Adults seeking treatment for ADD often come because their children have been identified; others come because they were diagnosed, or at least discussed, as ADD while a child. (For my purposes there is no distinction between ADD and ADHD; only a question of whether mental hyperactivity is externally obvious or not).
Stimulant medication is of course the first line of treatment; and it is most often given by a psychiatrist or a general practitioner who has no intention of providing psychotherapy of any sort, let alone psychotherapy that might be specially directed to adult ADDers. For many patients this simple intervention alone, along with some reading perhaps, can improve functioning enormously.
But what if it doesn’t?
What if executive functioning remains faulty and inadequate? What if procrastination and disorganization, poor planning and follow through, unreliability and lack of motivation persist? Then what?
At least as often as I see self-identified Adult ADD’ers, I see patients who have had no idea they have ADD, or at least no idea that ADD (“whatever that is?” they might say) could be having such a profound impact on their Panic Disorder, or their Depression, or their Obsessive-Compulsive Disorder, or their drug problem, or their work problem, or their marital problem.
The Mind as a Canvas
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.
In this two-part article I’m going to try to explain why Mindfulness and Hypnotherapy should be an essential part of the treatment approach to stuck, depressed and attentionally-challenged individuals. Yet if either of these approaches are to work well, even if they are to work at all, the canvas must be stretched; depressions – whether inherited (bipolar and serotonin) or acquired (norepinephrine/stress and dopamine/pleasure), must be identified and treated.
I have written before on the typology of depression, on the powerful role of the bright, ambitious person’s compensation for mild ADD in creating acquired stress and pleasure depressions and on the often missed relationship between ADD and anxiety disorders (please see my website, TheAttentionDoctor.com).
Getting the meds right is essential for any technique that attempts to take advantage of the brain’s natural neuroplasticity to rewire the brain. Bipolar depressions, which are probably electrical in nature, and the three other biochemical depressions must be identified and treated properly if meditation or hypnotherapy are to be effective.
Mindfulness Meditation
- Meditation is about awareness.
- Meditation is about modulating the connection between the left and right brain.
- Meditation is about learning to use more of your brain, more of the time.
- Meditation is about truly attending to oneself.
- Meditation is about observing yourself and your thoughts strongly and consistently enough to allow for a moment’s reflection before action.
- Meditation is about observing yourself and you thoughts lightly enough to fully experience yourself.
- Meditation is about learning to maintain many things in your mind at once, but lightly.
- Meditation improves “presence of mind” i.e. working memory.
- Meditation is an effective primary treatment for the underlying distractibility and impulsivity of ADD.
Let me explain…
Mindfulness, as taught in Jonathan Kabat-Zinn’s seminal MBSR (Mindfulness Based Stress Reduction) seminars, is based largely on simple introductory Buddhist meditative practices. MBSR seminars have been tested repeatedly over 25 years, and for those who complete the training there is no question that hypertension, peptic ulcer disease, back pain, insomnia, anxiety and depression are all ameliorated considerably.
The practice begins with the intention to pay attention to one’s breath, and the instruction to return gently to the breath whenever one notices oneself lost in some other thought.
A wonderful, brief written instruction for this meditative practice can be found at New York Insight Meditation Center’s website . There are literally dozens, if not hundreds of meditative mindful awareness practices which can be added to, mixed in with, and alternated with this basic one. Two very useful books by Charles Tart, “Living the Mindful Life” and “Mind Science: Meditation Training for Practical People” show a somewhat broader spectrum of meditative and awareness practice.
Much of my thinking on these issues has been influenced by Daniel J. Siegel’s landmark book: “The Mindful Brain”, and by my own recent experience running Mindfulness/Hypnotherapy groups over the past six months. Dr. Siegel says that the brains of experienced meditators have a thicker corpus callosum, the cord that connects the left and right cerebral cortex. He says that meditative brains are electro-physiologically more “Flexible, Adaptive, Coherent, Energized and Stable” (FACES).
Dr. Siegel says that meditation seems to turn on a large swath of brain that is devoted to empathically reading the faces and vocal tones of others, regions of the brain that are not usually “online” when we are alone. In essence, we seem to be able to become, electrically at least, more attentive to and more compassionate towards ourselves.
Dr. Siegel also talks about neuroplasticity generally; about the way in which our brains seem to be constantly “laying down track,” to be “remembering” our experiences by reinforcing and strengthening some circuits/pathways and allowing others to languish and decay. Apparently it is “attention” that determines what wiring is laid down, what aspects of out manifold experience of the moment gets recorded and preserved in our ever burgeoning neural architecture.
Meditation techniques of all sorts are apparently cleverly designed methods to channel attention so as to turn on and connect the logical “planning, labeling, naming, judging” Left Brain with the “feeling, seeing, doing, experiencing” Right Brain. The result of these strengthened connections is the ability to “feel” emotionally and experientially, and to “think” logically at the same time.
This matches up perfectly with what I have seen in the meditation groups I have been leading for adults with ADD. After a month or more of meditating, patients routinely report being less overwhelmed, less frazzled by emotions, less easily distracted from their plans, and more centered.
When one first begins to meditate it is challenging to keep one’s mind focused on the breath, and one may find oneself lost in some other mental phenomenon, over and over and over. One must simply, gently return to the breath — usually to the feeling of the belly as it moves with the breath — or the feeling of the air as it whistles across the threshold of the lips or the nostrils. Often the instruction is given “If thoughts come into your mind, just let them float away, like clouds passing before the sun, or raindrops sliding down a windowpane.”
After a time, one finds that one can keep the breath in mind, or various aspects of the breath in mind, and then one begins to “expand” ones awareness; to “play” with the meditative practice by including other aspects of the breath experience, to count it, or to elongate and slow it; to attend to the pause between the breaths, to imagine and feel the movement of the lobes of the lungs out into your chest as you breath and so on and so forth. Kabat-Zinn uses the body scan as a next element in the meditation; the instruction there is to feel your breath and to imagine a beam of light across your toes that gently and slowly rises up your body.
In the groups that I run we use a Gurdjieffian “sensing, looking, listening” exercise (described in Tart’s “Living the Mindful Life”) which involves extended periods of “sensing the hands and feet” with a small portion of the mind — about 15%. Gurdjieff was an Armenian, born in 1880, who traveled extensively in “The East” and who was then the first person to bring back to London a wide range of esoteric, meditative practices divorced, for the first time, from the “religious” traditions which had previously housed them.
Dr. Tart is both a Buddhist and a Gurdjieff scholar. ‘Gurdjieffians’ still exist here and there. (There’s a Gurdjieff community in West Virginia called Claymont — Robert Fripp of King Crimson is perhaps their most famous modern devotee). Students of Gurdjieff are all about the integration of layered aspects of consciousness.
Meditation is not just about focusing on your breath. That’s just the beginning. Meditation is about being able to hold more than one thing in your mind at the same time; being able to expand your awareness until it seems it can hold the whole universe.
And it can.
When my meditation class watches their breath, and moves Qi (chi-energy) back and forth in their hands, and simultaneously look up towards their third eye to watch the ‘movie’ that unfolds there — when they can do that, it doesn’t seem so hard for them to keep in mind not only what they are doing now, but what they intend to do later.
Hypnotherapy
Hypnosis, like meditation, is about awareness; about the modulation and integration of left- and right-brain functioning, and about learning to access and use more of your brain, more of the time.
Hypnosis is the same as meditation in that both are essentially brain wiring and re-wiring techniques. Hypnosis is different than meditation in that it ultimately restricts awareness, rather than expands it.
Hypnosis and Meditation have a widely overlapping tool chest; both using the ‘internal search’ as a cue to altered, more receptive, mental states. Hypnosis is a rapid and useful tool for the remediation of executive functioning deficits.
Let me explain…
Executive functioning deficits, as evidenced by procrastination, disorganization and poor cross-temporal planning, are a variable feature in adult ADD; across and within individuals. I have written elsewhere about how ADD, and other chronic childhood trauma: learning disabilities, divorce, substance-abusing or mentally ill parents, create a post-traumatic dissociative disorder that can interfere with self control, both of emotions and activities.
It turns out that fully healthy adult functioning involves a lifelong process of integrating the primary, experiential seeing-feeling-doing right brain (which is really 5/6th of the brain; the bottom two-thirds plus half of the upper-third) with the smaller (the remaining 1/6th) and younger, naming-judging-planning left brain.
Trauma disrupts this integration process. When children don’t like themselves, when they are subjected to situations that they can neither escape nor process, they build ‘selves’ to hold the trauma. Barriers between ‘selves’ are erected to keep this toxic experiential material from derailing development.
If one thinks of dissociation in electrical terms, of left- and right-brain operating separately or together — and we remember that distractibility in ADD is, in fact, a function of adequately stimulating the prefrontal cortex inhibitory system, we can see that people with ADD need to be integrated, to use both hemispheres simultaneously, to maintain focus.
Hypnotherapy, specifically a type called ego-state or self-relations therapy is a very good tool for integrating conflicting aspects of the self. This is, after all, what procrastination really is: a conflict between the “weaker” outer left-brain parts that “wanna” be responsible, and the inner stronger right-brain parts that “don’t wanna!”
The “don’t wannas” are stronger, and almost always win. But they’re not strong enough to get the “wannas” to give up and go home.
What we do in this sort of therapy is to personify the various aspects of the self, and have a series of meetings — meetings with inner-children, inner-parents, inner-guides. It turns out that when these meetings take place, a rewiring is taking place. Older barriers to co-consciousness are being removed. These inner meetings can be used to both alter wirings/associations, created by unresolved tensions/experiences from the past, and create new patterns and associations that work better.
Procrastination and disorganization are, more than anything, about reflexive, impulsive avoidance that occurs primarily, or substantially, out of awareness; avoidance that quickly takes us to another aspect of ourselves, to another “ego state”. We approach a task, or the planning of a task, and we feel something unpleasant — something we don’t like — and we pull back into another ‘self’ as if retreating from a roaring fire.
When the feelings we are avoiding are things like shame, doubt, fear or sadness, inner-child exercises create connections so that older, more mature parts of the self can soothe the troubled ‘child’. When the feelings that we want to avoid are anger and resentment and oppositionalism, inner-parent exercises can re-sculpt the parent that lives in your head so as to give you what you need and get out of your way. As Erickson said “It’s never to late to have a happy childhood”.
Hypnotherapy has also traditionally been about “utilization”, about using non-verbal representational systems (sound, sight, position), and about decreasing/modulating self-consciousness and vigilance.
There is a vast literature of hypnotic metaphors that can be used to stimulate problem-solving (D Corydon Hammond encyclopedic “Handbook of Hypnotic Suggestions and Metaphors for one) utilizing different aspects of mental functioning. In our Mindfulness-Hypnotherapy groups, we specifically attempt to use ‘spatial mapping’ to organize time and task.
It is certainly not always childhood or adolescent emotion that is being avoided in procrastination and disorganization. Perhaps the largest avoidance is that of planning and organizing in general — for the sense of waste, futility and disgust that accompany a lifetime of relative failures in these spheres. Meeting with the ‘self’, the generic same (or roughly the same) age inner-self, is required to renegotiate the basic agreement between ‘planners’ and ‘doers’. This meeting between inner and outer self is perhaps the deepest crux of the utility of hypnotherapy in the treatment of adult ADD.
Most often these parts of the self are angry, alienated, and are barely able to tolerate one another. The outer-self, who has most likely been judging and berating the inner-self for years, must pursue this meeting in a humble, loving spirit of reconciliation, accepting and valuing the inner-self, its feelings, wishes and abilities, offering a new vision of cooperation and communication.
I see the hypnotherapeutic process in adult ADD as one that builds over four to six sessions. Ultimately, one uses spatial time maps to make plans and state intentions, meeting with a newly befriended inner-self to ratify and operationalize those plans.
The Combination of Hypnotherapy and Meditation in Adult ADD
The idea of applying mindfulness practices to Adult ADD has begun to seep into the therapeutic world. Although hypnotherapy has been widely accepted as a treatment for trauma, to my knowledge there has been very little written specifically about hypnotherapy for ADD adults, let alone about the combination of the two. In my view, and in our growing experience, meditation forms a perfect base of mental practice from which to explore hypnotic approaches to reintegration of the self and for remediation of delayed executive functioning.
There exists in America a large cadre of both trained hypnotherapists and skilled teachers of meditation. I believe that the time is right for these groups to come together with the diagnosticians and prescribers who currently work with ADD adults to formulate simple effective testable therapy techniques for this huge under-served population.