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Most psychotherapists will at some point have clients who have ADHD or related forms of neurodivergence but many will be unaware of the nature of these conditions that are part of the neurobiological template.
Although the name directs a focus on a disorder of attention, this is not the main problem. ADHD is condition of deficit in the brain’s regulation of itself resulting in impulsivity, difficulties in affect regulation, outbursts of rage, states of anxiety and panic, and moods of depression. ADHD can be a core condition giving rise to the spectrum that attracts a diagnosis of ‘borderline personality disorder’. There are overlaps and comorbidity with autistic spectrum, addictive personalities, and bipolar. The person with ADHD has an enhanced need for empathic responsiveness from others to assist in regulating their own brain and emotions.
The genetically inherited ADHD characteristics of the person’s developing brain interact with the environment, often in ways that result in profound pain for both families and the individual. If that person subsequently sees a psychotherapist who does not understand the nature of the problem, the feelings of shame and despair are intensified. Any attempt to understand the ADHD characteristics purely in terms of psychodynamics will be futile and misleading. Instead, the focus can more usefully be upon helping the person understand their basic temperament, their sensitivities and needs, and how their personality has been shaped by the interplay of neurobiology and the family, school, and peer environment. Shame is often a key feature of the ADHD experience.
From a Freudian perspective it is a deficit in ego functioning. From a Kohutian self-psychological perspective, it expresses an enhanced need for selfobject responsiveness from others. At a neurobiological level, it is a deficit in the functioning of the frontal lobes. Shame, frustration, and rage at both self and others, are common emotional states.
Children and adults with ADHD commonly feel misunderstood and misperceived by others. The child may be seen as ‘naughty’ and the frustration of repeated experiences of empathic failures by others leads to spiralling rage. The person with ADHD neurobiology will experience life as inherently perplexing, infuriating, and terrifying. Struggling with continual threats of brain chaos, such people can feel on the edge of panic – hence the book title The Disintegrating Self. Low mood and anxiety are regular unwelcome guests in the ADHD mind. Motivation for anything that is not of immediate interest is always a problem. The ADHD brain may observe a task that needs to be done, but the impulse actually to do it, that may follow naturally for others, simply fails to appear. Procrastination and apathy rule. Fights with others are used to create stimulation and ward off boredom.
These include psychoeducation, facilitating insight into the effect of their behaviour on others, addressing trauma and shame, and helping them to think about realistic goals. Providing support in managing the ‘narcissistic economy’ can be important, as moods and self-states swing from grandiose elation to depressive feelings of inferiority. Tact and empathy are required. An intelligent person with ADHD may have a mind that is paradoxically both highly sophisticated and childlike.