Group Exposure and Response Prevention for College Students with Social Anxiety Artical review

Pay close attention to the highlighted and bolded sections.Purpose: The purpose of this assignment is for you to show your
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Psychology*. The article should describe an experimental
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articles. It is your responsibility to make sure that the journal article
you select is appropriate. If you are unsure about the relevance of your
article, contact your instructor for approval.).
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researchers’ prediction.)
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the findings and conclusions drawn?)
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psychology?
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discussion as you address these key issues.
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*Why the Journal of Clinical Psychology.
The Journal of Clinical Psychology is a peer-reviewed journal devoted to
research, assessment, and practice. It was founded in 1945, and is a
monthly, peer-reviewedpublications that consists of eight annual
issues. (Over the past 7 years, that is a lot of research.) The topics
covered are diverse and represent leading research in clinical
psychology.
Group exposure and response prevention for college students with
social anxiety: A randomized clinical trial
Zaboski, B. A., Joyce, B. D., Kranzler, J. H., McNamara, J. P., Gayle, C., & MacInnes, J. (2019).
Group exposure and response prevention for college students with social anxiety: A
randomized clinical trial. Journal of Clinical Psychology, 75(9), 1489–1507. https://doiorg.ezproxy.umgc.edu/10.1002/jclp.22792
Contents
1. 1 INTRODUCTION
2. 2 METHODS
3. 2.1 Participants
4. 2.2 Measures
5. 2.2.1 Liebowitz Social Anxiety Scale Self‐Report Measure
6. 2.2.2 The Social Anxiety Questionnaire for adults (SAQ‐A30)
7. 2.2.3 Brief Fear of Negative Evaluation Scale
8. 2.2.4 Beck Depression Inventory‐II
9. 2.3 Procedure
10. 2.3.1 Experimental group
11. 2.3.2 Active treatment control
12. 2.3.3 Data analysis
13. 3 RESULTS
14. 3.1 Descriptive statistics
15. 3.2 Attrition and baseline differences
16. 3.3 Primary analyses
17. 3.3.1 SAQ‐A30
18. 3.3.2 BFNE
19. 3.3.3 BDI‐II
20. 4 DISCUSSION
21. 4.1 Limitations
22. 5 CONCLUSION
23. ACKNOWLEDGEMENTS
24. CONFLICT OF INTERESTS
25. Footnotes
26. REFERENCES
Abstract
Objective: Social anxiety increases college student drop‐out risk and stifles employment
opportunities. Group cognitive‐behavioral therapy with exposure (CBT ERP) has the potential to
alleviate campus resource strain but remains under‐researched with college students. The
present study investigated the efficacy of group CBT ERP in a randomized clinical trial on
a college campus. Method: Thirty‐one postsecondary students were randomly assigned to an
exposure‐only group or an active control. Results: Linear mixed‐effects models indicated
significant Group × Time interactions for general social anxiety (t = −2.02, g = 0.62) and
depression (t = −2.77, g = 0.55); nonsignificant main effects were found for group and time
variables. On a measure of fear of negative evaluation, only the main effect of time was
significant (t = 2.15, p = 0.032). Conclusions: When compared to an active control group, CBT
ERP is an efficacious and time‐effective treatment for college students experiencing
social anxiety.
Keywords: CBT; cognitive‐behavioral therapy; college students; exposure therapy;
social anxiety
1 INTRODUCTION
Social anxiety disorder (SAD) is characterized by a fear of social situations or negative
evaluation by others that cause intense fear disproportional to the threat (American Psychiatric
Association, [ 2]). SAD is about as prevalent among college students in the United States as in
the general population (Schry, Roberson‐Nay, & White, [55]), affecting 7–8% of individuals
(Hofmann, Asnaani, & Hinton, [29]). SAD exacts several costs for
postsecondary studentsincluding increased drop‐out risk, decreased employment
opportunities, and more limited social support systems (Salzer, [53]). Moreover, SAD
symptoms, including a fear of interpersonal interactions, commonly deter individuals from
seeking professional help (Olfson et al., [43]).
One of the most effective treatment strategies for SAD is cognitive‐behavioral therapy with
exposure and response prevention (CBT ERP; Barkowski et al., [7]; Powers, Sigmarsson, &
Emmelkamp, [45]; Wersebe, Sijbrandij, & Cuijpers, [62]). CBT ERP integrates behavior therapy’s
extinction learning paradigm with cognitive therapy’s emphasis on disputing maladaptive
thinking patterns through expectancy violations (Abramowitz, Deacon, & Whiteside, [ 1];
Prochaska & Norcross, [46]). The result is an integrated theoretical framework that addresses
the relationship between behaviors, thoughts, and feelings through behavior change. CBT ERP
is considered a first‐line treatment by many researchers (e.g., Arch & Craske, [ 5]; Stewart &
Chambless, [58]; Whiteside et al., [64], [63]) and recommended by professional organizations
(American Psychological Association, [ 3]; Anxiety & Depression Association of America, [ 4];
National Institute for Health & Care Excellence, [40]; Society of Clinical Psychology, n.d[57]).
Although CBT ERP remains a safe and effective treatment for SAD, its efficacy as a group‐
delivered treatment option on college campuses remains an open question. In a meta‐analysis
of group‐delivered treatments, Barkowski et al. ([7]) investigated the efficacy of group
psychotherapy for SAD with 36 randomized controlled trials and 2,171 participants. When
compared to a wait‐list control, the pre–post difference for group psychotherapy was large (g =
0.84), corroborating the results of an earlier meta‐analysis (Powers et al., [45]; d = 0.86). Of the
included studies, five randomized clinical trials were conducted
with college students (Bjornsson et al., [11]; Heideman, [26]; Huang & Liu, [30]; Mácia‐Antòn,
Olivares‐Olivares, & Amoros‐Boix, [39]; Olivares, Rosa‐Alcázar, Olivares‐Olivares, & Rosa‐
Alcázar, [44]). An examination of the two studies that were based in the United States,
Heideman ([26]) and Bjornsson et al. ([11]), will highlight some of the strengths and weaknesses
of the literature.
The first included 18 college students experiencing co‐occurring SAD and alcohol abuse
(Heideman, [26]). After completing social anxiety and alcohol screening instruments,
participants were randomly assigned to either a group SAD treatment condition plus Brief
Alcohol Screening and Intervention for College Students (CBGT + BASICS; see Dimeff, Baer,
Kivlahan, & Marlatt, [22]) or a wait‐list control. Participants in the experimental group received
a 1‐hr BASICS feedback session and then completed 6 weekly sessions of group SAD treatment
lasting from 1 to 1.25 hr each with a manualized treatment protocol.
Of the original 18 participants, four dropped out, three of whom were assigned to the
experimental group (Heideman, [26]). There were no statistical differences on the
social anxiety measures between participants who completed the study and participants who
did not. After analyzing pre–post treatment differences, Heideman found differences between
the CBGT + BASICS group and the wait‐list control group on the Social Interaction Anxiety Scale
(SIAS; Mattick & Clarke, [37]; d = 1.15), but not on the Brief Fear of Negative Evaluation scale
(BFNE; Leary, [33]; d = 0.19). Further analyses controlling for BFNE scores resulted in a
nonsignificant difference on the SIAS. Despite its strengths and important contributions (i.e., a
randomized clinical trial, group therapy, college student population), the study used a sample
experiencing both SAD and alcohol abuse, which limited generalizability of results to
typical collegestudents with SAD. In addition, the wait‐list control group was unable to account
for common factors that contribute to therapeutic outcomes, such as therapeutic alliance,
expectancy effects, or rituals like meeting times or session durations (Baskin, Tierney, Minami,
& Wampold, [ 8]; Safer & Hugo, [52]).
The second US treatment study on college students was a randomized clinical trial of
45 collegestudents with a primary SAD diagnosis (Bjornsson et al., [11]). Treatment involved 8
weekly, 2‐hr sessions with 5–7 participants each. Participants were randomly assigned to either
CBGT (with a modified Heimberg & Becker [[27]] protocol) or a common factors control group.
The control group was fashioned from research by Yalom and Leszcz ([68]) that emphasized
group discussions, strong therapeutic alliances, and active homework assignments.
Twenty‐two participants completed at least the first session of the experimental group, and 23
participants completed at least the first session of the control group. Completer/noncompleter
analyses revealed no statistical differences. Results on the primary study measures revealed
moderate improvement in the experimental group on the Liebowitz Social Anxiety Scale (LSAS;
Liebowitz, [35]; d = 0.60) and the control group (d = 0.66). Similarly, on the Clinical Global
Impression Scale (CGI; Guy, [24]) the experimental group and control group both improved (d =
0.99 and 1.14, respectively). There were no differences between the groups on CGI severity
posttreatment or LSAS scores after controlling for baseline scores.
This study contained notable strengths, including randomization to an active control group and
linear mixed effects models to account for missing data. The strength of the study’s control
group was also inherent in its goal to control the common factors inherent in group therapy.
For example, they followed the seven‐step guidelines laid out by Safer and Hugo ([52]) to create
a control that was as structurally equivalent as possible to their exposure‐only experimental
group. In doing so, they attempted to control for effects such as therapeutic alliance,
opportunities to express emotions, expectancy effects, and practicing therapeutic skills.
A couple weaknesses in their design are worth mentioning. First, their control group may have
unintentionally received a dose of therapeutic exposures. For instance, group members were
asked to “support each other” and “take responsibility for group discussion,” as well as to
“share their impressions of one another and encouraged to explore what those reactions
taught them and how they appear to other people” (p. 1,036). Yet for many individuals with
social anxiety, leading group discussions and exploring thoughts/feelings with others over the
course of eight, 2‐hr sessions can be an effective, prolonged exposure. While the study authors
may have been providing typical, group therapy instructions to their participants, they do not
state the extent to which their participants actually engaged in these behaviors throughout
treatment. Second, it is unclear to what extent their protocol emphasized in vivo exposure, an
important treatment ingredient in CBT for SAD that allows clients to experience real‐life, social
situations (Craske, Treanor, Conway, Zbozinek, & Vervliet, [20]). Thus, without also knowing the
extent to which in vivo exposures were used in the experimental group, it is unclear whether
the study’s null findings resulted from some combination of exposures in the control group, lack
of prolonged, in vivo exposures in the experimental group, or an effective Yalom control in
which extinction only occurred within that group context.
In summary, both studies advanced our understanding of group CBT ERP
with college students using randomized designs. Although results from Bjornsson et al. dispute
the effectiveness of CBT ERP beyond an active control group, their treatment group protocol
may not have been exposure‐heavy enough to overcome the effects of their control. In
addition, their control participants may have received prolonged exposures, increasing the
difficulty of isolating the effect of the experimental group. We attempted to address some of
these limitations by testing group exposure and response prevention against a different active
control group, educational support. Importantly, in vivo exposures were utilized throughout the
entire treatment, many of which took place outside of the therapy room (e.g., participants
were asking bus drivers for directions, debating controversial topics with study researchers the
participants had not met, walking across pedestrian crosswalks unusually slowly, and handing
out university‐sanctioned leaflets on safe‐sex practices to peers on campus). We investigated
whether general ratings of social anxiety and fear of negative evaluation would improve
for college students in the exposure therapy group and examined the effect of treatment on
mild to moderate symptoms of depression.
2 METHODS
2.1 Participants
All procedures received Institutional Review Board approval. Undergraduate and
graduate students were recruited in January 2017 through campus flyers, advertisements in the
University’s Disability Access Center, announcements in undergraduate/graduate courses, an
article in the school newspaper, and emails to students from academic advisors. All eligible
participants were 18–30 years old. Interested participants first completed an online
demographics form including a screener for social anxiety, the Liebowitz Social Anxiety Scale
Self‐Report Measure (LSAS‐SR; Fresco et al., [23]). A participant required either a minimum
score of 47 on the LSAS‐SR (to maximize diagnostic specificity; Rytwinski et al., [51]) or reported
impairing symptoms consistent with Diagnostic and Statistical Manual of Mental Disorders, 5th
Edition (DSM‐5) criteria for SAD.
Participants were ineligible for the study if they reported heart conditions, current pregnancy,
autism spectrum disorder, or psychosis. Two participants, who completed the initial survey, did
not meet these inclusion criteria, both of whom reported a current pregnancy. In total, 48
participants completed the online survey, met inclusion criteria, and were randomly assigned to
either the experimental or control group. Thirty‐one participants completed at least one
session, with 15 people in the experimental group and 16 people in the control group. Table
contains participant diagnostic and treatment history.
1 Participant demographics, diagnostic, and treatment history.
Demographic
Gender
Male
Female
Age
18–21
22–25
26–30
Race
White
Non‐white
Educational status
Undergraduate
Graduate
Employed
Yes
No
Formal diagnoses (self)
Social anxiety disorder
Other anxiety disorder
OCD/related disorder
Initial survey (N = 48)Study participants (N = 31)
n
Percent
n Percent
22
26
46
54
1445
1755
26
16
6
54
33
13
1858
9 29
4 13
23
25
48
52
1652
1548
44
4
92
8
2890
3 10
20
28
42
58
1342
1858
9
10
1
19
21
2
7 23
8 26
1 3
Demographic
Initial survey (N = 48)Study participants (N = 31)
n
Percent
n Percent
8
17
7 23
7
15
5 16
29
60
1755
Mood disorder
ADHD
None
Treatment history
No formal treatment
20
Self‐help materials
9
Medication
10
Psychological treatment 9
Treatment duration
Less than 3 months
3
From 3 to 6 months
4
From 7 to 12 months
3
Longer than 12 months
8
Received exposure therapy
Yes
7
No
48
65
29
32
29
1125
6 19
7 23
7 23
6
8
6
17
2 6
3 10
3 10
5 16
15
85
4 13
3187
1 a Percent of sample may not add to 100% due to rounding.
2 b Participants were permitted to select more than one option.
2.2 Measures
2.2.1 Liebowitz Social Anxiety Scale Self‐Report Measure
The LSAS‐SR (Fresco et al., [23]) contains 24 items with separate measures for fear and
avoidance. Each item is measured on a 4‐point Likert‐type scale including fear ranging from 0
(none) to 3 (severe) and avoidance ranging from 0 (never) to 3 (usually). The sum of the fear and
avoidance measures constitutes the total score, with a maximum of 144 possible.
Cronbach’s α coefficients on the (LSAS‐SR) have been found to be acceptable for the total score
(r = 0.95–0.96; dos Santos, Loureiro, Crippa, & de Lima Osório, [54]), as is test–retest reliability
(r = 0.83; Baker, Heinrichs, Kim, & Hofmann, [ 6]). Factor analyses have revealed strong
correlations between subscales on the LSAS‐SR (Oakman, Van Ameringen, Mancini, &
Farvolden, [41]), supporting use of the total score on LSAS‐SR. The LSAS‐SR also has evidence of
convergent and discriminant validity (Baker et al., [ 6]).
2.2.2 The Social Anxiety Questionnaire for adults (SAQ‐A30)
The SAQ‐A30 (Caballo et al., [13]) contains 30 items assessing social anxiety on a 5‐point Likert
scale ranging from 1 (not at all to very slight) to 5 (very high or extremely high). The SAQ‐A30
provides an overall score with additional scores obtained for each of its five dimensions: (a)
public speaking/speaking with authority figures, (b) interactions with the opposite sex, (c)
assertive expression of annoyance, disgust, or displeasure, (d) criticism and embarrassment,
and (e) interactions with strangers. In a study with over 15,000 university students, Caballo et
al. ([12]) found a Cronbach’s α coefficient of 0.91. Between clinical and nonclinical individuals
across 20 countries, Caballo et al. ([13]) reported a convergent validity coefficient of r = 0.66
with an overall LSAS‐SR score.
Caballo, Salazar, Irurtia, Arias, and Nobre ([14]) reported that the SAQ‐A30′s five‐factor
structure and high Cronbach’s α coefficients (0.88–0.93) make it a “comprehensive self‐report
measure … providing a solid base for establishing the definitive structure, and the assessment,
of the construct of social anxiety” (p. 443). Caballo et al. ([12]) found evidence for two models:
A five‐factor solution, as well as a solution with five first‐order factors and one second‐order
factor. Although they found the unidimensional conceptualization of
social anxiety problematic, they still utilized the Global Social Anxiety score to test for
differences across Spanish regions. Thus, in the present study the SAQ‐A30’s total score was
utilized, as the five factors “form a global construct called social anxiety” (p. 27).
2.2.3 Brief Fear of Negative Evaluation Scale
The BFNE (Leary, [33]) is a 12‐item Likert scale with a range from 1 (not at all characteristic of
me) to 5 (extremely characteristic of me) that provides a final summed score ranging from 12 to
60. Cronbach’s αcoefficients for scores on the full BFNE were reported as ranging from 0.80 to
over 0.90 (Levinson & Rodebaugh, [34]; Rodebaugh et al., [49]; Weeks, Heimberg, Rodebaugh,
Goldin, & Gross, [61]). Evidence of convergent validity has been reported for undergraduate
populations with the SIAS, Social Phobia Scale (Mattick & Clarke, [37]), and Rosenberg Self‐
Esteem Scale (Rosenberg, [50]). Divergent validity results have been found with subscales of the
Illness and Injury Sensitivity Index (Carleton, Park, & Asmundson, [16]), and Beck Depression
Inventory (BDI; Carleton, Collimore, & Asmundson, [15]; Weeks et al., [60]).
2.2.4 Beck Depression Inventory‐II
The BDI‐II (Beck & Steer, [10]) is a 21‐item self‐report Likert‐type scale with each item scored
from 0 to 3, with higher scores indicating increased levels of depressive symptomology. All
items contribute to a total score ranging from 0 to 63, with cutoffs of 0–13 (minimal), 14–19
(mild), 20–28 (moderate), and 29–63 (severe). A review of 118 articles found coefficient αs of
0.90 (Wang & Gorenstein, [59]). Wang and Gorenstein also investigated the instrument’s
validity, presenting convergent validity coefficients ranging from r = 0.66 to r = 0.94 with the
Hamilton Depression Rating Scale (HAM‐D; Hamilton, [25]), Depression Anxiety Stress Scale
(DASS‐21), Hospital Anxiety and Depression Scale‐Depression (HADS‐D; Zigtnond & Snaith,
[69]), and BDI‐I. Discriminant validity coefficients for measures of pain, drug abuse, alcohol
abuse, and suicidality were evidenced of coefficients at or below r = 0.4. A measure of
depression was included in this study because social anxiety and depression co‐occur in about
20% of cases (Ohayon & Schatzberg, [42]). As such, determining the impact of exposure‐only
treatment for social anxiety on depression provides a more complete understanding of
treatment outcomes.
2.3 Procedure
Control and experimental groups both received six, 2‐hr weekly sessions conducted on a large
southeastern university campus by the first author, who received 2 years of prior supervised
training in CBT ERP through an intensive outpatient clinic specializing in exposure‐based CBT.
No participants in any group were removed from the study if they missed a session. So if a
participant missed Session 2, they were permitted to return for the others. However, groups
were closed to new members following the enrollment period.
2.3.1 Experimental group
Experimental group members first received psychoeducation about social anxiety and CBT ERP.
Next, each participant created an individualized fear hierarchy (Abramowitz et al., [ 1]). To do
so, each participant worked within a group to list their fears and then rank them on a scale
from 1 (provokes very little anxiety) to 10 (provokes the maximum amount of anxiety possible).
Common themes were extracted from each hierarchy, with near‐unanimous difficulty in
maintaining eye contact, initiating conversations, meeting new people, public speaking, and
being judged by others. While participants constructed their hierarchies, the principle
investigator coached them to further decompose their exposures into their component parts
(e.g., public speaking can be done in front of different numbers of people, friends/family,
wearing different clothes, or about different topics).
In Sessions 1 and 2, initial exposures included eye contact and one‐on‐one conversations about
noncontroversial topics (e.g., the weather); increasing in difficulty in later sessions to
discussions about anxiety‐provoking topics (e.g., abortion, politics, and climate change),
conversations on the phone, interactions with strangers outside of the therapy room (e.g.,
asking a stranger for directions); and ending with exposures to provide university‐sanctioned
pamphlets on sexually transmitted disease to peers. Participants had the right to opt out of any
challenges they did not want to perform but were encouraged by the principal investigator (and
their groupmates) to face their fear. Everyone chose to participate in the exposures, and
participants completed multiple trials until they reported they felt comfortable with them.
Participants were given exposure‐based homework assignments based on their individual fear
hierarchies at the end of each session, which they reviewed with the principal investigator.
Because the experimental group was exposure‐only, the protocol did not include or encourage
participants to discuss expectancy violations (see Craske et al., [20]) in a systematic way with
other group members, though these discussions were not discouraged a priori. Participants
were asked at the start of each session whether they completed their homework and were
permitted to discuss their homework if they chose to do so. On Sessions 1, 3, and 6 participants
completed the BFNE, the SAQ‐A30, and BDI‐II.
2.3.2 Active treatment control
The purpose of the active treatment control was to imitate a typical classroom environment on
campus, which naturally has some incidental exposure elements (e.g., raising one’s hand to ask
a question) but does not provide enough exposure to adequately challenge patterns of
avoidance or maladaptive thoughts. The control group received a series of interactive lectures
on the prevalence, symptoms, and co‐occurring diagnoses of SAD. Presentations also included
SAD treatment strategies and case conceptualizations from different theoretical orientations
including behavior therapy, mindfulness, psychoanalytic/psychodynamic therapies, cognitive‐
behavioral therapy, person‐centered therapy, and integrative therapy. To build rapport and
group cohesion, lectures were interactive with conversation and dialogue between the
therapist and group members. For example, Socratic dialogue was utilized to ask questions
about the lecture material, open discussions were encouraged, and questions/comments about
homework were discussed at the start of each session. In addition, the informed consent forms
completed before the first group explained that the purpose of the study was to compare two
efficacious treatments, that the active control has been demonstrated to improve symptoms of
SAD, and that similar groups are utilized on their college campus by the Counseling and
Wellness Center and Disability Resource Center. This information was reviewed by the therapist
at the start of the study.
The educational support group has been used as a control condition for studies on group‐
delivered CBT with exposure since Heimberg et al. ([28]). Subsequent researchers have
highlighted its flaws (e.g., lack of action‐oriented homework and the absence of group process
discussions; Bjornsson et al., [11]), which the present study attempted to remediate. For
example, in addition to receiving interactive lectures on therapeutic modalities, participants
were assigned active homework assignments congruent with the lecture they attended. For
example, on 1 week, participants were assigned exposures from the hierarchy they developed;
on another, they focused on mindfulness‐based stress reduction; subsequently, they completed
assignments centered on actively challenging their maladaptive thinking patterns; and lastly,
assignments on integrative therapy encouraged participants to complete daily exercises that
blended elements from the different therapeutic modalities they found most effective. As far as
group process, in neither the experimental nor control group was process emphasized. Indeed,
the protocol in the experimental group was designed to emphasize an exposure‐only treatment
paradigm in which participants were systematically but repeatedly engaging in exposures. And
although the control group engaged in frequent discussions, these discussions involved the
content of lectures and the procedure of completing homework rather than deep reflection
about learning or cognitive processes. Consequently, the key difference between the control
and experimental group was the experimental group’s intensive, systematic, prolonged, and
repeated social exposures.
To maintain structural equivalence; that is, have the same number of sessions, format, and
equivalent therapist training as the experimental group (see Baskin et al., [ 8]), the time allotted
for homework check‐in was equivalent in the experimental group, with breaks also taken at
equivalent times. Moreover, the same therapist delivered the treatments in the same blocks of
time. For example, when the experimental group received 30 min of exposure, the active
control group received 30 min of lecture. Participants in the active treatment group also
completed homework assignments to review and practice material from that session’s lectures.
Participants provided the same measures on Sessions 1, 3, and 6 as in the treatment group.
Lastly, control group participants were informed that they had the option to participate in the
exposure therapy group at the study’s conclusion (six control group participants, whose data
were not included in the analysis, chose to participate).
2.3.3 Data analysis
All analyses were conducted in R 3.3.1 (R Core Team, [47]) using the stats package, the lme4
package’s “lmer” function (Bates, Maechler, Bolker, & Walker, [ 9]), psych package’s “alpha”
function (Revelle, [48]), dplyr package (Wickham & Francois, [67]), and tidyr package (Wickham,
[66]). Plots were created with the packages ggplot2 (Wickham, [65]) and ggrepel (Slowikowski,
[56]).
First, statistics were obtained for the primary study measures and survey results, including
means, standard deviations (SDs), frequency distributions, and correlations where applicable.
Summed scores for each scale were used in all statistical analyses, and Cronbach’s α coefficients
were calculated to quantify internal consistency reliability for the study measures. To
investigate whether the results were clinically important, effect size measures were provided
between experimental and control groups at Sessions 3 and 6 (Cohen, [18]).
To investigate treatment improvement, a linear mixed effects analysis was utilized with each of
this study’s three dependent variables (BFNE, SAQ‐A30, and the BDI‐II). Two models were fit for
each variable. In the first (Basic) model, a fixed effect for group (control vs. experimental), fixed
effect for time (a continuous variable over the three measurement points), and a random effect
for subjects were included. The second model (Interaction) also included the fixed effect for the
Group × Time interaction term (Group × Time). When selecting a final model, χ2 tests were
conducted between the Basic and Interaction models to test for statistical significance. In
addition, the Akaike information criterion (AIC) was also examined for model fit. Alpha levels
were set to α = 0.05 for each model. To increase the ease of interpreting the intercept, Time
was coded from 0 to 2, with 0 representing the first session and 2 representing the final
session. Time was modeled as a continuous variable to increase power.
3 RESULTS
3.1 Descriptive statistics
Table presents the dependent variables’ total means, SDs, and Cronbach’s α coefficients, as well
as values at each measurement occasion. Analyses revealed an α level for the LSAS‐SR of 0.95
and an αlevel for the BFNE of 0.82. The SAQ‐A30 had an α of 0.92, and the BDI‐II an α of 0.91.
Overall the sample endorsed high levels of social anxiety, as evidenced by a M = 47.65 on the
BFNE, M = 110.61 on the SAQ‐A30, and a M = 75.13 on the LSAS‐SR. Mean depression scores on
the BDI‐II were 19.16, indicating the presence of mild to moderate symptoms of depression.
2 Ratings scale statistics
ExperimentalControlCombined
Measure,n
M
SD
n M
SD n M
SD α
LSAS‐SR
3175.13 24.870.95
BFNE
3147.65 7.00 0.82
Session 1 15
37.53 5.95
1639.75 5.30
Session 3 9
42.78 8.57
9 46.33 9.17
Session 6 7
36.29 13.74
8 46.50 8.35
SAQ‐A30
31110.6118.270.92
Session 1 15
106.67 18.29
16114.3118.02
ExperimentalControlCombined
M
SD
n M
SD n M
SD α
Session 3 9
102.56 19.31
9 104.7819.02
Session 6 7
77.88 38.04
8 105.7519.44
BDI‐II
3119.16 10.190.91
Session 1 15
17.13 8.82
1621.06 11.26
Session 3 9
11.44 9.75
9 20.44 16.97
Session 6 7
11.29 8.83
8 27.63 18.18
• 3 Note. BDI‐II: Beck Depression Inventory‐II; BFNE: Brief Fear of Negative Evaluation
Scale; LSAS‐SR: Liebowitz Social Anxiety Scale Self‐Report ; SAQ‐A30: The
Social Anxiety Questionnaire for Adults; SD: standard deviation.
Measure,n

4 a Values were obtained from scores summed across items. On the BFNE, items 2, 4, 7,
and 10 were reverse coded. On the BDI‐II, Item 9 (on suicidality) was excluded at the
request of the Institutional Review Board.

5 b Unadjusted means and standard deviations are provided.
Table also shows the effects of attrition throughout the study. These effects are evidenced by
decreasing sample sizes in each group as the study progressed. In the experimental group,
Session 1 began with 15 participants, decreasing to nine participants for Session 3, and ending
with seven participants in Session 3. The control group attrition rates closely paralleled those in
the experimental group, with Session beginning with 16 participants, decreasing to nine
participants by Session 3, and ending with eight participants in the final session. As far as
attrition, of the 31 participants who attended at least one session, 16 (52%) did not complete
the study.
3.2 Attrition and baseline differences
Analyses were conducted to investigate if participants completing the study were different than
participants who did not complete the study. No statistically significant difference was found
for any dependent variable. Results provided in Table indicate that participants who dropped
out of the study were not statistically different on the baseline study measures than their
peers. Moreover, analyses on the baseline differences between the control and experimental
groups revealed no statistical difference between the experimental or control group on any
dependent variable. Thus, this provides evidence that the randomization procedure was
successful. Results are summarized in Table.
3 Baseline differences between study groups and completer vs. noncompleter analysis
Measure
Baseline differences
LSAS‐SR
t
df
p
LL
UL
1.21 26.860.24−7.48 29.17
Measure
t
df p LL
UL
BFNE
0.49 28.870.63−3.96 6.46
SAQ‐A30
1.17 28.800.25−5.71 21.00
BDI‐II
1.08 28.140.29−3.49 11.35
Completers vs. noncompleters
LSAS‐SR
−0.2028.690.84−20.4316.79
BFNE
1.26 21.660.22−2.07 8.44
SAQ‐A30
−0.3828.330.70−16.2311.12
BDI‐II
−1.1023.930.28−11.703.54
6 Note. BDI‐II: Beck Depression Inventory‐II; BFNE: Brief Fear of Negative Evaluation Scale; LL:
lower limit for 95% confidence interval; LSAS‐SR: Liebowitz Social Anxiety Scale Self‐Report
Measure; SAQ‐A30: Social Anxiety Questionnaire for Adults; UL: upper limit for 95% confidence
interval.
3.3 Primary analyses
3.3.1 SAQ‐A30
Mixed model comparisons for the SAQ‐A30 are contained in Table. With regard to model
selection, the AICdecreased from 581.26 in the Basic model to 579.25 in the Interaction model;
similarly, the −2LLdecreased from −285.63 to −283.63. The Bayesian information criterion (BIC)
increased only slightly: 592.13 to 592.30. The statistically significant χ2 test, χ2( 1) = 4.01, p =
0.045, coupled with the decreasing AIC values was evidence for retaining the Interaction model.
4 Mixed model comparisons
Basic
Interactionχ2 dfp
Social Anxiety Questionnaire for Adults
Fixed effects
Intercept
126.21 118.34
Group
−11.44 4.68
Time
−9.32 −4.56
Group × Time
−9.72
Random effects
Subject residual
14.61 15.17
Model error
15.34 14.43
Fit statistics
−2LL
−285.63−283.63
AIC
581.26 579.25
BIC
592.13 592.30
Brief Fear of Negative Evaluation Scale
Fixed effects
Intercept
39.19 36.57
Group
−3.99 1.52
4.011 0.045
2.411 0.12
Basic
2.32
Interactionχ2 dfp
3.88
−3.28
Time
Group × Time
Random effects
Subject error
4.61
4.61
Model error
6.60
6.44
Fit Statistics
−2LL
−222.04−220.84
AIC
454.08 453.68
BIC
464.88 466.63
Beck Depression Inventory‐II
Fixed effects
Intercept
22.83 19.61
7.501 0.006
Group
−5.93 0.91
Time
−1.00 0.99
Group × Time
−4.25
Random effects
Subject error
10.55 10.40
Model error
4.75
4.34
Fit Statistics
−2LL
−226.73−222.98
AIC
463.45 457.95
BIC
474.25 470.91
• 7 Note. The Basic model included two fixed effects (Group and Time) with a random
intercept for Subjects. The Interaction model included the additional Group × Time
interaction term. p values are for the model comparisons.

8 2LL: Log‐likelihood ratio; AIC: Akaike information criterion; BIC: Bayesian information
criterion.

9 * p < 0.05, two‐tailed. Table summarizes the Final model. The SAQ‐A30's statistically significant Group × Time interaction (−9.73) implies differential effects over time for the control versus experimental groups. 5 Final model parameter estimates Value t SE LL UL p Social Anxiety Questionnaire for Adults Fixed effects Intercept 118.3416.017.39 104.09132.59

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