Attention Magazine October 2022

John is a forty-two-year-old accountant. He is married and has two kids; Jenny is ten and Jack is eight. John decided to seek services with a psychologist due to a few specific issues. At his job, he has a difficult time keeping on top of his work. He often ends up working late at night and sometimes works on weekends. At home, he experiences conflicts with his wife, often about his difficulty completing household tasks, being present with his kids (due to stress about completing work tasks and taking excessive time away from them to work on the weekends), and managing his share of child-related tasks (such as getting his kids places on time). While John takes stimulant medication, the issues noted above continue to persist. Furthermore, his experiences over the past few years with the COVID-19 pandemic have only worsened the severity of his issues.

People seeking professional services for issues related to ADHD often do not get a clear picture of how their clinician conceptualizes their difficulties, or how that individual plans how best to help them. Professionals may approach treatment very differently, based on their training, prior experiences, and numerous other factors, as well as the individual needs of the person they are helping. While various professionals might approach treating John differently, here is one psychologist’s approach to helping John make things better in his life.

The first appointment: what information would be helpful?

The following questions are an example of those a psychologist would ask.

1. What made you decide now to seek treatment?
2. What would you like to get out of treatment?
3. As an accountant, what responsibilities do you have? Do you work in an office, at home, or both? What job-related tasks are you good at? Which ones are most challenging?
4. What methods do you use to keep organized?
   • Do you use task lists, a calendar, paper lists, or keep all things in your head?
   • Which systems work well? Which only work in some instances? When do they not work? How consistent are you in using each one?
   • How are tasks assigned to you? (For example: via email, verbal, you identify them based on information received.)
5. What factors are contributing to not getting your work done in a timely manner? (Getting distracted, workload is too much, too stressed or anxious to focus, trouble prioritizing what tasks are important to do first.) How interested are you in specific types of tasks that you have to complete?
   • Do you genuinely find specific tasks to be interesting (such as researching tax questions, filling out tax returns)?
   • Are some tasks especially boring (responding to client’s tax questions via email, for example)?

Here are some additional questions that likely would be asked during the first appointment, followed by examples of a practitioner’s notes on John’s responses.

6. What specific difficulties are you having at home? Why do you think these are occurring?
   • Conflicts with wife; often occur when don’t follow through on household tasks that are expected or said would do.
   • Friction with kids; react strongly when minor misbehavior occurs because stressed. Difficult to shift attention, and leads to yelling. Then feel guilty about reacting strongly.
7. What would make things better in life for you?
   • Being more efficient with work.
   • Not having to work late nights and weekends to compensate.
   • Being better about completing tasks at home.
   • Less friction with kids and being able to be fully present with them.
   • Have friends and spend time with them.
   • Feeling less stressed and overwhelmed. This would likely occur by addressing the issues noted above.

As a psychologist, based on obtaining the information above, I might conceptualize approaching ways to help John as follows:

• Help him gain greater self-awareness of the specific difficulties and why they are occurring. This increased self-awareness can be especially important to more accurately target tools and strategies to help make things better.
• Help John to develop a comprehensive method for keeping track of his work tasks and planning out his time. For example, he could use an electronic task list program to record all main tasks and then use a section of the electronic program, specific piece of paper, whiteboard, or something else to make a daily plan.
• Help him schedule times during the day to make and update his daily plan and task list.
• Work on the follow through of using whatever systems he decides that he wants to use.
• Help John develop a concrete method for keeping track of his household responsibilities. For example, he could use a whiteboard or electronic task list that is shared with his wife so they can each see their tasks and predetermined deadlines for completing them. Having a weekly meeting to review the week, identify additional tasks, and set deadlines could work well.
• Assist John in coordinating blocks of time in the evenings and weekends at ideal times where he can get caught up on work if needed without external interruptions so that he can enjoy his non-work time with his wife and kids. Additionally, help him carve out time to have friends and do things with them.
• Work with John on basic lifestyle changes such as developing a consistent workout routine (and sticking with it), eating healthier, getting more sleep, and other similar things that would be helpful for virtually everyone whether they have ADHD or not.
• Have John explore with his psychiatrist whether his medication should be adjusted in some way (is the dosing not high enough, would a different medication better improve his focus, would he benefit from an afternoon booster dose). Additionally, ensuring that there are no unaccounted for medical issues contributing to his difficulties would be important.

As you can see, better understanding how John’s symptoms manifest, what strategies he uses, what works, and what does not are helpful starting points in figuring out where to begin in helping him to make changes to make things better. Next, looking at tangible tools that he can use to begin to make changes would be important.

While making improvements in of itself would likely reduce his anxiety and feeling overwhelmed, teaching him other coping tools such as meditation, CBT techniques, and helping him make general lifestyle changes, can further help him mitigate these negative feelings. Furthermore, processing John’s feelings on things, working on follow-through of implementing things that he wants, and helping him to stay the course in working through things (even if it takes longer than he would like) are other important parts of treatment.

Whether you have ADHD and have never sought behavioral treatment, are currently receiving treatment, or are considering resuming support, there is a lot that can be gained from it. I hope that the framework explained above help you understand how treatment can be useful and what kinds of information are beneficial to share. Even if it does not always seem like it, in most cases, professionals will have a clear plan of what they are doing to help you.

Carey A. Heller, PsyD, is a licensed psychologist based in Maryland. He specializes in the evaluation and treatment of ADHD and executive function issues. Learn more at hellerpsychologygroup.com. The coordinator for the Montgomery County chapter of CHADD, Dr. Heller also serves as co-chair of the editorial advisory board for Attention magazine.