This application addresses broad Challenge Area (01) Behavior, Behavioral Change, and Prevention and specific Challenge Topic, 01-GM-104: Mechanisms of Behavior Change Research. Cognitive-behavioral therapy (CBT) is well-established as an effective treatment for alcohol dependence. However, many of the pretreatment-posttreatment designs used to study CBT, while important in answering questions about if a treatment works, provide much less information about how CBT works. In recent years, there has been a resurgence of interest in studying what happens between the pretreatment and posttreatment assessment- the process of change-and a renewed understanding of the important role of this research in treatment development (Hayes, Hope, &Hayes, 2007). A central mechanism of CBT is the acquisition and use of coping skills. However, in a review of 10 studies that tested coping as a hypothesized mechanism of action of CBT, Morganstern and Longabuagh (2000) concluded that there is no support for the hypothesis that CBT works through its effects on coping. Although several possible mechanisms have been proposed to explain the effects of CBT, it is rare that more than one mechanism is studied. According to Kazdin (2007), the assessment of multiple mediators (viz. mechanisms) in a given study has enormous benefits. If two or more mechanisms are studied, one can identify if one is more plausible or makes a greater contribution to the outcome. In addition, the assessment of multiple potential mechanisms is cost efficient, given the amount of time and resources needed for any one treatment outcome study. Across many studies, some mechanisms may repeatedly emerge as possible contenders while others fall by the wayside. In addition to coping skills, two key mechanisms posited to underlie the effectiveness of CBT are increasing self-efficacy and self- confidence and reducing positive outcome expectancies for alcohol use (Moos, 2007). Two other mechanisms, thought to be operating across many different interventions, including CBT, are increasing the therapeutic alliance and reducing/regulating negative emotional states. For the present study, participants will be 72 alcohol dependent men and women who agree to participate in a 12-week trial of CBT for alcohol dependence. In addition, comprehensive research assessments will be conducted with patients at baseline, end of treatment, and 3-months posttreatment. The overarching goal of the present study is to map the process of change in successful CBT by measuring the aforementioned 4 theoretically relevant behavioral mechanisms of change on multiple (i.e., weekly) occasions during treatment. As Hayes et al. (2007) state, such a "map" would have several important implications, including, (1) further refinement of existing treatment procedures;(2) a clearer picture of the processes of recovery, treatment dropout, poor response, and relapse;and (3) further development of empirically supported treatment processes. Although several possible mechanisms have been proposed to explain the effects of CBT, it is rare that more than one mechanism is studied. The goal of the present study is to map the process of change in successful CBT by measuring 4 theoretically relevant behavioral mechanisms of change on multiple occasions during treatment (i.e., following weekly treatment sessions). Such a fine-grained analysis is needed in order to study the unfolding of processes over time. Such a "map" would have several important implications, including, (1) further refinement of existing treatment procedures;(2) a clearer picture of the processes of recovery, treatment dropout, poor response, and relapse;and (3) further development of empirically supported treatment processes.
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