Keeping ADD from Undermining Therapy
Dealing with the Disruptive
Effects of ADD
On the Therapy of
Adults and Couples
Marc D. Schwartz, MD
Adult ADD Center, New Haven, CT
Common symptoms of adult ADD include disorganization, forgetfulness, tardiness, and lack of focus. These symptoms can seriously undermine therapy, especially if they are not properly recognized as symptoms of ADD but are instead mislabeled as resistance to therapy, lack of motivation, or personality difficulties. When this mislabeling occurs, treatment is much less likely to achieve its goals. Recognizing and understanding how ADD can undermine therapy can help therapists and patients find ways to make treatment more effective.
Why Clinicians Often Don't Recognize and Diagnose ADD
Clinicians make diagnoses of the basis of what they are told and what they observe. Some patients starting therapy tell their clinician that they are "depressed" or "anxious", and their clinicians conclude that their diagnosis is depression or anxiety. But many people with ADD are depressed or anxious about the effects of their ADD on their lives without realizing that they have ADD. They view their interrupting others, forgetfulness, or failure to pay attention as personality patterns or character flaws rather than symptoms that might respond to an appropriate treatment. If the patient does not say "I have problems with attention", it is less likely that the clinician will think of ADD as a diagnosis. Such ADD patients are often treated for depression or anxiety only.
Complicating the diagnostic process is the fact that clinicians often are not able to observe ADD symptoms in people with ADD during the first session or two when patients are generally focused and attentive. Only after patients have become more comfortable in therapy do their disruptive ADD symptoms emerge in treatment. By that time, the clinician may not stop to reconsider the diagnosis he made but may instead attribute the patient's disruptive behavior to poor motivation, irresponsibility, or thoughtlessness.
Strategies for Managing the Treatment of People with ADD More Effectively
The Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association lists a number of identifying symptoms of ADD, noted below. Awareness of these symptoms and how they can disrupt treatment will allow the clinician to recognize them more readily and to develop strategies that allow them to carry out treatment more effectively.
DSM symptom: Individuals with ADD often have difficulty organizing tasks and activities. They often do not follow through.
Treatment disruptive behavior: Most people are able to keep the main idea they are discussing firmly in mind even if they occasionally digress. Many patients with ADD cannot do this, and their narratives during sessions wander farther and father from their original point. Their talk can become filled with irrelevant detail. Sometimes, in a very fluid way, with no apparent boundary between topics, they will meander from one subject to another. One patient compared his verbal style to channel surfing. Perhaps after talking for a while, the patient may return to the point he or she was making, but a great deal of treatment time can be wasted waiting for this to happen.
Patients may not follow up on significant topics addressed in prior sessions and, if they are not prompted, may fail to pursue important treatment issues. They may forget the therapist=s suggestions of new techniques or strategies for dealing with life. Not uncommonly, they forget them even when they have been helped by them.
Strategy: Therapist and patient should strive to keep the sessions organized. If the patient is unable to keep his or her presentation organized, the therapist may find it helpful at the beginning of sessions to solicit a list of topics the patient would like to address then suggest any important items that the patient omitted. It is best to write down the items and defer discussion of them until the list has been completed. Clinicians who are managing the patients' medication should always check while drawing up the agenda whether refills will need to be discussed and written and include time to make the next appointment on the topic list.
The patient and clinician can prioritize and order the topics, scheduling how much time to allocate for each. If there are too many topics for the scheduled time, some topics may need to be taken off the list. The session can then begin. After using this method for a few sessions, many patients get better at keeping the sessions organized and, the structured planning becomes less necessary.
DSM symptom: Individuals with ADD often talk excessively. They often interrupt and may not attend when spoken to directly.
Treatment disruptive behavior: ADD patients in treatment may begin sessions with extended social chitchat. Conversely, when their attention is captured by an idea, they may be unable to move on to another and will elaborate on it long after they have made their point. Not infrequently they ignore questions, comments, and interpretations made by their treating clinician. Or they may say, "Just let me finish what I was telling you before I answer that". After talking a while longer, they may forget that they planned to respond to the therapist's question.
Strategy: Limit Off-Topic Talk When patients with ADD talk excessively or get off the topic, the clinician=s desire to let the patient get to his point at his own speed may result in a great deal of wasted time. In these circumstances it may be more helpful for the therapist to gently shift attention back to the main topic, remind the patient of scheduled agenda, or merely to state the point that the patient was trying to make.
It can be helpful to tactfully let the patient know that talking at length without getting to the point is a common symptom of ADD. If the patient accepts this, he may better understand and cooperate with the clinician=s efforts to get the discussion back on track.
Interrupting and not listening are classical symptoms of ADD, yet they can come as a challenging surprise to the clinician when they are manifested in therapy, where patients are usually politely attentive. Once the clinician recognizes that a patient=s difficulty shifting from talking to listening is a manifestation of ADD and not resistance to therapy or impoliteness, it becomes easier to deal with the behavior calmly and persistently.
Because ADD patients are more likely than others to fail to hear or understand important comments, the clinician should monitor how well their patients understand what he or she said. It may be useful to review, at the end of the session and/or at the beginning of the subsequent session, the topics discussed.
DSM symptom: They often dislike tasks that require sustained mental effort. They are often forgetful.
Treatment disruptive behavior: They may have difficulty maintaining energy, focus, and motivation in treatment. They may forget their treatment goals or change them with little or no discussion with the treating clinician. Fluctuations in their motivation may contribute to their periodically missing appointments, losing interest in therapy, and even forgetting why they entered treatment. This can be particularly troublesome to clinicians who invest a great deal of effort in helping these frequently disorganized patients manage their lives.
Patients with ADD often forget to bring up significant events in their lives, like major disputes with their spouse or significant setbacks at work. Distracted by their own interesting anecdotes, they may even lose track of issues they have discussed in the current session. They may forget to take their medication or neglect to call for a refill until they run out over the weekend. When leaving phone messages for the therapist, they may forget to leave their telephone number. When patients fail to follow through with plans that were carefully worked out with them, the therapist may feel disappointed, even demoralized, and sometimes even resentful.
Strategy: The clinician and patient should take steps to foster continuity. It is sometimes helpful to write down a statement of the patient=s goals and reasons for being in therapy. This statement can later be used to orient the treatment when the patient loses his way. Sometimes, the best one can do is to wait patiently for motivation to return. If the patient and therapist are aware of the fact that this issue is common among patients with comorbid ADD and not a manifestation of resistance or a moral deficiency, it can help get the clinician and patient get through fallow periods to a time when more active treatment of the primary disorder can be resumed.
Other treatment disruptive behaviors:
Time related problems Not infrequently patient with ADD forget appointments or call to cancel shortly before the scheduled visit time, citing an unavoidable conflict or unanticipated event. If a patient being treated for depression or anxiety manifests this behavior more than once or twice in a period of a month of two, it should alert the clinician to the possibility that the patient also has ADD and, in fact, the problems the ADD is causing in the patient's life may be the source of the anxiety and depression.
ADD patients frequently come late for sessions. They may forget or misremember appointment times, may arrive at the wrong hour or even the wrong day. Reflecting their overall difficulty with time, they often don=t Apace@ treatment sessions, so take longer to get started talking about therapy issues. They frequently have little awareness of the passage of time and don=t sense when an office visit is nearing its end. They may not bring up important issues until the clinician states that the session is over. Many, if not interrupted, will talk beyond the scheduled end time, never glancing at their watches or a clock. Even when they are reminded that the time is up, they may continue talking.
They may not pay their bills on time and may not submit their bills for insurance reimbursement until it is too late for them to receive payment.
Strategy To avoid patient=s having to make excuses for lateness and to avoid fruitless discussions about its motivation, it is helpful to identify these behaviors to the patient at the out of treatment as common in ADD.
At the same time, it is important to have a clear policy about ending sessions on time even when the patient has arrived late. If the patient is consistently late, it is sometimes useful to ask him or her to arrive ten minutes early to insure that he gets the benefit of a full session.
To minimize the number of missed appointments, the clinician canY
To allow time within each session for important issues to be dealt with, it is wise to keep to the planned agenda and schedule. Sometimes it is helpful to notify the patient when there are ten minutes left in the session. Unfortunately, this will not stop some patients from continuing to talk until the clinician pleasantly but firmly ends the session.
Educate the Patient about ADD
Once the diagnosis of ADD is made, patients should be informed that they have the disorder and educated about its causes, symptoms, treatment, and course. Patients with ADD often do not fully appreciate the nature of their deficits and are not always able to monitor accurately the dysfunctions caused by them. For this reason, feedback about treatment effects should be obtained not only from the patient but, if possible, from an objective observer chosen by the patient.
When treating individuals with ADD, the clinician should keep in mind that they, like individuals with color blindness or some neurological problem, have a limited ability to overcome the difficulties that contribute to their interrupting, forgetfulness, and lateness even when a structured rehabilitation program is provided. Patience and understanding can often maximize the benefits of treatment.
Consider Using Medication
The use of appropriate medication for ADD should be discussed. For most patients, medication, when effective, is the most rapidly acting and least expensive treatment available for the disorder. A positive response to stimulants can reduce or eliminate many treatment disruptive symptoms. If medication is prescribed, its use and effectiveness should be regularly and carefully monitored.
Conclusion
The symptoms of Attention Deficit Disorder often disrupt the treatment of adults being seen for psychological disorders. If clinicians are familiar with the treatment disruptive symptoms of ADD, they can employ effective strategies to control them. This can be done with patients who are being treated for ADD and for ADD patients who are being treated for other psychological disorders. These strategies require that therapists be more managerial than usual to ensure that patients stay organized, pursue relevant therapy issues, and begin and end sessions when scheduled. Once co‑existing ADD is recognized, other treatments, including specific medication for ADD, can also be considered. Under these circumstances, treatment is more likely to succeed.