I think that people, parents and teachers need to know what happens and what to expect when a psychotherapist is involved with them or their children and families. When you enquire about therapy, a therapist might tell you on the phone, well come over and let’s see if we can work together.
My contribution here is to shed some light on the therapeutic process in my own way as an integrative psychotherapist particularly vis a vis the ADHD process. We are talking about adults and children who may be competent in many ways but when something doesn’t interest them enough and they have to do it anyway, or when there are not enough immediate consequences, they find it very hard to do the task at hand and often don’t make the effort.
We all try in various ways to organise our lives in terms of our needs and goals, around getting a sense of : Who am I in this life? How do I get what I need to live a good life, whatever that may mean to me? Can I get what I need within the various contexts of my life without compromising others in some way?
What happens in the case of people with ADHD?
These people are known as finding it hard to organize behaviour over time, to get their needs met in acceptable ways and meet the requirements of the various situations they are in. With disturbances in attention, poor impulse control and poor management of activity level related to the situations they are in and the goals they want to achieve, this is quite a struggle for 5% of children and 2.5 % of adults among us. (DSM5).
Something happens in the normal flow from first awareness of a need to the satisfaction of that need which ends up in messy behaviour and messy situations for the person who ends up feeling he or she just cannot get it right….something happens that shows the person up as incompetent in social situations and leaves him or her wishing things were different. Why did I say that? Seriously did I have to do that right then?? Couldn’t I wait a bit and see? For most of us this happens occasionally and hopefully we forgive ourselves, pick ourselves up and carry on. For some of us it happens too often and we feel broken and discouraged.
In psychotherapeutic terms we would say that what we see is:
“ a breakdown in field organization and the capacity to sustain an energized figure or goal of interest that the person identifies with in a sustained way, over time and across situational change”
A breakdown in the ability to be able to say: this is me, this is what I want, I know how to do it, I will myself to achieve my goal and …I will succeed…all this leading to satisfaction and the enhanced sense of self-worth a person may take with him towards another task or goal…
this cycle of success breaks down.
We all would like to experience a sense of ‘flow’ in our movement in life bur for people with ADHD the movement is more ‘staccato’ and fraught with setbacks, creating the need to repair situations and relationships that may have become damaged along the way.
In the safe space of the therapeutic relationship there are several opportunities for the person to take the time, at his own pace, to look at what’s happening in her life and in a friendly way, learn to guide herself towards easier ways of moving in her life…
….usually it means learning to slow down a bit.
This cycle of contact between the person and the environment in each and every contact-moment is in fact the focal feature addressed in phomenologically oriented psychotherapy and that’s what we shall be talking about here.
We say that a person with ADHD is so moment-bound that he or she
“doesn’t seem to know that they want beyond the present moment” and doesn’t stick to an idea or task, doesn’t develop an idea or carry a task through to fulfilment.
In cognitive/behavioural language, we could say there is an interruption of response modulation that disrupts the executive functions mediating the space between the environmental stimulus and the person’s response. Something happens in our brain that interrupts our ability to respond appropriately to the environment – usually this means disruptions in relationships with other people we’re with.
What we notice and turn our attention to in our daily lives depends on these complex executive functions working well for us and also on emotional and interactive factors such as subjectively felt experiences of hope, confidence, anger and fear.
Just to get an idea of how complex this process is I will give some examples. We need adequate mental energy control to fuel our alertness, mental activation to turn on other structures that help us interpret in coming information, focal maintenance to maintain concentration and satisfaction control to determine whether the current information is satisfying our needs. Other attentional controls are broader in implication: previewing enables us to foresee possibilities and assess potential outcomes. Once an outcome is assessed we need actions that support our direction of choice at the same time inhibiting other actions that are not needed at the time. Facilitation and inhibition help us to stay on task. Tempo control allows us to regulate the rate, pacing, and synchrony with the environment, while self-monitoring and reinforcement have to do with evaluating ourselves as we go along, estimating how effective our efforts are and learning in an ongoing way from feedback and experience.
So as we can see, between an impulse and satisfying contact so many mental processes have to work well for us…it’s not surprising if we don’t always get it right…..
In psychotherapy we look beyond the internal inborn deficit explanations to the wider considerations of personal, subjective field organization of and by the child or the adult. The personal experience and world view of the child or adult is primary in our thinking. What does the person think of and how does he feel in certain situations? At school? At home? At work? How does the person make use of past learning to organize his or her experience now?
This whole-field approach leads us explore his/her story, and ways of constructing reality, interpreting cues, ways of making sense of things.
What figures of interest are likely to be realizable and achievable in that particular child’s or adult’s environment?
What environmental conditions support or inhibit the realization of those goals and interests?
What skills and experiences does the child or adult have for knowing and identifying with his or her own feelings, wants and needs?
And very importantly,
What does his relational history show about how he or she has been received as a person throughout his development?
What kinds of stories come up during the sessions about him and his parents, siblings, teachers, peers, work colleagues.
Which recurrent themes stand out most in these relationships?
How does he see himself with these people?
Is mummy always right and he is always wrong? Is teacher always angry? Is it always his sister who takes his toys for no reason? Are the other workers always lazy or better on the job than he is or luckier than he is? Are other people always the cause of his/her problems?
Is it always his or her fault when things go wrong?
All these aspects impinge on his present process and are expressed in various ways, sometimes not appropriately… it is important to discover together what he allows into awareness, his intentions, wants, needs, desires and goals.
So we assess his personal level of self-support and the level of support in the situations he lives in.
I can give an example from my work in Education that stands out for me. I was working with an 8 year old boy who was very distressed and behaving very disruptively with temper tantrums several times a week.
When we considered as many factors as possible and the best interests of the child, only one option remained open to us…a change of school and also college.
Relationships where so ruptured within the school he grew up in, his self-image was so negative in this school where he was perceived negatively by most teachers that building his self-support was judged to be insufficient in that unfriendly situation. The result was a good one..thankfully for the therapist who put her reputation at risk for this young lad. He settled in the new school.. with effort on his side and the school’s…
He got a second chance.
What I’m saying is that if there is too little self-support and too little environmental support, success in contact is not possible.
A therapist intervenes in all levels of the contact experiences of the child or adult. In the case of children, working with teachers and learning support assistants in a friendly, one-to-one way, school management teams, addressing teachers on continuing professional development days and consulting with other professionals in college teams so we all have a clear idea of what needs to happen if this child is to make it in a particular classroom context.
I have found it especially helpful to meet teachers and particular students together. Teachers often don’t have the time to appreciate the person of the child and their interests and children may see teachers as the adversary or someone out to catch me getting it wrong. Taking the time to validate the feelings of both teacher and child often has led to the child’s growing sense that teacher is on my side after all…and relationship ruptures are healed. Only a few times in long years in the education sector have I found the teacher to be so rigid in her thinking that there was no amelioration in the relationship between teacher and student with good effects in child’s behaviour and emotional wellbeing. That’s sad of course.
Also I’ve been happy to present children’s relational needs to teachers as a group and the interest was remarkable. The markers for teachers to keep in mind in contact with children regarding children’s relational needs were used well.
Children need mirroring, re-phrasing what the child said and accurate feedback,
they need to feel connected to teacher and peers,
they need someone to hold their feelings and behaviour and also to confront them appropriately.
Working with adults with the ADHD structure of experience it has also been very fruitful to have couple sessions, family sessions and also involve grandparents with the person who came for therapy remaining the primary client. A change in perspective often preceeds our change in behaviour. Taking time to appreciate the struggles of a mother with her child, the efforts she was making in the face of real constraints both her own internally and her son’s difficult behaviours lead to the end of blaming and shaming and the beginning of understanding and encouraging feedback as well as offers of respite from grandparents…so crucial for survival of the couple’s relationship. Other forms of relief for parents have been a home tutor who took over the struggles over home work or making use of after school home work classes.
Besides, How many parents of children with ADHD do you know who could well have carried the title themselves during their development? How many struggle with attention, moodiness, choosing goals wisely, maintaining interest in goals and achieving goals as well as relationship problems due to saying something better left unsaid, or not so roughly, forgetting what they promised, shopping impulsively etc. not just occasionally but repeatedly.
What new patterns need to be put in place to substitute old ineffectual ones?
What happens in therapy to address the interruptions to contact that block a person?
Firstly the therapist shows a relaxed interested disposition to help client feel comfortable to even think of making contact. Clients may talk a lot and about non-linked issues, look around, ask questions, withdraw and go silent, stop themselves from expressing themselves emotionally or have intense emotional outbursts.
Talking a lot or in a loud voice, withdrawing, regulating the silence in the room helps us feel in control. Children often take over control by making a lot of noise for example, or constant interrupting while adults are trying to have a conversation. It is not surprising a person might need to feel in control of a strange situation such as a first session with a therapist as many questions are probably brewing. I can only cite my own experience in therapy training as a client when so much was going on in my mind: What is she thinking about me? How do I look to her? Does she think I’m ok or crazy or something like that? I must sound so stupid to this “wise” professional…..etc
Gradually clients feel more comfortable and the flow of contact and withdrawal is established. Contact making is difficult for clients with ADHD. There are so many competing figures of interest vying for attention and expression that it is easy to become confused.
Healthy contact-making depends on three components:
sensory contact-making, bodily contact-making and strengthening the self.
Within the three components the therapist needs to facilitate the identification and clearing of blocking factors. Children and adults who experience trauma, even the trauma of chronic trying to get it right and receiving repeated negative feedback, may tend to desensitize themselves sensorily in order to protect themselves.
A therapist may suggest activities focused on the senses, namely vision, hearing, taste, smell and touch both for children and for adults. With children, in play therapy, drawing, painting, clay work, sand-tray work are helpful. Listening to songs, using musical instruments to create different sounds and simple exercises like closing the eyes and listening to different sounds, saying how they feel during different sounds are useful too. I enjoy writing the words to songs with children and making up a tune sometimes using my guitar to make up the music along the way. Children’s hearing their own voice, owning their own voice and song helps them open up their hearing, appreciate this as safe to hear especially if they’ve been told to be quiet so many times. Creating your own song, drawing, painting, creating scenes with figures in the sand tray give a sense of mastery that we all need, especially children who have so little power in this world.
Even a simple affirmation of what was said and asking them to elaborate on the story is useful. For Example: a little girl is speaking about her school day and I say: “so you’re telling me what happened at school and you look excited, you know your face is bright right now as you said that……you said you took your dog to school on pet’s day..tell me more about this..would you like to draw what happened at school today? What did you see? What did you hear? A simple drawing can liven up the memory for the child or the adult prepared to put pen to paper and make the experience deeper, helping to increase focus, helping the person know themselves in a new way perhaps. I might use a mirror and invite the person to see themselves after having finished the activity…they might own a new perspective on themselves…enhancing the satisfaction part of the contact episode.
Making collages, choosing pictures of interest and making charts, taking photos with mobile in therapeutic playroom and talking about what they see sharpens the visual modality and keeps interest in seeing as a safe thing to do..compensating for some things that may have been difficult for the child or adult to see in the past. We need to make use of sight to investigate aspects of the world and sight has a direct impact on how we make contact with the environment and also with each other. An adolescent with ADHD may show little interest in many things but the therapist may become aware of what they like to do or talk about and focus on those interests in joining with him or her.
A dad and son came for a session recently, dad was wearing a motorbike jacket and the son was slouched in the chair looking down, withdrawn – not at all inclined to make any kind of contact with me at all until I asked the dad: “So what motorbike do you ride?” “ Eh you saw the jacket” he said. The son’s attention was drawn, his eyes brightened, he sat up and told me all about dad’s bike…. and the one he wanted. Needless to say we had lots to talk about next session with pictures of bikes and what he wants to ride later on and how come he can’t do it now etc…all this contributed to helping him maintain and develop a figure of interest, bikes, and to build rapport with me so that he felt safe to broach other subjects later on in therapy. What happened is that my observational process encouraged the boy’s own process in seeing, speaking, thinking and figuring out what to do in the mean time until he can get his licence. His self-support and expression was enhanced.
Therapy involves the phenomenological experience of both therapist and client creating something new..perhaps a new way of being with me, a new learning that he could take into his relationships with other adults.
In therapy various exercises are used to enhance sensory awareness, sight, hearing, taste touch and also exercises to enhance body awareness such as walking in different ways, using the hands to create shapes, or represent different things such as cutting, sawing, eating. Even doing different movements to show different emotions. Move like you’re happy, angry sad. Which animal do you walk like at school? At home? At football? At work? In this case I join in the movement and he can see a mirror of what he’s doing after which we talk about the different experiences and he is more aware of himself—he has a broader choice of how he wants to be in different situations.
Virginia Oaklander, well known in psychotherapeutic circles speaks about bodily contact making and says that children who are troubled tend to restrict their bodies and become disconnected from them. I’ve often seen this in children with ADHD. It seems like their bodies do things without their consent. I remember asking a boy who repeatedly disrupted the class with continual tapping, moving and getting out of his place what was getting him into trouble. “Boq I don’t know we can’t even move in class” he said.
Me: “And I’m not sure what the tapping was for” ?
Boy: “what? I wasn’t tapping you know miss”.
I had been in class and had seen him myself and heard the tapping so I was in a good position to say:: “like yesterday when I was in class there was that tapping sound often on your desk” to which he replied “eh that..that’s nothing miss…it’s the biro when I’m writing”. So I started tapping with my biro while he was talking as we continued the conversation. We said nothing about the tapping. I was told there was no more biro-tapping in class after that. Non-verbal communication is very powerful we should not underestimate it. I spoke to the teacher who gave him more responsibilities in class and offered him a system where he can use three cards during the day to spend some time out of class. This could only be put in place since he had an lse shared in the same class to accompany him. Often it cannot be done as children cannot be out of class on their own. Another thing I did was hold a session with him and his teacher so he could see her as a person and she could understand how it felt to be bored and unmotivated by some of the class tasks. So some adaptations were made for him in his learning environment, therapy sessions were held to strengthen his self-support and cope with boredom and restlessness and the relationship with the teacher was also enhanced.
At home the mother rewarded him for news of positive behaviour from the lse every day as noted in the communication note book. These factors helped the youngster inhibit his responses to disrupt in class and encouraged him to maintain positive behaviour. His ability to choose among competing impulses, inhibit behaviour, self-monitor and self-evaluate may be compromised but this was supplemented within the environment and in time he may be able to internalize this external support and do it for himself.
I’ve said something about sensory contact-making and bodily contact making. One way of connecting with our bodies is through our breathing. Children and adults who are anxious and fearful often restrict contact with themselves by restricting their breathing. Noticing breathing and actively suggesting breathing exercises and physical exercises during play therapy helps young children. Adolescents may pooh pooh this exercise but may welcome a casual “ Ok so now I know I need to take a deep breath , How about you?” or
“Can we take a moment and just breathe and just see what that’s like”?
People can learn how they use their bodies and posture and breathing to make and break contact. A youngster slinks down in his chair and I say:
“Oh so that’s how you do it”?
Boy: “What miss”?
Me: “You move away from me”.
He smiles, sits up, takes a breath (cause when we’re slouched we can’t breathe well) and says “cause miss, when you mention my mother I get tired… she’s always on my case….etc and the contact is re-established. He is with me again…and hopefully he has got some awareness of his contact-making and breaking and thus strengthened his sense of himself and his power. I also have useful information to use in parental guidance with parents – an important part of work with children.
Talking about bodily-contact, children and adults need to learn how to relax, as tension often contributes to psychosomatic symptoms like headaches, stomach aches, chest pain, sleep problems, among others. It can also affect posture such as walking with rounded shoulders, head down almost as if they want to shrink themselves so they’re not seen. Holding on to tension is often the way people protect themselves from physical or mental attacks or suppress themselves lest they get into trouble. They find it hard to express themselves appropriately, but in the safety of the therapy room, they can contact and express all emotions -even the ugly ones -because they sense that I can hold all these. I am not deterred or ruffled and I do not judge them.
A young boy was once referred for his very ugly drawings of people being hurt and blood featured repeatedly in his drawing. He came several times and drew such drawings. He spoke about them and seemed to get some satisfaction from this activity. I made few comments and no judgements…just saying back to him what he told me. He’d say something like “this man is dying” and I’d say: “ok so he’s dying what’s the other one doing”?
Boy: “he’s killing him”.
Me: “ok what happened then”?
Boy: “Heqq they’re both dead”
Me: “and then”?
He says: “that’s all….my mum doesn’t like these drawings”.
Me: “and you what do you think”?
Boy: laughs…
Me: “ok so mummy doesn’t like them and you continue to draw them…you know you can draw what you like here”
Boy: “yes I like that”.
The drawings continued until he had had enough of them, it seems, and he began to draw other things…all in his own time. He had quite a lot of anger for his mum and needed to find an outlet. He also exercised some power during the sessions which compensated for his powerlessness to control the situation at home – marital discord with quite a lot of shouting and expressed emotion…so his response was quite creative really…in the context.
To get back to tension and the need to relax, often a therapeutic intervention would be some training in relaxation skills people can use in difficult situations.
Physical exercises, bending and stretching and making sounds (when possible).
Talking about exercises, I’m reminded of a little boy who learned, once he watched me to his amusement,…to jump up and down in the corner every time he went down the snake in a game of snakes and ladders. Previously he had got so frustrated he would throw the board off the table…then it became a new game for us..down the ladder, up we got to jump up and own in the corner of the room shouting “oh no, oh no, down I go again”……this changed eventually to being able to stay at the table and chant:
“sometimes we win, sometimes we lose and its ok”…a new theme song. After much drilling, he learned how to manage himself during failure and this strengthened his sense of himself…He could say within himself: I can fail and pick myself up again and move on.
Now the mum was playing with us during the session and when she saw this transformation she was really happy to see her son having fun, learning to play co-operatively and even said later on that they continued to use this system at home. This type of filial therapy often helps repair relationships between kids and parents and parents see their kids with kinder eyes.
Getting back to relaxation suggestions after the little caveat around exercise and jumping up and down, other strategies are:
Teaching people to relax their muscles progressively from their toes to their ears and breathing deeply perhaps to relaxing music,
Singing your favourite song or hearing it on the mobile.
Using metaphor and fantasy : such as imagining you are a snowman and the sun is warm and you’re slowly beginning to melt, until you’re are a pool of cool water, you can dramatize this using your body,
Using guided imagery: we all like a good fantasy and can imagine a beautiful peaceful place in our minds and go there when we’re stressed…may be hard to believe when we are really stressed but it is true that with practice it works.
The third aspect of contact-making I will talk about is strengthening the self.
Without knowing and liking ourselves we cannot contact other people or tasks in a positive way. Babies are not born with bad feelings about themselves. How a child feels about himself depends to a great extent on early messages he gets about himself from family and others. In the end though it is the child who interprets these messages to himself. Even when parents are well-meaning they may give negative messages to children mostly without words. Looks, gestures as well as critical comments are introjected by the child. When I meet parents for the first time I make it clear that if we’re to work together for the improvement of child’s behaviour, hitting, shaming, put-downs need to stop…they do not build… and building the child’s sense of himself is what we’re after. So he can feel better and be better. It’s the same rule for adults in couple work.
Psychotherapists consider that acceptance of the shadow self is important on the journey to strengthening the real self. Children and adults must be helped to see and accept that sometimes they do not like themselves that they need to look at their beliefs that they are bad or not good enough or cannot do anything right. It’s a disservice to offer placations and reassuring remarks to a child who knows he has done something wrong. That’s why therapy takes time, it’s not just a few sessions to open things up and all will be ok. We need to understand that children and adults need a fair amount of time for expressing various parts of themselves, taking in the monitoring and feedback from the therapist until they internalize the monitoring and give themselves accurate feedback on their own actions and clear instructions for future behaviour.
Eventually people feel stronger in two major aspects of the self:
The sense that we are lovable and the sense that we are capable.
In the therapeutic situation a child or adult has the space to discover and explore different senses of themselves: the physical sense, the emotional sense, the intellectual sense, the behavioural sense, the social sense, the spiritual and the creative sense of self. They eventually come to define themselves, make choices, experience mastery and control, and own their own projections on others.
They learn about boundaries and limitations – what is acceptable to me in this situation, what are the rules here, what I can and cannot do in the therapeutic situation… I can take this learning with me to other situations in my life. In a holding atmosphere of acceptance, care and affirmation sometimes also playfulness, fantasy humour and confrontation I can show myself and see both my not so nice side and also encourage myself in recognition of all that’s good in me. I feel stronger in myself and more in tune with others.
I don’t need to dance only to the beat of my own drum, I can dance in time with others and enjoy them and they can enjoy me too.
