Navigating ADHD and Individualized Therapy

Can You Treat ADHD with TEAM? Does Humor Play a Role in Therapy? What's the Difference between Rejection Practice and Shame-Attacking Exercises? Featuring Dr. Matthew May

Note: Not all of the information covered here is in the podcast, and much of what we discuss in the podcast is not covered here.

Questions for the next two Ask David Podcasts:

1. Rich asks how you treat ADHD in TEAM.
2. Hwa-Chi Qiu Alvarez asks about the use of humor in therapy.
3. Rima asks about the differences between Rejection Practice and Shame-Attacking Exercises.

 

1. Rich asks: How do you treat ADHD?

From Richard: How about a podcast concerning ADHD? I feel that applying TEAM would work. No? I mean “disorders” arise from distortions…so what does a distraction “disorder” arise from?

Thanks for all you do David,

Rich

David’s reply:

Hi Rich,

I don’t treat “disorders,” I treat individuals at specific moments when they’re struggling and wanting help! Hope that helps.

As an aside, if you or a friend, colleague, or patient have ADHD and you can describe a specific moment when that person was struggling, I would love to hear about it! Then you’ll see how TEAM works it’s magic by focusing on individuals, and not “problems” or “disorders,” etc.

TEAM is a “fractal psychotherapy.” I will explain!

Warmly, david

Matt’s Take: Thanks for the question, Rich! I love what David is saying, about treating the individual, not the diagnosis.

There are a lot of things that can interfere with focus and attention, such as. medical problems, sleep difficulties, toxin exposure, substance misuse, and relationship problems. In addition, depression and anxiety can interfere with concentration and contribute to ADHD symptoms.

Below, I’ve listed many of the distracting thoughts that my clients have had. Along with a list of some good things about being Distracted.

Hope you enjoy!

Matt’s A – Z List of Distracting Thoughts:

1. I don’t feel like doing this
2. This is boring and no fun
3. I never get to do what I want
4. It’s not fair
5. I’ll do it later
6. There’s plenty of time
7. Best not to rush things
8. I might be missing out on something interesting or important
9. I’ll check my phone one more time, real quick, and then get right back to work
10. This time will be different. Seriously. I mean it.
11. Actually, I’m feeling too tired to concentrate
12. I’ll just take a quick, 5-minute nap
13. I’ll get to work when I feel more rested and motivated
14. I’ve had a hard day and deserve a little break and some fun
15. Tomorrow’s going to be really hard, so I need to rest up
16. I just *can’t* concentrate, at all
17. There’s something seriously wrong with me
18. I lack willpower / I have no ambition
19. I shouldn’t have to do this
20. There’s no point doing this
21. I’ll never be able to do this
22. I need to be doing important, interesting things
23. It would be really exciting and fun to … x, y, z, instead
24. I need to tidy up a bit before starting this big project
25. I don’t know where to get started / don’t want to mess up
26. I’ll be too distracted if I don’t take care of this one thing, first

 

Matt’s A – Z List of GOOD Reasons to be Distracted

1. I can be spontaneous, have fun and be present, in-the-moment
2. I won’t miss out on something interesting and important
3. I won’t waste my life doing boring stuff that leads nowhere
4. I’ll focus on what makes me happy
5. I won’t let other people control me or make my decisions for me
6. I like to feel powerful and in-charge; I call the shots
7. This is my time, nobody controls me
8. It’s calming to know that I’m in-control
9. I want to treat myself with respect
10. I want to be free, not shackled
11. It’s important to take breaks
12. I want to maintain a good work-life balance
13. It’s fun and exciting to be a bit of a ‘rebel’
14. I’m my own unique person, doing things my way
15. I just want to ‘go with the flow’, it’s easier
16. I want to be safe, protected me from failure. I can’t really fail if I don’t give it my all
17. I can get instant relief from the pressure anxiety when I outsource this task to ‘future me’
18. I deserve to do what I want, when I want to; I’m sticking up for me
19. I can reject others’ advice and feel superior
20. I don’t know where to start
21. I can have more time to plan
22. I’ll be less likely to mess up if I consider my approach carefully
23. I don’t want to do an average job, this needs to be amazing
24. I can prepare, talk, plan and complain; that’s more interesting and fun than doing
25. I don’t have to face how dull and boring some parts of life can be
26. I can daydream about a better life

On the live podcast, Matt and Rhonda gave examples of individuals diagnosed with “ADHD” who all needed completely different and highly individualized treatment, which is what TEAM is all about.

Matt described treating a boy with ADHD who would get anxious in class when he was called on to read out loud. He was afraid he’d get nervous and make mistakes, and the other students would judge him.

The technique that helped him was the Feared Fantasy.

Matt also described a fellow with ADHD who had trouble keeping appointments and getting places on time. He was helped by the technique I have called “Little Steps for Big Feats,” and the treatment was similar to the methods we used to treat procrastination.

Rhonda described someone with ADHD who felt anxious in social situations, and he was helped with the same types of techniques we would used to help anyone with social anxiety.

The bottom line: treat the person, not the so-called “disorder”!

 

2. Hwa-Chi Qiu Alvarez suggests: An episode focused on humor and its uses/impacts could be interesting, I didn't find any. What are some strategies for when humor backfires? How did you learn to appropriately use humor with patients?

David’s reply will include:

1. First, time I “discovered” humor when teaching the psychiatric residents with Aaron Beck.
2. How I think about my own use of humor: I just kind of blurt out things that are outrageous.
3. Buddhists have concept of “Laughing Enlightenment,” which occurred during the Terri jumping jacks video.
4. What laughing creates is the experience of not taking ourselves so
5. The time I laughed with a patient during the entire session.
6. When NOT to use humor, and what to do when it backfires.

During the live podcast, Matt, Rhonda and David talked about why and how humor can be helpful—in therapy, in teaching, during podcasts, and in life in general.

David talked about how he “discovered” humor when teaching a group of psychiatric residents at the University of Pennsylvania, and how he used a humorous Feared Fantasy to help a depressed FBI agent who was demoralized because he didn’t have a sense of humor. This was a problem because the men at work of joked around the water or coffee pot during breaks. When David modeled how to accept the fact that he had no sense of humor during the Feared Fantasy, it struck his funny bone, and he laughed so hard he fell out of his chair.

This was a paradox, since the very moment he accepted the fact, without shame, that he had no sense of humor, he suddenly discovered his awesome sense of humor! I, David, call that the Acceptance Paradox.

David also described how humor helped a woman who had struggled for ten years with terrifying panic attacks and extreme depression.

David also warned about the pitfalls of using humor with angry or severely depressed individuals who feel intense grief or extreme worthlessness and hopelessness.

Matt’s Take

I’ve noticed that if you’re ‘supposed’ to laugh, you won’t. But, if you’re not supposed to laugh, you probably won’t be able to stop laughing. Maybe that’s why, when we tried to talk about it, on the podcast, it was really dry and unfunny? Normally I’m hilarious.

3. Rima asks: I believe rejection practice is a fine art and I’m just trying to understand the specifics a little more, and how it differs from Shame Attacking Exercises.

David talks about some of his male patients doing rejection practice by asking as many women out as possible and collecting no’s from them. The way David explains it, it seems standard practice for the patients to self disclose to the women that they are doing the rejection practice and are collecting no’s. My question is, if you disclose this information, would that be considered a safety behaviour and maybe less powerful exposure than not disclosing what you are doing?

I’ll give you a personal example that hopefully will clarify more. I have been doing my own rejection practice to experience how it feels for myself. One of the things I set myself was to ask someone to sing a duet with me. I found that a little daunting so to make it easier for myself, I disclosed to a woman that I am doing shame attacking/rejection practice and thus would she help me and sing with me. I felt I was using a safety behaviour and protecting myself from certain judgements from her. Therefore, I’m wondering if the patient disclosing what they are doing would be as helpful exposure as not disclosing.

David Comment

You are confusing Rejection Practice with Shame Attacking Exercises. They are actually very different.

You can do Rejection Practice with or without telling the person what you are doing.

Shame Attacking is just done without giving away what or why you’re doing it. For example, if you want to sing in public, you can just do that. Or you can approach a person or couple and offer to sing for them, and then when done hold out your hand as if asking for a tip.

There are certain general guidelines for Shame Attacking that we can mention, as they are very important.

You can also do with as a duet with someone you know, so you are doing Shame Attacking together. But in this case, you are definitely not confusing it with Rejection Practice.

During the live podcast, Matt discussed the pros and cons of two different styles of Rejection Practice, and David and Rhonda and Matt sharpened the contrast between Shame-Attacking Exercises and Rejection Practice, which are actually quite different, although there is clear some overlap.

Rhonda described a Shame-Attacking Exercise that David persuaded her to do after a Sunday hike, in a Chinese restaurant when everyone was ordering dim sum. Rhonda went to a nearby table and asked the people who were seated if she could taste their food!

This was almost impossibly anxiety provoking, but to Rhonda’s surprise, they let her tase one of their dim sum and she said it tasted great. They asked if she wanted more! It was a great exercise in overcoming social anxiety.

Matt described one of his outrageous Shame-Attacking Exercises in a grocery store, lying on his back making angels in the snow in the produce section, talking loudly about what an awesome grocery store it was.

He said that he was surprised and relieved to discover that no one seemed interested in what he was doing. He said that one of our illusions is that people are incredibly interested in us, whereas in reality, most people are mainly interested in themselves!

Quite a useful discovery.

Matt’s Take

Hi Rima, thanks for this nuanced question, I can tell you’ve been paying close attention!

As a little background, the fear of getting rejected can cause a lot of suffering and deprivation, both emotionally and in the form of loneliness, relationship problems and career development. Overcoming this fear can improve one’s social life, relationships and career. However, there’s a ‘necessary’ part of overcoming any fear, which people don’t want to do. It is to lower our defenses and face the fear directly. This is the only way to prove that we are, in fact, ‘safe’, for example, when we are rejected.

Rejection Collection (getting rejected frequently and regularly, and counting these as ‘wins’) is a powerful social exposure method that has helped many people, including myself, overcome the fear of getting rejected.  Huge thanks to David for helping me overcome my resistance to trying this (extremely challenging) exercise. Doing so has helped me overcome my fear and has radically improved many aspects of my life.

Exposure may not work, however, for a variety of reasons. A common one is motivational. For example, we may not want to feel ok, if we’re getting rejected. We might prefer to feel upset, perhaps as a motivator to improve.

Surprisingly, there are many good reasons to base some portion of our worth on the approval of others: Wanting to live up to their expectations, wanting to be open to feedback, wanting to avoid conflict, wanting to be maximally motivated to work hard, in our relationships, to be mature and responsible.

TEAM therapy stresses the importance of raising these motivational elements to the surface for discussion, in an admiring way, before deciding whether to change anything about a person.

If someone can still convince me that they want to overcome the fear of rejection and are willing to do the hard work, rejection collection is extremely effective and powerful. It’s good to know that one’s nerves won’t be the thing that gets in the way of developing a wonderful social life.

Rejection collection can still fail, however, for other reasons. For example, it’s common to focus too narrowly on only one method. There are many, many methods that can help, and may be necessary, to overcome a fear of rejection. Just in the category of ‘Social Exposure’ there are quite a few:

TEAM Therapy Social Exposure Methods:

• ‘Smile and Say Hello’ practice
• ‘Talk Show Host’ technique
• ‘Self-Disclosure’
• ‘Flirting Training’
• ‘Survey Technique’
• ‘Shame attacking’
• ‘Rejection Collection’
• ‘Rejection Feared Fantasy’

You’re correct, too, Rima, about the problem of ‘safety behaviors’. Even if ‘rejection collection’ were the method that could lead to a cure, it still might fail if we are, in some way, ‘protecting’ ourselves, during the rejection collection exercise. The most common form of ‘safety behavior’ I’ve seen, when doing ‘rejection collection’, is to rush the process. Then, we can tell ourselves, ‘well, if I’d really tried and put in the time and all my effort, I wouldn’t have gotten rejected’. This defeats the most liberating experience of, ‘I got thoroughly rejected, despite my best effort, and it’s totally fine’.

You asked, is it would be a ‘safety behavior’. if you said this to a stranger: “Please reject me, to help me get over my fear of rejection.’,

I would not necessarily label it as a safety behavior, unless it was the only thing that was said. I would consider this to be ‘Self Disclosure’ (talking about oneself in a vulnerable way) combined with rejection collection. If this were the only thing you said to someone, then I’d agree that it’s a ‘safety behavior’, as there’s a rushed element to it, as opposed to a ‘best effort, still failed, it’s fine’ experience.

The liberation of a ‘real’ rejection is a glorious thing and is, in my experience, most often achieved by combining multiple of the above techniques, starting with, ‘smile and say hello’, ‘talk show host technique’, ‘flirting’, self-disclosure, survey technique and only then asking for a rejection. Practicing this for a bit using the ‘Rejection Feared Fantasy’ (a role-play/practice exercise with one’s therapist) is often great preparation for the real-life experience.

We thank Rhonda for recording for us today, when she is just starting to recover from COVID, and the day before a trip to visit her son, daughter in law, and two wonderful grandchildren.

We love you Rhonda, and wish you the best for a wonderful month!

Thanks for listening today, and thanks for submitting your excellent questions.

Stay tuned for more answers to your questions next week, including these:

1. Magellan asks about the effectiveness of TEAM without the guidance of a therapist.
2. Werner asks about the differences between Positive Reframing and the Positive Thoughts you record on the Daily Mood Log.
3. Anonymous asks several questions about the Feeling Great App.

Matt, Rhonda, and David