiple failures to control the diabetes can give rise to feelings of frustration, hopelessness and anger. Feelings of guilt can develop from the patient's belief that he/she must have done something wrong. Such feelings of distress foster a negative attitude towards diabetes and self-care, encouraging people to 'let it all go' instead of keeping up the effort, thereby reinforcing the negative cycle of negative emotions leading to poor management and control, giving rise to even more negative feelings.

This view is in line with the cognitive model: past experiences with diabetes may give rise to cognitive distortions that colour present events. When these past experiences have been mainly negative, events in the present will easily trigger negative automatic thoughts that, in turn, result in unpleasant feelings towards diabetes and inadequate self-management. Examples of cognitive distortions that might occur in people with diabetes are: the belief that blood glucose levels depend on 'chance' and are beyond personal control; the belief that sticking to the treatment will have no positive effects on blood glucose levels or future complications; the conviction that one is not capable of meeting all the demands imposed by the regimen. Such beliefs can easily lead to unpleasant emotions and poor self-management.

CBGT is designed to deal with a broad range of problems, addressing various themes. To evaluate which patients benefit most, what problems are best resolved and what the effects of CBGT are in the longer term, this intervention was piloted in a 2-year study. In the following sections, formative and summative evaluations of four CBGT groups that took part in this study are described, preceded by an outline of the intervention8 .

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