Alcohol dependency and social phobia are frequently co-occurring disorders and prior work suggested that 12-step therapy, the prevailing therapeutic model in the United States, may not be equally effective for alcoholic women with and without social phobia. This study investigated whether differential AA attendance or commitment to, and practice of, prescribed 12-step behaviors accounted for the relatively poor outcomes of socially phobic women assigned to 12-step therapy. Overall, the number of similarities in the ways that women practiced prescribed AA behaviors outweighed the differences between women with and without social phobia. As examples, during and after treatment, women with and without social phobia tended to report attending roughly the same number of AA meetings, and patterns of decay in AA attendance over 12 months was also similar regardless of social phobia status among women assigned to 12-step therapy. Likewise, there was no proportional difference in completing a 5th step between the two groups.
Noteworthy, socially phobic women reported, in general, lower rates of acquiring an AA sponsor during therapy, and rates of getting an AA sponsor for the first time among this group were even lower. Given the documented value of sponsorship for achieving and sustaining abstinence (Sheeren 1988
; Witbrodt and Kaskutas 2005
) this apparent deficit for alcoholic socially phobic women may be an important factor accounting for relatively poor outcomes for this group. Study findings more clearly amplify the work of Terra et al (2006)
that suggested that adults with SP might engage in AA in ways that are distinct from non-SP alcoholics. Specifically in severely underpowered analyses they suggested that some SP adults were less likely to assume roles of responsibility in AA and that they viewed the benefits of AA less favorably. Findings from this study parallel this interpretation, but do so from the perspective of a longer-term follow-up and a more rigorous prospective design.
Various clinical strategies to address a sponsorship deficit ought to be considered when SP women are offered 12-step therapy. First, therapeutic efforts to facilitate the acquisition of a sponsor ought to begin in the early phase of therapy for SP women. Typically, 12-step therapy begins with first promoting cognitive shifts that are consistent with AA ideology, (e.g., accepting powerlessness over alcohol, followed by more behaviorally anchored objectives) such as sponsorship. Work suggests, however, that few AA-related behaviors are initiated after treatment (Tonigan, Conners, and Miller 2003
). Given the apparent difficulties faced by SP women in acquiring an AA sponsor, it seems prudent to allow sufficient therapeutic time to aid SP women in this endeavor. Second, and related, SP women may benefit from focused social skill training aimed at asking an AA member to become a sponsor. Here, training may include effective ways to get phone numbers, dealing with rejection, and understanding the nature of the sponsee-sponsor relationship.
The present study has some limitations. Despite the large sample in Project MATCH, some of the sites were predominately male and the sample of women is small, as is the sub-sample of women with social phobia. In addition, the diagnosis of social phobia was made with a computerized survey, the C-DIS, which has been demonstrated to over diagnose Axis I diagnoses relative to the Structured Clinical Interview for Diagnosis (SCID), which is considered the gold standard (Ross et al. 1995
). Further, although it is not altogether clear from these analyses whether these finding are based on a gender by social phobia interaction, as compared to main effect for social phobia within the female group, future studies could further clarify this. Additionally, this study was retrospective in nature, using an existing database, rather than a prospective design, and as such suffers from the same limitations as the parent study, Project MATCH (e.g. excluding most other drug dependence and homeless individuals), which may limit its generalizability.
In sum, findings suggest that the study of social phobia and AA engagement is complex. Efforts to identify only the main effects of social phobia on drinking outcomes and AA attendance are likely to miss critical nuances that will result in making erroneous conclusions. This study, for example, did report that SP by itself was largely unrelated to how frequently one attended AA or how one became engaged in AA. The consideration of alcoholic gender, however, showed that female alcoholics with SP fared significantly worse in 12-step therapy and that this outcome may be related to the failure to acquire an AA sponsor.