Driven to Distraction (Revised)

by Edward M. Hallowell

  However, with this patient, I simply said, “I know the broken elevator is annoying. I am told it will be fixed this week. But I’m interested in hearing more about your feelings about the new development at work.” It may be argued that in doing this—essentially redirecting the patient back toward what I thought was most important—I lost an opportunity. But I did not want to lose the opportunity the patient had presented at the start of the session in telling about his possible promotion at work. In looking at both opportunities, I decided to take over and choose the promotion as what we should focus on.

  Now if the man had responded, “No, I really want to talk about the elevator,” I of course would have let him. But he didn’t. Instead, he very easily glided back into talking about the promotion, as if that was what he had really wanted to talk about in the first place.

  I had to decide whether he brought up the topic of the elevator for hidden reasons we had best look at, or if he brought it up just because it popped into his head, for no significant reason, like a distraction, like the sound of a train whistle outside my window or the telephone ringing in the next office. In making the decision I did, I was taking on the role of distraction censor, a role I often play with my patients who have ADD. The risk inherent in making such a decision for my patient is that I would unintentionally sidestep important material.

  Your therapist must make this kind of determination all the time in doing psychotherapy with you, if you have ADD. Even with people who do not have ADD, the therapist must constantly weigh what is heard and consider what to focus on and what to let slide by. However, with patients who have ADD, the therapist has to be more active along these lines than with other people.

  In addition, your therapist should take into account your perceptual problems in getting a sense of social situations. Often people with ADD respond inappropriately or awkwardly to other people. Sometimes they appear to be self-centered and remarkably unaware of the needs of others. Consider the following scene as an example.

  Dave, a thirty-five-year-old man with ADD paused at the office water cooler for a drink. As he was sipping his spring water, a friend joined him at the cooler. “Hi, Dave,” the friend said, filling his conic cup. Dave did not respond. “Be nice to get these estimates out on time, for once, huh? You’ve done a great job.” Dave still didn’t say anything. “You must have been here late last night?”

  Dave, who had been thinking about how to construct a three-dimensional oval, like an egg, for his daughter’s science project, threw his cup in the metal trash basket, saw his friend, grunted, and headed back toward his office. His friend called after him, “Nice talking to you, Dave.” Dave didn’t stop. His friend registered this encounter as just another example of spacey Dave being spacey Dave.

  It is not that Dave was too selfish to acknowledge or hear his friend. It is that he was mentally elsewhere. It would be important for his therapist to know of this tendency and to give practical advice on how to handle social situations. By practical advice I mean concrete pointers such as “When you are at the water cooler, a central stopping place, keep it in mind that other people might walk up to you,” or “When you see a friend, don’t just grunt, say something, give a real response,” or “In conversation, make eye contact and listen before you start to speak.” These kinds of counsel—concrete, obvious, perhaps tedious—can help a person with ADD immensely. People with ADD may not make friends or do well socially simply because they don’t know how. They don’t know the rules. They don’t know the steps of the dance. They have never been taught what we all assume everyone learns as second nature. People with ADD may lack this second nature. They may need lessons in how to interact. Social “reading” can be as difficult for these people as the reading of words. As painfully obvious as these social lessons may be to the socially adept, to the person with ADD, who can feel as lost in a conversation as he does in the middle of a written page, these lessons can impart nothing less than the ability to make contact with other people.

  Having stressed the importance of “coaching,” and the importance of focusing and directing the psychotherapy in working with patients with ADD, let us also make it clear that the work you and your therapist do is not simpleminded. While coaching may sound simple—and, indeed, at its best it is simple, deceptively simple—and while focusing the therapy may sound like a kind of traffic control—stopping this conversation, whistling it over there—the work can also be as subtle, unpredictable, and imaginative as any kind of psychotherapy.

  While individual therapy marks the starting point for most people with ADD, additional forms of psychotherapy can be extremely helpful, particularly family therapy, couples therapy, and group therapy. The main issues that come up in couples and families were discussed in previous chapters, so we will discuss here only group therapy.

  Groups—for any problem, not just ADD—can mobilize positive energy in ways that are truly remarkable. When groups are properly run, they are a safe, cost-effective, and highly successful kind of therapy for ADD. This applies to both children and adults. Indeed, with children individual therapy may not get at the real problems at all, because the problems only come up in groups. The child may sit with his or her individual therapist and happily play games, all the while showing none of the symptoms that cause the big problems in everyday life at school and at home. However, group therapy for children can address the issues as they come up, head on, in situ, as it were, in the group. For example, a child who cannot pay attention when other children are around will not show this in individual therapy. Or a child who becomes disruptive when asked to share with other children will not demonstrate this symptom in individual therapy. But in a group these kinds of behavior will appear.

  For adults with ADD, group therapy has several advantages. First of all, it gives people a chance to meet and interact with other people like themselves, people who have had to deal with many of the same problems and frustrations in life.

  Second, the members of the group can teach each other a great deal. They can talk about their own experiences and share tips and pointers that they have found helpful in their own lives while learning similar information from other members of the group. In a sense, the best therapist for someone with ADD is someone else with ADD, someone who has been there, someone who knows the place from the inside.

  Third, a group can validate its members’ experiences in ways that an individual therapist cannot. A group can understand its members and give powerful support. The acceptance one can find in a group can be uplifting.

  Fourth, a group can supply a tremendous amount of energy. Groups can be like reservoirs of fuel where members fill up each week.

  Fifth, as with groups for children who have ADD, adult groups can re-create the very situations that people with ADD are trying to learn how to cope with. Groups can re-create situations like Dave at the water cooler. Groups create situations where its members must listen to each other, wait their turn, where they must share, where they must keep silent for a period of time, where they must stay put, where they must take responsibility for what they say or do not say, where they can hear feedback as to how they come across to others. As the individual learns to bear with the tension of these feelings in the group, that skill can be carried into the outside world.

  Sixth, groups address the problem of disconnectedness. Many people with ADD have trouble finding a place where they feel connected, a part of something larger than self. Although people with ADD tend to be outgoing and gregarious, they can also harbor strong feelings of isolation, loneliness, and disconnectedness. Their stance in life is often one of reaching out but not quite making contact, as if running alongside a speeding train, trying to grasp the hand that is being held out to them to help them on board. Groups can bring people on board. Groups can provide a sense of belonging, a sense of connectedness. Once on board, the individual can feel more a part of things in other areas of his or her life.

  To illustrate the power of group therapy in ADD, let
me tell a story from one of the groups I conduct. Some time ago I began to organize groups for adults with ADD. I had never done this before, and I had not read of others doing it, but for all the reasons given above, it seemed to me a good idea. To start my first group I announced the idea at a lecture I gave. From the people who signed up, I selected a group of ten men and women, and we started to meet once a week.

  I did not know what to expect. Colleagues I mentioned the idea to rolled their eyes and said, “Ten people with ADD in a group?! How can you run herd on that?” Another colleague asked, “Will they ever show up on time?”

  Not knowing what would happen, I sat in my office the evening of the first meeting of the group. We were to meet from 7:00 to 8:15. By 7:15 not one of the ten members had appeared. I began to wonder if my own ADD had led me to write down the wrong day. At 7:20 the first member showed up. He burst into the office ready to apologize for being late, but when he discovered he was the first to arrive, he started laughing and said, “Well, what can you expect?” Seven people eventually arrived for that first meeting. Three others left messages saying they had gotten lost on their way to my office.

  The ones who did find their way began the most remarkable group I have ever participated in. They came together immediately, united in their desire to find mutual understanding, to tell their various stories, and to “be there” for each other.

  I gave the group some basic guidelines: Try to be on time. Don’t socialize with each other outside the group. If you are going to miss a session, try to let the group know about it in advance. We contracted to meet for twenty weeks with an option to continue for another ten weeks if people wanted to. I also called the members who had gotten lost and gave them directions for the following week.

  The next session all ten members showed up and on time. They laughed about the trouble they’d had with directions the week before, and started what became a regular practice in the group of giving good-natured kidding as a way of dealing with the problems of ADD. “It’s a miracle,” they laughed, “that we all got here this week, and on time no less.” Their exuberance filled the room even before they knew each other. It was as if, in some intuitive part of their minds, they already knew each other and how important the group would become. From the beginning they were ready for each other.

  They began to tell their stories. One by one, not on cue but spontaneously, tales of humor and tales of pain filled the room. They looked around at each other, giving nods of approval and looks of recognition as they would identify with one detail or another that was being related. To be with them was to be with people who had spent their whole lives feeling “different,” only now to discover in each other that they were not alone. They laughed back tears, and they faced each others’ pain with firsthand understanding, as they told of misunderstandings, frustrations, and lost chances as well as of tips and advice, tricks from the ADD trade.

  I didn’t have to do a thing. If one member interrupted another member, others would say something like, “Now don’t interrupt. Since we all have ADD, we have to be really careful about paying attention to each other.” They looked out for each other in this kind of way during every session. I sat back and answered factual questions about ADD now and then, but, by and large, the members of the group did all the work. When I had to miss a few meetings because of prior commitments, the group simply met in my office without me. They asked only if I would bill them for sessions I missed. I said of course not.

  Within a few weeks the group had developed a powerful sense of cohesion. One member, who was an aspiring actress, turned down a part in a play because rehearsal time conflicted with group time. Another member, who went on vacation, sent us a postcard. Members gave each other permission to call each other in case of an emotional crisis. I worried this might lead to subgrouping or breakdowns in confidentiality. It never did.

  When the option to continue the group for another ten weeks came up, everyone wanted to go on. However, one member stated she could not afford to. Later that week I received a letter without signature or identifying marks. It contained, in cash, the fee for an additional ten weeks of the group. The person who wrote the letter identified him- or herself only as “a member of the adult ADD group.”

  Now I, who was trained in psychoanalytically oriented Boston, felt racked by a dilemma. What should I do? Do I bring the money into the group? Give it back? To whom? What if the person who had said she could not afford to continue had said that as a way of leaving the group gracefully? Would this put undue pressure on her to continue? What if others felt cheated that they couldn’t get a “scholarship” also? What about the group’s curiosity as to the identity of the anonymous donor? What about my own curiosity? With these questions swimming through my mind, I called a colleague, experienced in group work, for advice. He felt a bit perplexed as well, but advised me to bring the matter up in the group and see how they handled it.

  At the next meeting of the group we decided to go on for ten more weeks and then to stop. At that point I informed the group that I had received an anonymous cash donation to cover the fee of the member who could not afford to continue.

  Well, thankfully, the group was not psychoanalytically trained. Their response was to say how generous it was for someone to donate the money, and then they moved on to other topics. I sat there biting my tongue, thinking, Yes, but, don’t you want to know more? Don’t you see the complicated dynamic issues involved here? Shouldn’t we analyze the implications of this gift? Etc., etc. However, I didn’t let myself make more of the matter than the group did, and so the incident passed into the group’s history as this: the group received a generous gift which allowed the group to remain intact for ten more weeks. In retrospect, I do still have all those questions I had originally. But most of all, I see the gift as evidence of just how important it was to the members of the group to be together and, at last, to be understood.

  MEDICATION

  The various medications that we now use in the treatment of attention deficit disorder can dramatically improve the quality of an individual’s life. Just as a pair of glasses help the nearsighted person focus, so can medication help the person with ADD see the world more clearly. When the medication is effective, the results can be truly astonishing and life-changing. However, medication is no panacea. It does not work for everybody who has ADD, and for those it does help, it ameliorates but does not cure the syndrome. When medication is used, it should be used only under medical supervision, and it should be used only as part of a comprehensive treatment program that includes a careful diagnostic evaluation; education about ADD and associated learning problems; practical suggestions as to how to restructure one’s life and manage one’s moods; counseling, coaching, or psychotherapy; as well as family or couple’s therapy as needed.

  The following information on medication is intended to supplement conversations with a physician or other counselor. You should never take any medication until you feel you know all you need to know and you feel comfortable with this course of treatment.

  Before beginning a course of medication, you of course want to be sure of the diagnosis. Then you must determine what the target symptoms are so that you will have an objective way of assessing the efficacy of the medication. Typical target symptoms in ADD would include: easy distractibility; inability to stay focused—for example, on a task at work or reading a book, homework, or classroom material; impulsive acts or words; difficulty maintaining attention during a conversation; poor frustration tolerance; angry outbursts; mood swings; difficulty getting organized; chronic procrastination; difficulty prioritizing; tendency to worry rather than act; a subjective inner feeling of noise or chaos; tendency to hop from topic to topic or project to project; and other symptoms associated with ADD. It is important to try to define these as concretely as possible.

  Once you have an accurate diagnosis and have defined what the target symptoms are, you may be ready to try medication to treat those target symptoms.

&nbs
p; Very often at the initial stage of treatment there is great reluctance to try medication. Parents do not want to “drug” their child, or the adult with ADD wants to make it on his own, without the aid of some unknown medication. This hesitancy may be deeply felt and must be dealt with carefully.

  Children, particularly boys, often feel that taking medicine is like admitting something scary is wrong with them, admitting they are “retarded” or “crazy” or “stupid,” all labels they are struggling to throw off. They also often feel that medication is a crutch they should not need to use. They frequently feel embarrassed or humiliated in taking the medication. It is essential that these feelings be explored and dealt with gently and respectfully. It may take months, even years, before a child—or adult—feels ready to give medication a try. That is all right. The medication should not be given until the individual is ready to take it. The decision to take medication should never be unilateral and should not be a struggle; it should be bilateral, emerging from a dialogue that lasts as long as it needs to.

  Of course, no one is obliged ever to try medication. And no one should try medication without wanting to do so and without a full understanding of the risks and benefits involved. But what too often happens is that one decides against medication without a full understanding of what is involved. One decides against medication on the basis of heresay, superstition, or gut feeling, not on the basis of fact and science. There is a great deal of misinformation spread around about the various medications used to treat ADD. It is extraordinary the number of false rumors that swirl around Ritalin, one of the chief medications used to treat ADD. “It will make you crazy,” people whisper to one another. “I saw an article in the paper that said Ritalin turned one man into a homicidal maniac.” “Ritalin is just the schools’ way of lobotimizing children.” “Ritalin turns you into a dwarf.” These tabloid-headline-type remarks are made all the time. They are utterly untrue.