Retiring High & Low Functioning: Why Language Matters in Care

When seeking out professional mental health care, you might encounter the terms “high functioning” and “low functioning.” 

“High” and “low” functioning descriptors often come up when seeking care for ASD (Autism Spectrum Disorder), but it’s not exclusive to just autism. People with varying levels of anxiety, depression, or other mental illnesses can be labeled as either high functioning or low functioning. 

In its typical usage “high functioning” describes someone who is able to function independently in their day to day life, while managing something like ASD, anxiety, or even a physical disability. 

In contrast, “low functioning” refers to someone that cannot function without a higher level of supportive care. They may need help making appointments, getting from place to place, etc. 

What’s the problem with the language?

One of the big problems with using “high” or “low” functioning as patient descriptors, is that it establishes a behavioral “normal” for individuals and adds judgment onto those who cannot meet it, and pressure on those who can meet it–if they deplete themselves completely. 

High functioning often leaves people feeling like they can’t ask for help because everyone views them as so capable, when it’s often an internal pressure making them “achieve” despite struggling. 

And the term low functioning can leave people who are already trying their best just to get through the day like they’re not doing enough, not living up to expectations, not “pulling their weight”, weak or lazy for needing to ask for so much help. 

The reality is our world is designed in such a way that it’s even hard for neurotypical people with lots of social and structural support to stay on top of everything they need to. Anyone who deviates from that “norm” of how to do things ends up feeling like they’re fundamentally incorrect, when really our society is only accommodating to a small fraction of people.  

There is also the issue that “high functioning” and “low functioning” are often influenced by how someone appears to function–not how much support would improve their quality of life. So someone high functioning may actually be using all of their energy to complete what is required of them at work, with no physical or mental energy left for anything else in the day. And low functioning isn’t often about all types of functioning–things like adaptive behavior, various presentations of intelligence, aren’t considered so the “low functioning” label can inadvertently reinforce ableist norms.  

Why ACNY has opted out:

While high and low functioning are terms we commonly encounter in the mental health care industry, we think the unintentional meanings attached to them are more harmful than the terms are useful. 

We’d like our clients to be familiar with the general usage of the terms within the industry, so that they can understand them when they encounter them outside of our care, but within our own work, we prioritize client centered language. We want the language we use with our clients to be supportive tools for them, rather than something that others or belittles them. 

An alternative to high and low “functioning” is to shift the language to focus on the support needs–so rather than “low functioning” someone would be described as having “high support needs.” This language is also much more clear in what it means for the patient–instead of feeling a general sense of not meeting expectations, it lets them know what can help, which is a higher level of support. 

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