Over the past 25 years researchers have made enormous strides in the implementation of cognitive-behavioral therapy (CBT) for social anxiety disorder (SAD), although considerable work remains to be done. The present paper discusses a treatment refractory case seen in our clinic. The young man presented numerous interrelated obstacles, such as low treatment expectations, poor homework compliance, and comorbid depression and alcohol dependence. We highlight the challenges presented by this complex presentation, as well as issues that arose over the course of treatment. We then elaborate on techniques that could have improved his outcome. The promise of motivational interviewing and behavioral activation techniques for these complex clients is discussed. Future research and treatment directions for refractory cases are considered.