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.The topics are: Medication, Meditation, Procrastination and Disorganization.
For the purposes of this discussion, when we say “left- brained” and “right-brained,” we are talking about two complementary modes of thinking that are at first primarily located as electrical activity in their respective hemispheres. They do not always stay so tightly localized. In people who develop in a healthy manner and remain relatively untraumatized, the selves become increasingly complex and increasingly able to hold both thinking styles in mind at once.
Context is everything. Under the proper circumstances, attention in children and adults with ADD can be more than adequate. In fact, overfocus can be as much of a problem for people with ADD as underfocus. Attention Regulation Disorder or Attention Modulation Disorder might be a more accurate name. It’s not just paying attention that is the issue, it’s facility in the shifting of attention: paying attention to the right thing at the right time.
Complicated individuals need to be addressed with appreciation of neurophysiological differences (ADD, Asperger’s, LD), inherited depressions (bipolar and serotonin), acquired depressions (arousal and motivations), and interpersonal and occupational adjustment. Then the treatment needs to be bolstered and continued by a judicious application of mindfulness and other esoteric practices.
Remember please, above all, that over and over and over it has been shown that even small amounts of psychiatric care applied consistently over time routinely pays for itself, many times over, in decreased general health care costs. If we can recognize how cost-effective enlightened mental health care can be then to me it stands to reason we should invest in creating the most skilled broadly trained cadre of mental health prescriber-therapists we can. This is of course the hardest of hard sells, a pipe dream from The Attention Doctor.
When I ask them to allow me to teach them personalized mental exercises, and when I ask them to perform these exercises in a disciplined manner when they are not with me, I want them to understand why I am doing what I am doing. I want them to begin to learn about their brains, as I have spent my entire life learning about mine: by reading. […] There are 18 titles here, books that reflect my need to instruct myself beyond what was available to me as a psychiatric resident 30 odd years ago, books that inform and supplement any work that one might do to develop one’s brain. I’ve divided these books as I group them in my mind. If you’ve read more than a even just a few of them, you’ll know a lot of what I know, and therapy with me (or anyone else) will be far easier and more productive than you can imagine.
Surge in psychotic gun violence in America is the unintended consequence of the relatively recent financially-motivated Balkanization of mental health care. […] Therapists come in many varieties — very few have insight into how ongoing medication treatment should influence therapy when the patient has underlying Asperger’s or ADHD as well as several different types of affective disorders. Insight-oriented exploratory therapy without accurate diagnoses, accurate medication and adequate psycho-education is generally useless for such complicated patients. Therapy needs to be directive, pragmatic, problem-solving and integrated with varying symptom patterns. Only prescriber-therapists can do that, but we’re a dying breed.
The mind remodels the brain ceaselessly, and one way to think about this is to see the mind as a canvas upon which we continually paint our understandings and ideas. When I want to explain medication, mediation and hypnosis, I often say that medication is like the frame upon which we stretch the canvas; meditation is the gesso that prepares the canvas to receive the pigments, and hypnosis is the meaningful/beautiful/arresting images we can paint upon that properly stretched and properly prepared canvas.
Despite ever-mounting evidence of the profound and pervasive influence of attentional disorders in a range of public spheres, from depression to substance abuse, from the educational system to the penal system, these conditions remain poorly understood, inaccurately diagnosed, and ineffectively treated. This is due, in large part I believe, to the complicated relationships between ADD and procrastination, dissociation, and trauma.
My quarrel with the fragmented American mental health system is that no one who is capable of diagnosing and prescribing accurately seems to have the time or the inclination to do the explaining, and educating is such a vital part of any successful psychiatric intervention.
In the first few meetings with any patient, I am almost always teaching the same little course I’ve been teaching for years about the four types of depression, two inherited and two acquired, and about their interaction with ADD.
In my view, undiagnosed milder forms of the badly named entity we now call “Attention Deficit Disorder” are at the heart of a truly staggeringly high percentage of anxiety disorders. When the attentional component is not recognized (and believe me folks it almost never is), the medication will be wrong, the therapy won’t ring true, and the treatment will be ineffective.
Bipolar illness is a very common but poorly understood set of conditions, a group of conditions that, like its cousin ADD, is routinely misdiagnosed and mistreated. When people are stuck, when they seem to be mysteriously unable to function at a level commensurate with their intellect, bipolar illness is often the lurking culprit.
I believe there is a thread that runs through these stories; the thread is the ongoing failure of modern American psychiatry to meet the outpatient mental health needs of our population. People who suffer from complex conditions that combine brain biochemistry and neurophysiology with psychology need to be treated by practitioners who are trained in both medication and psychotherapy. Anyone who has a biochemical mental illness also had emotional disturbances about that condition, and they require a practitioner who can teach them about their illness and create a relationship at the same time.
Even the most positive interpretation of antidepressant efficacy studies only claim a 60/40 advantage over placebo […] These studies don’t tell us anything much because they lump depressed patients together into one big basket, and they give everyone the same one or two drugs regardless of their specific symptoms and history. The problem here is that there are at least four different types of depressions, based on neurotransmitter type, and that these types can overlap, co-exist and come and go over time. No one drug addresses them all, and all types must be addressed in any affected individual if they are to feel “well.”
A study has been conducted at the UCLA department of psychiatry testing the proposition that training in mindfulness meditation in a group setting can have a positive effects on the symptoms of adult ADD. Results were highly promising and suggest that there is a role for structured mental exercise of various sorts in the treatment of both the underlying neurophysiology of ADD as well as in addressing the accumulated secondary complications in mood and executive functioning.
This is a simply wonderful book by seventh degree black belt and zen priest Jeff Brooks. Jeff runs a dojo (a karate studio) and a zendo (a school for Buddhist study and practice) in Northampton, Massachusetts, and I found his book so inspiring that I began recommending it to my patients the very next day. The book describes his journey as a martial artist and as a Buddhist meditator, and talks about the relation between the two, which he views as inextricably bound.