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With Mental Health, "High Functioning" Is Not Always Mild

How overfocus on functioning leads to underestimates of suffering.

Key points

  • The concept of "functioning" as a measure of mental health severity is flawed.
  • Focusing on external factors like work and appearance can miss hidden struggles.
  • Clinicians should prioritize understanding a person's internal pain and providing support.

"It's only 'not serious' until it kills you."

Decades ago, psychologists divided mental health conditions into two primary categories: neurosis (mild, often stress-related) and psychosis (more "severe" mental illness typically involving changes in perception of reality), with borderline personality disorder falling in the middle. In time, these notions proved imprecise, and by 1980, the American Psychiatric Association removed the term "neurosis" from the Diagnostic and Statistical Manual of Mental Disorders. Still, echoes of this division remain.

In my interactions with the mental health system, both personal and professional, there has seemed to be a line drawn between "serious" mental health conditions like schizophrenia and bipolar disorder and less severe ones, such as depression and anxiety. Even within diagnostic categories, "functioning" labels are still assigned. Sometimes, this leads to the needs of "higher functioning" individuals and the capabilities of "lower functioning" being missed. It has led me to ask:

What even is functioning?

Measures utilized in the mental health system to determine the level of functioning seem to rely primarily on three areas: hygiene, work, and relationships. A person who presents to a mental health professional well-dressed and working full time is likely to be seen as "higher functioning" than someone who is not.

In addition, scoring on scales such as the Daily Life Activities 20 instrument focus heavily on dress and hygiene (Scott and Presmanes, 2001). Beyond the subjective and potentially classist notion remains the question, can you look at someone and just "know" how they are doing?

Work is also a common measurement of functioning. The assumption is that if a person's challenges are great enough, they must affect their work, or they will not be working. Yet, this is also problematic.

For many, an excessive dedication to work can be utilized as a coping strategy for mental health difficulties. Research has suggested that working too much can predict depressive and anxious symptoms (Serrano-Fernandez et al., 2021).

Lastly, it has been suggested that there may be a subgroup of individuals with disorders of overcontrol (Dimaggio et al., 2018). Individuals within this trans-diagnostic group may exhibit traits of strong conscientiousness, perfectionism, and caution. They may show less distressing emotion on the outside, giving an appearance of high functioning.

Why It Matters and What We Can Do About It

Unfortunately, being 'high functioning ' does not mean these individuals are not suffering. Suicidal ideation, self-harm, and eating disorder behaviors are common among this group, and they are more likely to hide these challenges (Lynch, 2018).

A person's level of functioning is not always an indication of how much they are suffering or of their risk for things like suicide.

Focusing only on how someone appears to be doing on the outside can lead to underestimating their suffering and failure to offer robust support. All mental health conditions are "serious," in a sense. As clinicians, we must be diligent in looking beyond functioning labels to meet a person in whatever pain they are in, whether or not the two correspond with each other.


Dimaggio, G., MacBeth, A., Popolo, R., Salvatore, G., Perrini, F., Raouna, A., & Montano, A. (2018). The problem of overcontrol: Perfectionism, emotional inhibition, and personality disorders. Comprehensive psychiatry, 83, 71-78.

Scott, R. L., & Presmanes, W. S. (2001). Reliability and validity of the daily living activities scale: A functional assessment measure for severe mental disorders. Research on Social Work Practice, 11(3), 373–389.

Serrano-Fernandez, M. J., Boada-Grau, J., Boada-Cuerva, M., & Vigil-Colet, A. (2021). Work addiction as a predictor of anxiety and depression. Work, 68(3), 779-788.

Lynch, T. (2018) Radically Open Dialectical Behavior Therapy: Theory and Practice for Treating Disorders of Overcontrol. Context Press.

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