Received: 13 August 2018 | Revised: 29 January 2019 | Accepted: 28 March 2019

DOI: 10.1002/jclp.22792

RESEARCH ARTICLE

Group exposure and response prevention for

college students with social anxiety: A
randomized clinical trial

Brian A. Zaboski1 | Diana Joyce‐Beaulieu1 | John H. Kranzler1 |

Joseph P. McNamara 2
| Cindi Gayle 3
| Jann MacInnes 4

1
Department of Special Education, School
Psychology, & Early Childhood Studies, Abstract
University of Florida, Gainesville, Florida Objective: Social anxiety increases college student drop‐out
2
Department of Psychiatry, Division of
risk and stifles employment opportunities. Group cognitive‐
Medical Psychology, University of Florida,
Gainesville, Florida behavioral therapy with exposure (CBT ERP) has the
3
Independent Practice, Gainesville, Florida potential to alleviate campus resource strain but remains
4
Department of Human Development and
under‐researched with college students. The present study
Organization Studies, University of Florida,
Gainesville, Florida investigated the efficacy of group CBT ERP in a randomized
clinical trial on a college campus.
Correspondence
Brian A. Zaboski, Department of Psychiatry, Method: Thirty‐one postsecondary students were randomly
Division of Medical Psychology, University of
assigned to an exposure‐only group or an active control.
Florida, 8491 NW 39th Ave., Gainesville,
FL 32606. Results: Linear mixed‐effects models indicated significant
Email: bzaboski@ufl.edu
Group × Time interactions for general social anxiety
Present address (t = −2.02, g = 0.62) and depression (t = −2.77, g = 0.55);
†
Brian A. Zaboski, Department of Psychiatry,
nonsignificant main effects were found for group and time
University of Florida, Gainesville, Florida.
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, 2013). SAD is about as

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1490 | ZABOSKI ET AL.

prevalent among college students in the United States as in the general population (Schry, Roberson‐Nay, & White,
2012), affecting 7–8% of individuals (Hofmann, Asnaani, & Hinton, 2010). SAD exacts several costs for
postsecondary students including increased drop‐out risk, decreased employment opportunities, and more limited
social support systems (Salzer, 2012). Moreover, SAD symptoms, including a fear of interpersonal interactions,
commonly deter individuals from seeking professional help (Olfson et al., 2000).
One of the most effective treatment strategies for SAD is cognitive‐behavioral therapy with exposure and
response prevention (CBT ERP; Barkowski et al., 2016; Powers, Sigmarsson, & Emmelkamp, 2008; Wersebe,
Sijbrandij, & Cuijpers, 2013). 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, 2012; Prochaska & Norcross, 2013). 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, 2009; Stewart & Chambless, 2009;
Whiteside et al., 2014, 2015) and recommended by professional organizations (American Psychological Association,
2016; Anxiety & Depression Association of America, 2014; National Institute for Health & Care Excellence, 2013;
Society of Clinical Psychology, n.d).
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. (2016) 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., 2008; d = 0.86). Of the included
studies, five randomized clinical trials were conducted with college students (Bjornsson et al., 2011; Heideman,
2008; Huang & Liu, 2011; Mácia‐Antòn, Olivares‐Olivares, & Amoros‐Boix, 2012; Olivares, Rosa‐Alcázar, Olivares‐
Olivares, & Rosa‐Alcázar, 2009). An examination of the two studies that were based in the United States, Heideman
(2008) and Bjornsson et al. (2011), 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, 2008).
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, 1999) 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, 2008). 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, 1998; d = 1.15), but not on the Brief Fear of Negative Evaluation scale (BFNE; Leary,
1983; 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 college students 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, 2003; Safer & Hugo, 2006).
The second US treatment study on college students was a randomized clinical trial of 45 college students with a
primary SAD diagnosis (Bjornsson et al., 2011). Treatment involved 8 weekly, 2‐hr sessions with 5–7 participants
each. Participants were randomly assigned to either CBGT (with a modified Heimberg & Becker [2002] protocol) or
a common factors control group. The control group was fashioned from research by Yalom and Leszcz (2005) that
emphasized group discussions, strong therapeutic alliances, and active homework assignments.
ZABOSKI ET AL. | 1491

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, 1987; d = 0.60) and the control group (d = 0.66). Similarly, on
the Clinical Global Impression Scale (CGI; Guy, 1976) 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 (2006) 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, 2014). 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
1492 | ZABOSKI ET AL.

online demographics form including a screener for social anxiety, the Liebowitz Social Anxiety Scale Self‐Report
Measure (LSAS‐SR; Fresco et al., 2001). A participant required either a minimum score of 47 on the LSAS‐SR
(to maximize diagnostic specificity; Rytwinski et al., 2009) 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 1 contains participant diagnostic and treatment history.

T A B L E 1 Participant demographics, diagnostic, and treatment history.

Demographic Initial survey (N = 48) Study participants (N = 31)

a
n Percent n Percenta
Gender
Male 22 46 14 45
Female 26 54 17 55
Age
18–21 26 54 18 58
22–25 16 33 9 29
26–30 6 13 4 13
Race
White 23 48 16 52
Non‐white 25 52 15 48
Educational status
Undergraduate 44 92 28 90
Graduate 4 8 3 10
Employed
Yes 20 42 13 42
No 28 58 18 58
b
Formal diagnoses (self)
Social anxiety disorder 9 19 7 23
Other anxiety disorder 10 21 8 26
OCD/related disorder 1 2 1 3
Mood disorder 8 17 7 23
ADHD 7 15 5 16
None 29 60 17 55
Treatment historyb
No formal treatment 20 65 11 25
Self‐help materials 9 29 6 19
Medication 10 32 7 23
(Continues)
ZABOSKI ET AL. | 1493

TABLE 1 (Continued)

Demographic Initial survey (N = 48) Study participants (N = 31)

a
n Percent n Percenta
Psychological treatment 9 29 7 23
Treatment duration
Less than 3 months 3 6 2 6
From 3 to 6 months 4 8 3 10
From 7 to 12 months 3 6 3 10
Longer than 12 months 8 17 5 16
Received exposure therapy
Yes 7 15 4 13
No 48 85 31 87
a
Percent of sample may not add to 100% due to rounding.
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., 2001) 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, 2013), as is test–retest reliability
(r = 0.83; Baker, Heinrichs, Kim, & Hofmann, 2002). Factor analyses have revealed strong correlations between
subscales on the LSAS‐SR (Oakman, Van Ameringen, Mancini, & Farvolden, 2003), supporting use of the total score
on LSAS‐SR. The LSAS‐SR also has evidence of convergent and discriminant validity (Baker et al., 2002).

2.2.2 | The Social Anxiety Questionnaire for adults (SAQ‐A30)

The SAQ‐A30 (Caballo et al., 2012) 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. (2010) found a
Cronbach's α coefficient of 0.91. Between clinical and nonclinical individuals across 20 countries, Caballo et al. (2012)
reported a convergent validity coefficient of r = 0.66 with an overall LSAS‐SR score.
Caballo, Salazar, Irurtia, Arias, and Nobre (2013) 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.
(2010) 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).
1494 | ZABOSKI ET AL.

2.2.3 | Brief Fear of Negative Evaluation Scale

The BFNE (Leary, 1983) 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
α coefficients for scores on the full BFNE were reported as ranging from 0.80 to over 0.90 (Levinson & Rodebaugh,
2012; Rodebaugh et al., 2011; Weeks, Heimberg, Rodebaugh, Goldin, & Gross, 2012). Evidence of convergent
validity has been reported for undergraduate populations with the SIAS, Social Phobia Scale (Mattick & Clarke,
1998), and Rosenberg Self‐Esteem Scale (Rosenberg, 1965). Divergent validity results have been found with
subscales of the Illness and Injury Sensitivity Index (Carleton, Park, & Asmundson, 2006), and Beck Depression
Inventory (BDI; Carleton, Collimore, & Asmundson, 2007; Weeks et al., 2005).

2.2.4 | Beck Depression Inventory‐II

The BDI‐II (Beck & Steer, 1998) 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, 2013). 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, 1960), Depression Anxiety Stress Scale (DASS‐21), Hospital Anxiety
and Depression Scale‐Depression (HADS‐D; Zigtnond & Snaith, 1983), 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, 2010). 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., 2012). 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
ZABOSKI ET AL. | 1495

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., 2014) 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. (1990). Subsequent researchers have highlighted its flaws (e.g., lack of action‐
oriented homework and the absence of group process discussions; Bjornsson et al., 2011), 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., 2003), 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
1496 | ZABOSKI ET AL.

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, 2017) using the stats package, the lme4 package's “lmer”
function (Bates, Maechler, Bolker, & Walker, 2015), psych package's “alpha” function (Revelle, 2017), dplyr package
(Wickham & Francois, 2016), and tidyr package (Wickham, 2017). Plots were created with the packages ggplot2
(Wickham, 2016) and ggrepel (Slowikowski, 2018).
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, 1988).
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 | RES U LTS

3.1 | Descriptive statistics

Table 2 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 α level 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.
Table 2 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.
ZABOSKI ET AL. | 1497

T A B L E 2 Ratings scale statistics

Experimental Control Combined

Measurea,b n M SD n M SD n M SD α
LSAS‐SR 31 75.13 24.87 0.95
BFNE 31 47.65 7.00 0.82
Session 1 15 37.53 5.95 16 39.75 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 31 110.61 18.27 0.92
Session 1 15 106.67 18.29 16 114.31 18.02
Session 3 9 102.56 19.31 9 104.78 19.02
Session 6 7 77.88 38.04 8 105.75 19.44
BDI‐II 31 19.16 10.19 0.91
Session 1 15 17.13 8.82 16 21.06 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
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 .
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.
b
Unadjusted means and standard deviations are provided.

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 3 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.

T A B L E 3 Baseline differences between study groups and completer vs. noncompleter analysis
Measure t df p LL UL
Baseline differences
LSAS‐SR 1.21 26.86 0.24 −7.48 29.17
BFNE 0.49 28.87 0.63 −3.96 6.46
SAQ‐A30 1.17 28.80 0.25 −5.71 21.00
BDI‐II 1.08 28.14 0.29 −3.49 11.35
Completers vs. noncompleters
LSAS‐SR −0.20 28.69 0.84 −20.43 16.79
BFNE 1.26 21.66 0.22 −2.07 8.44
SAQ‐A30 −0.38 28.33 0.70 −16.23 11.12
BDI‐II −1.10 23.93 0.28 −11.70 3.54
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.
1498 | ZABOSKI ET AL.

3.3 | Primary analyses

3.3.1 | SAQ‐A30
Mixed model comparisons for the SAQ‐A30 are contained in Table 4. With regard to model selection, the AIC
decreased from 581.26 in the Basic model to 579.25 in the Interaction model; similarly, the −2LL decreased 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.
Table 5 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.

T A B L E 4 Mixed model comparisons

Basic Interaction χ2 df p*
Social Anxiety Questionnaire for Adults
Fixed effects
Intercept 126.21 118.34 4.01 1 0.045
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 2.41 1 0.12
Group −3.99 1.52
Time 2.32 3.88
Group × Time −3.28
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 7.50 1 0.006
Group −5.93 0.91
(Continues)
ZABOSKI ET AL. | 1499

TABLE 4 (Continued)

Basic Interaction χ2 df p*
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
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.
2LL: Log‐likelihood ratio; AIC: Akaike information criterion; BIC: Bayesian information criterion.
*p < 0.05, two‐tailed.

T A B L E 5 Final model parameter estimates

Value t SE LL UL p
Social Anxiety Questionnaire for Adults
Fixed effects
Intercept 118.34 16.01 7.39 104.09 132.59 <0.001*
Group 4.69 0.44 10.59 −15.75 25.09 0.658
Time −4.56 −1.35 3.39 −11.19 2.02 0.178
Group × Time −9.73 −2.02 4.82 −19.06 −0.21 0.044*
Random effects
Residual for subject 15.80
Model error 14.83
Brief Fear of Negative Evaluation Scale
Fixed Effects
Intercept 39.17 15.56 2.52 34.29 44.09 <0.001*
Group −3.98 −1.60 2.48 −8.79 0.88 0.109
Time 2.33 2.15 1.09 0.14 4.45 0.032*
Random effects
Residual for Subject 6.70
Model error 4.87
Beck Depression Inventory‐II
Fixed effects
Intercept 19.61 5.94 3.29 13.25 25.98 <0.001*
Group 0.91 0.19 4.74 −8.27 25.98 0.849
Time 0.99 0.94 1.05 −1.05 10.06 0.348
Group × Time 4.25 −2.77* 1.53 −7.28 −1.28 0.006*
Random effects
Residual for subject 10.77
Model error 4.46
Note. UL and LL represent the upper limit and lower limits of the 95% confidence interval around the parameters.
*p < 0.05, two‐tailed.
1500 | ZABOSKI ET AL.

FIGURE 1 Social Anxiety Questionnaire for Adults scores across three measurement occasions

Figure 1 contains plots of expected means over time, illustrating the interaction effect. By the second
measurement occasion, the exposure therapy group improved more than the active control group (108.74 vs.
113.78). Effect size calculations controlling for baseline differences indicated that these mean differences were
clinically meaningful at Time 2 (g = 0.48) and Time 3 (g = 0.62), which corresponded to improvement in the
experimental group by Time 3 of 0.62 SDs on the SAQ when compared to the active control group.

3.3.2 | BFNE
As shown in Table 4, the AIC decreased from 454.08 to 453.68 from the Basic to the Interaction model, though
the BIC increased from 464.88 to 466.63. The −2LL values decreased from −222.04 to −220.84, but the χ2 test
comparing the likelihood ratios revealed a statistically nonsignificant result: χ2(1) = 2.41, p = 0.12. Because the
AIC decreased only slightly, the BIC increased, and the χ2 test was not significant, the Basic model was retained.
A final model summary is provided in Table 5. Figure 2 displays the expected means. As shown, there is a linear
trend for BFNE scores across all measurement periods for both conditions, suggesting a steady and parallel
increase in both conditions that does not change because of treatment.
ZABOSKI ET AL. | 1501

FIGURE 2 Brief Fear of Negative Evaluation scores across three measurement occasions

3.3.3 | BDI‐II
Results from the model selection procedure for the BDI‐II are presented in Table 4, demonstrating lower fit
statistics for the Interaction model. The AIC decreased from 463.45 to 457.95; the BIC decreased from 474.25
to 470.91; and the −2LL decreased from −226.73 to −222.98. This evidence was sufficient to retain the
interaction for the Final model, a the χ2 test on the log likelihood values verified a statistically significant
difference: χ2 (1) = 7.50, p = 0.006. Table 5 summarizes the Final model. As with the SAQ‐A30, results for the
BDI‐II indicated the presence of an interaction, so Figure 3 shows a similar pattern of results. Although the
Control Group's expected means do not change much over the course of treatment (starting with M = 19.61
and ending with a M = 21.59), the experimental group means do, with an overall decrease from 20.52 to 14.00.
Effect sizes controlling for baseline differences showed a small effect at Time 2 (g = 0.29) and a moderate effect
at Time 3 (g = 0.55).
1502 | ZABOSKI ET AL.

FIGURE 3 Beck Depression Inventory‐II scores across three measurement occasions

4 | D IS C U S S IO N

The present study investigated the effect of group exposure therapy for college students with SAD. Random
assignment to an active control or experimental group allowed for causal inferences from the data. Moreover, the
study de‐emphasized the common thought‐challenging approaches used in some SAD CBT treatment protocols
(e.g., Clark & Wells, 1995; Heimberg & Becker, 2002), opting to maximize time spent on real‐life social exposures.
This enabled participants to generalize learning to settings outside of the therapy room. Additionally, compared to
counseling 31 participants individually for 60 min each, treatment was more efficient: One therapist saw 31
participants in a week over the course of 8 hr.
On overall social anxiety symptoms both groups improved, but the exposure therapy group improved more than the
control (g = 0.62). These results were larger than the effects reported by Barkowski et al. (2016) for group CBT ERP
when compared to a common factors control group (g = 0.31). Recall that participants in the educational support group
participated in natural discussions among themselves, much like students would in a classroom. Additionally,
participants were told at the outset of the study and on Session 1 that the active control had also been shown to be
effective for SAD. The interactive classroom presentations assisted in building rapport and group cohesion, evidenced
by several participants exchanging phone numbers and email addresses voluntarily. Thus, although control group
ZABOSKI ET AL. | 1503

participants engaged in social interaction that contributed to some improvement, the intensive, systematic, and
prolonged exposure in the experimental group contributed to more rapid treatment gains.
To some practitioners, the exposures used in the treatment group may seem extreme, such as handing out
condoms from the campus counseling center. However, for extinction learning to occur, it is important to “bulldoze
the anxiety over, or else, like weeds in a garden, the symptoms will grow back” (Abramowitz et al., 2012, p. 93). The
present study's protocol emphasizing in vivo exposures may therefore explain the contrasting results to Bjornsson
et al. (2011), who found null differences between their study groups on the LSAS that they attributed to their active
control. Thus, this study's results highlighted the importance of real‐world exposures to overcome the powerful
effects of placebos and common factors (see Laska, Gurman, & Wampold, 2014).
On fear of negative evaluation, scores increased from the beginning of the study to the end, implying that fear
of negative evaluation was more strongly endorsed by the end of the study. One plausible explanation for these
results is that the exposure‐intensive protocol may have exacerbated fears of negative evaluation during the study
while participants were completing the measures. As a result, the BFNE might be a more suitable measure of social
anxiety after more time has passed between exposures and measurement occasions. Alternatively, it is possible
that despite the increase in fear of negative evaluation, participants still believed they improved by the end of the
study. This is consistent with the inhibitory learning model (Craske et al., 2008, 2014), which emphasizes distress
tolerance and learning (e.g., I can do something even if I feel anxious.) rather than habituation (i.e., I am getting used to
the anxiety, so I'm getting better.) Thus, avoidance of anxiety‐provoking situations might have decreased, thereby
signaling improvement even in the presence of elevated fear of negative evaluation.
Another possibility is that between‐group effect sizes on fear of negative evaluation were decreased by the
study's use of a common factor control group with structural equivalence. Bjornsson et al. (2011) argued that the
educational support group used in prior studies may have been inadequate because it did not emphasize group
processes and was not as action‐oriented as cognitive‐behavioral group therapy conditions. However, in the
present study the lack of an interaction effect on fear of negative evaluation provides evidence that the control
group did address many important common factors. Lastly, a more prosaic explanation is that due to the high
attrition rate, the null results could have resulted from a lack of power. Additional studies with the BFNE will be
required to test these possibilities.
Lastly, because of the high co‐occurrence social anxiety and depression, we examined whether exposure
therapy would affect depression symptoms as measured by the BDI‐II. We found that individuals with depressive
symptoms in the experimental group improved more rapidly than participants in the control group. This study's
results are consistent with a randomized controlled trial for social anxiety (Kampmann et al., 2016), which found
that pre–post scores on the DASS‐21 (Lovibond & Lovibond, 1995) decreased for individuals in virtual reality and
within in vivo exposure therapy groups. This is potentially due to the nature of more severe, untreated SAD that
results in the onset of mild depression (Cummings, Caporino, & Kendall, 2014). In the present study, most of the
participants' social anxiety had been untreated, with 25% of participants reporting no formal treatment at all, and
only 13% of participants affirming CBT ERP treatment. Therefore, lack of treatment coupled with mild to moderate
depression provides evidence that some study participants could have experienced depression resulting from their
anxiety. Consequently, focusing treatment on impairing symptoms of anxiety may have decreased depressive
symptomology along with it.

4.1 | Limitations
One notable weakness of the present study was its higher rate of attrition than the 17% observed in the group
treatment literature for SAD (Barkowski et al., 2016). Thus, the present study's drop‐out rate highlights the
importance of managing attrition in research and for testing ways to decrease attrition in college student
populations. An additional weakness is that effect size calculations reflected only the observed effect sizes in the
present study; they cannot generalize to other studies. Also, they were based on decreasing sample sizes as
1504 | ZABOSKI ET AL.

attrition increased at each measurement point. Finally, only one therapist trained in exposure therapy conducted
the treatment sessions. Although all sessions and times were carefully prescribed, there were no treatment fidelity
checks or controls for a therapist allegiance effect (see Messer & Wampold, 2002).
To remediate these weaknesses, future studies should include a longer and more comprehensive recruitment
period to increase the sample size. Decreasing the time between random assignment and the study's first round of
baseline measures would also decrease risk of drop‐out before the first measurement opportunity. Additional
measurement occasions could also allow for more powerful statistical models. In future studies, the duration and
number of sessions should be experimentally manipulated to maximize participation and respect student schedules.
Fidelity checks should be completed by trained observers to ensure adherence to the treatment protocol, and
ratings of treatment credibility should be collected from participants to compare the credibility of the control and
experimental groups. Since no control group can adequately account for all common factors in treatment, future
researchers might consider comparing different types of active control groups within the same study. Finally, the
BFNE's reliability was lower than expected (though not unacceptably low), so future research utilizing it should
clarify whether its underperformance was due to higher fear of negative evaluation resulting from exposures, lack
of power, or psychometric inadequacies.
Finally, our data cannot answer the question of whether participants would have improved more with
traditional cognitive restructuring (e.g., examining evidence for/against a maladaptive thought) added to the
exposures. Inhibitory learning theorists (Craske et al., 2008; Craske et al., 2014) maintain that, while exposures are
important components for cognitive restructuring, cognitive‐based techniques (e.g., first discussing a patient's
greatest fear, completing the exposure, then discussing whether the fear came true) may augment an exposure's
effectiveness by maximizing expectancy violations. To increase the efficacy and efficiency of CBT ERP, this should
be studied more thoroughly.

5 | CONC LU SION

Overall, results indicated that group‐delivered CBT ERP for college students with SAD was a resource‐effective
therapy that decreased overall symptoms of social anxiety. Moreover, the study protocol—with frequent and
prolonged real‐world exposures and an active control group—addressed many of the limitations in prior research.
Because attrition was high, practitioners might opt to reduce it with appointment reminder emails, flexible
scheduling, and incentives for participation. Thus, the results of this study support an evidence‐based approach for
SAD that can meet the high need for effective and efficient interventions on college campuses.

A C K N O W L E D GE M E N TS

The authors acknowledge the contributions of Carol Matthews, Patricia Ashton, Beth Roland, Amanda H. Brown,
and Ernesto Escoto.

CO NFLICT OF I NTERE STS

The authors declare that there are no conflict of interests.

OR CID

Brian A. Zaboski http://orcid.org/0000-0003-4567-8694

ZABOSKI ET AL. | 1505

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How to cite this article: Zaboski BA, Joyce‐Beaulieu D, Kranzler JH, McNamara JP, Gayle C, and MacInnes
J. Group exposure and response prevention for college students with social anxiety: A randomized clinical
trial. J. Clin. Psychol. 2019;75:1489–1507. https://doi.org/10.1002/jclp.22792
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