Adult ADHD-Focused Couple Therapy

Clinical Interventions

Gina Pera, Arthur L. Robin, Gina Pera, Arthur L. Robin

• Publisher: Routledge
• Year: 2016
• ISBN:
  9781135087869
• Edition: 1
• Topic: Psicología
• Subtopic: Asesoramiento psicoterapéutico

Since ADHD became a well-known condition, decades ago, much of the research and clinical discourse has focused on youth. In recent years, attention has expanded to the realm of adult ADHD and the havoc it can wreak on many aspects of adult life, including driving safety, financial management, education and employment, and interpersonal difficulties. Adult ADHD-Focused Couple Therapy breaks new ground in explaining and suggesting approaches for treating the range of challenges that ADHD can create within a most important and delicate relationship: the intimate couple.With the help of contributors who are experts in their specialties, Pera and Robin provide the clinician with a step-by-step, nuts-and-bolts approach to help couples enhance their relationship and improve domestic cooperation. This comprehensive guide includes psychoeducation, medication guidelines, cognitive interventions, co-parenting techniques, habit change and communication strategies, and ADHD-specific clinical suggestions around sexuality, money, and cyber-addictions. More than twenty detailed case studies provide real-life examples of ways to implement the interventions.

Part I
Adult ADHD and Relationships

1
Meet the Couples and their Common Challenges

Gina Pera

The term ADHD looms over society as a confusing misnomer, a relic established decades before modern brain-imaging techniques allowed scientists to plumb the condition’s true and deeply complex nature. Yesteryear’s experts, by focusing primarily on the most obvious outer sign of physical hyperactivity, concluded that children with ADHD “outgrew” the condition, because hyperactivity usually lessened as the children matured. “Hyperkinetic reaction of childhood” first appeared in the Diagnostic and Statistical Manual (DSM) in 1968, but it represented only a narrow definition of what the 1994 DSM-IV-TR would recognize as a much more complex condition.

Today, we know that most adults who have ADHD manifest no physical hyperactivity, that even many children who have ADHD are not physically hyperactive, and that ADHD persists well into adulthood at a rate of at least 65–70 percent (Barkley, Murphy, & Fischer, 2008; Weiss & Hechtman, 1993). (Note: The term ADHD currently represents all presentations, including Inattentive, as explained later in this chapter.) Today, we also know that ADHD symptoms can wield even more debilitating effects in adulthood than in childhood: After all, adult life requires a great deal more self-management—including earning income, managing finances and households, parenting, driving, maintaining relationships, and taking care of one’s physical health (Barkley et al., 2008).

This chapter highlights the ADHD traits and behavioral patterns that commonly challenge couples and couple therapists, especially when ADHD has long gone unaddressed. This information lays the foundation for understanding the six couples, later in the chapter, whose stories illustrate familiar clinical scenarios.

The Evidence for ADHD

Researchers say ADHD has likely been with us throughout human history, with references to its familiar manifestations in the medical literature as far back as 1748 (Barkley & Peters, 2012). Today, we understand that ADHD carries a strong genetic component, generally about 76 percent (Faraone et al., 2005). That is, if one identical twin has ADHD, the chance of the co-twin having ADHD is 70–80 percent. With fraternal twins, the rate is half that because they share far less genetic material. With regular siblings, the rate is even lower, though still higher than in the general population. No genes have been discovered, however, that are unique to people with ADHD; rather, it is the combination of various genes that seems to result in this syndrome (Neale et al., 2010).

Since the 1990s, the so-called “Decade of the Brain,” revolutionary brain-imaging methods have exponentially increased our understanding of this most complex human organ and, thus, of conditions such as ADHD. In 1994, Adult ADHD was declared a legitimate diagnosis. And in 1998, the American Medical Association’s Council on Scientific Affairs called ADHD “one of the best-researched disorders in medicine, and the overall data on its validity are far more compelling than for most mental disorders and even for many medical conditions” (Goldman, Genel, Bezman, & Slanetz, 1998). To date, more than 15,000 papers with ADHD or ADD (the older term) as a major focus have been published since 1970, according to PubMed. The literature is clear: ADHD is real, it is more common than most people realize, and its treatments can be highly effective. Equally well documented: ADHD neurobehaviors, when left unaddressed, can limit the options, the self-fulfillment, and even the physical health of the people who have it, and adversely affect everyone in their spheres of influence.

Currently, the prevalence of Adult ADHD is thought to be 4.4 percent (Kessler et al., 2006), a figure largely viewed as extremely conservative, based on problematic diagnostic criteria, and likely to omit millions of people who suffer impairing symptoms. Even if it is a low estimate, 4.4 percent still amounts to more than 10.3 million adults ages 18 and older in the United States alone, according to the 2010 U.S. Census. Given that ADHD can be a highly impairing condition, even the conservative 4.4 percent prevalence rate poses a major public-health concern (Asherson et al., 2012; Hinshaw & Scheffler, 2014). Moreover, only a fraction of that 4.4 percent are diagnosed, perhaps one in ten, with even fewer in treatment, according to Kessler.

The implications of ADHD under-diagnosis loom even larger when we take into account a prevalence rate that some experts consider more realistic: An estimated 16.4 percent—not just 4.4 percent—of U.S. adults suffer sub-threshold impairment from ADHD (Faraone & Biederman, 2005). That translates to about 23–35 million people, not counting their partners and others affected by their difficulties, including siblings, parents, grandparents, friends, children, and co-workers.

By comparison, 150 million Americans wear some type of corrective eyewear to compensate for vision impairments (“Vision Problems in the U.S.”, 2008). In centuries past, as with ADHD today, the concept of vision correction (necessitated primarily by the invention of the printing press and the spread of literacy) was mired in stigma until it finally became commonly accepted.

The steady increase in ADHD diagnoses may be more than an artifact of increased awareness of it. Modern life increasingly threatens to over-burden everyone’s “cognitive capacity.” The world of today places outsized demands on our ability to manage responses to a mind-boggling array of details, temptations, distractions, and electronic stimuli that are tailor-made for hijacking the human attentional system and keeping it in its thrall. Simultaneously, the modern workplace demands a great deal more self-organization than it did in, say, the mid-20th century. For example, the days of secretaries handling paperwork, scheduling, and reminding are mostly long gone. So, too, are structured nine-to-five jobs where duties are clear and straightforward, and work is left at the office. Noisy “open offices” drive most of us (with or without ADHD) to distraction. And no-smoking regulations have eliminated one source of “self-medication” that previous generations accessed freely: nicotine, with its stimulating effect on the brain. Today’s employees are normally expected to manage their own schedules, projects, paperwork, and rapidly shifting priorities, with electronic communications keeping many virtually “at work” nearly 24/7. Two-income couples who have children must also juggle commutes, daycare, and the plethora of after-school activities as well as increased demands around schoolwork.

“We all have ADHD,” or “We live in an ADHD world.” So go the common refrains. Yet, as much as people who do not have ADHD feel the pinch of modern pressures, people who do have ADHD are an order of magnitude more vulnerable. Consider them the veritable “canaries in the coal mine” of our speeded-up, plugged-in milieu, at once less able to resist distractions and most likely to need the kind of daily structure and environmental supports grown scarce in the 21st century. The temptation is to lament bygone “simpler” times while glossing over the dark side, including the risks clearly evident through past centuries for people with ADHD in terms of educational and vocational under-achievement, substance abuse, parenting difficulties, financial mismanagement, relationship conflict, and even incarceration, to name a few deleterious effects. Even today, these same risks ensnare too many people with ADHD. Viewed more positively, modern knowledge offers an opportunity—unparalleled throughout human history—for millions of people worldwide to truly understand their “brain wiring” and take steps to elevate their lives.

The Primary Brain-Based Challenge: Self-Regulation

“You can pay attention when you want to.” That phrase painfully reverberates throughout the life trajectory of people with ADHD. In part, this accusation stems from the misnomer Attention-Deficit Hyperactivity Disorder. In fact, ADHD is not a disorder of attention so much as a disorder of self-regulation, according to psychologist Russell Barkley, who first detailed his theory in ADHD and the Nature of Self-Control (1997). For more than 30 years, researchers studying ADHD have identified brain deficits in areas such as inhibition, managing attention, and self-awareness—overall, the mental abilities that we humans use to regulate our own behavior. In fact, some experts consider the challenges around self-regulation, or self-control, so central to ADHD that the condition might be more accurately named Self-Regulation Deficit Disorder. As highlighted throughout this guide, ADHD particularly challenges self-regulation of attention, motivation, and emotion.

Neuroimaging research indicates that in people with ADHD, specific brain areas show less reactivity to stimulation than in people without ADHD; these areas include the frontal lobe, the basal ganglia, and the cerebellum (Swanson et al., 2007). To grasp this concept in layperson’s terms, we must first understand that the human brain is primed for stimulation. It is through stimulation that we engage in life. Our mere interest in something—an attractive person, a fun event, a new thought, and even potential danger or risk—triggers the release of neurotransmitters that arouse and maintain attention until the goal is met: We engage the person, make plans to attend the event, entertain the thought, or react to the danger and risk.

Simply put, people with ADHD find themselves closer-than-average to one end of the human spectrum: the end requiring greater stimulation in order to trigger interest and release those chemicals. These neurochemicals include but are not limited to the neurotransmitter most commonly associated with ADHD: dopamine, the so-called “pleasure” or “reward” molecule. That is why some experts quip that ADHD might best be called Search for Stimulation Syndrome. Imagine fully intending to quickly check the weather report online and get back to work but instead finding yourself three hours later immersed in fascinating YouTube videos about meteorology—and feeling certain that only 30 minutes has passed. This getting-lost-in-the-stimulation phenomenon can be as frustrating to these adults with ADHD as it is to their partners, leading one to coin this alternative moniker: If It’s Boring, It Ain’t Gonna Happen Unless You Make Me Disorder.

Neither phrase, of course, conveys the complete story of ADHD; each describes only one aspect of this highly variable and complex condition. For example, another key component of ADHD is a vulnerability to distractions; this vulnerability can intensify when the person faces performing tasks that feel overwhelming in size or scope. Nonetheless, phrases such as Stimulation Chasing Syndrome, simplistic as they are, still help to convey to the neophyte a very important concept: ADHD puts individuals at greater risk of getting distracted from what they should be doing at any given time—working, sleeping, housekeeping, grocery-shopping, bill-paying, and child-tending, and in general acting in alignment with long-term goals—and into activities that are more immediately stimulating, rewarding, or gratifying. Or simply any activity that requires less mental effort. Even people without ADHD might well recognize this phenomenon in their own lives, albeit on a smaller scale: When faced with a complex or tedious task, such as filing income taxes, it is tempting to give in to the suddenly compelling need to re-organize the spice rack, a much simpler task.

In a sense, then, there is a kernel of truth to the perception that ADHD adults can do something when they want to do it. As one middle-aged man with late-diagnosis ADHD put it: “I over-do what I want to do and under-do what I need to do.” But a kernel is not the whole truth. Many of these adults also want happier relationships, but they often can’t follow through on the myriad details required to make that happen. If “trying harder” were a solution, most of these adults would have surmounted their hurdles years ago. On an intellectual level, they typically understand that “more mature” behavior is required, that even the most rewarding things in life—fulfilling work, satisfying relationships, or good health—involve some tedium and delayed gratification. But on a neurological level, the perceived payoff of performing “boring” tasks is neither sufficiently immediate nor rewarding enough to kick the brain into gear. Moreover, what might feel simply boring or tedious to the person who does not have ADHD can feel downright unnerving and undo-able to the person who does—almost like subjecting oneself to physical and mental “static,” or even pain.

This stimulation-chasing characteristic explains a narrow but key aspect of ADHD. It also drops one important clue as to why stimulant medications are largely considered the first-line medication treatment for ADHD (Chapter 5). First, among the public, there is a widespread misconception that stimulants have a “paradoxical” effect. That is, it seems counter-intuitive that a stimulant could help people who are already mentally or physically restless. In reality, there is no paradox. Stimulants mitigate ADHD symptoms by increasing the availability of certain brain chemicals, such as dopamine and norepinephrine, which help to transmit signals along neural pathways. As a result, the individual can better inhibit the urge to act without thinking, letting thought rather than impulse guide actions. In a sense, therefore, taking a stimulant medication helps to regulate the “roller coaster” of erratically lurching from one over-the-top stimulation source to the next, from over-stimulation to under-stimulation and back again.

Medication is not for everyone, however, and it is only one part of the recommended multi-modal treatment for ADHD. As emphasized throughout this book, the strategies deemed most helpful for these individuals—and therefore helpful for the couple—include making the “daily tasks of living” and being in a relationship easier to perform and the perceived rewards for doing so more clear and immediate. These challenges, and their solutions, are explored further in Chapter 2, through the paradigm of Executive Functioning.

The Common Couple Issues: An Overview

Glib generalizations about Adult ADHD or its effect on relationships are, at best, unhelpful. This syndrome’s manifestations are wide-ranging. The individuals affected by it are complex in the ways that all humans are complex. Having ADHD, or being in a relationship with someone who has it, is only one aspect of a person’s complexity.

We can, however, confidently categorize the issues that bring these couples to counseling, because single adults with ADHD face precisely the same issues, including problems with employment, finances, education, driving, sexuality, emotional regulation, communication, health habits, ...