This article delves into the characteristics of high-functioning clients and examines practical approaches and specialised skills required to effectively support this unique client population.
Related articles: Working with the Highly Sensitive Client, Working with Aggressive Client Behaviour, Neurodiversity, Neurodivergence and Being Neurotypical.
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Introduction
High-functioning clients are often perceived as having their lives under control, with stable careers, relationships, and seemingly well-regulated emotions. They might include individuals like Sarah, a 38-year-old senior executive who successfully manages a demanding team while balancing family responsibilities. On the surface, Sarah appears confident and composed, yet she experiences chronic anxiety and relentless self-criticism, stemming from her perfectionistic tendencies and fear of failure. Similarly, high-functioning clients could also look like Mark, a 27-year-old medical resident excelling in his field but silently battling feelings of inadequacy and burnout. Mark’s outward achievements mask his inner struggles with insomnia and an overwhelming sense of imposter syndrome.
These examples illustrate how the ability to maintain outward functionality often conceals significant psychological distress. Such individuals may grapple with anxiety, perfectionism, depression, or trauma, but their polished exteriors lead to the underestimation of their mental health needs. Treating high-functioning clients presents unique challenges, including difficulties in recognising distress, fostering vulnerability, and addressing perfectionistic tendencies. This article explores the theoretical underpinnings and practical approaches to addressing these challenges, offering insights through case studies and clinical examples.
Understanding the high-functioning persona
High-functioning clients often exhibit traits of resilience, self-reliance, and high achievement, which are typically seen as markers of success. However, these characteristics can function as both strengths and defence mechanisms, shielding underlying vulnerabilities. For instance, resilience and self-reliance may help these individuals navigate challenging environments and achieve professional success, but they can also prevent them from seeking help or acknowledging their struggles. High achievement, while outwardly admirable, often comes at the cost of significant internal pressure and self-imposed expectations, leading to burnout, anxiety, and emotional exhaustion.
According to cognitive-behavioural theory (Beck, 2021), such individuals frequently internalise rigid, maladaptive beliefs such as “I must succeed at all costs” or “vulnerability is a weakness.” These core beliefs drive behaviours like overworking, avoiding emotional expression, or striving for unattainable standards. This relentless pursuit of perfection can mask feelings of inadequacy, perpetuating cycles of self-criticism and dissatisfaction.
From a psychodynamic perspective, early attachment experiences often play a crucial role in shaping these traits. High-functioning clients may have grown up in environments where love or approval was conditional on achievement, fostering an over-reliance on external validation (Fonagy et al., 2019). This dynamic can suppress emotional needs, as these clients learn to prioritise performance over authenticity to secure connection and acceptance. Consequently, their outward competence and success may obscure deeper struggles with loneliness, self-doubt, and emotional disconnection. Understanding these underlying dynamics is essential for clinicians to provide effective and empathetic care.
The role of masking and shame
Research on masking behaviours, particularly in high-functioning individuals with neurodivergent traits or mental health conditions, highlights the profound impact of internalised stigma on their emotional and psychological wellbeing (Hull et al., 2017). Masking refers to the deliberate effort to suppress or hide certain behaviours, emotions, or traits to conform to societal expectations or avoid judgment. For high-functioning individuals, this often means projecting a façade of competence and normalcy, even when they are struggling internally. This behaviour can be particularly pronounced in professional settings or social environments where vulnerability is perceived as a weakness.
The compulsion to maintain this façade is frequently driven by a fear of judgment, rejection, or being perceived as inadequate. For example, a neurodivergent client might suppress stimming behaviours or carefully rehearse social interactions to appear neurotypical, while a high-functioning individual with anxiety might over-prepare for meetings to ensure no mistakes are made. While these strategies may help them navigate their immediate environment, they come at a significant cost.
Over time, the relentless effort to mask true feelings or behaviours can lead to chronic stress, as the individual is in a constant state of hypervigilance. Emotional disconnection often follows, as these clients suppress their authentic selves and disconnect from their emotions to maintain their outward appearance. This disconnection can make it difficult for them to recognise or articulate their internal struggles, further compounding their distress.
Moreover, the persistent strain of masking significantly increases the risk of burnout. High-functioning individuals often push themselves beyond their limits, neglecting self-care in their pursuit of perfection or societal approval. The physical and emotional toll of maintaining their façade can manifest in symptoms such as fatigue, irritability, and a sense of emptiness. Understanding and addressing the drivers and consequences of masking is essential in supporting these clients, helping them move toward greater self-acceptance and emotional well-being.
Clinical challenges and solutions when working with high-functioning clients
Recognising distress beyond the surface
One of the most significant challenges is identifying the extent of distress in clients who excel at concealing their struggles. High-functioning clients may minimise their symptoms or rationalise them as part of their drive for success.
Case example: Jessica, a 35-year-old lawyer, sought therapy for “work stress.” While her presentation was calm and composed, further exploration revealed chronic insomnia, racing thoughts about failure, and persistent feelings of emptiness. Her ability to articulate her challenges without emotional expression initially masked the severity of her distress.
Clinical strategy: Therapists can use structured assessment tools like the Generalised Anxiety Disorder Scale (GAD-7) or the Patient Health Questionnaire (PHQ-9) to uncover hidden symptoms. Active listening and gentle probing questions, such as “What happens when things don’t go as planned?” can help elicit underlying emotions.
Fostering vulnerability and emotional expression
High-functioning clients may struggle with vulnerability, fearing that revealing their emotions will compromise their perceived strength.
Case example: David, a 42-year-old surgeon, described himself as “too logical for therapy.” He avoided discussing personal topics, focusing instead on solving problems analytically. Over time, it became evident that his detachment masked deep-seated fears of failure and inadequacy stemming from his upbringing.
Clinical strategy: Building trust is crucial. Approaches like motivational interviewing and psychodynamic therapy can help clients explore the origins of their emotional resistance. Therapists might use metaphors or non-confrontational language, such as, “It seems like you carry a lot on your shoulders; I wonder what it’s like to set that down, even briefly?”
Addressing perfectionism and burnout
Perfectionism is a hallmark challenge among high-functioning individuals, often driving them towards both success and psychological distress.
Case example: Anna, a 28-year-old graduate student, sought therapy for “writer’s block.” Further exploration revealed a pervasive fear of not meeting her self-imposed standards. This fear paralysed her, leading to procrastination and cycles of guilt.
Clinical strategy: Cognitive-behavioural therapy (CBT) can help clients identify and challenge perfectionistic thought patterns. Encouraging self-compassion through practices such as mindfulness or compassion-focused therapy (Gilbert, 2017) can also alleviate pressure. Specific exercises, like setting “good enough” goals, help clients practice flexibility.
Managing ambivalence towards change
High-functioning clients may exhibit ambivalence about therapy, as their functionality reinforces a belief that they “don’t need help.” This can hinder progress.
Case example: Tom, a 50-year-old executive, frequently missed sessions, citing work commitments. In therapy, he expressed doubt about the value of “dwelling on feelings” but acknowledged moments of loneliness and dissatisfaction.
Clinical strategy: Therapists can employ techniques from Acceptance and Commitment Therapy (ACT) to address ambivalence. Highlighting the client’s values and how therapy aligns with achieving a more fulfilling life can motivate engagement. For instance, reframing therapy as a tool for optimising performance and relationships may resonate with such clients.
Cultural and ethical considerations
Cultural considerations
Cultural norms play a significant role in shaping how high-functioning clients perceive and express their mental health challenges. In collectivist cultures, where the needs and expectations of the family or community often take precedence over individual desires, high-functioning individuals may experience additional pressure to maintain a façade of competence and emotional resilience. This can lead to an internalised belief that seeking help or showing vulnerability is selfish or shameful, further suppressing their ability to address personal struggles (Sue & Sue, 2012). Similarly, cultural expectations around gender roles may influence how clients interpret and cope with stress, with some cultures discouraging emotional expression, particularly among men, as a sign of weakness.
Therapists working with high-functioning clients must adopt a culturally sensitive approach, recognising how these dynamics affect the client’s behaviour and beliefs. This involves exploring the cultural values and traditions that shape the client’s understanding of success, vulnerability, and mental health. For instance, a client from a collectivist background might benefit from interventions that frame personal well-being as enhancing their capacity to contribute to their family or community, aligning the therapy goals with culturally resonant values. Incorporating cultural humility and an openness to learning about the client’s cultural perspective fosters a stronger therapeutic alliance and ensures the treatment plan is respectful and effective.
Ethical considerations
Working with high-functioning clients presents unique ethical challenges, particularly when their outward appearance of competence masks significant emotional distress or risk factors such as suicidal ideation. Therapists must carefully balance respecting a client’s autonomy with their ethical duty to prevent harm. High-functioning clients may downplay their difficulties or resist interventions, arguing that they are managing well enough without significant changes. This resistance requires clinicians to tread carefully, ensuring that they neither dismiss the client’s agency nor neglect the responsibility to assess for potential risks.
Regular risk assessments are critical, even when clients appear stable. Therapists should explore areas of vulnerability that may not be immediately apparent, such as the impact of chronic stress, burnout, or unacknowledged trauma. Documenting these assessments thoroughly is essential to protect both the client and the clinician, particularly in cases where the client’s external functionality might contradict internal distress. Clinicians should also engage in ongoing supervision and consultation to ensure they remain objective and attuned to the complexities of these cases. By maintaining a dual focus on the client’s autonomy and safety, therapists can navigate the ethical intricacies of working with high-functioning clients while upholding the highest standards of care.
Conclusion
Treating high-functioning clients requires a nuanced understanding of their unique challenges, including their ability to mask distress, resistance to vulnerability, and perfectionistic tendencies. Effective therapeutic approaches involve building trust, fostering emotional expression, and challenging maladaptive beliefs while respecting the client’s autonomy. By addressing these challenges with empathy and evidence-based strategies, mental health professionals can empower high-functioning clients to achieve genuine wellbeing.
Key takeaways
- High-functioning clients often mask significant distress, making comprehensive assessment essential.
- Fostering vulnerability requires trust, patience, and culturally sensitive approaches.
- Techniques such as CBT, ACT, and compassion-focused therapy can address perfectionism and ambivalence.
- Regular risk assessments and ethical considerations are critical when working with high-functioning clients.
References
- Beck, J. S. (2021). Cognitive Behavior Therapy: Basics and Beyond (3rd ed.). Guilford Press.
- Fonagy, P., Luyten, P., Allison, E., & Campbell, C. (2019). Mentalizing, epistemic trust, and the phenomenology of psychotherapy. Psychopathology, July, 2019. DOI:10.1159/000501526
- Gilbert, P. (2017). Compassion: Concepts, Research and Applications. Routledge.
- Hull, L., Petrides, K. V., Allison, C., Smith, P., Baron-Cohen, S., Lai, M. C., & Mandy, W. (2017). “Putting on My Best Normal”: Social Camouflaging in Adults with Autism Spectrum Conditions. Journal of autism and developmental disorders, 47(8), 2519–2534. https://doi.org/10.1007/s10803-017-3166-5
- Sue, D.W., & Sue, D. (2012). Counseling the culturally diverse: Theory and practice, 6th Ed. New Jersey: John Wiley & Sons.