Treating the high-functioning alcoholic

March 1, 2009
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These individuals' ability to maintain their lives makes the clinician's challenge tougher



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:

  1. 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.

  2. An individual obsesses about the next time he or she will be able to drink alcohol.

  3. 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.

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