Over the years since the publication of “Getting Unstuck” I have been refining and solidifying my approach to the treatment of adults with ADD, with or without depression. I have arrived at a four-pronged approach: four key topics that are addressed with both information and experience.This material is designed to be presented both in a one-to-one setting over 3-5 psychotherapy visits, and in day-long or weekend seminars as well. My intention here is to give some idea of what patients should expect to hear and experience when they consult me about attention and depression.The topics are:
Topic One: Medication
The purpose of this visit for patients, or section in my seminar is to:
- familiarize the patient with several ways of looking at attentional challenges
- normalize those challenges and to place them in context
- define and describe the four kinds of depression
- understand the interaction between attention and depression
- understand how medication can be applied to address these interlocking issues.
I have labored elsewhere to define ADD, and in fact, right now, as we post this article, we will be also making Chapter Three of “Getting Unstuck,” which discusses these ideas in detail, available for free download to anyone who subscribes to my newsletter. (If you’re already subscribed and would like the chapter, please just reply to one of the newsletters you’ve received.)
To be telegraphically brief:
- ADD is not an illness; it’s one end of a spectrum of normal, a mismatch between some of us and the rest of us
- ADD is poorly named; there is no deficit, the problem is the modulation of attention, not the absence of it OR the quality of it once it is applied
- ADD can be seen as a need for a higher level of stimulation, and as a difference in the relationship between motivation and attention
- Impulsivity and distractibility naturally improve through young adulthood; the need for high levels of stimulation not so much
- Procrastination and disorganization, thought of as problems with executive functioning, are not a primary or necessary part of ADD, they are secondary complications
- ADD is often complicated by depression, and this depression interferes with the very natural process of compensating for attentional issues through determination, maturity and experience
- ADD has a multitude of “looks”: social or withdrawn, unrestrained or inhibited, workaholic or slacker, rigid or chaotic. Once we have talked about various pictures and presentations, and matched them with the patients main complaints, we discuss affective disorders
There are four types of depression. Two are acquired; stress norepinephrine depressions and dopamine pleasure depression. Both of these are rather straightforward and simple in type, and are both selected for by ADD and the efforts to compensate for it.
- Stress depressions occur in ADDers because they over-use fear and adrenaline, our natural stimulant, to boost attention. This creates middle insomnia and hyper-arousal in general
- Dopamine pleasure depressions occur when we overuse will power and determination, and we lose interest, pleasure, energy and motivation
- There are two inherited depressions: serotonin/seasonal/obsessive and bipolar depressions, perhaps better thought of as multi-polar. These two are not selected for by ADD, but can certainly coexist
- If a bipolar illness is present it must be identified because medicines for ADD or depression can stimulate a range of dormant bipolar symptoms
- Both of the inherited types are quite complex and variable with many subtypes each which are primarily unified by the medications that they respond to. If ADD and depression are both present there are preferred ways to sequence the addition of antidepressants and stimulants.
- I like to describe depression and attention as a car with four tires (depression) and a drive shaft (ADD). Medicines can be used to fill all the tires that are flat and then to re-connect the drive shaft once the tires are inflated.
By the end of the first visit patients will be able to identify which of the four depressions are present, to separate out attentional symptoms from mood symptoms, and have a medication plan to address these issues.
Topic Two: Meditation
The purpose of this visit/section is to:
- introduce the idea of neuro-plasticity: how attention can be used to craft and shape your brain
- talk about the history and the spread of “esoteric practices” (meditation, hypnosis, guided visualizations and the like)
- see these practices as neuro-plasticity tools and understand how they might influence aspects of attentional function
- have some initial trance/meditative experiences
- and then personalize these into a take home exercise.
There is a relatively lengthy article about hypnosis and meditation elsewhere on the site, and I won’t repeat that material here.
This visit is strongly bolstered by the reading list (bibliotherapy) that we posted here last month. There exists a truly magnificent body of work created over the last few decades that seeks to integrate these ideas and practices with modern medical treatment, and to make this material accessible to the reasonably educated consumer who is willing to read. Top of the list for now remains “The Mindfulness Prescription for Adult ADD” by my colleague Lidia Zylowska, which is a fine work that adapts Jonathan Kabat-Zinn’s Mindfulness Based Stress Reduction program to better suit adults with ADD.
Topic Three: Procrastination
The purpose of this visit/section is to:
- address procrastination
- understand that procrastination is defined in terms of conflicts between “parts” of the self; some parts “left-brained” some parts “right-brained” (not strictly anatomic at all really, just a metaphoric shorthand for our two much discussed contrapuntal information processing styles; again see Bibliotherapy)
- explain how these “parts” of the self normally develop and integrate
- understand how trauma can interfere with the natural process of integrating the disparate “parts” of the self into a well functioning whole
- explain and demonstrate “ego state therapy,” a “neo-Ericksonian guided visualization family therapy for the self,” as a tool for reintegrating parts that are locked due to avoidance.
These techniques can be amazingly powerful, but they are not a panacea. The underlying idea of these techniques is strongly present in our culture as “inner child” work; personalized anti-procrastination work using these techniques can involve working with “inner,” “right-brained,” “experiential” selves of several ages and affects, such as sad frightened latency age children, angry defiant adolescents and defeated resigned adults.
The way in which the parts of the self integrate or don’t is really another aspect of understanding the neuro-plastic process of the brain creating itself. When we ask the outer left brain self who wants to do what he needs to talk with the inner right brained self who isn’t doing it, when we make them meet regularly, we are laying down pathways, creating connections, literally thickening nerves such that, henceforth, when one of the selves is present … the other one will be present as well.
The exercises in this section occur in the context of the deep relaxation meditation exercises that were taught previously. Specifically the initial exercise includes creating a safe space at the bottom of some stairs, creating a “cavern of yourself”. Now we use that cavern as a place to anchor our connection with the inner self; meeting with the inner self, and on ongoing repair of the traumatized relationship between the selves, becomes part of the personalized daily practice.
Topic Four: Disorganization/Time and Task Management
The purpose of the visit/section is to:
- introduce 3 tools for engaging our spatial intelligence in planning and accomplishing the tasks assigned by the self and by others:
- the request handling algorithm
- time maps
- pessimistically planned transitions
- observe current patterns of activity and transition
- propose realistic alterations that reflect optimal priorities
- commit to temporal/activity changes by consulting with inner self(ves),
- integrate temporal intentionality with a daily, personalized meditation-relation integration exercise.
The tools I mention are described in detail in chapter eight of “Getting Unstuck”. Not really available anywhere else quite yet, but one never knows.
These four topics can rather easily be presented in 2-3 hours. Many of our patients are already familiar with some of this material; people with any sort of previous trance experience such as musicians, artists, athletes and writers all seem to get a great deal out of this material very quickly. We have found that viewing adults with ADD though the lens of these four interventions addresses the overwhelming majority of present concerns in an effective, efficient and comprehensive manner.
If our approach appeals to you please get in touch, but also please be patient. As we have begun to post new written work on the Web, the demand for our services becomes overwhelming at times, especially as the new insurance reforms bring more and more young adults to the managed care panels with which we participate.
We are working towards presenting this material in a day-long seminar format, probably in-mid spring 2015. If you would be interested please sign up to our mailing list, and please spread this article to others who might be interested as well.