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Work Related Cognitive-Behavioral Therapy for Unemployed Persons With Social Anxiety Disorder

Work Related Cognitive-Behavioral Therapy for Unemployed Persons With Social Anxiety Disorder. Joseph Himle , Ph.D. Director, Vivian A. & James L. Curtis Research Center, University of Michigan, School of Social Work & Department of Psychiatry

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Work Related Cognitive-Behavioral Therapy for Unemployed Persons With Social Anxiety Disorder

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  1. Work Related Cognitive-Behavioral Therapy for Unemployed Persons With Social Anxiety Disorder Joseph Himle, Ph.D. Director, Vivian A. & James L. Curtis Research Center, University of Michigan, School of Social Work & Department of Psychiatry Ed Steinberger, M.A., Wayne Laviolette, M.A., Zipora Golenberg, M.A., YolithaHill, M.A. JVS Detroit NIMH 1R34MH083031-01

  2. Almost every new mental health intervention is designed, developed and tested in middle class, educated, majority communities

  3. Why not in an urban-based center with underserved, impoverished, multi-problem participants…

  4. It takes more effortIt is seen as a riskIt is unfamiliarIt requires cooperation

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

  6. New interventions can be developed and tested in underserved, mostly minority populations with unexpected success

  7. Study Goals • Design and develop a culturally informed, vocationally focused, sustainable, intervention for unemployed for persons with Social Anxiety Disorder

  8. Our Study Team • Joseph Himle, Ph.D., University of Michigan, Principal Investigator • Ed Steinberger, M.S., JVS, Co-Investigator, Group Leader • Wayne Laviolette, Psy.S, L.L.P JVS, Co-Investigator, Group Leader • ZiporaGolenberg, M.A., L.P.C., JVS, Co-Investigator, Group Leader • YolithaHill, M.A., Case Coordinator, JVS Detroit

  9. Our Study Team (cont.) • Deborah Bybee, Ph.D., Michigan State University, Co-Investigator • Co-Investigator, Sarah Vlnka, M.S.W., Study Coordinator • Debra Levine, M.S., Doctoral Student University of Michigan • Lisa O’Donnell, M.S.W., Doctoral Student University of Michigan • Katherine Zumberg, M.S., Doctoral Student, University of Michigan

  10. Our Study Team (cont.) • Nikhil Dhawan, M.D., Psychiatric Resident, University of Michigan • AmiramVinokur, Ph.D., Co-investigator, University of Michigan

  11. Key Supporters at JVS Jillian Struble Karen Zmich Barb Ossowski Bambi Hites Bert Dancer Norm Luzier Francis Bowen • Barbara Nurenberg • Leah Rosenbaum • Andrea Tolle • Mike Reaume (deceased) • Diane Bonds • KertrinaGordon

  12. Social Anxiety Disorder • SocAD involves fear and avoidance of certain social or performance situations like going on a job interview, giving a speech, or meeting new people • 12.1% of the general population will meet criteria for SocAD in their lifetime (Kessler et al., 2005) • SocAD negatively affects social relationships, role functioning, activities, overall well being and… WORK

  13. Social Anxiety and Work • Individuals with SocAD report: • Impairments in work productivity • Reduced time spent working (e.g., absences) • Reduced perceived work performance and productivity, relative to non-anxious controls (Davidson et al.,1993; Schneier et al., 1994; Wittchen et al., 2000)

  14. Social Anxiety and Work (cont.) • Large majority (92%) of social phobic sample significant occupational impairments (Turner et al.,1986) • One in five individuals with SocAD turned down a job offer or promotion as a result of social fears (Stein et al, 2000)

  15. Social Anxiety and Work (cont.) • Occupational success in SocAD is also limited by their lowered educational achievement, scholastic difficulties, and early school dropout (Davidson et al., 1993; Magee et al., 1996; Mogotsi et al., 2000; Stein & Kean, 2000). • Occupational dysfunction in SocAD leads to heightened levels of financial dependence (Schneier et al., 1992) and reduced income (Kessler et al., 1994; Magee et al., 1996).

  16. Why Might Social Anxiety Interfere with Employment? • Avoidance of job interviews • Few friends to provide job leads • Poor performance in job interviews • Problems forming strong relationships at work which can protect against job loss • Avoid telling superiors/coworkers about problems and successes • Embarrassment regarding unemployment • Lower educational attainment • Growing service based economy in U.S.

  17. Our Beginnings:Women’s Employment Study

  18. Women’s Employment Study • Five-wave longitudinal study of female welfare recipients in urban Michigan county • Examined how mental health, health and influence ability to enter or return to work • Face-to-face interviews with 753 randomly female welfare recipients • All respondents were African-American or non-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 disorder on employment among women receiving welfare benefits. Psychiatric Services, 60, 61-66.

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

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

  21. Work Related Cognitive-Behavioral Therapy for Unemployed Persons With Social Anxiety Disorder (WCBT)

  22. Study Site • Jewish Vocational Services (JVS), Detroit Michigan, Career Initiative Center (CIC) • JVS’s CIC provides comprehensive vocational rehabilitation services for homeless individuals • Primary clientele are economically disadvantaged, African Americans who are seeking work

  23. WCBT – Initial Screening • Screening all clients at JVS for SocAD • 24% (Detroit site) and 32% (Southfield site) screened positive for social anxiety disorder -using the MINI-SPIN (Connor, et al., 2001)

  24. MINI-SPIN

  25. WCBT - Intervention • Begin with existing group cognitive-behavioral treatment (CBT) for social anxiety (Heimberg & Becker, 2002) • CBT for SocAD involves: • Gradual exposure to anxiety provoking situations • Cognitive restructuring

  26. Building an Intervention Reviewing existing treatment manuals Innovating to fit vocational setting and work focus Site visit to Baltimore – JOBS program (Vinokuret al., 1995) Input from consultants Semi-structured interviews with JVS clients and staff Pilot Groups with in-vivo adjustments and post-group focus interviews

  27. WCBT - Intervention • Current providers at JVS lead WCBT • Offered as one of several classes occurring in an average day of programming at JVS • Two 2-hour sessions per week over 4 weeks • Session Content…

  28. Session One • Purpose of the Session: • Introduce the program • Explain the Concept of Social Anxiety • Create a welcoming environment and commitment • Three components of anxiety: • Physiological • Cognitive • Behavioral

  29. Negative Feedback Loop • Create Motivation • Components of the Program

  30. Session Two • Components of the program: • Thought Restructuring • In-Session Exposures • Practice Goals • Introduction to Automatic Thoughts • Identification of Thinking Errors • Practice Goals

  31. Session Three • Psychoeducational Topic: Relating Social Anxiety to the World of Work • How does social anxiety come up in the workplace? • Disputing Automatic Thoughts and Developing Rational Responses • List of Anxiety-Evoking Situations • Develop Hierarchy Charts • Practice Goals(set at the end of each session)

  32. Session Four • Psychoeducational Topic: Self-Defeating Behavior at Work • In-Session Exposures • Don’t always follow Psycho-ed topic • Important to validate what is important to participants • Client Story G. O. • Set Practice Goals

  33. Session Five • Psychoeducational Topic: Asking for Help • How to Ask for Help • ability or lack of – great indicator of probability of success • Who Can We Ask for Help? • Exposures – Working to re-establish family ties • Practice Goals

  34. Session Six • Psychoeducational Topic: Recognizing and Describing your Strengths • Card sorting exercise • Leaders role-play/modeling • Weaknesses into Strengths - Reframing • In-Session Exposures • Teaching new employees • Practice Goals

  35. Session Seven • Psychoeducational Topic: Talking with Supervisors and Coworkers • Cost/Benefit Analysis • Flip chart • Leaders role-play/modeling • In-Session Exposures • Re-building significant relationship • Practice Goals

  36. Session Eight • In-Session Exposures • Psychoeducational Topic: Saying Goodbye and Exposure Grab Bag • Saying Goodbye • Exposure Grab Bag • Lessons learned

  37. Experimental Trial • Experiment: • WCBT + Vocational Rehab as usual (N=29) • Vocational Rehab alone (N=29) • Random assignment • Blinded raters of progress • Manual, session checklists, participant workbooks • Fidelity ratings from independent expert

  38. Sample

  39. Randomized Trial Preliminary Results

  40. Liebowitz Total

  41. Job Related Anxiety

  42. PHQ - Depression

  43. Beck Anxiety

  44. Job Search Confidence

  45. Job Search Activities

  46. WCBT Trial • Excellent results so far! • Of the 29 who participated in WCBT so far, only five did not complete the group – excellent retention rate • Very interested in follow-up ratings • Strong cooperation between U of M study team and JVS • Challenges in community-based participatory research models like this

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