Some of the most successful people a psychiatrist meets are also some of the most dissatisfied with life. They don't necessarily look unwell. They are executives, entrepreneurs, doctors, lawyers and high achievers. They run companies and families. They are the people others depend on when something goes wrong. Often, they are exceptionally good at coping. Until they aren't.
A Case of Concealed Distress
Holly* came to see Dr Darren Lee after years of depressive symptoms and worsening substance use, both of which she had largely managed to conceal from family, friends and colleagues. Her GP recommended a residential treatment program. In her early 40s, she held an executive position in a demanding organisation. She was ambitious, respected and known for her extraordinary work ethic. She was also exhausted.
Outside work, things were beginning to unravel. She was struggling to sleep and increasingly used alcohol to switch off at night. There were periods of profound sadness and numbness. But Holly kept working.
In fact, work was the one place she still felt energised. She would often be in the office 12 hours a day. She told Dr Lee that when she was busy, she didn't have to think. There was always another meeting, deadline or problem to solve. Achievement gave her a sense of control and, temporarily, a sense that she was doing well in her life.
Roots in Childhood
Holly's story is something Dr Lee sees regularly – often the characteristics celebrated as resilience in society can also be ways of coping. In therapy, they began to understand why achievement had become so important to Holly. Her childhood had been unpredictable. She learned early to monitor the moods of the adults around her, avoid causing problems and become fiercely independent. Academic success brought praise and, crucially, higher self-esteem. So she became very good at succeeding, but this meant being harder and harder on herself when she failed.
None of this meant her ambition wasn't genuine. Nor does being ambitious mean someone has experienced trauma in their life. But for Holly, achievement had become tangled up with something deeper. She told him in one of their earlier sessions: "If I am successful enough, useful enough and busy enough, I know I will feel better about myself." This can be one of the more difficult manifestations of unresolved trauma to recognise because, from the outside, it can look remarkably functional.
Fear of failure can contribute to perfectionism. Difficulty resting can be mistaken for drive. Becoming highly attuned to other people's moods can make someone appear very emotionally perceptive.
When Achievement Becomes a Need
Nobody stages an intervention because you're answering emails at 1am or volunteering for another project. In fact, you may be promoted for precisely the behaviours that are exhausting you. The difficulty comes when achievement stops being something you pursue and becomes something you need. For some people, slowing down creates an uncomfortable silence. Without the next deadline or accomplishment, difficult emotions may have more room to surface, and the person can feel flat or depressed. So they keep working. Until a relationship ends. A parent dies. There's a redundancy. A child is born. The body simply becomes exhausted. Or the strategies being used to manage the feelings – alcohol, drugs, compulsive exercise or relentless work – begin creating problems of their own.
This was where Holly found herself. Treating her depression was important, but so was understanding what sat beneath her relentless productivity. Over time, she began recognising that some of the qualities that had once helped her cope earlier in life were also masking deeper difficulties with self-esteem, safety, intimacy and identity.
The goal of their sessions wasn't to strip her drive or trace every achievement back to childhood pain. Ambition can come from curiosity, passion, purpose, competitiveness and genuine enjoyment. Instead, Dr Lee raised questions such as: What happens when you stop? Can you rest without feeling guilty? Can you fail without feeling worthless? Can you say no without fearing rejection? Can you feel valuable when you aren't achieving anything? For Holly, these questions were surprisingly difficult.
Rethinking Success
After starting to address her depression and substance use, she began creating space in her life that had previously contained almost none. She learned to sit with her feelings rather than immediately working through them or suppressing them. This helped her separate her sense of worth from her role and productivity. She remained successful. But success was now less determined by external factors.
Sometimes the behaviours that helped us survive become so embedded that they mask our past traumas and adversity. The challenge isn't necessarily to give them up. It's to understand what drives them – and realise we are more than them.
*All clients discussed are fictional amalgams. Dr Darren Lee, MBBS BMed Sci FRANZCP FAChAM, is the acting medical superintendent at South Pacific Private, a trauma, addiction and mental health treatment centre.
