Social Anxiety and Peer Helping in Adolescent Addiction Treatment

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). The recent legalization of marijuana in several states, the plethora of prescription medications, and harder street drugs including methamphetamines gives youths the greatest access to controlled substances than our nation has seen since the initiation of the “War on Drugs” (Hurley and Mazor, 2013). In response, research targeting adolescent AOD use specifically has developed sophisticated tools to determine causal factors and effects of this epidemic. 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). The rising cost of AOD problems is estimated at $500 billion in increased criminal activity, higher healthcare costs, and lost productivity. Social instincts and developmental tasks 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 AOD use. 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; Zimmer-man 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 hookup with drinking” (Alcoholics Anonymous [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. Meta-analytic reviews of 12-step research show a modest benefit of 12-step participation on reduced AOD use (Forcehimes and Tonigan, 2008). 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). The daunting reality is that 60 to 90% of patients relapse in the initial 6 months posttreatment (Miller et al., 2001), and the lifelong illness of addiction requires ongoing recovery supports. 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 non-judgmental venues for social connectedness and personal growth is important to help socially anxious patients stay engaged in treatment and benefit from active participation.