Driven to Distraction (Revised) Page 5

  Case 3: Maria

  Maria Berlin came to me for a consultation after reading a piece in the newspaper about ADD in adults. “I didn’t know there was such a thing,” she said, crossing her legs at the calf as she settled back into my overstuffed office couch. “My husband showed me this article in the paper, and I started to wonder.”

  “Tell me a little about yourself,” I said. It is always hard to know where to jump in when I meet a patient for the first time. There is a standard way of taking a history—name, address, presenting problem, and so forth—but that can be overly structured and not give the person the chance to say what they really want to say. So I usually start with something that invites the person to say whatever he or she thinks matters. Of course, this can be misleading as well, because the inevitable jitters associated with the first appointment can lead one far astray.

  Maria, however, got right into things. “I don’t know what is wrong with me—maybe there’s nothing. Whatever it is, I’ve been like this for a long time. As long as I can remember. Since I’m now forty-one, that’s a long time. My main problem is that I don’t get around to doing the things I want to do. Maybe that’s just the pace of my life. I’m married and I have two children, eleven and eight, and they take up a lot of my time. But I have been working on my Ph.D. for years, and the dissertation keeps sitting there, half-done, winking at me like a sleeping turtle. Sometimes I wish it would walk away and leave me alone.”

  “Do you have a regular job as well?” I asked.

  “Yes. Well, when I want to, that is. I work at the library in town, and they’re very flexible about when I come and go. What I’ve really been trying to do, aside from finishing my dissertation, is start an exercise clinic for women over forty at our local health club. I have a brochure I’ve been wanting to write for what seems like forever. The management of the place has been very receptive. If I ever get to it, they’ll let me run it as my own business if I pay them a small rent. They think it would be good publicity for the club.”

  “Your Ph.D. is in—”

  “Totally unrelated. English literature. Don’t ask me what the connection between that and exercise is. I’m sure there is one somewhere, but I don’t know where. My dissertation is supposed to be on Eugene O’Neill. I fell in love with O’Neill when I read A Long Day’s Journey into Night when I was in high school, and that love continued through graduate school. But in case anyone hasn’t told you, the best way to fall out of love with something is to write a Ph.D. thesis about it. I’m so tired of O’Neill I could spit. Isn’t that sad? I thought at one time I had something original to say about him, but now I couldn’t care less.”

  “Do you remember what you had set out to say?” I asked.

  “Oh, please,” she said, “don’t make me dredge that up. It had to do with the autobiographical impulse and transforming that into art. Sounds pretty unoriginal, huh. But I had a new twist on it, or at least I thought I did. Maybe it was all just a daydream.”

  “You got sidetracked?”

  “Sidetracked?” she said with a big smile. “My whole life is one long sidetrack. I was supposed to marry Arthur, but instead I met Jim, and now we’ve been married for sixteen years.”

  “You haven’t been sidetracked from him?”

  “No, I haven’t. He’s my anchor. I don’t know why he hasn’t been sidetracked from me, but I don’t think he has. ‘Anchor’ is the wrong word, actually. It makes it sound like he’s holding me back. What he does is stabilize me. I don’t know where I’d be without him.”

  Maria’s energy and openness and her story so far were all typical of ADD, as was her tendency to get sidetracked, both in her life and in her conversation with me. “Tell me more.”

  “About what? I’m not trying to be a wiseguy, but what do you need to know?”

  “Well, tell me something about your childhood. In particular, what was school like for you?”

  “School was a real mixed bag. I loved to read from day one, but I was a very slow reader. The public school where I grew up was OK, but not very challenging. I got fair grades. They always said I could do better, but I was more interested in looking out the window or at some other kid. The classroom material was just very dull. It wasn’t where the action was, as far as I was concerned.”

  “You graduated from high school?”

  “Barely, but I did. Then in college I did really well. Can you imagine that? Which is why I went to graduate school. But that was probably a big mistake. I should have quit while I was ahead. You see, my problem is I don’t know whether I’m smart or if I’m stupid. I’ve done well, and I’ve done poorly, and I’ve been told that I’m gifted and I’ve been told that I’m slow. I don’t know what I am.”

  “It is not unusual for people with ADD to have erratic, inconsistent educational histories like yours,” I said. “Were you hyperactive as a child?” I asked. “Or any kind of discipline problem?”

  “Oh, no,” Maria said. “I was a good little girl. I wanted to please, whenever I could. I didn’t want to please so much that I paid attention in class—my father used to say, ‘If you really want to make your dad happy you’ll pay attention in class’—but I never disobeyed or acted up or anything like that. I just always had a fantasy world I could go off into.”

  “You got bored easily?”

  “I’ll say,” Maria answered. “But then, maybe I had dull teachers. I wasn’t bored in college.”

  “What’s in your way now?” I asked.

  “The same thing that’s always been. My erratic nature. One minute I’m there and then the next I’m not. I don’t finish things. I get started, and then I drift off to something else, and then I’ve forgotten about what I had started on in the first place.”

  “How did you get into exercise?” I asked. Maria was obviously quite fit. She didn’t look forty-one—maybe ten years younger. Dark hair, red lipstick, bright cheeks—she looked like she could have played a part onstage. I wasn’t surprised that she had taken up exercise. Aside from being one of our culture’s preoccupations, it is remarkably good therapy for ADD, both focusing and relaxing the mind.

  “Like everything else, it just happened. I had a friend who wanted me to take an aerobics class with her, and I said that sounded like death, but she persuaded me to do it. To my complete amazement I loved it. I’m not a fitness freak; I just loved how the aerobics made me feel. And I liked the social aspects of it. So I began to hang around the club, took extra classes, qualified as an instructor, and came up with this ‘over-forty’ idea, which I still think is a great idea but one I’ll probably never get to.”

  “How have you dealt with yourself so far?” I asked, thinking as soon as I asked it that it was a dumb question. But Maria seemed to understand what I meant.

  “Just by winging it. I thought I had a screw loose somewhere. I went to a shrink once. It was when I was still very invested in trying to get my dissertation done and I thought maybe I had some kind of block he could cure me of. But we really didn’t get anywhere, so I stopped going. Now you.”

  “Yes, now me,” I said. “At your husband’s urging?”

  “No, this was my idea. He just showed me the article. What do you think? Is there any hope for me?” she asked with mock melodrama.

  “You’re joking,” I said, “but I have a hunch this has been more painful for you than you let on.”

  “Yes, yes it has,” Maria said, looking past me out the window. “It’s such an insidious thing. I’ve always known there was something wrong, but I thought it was dyed into me, if you know what I mean. But with two kids, a husband, and a world to keep up with, I don’t let myself dwell on it too much. It sure would be nice, though, to begin to finish things at least.”

  “Yes,” I said. “It’s been very frustrating for you. How about reading? Can you read OK?” I asked.

  “If by OK you mean ‘Do the words get in?’ then yes. But I’m a very slow reader. Always have been. Plus I get distracted in the middle of a page and
there’s no telling when I’ll come back.”

  “Maria,” I said, “I think you might have ADD. We’ll want to do some tests and talk some more about your history, but everything you’ve said so far makes me think you’ve had ADD ever since you were a child. The daydreaming, the way you read, the getting sidetracked, your erratic nature, as you call it, your inconsistency, and your general sense of not knowing for sure how bright you are, all these things may be manifestations of ADD. You’ve compensated well, which is to say you’ve found ways of getting along, but you haven’t done the things you’ve wanted to do.”

  “What does that mean? Can my life be different?”

  “It is always difficult to answer that question in advance,” I said. “You just don’t know how the treatment for ADD will work before you try it. But, yes, things can be different if the treatment works.”

  It turned out that Maria did not respond to medication. While about 85 percent of adults will benefit from one of the several medications that are used for ADD, about 15 percent do not, for one reason or another. Some people have side effects to the medication they cannot tolerate. Some people simply find they do not like the way it makes them feel. Some people do not want to try medication at all. And for some people, like Maria, the medication just does not do anything.

  However, as we have mentioned, there is more to the treatment for ADD than just medication. Education, behavioral modification, and psychotherapy all can help. Maria derived benefit from all of these.

  In the first phase of her treatment we focused on developing an understanding of ADD. As Maria learned about the syndrome, she was able to rethink many of her long-held views about herself: that she had “a screw loose,” that she was not competent, that she was defective.

  As she began to see how many of her problems related to her being unusually distractible, we began to set up ways of restructuring her time to help her focus. She began to employ traits she knew about herself but had not used to best advantage: that she worked best in short spurts; that exercise helped her focus; that she benefited from lists, reminders, schedules, and rituals; that large, seemingly overwhelming tasks could actually get done if she broke them down into a series of small, manageable tasks; that she needed frequent feedback and encouragement; that it helped her to have someone, in this instance me, act as a kind of coach, keeping her on track.

  This was not traditional psychotherapy, but a variant of therapy that I call “coaching” to stress the active, encouraging role played by the therapist or “coach.” I would not tell Maria what to do, but rather I would ask her what she wanted to do; then I would remind her of what she had told me, regularly and repeatedly. One might say that at the beginning of her treatment we agreed upon a “game plan,” and that my role as coach was to remind her of her goals and objectives in an encouraging way, always with an eye toward keeping her on track. People with ADD can get off course so easily, they can so frequently get “sidetracked,” to use Maria’s term, that it can be very helpful to have an outside person keep them engaged.

  Done this way, the therapy can act as a structuring force in the person’s life, bringing her back, time and again, to where she wants to be but has trouble staying on her own. This is not psychoanalytically oriented psychotherapy, in that it does not depend upon the development and interpretation of transference, but the therapist does stand ready to receive and discuss the individual’s hopes, fears, fantasies, and dreams. And such coaching therapy does encourage the development of insight. Indeed, insight is one of the most powerfully transforming factors in working with people with ADD.

  We should add that both authors of this book respect the value of psychoanalysis, both in treating patients and in researching and understanding human nature. Psychoanalysis remains the definitive and most thorough treatment available for what is commonly called neurotic conflict or pain. We do not recommend it as a specific therapy for ADD—indeed, psychoanalyzing someone with undiagnosed ADD can be frustratingly ineffective—but once the ADD has been diagnosed and treated, the psychoanalysis can proceed apace. Certainly, the kinds of neurotic conflicts for which psychoanalysis is the definitive treatment can occur in people who have ADD, and the treatment for ADD will not resolve those conflicts. Such people can benefit greatly from psychoanalysis as long as their ADD is understood as well.

  Maria rearranged her view of herself and her way of running her life. In our work together the combination of education, encouragement, “coaching,” and insight led Maria to a new place. She completed her brochure for the health club and opened her business. It did very well. She decided she did not want to write her dissertation, that, really, she had never wanted to. She had been keeping it alive, as many people with ADD do, as an organizing principle in her life, something that although it regularly and predictably emanated pain and anxiety, still provided an axis around which she could organize. She replaced her daily mantra of “I haven’t done my thesis, I must do my thesis” with more useful self-directions. As she began to achieve success at something she really wanted to do, that activity became her new, and far more healthy, organizing principle. Most of all, she developed an awareness of how to work within herself, making the most of her abilities, while learning how to work around her limitations.

  Case 4: Penny

  Penny McBride’s parents came to see me after Penny’s fifth-grade teacher suggested she get a psychiatric evaluation. “I don’t know what to think,” her mother said at our first appointment. Her hands were interlocked at the tips of her fingers and she was looking down at them as she spoke. “I hate to think that we’ve done anything wrong.”

  “Coming to see me doesn’t mean that you’ve done something wrong,” I said, noting to myself that it is still the case, although much less so than it was twenty or thirty years ago, that consulting a psychiatrist about your child carries a stigma in many people’s minds. “What is going on with Penny?”

  “She’s falling behind,” her father said. “That’s all. She’s a good girl. Never any trouble.”

  “She just daydreams all the time,” her mother picked up. “Ever since I can remember, she’s been my little dreamer, my faraway child—”

  “Tell him about the stories,” the father interrupted.

  “She’s my youngest, my baby,” Mrs. McBride continued, holding one finger up to her husband as if to say, Just one minute. “We had four children two years apart and then six years later Penny appeared. I had more time for her than I did for the others. She was easier because she was quieter, more like me, I guess, than the four boys. I loved the boys.” She paused and looked out my third-floor window at the trees beyond, seeming for a moment to be lost in remembrance of her sons. Then she clicked back into the room. “But Penny and I were more tuned in to each other from the start, I think. When you’ve had four boys and never had a girl, well, you forget what being a girl is all about almost, and when Penny arrived, nothing against you, Joe, or the boys, but it was as if a compatriot had joined my life. I do not mean that we were enmeshed or entangled or whatever the psychological term is for an overinvolved mother, because we were not—believe me, we weren’t. But in a house full of males, it was good to balance things for me a bit. Anyway, the stories Joe was referring to are stories Penny and I made up. We called them the Faraway Stories, about children who lived in Faraway Land. The name came to me when I was telling Penny a story when she was three and the look in her eyes was so faraway. I wanted to come join her wherever she was, so I said let’s go to a faraway land. And that’s where the stories started.”

  “She liked the stories?” I asked.

  “Oh, she loved them. I could calm her down almost anytime with a story. Not that she got upset very often.”

  “Could she add to the stories?” I asked. “Make things up?” A crude assessment of imaginative and linguistic ability is the capacity to add on to a story line.

  “She was better at listening,” her mother said. “I could tell story after story and she would sit
next to me rocking and smiling. If I asked her a question, it would become clear some of the story had passed right by her. Because she was so far away, I’d tell myself. But I didn’t know what I meant by that. It was just a feeling I had.”

  “It sounds like you were well attuned to her,” I said.

  “But now I think she wasn’t getting it at all. She did love to listen, though.” Regret began to fill Mrs. McBride’s voice. “Why didn’t I get some help sooner?”

  Joe McBride, a ruddy-faced man smartly dressed in a business suit and a muted purple and turquoise tie, put his arm around his wife as she started to cry. Sitting together on my office couch, they looked frightened and embarrassed. “What Polly means,” Joe said, “is that we had no idea anything was wrong. Penny was a quiet little girl, that’s all.”

  “I understand,” I said. “Try to go easy on yourselves. You’re obviously concerned parents. It was hard for you to come here at all. Let’s see if I can’t make it worth your while.”

  Wearing a red wool sweater, jeans, and her slightly graying blond hair up in a bandanna, Polly looked like she’d come directly from a hike with her children. She was a casual contrast to her more packaged-for-the-public husband. “It’s a bit of a shock to the system to hear your daughter needs to see a psychiatrist,” she said, wiping her eyes not with the handkerchief her husband offered her but with the first knuckle of each hand.