ADHD Essentials for Therapists 2/2: Tasks of Therapy
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Phil Mollon
Interest in ADHD is rising, in both the wider culture and among therapy clients. Yet many therapists know little about the real nature of attention deficit hyperactivity disorder, and many people with undiagnosed ADHD do not realise it is a central part of their problems. In the second of two posts, psychoanalytic psychotherapist and ADHD specialist Phil Mollon sets out four key tasks for therapy when a client is struggling with this brain-based condition, suggests how we might spot its presence early in the therapeutic encounter, and draws our empathic attention to the central and ever-spiralling experience of shame.
Become a ADHD Certified Clinical Services Provider (ADHD-CCSP)
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 – a crucial and universal feature of ADHD
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.
Four key 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 also 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.