Learning to live with ADHD - where does psychotherapy fit in?

In recent years, the number of people approaching psychotherapists for assistance around ADHD has increased: ADHD is currently the third most popular search term on Counselling Directory, after anxiety and depression.

People present because they have had a diagnosis and want to think about what it means or perhaps because they haven’t been assessed yet but feel they may have ADHD. Some people present with an unrelated issue but mention during assessment that they might have ADHD. This reflects a growing awareness in society of ADHD and neurodivergence in general, but what is ADHD and could psychotherapy be helpful to someone living with it?

What is ADHD?

The DSM-5 (Diagnostic & Statistical Manual, 5th Edition) of the American Psychiatric Association (APA), notes that “People with ADHD show a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development.” For an adult to be diagnosed with the condition, they must have (on the attention deficit side), five or more of the following symptoms, present for more than six months.

Often:

• fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities
• has trouble holding attention on tasks or play activities
• does not seem to listen when spoken to directly
• does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g. loses focus, side-tracked)
• has trouble organising tasks and activities
• avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework)
• loses things necessary for tasks and activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones)
• is easily distracted
• is forgetful in daily activities

If combined with symptoms such as being restless, fidgety, and impulsive, unable to sit still for very long, this can lead to a diagnosis of Attention Deficit Hyperactivity Disorder, ADHD. A diagnosis of attention deficit disorder (ADD) is sometimes given if there is no hyperactivity.

The condition is caused by several factors, including genetic traits, being born prematurely or underweight, or living with epilepsy. Environmental factors (growing up in a chaotic, disorganised house, or in circumstances of abuse) can increase the risk, though the precise way this happens is not yet clear. Ratey and Hagerman, in their book, Spark! explain how the brain’s attention system works closely with the reward system, which relies upon the neurotransmitter, dopamine, to work properly. People living with ADHD often have a lack of dopamine, which makes it harder to focus.

Whatever the cause, ADHD/ADD, especially if undiagnosed, can cause major difficulties in education, employment, relationships, and other areas of life. People whose ADHD was missed as children often describe difficult experiences at school, where their struggles with attention were regarded by teachers as laziness or bad behaviour, leading to low self-esteem and a pervading feeling of being a failure or of not quite achieving their potential. Issues with organisation and punctuality can impact life at work.

Friends and partners can gain an impression of you as “unreliable”, forgetful, or disinterested (it can be unnerving if your partner appears to “drift off” in the middle of a conversation). The lack of dopamine can lead you to seek it in ever more extreme, risk-taking behaviour, including substance abuse. It can be difficult to focus during sex.

What interventions can help?

John Ratey and Edward Hallowell, in their book Driven to Distraction: Recognising and Coping with Attention Deficit Disorder,  recommend psychotherapy as part of a range of interventions including medication, exercise, and coaching.

Medication

If you have a formal diagnosis, you may be prescribed medication designed to stimulate the production of dopamine. Not everyone benefits but many people find this really helps them focus.

Coaching

Working with a coach can help you develop strategies to help you focus and organise your day to reduce the impact of distraction. To-do lists, the reminder function on your phone, and finding a study buddy if you’re a student. All these ideas and more can make a big, practical difference.

Exercise

Cardio (jogging, running, cycling, dancing, HIIT….) boosts dopamine production naturally and the best time to work out is in the morning, setting you up for a productive, focused day. Ratey, in his book Spark! explains how combining cardio with complex movement patterns stimulates the cerebellum area of the brain, promoting the flow of information around the brain and further boosting the attention system (dancing or boxing are good examples of this.)

How can therapy help those with ADHD?

A therapist can help you explore what it means to have an assessment and receive a diagnosis of ADHD and work through any traumas linked to the condition, still affecting you from your childhood: To live with undiagnosed ADHD can mean living with a nagging feeling of not quite fitting in and being constantly labelled at school as “lazy”, “difficult” “stupid”, words that leave an impact and affect self-image and mental wellbeing in later life.

Using an understanding of ADHD to revisit experiences at school and at home of being blamed and labelled but not understood, learning to look at yourself differently, can have a transformative impact on your self-esteem and self-image.

ADHD can impact negatively on sex and relationships. People with ADHD sometimes report issues with focus during sex, leading to what may be risky behaviours, to feel connected. Issues with distraction can come across as a lack of commitment in a relationship, leading to relationship breakdown and loneliness.

The difficulties ADHD can cause someone in their life are real and do need to be thought about but it’s also vital we don’t just focus on the negative, treating the condition as a pathology. To have ADHD is to be neurodivergent: not less than others, just taking a path through life, looking at life in ways alternative to those some other people might expect.

ADHD can have advantages and almost be a superpower. To live with ADHD is to be extremely creative, to see patterns, shapes, and possibilities in the world which others might miss. When you are interested in something, ADHD unexpectedly allows you to hyperfocus (the ability to lose yourself for hours in an idea, activity, book, film, or music).

Therapy isn’t about curing ADHD. Even if that were possible (which, as far as I am aware, it isn’t), it would be unethical as it would mean fundamentally changing who someone is, and their very nature. What therapy can do though, is help someone understand themselves better, how the condition impacts on them and the people around them, and where they might need to adjust (perhaps through medication, coaching or exercise), to get the most out of life.

It can help you understand how you are in relationships and how to thrive and feel safe, including how to talk with partners about what it means to live with ADHD. The awkward, difficult, embarrassing conversations that a relationship sometimes needs, about intimacy, sex, what works and what doesn’t, can be made easier if rehearsed and thought about in therapy first. But therapy should also be a space to understand and celebrate who you truly are.