This article examines some common assumptions made by clinicians about the relationship between intelligence and mental health difficulties. Drawing on work by Thomas Ogden (1976) and Alex Coren (1997) on academically successful students who present with serious mental health concerns, it aims to provide a psychodynamic, developmental conceptualization of this uneven clinical presentation. Using clinical illustrations, it attempts to help therapists who work with college students move beyond the focus on academic success to provide a clinical and theoretical perspective on selfhood and difficulties with authenticity in such students.