Childhood ADHD: Over-Diagnosed or Under-Treated?

Bob Dick PhDin
The Medicalization of Mental Health
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The Psychotherapy Relationship
17

Ritalin2I was planning to write an overview of the recent controversy in this area concerning frequency of childhood ADHD diagnosis and treatment with stimulant medication.  This very lively exchange of expert and personal views was touched off by a New York Times article citing a Centers for Disease Control and Prevention telephone survey of many thousands of parents.  However the latest issue of one of my favorite magazines scooped me.  I can say it no better than the two-page article in Scientific American, Are doctors diagnosing too many kids with ADHD? by Editors Scott Lilienfeld and Hal Arkowitz.  It's the most comprehensive presentation of good science concerning the important issues.

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Lying to Our Clients

Joseph Burgoin
Defense Mechanisms
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The Psychotherapy Relationship
136


During several recent sessions, one of my clients has been struggling to make an important decision in her life that's causing her considerable anguish -- whether or not to leave her husband. I don't normally give advice in such cases, but based on my lengthy relationship with this client, I strongly believe that she ought to stay for the time being and have told her so. Her doubts about what to do have continued to resurface and I've repeated my point of view whenever I thought it appropriate and helpful.

Over the weekend, I received an email from this client; she acknowledged feeling somewhat "paranoid" and wanted to touch base with me about her thought process. Her intuition told her that, in truth, I thought she ought to leave her husband but felt it would be "unprofessional" for me to tell her so. She worried that her decision to stay was foolish, that she was closing her eyes to the depth of her husband's emotional difficulties; she feared that by staying, she was setting herself up for even greater heartbreak down the line. She felt certain that I believed the same thing but couldn't bring myself to tell her so.

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How Feelings of Helplessness May Give Rise to Destructive Violence

Joseph Burgoin
Social Behavior
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The Psychotherapy Relationship
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Unbearable Emotion
26

Reading about Adam Lanza, the Newtown shooter, in today's New York Times brought to mind Anders Behring Breivik, the Norwegian mass murderer who set off bombs and murdered at least 76 people back in 2011. These two men have several features in common, including social isolation, a fascination with Call of Duty (a war-oriented video game) and a history of having been bullied.

In this earlier post about Breivik, I highlighted the role of basic shame in psychopathic behavior. Adama Lanza appears to have suffered from some kind of autism spectrum disorder, which suggests early and pervasive psychological damage -- the kind that might leave a person with a core sense of defect or shame. On the other hand, Lanza's mother and father didn't divorce until he was 17 years old and, according to court records, appeared to be caring, involved parents who divorced without much animosity. Perhaps as we learn more, we might uncover a history of family discord and evidence of early trauma. We do know that Adam had broken off relations when his father began dating and eventually married another woman, suggesting that the divorce had troubled Adam deeply. Then there's the mother who let her son amass his own private arsenal of lethal weaponry. Surely we're not dealing with your average American family here.

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Why Free Association is So Difficult

Joseph Burgoin
Shame/Narcissism
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The Psychotherapy Relationship
58

Most people understand what free association means: to voice all thoughts, feelings and ideas that come to mind during a therapy session, without deciding in advance whether they're relevant or "worth saying." At the beginning of traditional psychoanalysis, clients are instructed to freely associate and occasionally reminded to do so as the treatment proceeds. We call it the "fundamental rule" of psychoanalysis; we believe that free association brings apparently unconnected ideas into relation with one another, revealing links that give us access to the unconscious.

Here's an an example. In session this week, my client Tom was discussing his work schedule. Tom is a highly successful entrepreneur with several thriving businesses; he works enormously long hours and operates himself as if he were a machine, with little regard to his needs, feelings and limitations. In this particular session, Tom spent a long time discussing the demands of the workplace in a light-hearted manner, telling jokes about problems he encountered, making light of his frustration. In a practical vein, I kept pointing out that he could say "no" to certain demands upon his time. I wondered aloud whether he had room to acknowledge just how exhausted he felt, how far beyond his limits.

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The Controlling Client

Joseph Burgoin
The Psychotherapy Relationship
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Unbearable Emotion
59

Early in my personal therapy, my analyst used to tell me I was trying to control him. He'd talk about the way I left pointed openings for him to speak. He identified a pattern -- how I'd relate events in order to elicit a particular response from him, the one that I wanted. He showed me how I would bring in material that repeated themes from prior sessions, hoping I could "predict" what he would have to say.

This kind of interpretation focuses on the role of unbearable need and dependency in the psychotherapy relationship. When we can't tolerate needing someone else and having to wait for him to give us what we need, we feel helpless. One response to such a feeling of helplessness is attempting to control the person you need. This view holds that control is a defense mechanism developed during infancy, where the helpless baby strives to control the object of need -- i.e., the mother. It assumes that, as an adult, he or she will have similar issues with dependency and control in other relationships. Clients who want to feel in control of their therapists would likely strive for control in any relationship that stirs up feelings of need, dependency or helplessness.

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