Drug addict businessman in the office

Stereotypes regarding addictive behaviors are still quite prevalent. One of the very common stereotypes regarding addictive behaviors is the old notion of the “skid row” alcoholic or addict that many individuals who engage in significant substance abuse use as a comparison model to convince themselves that they do not have a problem. The other end of the spectrum consists of the notion of the functional alcoholic or high-functioning addict. To say that someone is “high-functioning” compared to “low-functioning” requires a subjective comparison of terms, and certainly, some individuals with substance use disorders are able to function better in their environments than others, but this does not mean that there is a specific type of addict that is high-functioning.

In fact, the very definition of being diagnosed with a substance use disorder (the current clinical term that describes both substance abuse and addictive behaviors) encompasses the notion that the individual is suffering from some form of significant distress or dysfunction as a result of their substance use (more on this below).

The notion of the high-functioning addict comes from earlier notions that all individuals with addictive behaviors inevitably progress into the stereotypical skid-row type; their inescapable cravings to use their drug of choice results in them losing their jobs, family, and other social contacts, and they are essentially homeless and destined to spend the majority of their time trying to find drugs or alcohol and engaging in substance abuse. Individuals who are deemed as high-functioning addicts do not fit this stereotype.

Signs of a High-Functioning Addict

Individuals with substance use disorders have different presentations and numerous levels of dysfunction, but having any type of substance use disorder automatically implies that there is some level of dysfunction; otherwise, the individual would not have a disorder. Sources like the book Understanding the High-Functioning Alcoholic tend to propagate the notion of a high-functioning addict, when in reality, these individuals are simply better at hiding their level of dysfunction than others.

Other sources, such as the book Understanding Why All Addicts Are Not Alike, help to raise awareness that individuals with substance use disorders do not represent a homogeneous group and that different levels of dysfunction occur within this group of individuals.

According to both of these sources, there are certain characteristics that are common to individuals who are labeled as high-functioning addicts.

  • They are often employed, have relatively good incomes and higher education levels, and are married or partnered. This presentation is at odds with the stereotypic notions of the skid-row addict that are still prevalent.
  • They have fair success at limiting their substance use to certain times or circumstances, which gives the illusion that they have control over their substance use.
  • They have fair success at concealing complications associated with their substance use.
  • When their substance use results in the neglect of personal responsibilities, they are somehow able to minimize the contribution of their substance use disorder to this situation.
  • They are very often able to get cooperation from family members or friends to cover for them (e.g., having a spouse call in sick for the person when they are too hungover to go to work).
  • They have convinced themselves and others that their substance use and any other issues they have are “normal” for them.
  • They often engage in isolation from others when they are using their substance of choice, such as not going to social or family activities, drinking while alone, etc.
  • They often have some co-occurring mental health disorder, but are able to convince themselves and others that this situation is “normal for them.”
  • As a result of many of these factors, these individuals are able to rationalize their use of drugs or alcohol.

In fact, when these individuals are scrutinized by competent mental health professionals, it becomes very clear that they have a significant issue with substance abuse and that their use of their substance of choice is resulting in significant distress and dysfunction for them, their family, and others who are important to them.

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Some Form of Corroboration Is a Key Factor in the Illusion of the High-Functioning Addict

High functioning addicts require some form of corroboration from others to maintain the misconception that their behavior is not dysfunctional. When individuals perceive this type of corroboration and are labeled as high-functioning addicts, their behaviors become normalized, and the illusion that the individual is in control of their situation in spite of serious issues is maintained. These individuals often need to maintain a sense of control over themselves and others in order to foster the impression that they are functioning within their normal limits. Like many individuals with substance use disorders, they are experts at manipulating other people.

Often, a term used to describe the types of relationships that occur when one individual is labeled as a high-functioning addict and the other person acts in a manner to propagate their addictive behavior is codependency. This is not a clinical term, but it is often used to describe a specific type of dysfunctional relationship where partners both feed off and into the pathology of the other. Codependency describes a situation where partners become enmeshed in the dysfunctional aspects of their relationship and tend to foster their partner’s level of malfunction in order to control one another and be able to predict how their interactions will play out over time. Interestingly, many of these so-called functional addicts often end up in treatment for relationship issues, legal issues, or issues that occur at work, and the nature of their addictive behavior is uncovered during the assessment or treatment phases.

Myths about Functional Addicts

Several myths associated with functional addicts tend to propagate this misrepresentation of addictive behavior. According to the book, To Relieve the Pain: Demystifying Addiction, these myths include:

  • Functional addicts do not have a problem. By definition, any individual who has met the diagnostic criteria for a substance use disorder (substance abuse and/or addiction) has a form of psychiatric disorder, psychological disorder, mental disorder, or mental illness (whichever term you prefer). Having a mental illness is obviously a problem for the individual.

  • People who are high-functioning addicts do not display the symptoms of addiction. This is a contradiction of terms. Anyone who is an “addict” must display some symptoms of addiction. Displaying some symptoms of addiction is equivalent to displaying symptoms of a psychiatric disorder, psychological disorder, etc.

  • High-functioning addicts are in control of their addiction. By definition, people engaging in addictive behaviors have a significant loss of control associated with their use of drugs or alcohol; otherwise, they would not be engaging in addictive behaviors.

  • High-functioning addicts do not need treatment. By definition, anyone with any type of psychiatric/psychological disorder requires some intervention. Anyone deemed addicted to drugs or alcohol has displayed significant dysfunction, distress, and issues controlling their use of drugs or alcohol, and needs assistance.

The bottom line here is that so-called functional addicts are able to hide many of the dysfunctional aspects of their behavior from others, get corroboration from others to help them engage in their addictive behaviors, invest significant energy to put forth the impression that their situation is “normal” for them, and minimize the effect of their substance use on important areas of life.

Definitions of Addiction

Definitions of substance use disorders (substance abuse and addiction) automatically infer the presence of distress and dysfunctional behaviors. Some of the major organizations that describe addictive behaviors include these in their description of addictive behaviors.

  • The diagnostic criteria for substance use disorders are provided by the American Psychiatric Association (APA) in the United States. APA specifically states that substance use disorders must result in significant clinical distress or impairment in the individual’s functioning in order for them to be formally diagnosed.
  • The National Institute of Health (NIH), which encompasses organizations such as the National Institute on Drug Abuse (NIDA), defines addictive behaviors as chronic, relapsing brain diseases that involve compulsive drug-seeking, compulsive drug use and abuse, and continued seeking and using of drugs despite experiencing harmful consequences associated with the individual’s drug use.
  • The American Society of Addiction Medicine (ASAM) is the largest body of physicians who treat addictive behaviors in the United States. This organization defines an addiction as an inability to consistently abstain from using the drug of choice, powerful cravings for the drug of choice, a significant impairment in controlling use of the drug of choice, significantly diminished ability to recognize significant problems with drug use, and dysfunctional interpersonal relationships and emotional responses as a result of drug use.

There is no major organization in the United States that is involved in the research, diagnosis, and treatment of substance use disorders that does not include the notion of some level of dysfunction, impairment, and distress in its diagnosis of addictive behavior. Individuals who are deemed high-functioning addicts are simply individuals who conceal their level of dysfunction from others and are able to maintain the impression that their behavior is not problematic for them, but would be problematic if any other person displayed it. This is actually part of their pathology.

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Diagnosis and Treatment

There is no diagnostic category for “functional addicts.” Again, individuals who might be labeled as high-functioning addicts are actually addicts who have been able to hide and minimize the level of dysfunction associated with their substance use. There is no such thing as a single presentation of an individual with a substance use disorder. Instead, individuals display different levels of severity associated with their substance abuse, but at every level, there is must be some manifestation of dysfunction and distress or the individual would not have a formal mental health disorder.

In order to recognize an individual who might be labeled as a high-functioning addict, look for the following signs:

  • The individual has a specific routine regarding their use of their substance of choice, such as only drinking at specific times or in specific contexts.
  • The person appears to have a fairly stable living condition, but there are numerous instances, such as absences at work, domestic quarrels, financial issues that are often covered up by the individual’s partner, etc., that suggest there might be a significant problem.
  • Both the individual and close family members insist that the person’s substance use is “normal” for them, even though in other contexts, they may admit it would be a problem for someone else.
  • The individual may have numerous unsuccessful attempts to cut down on their level of substance use, express anger or strong reactions when someone mentions that their substance use might be dysfunctional, may at times feel guilty about their substance use, and/or may often use alcohol or drugs early in the day as a method to start their day. Any one of these signs is suggestive that the person may have a problem with a substance use disorder.

Attempts to coax these individuals into treatment for substance abuse are often met with resistance by both the individual and their family. Instead, it may be more fruitful to attempt to coax the individual and family members into treatment for family-related issues, such as domestic quarrels, legal issues that may have occurred as a result of the individual’s abuse, or financial issues related to the substance abuse. Trained mental health clinicians will often recognize the contribution of substance abuse to the individual situation. Once the person is in treatment, providers should ascertain the individual’s level of awareness regarding their substance use.

Following a paradigm such as the Motivational Interviewing paradigm, that takes into account the individual’s understanding of their behavior and their desire to change their behavior, can be a useful starting point. This often results in significant psychoeducation in the early stages of treatment to allow the individual to observe aspects of their dysfunctional behavior and how it controls them. Over time, individuals can then transition to more standard treatment approaches once they begin to understand that their substance use is dysfunctional and they need help.

Keeping the individual involved in family therapy and group therapy, including social support groups, can be extremely productive. Confrontational approaches will initially have limited success, but over time, they may be used to spur the individual to change their behavior once their level of awareness regarding the dysfunctional aspects of their behavior becomes apparent to them.

Because these individuals often strive to be in control of all aspects of their life, this can be used to the advantage of the treatment; however, it is also important for the individual to be completely honest regarding their substance use in order for treatment to be successful. This level of honesty is often dependent on having a positive relationship with one’s therapist, peers in recovery, and family members.

The use of the therapeutic alliance (the relationship between the therapist and the client) is a powerful tool to motivate change. Therapists should endeavor to engage the trust of the individual, try to understand the situation from the client’s point of view, and always express positive regard for the client. This results in a working bond between the therapist and client that can overcome numerous obstacles to lead to success.