Interventions Targeting Negative Mental Imagery in Social Anxiety: A Systematic Review and Meta-Analysis of Characteristics and Outcomes.

Psychological treatment for social anxiety disorder (SAD) has been found to be less effective than for other anxiety disorders. Targeting the vivid and distressing negative mental images typically experienced by individuals with social anxiety could possibly enhance treatment effectiveness. To provide both clinicians and researchers with an overview of current applications, this systematic review and meta-analysis aimed to evaluate the possibilities and effects of imagery-based interventions that explicitly target negative images in (sub)clinical social anxiety. Based on a prespecified literature search, we included 21 studies, of which 12 studies included individuals with a clinical diagnosis of SAD. Imagery interventions (k = 28 intervention groups; only in adults) generally lasted one or two sessions and mostly used imagery rescripting with negative memories. Others used eye movement desensitization and reprocessing and imagery exposure with diverse intrusive images. Noncontrolled effects on social anxiety, imagery distress and imagery vividness were mostly large or medium. Meta-analyses with studies with control groups resulted in significant medium controlled effects on social anxiety (d = -0.50, k = 10) and imagery distress (d = -0.64, k = 8) and a nonsignificant effect on imagery vividness. Significant controlled effects were most evident in individuals with clinically diagnosed versus subclinical social anxiety. Overall, findings suggest promising effects of sessions targeting negative mental images. Limitations of the included studies and the analyses need to be considered. Future research should examine the addition to current SAD treatments and determine the relevance of specific imagery interventions. Studies involving children and adolescents are warranted.

The relationships among working alliance, group cohesion and homework engagement in group cognitive behaviour therapy for social anxiety disorder.

OBJECTIVE: Few studies have investigated the role of generic relational factors, such as group cohesion and working alliance, in group cognitive behaviour therapy (CBT) for social anxiety disorder (SAD). The aim of this study was to examine the temporal associations among working alliance, group cohesion, and an index of a CBT-specific factor, homework engagement, as correlates of fear of negative evaluation and symptoms of social anxiety in group CBT for SAD. METHOD: There were 105 participants with a diagnosis of social anxiety disorder who were randomly assigned to 12 sessions of group imagery-enhanced or standard CBT. Participants completed measures at various time points during the 12-session interventions, and the relationship among variables was examined through random-intercept cross-lagged panel models. RESULTS: Group cohesion was significantly associated with social anxiety symptoms at the end of treatment, however there was no significant relationship with working alliance. Greater homework engagement predicted lower social interaction anxiety, but only during mid-treatment. CONCLUSION: The results highlight the importance of supporting group cohesion and maximising homework engagement during core components of social anxiety treatment such as behavioural experiments.

More than doubling the clinical benefit of each hour of therapist time: a randomised controlled trial of internet cognitive therapy for social anxiety disorder.

BACKGROUND: Cognitive therapy for social anxiety disorder (CT-SAD) is recommended by NICE (2013) as a first-line intervention. Take up in routine services is limited by the need for up to 14 ninety-min face-to-face sessions, some of which are out of the office. An internet-based version of the treatment (iCT-SAD) with remote therapist support may achieve similar outcomes with less therapist time. METHODS: 102 patients with social anxiety disorder were randomised to iCT-SAD, CT-SAD, or waitlist (WAIT) control, each for 14 weeks. WAIT patients were randomised to the treatments after wait. Assessments were at pre-treatment/wait, midtreatment/wait, posttreatment/wait, and follow-ups 3 & 12 months after treatment. The pre-registered (ISRCTN 95 458 747) primary outcome was the social anxiety disorder composite, which combines 6 independent assessor and patient self-report scales of social anxiety. Secondary outcomes included disability, general anxiety, depression and a behaviour test. RESULTS: CT-SAD and iCT-SAD were both superior to WAIT on all measures. iCT-SAD did not differ from CT-SAD on the primary outcome at post-treatment or follow-up. Total therapist time in iCT-SAD was 6.45 h. CT-SAD required 15.8 h for the same reduction in social anxiety. Mediation analysis indicated that change in process variables specified in cognitive models accounted for 60% of the improvements associated with either treatment. Unlike the primary outcome, there was a significant but small difference in favour of CT-SAD on the behaviour test. CONCLUSIONS: When compared to conventional face-to-face therapy, iCT-SAD can more than double the amount of symptom change associated with each therapist hour.

Internet-delivered therapist-assisted cognitive therapy for adolescent social anxiety disorder (OSCA): a randomised controlled trial addressing preliminary efficacy and mechanisms of action.

BACKGROUND: Cognitive therapy for SAD (CT-SAD) is a first-line recommended treatment for adult social anxiety disorder (SAD) and shows considerable promise for youth. However, the high prevalence of adolescent SAD and limited number of therapists presents an implementation challenge. Delivery of CT-SAD via the Internet may offer part of the solution. METHOD: Forty-three youth (14-18 years) with SAD recruited through schools were randomly allocated to therapist-assisted Internet-delivered CT-SAD (called OSCA) or waitlist for 14 weeks (ISRCTN15079139). RESULTS: OSCA outperformed waitlist on all measures and was associated with large effects that were maintained at 6-month follow-up. In the OSCA arm, 77% of adolescents lost their SAD diagnosis at post (vs. 14% in the waitlist arm), increasing to 91% at 6-months. Beneficial effects of OSCA were mediated through changes in cognitions and safety behaviours as predicted by cognitive models of SAD. OSCA was associated with high credibility and therapeutic alliance. CONCLUSIONS: This preliminary trial suggests OSCA holds promise as an effective, accessible treatment for adolescent SAD. Future definitive trials could compare OSCA to active comparators to examine specificity of effects.

The Role of Distorted Cognitions in Mediating Treatment Outcome in Children with Social Anxiety Disorder: A Preliminary Study.

This study examined whether distorted cognition changes during cognitive behavioural therapy (CBT) in children (N = 61; aged 7-12) with social anxiety disorder (SAD) and whether changes in distorted cognition from pre- to post-treatment predict SAD at 6-month follow-up. Baseline distorted cognition was also examined as a predictor of post-treatment outcome. Multiple informant SAD-measures were obtained pre-treatment, post-treatment and at 6-month follow-up. Children reported on interpretation bias and dysfunctional beliefs. A decrease in interpretation bias and dysfunctional beliefs was prospectively related to greater SAD change between post-treatment and 6-month follow-up. Child-reported SAD-change at post-treatment predicted greater change in dysfunctional beliefs at 6-month follow-up. Higher baseline interpretation bias predicted greater change in SAD-severity at post-treatment. Children with greater distorted cognition reductions during treatment, showed greater treatment gains at 6-month follow-up. Children who do not show this reduction may require additional efforts focused on distorted cognition to maximally benefit from treatment.

Does treatment preference affect outcome in a randomized trial of a mindfulness intervention versus cognitive behaviour therapy for social anxiety disorder?

Research suggests that treatment preference may affect outcome of randomized clinical trials, but few studies have assessed treatment preference in trials comparing different types of psychosocial interventions. This study used secondary data analysis to evaluate the impact of treatment preference in a randomized trial of a mindfulness-based intervention adapted for social anxiety disorder (MBI-SAD) versus cognitive behaviour group therapy (CBGT). Ninety-seven participants who met DSM-5 criteria for SAD were randomized. Prior to randomization, twice as many participants expressed a preference for the MBI-SAD over CBGT. However, being allocated or not to one's preferred treatment had no impact on treatment response. Additionally, with the exception of perception of treatment credibility, treatment matching had no impact on treatment-related variables, including treatment initiation, session attendance, homework compliance, satisfaction with treatment and perception that treatment met expectations. In sum, despite the greater preference for the mindfulness intervention in this sample of participants with SAD, we found little evidence of preference effects on our study outcomes. Findings should be viewed as preliminary and require replication.

The Use of Dynamic Cognitive Behavioural Therapy (DCBT) in Social Anxiety Disorder (SAD): A Theoretical Integration Initiative.

Psychotherapy theorists can often become fervent advocates of the schools they follow and place the doctrines of the theories they adopt above all else. This situation can sometimes turn into a war of theories between researchers as well. However, therapists should not aim to shape therapy sessions according to their methods but to use them in line with clients' needs. Although it is emphasised that the integration of both psychoanalytic and cognitive behavioural therapy techniques, which is going to be named dynamic cognitive behavioural therapy (DCBT) in this case report, will provide more effective and permanent treatment, a discernible gap exists regarding the integration of these theories and their use in psychotherapy. Taking into account this gap, it is considered important to use this approach with a client who has a social anxiety disorder (SAD). Therefore, this study aims to describe the almost forgotten DCBT approach step by step through a case report and reveal the effectiveness of this approach. As a result, DCBT seems to be effective in the treatment of SAD.

Mitigating adolescent social anxiety symptoms: the effects of social support and social self-efficacy in findings from the Young-HUNT 3 study.

Adolescents' exposure to negative life events (NLEs) and potentially traumatic events is highly prevalent and increases their risk of developing psychological disorders considerably. NLE exposure has also been linked to the development of social anxiety disorder (SAD) among older children and young adolescents. Despite the relatively low treatment efficacy reported for children and adolescents suffering from SAD, few studies have addressed the extent to which resilience factors, such as social support and social self-efficacy, are associated with SAD symptoms. This study examined whether social support and social self-efficacy predict, and buffer against SAD symptoms using a large, population-based sample of adolescents, among whom a large proportion have experienced NLEs. The results reveal that NLEs are significantly associated with SAD symptoms, while social support and social self-efficacy are both negatively associated with SAD symptoms. Only the NLEs × social support interaction significantly predicted SAD symptoms, with social support attenuating the association between NLEs and SAD symptoms. Moreover, increases in both social self-efficacy and social support were associated with reduced SAD symptoms, over and above variance explained by social support alone. Our cumulative results suggest that interventions that can modify both social support and social self-efficacy may help reduce SAD symptoms in at-risk adolescents.

The benefits of a longer course of cognitive behavioral therapy for some patients with social anxiety disorder.

Historically, cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) has been evaluated in randomized-controlled trials as a 12-16 session treatment and has demonstrated response rates ranging from 58% to 75%. Despite these promising results, some patients do not improve substantially after this short course of CBT. It is unclear whether non-responding patients would make substantial improvements in social anxiety with further treatment. In a university outpatient clinic specializing in CBT for SAD, we compared outcomes for patients who ended treatment after approximately 20 sessions of CBT (n = 38) to those who continued treatment for a variable number of additional sessions (n = 34). We found no between-group differences in demographic characteristics, number of comorbid diagnoses, comorbid generalized anxiety disorder or major depressive disorder, or severity of depression at baseline. Patients who ended treatment after 20 sessions experienced greater improvements in SAD over those 20 sessions compared to those who continued treatment. Both groups experienced changes in depression and quality of life over the first 20 sessions. Those who continued treatment showed additional decreases in social anxiety beyond session 20. For those who initially appear to be non-responsive to CBT for SAD, a longer course of treatment may elicit significant improvements.

The Efficacy of Intensive Short-Term Dynamic Psychotherapy for Social Anxiety Disorder: Randomized Trial and Substudy of Emphasizing Feeling Versus Defense Work.

This research examined the efficacy of intensive short-term dynamic psychotherapy (ISTDP) in the treatment of social anxiety disorder (SAD) and compared the therapeutic outcomes of ISTDP when feeling focus or defense work is emphasized. A three-group randomized design with 6-month follow-up was used. Forty-one subjects were selected among volunteer college students diagnosed with SAD. They were assigned randomly into three groups; 14 cases to feeling-focused ISTDP (FF-ISTDP) group, 14 cases to defense-focused ISTDP (DF-ISTDP) group, and 13 cases to a control group. All subjects were evaluated at pretest, posttest, and six-month follow-up through clinical interviewing using DSM-5 criteria for SAD along with the Liebowitz Social Anxiety Scale. Each experimental group had a course of 8 to 10 sessions of ISTDP treatment. Analysis of variance showed that ISTDP is an effective treatment for SAD compared with a control group. No outcome differences were found between FF-ISTDP and DF-ISTDP in treating SAD.

Efficacy and cost-effectiveness of an unguided, internet-based self-help intervention for social anxiety disorder in university students: protocol of a randomized controlled trial.

BACKGROUND: Social anxiety disorder (SAD) is highly prevalent among university students, but the majority of affected students remain untreated. Internet- and mobile-based self-help interventions (IMIs) may be a promising strategy to address this unmet need. This study aims to investigate the efficacy and cost-effectiveness of an unguided internet-based treatment for SAD among university students. The intervention is optimized for the treatment of university students and includes one module targeting fear of positive evaluations that is a neglected aspect of SAD treatment. METHODS: The study is a two arm randomized controlled trial in which 200 university students with a primary diagnosis of SAD will be assigned randomly to either a wait-list control group (WLC) or the intervention group (IG). The intervention consists of 9 sessions of an internet-based cognitive-behavioral treatment, which also includes a module on fear of positive evaluation (FPE). Guidance is delivered only on the basis of standardized automatic messages, consisting of positive reinforcements for session completion, reminders, and motivational messages in response to non-adherence. All participants will additionally have full access to treatment as usual. Diagnostic status will be assessed through Structured Clinical Interviews for DSM Disorders (SCID). Assessments will be completed at baseline, 10 weeks and 6-month follow-up. The primary outcome will be SAD symptoms at post-treatment, assessed via the Social Phobia Scale (SPS) and the Social Interaction Anxiety Scale (SIAS). Secondary outcomes will include diagnostic status, depression, quality of life and fear of positive evaluation. Cost-effectiveness and cost-utility analyses will be evaluated from a societal and health provider perspective. DISCUSSION: Results of this study will contribute to growing evidence for the efficacy and cost-effectiveness of unguided IMIs for the treatment of SAD in university students. Consequently, this trial may provide valuable information for policy makers and clinicians regarding the allocation of limited treatment resources to such interventions. TRIAL REGISTRATION: DRKS00011424 (German Clinical Trials Register (DRKS)) Registered 14/12/2016.

[Negative Indicators in the Psychotherapeutic Process: Frequency and Relationship with Attachment Characteristics and Treatment Outcome among Patients with Social Anxiety Disorder]. / Negative Indikatoren im psychotherapeutischen Prozess: Häufigkeit und Zusammenhang mit Bindungsmerkmalen und Therapieerfolg bei Patienten mit sozialer Angststörung.

Within the SOPHO-Net-Project, mainly focusing on a randomized-controlled trial comparing short term cognitive and psychodynamic psychotherapy for social anxiety disorder, a subsample consisting of 88 patients from 3 of the 5 study sites was investigated to examine the relationship between outcome, initial attachment characteristics and negative indicators during the process. These negative indicators were assessed with the Vanderbilt Negative Indicators Scale which was applied to an early (3rd), a middle (9th) as well as a late therapy (22nd) session. The study shows that negative indicators as a whole were relatively rare with a higher frequency within the psychodynamic therapies for which a relationship between negative indicators and outcome could be found. Contrary to expectation, initial attachment characteristics were not related to negative indicators.

Optimal Cut Points for Remission and Response for the German Version of the Social Phobia Anxiety Inventory (SPAI).

OBJECTIVE: The German version of the Social Phobia and Anxiety Inventory (SPAI-G) is a validated measure for the detection of social anxiety disorder (SAD). The aim of the present study was to develop optimal cut points (OC) for remission and response to treatment for the SPAI-G. METHODS: We used Receiver Operating Characteristic methods and bootstrapping to analyse the data of 359 patients after psychotherapeutic treatment. OCs where defined as the cut points with the highest sensitivity and specificity after bootstrapping. RESULTS: For remission, an OC of 2.79 was found, and for response, a change in score from pre- to posttreatment by 11% yielded best results. CONCLUSIONS: The OC we identified for remissionmay be used to improve the diagnostic utility of the SPAI-G. However, the cut point for response achieved only borderline-acceptable levels of sensitivity and specificity, calling into doubt their utility in clinical and research setting.

Assessing Clinical Improvement in School-Based Treatment for Social Anxiety Disorder: Agreement Between Adolescents, Parents, and Independent Evaluators.

The Clinical Global Impressions of Improvement (CGI-I) scale is widely used in clinical trials to monitor clinically meaningful change during treatment. Although it is standard practice in research to have independent evaluators (IEs) complete the CGI-I, this approach is not practical in school and community settings. Few studies have explored the potential utility of other informants, such as youth and parents. Therefore, this study aimed to investigate agreement between IEs and both adolescents and parents in CGI-I improvement ratings in the context of a randomized controlled trial of cognitive-behavioral therapy for social anxiety disorder, as delivered by psychologists and school counselors. Multilevel growth models indicated that IEs were generally more conservative in their ratings of positive treatment response across time and treatment conditions, though greater agreement was observed between parents and IEs by post-intervention and 5-month follow-up. Possible explanations for these findings and suggestions for alternative approaches are discussed.

Social Anxiety and Fear of Causing Discomfort to Others: Diagnostic Specificity, Symptom Correlates and CBT Treatment Outcome.

BACKGROUND: Patients with social anxiety disorder (SAD) report fear content relating to the perceived aversive consequences of their anxiety for others in their social environment. However, no studies to date have examined the diagnostic specificity of these fears to SAD as well as predictors to treatment response of these fears. AIMS: To examine relative specificity of fears related to causing discomfort to others, as measured by Social Anxiety-Fear of Causing Discomfort to Others (SA-DOS), among patients with anxiety disorders, obsessive compulsive disorder (OCD) and major depressive disorder (MDD), in addition to relation between dysfunctional attitudes and treatment response among patients with SAD. METHOD: In study 1, a large (n=745) sample of DSM diagnosed OCD, MDD and anxiety disorder participants completed the SA-DOS. In study 2, patient participants with SAD (n=186) participated in cognitive behavioural group therapy (CBGT) and completed measures of social anxiety symptoms and dysfunctional attitudes. RESULTS: In study 1, the SAD group demonstrated significantly elevated SA-DOS scores compared with participants with generalized anxiety disorder (GAD), OCD and panic disorder with or without agoraphobia (PD/A), but not the MDD group. In study 2, CBGT treatment was found to lead to significant reductions in SA-DOS scores. Need for approval (NFA) but not perfectionism, predicted treatment response to fears related to causing discomfort to others, with greater change in NFA relating to greater change in SA-DOS scores. CONCLUSIONS: These findings extend previous research linking allocentric fears to the phenomenology and treatment of SAD.

The effects of cognitive and behavioural therapies for anxiety disorders on depression: a meta-analysis.

BACKGROUND: The effects of cognitive behavioural therapy of anxiety disorders on depression has been examined in previous meta-analyses, suggesting that these treatments have considerable effects on depression. In the current meta-analysis we examined whether the effects of treatments of anxiety disorders on depression differ across generalized anxiety disorder (GAD), social anxiety disorder (SAD) and panic disorder (PD). We also compared the effects of these treatments with the effects of cognitive and behavioural therapies of major depression (MDD). METHOD: We searched PubMed, PsycINFO, EMBASE and the Cochrane database, and included 47 trials on anxiety disorders and 34 trials on MDD. RESULTS: Baseline depression severity was somewhat lower in anxiety disorders than in MDD, but still mild to moderate in most studies. Baseline severity differed across the three anxiety disorders. The effect sizes found for treatment of the anxiety disorders ranged from g = 0.47 for PD, g = 0.68 for GAD and g = 0.69 for SAD. Differences between these effect sizes and those found in the treatment of MDD (g = 0.81) were not significant in most analyses and we found few indications that the effects differed across anxiety disorders. We did find that within-group effect sizes resulted in significantly (p < 0.001) larger effect sizes for depression (g = 1.50) than anxiety disorders (g = 0.73-0.91). Risk of bias was considerable in the majority of studies. CONCLUSIONS: Patients participating in trials of cognitive behavioural therapy for anxiety disorders have high levels of depression. These treatments have considerable effects on depression, and these effects are comparable to those of treatment of primary MDD.

Letting go of yesterday: Effect of distraction on post-event processing and anticipatory anxiety in a socially anxious sample.

According to cognitive models, post-event processing (PEP) is a key factor in the maintenance of social anxiety. Given that decreasing PEP can be challenging for socially anxious individuals, it is important to identify potentially useful strategies. Although distraction may help to decrease PEP, the findings have been equivocal. The primary purpose of this study was to examine whether a brief distraction period immediately following a speech would lead to less PEP the next day. The secondary aim was to examine the effect of distraction following an initial speech on anticipatory anxiety for a second speech, via reductions in PEP. Participants (N = 77 undergraduates with elevated social anxiety; 67.53% female) delivered a speech and were randomly assigned to a distraction, rumination, or control condition. The following day, participants reported levels of PEP in relation to the first speech, as well as anxiety regarding a second, upcoming speech. As expected, those in the distraction condition reported less PEP than those in the rumination and control conditions. Additionally, distraction following the first speech was indirectly related to anticipatory anxiety for the second speech, via PEP. Distraction may represent a potentially useful strategy for reducing PEP and other maladaptive processes that may maintain social anxiety.

Cognitive Therapy and Task Concentration Training Applied as Intensified Group Therapies for Social Anxiety Disorder with Fear of Blushing-A Randomized Controlled Trial.

The current study examines the efficacy of intensified group therapy for social anxiety disorder with fear of blushing. Task concentration training (TCT) and cognitive therapy (CT) were applied during one weekend and compared with a waiting list condition in a randomized controlled trial including 82 patients. On a second weekend, another intervention was added (resulting in TCT-CT and CT-TCT sequences) to examine order effects. Task concentration training and CT were both superior to the waiting list and equally effective after the first therapy weekend. Also, no differences were found between the sequences TCT-CT and CT-TCT at post-assessment. At 6- and 12-month follow-up, effects remained stable or further improved. At the 6-month follow-up, remission rates in completers, established by diagnostic status, were between 69% and 73%. Intensified group therapy is highly effective in treating social anxiety disorder with fear of blushing. Group formats for patients sharing a common primary concern may contribute to the dissemination of cognitive-behavioural therapy. Copyright © 2015 John Wiley & Sons, Ltd. Key Practitioner Message: This study focuses on blushing from fearful individuals within the SAD spectrum to improve evidence for treatment efficacy in those whose social fears are centred around observable bodily sensations. This study integrates task concentration training into the SAD model of Clark and Wells to combine two evidence-based treatments for SAD under one treatment model. This study uses an innovative format of brief, intensified group therapy, conducted on two full-day weekend group sessions delivered over two weekends, with strong observed effect sizes.

Effectiveness of cognitive behavioral group therapy, psychodrama, and their integration for treatment of social anxiety disorder: A randomized controlled trial.

BACKGROUND AND OBJECTIVES: Although cognitive behavioral group therapy (CBGT) is an effective treatment for social anxiety disorder, many socially anxious patients are still symptomatic after treatment. A possible improvement for CBGT could come from the more experiential group psychotherapy, psychodrama (PD). The integration of CBGT and PD (labeled CBPT) might offer an even more effective treatment than CBGT or PD alone. With the present study, we investigated first whether three kinds of group therapy (CBGT, PD, and CBPT) are superior to a waitlist (WL). Second, we investigated whether CBPT is more effective than CBGT or PD alone. METHODS: One hundred and forty-four social anxiety patients were randomly assigned to three active conditions or a WL. After wait, WL-participants were randomized over the active treatment conditions. RESULTS: The results of a multilevel analysis showed that all treatments were superior to WL in reducing social anxiety complaints. Only CBGT and CBPT differed significantly from WL in reducing fear of negative evaluations. There were no significant differences between active conditions in any of the variables after treatment and after six-month follow up, neither were there significant differences in treatment dropout. LIMITATIONS: First there is the lack of a long-term follow-up. Second, because of loss of participants, we did not reach the planned numbers in the active treatment groups in comparison to WL. Moreover, this study was not designed as a non-inferiority or equivalence trial. CONCLUSIONS: Although the integrative CBPT showed good results, it was not more effective than the other treatments.

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.