Counseling Today, Features

Hidden in plain sight

Jenny Christenson March 14, 2009

According to a 2007 study by Howard B. Moss, Chiung M. Chen and Hsiao-ye Yi that appeared in the journal Drug and Alcohol Dependence, less than 10 percent of the 18 million alcoholics living in the United States fit the “falling down drunk” stereotype. In fact, says Sarah Allen Benton, a mental health counselor in a counseling center at a college in Boston, the majority of alcoholics go to work every day, hold highly responsible and visible positions — including as teachers, lawyers and doctors — and have families.

“A high-functioning alcoholic (HFA) is an alcoholic who is able to maintain his or her outside life, such as a job, home, family and friendships, all while drinking alcoholically,” explains Benton, the author of the new book Understanding the High-Functioning Alcoholic: Professional Views and Personal Insights. But those outward evidences of success come with a high price. Because HFAs are often overachievers, society doesn’t necessarily view them as being “true” alcoholics and, as a result, they are at higher risk of not getting the help they genuinely need. Another reason HFAs don’t “get caught” or identified as alcoholics, Benton says, is because they tend to live very compartmentalized lives. “The people they drink with are different from those they work with and from their family,” she says, adding that HFAs often live the drinking portion of their life outside of what they consider their life morals to be.

Regardless of outside appearances, Benton says, internally, HFAs are suffering, and the consequences of their alcoholism are all too real.

Kelly Aissen, a substance abuse therapist at Shands Vista Florida Recovery Center, agrees. “Examples of the internal consequences that can go on for decades include, but are not limited to, the inability to communicate well, low self-esteem, inability to reach potential and comorbid depression and/or anxiety,” says Aissen, a member of the American Counseling Association. “Many people with active addictions are sensitive and are suffering internally even as their families and associates remain unaware of the severity of their addictions.”

HFA characteristics

Benton says HFAs possess specific personality traits that allow them to pursue other endeavors even while drinking. These characteristics include the drive to succeed externally, motivated in part by an internal belief that if they are successful professionally, it proves that they are not alcoholics. In fact, Benton says, HFAs often rationalize along the lines of, “If my drinking is such a problem, why is my career going so well?” Another common characteristic exhibited by HFAs is an almost obsessive focus on getting tasks done. “A lot of these traits can be part of a family’s culture, passed down through a family,” says Benton, who leads an alcohol skills training program that helps college-age problem drinkers. “It’s sort of like the perfect storm: Genetics and certain personality characteristics must all come together to consider a person an HFA.”

Because of their personal achievements, HFAs are often in denial that they have a problem requiring treatment, Benton says. Colleagues and loved ones are also less likely to recognize the role that alcohol is playing in an HFA’s struggles. When HFAs do seek help, Benton says, “They oftentimes will not come into counseling for anything to do with alcohol. Instead, they’re coming in because they are having marital problems or problems with work or school. There’s not a whole lot of leverage people can use against HFAs for intervention initially because they are holding things together.” Only over time do many HFAs start to see a connection between their drinking and other problem areas in their life, she says.

HFAs often “slide through the cracks of the health care system,” Benton says, because they are not always diagnosable under the criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders. For example, she says, alcohol withdrawal is one component of the diagnosis for alcohol dependence. “Many HFAs are neither daily drinkers nor physically addicted to alcohol,” she says, “but are instead psychologically addicted to alcohol and, therefore, do not fit the diagnostic criteria.”

Benton believes it is more accurate to diagnose an HFA according to the guidelines provided by the Alcoholics Anonymous book Alcoholics Anonymous (commonly referred to as the Big Book.) As described by Benton, the diagnostic criteria have three parts:

  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 he or she consciously no longer wants to.

Working with HFAs

Working with HFAs can also be different from working with other alcoholics, Benton says. For example, she says, the outlooks of the two groups may vary dramatically. Those who fit the stereotype for alcoholics are more likely to have already hit rock bottom, to have lost a great deal in their lives and to feel a sense of desperation, Benton says. As a result, they are typically more open to participating in recovery programs. HFAs, on the other hand, are experiencing success in other areas of their life, “So when someone says, ’Your way isn’t working,’ they are resistant to that,” Benton says. “A counselor has to peel away the layers of the person to the point where they are open to change.”

For HFAs, the potential repercussions of continuing their lifestyle are many. Their work performance eventually may begin to suffer, and they may start experiencing difficulties in their relationships, says Jack Culbreth, an associate professor of counseling at the University of North Carolina at Charlotte and the International Association of Addictions and Offender Counselors representative to the ACA Governing Council.

“The brain, cognition and memory are also affected by drinking,” says Benton. While their overachieving personas may enable them to continue doing just enough to get by, she says, HFAs often experience “blackouts” after drinking, during which time they walk around and do things they have no recollection of later, including driving drunk or breaking other laws. Because of their connections, social status or appearance, HFAs are often treated more leniently than other alcoholics under those circumstances, Benton says.

Counselors can choose from a variety of techniques when treating HFAs. Many times, Benton says, HFAs come into a counselor’s office believing they can control their drinking. In these cases, she says, presenting them with moderation goals is sometimes helpful. “See if they can maintain adherence to goals that they keep records of. Maybe even set up a contract with them,” she says. “HFAs like this type of challenge.” Benton adds that it takes a willingness to explore the HFA’s life — particularly his or her “drinking life” — to open up the therapeutic relationship. “It’s really important to have clients get honest with themselves in a nonjudgmental way,” she says. “Develop rapport, because it is a collaborative effort to get control of their drinking.”

Culbreth recommends that counselors use a technique called motivational interviewing to address “where the client wants to go and what their goals are. Motivational interviewing is relatively new, having been developed in the past 10 to 15 years. It basically says rather than forcing clients to accept whatever you proclaim is the problem and treatment, the counselor tries to align with the clients and understand what they want to do. In a session, you can get them to acknowledge there is some sort of a problem going on. They might not say they are an alcoholic, but they may say they’ve had difficulty with drinking and say they want to do something about it to make other parts of their life better. So you work from that angle.”

Aissen says counselors can “help break the denial clients experience by helping them look at their internal consequences. How has alcoholism affected family and working relationships or their relationships with themselves? Allow for a safe place to acknowledge and experience any guilt and shame they may have around their addiction. Surrendering themselves to this disease provides room to heal and to be in recovery. Clients, through the surrender process, realize their addiction is not something they can make go away, even though they’ve often succeeded in many other ways.”

One of the major challenges in counseling HFAs is removing the illusion of control that they have, says Aissen. This illusion can cause HFAs to suffer unnecessarily — sometime for decades — before seeking help, she adds. HFAs also have certain enabling factors that other addicts may not have, such as financial stability, family support, low levels of accountability or unstructured work environments. “People without financial concerns can afford their alcohol, therefore providing another justification for it not being problematic,” she says. And while having family support can be a very positive thing, for HFAs, it often comes in the form of people who are willing to cover up for them or otherwise excuse their behavior. Aissen stresses the importance of educating clients, their friends and family members to the fact that the HFA lifestyle isn’t an indication that they are somehow “healthier” than other addicts or alcoholics; it simply means they are at greater risk of suffering with the disease of alcoholism longer.

Recovery programs

Benton is a proponent of the 12-step recovery program for HFAs. “Based on my research and interviews for my book, the 12-step model has been found to help the most individuals recover,” she says. “Part of its effectiveness is that it really promotes change. It promotes having some type of spiritual awakening, and that in itself is a change. It can be seeing the world just a little bit differently, and that can mean behaving differently than you did when you were an alcoholic. If you don’t change the person you were when you were drinking, then you won’t stop drinking.” Benton, herself an HFA who has been in recovery for five years, says she found the 12-step program to be a personally transformative and healing experience. She has created a website ( detailing her professional and personal insights to assist HFAs.

Benton says the spiritual aspect of 12-step programs is especially important because spirituality can be instrumental in recovery from both medical and psychological conditions.

At the same time, Aissen says, many people have a misconception that 12-step programs are religious in nature. “Persons of all faiths, or not ascribing to any faith, can benefit from 12-step programs,” she says.

Adds Culbreth, “The 12-step program by itself is not generally considered a theory or model of treatment. It is a system of support for people that have an addiction. What I want to do as a professional is to help every client to get better. And it may be that 12-step programs are a way to do this, along with counseling. But it doesn’t necessarily take the place of counseling.”

Benton, who did a practicum at the Benson/Henry Institute for Mind/Body Medicine and has attended multiple professional trainings there, is also an advocate of using meditation exercises with HFAs. “Dr. Herbert Benson was a leader in the field of mind-body awareness,” she says. “He advocated the power of meditation in healing not just addictions, but in healing chronic medical conditions.”

Other recovery programs for alcoholism include Smart Recovery, an abstinence-based program that features cognitive behavioral therapy work. “The idea is that you graduate, and then you go back for tune-ups,” Benton says. There are also moderation programs, which seek to help clients control, rather than abstain from, drinking. Benton says approximately one-third of the people who go into moderation programs realize they are alcoholics and end up entering an abstinence program. Another program is called Women for Sobriety, founded by Jean Kirkpatrick, who saw a need for a recovery program aimed more exclusively at females. A program that clients do on their own, without having support group meetings, is called Rational Recovery. To increase the likelihood of successful recovery, Benton believes HFA clients should be in a recovery program of their choice while simultaneously participating in therapy.

Overall, Culbreth says, the prognosis for recovery is excellent for HFAs if they follow the 12-step program. However, he cautions, “The reality is that this is a very difficult program, and even those who follow the 12-step program are at risk for relapse. But if the HFA can get past their obsession with professional success, they have the opportunity for success over alcoholism as much as anyone else. Their opportunity for success may be even higher because they haven’t lost everything.”
Jenny Christenson is a former staff writer for Counseling Today.

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