Editor's note: This text-based course is an edited transcript of the webinar, Working with High Functioning Anxiety: Supporting Our Overachievers, presented by Jenny Maenpaa, MSW, EdM, LCSW.
Learning Outcomes
After this course, participants will be able to:
- Appraise high functioning anxiety and identify how it manifests physically and emotionally.
- Consider the root causes or underlying factors that contribute to high functioning anxiety.
- Integrate interventions in treatment that help clients to implement effective coping skills into their everyday lives to decrease anxiety.
Introduction
High functioning anxiety is my bread and butter. As we often do, I came into this because I couldn't find a person I needed to work with myself. So I became the practice I wished I'd had in my 20s. As Katrinna said, I am a licensed clinical social worker with a master's in education of curriculum and instruction. I also completed New York University's graduate certificate in organizational and executive coaching. I am the founder of Forward in Heels, an intersectional feminist group therapy practice that empowers all women to stand tall and own their worth so they can light up the world.
In my 20s, I was the classic overachiever. I completed multiple graduate degrees and fellowships and was always looking for the next gold star to make me feel valid. I wondered why I was constantly making lists and plans only to have to rewrite them when something unexpected came up, as it always does. I would go to a therapist, spill my guts, and say everything I thought. After three or four sessions, they would say, "Well, okay, I mean, there's nothing wrong with you." I'd think, "Okay, clearly, I just have to work harder. Message received." Finally, I realized that I suffer from high functioning anxiety and that just because I'm often able to supplement my anxious tendencies into achievements doesn't mean it isn't still negatively impacting me.
As I said, I created the practice I wished I'd had in my 20s, one that recognizes that being a badass doesn't mean you never have doubt, that being the strong one doesn't mean you never need to be checked on, and that being the one everyone always goes to for solutions doesn't mean you're never vulnerable. I was told in my early 20s that I can conflate vulnerability with weakness. To me, there was nothing worse than being weak. That really stuck with me all these years. Then I found Brene Brown, so I figured out vulnerability. What makes me come alive is seeing women realize the unlimited potential within them. When women can take care of themselves, their light shines through, and the best version of them shows up professionally.
That version stands tall, knows her worth, and lights up the world. As I said, in our therapy practice, we work with all genders because patriarchy is a system, not an individual. As therapists, we specialize in combining cognitive behavioral therapy and psychodynamic therapy to help stressed-out overachievers overcome imposter syndrome and dissatisfaction. As a result of working with my therapists, our clients go from just chasing the brass ring to achieving sustainable happiness in every aspect of our lives. Our practice's goals are to help clients examine their past, understand the limitations on their present, and unleash their vision for an ideal future. In addition to our therapy and coaching credentials, I am a graduate of a Yoga Alliance certified program, which allows me to infuse mindfulness and grounding techniques into our practice's approach to give clients additional tools to calm anxieties.
I say all of this for a couple of reasons. One, I always want to know who I'm listening to and why I should listen to them. Two, I think that a lot of our type A's, a lot of our overachievers, in the beginning, hear words like mindfulness and grounding and roll their eyes and think, I don't want to do an hour-long silent meditation. One of the things I will talk about today is how mindfulness can be a beneficial tool for overachievers and high functioning anxiety in addition to CBT, psychodynamics, and a lot of physical manifestations of that pent-up energy that a lot of them are feeling.
What is High Functioning Anxiety?
Let's start with what it's not. High functioning anxiety does not meet the full clinical criteria for an anxiety disorder diagnosis, although they can coexist. Don't let that trick you into thinking that it doesn't create problems that negatively impact our clients' overall quality of life.
High functioning anxiety can prevent our clients from functioning at their fullest potential. It can stop them from feeling their best and enjoying the life they've worked so hard to create for themselves. If they're in therapy with you, they're already taking the steps towards feeling better. However, they may be applying the wrong mentality or the wrong strategies to what they're feeling and then feeling like they're just spinning their wheels in the mud. Maybe this sounds like your clients. They're strong and ambitious, but perhaps they feel like something's missing. They feel like they've done everything right, gotten the education they were supposed to, the job, the accolades, but they're not quite sure what it's all been leading to.
Maybe their work-life balance is out of sync. Maybe their relationships that were supposed to be the be-all and end-all just don't make them happy, and they're burned out. No matter how many boxes they keep checking off, they still don't feel good enough. It may be a struggle for them to keep everything together, and they just aren't sure they can do it anymore. Where some people's struggle with anxiety holds them back in life, your client's anxiety may propel them forward. It has probably helped drive them to work towards and achieve their goals. It may sound like a good thing at first, but when they're driven by a fear of failure and being afraid to disappoint others, it eventually catches up with them.
Excessive Worry
One symptom of high functioning anxiety is excessive worry. Sometimes we call it catastrophizing. That "what if" spiral can sound a little like this. My boss scheduled a 15-minute meeting with me, that's never happened before. What if I royally messed up the last assignment? What if I ruined everybody else's ability to do their jobs? What if I'm costing the company money? What if I've bankrupted the company? What if I'm getting fired? What if I'm getting sued? What if I have to move back home and be stuck there forever? What if I never get another job after that? What if I never find a partner because I'm such a failure? The parts of their brains that make them successful at planning and identifying missing pieces are also the parts that make them their own worst enemies.
Fear
Clients are often terrified of saying no to others in their lives for fear that they will no longer be valued. To them, setting boundaries sounds like a guarantee that their needs won't be respected and that they'll lose whatever they feel they have a tenuous grip on. You may hear them say things like, well, I can't tell them that I don't like that because then they won't include me anymore. Or I can't say no to my boss's Saturday night work request because I'll get fired. Or I can't tell my partner that this is bothering me, or they'll leave me. I often have to work with clients on boundaries and frame that boundaries are not to exclude people but to invite them to meet clients at their needs. It's a tough thing for many clients with high functioning anxiety to wrap their brains around because by saying I can't, or I won't, or I'm not going to do that, they're not the provider for the people in their lives that they have been for so long.
Overthinking
Clients with high functioning anxiety often get stuck in a thought loop, trying to figure out where they could miss something important and pre-plan for it. It sounds like a great strategy to keep analyzing something, plan for the worst, and hope for the best. But in reality, they're just repeating the same things back to themselves in an echo chamber and then becoming more worried because they're reinforcing the idea that their worst fears will come true. Maybe they finish a presentation, but then they keep coming back to make edits and end up delivering a lower quality product in the end because they could not stop iterating.
Difficulty Relaxing
Your clients may tap their fingers, bounce their legs, pick at their cuticles, or any other subconscious physical manifestations of their swirling insides. You might hear them say things like, "Ugh, I'm so excited. I finally have Sunday off, and I'm just going to relax." Then the next week, you see them and ask how Sunday went, and they might say something like, "Oh my God, I finally sat down by the pool, and I was so bored." Or "I kept getting up and sitting down, picking up something new to do." Or "I tried to read the book that everyone's been reading, and I just couldn't focus." They work so hard towards this goal of relaxation, but when they get there, they can't stop thinking about everything they're supposed to be doing.
Insomnia or Trouble Sleeping
This can often lead to insomnia or trouble sleeping. How could you sleep when all of these ruminating thoughts are swirling? They often prevent our clients from sleeping well, whether it's difficulty falling asleep, staying asleep, or feeling rested once they wake. Their spiraling thoughts often create a self-fulfilling prophecy where they're so exhausted that their executive functioning is diminished, and they're unable to use their critical thinking skills to calm themselves down in the face of uncertainty. We all know the fight, flight, freeze responses, and the newer additions of fawn and fold. Fight, flight, and freeze can be very present and prevalent for overthinkers.
Here's how it might look. Instead of getting stuck in one fight, flight, or freeze response, they might cycle through them repeatedly. This may sound familiar to your clients. They're lethargic all day. They're having trouble deciding which pressing issue to do first because it all has to get done. They feel stuck on a hamster wheel and can never finish the list faster as more gets added to it. They end up stuck in freeze all day, conserving energy for some imaginary future need. Then when it's finally time for bed, they're wide awake. Their mind is racing, and they cannot fall asleep no matter how many of the trusty sleep hygiene strategies you've given them they're using. Now, their brain thinks it's time to fight and tries to identify all the possibilities of what could happen and what they need to do if that happens. When they finally fall asleep, no matter how long they sleep, they don't wake up well rested. This is because instead of letting their brains get into deep REM sleep, their flight response keeps them closer to the surface, just in case something happens while they're asleep and they have to jump out of bed and run. They're essentially catnapping all night long. You know, when a cat seems asleep, but you walk by, and they open one eye just to ensure you're not a threat? That's what cats are supposed to do evolutionarily. Humans are not, but prolonged stress has crossed their brain wires. They wake up after however many hours of non-restful sleep and start the cycle of lethargy all over again. Then they beat themselves up for not being productive.
Perfectionism
Perfectionism can often manifest in procrastination or paralysis. Many clients unconsciously feel that if they can't guarantee they can do something perfectly, they shouldn't attempt it. They're often used to being good at things they try and learned early on in life to avoid things they may not be good at for fear of failure and not being perfect. This can also lead to paralyzing fear if they're asked to try something they don't already know they'll be good at. They may be invited on a ski trip with people they'd love to connect more deeply with, but they're terrified of not being the best skier in the group, so they decline and miss out on building community. They might decline being nominated for an award or promotion by thinking that they're not perfect at the thing, and if they're put forth, they'll be discovered as a fraud. This can also manifest in imposter syndrome, thinking that they have lucked into their position by somehow tricking others and that they don't really deserve it. This can lead them to feel hyper-vigilant all the time about potential mistakes.
Magical Thinking
How many of your clients have said something like, if I just do X, it will all be perfect? If I just lose 20 pounds, I'll be happy. If I just find a partner, I'll have everything I want. Everything will be fine if I can just make it to the weekend. Clients with high functioning anxiety are often stuck in a fixed mindset, meaning they believe something either is or isn't, versus a change mindset, meaning they believe they just don't know how to do something yet. These clients often love a timed challenge, like a whole 30 diet or dry January, where they don't drink for the entire month of January. But they usually don't plan for what happens on day 31 or February 1st because they're so focused on the achievement. They often frame things in sprints when a situation might call for a marathon.
What Puts Your Clients At Risk for High Functioning Anxiety?
Where does it come from? Many different factors can lead to anxiety, including high functioning anxiety, which, as we said earlier, may not reach the clinical criteria but still impacts our clients. Here are some of the common ones. Anxiety, whether high functioning or not, can be caused or exacerbated by genetics, relationship issues, financial concerns, and job-related stress, which can also result from internal insecurities or low self-esteem.
Genetics
Anxiety disorders, like many diagnoses, often appear in family history and may be hereditary. How much of this is pure genetics and how much of it is how our parents and grandparents behave is still a matter of debate. For example, maybe your client's mom had anxiety, which could be a hereditary or genetic aspect, but perhaps she also often let her child see her worry, and her spiraling thoughts were said out loud when she ran around the house cleaning and organizing for hours before guests came over, teaching your client unconsciously, that the only way to prepare for the unknown was to make yourself tense and sick beforehand. As a child, maybe your client had a parent, teacher, or coach who pushed them to achieve. Perhaps they thought they were helping by challenging your client to be better every time. They might not have realized that they were unconsciously telling your client that they were never going to be good enough and that no matter what they achieved, they still had to work harder for the next accolade.
Does this sound familiar for any of your clients? As a kid, they were really good at something. A teacher, a parent, or a coach saw this talent and encouraged them to work really hard at it. Maybe this meant two a day swim practices or extra piano lessons or tutors to ensure they got fives on every AP exam they could take. Your client took this encouragement, internalized it, and ran with it, focusing all their energies on achieving what was expected of them. Then maybe they went to college, a graduate school, a med school, or a law school. They continued to receive validation for success. Then they get out into the working world, and that validation disappears.
They rarely, if ever, hear praise and often hear either nothing or criticism meant to improve their work. They have now internalized these childhood messages and believe they just have to work harder. The adult that was represented from their childhood is now being transposed onto this person at work. Maybe it's a boss, a colleague, a manager, or a CEO. So your client works longer hours. They repeatedly scan their emails or presentations for errors long past when they should have just submitted. They take on more and more responsibility, even if they have no capacity for more. Now, anytime someone says, can I talk to you, or puts a meeting on your client's calendar without context, they immediately spiral.
It might sound like this. Think about the example I gave before when my boss scheduled a 15-minute meeting with me, which had never happened before. I obviously messed up. I've ruined the company. I'm getting bankrupted and fired and possibly sued. That's what the spiral might look like that goes into the negative. They don't even realize that with that mindset, they go into the meeting with a defensive stance, shoulders hunched, fists balled, and jaw clenched. They're looking for any way to defend themselves. Their boss then, or the person who's called this meeting, subconsciously receives these signals and, in turn, responds defensively because they don't understand why this person has come in at this level. The conversation quickly escalates, and now your client has created a self-fulfilling prophecy that they are a failure, they are not good enough, and they should always be looking for where they have messed up. This now reinforces their hypervigilance and keeps their anxiety peaked for extended periods.
Early Childhood Experiences
People who might be especially susceptible to high functioning anxiety, in particular, can include folks who've achieved success in a concentrated way, like someone who was a strong reader in elementary school and quickly realized that pursuing literature-related accolades like writing contests, public speaking competitions, and academic study in the English language would continue to provide validation. Those early childhood experiences keep compounding on themselves.
Traumatic Life Events
Traumatic life events include exposure to negative or stressful life events, so we no longer have a debate about nature versus nurture. We talk more about if someone has a predisposition to something and did they have experiences that have exacerbated that predisposition. Perhaps you have a client who was a highly conscientious child. They were empathic, and they paid attention, and they were the kid who noticed when a kid was sitting alone at lunch or noticed when someone's shoes were untied, and maybe they then had a traumatic experience. Perhaps they were in an assault or witnessed something that amplified that conscientiousness into being hypervigilant. Now that noticing has become looking everywhere for potential landmines, causing them to exist in a high state of worry most days, for most hours of the day.
Personality and High-Stress Jobs
High functioning anxious achievers will often look for jobs with specific keywords. These jobs, in turn, will exploit your client's perfectionism and desire to please. Many employers will look for employees who will quote "go the extra mile" and "be willing to work overtime for no additional compensation" out of a desire to be seen as a star employee. This becomes a self-fulfilling prophecy where clients seek out jobs that will feed into their desires for gold stars and feel validation when they are praised, but maybe not realize that they might actually be feeling exploited or resentful when those other markers of validation don't show up like a promotion, a raise or any other life-changing measure.
What Does High Functioning Anxiety Look Like?
How does this show up in our clients? What does high functioning anxiety look like in real life? It's easy to read through a list of high functioning anxiety symptoms or medical definitions and think it doesn't apply to our clients. As I said before, high functioning anxiety may not rise to the level of clinical criteria, whether it's a generalized anxiety disorder or adjustment disorder with anxious symptoms. It may not hit those exact criteria. You may think, oh, maybe this isn't the correct diagnosis. High functioning anxiety is not a clinical diagnosis, but it is so common that everything we've said so far, you're probably naming clients in your head that you're like, yep, that's them.
Let's dive into how this can play out in your clients' everyday lives. Here are some common struggles and feelings that people with high functioning anxiety experience. We'll get to the many strategies to help your clients overcome the obstacles caused by high functioning anxiety. First, we have to identify the common thoughts and beliefs that may make it difficult for our clients even to recognize that there may be some challenges in this behavior because it often, as I described previously, may have given them a lot of things in their life, including their promotion or rise up the ladder. It may be hard for them to recognize that this could be both beneficial and harmful to them at the same time.
Having It All Together
Appearances can be deceiving; we all know that. For instance, think about Instagram versus reality. But knowing that and feeling it can be hard enough for us as practitioners. It can be even more challenging for our clients who are seeing things or being seen in a certain way. Many of our clients will prioritize having the outward appearance of having it all together, which can make it difficult to recognize and identify high functioning anxiety. Women, in particular, are susceptible to others praising them by saying, "How does she do it all?" or "What a superwoman," or "What a super mom," which makes them feel like they have to maintain this facade forever, that they've set this baseline expectation for their perfection. Now they can never dip below that.
Many of these clients will put a lot of thought and effort into their appearance, which may cause them to develop body dysmorphia or to overspend into debt when they can't afford it, just to keep up the standard they set for themselves. Maybe it's social media, and maybe it's just life, but you may have clients who say, I just need to work out more. I need to work harder because I don't look like I did before I had a kid, or I don't look like that 25-year-old when maybe they're 45. They don't internalize the idea that that's not them, that they are probably comparing themselves to some sort of touched-up or false representation, and that maybe the 25-year-old they're comparing themselves to can spend two hours a day at the gym. They have a full-time job, multiple kids, a family, hobbies, and so on.
They're often taking out all the variables and saying, I should look like that, or I'm going to do everything I can to look like this. I'm going to buy designer clothes because I like when people say, oh, I never see you in the same outfit twice. I don't care that I can't afford it. I don't care that I fundamentally feel at odds with contributing to fast fashion because I care about the environment. It doesn't matter. I have to keep up with this appearance. You'll hear a lot of that fixed language that I must, I have to, I can't, as opposed to I'm choosing to, or this is important to me.
Bottling Up Their Emotions
Clients may tend to bottle up their emotions or sweep them under the rug when they experience high functioning anxiety. Doing this might allow them to trick themselves into thinking there isn't a problem for a little while. Compartmentalization is a healthy strategy in moderation. If we were consumed by our argument with our spouse all day at work, we wouldn't get any work done. There is a benefit to saying, I need to deal with that later, but when it becomes extreme, and we go straight from the argument into insisting everything is fine and never process it, we don't get over the negative experience; we just bury it until the next time the same thing happens. Then we overreact because we're reacting to multiple events in our head, but our partner doesn't know that.
Then it creates a different, even bigger argument and our partner is like, why are you freaking out? We think because I didn't process the last time we got an argument over this, but that's not actually what gets said. A lot of clients will just move forward and power through. You'll hear them use a lot of strong language and say they're just going to muscle on. I don't mean this in a gendered way, but there's masculinity to the power through and get through it where emotions take more processing, and often we have to sit in them. Our high functioning anxious clients don't like sitting in discomfort. Nobody does, but they really don't because that doesn't have a solution or an end. That just feels gross so they just go straight through.
Toxic Positivity
Some clients deal with toxic positivity or not believing their struggles are valid. The fact that their struggle with anxiety isn't obvious to others doesn't mean it's not real, but they may fear others will think they're being ungrateful or making a big deal out of nothing. Others in their lives may look up to them as the one who has it all together. So if they complain or indicate things aren't perfect, others may say something like, "Well, just look on the bright side, you have all this or you'll figure it out. You always do." This just makes them feel like they can't go anywhere with their imperfect feelings.
When I hear clients say things like, "Well, I don't have it as bad as this person, so I can't complain," I often say to them, there's no gold medal for the suffering Olympics. You don't lose because someone else has it worse. Your experience is valid because you're experiencing it. So you not addressing this fight that you had with your sister isn't going to impact the person next to you who lost their house. One has nothing to do with the other. You not addressing the fight you had with your sister is going to impact you and your sister, and that person will deal with their house.
A lot of times our clients will do that comparison game, that compare and despair you've probably heard, which usually applies to social media like I was referencing before. We do it in all aspects of our lives such as, "Oh, I don't have that. What I have is not good enough." Ironically, clients can apply that and think I don't have it as bad as someone else, so my struggles aren't good enough or valid enough, which just sends them down a rabbit hole that they can't get out of.
Reluctance to Seek Help
This goes with many of the things we've been saying so far. When they're the dependable person to whom others come for help, it can be hard, if not impossible, to admit when they need the help. They may struggle with feeling like they aren't good enough if they can't get through it on their own. They often also might feel like they are taking from someone in their lives. If they're used to being the one who gives, they may look at it like a binary, like a give or take.
If you think about a seesaw you may have played on as a child, it doesn't balance perfectly in the air when there's no weight on it. In order to balance it needs to have pressure on both sides. When you go up and down on that seesaw, one person in your relationship is going to need 90%, whether they're romantic, family, work, or your children.
That means the other person might give 90% and only take 10%. The idea of reciprocity, a balance of a true relationship that is symbiotic and mutual, and not perfectly even is that at times it will go in the other direction. Maybe our high functioning clients have to recognize that they may be the person who needs the 90% or the 80 or the 50, or whatever it is in a given moment. They are not taking something away from somebody else. They are inviting that person to be the dependable person that they've always been for them. People want to give reciprocity, but our clients often don't see that because they're just used to the giving, not the reciprocity.
Nervous Habits
I don't know how many of you have gone remote during the pandemic, but I saw this a lot in person pre-pandemic. I saw a lot of unconscious nervous habits that show up as fidgeting, nail biting, pulling at cuticles, hair twisting or pulling, repetitive scratching on like forearms, knuckle cracking, or lip chewing. Those feelings that got bottled up before don't go away, so they come out physically. They come out in your body saying, I've gotta get this feeling out, but you're not letting me talk about it, or you're not letting me process it, so it's got to come out somehow. It's similar to a pressure cooker or an Instant Pot, where you have to turn the valve and let the steam out. Otherwise, that steam goes right in your face when you open the lid. It's the same with our clients. They don't realize that that steam hasn't gone anywhere. It's coming out one way or another.
Perfectionism
Perfectionism, the struggle to feel like they need to be perfect to be good enough, is this great irony in life. They have to be perfect to be good enough. Just listening to that sentence breaks my heart. Anything less than perfect is unacceptable. They may have high expectations from those around them, but it doesn't even compare to the expectations they have for themselves. This causes them to spend copious amounts of time on projects to get it right. They read through emails repeatedly, looking for errors or ways to reword sentences or do it just perfectly. They skip lunch to put in extra time. They struggle with getting started on tasks, especially ones they're unfamiliar with, because procrastination, as we said earlier, can be connected to perfectionism. Why begin if I'm not sure that I can finish it perfectly?
You may have seen an ad on the internet or a headline that says to click here for the five things billionaires do before 5:00 AM. Everyone's always looking for a productivity hack. How can we do more with less? Optimize, optimize, optimize. So many of us are taught that we need to use our time more efficiently to get more done. The idea is that you can outsource your food with a meal delivery kit, send your laundry and dry cleaning out, get a manicure at the same time as a facial and get your teeth whitened. You can do a 20-minute workout class that gets you the results of a 60-minute class. What are you supposed to do with the rest of that time you've saved? The world wants you to work more. Don't have time to shower? Use dry shampoo and get in front of that laptop.
Meanwhile, how often is the shower the only place you can be alone with your thoughts? How often do you gain great insight in that five to ten minutes in the shower because you're not distracted for once? Your brain has a moment to synthesize everything it's absorbed. If we look pre-pandemic at places like Google, people thought they have great perks. They have an onsite masseuse, foosball tables, and pay for your breakfast, lunch, dinner, and free beer. That's not out of the goodness of their heart. It's so that you stay at work all day and all night. If they can take all those decisions off your plate, you'll just work, work, work.
Fear of Failure
This leads to our fear of failure and goes along with perfectionism for many of our achievers. They are afraid. They are terrified to fail, making it even more difficult to step out and try something new. They're often not just worried about failing; although they are, they also don't want to let others down. They're worried they won't meet the expectations of those around them, and may struggle with feeling like they're not meeting their own expectations either. Hence, they work harder and increase their effort because they feel they have to succeed, that there's no alternative. For them, experiencing failure, even small failures, can feel catastrophic when living with high functioning anxiety. You may have clients who hate their jobs that they shut down whenever you start talking about maybe doing something different. They clam up because the idea that they might do something different and not be perfect at it is too heavy to bear for them right now. They would rather stay in a job that they are miserable at, but they at least can do, than try something that they might be miserable at, or they might be delighted, elated, love, dream job, but not do perfectly right out of the gate.
Overthinking
Overanalyzing things is a daily struggle for our clients. They're constantly second-guessing and doubting the decisions they make. They're afraid of making the wrong choice, saying the wrong thing, or doing something they shouldn't. They overthink it all to the point where it's hard to take action. They may feel paralyzed when a decision rests on their shoulders, or they may be able to make a decision but then keep rethinking it, wondering if they made a mistake. Do you remember the choose your own adventure books? I always ask my clients, were you the kid who kept your fingers in all the different pages just in case you picked wrong, and then if you ended up dying, you could go backward and say, no, I meant to pick this other one? You could game the system. I can say that because that was me. I was the kid who thought I had to make the right decision. Again, physician heal thyself. I am an expert in this because I had to do a lot of work on test case number one over here.
Workaholism
Your clients may feel the need to be constantly productive at all times. That may look like working long hours or being unable to disconnect from work at the end of the day, or they may find that their thoughts keep returning to work long after the work day is done. I want to note that working long hours isn't always a sign of being a workaholic or high functioning anxiety. It may be that someone loves their job and is passionate about it. The key is to look at where the motivation for working long hours stems from. If it comes from enjoying the work, that's one thing.
I know there are times when I think about a client outside of the session because I'm thinking through the challenge that we're focused on right now, and I want to look up a new resource or talk to another practitioner about something. That is because I know that if I can talk through this, I can bring something back to them, and we can make progress. That's different from ruminating over whether you said the wrong thing. Should I not have done that? I was certainly more susceptible to this early in my career. But if this overthinking and workaholism comes from anxiety or fear that they'll get fired or they won't be perfect, that's when we can look at it as indicating a problem.
This can also spread outside of a job. If our clients are limited to how much time they can spend at work, such as they have an in-person job where they have a desktop computer or it's protected in some way where they can't access it outside of work, they may find themselves filling their free time by serving on a board or doing something else that feels like work. Then they can tell others, see, I'm super productive outside of my work hours because I can't work 80 hours a week, so I have to make up for it by being a valuable member of society. Again, it's not about where the hours are spent. Clients may serve on a board they love that fulfills them, creates community, and serves a need that they care passionately about. It's about how the hours spent feel to the client. Did they say yes to it because someone asked and they don't actually care that much about the topic? Now they're doing twice as much as they would at their real job for something they're not passionate about.
Catastrophizing
Finally, back to catastrophizing and assuming the worst. Fear leads our clients to assume the worst in every situation. They might get an unexpected email from their boss, drop a meeting on their calendar, and assume they're fired. Their best friend doesn't respond to a text, so they assume she's angry with them. Their partner is late getting home, so they assume they're cheating, or they got in a terrible accident. Clients frequently cause unnecessary stress and anxiety by assuming the worst; even when everything seems to be going well in their lives, they just can't beat the uneasy feeling that something terrible is about to happen. Maybe if they can think about it, they can prevent it. It usually doesn't work that way, making it impossible for them to rest and relax while waiting for the other shoe to drop.
Note: The following information comes from a poll taken during the live presentation of this course.
I asked everyone attending the live event which symptoms of high functioning anxiety are showing up in their clients now. I hope you can see you're not the only person dealing with this. This helps provide a little sense of solidarity when so much of our work is so siloed as we're alone in a room with a client, and the clients are alone with their thoughts in their heads. It can feel really nice to realize that everyone else is experiencing the same challenging things right now. Here are the results of the poll.
Which symptoms of high functioning anxiety are showing up in your clients right now?
- Having it all together - 50%
- Bottling up emotions - 65%
- Toxic positivity - 25%
- Reluctance to seek help - 38%
- Nervous habits - 58%
- Perfectionism - 65%
- Fear of failure - 65%
- Overthinking - 78%
- Workaholism - 40%
- Catastrophizing - 53%
As you can see, our clients are experiencing a lot of similar things to each other.
Tips for Managing High Functioning Anxiety
What do we do about it? You can take several actionable steps with your clients to address their high functioning anxiety. Here are just a few.
What If?
Let's go back to that what if. We can just flip that. Even though our clients are used to using what if as a negative spiral, they can also use that same skill to go down a positive spiral. What if the good thing happens? Then what? Then what if that works out too? What would I need to do? I often challenge my clients. They say, you know what if blah, blah, blah happens, and I say, okay, let's follow that to the end. What if? Well, then this will happen. I continue and then tell them we're going to do that for the opposite. I walk them through, modeling how they can positively use that. Sometimes we say things to clients, and they just stare at us because they're used to doing it one way.
Feelings Identification
I am a huge fan of a feelings wheel. While we often use this technique with children, it can be beneficial for adults who have often defaulted to using the same words repeatedly for their emotions.
Many clients with high functioning anxiety use cerebral thinking words like annoying instead of emotional words like hurtful. Practice with them how to identify the feelings beneath the feelings.
Acknowledge the Anxiety
Sometimes we forget just to say the thing out loud. Once our clients become more informed on how high functioning anxiety can show up in their lives, it's time to recognize the symptoms for what they are. It's okay for them to acknowledge the areas where they're struggling by being honest with themselves. Clients often think that naming a negative emotion is synonymous with blame, so they'll say, I can't be angry they got COVID and had to miss my wedding because it's not their fault. Helping clients identify that they can have a negative emotion towards a situation without blaming others or themselves can be very helpful and cathartic. This may sound like I am so angry that we've been living with COVID for two and a half years. It sucks that our lives have changed so immensely. I hate this situation for taking my best friend away from my wedding. I wish they could have been there.
Ask for Help
Asking for help is something our clients are often not very good at. This is often incredibly difficult for clients who are used to being the ones others ask for help. It can feel like a blow to their identity. Work with clients to identify a bite-size piece they can ask someone else to take care of. It can be very simple to start to help the client practice asking with a low consequence item first. When we're feeling overwhelmed at work, it's easy to think the solutions have to be significant, like calling out of work to go on an impromptu vacation or resigning immediately. Alternatively, we believe it's our job as healthcare providers to keep our thoughts to ourselves, remain strong, and appear capable. We don't have to do it alone, though. We should model for our clients that they don't have to either. Often, the first step is asking a superior for guidance on managing their workloads. If they're not able, or that person's not willing to help them, they can begin escalating their concerns through the appropriate channels. That doesn't have to be punitive. Saying escalating a concern doesn't have to be marching to HR, but it's saying, "Who else can support me in this?"
Sublimation
We often think of sublimation with things like anger. I've always heard the term sublimation in mental health refer to a client who is really prone to anger, so let's sublimate, or channel, that into boxing or another structured contact support for release. We can encourage our clients to reframe their negative quality of anxiety as they see it as a driver and a motivator and work with them to channel it into productive work instead of rumination. For example, if their anxiety causes them to make endless list after list after list, let's talk about strategies like a bullet journal or the Eisenhower matrix.
A bullet journal requires journalers to hand write their lists each day. This forces clients to recognize if they're just pushing the same item out each day and if that item is actually necessary. So many of our clients put things on their to-do lists that they think they should be doing, but it's not a priority, or it's something that someone else might think they should do. There's a reason that it keeps getting pushed to the next day.
The Eisenhower matrix is allegedly a strategy that President Eisenhower used to determine priorities, and it's a four-square box. It is a task management tool that prioritizes tasks by urgency and importance. Across the top is urgent and not urgent and down the sides is important and not important. In box one, you do it now if it's both urgent and important. If it's box two, which is important but not urgent, you do it later. You delegate if it's box three, which is urgent but not important. If it's box four, which is neither urgent nor important, you don't do it. I often say this to clients, and then I follow up by saying, I can see your brain working. You're not going to put anything in don't do. They start laughing and say, how'd you know? I tell them, "You're also not going to put anything in delegate or do later." They often say, "Yeah, everything feels like due now." Then we go back through it and discuss what is truly important. How do you define important in your life? That can look different for everybody.
Utilize Relaxation Techniques
Let's think back to mindfulness. So often, I can see the wall go up in my clients when I start to talk about mindfulness. They often think, great, I'm going to go to a yoga class, and what, that's going to solve all my problems? No, of course not. When we're in conflict or in danger, human beings enter a heightened state of arousal. Conflict or danger could be emotional, not physical. This arousal has protected our species for millennia. It's why your hair stands up when you hear things go bump in the night. It's why you pull your hands away from a hot stove or walk away from a boss who's been criticizing you for the last 45 minutes.
This built-in alarm system is called diffuse physiological arousal, or DPA. When your body's in DPA, your heart speeds up, and blood flow to your gut and kidney area slows down. Adrenaline starts to pump. Ultimately, you head into the infamous fight, flight, freeze response. Blood flow to your gut and kidneys slows down, so of course, that's going to impact digestion. Practicing deep breathing, yoga, and meditation can help clients find relief from some anxiety symptoms. Box breathing, also known as four-square breathing, involves inhaling, holding, exhaling, and holding on four counts. It's simple. It's not complicated, but it forces the brain to focus on one repetitive thing and to slow breathing, which leads to a calmer nervous system in the body and a more relaxed mind. Like a shorter version of meditation, it can increase resilience to stress, decrease feelings of depression, and increase positive feelings.
Positive Reframing
If our clients struggle with negative thinking, they can benefit from practicing a strategy called positive reframing. Positive reframing is not toxic positivity. It is not pretending everything is fine when it isn't. It's not about stopping them from experiencing negative or painful thoughts and emotions. Instead, it's about evaluating whether or not they want to believe a thought. Based on their decision, they can decide to support themselves instead of constantly criticizing themselves.
For example, the first thought might be, I hate my job, I hate my coworkers, I hate everything. I don't want to adult anymore. I don't know if you all work with gen Z, but I often hear that. Replace those words with something like, things are tough right now, and I'm feeling pretty disconnected from my work. I wonder if I can change anything about my job, my situation, or even my expectations and start to feel better. It doesn't say chin up; everything's fine. It agrees and acknowledges things are tough right now, and I'm feeling disconnected. Instead of that fixed mindset of, I hate everything; it's that changed mindset of I wonder what I can change right now.
Yes, and
I'm a huge fan of "yes, and." You may have heard it used in improv, but we often have a natural tendency to use the word "but" in our language, which disqualifies positive situations. For example, I really want a pandemic puppy, but it will require much training, cleaning, and cost. While those things are factually accurate, they immediately dampen your excitement and make you feel like you can't enjoy anything. Instead, reframing and using "yes, and," says, I really want a pandemic puppy, and I know there are things I'm going to have to be aware of, such as training, cleaning, and cost. If I start planning and preparing now, I can make a plan. Then when I get the puppy, I'll be able to focus only on how much joy and positive physical activity it will bring into my life. Again, it doesn't take away that training, cleaning, and costs are there. It just changes how it's seen. It's a both and.
Cognitive Behavioral Therapy (CBT)
Cognitive restructuring helps clients examine the idea of perfectionism and ask themselves if it's serving them. Where does the idea of perfectionism come from? Going back to those causes, such as societal norms, childhood pressures, social media, and everything we discussed. CBT is particularly effective for high functioning anxiety because it asks clients to identify life experiences that taught them messages about achievement and perfection. Then the therapist and the client can break down those cognitive loops and learn new behaviors to achieve preferred outcomes.
Looking at the evidence versus the narrative, our brains can tell us all kinds of stories. Where's the evidence? For example, I'm a failure, I'm bad at my job, and I'm going to get fired any second. That's a narrative. Does the evidence support that? Have clients think about their most recent annual or quarterly review, a recent email from a colleague praising their work, et cetera. Remind clients that when they are in a relatively anxiety-free mood, that's the time to compile all the nice things their boss, colleagues, and friends have said about them into one folder. This could be on their phone, on their computer, or it could be physical. That way, when the anxiety is spiraling, they don't have to search for evidence that they are worthy. It's all right there in a folder they can grab.
Building Strong Support Networks
Family, friends, and group therapy members must be dependable, compassionate, empathetic, nonjudgmental, and nurturing. Remind clients that no one person will be their be-all-end-all. Asking a partner, a family member, or a best friend to fulfill that role will lead to disappointment. Instead, help clients identify whose strengths lie where so that when the client needs a pep talk, they can go to friend A, but when they need a thought partner, they can go to friend B and get what they need out of each relationship.
Use Mindfulness Techniques
There are tons of grounding techniques you can use. One is 5, 4, 3, 2, 1, which is name five things you can see, four things you can hear, three things you can touch, two things you can smell, and one thing you can taste. In the 3-3-3 rule, name three sounds you hear, three things you see, and move three parts of your body. Other techniques include meditation, whether guided or solo, and movement, including yoga, walking, and exploring in nature.
Mindfulness is about bringing the client back to the present by grounding them in the current moment. Anxiety can mentally exhaust our clients and have real impacts on their bodies. Research has shown that simple mindfulness practices can reduce their anxiety and stress. It's about paying attention to daily life and the things we typically rush through. It's about turning down the volume in their minds by coming back to the body. Anxiety tells them they must control everything, and mindfulness is about noticing and letting go. It doesn't ask clients to ignore their thoughts but to recognize them for what they are. Just thoughts.
Establish Healthy Daily Patterns
Establish healthy daily patterns, especially for sleep. This includes getting eight hours of sleep and refraining from using technology after sundown as the light from smartphones and other electronic devices throws off our circadian rhythm. Eat your last meal no more than two hours before bed and monitor your alcohol and sugar intake. We know about this advice, but it's not exciting. It's not something that goes viral. It's just steady. A healthy sleep practice, in particular, helps regulate the nervous system, diminish anxiety, and manage those circadian rhythms. Our clients will often take an all-or-nothing approach to this, meaning they might say, great, I'm going to start going to a social club five days a week and meditating and journaling and doing yoga every day and create a perfect sleep environment in my home, and then I'll be cured.
Work with them to recognize that this part of their high functioning anxiety, the magical thinking, is still present and that they are not sprinting towards a goal of self-actualization or their end goal but pacing themselves in the marathon towards a goal they may never fully reach. The goal is not perfection. It is the journey toward self-actualization and contentment. No one is ever going to be happy every second of every day. It is about working towards it and feeling more of it than not. The message about self-care that's out there is that it's a reward for working ourselves to the bone. But self-care is mandatory for our clients to make sure that they don't harm themselves and others, emotionally, physically, and mentally, when they give and give until they're empty and then try to give some more. They think they're being martyrs, always being available, always being able to reschedule, and always being gracious when someone is late or no shows. It sounds like they're being caring, but they're building exhaustion and resentment inside themselves.
How can they show up and be present, attentive, empathetic, and focused if they're not taking care of themselves? They can do permanent, irreparable harm to themselves and others. I've seen it show up in clients who won't stop working, throw their back out, get really sick because their immune system is run down, and snap at their kid when they don't mean to in a moment of vulnerability that has long-lasting repercussions. Achievers are often praised for how giving they are. But one thing no one talks about is that they can do harm if they're trying to give from an empty vessel. If my job as a therapist is to hold space, to observe and reflect, to validate and challenge, and to listen actively, yet I am stressed out, burned out, and not nourishing myself, I can do actual harm. I can't fix anyone's problems in one day, but if I'm in a bad head space, I could exacerbate them and possibly do permanent harm. This is also true for our clients regardless of their fu, work, roles or family roles.
Questions and Answers
Does a person with high functioning anxiety normally criticize others to cover their own inabilities?
Yes, it can be one of the hallmarks or one of the symptoms of someone noticing in themselves some area that they feel they have a flaw. Instead of being able to look at that and wonder why they are feeling this way and examining and processing all the things that we would do with them in therapy, they might turn outward and lash out and point out in someone else the thing that they're most insecure about themselves. It could be something totally different to deflect and shine a light on someone else. Someone with high functioning anxiety could criticize others to cover their own abilities. It's not necessarily a 100% hallmark because I've also seen it go in the other direction with clients who internalize the messaging of, if I feel like I have a flaw or an inability, then I need to go inward and self-flagellate and really criticize myself and work harder. After all, if I'm imperfect, the people in my life won't want to be around me, they will abandon me. So I've seen it go in both directions, but it definitely can.
Going back to the nervous habits, is having GI issues a sign?
100% yes. Our gut is so connected to our brain; it's why we often say we have a gut reaction because the microbiome, the bacteria that are in our gut, is directly connected to our brain. If clients have digestive or gastrointestinal issues, it can often be a manifestation of anxiety that they haven't yet addressed or aren't even recognizing might be connected. That's a very good sign with gastrointestinal or digestive issues that can also fall under those nervous habits.
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Citation
Maenpaa, J. (2022). Working with high functioning anxiety: Supporting our overachievers. continued.com - Social Work, Article 165. Available at www.continued.com/social-work
