Alcoholism is commonly used to refer to alcohol abuse and dependence. As research has continued into this very serious public health issue, a more comprehensive understanding has evolved, resulting in new terminology and diagnostic criteria.
Alcohol use disorder is a pattern of alcohol use that includes difficulties controlling drinking, a pre-occupation with alcohol, continuing to drink regardless of the consequences, building up a tolerance, continually needing to consume more, and withdrawal symptoms when use is sharply curbed.
Any use that puts health or safety at risk, or causes other problems related to alcohol, is unhealthy use. According to The National Institute on Alcohol Abuse and Alcoholism (NIAAA), heavy drinking involves consuming about eight alcoholic beverages per week for women, and fifteen for men. Anyone doing that on a regular basis has a drinking problem.
The Substance Abuse and Mental Health Services Administration (SAMHSA) defines binge drinking as reaching a blood alcohol concentration of 0.08 grams or higher, in a very short period of time. Typically, this would mean consuming four drinks for women, or five for men, in about two hours. Heavy use would be binge drinking on at least five days in the previous month.
This pattern of abuse is particularly dangerous because it can lead to alcohol poisoning and other acute health problems like liver disease, low blood pressure, and heart failure. The liver processes alcohol at the rate of about one drink per hour, and consuming more than that results in the body becoming intoxicated. This significantly increases the likelihood of risky behaviour and poor choices, which can lead to potentially fatal accidents or causing harm to others.
Alcohol use disorder can range from mild to severe, and it can cause significant problems with work, personal relationships, finances, and virtually every other aspect of daily living. Many individuals experience job loss, divorce, difficulties with neighbours, and involvement with law enforcement.
Often, it may seem that there are no issues, and that the person is actually doing quite well. Alcohol abusers are usually very adept at concealing their addiction, and they may be in denial themselves. They can appear normal and sober, and seem able to function in society while achieving great success.
Redefining Alcoholism – The Functioning Alcoholic
The functioning alcoholic defies the stereotype of a person who is destitute and homeless, having lost everything because of their drinking. They actually suffer from all of challenges associated with alcohol use disorder, and meet the criteria for diagnosis, while still appearing to be healthy and capable of leading stable lives.
These individuals are often able to hide their addiction from family members, and are in denial themselves. This makes getting them into an appropriate treatment program much more difficult, which puts them at greater risk.
Sarah Allen Benton, author of Understanding the High-Functioning Alcoholic, is a licenced Mental Health Counsellor, living and working in the United States. It was her own experiences with alcohol addiction, and her struggles to get help because of the preconceived understanding of what an alcoholic is, that inspired her to write the book, and to want to dispel the myth of the “typical alcoholic”.
Ms. Benton describes the high-functioning alcoholic (HFC) as someone who displays all of the behaviours associated with alcohol use disorder, and suffers the effects, while maintaining an outward appearance of being in control of every part of their life.
However, eventually the façade slips, and the abusive drinking results in serious issues. A charge for driving while impaired (DUI) is one of the direst of these, especially if a fatality is involved. Regularly engaging in excessive drinking can cause blackouts, risky sexual encounters, and damage to reputation. The impact on career and friendships is inevitable.
Recognizing a Functioning Alcoholic
High-functioning alcoholics make jokes about drinking, like so many well-known addicts. They also have challenges with relationships, and divorce is frequently a reality. An inability to maintain major responsibilities at work can result in damage to career, and difficulty obtaining and maintaining employment.
Other reasons for concern include legal problems, drinking alone or in the mornings, needing to consume alcoholic beverages to feel confident, repeatedly becoming intoxicated when not planning to, denial, and hiding the evidence of heavy drinking, making excuses for the drinking, and an extremely high tolerance to alcohol.
An absence of symptoms does not mean that there is not a serious problem, it may just mean that the addict is doing a very skillful job of concealing it, even from themselves.
Masters of Denial
The ability to ignore and mask all of the evidence of alcoholism, and to deny that there is any problem, to everyone in their lives, is the defining characteristic of a functional alcoholic, and it is what puts this individual at so much risk. They don’t realize the impact of their drinking on those around them, and because everything appears to be in control, they convince themselves there are no issues.
Because they are so skillful at creating the illusion of being a healthy, stable person, they are usually not the only ones in denial. Friends and family often don’t see the warning signs, or they refuse to believe that their loved one has a problem. They may even congratulate them on their ability to function while under the influence of alcohol.
Denial is also problematic because it facilitates tolerance and a deeper dependency. Light or moderate drinking on a regular basis will lead to a tolerance being built up in almost any user. More and more alcohol must then be consumed to achieve the previous level of intoxication. This means that even a social drinker will occasionally overindulge, but will be able to appreciate the ill effects, and not repeat the behaviour.
However, if this cycle of abusive drinking continues, the individual will develop a dependency. When this happens, the over-indulgence occurs on a regular basis, and eventually, there may be no ill effects at all. This intensifies the denial. Because the functional alcoholic has developed a physical tolerance to drinking large amounts of alcohol, he or she is able to manage all of the aspects of daily living, reinforcing the message that there is no problem.
Based on research findings, the Centres for Disease Control and Prevention (CDC) estimate that alcohol abuse can shorten life expectancy by up to 30 years, and results in 88,000 deaths per year in the United States. Regular and continued excessive drinking can be dangerous, and even fatal, if ignored and not treated.
Mental Illness and the Functioning Alcoholic
Alcohol use disorder is strongly linked in the research to mental illness. Drinking may be a way to temporarily relieve anxiety and depression symptoms. The National Institute on Drug Abuse (NIDA) reports that as many as one-third of alcohol abusers suffer from a mental health condition, and approximately one-quarter have suffered from a major-depressive illness at some point in their lives.
Often, the mental illness is undiagnosed, and the functioning alcoholic is unaware that they may be self-medicating with alcohol. Family likely do not know either. As long as the underlying or related cause of the addiction remains untreated, the addict will continue to engage in abusive drinking to manage the symptoms.
When two conditions occur together, like addiction and mental health disorders, they need to be treated simultaneously, in an integrated fashion, by a team of specialists. This generally includes medication, counselling, therapy, support groups, and a period of detoxification.
Because denial is such an issue with functional alcoholics, getting them and their families to admit that there is a problem may be very difficult, and this is often an impediment to seeking help. As a result, the disease is frequently allowed to progress untreated for many years, causing more health challenges and an ever-increasing risk of death.
The only way for an addict to adopt a sober lifestyle is for them to want to change their behaviour. If they are unwilling, there is no way to force them into recovery. Only a very few specific circumstances would allow that, legally. It is then essential for family members and friends to change the way they approach the individual who is struggling with substance abuse.
Unwittingly, the support system often enables the destructive behaviour in the person. The individuals in the addict’s life develop their own coping strategies for dealing with their loved one’s actions. They help conceal the drinking, and the fallout from it, in order to protect the functional alcoholic, who continues to maintain the illusion that everything is fine.
It is critical to stop facilitating the problem drinking in order to begin to break through the denial. Stepping in to cover for them, or making excuses, just gives them another reason not to get help. Allowing the individual to deal all with of the negative consequences, and full repercussions – letting them approach “rock bottom”- is often the only way to begin to break the cycle of drinking and alcoholic behaviour.
Another option is to have a personal intervention. It is important to plan this carefully, solicit assistance from friends and health care professionals, and to choose the time and location thoughtfully. A time when everyone is calm and sober will offer the best chance of success.
Those participating in the intervention should be honest with the addict, while maintaining compassion, about the effect that his or her drinking has had on everyone. It is important to share specific examples of incidents that were caused by alcohol consumption. Reassure the person that the intervention is happening out of concern.
The conversation should include what will happen if the individual is unwilling to curb their drinking and begin some type of treatment. Again, providing specifics about what will happen in terms of the relationships with family and friends is crucial. This may mean ending a friendship, cutting off all contact, or even divorce. Everyone must be prepared to follow through, or they are continuing to enable the addiction.
Intervention participants need to give the functioning alcoholic time to consider the full impact of what is being said, while reinforcing the message that there are consequences associated with choosing not to start recovery in some form.
Detox from alcohol can be life threatening, and should only be attempted in a medical facility, with supervised care. Withdrawal symptoms may include anxiety, shakiness, sweating, rapid heart rate, seizures, hallucinations and delirium tremens (DTs). They are generally more severe the longer, and more frequent, the problem drinking has occurred.
Stopping suddenly, or going “cold-turkey”, is very dangerous, and the effects can be very unpleasant, but they can be managed with medications by a health care professional. Detox is one part of the process, following which the individual will begin rehabilitation.
Rehab is a program designed specifically to meet the medical needs of the functional alcoholic. Group therapy, individual or family counselling, support group meetings, and medication may be included as part of a comprehensive treatment plan.
Therapy is designed to aid patients in analyzing the possible underlying causes for the addiction, and to identify triggers so that they can begin to develop better strategies for responding to stressors, increasing the probability of avoiding a relapse.
12-step programs, like Alcoholics Anonymous, were among the earliest interventions for this particular type of addiction. They provide a warm, welcoming, non-judgemental environment, and a self-help approach to recovery. For many functional alcoholics, AA, or similar organizations, may be a good compliment to therapy, particularly as part of the aftercare plan.
The level of dependency, the length of time abusing alcohol, and family and medical history, all determine the most effective treatment for the individual. If there is a strong support system in place, an outpatient program that involves attending counselling, therapy and educational sessions, while continuing to live at home, may be appropriate.
Alternatively, a more intensive program at an inpatient rehab centre may be indicated for others. In addition to the services provided to outpatients, these facilities may be better equipped to manage more severe detoxification, and they can provide a break from the stresses of everyday life. They also offer the emotional support that may be lacking from family and friends.
The Mask Slips – Finally
Many people suffering from a substance use disorder will make many excuses to justify any behaviour, and the functioning alcoholic is especially skilled at this. The first step toward recovery for these individuals is for their friends and family to hold them accountable for their actions. Otherwise, there is no reason for them to change.
High-functioning alcoholics have convinced themselves that their lives and loved ones are unaffected by their drinking. However, no matter how masterful they are at concealing their addiction, eventually the illusion will be shattered, and the toll on health, career, finances, and personal relationships will be undeniable.
The High Functioning Alcoholic Sarah Allen Benton, Psychology Today, Copyright 2019
NIAAA Spectrum – Alcohol and the Deaths of Despair National Institute on Alcohol Abuse and Alcoholism (NIAAA), Fall 2019
Alcohol Use Disorder Andre F. Carvalho, M.D., et al., The Lancet, August 31, 2019
Alcohol and Public Health Centres for Disease Control (CDC), Last Reviewed: June 10, 2019
Alcohol World Health Association (WHO), December 7, 2018
Understanding Alcohol Use Disorders and Their Treatment American Psychiatric Association (APA), Last Reviewed: September, 2018
Saving a “Lost Generation”: The Need to Prevent Drug and Alcohol Abuse in Midlife | NIDA Dr. Nora Volka, January 28, 2016
Picture credit: The New York Post – Brad Pitt And The New Alcoholism