The high-functioning alcoholic: How to initiate treatment for people who think they’re OK
What if alcoholism hasn’t yet torn you apart?
Alcoholism can affect your physical health, your emotional well-being, personal relationships, and your professional life. However, many alcoholics manage to function effectively while caring for the family and staying devoted to their jobs. In fact, some people may hide alcohol abuse for years without suffering any major losses. But under the surface, this subtype of alcoholic can cause severe psychological and emotional damage to the individual and his or her loved ones.
Sarah Allen Benton MS, LMHC, LPC is author of the book “Understanding the High-Functioning Alcoholic“. She is the owner of Benton Behavioral Health Consulting, LLC and a therapist at Insight Counseling, specializing in outpatient adolescent/young adult addiction services, mental and behavioral health, and family clinical services for clients of all ages in Ridgefield, CT.
In this interview, Sarah explains how problems with high-functioning alcoholics (HFAs) may manifest and can also be addressed. We’ve also asked her to detail some tips for family members to take if/when you identify a drinking problem in a loved one’s life. At the end, we invite your thoughts and questions on this topic in the comments section below. We’ll try to respond to all questions with a personal and prompt reply.
ADDICTION BLOG: How many HFAs or problem drinkers do you estimate there are currently in the U.S.?
SARAH ALLEN BENTON: According to the National Institute of Alcohol Abuse and Alcoholism (NIAAA), approximately 7.2 percent or 17 million adults in the United States ages 18 and older had an alcohol use disorder (AUD) in 2012. This includes 11.2 million men and 5.7 million women. Adolescents can be diagnosed with an AUD as well, and in 2012, an estimated 855,000 adolescents ages 12-17 had an AUD.
In 2007, there was a study by the NIAAA indicating that 19.5% of these alcoholics are “functional” and 31.5% of these alcoholics are the “young adult” subtype (it is unclear what percentage of the young adults would progress to adult functioning alcoholics).
ADDICTION BLOG: What are the main signs of problems with alcohol among this population and how can families or loved ones identify a problem (especially if/when it’s hidden)?
SARAH ALLEN BENTON: The warning signs for HFAs vary, but there are common patterns that can include the following.
1. Inability to control alcohol intake after starting to drink
2. Obsessing about alcohol (i.e., next time the person can drink, how they are going to get alcohol, who they are going to go out drinking with)
3. Behaving in ways, while drunk, that are uncharacteristic of their sober personality, such as surrounding themselves socially with heavy drinkers
4. Getting drunk before actually arriving at parties/bars (pre-partying)
5. Increasing sense of denial that their heavy drinking is a problem because they are able to succeed professionally and personally
6. Setting drinking limits (i.e., only having 3 drinks, only drinking 3 days per week) and not being able to adhere to them
7. Driving drunk and, by sheer luck, not getting arrested or involved in an accident
8. Always having to finish an alcoholic beverage or even another person’s unfinished beverage
9. Using alcohol as a reward
10. Living a double life by separating drinking life from professional or home life
11. Drinking daily or binge drinking (more than 5 drinks in one sitting) on weekends
12. Having blackouts (memory lapse due to excessive drinking) and not remembering what they did for a portion of their drinking episode
13. Feeling guilt and shame about their drunken behaviors
14. Taking breaks from drinking and then increasing alcohol consumption when they resume drinking after a period of time
15. Engaging in risky behaviors when intoxicated
16. Not being able to imagine their life without alcohol in it
ADDICTION BLOG: How do high-functioning alcoholics tend to avoid or deny their problems? What’s the thought process?
SARAH ALLEN BENTON: The societal stereotype of the “typical” alcoholic feeds the denial of HFAs and their loved ones. High functioning alcoholics use their external successes to deny that they may be alcoholic, based on these societal messages about the alcoholic image.
In the mind of HFAs and their loved ones, alcoholics are unemployed, have poor work performance, have poor academic records and are typically homeless. Therefore, the fact that high functioning alcoholics are functioning well on the outside allows them and their loved ones to deny their alcoholism and to falsely feel that they are “better than” a lower functioning alcoholic.
Professional stability and success, as well as continued ability to function allows these individuals to justify their drinking and to truly believe that they are not alcoholic or that their drinking is not a “problem”.
ADDICTION BLOG: What commonly gets in the way of a high-functioning person from getting help? Are these barriers difficult to overcome?
SARAH ALLEN BENTON: The most notable [but not researched] barrier to a high functioning alcoholic getting help is that they are functioning and therefore, do not feel that they need outside help.
Additionally, a NIAAA research study indicates that 15-25% individuals with drinking problems seek help from a physician or treatment center, but do so only when forced by family, court or employer. They have identified that social stigma is the largest barrier as well as privacy concerns. The U.S. Department of Health and Human Services 2005 study also identified “stigma” as the top reason that only 20% of those with alcohol/drug addiction sought treatment.
A study conducted by the Journal of Studies on Alcohol additionally concluded that barriers for individuals to seek treatment included that alcoholics:
- “thought it was something you should be strong enough to handle”
- “didn’t think their drinking problem was serious enough”
- “thought the problem would get better by itself”
These barriers can often be challenging to overcome, but it is important to first educate individuals and families about what it means to be alcoholic- that it is about an individual’s relationship to alcohol and not about external appearances nor negative consequences.
ADDICTION BLOG: Most importantly, how can loved ones address denial and motivate a high-functioning alcoholic to get help? What messages work? What messages don’t work?
SARAH ALLEN BENTON: This powerful sense of denial, as well as misinformation about alcoholism often prevents the loved ones of HFAs from intervening because they may not have concrete evidence that their alcoholic loved one’s drinking is leading to tangible losses. High functioning alcoholics may provide the main source of income for a family and therefore, the spouse or partner may not feel that they have the leverage to persuade the HFA to get help.
Any conversation with an HFA about his or her drinking should occur when the alcoholic is NOT under the influence of alcohol and can often be most effective when s/he is hungover and possibly feeling guilt or remorse. It is crucial to “plant seeds” with a loved one instead of avoiding the topic, as this may increase the chances that this individual will get help in the future.
It is important to express to an alcoholic how his or her drinking is negatively affecting you (emotionally, spiritually, and physically) and how you perceive it is harming others as well (friends, children). In order to prevent your loved one from getting overly defensive, you can place the emphasis on your feelings and concerns…instead of stating how you think he or she should be living or acting. You can also dispel some of the myths and stereotypes.
If the HFA is open to your concerns and is willing to seek help, he or she should also receive an assessment by a therapist or physician about what level of care may be appropriate. You can also suggest finding a recovery program support group such as Alcoholics Anonymous (aa.org), SMART Recovery® (smartrecovery.org) or Women for Sobriety (womenforsobriety.org) that have meetings online and in person throughout the country and internationally. You can even offer to attend an “open” meeting of one of these support groups with your loved one to ease their fears.
Sometimes a high functioning alcoholic may become defensive and express that they are unwilling to seek help for their drinking. He or she may not believe that they are alcoholic and believe require more concrete evidence of being alcoholic in order to even consider getting sober. If this is the case, you may suggest that they visit the NIAAA “Rethinking Drinking” Website and, if necessary, try to set low risk drinking limits for themselves through this online program rethinkingdrinking.org. If the HFA is not able to adhere consistently to low risk drinking limits (i.e., no more than 3 drinks in a sitting, no more than 2 times a week), his or her lack of control over drinking may become clear and he or she may become more open to seeking help.
ADDICTION BLOG: What kind of help can be offered to high-functioning alcoholics to overcome this problem?
SARAH ALLEN BENTON: Given the barriers to treatment that are mentioned above, it is recommended to provide alcoholism treatment options that are discreet and private.
Additionally, trying to pair an HFA with the treatment or support groups that include other HFAs whom they may connect with. For example, there are specific lawyer and physician recovery meetings as well as for other professions. There are also certain treatment centers that specialize in treating certain professions and this can increase the chances that an HFA would identify with other clients – as well as therapists who are skilled at working with this population. Interventionists who have expertise in working with HFA clients can also be a helpful resource. More specific descriptions of addiction treatment levels of care are available on my Psychology Today.com blog post.
ADDICTION BLOG: How often do HFAs also struggle with co-occurring mental illness?
SARAH ALLEN BENTON: There is a high prevalence of individuals with alcoholism and substance use disorders having co-occurring mental health issues (this is also referred to as dual diagnosis). I am not aware of HFA specific research in this area, however SAMSHA research indicates that 55-65% of those seeking treatment present with dual diagnosis. Additionally, 8.9 million Americans have co-occurring disorders.
ADDICTION BLOG: What motivates a high-functioning person to continue the process of addiction recovery?
SARAH ALLEN BENTON: The motivation for HFAs to maintain recovery varies, but the hope is that over time it becomes internal. When the motivation to stay sober is primarily for other people or to obtain external “things”, then this may be a shorter term process. The recovery process takes effort, time and patience and therefore, it is important that the HFA eventually reaches a place of acceptance about being alcoholic and the importance of maintaining sobriety.
Sometimes negative consequences (i.e., legal, marital, professional) can be the lead an HFA to get sober. However, the initial fear usually wears off pretty quickly. Professional leverage through programs such as Physician Health Services can lead individuals in the medical field to stay sober in order to maintain their license. Finding points of leverage and accountability can also spark motivation for HFAs to engage in their recovery. Ideally, a person in recovery becomes internally motivated and also connects socially with others who can support them when they inevitably have natural “dips” in motivation.
ADDICTION BLOG: What are some dangers of cross addiction or behavioral compulsion to look out for (i.e., Work addiction)?
SARAH ALLEN BENTON: Balance is the key to recovery from addiction. Therefore, it is suggested that individuals who are sober from a substance addiction also get the support/treatment needed to address other addictive behaviors.
It is common that if an individual has multiple addictive behaviors, and only treats the substance addiction that they may begin to again turn to the other untreated addictive issue (which could in turn lead to a future substance relapse). Often, work stress can be part of the reason why alcohol was used as an outlet or reward. Therefore, sober HFAs must learn new ways to cope with stress or to set limits regarding the amount or type of work that they are engaging in.
ADDICTION BLOG: How can a partner deal with the consequences of alcoholism and build a stronger relationship and trust?
SARAH ALLEN BENTON: Trust equals time and consistency.
Therefore, the loved ones of HFAs also need time to develop and explore their own recovery and healing. I would suggest that loved ones seek their own therapy or coaching with an addiction specialist and support group meetings (i.e. Al-Anon, ACOA). Open communication is important, and also allowing the HFA to obtain stability in their recovery before delving into deeper emotional issues can be effective.
ADDICTION BLOG: Is there anything else you would like to share with our readers?
SARAH ALLEN BENTON: There are many resources available for HFAs and their families as well as hope for recovery. You are NOT alone!