Social drinkers, problem drinkers, and high-functioning alcoholics

I know nothing about anything other than AA.  And I know next to nothing about AA.  So psychiatrists, doctors, med students with a clue, people who have ever had a drink in their lives, whoever – please explain.

Yesterday I finished reading Drinking: A Love Story.  The author said that reading A Drinking Life by Pete Hamill was a major factor in her sobriety, so I bought and read that book last night.

I just finished the last chapter, and am sitting in bed with the cat, thinking about it.

Both authors talk about how muddled the line is between a “problem drinker” and an “alcoholic” – and both had convinced themselves that because they were achieving and maintaining successful careers, they couldn’t possibly be the latter – even though they knew they drank more than most people.

Both authors define themselves as “high-functioning alcoholics” and admit it’s a troubling category.

I agree, it’s troubling.  The DSM doesn’t currently recognize “alcoholism” as being a thing – just Alcohol Dependence and Alcohol Abuse, which is – to put it mildly – completely confusing.  Alcoholism itself doesn’t fit neatly into either category.

But alcoholism, at least, can be shoved into one of those umbrellas – as long as you acknowledge that the patient has genuine social or work problems as a result of their alcohol abuse.

But high-functioning alcoholics don’t.  So what do you call that?  They’re still dependent on the alcohol, and that’s still extraordinarily dangerous.

So how do you draw the line between being a social drinker, a problem drinker, and a high-functioning alcoholic?  

Here’s why I think that’s an important question, and not just a word game:  All of the psychiatrists I’ve talked to about this have said that recovery doesn’t necessarily mean abstinence. Abstinence isn’t even included in the new SAMHSA definition of recovery.

I’m guessing that has more to do with methadone treatment for heroin addiction than it has to do with alcoholics eventually drinking moderately – but the possibility is there.  Moderation Management seems to have been accepted as a legitimate form of cognitive-behavioral therapy, albeit one that doesn’t seem to work in the most severe alcohol abusers.

Is alcoholism so ingrained in genetics and environment that an alcoholic should never have had their 1st drink to begin with?  Or is there a straight line of progression in alcoholism, from “social drinker” to “problem drinker”?  Is “high-functioning alcoholic” a step along the way, or an end-point alternative to true alcoholism for some people?

And if it is a straight line of progression, is it possible to intervene with a Moderation strategy before they hit the alcoholic state?

If so, shouldn’t this be the sort of thing we’re billing to problem drinkers?  “If you keep on the way you are, you may have to go into AA and never drink again.  Sound scary as hell?  Maybe you should learn strategies to cut back now to avoid it, then.  Here’s a pamphlet, here’s a website, here’s a Moderation hotline.”

Seems like it’d be easier to get someone to agree to that then to agree to abstinence.  But would that just inevitably be a speed bump on their way to complete abstinence or death?

The founder of Moderation Management ended up joining AA, relapsing, and killing two people in a drunk driving accident.

Where’s the line, and – in light of the above example – is it worth finding?

14 thoughts on “Social drinkers, problem drinkers, and high-functioning alcoholics

  1. Like much of psychiatry, I think it depends on the person and their reasons for drinking…

    I had a friend in high school who became an alcoholic because he thought drinking made him cool, then starting doing cocaine, lost his license, still kept drinking, finally completely quit drinking and was doing really well for about a year, then was convinced by a “friend” to have “just one drink,” ended up getting wasted, doing coke, and getting arrested (for having the cocaine on him, not for hurting anyone else). So, that friend should definitely not ever drink again ever.

    I have another friend who is currently drinking too much, who I think could do the moderation thing. I believe she drinks mostly when she is unhappy. So when she’s around her family she drinks way too much. And right now she’s living in a small town with only one friend, so she’s drinking too much. But when she’s around good friends and her few good family members, she doesn’t drink as much.

    So yeah, I wrote a lot… I think about this a lot.. I know a whole lot of alcoholics for someone who hardly ever drinks…

  2. That book sounds really interesting. I just downloaded it to my kindle. I really have no idea what the answer is to your question but it’s an interesting one. The only patients of mine who were alcoholics were most definitely not the high functioning type. I think for most addicts of any kind moderation isn’t really an option- it’s kind of a gateway. Maybe if you identified the patients who were drinking a lot but weren’t yet physically or psychologically dependent on alcohol and steered them in the right direction you could curb it.

  3. Alcohol abuse is a problem in and of itself. The problem with ambivalence toward high functioning alcoholics is that alcohol abuse doesn’t exist within a vacuum. Let’s face it: drunks are dickheads. Their personalities are warped and their behavior is dysfunctional at best. I know too many alcoholics who are unwilling to face their alcohol abuse, and even more unwilling to change their dysfunctional behavior and thinking, because as long as they’re able to show up for work and maintain even a negligibly satisfying personal life, they’re not interested or willing to give up the drink. They carry on for years and years until the disease eventually progresses and they crash their cars, get arrested, or lose their jobs and their high functioning status is no more. In the meantime, they stay dickheads who claim they don’t have a problem.

    When it comes to problem drinking, I invariably suggest more drinking – drink every drink you can get your hands on. There’s an old saying that goes like this: the man takes a drink, the drink takes a drink, the drink takes the man. In my experience, I’ve never seen it work any other way. Not once. Real, meaningful recovery from alcoholism comes only after the alcoholic has tried his own willpower and truly has failed. Only then can they find themselves in a state of adequate willingness to recover. “It finally beat us into a state of reasonableness.”

    I think what’s causing your confusion is a real stinker of a paradox: recovery isn’t possible until drinking is a problem that has exhausted every humanly solution; except your job as a professional is to intervene and try to arrest the disease process before the situation becomes desperate and unsolvable.

    Some problem drinkers go on to moderate, if their circumstances become uncomfortable enough to motivate them to do so. In my experience, most progress to true alcoholism over many, many years. By the time they have an interest in moderating or quitting, they have lost the power to do so, and drink out of sheer compulsion.

    At some point in your career, I hope you have time to read the Big Book of AA. It’s antiquated, it’s packed with some really queer language and ridiculous ideas about allergy and the phenomenon of craving (very scientific terms for the 1930s, when it was written), and it’s chock full of cultish nondenominational Christian hype. But the personal stories and the first few chapters are still relevant, and they will surely help you sort through the different degrees and stages of the disease. At the minimum, the book’s description of warped alcoholic thinking is uniquely accurate.

    • Oops. I forgot to say that I’m not an abstinence nazi. I’m totally not. I’ve just been up to my ears in dickhead drunks for the past 10+ years, and they’re very predictable.

    • I totally agree with your ideas. After fourteen years of marriage to a problem drinker I had enough and walked out. He, and his family would never admit that he has a drinking problem or god forbid , that he is an alcoholic because to most people an alcoholic is a person that drink every day and hides the bottles in the toilet tank!

  4. What about food addiction? As someone who has struggled with food issues, there are days when I really wish I didn’t have to eat to survive. It would be much easier to avoid food altogether.

    • You know, I hear the same thing from people with eating disorders. It’s so tough, since abstinence isn’t an option in either case.

      I don’t have an eating disorder, but some people would argue that I had disordered eating in my past – and I find that it’s hard to ever completely get rid of that mindset. How can you? Food’s a necessity, not an option.

      I hear you.

  5. Europe does moderation, not abstinence and I believe their issues with alcohol exceed ours (I think data supports that, but I could be wrong). Having dealt with alcoholics as a lay person, high functioning ones…

    Yes their life is impacted, they just don’t want to see it. They do hurt people in their lives. For them not to would mean they are perfect, which is impossible. There is a psychology there that enables their behavior. Excuses are a huge red flag and the idea that ‘nothing bad happened’ is just an excuse. I bet, if you dig, you’d find a lot that happened.

    It’s true high functioning alcoholics hide better and go longer, but they are still alcoholics.They aren’t as special as they’d like to believe.

    I would not trust any alcoholic who identifies as such, but claims everything was fine and nothing bad happened. Huge huge red flag. I know that alcoholic. Took them 10 years to take recovery seriously.

    This forum might be a good place for you to hang out and read further:

  6. I think an alcoholic or anybody that drinks alcohol with abuse patterns should sustain completely from alcohol. PERIOD. I live with an alcoholic who works hard everyday to remain sober. He wasn’t given a choice (trouble with the law) — but it still would be difficult if he were drinking in moderation.

  7. My uncle had a PhD from an Ivy League school and worked in a position of heavy responsibility during his a long, successful career. He was also an alcoholic, although I never saw him angry, abusive, manipulative, or “drunk”; OTC, he was intelligent, well-read, witty, charming and a welcoming host. He always had a drink in his hand, though. My uncle died relatively young as a result of liver failure, because he wouldn’t, or couldn’t, quit drinking. We all miss him.

    When I think of a high-functioning alcoholic, I think of my uncle.

  8. I’ve wondered myself about the distinction between problem drinking and alcoholism. Social drinking doesn’t seem as difficult to define: one or two drinks only in occasional situations when the goal of the socializing does not have anything to do with drinking (ie it’s not social drinking if you’re attending parties for the purpose of drinking).

    When I was 18, a friend introduced me to California Coolers. Yum. Life no longer sucked quite so much. Being under age, I couldn’t buy alcohol on my own. I’d walk into the student union building, find a table full of older guys, and offer to pay for a 6-pack of beer for whoever would go to the 7-11 with me and buy me my CC’s. Before long there were a couple guys who would come find me and ask if I wanted them to go to the store. One day one of them asked if I’d tried Southern Comfort in OJ, and off we went to the liquor store.

    When I left the house every morning, I’d take a huge travel mug full of orange juice with me – and spike it when I got in the car. I’d drink my OJ while driving to school. Friends in my 7am calculus class thought that was too early to be drinking, and too frequent to be acceptable. People can have one drink every evening and it’s considered normal. Have one drink every morning, and it’s viewed very differently.

    Summer arrived, and with no classes, I had nobody to buy my alcohol for me. I had to quit, and found it a lot more difficult than I’d expected. It had only been one quarter drinking occasionally, and another quarter having one or two drinks five days a week, never drunk, but it was hard to quit. Around that time I became interested in genealogy, and discovered that my great-grandfather had been an alcoholic, as were his mother and aunt. One of them died when she fell down the stairs drunk and drown in her own vomit. I decided that with that kind of heredity, it would be better to avoid alcohol.

    A few years later, after I’d turned 21 and could drink legally, I would occasionally have a social drink. I learned that always led to wanting another one the next day, and the next. I was better off with abstinence.

    Away from student life and out in the real world, I would have one social drink at the company Christmas party every year. Finally I realized how stupid it was to drink just because I was expected to. Adults should be past teen peer pressure. All those people thought I was a social drinker because of how they’d seen me behave. They didn’t realize that they saw me nursing the only drink I drank all year, so I stopped. Every bar carries cranberry and orange juice, and I can drink those in social situations without making a big production out of it. I have a good life, and alcohol isn’t necessary.

    I don’t know if it really matters where the line is between problem drinking and alcoholism. If a person is attempting to justify that their alcohol consumption “isn’t that bad,” then it IS that bad. They can try moderation (which needs to be defined). If that’s too much temptation, then abstinence is better.

  9. My only experience with alcoholism in its true definition is one of my very close friends. The worst part was that in the 3 years we had been friends I never knew. She was very high functioning for a long time but then aspects of her life began to unravel and we found out all of her secrets she had been hiding for so long. Now, I barely see her and she is trying to find a new environment while she gets sober. I miss her a lot and wonder if it might have been different if we all knew what was going on years ago.

    On a related note, numerous friends of mine have decided to just stop drinking all together. Not because of true alcoholism but just to see how they felt without it in their lives. A lot of us use it a social lubricant and it is interesting to see how we must adapt without alcohol in situations where we normally would use it. My husband and I have decided to stop drinking for our New Years resolution to see what it is like without social alcohol. It should be interesting and I hope to learn more about myself.

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