Work Related Cognitive-Behavioral Therapy for Unemployed Persons With Social Anxiety Disorder Joseph Himle, Ph.D. Director, Vivian A. & James L. Curtis.

Work Related Cognitive-Behavioral Work Related Cognitive-Behavioral Therapy for Unemployed Persons Therapy for Unemployed Persons

With Social Anxiety DisorderWith Social Anxiety Disorder

Joseph Himle, Ph.D.Joseph Himle, Ph.D.Director, Vivian A. & James L. Curtis Research Center, Director, Vivian A. & James L. Curtis Research Center,

University of Michigan, School of Social Work & University of Michigan, School of Social Work & Department of PsychiatryDepartment of Psychiatry

Ed Steinberger, M.A., Wayne Laviolette, M.A., Ed Steinberger, M.A., Wayne Laviolette, M.A., Zipora Golenberg, M.A., Yolitha Hill, M.A.Zipora Golenberg, M.A., Yolitha Hill, M.A.

JVS DetroitJVS Detroit

NIMH NIMH 1R34MH083031-01

Almost every new mental Almost every new mental health intervention is health intervention is

designed, developed and designed, developed and tested in middle class, tested in middle class,

educated, majority educated, majority communitiescommunities

Why not in an urban-based Why not in an urban-based center with underserved, center with underserved,

impoverished, multi-problem impoverished, multi-problem participants…participants…

It takes more effortIt takes more effortIt is seen as a riskIt is seen as a risk

It is unfamiliarIt is unfamiliarIt requires cooperationIt requires cooperation

Our work will show that with Our work will show that with effort and teamwork… effort and teamwork…

New interventions can be New interventions can be developed and tested in developed and tested in

underserved, mostly minority underserved, mostly minority populations with unexpected populations with unexpected

successsuccess

Study Goals Study Goals

Design and develop a culturally informed, Design and develop a culturally informed, vocationally focused, sustainable, vocationally focused, sustainable, intervention for unemployed for persons intervention for unemployed for persons with Social Anxiety Disorderwith Social Anxiety Disorder

Our Study TeamOur Study Team Joseph Himle, Ph.D., University of Michigan, Joseph Himle, Ph.D., University of Michigan,

Principal InvestigatorPrincipal Investigator Ed Steinberger, M.S., JVS, Co-Investigator, Ed Steinberger, M.S., JVS, Co-Investigator,

Group LeaderGroup Leader Wayne Laviolette, Psy.S, L.L.P JVS, Co-Wayne Laviolette, Psy.S, L.L.P JVS, Co-

Investigator, Group LeaderInvestigator, Group Leader Zipora Golenberg, M.A.Zipora Golenberg, M.A., L.P.C., JVS, Co-, L.P.C., JVS, Co-

Investigator, Group LeaderInvestigator, Group Leader Yolitha Hill, M.A., Case Coordinator, JVS DetroitYolitha Hill, M.A., Case Coordinator, JVS Detroit

Our Study Team (cont.)Our Study Team (cont.) Deborah Bybee, Ph.D., Michigan State University, Deborah Bybee, Ph.D., Michigan State University,

Co-InvestigatorCo-Investigator Co-Investigator, Sarah Vlnka, M.S.W., Study Co-Investigator, Sarah Vlnka, M.S.W., Study

CoordinatorCoordinator Debra Levine, M.S., Doctoral Student University Debra Levine, M.S., Doctoral Student University

of Michiganof Michigan Lisa O’Donnell, M.S.W., Doctoral Student Lisa O’Donnell, M.S.W., Doctoral Student

University of MichiganUniversity of Michigan Katherine Zumberg, M.S., Doctoral Student, Katherine Zumberg, M.S., Doctoral Student,

University of MichiganUniversity of Michigan

Our Study Team (cont.)Our Study Team (cont.) Nikhil Dhawan, M.D., Psychiatric Resident, Nikhil Dhawan, M.D., Psychiatric Resident,

University of MichiganUniversity of Michigan Amiram Vinokur, Ph.D., Co-investigator, Amiram Vinokur, Ph.D., Co-investigator,

University of MichiganUniversity of Michigan

Key Supporters at JVSKey Supporters at JVS

Barbara NurenbergBarbara Nurenberg Leah RosenbaumLeah Rosenbaum Andrea TolleAndrea Tolle Mike Reaume (deceased)Mike Reaume (deceased) Diane BondsDiane Bonds Kertrina GordonKertrina Gordon

Jillian StrubleJillian Struble Karen ZmichKaren Zmich Barb OssowskiBarb Ossowski Bambi HitesBambi Hites Bert DancerBert Dancer Norm LuzierNorm Luzier Francis BowenFrancis Bowen

Social Anxiety DisorderSocial Anxiety Disorder

SocAD involves fear and avoidance of certain SocAD involves fear and avoidance of certain social or performance situations like going on social or performance situations like going on a job interview, giving a speech, or meeting a job interview, giving a speech, or meeting new peoplenew people

12.1% of the general population will meet 12.1% of the general population will meet criteria for SocAD in their lifetime criteria for SocAD in their lifetime (Kessler et al., 2005)

SocAD negatively affects social relationships, SocAD negatively affects social relationships, role functioning, activities, overall well being role functioning, activities, overall well being and… WORKand… WORK

Social Anxiety and WorkSocial Anxiety and Work

Individuals with SocAD report:Individuals with SocAD report: Impairments in work productivityImpairments in work productivity Reduced time spent working (e.g., absences) Reduced time spent working (e.g., absences) Reduced perceived work performance and Reduced perceived work performance and

productivity, relative to non-anxious controlsproductivity, relative to non-anxious controls

(Davidson et al.,1993; Schneier et al., 1994; Wittchen et al., 2000) (Davidson et al.,1993; Schneier et al., 1994; Wittchen et al., 2000)

Social Anxiety and Work (cont.)Social Anxiety and Work (cont.)

Large majority (92%) of social phobic Large majority (92%) of social phobic sample significant occupational sample significant occupational impairments impairments (Turner et al.,1986) (Turner et al.,1986)

One in five individuals with SocAD turned One in five individuals with SocAD turned down a job offer or promotion as a result down a job offer or promotion as a result of social fears of social fears (Stein et al, 2000) (Stein et al, 2000)

Social Anxiety and Work (cont.)Social Anxiety and Work (cont.)

Occupational success in SocAD is also Occupational success in SocAD is also limited by their lowered educational limited by their lowered educational achievement, scholastic difficulties, and achievement, scholastic difficulties, and early school dropout early school dropout (Davidson et al., 1993; Magee et al., 1996; (Davidson et al., 1993; Magee et al., 1996;

Mogotsi et al., 2000; Stein & Kean, 2000).Mogotsi et al., 2000; Stein & Kean, 2000). Occupational dysfunction in SocAD leads Occupational dysfunction in SocAD leads

to heightened levels of financial to heightened levels of financial dependence dependence (Schneier et al., 1992) (Schneier et al., 1992) and reduced and reduced incomeincome (Kessler et al., 1994; Magee et al., 1996). (Kessler et al., 1994; Magee et al., 1996).

Why Might Social Anxiety Interfere Why Might Social Anxiety Interfere with Employment?with Employment?

Avoidance of job interviewsAvoidance of job interviews Few friends to provide job leadsFew friends to provide job leads Poor performance in job interviewsPoor performance in job interviews Problems forming strong relationships at work Problems forming strong relationships at work

which can protect against job losswhich can protect against job loss Avoid telling superiors/coworkers about Avoid telling superiors/coworkers about

problems and successesproblems and successes Embarrassment regarding unemploymentEmbarrassment regarding unemployment Lower educational attainmentLower educational attainment Growing service based economy in U.S.Growing service based economy in U.S.

Our Beginnings:Our Beginnings: Women’s Employment StudyWomen’s Employment Study

Women’s Employment StudyWomen’s Employment Study Five-wave longitudinal study of female welfare Five-wave longitudinal study of female welfare

recipients in urban Michigan countyrecipients in urban Michigan county Examined how mental health, health and Examined how mental health, health and

influence ability to enter or return to workinfluence ability to enter or return to work Face-to-face interviews with 753 randomly Face-to-face interviews with 753 randomly

female welfare recipients female welfare recipients All respondents were African-American or non-All respondents were African-American or non-

Hispanic White between ages 18-54.Hispanic White between ages 18-54.

Tolman, R., Himle, J., Bybee, D., Abelson, J., Hoffman, J., & Van Etten-Lee, M. (2009). Impact of social anxiety Tolman, R., Himle, J., Bybee, D., Abelson, J., Hoffman, J., & Van Etten-Lee, M. (2009). Impact of social anxiety disorder on employment among women receiving welfare benefitsdisorder on employment among women receiving welfare benefits . Psychiatric Services, 60,. Psychiatric Services, 60, 61-66 61-66..

Relevant ResultsRelevant Results

SocAD was negatively associated with SocAD was negatively associated with percentage of months worked, even after percentage of months worked, even after the analyses controlled for other relevant the analyses controlled for other relevant variables (e.g., demographic variables (e.g., demographic characteristics and human capital characteristics and human capital variables)variables)

Results, cont.Results, cont.

Depression, post-traumatic stress Depression, post-traumatic stress disorder, and alcohol/drug dependence disorder, and alcohol/drug dependence were not significant predictors of the were not significant predictors of the percentage of months worked in this percentage of months worked in this sample. sample.

Work Related Cognitive-Work Related Cognitive-Behavioral Therapy for Behavioral Therapy for

Unemployed Persons With Unemployed Persons With Social Anxiety Disorder Social Anxiety Disorder

(WCBT)(WCBT)

Study SiteStudy Site

Jewish Vocational Services (JVS), Detroit Jewish Vocational Services (JVS), Detroit Michigan, Career Initiative Center (CIC)Michigan, Career Initiative Center (CIC)

JVS’s CIC provides comprehensive JVS’s CIC provides comprehensive vocational rehabilitation services for vocational rehabilitation services for homeless individuals homeless individuals

Primary clientele are economically Primary clientele are economically disadvantaged, African Americans who disadvantaged, African Americans who are seeking workare seeking work

WCBT – Initial ScreeningWCBT – Initial Screening

Screening all clients at JVS for SocADScreening all clients at JVS for SocAD 24% (Detroit site) and 32% (Southfield 24% (Detroit site) and 32% (Southfield

site) screened positive for social anxiety site) screened positive for social anxiety disorder -using the MINI-SPIN (Connor, et disorder -using the MINI-SPIN (Connor, et al., 2001)al., 2001)

MINI-SPINMINI-SPIN

WCBT - InterventionWCBT - Intervention

Begin with existing group cognitive-Begin with existing group cognitive-behavioral treatment (CBT) for social behavioral treatment (CBT) for social anxiety anxiety (Heimberg & Becker, 2002)(Heimberg & Becker, 2002)

CBT for SocAD involves:CBT for SocAD involves: Gradual exposure to anxiety provoking Gradual exposure to anxiety provoking

situationssituations Cognitive restructuringCognitive restructuring

Building an InterventionBuilding an Intervention Reviewing existing treatment manualsReviewing existing treatment manuals Innovating to fit vocational setting and work focusInnovating to fit vocational setting and work focus Site visit to Baltimore – JOBS program (Vinokur Site visit to Baltimore – JOBS program (Vinokur

et al., 1995)et al., 1995) Input from consultantsInput from consultants Semi-structured interviews with JVS clients and Semi-structured interviews with JVS clients and

staff staff Pilot Groups with in-vivo adjustments and post-Pilot Groups with in-vivo adjustments and post-

group focus interviewsgroup focus interviews

WCBT - InterventionWCBT - Intervention

Current providers at JVS lead WCBTCurrent providers at JVS lead WCBT Offered as one of several classes Offered as one of several classes

occurring in an average day of occurring in an average day of programming at JVSprogramming at JVS

Two 2-hour sessions per week over 4 Two 2-hour sessions per week over 4 weeksweeks

Session Content…Session Content…

Session OneSession One Purpose of the Session:Purpose of the Session:

Introduce the programIntroduce the program Explain the Concept of Social AnxietyExplain the Concept of Social Anxiety Create a welcoming environment and Create a welcoming environment and

commitmentcommitment Three components of anxiety: Three components of anxiety:

PhysiologicalPhysiological Cognitive Cognitive BehavioralBehavioral

Negative Feedback LoopNegative Feedback Loop

Create MotivationCreate Motivation

Components of the Program Components of the Program

Session TwoSession Two

Components of the program:Components of the program: Thought RestructuringThought Restructuring In-Session ExposuresIn-Session Exposures Practice GoalsPractice Goals

Introduction to Automatic Thoughts Introduction to Automatic Thoughts Identification of Thinking Errors Identification of Thinking Errors Practice GoalsPractice Goals

Session ThreeSession Three

Psychoeducational Topic: Relating Social Psychoeducational Topic: Relating Social Anxiety to the World of WorkAnxiety to the World of Work How does social anxiety come up in the How does social anxiety come up in the

workplace?workplace? Disputing Automatic Thoughts and Disputing Automatic Thoughts and

Developing Rational Responses Developing Rational Responses List of Anxiety-Evoking SituationsList of Anxiety-Evoking Situations

Develop Hierarchy ChartsDevelop Hierarchy Charts Practice GoalsPractice Goals (set at the end of each session)

Session FourSession Four

Psychoeducational Topic: Self-Defeating Psychoeducational Topic: Self-Defeating Behavior at Work Behavior at Work

In-Session ExposuresIn-Session Exposures Don’t always follow Psycho-ed topicDon’t always follow Psycho-ed topic Important to validate what is important to Important to validate what is important to

participants participants Client Story G. O. Client Story G. O. Set Practice GoalsSet Practice Goals

Session FiveSession Five

Psychoeducational Topic: Asking for HelpPsychoeducational Topic: Asking for Help How to Ask for Help How to Ask for Help

ability or lack of – great indicator of probability ability or lack of – great indicator of probability of successof success

Who Can We Ask for Help?Who Can We Ask for Help? Exposures – Working to re-establish family Exposures – Working to re-establish family

ties ties Practice GoalsPractice Goals

Session SixSession Six

Psychoeducational Topic: Recognizing Psychoeducational Topic: Recognizing and Describing your Strengthsand Describing your Strengths Card sorting exerciseCard sorting exercise Leaders role-play/modelingLeaders role-play/modeling

Weaknesses into Strengths - ReframingWeaknesses into Strengths - Reframing In-Session ExposuresIn-Session Exposures

Teaching new employeesTeaching new employees Practice GoalsPractice Goals

Session SevenSession Seven

Psychoeducational Topic: Talking with Psychoeducational Topic: Talking with Supervisors and Coworkers Supervisors and Coworkers

Cost/Benefit AnalysisCost/Benefit Analysis Flip chartFlip chart Leaders role-play/modeling Leaders role-play/modeling

In-Session ExposuresIn-Session Exposures Re-building significant relationshipRe-building significant relationship

Practice GoalsPractice Goals

Session EightSession Eight

In-Session ExposuresIn-Session Exposures Psychoeducational Topic: Saying Psychoeducational Topic: Saying

Goodbye and Exposure Grab Bag Goodbye and Exposure Grab Bag Saying GoodbyeSaying Goodbye Exposure Grab BagExposure Grab Bag

Lessons learnedLessons learned

Experimental TrialExperimental Trial

Experiment: Experiment: WCBT + Vocational Rehab as usual (N=29)WCBT + Vocational Rehab as usual (N=29) Vocational Rehab alone (N=29)Vocational Rehab alone (N=29)

Random assignmentRandom assignment Blinded raters of progressBlinded raters of progress Manual, session checklists, participant Manual, session checklists, participant

workbooksworkbooks Fidelity ratings from independent expertFidelity ratings from independent expert

SampleSampleControl Intervention Total

Freq % Freq % Freq %

Race

African American 22 78.60% 27 93.10% 49 86%

White 4 14.30% 2 6.90% 6 10.50%

Multiracial 2 7.10% 0 0% 2 3.50%

Sex

Men 19 65.50% 20 69.00% 39 67.20%

Women 10 34.50% 9 31.00% 19 32.80%

Education

8 years or less 1 3.40% 3 10.30% 4 6.90%

9-11 years 9 31.00% 10 34.50% 19 32.80%

High School Graduate 12 41.40% 9 31.00% 21 36.20%

13-16 years 5 17.20% 6 20.70% 11 19.00%

College Graduate 2 6.90% 1 3.40% 3 5.20%

Age

19-30 4 13.80% 0 0.00% 4 6.90%

31-40 7 24.10% 6 2.07% 13 22.40%

41-50 12 41.40% 18 62.10% 30 51.70%

51-60 6 20.70% 5 17.20% 11 18.90%

Mean Age 42.24 44.93 43.59

SD 10.21 6.19 8.48

Marital Status

Married 1 3.40% 0 0% 1 1.70%

Separated 2 6.90% 6 20.70% 8 13.80%

Divorced 7 24.10% 6 20.70% 13 22.40%

Widowed 2 6.90% 0 0% 2 3.40%

Never Married 17 58.60% 17 58.60% 34 58.60%

Employed any time in past year

Yes 12 41.40% 19 67.90% 31 54.40%

No 17 58.60% 9 32.10% 26 45.60%

Household income in past year

Less than $10,000 26 89.70% 26 89.70% 52 89.70%

$10,000 - $19,999 1 3.40% 1 3.40% 2 3.40%

$20,000 - $29,999 1 3.40% 2 6.90% 3 5.20%

Randomized Trial Randomized Trial Preliminary ResultsPreliminary Results

Liebowitz Total Liebowitz Total

F=7.557 P=0.009

Job Related Anxiety Job Related Anxiety

F= 3.613 P=0.065

PHQ - DepressionPHQ - Depression

F=4.917; p< 0.032

Beck AnxietyBeck Anxiety

F=3.355 p=0.075

Job Search ConfidenceJob Search Confidence

F= 4.179 P=0.001

Job Search ActivitiesJob Search Activities

F=7.023 P=0.015

WCBT Trial WCBT Trial Excellent results so far!Excellent results so far! Of the 29 who participated in WCBT so far, Of the 29 who participated in WCBT so far,

only five did not complete the group – only five did not complete the group – excellent retention rateexcellent retention rate

Very interested in follow-up ratingsVery interested in follow-up ratings Strong cooperation between U of M study Strong cooperation between U of M study

team and JVSteam and JVS Challenges in community-based Challenges in community-based

participatory research models like thisparticipatory research models like this

What Our Participants SayWhat Our Participants Say

““Originally came for the money, but got so much out of it, I didn’t think I was going to get anything out of it but I learned so much.” “It changed my life.”

subject stated that WCBT “changed his life.” Said that group really helped him because, "It helped me put a label on what I had and I could then deal with it."

The Agency Point of View:The Agency Point of View:BenefitsBenefits

Part of an exciting project – something new Part of an exciting project – something new in the field of vocational rehabilitationin the field of vocational rehabilitation

Chance to learn something new that might Chance to learn something new that might improve servicesimprove services

Collaborate using each other’s strengthsCollaborate using each other’s strengths University knows social anxiety and researchUniversity knows social anxiety and research JVS knows the world of work and populationJVS knows the world of work and population

Working with new, inspirational, hard Working with new, inspirational, hard working people from the Universityworking people from the University

The Agency Point of View:The Agency Point of View:Benefits (cont.)Benefits (cont.)

Led to a desire to learn more new things Led to a desire to learn more new things and acquire new skillsand acquire new skills

Anticipation about whether it might help Anticipation about whether it might help improve employmentimprove employment

Chance to present and participate in Chance to present and participate in writing articleswriting articles

The Agency Point of View:The Agency Point of View:ChallengesChallenges

JVS programming changes required JVS programming changes required consideration of the research projectconsideration of the research project

Limited communication at times regarding Limited communication at times regarding progress on project and rationale for the progress on project and rationale for the research-related rules (e.g., SCID training)research-related rules (e.g., SCID training)

Not able to run the groupsNot able to run the groups Maintaining the “blind” – not knowing who Maintaining the “blind” – not knowing who

go the treatmentgo the treatment Extra work on busy daysExtra work on busy days

Community-Based Participatory Community-Based Participatory Research at JVS – Why is it Working? Research at JVS – Why is it Working? Shared effortsShared efforts Shared rewardsShared rewards Appreciating and accepting agency and Appreciating and accepting agency and

university cultures and prioritiesuniversity cultures and priorities Building a great teamBuilding a great team ““Skin in the Game”Skin in the Game” Exciting future togetherExciting future together ChallengesChallenges

Next StepsNext Steps

Complete follow-up ratingsComplete follow-up ratings Apply for new grant to extend study Apply for new grant to extend study

More participantsMore participants Two sitesTwo sites Longer follow-upLonger follow-up

Thank You and Thank You and QuestionsQuestions