Category: ADD/ADHD

A Neurodivergent Clinicians’ Personal and Professional Journey of Self-Discovery

Posted on by rezendevknowfully.com

My journey of self-discovery is probably similar to those of many others, with the exception that becoming a therapist, at least to me, is unlike any other career. The things I witness, hear, and experience, have no comparison. For the sake of myself and my clients I must continue to evolve, grow, and remain a lifelong learner. The space of shared stories and experiences is the one from which therapeutic connections can, and have, been made; where I join fully as a human being, and can bring together the various intersectional elements of my own identity. And just like my clients, I have my own story.

Recently, a student asked me about working with neurodivergent clients who have not experienced trauma. I thought it was a great question. In my experience as a neurodiverse therapist and citizen of the world, society is not set up for neurodivergent people and this binary of trauma or no trauma must yield to a more fluid, continuum-based way of thinking. Simply existing can feel traumatic for those who are neuroatypical.

In researching this topic through the scientific lens of my academic identity, I’ve simply not been able to keep pace. There is so much! Through another lens at the intersection of my identities, that of practicing clinician and neurodivergent, I have come to recognize the limitations of purely empirical investigation and have begun visiting social media sites in order to better understand the autistic and neurodivergent community through the lens of experience. I learned more from direct, and very personal narratives, than I did from any textbook or any clinical training.

Working with Bee: An Answer Deferred

Years ago, I worked with an older teenager, Bee, in a rural community who identified as queer. She initially came to see me because her gender fluidity and sexual orientation created conflict with her mother and her mother’s belief system. I want to emphasize the conflict was not between her and her mother, per se, but with the mother’s religious beliefs. This is not an uncommon experience where I practiced. While Bee had social anxiety and low self-esteem, she did have a good support system with her family and friends.

I worked individually with Bee and did some relational work with the family as well. Throughout our time together, she was able to build self-confidence and find employment. By her senior year, she was doing all kinds of things including taking on leadership roles as she fully embraced the trajectory into adulthood. It was for all intents and purposes, an effective therapeutic relationship in which we met the goals of treatment, individual symptomatology diminished, and her relationships improved, as did her attachment experiences and communication skills.

I remember one point during our time together when Bee asked me if she “could have ADHD or be autistic?” I said I wasn’t sure, so I did an ADHD screener, which was diagnostically inconclusive, after which we had several discussions about the results. I even talked about referring for a more comprehensive psychological evaluation, but did not really see the need for it. I talked about some traits but nothing within the clinical range. To support this, I pointed out to Bee that she was doing well socially, involved with extracurricular activities, had friends, and an active social life. At that point, we ended our work.

Through some happenstance around 2-3 years later, Bee’s family reconnected with me to share all the positive things that had occurred in their lives. I met this invitation with openness and curiosity. After the update of Bee going to college and studying a topic of her choice, I immediately shared my need to apologize. Bee asked what I meant. I remember asking, “do you remember when you asked me if you were neurodivergent and I said I really do not think so?” She quickly replied affirmatively.

I went on to tell Bee that I had spent the last several years learning about autism and ADHD, and that in retrospect, she was right. I admitted to her that I was neurodivergent, and that, “I believe you are too.” We shared a laugh about the experience. I was glad she was not angry and that she didn’t feel dismissed but said that “it would have been okay if you had been upset with me.” She knew back then that I genuinely did not think she was on the spectrum, but she was personally unsure. She knew I was not trying to dismiss her and reminded her of my recommendation for a comprehensive evaluation. But those evaluations were not as accessible or affordable as they later became. This was where the field was at that time, and it is where I was along my own path of self-discovery. Statements like the one I made back then, “You have some traits but don’t really meet criteria,” were likely very common before the idea of spectrum was more fully embraced. A few observable traits no longer mean that deeper pathology is being masked, awaiting a full assessment followed by a definitive diagnosis. Neurodivergence means just that…divergence, or variation on a theme. And that variation extends to race, gender, culture, and age.

I am glad I could repair, at least from my perspective, what I considered a therapeutic rupture, although Bee did not experience that rupture in a traditional way to the point that therapy hits an impasse or ends abruptly. The version of myself that spoke with Bee that day knew that she presented with all the “usual” observable symptoms that accompany autism, and that had I dug deeper, the diagnosis would have been clear. I missed or perhaps had resisted the diagnosis because I had not yet found a place for that label in my own identity. I could have let Bee’s narrative lead the way rather than the dictates of my formal training and that of impersonal scholarly investigations. Just as I now have a far clearer understanding of the complexity of my own intersectionality, I now more fully embrace the importance of honoring my clients’ narratives.

Postscript

Quite a while after my work with Bee and her family, I had taken my son at age 7 for an ASD evaluation. The psychiatric resident looked at him and said, “he is not autistic, you see this is the autistic bible––” he slapped his book on his desk––“I can tell by looking that he is not autistic.” My son returned to the room with blue cupcake icing on his face. I felt flooded with embarrassment and rage. I wanted someone to tell me why my son was struggling in so many ways in his life. I firmly said, “I want to see my attending physician.” She subsequently met me with compassion and kindness; however, not even an ADOS was performed.

The irony, or better yet, outrage I felt was because my son had classic symptoms of autism–– hand flapping, lining up toys, and a host of other stereotypical stuff for most of his early childhood, some of which reduced somewhat by age 7. Maybe the resident, and my attending, thought he was too old to be first considered for the diagnosis. But then again, I really don’t know the basis for their preemptory conclusion. I do know that the experience left me angry, feeling rejected, and dismissed, and like there was no help.

To have personally attended a state university that provided evaluations, only for the doctor to not even ask me any questions about my son was so disturbing, if not insulting. I am sure the progress note read something like, “Mother was emotionally unstable and reactive.”

I knew from that moment on I never wanted anyone else to feel that way. At the time of that visit with my son, I had been working on my PhD which paved the way for my own self-study and re-orientation to the whole experience of autism and neurodivergence. The research is clear, at least to me, as a citizen, parent, and clinician.

The field is failing neurodivergent people––kids, teens, adults, families, and couples. Social media has become a substitute, or perhaps a primary place for validation because they can’t receive it from the professional world. When clinicians and the medical community correct clients and dismiss the importance and validity of self-diagnosis, what can be expected? I view this very differently since social media was the source of my own self-discovery of neurodivergence, and a tool for assisting my clients on their own journeys. The entire experience, from my work with Bee to the evaluation of my son to my own self-acceptance, has awakened a deeper awareness that has highlighted the importance of embracing and advocating for the evolution of the professional landscape.

Therapeutic Reimagining

Posted on by Psychotherapy.net Team

An Introduction to Therapeutic Reimagining

I’m very proud to have recently published my first book, Reimagine Your Life: How to Change Your Past and Transform Your Future, in which I introduce a process that I have named “therapeutic reimagining.”

There are many reasons why I am proud of this book, but the greatest achievement is to have overcome the intergenerational narrative provided by my “working class” upbringing in the United Kingdom, with its self-limiting beliefs about myself, others and the world.

I come from a family of six siblings, three of whom left school virtually unable to read or write. My father was an Irish immigrant who worked on a building site doing unskilled work, and my mother left school at the age of 14 to look after cows on a local farm. I too was educationally backward as a child, and was never given a book, or helped with reading by my parents. So, if they were alive today and I told them that I have written a book about a new way of doing psychotherapy, it would be incomprehensible to them.

It has taken me 20 years of hard study and practice to put all of the puzzle pieces together and create this process that I call therapeutic reimagining. I simply couldn’t have done it earlier in my life. That is the gift of ageing: being able, over time, to integrate a multitude of different experiences.

Although writing Reimagine Your Life was conceived as a way of helping people who either couldn’t afford therapy or couldn’t access it for other reasons, the core process of therapeutic reimagining was born in my psychotherapy practice in Cambridge, England as a way of accelerating clients’ progress in therapy. Simply put, they were able to get much further forward in their healing journey by being empowered and encouraged to continue their transformational work outside of sessions.

The book cover has a clock face and the question, “How far would you wind back time and what would you change?” This gives us a clue that it is about overcoming trauma by redoing the past.

Often in people’s lives something goes wrong or there is trauma that leads to a whole downward trajectory of events. So, I invite my clients to wind back time to a point before it happened and explore an alternate timeline or alternate history.

This might sound like time travel and science fiction. However, it is actually science fact: the psychology of counterfactual thinking. You may have never heard of it, but it is something we do with our clients all the time. Every time we ask a question like “How do you wish your childhood was different” we are inviting them to imagine an alternate history with a new narrative.

In Gestalt Therapy, we ask the client to go back in time and “Be there now.” In Transactional Analysis, it is called “early scene work;” “enactments” in Psychodynamic Therapy, and “portrayals” in some other therapies.

However, where therapeutic reimagining is different from all of the above, is that it provides a roadmap of how to do the process, so that clients can create their own portrayals at home. It has worked so well with my clients that I wanted to write a self-help book that would allow those who can’t afford or can’t access one-to-one therapy to benefit from the process. It is safe to do at home because the reader is invited to imagine a more pleasant alternative to what actually happened.

The book contains nine stories, written by the clients themselves, explaining how they used therapeutic reimagining to overcome shame, guilt, fear, anxiety, overeating, and even medically unexplained physical symptoms.

One of the stories concerns a theme that many people encounter in later life, the illness and death of their life partner. Stephanie was 73 when she came to see me, full of toxic guilt related to the circumstances of the death of her husband several years earlier. Her guilt interfered with the grieving process and caused her a great deal of emotional pain and suffering. With Stephanie’s consent I am sharing her therapeutic reimagining journey.

Stephanie’s Story: Grief Without End

I was struggling with the knowledge that I had not done everything that I could have done for my husband in his last few days of life. He was in hospital, and the doctors told me he had kidney failure which they were planning to treat with dialysis.

I had no idea that he was going to die soon. On the fourth night, they called me into the hospital because he was dying. He died the next day. All the time that he was in the hospital I believed that they were trying to help him.

All the time he was in the hospital he was asking me to take him home. Once he had died, I realized that he knew he was dying, and he wanted to die at home. I had no way of knowing that he was dying at the time, and I persuaded him to stay in the hospital where I believed that he was getting treatment that would help him, and that although he was seriously ill with lymphoma and we knew that it could not be cured, we thought we had a few years more.

For more than three years after he died, I suffered profound guilt about my behavior during these days. This feeling haunted me, and even though I knew that I wasn’t aware that he was dying during his last days, I found it hard to forgive myself for not paying attention to his requests to be taken home. My intelligent self knew that if I had known, I would have acted differently, but this knowledge had little or no effect on the extremely painful feelings that I was experiencing day after day.

Anthony encouraged me to visualize an alternative narrative. To imagine moment by moment what would happen if I had taken him home instead of persuading him to stay in the hospital. I found this extremely difficult at first, I could imagine investigating the possibilities of bringing him home, of engaging a nurse and arranging for a hospital bed to be brought to our flat. I got as far as imagining the ambulance people bringing him up the flight of stairs to the room I had prepared for him. But it was really difficult to continue the story.

At first, I found it very difficult to imagine him actually in his bedroom and actually dying there. But I persisted and over a week I was able to visualize everything from the point of deciding to bring him home and preparing a room for him and then imagining his death at home. I was able to borrow from the actual experiences. For example, there was a very compassionate nurse who had helped him in the hospital. In my imagination, she was in the bedroom at home. I remembered the night I spent stroking and talking to him whilst he was dying and unconscious, but I reimagined these experiences and saw them in the bedroom in our flat with me sitting on one of our chairs and not the hospital chair.

This new experience became very real to me. Although I knew it was a new narrative, and I knew that it hadn’t happened this way, I was able to experience the events emotionally. It made such a difference, and afterwards I didn’t dwell on the original painful experience to the same extent. Over time that pain has receded: not the pain of his death, but the pain of the guilt that I felt around the circumstances of his death.

In some ways, it feels like magic. I know how things happened. I know the real story of how John died. But I have been able to overcome the extremely painful feelings of guilt and responsibility that had troubled me so deeply and for such a long time. Something had changed, and it has helped me to recover. I’m not sure I forgive myself entirely for not being aware enough at the time to act differently, but I’m not punishing myself for my oversight anymore.

Learning Points from Stephanie’s Story

I’ve re-read Stephanie’s story many times over the last few years, but I still feel very moved by it. Her story gives us an idea of how simple, yet powerful, therapeutic reimagining can be. Although she says, “At first I found it extremely difficult to imagine,” she persists over one week and is able to add all of the details. Crucially, she is able to include the very moving emotional elements of her husband actually dying in his bedroom at home.

As a human being, I felt some resistance to suggesting she imagine this very emotionally challenging scene, especially knowing I would not be with her when she did. However, as a therapist, I knew there was a very good chance that if she did, she would be freed from endless toxic guilt. She would no longer be “haunted” by it and would get the closure that she needed.

In session, as soon as Stephanie said, “If I had known he was going to die, I would have looked after him at home,” I was immediately alerted to the possibility of using counterfactual thinking to redo the past. This was a classic “If I knew then what I know now” example of a situation in which we can use counterfactual thinking to heal a painful regret. In fact, whenever a client says, “If only” or “I wish,” it is a cue for therapeutic reimagining.

However, I don’t wait for the client to stumble across the answer. Instead, I ask questions like “What should have happened?” and “What could have happened differently?” These are the key questions that I encourage clients to ask themselves, in order to reimagine their life.

Another way in which to conceptualize what needs to happen differently is: what happened that shouldn’t have happened, for example trauma; and what didn’t happen that should have, for example being loved by one’s parents as a child, or getting to say goodbye before the death of a loved one. Although she never wrote about it in her brief story, saying all the things she had wanted to say to her husband before he died was another aspect of Stephanie’s healing in her therapeutic reimagining. It helped give her closure and is sometimes called a completion portrayal when done in the therapy room. We had never discussed doing a completion portrayal in session. However, her creative unconscious guided her in doing it on her own.

Trusting the Client’s Creative Unconscious

Although I offer lots of ideas and suggestions, it is always the client’s choice of what new narrative they will create in their therapeutic reimagining at home. Sometimes, I suggest they write a letter to their younger self or even an internalized parent, imparting important information about their future that will help their younger self. However, they often come back the following week and rather sheepishly say, I did the homework, but not as you suggested. I usually say, “Great! I bet your creative unconscious mind came up with something even better than either of us could come up with in the session.” And often, they have.

This was the case in Viktor’s story. He had come to see me about his problem of forming relationships with women. After some time, we realized that part of the problem was connected with his relationship with his mother as a child. I suggested that maybe he should write a letter to his mother from his childhood, warning her that the way she was treating him would have serious consequences for him in the future.

However, he seemed to have intuitively known that his mother from the past wouldn’t have listened to his present-day self, so he chose to do the process in a very different way. He informed me that, instead, he had talked to his present-day mother (the version of her in his head) who “instantly knew what to do,” he said. She then talked to her younger self, explaining why she must desist from her harsh treatment of him. Victor explained that it was hard work even for his present-day mother to get through to her younger self, but eventually she succeeded. This all occurred at home as a conversation in his mind between these parts of himself, which he created entirely on his own.

Now that he had found a viable solution that was believable to him, Viktor was able to imagine his mother being different in his childhood, he was able to experience a number of therapeutically reimagined scenes, where she did not treat him so harshly. Victor reported that the effect of this work on his present-day relationships with women, had been rapid and transformational.

All of the nine stories in the book are very different and so the therapeutic reimagining scenes that they needed were also very different, but it is always the client who decides what they need. However, I do always encourage the client to experience the emotions of the new scenes, so that it feels real, as this is a key ingredient in making the outcome therapeutic.

Why ‘Therapeutic Reimagining’ Works

Some of the theory of why it works comes from the neuroscience of memory reconsolidation and the juxtaposition of old and new memories. Creating an imaginary alternate timeline with a new narrative may allow the brain to un-anchor from the old painful memory. However, it is more important to understand psychologically what was needed in the past and to know how to do the process of therapeutic reimagining than to understand why it works at a neuronal level. This is what the book provides, a roadmap for the process. The nine client stories offer lots of examples of what could be reimagined and how they did it.

Although I do explain some of the theory of why the technique works in the main chapters, I’ve gone a lot deeper into the theoretical underpinnings of the process for mental health professionals in “Appendix A for therapists” at the back of the book.

How Hard do Clients Find Therapeutic Reimagining?
For some clients like Stephanie, who had been dealing with chronic toxic guilt, the solution and resolution of the problem can be surprisingly rapid because they have always unconsciously known the solution. “If I had known he was going to die, I would have looked after him at home,” she said. If we stay alert, we can often notice that the client has already glimpsed an alternate timeline that will allow them to create a new narrative. All we need to do is encourage them to explore that new path.

With others, it may take longer as the client hits some blocks to doing therapeutic reimagining. We saw this in Victor’s story. Initially, he could not see his mother in his childhood treating him any differently, not even if he explained to her the consequences of her actions in a letter. However, he quickly came up with an ingenious solution of speaking to his internalized mother from the present who was able to persuade herself from the past. I’m often amazed and delighted by my client’s creative unconscious ability to find exactly what they need to set themselves free.

There have been a few clients for whom therapeutic reimagining didn’t work initially, until we figured out what the block was. For example, Fergus, who had a problem with catastrophizing events in the future. When he first tried to use the technique, instead of imagining therapeutic outcomes, he simply catastrophized the past instead of the future, and we abandoned using it for some time as it was not helpful. However, one day we did get to the bottom of what function catastrophizing was fulfilling for him, and then he was able to use the process therapeutically.

Is it Safe When the Client’s Sense of Reality is Distorted?
Some clients are already living constantly in a fantasy world, one where they are always the hero. This was beautifully depicted in the film, The Secret Life of Walter Mitty played by Ben Stiller. With such clients, it is important to first confront them with the reality of their actual life before using therapeutic reimagining otherwise they would most likely do what Fergus did above, take his defense into the reimagined past, which would have no therapeutic benefit.

The process of therapeutic reimagining was even used successfully with a client who was recovering from psychosis and hospitalization, and was still taking anti-psychotic medication. However, it was only after thoroughly assessing the client’s current grasp on reality that I considered using it with him. Additionally, I regularly checked with him to see that he was completely aware of the differences between his actual life and the therapeutically reimagined scenes that he created to resolve attachment issues with his father.

Clients who Might Struggle to do Therapeutic Reimagining

One category of clients who often find therapeutic reimagining more difficult to do at home on their own is people with ADHD. These clients, who struggle to remain focused enough to imagine scenes outside of sessions, may need the work to be done as a portrayal in the therapy room instead. Similarly, some clients might need the work to be done in session for their therapist to help them regulate their emotions. My experience, however, has shown me that our clients are often more resilient than we believe and able to reimagine scenes that are healing.

***

Although Reimagine Your Life was conceived as a book that could help a lot of people who can’t for some reason access therapy, therapeutic reimagining was born in my psychotherapy practice as a way of accelerating clients’ progress. Simply put, clients were able to get much further forward in their healing journey by empowering them and encouraging them to continue their transformational work outside of sessions.

Bethany Brand on the Identification and Treatment of Dissociative Identity Disorder

Posted on by Psychotherapy.net Team

Lawrence Rubin: Bethany Brand is a professor of psychology at Towson University. She’s an expert in trauma, specializing in trauma related disorders, including post-traumatic stress disorder and dissociative disorders. She also maintains an independent practice in clinical psychology in Towson, Maryland. Doctor Brandt serves on international and national task forces developing guidelines for the assessment and treatment of trauma disorders. Welcome, Bethany. Thank you for joining.

Bethany Brand: Thank you so much for having me.

Right Place, Right Time

LR: What got you interested in dissociative disorders, trauma, and ultimately dissociative identity disorder from a personal perspective?

BB: It was a number of things. One of the early experiences I had as an undergraduate at the University of Michigan was working in a shelter for women who’d been battered, which is what it was called back then—not interpersonal violence like we call it now. I started hearing about trauma and remember being very interested in it. In my first semester of graduate school, I was doing a psychological testing practicum at Johns Hopkins Hospital on the kids’ unit. This was in the late 80s, so many of the kids had been abused or neglected according to their charts. I asked my supervisor how that experience might be reflected in their psych testing—how would they be different? And there we were at Hopkins, one of the premier institutions in our country, and she did not know.

To her credit, she acknowledged that and asked her supervisor, who later gave us this fascinating off-the-cuff talk about trauma and his experience with traumatized kids. It was so compelling that I decided that was what I wanted to do my master’s thesis on. I was lucky enough at the time that Frank Putnam, one of the legends in the field of dissociation, called my graduate program, asking for students who might be willing to volunteer on his project—a longitudinal study of girls who’d been sexually abused. I was incredibly lucky to be at that right place at the right time, working with a pioneer.

To be honest with you, I wasn’t sure about the whole idea of dissociative identity disorder because we didn’t see that in the lab and that was not what we were studying, even though Frank was studying it at the National Institute of Mental Health. When I later went on internship at George Washington University Hospital, a woman there said she had multiple personality disorder, with whom I had done the testing.
The treatment team was a little skeptical, but my supervisor referred me to Judy Armstrong at Sheppard Pratt Hospital in Baltimore who offered to review the data with me. After she did so, she said, “You know what; you actually might have somebody with MPD.” After that, it was just luck because I got a postdoctoral fellowship at Pratt, where they had just opened up a trauma disorders unit, and where I did my dissertation on trauma. I remained there and began working very heavily with folks with DID, and other serious, complex trauma disorders. Right place, right time, and fortunately, amazing training with amazing clinical supervisors.

DID and the Dissociative Spectrum

LR: Before I ask you what readers most likely want to know, which is, “What actually is DID,” why the transition from “multiple personality disorder” as a label to, “dissociative identity disorder?”

BB: There were a lot of reasons, but just to be very brief; by calling it multiple personality disorder, many clinicians thought it was a personality disorder like borderline personality disorder, and it’s not in that category. The experts in the field wanted to emphasize it was a trauma related disorder connected to dissociation, not a disorder of personality. The name change was an attempt to reflect that.

LR: Well, I guess relatedly—and I may get back to my initial question—does the DSM’s characterization of DID as a complex post-traumatic developmental disorder, ‘capture it?’

BB: It’s a terrific start. It’s a foundational start, because it implies that it starts in childhood, which is what developmental disorder means. The research strongly points to very early severe chronic child abuse as the cause. But we also know that there is genetic tendency towards dissociation. And often these clients who end up as individuals who develop DID also have attachment problems because they didn’t have secure attachment. There are multiple things going on, but trauma really has an early childhood foundation.

LR: In your writing, you discuss TRD or trauma related dissociation and suggest that DID is almost always related to early childhood trauma and severe disruption of the attachment relationship. Is there such a thing as a NTRD, or non-trauma related dissociation?

BB: Yes! We all dissociate to some extent, so normal non-pathological dissociation can occur. It can be going into a state of automatic pilot. For example, when we’re driving down the highway and we’re really thinking about something, and barely remember the drive when we get home. Or we’re driving down the highway and we miss our exit because we’re so preoccupied, not because of traffic, but because of our mental disconnection from what we’re doing.

It can also happen at moments of peak spiritual experiences or athletic experiences when people can disconnect from their bodies or feel out of their bodies and have this incredible experience. But none of these experiences interfere with functioning.

LR: I imagine getting lost in a book or a song or a movie or a conversation containing elements of dissociation, but on the left side, or benign side of the spectrum.

BB: Exactly. Those are called absorption, and some people are very prone to absorption. We know from research that the more somebody is prone to absorption, they may be more at risk for dissociation. There’s been some debate over whether absorption should be called dissociation or not? For now, it is understood as one of the lower levels, not-so-problematic types of dissociation, which comes from self-report measures.

LR: Is it clinically useful to think of a dissociative spectrum with absorption type experiences on the left or benign side, and DID as the most extreme and pathological form all the way to the right?

BB: Yes, I think it is. But I’ll say that with awareness that some people living with DID really resent that, because understandably, this was an adaptation to horrendous, overwhelming circumstances. And so, I completely get it and respect that they had a brilliant way of adapting and getting through what would have been just harrowing experiences. The research actually supports exactly what you said.
As I said earlier, all of us dissociate to some extent. And then when you start studying dissociation and different psychological disorders, there’s a range of scores that people have on the different, self-report questionnaires. And it starts out with people having [scores] a little bit above what might be for people who are not struggling with any emotional disorder.

And then it gets at the highest level is folks with DID. And in between, there might be people with eating disorders and maybe borderline personality disorder, because there’s often a lot of trauma in those people’s background, and then you start getting into PTSD. And then the dissociative disorders indeed are at the end with the highest levels of dissociation.

LR: I would think that someone who is engaging in non-suicidal self-injury or someone who is in the middle of an intense food or substance binge is in an acute state that requires a certain amount of dissociation to be able to inflict that level of harm on to yourself.

BB: Is there some dissociation that goes on during those moments? The answer is yes! Often people are somewhat disconnected from their bodies. An example is a client who, with DID or severe dissociation, may be cutting and not feel it and be kind of fascinated with what they’re seeing under their skin, like really extreme cutting with the detachment. And they don’t feel the pain.

LR: Is it possible that someone with DID could be cutting while there’s another element of that personality that’s watching? Am I using the right nomenclature for the other “states?”

BB: There are people in the field that are really pushing for those parts to be called dissociative self-states. In the literature, they’re alternatively called identities, personalities, parts, and alters. We’re really trying to emphasize that whatever they’re called, that they’re all parts of one person. They’re self-states. They’re not different people. That’s why we’re encouraging that name to be adopted in the next DSM.

LR: I find myself gravitating toward more questions that may be more of a popular culture artifact, but I’ve heard that different self-states can have symptoms of a particular medical illness or disease while another is asymptomatic. Is that possible in your experience?

BB: It depends on what illness you’re talking about. We know that, depending on our emotional state, our blood pressure may change, right? And Frank Putnam, who I referred to earlier, did some of the early research showing that different self-states have different EEG patterns.

Simone Reinders in the Netherlands has done a bunch of research studying neurobiological differences among some self-states. She’s tried having professional actors impersonate self-states while they were hooked up with all kinds of biological markers, including brain scans. They could not emulate different self-states.

It’s remarkable. It’s not magic. It’s a disorder that is linked to neurobiological changes and differences. And of course, these different self-states are going to include the traumatized self state, the one that remembers trauma and has all the symptoms that go with that PTSD. When they’re scanned, of course you might expect their heart rate to be much faster and for them to have more activity in their limbic system, versus a part that’s very detached and doesn’t recall that trauma. The heart rate of that self-state is not going to be as elevated. And they’re not going to have the intense amygdala activation.

LR: I can see that if someone is in a moment of active sexual abuse, sexual trauma, that it’s in the body’s interest to down-regulate the heart rate and cortical activation.

BB: Yes. There are studies about that, talking about how animals go into survival mode and, you know, like the faint mode or the feigning death mode. There are some animals that have that response of total disconnection from their bottom up to allow them to survive attack. Well, there’s some parallels with humans that have been horrendously abused repeatedly. Their brains shift into dissociation as a survival mechanism.

Their access to memory can be quite different as well. One of the diagnostic requirements is that there be amnesia for some of their life experiences, that are not due to drugs, alcohol, or head injury. Or they may not remember key autobiographical events, like their own wedding. We call that dissociative amnesia.

LR: What are some of the myths and misconceptions about DID that clinicians should know about?

BB: There are a lot, unfortunately. One is that DID is exceptionally rare. On and across different prevalence studies, at least 1% of the general population meets criteria for DID. That’s the same prevalence rate roughly as bipolar disorder and schizophrenia. So, it’s not rare, but there have been some critics.

Critics of the whole notion of dissociation and DID have been putting it out for a long time in articles that are published in journals. And that has found its way into psychology textbooks that undergrads and grad students read that put forward that myth so that unfortunately, many people, even mental health clinicians, think it’s rare. Another myth put forward by the critics is that DID folks exaggerate their symptoms or are prone to create false memories of abuse.

When you actually compare people with DID to people with PTSD to what are called healthy controls, people who don’t have any emotional problem, and professional actors who try and emulate all of this stuff, there are some studies we’ve done that show that people with DID
are no more likely than people with PTSD to develop false memories.

The important thing that most mental health clinicians have not been trained to know is that they are highly symptomatic across a bunch of different domains. They don’t just have amnesia and different dissociative self-states. They also have PTSD. And we know PTSD is a complicated disorder with 17 potential symptoms. And so, at times they’re flooded with traumatic intrusions, pictures, awful memories, awful nightmares. And then there’s periods where they’re shut down and avoid it because it’s so awful to remember and feel that stuff.

And then there can be incredible periods of irritability and sleeplessness and feeling like they’re an awful person and different from the rest of the world. There’s a lot of research showing that dissociation is very common among people with PTSD. They also have major depression and because living with all these symptoms is so brutally difficult, many of them have substance use problems.

They try to knock out the memories by drinking too much or using drugs. They often also have eating disorders because they have a very difficult time tolerating their bodies. They blame their bodies for their abuse, and so they try and get really big so that nobody’s ever attracted to them or—and they often go back and forth, or they get really anorexic and starve themselves hoping to die or to look unappealing that way.

All of that is shown in the literature. And with regard to feigning DID, one of the ways that you look for malingering is when somebody is reporting too many symptoms or reporting exceedingly severe symptoms. They are much more likely to be classified as potentially malingering on some of the evidence-based measures and interviews for malingering. I’ve developed research that helps mental health clinicians and forensic experts know how to differentiate when somebody has true DID and when somebody is attempting to simulate it.

The critics also don’t really understand complex trauma. They are typically not clinicians or academics. But because so few mental health folks are getting trained in the evidence-based information about DID, they come away with these stereotypes out of textbooks that are just wrong. They’re just flat wrong. And myths.

LR: Is there a short list of the cardinal presentations that differentiate DID from some of the other severe forms of psychopathology?

BB: Back when I was trained, I was taught that if you hear voices, you are psychotic. But more than 75% of people who have DID hear voices.

LR: Schizophrenic?!

BB: Yes, schizophrenia or maybe the psychotic phase of bipolar disorder. I would encourage therapists to not automatically assume that hearing voices means psychosis. There’s a whole bunch of research, including people who don’t have DID, experience voice hearing, and this is strongly associated with trauma exposure. There have been meta-analyses that support this, so I suggest that clinicians always ask every client, no matter the setting, if they have been exposed to trauma. So, learn how to do a good trauma assessment.

If somebody endorses having experienced trauma, then ask about PTSD symptoms and dissociative symptoms. Ask about the different types of dissociative symptoms. Ask about depersonalization. Does the person ever feel numb when they should have feeling? Does the person ever feel like their body doesn’t belong to them? Do they ever see themselves at a distance, like outside of themselves, like they’re watching a movie? Those are three common symptoms of depersonalization, and there’s a range of other symptoms they can ask about, like do you sometimes feel like you’re younger or not your own biological age. Ask about voice hearing.

LR: What’s your gut feeling about why there’s such resistance among clinicians to embrace the reality of DID?

BB: It does sound farfetched, right? But that’s because people are misunderstanding the disorder. It is impossible for people to have multiple people inside themselves. It is impossible. Right. But, Lawrence, you don’t have a little Lawrence running around in your brain, and I don’t have a little Bethany running around in my brain. How do you know you’re not me?

LR: I’ll have to check.

BB: I stump my students when I ask that question. You know who you are because you know that you have a cat and that you’ve been married and lived in Michigan, and that you like Hello Kitty, and that you like certain kinds of music and food, and you have knowledge and memory of family and life experiences. But people with DID don’t always feel like all that.

First of all, they have periods of time missing. And so, they’re confused about who they are and what’s happened in their lives. But they’re not different people inside. Now, I’m going to say that, and some of the readers who have the idea are going to object to what I just said, because some people with DID do feel like they are different people.

That is their perceived experience, but people with DID don’t literally have little people running in their heads either. Our personalities are based on the neural firing of networks in our brains. And like we were saying earlier, there’s a neurobiological pattern that is characteristic for trauma related self-states versus ones that are very detached and don’t remember the trauma.

So, I think a lot of mental health people are mistaken and don’t understand what they have heard. It’s rare and I’ve been told this so many times, “Doctor Brand, I’ve been in the field for 30 or 40 years, and I’ve never seen a DID patient.” But I guarantee you, if they’ve really seen a lot of clients, they actually have, but missed it because perhaps they’re looking for dramatic presentations like Sybil. If it was that obvious, then when people switched states, it would be easy to diagnose. But that’s what movies do to make it look right to the audiences. That is not actually what DID really looks like.

A Tiered Approach to DID Intervention

LR: What is a multi-phasic approach to intervention with DID, and why is it considered the gold standard?

BB: It means that clinicians who work with DID and other serious dissociative disorders are realizing that there needs to be three stages of treatment. When somebody comes into treatment with complex trauma, and especially if it’s very serious, there needs to be an initial stage of stabilization of their symptoms. At this early stage, they may be suicidal, self-harming, drinking and using drugs, or engaging in some other kind of addictive behavior.

They often have really high levels of hospitalization, so they need to learn other ways of regulating themselves that are safe and that they can do out of the hospital. If and when they get stabilized, they begin learning how to regulate emotions in ways that ground them, which is the opposite of dissociation.

Once they’re stable and want to go on to stage two work, we are talking about trauma processing. That’s where they may then talk about some of the trauma so that gradually they can heal from that and not have so many intrusions of nightmares and flashbacks and horrible memories or feeling numb to it.

It’s an awful thing to feel like you’re deadened inside. That would be stage two work, which can take a very long time. So can stage one, by the way. And then comes stage three. For complex trauma—and I’m not just talking DID now—but in general, the person works more on developing their life, their friendships, their career goals; they’re no longer so focused on the past and trauma, but integrating into whatever kind of life and relationships they want.

LR: Is this in line with your “Finding Solid Ground” program?

BB: Yes. The program I’ve created with colleagues called “Finding Solid Ground” is a staged stabilization approach where we help clients learn about, first of all, grounding. But it’s not just for people with DID, but also for people with complex PTSD, and what in the United States is called the dissociative subtype of PTSD.

Our research is showing it helps all these folks, not just DID, but they learn to be more present to their emotions and deal with emotions in healthier ways. They learn about how to deal with PTSD so it’s more contained and not so intrusive so they can sleep better so that they’re not having these awful images pop into their mind and interrupt their functioning all day.

We help them learn to separate past and present. When somebody has very bad PTSD, the brain cannot really distinguish the difference between a flashback and the present moment. It feels to the person it is happening now. So, we teach them how to catch their warning signs that they may start being close to being at risk for intrusions of PTSD, that they might start dissociating, that they might start drifting towards self-harm, and then find ways to get out of that cycle. Among other things, we teach them a little bit about the neurobiology of trauma and that it’s not their fault.

LR: Is integration of self-states the absolute end goal for treatment?

BB: When I first accepted that postdoc at Sheppard Pratt in 1993, the emphasis in the field was integration of personality states. And yet that’s not what I was hearing and seeing was happening very often. I was the leader of a study where we asked experts around the world how many patients had they integrated in their careers. It was small numbers.

That may not sound like a jolt of lightning to readers, but it did lead us to rethink whether that was very achievable for most patients or not?

At the same time, many people living with DID do not want to integrate their parts because they have lived often for decades with these parts. And that helps them function from their perspective. That is who they are. They value their parts, or eventually you hope that therapy can help them learn to respect and value their parts rather than be at war. Some of the self-harm and suicide attempts are about one part trying to kill off another. At the time, they don’t recognize they will all die if they commit suicide. So now I have a different perspective and I think there are different options. I think clients should have the right to choose what they want their endpoint to be.

And that may change over treatment. In the beginning, some clients absolutely say get rid of these parts, but they don’t understand. They can’t. I use the metaphor that you can’t live by cutting out your heart or your liver. And it’s the same thing with self-states. You have survived because of the self-state. You can’t get rid of one. You can learn to work as a coherent collaborative group like a business or a healthy family rather than being at war.

DID and the Family Connection

LR: Are there useful systemic interventions that involve family, spouses, children?

BB: Of course, as a therapist, I’m teaching them, but I don’t want their spouse or partner to be doing therapeutic things. Right! But it gets really messy. If they have children who see them switch, and mom or dad doesn’t seem to remember things they’ve said or done, I find ways to explain DID to the kids in an age-appropriate way.

It is incredibly important that they’re not switching a lot in front of their children. Parents should be consistent no matter what, no matter who they are, whether they have DID, bipolar disorder, or PTSD. Children need consistency. So I would work with a client to help them develop the parenting parts and having them learn to look similarly and act similarly with the kids, so they’re not confusing the kids.

LR: In this context, can a person with DID voluntarily call on another self-state, rather than it “taking over” during a time of crisis or trauma-related moment?

BB: Yes. So that might be something that we’d work on, to go back to that last example, when they’re around their children. You would want them to work towards having parts that can be very supportive, caring, loving, consistent parents. And the parts that are little, that feel as if they are young children, terrorized, traumatized themselves, would be in the back of the mind.

All this is metaphor, however, right? There are no little people, right? But metaphorically, those self-states are taken care of internally so that they are consistent. Same thing with work, same thing when they’re driving.

LR: You said earlier, Bethany, that invariably, dissociative states and DID in particular are born out of severe trauma in childhood and attachment disruptions. At what point might a clinician begin to suspect dissociative identity disorder in childhood?

BB: Really good question. Some of the same symptoms that later develop and become more severe in adulthood can be seen in little children with the beginning stages of a dissociative disorder. One thing I haven’t mentioned is that adults with DID can go into trance states where they’re not responsive to the outer world.

Little kids start showing attention and zoning out. They’re often misdiagnosed as having ADHD. So again, we need all clinicians to be trauma-informed and trained. Not that they’re expecting to see a dissociative kid, but they might, especially if they have symptoms of PTSD like nightmares and flashbacks, or report having imaginary friends. Some talk about that for a second.

Developmentally, it’s normal for children to have imaginary friends. But if imaginary friends start to be frightening, or upsetting, or tell the child to hurt their sibling or a pet, or to destroy their toys, that’s not a “normal” kind of scenario. Little kids usually stop talking about imaginary friends around age seven. But people with DID report that they never went away. Those actually linger as parts of their dissociative self-states.

Keyword, Avoidance!

LR: There are clinicians who believe that if we look hard enough for trauma, we will find it. Is it similar for dissociation and DID?

BB: It might be! During medical training, students commonly think they have all the different disorders. The same thing may be happening in our field. For 26 years, I taught a course on differential diagnosis and interviewing. At the beginning of the class, I warned the students that they were going to be tempted to diagnose themselves along with everybody they loved or hated. It is a normal phase of learning the DSM but I asked them to be respectful and stick to the diagnostic criteria, so they don’t go telling people they’ve got borderline personality disorder.

There is a normal stage of training in which, at least for a while, we may overuse certain concepts as we’re learning them. But again, if clinicians are well-trained in differential diagnosis they will be less likely to overdiagnose certain symptoms and disorders—in this case, dissociation and DID. This is one of my research streams.

There is a lot of research out there, and I’ve written a book about how to assess dissociation and how to distinguish it from other symptoms and disorders. Here is where training is critical. The ways you treat schizophrenia and bipolar disorder are very different from the way you treat DID. Schizophrenia and bipolar are the two disorders that people with DID are most often misdiagnosed with.

People with DID don’t need mood stabilizers or heavy-duty antipsychotics. Instead, you do a trauma-informed stabilization approach. Two of my earliest DID clients were misdiagnosed with schizophrenia and treated accordingly for years. One passed away and gave me permission to share her story. By the time I saw her, she had horrible tardive dyskinesia. She had been disfigured by the treatment for schizophrenia that she didn’t have. Once we started working together, she got a lot better— not cured, but a lot better, and she was much more functional. She had dropped out of school and midway through high school, she went back and became a minister in her community.

LR: What do you see as the core elements of training that need to be incorporated into graduate programs so that DID can be correctly identified, and interventions designed?

BB: Only 8% of APA-approved doctoral programs require a course in trauma. That’s gotta change. Information about trauma should be a required part of graduate training in psychology, social work, and related fields. As part of that training, they also need to learn about dissociation and the range of dissociative disorders, and how you assess for dissociative disorders, and how you do differential diagnosis. And, of course, something about evidence-supported treatment. There’s only one program so far based on randomized controlled trial data that shows it helps people with profound dissociative disorders. But they should hear about that. That should be in the textbooks.

LR: What do you think is contributing to that incredible avoidance by the APA of mandating graduate-level trauma training at graduate level?

BB: A group of us have been pushing for different guidelines about working with complex trauma that finally got approved by the APA this last summer. But there is pushback. And a lot of us think there’s a political issue. Let’s just think about what PTSD means. The required criteria center around avoidance. You nailed it there!

Even people who’ve been traumatized don’t want to think about it. It’s human nature not to want to know, think, and talk about trauma. Believe me, it’s a hard part of my job. I do it, and of course I know how to do it. But hearing the stories of what has happened to little children is incredibly difficult.
And there’s some real doubters out there when it comes to thinking about child abuse. Maybe they should read a little bit about child pornography and child trafficking and how rampant they are, because we’ve got plenty of evidence that that happens. Some individuals report that part of their abuse was being the victims of child pornographers.

So, I think we don’t want to think about that stuff!

LR: Avoidance on a large scale.

BB: Avoidance. You nailed that.

LR: Not to get sidetracked, but I wonder if this is what Bessel van der Kolk experienced when he tried to get his developmental trauma disorder approved by APA.

BB: I’m sure that’s some of it, but not-unshockingly, it likely goes back to financial issues.

LR: It’s hard to imagine.

BB: At this point, the National Institute of Mental Health has never once funded a study of the treatment of DID. So, I have literally had to get donations to fund my studies. Do you think cancer researchers do that? Do you think researchers of any other disorder must have bake sales and pass the plate at college?
Where is the money in trauma right now? It’s in the Veterans Administration. I’ve heard this from various people who work there. They do not recognize DID, and they don’t want anybody in the VA system being diagnosed with DID, because that’s a real problem for our military, right? Everybody there has a dissociative disorder. Although believe me, I have assessed people in that system and helped them get honorary discharge. Anyway, there’s a huge amount of funding that goes to VA research and they emphasize working with adults. They want to keep the soldiers “strong” and ready to go or whatever the branches to ready to fight. Yeah. The childhood trauma.

LR: It’s hard not to introduce politics into conversations at this level. But do you have any concerns about funding for dissociative and other disorders as the incoming administration takes form?

BB: I do, and I think many, many researchers are very concerned about funding for new science research in general. But then when you get into groups like research on women, research on children, research on traumatized people, research on any kind of minorities, but especially LGBTQ groups, people are very worried. My funding has always been a problem. But I do have many generous donors.

Wrapping Up

LR: There’s so many big sales you can have, and winter is coming.

BB: So, we’ll have some hot chocolate sales and some coffee. Yes, there is a group called the International Society for the Study of Trauma and Dissociation (ISSTD). They do lots of multi-level, face-to-face and online training for dissociation and children, adolescents, and adults. They also supported RCT studies for our Finding Solid Ground program.

I’m strongly urging clinicians to learn about that program. We’ve got two books out there. One for people living with the disorder, and one for therapists. Our research shows that the Finding Solid Ground program works best when the therapist knows the program and the clients working with the therapist who knows the program.

LR: Has counter transference entered into your work with any particular client?

BB: For anybody working with complex trauma, there is going to be countertransference and traumatic countertransference. And the client will experience transference. There’ve been times I felt like I wanted to rescue somebody because they’ve had such a hard life. But you’ve got to keep the boundaries strong. I consult with a lot of therapists. One of the mistakes I hear from therapists is they do try and rescue, or they go too far. It’s not uncommon that therapists will see a DID client for free and become very burned out. I don’t ever advise that.

The psychotherapy research shows that people benefit from treatment more if they’re paying something. It’s also common for therapists to alternate between feeling helpless, like the child was back during trauma time, and at other times harsh and mean which the client may experience as harsh and mean, almost like the perpetrator or a non-protective bystander. Those three roles are extremely common in the treatment, so I teach a therapists to watch for that, to work on that, and to make that understood.

Something they actually talk about with their clients so neither get stuck in those spaces and can learn from it. It’s part of the healing, rather than becoming the point where the treatment comes off the rails.

LR: I think that we could talk for hours, Bethany. It’s been a fascinating conversation for me as I hope it was for you. Is there anything I’ve left out?

BB: Yes. There are people out there who have died because of this disorder, but there is hope, even despite the tremendous suffering. It’s important that these people know that they are not alone, and neither are their therapists. It’s important that therapists convey that they’re not alone, it’s not their fault, and that they are not weak or dumb. They don’t have to suffer endlessly, and neither do therapists need to feel powerless. There’s hope.

LR: I think the clinical world is a smarter place for your presence in it. Thank you, Bethany.

BB: Thank you!

When Symptoms Overshadow a Diagnosis: Psychotherapy as Archeology

Posted on by Psychotherapy.net Team

When a prospective client makes an appointment to “work on my anger,” I can never be sure what other, deeper issues might lie beneath that common presenting concern. In my clinical experience, anger rarely exists in a vacuum, leaving me to wonder if it is driven, for instance, by personality pathology, trauma reactivity, or rooted in a specific mood disorder that will also need addressing. The person might hyperbolize or downplay their anger problem details during the phone screening. I have also come to wonder if their anger could fuel hair-trigger sensitivity and reactivity, which might add an element of danger to the therapeutic relationship.

Early in my career, I worked in a jail where I intervened with many acutely angry individuals. I knew my way around potentially dangerous people. While their anger required more immediate address, often with solution-oriented methods, what had always interested me more deeply was discovering the person beneath the anger. However, given the nature of corrections, inmates frequently moved for programmatic and security reasons, so my time with them was short, and my interventions were symptom- and situation-focused.

An existentialist at heart, I always wondered about peoples’ internalized experiences. What kind of meaning do they assign to phenomena? What defenses are at play? How does that all affect the clinical picture and what kind of material is in there to work with for better gains? Thus, what I later came to appreciate about working in private practice rather than institutional settings was spending more time with people and really getting to know them. I was better able to contextualize and understand symptom functions and help clients learn about themselves and to relate more effectively with others — especially when anger entered the clinical frame.

Robbie Needs Anger Management

When Robbie’s mother, Jane, called for an appointment for him, I was expecting him to be a child, perhaps even a teen as opposed to being in his early 20s. “He lives with me and is doing OK, but he’s been diagnosed with ADHD for years and can get rageful. He’s got to clean this up and stop living in the fast lane if he hopes to hold a job,” she shared.

I learned that at one time Robbie was on ADHD medication, but discontinued it after he completed high school, and had no interest in restarting it. Jane shared that it was questionable whether the stimulant medication had much of an effect, anyway. She was hoping that meeting with a male therapist, someone he might relate to, who encouraged exploring his emotions and aspirations, would prove more effective.

For his first appointment, Robbie arrived with Jane. They sat next to each on the couch across from me and seemed to interact amicably, something that didn’t always happen when family members arrived together. Robbie nodded along to Jane’s historical details about his development and family matters. He sometimes reminded her of a detail or filled in a blank with his personalized recollection. While Robbie was fidgety at times, he did not exude a hyperkinetic or inattentive vibe. Throughout, he maintained a bit of brightness, as if there were some contained excitement, but it was too early to explore deeply.

At first glance, I considered the possibility of ADHD. Clients I’ve worked with who have been diagnosed with ADHD have low frustration tolerance that often led to angry outbursts. Further, like the prototypical class clown who has that ever-present grin, Robbie had an ongoing light smile of sorts, and he could be a little interruptive and fidgety. “Perhaps, if he indeed has ADHD, he’s just learned to manage well,” I thought as the interview went on.

Therapy with Robbie Begins

On the day of our first therapy appointment, I heard a motorcycle pull up out front, and a second later, in walked Robbie with his helmet. “What a day for riding,” he beamed, taking off his jacket and making himself comfortable on the couch. “What do you enjoy most about being on your motorcycle?” I asked.

“It’s the thrill,” replied Robbie. “King of the road! Just taking off and maneuvering. It’s harder for a cop to get you, too!” he laughed.

Settling into the session, I said, “I wanted to ask, how was it for you last week when we met for the first time with your mom here?” “It’s all good,” said Robbie. “We have a great relationship. She told you everything.”

“She gave me a lot of information, for sure. Given it’s your time to meet with me, I was hoping to hear more of your thoughts about what you’d like to get out of coming here.” Robbie admitted he wasn’t sure.

He explained he knew he was directionless, watching friends finish college or settle into long-term relationships and jobs. Nonetheless, he said he felt free and like he was having a good time and that it would all work out. “Maybe I’m a ‘live fast, die young’ kind of guy. My mother always tells me I can’t last if I don’t get some direction,” he finished, rolling his eyes.

Clasping his hands behind his head and looking about the room, Robbie circled back to my question. He wondered out loud what one does in therapy. “I mean, I do get frustrated easily, and bored quickly. Those medications I took way back didn’t do much. Maybe I focused a little more in school, which was cool, but, you know, this is me. Why do people get frustrated with me if I get frustrated or want to do something? That’s ADHD, right?” he grumbled.

“What can you tell me about people getting frustrated with you for getting frustrated?” I asked.

“People can get under my skin. It’s not just my mom about ‘getting direction.’ She just wants me to be successful. I’m not too irritated with her. I get it. But other people, it’s like they can’t keep up with me or something. I’ve had girlfriends say it, and when I get people together for ski trips or rock climbing, they can’t keep up. If I want to have fun, it seems it’s got to be on my own. I get pissed off. I don’t want to, but people come with me, know I go all out, then complain I’m wearing them out when we’re skiing at first light until dusk. I don’t want to waste time, you know? Make use of time on that vacation!”

“What exactly happens?” I asked.

“Err, I got really pissed one time last year and smashed my GoPro camera as I let my friend know what I thought about his whining,” Robbie said, irritably. “I mean, c’mon, you come on a ski trip and don’t want to ski? Then I’m like, ‘f*&k it, I’m still gonna have a good time,’ and skied off.”

Robbie quickly lit back into a bright expression.

“Are you still friends?” I continued.

“Yeah, he knows it’s just me. He’s seen it before. I guess I’m an acquired taste,” laughed Robbie.

Throughout, Robbie could veer off course, getting distracted by a topic that seemingly popped into his head. It never seemed he had much attachment to the discussion.

Over time, I learned more about other relationships, such as when Robbie told me that dating was tough. It wasn’t because of aggression, but rather he felt he burned out girlfriends. “I’ll find a girl who I really vibe with, and we’re climbing and stuff, and hanging out a lot at the start. A lot of energy, you know? But then, like this one girl, she wanted to do more chill stuff like typical dates to movies and dinner and family events. I really tried to accommodate. I liked her a lot. I tried to have my cake and eat it too by getting together during the week for after work cycling or going to the climbing gym. She told me she just couldn’t handle that activity load. We’re still friends though.” Robbie’s brightness flattened.

I replied, “I can’t help but notice your expression changed, Robbie.”

“Hell, I do get lonely,” he admitted. “I want someone to do stuff with! I like sex and all, but I can get that on demand with girls I’ve known over the years. Chicks dig me, haha! But those girls don’t have to deal with me like a relationship girl would, I guess.”

“What more can you tell me about this loneliness?” I followed.

Robbie explained that he never quite felt “full.” On one occasion when he seemed dull compared to his usual energized self, I acknowledged that I noticed he did not seem the usual Robbie. He said it was one of the “not full periods.” Robbie was able to liken it to a silo that gets filled with grain but has a leak, emptying it again, then hearing an echo within. After some exploration, it seemed that Robbie’s activity level was the grain, keeping him feeling full, but even that had its limits when he couldn’t keep up with it.

“What happens on the occasions you encounter the echoing silo? What’s it like? How long might it stay empty?” I inquired.

“Dang,” began Robbie, looking away. “I lose my excitement vibe, you know?” He continued that he force feeds himself activity to try and get back the momentum and fill the silo, but it’s a trudge. He might have days of feeling apathetic and stuck in his head, thinking too much. He described how he can get to belittling himself for probably being a disappointment to his mom, who had it tough and had dreams for him. “It’s all kind of exhausting,” he finished. With half of his usual energy, he grinned and said, “But I’ve learned to accept myself.”

It sounded to me that Robbie was prone to crashes into depression and that he had a polarized self-concept.

Between sessions, I found myself realizing Robbie’s restlessness and impulsivity weren’t so ADHD-like afterall. When I combined this with how Jane denied any clear early history of typical ADHD symptoms in Robbie, and that she denied having any perinatal ADHD risk factors, I began drawing a different conclusion.

A Hypomanic Personality Dynamic

Robbie was clearly a depressed young man, and it seemed he had a sort of “keep active” or “moving target defense.” He was living a duality—a depressed inner world that he kept suppressed with a hypomanic defense. Perhaps the ultimate denial!

I didn’t realize it at the time, but Robbie was exhibiting what some have called a hypomanic personality, sometimes referred to as a hyperthymic temperament. While not included in the DSM or ICD, the hypomanic or hyperthymic personality are nothing new, and, in fact, have remained of interest to various personality experts (see references).

Millon provided descriptions of this personality style from historical giants. Kraepalin, for instance, said that these are patients who, “…throughout their entire lives display a ‘hypomanic personality’ pattern without severe pathogenic developments [i.e., crashes into full affective disorder episodes].” Schneider wrote, “hyperthymic personalities are cheerful, kindly-disposed, active, equable, and great optimists. Often, however, they are shallow, uncritical, happy-go-lucky, cocksure, hasty in the decision, and not very dependable.” McWilliams, perhaps the modern authority on this personality 100 years later, provides similar descriptions.

A movie character fitting a hypomanic personality that readers may be familiar with is Paul Mclean, played by Brad Pitt, in A River Runs Through It. Also, the portrayal of Scott Scurlock, an infamous 1990s bank robber, featured in the recent Netflix show called How to Rob a Bank, exemplifies a more intense case in that Scurlock’s personality also entailed sociopathic characteristics.

In time, I learned that those with what could be considered a hypomanic/exuberant personality may feel more alive chasing rainbows than the idea of long-term success, for this would require a type of settling, and thus, stagnation in their eyes. This is dangerous because they depend on being a moving target, lest their depressive ghosts catch up with them. Unfortunately, while an immediate salve, this perpetual motion encourages the cycle, for lack of success engenders a sense of failure, feeding depression, which the hyperthymic activity defends against.

Their solution to troubling emotions is the problem. As described by McWilliams, living this energized, unstable existence can become exhausting. Thus, the defense becomes weakened enough that the suppressed internal depressive experience crashes the gate until the energized state reconstitutes and corrals the depressive escapee back to the sidelines where it can only shout insults, which the guard ignores via enthusiastic distraction once again.

The Therapeutic Work with Robbie Deepens

After spending numerous sessions learning about Robbie and encouraging him to engage in sharing/self-revelation, we began more pointed work.

“Robbie,” I began, “from what you shared, correct me if I’m wrong, but it seems like that ‘being active’ protects you from having to deal with that hollow feeling?”

He agreed that it’s the pattern. “It seems like, if you really look at it, life has become a defensive act against feeling that hollowness,” I continued.

“I’m curious,” I began again, “have you ever thought about what life would look like when it’s really going your way?”

“Yeah, not having this moody stuff. Finishing things.”

I asked, “When can you recall that you weren’t moody?”

“I’m not sure. Maybe when I was pretty little. I remember playing and being happy with my dad and brother, the whole family.” Robbie had shared that his father eventually cheated on his mother and left, and she had to work, so wasn’t around as much. Eventually she got a divorce settlement and was able to stay at home more.

It became clear that Robbie harbored a lot of feelings of rejection and subsequent sadness; he was living two sides of the same coin with the ever-present sadness being defended against by an exuberant denial.

In order to stop this rollercoaster, since the hypomanic defense was a product of his bleak internal world, therapy would need to resolve his feelings of rejection that encourage the sadness.

“Like I said, I want a steady girlfriend,” explained Robbie.

“You’d like a meaningful relationship, some real intimacy?”

“Of course.”

“Strictly romantically, or?”

“I don’t want to have arguments with people like what happened with my friend, either.”

As if Jokey Smurf entered the room, Robbie laughed about breaking the Go-Pro camera and the horrified look on his friend’s face. “It’s crazy! I’m like some f**ked up movie character sometimes. But that’s being human, right?”

“Humans can act f**cked up sometimes, for sure, but I recall you saying you really didn’t want it to keep happening for you. I’m curious about what’s behind the laugh about it,” I inquired.

“Man, you therapists find stuff under every rock, don’t you?” asked Robbie, trying to evade my question.

“Hey, you told me you want to learn to make some changes, so it’s my job to notice things that might get in the way. To me, if someone has a contradictory response, it tells me they could be struggling to be real with themselves. Make sense?”

“So, what, I can’t laugh at myself?” he followed.

"Not taking oneself too seriously can ease the pain, can’t it?” I continued.

“It’s the best medicine!” Robbie added.

“Robbie, what are you medicating?”

With that, Robbie said he can’t escape some frustrations so laughs about them. Upon examination, his frustrations were rooted in painful ruminations, coupled with the exhaustion inherent in not being able to stop running if he is to “deal” with them. Distraction was corroding him, but admitting he had little steam left made Robbie feel vulnerable. He would often run on fumes, only to discover some psychological alchemy that provided fuel for the escape rides, which, over time, we saw were getting shorter, almost episodic. Whether this was the result of something therapeutic, such as feeling there was someone to help him manage what lay beneath, incrementally lowering his defenses, or a natural dip in childish energy that occurs as one eases into adulthood, it is hard to say. Regardless, Robbie’s more frequent low points were taken advantage of, where he would become more revealing of his years-long festering conflicts.

Effecting Deeper Therapeutic Changes

In months that followed, Robbie continued with an almost cyclothymic presentation. But the nature of the moods changed. There were peeks at more vulnerable parts of him. He kept up an energetic cheerfulness, but it wasn’t so charged. There were often peeks at actual lamentation and sadness that accented what was left of the hypomanic demeanor. At times, it was more of a reactive, temperamental mood. This seemed corollary to being more in touch with the depressive foundation; making contact with painful memories can be anger-provoking, and great therapy material.

There was still restlessness at times, but not in the old hypomanic sense. It was rather a more nebulous anxiety as Robbie edged into being more self-revealing and exposing his internal landscape. We seemed to be contacting bedrock issues, which, like in geology, would seem like stable turf, but if there are nearby fault lines, that could all change.

But Robbie learned more about the language of emotions and being real with himself. He realized that under it all, he hoped someday to discover it all never happened, but eventually accepted the idea he can’t somehow have a better best. With the disintegration of the denial, the smoke screen of exuberance he made for himself continued to lift. Relationships improved. When he felt more in them, he related better, leading to people being able to have more constructive, stable relationships with him and his fear of rejection no longer had a leg to stand on.

Over this two-year span of meeting with Robbie, I was never sure of how tenuous progress was. Would his psychological fault lines quake? He was invested, rarely missing an appointment, and had made strides in reducing the initial concerns and being more real. It often felt like skiing in avalanche country where anything could upset the delicate structure of snowfall and off it goes, taking everything established in its path with it.

As we wrestled with his long-simmering conflicts and learning to better understand himself and relate to others, Robbie began taking non-matriculated college classes to see what school was like. This was good grist for the therapy mill. Productive, real-world structure. In the meantime, Robbie still enjoyed his interests. Along came a part time job, then a girlfriend. Then the end of our sessions. Sometime after, Robbie left a voicemail asking for a letter about his having been in therapy and if he was ever a danger to anyone. Apparently, he was moving in with his girlfriend, who had a child whose father was contentious and heard Robbie had been in mental health care for being explosive in the past.

Postscript

I can’t help but feel that Robbie wouldn’t have reached this stage if his encounter with mental health care continued to see him as having ADHD, or as having problems with anger control. Some people say diagnoses don’t matter, that “we treat symptoms and not diagnoses,” which has the implication that symptoms can always be treated similarly. This can be a specious and dangerous outlook. Symptoms may occur across diagnoses, but that doesn’t mean they’re treated similarly. This diagnostic consideration of hypomanic personality, despite the debates about its legitimacy, allowed me to contextualize the nature of Robbie’s symptoms, which guided my approach to intervening with him. If merely addressing symptoms was sufficient, it wouldn’t have mattered if Robbie’s presentation was chalked up to ADHD or a hypomanic personality. The ADHD medications in theory would’ve fixed him.

We generally never know how our patients fare in the long term. Robbie’s hypomanic presentation was deconstructed, and an honesty about his life settled in. Consistent structure followed, highlighted with the activities he’d escape through, but now in more moderation. A semblance of a well-balanced interaction with himself and the world took form. Chances are, spot-reducing symptoms wouldn’t have allowed such a rich experience. Symptom reduction is great, but how does the person now live with their newfound experience? Does it have stability?

Personality is important, whether it’s pointedly treating personality disorders or helping someone integrate updated parts of existence into their being and work that into the world around them. Hopefully, Robbie is a reminder about the intricacies of therapy. It certainly was to me! It’s more than what’s observable, and what’s observable isn’t always what it seems.

References

Akiskal, H., Placidi, G., Maremmani, I., Signoretta, S., Liguori, A., Gervasi, R., Mallya, G., &Puzantian V.R. (1998). TEMPS-I: Delineating the most discriminating traits of the cyclothymic, depressive, hyperthymic and irritable temperaments in a nonpatient population. Journal of Affective Disorders (51),1, 7-19.

Jamison, K. (2005). Exuberance: The passion for life. Vintage.

McWilliams, N. (2011). Psychoanalytic diagnosis: Understanding personality structure in the clinical process. Guilford Press.

Millon, T. (2011). Disorders of personality (3rd ed). Wiley.

Oser, D. (2019) Hyperthymic temperament. Psychiatric Times, 36(9). https://www.psychiatrictimes.com/view/hyperthymic-temperament  

Containing The Adult ADHD Fad — With a Rejoinder from ChatGPT

Posted on by Psychotherapy.net Team

A sad and fairly ubiquitous aspect of human fallibility is that we are extremely suggestable suckers for fashion. Psychiatry is no exception — its history is littered with recurrent fads. The specific details vary, but the pattern is always pretty much the same.

Dangerous Psychiatric Fads

  1. Charismatic promoters identify a new and plausible diagnosis; do some second-rate research suggesting it “exists,” write a lot of papers, and give a lot of workshops and conferences.
  2. Media picks up the story, sensationalizes the “new findings,” and transforms lousy evidence into a vital new discovery.
  3. Whenever a potential pill treatment is available, Pharma marketing goes into an extravagantly financed, high-gear marketing mode — enthusiastically hyping the diagnosis and the medication in every possible venue.
  4. Benefits of the new diagnosis and treatment are widely publicized; risks and harmful unintended consequences are neglected.
  5. Primary care docs are especially targeted because they do most of the prescribing of psych meds, have the least training, and aren’t given adequate time to do careful evaluations.
  6. Patients are seduced by drug ads to “ask your doctor” about the diagnosis and the pill to treat it. “Asking your doctor” usually results in getting the medication.
  7. These familiar patterns of fad development are now greatly speeded up and given immediate worldwide distribution via social networking on the internet.
  8. Diagnostic rates rise exponentially in a very short time.
Some dangerous fads in medicine have lasted thousands of years (e.g. bleeding, purging, popular meds that turned out to be poisons). But most fads come and go fairly quickly once the risks of treatment become obvious and the over-promised benefits don’t pan out. As the excitement surrounding one fad wears off, suggestible clinicians and patients become enthusiastic about, and eagerly await, the next fad.

Cold Hard Psychiatric Facts about ADHD

Why The Explosion of ADHD Rates in Kids? We are in the midst of a 30-year fad of excessive diagnosis of childhood ADHD. Rates have tripled to about 10% — partly because DSM definitions have gotten looser — mostly because of aggressive Pharma marketing to MDs, parents, and teachers. How Do We Know That Rates of ADHD are Wildly Exaggerated in Kids? Studies done in a dozen countries on millions of kids have returned a remarkably consistent and disturbing result. All over the world, the best predictor of ADHD is the child’s birth date — the youngest kid in the class is almost twice as likely to get an ADHD diagnosis than the eldest. There is only one possible interpretation of this powerfully robust finding: ADHD is being wildly over diagnosed — we have turned simple immaturity into a mental disorder. Does ADHD Ever Occur in Adults? Yes, of course — because many kids don’t outgrow their ADHD symptoms once they become adults. The rate of persistent ADHD into adulthood varies widely across longitudinal studies — but probably about half the kids who have a childhood ADHD diagnosis continue to have clinically significant symptoms in adulthood. When the symptoms do persist, they usually become milder with age (especially true of hyperactivity). Can ADHD Ever Have Its Initial Onset in Adulthood? The simple and very important answer is an empathic NO! By definition, ADHD has to have its onset in childhood. This requirement is absolutely necessary in order to distinguish true ADHD from all the many other causes of inattention and hyperactivity in adulthood. Why Is ADHD So Often Overdiagnosed in Adults?
  1. Almost all mental disorders and almost all substance addictions can perfectly mimic ADHD since they can cause its two classic symptoms — hyperactivity and trouble focusing attention.
  2. Real or imagined attention problems are a very common complaint among perfectly normal people.
  3. Getting an ADHD diagnosis is a gateway to legal speed — desired for performance enhancement, all-nighters for school tests or work assignments, recreational purposes, or for sale into the extensive secondary ADHD pill market.
  4. Careless diagnosis and prescribing by MDs.
  5. An inevitable consequence of overdiagnosing ADHD in kids is overdiagnosing ADHD in adults.
  6. Promotion via drug companies and social networking.
What Are Current Reported Rates of ADHD in Adults? In general population surveys, the prevalence of current adult ADHD is reported to be 4.4% (males 5.4%; females 3.2%). Estimated lifetime prevalence of ADHD in U.S. (United States). adults aged 18 to 44 years is 8.1%. These numbers are absurdly high — reflecting the fatal flaws in the survey method. These rates are determined by casual telephone interviews done by non-clinicians. There is no careful differential diagnosis to rule out all the many causes of inattention and hyperactivity that should not be labeled ADHD, and to ensure symptoms are of clinically significant severity and duration. What is The Real Rate of ADHD in Kids? The best guide to the “real” rate of ADHD is the view of Keith Conners, considered to be the father of the ADHD diagnosis. He did the first studies on ADHD (even before there was an official DSM diagnosis called ADHD), and continued throughout his long career, until his death a few years ago, to do the best studies and have the most influence on the field. Keith believed the most appropriate rate of childhood ADHD would be about 2-3% and about half that number in adults — just a very small fraction of the inflated rates now reported. Risks Of Overdiagnosing ADHD in Adults:
  1. Meds used for ADHD are usually quite harmful if the person’s symptoms are due to another psychiatric disorder that has been missed — especially bipolar disorder, depression, schizophrenia, eating disorders, or anxiety disorder.
  2. Overdiagnosis of ADHD results in over-medication with drugs that cause harmful side effects and can lead to or worsen addiction.
  3. There is now a huge secondary market for ADHD meds, especially on college campuses.
  4. There is also a nationwide wide shortage of ADHD meds for patients who really need them — because the meds are so often prescribed for those who don’t or diverted to the illegal market.
Proper Differential Diagnosis of ADHD In Adults Before ever making a diagnosis of adult ADHD, there must be a careful evaluation that:
  1. Rules out the possibility symptoms are caused by another psychiatric disorder, substance use, drug side effect, head trauma, or another neurological or medical illness.
  2. Determines that the symptoms had their initial onset in childhood — adult onset of symptoms rules out ADHD.
  3. Ensure that symptoms are severe and persistent enough to cause clinically significant distress and impairment. Most people worry about their ability to focus — this is not sufficient evidence to diagnose mental disorder. Many people have transient episodes of inattention or hyperactivity due to everyday stress — this is also not adult ADHD.
  4. Consider the risk of malingering to get legal speed for performance enhancement, recreation, or resale.

Bottom Line

Most of what looks like adult ADHD is not adult ADHD. Distractibility is ubiquitous in the general population — most of it is normal; sometimes it’s caused by another psychiatric or medical problem or substance use. People who didn’t have ADHD symptoms in childhood should not be diagnosed with ADHD as adults. ADHD drugs are unsafe except when carefully used for accurately diagnosed ADHD. They are currently in short supply for appropriate use because they are so often used inappropriately. ADHD drugs are useful when appropriately prescribed for the few, but harmful when carelessly prescribed for the many. It is past time to stop the adult ADHD fad before it gains even more traction. The harm caused by the adult ADHD fad is great, both for the individual and society. Easy access to legal “speed” has created a large illegal secondary market of diverted pills. ADHD drugs have become the campus recreational drug of choice at parties and the performance-enhancement drug of choice for all-nighters during finals week. Legal speed can cause many medical and psychiatric adverse effects, and emergency room visits for complications are skyrocketing. The Drug Enforcement Agency and the FDA are now trying to contain the epidemic — but their efforts are too little/too late. The adult ADHD fad will be stopped only if clinicians and patients fight against its seduction and insist on more careful diagnosis and cautious treatment.

ChatGPT Asked the Same Question

[Editor’s Note] Once again, Dr. Frances’ granddaughter posed the same question to ChatGPT with the prompt: “What are the dangers of diagnosing ADHD in adults and how best to avoid them (in 500 words)?” “Diagnosing Attention-Deficit/Hyperactivity Disorder (ADHD) in adults comes with its own set of challenges and potential dangers that need to be carefully considered. While accurate diagnosis can provide individuals with the appropriate interventions and support, the risks associated with misdiagnosis or overdiagnosis are significant. To avoid these dangers, a comprehensive and cautious approach is crucial. Dangers of Diagnosing ADHD in Adults
  1. Misdiagnosis: ADHD symptoms can overlap with those of other mental health conditions such as anxiety, depression, or even medical conditions like thyroid disorders. Misdiagnosis can lead to inappropriate treatments and exacerbate underlying issues.
  2. Stigmatization: An incorrect diagnosis can lead to stigmatization, where individuals might feel labeled or misunderstood. This can negatively impact self-esteem and overall mental well-being.
  3. Overmedication: Misdiagnosis may result in the unnecessary prescription of stimulant medications, which are commonly used to treat ADHD. These medications can have side effects and may be harmful if taken without a valid reason.
  4. Self-Fulfilling Prophecy: Once diagnosed, individuals might attribute all their challenges solely to ADHD, overlooking other contributing factors and hindering personal growth and development.
  5. Masking Other Concerns: ADHD symptoms might overshadow coexisting conditions like learning disabilities, which require specific interventions. Treating only ADHD could leave these underlying issues unaddressed.
How to Avoid These Dangers
  1. Comprehensive Assessment: A thorough evaluation by a qualified mental health professional is essential. This should include a clinical interview, medical history review, and collateral information from family members or close associates to ensure a comprehensive understanding of the individual’s history and current challenges.
  2. Consider Differential Diagnosis: Since ADHD symptoms can mimic other conditions, it’s crucial to explore the possibility of comorbidities. This might involve additional assessments, screenings, or consultation with specialists.
  3. Longitudinal Perspective: Assessing symptoms over time helps differentiate between chronic ADHD-related impairments and situational factors that might be causing temporary difficulties.
  4. Multimodal Assessment: Utilize a combination of assessment tools, such as self-report questionnaires, cognitive tests, and behavioral observations, to gain a holistic view of an individual’s functioning.
  5. Functional Impairment: Focus on the degree to which symptoms interfere with daily functioning in various domains, including work, relationships, and personal responsibilities.
  6. Psychoeducation: Educate individuals about the diagnostic process, potential pitfalls, and the multifaceted nature of their difficulties to prevent over-identification with ADHD symptoms.
  7. Second Opinions: Encourage seeking a second opinion, especially if the diagnosis or recommended treatment plan feels uncertain or uncomfortable.
  8. Collaborative Decision-Making: Involve the individual in the diagnostic process and treatment planning. Discuss the potential benefits and drawbacks of medication, therapy, and lifestyle modifications to make informed choices.
  9. Holistic Approach: Address physical health, sleep patterns, stress management, and other factors that can impact attention and focus. Sometimes, lifestyle changes alone can lead to significant improvements.
  10. Regular Follow-ups: Periodically reevaluate the diagnosis and treatment plan to ensure they remain appropriate as the individual’s circumstances evolve.
In conclusion, diagnosing ADHD in adults requires a cautious and comprehensive approach to avoid the potential dangers associated with misdiagnosis or overdiagnosis. A multidimensional evaluation, consideration of differential diagnoses, and involving the individual in the diagnostic process are key strategies to ensure accurate diagnosis and promote the well-being of those seeking assistance for their difficulties.”

***

Afterword from Dr Frances

The response from Chat-GPT is remarkably good, especially considering that it took it one second to produce while my piece took 90 minutes to write. But ChatGPT did leave out two critical issues:
  1. The requirement that ADHD cannot, by definition, be diagnosed in adults unless symptoms were present in childhood and why this is so critical.
  2. The societal impact of the adult ADHD fad.
All in all, I think my piece is better than Chat’s – but not by much!

In the Shadow of COVID, It’s Play Therapy to the Rescue

Posted on by Psychotherapy.net Team

Kevin’s Worried Parents

In March of 2021, families were emerging from almost a year of isolation due to the COVID pandemic. As a Licensed Professional Counselor Supervisor and Registered Play Therapist Supervisor in private practice specializing in children, I was flooded with requests for services.

During one particular intake interview, the parents of a four-year-old boy I’ll call Kevin asked me a fair question. “How will our son’s development and mental health be impacted by this year of isolation?” I immediately reflected their feelings with, “You are really worried about the long-term impact on your son.”

Their worry was understandable given the emerging research showing increases in children’s anxiety and depression since COVID began. Yet, multiple factors of genetics, parents’ behavior, peer interaction, and available resources contribute to children’s developmental and mental health trajectory after a crisis. To respond to their fair question, I needed more information from them.

I asked, “What is concerning you the most?” Both parents had college degrees and were well read so they had valid concerns in mind. “Our son has not seen, much less interacted with, another child for over a year. He is our only child. Even though we took him to the public playground, as soon as another child got within 20 feet of us, we would leave quickly.” I thought to myself, risk factor one — no peer interaction during a critical developmental period.

Preschool is when children learn to tune into peer facial cues, scaffold their own physical and cognitive learning by watching other children, negotiate sharing, and so on. I needed to provide some hope to the worried parents, so I tried to normalize the fact that most of his peers had a similar experience. I replied, “Some children’s social, physical, and cognitive development may be a bit delayed during COVID. Fortunately, children are resilient and can learn together, starting from where they left off.” They nodded with seeming understanding.

Then Kevin’s parents said, “Our son could tell we were stressed when we were working from home and paying bills with less money. We tried to play with him, but we had many conference calls. He didn’t understand and thought that we were ignoring him. He became clingy and we became irritated, occasionally speaking to him more harshly than we desired.”

I thought to myself, risk factor two — parent behavior that was interpreted by the son as anger, resulting in increased anxiety. Being a parent myself of an only child who also has ADHD, I empathized and normalized with a compassionate groan. “I get it. I experienced something similar with my child.

We can feel so disheartened, trying our best to juggle it all, and losing our temper more than we want. We are human, not superheroes. We need self-compassion. That’s why I go by the 80-80 rule of parenting. About 80 percent of the time, I try to do about 80% of what I know to be helpful. But during COVID, I lowered my standard to 70-70 because that is passing.” They laughed!

The parents added with a heavier tone, “We are also concerned about his anxiety because we both suffered with anxiety during our childhoods.” I thought to myself, risk factor three — genetics. Research shows a strong genetic influence on the development of childhood anxiety disorders. Again, the parents needed some hope. I reflected, “You both know the pain and struggle as a child with anxiety. You love your son so much that you want to intervene as early as possible. You are wise to do so. I can help with that. Research shows that play therapy can decrease children’s anxiety. Together, we can work to build those limbic system neural networks toward calmness rather than fight or flight.”

Yes, the risk factors for this child were compounded during COVID. He had no peer interaction for a year, stressed and distracted parents, and a genetic predisposition toward anxiety. Yet, he also had the biggest protective factor we could hope for — caring and proactive parents. This plus mental health treatment, interventions of parent guidance, twelve sessions of Child-Centered Play Therapy (CCPT), and psychoeducation could shift this boy’s development and mental health toward a more positive path.

Prior to beginning my work with Kevin and his parents, and to gauge the level of his behavioral and emotional difficulties, I sent his parents a link for the web-based child version of Achenbach’s System of Empirically Based Assessment (ASEBA) Child Behavior Checklist for ages one and a half to five. The results revealed a pattern of emotional reactivity, anxious and depressive symptoms, and sleep problems. While Kevin’s scores on the DSM-related scales for Autism and ADHD were in the normal ranges, his other scores were consistent with DSM anxiety and depressive symptomatology. These results corroborated his parents’ concerns.

The parents’ main goal was to decrease Kevin’s anxiety so that he could calmly engage with others without clinging to his parents. Their prior attempts to reassure him through reason were ineffective. Using Daniel Siegal’s Hand Model of the Brain, I explained strategies to calm the lower regions of the brain through deep breathing, rocking, and soft voice rather than trying to reason with his prefrontal cortex, which was “offline” during his anxious times.

To reinforce these concepts, I asked Kevin’s parents to watch a parenting video by Tina Payne Bryson called 10 Brain-Based Strategies: Help Children Handle Their Emotions, and to read Siegal and Payne Bryson’s No Drama Discipline. These two resources helped them improve their ability to calm their own anxieties so their son would co-regulate with their calmness. To deal specifically with anxiety, I also recommended Calming Your Anxious Child: Words to Say and Things to Do by Kathleen Trainor to guide them in the step-by-step process of systematically desensitizing his fears.

A World Opens

In the waiting room prior to his first play therapy session, I greeted Kevin, commented on his red tennis shoes and matching shirt, and said, “It is time to go to the playroom. Your mom will be waiting right here.”

I smiled with friendly confidence, moving toward the door, and gestured for him to follow me. “We have lots of toys there.” His curiosity was stronger than his anxiety, so, he followed me. Kevin’s eyes opened wide seeing my play therapy room filled with carefully selected toys for nurturing (dolls, doctor’s kit), creativity (puppets, paints and easel, dress-up clothes), real-life mastery (kitchen, tool bench), and aggressive release (swords, bop bag, army men). As we entered, I said, “In here you can play with all the toys in most of the ways you like.”

Kevin was hesitant and stood near me, asking questions. “What do I do first?” Given his anxiety, this was not surprising. “In here you can decide.” He moved his eyes but not his body. I view this as a “freeze” state, a survival response for people perceiving threat and feeling overwhelmed. The threat was not necessarily coming from the playroom but from being separated from his parents or close family members for the first time in over a year. I reflected his feeling with reassurance, “You are a little scared being in a new place,” and role modeled taking a deep breath. I waited patiently so he could sense my calmness and confidence, thereby communicating this was a safe place.

Kevin moved toward some small cars on the shelf and pushed them along the floor. This action with familiar toys gave him a sense of security and mastery. I reflected his feelings by saying, “You enjoy seeing how far you can push those cars.” My statement reassured him that he really was welcome to play and built his confidence. He said, “Yes, I have a blue and red one at home that I like to race.” I gave him credit for his skills, “You are an experienced car racer!” He smiled and pushed the cars toward the four-foot red bop bag, named “Bobo.” Kevin lightly pushed on it to see how quickly it moved. “What’s this for?”, he asked. I returned responsibility to him with “You are curious what you can do with that. In here, you can play with it in most of the ways you like.”

Little by little, he courageously experimented with different actions from punching it, sitting on it, hitting it with a sword, and shooting at it with a dart gun. With each step, his sense of power grew. Toward the end of the session, he expressed creativity by painting a picture of the bobo. I ended the session with 10 minutes of psychoeducation on managing stress. I demonstrated and guided him through deep breathing, progressive muscle relaxation, and a self-soothing butterfly hug. After walking Kevin back to the waiting room, I prompted him to demonstrate his new skills for his parents and asked them to practice at home each day.

Bugs All Over You

In the fourth session, Kevin began with rolling cars again followed by punching Bobo, providing him with a familiar rhythm and routine. Once he established his sense of mastery and power, he collected toy spiders, snakes, and bugs and put them on my legs, hands, and shoulders. “You have bugs all over you. You can’t move.” I stated, “You are showing me it is scary to have bugs on me and not be able to move around.”

He exclaimed, “Yes, you are going to be stuck there forever.” I responded, “It seems like it will never end!” Eventually, Kevin decided to rescue me by knocking off the bugs with a sword. His symbolic play reflected his experience during the pandemic of feeling scared and trapped. Yet now he was in charge, rather than being the one trapped. He was gaining an emotional understanding to master his traumatic experience of COVID isolation.

At the end of the session, I engaged him in a children’s book that illustrated listening to his body to notice when he may need to take deep breaths and seek soothing sensations such as rubbing his hands and legs. This combination of child-led restorative play reenactment plus the intentionality of anxiety management skills strengthened his ability to emotionally self-regulate.

Mommy Dies

By the sixth play session, Kevin had gained enough comfort in the playroom that he was ready to play out a hidden fear — mommy dying. He approached the playhouse and put the “daddy doll” upstairs in the office to do his work. The “boy doll” was downstairs by himself watching TV. The mommy doll ran out of the house to go to a work meeting on a nearby table. Kevin drably said, “Mommy went out of the house, got COVID and died.” I reflected, “Super scary and so sad she died.” Kevin quipped, “Yup. Now who’s going to make dinner? Daddy is busy working.The boy will have to go out and hunt for food.”

I responded, “The boy feels all alone AND he knows how to get some of what he needs.” Eventually, Kevin brought in the army to help him hunt for food. I facilitated understanding: “There were strong people out there who could help the boy when he needed it. They kept him safe.”

Underlying Kevin’s fear of his mother dying was the basic existential question of “Will I survive?” Through play, Kevin created his answer — letting strong people help him. During the last 10 minutes of the session, I facilitated psychoeducation by playing a detective game with Kevin. “Let’s list lots of things many kids are worried about these days.” Kevin said, “Losing their favorite toy and their dog running away.” I added, “Family members getting sick, going to the hospital, and dying.”

Then I challenged his all-or-nothing thinking. “There are 100 kids. One kid loses their toy. Does that mean every kid loses their toy?” “No.” “There are 100 dogs. One dog runs away, does that mean everyone’s dog will run away?” “No.” “There are thousands of people. One person may get sick from COVID and die. Does that mean everyone will?” “No. If someone gets sick, they go to the doctor and the doctors do their best to help them.” “Let’s think about all the kids who are playing with their toys, dogs, and family members. What would they be doing?” “Playing fetch.” “Yes! I love to play fetch with my dog.” Since Kevin was calm, he could engage in basic reasoning that most people will be OK and the importance of focusing on the positives in the here and now.

Doctor Superhero

In the tenth session, Kevin walked in with confidence. He rolled the cars, punched the Bobo, and took the baby to the doctor. “Your baby is sick. I am the doctor.” He used the stethoscope, took the temperature and blood pressure, and gave the baby a shot. I reflected, “You knew how to doctor the sick baby and get the baby better.” He got the cash register and declared, “That will be $10,000.” I paid up — a small price for his victory.

Then Kevin put on the Superman costume and flew around the room “saving everyone.” I enlarged the meaning: “You are an important, powerful person who can help so many — even yourself.” With his chin tilted up, he said, “Yup, I’m not scared anymore!” Indeed, his parents had confirmed that he was no longer sleeping with them, and he was willing to stay with a babysitter for them to have a date night.

Reflections

From a Child-Centered Play Therapy perspective, Kevin was experiencing incongruence between his ideal self as a confident, engaging boy, his current self as an anxious boy, and his experiences of isolation and fear during the COVID pandemic. He was not accurately symbolizing the behavior of his parents and other adults in that he interpreted their cautions as a lack of confidence in him. Over months of physical and emotional isolation, his self-concept was of a timid, weak child who was unable to move forward in his world.

Kevin’s time in the playroom with me along with his parents’ support provided him with a developmentally appropriate intervention in a safe playroom with an empathic play therapist, representing a microcosm through which he could master his world. He was able to come to an emotional understanding that his past anxious experiences were about an illness doctors were trying to heal and not about him. His self-concept strengthened to see himself as a strong, powerful boy who knew how to get help, help others, and help himself. Parent consultation, Child-Centered Play Therapy, and psychoeducation were the healing components of treatments that showed such love to this family. Kevin emerged from his isolation and anxiety. He flies like Superman toward a more positive developmental trajectory.

Parents and children experienced suffering during COVID. Many experienced existential anxiety from recognizing mortality, confronting pain and suffering, and struggling to survive. Mental health professionals were trained to support people in crises such as COVID. Yalom and Josselson remind us, “No relationship can eliminate existential isolation, but aloneness can be shared in such a way that love compensates for its pain.”

Reference

1. Yalom, I. D., & Josselson, R. (2011). Existential Psychotherapy. In R. Corsini & D. Wedding (Eds.), Current psychotherapies (9th ed., pp. 310–341). Brooks/Cole, Cengage Learning.  

Russell Ramsay on Attending to ADHD in Adulthood

Posted on by rezendevknowfully.com

Three Avenues to ADHD

Lawrence Rubin:  Hi, Russell. Can you tell us about the typical clinical presentation of someone who has either been diagnosed with or is a good candidate for the diagnosis of ADHD in adulthood?


Russell Ramsay: Well, there’s a couple of different avenues.

If there is a history of ADHD or suspected ADHD they may think, 'All right, I’d better see somebody about this for managing adult life.'
The first is exemplified by somebody who may have been diagnosed in childhood or adolescence and is seeking out continuity of care in adulthood. They may not have come to us right out of high school but are usually making a transition, when all of a sudden and with increased chronological age, there are increased demands for self-regulation and self-management. Waking up and getting to class in college, managing homework, getting to a job on time, things like that. Usually, these clients will say things like, “You know what? I struggled with the same things over several years as I am right now and I keep starting anew, but I’m not making progress.” If there is a history of ADHD or suspected ADHD, they may think, “All right, I’d better see somebody about this for managing adult life.”

This may sound much more pessimistic than I actually intend, but there’s no end of the school year in adult life. You keep going, unless you're a teacher, whereas for children and adolescents, not that it’s any easy go, but if they can hang on until summer, everything stops. And then they can start over in the fall with a fresh slate—which also keeps some people from getting diagnosed until they move into adulthood. Maybe they can hold it together until the end of the school year when they say something like, “I should probably get an assessment,” followed by, “All right, I got through. It was okay and I started off the new school year okay. So maybe it was just last year.” But that gets repeated, and it becomes a continuity of care issue, with some people saying, “Okay, I had treatment in high school, and now I need some help in college.”

For people who do not come to us until adulthood and weren’t diagnosed in childhood or adolescence, we call them late-identified, not late diagnosis. With a full and thorough evaluation, we can usually confirm that there was emergence of symptoms in childhood or adolescence, even if they weren’t diagnosed at that time. And so people will come to us saying, “I’ve tried to make changes. I’ve made adjustments.” We’ve actually had college students who quit a sports team saying, “I have more time, but I’m not getting any farther ahead.”

a client may present in adulthood with repetitive difficulties managing what previously seemed to be manageable affairs
Or a client may present in adulthood with repetitive difficulties managing what previously seemed to be manageable affairs. And it is not all or nothing. It’s not like, “I never go to class. I never hand in homework.” The frustrating thing is, it’s something within reach, or there’s some documented evidence that “I know I can do this. The admission committee let me in the school. I did well in this class or I did well through midterms, but then I lost it later on.” That consistent inconsistency.

And that sort of drives some of the self-mistrust that can develop within these individuals. So, the second avenue is people saying, “I’m not fulfilling my potential.” We could have a philosophical argument about whether there is such a thing as potential, and if we’re not reaching it, is it reachable? But usually what people mean is, “I’ve done it well, but I don’t sustain it.” There are often college-related difficulties, dropping classes due to falling behind. And it’s not necessarily due to trying to be a physics major, then just finding out you’re not wired for physics.

In managing workplace affairs, even if it’s not a performance improvement plan, people might say, as one of my colleagues so insightfully described, that they’re “working twice as hard for half as much.” Or they might say, “People think I’m so dedicated because I stay late, but that’s how long it takes.” Or they do a lot of extra work on the weekends, which we are all familiar with, but it’s not because they are trying to get ahead so much as they are saying, “No, this is not me going above and beyond. This is me trying to catch up before Monday comes.”

The third avenue, which has recently gotten more clinical and research attention, is people experiencing the effect of ADHD on relationships, be it committed romantic relationships, parenting, or just keeping up with friendships. We see this occurring a lot after college, where people lose touch with people because it takes more maintenance to keep up with friends, as does scheduling and coordination.

We really need to think about ADHD as a problem of self-regulation
From the diagnostic standpoint, ADHD, the name, is probably not going to change. It’s a brand. The A and the H of ADHD are really red herrings. A friend and colleague, Russell Barkley, who is probably a leading, if not the leading figure in ADHD and other matters, has a great line for it. He says, “Calling ADHD an attention problem is like calling Autism eye gaze disorder or saying, ‘Oh, their eye contact seems to be okay, so it’s not autism.’” Some people, whether diagnosed with Autism or ADHD, can perform well in some circumstances. We really need to think about ADHD as a problem of self-regulation. How efficiently do you do what you set out to do?

And without diving too deeply into that, these folks can function pretty well some of the time, but there are enough recurring areas of difficulty. These include difficulties following through, usually towards deferred goals that take sustained effort to reach. And this could be retirement funds, papers for school, organizing behavior across time towards these ends.
LR: So ADHD, whether first recognized as an adult disorder or a continuity of a child/adolescent disorder, is a life management disorder based in part on continuous and pervasive deficits in self-regulation and executive function.
RR:
we’re probably not treating the symptoms of ADHD, we’re treating the life problems associated with ADHD
Right. As psychologists, we understand that medication use is evidence-based and that it can be very helpful, like prescription eyeglasses. And whether we’re speaking of medication or eyeglasses, some people will say that’s all they need. This is just like cognitive therapy for depression. I’m sure this isn’t empirically accurate, but the rule of thirds applies. One-third of people do well with meds only, one-third with therapy only, one-third with combined. A lot of people can do fine with medications alone. But even with a positive medication response, many people will say, “Yeah, but I still procrastinate,” or “I still don’t look forward to reading Beowulf or working on my income taxes, so I still put it off, but I can really pay attention to the sports page or whatever I’m reading.” So we’re probably not treating the symptoms of ADHD, we’re treating the life problems associated with ADHD.

Psychiatric Comorbidities

LR: You say in your writing that psychiatric comorbidity is the rule rather than the exception. What type of psychiatric syndromes or symptoms have you noticed in your work with this population?

RR: Well, both from my noticing it, and also from what has been found in the literature, the top three in ascending order are anxiety, depression, and substance use or addiction problems. And with that, we can probably even bundle in dealing with technology as a distraction.

Now, comorbidities are always interesting because anything could be a comorbidity, really. It makes sense that among these top three, anxiety, which we often see even in subthreshold form, is number one. I think that in the DSM-IV, this particular subthreshold phenomenon was relegated to the “not otherwise specified” domain. Now, in the DSM-5, it’s “other specified” or “unspecified.” In adult-identified ADHD, this anxiety is related to that consistent inconsistency, that uncertainty which is often associated with underlying fear and risk.

uncertainty creates the apprehension, and creating uncertainty is exactly what ADHD does. “I know I can do it, but I don't know if I’m going to be able to make myself
Uncertainty creates the apprehension, and creating uncertainty is exactly what ADHD does. “I know I can do it, but I don't know if I’m going to be able to make myself. I did fine on the midterm exam, but am I going to be able to study and retain and test well enough on the final to get a decent grade or pass the course?” Domains of difficulty can be layered with that uncertainty.

In some ways, anxiety is adaptive because it makes somebody pay attention more and focus on it, like gasoline on fire. But it can also lead to avoidance. And then depression is a sense of loss, so that can lead to disappointment. And that can create a cycle of avoidance, and then comes the self-fulfilling prophecy of, “Oh, you see, it didn’t work out well.” Or, “I tried my therapy and it’s not working, so nothing works for me.” And then comes disengaging.
LR: Hopelessness?
RR: And there’s hopelessness. And then the substance use problem seems to be tied in with the need to self-medicate or self-soothe or, in other cases, it’s maybe related to early initiation due to poor impulse control.
LR: So when you see these comorbidities like anxiety, depression, or substance abuse, is it more helpful for a clinician to conceptualize those as sequelae, with ADHD as the foundational deficit? Or can depression or anxiety or substance abuse lead to symptoms that mimic ADHD? Seems to be a nuanced differential diagnostic issue.
RR: Right. Taking that last point first, absolutely! And even going back to the executive functioning model or that self-regulation model, which addresses the importance of organizing behavior across time towards a delayed goal. We all have executive functions. Going back to Walter Mischel’s marshmallow study, we saw kids who were sitting on their hands during the study so they could earn the second marshmallow—that’s self-regulation. At age eight, sitting on your hands is self-regulation. Just like if those kids had marshmallow issues later on in life, not bringing marshmallows into the house so they weren’t tempted to snack on them would be an example of how this self-regulatory skill followed them forward in life.

So, just like attention problems are ubiquitous in the psychiatric emotional disorders, they’re also a symptom of pretty much every one of the disorders. If you’re in the midst of a major depressive episode, your executive functioning will go down. In the midst of an anxiety disorder, executive functioning goes down. If you have a sleep disorder, executive functioning goes down. In tracking these generally episodic conditions, it becomes important to ask these clients if these executive functioning problems or ADHD predate their emergence?

asking people later on in life which came first, the symptoms of ADHD or the trauma, can be a very difficult discrimination for them to make
One of the tricky ones is when there’s an early childhood trauma. Asking people later on in life which came first, the symptoms of ADHD or the trauma, can be a very difficult discrimination for them to make. Problems with attention and dissociation can both look very ADHD-like. They can also coexist, or the persisting executive functioning problems can exist and endure outside of specific triggering situations or a year with a teacher who might have been abusive and not effective in working with that client when they were younger. Experiences that occurred outside of the triggering situation and outside of any other explanation would warrant further follow-up about the possibility of ADHD.

Then there’s a second conceptualization, where we are simply seeing true coincidental disorders. This would be a clinical scenario where the disorders don’t necessarily or typically overlap, like panic disorder and ADHD, or maybe obsessive-compulsive disorder and ADHD. Social anxiety is another one, because sometimes the ADHD difficulties are very public, like the uncertainty and fear accompanying being called on in class.
LR: When evaluating a client for anxiety, depression, or substance abuse, would a clinician be well advised to also consider some sort of ADHD questionnaire, just to get a sense of executive functioning capacity and the possibility of a more pervasive underlying ADHD?
RR:
there are some good screening scales in the public domain for assessing the components of ADHD
I can be very liberal with heaping more work on some hard-working therapists out there, but there are some good screening scales in the public domain for assessing the components of ADHD. It’s important to remember that screening scales are designed, both for psychological psychology and medical practice, to cast a little bit of a wider net, trying to reduce some false negatives and maybe tolerate some false positives. But in order to identify potential follow-up as a differential diagnosis, sure, they can be helpful.

ADHD as Executive Dysfunction

LR: Okay. Let me drop back a step, Russell, because you’ve used a couple of terms that a lot of therapists out there may be familiar with but haven’t really connected to other disorders. You say that ADHD is an executive dysfunction disorder and a deficit in self-regulation?
RR: Executive functions pretty much are self-regulation, and as an umbrella term within the neuropsychology literature, they generally cluster around one factor. How efficiently do you do what you set out to do? And a lot of this comes right from some of the research of Russ Barkley, Martha Denckla, Tom Brown. There are several executive functioning scales out there, and they generally cluster around goal-focused behavior, referring to goals that we want—we have skin in the game.

Executive functions include task initiation, time management, organization, problem solving, motivation, impulse control, and emotional regulation. We now know that difficulty with emotional regulation within the domain of executive functions is a core feature of ADHD, even if it’s not in the DSM. And it’s not necessarily a mood or anxiety disorder itself. It’s managing the same frustrations and stressors in day-to-day life that we all face, but they just tend to be more disruptive and distracting for individuals with ADHD. And they have a harder time rebounding from them.

I use the example of taking your car in for an oil change, finding out that you need a whole new transmission, and having to decide whether or not to get a new car. Yeah, that’s going to be a little bit distracting, but most people can say, “You know what? When I get home, I’ll talk it over with my partner, and we’ll decide.” While somebody with ADHD may be more prone to say, “I have to look up things now and figure this out now and skip class or lose half a day at work.”
LR: Along these lines of executive dysfunction, which is associated with the frontal lobe, what are the implications of calling ADHD a neurodevelopmental disorder?
RR: I think it draws on evidence, on one of the more consistent findings, that within that particular category, there is a high genetic loading for ADHD. Whether or not genetics are destiny, the unfolding of that predisposition has a lot to do with environmental influences.

there is a high heritability rate in ADHD, which is tied with several interdigitating brain networks, particularly the prefrontal cortex, where the executive functions are housed
We also know there is a high heritability rate in ADHD, which is tied with several interdigitating brain networks, particularly the prefrontal cortex, where the executive functions are housed. It’s not a matter of justifying it one way, as genetic or environmental. I think where we are going with this is that there is going to be a predisposition, and these disorders that emerge in childhood might require some form of lifetime management. This would be similar to the case of diabetes in the medical model, which requires ongoing insulin or paying attention to one’s diet.

We all do that to some degree in the event of more chronic or lifelong conditions, but with ADHD, there might be more specific domains, a little different for each person, that require ongoing, intentional management. Another term in the literature related to this discussion is that ADHD is a quantitative difference, not a qualitative difference, particularly with regard to executive functions. The difference with somebody who, for lack of a better phrase, has intact executive functions is that they have a relatively consistent baseline, while that baseline for someone with ADHD is more variable.

'Well, if you’ve seen one person with ADHD, you’ve seen one person with ADHD.'

It’s almost like the baseline for the ADHD client is a moving target, that consistent inconsistency. And there can be different domains of the executive functions, each of which has its own developmental timing and unfolding. In this sense, different people can have different rabbit holes that can pull them down. One of the lines in my field is, “Well, if you’ve seen one person with ADHD, you’ve seen one person with ADHD.”

Culture and Society

LR: Contemporary clinical practice revolves around an increasingly diverse client base. Does ADHD target any one culture, SES, or race more than it does others?
RR: From the available evidence, it seems like ADHD is equal opportunity. Wherever there are human brains, the risk factor for ADHD is probably around 1 to 3%. Now, what we will see is in terms of identifying ADHD and seeking help specifically for it, that can be where we will hear people of a certain age say, “I grew up in the ‘70s or ‘80s. We didn’t have ADHD back then.” Actually, we did, but it probably just wasn’t as recognized. Or somebody will come from a different country, culture, or family system where they say that mental health issues were not first on people’s minds in terms of looking at what could be helpful.

I think there was an international study conducted around 2001 with college students. They might have found that there were zero Italian women with ADHD, but that was probably more of a cultural difference at that time. They couldn’t determine the differences in prevalence were culturally bound or related to gender. So, I think it would be safe to say that wherever there’s a brain, or a population of people with brains, there’s probably roughly the same prevalence of ADHD. But then there is a difference in rates of help-seeking behavior.
LR: Before we shift into some questions about treatment, Maggie Jackson’s book, Distracted, came to mind. Is the prevalence of ADHD somehow related to the complex, increasingly technology-dependent, fast-moving pace of our society? Or has it always been there, just waiting to come out, as would a previously latent viral threat?
RR:
even though ADHD is not environmentally caused, it is environmentally bound
You know what? It has always been there, because we see early accounts in the literature going back to the early 1700s. Even William James talked about attention and what grabs it. Now that said, even though ADHD is not environmentally caused, it is environmentally bound.

People say, “What about the anxieties and uncertainties in hunter gatherer or farming societies,” like forgetting to close a fence or things like that. When you start looking, there are different manifestations of it. But I would say from a diagnostic standpoint, and in the past 18 months or so of COVID reactions and working from home, there may be more people who are struggling with executive functions now than in the past. And where we rely on environmental scaffolding, like something as simple as going to the office, we can otherwise spend all day not working. But there’s limitations on what we’re going to do. Actually, there’s a term for that. It’s called presenteeism.
LR: Presenteeism?
RR: You’re at work but are nonproductive. This kind of phenomenon might be part of a thorough developmental review of different levels of academic achievement. Whether somebody was valedictorian of their high school class or, on the other hand, struggled with low or mediocre grades, people might have said, “You’re not fulfilling your potential.” You might even hear the class valedictorian say, “Well, my parents had to sit with me every night, even through high school.” Or somebody might have had mediocre grades whose parents said, “You’re not fulfilling your potential,” and they responded with, “No, I can do it. I choose not to. And I can pull it together, and I know what I am doing. And I do enough to stay on my sports team.”

we’re probably going to see some research on how this access to technology affects brain functioning for kids compared with other people
Bringing this back to issues like managing technology and whatnot, you’re right. The advent of digital technology is a unique watershed event in human history, this jump—I mean, humans have always had tools, but nothing like this. And so, that is part of the assessment. And even developmentally, children now have access to smartphones and tablets early on. And I think we’re probably going to see some research on how this access to technology affects brain functioning for kids compared with other people. Going back to self-regulation, there can be a lot of distractions, so it becomes important to ask about screen time and how much they are actually getting done. On the positive side, technology can help us to be more efficient and get more done in less time.

And then, somebody might say, “Yeah, I binge watched the show, I did all this, but when I was at work, I also got all my work done. And I’m on top of things. I clean up the kitchen when I say I’m going to.” It comes down to looking at that executive function. Someone might be struggling, and it could be ADHD that pre-dated COVID. And it’s just that the pandemic kicked it over in terms of their holding it together. But even in that case, they might say things like, “You know what? It was hard enough before. I was staying at work late and all these things. And now that I’m at home and have to make sure my kids are doing classes and things like that, that was the proverbial straw that broke the camel’s back.”

Shifting Focus to Treatment

LR: Russell, I’d like to shift gears a bit and chat about treatment by asking, what is it about CBT that lends itself so well to the treatment of ADHD in adulthood?

RR:
the initial and immediate appeal of CBT was its structured orientation and focus on performance and implementation outside of the session
I think the initial and immediate appeal of CBT was its structured orientation and focus on performance and implementation outside of the session. And not that other good therapies don’t do this, but that initial appeal came from the behavioral side and then along the way, seeing the role that cognitions play. And then we found that the emotional part, anxiety or discomfort, for example, were related to that “ugh” feeling. It’s like, “Ugh, I don’t feel like doing the lawn right now.”

It became important to help these clients to put words on the emotion. The cognitive piece plays a role in follow-through and emotional management. So, I think it started with the structure and the focus on behavioral follow through, setting up the environment differently, and then it became more nuanced over the past couple decades, including expanding into focusing on strengths and making the most of those as well.
LR: In what way does CBT specifically address the cognitive and emotional components of ADHD, including cognitive schema?
RR:
From the behavioral side, CBT’s value comes in helping these clients with engagement versus avoidance, because avoidance is probably the number one problem with adult ADHD
From the behavioral side, CBT’s value comes in helping these clients with engagement versus avoidance, because avoidance is probably the number one problem with adult ADHD. It’s not from a lack of caring, but instead they might say things like, “These things are difficult. It’s easy not to do them.” Their challenges can come from feeling overwhelmed or mismanaging time. There are a lot of ways that we don’t budget ourselves and end up spreading ourselves out.

From the emotional side, there is no single theme, but I think the main emotional task is avoidance and managing discomfort. The “ugh” feeling. Addressing the discomfort is very similar to progressive exposure for anxiety. We ask them, “How can you handle the discomfort by changing your relationship with it?” And we remind them that the discomfort doesn’t have to stop them and that they can then follow through with a plan for engagement and, by engaging, have the discomfort diminish. This is the proverbial, “Once I get started, it’s not as bad.” And then, hopefully, they can access their skills.

It’s not that they can simply think themselves into it. So much of it is about things we want to do and achieve, even if it’s stuff like homework that we just want to get out of the way so we don’t have to think about it anymore. But it can also be things that we want to do, like following through on an exercise plan or being able to play a sport.

it is important to remind them that even if ADHD is not their fault, it is their responsibility
If ADHD gets in the way of these goals, it may lead to disappointments and frustrations, and those then get turned back on the self in the form of negative self-talk and low self-esteem. One of the early popular books on adult ADHD was called You Mean I’m Not Stupid, Lazy, or Crazy? I think that’s very often the attribution that people have. While it is important to help these people with this negative attribution, it is important to remind them that even if ADHD is not their fault, it is their responsibility.

So we look towards coping strategies for ADHD that include reframing the mindset. That involves an understanding of ADHD, why things were difficult, and why some of the setbacks happened, and trying to set up systems and expectations moving ahead so that people feel more efficacious. I use that term decidedly because within cognitive therapy, different disorders have different themes. In depression, the cognitive theme centers around loss—loss of esteem, loss of opportunity. With anxiety, it’s dealing with uncertainty and the threat or risk that comes from that.

I landed on the recently-deceased Albert Bandura’s notion of self efficacy, which initially seemed too general. But in going through some of his writings, I came across the concept of “self-regulatory efficacy,” which is about one’s ability to stick through with all the dirty work that you have to do for those outcomes. I’ve got to sit down, I’ve got to study. I’ve got to write the paper. I’ve got to do something I don’t feel like, and that sort of gets to that emotional “ugh” feeling. It was virtually a rewording of the executive functions, without ever using that word.

And my sense of Bandura’s writings was that this capacity is assumed to be intact for most people. If somebody’s depressed and they have problems with efficacy, it’s more at the depression level. But I saw that as more of a fundamental feature for folks with ADHD. They know at some level that “I know I can do it, but I’m not sure I can get myself to do it when I have to do it.” And I think that’s what goes into the thoughts of procrastination: “I’ll do it later, and hopefully, at that time, then I’ll be ready to do it.” Interestingly, some of my colleagues have developed an ADHD cognition scale that actually includes distorted positive thoughts which lead to avoidance.
LR: Distorted positive thoughts?!
RR: They are permission-giving beliefs. A non-ADHD example is, “You know what? I’m going to have a second scoop of ice cream, and I’ll work out twice as hard tomorrow.” And if they do it, that’s fine. But these distorted permission-giving beliefs are things like, “I know this usually sucks me in, but I’ll just do it for a minute. Being impulsive is a big part of who I am. I work best waiting until the last minute.” Or these self-justifications for not now, later. And I think it is coming from that point of, “All right, I’m not feeling up to this now, but maybe I will be later.” But later then becomes now. What did George Carlin say, “‘Now’ is the only word in the English dictionary that changes definition every time it’s used?” But there’s always that “I’ll do it a little later, a little later, a little later” that then comes back to bite them.

Intention to Action

LR: Is this why you say that one of the core elements of CBT treatment with ADHD adults is converting attention into action?
RR:
we CBT psychologists are pretty good at helping people understand how they don’t do things
People say, “I know what I need to do, but I just don’t do it.” And there’s no trade secret about the strategies. I mean, it’s useful having different reframes or different ways to approach it, but we generally know what we need to do. And so, people say, “I know exactly what I need to do. If I could do all these things, I wouldn’t need you, psychologist. So what good is talking with you going to do about it?” And my answer to that is that we CBT psychologists are pretty good at helping people understand how they don’t do things.

Almost like a reverse engineering of the executive function. If we’re talking about procrastination, I’ll tell my clients, “You know what? You really need to start earlier.” Please, sue me for malpractice. But if we look at situations, and this is cognitive behavioral therapy in general, “Let’s reverse engineer it to understand how you procrastinated, because it could be a planning issue.”

If they say, “All right, I knew I had to do it, but I never made an appointment or told myself, ‘I really should do this Saturday at 10:00,’” in this instance, it could be organization. If they say, “I had the plan, but I lost it or didn’t check it,” it could be that they had the plan but didn’t feel up to it at the time and thought themselves out of executing it. The “ugh” feeling. Or they may say, “I just didn’t feel right, it was too uncomfortable or overwhelming,” or “I saw something else that needed to be done. Tell you what, let me clean up the kitchen, then I’ll be in the mood to work on taxes.” In actuality, they probably weren’t. If they were, that’s great.

I’m a big believer in the idea that there are multiple ways to do things well, which is what I mean by helping these clients to convert intention into action
I’m a big believer in the idea that there are multiple ways to do things well, which is what I mean by helping these clients to convert intention into action, by following our grandmothers’ rule of breaking it down into manageable tasks. But it is also sitting with somebody and being able to work through it. Like, how do I do that with this task to get to the point that they can say, “I can get started with that. This is manageable. It’s some sort of bounded task. I can see the end point and then I can work from there, reach the next end point, and then do it again and again.”
LR: Is this self-regulatory efficacy or lack of self-regulatory efficacy what you might consider a core schema underlying ADHD? And how do you address such an embedded belief system that is so potentially debilitating?
RR:

Core ADHD Schema

Right—that is my clinically informed hypothesis. And with that theme, within cognitive behavioral therapy, there’s the automatic thought, so we might ask the client, “What thought went through your mind at 10:00 on Saturday that led you to go mow the lawn rather than work on homework, or whatever it may be?” That’s like Freud’s notion of the preconscious, which is that there is a flow of thoughts or self-talk that we have going through our head. And if we pay attention to it—and that was one of Aaron Beck’s revolutionary ideas—then people can catch themselves thinking in this way and change it. You know, sort of promoting efficacy.

As the field of cognitive therapy for depression went forward and we saw that some people did really well, while others who didn’t had these core beliefs, it became clear that these nonconscious beliefs were probably being encoded emotionally. We could help people to become more aware of this process and catch themselves. This might sound something like, “You know what? If I feel okay, if it feels good, I can do it. Or if it’s interesting, I can do it.” This is the conditional rule. Or another version of that rule might be, “But if it doesn’t feel good, it must be bad, or I don’t do this.”

What we’re really doing is putting words on emotions. At the level of automatic thought, it becomes more about semantics. If we say the person has self-distrust thoughts, then it is a more localized process, as opposed to the embedded schema or global belief system around the notion of self-mistrust, which is more pervasive. They are related to each other.

in two studies of schema in adult ADHD, failure was the number one schema endorsed in both
In the case of ADHD, some people may say, “Hey, I know I’m good. I know I can do it, but it’s just, I really struggle in this specific domain at work.” Here, it’s relatively circumscribed, while for others, it extends beyond the workplace and is more pervasive. These people might believe, “I’m a failure. I’m no good.” Actually, in two studies of schema in adult ADHD, failure was the number one schema endorsed in both.

This makes sense, tying in with the efficacy. All the have-tos and many of the want-tos in adult life feel like, “I haven’t achieved as I ‘should.’” But when dealing with schema, we’re recognizing them—“All right, let’s put words on the old belief or the old frame.” And very often, it could be a failure belief of, “I haven’t done, and I can’t do, what I need to do, and nothing is ever going to work out.” That may be so, but it’s only one view.

Is there evidence to the contrary? And even if you say, “Well, no, I dropped out of school, did whatever”—all right, well, what do you want to do now? With getting treatments, medications, whatever it is for ADHD, what would you like to re-approach? And is there a different view you can have that’s like, “Okay, this has been difficult for me before, but I can at least give it a try and maybe put forth a better effort now that I have these supports and see what happens.” There may not be any guarantees, but it’s worth the try.

The Power of Framing

RR: There is support for this thinking from research on the power of framing. Just having a counterpoint of, “Is there something else I’m working towards or a different way of looking at this?” Even if we don’t buy it yet. It can feel like being an actor learning lines when the other ones had a head start. But at least now you doubled your options. There’s the, if you will, the failure outcome of this. But let’s come with at least, at the very least, the possibility view and consider how to manifest that. And then, nothing convinces like experience. Emotional, cognitive, behavioral—and each of them can change the other two.
LR: I can imagine, then, that a clinician can also draw on some of the techniques of Solution Focused Brief Therapy and Narrative Therapy to help a person draw out success experiences that they’ve had as a foundation for building future successes. How did you get yourself to class? How did you get that work done?
RR:
that’s the insidious thing about ADHD. It can overgeneralize and contaminate everything
Robert Brooks and Sam Goldstein talk about islands of competence. Sometimes, that’s the insidious thing about ADHD. It can overgeneralize and contaminate everything. It might be helpful to ask somebody who is really good at getting to the gym or really good at a sport, “How do you practice all the time?” or “How do you get yourself at the gym?” Or you might point out to them, “There’s got to be plenty of days you don’t feel like doing it. Is there any way you can translate that into getting started on whatever chore it is or homework? Just as an analogy, just have that mode that you go to.” And they may respond with, “All right, here’s something I can try, and this can be like the first 10 minutes on the treadmill. Where it’s like, okay, it’s not my workout yet, but I need to break a sweat. So, I can give myself 10 minutes to break a sweat on homework or something like that.” I think the restorying that happens with narrative therapy is relevant here.

As an aside, I did my doctoral dissertation on personal narratives, so that’s near and dear to my heart. The thing about editing a story in the here-and-now is equivalent to saying, “Okay, this is sort of like there’s been a plot change, with the diagnosis of ADHD. What do I want to do with my character now?” It can be very useful to build on positives and things that might have gotten short shrift, either projects or wishes, or passions abandoned prematurely at the first sign of trouble, before the knowledge of ADHD was there. Or maybe it’s about things that somebody previously said “I can’t do.” And I might offer something like, “You know what? I can’t guarantee anything. That might be true, but is that something you’re willing to give a chance or give a try? And what does that look like, and how can you do it differently now?”
LR: As we wind down, Russ, I wonder if some of the symptomatology—the behavioral, emotional, and cognitive patterns that you described in folks with ADHD—also complicate treatment by leading to treatment resistance or avoidance or not following through outside of session?
RR:
therapeutic alliance plays a big part, because the therapist who is familiar with ADHD can validate the difficulties and setbacks, but also the successes
I think this is why we try to set up early success experiences, which also comes from the change literature and specifically the stages of change model. It’s sort of like building up momentum or getting a running start. If somebody has some big issues, like a performance improvement plan at work or getting ready for a final exam, there may be smaller examples from their day-to-day lives, like unloading a dishwasher or submitting their room application for next semester, that also have to be done. In these instances, my line for that is, “We procrastinate on the small stuff the same way we do the big stuff.” So it’s not like we have to go through every single thing, like, “Okay, here’s how you procrastinate on income taxes. Let’s talk about how you procrastinate on your local taxes.” No, we can take some of those elements and then adapt them, they can generalize to other things. And that’s similar to what we were talking about before, the solution focused, “All right, what can you use here over there for help?” So we try to have some success experiences. I think this is where the therapeutic alliance plays a big part, because the therapist who is familiar with ADHD can validate the difficulties and setbacks, but also the successes.

And it’s important that the clinician focus on normalizing by saying, for instance, “You know what? As we move ahead, there will be areas of difficulty. But that’s the name of the game.” So two things are at play which go back to the cognitions. People with ADHD tend to compare themselves unfavorably to others, thinking that everybody else has it so much easier. It becomes therapeutically important to validate that taxes and homework, especially writing assignments, can be very challenging.
LR: For everybody.
RR: Actually, writing assignments among college students, ADHD or not, are the number one procrastination target. People procrastinate on writing assignments because writing is hard. And even that reframe of, “Okay, this is hard for everybody” can be empowering, because we know that misery loves company, and we can point out that it’s a matter of degree. ADHD makes it harder, but can we get in there and then, you know, tolerate the discomfort that may be associated with that?

most people just want a clearer, more consistent sense of cause and effect. 'If I put in the effort and the time, then I’ll be able…'
And there can be this overgeneralization. “If I can’t do this, then there are other things I can’t do.” We want to ask, ”Let’s find out what you can do. And can you do this better? And it still may be difficult.” Most often, people say, “If I can just get the assignment done, if I get a B, I’ll take it.” And it gets back to that notion of efficacy, in that most people just want a clearer, more consistent sense of cause and effect. “If I put in the effort and the time, then I’ll be able…” to submit the homework, finish my classes by the end of the semester, whatever it is. It may not be “I have to be the CEO of some Fortune 500 company.”

But it’s just attending to the more immediate cause-effect relationships, like, “Okay, I did the work and I got the outcome, and now it’s gone. I did it. Now I don’t have to worry about it anymore.” And that’s just a nice starting foundation for people finding out that they can do the things that they want to do, and then maybe even start to expand beyond that more.

We can almost look at this process through a medical lens. There’s “rehabilitation,” and that is getting back to a baseline, such as rehabilitating a knee. Then there is “habilitation,” which is making the most of it with whatever resources we have. Here, someone might say, “I don’t have dyslexia or anything, but I’m just a slow reader. I have to read things a couple times.” Whatever it may be. It’s like, okay, how are you going to work with that?

So there are ways that you can play to their strengths and things like that. And my own cutesy line is “abilitation.” Like, after you take care of managing the problems with ADHD, are there some things, maybe some newfound directions that you can go in?

It’s like, “Hey, maybe I can try this.” It could be going back to school. It could be trying a new endeavor. It could be somebody saying, “No, I don’t want to go back to school and read textbooks. But if I read a biography of my favorite athlete, maybe I can get back to pleasure reading.” Whatever, however people define it. And that’s how newfound avenues get unlocked.
LR: I think that’s a good note to stop on. I want to thank you so much, Russell, for sharing your wisdom and your experience with our readers who may be struggling to succeed with their adult ADHD clients.
RR: Sure thing. You’re welcome.

Counseling Gifted Clients: Journeys through the Rainforest Mind

Posted on by Psychotherapy.net Team

“What do you do with the clients you suspect are super smart?” You know, those who talk fast, think fast, and ask probing questions; those who are so articulate and seemingly high functioning that you can’t understand why they say they are depressed and anxious. How do we begin to understand, let alone help, those clients who are paralyzed by fears of failure and the pressures of their “great potential”; who have exceedingly high standards and expectations for themselves and others? They change jobs frequently, are continually questioning themselves, and express frustration, impatience, and confusion with slower thinking co-workers. How can we walk alongside those clients who feel such deep and unrelenting loneliness, even if they have many friends and are in partnerships, and who were perhaps bullied and bored in schooling situations when they clearly have (or had) an enormous passion for learning? How can we fully and deeply assist those clients who have an unusual number of sensitivities to sounds, textures, visual stimulation, chemicals, and emotions? Or even begin to co-construct a meaningful treatment plan with clients who feel a responsibility for making a difference on the planet, have extraordinary empathy, and feel despair and idealism about the future? And how do we stay intimately attuned with clients who have experienced serious trauma in childhood but appear to be unscathed, those who are so tuned into us in therapy that they can sense when our attention is drifting, are afraid of overwhelming us, and who, in fact, do overwhelm us with their intensity, depth, intuition, and levels of awareness?

These are some of the challenges I experience working with gifted clients. Perhaps you do, too.

What is Giftedness?

Defining giftedness is difficult and controversial. There are many theories and definitions. Concerns over justice and equality can make this discussion tense and uncomfortable. Here is one way to think about it: all humans ought to be valued and appreciated and are worthy of love and respect. All humans differ in their strengths, weaknesses, learning styles, intellectual capacities, sensitivities, preferences, talents, temperaments, experiences, cultural backgrounds, and desires. It can get tricky when we talk about intellectual differences. And yet, intellectual differences exist. Giftedness exists—in all cultures, races, religions, and socio-economic groups.

It can be easier to see giftedness in children because they are often reaching typical childhood milestones earlier. Their precocity can be apparent in their language, curiosity, interests, and questions. They often read before they get to school and have abilities and wisdom beyond their years. I consult with parents of gifted kids. Here are some examples of children I have heard about: the eight-year-old who wants to be Richard Feynman for Halloween. The five-year-old reading The Chronicles of Narnia. The four-year-old who cries when listening to Mozart because the music moves him. The ten-year-old whose favorite pastime is watching BBC documentaries. The six-year-old who refuses to eat meat for ethical reasons. The nine-year-old who rescues the grasshoppers on the playground. The ten-year-old whose poetry breaks your heart. The fourteen-year-old who’d rather read David Foster Wallace than hang out on social media.

Notice I did not describe the child who performs well in school. Gifted children may test well and get high grades, and they may not.
So, defining giftedness is complicated. But we don’t actually need a clear, concise, undisputed definition to serve clients who fall into this category in one way or another. We don’t need to give them a label. We just need to understand what they may be dealing with due to their gifted traits and how to help them.

Traits of the Gifted Client

These are some of the characteristics of gifted clients with whom I’ve worked:

  • Advanced vocabulary, existential questions and concerns from an early age, multiple in-depth interests
  • A range of deeper-than-normal emotions and sensitivities (often underground in men), advanced analytical abilities, need for precision in fields of interest, perfectionism
  • Rapid thinking, talking, and learning
  • Excessive worry, great empathy for all living things, unusual insight into themselves
  • Avid reading, unending curiosity, and passion for learning (not necessarily for schooling)
  • More complex ethical, moral, and justice concerns, insight about things that others don’t notice, tendency to argue for fun or for intellectual stimulation
  • Idealism, wit, imagination, creativity, questioning authority, and needing to understand the meaning of life
  • Loneliness, anxiety (particularly when bored or during extreme bouts of thinking), existential depression, self-doubt even with seeming successes
  • Difficulty finding friends, serious schooling frustrations, uneven development

The Rainforest Mind

I have discovered that one way to manage discomfort with the label and definition of giftedness is to use the metaphor of the “rainforest mind.” I was a teacher of gifted children before becoming a therapist, and many educators were not happy about identifying them as such. I suggested we think of it this way: people are like ecosystems. Some are like meadows, some deserts, some volcanoes, and some rainforests, for example. They are all beautiful and valuable. One is not better than the other. The client with a rainforest mind is the most complex: multilayered, intense, overwhelming, colorful, highly sensitive, full of complicated creativity, and misunderstood. I have many clients who have read my blog/books and come to me saying “I’m not gifted, but I have a rainforest mind.” These clients are often uncomfortable with the label, too, and many deny they are gifted.

You may be using your most tried-and-true therapeutic methods with these clients but feel something is not quite working. You feel you are missing a very important piece of their puzzle but do not know what. Your client says they are struggling, but they seem to be capable, compassionate, and insightful. At times like these, I have found it useful to consider that my client has a rainforest mind.

Giftedness is a phenomenon that has its own set of complications. These clients desperately need us to see all of who they are and all of who they want to be. They need to be able to feel safe to be vulnerable and to trust that you can handle their exuberance, intense emotions, questions, contradictions, complexities, fears, intuitions, sensitivities, and, yes, their brilliance.

Some of the Issues

The gifted clients with whom I’ve worked come to therapy for the same reasons most clients do. They might be dealing with depression, anxiety, PTSD, attachment issues, addictions, or childhood trauma. But there will likely be other issues that will need your attention. The following are some of the concerns I see in my office every day:

  • Unhealthy perfectionism that stems from early intense pressure to achieve. Healthy perfectionism that is often misunderstood and stems from an innate desire for beauty, balance, harmony, justice, and precision.
  • Multipotentiality, which is a desire to pursue many career paths and multiple interests. This is often mistaken for irresponsibility, inability to focus, or even ADHD.
  • Extreme difficulty with decisions due to the ability to see too many options and to worry about the implications of every choice.
  • Existential depression and despair, particularly rooted in an early and ongoing sense of justice and social responsibility.
  • Difficulty finding friends and partners because of differences in intellectual capacity and in emotional depth and sensitivity.
  • A history of bullying in school and boredom over many years in a traditional classroom where they already know the material. Great frustration with coworkers and supervisors who are less competent or less conscientious.
  • Being given too much responsibility for siblings and parents in a dysfunctional family. The tendency to be the counselor for family and friends with no reciprocation. A capacity for resilience when raised with abuse, masking serious self-doubt, self-hatred, depression, and anxiety.

What Can a Therapist Do?

These are some of what I hope will be helpful hints and strategies I have found effective with these clients.

  • Get familiar with the traits that often accompany giftedness. Explain these to your clients. Learn to differentiate the issues that come with giftedness from the effects of growing up in a dysfunctional family. Explain how having a rainforest mind can be challenging. Suggest books, articles, and websites.
  • Look for ways your clients are masking their pain because they are used to practitioners who assume they are just fine and often their friends and family members overly rely on them because they are so capable.
  • Allow them to talk a lot without being linear or chronological; take notes if it helps you keep track. Create a very large container to hold what is likely to be a great deal of intensity. Love their difficult questions, big emotions, deep dives, and quests for justice and a better world.
  • Be authentic and sensitive. Listen deeply. They are often particularly intuitive and will be able to sense when you are irritated, not feeling well, or distracted.
  • Get your own therapy. If you are also gifted, take time to explore the resources for yourself.
  • Be careful that you don’t misdiagnose—giftedness can look like ADHD, ASD, OCD, and even bipolar disorder. (Note: Some clients can be gifted and also have a mental health diagnosis or learning disability, called twice-exceptional or 2e. It will be important for you to know about this as well.)
  • Know your limits and notice if you are intimidated by their intelligence. Refer if you are frequently overwhelmed or uncomfortable.

The Case of Marilyn

For the purposes of this article, this case example will focus mostly on psychoeducation around giftedness rather than the childhood trauma the client experienced. This case description is adapted from my book, Your Rainforest Mind.

Thirty-year-old Marilyn, a graduate student in anthropology and women’s studies came to counseling because, as she said, “I reached the end of my own abilities to fix myself.” Marilyn’s mother had died a year earlier, and her intimate relationship was “faltering.” In describing her goals in counseling, she wrote, “I want to stop carrying the weight of my family’s legacy, to untangle the mess in my head, to be free.” Marilyn had a history of difficult relationships with partners and trouble finding emotionally healthy friends. Like many of my clients, Marilyn did not initially know that she was gifted.

She described a bipolar, physically and sexually abusive mother. Her father was kind and loving to her but didn’t stand up to stop the abuse. According to Marilyn, her parents were “spectacularly unsuccessful in the real world.” And when Marilyn was twenty-two her father died suddenly.

As a child in school, Marilyn was bullied. She was excited about learning, academically ahead of her peers, and a talkative extravert whom teachers dismissed with impatience and children rejected.

As with most of my clients, we worked on two main tracks. Track one was the long road to healing from severe childhood trauma. Convincing Marilyn through lots of counseling processes based in attachment theory and somatic experiencing that the abuse wasn’t her fault, that she was, in fact, worthy of love, was the more complicated task. Over time, Marilyn felt more trust in me and allowed herself to grieve the losses she had experienced for so many years.

Marilyn, like many gifted folks, had shown a powerful resilience. In spite of her rejecting, critical, abusing mother, Marilyn was a kind, loving, competent woman. The damage was evident, though, in her distorted view of herself, her existential depression, somatic symptoms, and her inability to believe she was worthy of love. It took time for her to feel safe enough in therapy to allow herself to grieve and to trust.

Like many gifted clients, Marilyn did much self-examination. She particularly enjoyed art projects and used journaling and other art forms to delve deeper. She was a big reader and was always looking for resources that would expand her knowledge, particularly in the areas of body image and women’s issues.

The second track is simpler but essential. Even though Marilyn had experienced academic success, she did not identify as gifted or understand the traits. She wrote about this: “There were—and still are—so many times in my life I felt an unbridgeable distance between myself and others, like I fundamentally see the world in a different way that I can’t even explain because we don’t speak the same language.” Even though Marilyn found friends, she felt extremely lonely much of the time. She was often the caretaker in the relationship, giving much love and support but not getting much back. She wrote, “I get hungry for people who are socially competent and intellectual and curious about literally everything and creative and broad-minded and motivated by justice…People who care and feel deeply but also think in complex wide-ranging ways.”

Even though she was an optimist, Marilyn felt despair over finding a truly loving and kind, intimate relationship. And with both friends and partners, Marilyn had difficulty setting boundaries and asking for what she needed. Being gifted, this was even more challenging, because it wasn’t easy finding other sensitive, intelligent souls. I referred her to my blog, books, and other articles about giftedness to reinforce that her difficulties with peers and her enthusiasm for learning outside of school were also typical traits of the gifted.

As time passed in our work together, Marilyn graduated with her Master’s degree. Her advisor may have been the first teacher who recognized and appreciated her giftedness, telling her she was the brightest student she had ever worked with. This was an important acknowledgement. Marilyn and I continued therapy as she looked for employment. Fairly quickly she found a job that was not in her field of study but that suited her well.

Marilyn was employed in social services as a case manager and was wildly successful. The combination of her rainforest-minded traits of sensitivity, empathy, energy, attention to detail, and intelligence worked well with the population of families she helped. She often took on extra responsibilities to keep herself busy and mentally stimulated. In meetings, she saw the big picture and solutions long before her colleagues. So she was restless in the job when she had accomplished her goals and was not recognized for her skills. These can be the frustrations of many rainforest minds on the job. It was likely that Marilyn would find more challenging, financially rewarding work as her confidence grew, but this position was satisfying her need to make a difference.

In many of our sessions, as we talked about relationships both personal and professional, I would remind Marilyn that some of her struggles were due to her complex intellect, high level of sensitivity, multiple interests, divergent thinking, very high standards, fast learning abilities, and deep empathy. In other words, her rainforest mind.

Over our years together, Marilyn made enormous progress. She could acknowledge how severe her losses had been and grew more and more self-accepting. Her self-criticism had decreased significantly, and she became able to recognize her many strengths. She began to imagine that she would find deep friendships and a kind loving partner. Eventually, she accepted the idea that she was, indeed, gifted.

Marilyn described her experience this way: “I keep hoping to meet people with whom I can relax and be just me, all of me, unafraid to let them see who I really am, in all my dorky, questing, art loving, social justice-obsessed, bibliophile, rebellious, intersectional feminist, world-changing glory.”

***

Marilyn is but one example of the many fascinating gifted clients with whom I have been privileged to work. If you can identify who among your clients is gifted, has a rainforest mind, and if you can listen to, understand, and explain the particular challenges that these folks often face, it will make a big difference in the effectiveness of their therapy. You will be seeing and knowing them in a way that very few others, if any, have. And that will change everything.

Helpful Resources

Books/Articles
The gifted adult: A revolutionary guide for liberating everyday genius™.
The Social and Emotional Development of Gifted Children: What do we know?
Your Rainforest Mind: A guide to the well-being of gifted adults and youth.
Journey into your Rainforest Mind: A field guide for gifted adults and teens, book lovers, overthinkers, geeks, sensitives, braniacs, intuitives, procrastinators and perfectionists. .
Webb, J. T., & Amend, E. R. (2016). Misdiagnosis and dual diagnoses of gifted children and adults: ADHD, Bipolar, OCD, Aspergers and other disorders. Great Potential Press, Inc.

Websites
Supporting the Emotional Needs of the Gifted (SENG)
Your Rainforest Mind
Gifted Challenges
Puttylike

John Arden on Brain-Based Therapy

Posted on by rezendevknowfully.com

Why Brain-Based?

Rebecca Aponte: Why did you call your book Brain-Based Therapy? What does “brain-based therapy" mean?
John B. Arden: I've got to say that the actual title of the book was chosen by Wiley, the publisher. The earlier title had something to do with neuroscience—I forget, actually, what it was. But when this one was chosen, my initial reaction was, "Geez, that sounds so reductionist."
RA: That’s what I thought, too.
JA: And there's so much out there about neuroscience. A good friend of mine, Lou Cozolino, wrote a book called The Neuroscience of Psychotherapy, so maybe it was too close to his title. But from my point of view, it doesn't have anything to do with reductionism. I still regard Jung's analysis of culture and fairy tales and religion to be fascinating. In fact, I spent a lot of time sitting in yoga ashrams in different parts of the world meditating, and those parts of my development are still with me. I'm still interested in all of that, but I want to integrate it all. And it has to be integrated from a nondualistic perspective. It seems to me that for many years we were in what I call the Cartesian era.

RA: The separation of the body and the mind.
JA: Right. Between 1890 and about 1980, we were in the Cartesian era with no scientific grounding for this view whatsoever because, despite the fact that Freud was a neurologist and wrote a hundred articles in neurophysiology, on such things as the neurophysiology of the crayfish, we didn't really know much about the brain at the time. So the schools of psychotherapy just splintered all over the place—everything from primal scream all the way to radical behaviorism—because there was no common language, no common integrative core.

The picture changed around 1979 to 1981 due to the convergence of a number of different factors. For one thing, the DSM-III—the third Book of Bad Names—developed. And it was a whole lot better than DSM-II and DSM-I, because you didn't have a lot of terms like "neurosis." Even homosexuality, believe it or not, was in the DSM-I. Finally, in 1974, when the DSM-II came out, millions of Americans and Europeans became cured of their disorder. That's why people get really caught up with the diagnostic terms. So DSM-III came about, and there was a whole lot more science to it. People were saying, "Wow, geez, this is so much better. This makes a little bit more sense."

Also, up until about 1980, the efficacy studies for psychotherapy were pathetic. Way back to Hans Eysenck, the mere passage of time was as effective as psychotherapy. Before Timothy Leary went to Harvard, he actually worked for us as a chief psychologist at Kaiser Oakland. He was a pretty bright guy before he started taking acid and flipping out. And he did a study there where he found that people on the waitlist did as well as people in psychotherapy. So imagine all that.
RA: A huge crisis for the field to go through.
JA:

The Age of Pax Medica

Exactly, until the Smith and Glass studies, which came out in 1979 or 1980. I was at University of New Mexico at the time, and we were pretty excited because this big meta-analysis found that, actually, psychotherapy worked. "Oh, my god. What we're studying and what we're doing really makes sense. We're helping people. Thank God!" Then, too, the development of these SSRIs in the '80s was a major factor in the development of what we call Pax Medica.
RA: Can you elaborate on that term?
JA: Pax Romana was a term used to describe the Roman world roughly 2,000 years ago. You could travel anywhere in the Roman world, and as long as you didn't insult Roman gods and Roman law, everything was cool. Similarly, since 1980, as long as you recognize that that psychiatry is in charge and that the number one factor is psychotropic medication, everything's going to be cool. That's why we call it Pax Medica. We've been operating in Pax Medica roughly since 1980. I think we're ready to leave it.
RA: Yet you recently said in a lecture that, in some ways, Pax Medica benefitted mental health.
JA: Because it got us all on the same page. We were all over the place. We were talking about interjected self-objects on one side and behavioral reinforcement paradigms on the other. We didn’t have a common language.

But Pax Medica’s page is extremely one-dimensional. In fact, the common language that we began to use is rather clunky and presumptuous. So we became a medicalized group, and the psychotherapy world became medicalized psychotherapy. And instead of being called “psychotherapists,” we became “clinicians.” “Now, you’re talking.”
RA: “Now you sound medical.”
JA: Now you’re clinically speaking, but what were you speaking before? Is this a new language or something? I’ve sat around in these big meetings where people say, “So what’s the diagnostic picture here?” In other words, they want a name quick, from the Book of Bad Names. And then they say, “What’s medically necessary?” Medically necessary, what? The guy just had a divorce. He’s really bummed out. “Medically necessary” sounds kind of silly.
RA: It sounds you're saying there's a fundamental disagreement about what the role of the therapist is.
JA: Yeah, and I think that the disagreement resulted in a compromised agreement. And the compromised agreement became the clinical role. And the clinical role is, I think, very antiseptic and one-dimensional, and in some ways very subservient to the so-called "principal treatment," which was medication.

Now we know the efficacy studies for antidepressants are rather suspect. The negative studies outnumber the positive studies by 12 times. So the pillars of Pax Medica are actually falling apart in major studies in JAMA and New England Journal of Medicine and other places.
RA: Within the Pax Medica frame, what do you think has been the cumulative effect of the outcome studies that focus on a specific treatment for a specific problem?
JA: Another part of Pax Medica was evidence-based practice. From roughly the early '80s on, various CBT-oriented therapists were the ones doing a lot of the studies on specific methods. David Barlow and others were showing that specific approaches to panic or OCD were more efficacious, and that dovetailed really nicely with the Pax Medica model, whereby you had a diagnosis and you had a prescribed treatment for the diagnosis. There was a positive part of that, because, come on, now—a person with a panic disorder, you want to sit around and analyze their feelings about their mother endlessly? No, you want to get them doing interoceptive exposure and other approaches that have been found for the last 35 years to be much more efficacious than sitting around analyzing archetypes and other things that, even though I find them intellectually stimulating, are a waste of time with somebody with a panic disorder.

So there's a lot more science in Pax Medica, and that's a good thing. But I think we're ready to integrate many strata of science now, to emerge out of the one-dimensionality. Evidence-based practice is still going to be part of the picture, despite the knowledge that the outcome management people have provided us, which is that there are diffuse boundaries between these psychotherapeutic schools.

I'm arguing that we don't need any more gurus.
I'm arguing that we don't need any more gurus. I certainly don't want to be anybody's guru. We don't need another school. I'm not suggesting brain-based therapy is a school and now everybody's got to be an Ardenian. Oh, what a terrible burden it would be to be one of these gurus—and a hollow experience, at that.

Rather, I think we have the opportunity to integrate evidence-based practice—which still is part of the picture for anxiety disorders and depression—with a better look, for instance, at the building of the alliance. The Adult Attachment Inventory and things like that give us insight into the various types of relationships we have been taught to develop, that are going to be replicated in the therapeutic encounter anyway. So why not include that as part of the overall picture? And we know that certain types of brain dynamics and temperament are associated with relationships—neuroscience is a big part of this new equation, as well.
RA: The brain is a popular topic right now, but do you feel that we’re really there yet with the science backing biological theories about how the brain works?
JA: More than we ever have been. I’m also convinced that in five years, I’ll be looking back at what I’m saying to you right now and thinking, “God, John, you had such a limited understanding of what’s going on.” And I think that’s a good thing. So, yes, I think that we can begin to have a dialogue about neuroscience, but are we there yet? No. I don’t think we’re ever going to be totally there. There is no “there.” But we’re going to be far more enlightened about what’s going on. And certainly, not everybody’s brain is exactly the same, but we know that there are psychological syndromes, like anxiety and depression, that have some commonality across people. We ought to be talking about that among ourselves as therapists, and also in therapy with our clients. I’m always talking about the brain with my clients.
RA: A lot of people feel that there’s been an overemphasis on the brain and that therapy has really moved away from focusing on emotions and the human experience. Related to what we were talking about with Pax Medica, there’s a concern that overfocusing on biology closely ties in with overfocusing on pharmaceutical therapy.
JA: I think otherwise. In fact, I think it's an opportunity to focus less on psychopharmacology. Out of the 2,000 of us in the Kaiser system, I'm among the people who refer my clients less for medication evaluations, because I want to work with emotion. That's our province. So how do you work with emotion? Well, if you have people narcotized, you're not going to have access. And certainly with people who have anxiety disorders, anybody on a benzo I'm trying to get off of benzos as quickly as possible.

SSRIs I'm less concerned about, but I only go there when I exhaust all other avenues, including diet, which I'm always talking about at length. Exercise is the most effective biochemical boost that there is—as effective as psychotherapy. Exercise is as good as psychotherapy in alleviating depression. We ought to be doing that and psychotherapy together.

Including all these biophysiological dimensions that don't include the drug cartels is a good thing. Now, the reductionism to a specific neuron—no, I don't go there. Remember, I'm a guy steeped in psychodynamic theory, and I still love all the allure associated with it and all these characters that are battling with one another. It's fun, and it's enlightening in many ways. I think the new psychodynamic perspectives are quite a bit more advanced than the original psychoanalysis.
RA: So you see the new role of the therapist incorporating biology, traditional psychology, but also sleep hygiene, exercise, and nutrition.
JA: Absolutely. I'm not suggesting that we don't pay attention to the alliance. In fact, that's one of the principal effective agents. And we know that from psychotherapy research; the outcome management people have shown that to be pretty powerful. But why not pay attention to those parts of the brain that make that possible mirror neurons, the anterior cingulate, the orbital frontal cortex, the insula, the spindle cells? It's interesting for us to know that some people, if they've had a poor attachment history, have underdeveloped areas like the ones I just mentioned.
RA: You mentioned that you can see this information as a opportunity to teach clients about what may be happening in their brains. How does that help?
JA: Let me give a fairly common example. Say you have a client who says to you, "I just don't know why in the first part of the day, when I lie there in bed, I get so overwhelmed and I get paralyzed with this totality of anxiety. I don't know what's going on there. I get anxious and depressed. What am I going to do?"

Well, we know now from all these affective symmetry studies that people who get hyperactive right prefrontal cortex plus underactive left prefrontal cortex get more anxious and more depressed. And what kindles the right prefrontal side are withdrawal and avoidant behaviors. So when she gets into the withdraw-avoidant behavioral response, she's kindling up the right prefrontal cortex.

Now, how to get out of that? You've got to do what are called approach behaviors. The CBT people have known this a long time—it's called behavior activation. What do you do with depressed clients? Do you sit around and analyze things to death? No, you get them doing stuff. And you get them doing it quick. As soon as you start to feel overwhelmed, it's time to do something, because that kindles the left prefrontal cortex, which is about approach behaviors. But you do it incrementally, because it's always very overwhelming to do big, big projects.

We're not talking about the left hemisphere as being the new cool one now and the right hemisphere as passé, where it was the right hemisphere that was the cool one before. No, we're going to be talking about a relative activation of the two hemispheres. In fact, we know, too, that if you get the right prefrontal cortex knocked out, you lose your sense of humor. What's that about? Well, you want to have a sense of humor, right? A sense of humor is about plays on words, metaphors, juxtapositions, and all of that. You want to have that larger picture.
RA: So all of that also really speaks to how behavior changes the brain.
JA: Absolutely.
Behavior changes the brain and the brain changes behavior. It’s a bidirectional flow of information. It’s not one way or the other.
Behavior changes the brain and the brain changes behavior. It’s a bidirectional flow of information. It’s not one way or the other. Pax Medica had it one way: “Brain changes behavior. All you’ve got to do is tweak up some neurotransmitter system like serotonin, and everything’s going to be fine.”
RA: “Because you have a chemical imbalance.”
JA: "Chemical imbalance" is so American, isn't it? "Okay, let's just go in there and change that chemical imbalance. I want to fix it quick, will you, Doc?"

Come Together

RA: Where do you think we are in the grand scheme of integration?
JA: I think it's slowly developing. There will always be tidal pools that pull back. For example, you mentioned earlier that some people are saying, "Oh, neuroscience. What's the big deal? Neuroscience isn't going to be part of the picture. Get over it." It's going to be, but how is the bigger picture? I think that there are a lot of people jumping in the bandwagon who aren't paying attention to the science in neuroscience. I'm not going to get into names, but some people make it rather New-Agey, and that kind of turns my stomach.

Science is a good thing. We ought to be paying attention to how the research actually shows this or that instead of, "Well, that's kind of a cool thing. Why don't you just talk about the so-called limbic system?"
How we incorporate neuroscience, I think, is going to be a big part of how we advance toward the future. And it's not going to be reductionistic. It's going to be a part of the picture. We're still going to talk about the relationship and pay very close attention to the alliance. And as I said earlier, it works both ways, because there are parts of the brain and parts of our nervous system that respond to close relationships, and that's something we ought to be paying attention to.

The psychological theories and all the alphabet-soup therapists—EMDR, EFT, CBT—the advances in some of those areas, I think, are going to be part of the picture. But I think the allegiance to the schools is going to be increasingly less of an issue.

Reshaping Memories

RA: I think a lot of people in the field really hope that your view is right. What evidence do you see that indicates the field is moving in this direction?
JA: It seems to me that the studies that show actual change in the brain resulting from psychotherapy are what will convince everybody that we’re moving in the right direction. And there’s a wealth of information out there that’s developing and will become stronger and stronger, and it’ll be undeniable that there’s an intersection here. Again, it’s all not reductionism: it’s integration. And memory is a major part of the picture here.
RA: Say more about that.
JA: Understanding memory and the complexities of our various memory systems, including the various types of implicit and explicit memory and how those systems work together to make us who we are, and how we, as therapists, interact with these memory systems—that, to me, is the foundation of therapy. Our job is to help people reconsolidate memory in a much more adaptive and effective way, because there is no such thing as a memory encapsulated in some sealed-off portion of time, where you go back in and you pull it up. That's where the early psychodynamic theorists had it all wrong. Every time we bring up a memory, we change the memory.

That's what we do for a living: we bring up memories in the new context and help people re-adapt in a much more effective way.
That's what we do for a living: we bring up memories in the new context and help people re-adapt in a much more effective way. I regard memory as one of the major foundational aspects to psychotherapy in this unfolding sea change—not a paradigm shift, but actually a sea change—that's occurring in mental health.
RA: You’ve said that it really seems like we’re moving beyond brand-name therapies, but do you think we’ve just substituted techniques? You mentioned CBT. I’m not completely clear on what the theory behind CBT is, other than that it seems very removed from things like memory and emotional experience.
JA: Actually, it does incorporate them. If you think in terms of anxiety, for example, it's quite clear that avoidant behaviors make anxiety worse even though, over the short term, they make it feel less severe.

Let's say I'm a socialphobe and I walk into a room. I feel better for the first minute, and then I feel terrible, and my amygdala gets hyperactive as a result. In other words, I'm painting myself into a corner. Exposure is the antidote—the therapeutic direction that we ought to be working in. And that goes back to Joseph Wolpe, who doesn't get enough credit now, even in the CBT community. The whole idea of incremental exposure is critically important in psychotherapy for people with anxiety disorders. So the CBT people are talking about the brain even though they're not using the brain in their dialogue. They're not mentioning the brain because they haven't been really incorporating it into their understanding. But they are changing the brain, because exposure actually changes the brain. It could make the anxiety worse by flooding too quickly, but incremental change could make it much more resilient and adaptive.
RA: Let me see if I’ve got this right. It sounds like you’re expecting that there would be a much more integrated theory about how psychotherapy works, because it’s going to include neuroscience. And because we have more technology now, we’re going to be able to actually see these changes and understand it, and we’ll continue to see even more levels of complexity.
JA: We are seeing these changes. And in fact, with psychodynamic theory, the whole concept of working through is the same thing as incremental exposure. A book that I like to recommend that's now 20 years old is Psychodynamics in Cognition, by Mardi Horowitz. I really like that book. It was Horowitz's attempt by to talk about the overlap between psychodynamic theorists and cognitive theorists-maybe they aren't talking about something so different. Let's talk about how defense mechanisms and schemata have an overlap. That's what I'm talking about: finding the overlap between these therapy types. Just because they use different language doesn't necessarily mean that they're not talking about the same thing. Where there is an overlap, I get excited about it.
RA: So neuroscience is going to be what shows us that we’re all talking about the same thing.
JA: Neuroscience, and a look at these therapeutic styles. Defensive maneuvers are still relevant, and we can look at them from a cognitive perspective, and from this whole affective symmetry dynamic, as well. In other words, we could look at them from a number of different vantage points, and if all those vantage points have a cohesive quality to them, then I feel much more confident about it.

So we’re not just talking neuroscience or just talking psychodynamic or just talking CBT or memory, but rather how these all can overlap and say the same thing to give us a much more robust understanding of what goes on in psychotherapy and what goes on in our own heads.
RA: Do you believe this integrationist’s frame of reference changes the way that you work with clients?
JA: Absolutely. I've been in the mental health world for 35 years, and when I first started, I was part of this whole the institutionalization movement—we were creating alternatives to hospitals in San Francisco, and then wrote a bill for the New Mexico state legislature in 1980 to do the same thing. What I thought was going on back then is quite a bit different from what I think about what's going on now.

Even in 1976, when I was working with autistic kids—God, we had a stupid understanding of what was going on with those kids back then, because we didn't understand what was happening in their brains. We thought it had to do with these really cold mothers. Bettelheim was our popular hero. My God, what a dumb, dumb way of understanding.

It didn't mean, though, that what we were trying to do, in terms of developing a good relationship with the kids, wasn't a good thing to do. We called it reparenting, but nowadays we'd think about it as being helpful to the kids so they could acquire better social skills and develop a better ability to have human relationships.
RA: This makes me think about some of the preliminary studies in the news now about sudden-onset OCD in children after they have strep infections.
JA: And that has helped us to understand the role of the striatum very well, because that’s the area of the brain that gets attacked viciously in these kids during the infection. And we know that the front part of the striatum is kind of like a spam filter. In people with OCD, unfortunately, that striatum doesn’t work like a spam filter, and the orbital frontal cortex gets flooded with all this nuisance information: “This is wrong, this is wrong, we’ve got to do something, wash your hands, wash your hands,” or whatever it is. Baxter’s group down at UCLA showed very clearly the orbital frontal cortex being flooded with all this nuisance information, and that what can help alleviate the OCD is to “rescue” the orbital frontal cortex with the dorsal lateral prefrontal cortex (which has a lot to do with working memory) via CBT with a mindfulness approach. In these imaging studies, you could see OCD patients before and after the treatment. And the strep infection material was supports the idea that OCD involves this “gate” that is left open in the striatum.

But How Does It Work?

RA: Let's walk through a hypothetical. I come to see you because I feel depressed and generally anxious, and this has been going on for some months now. Where would you start to look for the cause of my feelings and some relief?
JA: It's interesting that you say depressed and anxious, because under Pax Medica, if you were depressed and anxious together we would have two diagnoses on Axis I—a comorbid problem. Well, you're one person. Are these two genetic disorders you have? What a silly idea. And the prescribed pharmacological agents actually work against one another. These stupid benzos, which are really a nuisance in the mental health world, would actually contribute not only to addiction, tolerance, and withdrawal problems, but also to depression. And then you'd toss in an SSRI or something like that, so you'd have this weird cocktail.

There is an interesting neurochemistry that occurs with anxiety and depression. For example, for 90 minutes after you experience a severe stressful incident, your levels of dopamine, norepinephrine, and serotonin will be down. Let's say that you've just found out that you can't get into school. All the PhD programs have turned you down. That's a pretty big blow, right?

So you're going to get a downregulation of all those neurotransmitter systems, and you're going to withdraw a little bit. But it's what you do with that neurochemistry and those neurodynamics that can tumble you into more anxiety and more depression, or get you out of it. If you do things that kindle up the same systems that would get you more anxious and depressed, you'll get more anxious and depressed.

Now, we're going to have bumps in the road. It's what you do in response—it's that resiliency. Some of the positive psychology spinoffs are paying attention to that, and of course the counseling psychologists have long done that.
RA: So, if I were your client, would you want me to tell you about something stressful that happened and what I did afterwards?
JA: I often do that, just to get an idea of how people react to certain events in their lives—to get a characteristic description. I'm also paying attention to the way they describe them to me, because that interaction between us is so important. It replicates other relationships they're having that might have great continuity with the earlier attachment-based relationships. It tells me a lot about how I can intervene, because I don't want to create more resistance. I do like Milton Erickson a lot—that indirect approach. I'm not going to want to shut you down and have you screen me off, but rather do some motivational interviewing to some degree—which is very Rogerian, in fact. Bill Miller was a Rogerian from the school that I came from.
RA: Out of curiosity, did you study with him at UNM?
JA: No, I didn't. In fact, I didn't know about him until after I left. I don't know if he was there then—that was 30 years ago. But had he been there and I missed him, I would have been disappointed, because I really like his contribution to the substance abuse community.

Addiction: A Sliding Scale?

RA: And substance abuse is one thing that we haven't really touched much on in terms of what neuroscience is really teaching us. There's big debate about whether addiction is a genetic disorder.
JA: There is some literature to suggest that if you have two alcoholic parents, your vulnerability to become an alcoholic is heightened. But let's say the concordance rate is 50 percent. Well, what about the other 50 percent? It isn't a one-and-one factor.

In a discussion I had with Fred Blume, one of the pushers of the alcohol gene concept, I asked, "How about an acquired disease? You guys are really into this disease concept." AA's really into it. AA and NA are the most powerful self-help groups in the world, in my opinion. My sister-in-law's life was saved as a result. Fantastic groups. I love their little jingles and all that. But they're too into this disease concept. It's useful in early recovery, but you could create a disease. It's bidirectional. The more I drink alcohol, the more I feel like I need alcohol, because my biology changes. I downregulate various neurotransmitter systems, so now I feel like I need to mellow out because now I'm downregulating the synthesis of GABA. That means I need more GABA-like effect because I'm always dampening down glutamate.

What I think therapists ought to be paying attention to is how these various substance abuse habits, if you want to call it that, create psychological symptomatology. “I see all sorts of people here in the North Bay who are suffering from anxiety and/or depression, and I find out they're just drinking a glass or two of wine at night.”
RA: That’s a lot of wine, though.
JA: I think it’s a lot of wine. I drink a glass every week or two. It would be nice if you could have two glasses of wine a night, but my sleep gets all messed up. You get the mid-sleep-cycle awakening and all that. And that’s a small snapshot. What about the next week? These are subtle effects, but when I used to do neuropsychological testing and psychological testing, and then later teach it, we used to say, “Don’t test a wet brain for up to three months after your last drink.” There are all sorts of artifacts to subtle alcohol consumption.

And red wine isn’t that cool, you know. It’s the resveratrol in the skin of the red grape. You can drink Welch’s grape juice and still get the same effect. You don’t need the alcohol.
RA: And what about other drugs? I haven’t heard too many therapists saying that they necessarily ask their clients, “Do you smoke pot?”
JA: Everybody here does. And pot is one that I really pay close attention to in the North Bay, because of all these people on medical marijuana cards. They have a sore back. Well, give me a break. So do I, but I don’t smoke marijuana now. I did 40 some years ago as a young hipster, but I’m glad I stopped 40 years ago, because otherwise I’d be muddled and kind of down. THC is chemically structured like a neuromodulator called anandamide, which is Sanskrit for “bliss.” It orchestrates the activity of a number of neurotransmitters, so when you’re stoned you get what we call virtual novelty. “Look at this cup! God, that is so incredible. Look at the way it’s shaped, and the colors! This is amazing.” Then the next day you get what we would call in the ’60s “jelly brain,” because everything’s downregulated now. And you never get the same high.

So now what we see are all these people smoking medical marijuana who have low-grade depression. They can’t remember much, because they downregulate the acetylcholine release in their hippocampus and have symptoms very much like ADD. God, I get people with ADD evals all the time who are smoking marijuana.

So with regard to substance abuse, psychotherapists should perform a full analysis of everything the clients are doing, instead of saying such things as, “Do you abuse alcohol?” I want to know what they’re consuming rather than ask blanket questions.
RA: Well, what’s abuse? “Yeah, I have five beers a night, but I’m fine.”
JA: Exactly. But if somebody’s drinking two, I’m concerned about that, especially if she’s anxious or depressed. Or if somebody’s taking a toke of marijuana a night, and he’s coming in with this low-grade depression, muddled thinking, and attentional problems, I’m concerned about that.

Defining Therapeutic Success

RA: In the way that you’re visualizing therapy, how do you define therapeutic success?
JA: We're always a little too symptom focused. I still think we ought to be paying attention to symptoms—that's an important part of the picture—but we also ought to pay attention to what clients are telling us about their overall improvement and their perspective in life: "I'm feeling so much more hopeful and so much more resilient and I'm not as easily stressed." And we're getting more of that from the outcome management process, instead of, "You originally came in with these panic symptoms. How's the panic doing?" "Oh, I don't have those panic symptoms anymore." Well, that's good. That's only part of the picture, though. There's got to be a larger look at things: is the relationship improved, for instance?

Therapists: The Next Generation

RA: As a mental health training director for Northern California for Kaiser, you work constantly with the next generation of therapists. What do you see in their training that concerns you?
JA: What got me intensely concerned and preceded the development of Brain-Based Therapy was typified by an answer to the question, "What do you want to do in the next year?" In the Kaiser Northern California, we have 60 postdocs in 20 medical centers, and another 50 interns. When I interview a postdoc and ask, "What do you want to do over the next year?" they say, "I really want to find my theoretical home." You want to what? We're certainly not going to be helping you find your theoretical home. In fact, I want to dissolve those theoretical homes into a grand unified area. So that's a concern.

And a lot of young therapists come out of these schools too young and inexperienced—they haven't had to go out in the world and learn business and all this, to augment their academic understanding. Between undergraduate and graduate, I spent a year in Asia and the Middle East, and I just kept circling the globe. I was gone for a year, and I don't know how many countries I visited. What an incredible education. I matured so much during that period.

Life experience is critically important. Having to deal with some stressful events can really help a therapist. Just being pumped out of all these professional schools with all these fancy degrees and all that, boy, that's such a limited area. I get a little concerned about too-young therapists being plopped out and wanting to be Dr. Somebody-or-other.
RA: That seems to address my next question: do your intern therapists seem to come with a broad base of knowledge about other aspects of the human condition—literature and art and history?
JA: That's a pretty interesting question. I remember when I was being interviewed for my PhD program, that was a question in the interview. I was in the Counseling Psych department, even though I later got involved in both departments. I was really into talking about Dostoevsky and D. H. Lawrence, and that perked up the interest of the interviewers. Contrast this with the clinical program applicants—I call them the GREs. All they got was a high GRE score and a good GPA. Big deal!
RA: In the next generation, are you seeing much of that?
JA: If you immediately go from a bachelor's to a master's and, usually, especially the professional schools, straight to a PhD program, I see a lot of that. And physicians, unfortunately, hardly read at all. It's just shocking that the educational system kills the quest for reading in diverse areas. It's amazing.

Therapists don't read enough. And when they do read, unfortunately, they read in their own little clubhouse. Where you get more cognitive reserve, if you will, is where you step out of your own zone of comfort. I particularly like to step out of all these mental health areas completely and pay attention to what other scientists are doing.

Particularly, I love complexity theory. When I'm back in Santa Fe, I like to go to the Santa Fe Institute. This place is incredible—founded by three Nobel laureates, two physicists, and an economist. And then there are biologists and computer scientists and archaeologists, all talking about the change in complex systems. Well, aren't we a complex system?

So I think we don't read enough, and not only of another psychotherapeutic school, but, also another area of science. It would be really good for us to do that on a regular basis. I'm perpetually advocating for that.
RA: There are some people who are advocating for academia to do something similar to what you’re saying psychotherapy should do, arguing that there really shouldn’t be such big walls in between each department.
JA: Yeah. In fact, in the Sonoma State University, there’s the Hutchins School, which is very much like St. John’s College in Santa Fe, whereby you have more of an interdisciplinary approach. At St. John’s it’s more of a classics approach, but at Hutchins, you have a department with anthropologists and biologists and other people all there. It’s that interdisciplinary approach that I think is so valuable.

Inside Kaiser

RA: Do you think, working at a large health maintenance organization, that this move toward integration will also eventually break down some of the barriers for clinicians to be able to determine what kind of treatment they want to give to a particular client? Right now, HMOs rely very heavily on CBT because there are so many studies of a specific symptom with a specific treatment.
JA: I don’t necessarily see Kaiser as being a CBT mental-health dispensary. I’d look around at all my colleagues, and one person might be into EMDR, another person CBT, another person steeped in psychodynamic or narrative. But we do pay attention to evidence-based practice. In fact, we have a whole administrative structure just for that. But we also have an administrative structure just for outcome management. The convergence of the two is pretty important.
RA: I’m sure that you’ve heard some of the recent complaints about Kaiser that people have a difficult time getting timely access to mental health care.
JA: That's kind of old news—20 years old. All departments are graded for access right now. I was hired during the Model of Care, which was 20 years ago, where we tripled or quadrupled the size of many departments because it was all about access. Every department now is graded on how quickly a client can come to see someone. If you call in right now, we've got to give you an appointment within two weeks. That's called initial access for the new, and there's a seen-to-seen that we're being graded in, too. We've improved dramatically in the last 20 years.
RA: There is a recent report that union leaders and employees were asking for an investigation to make sure that it was happening in a timely manner. Do you feel like the treatment model that you’re describing can fit well into an organization like Kaiser?
JA: Kaiser's in a difficult position because it's swimming in this vast sea of other medical providers, and it's trying to survive at the same time as thrive—to use that term. So I know what those folks are saying, and we're not immune from any criticism. There are always these concerns about improving, and that's a good thing.
RA: And people having access.
JA: Absolutely. Access is critically important. I know that we're trying to do whatever we can. I'm in meeting after meeting about improving access. We're always talking about improving access, while at the same time we're talking about hiring new people. But where are you going to get the money to hire the new people unless the membership rates go up? It's a complex situation.
RA: You obviously have a very expansive knowledge base that you're integrating. What wisdom do you hope the clinicians that you're training will take away from it?
JA: That there is this exciting sea change occurring in mental health, if you pay close attention to it and if you read voraciously. Just because you’re out of graduate school, we don’t want you to stop reading. We don’t want you to get rigor mortis. In fact, we want you to now read more than you read before, and go to more workshops in areas that you don’t even have any interest in initially. That’s where you get the best change, really, is if you go, “I have no idea what that person is going to be presenting over there.” Those are the ones you want to go to, rather than, “Yeah, I’m really into that kind of therapy.” How many more times are you going to hear that particular frame with a little bit of a twist to it here and there? In fact, you get more neuroplasticity if you get into an area you have no knowledge about at all. What we want to do for this next generation of therapists is to be integrators and to be active consumers of diverse areas of science.
RA: What are your hopes and concerns about the future?
JA: I'm concerned about the economy affecting mental healthcare and, again, as somebody who in the '70s and '80s was helping people who were chronically mentally ill and homeless, I'm really concerned about mental healthcare for the poor. Here I'm in Kaiser right now, and who are the Kaiser members? Well, they're people with jobs. So I'm really concerned about the disadvantaged groups, and that has a political component, too, because if we go Tea Party zone, you're talking about massive cuts in the safety net, and it's pretty primitive.

Into the more advantaged stratum, I'm concerned that, even though I think there's a sea change going on, it could go the other way—the continued focus on these clubhouses. But I'm heartened that things are going to change eventually. I'm totally convinced that they will, because of these converging fields. When it will happen is another thing. It might be more in your generation and in my son's generation who, like you, is applying for graduate schools right now, than my generation. I think for quite a while, we're still going to have the gurus out there. But hopefully they will be talking in more integrative ways and less about themselves, so to speak.