Professional Voices—Engaging the High-Rolling Client

By Arnold M. Washton Ph.D. 11/26/14

The extremely successful attain their exalted positions for good reasons: they are smart, driven and accustomed to winning. It can be hard to know, let alone convince them, that they need help.


This week's Professional Voices is from Arnold Washton PhD, a psychologist, author and pioneer in addiction psychotherapy. His piece highlights the importance of offering clients individualized treatment options, as opposed to maintaining a dogmatic approach that dismisses client preferences as evidence of denial or an indication that the client is "not ready" for recovery. As always, please feel free to participate in Professional Voices by leaving a comment after the article.

Many people were shocked when, earlier this month, a front-page story in the New York Times Business section featured allegations of serious drug and alcohol misuse by top executives at a reputable Wall Street investment firm.

Frankly, I was among the ranks of the totally un-surprised. As an addiction psychologist practicing for almost 40 years, I've treated countless high-functioning, successful, supercharged individuals living on the edge: executives, professionals, and many other high-achievers that somehow manage to maintain high-level responsibilities, careers, and incomes despite having serious problems with alcohol or other drugs. The recent scandal, the reactions on Wall Street, and reflexive efforts by the firm to bolster investor confidence by widespread drug testing of top executives, are exactly the kinds of situations that many of my clients come to treatment trying to avoid.

I first heard from “David” about a week after he woke up one morning, in a panic, in a hotel room, with a strange woman in his bed and no memory of how either of them had gotten there. He had failed to call his wife before heading off to the hotel bar, and the next morning slept right through an important board meeting. He managed to come up with credible excuses for his wife and colleagues, but realized that he had taken things to the edge, was flirting with disaster, and needed to get help before something really awful happened. Upon returning home, he immediately went to see his internist for STD tests, asked the doctor for referral to a private addiction specialist, and was given my name.

Like David, not everyone who abuses substances has to hit rock bottom before deciding to get help. The extremely successful attain their exalted positions for good reasons: they are smart, driven and accustomed to winning—so they can often hold it together on the outside, despite falling apart on the inside. Many are living dual lives: high performing executives by day, heavy drinkers or drug users by night. The lucky ones get help before encountering major trouble in their personal or professional lives. Unfortunately, many others experience serious consequences that may not receive coverage in a national paper but nonetheless lead to the tragic unwinding of their careers and families. Regardless of what prompts these “masters of the universe” to seek professional help, successfully engaging them in treatment requires a flexible, personalized approach and other adjustments that go beyond what many addiction treatment programs are able to offer.

My work with David, a 45-year-old high profile financial services executive with an Ivy League MBA, reflects some of these adjustments. When he first contacted me, David had a litany of questions and concerns about confidentiality, as is frequently the case with these clients. He used a fictitious name and let me know during the call that he was doing so. "I'm not famous," he said, "but I'm highly visible in my part of the business world and scared to death of the possibility that my wife, my business associates, or my clients would ever find out about my secret life of heavy drinking and sexual encounters. It would be devastating. I'd probably lose my marriage, my livelihood, and possibly my career. I have to break out of this risky pattern before my world completely falls apart.”

As with many other high-profile clients, David's ambivalence about treatment was compounded by concerns that simply being in treatment might cause harm to his career. He insisted: “I don't want to be seen going into an addiction clinic or AA meeting."  And, like many others whose career could be derailed by an extended absence, he stated an unwillingness to even think about going away to inpatient rehab. Obviously, pressing him about going to rehab or AA at that point would not have gone well. Besides, he seemed to be a good candidate for outpatient treatment. He was highly motivated, not physically dependent on alcohol, and purposefully sought out treatment that would not disrupt his work schedule or home life. His litany of questions included: “Are your records truly confidential? What if my wife or someone else calls to find out if I've ever seen you for an alcohol problem?"

I assured David that our contact would be completely confidential and that I had an ethical and legal obligation to protect his confidentiality. I also let him know that not revealing his true identity to me would not affect my willingness to see him. If remaining anonymous, for the time being, made it less threatening for David to come in for an initial consultation and possibly get started in treatment, that was okay with me. I expressed optimism that in our first meeting he would probably feel more trusting and that revealing his identity would cease to be an issue of concern. As far as protecting his privacy on the premises of my office, I explained that while he would inevitably encounter other patients in the waiting room, they shared the same strong concerns about personal privacy, and that over many years of practice I'm not aware that any of my patients, including public figures, have suffered negative consequences as a result of being seen on the premises of my office or participating in any of my recovery groups. I further explained that because Compass Health Group is a private behavioral health practice, not an addiction treatment program, entering our office would not automatically label him as an alcoholic.

David made clear at the outset of treatment that his goal was to learn how to moderate his drinking, not stop completely. “I don’t want to be told that I have to give up drinking for the rest of my life,” he said, concerned that I would only work with him if he made an ironclad commitment to total abstinence. I described my clinical approach as flexible, open-minded, and individualized. I made clear to David that I place a great deal of importance on developing a positive therapeutic relationship with each and every client as the cornerstone of my approach and that I help clients work toward moderation or abstinence goals. I offered to work collaboratively with him to develop a personalized treatment plan that addressed his individual needs and accommodated his demanding schedule without disrupting his work and home life.

On the heels of this telephone conversation, David made an appointment to come in for an initial consultation. During our first meeting, he quite readily revealed his true identity to me and engaged in a detailed discussion of his personal history, substance use, and other problem behaviors. He described himself as a moderate drinker for most of his adult life until approximately five years ago when he was promoted to his current job, his income skyrocketed, and his first child was born. Since then he was spending less time at home, more time at work, and more time at business dinners drinking along with other heavy drinkers—a situation that inadvertently helped to camouflage the true extent of his drinking problem. Sometimes after dinner, when on the road, David went to the hotel bar so he could continue to drink and maybe hook up with a woman for sex. As with many other hard-driving clients, a combination of increased responsibility, status, income, and heavy travel often correlate highly with increased substance use and a marked increased in other risky behaviors. 

David was able to maintain exemplary functioning at work despite his episodic drinking binges. That, along with the fact that he experienced no alcohol withdrawal symptoms in between drinking episodes, reinforced David's view that he was not alcoholic and that cutting back rather than giving up drinking completely was a realistic goal. After discussing the pros and cons of moderation versus abstinence, including the imminent threat that further drinking binges posed to his job and marriage (as indicated by recent events) David still opted to pursue moderation and I agreed to work with him on developing a detailed moderate drinking plan. But first—I raised with him the idea of starting off by taking a temporary break from drinking to help "reset the baseline" and increase his chances of succeeding at moderation. I further explained that an "experiment" with abstinence would immediately eliminate the risks associated with drinking and provide him with a valuable opportunity to develop new perspectives and coping skills that would serve him well in his later attempt to manage his drinking. By the end of this discussion, David agreed to stop drinking for a trial period of 60 days. We had successfully “negotiated” a deal, a familiar situation for him and much more palatable than being given an ultimatum—something that high-functioning executives, in particular, react to badly.

David agreed to start treatment with twice weekly individual sessions. Our sessions focused initially on David's anxiety about an upcoming business trip that presented another "window of opportunity" for heavy drinking. I suggested that he consider the option of taking Antabuse (disulfiram) on a daily basis, starting several days prior to leaving for his business trip, and continuing until he returned home. I explained that while the medication was not a long-term solution, it could provide him with "insurance" against drinking in his highest-risk situation. He agreed. We also discussed his marital issues. David spoke mainly about feeling disconnected from his wife—both emotionally and sexually—since the birth of his son, and not knowing what to do about it. Since his recent blackout experience he started to to recognize a connection between his heavy drinking, risky sexual behavior, and marital dissatisfaction. He felt that waking up with a stranger in his bed and sleeping through a board meeting was a "moment of truth" that exceeded the threshold of his risk tolerance, although he routinely thrived on taking big risks in his business life. This situation was different. He was now gambling with his life and faced the prospect of losing everything if he didn't put the brakes on his downward spiral. David revealed that his father, a successful attorney and chronically relapsing alcoholic, died of liver disease at age 57. "I've been determined not to repeat his tragic story," David said, "but here I am, a locomotive with no one at the controls charging full-speed ahead down the same track. It all has to stop here."

After a few weeks of individual sessions I raised with David the possibility of joining a small recovery group that I run for executives and professionals. He hesitated, not surprisingly. In an attempt to help David overcome his ambivalence, I suggested that he meet informally with a current group member, also a high-level executive, to get a better sense of how the group worked and how it might help him. Within a few days after that meeting, David decided to enter the group and was pleasantly surprised by how comfortable he felt in the first session, interacting with peers who shared similar lifestyles, issues, and goals. David told the group that it had been 30 days since his last drink and that he intended to remain abstinent for the balance of at least 60 days before deciding whether or not to try moderation. He was warmly accepted into the group and, as of this writing, has elected to remain abstinent for another 60 days while continuing in both group and individual therapy.

My work with David highlights the importance of meeting substance users "where they are" with private, flexible, personalized care that is customized to meet their individual needs. Not surprisingly, high-functioning clients typically seek initial help from private practitioners rather than addiction treatment programs and have a strong preference for individual rather than group therapy, at least at the beginning of treatment. Often they prefer to be seen by an addiction specialist that is also a highly-trained mental health clinician (e.g., psychologist, psychiatrist, other professional therapist) recognizing the need to identify and address complex psychological issues that often underlie and co-exist with addictive behaviors. The value of participating in an ongoing recovery group with other like-minded clients cannot be underestimated, especially when combined with ongoing individual psychotherapy.

Not very long ago, traditional treatment programs were philosophically opposed to accommodating the special needs of "high-rolling" clients, not wanting to inadvertently feed into these clients' presumed "narcissism," "grandiosity," and "sense of entitlement." Now there is fierce competition, particularly among private inpatient rehabs, to attract these clients with offers of luxury hotel-like accommodations and holistic services that cater to their special needs. My how things have changed!

Arnold M. Washton, Ph.D., an addiction psychologist and book author, is co-founder and executive director of Compass Health Group, a team of psychologists and physicians specializing in the treatment of executives, professionals, and other high-functioning adults. His most recent book, co-authored with Joan Zweben, "Treating Alcohol and Drug Problems in Psychotherapy Practice: Doing What Works" is published by Guilford Press.


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Arnold M. Washton, Ph.D., is an addiction psychologist in private practice in New York City and Princeton, New Jersey. His practice specializes in treating executives, professionals, and other high-functioning adults for substance use and other behavioral health problems. He has also previously written in The Fix's Professional Voices column. You can find Dr. Washton on Linkedin, or click here for his full bio.