Q: I've seen a number of anxious and depressed adults who I suspected had AD/HD. Although they benefit somewhat from my typical therapeutic techniques, they eventually seem to hit a wall and get stuck. What am I missing?
A: AD/HD is still generally underdiagnosed in adults, leaving three to five percent of the population suffering from this difficulty without adequate treatment. Of course, adults with AD/HD have the same issues that we all struggle with, but their deficits, which are neurologically based, create unique challenges that need to be addressed differently.
Unfortunately, AD/HD symptoms are often attributed to the commonly comorbid conditions of anxiety and depression, and, therefore, addressed only indirectly. Given the frequent unpleasant surprises that arise from their inattention, hyperactivity, and impulsivity, these clients have good reason to feel anxious. And given their lifetime of struggles and failures, it's no wonder they feel depressed. But no amount of traditional therapy will help them completely overcome their anxiety and depression, which are so tied to the experience of living with AD/HD itself. Trying to achieve that outcome is akin to trying to fill a bucket with a hole in the bottom.
To patch that hole, I recommend a four-part treatment to help the client become more functional in the present, helping to diminish anxiety. This goes a long way toward vindicating past failures and the depression attached to them, too.
Step 1--The first aspect of this treatment approach is educational: teaching the client and family about AD/HD and the typical difficulties it causes. This reduces the unproductive blame and guilt that can undermine progress. For example, one client felt great relief at "finally not feeling like a screw-up all the time." Learning that his difficulties with attention and memory were based more in neurology than in his character or some willful choice made it easier to stop blaming himself for his lapses, like often not finishing tasks he'd agreed to do. Folks with AD/HD can do anything once or twice; the killer is doing it on time, every time.
At a deeper level, reframing past difficulties as being based in neurology can have a profound impact on the client's self-esteem. People suffering from this condition carry around a lot of negative thoughts about themselves. As the title of one popular book on adult AD/HD put it, You Mean I'm Not Lazy, Stupid, or Crazy?!
Step 2--The second feature of the treatment is medication. Although there are no silver bullets, generally AD/HD medications are well tolerated and help folks with AD/HD meet demands more consistently and accurately. They increase focus and concentration, allowing the person's true abilities to shine through. Once on medication, clients have described experiencing a sense of clarity, in contrast to their usual disorganized jumble of thoughts.
Step 3--Pills don't teach skills, which become the third part of the treatment. Understanding why certain kinds of mistakes are common to those with AD/HD, coupled with the improvements in functioning that come from medication, enables clients to begin to make further changes. Coaching can help them handle daily demands more effectively. By coaching, I don't mean giving obvious, generalized advice (e.g., "Try to finish your work assignments in a timely manner"), but helping them figure out and practice concrete strategies for overcoming their natural lack of focus and consistency.
My client Jen paid her bills late far too often.
"Where do you put your mail?" I asked.
She thought about it for a moment and said, "All over the place. Sometimes in the kitchen. Sometimes it gets left in the bathroom, if I'm reading it there. Or in the bedroom. I once left it in a kitchen cabinet because I somehow put it there when I took something else out!" She laughed at this last, but it was a bittersweet laugh.
Thus, before she could pull out the checkbook to pay bills, she had to track them down in a house where too many things weren't where they should be anyway. She might spend half an hour locating all the bills (hopefully) before writing the first check, assuming she didn't get sidetracked along the way.
"Okay," I said, "where's one place that you can always put the bills?"
Her response was tentative. "In the kitchen?"
"Do you always go there first thing?"
"Hmm, not necessarily."
This then was the problem: every extra step she took between the front door and the kitchen was one more chance to get sidetracked. We discussed this and finally settled on putting a shoebox next to the front door where she'd drop only bills (to prevent it from becoming a dumping ground where the bills are once again lost). Jen won't win any decorating awards with the approach, but at least she's less likely to misplace bills.
Coaching in this manner seems simple, but the simplicity of the approach must reflect an understanding of how AD/HD works. Therapists need to use their knowledge of the functional weaknesses caused by AD/HD to offer specific, practical solutions that increase the odds of success for clients. And clients must understand how their AD/HD affects their functioning, so they can participate in creating these solutions.
Of course, when the new strategy is implemented, clients have to make a point of doing it, even if that means fighting their natural tendency to plow forward on whatever they're already focused on. In this case, Jen would often prefer to walk past the shoebox and throw the mail down elsewhere, rather than take the few seconds required to pull out the bills. It takes a conscious effort for an adult with AD/HD to make these seemingly simple tasks automatic. For them, changing course from one task to another can feel like turning a barge around; it can be done, but it isn't easy.
Step 4--This is where psychotherapy comes in as the final piece of the treatment puzzle. The therapist's job is to work with clients to overcome their avoidance of trying new things, often based in a pessimistic view that it won't help anyway, since nothing else ever has. Based on history, there's a certain logic to this belief.
However, it's important to point out to clients with AD/HD who are reluctant to put in the effort to try yet again to overcome problems in their lives that the education and medication stages of their treatment already have improved their functioning, and perhaps this time can be different. Another point to make is that, because these new strategies incorporate a solid understanding of their condition, they're more likely to be successful.
The success in learning new coping strategies is what'll help your clients with AD/HD feel less anxious and depressed. But most important, it'll overcome their disempowering belief that there's something profoundly wrong with them.
Ari Tuckman, Psy.D., M.B.A. is a psychologist in private practice in Exton, Pennsylvania. He specializes in the diagnosis and treatment of AD/HD in children, teens, and adults. He's the cochair and psychology expert on www.ADHDBalance.net and is working on a book on the diagnosis and treatment of adult ADHD.
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