Social anxiety/phobia, often mischaracterized as extreme shyness, constitutes a potential pathway into addiction and a major obstacle to addiction treatment and recovery.
Robert and Kaisha could not be more different at a quick glance, but they shared the curse of what others perceived as extreme shyness. Robert and Kaisha dreaded any social situation filled with strangers, the expectation of conversation, or any undue focus upon themselves. Just the thought of entering such a situation induced a trembling voice, a racing heart, sweaty hands, a blushing face, dizziness, nausea, extreme self-consciousness, and fears of embarrassment and humiliation. In social situations that could not be escaped, they sought invisibility, shunning as much contact as possible, avoiding eye contact, speaking very little or not at all, and spending inordinate time afterwards harshly judging their social performance.
Robert and Kaisha found something of a solution for their social anxiety. They discovered magic elixirs that lessened or dissolved their fears and loosened their tongues. The problems only came when their increasing dependence on ever-increasing dosages and frequencies of these elixirs created all manner of other problems in their lives. When these escalating problems forced them to seek help, imagine their mortification to hear that their "treatment" would involve group therapy and participating in recovery mutual support groups in their local community.
The situation faced by Robert and Kaisha is by no means rare. A study by Book and colleagues found that 37% of people entering addiction treatment also experienced clinically significant social anxiety. The 37% figure would extrapolate to more than 740,000 individuals entering addiction treatment each year. The Book study raises several important questions.
Of 21.7 million Americans in need of help for a substance use disorder in the past year, only 2.3 million received specialized SUD treatment. What portion of those not receiving treatment were dissuaded from seeking help due to social anxiety and the group-orientation of addiction treatment and recovery mutual aid?
Since 1999, more than 770,000 Americans have died from drug overdoses. What portion of those lost lives chose not to seek help due to social anxiety and the group-orientation of addiction treatment and recovery mutual aid?
Since 1999, nearly one million individuals died from alcohol-related causes. What portion of those lost lives chose not to seek help due to social anxiety and the group-orientation of addiction treatment and recovery mutual aid?
There are an estimated 1.4 million suicide attempts and more than 47,000 deaths by suicide in the United States each year. What portion of these people suffer from a substance use disorder and fail to seek help due to social anxiety and the group-orientation of addiction treatment and recovery mutual aid?
The situation faced by people who need help for a substance use disorder but who shun such help due to social anxiety could be improved if:
*Addiction professionals assessed the presence and degree of social anxiety of every person seeking help for a substance-related problem.
*Integrated addiction and mental health services existed that could concurrently treat SUDs and anxiety disorders via potential combinations of psychosocial support and medication.
*Treatment adjuncts/techniques potentially helpful to those with social anxiety (e.g., thought-stopping, reframing, biofeedback, systematic desensitization, situation rehearsal, progressive relaxation, breath training) were routinely available in addiction treatment programs.
*Outpatient individual counseling was universally available as an alternative to the dominant group-oriented intensive outpatient and residential models of addiction treatment.
*Prescriptive bibliotherapy and self-guided manuals were more widely available as adjuncts and alternatives to addiction treatment.
*E-therapy and e-recovery support services, including online recovery support chat rooms and online meetings (e.g., In the Rooms) were assertively promoted to people with social anxiety.
*Each person with social anxiety was assigned a recovery coach as a personal travel guide into the social worlds of addiction recovery.
*People with social anxiety were phased in to recovery-focused social contact, beginning with orientation to program literature and rituals, one-on-one contact, and large speaker meetings where there is no expectation for participation prior to exposure to smaller closed meetings.
Social anxiety constitutes a major obstacle to addiction treatment and recovery. Human connection is a key mechanism of change within addiction recovery, but people with social anxiety may need special support to access such connection. Scientific research, careful clinical observation, and personal lived experience may offer such people improved solutions for the future.
Acknowledgement: Thanks to members of the Recovery Rising Book Club for comments on an early draft of this blog.
Book, S. W., Thomas, S. E., Dempsey, J. P., & Randall, P. K. (2009). Social anxiety impacts willingness to participate in addiction treatment. Addictive Behaviors, 34, 474-476.
Substance Abuse and Mental Health Services Administration, (2019). Treatment Episode Data Set (TEDS): 2017. Rockville, MD: Substance Abuse and Mental Health Services Administration.
White, A. M., Castle, I-J., P., Hingson, R. W. & Powell, P. A. (2020). Using death certificates to explore changes in alcohol-related mortality in the United States, 1999-2017. Alcoholism: Clinical & Experimental Research. 44(1). 178-187.