Work related cognitive behavioral therapy for unemployed persons with social anxiety disorder
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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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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


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


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


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


Our work will show that with effort and teamwork…


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


Study Goals

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


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


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


Our Study Team (cont.)

  • Nikhil Dhawan, M.D., Psychiatric Resident, University of Michigan

  • AmiramVinokur, Ph.D., Co-investigator, University of Michigan


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


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


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)


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)


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).


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.


Our Beginnings:Women’s Employment Study


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.


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)


Results, cont.

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


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


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


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)


MINI-SPIN


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


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


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…


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


  • Negative Feedback Loop

  • Create Motivation

  • Components of the Program


Session Two

  • Components of the program:

    • Thought Restructuring

    • In-Session Exposures

    • Practice Goals

  • Introduction to Automatic Thoughts

  • Identification of Thinking Errors

  • Practice Goals


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)


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


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


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


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


Session Eight

  • In-Session Exposures

  • Psychoeducational Topic: Saying Goodbye and Exposure Grab Bag

    • Saying Goodbye

    • Exposure Grab Bag

  • Lessons learned


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


Sample


Randomized Trial Preliminary Results


Liebowitz Total


Job Related Anxiety


PHQ - Depression


Beck Anxiety


Job Search Confidence


Job Search Activities


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


What 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:Benefits

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

  • Chance to learn something new that might improve services

  • Collaborate using each other’s strengths

    • University knows social anxiety and research

    • JVS knows the world of work and population

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


The Agency Point of View:Benefits (cont.)

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

  • Anticipation about whether it might help improve employment

  • Chance to present and participate in writing articles


The Agency Point of View:Challenges

  • JVS programming changes required consideration of the research project

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

  • Not able to run the groups

  • Maintaining the “blind” – not knowing who go the treatment

  • Extra work on busy days


Community-Based Participatory Research at JVS – Why is it Working?

  • Shared efforts

  • Shared rewards

  • Appreciating and accepting agency and university cultures and priorities

  • Building a great team

  • “Skin in the Game”

  • Exciting future together

  • Challenges


Next Steps

  • Complete follow-up ratings

  • Apply for new grant to extend study

    • More participants

    • Two sites

    • Longer follow-up


Thank You and Questions


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