Study protocol: A multisite trial of Work-Related Cognitive behavioral therapy for unemployed persons with social anxiety

Multiple Stakeholder Perspectives of Implementing Work-Related Cognitive Behavioral Therapy (WCBT) in Vocational Service Settings: A Qualitative Exploration of Intervention Acceptability and Sustainability

Growing mental health treatment access disparities elevate the urgency for identifying and implementing innovative approaches for delivering evidence-supported interventions. Work-related cognitive behavioral therapy (WCBT), a technology-assisted CBT (t-CBT) designed to address social anxiety and employment outcomes among job seekers at vocational service centers and for delivery by vocational service professionals, offers a promising way to increase access to needed mental health care. This qualitative study, guided by the Organizational Transformation Model (OTM), explored factors related to WCBT's implementation at two Jewish Vocational Services (JVS) Human Service sites in Detroit, MI and Los Angeles County, CA. Twenty-seven staff-stakeholders across the two JVS sites completed in-depth, semi-structured interviews focused on their experiences with WCBT over the four-year study period. Thematic analysis identified five core codes that most broadly captured participants' perceptions of WCBT implementation and the factors influencing implementation, including: (1) Need, (2) Buy-in and engagement, (3) Communication, (4) Sustainability concerns, and (5) Implementation facilitators. Core codes aligned with OTM factors related to impetus to transform, improvement initiatives, integration across boundaries, alignment from top to bottom, and leadership. Findings identify implementation strategies likely to optimize uptake and sustainability of WCBT within JVS sites that can be tested in a larger, multi-site implementation trial.

Generalization Between Perceptually Similar Stimuli Is Associated With Improvement in Social Anxiety Following Cognitive-Behavioral Therapy

Cognitive-behavioral therapy (CBT) for anxiety disorders requires that people learn to inhibit their fear during exposure to stimuli that no longer pose a threat. We investigate whether individual differences in this inhibitory learning ability, measured prior to treatment, can predict responsiveness to CBT for social anxiety disorder. Participants (N = 128) were randomized to CBT or a wait-list control and completed tests of fear generalization and extinction prior to and following the intervention period. Contrary to expectations, individual differences in extinction, measured at pretreatment, were not associated with treatment responses but there was evidence that these abilities changed over time due to treatment. Individual differences in fear generalization at pretreatment were associated with treatment responses. Weaker generalization between dangerous and perceptually similar but novel safe stimuli was associated with enhanced responding to CBT. These findings contribute to the development of a mechanistic approach to patient stratification where participants who are least likely to respond to CBT can be identified prior to treatment.

The Relationship between Major and Everyday Discrimination and Suicide Thoughts and Behaviors among a Sample of Socially Anxious Job Seekers

Discrimination predicts psychopathology, including suicide risk. Few studies have examined broad effects of major and everyday discrimination. This study examined whether major and everyday discrimination predicted suicide thoughts and behaviors in a diverse sample of socially anxious adults (N = 295). Exploratory analyses assessed the moderating role of identity and mediating role of depressive symptoms. Everyday discrimination predicted suicide thoughts and behaviors (p = .04). This relationship was reduced to non-significance after controlling for depression (p = .16). Identity characteristics did not moderate this relationship (p > .05). Depressive symptoms mediated the relationship between everyday discrimination and suicide thoughts and behaviors (95% CI [.001, .006]). Major events did not predict suicide thoughts and behaviors before or after controlling for depression (ps > .12). Findings highlight the relevance of repeated instances of discrimination to suicide risk and relatedly, the importance of comprehensive discrimination assessments in research and clinical practice.

Bidirectional Relationships Between Hours Worked and Social Anxiety and Depression Symptoms: A Longitudinal Study

Objective

Previous research has found that social anxiety and depression are associated with occupational impairment, including unemployment and decreased productivity. However, longitudinal studies are limited to depression and only examine effects of anxiety cross-sectionally. Furthermore, prior studies only measured occupational impairment dichotomously as either employed or unemployed. The present secondary data analysis sought to build upon these gaps and investigate bidirectional relationships between hours worked, measured continuously, and symptoms of social anxiety and depression over the course of 48 weeks following a brief intervention for job-seekers with social anxiety disorder, many of whom reported elevated levels of depression. Employment was operationalized as the average number of hours spent working in a given week.

Methods

Two cross-lagged panel models were tested to investigate these relationships in 250 diverse job-seeking individuals (59.2% female, 40.8% Black or African-American, and 16.4% Hispanic/Latine).

Results

In partial support of initial hypotheses, social anxiety and depression symptoms both negatively predicted subsequent hours worked. Hours worked did not predict subsequent social anxiety or depression symptoms.

Conclusions

This was the first study to investigate relationships among depression, social anxiety, and employment that operationalized employment as a continuous variable. The findings contribute novel information about the longitudinal impact of both social anxiety and depression on hours worked and suggest that symptoms of social anxiety or depression may serve as a barrier to seeking or maintaining employment. Interventions for unemployment should consider incorporating simultaneous treatment of social anxiety and depression.

Work-Related Cognitive Behavioral Therapy for racially and economically diverse unemployed persons with social anxiety: A randomized clinical trial

Individuals with Social Anxiety Disorder (SAD) are at risk for employment problems. This multi-site trial examined the efficacy of Work-Related Cognitive Behavioral Therapy provided alongside vocational services as usual (WCBT+VSAU), a group-based treatment designed to improve mental health and employment outcomes for individuals with SAD. Vocational service-seeking participants with SAD (N = 250) were randomized to either WCBT+VSAU or VSAU-alone. Hypotheses were that participants randomized to WCBT+VSAU would report less social anxiety, less depression, and more hours worked than participants randomized to VSAU-alone. WCBT+VSAU participants had significantly greater improvements on the Liebowitz Social Anxiety Scale (LSAS; d=-.25, CI=-0.49 to -0.02, p = .03) at post-assessment compared to VSAU-alone. The conditions did not differ on any variable at later time points or on secondary outcomes. Unexpectedly, participants randomized to VSAU-alone experienced LSAS improvements, similar to WCBT+VASU at later timepoints. Baseline psychological flexibility (beta=-.098 [-0.19-0.008]) and depression (beta=-0.18 [-0.34-0.009]) moderated change in social anxiety. Participants with lower psychological flexibility and higher depression responded more strongly to WCBT+VSAU than VSAU-alone over the duration of the study, suggesting that WCBT+VSAU may particularly benefit those with greater psychopathology. Results indicate that vocational centers are promising settings for treating SAD and employment-focused refinements are likely needed to improve work outcomes.

Perceived interpersonal competence as a predictor of clinical outcomes in a randomized controlled trial for social anxiety and employment

This study explored relationships among perceived interpersonal competence and demographic and work history variables in a randomized control trial for social anxiety disorder (SAD) that compared work-related group cognitive behavioral therapy plus vocational services (WCBT+VSAU) to vocational services only (VSAU-alone). Intervention effects of perceived interpersonal competence on treatment outcomes over 12 weeks were also examined. Data from 250 job seekers with SAD (59.2% Female; 40.8% Black/African American; 82.4% Non-Hispanic/non-Latino/a) were analyzed. We predicted negative relationships between perceived interpersonal competence and symptoms/impairment and that individuals with lower perceived interpersonal competence would benefit more quickly in WCBT+VSAU relative to VSAU-alone. Results indicated that perceived interpersonal competence did not vary by gender, race, ethnicity, homeless status, or employment history. There were no intervention effects of perceived interpersonal competence regarding social anxiety or overall functional impairment, but results supported negative relationships between perceived interpersonal competence and lower social anxiety and overall functional impairment in both conditions. Separately, perceived interpersonal competence moderated effects in the depression model such that there were faster declines in depression at lower perceived interpersonal competence levels in WCBT+VSAU, but not in VSAU-alone. Results indicate the value of attending to perceived interpersonal competence in interventions, which may result in mood benefits.

Persistence, Impairment, Disability and Unmet Treatment of Lifetime and 12-Month Anxiety Disorders in Black Men and Women, 50 Years of Age and Older

Objectives: To examine anxiety disorders in aging Black adults. Methods: Using nationally representative data from the National Survey of American Life, we estimated lifetime/12-month prevalence of anxiety disorders in Black men and women, age 50+ (N = 1561). Disorder-specific persistence and severity, functional impairment, and mental health service utilization were investigated using multivariate regressions. Results: Black men and women who met criteria for anxiety disorders (lifetime prevalence=12.4%/18.3% in men/women) also demonstrated persistent disorders (percent meeting criteria = 40.3%-61.2%). Those with a 12-month anxiety disorder (6.2%/10.5% of men/women) typically reported severe task interference (38.3%-85.7%). Those with any 12-month anxiety disorder, compared to those without, experienced greater impairment in days out of role, work, family burden, cognition and, in women, mobility (p's < .05). Only 47.0%/65.2% of Black men/women with any lifetime anxiety disorder used mental health services. Discussion: Despite low prevalence, older Blacks with anxiety disorders experience substantial mental health burden in middle age and later.

Prevalence, Severity and Burden of Post-Traumatic Stress Disorder in Black Men and Women Across the Adult Life span

Objectives: To examine post-traumatic stress disorder (PTSD) among Black adults in younger, middle, and older ages. Methods: Using nationally representative data from the National Survey of American Life, we estimated lifetime and 12-month prevalence of PTSD in Black men and women ages 18-34, 35-49, and 50+. We determined PTSD persistence and severity by age group, then associations of PTSD with socio-economic status, chronic stress, and racial discrimination in middle age. Results: The lifetime prevalence of PTSD was higher in Black women/men ages 18-34 (prevalence=14.0%/6.3%) and 35-49 (12.8%/4.6%) versus 50 and older (8.7%/5.1%). Those ages 35-49 were more likely than younger/older Black adults to have severe interference in work, relationships, and activities domains. In middle age, PTSD was associated with unemployment, lower education, poverty, and stress in Black men, and unemployment, divorce, poverty, stress, and discrimination in Black women. Discussion: Black women experience a disproportionate burden of PTSD in middle age.