Susan is a case example of a high-functioning alcoholic (HFA) in that she is able to maintain her outside life (job, home, family and friendships), all while drinking alcoholically. HFAs have the same disease as the stereotypical “Skid Row” alcoholic, but the illness manifests or progresses differently.
A landmark 2007 study by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) categorized alcoholics into five subtypes. The study found that about 19.5% are the “functional” subtype, 31.5% are the “young adult” subtype, 21% are the “young antisocial” subtype, 19% are the “intermediate familial” subtype (middle-aged with mental illness), and only 9% are of the “chronic severe” subtype that fits the stereotype of the low-bottom alcoholic.1 Other addiction experts estimate that between 75 and 90% of alcoholics are high-functioning.
Society does not view many HFAs as being alcoholic, because these individuals have succeeded and overachieved throughout their lives. These achievements often lead to an increase in personal denial as well as denial from colleagues and loved ones. Some common characteristics of HFAs include but are not limited to the following:
Denial. HFAs have difficulty viewing themselves as alcoholics because they don't fit the stereotypical image and because they feel their lives are manageable. They also avoid recovery help, and they make excuses for drinking by using alcohol as a reward or to relieve stress.
Professional and personal life. HFAs are well respected for job/academic performance and accomplishments. They can maintain a social life and intimate relationships, and they surround themselves with people who drink heavily.
“Double life.” HFAs appear to the outside world to be managing life well, but they are skilled at living a compartmentalized life (separating professional, personal and drinking lives).
Hitting bottom. HFAs experience few tangible losses and consequences from their drinking, often by sheer luck. They experience recurrent thoughts that because they have not “lost everything,” they have not hit bottom. Often they hit bottom and are unable to recognize it.2
HFAs are less apt to feel they need treatment for their alcoholism and often slide through the cracks of the healthcare system, both medically and psychologically, because they are not diagnosed. Clinicians might have difficulty identifying HFAs as being alcoholic because they don't always fit DSM-IV-TR diagnostic criteria for alcohol dependence or abuse.3 For example, in terms of alcohol dependence, alcohol withdrawal is a major component of diagnosis. Many HFAs are neither daily drinkers nor physically addicted to alcohol, but are instead psychologically addicted to alcohol and therefore may not fit those criteria. Regarding alcohol abuse, the diagnostic criteria consist mainly of a deterioration in academic, job and personal functioning-HFAs again can escape detection here.
It can be more effective to diagnose an HFA according to the symptoms described in the “Big Book” of Alcoholics Anonymous (AA). There are three main components of the symptoms:
When an individual has one drink, he or she then experiences a craving to have more and cannot predict what his or her alcohol intake will be.
An individual obsesses about the next time he or she will be able to drink alcohol.
An individual, while drunk, behaves in ways that are not characteristic of him or her and continues to repeat these behaviors and patterns even when no longer wanting to.4
Challenge for clinicians
HFAs are challenging to treat compared with lower-functioning alcoholics. Their ability to maintain their personal and professional lives often makes it difficult to have “leverage” in assisting them to change their drinking habits or to abstain. They might appear resistant and use their outside successes as evidence that they are not alcoholic. However, this provides an opportunity to engage in a discussion about the stereotypes of alcoholics that exist in society.
It would be appropriate to challenge an HFA client about the stereotype of the “Skid Row” alcoholic and to state that only 9% of all alcoholics actually fit that description, while many more are high-functioning. Psychoeducation about alcohol use disorders can be effective by explaining what it means to be alcoholic and by allowing the client to realize that it is not about how his/her life appears on the outside, but rather about an individual's relationship to alcohol.In addition, recommending books written by or about HFAs, such as Drinking: A Love Story by Caroline Knapp 5, A Drinking Life by Pete Hamill 6, or my recent book Understanding the High-Functioning Alcoholic: Professional Views and Personal Insights, can provide your client with first-hand perspectives and healing.
Determining the stage of change of an HFA client is essential for effective therapy. To a clinician, treating the client's alcoholism might seem logical, but the client might have a different agenda for therapy. Therefore, establishing rapport and trust with the client should include letting the person know that if at any time he/she wants to deal with issues around alcohol, you will always be there for support. From that point, identifying and discussing connections you see between the client's drinking and the life difficulties he/she reports can be helpful.
HFAs often bring up issues in therapy that they perceive do not involve drinking, such as interpersonal issues, insomnia, or mood disturbances. Often these issues are connected to drinking, but HFA clients are unable to see the connection. These other presenting issues often can be used as a pathway to addressing the client's alcohol problem. In one case example, a client's presenting issue was sleep problems, but she did speak about irregular bed times, drinking, and excessive socializing. I suggested that she keep a sleep log so that we could track her sleeping patterns, including a column for the number of drinks she consumed each evening. I explained that alcohol often affects sleep and I wanted to see if the two were connected. Keeping my emphasis on sleep patterns allowed the client to feel comfortable charting her drinking. After several weeks, she stated that she had never realized how much she had been drinking, and discovered for herself the connection between her heavy drinking patterns and her sleep problems.
HFAs might report trying various methods to control their drinking, such as drinking only on weekends, avoiding hard liquor, abstaining for weeks or months, drinking only socially, etc. The time and effort expended on controlling their drinking is important to point out to HFAs. Explaining that “if you have to control something, then it is out of control” can sometimes allow such clients to adopt a different perspective.
HFAs tend to be goal-oriented and therefore the strategy of collaborative goal setting can lead them to gather clear evidence of their lack of control over drinking. Creating clear moderation drinking goals can often lead them to come to their own conclusions (for example, agreeing on the goal of limiting drinking to two days of the week and not having more than three drinks in one sitting). It is crucial to agree on these goals in writing, and in subsequent sessions to track the client's adherence to the goals. If a client is alcoholic, then he/she eventually will fail at moderation goals, therefore providing concrete evidence of the need for abstinence.
Benefits of support
When HFA clients are ready to address their alcoholism, several strategies can help to streamline the process. If it is determined that the client does not need to be admitted to a detox or rehab facility, then he/she needs assistance with a lower level of care. Research indicates that all alcoholics benefit from recovery program support group meetings such as those run by AA, SMART Recovery®, or Women for Sobriety in addition to individual therapy and, if necessary, treatment with medication. Although as a clinician you are a part of the recovery picture, HFAs should eventually establish an additional support system.
AA has the largest membership of any other recovery program-more than 2 million worldwide7-and a high success rate compared to other programs. Therefore, many addiction experts agree that AA offers the best starting option, even if the client does not have a strong spiritual belief system. You can suggest that your client try the program for about two months and that if he/she is unable to make it work, you'll help the client look into other options. When sending HFA clients to AA meetings, it is vital to prepare them: They are going to hear stories from low-functioning/low-bottom alcoholics who possibly have lost everything. A key suggestion to pass on to clients is to try to “identify with but not compare” themselves with all the stories told at a meeting.
Encourage the client to try different AA meetings; if he/she does not like a particular one, there are plenty of others from which to choose. For adolescents and young adults, there are “young people” meetings that allow these clients to connect with other sober individuals in their age group. As an addiction expert, you might want to attend an “open” AA or another recovery program support group meeting ahead of time so you can better prepare your clients.
HFAs might report feeling worse emotionally and physically during early sobriety. They also might report not being able to handle their professional or personal responsibilities as well as they could while they were drinking. In contrast, many lower-functioning alcoholics who get sober report that their relationships begin to strengthen, or that they have obtained housing and are finally able to keep a job. HFAs need reassurance that these initial losses and negative results of getting sober are all part of their journey to recovery, and are not a reason to start drinking again.
In addition, expressing that through the pain of change a sober way of life will emerge, and allowing internal as well as external growth, is critical. The support HFAs can receive through a recovery program is also necessary in allowing them to see others move through the recovery process, which cultivates hope through the experiences of other sober alcoholics. Over time, sober HFAs begin to see that all that separates them from lower-functioning alcoholics are their stories.Sarah Allen Benton is a Licensed Mental Health Counselor at the Emmanuel College Counseling Center in Boston and has held several counselor positions at McLean Hospital in Massachusetts. The author of Understanding the High-Functioning Alcoholic: Professional Views and Personal Insights, she has been sober since February 2004. Her e-mail address is firstname.lastname@example.org.
- Moss HB, Chen CM, Yi HY. Subtypes of alcohol dependence in a nationally representative sample. Drug Alcohol Depend 2007; 91:149-58.
- Benton SA. Understanding the High-Functioning Alcoholic: Professional Views and Personal Insights. Westport Conn.:Praeger Publishers; 2009.
- American Psychiatric Association. Diagnosis and Statistical Manual of Mental Disorders, Fourth Edition Text Revision. Washington D.C.:American Psychiatric Publishing; 2000.
- Alcoholics Anonymous. Alcoholics Anonymous, Fourth Edition. New York City:Alcoholics Anonymous World Services Inc.; 2001.
- Knapp C. Drinking: A Love Story. New York City:Delta Trade Paperbacks; 1996.
- Hamill P. A Drinking Life. Ontario Canada:Little, Brown and Company; 1994.
- Alcoholics Anonymous. Alcoholics Anonymous 2007 Membership Survey. New York City:Alcoholics Anonymous World Services Inc.; 2008.
Susan is a 31-year-old librarian who had her first drink when she was 11. She didn't go to parties in high school because she was extremely focused on getting into a good college. Susan went to her first party during her freshman year in college. She remembers that she had one beer and then experienced a blackout. After she graduated from college, she began to drink daily for a short while and feared that she was beginning to drink like her alcoholic father. Armed with this self-knowledge, she attempted to control her drinking, but failed. Susan attended graduate school, and her drinking binges began to occur “out of the blue” every few months. She successfully completed her master's degree and was immediately hired at a library. She maintained her job but continued to break her promises to herself about her drinking patterns.Addiction Professional 2009 March-April;7(2):26-29