Key points for psychotherapists in relation to ADHD
Part 1
ADHD is a neurobiological condition that interacts with a child’s and adult’s interpersonal environment to create a variety of difficult and painful experiences and profound effects on a person’s self-esteem. Most psychotherapists, clinical psychologists, or counsellors will have clients with ADHD, but perhaps without understanding the nature of this condition. Many people with ADHD do not realise this is a central part of their problems. Vast amounts of time and money may be invested in fruitless explorations of psychodynamic explanations for the individual’s anxiety, procrastination, emotional upheavals, mood swings, episodes of rage, impulsiveness, failure to follow through on commitments, chronic lateness, and generally erratic behaviour. Years of difficulty, helped only minimally by mental health professionals, may leave an adult with ADHD deeply wounded in their feelings about self and life.
A person with ADHD may know they cannot manage many ordinary aspects of life, may know they tend to be disorganised and forgetful, may know they get bored easily and find this very aversive, may know they can be impulsive, and easily get into fights and arguments, may know they tend to experience life as tedious, painful, frustrating and unrewarding, may know they can feel depressed and anxious – but they may not know they have ADHD!
There are many variants of AD(H)D. Some tend more towards hyperactivity and some are more dreamy. It is a spectrum and a mixture, without neat categories. There is also much overlap with the autistic spectrum,
The name ‘Attention Deficit Disorder’ is misleading
Much misunderstanding arises from the name, with its emphasis on attentional problems. Whilst difficulties in sustaining attention can be a feature, this is not the key defining factor – and, in fact, people with ADHD are often capable of sustaining obsessive attention for long periods on a task that is of interest to them (a phenomenon called hyperfocus). The core feature of ADHD is a difficulty in the brain’s management of itself. Although many complex brain functions may be involved, it is generally recognised that under-functioning frontal lobes are crucial. The frontal lobes are somewhat like the Freudian ego, managing the interface between inner needs or drives and the outer environment. It is the frontal lobes that apply the emotional brakes and inhibit impulses in order to achieve longer term goals. With these functions in deficit, the person with ADHD is often overwhelmed and floundering.
A person with ADHD needs external assistance in managing their brain
We are all, throughout the lifespan, dependent on empathic and responsive others for our well-being, but particularly so during childhood. In the case of the person with ADHD, this need for the presence of a responsive other, who can function like an external ego, is more pronounced. The responsive other is needed as someone to talk things through with, to help motivate, to sooth and reassure, and to remind the person of priority tasks. When this responsive other is not available, or fails in some way, the person with ADHD may feel extremely anxious, may panic, or fly into a rage.
The brain of a person with ADHD will seek stimulation – as if trying to wake itself up. Unfortunately, this stimulation sometimes takes the form of fights and arguments with others, or the creation of drama. This can be addictive.
For some people, stimulant medication is helpful because it wakes the brain up and increases arousal in the frontal lobes. This has a paradoxical calming effect. The drug takes the place of the other person as an external ego.
Deficits in reward and motivation
It can be very hard for a person with ADHD to engage in tasks that are not immediately of interest or rewarding. Procrastination can be a significant problem – a difficulty starting, and then sometimes a difficulty stopping. Their neurobiology is such that they are deficient in the processes mediating reward and motivation. As a result, they are inclined to experience life as dreary and to feel depressed. This may lead them to seek activities and substances that provide immediate reward and pleasure.
The deficit in reward neurobiology leads to negative emotional interpretations of events and other people’s motivations. This neurobiology also leads them to feel unloved, because their inner brain responses do not match the external expressions of love by others.
Part 2. The focus of therapeutic work
It is important to develop a feel for the various presentations of ADHD and an empathy for the helplessness the person may feel in relation to their own mind and brain.
How to quickly spot ADHD
ADHD is often revealed easily through the person’s conversational style. He or she may not listen well, may speak rapidly as if under pressure, may interrupt the other person before they have completed a sentence, and may interject with their own associations. Their discourse is impulsive, and has the quality of a discharge of tension rather than an intentional communication of thought. In a psychotherapeutic context, the person may not stop to listen to the therapist’s remarks but will plough on with their own stream of words. Some other ADHD clients may, by contrast, appear inarticulate, incoherent, and extremely anxious.
Shame
Shame is always a feature of the experience of people with ADHD, and it is crucial that this is explored. It stems from repeated experiences of failing at multiple basic tasks of life and in social interactions. The person feels shamed and humiliated and embarrassed by his or her own erratic behaviour and the intensity of their emotional states. When the person is emotionally aroused, in anger or anxiety, he or she feels overwhelmed and out of control – a state of disintegration. This may be regarded as an endogenous trauma, evoked by the intensity of the person’s own emotions that overwhelm the ego. Such experiences then give rise to mortifying ruminations around shame. A spiral of shame, rage, and panic may ensue.
Shame may also lead to attacks on the self – both internal, in the form of critical and judgemental self-talk, and in external behaviours of harming the body. The latter will then lead to more shame.
Psychotherapeutic tasks
- The first task is to help the person understand the nature of their ADHD and how it has affected them throughout life. This can help reduce feelings of shame and facilitate compassion for self.
- A second task is to address the multiple shame-based traumas that have resulted from having an ADHD temperament. Methods such as EMDR and/or energy psychology modalities such as EFT can be very helpful. When using energy psychotherapy, tapping on acupoints or other energy centres can be combined with a global phrase such as “all the times and ways I have felt overwhelmed by my own emotions”. Out of this, significant specific experiences may emerge, which can then be tapped through until the shame and other emotions have dissipated.
- The third task is to help the person find strategies for managing ADHD. An important aspect of this is to identify some of the positive benefits of ADHD, such as creativity and the capacity to sustain long periods of work on a task that is of interest. People with ADHD are naturally rebellious and seek stimulation and novelty, and a degree of brain ‘chaos’ can facilitate making unusual connections – this combination of factors can often be a good basis for an entrepreneur.
- A fourth task is to help the person identify goals, and then clarify the steps involved in achieving these. Often a person with ADHD will have a goal, but no realistic idea of how to get there. Their goals and expectations may also be quite grandiose. Asking practical questions can be important in introducing reality to the fantasy. Empathy and tact are required in addressing grandiosity and narcissistic vulnerability.
It is important to convey that neither the individual nor their family of origin are to blame for the ADHD constellation. The basis is neurobiology, and the family and individual psychodynamics are secondary to this. All involved in the situation will have suffered, and no-one is to blame.
Phil Mollon PhD
Psychoanalyst and Energy Psychotherapist
References:
Mollon, P. (2015). The Disintegrating Self: Psychotherapy with Adult ADHD and Autistic Spectrum. London. Karnac.
Video: So you think you have ADHD…
(1048) So you think you have ADHD - YouTube