Deficits in Emotion-Regulation Skills Predict Alcohol Use During andAfter Cognitive–Behavioral Therapy for Alcohol Dependence

Matthias BerkingUniversity of Marburg

Matthias MargrafUniversity of Lubeck

David EbertUniversity of Marburg

Peggilee WuppermanJohn Jay College/City University of New York and

Yale School of Medicine

Stefan G. HofmannBoston University

Klaus JunghannsUniversity of Lubeck

Objective: As emotion regulation is widely considered to be a primary motive in the misuse of alcohol, ouraim in the study was to investigate whether deficits in adaptive emotion-regulation skills maintain alcoholdependence (AD). Method: A prospective study investigated whether emotion-regulation skills were associ-ated with AD and whether these skills predicted alcohol use during and after treatment for AD. Participantswere 116 individuals treated for AD with cognitive–behavioral therapy. Emotion regulation and severity ofAD symptoms were assessed by self-report. Alcohol use during treatment was assessed by Breathalyzer andurine analysis for ethyl glucuronide; alcohol use during the 3-month follow-up interval was assessed byself-report. Results: Pretreatment emotion-regulation skills predicted alcohol use during treatment, andposttreatment emotion-regulation skills predicted alcohol use at follow-up, even when controlling for otherpredictors potentially related to emotion regulation. Among a broad range of specific emotion-regulationskills, the ability to tolerate negative emotions was the only skill that negatively predicted subsequent alcoholconsumption when controlling for the other skills. Individuals in the AD sample reported significantly largerdeficits in emotion-regulation skills than did those in a nonclinical control sample but significantly less thandid those in a sample of individuals exclusively meeting criteria for major depressive disorder. Conclusions:Enhancement of general emotion-regulation skills, especially the ability to tolerate negative emotions, appearsto be an important target in the treatment of AD.

Keywords: alcohol, treatment, relapse, emotion regulation, skills

Alcohol dependence (AD) is the most serious form of alcohol-use disorder. AD is associated with intense mental, physical, andfunctional impairment; high societal costs; and long-term sufferingby both the dependent individual and the individual’s family

members (e.g., Caetano, Nelson, & Cunradi, 2001). However, ADis also fairly widespread, with a 12-month prevalence rate ofnearly 4% in the general population (Hasin, Stinson, Ogburn, &Grant, 2007). Despite the development and implementation ofseveral empirically supported treatments, only about 25% of cli-ents have been found to remain abstinent during the first yearfollowing treatment termination (Miller, Walters, & Bennett,2001). Thus, there is a strong and pressing need to improve theefficacy of treatment for AD.

According to the relapse prevention model proposed by Marlattand Witkiewitz (2005), relapse is likely to occur when at-riskindividuals are confronted with high-risk situations and lack thecoping skills necessary to deal with such situations effectively.Consistent with this model, a number of studies have focused onidentifying specific high-risk situations. Extensive evidence fromthese studies has shown that negative affect is one of the mostprominent factors associated with relapse to maladaptive drinking.First, AD is highly associated with affect-related disorders, such asanxiety, depression, and borderline personality disorder (Gregoryet al., 2008; Hasin et al., 2007), and individuals with co-occurringsymptoms of these disorders display significantly higher rates ofrelapse after treatment (Bradizza, Stasiewicz, & Paas, 2006). Sec-

This article was published Online First May 2, 2011.Matthias Berking and David Ebert, Department of Clinical Psychology

and Psychotherapy, Philipps-University Marburg, Marburg, Germany;Matthias Margraf and Klaus Junghanns, Department of Psychiatry andPsychotherapy, University of Lubeck/AHG Klinik Holstein, Lubeck, Ger-many; Peggilee Wupperman, Department of Psychology, John Jay Collegeof Criminal Justice, and Department of Psychiatry, Yale University; StefanG. Hofmann, Department of Psychology, Boston University.

Stefan G. Hofmann is a paid consultant of Schering-Plough for researchunrelated to this study, and he is supported by National Institute of MentalHealth Grant MH078308. Preparation of this paper was supported by SwissNational Science Foundation Grants PA001-113040 and PZ00P1-121576to Matthias Berking. The study was also supported by German Society forResearch in Rehabilitation Medicine Grant vffr-sh 91.

Correspondence concerning this article should be addressed to MatthiasBerking, Department of Clinical Psychology and Psychotherapy, University ofMarburg, Gutenbergstrasse 18, D-35032 Marburg, Germany. E-mail:berking@staff.uni-marburg.de

Journal of Consulting and Clinical Psychology © 2011 American Psychological Association2011, Vol. 79, No. 3, 307–318 0022-006X/11/$12.00 DOI: 10.1037/a0023421

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ond, the majority of clients retrospectively attribute relapse tonegative affective states (Lowman, Allen, & Stout, 1996; Zywiak,Connors, Maisto, & Westerberg, 1996). Third, negative affect—such as stress or nervousness, anxiety, anger, dysphoric/depressedmood, and feelings of loneliness, uselessness, or boredom—predicts subsequent desire to drink and drinking level in epidemi-ological studies, as well as relapse in treatment-outcome studies(Falk, Yi, & Hilton, 2008; Gamble et al., 2010; Hodgins, el-Guebaly, & Armstrong, 1995; Swendsen et al., 2000; Willinger etal., 2002). Fourth, in laboratory paradigms, the induction of neg-ative affect was shown to predict increased urges to drink andincreased expectancies of relief after drinking (Birch et al., 2004;Cooney, Litt, Morse, Bauer & Gaupp, 1997; Sinha et al., 2009).Fifth, interventions focusing on the reduction of depressed moodor anxiety symptoms have been shown to decrease relapse andseverity of alcohol use disorders (Brown, Evans, Miller, Burgess,& Mueller, 1997; Watt, Stewart, Birch, & Bernier, 2006), andinterventions with a strong focus on emotion-regulation skills,such as dialectical behavioral therapy (Linehan, 1993a), have beenshown to reduce substance use (including alcohol) in clients withborderline personality disorder (Harned et al., 2008; Linehan et al.,2002). Finally, evidence suggests that although alcohol may ini-tially reduce negative affect to some extent (Armeli et al., 2003;Kushner et al., 1996; Swendsen et al., 2000), maladaptive useeventually leads to the continuation and potential increase of suchaffect, thereby generating a vicious cycle contributing to thechronic and escalating nature of AD (Heinz et al., 1998; Koob &Le Moal, 2001; Witkiewitz & Villarroel, 2009).

In line with these findings, a number of theories contend thataffect regulation is a primary motive for alcohol use; such modelsinclude the affective processing model (Baker, Piper, McCarthy,Majeskie, & Fiore, 2004), the motivational model of alcohol use(Cooper, Frone, Russell, & Mudar, 1995; Cox & Klinger, 1988),the stress and negative affect model (Colder & Chassin, 1993), theself-medication model (Khantzian, 1997), the stress-responsedampening theory (Levenson, Sher, Grossman, Newman, & New-lin, 1980), and the tension reduction hypothesis (Conger, 1956).The implication of these models is that emotion-regulation skills(i.e., skills relevant for “monitoring, evaluating, and modifyingemotional reactions, especially their intensive and temporal fea-tures, to accomplish one’s goals”; Thompson, 1994, pp. 27–28),should be important—if not essential—for preventing relapse inAD. This hypothesis received preliminary support from studiesdemonstrating that trait emotional intelligence (defined as theability to be aware of emotions, identify emotions correctly, andmodify emotions effectively) was negatively associated withalcohol-related problems (Riley & Schutte, 2003) and that emo-tional intelligence moderated the association between negativeemotions and craving for alcohol in patients with AD (Cordovil deSousa Uva et al., 2010). Additional research has shown thatabstinent alcoholics report more difficulty effectively regulatingtheir emotions than do social drinkers (Fox, Hong, & Sinha, 2008).However, research has yet to investigate the predictive effects ofemotion-regulation skills on alcohol use during and aftertreatment.

To facilitate the utilization of the emotion-regulation frameworkfor clinical purposes, Berking (2010) has synthesized and ex-panded upon previous theories (e.g., Greenberg, 2002; Gross,1998; Larsen, 2000; Saarni, 1999) and proposed a skill-based

model of emotion regulation. According to the adaptive copingwith emotions (ACE) model (Berking, 2010), effective emotionregulation can be conceptualized as the situation-adapted interplayof the abilities to (a) be aware of emotions, (b) identify and labelemotions, (c) correctly interpret emotion-related body sensations,(d) understand the prompts of emotions, (e) actively modify neg-ative emotions to feel better, (f) accept negative emotions whennecessary, (g) tolerate negative emotions when they cannot bechanged, (h) confront (vs. avoid) distressing situations in order toattain important goals, and (i) compassionately support (encour-age, self-soothe) oneself in emotionally distressing situations (inorder to counterbalance potential short-term negative effects thatengagement in the other skills may have on one’s emotions).Empirical studies have shown that all skills included in the ACEmodel are significantly associated with various indicators of men-tal health in clinical and at-risk populations (Berking, Meier, &Wupperman, 2010; Berking, Orth, Wupperman, Meier, & Caspar,2008; Berking, Poppe, et al., 2011; Berking, Wupperman, et al.2008; Berking & Znoj, 2008). However, research has not yetinvestigated whether these skills are associated with AD andwhether they facilitate abstinence during or after treatment for AD.In addition, as deficient emotion-regulation skills are likely to beassociated with other potential predictors of relapse, such as symp-tom severity (Langenbucher, Sulesund, Chung, & Morgenstern,1996), degree of comorbidity (Tate, Brown, Unrod, & Ramo,2004), cognitive abilities (Blume, Schmaling, & Marlatt, 2005),and negative mood (Hodgins et al., 1995), it is important toinvestigate whether emotion-regulation skills predict alcohol usebeyond these additional factors.

Moreover, there is a lack of research comparing the emotion-regulation skills of populations with alcohol-use disorders andthose of other clinical populations. Although some evidence existsfor the transdiagnostic nature of emotion-regulation skills (Aldao,Nolen-Hoeksema, & Schweizer, 2010), deficits in these skills maybe more integral to some disorders than to others. For example, inthe emotional disorders (i.e., depression and anxiety), the inabilityto effectively regulate dysfunctional emotions can be conceptual-ized as the core of these disorders (Moses & Barlow, 2006);whereas in disorders such as AD, deficits in these skills might beseen as one relevant factor among many that contribute to the onsetand maintenance of the disorder (Marlatt & Donovan, 2005).Finally, few studies have assessed a broad range of emotion-regulation skills in order to identify the skills most strongly asso-ciated with (changes in) psychopathological symptoms (e.g., Berk-ing, Wupperman, et al., 2008) and, thus, the skills that should beconsidered important targets in treatment. At this point, no suchstudy is available for AD.

Therefore, our major aim in the present study was to test theprimary hypotheses that (a) more effective pretreatment emotion-regulation skills would negatively predict alcohol use during treat-ment and (b) more effective posttreatment emotion-regulationskills would negatively predict alcohol use during the 3 monthsfollowing termination of treatment, even when controlling forother predictors potentially related to emotion regulation.

Additionally, we investigated whether (a) more effective pre-treatment emotion-regulation skills would be associated withlower pretreatment AD symptom severity, (b) patients with ADwould report less successful emotion-regulation than did nonclini-cal controls but more successful emotion regulation than did

308 BERKING ET AL.

patients meeting criteria for major depressive disorder (MDD), and(c) specific emotion-regulation skills could be identified as partic-ularly important in negatively predicting alcohol use during andafter treatment for AD.

Method

Participants and Procedures

Participants were 116 inpatients referred to a hospital that spe-cialized in treating alcohol use disorders (AHG Clinic; Lubeck,Germany). Inclusion criteria for the study were (a) diagnoses ofalcohol dependence based on International Statistical Classifica-tion of Diseases and Related Health Problems (10th rev.; ICD-10;Dilling, Mombour, & Schmidt, 2004); (b) successful completion ofdetoxification; (c) an intended treatment length of at least 6 weeks;and (d) sufficient German spelling skills. The only exclusioncriterion was a significant risk for suicide, which was assessedduring the intake interview by trained clinicians. As part of thisassessment, the clinician gathered information on the history ofsuicide attempts, current intention and plans to commit suicide,availability of specific suicide means and plans, and reasons forliving. Enrollment occurred between November 2006 and Septem-ber 2007. Diagnoses were based on ICD-10 criteria for AD(Dilling et al., 2004). Assessments of diagnoses and other studycriteria were conducted during an intake interview by experiencedpsychotherapists. They were either psychologists or physicianswith master’s degrees or above and had been trained extensively inthe Structured Clinical Interviews for DSM–IV (German version;Wittchen, Zaudig, & Fydrich, 1997). In addition to self-report andinterview data, measurement of alcohol use included urine andbreath-analyzer tests (see Measures). All participants met criteriafor AD according to ICD-10 (F10.2). In addition, 70.7% of par-ticipants met ICD-10 criteria for at least one comorbid mentaldisorder, and 34.5% of participants met criteria for at least twocomorbid disorders. The most common comorbid disorders werenicotine dependence (52.6%), anxiety disorders (19.9% total;12.9% social anxiety disorder, 6.9% specific phobia, 3.5% post-traumatic stress disorder), substance-related disorders other thanalcohol or nicotine dependence (15.5% total; 9.5% politoxicoma-nia, 2.6% cannabis, 1.8% tranquilizer, 0.9% opiates), affectivedisorders (13.8% total; 12.9% MDD, 0.9 dysthymia), and person-ality disorders (8.6% total; 2.6% borderline personality disorder,1.7% avoidant personality disorder).

The majority of participants were male (84%), and all wereCaucasian. The average age of participants was 43.10 years(range � 23–68 years; SD � 9.75). The highest level of educationachieved was as follows: 9 years of school with no degree for9.2%, 9 years of school with the corresponding degree for 65%, 10years of school with the corresponding degree for 20%, highschool degree for 3.3%, and college/university degree for 2.5%.Among all participants, 21.6% reported living in a steady relation-ship and 27.7% reported being currently employed or having asteady job. According to self-reports, average consumption ofalcohol prior to detoxification was 1,728.09 grams of alcohol perweek (range � 100–6,860, SD � 1,127.90), and average length ofproblematic use 154.11 months (range � 6–420 months, SD �95.25).

To compare the pretreatment emotion-regulation skills (assessedwith the Emotion-Regulation Skills Questionnaire; ERSQ; Berk-ing & Znoj, 2008) of individuals with AD (N � 116) with the skillsof a nonclinical control group and a clinical MDD group, we useddata from several previous community and clinical studies inwhich the ERSQ was administered. For the nonclinical controlgroup, we used a sample of 385 participants (assessed betweenDecember 2008 and November 2009) who had reported that theyhad never engaged in psychotherapeutic treatment. For the clinicalcontrol group, we began with a combined sample of 4,096 non-suicidal patients from a German mental health clinic and identified680 patients who met criteria exclusively for MDD according toICD-10 criteria, as assessed by experienced clinicians at intakebetween January 2008 and December 2009. When suicidality wasassessed, the same criteria and procedures were used in the MDDand the AD sample. For each participant of the AD sample, wefirst narrowed the control sample to the matching gender. In asecond step, we selected those controls who matched the patientwith AD with regard to age. In the absence of a perfect match, thecontrol with the smallest difference in age was chosen; if severalcontrols showed the same age difference, we chose by the toss ofa coin. Because the AD sample was predominantly male and thebasis for both other samples was predominantly female, we did notachieve a perfect fit. Average age of the nonclinical control samplewas 43.2 (range � 22–65 years, SD � 9.9), and 88% were male.Average age of the MDD sample was 44.5 (range � 22–63 years,SD � 9.8), and 78.8% were male. All participants in the nonclini-cal control and the MDD sample were Caucasian. There were nosignificant differences regarding age, gender, and ethnic back-ground among the three samples. For all participants, study par-ticipation was voluntary, informed consent was obtained, andinternationally accepted human-research guidelines (e.g., HelsinkiProtocol) were followed.

Treatment

Average length of treatment was 98 days (range � 42–126 days,SD � 21.26). Treatment consisted primarily of cognitive–behavioral relapse prevention (based on Marlatt & Donovan, 2005)explicitly aimed at complete and sustained abstinence. All patientscompleted medical detoxification prior to treatment. Each patientreceived one 50-min session of individual therapy and four 90-minsessions of group-based therapy per week. Additionally, eachpatient participated in specific target groups, such as psychoedu-cation and motivation enhancement (six sessions), advanced re-lapse prevention training (nine sessions), and social skills training(eight sessions). Patients meeting criteria for co-occurring anxietydisorders also participated in a treatment group focusing on anx-iety disorders (10 sessions). Following established principles andstrategies of cognitive–behavioral therapy (CBT), all treatmentcomponents focused on changing cognitions and behavior. Nospecific emotion-regulation training (e.g., Berking, 2010) oremotion-focused techniques (Greenberg, 2002) were applied.Emotion-related skills were targeted only to the extent that thera-pists considered these skills relevant for CBT relapse preventionskills and/or to the extent that they referred to specific emotionsrelevant for co-occurring problems (e.g., social anxiety manage-ment skills in the social skills training group). Therapists werelicensed psychotherapists (n � 5) or postgraduate fellows in ad-

309EMOTION REGULATION IN ALCOHOL DEPENDENCE

vanced stages of clinical training (n � 3). All had been trained inCBT-based relapse prevention for AD and had at least 2 years ofclinical practice (range � 2–22 years; M � 11.38, SD � 8.12).Additionally, adherence to the treatment protocol was ensured byweekly supervision delivered by experienced licensed therapists.In addition to receiving the CBT-based psychotherapeutic inter-ventions, all patients received four sessions per week of occupa-tional therapy, two sessions per week of sports therapy, and onesession per week of art therapy. None of these adjunctive measuresfocused systematically on emotion-regulation skills.

Measures

Emotion-regulation skills. Emotion-regulation skills wereassessed with the Emotion-Regulation Skills Questionnaire(ERSQ; German version; Berking & Znoj, 2008). The ERSQ is a27-item self-report instrument that utilizes a 5-point Likert-typescale (0 � not at all to 4 � almost always) to assess the adaptiveemotion-regulation skills described in the Introduction. Each skillis assessed with a subscale of three items. Items are preceded bythe stem, “Last week . . .” Items include “I paid attention to myfeelings” (Awareness); “my physical sensations were a good indi-cation of how I was feeling” (Sensations); “I was clear about whatemotions I was experiencing” (Clarity); “I was aware of why I feltthe way I felt” (Understanding); “I accepted my emotions” (Ac-ceptance); “I felt I could cope with even intense negative feelings”(Tolerance); “I did what I had planned, even if it made me feeluncomfortable or anxious” (Readiness to Confront DistressingSituations); and “I was able to influence my negative feelings”(Modification). In addition to the subscales, the ERSQ consists ofa total score that is computed as the average of all items.

In previous studies, the ERSQtotal score displayed adequate-to-good internal consistencies (Cronbach’s � � .90) and adequateretest stability (rtt � .75; 2-week interval); results from exploratoryand confirmatory factor analyses provide support for the assumeddimensionality of the measure, and sensitivity to change has beendemonstrated in multiple samples of clients undergoing psycho-therapeutic treatment. Consistent with theoretical expectations, allscales have demonstrated positive associations with measures ofwell-being and mental health and negative associations with mea-sures of ill-being, psychopathology, and emotion-regulation defi-cits (Berking, Wupperman, et al., 2008; Berking & Znoj, 2008). In

the current study, the ERSQ showed good internal consistenciesfor most scales, with alphas ranging from .7 to .9. The scalesSensations, Acceptance, Self-Support, and Readiness to Confrontshowed alphas between .6 and .7 (see Table 1).

AD symptom severity. Severity of AD was assessed with thetotal score of the Severity Scales of Alcohol Dependence (SESA;German version: John, Hapke, & Rumpf, 2003). The SESA is aself-report questionnaire consisting of 33 items addressing theseverity of AD symptoms as included in the Diagnostic andStatistical Manual of Mental Disorders (e.g., tolerance, with-drawal, craving/persistent desire to drink, loss of control overdrinking, preoccupation with alcohol use; American PsychiatricAssociation, 2000). A total score with a potential range of 0 to 100is computed. The reliability and validity of the SESA have beendemonstrated in several studies (John et al., 2003). Additionally,self-reports of average amount of alcohol consumed per day wasassessed at intake based on the most recent drinking phase prior todetoxification. Assessment of alcohol consumed per day includedthe type and quality of all beverages containing alcohol and wasbased on procedures developed by Sobell, Sobell, Klajner, Pavan,and Basian (1986). Information provided by participants was sub-sequently converted to grams of alcohol per day.

Alcohol use. According to facility rules, patients were pro-hibited from consuming any alcohol during treatment, and theywere informed that disclosure of repeated use might lead to ter-mination from the program. Given these rules, self-reports wereunlikely to be reliable indicators of alcohol use during treatment.Therefore, consumption of alcohol during treatment was assessedwith a breath-analyzer machine (Breathalyzer; Alcotest 7410,Draeger Inc.) and urine toxology screens. Breathalyzer tests oc-curred throughout the treatment at three preset times per day, aswell as anytime clinical staff suspected alcohol use. Any level ofalcohol measured after patients rinsed their mouths was recordedas evidence for alcohol use. To detect alcohol after patients wereaway from the facility for more than a few hours, staff urinesamples were collected and analyzed for ethyl glucuronide (EtG).Urinary EtG was analyzed at the Institute of Clinical Chemistry ofthe University Clinic of Lubeck. EtG was determined by a directnegative electrospray ionization liquid chromatography–massspectrometry method using a 500-ms ion trap, a binary ProStarsolvent delivery system, and a 410 autosampler (all from Varian,

Table 1Alphas and Intercorrelations of ERSQ Scales for the AD Sample (Pretreatment)

ERSQ scale � 1 2 3 4 5 6 7 8 9 10

1. Awareness .83 —2. Sensations .61 .56 —3. Clarity .78 .45 .68 —4. Understanding .78 .52 .58 .73 —5. Acceptance .68 .57 .61 .66 .62 —6. Tolerance .84 .38 .48 .59 .55 .70 —7. Self-support .67 .33 .49 .56 .45 .48 .51 —8. R. to confront .66 .34 .51 .51 .42 .43 .55 .62 —9. Modification .76 .46 .62 .55 .61 .53 .58 .58 .53 —

10. ERSQtotal .94 .67 .79 .83 .80 .81 .78 .73 .71 .80 —

Note. All intercorrelations are significant with p � .001. ERSQ � Emotion-Regulation Skills Questionnaire; AD � alcohol dependence; R. to confront �Readiness to Confront Distressing Situations.

310 BERKING ET AL.

Darmstadt, Germany). EtG tests have been shown to reliablydetect the use of alcohol several days after consumption (Beck etal., 2007). In order to reduce the risk of false positives, a conser-vative limit of quantification (0.4 mg/L) was used.

Alcohol use during the 3 months following inpatient treatmentwas assessed as follows: Upon completion of treatment, eachparticipant was provided with a 3-month diary and instructed tomonitor alcohol consumption during the subsequent 3 months. Foreach day during this period, participants were instructed to ratehow much alcohol they had consumed: (a) none, (b) equal to orless than 26 but more than 0 grams, (c) equal to or less than 60 butmore than 26 grams, (d) equal to or less than 150 but more than 60grams, or (e) more than 150 grams. Participants were providedwith a table of information on alcohol contents of typical alcoholicdrinks (e.g., 0.3 mg/0.5 L beer). They were given a stampedenvelope and asked to mail the completed diary to the clinic at theend of the 3-month period. If no such mail was received, a newstamped envelope was sent to the participant with a reminder toreturn the diary. This reminder also included a short questionnaireasking whether or not he or she had consumed alcohol in the past3 months. If participants could not be reached by mail, an effortwas made to obtain the new addresses by contacting local registryoffices. If no diary was returned, up to five attempts were made toreach the participants by phone. If the participants could bereached by phone, they were asked whether they have been “ab-stinent throughout the entire past three months.” Those who an-swered anything other than “yes” were classified as having con-sumed alcohol. Participants were also classified as havingconsumed alcohol if this was reported by other treatment facilitiesor if they could not be contacted by mail or phone.

Potential confounds. Symptom severity and number of co-morbid disorders were assessed as described above. Cognitivecapacities were assessed with the Raven’s Standard ProgressiveMatrices (German version: Kratzmeier & Horn, 1988), the short-term memory subtest of the Verbaler Lern- and Merkfahigkeitstest(VLMT; German for Verbal Learning and Memory Test; Helms-taedter, Lendt, & Lux, 2001), and the Mehrfach-Wortschatz-Intelligenztest (MWT; German for Vocabulary-Based Test of In-telligence [assessed only at pretreatment]; Lehrl, 1999). Negativeaffect was assessed with the negative affect scales of the Positiveand Negative Affect Schedule (PANAS–NA; German version;Krohne, Egloff, Kohlmann, & Tausch, 1996). The Standard Pro-gressive Matrices is a commonly used test for logical reasoning. Inthe VLMT subtest, a list of 15 words is presented, and participantsare asked to recall as many words as possible. In the MWT,participants are instructed to define a series of words of increasingabstractness. The PANAS–NA assesses the intensity of negativeaffect with 10 items. In this study, these items referred to theprevious 7 days in order to cover the same time period as theERSQ. All instruments are widely used in psychological researchand have demonstrated at least satisfying psychometric properties.

Statistical Analyses

To assess the bivariate associations between pre- and posttreat-ment ERSQ scores and subsequent alcohol use, we computedpoint-biserial correlations. In order to test our primary hypothesiswe used multivariate binary logistic regression analyses with in-dicators of symptom severity as the first step, cognitive capacities

as the second step, negative mood as the third step, and emotion-regulation skills as the fourth step. Within these hierarchicalblocks, we used standard inclusion procedures. For the secondaryanalyses, we used Pearson’s correlations in order to test whetherpretreatment ERSQ scores were significantly associated with in-dicators of symptom severity. For the comparisons among the AD,the nonclinical control, and the MDD samples, we used indepen-dent t tests. We additionally used dependent t tests to test whetherERSQtotal scores increased during treatment. In order to identifyERSQ subscales that best discriminate between subsequently ab-stinent and nonabstinent AD individuals when the influence of theother subscales was controlled, we utilized stepwise multivariatelogistic regression analyses. To keep the number of predictorswithin a range appropriate for the sample size, we included all nineERSQ subscales as predictors but none of the potential confoundsused when testing the primary hypotheses. We utilized stepwiseprocedure in these analyses because we conducted this researchwith a focus on the identification of potential targets for treatment.Setting realistic and effective targets is a crucial element in anypsychosocial intervention and involves decisions on how to dis-tribute limited therapeutic resources (Berking, Grosse Holtforth,Jacobi, & Kroner-Herwig, 2005). In order to facilitate an effectivedeployment of resources when working to enhance emotion-regulation skills, data are needed on (a) the most important skillsto target during treatment for AD and (b) whether the outcome canbe further enhanced by providing a secondary focus on any of theadditional skills. Thus, identifying the strongest predictors of al-cohol consumption and, subsequently, predictors that are impor-tant beyond the effects of already included predictors is arguablemore appropriate than including all potential predictors simulta-neously.

We used one-tailed tests when testing directional hypothesesand report Cohen’s d (Cohen, 1988), point-biserial correlationcoefficients, odds ratios, and Nagelkerke’s R2 as effect sizes.Preliminary analyses indicated that all assumptions required forthe analytical approaches were met. All analyses were performedwith SPSS 18.0.

Results

Consistent with our first primary hypothesis, participants whoconsumed alcohol during treatment (n � 39) had significantlylower ERSQtotal scores at pretreatment than did participants whoremained abstinent (n � 77; see Table 2). A small-to-moderatepoint-biserial correlation coefficient indicated that pretreatmentERSQtotal scores were significantly associated with alcohol useduring treatment. As shown in Table 3, ERSQtotal scores at pre-treatment predicted alcohol use during treatment even if the effectsof other potential predictors were controlled. The logistic regres-sion analysis indicated that a one-unit increase on the ERSQ atpretreatment corresponded to a reduction of the likelihood ofalcohol use during treatment by 48%.

Classification of alcohol use for the follow-up assessment wasbased on the consumption diary (n � 50), response to the reminderletter (n � 19), the telephone interview (n � 29), and informationprovided by other treatment facilities (n � 4). Patients who couldnot be contacted in any way (n � 14) were classified as nonab-stinent. In line with our second primary hypothesis, participantswho were classified as nonabstinent (n � 58) displayed signifi-

311EMOTION REGULATION IN ALCOHOL DEPENDENCE

cantly lower ERSQtotal scores at posttreatment than did partici-pants who were classified as abstinent (n � 58; see Table 2). Asmall-to-moderate point-biserial correlation coefficient indicatedthat posttreatment ERSQtotal scores were significantly associatedwith alcohol use during the 3-month follow-up period. Moreover,ERSQtotal scores predicted alcohol use during and after treatmenteven if the effects of other potential predictors were controlled (seeTable 3). In the final regression model, a one-unit increase on the

ERSQ at posttreatment corresponded to a reduction of the likeli-hood of alcohol use during follow-up by 64%.

An additional bivariate logistic regression analysis indicatedthat posttreatment ERSQtotal scores continued to predict alcoholuse at follow-up even when including only patients who hadcompleted the report-based assessment or who had been unambig-uously identified as users with the help of other treatment facilities(n � 98; n � 102, respectively; B � �0.63, SE � 0.38, p � .05,

Table 2Mean Values and Standard Deviations for ERSQ Scores in Abstinent and Nonabstinent Participants in the AD Sample

ERSQ scale

During treatment

rpb

During follow-up interval

rpb

Abstinent(N � 75)

Nonabstinent(N � 38)

Abstinent(N � 58)

Nonabstinent(N � 58)

M SD M SD M SD M SD

Awareness 2.52 0.88 2.27 1.00 �.13 2.86 0.63 2.59 0.97 �.17�

Sensations 2.68 0.78 2.47 0.70 �.13 2.78 0.67 2.63 0.73 �.11Clarity 2.67 0.89 2.40 0.93 �.14 2.91 0.73 2.60 0.79 �.20�

Understanding 2.38 0.98 2.31 0.78 �.04 2.80 0.74 2.43 0.73 �.24��

Acceptance 2.69 0.84 2.42 0.71 �.16� 2.91 0.67 2.64 0.71 �.17�

Tolerance 2.64 0.99 2.24 0.95 �.19� 2.90 0.69 2.54 0.79 �.24��

Self-support 2.56 0.86 2.34 0.88 �.12 2.71 0.68 2.51 0.70 �.16�

R. to confront 2.77 0.81 2.44 0.85 �.19� 2.83 0.71 2.57 0.70 �.19�

Modification 2.19 0.98 1.82 0.80 �.19� 2.57 0.82 2.24 0.80 �.20�

ERSQtotal 2.57 0.70 2.30 0.61 �.19� 2.81 0.52 2.53 0.58 �.24��

Note. Sample sizes for during-treatment analyses reflect two missing ERSQ scores in the abstinent group and one missing ERSQ score in the alcohol-usegroup. ERSQ � Emotion-Regulation Skills Questionnaire; AD � alcohol dependence; rpb � point-biserial correlation coefficient; R. to confront �Readiness to Confront Distressing Situations.� p � .05. �� p � .01.

Table 3Summary of Logistic Regression Analysis for ERSQ Scores Predicting Alcohol Use in AD Patients, Controlling for PotentialConfounds

Predictor

During treatment During follow-up interval

B SE eB Wald B SE eB Wald

1. Symptom severityPretreatment alcohol per day 0.00 0.00 1.00 0.26 0.00 0.00 1.00 1.91SESAtotal �0.01 0.01 0.99 0.72 0.01 0.01 1.02 1.40No. comorbid psych. disorders 0.13 0.22 1.14 0.38 0.19 0.20 1.21 0.94

2. Cognitive capacitiesSPM �0.01 0.03 0.99 0.17 �0.02 0.02 0.98 0.64VLMT 0.08 0.03 1.08 5.97�� �0.01 0.02 0.99 0.10MWT 0.09 0.06 2.16 2.04 n.a.

3. Negative affectPANAS–NA 0.56 0.32 1.74 2.96� �0.01 0.23 0.99 0.00

4. Emotion-regulation skillsERSQtotal �0.65 0.37 0.52 2.99� �1.03 0.39 0.36 7.02��

Constant �5.89 2.32 0.00 6.45�� 2.55 1.68 12.83 2.30�2/df/R2/% correctly classified 19.82/8/.22/69.9 14.01/7/.15/57.8% abstinent 33.63 50

Note. Alcohol use during treatment was predicted by pretreatment ERSQtotal scores, and alcohol use during the 3-month follow-up interval was predictedby posttreatment ERSQtotal scores. n � 1/1/4 pretreatment SESA/SPM/VLMT scores were replaced by AD pretreatment mean scores; n � 3/2/1posttreatment SPM/VLMT/PANAS–NA scores were imputed from pretreatment scores with multiple regression analyses. ERSQ � Emotion-RegulationSkills Questionnaire; AD � alcohol dependence; SE � standard error; SESA � Severity Scales of Alcohol Dependence; No. comorbid psych. disorders �number of comorbid psychiatric disorders; SPM � Raven’s Standard Progressive Matrices; VLMT � Verbal Learning and Memory Test; MWT �vocabulary-based test of intelligence; n.a. � not applicable, as the MWT was assessed only at pretreatment; PANAS–NA � Positive and Negative AffectSchedule—Negative Affect; df � degrees of freedom; R2 � Nagelkerke’s R2.� p � .05. �� p � .01.

312 BERKING ET AL.

eB � 0.53; B � �0.83, SE � 0.41, p � .05, eB � 0.44, respec-tively). Additional analyses within the subgroup of patients pro-viding quantitative information on alcohol consumption duringfollow-up (n � 58) showed a trend for the association of the totalamount of alcohol (computed by transforming diary categoriesb/c/d/e into 13/44/105/151 grams) consumed during this period(M � 300.22 grams, SD � 818.13, range � 0–5,000) and post-treatment ERSQtotal scores (r � .19, p � .08).

With regard to secondary hypotheses, we found that pretreat-ment ERSQtotal scores were not significantly associated with pre-treatment SESAtotal scores (r � .04, p � .33) nor with the amountof alcohol consumed per day prior to treatment (r � .006, p � .47).Additional analyses indicated that gender was not associated witheither ERSQtotal scores pre- or posttreatment, nor with changes inthese scores during treatment, nor with alcohol use during and aftertreatment. In contrast, the number of comorbid psychiatric disor-ders was significantly associated with pre- and posttreatment ER-SQtotal scores (r � �0.20, p � .05; r � �0.18, p � .05), althoughnot with changes in ERSQtotal score during the treatment (r ��0.03, p � .37). Although psychiatric comorbidity was signifi-cantly associated with alcohol use during follow-up (r � .17, p �.05), only a trend emerged for the association between comorbidityand alcohol use during treatment (r � .13, p � .09).

With regard to group differences, findings presented in Table 4show that ERSQtotal scores in the AD sample were significantlylower than those in the nonclinical sample and significantly higher(better) than those in the MDD sample. The AD versus nonclinicalcontrols difference shows a small-to-moderate effect, and the ADversus MDD comparison shows a large effect according to Cohen(1988). Additional analyses also presented in Table 4 indicatedthat ERSQtotal scores increased significantly over the course oftreatment, with pre–post changes indicating a small-to-moderateeffect. After treatment, ERSQtotal scores no longer differed signif-icantly from those of the nonclinical control group. A small trend(r � �0.14), which narrowly missed the level of statistical sig-nificance (p � .069), was found for the association between anincrease in ER skills and alcohol use during follow-up.

With regard to specific emotion-regulation skills, the effect sizespresented in Table 4 suggest that the largest differences betweenthe pretreatment AD sample and the nonclinical controls can befound in the subscales Understanding, Tolerance, Modification,and Clarity. The greatest gains during CBT for AD occurred forModification and Awareness. As shown in Table 2, Acceptance,Tolerance, Readiness to Confront, and Modification were the onlysubscales (assessed at pretreatment) significantly associated withalcohol use during treatment. The multivariate logistic binaryanalysis indicated that only Tolerance (B � �0.42, SEB � 0.21,Wald � 4.07, df � 1, p � .05, eB � 0.66) had a unique contri-bution to the prediction of alcohol use (�2 � 4.23, df � 1, p � .05,R2 � .05). For the prediction of relapse after treatment termination,all subscales (assessed at posttreatment) except Sensations weresignificantly associated with alcohol use during follow-up (seeTable 2). In these analyses, the subscales Tolerance, Understand-ing, Modification, and Clarity were most strongly associatedwith subsequent alcohol use. The multivariate analysis demon-strated that only Tolerance (B � �0.69, SEB � 0.27, Wald �6.45, df � 1, p � .01, eB � 0.50) made a unique contributionto the prediction of alcohol use after treatment (�2� 7.09, df �1, p � .01, R2 � .08).

Discussion

Building upon substantial evidence that negative affect is asso-ciated with alcohol use, the current study added to the literature byexamining whether deficits in effective emotion-regulation skillscontribute to the use of alcohol in individuals treated for alcoholdependence (AD). Consistent with the primary hypotheses, deficitsin pretreatment emotion-regulation skills predicted alcohol useduring CBT for AD, and deficits in posttreatment emotion-regulation skills predicted alcohol use during a 3-month follow-upperiod, even when controlling for the effects of other potentialpredictors (symptom severity, number of comorbid disorders, cog-nitive capacities, and negative affect).

Table 4Comparisons of Pretreatment ERSQ Scores in the AD Sample With Those of Nonclinical Controls, the MDD Sample, and ADPosttreatment Scores

ERSQ scale

ADpre NCC MDD ADpre–NCC ADpre–MDD ADpost ADpost–ADpre ADpost–NCC

M SD M SD M SD t d t d M SD t d t d

Awareness 2.44 0.93 2.37 0.93 2.01 0.90 0.60 0.08 3.58�� 0.47 2.73 0.83 3.77�� 0.33 3.10�� 0.41Sensations 2.61 0.76 2.76 0.73 2.11 0.89 �1.55 �0.20 4.49�� 0.60 2.71 0.70 1.24 0.14 �0.56 �0.07Clarity 2.58 0.91 2.94 0.67 1.96 0.99 �3.37�� �0.45 4.88�� 0.65 2.76 0.77 2.04� 0.21 �1.88� �0.25Understanding 2.36 0.92 2.85 0.65 1.78 1.01 �4.63�� �0.62 4.51�� 0.60 2.62 0.76 3.09�� 0.31 �2.45�� �0.33Acceptance 2.60 0.80 2.80 0.71 1.75 0.91 �1.96� �0.26 7.48�� 0.99 2.77 0.70 2.33� 0.23 �0.25 �0.04Tolerance 2.50 0.99 2.86 0.78 1.41 0.97 �2.98�� �0.40 8.39�� 1.11 2.72 0.76 2.53�� 0.25 �1.35 �0.18Self-support 2.49 0.87 2.52 0.81 1.71 0.95 �0.24 �0.04 6.39�� 0.86 2.61 0.69 1.49 0.15 0.94 0.12R. to confront 2.66 0.83 2.89 0.74 1.77 0.95 �2.17� �0.29 7.49�� 1.00 2.70 0.71 0.45 0.05 �1.95� �0.26Modification 2.06 0.94 2.36 0.84 1.31 0.93 �2.52�� �0.34 6.04�� 0.80 2.40 0.82 3.73�� 0.39 0.38 0.05ERSQtotal 2.48 0.68 2.70 0.55 1.76 0.78 �2.74�� �0.36 7.40�� 0.98 2.67 0.57 3.26�� 0.30 �0.48 �0.05

Note. All ts have 1 degree of freedom, and N � 232. ERSQ � Emotion-Regulation Skills Questionnaire; AD � alcohol dependence sample; pre �pretreatment; NCC � nonclinical control sample; MDD � major depression sample; post � posttreatment; R. to confront � Readiness to ConfrontDistressing Situations; � � Cronbach’s alpha; d � Cohen’s d.� p � .05. �� p � .01.

313EMOTION REGULATION IN ALCOHOL DEPENDENCE

Secondary analyses demonstrated that (a) pretreatment emotion-regulation skills were not significantly associated with indicatorsof pretreatment AD symptom severity; (b) individuals seekingtreatment for AD displayed greater difficulties with adaptive reg-ulation of negative emotions at pretreatment than did nonclinicalcontrols but less difficulty than did individuals seeking treatmentfor MDD; and (c) among a broad range of emotion-regulationskills, the ability to tolerate negative emotions was the only skill ofthe ACE model that negatively predicted subsequent alcohol usewhen controlling for the other skills. This pattern was consistentfor the prediction of alcohol use both during and after treatment.

These findings have important implications. The confirmationof the primary hypotheses is in line with research demonstratingthe importance of negative affect in the maintenance of AD (e.g.,Lowman et al., 1996) but significantly extends such research byshowing that emotion-regulation skills (i.e., specific abilities rel-evant for effectively coping with negative affective states) helpmaintain abstinence both during treatment and during the high-riskperiod within the first months following treatment. In addition, asdeficits in emotion-regulation skills predict alcohol use even whennegative affect is controlled, these skills appear to reduce alcoholuse not just by reducing the negative affect that may precede usebut by helping maintain abstinence even in the presence of nega-tive affect, likely by providing ways of dealing with negativeemotions other than the use of alcohol. As such, the enhancementof general emotion-regulation skills may be an effective target inpsychosocial treatments for AD. Although the need for specifictreatments for co-occurring AD and borderline personality disor-der (BPD) has been acknowledged in the literature (Gregory et al.,2008; Gregory, DeLucia-Deranja, & Mogle, 2010), findings fromthis study (which included only a small percentage of participantswith co-occuring BPD) suggest that individuals with AD mightbenefit from enhanced emotion-regulation skills even if they donot display emotional dysregulation to the extent found in BPD.However, the association between the increase in emotion-regulation skills during treatment and alcohol use at follow-up wassmall and did not reach the level of statistical significance. It ispossible that CBT did not explicitly target emotion-regulationskills and, therefore, did not affect these skills as strongly as wouldhave been necessary to predict subsequent use from skill enhance-ment. However, this post hoc explanation is speculative, and werecommend future research to examine the mechanism of CBT,including the role of emotion-regulation strategies.

It is interesting that participants’ self-reports of emotion-regulation skills were not associated with pretreatment AD symp-toms. This might be explained by the incomplete overlap ofassessment periods addressed in the three measures (ERSQ, lastweek; SESA, last month; average daily consumption, last period ofnotable alcohol use). Alternatively, given evidence that ERSQscores tend to be highly correlated across several weeks (Berking,Orth, et al., 2008; Berking & Znoj, 2008), this finding mightindicate that once an individual has begun to engage in heavyalcohol use, the availability of adaptive emotion-regulation skillsdoes not further affect symptom level. Instead, at this stage of therelapse process, factors such as conditioned responses to alcohol-related cues may be more closely related to symptom variationthan are unregulated negative affective states (Jansma, Breteler,Schippers, De Jong, & Van Der Staak, 2000). Consequently, at thisstage, severity may depend on factors other than effective emotion

regulation (e.g., specific disengagement skills, social support,and/or access to treatment facilities; Broome, Simpson, & Joe,2002; Marlatt & Donovan, 2005). However, after a successfullycompleted detoxification and/or treatment for AD, the availabilityof effective emotion-regulation skills appears to be significantlyrelevant for the maintenance of abstinence.

The secondary finding of significant differences in emotion-regulation skills among the AD, nonclinical control, and MDDsamples should be interpreted with care because of the differencesin assessment periods. However, as we have found no effects forseason or economy within or across the numerous studies we haveconducted over the past decade, we propose that the finding thatthe AD sample reported less successful pretreatment emotionregulation than did nonclinical controls can be seen as furthersupport for the affect-based theories of AD. As such, this resultadds to the findings of numerous other studies showing thatdeficits in emotion-regulation skills are associated with a variety ofmental disorders (Aldao et al., 2010; Berking, Wuppermann, et al.,2008; Cisler, Olatunji, Feldner, & Forsyth, 2010). However, thefinding that the AD sample reported smaller deficits in emotion-regulation skills than did the MDD sample also suggests that theavailability of specific emotion-regulation skills differs acrossdisorders and that such deficits might be more important for thedevelopment and maintenance of MDD (as an “emotional disor-der”) than for AD. Alternatively, at least to a certain extent, theMDD–AD differences might also be explained by assuming adisorder-specific bias in the perception, evaluation, and report ofskills: Depressed individuals are more likely to underestimate theirskills than are nondepressed individuals (e.g., Johnson, Petzel,Hartney, & Morgan, 1983), whereas AD has been associated withthe phenomenon of overconfidence, such as the systematic over-evaluation of the ability to remain abstinent (e.g., Ferrari, Groh,Rulka, Jason, & Davis, 2008).

Because of the lack of an untreated control condition, theobserved changes in ERSQ scores during treatment should beinterpreted with great caution. However, the data are consistentwith research demonstrating that emotion-regulation skills in-crease during CBT and that the largest gains result in the abilitiesto be aware of emotions and to modify emotions (Berking, Ebert,Filipek, Cal, & Dippel, 2010; Berking, Wupperman, et al., 2008).Moreover, these findings are in line with conceptualizations ofCBT as aiming to actively solve problems, such as unwantedemotions, by first raising awareness of the problem and thenteaching patients effective coping skills (e.g., cognitive restructur-ing). Although CBT has a tradition of fostering acceptance (e.g.,Ellis, 1962), it has been criticized for focusing too strongly onchange (Ciarrochi & Bailey, 2008; Hayes, Strosahl, & Wilson,1999), which might be particularly problematic in the context ofissues that may be difficult to change (e.g., negative emotions;Linehan, 1993a). In this study, CBT arguably demonstrated itslargest effects on the subscales Modification and Awareness, al-though Tolerance was identified as the most important predictor ofrelapse. These findings suggest that CBT-based treatments for ADcould be improved by incorporating interventions that systemati-cally target emotion-regulation skills with a particular emphasis onthe ability to tolerate negative emotions. Such treatments includeaffect regulation training (Berking, 2010), emotion focused ther-apy (Greenberg, 2002), and/or the emotion regulation, mindful-ness, and distress tolerance modules of dialectical behavioral ther-

314 BERKING ET AL.

apy (Linehan, 1993b). In line with this conclusion, CBT-basedtreatments that incorporate mindfulness interventions have shownpromise for treating both alcohol-use and drug-use disorders (Bo-wen et al., 2009; Hofmann, Sawyer, Witt, & Oh, 2010; Witkiewitz,Marlatt, & Walker, 2005). These treatments are theorized to en-hance the ability to tolerate negative affective states by facilitatinga nonjudgmental attitude toward aversive experiences while alsoincreasing habituation through formal and informal practices(Brown, Ryan, & Creswell, 2007; Witkiewitz et al., 2005).

Limitations of the current study include (a) lack of reliabilitychecks for diagnoses; (b) exclusive use of self-reports, assessed attwo time points, for emotion-regulation skills; (c) exclusive use ofself-reports for the majority of cases in the assessment of post-treatment alcohol use, which may in part be biased by last-minutecompletions of diaries; (d) use of control groups that were assessedat time points other than those of the AD sample and that could notbe matched for education level; (e) the demographics of the ADand, consequently, the matched control samples, which were pre-dominantly male and 100% Caucasian; and (f) the dichotomousassessment of the main outcome criteria, which is likely to beassociated with a loss of quantitative information. Moreover, dueto the lack of an untreated AD control sample, empirical indicatorsof treatment adherence, and process data detailing ways emotion-regulation skills were targeted in treatment, we cannot specifywhether changes during treatment were caused by the CBT-basedtreatment or what mechanisms might be responsible for theseeffects.

With regard to the lack of reliability checks for diagnoses, it isof note that diagnostics were conducted by experienced clinicianswho had the opportunity to observe the patients for several monthsand correct potential errors if necessary (although no such correc-tions were deemed necessary in the present study). Additionally,all patients had been given the diagnoses of AD prior to treatmentby health professionals who were responsible for the referral to theclinic. The dichotomous outcome criteria were primarily necessi-tated by our utilization of objective biological markers of alcoholuse, such as the Breathalyzer and the EtG test. The use of objectivemeasures was particularly important during the inpatient treatment,when reporting alcohol consumption had the potential of leading toundesirable contingencies (such as disapproval from treatmentstaff), thus increasing the likelihood that patients might denyconsumption that occurred. Although these objective tests providereliable information on whether or not a participant has consumedany amount of alcohol, they cannot provide reliable information onthe amount consumed (Wurst, Kempter, Seidl, & Alt, 1999). Forthe follow-up assessment, we relied on self-reports (and informa-tion provided by other treatment providers) because includingbiological measures likely would have led to a significant increasein the attrition rate and thus endangered validity. Self-reports ofalcohol use have been shown to be strongly associated with ob-jective markers and collateral reports (Whitford, Widner, Mellick,& Elkins, 2009). However, according to our clinical experiencewith self-reports, the amount of alcohol consumed is particularlyaffected by tendencies of underreporting. Thus, we focused on thequestion of whether or not the participant had consumed (asopposed to how much the participant has consumed) in order toreduce the impact of these tendencies. This approach also in-creased the validity of the assessment by allowing (a) the inclusionof dichotomous information on posttreatment alcohol use provided

by other treatment facilities and (b) the direct comparison offindings from during- and posttreatment analyses.

Given the strengths of the study (e.g., fairly large clinicalsample, prospective design, predicting alcohol use both during andafter treatment, use of objective indicators of alcohol use duringtreatment, addressing incremental predictive validity), the resultsprovide considerable support for the importance of emotion-regulation skills in the prevention of relapse in individuals treatedfor alcohol-use disorders and thus suggest the need to target theseskills in treatment. Future research should investigate the associ-ation of emotion-regulation skills and subsequent alcohol con-sumption utilizing reliability checks of diagnoses, adherencechecks, process data on interventions potentially targetingemotion-regulation skills, more thoroughly matched control sam-ples, and an untreated AD control sample. Moreover, we recom-mend that future studies include several measurement points as-sessing multiple and independent indicators of emotion-regulationskills and alcohol use, which would allow more stringent tests ofcausal relationships (e.g., latent difference score models; Berking,Neacsiu, Comtois, & Linehan, 2009). Finally, future researchshould investigate the effects of experimental manipulations ofemotion-regulation skills on subsequent alcohol use in randomizedcontrolled trials.

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Received May 12, 2010Revision received January 18, 2011

Accepted January 31, 2011 �

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