Driven to Distraction (Revised)
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10. Coach the child on how he might answer questions other people might have, especially peers. The guiding principle is the same: tell the truth. You might try role-playing a scene where a peer is teasing the child in order to anticipate and deal with such a problem in advance.
STRUCTURE
The new understanding of oneself that the diagnosis and education provide leads naturally to a rearranging or restructuring of one’s life, both internally and externally. By taking ADD into account and trying to get rid of long-held negative perceptions of oneself, one rethinks or reshapes one’s self-image; this is the internal restructuring. And one rearranges the nuts and bolts of one’s daily life, setting up means of improved organization and control; this is the external restructuring.
Structure is central in the treatment of ADD. The word “structure” is a homely one, perhaps conjuring up dull images of blueprints or two-by-fours. However, structure can dazzle with its results. Structure makes possible the expression of talent. Without structure, no matter how much talent there may be, there is only chaos. Think of what a tight structure Mozart worked within. The very tightness of the structure helped create the intensity of the expression of Mozart’s genius. Whether it be the iambic pentameter of Shakespeare or the rhymed couplets of Pope or the rhythm of the long-distance runner or the timing of the short-order cook, all creative expression requires structure. Many adults with ADD have not fulfilled their considerable creative potential because they have been unable to shape and direct their creative energies.
Think of a thermometer and the mercury it contains. If you have ever broken a thermometer, you know what happens to the mercury. The ADD mind is like spilled mercury, running and beading. Structure is the vessel needed to contain the mercury of the ADD mind, to keep it from being here and there and everywhere all at once. Structure allows the ADD mind to be put to best use, rather than dissipating itself like so many tiny beads of mercury on the floor.
Structure refers to essential tools like lists, reminders, notepads, appointment books, filing systems, Rolodexes, bulletin boards, schedules, receipts, IN- and OUT-boxes, answering machines, computer systems, alarm clocks, and alarm watches. Structure refers to the set of external controls that one sets up to compensate for unreliable internal controls. Most people with ADD cannot depend upon their internal controls to keep things organized and to keep themselves on task over time. For them a reliable system of external controls is essential. Setting up a system does not have to be boring; in fact, one can be quite creative in devising a workable structure. And once in place, the system will be calming and confidence-building.
We particularly recommend a scheme of reorganizing one’s life that we call pattern planning. This system of time management operates on the same principle as automatic withdrawals from your bank account: by making the withdrawals (of money or time) from your account automatic, you don’t have to plan them every time; they just happen. You plug certain regular appointments or obligations into the pattern of your week so you attend to them automatically. This frees up your limited planning time to focus on other activities. Simple in its conception, pattern planning can reduce the stresses of planning one’s life considerably.
It is easy to set up. You start by making a list of all the regular tasks, obligations, and appointments you have every week—your fixed-time expenditures, so to speak. You then make a grid of your week on a calendar or appointment book and plug each fixed obligation into a regular time slot. For example, you may decide you will pick up your dry cleaning every Thursday afternoon at 4:30; you will work out Wednesday and Friday at 7 A.M.; you will go to the bank Monday and Thursday at noon; and you will attend your professional seminar alternate Tuesdays at 6 P.M.
Before you know it, these regular appointments take root in your subconscious. Thursday afternoon becomes dry cleaners’ time, and after a while you drive to the cleaners almost without thinking about it. Wednesdays and Fridays become work-out time, and not only does the time become automatically reserved for you, but also you do not have to worry about when you will find the time to work out. You have decided in advance, not impulsively, what you want to make enough of a priority to pre-plan, and where to put each such activity or obligation. You know that you will do these things, and you know when you will do them. This means you do not need to wonder every day when you will get to the dry cleaners, or if you will get to the bank, or how you will find time to work out, or whether you can ever make it to that professional seminar again.
Through the use of pattern planning you can streamline your life considerably. It is remarkable how much mental energy the planning of these humdrum, everyday tasks can take, and how easy pattern planning can make them.
People with ADD can spend a lifetime dodging the necessity of organizing themselves. They avoid getting organized the way some people avoid going to the dentist: repeatedly postponing it as the problem gets worse and worse. One man hadn’t paid his taxes in eight years, not because he was protesting or didn’t have the money but because he couldn’t face up to the organizational task of doing so. A woman was on the brink of divorce because her inability to throw anything away had led to her house being overrun with junk. Another man cost himself literally tens of thousands of dollars a year in tax deductions because he felt constitutionally incapable of saving receipts. The task of getting organized, one that bedevils us all, particularly vexes the ADD mind.
“Vexes” is an understatement in children with ADD. The failure to get organized can be the ruination not only of the child with ADD but of the whole family. Disorganization is a time-honored component of any normal, ordinary childhood, or one hopes it is. The “too-neat” child has problems of his or her own. But the child with ADD can go to the other extreme.
For example, I once treated an eleven-year-old boy named Charlie. A Tom Sawyer clone, Charlie was unintentionally making his family crazy due to his completely disorganized ways. Together, as a family, we zeroed in on key problem areas. One in particular enraged Molly, his fifteen-year-old sister: Charlie left the bathroom a mess every morning just before Molly used it. He would leave his underwear on the floor, a dirty towel in the bathtub, bits of toothpaste stuck to the sink, dirty handprints on the mirror, the toilet seat up (often covered with evidence of Charlie’s poor aim), the water dripping, and the fan turned off so that steam still filled the room. Molly had asked Charlie a hundred times about these things, and he always told her he’d try to do better, but nothing changed. She wanted to kill him, or at least maim him severely.
After some negotiation we came up with the following plan. Charlie and his sister wrote up a list of ten items that Charlie needed to check off before leaving the bathroom each morning. They posted the list on the inside of the bathroom door where Charlie could not miss seeing it. Each morning Charlie checked off the list before he left the bathroom. He also added an eleventh item to the list which he happily checked off last. It read, “I’m outta here!!!” This simple plan, this bit of structure, worked very well. Charlie and Molly made up, with Charlie unmaimed.
Some tips might be useful in helping children with ADD get organized.
TEN TIPS ON STRUCTURING AND ORGANIZING THE LIFE OF THE CHILD WITH ADD
1. Write down the problem. Sit down with the child—or the whole family—and write down exactly where the problem areas are—the dining-room table, the bedroom, the bathroom, wherever. It is good to define, and thereby limit, the problem instead of leaving it in the realm of the infinite.
2. Come up with specific remedies for each problem area.
3. Make use of concrete reminders like lists, schedules, alarm clocks, and the like.
4. Incentive plans are fine. Don’t think of them as bribes, but rather as incentives. Children with ADD are born entrepreneurs.
5. Give frequent feedback. Kids with ADD often don’t see what they are doing as they are doing it. Don’t wait until the house is completely torn apart before suggesting that it be put back together.
7. Make copious use of praise and positive feedback. More than most people, people with ADD blossom under the warmth of praise.
8. Consider using a coach or tutor when it comes to schoolwork. You do not want to give up your role as parent to an ad hoc role of supervisor-tutor-badgerer-teacher.
9. Provide the child with whatever devices he or she demonstrates can help. Ask the child what will help. Experiment with different plans and devices. One child organized his homework by setting his alarm clock to go off at twenty-minute intervals; he would plan out his homework in twenty-minute chunks. Another child found that a word processor made the task of writing immensely easier. Another found that studying with earphones on allowed for better concentration. Use as your guiding principle: whatever works (but isn’t illegal or dangerous).
10. Always remember: negotiate, don’t struggle.
PSYCHOTHERAPY AND COACHING
The person with ADD can best get started in treatment for ADD by establishing a relationship with a therapist who knows about both ADD and psychotherapy.
Your therapist must keep several issues in mind. While attending to your neurological problems, the therapist should help you grapple with your emotional problems as well. He or she should remain attuned to the omnipresent therapy issues of hidden meanings, covert signals, concealed motives, repressed memories, and unspoken desires. Your therapist should leave aside all preconceived ideas derived from diagnosis and should seek first of all to know you as you really are. You should feel understood. This may sound simple, but there is probably no act between two humans that requires greater skill.
We must underline this point with a thick red pencil: the treatment of ADD should never overlook that the patient is a person first, and a person with ADD second. While the symptoms of ADD may dominate the picture, they should never be allowed to supercede the patient’s humanity. The patient needs the chance, as we all do, to be heard and understood as an individual, with a specific history, an idiosyncratic set of habits and tastes, a personal chest of drawers of memories and mementos, not as just another person who has ADD.
While your therapist may know a lot about ADD, he or she knows nothing of your particular life. Indeed, what keeps the therapy fresh and exciting is not what your therapist knows, but what he or she does not know. Your therapist must stand ready and eager to learn from you.
The feeling within you of being understood can heal more wounds than any medication or kind words or bits of advice. And the only way for you to find this feeling of being understood is for your therapist to take the time to listen, and it does take time, and to apply the discipline of staying with you, and it does take discipline. With time, and with work, your therapist and you can build, syllable by syllable, image by image, a sense of being known, and sometimes known for the first time.
Once this human bond has been established, or, really, while it is being established, some kind of external supports can help a great deal in restructuring one’s life. People with ADD do very well when given support. While you may never get organized on your own, if you feel a part of a team, you will do much better.
We particularly like the idea of a coach. This person may also be a therapist, but need not be. It may be a friend or a colleague, anyone who knows something about ADD and is willing to put in the time—ten or fifteen minutes a day—to coach.
What is an ADD coach? The person is just what the name implies: an individual standing on the sidelines with a whistle around his or her neck barking out encouragement, directions, and reminders to the player in the game. The coach can be a pain in the neck sometimes, dogging the player to stay alert, in the game, and the coach can be a source of solace when the player feels ready to give up. Mainly, the coach keeps the player focused on the task at hand and offers encouragement along the way.
Particularly in the beginning phases of treatment—the first couple of months—the coach can stave off a reversion to old bad habits: habits of procrastination, disorganization, and negative thinking, the most damaging and pernicious of which is the negative thinking. Treatment begins with hope, with a jump-start of the heart. A coach, someone on the outside, can holler at the ADD mind when it starts down the old negative grooves and bring it back to a positive place.
Tips for the Coach
At the beginning of treatment there should be brief (ten-to-fifteen-minute) daily check-ins with the coach, in person or over the phone. The discussion should focus on the practical and concrete—what are your plans? what is due tomorrow? what are you doing to get ready for tomorrow?—as well as on the abstract—how do you feel? what is your mood? These questions can be organized by the initials H.O.P.E. as follows:
H—Help: Ask the person you are coaching, what kind of help do you need? Begin by getting an update and seeing what specific assistance is needed.
O—Obligations: Ask specifically what obligations are upcoming and what the person is doing to prepare for them. You must ask. If you don’t ask, the individual may forget to tell you.
P—Plans: Ask about ongoing plans. It is very helpful to remind people with ADD of their goals. They often forget them, quite literally, and so stop working toward them. If they say they don’t know what their goals are, try to help them define them. Goals function as a kind of guard against aimlessness, drawing the individual through time toward a desired place.
E—Encouragement: The most fun part of the coach’s job. The coach should really get into it and not be embarrassed to be rah-rah. The coach is joining a battle against chaos and negativity; the more affirmative he or she can be the better. Don’t be daunted by cynicism. It takes a while to undo a lifetime of negativity.
Traditional psychotherapy is sometimes indicated for people with ADD because of the problems with self-esteem, anxiety, and depression that build up in the wake of ADD. While the primary problem of ADD is best treated with structure, medication, and coaching, the secondary psychological problems often require ongoing psychotherapy. It is a mistake to treat the primary problems of attention, distractibility, impulsivity, and restlessness and overlook the considerable secondary problems with self-esteem, depression, or marital or family discord.
In doing psychotherapy with adults with ADD, the therapist will help structure sessions; he or she will be quite active. The fundamental rule of psychoanalysis, for the patient to say whatever comes to mind, often leaves the person with ADD at a complete loss. There is so much coming to mind that you don’t know where to begin. Or, once you do begin, you don’t know where to stop. You may become flooded, not with interesting unconscious material, but with bushels of detritus—useless material that risks turning the psychotherapy into a kind of aimless monologue, going nowhere, frustrating both you and the therapist.
If your therapist can provide some structure and direction, you can often get on track. If you have trouble getting started, your therapist might ask a directive question, like “How is that problem with your boss working out?” Or if you start to go off on a tangent that seems to be leading nowhere, your therapist might try to help by bringing you back to the original subject. This is quite counter to what a good therapist usually does in open-ended, insight-oriented psychotherapy. In that kind of therapy the therapist often wishes the patient would get off track, would let go of conscious control to some extent in order to uncover what lies beneath the surface. However, in patients with ADD this approach can backfire, leaving both patient and therapist lost in a meaningless maze made of distractions and incomplete thoughts and images.
If you have ADD, you need the therapist to guide you through your thoughts and associations, helping you prioritize your mental productions and pay attention to what is germane while letting go of what is extraneous. If in the process you let go of a pea
rl, that is too bad; but it is better than spending the whole therapy shucking pearl-less oysters.
Let me give an example to illustrate this point. At the beginning of a session one of my patients, a forty-two-year-old man in treatment for ADD and depression, said, “Well, I sure won’t be needing my wife’s money anymore.” His reliance on his wife’s considerable inherited wealth had become a central issue in therapy because it undermined his sense of independence and self-esteem. In fact, he relied on it only in his imagination, as the couple lived on the incomes each member earned, and they earned about the same amount.
In response to his question I looked interested and said, “Oh, really, why is that?”
“Because I’ve had a breakthrough. The store has said they will pay me to get special training that will enable me to take over the whole department probably in about a year.”
“Really,” I said, hoping for more.
“Yes, but I also want to talk to you about the elevator in this building. Why can’t they get it fixed? It’s a real pain walking up four flights of stairs.”
Now at this point I had a decision to make. In psychotherapy with a patient without ADD, I would probably remain silent, or I would ask more about the elevator, thinking in the back of my mind that the patient was inching in on significant transference feelings, feelings about me, his therapist, through his feelings about the elevator, and the pain it caused him to get to me, to our sessions. Why couldn’t I make it easier? he might be asking me. Why couldn’t I take better care of my building, of my elevator, of my patients, of him? Couldn’t I be relied on for that much? Or, looking for past memories or unconscious fantasies, I might ask for my patient’s associations to elevators. Sometimes such a question can jar an old memory loose and lead to a whole new and unexpected vein of material. On the other hand, my patient’s bringing up the subject of the broken elevator right on the heels of announcing a big promotion certainly could make me wonder if he did not feel conflicted about the promotion. Did the promotion make him think of things that needed repair, like the elevator, like himself? Was he wondering, in the punning way the unconscious often uses, if he were “up” to the job, if he were entitled to “rise” in his field, or if he needed an extra “lift,” perhaps from me? With another patient I might have pursued any or all of these ideas.