Driven to Distraction: Recognizing and Coping with Attention Deficit Disorder

by Edward M. Hallowell

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.

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.

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.

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.

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.

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.

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.

When the medication is effective, the results can be truly astonishing and life-changing.

There is a great deal of misinformation spread around about the various medications used to treat ADD.

Today, as in the past, we have two main classes of medication that are approved by the FDA in the treatment of ADD: the stimulants and the antidepressants.

The medication does not always work, and even when it does work, sometimes it must be discontinued due to intolerable side effects. In these cases, the nonmedication forms of treatment can still produce significant therapeutic gains.

Of the antidepressants used to treat ADD, Strattera, Wellbutrin, and Norpramin are the most commonly used. Strattera is the newest of this group and has achieved much popularity, though it often has the uncomfortable side effects of nausea and fatigue. Although they are completely different substances, chemically, than the stimulants, they often have a similar effect upon the target symptoms of ADD. Sometimes, when a stimulant does not work, this group will, and vice versa.

No scientific evidence linking a proneness to PMS with ADD has been offered. But many of our female patients report unusually severe PMS symptoms.

For most people who have ADD, medication has proven to be extremely useful. For some it has proven to be ineffective. For a very few it has proven to be harmful. If the diagnosis of ADD is carefully made, the best research data we have states that a trial of medication is indicated. However, it might not work.

Medication is not the whole treatment for ADD. It is a useful and powerful adjunct, but it should never be regarded as the complete treatment.

A word of caution should be added. Often when people read these tips for the first time, they become excited about incorporating them into their lives right away. After an initial burst of enthusiasm and improvement, however, they find that the old habits associated with their ADD start to creep back into their lives, and they find that the tips, although “correct,” are hard to follow consistently.

It is important, therefore, to keep in mind that the tips are only one part of a treatment program. Very few people with ADD can implement these tips consistently on their own. They need help, either from what we call a “coach,” or from a group, or from a therapist, or from some other external source.

2. Educate yourself. Perhaps the single most powerful treatment for ADD is understanding ADD in the first place. Read books. Talk with professionals. Talk with other adults who have ADD. These may be found through ADD support groups or local or national ADD organizations like CHADD. You’ll be able to design your own treatment to fit your own version of ADD.

4. Seek encouragement. ADD adults need lots of encouragement. This is in part due to many self-doubts that have accumulated over the years. But it goes beyond that. More than most people, ADD adults wither without encouragement and thrive when given it. They will often work for another person in a way they won’t work for themselves. This is not “bad,” it just is. It should be recognized and taken advantage of.

8. Listen to feedback from trusted others. Adults (and children, too) with ADD are notoriously poor self-observers. They use a lot of what can appear to be denial.

9. Consider joining or starting a support group. Much of the most useful information about ADD has not yet found its way into books but remains stored in the minds of the people who have ADD. In groups this information can come out. Plus, groups are really helpful in giving the kind of support that is so badly needed. 10. Try to get rid of the negativity that may have infested your system if you have lived for years without knowing that what you had was ADD. A good psychotherapist may help in this regard.

14. Establish external structure. Structure is the hallmark of the nonpharmacological treatment of the ADD child. It can be equally useful with adults. Once in place, structure works like the walls of the bobsled slide, keeping the speedball sled from careening off the track. Make frequent use of lists, notes to self, color coding, rituals, reminders, files. Also use pattern planning, as described earlier.

15. Use pizzazz. Try to make your environment as peppy as you want it to be without letting it boil over. If your organization system can be stimulating (imagine that!), instead of boring, then you will be more likely to follow it. For example, in setting things up, try color coding. Mentioned above, color coding deserves emphasis. Many people with ADD are visually oriented. Take advantage of this by making things memorable with color: files, memoranda, texts, schedules, etc. Virtually anything in the black-and-white of type can be made more memorable, arresting, and therefore attention-getting with color. 16. When it comes to paperwork, use the principle of O.H.I.O: Only Handle It Once. When you receive a document or a memo or any kind of written material, try to only handle it once. Either respond to it right away, on the spot, or throw the document away, or file it permanently. Do not put it in a TO DO box or pile. For people with ADD, TO DO piles might just as well be called NEVER DONE piles. They serve as little menaces around one’s desk or room, silently building guilt, anxiety, and resentment, as well as taking up a lot of space. Get in the habit of acting immediately on your paperwork. Make the wrenching decision to throw something away. Or, overcome inertia and respond to it on the spot. Whatever you do with the document, whenever possible, only handle it once.

18. Acknowledge and anticipate the inevitable collapse of X percent of projects undertaken, relationships entered into, obligations incurred. Better that you anticipate these “failures” rather than be surprised by them and brood over them. Think of them as part of the cost of doing business.

21. Break down large tasks into small ones. Attach deadlines to the small parts. Then, like magic, the large task will get done. This is one of the simplest and most powerful of all structuring devices. Often a large task will feel overwhelming to the person with ADD. The mere thought of trying to perform the task makes one turn away. On the other hand, if the large task is broken down into small parts, each component may feel quite manageable. (For example, it was only by using this technique that we managed to write this book.)

22. Prioritize rather than procrastinate. If you cannot handle it only once (tip 16), then be sure to prioritize. When things get busy, the adult ADD person loses perspective: paying an unpaid parking ticket can feel as pressing as putting out the fire that just got started in the wastebasket. Sometimes one becomes paralyzed. Prioritize. Take a deep breath. Put first things first. Then go on to the second and the third task. Don’t stop. Procrastination is one of the hallmarks of adult ADD. You have to really discipline yourself to watch out for it and avoid it.

24. Notice how and where you work best: in a noisy room, on the train, wrapped in three blankets, listening to music, whatever. Children and adults with ADD can do their best under rather odd conditions. Let yourself work under whatever conditions are best for you.

25. Know that it is OK to do two things at once: carry on a conversation and knit, or take a shower and do your best thinking, or jog and plan a business meeting. Often people with ADD need to be doing several things at once in order to get anything done at all.

28. Keep a notepad in your car, by your bed, and in your pocketbook or jacket. You never know when a good idea will hit you, or you’ll want to remember something else. 29. Read with a pen in hand, not only for marginal notes or underlining, but for the inevitable cascade of “other” thoughts that will occur to you.

32. Choose “good,” helpful addictions, such as exercise. Many adults with ADD have an addictive or compulsive personality such that they are always hooked on something. Try to make this something positive.

33. Understand mood changes and ways to manage these. Know that your moods will change willy-nilly, independent of what’s going on in the external world. Don’t waste your time looking for someone to blame. Focus rather on learning to tolerate a bad mood, knowing that it will pass, and learning strategies to make it pass sooner. Change sets, i.e., get involved with some new activity (preferably interactive), such as a conversation with a friend, or a tennis game, or reading a book. 34. Related to number 33, recognize the following cycle, which is very common among adults with ADD: a. Something “startles” your psychological system, a change or transition, a disappointment or even a success. The precipitant may be quite trivial, nothing more than an everyday event. b. This “startle” is followed by a minipanic with a sudden loss of perspective, the world being set topsy-turvy. c. You try to deal with this panic by falling into a mode of obsessing and ruminating over one or another aspect of the situation. This can last for hours, days, even months. To break the negative obsessing, have a list of friends to call. Have a few videos that always engross you and get your mind off things. Have ready access to exercise. Have a punching bag or pillow handy if there’s extra angry energy. Rehearse a few pep talks you can give yourself, like, “You’ve been here before. These are the ADD blues. They will soon pass. You are OK.”

35. Learn how to name your feelings. Many people with ADD, particularly men, get frustrated and angry because they cannot put their feelings into words. With practice and coaching, this is a skill that can be learned. 36. Expect depression after success. People with ADD commonly complain of feeling depressed, paradoxically, after a big success. This is because the high stimulus of the chase or the challenge or the preparation is ove...

38. Use “time-outs,” as with children. When you are upset or overstimulated, take a time-out. Go away. Calm down. 39. Learn how to advocate for yourself. Adults with ADD are so used to being criticized, they are often unnecessarily defensive in putting their own case forward. Learn to get off the defensive. 40. Avoid premature closure of a project, a conflict, a deal, or a conversation. Don’t “cut to the chase” too soon, even though you’re itching to.

41. Try to let a successful moment last and be remembered and become sustaining over time. You’ll have to train yourself consciously and deliberately to do this because you’ll naturally tend to forget your successes as you brood over your shortcomings or pessimistically anticipate the worst. 42. Remember that ADD usually includes a tendency to overfocus or hyperfocus at times. This hyperfocusing can be used constructively or destructively. Be aware of its destructive use: a tendency to obsess or ruminate over some imagined problem without being able to let it go. 43. Exercise vigorously and regularly. You should schedule exercise into your life and stick with it. It helps you work off excess energy and aggression in a positive way, it allows for noise reduction within the mind, it stimulates the hormonal and neurochemical system in a most therapeutic way, and it soothes and calms the body. When you add all that to the well-known health benefits of exercise, you can see how important exercise is. Make it something fun so you can stick with it over the long haul, i.e., the rest of your life. One particular form of exercise, sexual activity, is very good for ADD.

mate. 45. Learn to joke with yourself and others about your various symptoms, from forgetfulness to getting lost all the time to being tactless or impulsive. If you can bring a sense of humor to your failings, others will forgive you much more quickly. 46. Schedule activities with friends. Adhere to these schedules faithfully. It is crucial for you to keep connected to other people. 47. Find and join groups where you are liked, appreciated, understood, enjoyed. Even more than most people, people with ADD take great strength from group support.

48. Don’t stay too long where you aren’t understood or appreciated. Just as people with ADD gain a great deal from supportive groups, they are particularly drained and demoralized by negative groups, and they have a tendency to stay with them too long, vainly trying to make things work out, even when all the evidence shows they can’t. 49. Pay compliments. Notice other people. In general, get social training if you’re having trouble getting along with people. 50. Set social deadlines. Without deadlines and dates your social life can atrophy. Just as you will be helped by structuring your business week, so, too, you will benefit from keeping your social calendar organized. This will help you stay in touch with friends and get the kind of social support you need.

There is no one recipe for the treatment of ADD. Each case presents its own problems and requires its own solutions.

2. After an initial burst of improvement, progress slows. Often when the diagnosis of ADD is made—particularly in adults—there is an initial period of euphoria: at last there’s a name for all the suffering the person has endured through the years. And usually there is an initial spurt of emotional growth as the treatment begins. However, after some months, the growth curve begins to level off, and the individual may become despondent. This is normal and understandable. The beginning of treatment is exciting, and it is disappointing to confront the fact that the treatment does not make all of life’s problems go away. It is at this point of dismay that support is crucial—from a therapist, from a support group, from friends, from family, from books.

Some people are exquisitely sensitive to medication. This is not a problem as long as it is recognized. Some people cannot tolerate anything but the tiniest dose of any medication.

It can be very frustrating for the patient—and the doctor—as they try to find just the right medication, or combination of medications, and the right dosage, but it is important to keep trying.

have ADD. One of the hardest parts about having ADD can be the feeling of being alone, of being “different,” of feeling misunderstood. An excellent way to deal with this problem is to join a support group.

8. It is impossible to find a knowledgeable clinician in your area to diagnose and/or treat ADD, or you can’t find information on ADD.

There are several good places to go for information on where to get treatment. First, there is your state medical society, as well as your state neurological, pediatric, and psychiatric societies. Second, any medical school in your area can help you find a specialist in ADD. Just ask for the department of neurology or the department of pediatrics or the department of psychiatry or child psychiatry. Third, there are several organizations and newsletters devoted to ADD. These are excellent sources of information as well as support groups. We offer a partial listing here and a fuller listing at the end of this book.

As is known by clinicians who work with the ADD population, and by parents of ADD children, and by adults who have ADD, one of the most frustrating aspects of ADD is the inability to profit from one’s experience, the inability to focus on consequences, the inability to navigate through tasks or social situations or the world at large by using what has been learned previously.