Therapy for Founders and CEOs: The Loneliness of the Top

THERAPY FOR DRIVEN WOMEN • June 15, 2026

The Weight of the Final Call

It’s 2:00 AM, and you are sitting alone at your kitchen table staring at a cash flow projection spreadsheet, the blue light of the laptop the only illumination in the room. Your tea went cold an hour ago. Your team thinks everything is fine. Your investors think you are crushing it. Your partner thinks you are just “working late again.” You are the only person in the entire organizational ecosystem who knows exactly how close to the edge the company actually is, and you have been carrying that knowledge alone for months, maybe longer, because there is no one it would be appropriate to tell.

You are exceptionally good at projecting confidence. You have to be, it’s part of the job description in a way that no one writes into the job description. The founder who shows panic signals the panic to her entire organization, and a panicked organization doesn’t perform well, and a poorly performing organization gets the founder fired. So you’ve learned to perform equanimity with the same precision you once performed for board presentations, and the performance has become so seamless that you sometimes can’t locate the line between the face you’re showing and whatever is left beneath it. The psychological weight of being the final decision-maker, the person who absorbs all the downside risk and manages everyone else’s anxiety while carrying your own entirely alone, has left you feeling profoundly, dangerously isolated. You have built something remarkable, and you feel like you are trapped inside it.

If you’re a female founder or CEO, you know this specific flavor of loneliness. It’s not the loneliness of being unpopular or unloved. It’s the structural loneliness of a role that demands you be everything to everyone, while offering you absolutely no safety net, no peer, no person to whom it is professionally safe to say: I’m scared. I don’t know if this is going to work. I need someone to hold some of this with me.

What Building a Company Does to the Nervous System

The startup ecosystem is built on the premise of infinite scale and perpetual urgency. The narrative of startup culture, the TechCrunch profiles, the investor pitch decks, the conference keynotes, presents the founder experience as one of exhilarating momentum, bold vision, and the heroic individual will that moves markets. What it doesn’t describe is what happens in the nervous system of the person living that narrative: the cortisol that spikes with every board meeting, the adrenaline that keeps you functional at hours that would incapacitate a non-founder, the hypervigilance that has you scanning every Slack channel at midnight not because you want to but because your nervous system has been conditioned to treat every communication as a potential existential threat.

When you are the founder, every problem is ultimately your problem. Your nervous system learns to treat every churned customer, every hiring mistake, every negative press mention, and every investor email that begins with “Can we chat?” as a high-stakes threat requiring immediate mobilization. This is not a pathological response, it is an adaptive one. The problem is that it was never designed to be the permanent state of operation, and yet for many founders, it becomes exactly that. The company doesn’t have an “off” setting, so neither do you.

When your nervous system is constantly mobilized for threat, it loses the capacity to down-regulate. The body was designed to spike cortisol in response to acute danger and then, after the threat has passed, to return to baseline through a natural completion of the stress cycle. What it was not designed to do is maintain the spike indefinitely, but the founder role often requires exactly that. You spend years running on cortisol and adrenaline, and your body adapts to this state of chronic hypervigilance, treating it as the new baseline. You forget what it feels like to be relaxed. You forget what it feels like to not be needed. And when the company has a good week, you don’t feel happy, you feel the terrifying absence of an immediate threat, which your now-dysregulated nervous system processes as suspicious rather than safe.

Many driven women I work with didn’t experience overt abuse, they experienced something subtler and, in some ways, harder to name: childhood emotional neglect, the absence of attunement that teaches a child her emotions don’t matter.

The Neurobiology of Founder Isolation

The human nervous system is designed, at its most fundamental level, to co-regulate with others. When we are stressed, we seek connection, not as a luxury or an emotional indulgence, but as a biological imperative. Physical proximity, eye contact, the sound of a calm voice, and the experience of being genuinely witnessed by another person all activate the ventral vagal system and signal to the body that the threat has passed, that safety is available, that it can come down from high alert. This is what Stephen Porges, PhD, neuroscientist and creator of polyvagal theory, calls the social engagement system: the body’s primary tool for self-regulation.

But for a founder, the people you interact with most, your team, your investors, your board, your advisors, even your most trusted mentors, are not safe sources of co-regulation. They are stakeholders. They have interests, expectations, and anxieties of their own, and it is your job to manage those, not to unload yours onto them. You cannot show your team the full extent of your panic without risking organizational stability. You cannot tell your lead investor that you haven’t slept in three weeks without risking a difficult conversation about your fitness to lead. You can’t call your board chair at 2:00 AM with the spreadsheet you’re staring at and ask her to help you carry it. The role demands that you be the regulating presence for everyone else, and it offers you almost no reciprocal regulation in return.

For many driven women, this dynamic echoes what clinicians call betrayal trauma, the specific injury that occurs when the person or institution you depend on is also the source of your harm.

Bessel van der Kolk, MD, psychiatrist and trauma researcher and author of The Body Keeps the Score, explains how the body adapts to chronic stress without co-regulation: it learns to handle all threats alone. This adaptation is efficient in the short term and deeply corrosive in the long term. The body develops what looks like stoicism, an apparent capacity for enormous stress tolerance, but which is, physiologically, a progressive loss of the capacity for genuine felt safety. The founder who says “I’m fine” and means it has often simply lost the ability to notice that she’s not. She presents as capable, decisive, and emotionally regulated. Internally, she is physiologically rigid, unable to delegate, unable to trust, unable to let her guard down even when she is technically off the clock, because the off-clock switch has been disconnected.

Over time, this kind of sustained, inescapable stress can produce symptoms that look remarkably similar to complex PTSD, not from a single event, but from the cumulative weight of years spent in a system that treats human limits as defects.

How This Shows Up in Driven Women

In my clinical work with female founders and CEOs, the psychological presentation is consistent enough that I can describe it with some specificity. These are not women who lack self-awareness. They are often extraordinarily self-aware. What they lack is the ability to act on what they know, because the same systems that make them exceptional leaders have been running at such high intensity for so long that they’ve calcified into chronic patterns.

The Imposter Syndrome: Despite the revenue, the funding rounds, the press coverage, and the team she’s assembled, the founder constantly fears that she is one mistake away from being exposed as a fraud who got lucky. She attributes success to favorable market conditions and failed to notice the obstacles in her way. She attributes failure, or near-failure, or the perception of failure, to fundamental character defects. Brené Brown, PhD, LMSW, researcher and author studying vulnerability, courage, and shame, has documented how shame operates in driven individuals: it attaches most powerfully to perceived identity, not just behavior. The founder doesn’t fear she made a bad decision. She fears she is a bad decision.

The Inability to Delegate: She hires talented, capable people and then finds herself reviewing their work at midnight, subtly or not-so-subtly redoing things they did well enough, or simply unable to create the psychological space to let the outcome be determined by someone other than herself. This isn’t a management problem; it’s a nervous system problem. When your sense of safety is fused with the company’s performance, and the company’s performance feels like it depends on your personal control of every variable, delegation doesn’t feel like professional development. It feels like exposure. It feels dangerous.

The Post-Fundraise Crash: She has spent three to six months running on pure adrenaline, the pitch circuit, the due diligence, the term sheet negotiations, the closing mechanics, maintaining a public performance of confidence and momentum. When the wire finally hits, when the term sheet is signed, when the moment of “success” arrives that she has been orienting every decision around for months, instead of relief she experiences a plunge into flat, gray depression. Her body, deprived of the adrenaline that has been its fuel, has nothing left to run on. The crash is physiologically real, and it is almost never talked about in founder communities, because the cultural narrative of a successful close is supposed to end in celebration, not in staring at the wall unable to generate an emotion about anything.

The Childhood Pattern in the Board Room: What I see consistently in my work with driven founders is that the specific ways they lead, struggle, and relate to power are not random, they are deeply autobiographical. The founder who cannot tolerate ambiguity in her organization likely grew up in a household where unpredictability was dangerous. The founder who cannot let anyone else be competent was probably the responsible one in her family of origin long before she ever ran a company. The founder who over-explains herself in every board meeting may have grown up in a home where her observations were consistently dismissed, where she learned that she had to build a fortress of evidence before anyone would take her seriously. The company becomes the canvas on which childhood relational patterns play out at organizational scale, and until those patterns are named and worked with directly, they will continue to shape leadership decisions in ways that are costly, compulsive, and often invisible.

The Achievement as Sovereignty Framework

Many driven women who become founders developed what I call Achievement as Sovereignty early in life. In childhood environments where love, safety, or approval was conditional, where a parent was emotionally unavailable, chronically anxious, or whose affection had to be earned through performance, achievement became the primary vehicle for control. If you were the smartest, the hardest working, the most successful person in the room, you were safe. You were needed. You were not at risk of being left, dismissed, or found inadequate. Excellence was not ambition. It was self-protection.

Building a company is, in many ways, the ultimate expression of this survival strategy. It is the most complete possible form of Achievement as Sovereignty: you create your own environment, you command your own respect, and you prove your worth not just to one person or institution but to the entire marketplace. The company is simultaneously the evidence and the vehicle. It says: I am worth funding. I am worth following. I am worth betting on. For a woman whose childhood offered her very little unconditional confirmation of those things, the company is not just a professional endeavor. It is a psychological project. It is the most elaborate answer she has yet constructed to the question that has followed her since childhood: Am I enough?

But this architecture is also a trap. When the company becomes the primary vehicle for your sense of worth and safety, you can never, ever let it fail, because the company’s failure is not just a business setback. It is existential. It is confirmation of the wound. Your inability to distance yourself from the P&L isn’t a professional failing or a lack of emotional sophistication. It is the entirely predictable consequence of having built a company on top of an unhealed wound. And the wound doesn’t get healed by building a bigger company. In my experience, both clinical and personal, it gets bigger the bigger the company gets.

I built Evergreen Counseling from the ground up: the initial vision, the early hiring, the first lease, the scaling of clinical services, the operational infrastructure, the eventual successful exit. I know what it feels like to sit in the driveway and not be able to go inside. I know what it feels like to look at a cash flow statement at 2:00 AM and have it feel like a verdict on your worth as a human being. I also know what it feels like to have done the personal work, to have separated, at the level of the body and not just the mind, who you are from what you’ve built. That work is possible. It is the most valuable work I’ve ever done. And it is what I bring to every session with a founder client.

Both/And: You Are a Visionary AND You Are Exhausted

One of the most important things we do in therapy is hold the Both/And. The startup culture offers founders a very specific and very narrow emotional range: you are crushing it, or you are struggling, and struggling is framed as a failure of vision, character, or execution that you need to fix as quickly as possible and then return to the performance of crushing it. There is no official space in the founder narrative for “I am doing remarkable things AND I am profoundly exhausted AND I sometimes wish I could walk away from all of it AND I am genuinely terrified AND I am still doing the work.” But that is the true experience of most founders I know.

You are a brilliant visionary AND you are profoundly exhausted. You are proud of what you built, the jobs you created, the customers you served, the problem you were uniquely equipped to solve, AND you sometimes lie awake wishing you could burn the whole thing down and disappear. You are grateful for the opportunity AND you feel completely isolated in a way that almost no one in your life has the capacity to understand. You love your team AND you are resentful that they get to clock out and you don’t, that they get to be wrong without it costing them everything, that their anxiety is something you have to manage rather than something you’re entitled to feel yourself.

Richard Schwartz, PhD, founder of Internal Family Systems therapy, describes the psyche as containing many “parts”, internal voices, roles, and managers that developed in response to circumstances and now operate largely outside of conscious control. For many founders, the part that keeps them in relentless motion, the one that believes that slowing down equals failure, that asking for help equals weakness, that admitting exhaustion equals confirming everyone’s worst suspicions about you, is a part that deserves not judgment but curiosity. It developed for good reasons. It worked, for a long time. Therapy is the process of recognizing it, understanding what it’s protecting, and gradually teaching it that the conditions that required its extreme measures are no longer the whole story. You get to rest now. You are allowed to be exhausted. The company does not require your constant self-erasure in order to survive. Therapy is the place where you don’t have to pretend that the title makes the pressure disappear.

The Systemic Lens: A Culture That Monetizes Resilience

Silicon Valley culture was not designed with founders’ nervous systems in mind, or with women’s nervous systems specifically. It was built around an archetype that is still, despite decades of superficial diversification, predominantly modeled on the young, unencumbered, hyperfocused male founder who is able to dedicate every waking hour to the company because he has, invisibly, a domestic infrastructure that supports his total immersion. The “hustle culture” mythology, move fast and break things, sleep is for the weak, the market rewards the relentless, is not culturally neutral. It is a narrative designed to extract maximum labor from founders while framing any resistance to that extraction as a personal inadequacy rather than a reasonable human response.

When a female founder struggles, when she can’t maintain the performance, when the exhaustion becomes visible, when the isolation begins to cost her leadership capacity, the culture often responds not with structural support but with individual advice: hire a better COO, read a better leadership book, work with a better executive coach on your “scale issues,” meditate. The implication is always that the founder’s struggle is a problem of her own making, solvable by better individual optimization. It is almost never framed as the predictable outcome of a culture that demands total identity merger and then offers no support when that merger begins to destroy the person.

The data on this is stark. Female founders receive a staggeringly disproportionate share of venture capital, according to Crunchbase, companies with all-female founding teams received just 2.1% of venture capital in 2023, while mixed-gender teams fared only marginally better. The financial landscape of startup culture sends an unambiguous message about whose vision is worth backing. Female founders navigate this reality on top of all of the structural challenges that male founders face, and they do so in a culture that has historically offered them few peers, fewer mentors, and almost no language for the specific psychological terrain of building a company while female. The loneliness at the top is not accidental. It is, in part, engineered.

What Trauma-Informed Therapy Looks Like for Founders

Therapy for founders isn’t about helping you optimize your morning routine, set better OKRs, or develop a “healthier relationship with failure.” You have probably already read the books that promise those things. What you haven’t done, what the founder ecosystem rarely creates space to do, is address the psychological infrastructure beneath the leadership performance. That is what therapy is for.

These relational patterns often trace back to early attachment experiences, the blueprint your nervous system created in childhood for how relationships work, what you can expect from others, and how much of yourself it’s safe to show.

As an LMFT and an executive coach who built, scaled, and successfully exited my own multimillion-dollar therapy center, I understand the specific psychological terrain of the founder landscape with a precision that is clinical and personal simultaneously. I know what it feels like to sit in the driveway unable to go inside. I know what it feels like to have a team that depends on you and no one to depend on yourself. I know the particular shame of a failed hire, the particular terror of a missed payroll, the particular dissociation of performing confidence when you’re genuinely afraid. I work with founder clients from that place of deep recognition, not as someone who has read about it, but as someone who has lived it and done the work to heal it.

In practice, this work operates on several levels. At the somatic level, using approaches informed by Pat Ogden, PhD, founder of Sensorimotor Psychotherapy, we work directly with the nervous system patterns that years of high-stakes stress have created, the chronic bracing, the inability to rest, the physiological hypervigilance that doesn’t power down even on vacation. At the parts level, using Internal Family Systems, we identify and work with the specific internal parts that are running your leadership, the relentless driver, the terrified protector, the wounded child who started this whole thing because she needed to prove something. At the relational level, we address the specific ways your childhood relational experiences are showing up in how you lead, hire, manage, and relate to power and authority.

We work on retrieving the parts of yourself that you had to exile to survive the startup ecosystem, the playful one, the uncertain one, the one who could be genuinely delighted without it feeling like a distraction. We build a psychological foundation, what I call Terra Firma, that remains stable regardless of your MRR or your cap table, so that you can make leadership decisions from clarity rather than from fear, and so that you have a self to return to when the company is eventually, inevitably, no longer the same size or shape or stage that it is today.

If you’re ready to build an identity that doesn’t require a pitch deck, I’d love to support you. You can schedule a free consultation here, or learn more about my therapy practice.

Related Reading

[1] van der Kolk, B. (2014). The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. Viking.
[2] Maté, G., & Maté, D. (2022). The Myth of Normal: Trauma, Illness, and Healing in a Toxic Culture. Avery.
[3] Schafler, K. (2023). The Perfectionist’s Guide to Losing Control: A Path to Peace and Power. Portfolio/Penguin.
[4] Nagoski, E., & Nagoski, A. (2019). Burnout: The Secret to Unlocking the Stress Cycle. Ballantine Books.