Perhaps the most frustrating situation for a health professional is having an effective treatment for an illness but no way to get it to those afflicted. Unfortunately, such is the case with social anxiety disorder (SAD) among high school students.
As mental disorders go, social anxiety disorder has a fairly high prevalence rate, affecting roughly 7% of adult Americans1 and a similar number of adolescents2-3.
Fortunately, psychologists, using the principles of cognitive behavioral therapy (CBT), have developed a number of effective treatments for socially related anxiety. So much so, in fact, that two recent large-scale analyses concluded that CBT is “highly effective” at treating social anxiety disorder4-5. However, despite the progress made in developing treatments, high schoolers with social anxiety disorder are among some of the individuals least likely to seek treatment for their disorder6.
What makes the situation even more frustrating is that social anxiety can be crippling for an individual undergoing the extreme social pressures of high school. Social anxiety disorder, previously diagnosed as social phobia, involves intense anxiety regarding social situations where an individual believes others might judge them. In particular, individuals with this disorder often fear that their actions will reveal their anxiety, leading their peers to reject them7. Such anxiety can become so pronounced that an individual begins avoiding social situations altogether, which can greatly disrupt a high school student’s social life and education.
Noting the debilitating nature of social anxiety, Dr. Carrie Masia Warner, of William Patterson University, and her colleagues sought to bridge the gap between therapists and students needing treatment8. Specifically, they examined the feasibility of introducing CBT for social anxiety to high schools. Treating social anxiety at school has strong appeal for a few reasons. First and foremost, therapists can bring therapy directly to those who need it, removing physical distance as a barrier to treatment. Second, it allows therapy to occur in the social situation in which the anxiety occurs, which is crucial for treating anxieties and fears9.
Typically, implementing a CBT program in schools requires an outside, licensed therapist trained in CBT. Though this route ensures the quality of the treatment students receive, bringing in an outside therapist can be difficult and expensive. Consequently, Dr. Masia Warner and colleagues wanted to know if they could train school counselors, who work within high schools, to administer CBT as effectively as outside therapists.
For this study, the researchers examined a particular form of CBT for treatment of social anxiety in high school, called Skills for Academic and Social Success (SASS)10-11. In this program, students participate in group sessions that last approximately as long as a typical high school class period. Students receive weekly training sessions for 12 weeks, with several additional meetings, including 4 weekend social events. In the weekly sessions, students receive training on tasks such as initiating and maintaining conversations, establishing friendships, and assertiveness, and the weekend social events provide a safe environment for students to implement these skills.
To evaluate whether school counselors could effectively administer SASS to students, the researchers randomly assigned high schoolers diagnosed with social anxiety disorder to SASS treatment by a school counselor, SASS treatment by a doctoral level, outside therapist, or an unrelated skills training program that would serve as a baseline. The researchers found that students in the SASS condition led by school counselors demonstrated significant improvement in social anxiety related symptoms over the baseline condition. Crucially, though, they showed the same level of improvement as the students in the SASS treatment led by an outside therapist. In other words, school counselors provided the same quality of treatment as the outside therapists, demonstrating the feasibility of having school counselors leading such a treatment.
This finding is immensely promising. If school counselors can administer this form of CBT effectively, it is possible that they could administer other forms of CBT for other disorders. In so doing, therapists could greatly expand their reach in high schools and treat thousands of adolescents who would have otherwise never received care. Crucially, though, this study is simply the first step. As the researchers point out, the school counselors in this study received copious amounts of training from skilled therapists. However, it is unclear how counselors could receive such training outside of such a perfect situation, especially in school systems that lack proper funding. To be sure, though, this study provides a tremendously important proof of concept, and opens the door to introducing other forms of CBT to schools.
1. Ruscio, A. M., Brown, T. A., Chiu, W. T., Sareen, J., Stein, M. B., & Kessler, R. C. (2008). Social fears and social phobia in the USA: results from the National Comorbidity Survey Replication. Psychological medicine, 38(01), 15-28.
2. Costello, E. J., Mustillo, S., Erkanli, A., Keeler, G., & Angold, A. (2003). Prevalence and development of psychiatric disorders in childhood and adolescence. Archives of general psychiatry, 60(8), 837-844.
3. Wittchen, H. U., Stein, M. B., & Kessler, R. C. (1999). Social fears and social phobia in a community sample of adolescents and young adults: prevalence, risk factors and co-morbidity. Psychological medicine, 29(02), 309-323.
4. Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of cognitive-behavioral therapy: a review of meta-analyses. Clinical psychology review, 26(1), 17-31.
5. Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: a review of meta-analyses. Cognitive therapy and research, 36(5), 427-440.
6. Merikangas, K. R., He, J. P., Burstein, M., Swendsen, J., Avenevoli, S., Case, B., … & Olfson, M. (2011). Service utilization for lifetime mental disorders in US adolescents: Results of the National Comorbidity Survey–Adolescent Supplement (NCS-A). Journal of the American Academy of Child & Adolescent Psychiatry, 50(1), 32-45.
7. American Psychiatric Association. (2013).Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
8. Masia Warner, C., Colognori, D., Brice, C., Herzig, K., Mufson, L., Lynch, C., … & Ryan, J. (2016). Can school counselors deliver cognitive‐behavioral treatment for social anxiety effectively? A randomized controlled trial. Journal of Child Psychology and Psychiatry.
9. Wolpe, J. (1958). Psychotherapy and reciprocal inhibition. Stanford, CA: Stanford University Press.
10. Masia, C., Beidel, D.C., Albano, A.M., Rapee, R.M., Turner, S.M., Morris, T.L., & Klein, R.G. (1999). Skills for academic and social success. New York: Child Study Center.
11. Masia-Warner, C., Klein, R. G., Dent, H. C., Fisher, P. H., Alvir, J., Albano, A. M., & Guardino, M. (2005). School-based intervention for adolescents with social anxiety disorder: Results of a controlled study. Journal of abnormal child psychology, 33(6), 707-722.
Sam Hunley holds a doctorate in cognitive psychology from Emory University. He pursued his Bachelor's degree in psychology from Furman University and a master's from Emory. Sam's research, alongside Dr. Stella Lourenco, focuses on human perception of the space surrounding the body, exploring the impact of anxiety and phobias on this perception. Together, they contribute to Anxiety.org articles. Post-graduation, Sam became a Presidential Management Fellow.