The literature has consistently demonstrated that social anxiety disorder has substantial impacts on occupational functioning (
3,
8). Work-related impairments among persons with social anxiety disorder include reduced productivity and job performance (
4), lowered educational attainment (
3), unemployment (
9), financial dependence (
10), and reduced income (
11). Approximately 20% of persons with social anxiety disorder reported declining a job offer or promotion because of social fears (
3), and primary care patients with social anxiety disorder reported significantly greater absenteeism and reduced productivity compared with patients without psychiatric problems (
12,
13). A recent longitudinal study examined unemployment rates and work impairments among primary care patients. Those with social anxiety disorder were over two times more likely to be unemployed than patients without social anxiety disorder, and they had higher rates of unemployment and greater work impairments than those with other anxiety disorders or depression (
14). Another longitudinal study found that among women receiving welfare, social anxiety disorder was the only one of the mental illnesses assessed that was associated with reduced employment over time (
15). Despite the substantial impact of social anxiety disorder on occupational functioning (
3,
4,
8–
10,
14,
15), scant attention has been paid to the specific nature of the vocational problems associated with the disorder.
Although existing treatments for social anxiety disorder target occupational deficits to some extent (
17), data suggest that they have limited occupational benefits (
18,
19). For example, psychosocial treatment is effective for social anxiety symptoms (
5,
20), but it is often less effective for occupational and other functional deficits associated with the disorder (
18,
19). These findings support the need for treatment innovations that more fully address occupational impairments.
A limited number of treatments with a basis in cognitive-behavioral therapy have been designed specifically to address vocational problems among persons with mental health conditions. These specialized treatments have been provided in vocational rehabilitation (
21,
22) and mental health settings (
21–
23). Evidence suggests that these treatments improve vocational functioning and increase employment rates. Vocationally focused cognitive-behavioral therapy, whether delivered in vocational service or mental health settings, appears to have been developed largely through input from professionals and from qualitative impressions provided by unemployed persons with mental health problems (
21–
23). There is a paucity of quantitative research to guide efforts to modify existing cognitive-behavioral therapy to address specific employment-related issues. Notably, we found no studies involving the use of vocationally focused cognitive-behavioral therapy for social anxiety disorder, although the disorder may be among the psychiatric disorders with the greatest impact on employment (
3,
14,
15,
24).
Discussion
A range of cross-sectional (
3,
4,
8,
10,
24) and longitudinal (
14,
15) studies indicate that social anxiety disorder has a negative impact on employment and that the impact is stronger than that of many other mental disorders. The high rate of social anxiety problems in this sample (35%) further underscores the relationship between social anxiety and employment problems. Given this negative relationship, it is important to ascertain how social anxiety undermines employment. This study is the first to examine the relationship between social anxiety disorder and specific employment-related barriers, skills, and aspirations. In addition, the sample consisted of traditionally underserved, urban-based, impoverished job seekers, most of whom were from racial minority groups—individuals who are typically underrepresented in studies of the functional impact of mental disorders (
33,
34).
The results of the multiple regression analysis showed that participants who screened positive for social anxiety disorder reported greater barriers related to experience and skills. The bivariate comparisons found that participants with social anxiety disorder were significantly more likely to report poor interview skills, limited job training and work experience, and lower educational attainment. These findings reveal important information for designing effective, targeted interventions that focus on the occupational deficits associated with the disorder. For example, cognitive-behavioral therapy can address lack of interview skills, an important barrier to employment (
35,
36), by encouraging patients to expose themselves to as many job interviews as possible in order to reduce fear and avoidance.
Lack of work experience was also associated with social anxiety. An interesting question is whether the experience deficit was primarily related to problems with job attainment or with limited job tenure. Clinical experience suggests that both issues contribute to this finding. In addition, clinical impressions indicate that unemployed persons with social anxiety disorder often report difficulties interacting with coworkers and supervisors in a number of domains, including reporting problems that require immediate attention, sharing work-related accomplishments, and building relationships. Our clinical and research-based interactions with unemployed persons with social anxiety disorder revealed that some individuals believed that they were laid off before others not because of their job performance but because they were not as well known to colleagues and supervisors.
Other important items in the category of experience and skills barriers included lack of training and limited education. Social anxiety was associated with less education but was not associated with any other demographic variable. These findings were not surprising, given that other studies have also reported reduced educational attainment among persons with social anxiety disorder (
3,
5,
7). Our results suggest that unemployed persons with social anxiety should be carefully assessed for educational and training needs. Educational deficits are critical in today’s economy, given that many job openings require specialized knowledge and skills attainable only with education and training beyond high school (
37). Unfortunately, attending school or other training programs presents a range of challenges for many persons with social anxiety, such as interacting with fellow students and instructors, asking questions in class, and being observed while working, taking tests, and giving presentations. To achieve substantial improvement in these important domains, a socially anxious person would be likely to require specialized psychosocial therapy or pharmacotherapy from either a vocational service center (unpublished data, Himle JA, Bybee D, Steinberger E, et al, 2013) or a mental health clinic.
Among the most notable findings, the multiple logistic regression analysis revealed that after adjustment for other factors, possessing fewer skills related to social occupations was significantly associated with social anxiety disorder. These results fit with prior research that identified social skills deficits among some persons with social anxiety disorder (
38) and suggest that these individuals may benefit from social skills training (
38). It may be particularly important for vocational programs to identify clients with deficits in skills related to social occupations, given that they are likely to view employment-related social deficits as part of their scope of service. Also, job sectors requiring strong workplace-based social capabilities, such as health care and hospitality, are among the most active in the current economy (
37).
The bivariate analyses suggested that socially anxious job seekers have significantly different career aspirations than job seekers without social anxiety. Participants with social anxiety disorder were significantly more likely to aspire to realistic jobs, such as manufacturing, which generally require less social interaction, and were significantly less likely to aspire to social jobs, which require frequent interaction with others. This situation presents a challenge for vocational service professionals, who wonder whether to support the socially anxious job seekers’ job aspirations or encourage them to consider social jobs that they are interested in but are afraid to pursue. Socially anxious job seekers who want to overcome their fear and avoidance of social jobs could benefit from mental health treatment. Immersion in cognitive-behavioral therapy could lead socially anxious persons to modify their aspirations to include social jobs, thereby increasing the scope of their job search. Notably, after the multiple logistic regression analysis accounted for perceptions about barriers to employment, employment skills, and educational attainment, it indicated that job aspirations were not significantly associated with social anxiety disorder, suggesting that aspirations did not independently differentiate individuals who did and did not screen positive for social anxiety disorder.
Bivariate analyses should be interpreted with caution, but beyond advising caution with respect to these comparisons, we recognize that this study had other limitations. First, the study population comprised unemployed persons who were seeking vocational services. This group likely differed from unemployed persons who are able to find work without help and from those who are reluctant to use a vocational service center. Second, this investigation involved impoverished African Americans, a group that is largely unstudied with respect to social anxiety and unemployment, and the findings may not generalize to other unemployed groups. There is a need for further research involving a more representative sample of unemployed persons with social anxiety.
Third, although this study used an established theoretical framework to construct conceptually meaningful indices of employment-related barriers, skills, and job aspirations, these measures are not standard and have not been empirically validated. However, these measures were developed in a systematic process involving input from three vocational experts with extensive experience. In the future, researchers may wish to utilize additional, alternative measures, including qualitative interviews to assess job aspirations and direct observation strategies to assess employment skills. Fourth, the presence of social anxiety was measured by a cutoff score of 5 on the Mini-SPIN. Ideally, the assessment of participants would have included structured interviews or a second self-report measure of social anxiety. However, prior research in this population found that the Mini-SPIN cut-off score of 5 was highly concordant with the detection of social anxiety diagnoses by structured interviews (unpublished data, Levine DS, Himle JA, Vlnka S, et al, 2013).
Fifth, comorbid psychiatric illnesses likely contributed to the job aspirations and employment-related barriers among the persons in this sample, and future research would benefit from investigation of these factors. However, it is important to note that prior research involving a sample of impoverished members of racial-ethnic minority groups found that social anxiety was the only one of the mental disorders assessed that had a significant effect on employment (
15). Finally, this cross-sectional study did not provide data on the relationship between social anxiety and employment over time. Future longitudinal studies of employment differences over time between unemployed persons with and without social anxiety disorder would be invaluable in furthering understanding of the relationship between social anxiety and unemployment.
This study sets the stage for further research aimed at uncovering how social anxiety undermines employment. Studies with larger and more diverse samples, structured diagnostic interviews, and refined measures of employment skills and job aspirations are needed. Semistructured interviews with unemployed job seekers would also likely yield further insights into the relationship between social anxiety and employment difficulties. These important future steps notwithstanding, the present results help to guide both vocational service and mental health professionals who seek to assist unemployed persons with social anxiety.