Often the symptoms can bring a couple to the brink of divorce. Sam and Mary Rothman, for example, were referred to me by Sam’s therapist, whom Sam had been seeing because Mary felt it was the only alternative to separation. Now both in their early forties, they had been married eight years, and they had one child, a boy, David, age five.
They arrived fifteen minutes late for their first appointment. Sam blamed the traffic. “The traffic wouldn’t have mattered if we had left on time,” Mary quickly added.
“She’s right,” Sam said. “But that’s the way I am. I’m late everywhere.”
“What kind of work do you do?” I asked.
“I’m an emergency-room physician,” he answered. “But I haven’t practiced in a few years. I was a cartoonist for a while, and right now I’m trying to make it as a freelance writer.”
“How’s it going?” I asked.
“It’s tough, but I’m getting work. So far, at least.”
“Sam, let’s tell him why we’re here,” Mary interjected.
“Do you want me to, or do you want to?” Sam asked, looking at Mary. They had seated themselves at opposite ends of my couch. Both looked younger than they were—Sam, tall, trim, with thick curly black hair, and Mary, shorter, black hair parted down the middle, tortoiseshell glasses, and a notebook in her hands.
“We’re here because …” Mary began, then paused, as if gathering many thoughts. “We’re here because quite frankly this man is making my life into a living hell. No, he doesn’t beat me or cheat on me, or drink, or gamble. He just behaves like an irresponsible little boy. I don’t mind that he changes jobs because he finds being a doctor isn’t interesting enough. I don’t mind that he gets up in the middle of the night because he’s bored and wants to go flying; I don’t mind that he makes plane reservations for Australia for all of us without asking me about it and then calls me a wet blanket for not being overjoyed; I don’t mind that he travels more than he’s at home; I don’t mind that our life insurance is so expensive it’s not worth having because of his flying and gliding and skydiving; I don’t mind that Sam is incapable of picking things up or remembering where anything is or keeping track of anybody’s birthday or anniversary; I don’t mind that he can’t watch one TV show for more than five minutes without needing to see what else is on even if he’s liking the show he’s watching—I don’t mind any of that so much. But what I do mind is that he doesn’t know that I exist. He is so wrapped up in himself that I might as well be a robot. He has no conception of what my inner life is. He doesn’t even know that I have an inner life. He doesn’t know who I am. After eight years of marriage, the man I’m married to doesn’t know me. And he doesn’t know that he doesn’t know me. That’s what makes it hell. None of this bothers him. He’s so oblivious. That is why we’re here, doctor. That is why we’re here. At least that’s my side of it. Would you like to tell yours, honey?”
We both looked at Sam. Sam took a deep breath and let it out slowly. “You always did have a way with words. What can I say? She’s right. But I don’t do it on purpose. The stuff about your inner life isn’t fair. I know you have an inner life. I think I know what’s on your mind most of the time, in fact.”
“Oh, really?” Mary said. “Then tell me.”
“Well, I’m on your mind for one thing—” Sam began.
“There, you see,” Mary interrupted, “he’s so self-centered he thinks he’s the only thing on my mind.”
“May I cut in here for a minute?” I asked. “There was a reason you came to see me, as opposed to some other psychiatrist, am I right?”
“Yes,” Sam said. “At my wife’s insistence, I started psychotherapy a few months ago.” Mary sighed at that remark and rolled her eyes, but she let Sam talk on. “My shrink—you don’t mind if I call them, or you, a shrink, do you?—anyway Harry, which is actually what I call my shrink, I like him, you know I wasn’t sure I would, no offense but psychiatry isn’t one of the fields of medicine I trust all that much, anyway, Harry said he thought maybe I had ADD, and if we were to get couples therapy, maybe it would make sense to kill two birds with one stone, so to speak, and do it with someone who knows about ADD. Make sense?”
“That’s another thing,” Mary put in. “After he rambles on, he says, ‘Make sense?’ You nod reflexively, but you’re thinking, No, that didn’t make sense at all.”
“Actually, I did understand this time,” I said. “As I think Harry told you, he called me before you came here to tell me his concerns.”
“OK, great,” Sam said. “Harry’s on the job.”
As we reviewed Sam’s history, the evidence mounted for a diagnosis of ADD. “But,” Mary asked, “how do you tell ADD from being selfish? I mean, I’m not a psychiatrist, but isn’t there such a thing as pathological narcissism? That’s what I think Sam has. He’s only aware of himself.”
“Maybe we could look at it a bit differently,” I suggested. “He seems only to be aware of himself because he’s constantly being distracted, or he’s being drawn to some form of intense stimulation to avert boredom.”
“So he finds me boring,” Mary said.
“No, it’s not you. It’s everyday life. He hasn’t learned how to focus in on everyday life and be there. Instead, he needs the emergency room, speaking concretely as well as metaphorically, to get his attention.”
“I don’t find you boring, Mary. Really, I do not,” Sam said emphatically.
“But if I matter to you, why don’t you pay attention to me, why don’t you remember things? Even if you don’t care about them, if you cared about me, you’d remember, because you’d know how much they matter to me.”
“But you see,” I interrupted, “it might be that he can’t remember, at least not the way other people do.”
“He got through medical school,” Mary said.
“It was a struggle,” Sam quickly added. “You don’t know. All the cram sessions. My friends would coach me before exams. It wasn’t easy.”
“Plus there was the high intensity of the situation to motivate and focus you,” I added.
“So our marriage is too low-intensity to keep his attention, is that what you’re saying?” Mary responded.
“Not exactly, but I doubt you’d want your marriage to be under the gun the way medical school is,” I said.
“That’s my whole problem,” Mary said. “It seems like the only way I can get any of his attention at all is to put everything under the gun. And I’m tired of living that way. I want him to take some of the responsibility. I don’t care whether you call it ADD or selfishness, or just being a jerk, I’m tired of it. I want him to get to know me. I want him to worry with me about where David’s going to school instead of just nodding. I don’t want to feel like I have to squeeze everything I have to say into the five seconds of attention he gives me a day. I don’t want to feel like I’m married to an immature person who’s still trying to find himself. Can’t he just grow up?”
“If I told you that the kinds of things you are saying are precisely the kinds of things that usually get said to people with adult ADD, what would you think?” I asked.
“I’d say, ‘So what?’ I still want a life.”
Mary and Sam found a life, it is fair to say. It took some time, because, in addition to making the diagnosis of ADD, other work had to be done, much of which was facilitated by Harry in his individual sessions with Sam, and some of which was done in our couples therapy.
Once Sam’s ADD was diagnosed, he started on Ritalin at a dosage of 10 mg three times a day, and it worked well in helping him focus and reducing his mood swings. He experienced no side effects, and the medication allowed him to sustain focus in a way he never had been able to before. The medication took him out of the self-centered, fast-paced, stimulation-seeking, always-distracted cloud he’d come to live in and deposited him in the ordinary here and now. It allowed him to get to know his own feelings, to get to know his wife, and to be present wherever he actually was.
The struggle didn’t end with the diagnosis, however. Sam and Mary had to work hard to make their marriage last. It took persistence and a daily, habitual tending to each other. Sam had to unlearn a number of habits, and Mary had to get past a backlog of anger and resentment. They loved each other and wanted to be together, and they worked to stay together. But it was by no means easy.
ADD does not occur in a vacuum. The partner of an individual with ADD can benefit from a receptive forum as much as the person with ADD can. The stresses on the partner can mount as he or she tries to hold things together, keep the family from sinking, either financially or emotionally, and generally try to bring order out of the chaos. In Mary’s case the single most useful tool was knowing about ADD. Before she knew what ADD was and that Sam had it, she was left with explanations like “selfish” or “narcissistic” to explain what she didn’t like about Sam. Once she understood what ADD was, and once she understood that it was a neurological condition, she was much better able to forgive Sam his shortcomings and work on finding solutions.
In addition to rethinking Sam’s behavior in terms of ADD, Mary also needed Sam to pay attention to her life. Being the spouse of an adult with ADD can be exasperating, as Mary could attest. The spouse often feels enraged and unheard. The more angry the spouse becomes, the more devaluing she becomes, and the more devaluing she becomes, the more her partner withdraws.
We often see the following cycle in couples where one member has ADD:
In order to interrupt the cycle, one needs not only to treat the ADD but also to address the feelings of anger the non-ADD spouse harbors. Those angry feelings may have built up quite a head of pressure over the years and it may take more than a few weeks or months for them to subside. If the non-ADD spouse has been running the ship for years, feeling unsupported and overlooked all the while, then that person is bound to feel angry. Simply saying “Well, I have ADD” will not make the anger go away. In fact, it may make it worse. The spouse may feel doubly angry finding out, after all these years, that there was a reason for the disorganization and distractibility, a medical condition that was going untreated. “You mean all this suffering has been unnecessary?” one spouse exclaimed. “Now I really want to kill him.”
The anger is entirely understandable. It must be acknowledged, expressed, and, finally, put into perspective. It was important for Mary to feel validated and heard. It was important that Sam acknowledge how difficult he had been, whether it was his “fault” or not. It was not that Mary needed to blame Sam, but rather that she needed for Sam to know how much pain she had been in due to Sam’s ADD. Just as Sam needed Mary to understand what ADD was and how it affected his behavior, Mary also needed for Sam to understand what living with a spouse with untreated ADD was like, and how that had affected Mary’s behavior. It is essential in treating a couple where one partner has ADD that the feelings of both partners be heard and taken up with equal seriousness.
Sometimes one member of a couple will present himself as the “identified patient” and request that the spouse be left out of the treatment. A patient named Edgar brought his wife with him, but he wanted to speak with me alone first, he said. Edgar came to see me because he had been thrown out of the family system. His extended family decided they had had enough of him. Since they owned the car business Edgar worked for, they had the power to fire him. One day they called him in and told him that because he was so irresponsible they could no longer employ him. They would see to it that he didn’t starve, but he was no longer welcome in the business or at their homes. They were fed up with him, tired of his shenanigans, and they felt the only way to deal with him was to put him out. They thought he was a born loser, and an annoying one at that.
“What can I tell you, Doc?” he said, looking at me through thick glasses, chewing a piece of gum, his forehead wrinkled in worry. “I am obnoxious. I’m extremely obnoxious. My family couldn’t stand me anymore so they threw me out. I can see their point, to tell you the truth. It’s probably just a matter of time before my wife does the same.” Then the wrinkles in his forehead relaxed and he smiled. He lowered his voice now, speaking sotto voce, so as not to be overheard, even though there was no one else in my office. “But you know what, Doc? I like being the way I am. It’s me. I’ve gotta be me, and all that, you know? So I blow a few grand on a cruise to nowhere. So why shouldn’t she be thrilled that I give her a trip? So I ride down the highway with Dylan blasting, smoking a joint. So what? It’s how I do my best thinking. I can’t sit in an office and look at the nice little people in the showroom and make my plans for the day and be a good little schmuck. It’s just not me. Is that so bad? Am I a worthless piece of scum just because I haven’t been to the dentist in ten years? That was on their list, can you believe that? What’s it to them if I go to the dentist? Who likes to go to the dentist? So I get excommunicated for that? I’m telling you, Doc, I may be obnoxious, but I don’t deserve what’s happening to me.”
“Do you really mean that you’re obnoxious?” I asked.
“Yes, I am. But I can’t help it. I see something that I want to do, and before I’ve had the chance to think about it, I’m doing it. I’ve stopped making promises to Amanda, I’ve broken so many of them. I’m impossible, just like she says. You know what I really like to do? I like to go down to the showroom about three o’clock in the morning when I can’t sleep and turn on the radios of all the cars on the showroom floor and just let ’em blast. It’s a great feeling, standing in there with the lights on and all the radios blaring when outside everybody else is asleep. I can have the world to myself then, the way I like it, on my terms.”
“But the family—” I started to say.
“Just about pukes,” Edgar answered. “They say, ‘How does that look to the rest of the world, someone playing around in the showroom in the middle of the night?’ They say, ‘Grow up, Edgar,’ and I say, ‘You’re right, I’ll try.’ But I can’t grow up. I guess that’s my problem, Doc. I’m just permanently stuck in childhood.”
Although Edgar’s behavior was peculiar, the description of an adult with ADD as immature or childish is not uncommon. People don’t know how else to make sense of this kind of behavior, so they attack it as being beneath adult standards. They hope to shame the person into changing his ways. That tactic usually doesn’t work. “Edgar,” I said, “why do you think you do these things?”
“I don’t know, Doc! Jeez, that’s why I’m here. You’re supposed to tell me.”
“I’ll try to, but I need more information. What are some other things you do that people object to?”
“Well, there’s the speeding I told you about, and the showroom. Insulting the customers, that’s a biggie. I mean, what can I tell you? I don’t like someone’s attitude, I don’t have much patience with them. I told one the other day she should work at the Department of Motor Vehicles, her personality would fit right in. I mean, she kept handing me all these forms and not speaking to me, it was annoying, you know what I mean? But they’re right, I shouldn’t speak like that to a customer. The customer’s always right, and all that. Sometimes I just can’t help myself.”
“It’s kind of fun, isn’t it?” I said.
“It sure is. They think so, too, underneath it all. They’re gonna miss having me around. Who else have they got to tell those jokers off?”
As is usually the case, Edgar’s problem was not just ADD, but ADD was a big part of it. His impulsivity, restlessness, tactlessness, and high energy all contributed to the fix he was in. Despite how obnoxious he said he was, he was also quite likable, and I was sure that he was right, his family would miss having him around.
“Do you ever get sad, Edgar?” I asked.
“Try not to,” he said. “Don’t slow down long enough. What’s the point? Red roses for a blue lady and all that? You can have it. My philosophy is live, live, live.” He took off his glasses, produced a handkerchief from his back pocket, and wiped his forehead.
Later I met with Amanda and Edgar toge
ther. Amanda was a kind-faced woman a half a foot taller than Edgar who was as calm as Edgar was excitable. “I can’t tell you why I love him, but I do. Isn’t that a line in a song? Anyway, it’s true. But he does drive me crazy. The thing about it is, he drives himself crazy, too. He’s not a bad man, don’t let anybody tell you that. He’s like a pot that boils over, that’s all. Is there any way to turn down the heat?” she asked.
“How do you manage life with him?” I asked.
“Oh, it’s a trip,” she said. “Never a dull moment. I’m just getting a little tired, and I know he is fed up with these messes.”
After a few weeks of getting to know Edgar and getting some tests, I was confident that he had ADD. His ADD had to be discriminated from mania. In mania, the “high” is higher than in ADD. That is to say, the person with mania is under greater pressure and is more out of control than the person with ADD. The person with mania exhibits certain symptoms that the person with ADD does not show, symptoms such as pressured speech, where the words literally seem to fly out of the individual’s mouth under great pressure, and flight of ideas, where the individual flies from topic to topic without a moment’s pause. Mania and ADD leave a qualitatively different impression. The person with mania seems uncontrollable to the outside observer, whereas the person with ADD simply appears hurried or distracted. On the basis of Edgar’s childhood history, which was suggestive of ADD, and his current situation, which showed periods of agitation but not mania, and on the basis of psychological testing, the determination was made that Edgar had ADD.
Driven to Distraction (Revised) Page 15