We suggest you first read “How to Recognize a High-Functioning Alcoholic” to help you eliminate any denial or soft-pedaling by family members. The high-functioning alcoholic can be one of the most difficult to do an intervention on because denial is so strong.

Families often proceed with an alcohol intervention when the alcoholic has really done significant damage, such as been arrest for DUIs, ended up in the hospital, been in a car wreck, or has completely ruined their financial, professional, and family lives.

It’s different with the high-functioning alcoholic.

This person is often at the top of their profession, making good money, and managing to keep all those balls in the air despite their heavy drinking. They can be some of the toughest interventions because they will challenge you thus: If I’m such an alcoholic, why am I so successful at work?

A professional alcohol intervention is absolutely critical in getting any high-functioning alcoholic to see that he or she needs help. The professional interventionist will be very experienced in getting past this powerful denial. They will know exactly how to best get across the point that just because you’ve been getting away with it, doesn’t mean it’s not a problem.

An alcohol intervention is essential if the high-functioning alcohol you love is in a profession where impaired judgment can truly harm others – such as a doctor who could harm a patient, an attorney who could seriously undermine a legal case for a client, or a high-level executive who could make decisions that threaten jobs and livelihoods.

The high-functioning alcoholic is not as invulnerable to criticism as you might think at first glance. The professional interventionist will do a thorough pre-intervention and will likely come up with many ways to overcome denial. Certainly if you see a problem that is big enough to warrant looking into an intervention, it has more than likely been a problem for a while. Consequences might not be devastating yet, because the HFA often has the money and the power to hide behavior or make the consequences “go away.” But consequences do eventually pile up for everyone.

Typically the cracks in the armor begin appearing when the alcoholic begins to harm family members. Maybe he gets arrested for drunk driver or embarrasses himself at a work event; maybe she makes poor choices while intoxicated, such as an affair; maybe he develops some health problems such as stomach or liver problems. While the HFA can hide the problem at work, the spouse usually gets the brunt of the bad behavior, and divorce is often one of the signs that the behavior is out of control.

The best way to do an alcohol intervention on a high-functioning alcoholic is to hire a very successful interventionist who has a long history of doing difficult or high-end (such as celebrity) interventions. They will understand the denial, the ego, and the obstacles that can undermine an intervention.

Both programs address the challenges problem drinkers face, including environmental drinking cues and problems with motivation for replacing drinking with healthy activities such as a hobby or exercise.

The study’s lead author, Professor Miles Cox, said the results were very encouraging and show that people can curb their drinking habits with these two simple programs.

Both programs were found to significantly decrease weekly alcohol consumption and alcohol-related problems; increase participants’ confidence in avoiding drinking in risky environments; and increase drinkers’ motivation to curb their drinking habits.

The study, funded by the Economic and Social Research Council (ESRC) could change the way physicians treat people with alcohol problems.

Source: Bangor University, A LEAP Forward in Addiction Awareness and Control, July 30, 2010

Charles J. Neighbors recently led a group of researchers in examining the cost-effectiveness of different types of intervention for youth that enter emergency departments for alcohol-related injuries.

The study was initiated because interventions in the emergency department have been shown to be effective in preventing future youth alcohol involvement, and to reduce future alcohol-related injury. The study modeled the cost-effectiveness of different types of intervention.

The study looked at the cost-effectiveness of a motivational interviewing-based intervention relative to standard card. Standard care is considered offered when brief advice is given to the youth to stop alcohol-related risk behaviors.

The study compared average cost-effectiveness ratios between the two types of interventions. A cost-utility analysis was also completed to look at the incremental cost of motivational interviewing per quality-adjusted life year gained.

The researchers used microcosting methods to estimate the marginal costs of the two types of intervention (motivational interviewing and standard care) in addition to two methods of patient screening: standard questioning by emergency department personnel and a more proactive outreach by counseling staff.

The researchers investigated average cost-effectiveness rations for drinking and driving, injuries, vehicular citations and negative social consequences. The estimates of marginal effect of motivational interviewing in reducing drinking and driving, traffic fatality risk from drinking and driving youth, and national life tables were used to find the societal costs saved per year by motivational interviewing.

These results were compared with those found for standard care. The researchers used national databases to approximate alcohol-attributable traffic fatality risks.

The study found that invention costs per participant were $81 for standard care, $170 for motivational interviewing with standard screening, and $173 for motivational interviewing with proactive screening.

The researchers found that the cost-effectiveness was better for motivational interviewing than standard care across all study outcomes, and that cost-effectiveness was better for men than women.

The results of the study indicate that the benefit of using brief intervention was a good societal investment. The societal cost per quality-adjusted life year of using motivational interviewing was $8,795. The cost of adopting brief intervention was a better investment than the other options available to emergency departments.
 

The qualities of a "teachable moment" are complicated, said Emily C. Williams, research project director at the VA Puget Sound Health Care System and corresponding author for the study. "On one hand, it may be the first time that a patient realizes that their drinking is responsible for a very serious illness or event requiring acute hospital care," she said. "On the other hand, there are people who continue to drink heavily despite knowing the consequences associated with it. For the former group, hospitalization may serve as a strong impetus of change whereas, for the latter group, hospitalization may be met with a neutral attitude (or worse) toward change."

This is an important issue to address because of the large number of patients and substantial healthcare resources that are involved, added Daniel Kivlahan, director of the Center of Excellence in Substance Abuse Treatment and Education at the VA Puget Sound Health Care System, and associate professor in the department of psychiatry and behavioral sciences at the University of Washington.

"Most providers in inpatient medical settings will see patients similar to those sampled for this study, and we need more evidence about better ways to recognize and address the clinical needs of this diverse group of patients," said Kivlahan. "Hospitalizations need to be considered part of the continuum of integrated healthcare with implications for post-hospital follow-up, rather than isolated events."

Researchers recruited 341 adult medical inpatients from a university medical center (242 men, 99 women) — who self-reported "risky drinking" during the previous month — based on their initial hospital screening. Participants were then enrolled in a randomized trial of brief alcohol counseling, and interviews were conducted at enrollment as well as three months after hospitalization. Information on five measures of physical health was gathered, and compared to two outcomes: abstinence and number of heavy drinking days three months later.

"We found that among inpatients with unhealthy alcohol use whose drinking is less severe — those not dependent on alcohol and those reporting low levels of problem perception — alcohol-attributable illness may serve as a strong catalyst of changes in drinking," said Williams. "As such, alcohol-attributable illnesses could become a focus of hospital-based brief counseling interventions.

"This study provides an important alert to providers that they should not assume that patients recognize a link between their alcohol use and their alcohol-related medical diagnoses," said Kivlahan. "Although most patients may be aware of this link that is typically obvious to providers, a small subset of patients may benefit from having it addressed directly during the hospitalization."

Both Williams and Kivlahan noted the relevance of these findings for helping providers recognize a need for conversation about ways to improve hospital-based brief interventions for patients with unhealthy alcohol use.

"This study offers suggestions regarding the content of hospital-based brief interventions," said Williams. "If physical health is important to the patient, and they see the connection between physical health and their drinking, counseling interventions that make sure to include covering such topics could make the interventions more effective. Also, if the patient links his/her drinking with his/her physical health, they may be willing to follow-up with care in settings where medical and alcohol care are integrated, which could lead to improved outcomes."

"For clinicians, it is worth noting that most of these patients at risk due to unhealthy alcohol use did not have alcohol-attributable medical diagnoses, and only 15 percent had such a diagnosis listed as the primary reason for admission," said Kivlahan.

"Further, even though more than one in five reported abstinence at a three-month follow-up, this was not reliably associated with self-reported worse health after other explanatory variables were considered. Thus, we can see that medical hospitalization is not a sufficient factor to eliminate heavy drinking for many patients. We need to replicate these results under circumstances more similar to clinical practice and with larger samples in the subgroups of interest."

A comparison of the effects of two interventions on DWI recidivists with alcohol problems found that one—Brief Motivational Interviewing (BMI)—was more effective. Results will be published in the February 2010 issue of Alcoholism: Clinical & Experimental Research.

"Traffic crashes contribute more to morbidity in teenagers and young adults than any other cause, and DWI contributes to about a third of the overall toll," explained Thomas G. Brown, assistant professor in the department of psychiatry at McGill University and principal investigator for the study.

"In dollar terms on a yearly basis, total estimated loss due to DWI is estimated at five percent of the gross national product of Canada. This is a staggering figure, associated with a huge amount of personal suffering and loss, and is all the more tragic given that DWI is preventable,” Brown said.

Sandra C. Lapham, senior scientist and director of the Behavioral Health Research Center of the Southwest in Albuquerque, New Mexico, said the problem is equally huge in the United States.

"Approximately 1.5 million people are arrested in the U.S. each year for this crime," she said. "About one in three to one in five convicted offenders will repeat the offense, and repeat offenders are more likely than other drivers to cause alcohol-related crashes."

"While probably the majority of drivers who are arrested and ultimately convicted for DWI will take appropriate measures to not drive again after recent use of alcohol and drugs, so-called DWI recidivists contribute to a disproportionate amount of the carnage occurring on our roads," said Brown.

"As well, many recidivists do not participate in the DWI evaluation and remedial programs that are an obligatory part of regaining their licenses in most jurisdictions. Unfortunately, there is relatively little research about these individuals’ characteristics and the measures that could be taken to reduce their risk, as most research is conducted with drivers who are participating in intervention programs."

Brown and his colleagues divided 184 male and female recidivists with drinking problems and not currently engaged in DWI intervention into two groups: 92 (86 men, 6 women) received a 30-minute BMI session, a brief but powerful psychosocial intervention where the client was encouraged to review personal reasons for change; 92 (79 men, 13 women) received a 30-minute "control" intervention, where the client received information about the hazards of excessive drinking related to health and DWI. Outcomes measured at six- and 12-month follow-ups included percent of risky drinking days in the preceding 6 months, biomarkers of alcohol abuse, and alcohol abuse-related behaviors.

"The drivers we studied may be among the most dangerous drivers, what some authorities call ‘hardcore drunk drivers,’" said Brown. "We figured that an intervention tailored to their specifications would have to be very brief, something that could be applied opportunistically, say at the time of a court appearance. Our results indicated that BMI, compared to the control procedure, was superior in reducing by around 30 percent the number of risky drinking days for up to a year after receiving the intervention. A risky drinking day is when an individual drank enough on a given day that he or she would probably be impaired if they were to drive shortly after."

As for why the BMI intervention was more effective than the control intervention, Lapham responded: "We all have inner conflicts, but these conflicts between how we act and how we would like to be are sometimes not obvious to us. BMI techniques expose these conflicts and allow the person to be more aware of how their harmful alcohol use is at odds with their self image; in other words, how their behavior sabotages their own personal goals for the future. Some interventions try to lead the person into setting goals developed by the therapist, whereas BMI allows the person to fashion his or her own agenda: uncover their own reasons, and motivations, for changing, and set their own goals."

"What is new here is that this may be the first published report of a beneficial effect of a very brief version of MI with individuals who are not in a clinical setting, not particularly motivated to reconsider their drinking (as an individual in an emergency room following an injury might be), and who are generally considered to be hardcore drunk drivers. Nonetheless, the results underscore how, in the right hands, even very brief psychosocial interventions can have important and enduring effects in individuals who are often seen as impervious to change,” said Brown.

He added that encouraging the DWI offenders to participate was rather easy: offering a monetary incentive of about $70, which not only illustrated the power of "immediate positive rewards" but also seemed like a reasonable investment in the name of public safety.

"We need to remember that these repeat offenders reported…drinking 23 to 24 drinks per week, indicating a need to cut down on drinking for both health and public safety reasons," said Lapham.

"The take-home message here is that brief interventions—which can be administered in a health-care provider’s office during a routine visit, and in a variety of other settings—can be very effective tools for helping people change their harmful drinking patterns, changes that can persist for long periods. That said, the most important comparison has not been done yet. The authors are following up to determine what changes, if any, occur in the drinking and driving arrest statistics over time, and whether re-arrest rates will differ between the two groups."

The most common reasons for an alcohol intervention are:

• The alcoholic is in denial and needs to hear how his or her behavior is affecting others
• The family would like a professional interventionist help them find the right treatment choice
• The alcoholic is hostile toward family members and would be more likely to listen to an unbiased outsider
• The family lives far away and wants someone to help them intervene and get a loved one into treatment

Many times an alcohol intervention is done because the alcoholic is unwilling to admit he or she has a problem. The intervention is no guarantee the alcoholic will admit this, but by having a professional address the behavior in a controlled environment, it is often the first time the alcoholic sees through the haze of their denial.

It is strongly advised that you choose an alcohol interventionist with many years of experience and who is aboard registered Interventionist.