You have a client who has been with you for a while. Sometimes she seems very motivated to reach her goals, other times she sporadically shows up for sessions and slips back to “square one.” When she doesn’t show up, she gives excuses that make you question if she’s telling you the truth. At some point, you begin to suspect that she may be abusing alcohol, but you skip over the topic, because it is such a sensitive one. After all, you drink alcohol on occasion, so who are you to “preach” to her. Over time, however, it’s clear that something else is going on, and it’s preventing your client from reaching her goals and affecting her health and other aspects of her life.

You may think that your clients’ alcohol use is out of your scope of practice. Or maybe you feel it’s just none of your business. But it’s all health-related, and as a health and exercise professional, you’re in a unique position to help clients become aware of their alcohol use—and possible abuse. When handled with sensitivity and care, you can learn to broach this difficult topic with grace and help your clients become more mindful of this area of their lives. 

What Is Alcohol Use Disorder?

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published and frequently updated by the American Psychiatric Association. While DSM-IV separated the diagnoses and terminology for “alcohol abuse” and “alcohol dependence,” the newer fifth edition combines the two into one disorder, alcohol use disorder (AUD); it then breaks it down into mild, moderate and severe subclassifications. (Note: While only a qualified healthcare provider can diagnose AUD, you might find it interesting to read more about the criterion for it, including this study from Addiction Science & Clinical Practice.)

To give you an idea of the prevalence of AUD, here are summary results of a 2018 National Survey on Drug Use and Health by the National Institute on Alcohol Abuse and Alcoholism (NIAAA):

• Adults (ages 18+): 14.4 million adults ages 18 and older (5.8% of this age group) had AUD. This includes 9.2 million men (7.6% of men in this age group) and 5.3 million women (4.1% of women in this age group).

• About 7.9% of adults who had AUD in the past year received treatment. This includes 8.0% of males and 7.7% of females with AUD in this age group.

• Youth (ages 12 to 17): An estimated 401,000 adolescents ages 12–17 (1.6% of this age group) had AUD. This number includes 173,000 males (1.4% of males in this age group) and 227,000 females (1.9% of females in this age group).
• About 5.0% of youth who had AUD in the past year received treatment. This includes 5.6% of males and 4.6% of females with AUD in this age group.

“The long and short of it,” explains Mark Zissman, PsyD, CACD, clinical director at Gateway Foundation, an evidence-based treatment program, “is that industry experts define substance abuse as occurring when someone experiences some problems with their use of substances but is generally able to manage their use safely over time. Conversely, we define addiction as a chronic, relapsing brain disease that is characterized by compulsive substance use. Individuals struggling with an addiction are unable to discontinue their use of substances—or alter their behaviors—on their own and without support, even when the use results in significant consequences.”

“In simple terms,” says Todd Crandell, LPCC-S, LICDC-CS, founder of Racing for Recovery and author of multiple books, including his latest, Choices and Consequences, “addiction would be when a physical dependency is occurring and as a result, the individual’s life is in turmoil in a plethora of ways. The term ‘disorder’ means aspects of a person’s life are chaotic and disorganized, which brings the question as to why this is occurring. [This ‘why’ is also the underlying reason for] the substance use.”

As with our opening client example, there are signs that can be red flags for health coaches and exercise professionals. Physically, says Harold Jonas, PhD, LMHC, CAP, signs might include diminished endurance, profuse sweating, shortness of breath, being quick to fatigue and an increase demand in wanting to take a break. 

Tyler Harrell, CEO of Greenhouse Treatment Center, says the following common behaviors can be indicative of addiction or substance abuse:

• Sudden changes in behavior, such as becoming unreliable
• Physical changes, such as weight loss or a disheveled appearance
• Mood swings
• Uncharacteristic periods of excitement or agitation
• Constant congestion
• Exhibiting a lack of motivation or being highly distractible
• Intermittent complaints of not feeling well or having flu-like symptoms
• Periods of anxiety, fear or paranoia with no discernible reason
• A decline in performance
• Uncharacteristic dishonesty or financial issues

So You Suspect Substance Abuse. Now What?

As a health and exercise professional, you’re in a unique position to spot the warning signs of addiction, says Zissman, but as a professional, you also need to be careful about how you broach the topic. 

“This is definitely a sensitive topic for lots of people,” Zissman explains. “If a client comes to you for health and fitness coaching, you can subtly point out symptoms you see and, with sensitivity, ask if he or she may be struggling. If the client is willing to be open, it can lead to a deeper conversation that may in turn allow the individual to [seek] the help that he or she needs.”

Zissman suggests that if the client is not open to this area of change, then it’s best to respect the individual’s autonomy. “Put the conversation on the back burner if you find the client is not receptive to engaging in a conversation about his or her use. By doing so, you may preserve the relationship and there may be another opportunity to explore such issues at a later point in the future.”

“When bringing this up,” cautions Harrell, “it should not be done in a confrontational manner. Assure them that your concern is coming from a caring place, because you’re worried about their health and well-being. Allow them to respond to you and speak, as well. Encourage them to seek help, and most importantly, let them know that they have your support in whatever is needed to get them the treatment they need.” 

Regardless of whether your client admits to having a problem or not, you as the professional are faced with the decision of whether or not to continue to work with him or her. Jonas suggests considering the safety of the client. “Safety in all areas first, then the decision to continue, suspend or stop will be clear,” he says. “What is in the best interest of the client should always be the question asked and answered.”

It’s important to note that your safety, as the professional, needs to be taken into account, as well. “If the client has displayed a complete and noticeable shift in personality and behavior, and the coach is increasingly worried about his or her own well-being, it would be wise to contact an addiction professional who can help determine next steps,” advises Harrell.

Assuming safety isn’t an issue, Crandell, who himself is a recovered addict and has been clean and sober since 1993, feels there are benefits to continuing to work with the client. “I believe the [health and exercise professional] should continue working with the individual on other areas, as that may be a catalyst to address the substance use disorder properly and effectively. I professionally believe in consistently providing clinical and educational ‘seeds’ that can lead to change.” 

Zissman agrees. “If the health coach feels comfortable continuing to do the work, I think it could be potentially very helpful. For example, if he or she is able to build a supportive, safe and client-centered relationship with the client, it is very possible that an individual struggling with an addiction may turn to his or her coach for help. If the health coach believes that the client is at risk of serious physical consequences as a result of continued use, it is important to convey such concerns to the individual—regardless of whether the coach decides to continue working with the client.” 

This is a good time to revisit a health and exercise professional’s scope of practice. While it is outside the scope of practice for health and exercise professionals to diagnose AUD, if a client expresses concern about alcohol use, the coach is in the perfect position to assist the client with behavior-change support. For example, clients may be open to discussing the pros and cons of their behavior and health and exercise professionals can use motivational interviewing to empower clients to see the discrepancy between their goals and alcohol use. This may lead to collaborating with clients on strategies for change and contacting an appropriate health professional with the client’s permission.

It’s not surprising, then, that Jonas believes that health coaches are vital. “Coaching has evolved to encompass many areas of specialties. It is critical that coaches know their limitations and understand their role. [Coaches can serve as a] guide in the overall improvement of a person’s well-being, [help clients strengthen areas of their lives that will make them a more balanced person] and serve them unselfishly.”

In the end, it may just be their new beginning.