We see the same difficulty in tolerating tension interpersonally in his description of not being able to explain himself to Melanie. “I always feel as if describing how I feel and think about myself is too complicated—it’s as if I can hear the whole conversation in advance, and I know all of the twists and turns it will take before they happen, so why bother? The effort just isn’t worth it.” It was not that he couldn’t think it through. He certainly could do that. It was bearing with the tension of explaining himself that so upset him. The tension of constructing an explanation, from A to B to C to D, apparently so simple a task, irritates many people with ADD. While they can hold the information in mind, they do not have the patience to sequentially put it out. That is too tedious. They would like to dump the information in a heap on the floor all at once and have it be comprehended instantly. Otherwise, as Douglas says, it’s just not worth the effort. It’s too boring.
Other symptoms are worth noticing. He used intense living and alcohol to treat depressive moods, and he used structure to relieve anxiety. His flight home from the skiing trip to the structure of his office, which in one individual may have represented a problem with intimacy or in another person a kind of agoraphobia, in Douglas was a way of quelling the anxiety the unstructured activity at the ski lodge created.
What of Douglas’s need for structure? In chapter 8, on treatment, we will stress how important structure can be, and how upsetting its absence is in children and adults with ADD. Douglas sought structure regularly, and desperately missed it on his skiing trip. While we all need external structure in our lives—some degree of predictability, routine, organization—those with ADD need it much more than most people. They need external structure so much because they so lack internal structure. They carry with them a frightening sense that their world might cave in at any moment. They often feel on the brink of disaster, as if they were juggling a few more balls than they’re able to. Their inner world begs for reassurance, for signposts and guidelines. They need the devices Douglas reached for in his moment of misery—in his words, “my computers, my card files, my IN-box, my calendar”—because they feel overwhelmed by chaos without them. What differentiates their need for structure from everybody’s ordinary need for it is a matter of degree. They need it a lot, and they need it often. While someone else might bolt from the ski slope and rush home to take a medication, or make a deadline, Douglas rushed home to find his computers and calendars, to find the signposts he had set up to give himself organization and control. Without these structures, when challenged by open-ended time, he felt he was coming unhinged. Intuitively, desperately, he sought out what he needed; he found his best treatment. One can almost see him settling into his office, reaching for his calendar, turning on his computer, checking through his IN-box, and imagine him heaving a sigh of relief as the anxiety subsides from within and he is calmed by an old friend.
Douglas shows us how he used structure to “treat” himself, but how does a therapist work structure into an actual treatment regimen?
The therapist must become active and directive in helping the patient reorganize his life. Contrary to the practice of psychoanalytic psychotherapists, the ADD therapist must offer concrete suggestions concerning ways of getting organized, staying focused, making plans, keeping to schedules, prioritizing tasks to be done, and, in general, dealing with the chaos of everyday life. The therapist should not do this for the patient, but with the patient, so that the patient can learn to do it for himself.
The therapist might, for example, suggest that the patient buy a daily organizer, and then go over with the patient how to set it up. Or the therapist might suggest ways of finding a financial planner, and then remind the patient to do it until it gets done. This is anathema to most traditional therapy, but with people with ADD it is essential. They need direction. They need structure. The therapist should not tell the patient whom to marry, but the therapist most certainly should coach the patient on how to get organized for a date.
Douglas knew intuitively about the importance of structure. I can use myself as another example of someone who knew intuitively that he needed structure more than most people do. Long before I knew I had ADD, I realized that I needed special kinds of organizational aids. In medical school, for example, I relied heavily upon flash cards to help me master the huge amount of information one must assimilate during those four years. Particularly during the first two years of medical school when the basic medical sciences are presented, I broke down each course into hundreds of index cards. Each card would contain one or two facts I had to remember. Each card was manageable, and by focusing on one card at a time, I never had to deal with the seemingly unmanageable entirety of any one course. This structuring technique of breaking down large tasks into small ones—in my case a large course into a series of small index cards—is a valuable technique for anyone to learn to use, but it is particularly valuable for those of us who have ADD, because we can quickly feel overwhelmed by big projects or complex undertakings. When I learned what ADD was, I realized that I had been effectively “treating” my ADD throughout my education with various structuring techniques.
As Douglas learned more about ADD, he also became articulate in describing his feelings associated with the condition. One of his best descriptions was the recounting of a dream he had:
Melanie and I were sitting in a chemistry classroom with twenty or so other students and a fifty-six-year-old professor. He was furiously writing on the blackboard. He was putting down a long series of equations, and he was defining the constants, represented by x, y, and z. He was thinking carefully.
After a few minutes he turned around and began to engage all of us, telling us this was about the development of Cizimar. But he didn’t tell us what Cizimar was, what it was used for, or why you would want to know how to “develop” it.
He then began to “solve” the series of equations, plugging in the constants as he went, and in a very short time he arrived at the answer—zero—and he turned around proudly. Everyone else in the class looked proud, too.
He then began to talk about the process of solving this equation, and I asked in a relatively quiet voice, because it was clear I was the only one who didn’t understand what the point of all this was, “What is Cizimar and why do we want to develop it?” But he didn’t hear me because he was quite worked up about the explanation of everything following the solution of the equation. I asked again, this time in a louder voice which got his attention, and he stopped and looked at me, as did everyone else in the class. He said, “It is used to balance macadam,” and proceeded down whatever course he was pursuing. I paused for a second, presuming I could apply this piece of knowledge and everything would become clear, but even though I knew what macadam was, I had no idea why one would want to “balance” it. So I asked, “Why do you want to balance macadam, or when do you want to balance macadam?”
It was now clear I was interrupting his train of thought, along with everyone else’s. But I needed to know what was going on because it was very frustrating to listen to the discussion with no idea what it was about. The professor came over to me, having picked up a spoonlike object from his desk which was filled with something that looked like oily, black salt, clearly measured with some precision, and he began to talk to me—he was standing and I was sitting—in a fairly severe fashion about how this ladle full of Cizimar, which is an example of the result of everything he has just explained, is used in some sort of circumstance to balance macadam. All the while I was straining to understand what he was going on about, but it was hopeless. He and everyone else understood, but I didn’t. So I got up, threw my hands in the air, and said, “This is stupid, I’m out of here!” and I left the classroom, knowing that everyone in the room (with the probable exception of Melanie) thought I was a dunce.
But somewhere in my brain I knew I was not a dunce, even though right at that moment I felt like one. I thought to leave the situation for a moment and get some fresh air would solve
the problem.
And the fact is that often in my life it has.
Douglas’s dream is one of the most vivid examples I’ve heard of the feeling of just not getting it that bedevils so many people with ADD. In fact, Douglas was very good at math and chemistry, but sometimes there were moments, as in the dream, when he didn’t get it at all—because of his ADD. The sense of growing panic, the feeling that gibberish is being passed off as coherent conversation, the fear that the world is engaged in meaningless discourse masquerading as meaningful exchange—these are the blurry states individuals with ADD negotiate each day.
While Douglas continued to need his individual therapy—treatment for ADD does not remove all psychological conflict or pain—the treatment for his ADD helped both Melanie and him reach a new place in their lives. Using a combination of couples therapy, medication, and structure, Douglas learned how to bear with some tension, how to talk to Melanie about his feelings and how to listen to Melanie talk to him, and how to plan and anticipate his emotional needs rather than reacting impulsively to them. As Melanie grew able to understand much of Douglas’s behavior in the context of ADD, she became less resentful of him. As Douglas became a better listener and communicator, someone who could “be there” more, he also found that he drank less. This was in part due to an effort initially to please Melanie in recompense for all the hard times he’d caused her, but more and more it was due to a reduced desire to drink. Melanie and Douglas are now both doing well.
The next case takes us into the life of a woman who was told from an early age by her father that she “had no more sense than a jaybird” and that her main problem was that she was “lazy.” Although a part of her bristled at these remarks, knowing they were untrue, another part of her accepted them, took them in, and incorporated them into her self-image. Now fifty years old, married with grown children, Sarah has a career as a potter. She came in from out of town for a consultation because her husband had discovered he had ADD and Sarah thought many of her symptoms might be understood in a similar light.
She and her husband, Jeff, arrived, sat down, and immediately Sarah smiled back tears. “I don’t want to cry. I told myself I wouldn’t cry,” she said.
“It’s OK to cry in here,” I said. “Maybe you can try to tell me what the tears are about?”
“It’s been so many years living like this, thinking I’m stupid, but knowing I’m not. I brought along this list,” she added, holding up some papers. “I wrote down everything I could so you could read it.” She handed me the papers, bunched up like a scarf.
The first item on the list referred to a cough drop. As I read it, I asked her about it.
“Oh,” she answered, “that is about a cough drop someone left on the dashboard of our car. The other day I saw the cough drop and thought, I’ll have to throw that away. When I arrived at my first stop, I forgot to take the cough drop to a trash can. When I got back into the car, I saw it and thought, I’ll throw it away at the gas station. The gas station came and went and I hadn’t thrown the cough drop away. Well, the whole day went like that, the cough drop still sitting on the dashboard. When I got home, I thought, I’ll take it inside with me and throw it out. In the time it took me to open the car door, I forgot about the cough drop. It was there to greet me when I got in the car the next morning. Jeff was with me. I looked at the cough drop and burst into tears. Jeff asked me why I was crying, and I told him it was because of the cough drop. He thought I was losing my mind. ‘But you don’t understand,’ I said, ‘my whole life is like that. I see something that I mean to do and then I don’t do it. It’s not only trivial things like the cough drop; it’s big things, too.’ That’s why I cried.”
It was such a classic ADD story that I’ve come to call it the “cough drop sign” when a person habitually has trouble following through on plans on a minute-to-minute, even second-to-second, basis. This is not due to procrastination per se as much as it is due to the busyness of the moment interrupting or interfering with one’s memory circuits. You can get up from your chair, go into the kitchen to get a glass of water, and then in the kitchen forget the reason for your being there. Or, on a larger scale, the most important item on your agenda for a given day might be to make a certain telephone call, a call that, say, has crucial business consequences. You mean to do it, you want to do it, you are not afraid of doing it, indeed you are eager to make the call and feel confident about doing it. And yet, as the day progresses, you never get around to making the call. An invisible shield of procrastination seems to separate you from the task. You sharpen your pencil instead, talk to an associate, pay some bills, have lunch, get interrupted by a minor problem, return some other calls to clear your desk so you can make the important call, only to find that the end of the day has come and the call still has not been made. Or, on an interpersonal level, you may mean to bring home flowers to your spouse, have it in mind to do it all day, really want to do it, in fact on the subway home envision just which florist shop you will stop at, only to find yourself standing in front of your spouse, saying “Hi, honey” with no flowers in hand. Sometimes this is due to unconsciously not wanting to buy the flowers. But sometimes, far more often than most people realize, it is due to ADD. Wanting to do something, meaning to do something, but just not doing it: this is the “cough drop sign” and it is common among adults with ADD.
The rest of Sarah’s list of symptoms read as if lifted from a text on ADD:
Daydreamed a lot in class as a child.
Called “lazy” and “no more sense than a jaybird” by my father.
Got 730 on the verbal college boards but couldn’t get my papers in on time so got C’s in English.
Like novelty, lots of changing interests.
Have lots of ideas but have a hard time structuring things so they actually happen.
Desk cluttered.
Forgetful.
Often have a hard time finding the right word so impulsively say any word or just stay silent and feel stupid.
Work best in a framework: things need to fit into the whole picture. Feel like I’m always looking for a structure.
Difficult to walk a straight line—tend to veer into things or people.
Have always felt that I think differently from most people.
Unless I’m very involved, usually get sleepy during lectures.
Handwriting: sometimes I write things I don’t mean to; skip letters or form them wrong.
Bathroom cleaning on Sat.: look at job, feel overwhelmed. Turn on radio to get me going. Find the music irritating later and turn it off. Remember the job and tackle it, then it goes all right. Often I feel like I have to push through a wall to get into a job.
No matter how organized I try to be, I always mess up!
Stream-of-consciousness way of doing housework—hop from this to that with no apparent logic, just a schedule.
Always trying to organize things, but it doesn’t come easily. If I don’t organize them, I won’t know where they are.
Lose what’s in my head very easily.
Organize my life around projects. They give me something to think about.
Feel that I have to push myself all the time, especially getting into things.
Like things simple—early music, not romantic.
Weed the garden, remove the clutter. I like to do that.
Problem with lateness. Even when there is plenty of time, I fill it up and then cut things too close or lose track of the time. I don’t have a sense of the passing of time.
Inwardly feel desperate. Reassurances from other people don’t help. There is something inside that needs to change.
Doors and drawers—never close them after myself, then come back and see them and close them.
Inside, I feel like I’m saying, “I’m not stupid!”
Easily hurt and rejected.
Don’t clean up after myself well. Get overwhelmed by a large confused mess.
General problems with distractibility and disorganizati
on.
Most at peace when I’m doing something with my hands like gardening or pottery.
After I read through Sarah’s list, I asked her how she composed it.
“Jeff took notes and I just spoke it out. What do you think?”
“I think,” I said, “that your list could serve as a pamphlet on adult ADD. Running through it, just about everything here fits the picture. But there’s more, of course.”
There is always more. The problem is almost never just ADD, especially in adults. Sarah’s problems—her sense of being desperate and different, her feeling that “there is something inside that needs to change”—these problems were caused by more than just ADD. However, the most successful treatment of them must take ADD into account. Sarah needed to address her issues of insecurity, her feelings about the cruel treatment she received from her father, and her sense of being different. In addressing those issues, she would do best by also understanding how ADD was complicating the picture.
We started medication, but Sarah did not benefit from it at first. She did, however, benefit a great deal just from getting the diagnosis and the knowledge of what ADD is and how it explained many of her symptoms. She also benefited from the practical tips I gave her on the nonmedication management of the disorder. A complete list of these tips is included in chapter 8, but I will mention here some that particularly helped Sarah:
1. Consider joining or starting a support group.
2. Try to get rid of the negativity that has infested your system.
3. Make copious use of external structure: lists, reminders, files, daily rituals, and the like.
4. When it comes to paperwork, use the principle of O.H.I.O.: Only Handle It Once.
5. Make deadlines.
6. Do what you are good at, instead of spending all your time trying to get good at what you’re bad at.
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