How Therapy Fosters Courage

mountain-climber2

You came to the therapy session. Courage was required. You admitted things were too messy, desperate, painful. A brave step was needed. Despite hesitation you took the road less traveled.

The therapist was not a monster. He invited you into his office. Your courage was reinforced.

Now you find he hears your words, watches without blinking. The attention is encouraging. Few ever took you seriously, showed patience, gave you their time — listened with quiet intensity.

You discover the contact has value — the relationship is worth something. Again, the effort didn’t meet with the disaster you expect as a matter of routine. The reinforcement makes future risks more likely. You begin to wonder if perhaps you previously fulfilled some of your own dire prophecies.

The counselor is reliable. At first you think he is a unique example of dependability in an undependable world. What luck! Later you recognize the truth: others as good, or close to it, might exist if only you raise your eyes to look. An intrepid search begins for those who are also decent and caring.

Issues too deep for words are exposed in session. You surprise yourself with your openness. Your vow never to make yourself vulnerable again is set aside. Courage grows.

Perhaps you begin to recognize grit is not always a matter of physical bravery. Indeed, you identify its presence when you look in the mirror. Especially if you face your short comings in the reflection. Change takes more bravery than what is demonstrated on the football field. Your moral muscle increases in size. Your heart becomes toned. You develop something called “therapeutic integrity:” to stick with treatment despite the punishment it inflicts. Your head is held higher. Avoidance is less often your first choice.

Yes, the rose of life is full of thorns, but the scent and beauty are worth an occasional prick. Your bravery makes this revelation possible. You learn to survive such pricks and avoid them when you can. Especially the human kind.

You voice strong opinions to your counselor and the world does not end. He applauds the growth to which he is witness. You begin to internalize his approval and the strength in you he identifies. More and more you come to lead the process — more evidence of therapeutic integrity.

The things you never thought possible — the behaviors others could enact but you didn’t — are done. You explain this not by some sort of therapeutic magic, but by the virtuous qualities inside you of which you had no awareness.

More chances are taken. You learn to say no, to travel alone, speak your mind, grieve, enjoy a restaurant dinner solo, date again (or perhaps, for the first time), recognize the toxic takers, act in spite of fear, dust yourself off when you’re down and come back for more. Your pulse quickens not with fear, but a lust for life.

Your intrepidity manifests itself in “baby steps” at first. Later they are well-placed strides. Eventually you run with joy, recognizing life is in the running, not always the winning of the race. You have discovered you can “take a licking and keep on ticking.” The scars you were ashamed of become badges of honor. The lines in your face are earned. They enhance your beauty to those who recognize the richness in you, not just your sausage casing.

Lord Byron wrote in Prometheus Unbound:

To suffer woes which Hope thinks infinite;
To forgive wrongs darker than death or night;
To defy Power, which seems omnipotent;
To love, and bear; to hope till Hope creates
From its own wreck the thing it contemplates;
Neither to change nor falter nor repent;
This, like thy glory, Titan, is to be
Good, great and joyous, beautiful and free;
This is alone Life, Joy, Empire and Victory.

“Good, great and joyous, beautiful and free …”

Blame and lament are past. Fear is no longer a constant companion.

You are your own self, the maker of your life in so far as we are ever able. Take up your chisel and approach the marble — create the art that is your life.

You’ve learned the sculptor’s hand is never finished with you; and that fate is but one sculptor.

You are the other.

Courage made it possible.

Too Many Balls in the Air: The Frustrated and Frustrating Life of ADHD

https://i0.wp.com/upload.wikimedia.org/wikipedia/commons/c/c8/Carbon_Cycle-animated_forest.gif

He was dynamic, outgoing, and enormously entertaining.

He was creative, full of ideas, and energetic.

And he was one of the most frustrating people you would ever care to be around.

About whom do I speak? A bright, charming man with Attention Deficit Hyperactivity Disorder.

ADHD is more complicated than you might think. Although there is much written about it, I want to cover a few of the things that can be missed about the condition. But first, let me explain the name and define it.

There are three types of ADHD (Attention Deficit Hyperactivity Disorder):

  • 1. ADHD, Predominantly Inattentive Type. This used to be called ADD, but technically speaking, sufficient inattentiveness is considered a category of ADHD, even though little hyperactivity may be present. These are the folks who seem to be listening, but are lost in space; easily taken away by a tune, a sound, or an idea; the people who miss the details and forget the assignments.
  • 2. ADHD, Predominantly Hyperactive-impulsive Type. This is what most people think of when they hear or read the four letter acronym ADHD. People with this diagnosis are characteristically talkative, active, intrusive; a bundle of unmanaged, impulsive activity.
  • 3. ADHD, Combined Type (meaning it includes the symptoms typical of the first two categories); too many balls in the air, for sure.

What about the man I mentioned at the top; a person who had the “combined type” of ADHD?

He had lots of energy and ideas, so people found him engaging. But it wasn’t a very productive sort of energy. He would begin things, but not complete them. He was disorganized — losing keys and papers, and forgetting appointments. He promised to do things, but couldn’t be relied upon to do them as quickly or as well as expected, if at all.

This man (let’s call him A.T.) went nowhere fast; very fast. A.T. looked liked the “Energizer Bunny,” but mostly traveled in circles.

https://i1.wp.com/upload.wikimedia.org/wikipedia/commons/5/5f/Tux_Linux_crystal_award_nevit.gif

He tended to over commit himself, taking on more tasks than he could handle effectively, chronically underestimating what he could accomplish in the time available. A.T. was routinely late for appointments, and made decisions quickly, without fully considering the longer term consequences of his actions. Bored easily, distracted more easily, and prone to procrastination, he knew that he wasn’t what others hoped for and expected. Although he was full of promise, his reputation was that of someone who was a thoughtless, irresponsible underachiever — an individual who needed minding.

Employers were disappointed, co-workers were frustrated by A.T., and his spouse was driven just a little crazy, feeling that she couldn’t depend on her partner. She’d married someone who was exciting, only to find that the excitement he produced was more of the “Oh, no!” kind that made her sweat when she discovered he was late to pay a bill or pick up the kids. Not surprisingly, she started to see him as just another one of the kids, as their partnership turned into more of a “disapproving mother/resentful child” relationship than either of them wanted.

https://i0.wp.com/upload.wikimedia.org/wikipedia/commons/thumb/9/96/Europa-Park_-_getroffen_4_-_von_Mama_ausgeschimpft.jpg/240px-Europa-Park_-_getroffen_4_-_von_Mama_ausgeschimpft.jpg

Before I tell you about A.T.’s treatment, let me say a few things that might not automatically come to mind about the condition and its consequences:

1. Hyperactive/impulsive ADHD individuals can sometimes look like they are world beaters, but mostly beat themselves; indeed, they are often chronic underachievers. If you are planning on forming a working group or partnership with such a person, don’t be fooled by a positive first impression of excitement and energy. You will almost certainly be disappointed down the road.

2. ADHD, even today, is sometimes not detected in schools. There are several reasons:

  • The inattentive form of this condition may well produce school failure, but not misbehavior. Inattentive children are often quiet and relatively well-behaved, unlike their hyperactive-impulsive counterparts.
  • School personnel may incorrectly attribute ADHD-like behavior to laziness or oppositionality. Moreover, school systems, even when they do formal evaluations, are frequently reluctant to identify problems that require additional resources and personnel, which they are hard-pressed to provide given their limited funds.
  • An ADHD child who is bright can compensate (to some extent) for his attentional problems by relying on his excellent intellectual abilities, at least for a while. Eventually, however, many of these children (as they age and school begins to demand more of them) find out that advanced intelligence is no longer sufficient to permit success.
  • There is no single standard measure that reliably identifies ADHD. Evaluators commonly use some combination of paper and pencil tests, clinical judgment, and attentional measurements. Intelligence (IQ) and neuropsychological tests can easily miss some of the most clinically obvious cases of this condition.

3. The fact that ADHD children are able to become “hyperfocused” on things like computer games or other tasks that they find especially interesting, does not invalidate the diagnosis of ADHD. Indeed, this sort of selective attention is seen fairly often.

Some researchers believe that those games provide rewarding stimulation in the form of frequently changing images, sounds, and challenges; as well as the success of achieving points or increasing levels of success, thus “capturing” the attention and imagination of the ADHD youngster. By comparison, the real world school room seems boring. Recommendation? Limit your child’s screen time, even in front of regular TV shows.

https://i0.wp.com/upload.wikimedia.org/wikipedia/commons/thumb/a/a3/2_men_using_their_computers.jpg/500px-2_men_using_their_computers.jpg

4. Although many people are hesitant to take medication, ADHD is a diagnostic category that is especially responsive to psychotropic medication. Hundreds of studies support the effectiveness of such treatment for about 85% of children with this condition according to Russell Barkley’s authoritative 2006 book Attention-Deficit Hyperactivity Disorder. In a 2007 paper by Elliot and Kelly — “ADHD medications: an overview” published in the journal Attention — the authors state that “No medicine available to psychiatrists produces a more rapid and dramatic effect more safely than the proper dose of a stimulant to a patient with ADHD.”

5. If medication does work, it will likely be needed on a continuing basis, not as a temporary fix. The irony is that stimulant medication, which will cause internal agitation in those who are not suffering from ADHD, actually permits the person with the condition to focus more and become less prone to the hyperactivity/impulsivity that had been a problem.

6. ADHD is correlated with a greater risk of developing a Conduct Disorder, typically characterized by antisocial misbehavior and defiance of authority. Not surprisingly, such individuals often abuse alcohol or drugs (not only as an act of rebellion, but also as a self-medication designed to calm their hyperactive state). Adolescents and adults who have ADHD are thought to make up at least 25% of the population of prisons according to Barkley.

In all these examples, the impulsive, ill-considered behavior that is typical of ADHD takes a fearful toll. Such individuals are easily bored, requiring intense and novel reinforcement (rewards) to motivate them, and are prone to “sensation-seeking” — looking for extreme excitement that their condition seems to make them crave. Indeed, one patient of mine reported driving at speeds approaching 100 MPH on city streets simply for the feeling it produced in him. Nor did he think he was at much risk (or putting others at much risk) in doing so, thus demonstrating the poor judgment characteristic of those with the hyperactive-impulsive form of ADHD, as well as their tendency to disregard rules and authority figures.

7. While many general medical practitioners (GPs) can prescribe medication for ADHD quite well, some are hesitant to do so, sometimes due to lack of training or inexperience with this particular diagnosis. Cautious GPs will prescribe psychotropic medication, but are prone to giving doses that are too small. It is generally best to see a psychiatrist in such cases; that is, someone who specializes in the prescription of medication for psychiatric disorders.

8. The frustration that ADHD produces in school children can make them give up (and eventually drop out), believing that nothing they can do will make any difference in their performance. Some of them will become avoidant of academic or other work tasks because they believe that they will fail, thus producing a self-fulfilling prophecy. Many will get angry at the teachers, bosses, and parents who so often are reminding them of their inadequacies. Thus, ADHD fuels other behaviors that make a good life difficult.

What happened to our friend A.T?

You’d think it was simply a matter of telling him of the benefits of medication, wouldn’t you?

Not so fast.

He was one of those folks who was uncomfortable with the “idea” of having to be reliant on medicine. He told me that he didn’t “believe” in medication, as if it was a matter of religious faith.

A.T. was also quite narcissistic; in denial concerning his own responsibility for the things that went wrong in his life. Similarly, he had no trouble blaming others including bosses and wives. Not to mention that he drank too much and didn’t acknowledge that it was a problem. Indeed, he had only come into treatment at his spouse’s insistence.

One of the challenges of psychotherapy is the fact that few people fit “pure” diagnostic types. Instead, one must be aware of all the complicating factors that can make effective therapy difficult. This man’s narcissism, denial, and alcohol abuse certainly created just such complications.

Had A.T. been more motivated and self-aware, less prone to denying the misery he was creating around him, a cognitive-behavioral (CBT) approach to his ADHD could well have helped, even if he chose not to take medication.

CBT programs include formal guidance in planning and organizational skills, assistance in problem solving and decision-making, help in reducing the number of distractions in the environment, practice in new thinking skills, training in ways to reduce procrastination, and advice to help you cope with failure. Homework is required between sessions.

The program described by Steven Safren and his associates in the work book Mastering Your Adult ADHD, developed by psychologists at Massachusetts General Hospital and Harvard University, was able to produce significant improvement in about 50% of those patients who continued to have clear problems even after being treated with medication.

So, if you have ADHD, medication and CBT provide reasons for optimism that things can get better.

Just don’t drop the ball!

Thumbnail for version as of 15:40, 14 September 2005

The top image is the Carbon Cycle created by the U.S. Government Department of the Interior. The one that follows is the Tux Crystal Linus Award by Nevit Dilmen. The next photo was created by Thomas Pusch and is called Scolded By Mama. The fourth picture is of Two Men Playing a Computer Game by Love Krittaya. Finally, a picture of a Geode  by Whitsoft Development. All are sourced from Wikimedia Commons.

The Stories That We Tell Ourselves

https://i1.wp.com/upload.wikimedia.org/wikipedia/commons/thumb/4/49/Don_Juan_and_the_statue_of_the_Commander_mg_0119.jpg/500px-Don_Juan_and_the_statue_of_the_Commander_mg_0119.jpg

Therapists hear stories. Tons of them.

Everyone has one.

But the stories that are most important are those that represent the essential narrative of a person’s life. You might have just one such story, one that tells you how you see yourself and your journey through life.

It may not even take the form of a specific tale or recollection, instead describing a view of how your life has progressed.

Perhaps you think you are lucky or, alternatively, unlucky. Maybe you see yourself as a “mover and a shaker.”  Do you imagine a handsome and suave (or beautiful and charming) persona as you look in the mirror? Or someone who is lazy or hardworking or resilient or weak?

But even if there is no story attached to the qualities that you ascribe to yourself or to your life path, the character traits you claim still are central to how you see of yourself, something you refer back to repeatedly.

Nor does the story or characteristic even have to be true. It just has to be something that you believe is true.

An example. An old acquaintance thought of himself as a “lady’s man,” making such politically incorrect comments as this simile: “A woman is like a taxi cab — if you miss this one, there will be another one along in 10 minutes.” He was clever, energetic, interesting, and outgoing, but unremarkable in his level of success and appearance — not particularly tactful either. When a woman rejected him, he was usually undaunted.

This gentleman even had a theme-song, of sorts. It was the soaring horn call from the Richard Strauss orchestral tone poem “Don Juan,” representing the bold, dashing title character he believed himself to be. And so, ever on the look-out for attractive women, he did, in fact, have numerous love affairs. Many ended badly, and he was as often rejected as he was the person who terminated the relationship.

Another person, no less likeable or successful with the opposite sex, might have seen the identical romantic life as a disappointment. But, our “Don Juan” never showed regret, rarely was chagrined for long, and continued to pursue women with the vigor he had always demonstrated.

Well, you might say that our hero had little self-awareness and you might be right. But, the case can be made that he was more satisfied in living-out his romantic life through his chosen vision of himself — through the story he was telling himself about himself — than if he had defined his role in the story differently, or come up with an alternate narrative altogether, especially if it was that of the jilted, luckless lover.

Now, I am not recommending either this man’s approach to women or his less-than-fully realistic view of himself. Nor would I have been pleased if one of my daughters found someone like him appealing. But his view did enable him to have much romance and fun in his life. In other words, he would have told you that it worked for him.

Unlike our friend, I have seen people change their stories over a life-time. For example, from feeling unlucky to feeling lucky, or from being timid and unsure to becoming more bold, assertive, and capable.

It is worth asking ourselves what stories we tell ourselves about ourselves. Again, they might not stand up to external scrutiny, but they don’t necessarily have to in order to be useful. We frequently create self-fulfilling prophecies for ourselves, succeeding or failing because of what we believe will happen or who we believe we are. In large part the man in question had much romance because he believed in his “Don Juan” myth. Had he seen himself as an undiplomatic opportunist (something as fitting as his chosen vision), he would have had much less female companionship. Even worse, if he saw himself as a schlemiel.

Was his glass half-full or half-empty? That too is part of his story, and he certainly looked at life with a hopeful, optimistic gaze and focused on what was best in himself, not his weaknesses.

The person I’ve described had many, many friends and had much pleasure, not only with women. He led an interesting life. Even if it is not one you would personally choose, do not be too hasty to judge it (especially after I tell you that he was a loving father).

A great man?

No, but then, there aren’t too many of those.

But he was one who found a useful story.

Many of us do worse.

The above image is Don Juan and the Statue of the Commander by Alexandre-Evariste Fragonard, oil on canvas, circa 1830–1835; sourced from Wikimedia Commons.