In treatment, youths with social anxiety disorder (SAD) may avoid participating in therapeutic activities with risk of negative peer appraisal.
Peer-helping is a low-intensity, social activity in the 12-step program associated with greater abstinence among treatment-seeking adults. This study (1), hot off the press as published May 2015, examined the influence of SAD on clinical severity at intake, peer-helping during treatment, and outcomes in a large sample of adolescents court-referred to residential treatment.
This study found evidence of an association between SAD and earlier age of first use, incarceration history, and lifetime trauma. SAD was associated with higher service participation during treatment, which was associated with reduced risk of relapse and
incarceration in the 6 months post treatment. Findings indicate the benefits of service participation for juveniles with SAD which provides a nonjudgmental, task-focused venue for developing sober networks in the transition back into the community.
We now widely use certain excerpts from this study.
“THE 21ST CENTURY has witnessed a dramatic increase in addiction among U.S. youth, with similar rates of alcohol and other drug (AOD)-use disorders among both boys and girls (Mulye et al., 2009).
Adolescent AOD use curtails brain development and scholastic achievements; increases incidence and spread of infectious disease; potentiates the danger of risky sex, teenage pregnancy, school dropout, and criminal activity; and shortens life-course trajectories with associated medical comorbidities (Guerri and Pascual, 2010).
Social instincts and development during adolescence can intersect in ways that increase risk of AOD-use disorders.
The need to fit in, the prominence of peers, establishing an identity independent of parents, and the tendency for drinking to organize social activities are forefront in this developmental stage (National Institute on Drug Abuse, 2014). Symptoms of social anxiety disorder (SAD) emerge well before adolescents begin experimenting with
SAD is 5 times more likely to precede AOD-use disorders and the most common co-occurring anxiety disorder with AOD-use disorders (Buckner et al., 2008; Zimmerman et al., 2003).
The types of situations feared usually involve interacting with others, such as socializing at a party, performing in front of others, or speaking to a group (Randall et al., 2001). Socially anxious youths soon discover that AOD use can diminish their discomfort (Robinson et al., 2011; Terra et al., 2006); this self-medicating response can develop into addiction and set in motion a drink/trouble, drink/trouble cycle that may require treatment to interrupt. Young adults in correctional facilities well describe the drink/trouble, drink/trouble cycle: “We saw how often we got into trouble while drinking. Over and over, our troubles had some hook up with drinking” (AlcoholicsAnonymous [AA], 2000).
Addiction treatment approaches for adolescents are frequently
delivered in groups and behavioral in nature, as addiction medications have not been approved for use with minors. The majority of treatment programs encourage patients to attend AA, and the 12-step model is the prevailing therapeutic approach for treating substance abuse in the United States.
Most active ingredients accounting for AA’s benefit are social in nature, such as attending meetings, and the 12 steps mention “we” 6 times but not “I” once.
The social platform of formal treatment and AA, however, may pose a challenge to socially anxious patients who no longer have alcohol or drugs to mitigate their discomfort.
Treatment-seeking adults with social anxiety are less likely to
speak up in group therapy, talk to their therapist, or participate
in treatment activities involving public speaking (Book et al., 2009).
Social anxiety can also interfere with participation in 12-step activities. For example, adults with SAD report not feeling as good after a meeting as those without SAD and are less likely to chair a meeting, and women with SAD are less likely to ask someone to sponsor them (Terra et al., 2006; Tonigan et al., 2010).
Addiction treatment usually does not assess for nor treat SAD specifically, SAD is nonremitting without treatment for this condition (Bruce et al., 2005), and patients with SAD are more
likely to relapse after treatment if SAD is left untreated during
addiction treatment (Kushner et al., 2005).
Finding nonjudgmental venues for social connectedness and personal growth is important to help socially anxious patients stay
engaged in treatment and benefit from active participation.
Service is a programmatic component of the 12-step program
that is associated with greater abstinence (Pagano et al., 2004, 2013b), reduced symptoms of depression and negative self-appraisal (Pagano et al., 2007, 2009), and increased social involvement (Pagano et al., 2013a). The benefits from helping others appear to be greatest for individuals who are socially isolated (Piliavin, 2005), and patients with SAD are prone to withdraw from others to avoid negative appraisal.
Midlarsky (1991) proposed that helping others may benefit the helper because it distracts one from one’s own troubles, enhances a sense of value in one’s life, improves self-evaluations, increases positive moods, and causes social integration.
The myriad of existing service activities in AA are readily available inside and outside of meetings; are low intensity; and do not require special skills, prior experience, time sober, long-term commitment, transportation, insurance, or parental permission.
Peer-helping in AA, such as having the responsibility of making coffee at a meeting, empathetic listening to others, reading inspirational meditations to others, or sharing personal experiences in learning to live sober, may have the effect of greater engagement in treatment and improved outcomes due to patients’ active contributions.
Given the extreme self-consciousness in social situations that characterizes SAD and the applicability of prosocial behaviors enhancing youth development, the limited data on youth participation patterns in peer-helping and effectiveness, particularly with socially anxious patients, are surprising.
Many 12-step investigations consider the effects of getting but rarely giving support on improved outcomes, most addiction studies usually do not assess SAD specifically, and SAD studies tend to exclude participants with AOD-use disorders. Given the priority of peer-evaluations during adolescence and high sensitivity to deprecatory judgments—the hallmark of SAD—peer-helping may be particularly relevant to adolescents learning to live sober with and
This study sought to extend prior research by evaluating effects of SAD on clinical presentation at intake, 12-step engagement patterns during treatment, and treatment outcomes in a large sample of high-risk minors (52% female, 30% minority) court-referred to residential treatment.
Because SAD has been associated with lower meeting attendance
and rates of having a sponsor among treatment-seeking adults (Tonigan et al., 2010), we hypothesized that SAD would be associated with lower meeting attendance and obtaining a sponsor during treatment. Because many forms of service involve low risk of public scrutiny (i.e., putting away chairs) and the evidence of improved outcomes associated with helping others during treatment (Pagano et al., 2013b), we hypothesized that SAD would be associated with peer-helping during treatment, which would increase the chances of SAD youths staying sober and out of jail in the high-risk, initial 6 months following discharge.
Our hypothesis of higher peer-helping associated with SAD was confirmed, with one-to-one service activities engaged in the most. In contrast, youths without SAD had higher rates of service activities performed in front of an audience, such as reading literature at the opening or closing of a meeting. Contrary to our hypothesis, meeting attendance and rates of having a sponsor were similar between youths with and without SAD.
Higher peer-helping among SAD youths is likely to have promoted their meeting attendance and facilitated conversations with other AA members to ask for their sponsorship.
Results indicated that peer-helping increased the chances
of SAD youths staying sober posttreatment.
…helping others during treatment doubled the chances of staying sober in the initial months following treatment, a high-risk period when most patients relapse and meeting attendance sharply
…SAD youths with low helping behavior had the lowest rate of sustained sobriety in the 6 months posttreatment, whereas SAD youths with high helping maintained sobriety at rates comparable to high helpers without SAD.
Learning to live sober with social anxiety is a challenge in a competitive society where people can be quick to judge others
(Aronson et al., 2010; Gray, 1993). Coping with a persistent fear of being scrutinized in social situations often requires learning to tolerate the opinions of others, feeling different, appropriate boundary setting, and enduring short term discomfort for long-term gain—skills that are in short supply among adolescents and those in early recovery.
The low-intensity service activities in AA offer youths—and those with SAD in particular—a nonjudgmental, task-focused venue for social connectedness, reduce self-preoccupation and feeling like a misfit, and transform a troubled past to usefulness with others (Pagano et al., 2011).
Given finite treatment resources and the reality that addiction is lifelong, AA should be encouraged for socially anxious youths in particular. Many patients may not be aware of the many ways they can participate in this programmatic activity that
clinicians should bring to their attention, thereby increasing the chances for hypersensitive youths to thrive in sobriety.
As stated by a young adult, “I wanted to be at peace with
myself and comfortable with other people. The belonging I
always wanted I have found in AA. I got into service work
right away and really enjoyed it” (Alcoholics Anonymous,
1. Pagano, M. E., Wang, A. R., Rowles, B. M., Lee, M. T., & Johnson, B. R. (2015). Social Anxiety and Peer Helping in Adolescent Addiction Treatment.Alcoholism: Clinical and Experimental Research, 39(5), 887-895.