Q: A couple has asked me to help them deal with the husband's new AD/HD diagnosis and their past 20 years of discord. Financial problems loom large, and both seem exhausted. Where do I begin?
A: You describe an all-too-familiar scenario. By the time couples finally realize that adult AD/HD is the common thread running through their long-term woes, they're often hanging onto their last, frayed nerve—and maybe their last dollar, too. It often takes a decisive event—discovery of secret debts, a job loss, an affair, an eye-opening article about AD/HD—to focus attention after years of missed red flags.
It's not solely the symptoms that afflict relationships, though adults with untreated AD/HD have roughly double the divorce rate. It's also the years of misattributing the symptoms to lack of caring, selfishness, passive-aggressiveness, and immaturity. Undiagnosed adults often lug around a lifetime of poor coping strategies and cognitive distortions; over time, the same becomes true for their mates. With both people reacting blindly to the effects of AD/HD, which counseling frequently doesn't identify, their life together can feel like a wild roller-coaster ride.
Jeanine complains she's been riding the roller coaster throughout her 20-year marriage to Bart, trying to hang on and "manage the unmanageable" of his chronic forgetfulness, perpetual tardiness, disorganization, and erratic sleep schedule. She repeats a common refrain: "I feel like I've been parenting another child!"
In response, Bart has long chided her for being too uptight and controlling. "She's always at me about every little thing." His lack of perspective makes sense, when you consider he knows no other way to be in the world (his dad had AD/HD, too) and that the symptoms themselves can inhibit insight and objectivity. Without a better understanding of their discord, Jeanine has often accepted her husband's viewpoint and tried to back off. The more she's done this, though, the more their household has spiraled into a dysfunctional mess of mislaid bills, huge credit-card debt, missed appointments and social events, lost keys and wallets, and uncompleted domestic tasks.
Bart's AD/HD diagnosis, revealed when their child was diagnosed, comes as a relief to both of them, providing an explanation for many of the challenges they've had to confront. That doesn't mean, however, that Jeanine can easily let go of the resentment she feels for having been blamed for the family's problems all these years and for now having to dig their family out of debt.
For his part, Bart struggles with a lifetime's worth of baggage, always feeling unfairly beaten down, criticized, and frustrated with (and by) the people around him. Even though he's willing to accept the diagnosis, he lacks the fortitude to withstand Jeanine's anger, especially when he, like many adults with late-diagnosis AD/HD, holds out little hope for change. Nothing he's tried in the past has worked.
This couple needs a walloping dose of optimism. They need to start feeling that they can turn their relationship around, with the right help. Their therapist might feel like the little Dutch boy at the dike, but not knowing which holes to plug first: the emotional, the medical, or the practical. In fact, effective treatment covers all those issues and more. Fortunately, though AD/HD is considered the most impairing outpatient condition, it's also the most treatable.
Flying Beneath the Radar
One reason therapists often overlook AD/HD is that the challenges with communication, cooperation, discordant parenting styles, sexual intimacy, domestic chores, and money management that arise from it resemble those brought into therapy by many other distressed couples; however, with AD/HD, these issues have a greater severity.
When novelty and stimulation are higher—at the beginning of a relationship or a job, for instance—many people with AD/HD function at a high level. Frequently, their mates fail to recognize certain behaviors as red flags for long-term AD/HD. These are both reasons AD/HD can fly under the radar. With previously high-functioning AD/HD adults, it's sometimes the gradual addition of new responsibilities that can ultimately overwhelm their brains' capacities, diminishing competencies over time and exposing counterproductive coping strategies.
For instance, until their first child arrived, Bart had always coped with his disorganization and poor time sense by strictly structuring his day. It wasn't easy, but Jeanine managed to accommodate him—until they had a family. Judging solely by appearances, one might think that his newfound difficulty lay in adapting to fatherhood, but more accurately, fatherhood exposed the real issue: unrecognized AD/HD, compounded by counterproductive coping strategies.
What Therapists Can Do
Effective treatment begins with recognizing that AD/HD has a neurogenetic basis. Once both partners understand the real problem, psychoeducation-focused therapy can help them identify AD/HD traits, such as impulsivity and distractibility, and address the emotional baggage of a lifetime of unresolved frustrations. Then the therapist can help clients develop new strategies for handling life's practical details, because with AD/HD, it's the practical matters that create so much daily stress.
Clarifying the neurobiological nature of AD/HD can go a long way toward increasing optimism and goodwill between partners. Late-diagnosis adults tend to describe themselves with terms like failure, defective, socially undesirable, and incompetent. Similarly, their mates have acquired self-blaming misattributions, like bad-tempered, nagging, and fault-finding. Correcting these cognitive distortions gives everyone the space to develop more productive strategies.
AD/HD experts agree that the best tool currently available for improving cognitive function is medication. If the client responds positively to medication, many treatment-disruptive symptoms, such as interrupting, deflecting responsibility, losing track of the discussion, and not listening attentively, are reduced or eliminated. Because clients spend more time with their therapist than with the prescribing physician, therapy is the logical place to examine a couple's attitudes toward medication to help inform their decision.
Many AD/HD clients have difficulty accurately monitoring their behavior and their response to medication. Therapists can play an important role by providing feedback to the physician and soliciting feedback from the spouse. They can assist in identifying poor health habits that worsen cognition, such as an unhealthy diet and insufficient sleep or exercise, and help the client practice new behaviors.
Experienced clinicians treating AD/HD use approaches that traditionally have been viewed as overstepping therapeutic boundaries or being too "active." For example, they might create automated e-mail reminders for clients. At each session's end, they may provide clients with a copy of their notes to help them remember what was discussed and the strategies that were developed. Giving clients structured tasks to work on between sessions accelerates therapy and provides opportunities to succeed during the week.
Medication can help immensely, but challenges remain. Developing and consistently using externally supportive strategies constitutes the heart of taking charge of this condition. For example, clutter and disorganization dog most couples affected by AD/HD. Consider teaming up with an AD/HD-savvy professional organizer to help establish work- and home-based systems. This not only boosts clients' confidence that workable solutions exist, but also relieves the non-AD/HD spouse from having to continue "nagging" to get things organized. It's helpful to devote in-session time to solving any compliance issues with these systems, such as helping AD/HD adults, who tend to think in all-or-nothing terms, understand that progress, not perfection, is the goal.
The consensus among AD/HD experts is that Imago Relationship Therapy often works well for these couples. This approach trains people to communicate and slow down enough to understand their partner's point of view. The structure of the dialogue is especially useful, because it encourages the person with AD/HD to stay on track and focuses on empathy, often a casualty of the untreated symptoms. Cognitive-Behavioral Therapy (CBT) seems effective, although it's important to bear in mind that recent studies touting it have utilized a form of this treatment specifically tailored to AD/HD and in conjunction with medication.
Individual or Couples Sessions First?
Each partner in a couple has been suffering a different type of fallout from unrecognized AD/HD, and it's admittedly tricky to meet both persons' needs at the same time. At least initially, Jeanine and Bart might benefit from individual therapy that would allow them to deal with their pent-up frustration and provide the psychoeducation about AD/HD that's a critical first step. The sooner each partner can start separating the symptoms from the person, the better. Later on, joint couples therapy with a therapist skilled in AD/HD would add an important component.
Starting out with joint couples therapy might be worth considering, however, because the therapist would have a greater chance of hearing the full story. "My partner's inaccurate self-observation with therapists has been a tremendous problem," one client in an AD/HD support group explained. "They all believed her characterization of events, and just encouraged her misperceptions, which only made her work life and our family life worse. Couples therapy has been a little better, because I can provide some checks and balances."
The good news is that adult AD/HD is eminently treatable. The first and most essential step for therapists is to reverse the trend and learn to recognize and diagnose its symptoms.
Gina Pera is the author of the bestselling Is It You, Me, or Adult A.D.D.? winner of four national book awards, including ForeWord Reviews' Psychology Book of the Year. An international speaker on adult AD/HD, especially as it affects relationships, she leads workshops and support groups for adults with AD/HD and their partners. Contact: www.ADHDRollerCoaster.org.
Photo by Tara Winstead/Pexels
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