Communication-Focused Therapy (CFT) for ADHD
Dr. Christian Jonathan Haverkampf, M.D.
Attention Deficit Hyperactivity Disorder (ADHD) is often treated mainly or exclusively with medication. However, psychotherapy should have an important place in the treatment of ADHD and may in lighter forms be the only therapy needed. Communication-Focused Therapy (CFT) is a psychotherapy developed by the author, which can be applied to several mental health conditions, including attention deficit disorder (ADHD). The focus is on the internal and external communication patterns the patient uses and on his or her basic parameters, the values, needs and aspirations. With awareness, reflection and experimentation these factors can be very helpful in a psychotherapeutic approach to treat ADHD.
Keywords: ADHD, attention deficit hyperactivity disorder, communication-focused therapy, CFT, communication, psychotherapy, treatment
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Table of Contents
Understanding Communication. 4
Attention Deficit Hyperactivity Disorder (ADHD) 6
Communication-Focused Therapy (CFT) 8
Values, Needs and Aspirations. 14
Meaningful Messages as the Instrument of Change. 15
Better Communication Patterns. 16
Towards Interests and Values. 16
Attention Deficit Hyperactivity Disorder (ADHD) can interfere significantly with a person’s private and professional life. Often, there are already problems in school which cause low self-confidence and prevent a healthy belief in one’s resources and talents before they can even be tested. Difficulties concentrating and focusing on the work at hand can be so severe to make school work, or later performance in one’s job, close to impossible. This can cause huge suffering, as both the individuals afflicted with ADHD and their family and close friends often feel helpless as the ADHD symptoms seem to make success in many areas of life impossible.
Medication is often very effective in treating the symptoms of ADHD. However, this should in most cases be accompanied by a course of psychotherapy to help with the problems resulting from the ADHD und to treat the ADHD itself. Also, treatment with stimulants has been shown to be effective for over a year, while its long-term effectiveness is still considered unclear. This is where a communication focused approach can be helpful which targets changes for the long-run, and establishing better communication patterns early can
ADHD has a lot to do with how one interacts with the environment. Strategies, which maybe worked for a while, are not as helpful anymore. In therapy, in the interaction between therapist and patient new communication patterns can be developed. Patients suffering from ADHD have often developed maladaptive interaction strategies with their environment, which contribute to the life impairment brought about by the ADHD symptoms. One strategy developed in childhood may simply be avoidance, as one has learned that committing to an interaction or an activity has been unsatisfying due to the inability to stay focused. Rather than trying to make interactions and activities more interesting and meaningful to oneself, the patient learns to withdraw. To reverse this, it is important to help patients see meaning in activities and interactions again by helping them connect with themselves in better ways.
Communication patterns used in an interaction with oneself and in interactions with others are interrelated. Both entail observing and decoding flows of information, identifying relevant and meaningful pieces, and interpreting them, and then responding by encoding and sending out information. Looking at these processes in therapy can be very helpful in making communication again a tool that benefits the patient rather than interfering with his or her life.
The ability to observe the flows of information and the reactions they cause, both internally and externally, is also an important skill to build and shape in therapy. It helps the patient to develop strategies to interact with oneself and others over a life-time. In ADHD, this can help a patient find motivation for relevant activities more easily and focus more easily what is truly important to the individual.
Understanding how communication works can be very helpful to a patient suffering from ADHD. This means not just explaining how messages and meaning are sent and received, but also to allow the patient to experiment in the therapeutic setting. This should be the space where the patient feels safe and supported enough to engage in experimenting with communication which in the long run is effective in dealing with the ADHD itself as well as the secondary communication and relationship effects. The more a patient understands how meaning and relationships are created and maintained in relevant and effective communication, the more of a sense of control he or she will have. For a child it may also be helpful to demonstrate and experiment with the explanation in a playful way. This also helps strengthen the therapeutic relationship and motivate towards therapy.
Communication patterns are different from communication scripts. They describe how a person uses information in specific situations or quite generally. For example,
- external general communication patterns may be not to ask questions, not to communicate dislike (saying ‘No’) or to prevent feeling sadness (blocking the signal ‘I am sad’)
- external specific communication patterns may include not talking about one’s anger with one’s parents or sexual issues with a partner
- internal general communication patterns may include to think about all different angles before deciding on anything
- internal specific communication patterns may include not to allow feelings of sadness to reach consciousness
There is little difference in the communication flows that are conscious or unconscious, except that some are being made conscious. This plays a special role in ADHD where it is more difficult for information (and the emotions associated with it) to hold the focus. However, if one sees the communication processes within and outside the focus as being subject to the same rules and mechanisms, one can increase the emotional value or focus pull attached to some information to hold the focus firmer on the information flow connected with an activity or a thought process.
Focusing on things that are relevant and meaningful to oneself motivate, benefit oneself and make happy. Unfortunately, many people in their work, at school or in social interactions feel a need to focus on things that on deeper reflection are neither very relevant nor meaningful to themselves. Often, people have little insight into what is relevant or meaningful to them, which can lead to less satisfaction in an activity, which also leads to less focus and concentration. Hyperactivity can then often be a result of it as well. Of course, life does not only consist of enjoyable activities, but the search itself to find more meaningful activities in itself can feel relevant if one understands that one is engaged in this process.
Children and adults with ADHD often do not have the opportunity to do things they enjoy, and feel are relevant to them, which usually makes the symptoms and their underperformance and lack of focus worse. In those cases, where this is possible, individuals can be high achievers. For example, in the case of one IT specialist with classic ADHD symptoms in many areas outside his IT area, he was tremendously successful and happy in his job, because he was able to do the job he loved. The positive experiences from his job also translated into a happy family life despite a clear ADHD diagnosis. This sounds like an exception, but it is quite obvious how schools, colleges and society as a whole could help individuals suffering from ADHD by supporting them in making things more meaningful and helping them to find out what is meaningful to them. Especially in the case of ADHD, once size fits all does not apply.
This does not mean one just has to give children total freedom to ‘find themselves’, but it is important to support them to find what is important to them by fostering better communication with themselves and with others. The same also applies to adults with ADHD, who have often developed maladaptive communication patterns with themselves and others, which solidify and entrench the ADHD. By helping children and adults acquire better communication patterns with themselves and others, they can find more relevance and meaning in activities. For example, often there is a lack of information to make the link between an activity or a relationship, for example, and the basic values, needs and aspirations the individual holds. The ADHD can make it more difficult to select and find this information. It can thus increase motivation, focus and concentration by working with a patient on finding more relevant information through reflection with oneself and communicating with others. Communication itself should become more interesting to the patient and be seen as an important tool in overcoming the limitations imposed by the ADHD.
Attention Deficit Hyperactivity Disorder (ADHD)
Attention deficit hyperactivity disorder (ADHD) is a mental disorder of the neurodevelopmental type. It is characterized by problems paying attention, excessive activity, or difficulty controlling behavior which is not appropriate for a person’s age. The symptoms appear before a person is twelve years old, are present for more than six months, and cause problems in at least two settings (such as school, home, or recreational activities). In children, problems paying attention may result in poor school performance. Although it causes impairment, particularly in modern society, many children with ADHD have a good attention span for tasks they find interesting. Its causes are unknown.
It is thus not a condition which interferes with the ability to focus and concentrate globally, but one that makes it important to help patients see enjoyment and meaning in everyday tasks. If something feels relevant, patients with ADHD often have less of a problem with it. The important task is to help the patient in seeing the connections between activities and their basic parameters, their needs, values and aspirations. While medication is often needed in more severe cases of ADHD, it can lower the ‘pressure’ to select more relevant and meaningful activities. This in turn can dampen changes which may help a patient with ADHD to be engaged in more meaningful and relevant activities in more interesting settings. Even when it comes to reading a book, patients with ADHD have far less difficulties with one that captivates them. Regarding adult ADHD, it is obvious in clinical practice that many patients are stuck in jobs they can only identify with partially but are afraid to leave, in part at least due to the greater feelings of uncertainty and instability brought on by the ADHD. In these cases, efforts are better invested into making the job more meaningful or finding ways to change it rather than coping skills. The former relies heavily on internal and external communication processes, which should be a chief focus in therapy.
Cutting Through Complexity
An individual suffering from ADHD sees a lot of fragments in the world as the mind wanders from one place to the next. This can lead to a feeling of being overwhelmed as the seemingly unresolved complexity of the world, the relationships with others and the own person increases. Observing how the patient takes in information and how he or she responds to it provides important insight. As already mentioned, being more aware of own needs, values and aspirations, the basic parameters (Haverkampf, 2018b), helps to prioritize information. However, discovering what these parameters are shows in how an individual interacts with oneself and the world. As activities in life are associated with particular ways of communicating and exchanging information, having insight into preferred communication patterns and structures also provides information on the basic parameters.
Observing and creating more awareness for communication and the processes which facilitate the transfer and recognition of meaningful information, also helps to see meaningfulness in how individuals and topics are connected. When a person with ADHD gets overwhelmed by too much incoming information, it is often because there are difficulties in selecting and prioritizing information and sources of information. One reason that is compromised is because the connection between information is lost, such as the act of going back to the house and the reason that one forgot the key, or cause and effect chains. Focused attention and the ability to inhibit other detractions and impulses keeps one on the connections, but since they are imagined, a shifting focus can make it difficult to return to them. In psychotherapy one would observe what happens when the attention jumps and cannot be brought back, and to find ways to see relevance in the information in away that it is easier too return to it. Communication-Focused Therapy focuses on how an individual exchanges and processes meaningful information. If meaning is not fully accessible because of a wandering mind, one needs to find ways to hypothesize meaning in order to pull the focus back to the original information. For example, if one gets very easily distracted in a lecture, taking a step back and thinking or visualizing how the material could fit into something larger one truly needs, values and aspires to can help to keep the focus on it. This, however, requires seeing connections between something that takes place in the present and something that happens in the future, and the inquisitiveness to look underneath the surface of particular information. If listening to someone in a group, no matter how difficult, can be viewed as an opportunity to get insight into how that person ticks, which can in turn be useful if one needs a favor from that person. Controlling attention is related to the ability to make connections and identifying more meaning and relevance in something.
Helping the patient see connections helps to see relevance to themselves and the meaningfulness of a task. One way to get there is to make complex relationships between tasks and own interests and aspirations easier to see. Schoolwork as an end in itself may not be very motivating, not just to people suffering from ADHD, but if a subject matter can be tightly linked to a unique interest focus and concentration can often be restored. For someone with ADHD it is not enough to do things because one does them. There has to be heartfelt reason for it. People without ADHD have the reward of some reward in the future, for individuals with ADHD the reward needs to be closer at hand. The therapeutic relationship, supported by the flow of meaningful messages, should convey to the patient that tools to get what they need and want are available. Together with others, things can become possible.
Communication-Focused Therapy (CFT)
Communication-Focused Therapy (CFT) was developed by the author to focus more specifically on the communication process between patient and therapist. The central piece is that the sending and receiving of meaningful messages is at the heart of any change process. CBT, psychodynamic psychotherapy and IPT help because they define a format in which communication processes take place that can bring about change. However, thy do not work directly with the communication processes. CFT attempts to do so.
We engage constantly in communication. The cells in our bodies do so with each other using electrical current, molecules, vibrations or even electromagnetic waves. People communicate with each other also through a multitude of channels, which may on several technologies and intermediaries. It does not have to be an email. Spoken communication requires multiple signal translations from electrical and chemical transmission in the nervous system to mechanical transmission as the muscles and the air stream determine the motions of the vocal chords and then as sound waves travelling through the air, followed by various translations on the receiving end. At each end, in the sender and in the receiver, there is also a processing of information which relies on the highly complex networks of the nervous system. Communication, in short, happens everywhere all the time. It is an integral part of life. Certain communication patterns can, however, also contribute to experiencing anxiety and panic attacks.
Communication is an autoregulatory mechanism. It ensures that living organisms, including people, can adapt to their environment and live a life according to their interests, desires, values, and aspirations. This does not only require communicating with a salesperson, writing an exam paper or watching a movie, but also finding out more about oneself, psychologically and physically. Whether measuring one’s strength at the gym or engaging in self-talk, this self-exploration requires flows of relevant and meaningful information. Communication allows us to have a sense of self and a grasp of who we are and what we need and want in the world, but it has to be learned similar to our communication with other people.
Giving patients with ADHD a greater sense of being in control of their own destiny and interacting with others and shaping the world in a way which gets their needs and wants met. Even though young patients with ADHD seem demanding and in control of things in a wild way, at the core they are very conscious of not being in control over events in life. There is the constant sense of not getting what one needs and wants, especially in older patients, which leads to misdiagnoses of personality disorders, particularly narcissism or dissocial personality disorder. It is important to see the ADHD with its maladaptive communication patterns with oneself and others at the core.
In ADHD there is often a strong sense of disconnect, which also causes a loss of insight into what is meaningful and relevant to the own person. This, however, makes it more difficult to find the activities and relationships that one can more easily focus on and engage with. Reconnection on an emotional level means reflecting on activities and interactions in the past which generated positive feelings, reconnecting on a cognitive level means reflecting on one’s thought patterns and content, often with the help of a therapist.
The therapeutic setting has the advantage that the focus is on this reconnecting work and there is little distraction from other people and everyday life demands. The work of the therapist is to support the patient in this journey of reflecting on interaction patterns and reconnecting with self and the world.
Someone suffering from ADHD can focus quite well on things that are motivating. However, for things that are not motivating it can be far more difficult to focus and concentrate on. Thus motivation, or seeing relevance and potential excitement and satisfaction, in things is probably more relevant to someone suffering from ADHD.
Many therapeutic approaches target the focus or concentration rather than motivation. However, changing motivation and making things more meaningful may be a better long-term strategy. This can develop if changes in perspective lead to the perception of more meaning in oneself and in the word around, in behaviors and thoughts.
There is a vicious cycle in which the symptoms of ADHD cause a disconnectedness from oneself and others. This not only leads to feelings of loneliness, but also to a loss of a sense of effectiveness in the world, the ability to effect changes and to get ones needs, wants and aspirations met. The disconnect is often a result of the perceived failure in carrying out tasks which seem effortless to others, like schoolwork or otherwise simple repetitive tasks. Later in life, they can lead to resignation on the job and resentment towards others. Of course, at the core is anger, hopeless and helplessness about oneself. The antidote to this is the reconnection already mentioned above.
Motivation is a key parameter n ADHD because if one is genuinely motivated about an activity, the ADHD symptoms often vanish, particularly the difficulties in focus and the tendency of the mind to wander. Using better communication with oneself and others to build motivation is usually the best way to achieve a more permanent effect. The patient should develop the skillset to be able to motivate myself or herself to choose and do the things in life which are relevant to himself or herself.
In therapy an important part is to rediscover meaning, and find it in the things that are relevant to the patient. Relevant is anything that is close to his or her values, basic interests, aspirations, wants, wishes and desires.
Seeing communications as meaningful requires perceiving a relevance to oneself in them, as well as a message that can bring about some change. In many situations it may be that it is difficult to spot meaningfulness in something before it has been tried out, but people often engage in it anyhow if they believe that it holds the potential to be meaningful. Much in the world would never have been accomplished without this course of action. To people suffering from ADHD, such a way of doing things seems to be closed off. The emotionally felt relevance and meaningfulness has to be there right away. So, an important question becomes how to bridge this gap in time. CFT aspires to do just this by working with meaningful messages in the exchange between therapist and patient.
Experiencing the World
Communication helps in identifying and finding meaning, either communication with oneself or with others. The exchange of messages is like a learning process in which meaning can be identified, found and accumulated. Through meaningful interactions one accumulates more meaning, more connectedness with oneself and the world and reduces the need for thoughts and behaviors which are triggered by fears, guilt, self-blame and other negative emotions. This also helps against depression and anxiety.
Perceiving more meaning also makes interacting with others and oneself more meaningful. This has a positive effect on one’s interaction patterns, how and in which one ways one relates to one’s environment and exchanges messages with it. The fact that meaning can be created in an interaction, or any instance of communication, can be liberating from someone with ADHD because it means one does not have to wait for meaning. It is already there, if one just engages in it.
‘Experiencing’ should be taken quite literally. It means interacting and engaging with the human- and non-human worlds. Since meaning comes out of these interactions, it cannot be understated how helpful and effective it is to support a patient in potentially meaningful interactions with the environment. The interaction with oneself is the flip side of the interactions with the environment. A person suffering from ADHD usually needs to learn communication patterns that make it easier to engage with the internal and external worlds. Fears an anxiety may even become greater for a short time in the beginning before thy fall off. It may be helpful to follow treatment suggestions for anxiety to support the patient in overcoming these fears and anxieties.
The patterns in which people communicate determine the benefits the communication process. If the interaction patterns are not helpful in understanding messages or in reacting to the messages from others, they are maladaptive. Unfortunately, since communication is the mechanism which drives autoregulatory processes, these maladaptive communication patterns may not necessarily result in more adaptive ones, even if there is the pressure to change. In not so few cases, this pressure may even result in a deteriorating vicious cycle if the maladaptive communication patterns need to be relied on by autoregulatory processes. For example, if a patient suffering from ADHD feels he or she needs to socialize more and make small talk in informal gathering, it can lead into a vicious cycle if the negative self-talk is not resolved at the same time. Otherwise, anxiety will lead to more self-consciousness, more anxiety, less ability to interact as one would want to, even more negative thoughts, even ore anxiety, and so on. To break this cycle it is thus important to go through four stages of addressing maladaptive communication patterns:
Those stages can also be worked on in parallel, although the focus on specific topics should be slightly different then. Any information that leaves a trace within the neuronal network brings about lasting change, because it effects how communication will be processed and communicated in the future. As neurons make new connections with each other and assign different weights to these connections as result of information, future information will be processed differently. Once information has been committed to memory within the neural network, it becomes part of it. Internal and external communication patterns and structures change as a result of it. If in therapy, these communication patterns themselves become the focus of observation, reflection and insight, new meaningful information can be sought that brings changes in them (Haverkampf, 2012a, 2015). This holds true whether a person is suffering from ADHD or not.
A change in communication patterns can happen in any meaningful interaction, such as a therapeutic setting, where feedback is possible within a safe space. Particularly in a case of ADHD, where cognitive functioning is significantly better when a task is experienced as more meaningful, providing the support and guidance to see more meaning is important. The primary objective is not to tell a patient what is meaningful, but to help him or her develop the skills to observe, reflect on and develop insight into these communication systems which determine to a large extent the interactions with the environment and oneself, and how information sources are selected, information decoded and processed. In therapy, the patient should not only become aware of his or her own communication patterns, but also experience how using modifications to communication patterns can lead to real changes in the world and within oneself. This is no different from how children also experiment with communication patterns, send meaningful information, such as a smile, read feedback and adjust their communication patterns in line with furthering their basic parameters (Haverkampf, 2018b), their needs, values and aspirations. The content that is being communicated is important as well, but the communication patterns and structures have a more significant effect on the whole of the integrated information over time.
Communicated information is our reality. In ADHD, using the communication space for the own benefit in a therapeutic setting can help the patient find more confidence and experience more authorship in affecting the information dynamic which underlies any real change. It also helps her to develop insight into herself and how to see more meaning in the world. Interpersonal and intrapersonal interactions bring about the discovery of more meaning in the world. This is a basic axiom of communication theory and shows again and again in the practice of psychotherapy (Haverkampf, 2018a).
Values, Needs and Aspirations
Often, individuals suffering from ADHD have become uncertain about what is genuinely important to them and the fit between these values and interests and their current life situation. Whether in the professional or romantic realms, having one’s needs, values and aspirations met, makes happy in the long run. This also applies to obviously altruistic situations. If I value helping people, I will do it because it makes me happy. Unhappily helping someone usually is not very effective. One problem may be that children are told not to be selfish, rather than distinguishing between a ‘positive’ and ‘negative’ selfishness. Positive selfishness is when I look after my values, needs and aspirations with the awareness that I am part of an interconnected whole and that there are others who also think and feel.
Some people need to spend more time by themselves, while others thrive in social settings. In the end, a mix appropriate to the individual leads to the greatest motivation and positive feelings. This applies to many personality and character attributes as well. Some can slowly change over time, but many, such as a person’s core values, change little, if at all. Particularly for an individual with ADHD, it helps to have a good grasp of what is truly important to them, what they value need and aspire to, because pursuing these basic parameters can lead to a much better focus and greater satisfaction and success. For everyone, but particularly for those with ADHD, a major task in life is to steer one’s life in the direction of one’s basic needs, values and aspirations. When a person with ADHD can find a niche interest, for example, that they find truly meaningful and relevant, there can even be a hyperfocus that leads often to higher achievements than in people without ADHD. One theory is that the purpose of the hyperfocus is at least partially to limit the focus from getting lost in distractions. However, the hyperfocus does seem more the result of a pull of something meaningful and relevant than the push from somewhere else.
Observing the individual communication patterns with ourselves and others helps us to identify the basic parameters, the needs, values and aspirations (Haverkampf, 2019). To discover what is meaningful and relevant, it is helpful to spend some effort on identifying values, needs and aspirations, which usually also includes being connected with others, sharing emotionally in experiences of others and helping others. The awareness of a mutual connectedness springs from the ability to observe communication within oneself and with others (Haverkampf, 2010a, 2012b, 2018a). Awareness for communication dynamics, patterns and structures and recognition of mutual connectedness can be built at any age, which begins in childhood, but can interrupted and compromised in the face of trauma and negative life experiences, which deliver a blow to the attributes and coherence of the self, such as self-confidence and self-efficacy. In children, therapy may foster engaging in play or other activities where the basic parameters can be identified by experiencing them, which can be non-verbal. In adults, one often has to work beyond the verbal to reach an experience, psychological and physical, of the needs, values and aspirations. Since communication is the main tool used in psychotherapy, a greater awareness for it occurs automatically when focusing on what is meaningful and relevant to the patient, such as the basic parameters (Haverkampf, 2017b, 2017c).
Meaningful Messages as the Instrument of Change
Communication is the vehicle of change. The instruments are meaningful messages which are generated and received by the people who take part in these interactions. In a therapeutic setting, keeping the mutual flow of information relevant and meaningful brings change in both people who take part in this process. The learning curve for the patient may be steeper in certain respects because he or she spends less time in this interaction style than a therapist.
Better Communication Patterns
For patients with ADHD, communication patterns have often developed as short time strategies at first, and where then kept for the perceived lack of better choices. Often, they become quite maladaptive over time, partly because of social isolation or conflict due to worsened ADHD symptoms, which can make them even less suited to benefit the patient. As described above, to get out of this vicious cycle awareness and insight into present patterns and the development of new patterns is key.
Towards Interests and Values
Behaviors and activities will only increase satisfaction in the long run if they take into account the basic interests, values and aspirations of the individual. This requires identifying them first, as described above, and then finding ways to implement them more into the person’s life. Fears and conflicts may need to be addressed, which are often associated with more substantial changes in a person’s life. However, to find these basic parameters requires connecting with oneself to be able to retrieve this information, which requires overcoming any fears or anxiety that may prevent this. The therapeutic setting should offer the space where this is possible.
Succeeding in life is both and individual and communal accomplishment. Communication with oneself and others is the important link and mechanism in attaining it. Especially for someone suffering from ADHD, failures at school or on the job often lead to less self-confidence and secondary psychiatric symptoms. To turn this around, it is important for the person suffering from ADHD to develop the communication skills and insight to reconnect with oneself and the world around. More specific techniques for communication-focused therapy are described elsewhere (Haverkampf, 2010b, 2017a).
Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. The author can be reached by email at jo****************@gm***.com or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.
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