Identifying Multiple Mechanisms of Change in Alcoholism Treatment

描述（由申请人提供）：本申请涉及广泛的挑战领域（01）行为，行为改变和预防以及特定的挑战主题，01- gm -104：行为改变研究的机制。认知行为疗法（CBT）是公认的治疗酒精依赖的有效方法。然而，许多用于研究CBT的治疗前-治疗后设计，虽然在回答治疗是否有效的问题上很重要，但提供的关于CBT如何起作用的信息却少得多。近年来，人们对研究治疗前和治疗后评估之间发生了什么——变化的过程——重新产生了兴趣，并重新认识到这项研究在治疗发展中的重要作用（Hayes, Hope, & Hayes, 2007）。CBT的核心机制是应对技能的获得和使用。然而，Morganstern和Longabuagh（2000）在回顾了10项将应对作为CBT的假设作用机制进行测试的研究后得出结论，认为CBT通过其对应对的影响来起作用的假设没有得到支持。虽然已经提出了几种可能的机制来解释CBT的效果，但很少有一种以上的机制被研究。根据Kazdin（2007）的说法，在给定的研究中对多种介质（即机制）的评估具有巨大的好处。如果研究了两种或两种以上的机制，就可以确定哪一种机制更合理或对结果的贡献更大。此外，考虑到任何一项治疗结果研究所需的时间和资源，评估多种潜在机制具有成本效益。在许多研究中，一些机制可能反复出现，成为可能的竞争者，而另一些机制则被搁置在一边。除了应对技能外，CBT有效性的两个关键机制是提高自我效能和自信，降低对酒精使用的积极结果预期（Moos, 2007）。另外两种机制，被认为在许多不同的干预措施中起作用，包括CBT，正在增加治疗联盟并减少/调节消极情绪状态。在目前的研究中，参与者将是72名酒精依赖的男性和女性，他们同意参加为期12周的酒精依赖CBT试验。此外，将对基线、治疗结束和治疗后3个月的患者进行全面的研究评估。本研究的首要目标是通过测量上述四种理论相关的行为机制，在治疗期间多次（即每周）的改变，来描绘成功的CBT的改变过程。正如Hayes等人（2007）所说，这样的“地图”将有几个重要的含义，包括：(1)进一步完善现有的治疗程序；(2)更清晰地了解康复、退出治疗、不良反应和复发的过程；(3)进一步发展实证支持的治疗过程。虽然已经提出了几种可能的机制来解释CBT的效果，但很少有一种以上的机制被研究。本研究的目的是通过测量治疗期间（即每周治疗后）在多个场合（即每周治疗后）的4种理论相关的行为改变机制，来绘制成功的CBT的改变过程。为了研究过程随时间的展开，需要这种细粒度的分析。这样的“地图”将有几个重要的含义，包括：(1)进一步完善现有的治疗程序；(2)更清晰地了解康复、退出治疗、不良反应和复发的过程；(3)进一步发展实证支持的治疗过程。

DESCRIPTION (provided by applicant): 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.