Photo credit BigStockPhoto Maridav
by Dr. Danna Bodenheimer, LCSW, DSW, author of Real World Clinical Social Work: Find Your Voice and Find Your Way and On Clinical Social Work: Meditations and Truths From the Field
In clinical spaces, we are trained to assess impairment. We look for dysfunction, instability, disruption. We’re taught to notice when someone can’t work, can’t maintain relationships, can’t regulate.
But many neurodivergent clients walk into our offices carrying the opposite problem.
They can do everything.
They are employed, articulate, insightful, empathic. Often the emotional caretaker in their families. They make eye contact. They track the conversation. They show up on time. They apologize for taking up space.
And because of this, they are frequently labeled — implicitly or explicitly — as “high functioning.”
The problem is that what we are calling functioning is often masking.
Masking is not wellness. It is adaptation under pressure.
What masking actually is
Masking refers to the conscious or unconscious suppression of neurodivergent traits in order to appear socially acceptable, safe, or competent. It is not simply trying hard. It is a nervous system strategy developed in response to repeated social consequences.
Many clients learn early:
- If I stim, I am teased.
- If I speak directly, I am rude.
- If I don’t smile, I am a problem.
- If I’m overwhelmed, I am dramatic.
- If I ask for help, I am too much.
So they build a second operating system.
They study other people. They script conversations. They rehearse facial expressions. They monitor their tone. They override sensory needs. They force eye contact. They perform warmth. They perform calm. They perform competence.
This performance is often praised.
- “Such good social skills.”
- “So insightful.”
- “You’re doing so well.”
But internally, the cost is accumulating.
The clinical illusion of “doing fine”
Social workers are especially vulnerable to misreading masked clients, because we are trained to respond to visible crisis.
The client who is dissociating but still verbally engaged can look regulated. The client who is in shutdown but smiling can look like they’re coping. The client who has spent their life intellectualizing their experience can look self-aware.
We may even experience relief.
Good, this one isn’t falling apart.
But masking clients are often not coming to therapy because things are easy. They come because the system they built to survive is no longer sustainable.
Common presentations include chronic burnout without a clear cause; sudden loss of functioning after years of competence; panic attacks that seem to come out of nowhere; somatic symptoms with no medical explanation; exhaustion after basic social interactions; and a persistent sense of being fraudulent, empty, or not real.
When we interpret competence as capacity, we risk reinforcing the very strategy that is harming them.
How our language reinforces masking
Well-intentioned clinical praise can unintentionally push clients further into self-erasure.
When we say, “You’re so high functioning,” “But you’re doing great,” “You’re very resilient,” or “You seem fine,” we may be affirming their performance, not their personhood.
For many neurodivergent clients, competence was never a freely chosen identity. It was a survival requirement. They did not become resilient because they were thriving. They became resilient because there was no room to fall apart.
When we center their ability to function in neurotypical systems, we subtly communicate: keep doing that — that’s the part we value.
This can delay access to accommodations, deepen shame, and increase the risk of collapse.
The hidden cost of looking put together
Masking is neurologically expensive. It requires continuous self-monitoring and inhibition. Over time, this contributes to nervous system dysregulation, executive functioning depletion, increased anxiety and depression, loss of interoceptive awareness, identity confusion, and autistic burnout or skill regression.
By the time many clients reach us, they are not asking how to function better. They are asking, often quietly: How do I stop disappearing?
What social workers can do differently
Supporting masked neurodivergent clients requires a shift in what we pay attention to and what we interpret as health. Many of these clients have spent years being praised for what they can accomplish, while the internal cost of that accomplishment has gone unseen. Therapy can unintentionally become another place where performance is reinforced if we focus primarily on outcomes rather than internal experience.
A client who handled a difficult interaction, completed a demanding week, or maintained composure in a stressful situation may indeed have demonstrated skill — but they may also have overridden sensory, emotional, or cognitive needs to do so. When we slow down enough to explore what it took to get through something, we begin to see the nervous system labor that competence can conceal.
This shift also asks us to reconsider how we define functioning. Neurodivergent clients are often highly capable of complying with environments that are misaligned with their nervous systems. They can tolerate noise, social demand, unclear expectations, or emotional labor far beyond sustainable limits — until they can’t. From the outside, this tolerance can look like resilience or stability. From the inside, it may feel like constant bracing. Just because a client can endure something does not mean it is neutral or healthy for them. Therapy becomes a place not only to increase capacity, but to discern where capacity has been confused with survival.
We are also invited to loosen our reliance on neurotypical social cues as indicators of regulation. Eye contact, tone, facial expressiveness, and conversational rhythm are culturally shaped and neurologically variable. A flat affect may signal safety, not disengagement. Reduced eye contact may lessen cognitive load. A still body might reflect shutdown rather than calm. When we equate familiar presentation with well-being, we risk missing distress that does not look the way we were trained to expect.
As masking fatigue sets in, clients often begin to question their own identities. They may describe feeling fraudulent, empty, or unsure of who they are when they are not performing for others. They may say they can’t keep this up, that they used to be able to do more, or that something in them is breaking down. These are not simply statements of low self-esteem; they are often signals that a long-standing adaptation is becoming unsustainable. When we understand these moments as the nervous system reaching its limit rather than as personal failure, the clinical stance shifts from correction to support.
From this place of understanding, our interventions can begin to support authenticity and sustainability rather than reinforcing performance.
Practical shifts in clinical practice
- Get curious about effort, not just outcome. Ask what it took to get through an experience and how the client felt afterwards, rather than focusing only on whether they managed it.
- Name the difference between capacity and compliance. Help clients explore whether what they are tolerating is actually sustainable for their nervous system.
- De-center neurotypical presentation as the measure of regulation. Stay curious about internal state rather than assuming affect, eye contact, or tone tell the full story.
- Listen for identity statements that signal masking fatigue. Comments about feeling fake, lost, or unable to keep going may reflect the collapse of a survival strategy.
- Shift praise toward self-attunement. Affirm noticing limits, resting, setting boundaries, asking for support, and honoring sensory or emotional needs.
When a client appears put together, it can be tempting to measure success by how well they are functioning in the world as it is. But our work is not to help people disappear more efficiently. It is to help them live in ways their nervous systems can actually survive.
Masking is often the invisible labor beneath competence, and many clients have spent years believing that this labor is simply who they are. When therapy becomes a place where the cost is finally named — where effort is seen, where exhaustion makes sense, where adaptation is understood as adaptation — something begins to soften. If we only see the competence, we miss the person. And if we miss the person, we risk helping them keep a life that is quietly breaking them.
Dr. Danna Bodenheimer, Founder and Director of the Walnut Psychotherapy Center, has worked in the field of mental health for more than 15 years. Her expertise is most centered around working with the LGBTQ+ population and neurodivergent population. She takes different, cutting edge approaches to thinking about and treating individual and organizational trauma. She has also long studied the impacts of dual marginalization on the psyches of individuals in treatment and in the workplace.
Dr. Bodenheimer received her bachelor’s and master’s degrees from Smith College, her post-baccalaureate degree from Columbia University, and her Doctor of Social Work from the University of Pennsylvania. She has taught at Temple University, Rutgers University, Bryn Mawr College, and Penn. She can easily discuss complex issues of life along the gender spectrum, neurodivergence, racial dynamics in the workplace and interpersonally, and the lifelong impact that trauma has on overall human functionality. She has also authored two books on how to practice in the field of psychotherapy and has mentored hundreds of developing clinicians as they have grown their own practices.
Dr. Bodenheimer is unusually adept at having difficult dialogues, identifying language to help communicate intricate psychological processes, helping people to say what feels hardest to say, and creating relational environments that allow for lasting connection and safety.
Dr. Bodenheimer has recently developed an expertise around neuro-affirming care derived from multiple avenues of study and clinical work. First, she has long criticized and studied the harmful impacts of ABA (applied behavioral analysis) treatment, while trying to cultivate relational alternatives to this pervasive practice. Dr. Bodenheimer's own caseload is largely made up of neurodivergent clients, immersing her in the world of how different brains work daily. In Dr. Bodenheimer’s own research, her focus has also been on the strong intersection between gender expansion, queerness, and neurodiversity. She offers several trainings on what concrete steps a therapist can use to create a more neuro-affirming space for clients. This often means subverting and deconstructing our dominant understanding of what does and does not actually work, and how to create both relief and the opportunity for unmasking in treatment.
She is working on a book that affirms that self-diagnosis process and will serve as a guide and journal for those exploring their own neurotypes, which will be out in March 2026.