Psychotherapist Ionel-Mihai Stancu

Why person-centered therapy is useful in ADHD and how ADHD relates to the "19 proposals" of Carl Rogers for personality and relationships?

Translation and adaptation by Andrei Hodorog, one of Mihai's patients

I am of the opinion that a review of the "19 proposals" Rogers' framework for personality and relationships (Rogers, 1951/2015, p.481) may shed light on how deficits Executive Function specific to ADHD could affect self-actualization and personality development within the person-centered therapeutic model.

Glossary of Rogers terms

Before starting the analysis of the Rogersian proposals, we find it necessary to detail a glossary of Rogersian terms for readers who are less familiar with this semantic field.

Conditions for recovery

Organic valorisation

Propositions 1 and 2 (concerning the phenomenal field and the perceptual field as reality):

Awareness of the overall phenomenal field is limited and a small part of the total field is available to consciousness (Rogers, 1951/2015, p.483). Executive functions appear to be essential to the construction of one's phenomenal field, implying that executive functional deficits would reduce the completeness and accuracy of the perceptual field.

Rogers wrote: "The more all his experiences are available to his consciousness, the more it is possible for him to convey a total picture of his phenomenal field" (Rogers, 1951/2015, p.496) Changes in perception are essential for therapy (Rogers, 1951/2015, p.486), but ADHD affects the perceptual field, implying a fundamentally impaired sense of reality, even in the absence of distress. Time sense, coordination and timing are problematic, with "an inner restlessness and body arrhythmia" and "an intersubjective desynchronization between the individual and the environment" (Nielsen, 2017, pp.260-272). Subconscious filtering of non-goal-related stimuli is less effective in ADHD due to deficits related to the dopaminergic system (Volkow et al, 2011, pp.1147-1154). 

Difficulties in discerning the ground figure (Rogers, 1951/2015, p.483) (e.g. the effect of "cocktail party") are common in ADHD. Phenomena of this type prevent effective integration of experience and, perhaps, a greater propensity towards undervaluing it (Rogers, 1951/2015, p.513).

The rarely mentioned condition of "ADHD psychosis" (Bellak et al, 1987, pp.239-63) is an irrational, conscious, non-hallucinatory behavior that occurs as a result of poor perception and/or integration of experience. ADHD may also involve a type of thought disorder in which up to 5 trains of thought occur simultaneously, further implying a fundamentally different phenomenological infrastructure from that of an individual who perceives reality in a typical way (Jerome, 2003, p.23).

Proposals 3 and 4 (reaction to the phenomenal field and tendency to discount):

Carl Rogers describes the organism as a "totally organized system, in which alteration of any one part can produce changes in any other part" (Rogers, 1951/2015, p.487). Therefore, Executive Functions undernourished could constrain a person's ability to react "as an organized whole" (Rogers, 1951/2015, p.486). ADHD involves an impaired ability to resist distractions, return to task, and persist toward future goals. It involves processing difficulties, including problems recognising salient features of their experience and difficulties with valuing: perceiving priorities.

Carl Rogers alluded to the interaction between consciousness and the process of valuing: "Why do choice factors need to be clearly perceived for this tendency to go forward to work?". It would seem that if the experience is not adequately symbolized, if not sufficiently precise differentiations are made, the individual confuses regressive behavior with self-enhancing behavior (Rogers, 1951/2015, p.491). In the case of executive deficits in ADHD, the symbolisation of experience is impaired. For example, delayed language development in some children with ADHD may reflect limitations in the ability to integrate experience/self-actualization.

Proposals 5 and 6 (goal-oriented behaviour exists to satisfy perceived needs):

ADHD involves motivational difficulties and impairments in goal-oriented behaviour. Emotions drive behaviour, linking experiential stimuli (thoughts, memories and behaviours) and responses to stimuli (thoughts, feelings, behaviours and language-based symbolisation) (Sanders, 2014, p.72).  

Lack of stability of emotions (Barkley, 2014, p.81) is a core feature of the clinical picture associated with ADHD. It probably reflects difficulties in maintaining perspective in the individual's experience and frustration with the difficulty in differentiating a coherent and ongoing sense of self, particularly when the person is under pressure.

Deficiencies of dopaminergic systems specific to ADHD affects emotional and motivational mechanisms, which are vital to stay on task. This could also result in difficulties in precipitating or sustaining action towards the goal due to the lack of differentiation between figure and ground within the phenomenological field. 

If the priority of things changes unexpectedly, action on that previous task will have to wait until the desire returns again. ADHD has been dubbed intention deficit disorder (Barkley, 2009), and adults with ADHD typically report helplessness - "I want to, but I can't" (Schrevel, 2014, pp.39-48). Thus, the motivational and behavioral impairments of ADHD often precipitate harsher socialization, making individuals with ADHD more vulnerable to abuse (Endo et al, 2006).

Proposal 7 (the best point of view is that of the customer)

Carl Rogers wrote that the subjective world of the other can be perceived "only in a cloudy way" (Rogers, 1951/2015, p.495). It can be hypothesized that self-description in ADHD is less accurate than in non-ADHDers. An analogy might be a person with poor vision describing what they see in a mirror when that mirror is dirty and distorted: the result is an impaired self-image.

By definition, stress can reduce one's experiential awareness, or attention: we get lost in thought and drift away from the moment. Mindfulness promotes neural integration, through the mechanism of self-realization (Siegel, 2012, p.45).

In ADHD, the individual is particularly prone to stress, and this suggests that the reflective, observing self easily disappears as the spontaneous, experiencing self comes to dominate consciousness. The more time we spend in ruminative, discursive thinking ('mindlessness'), the more processing and self-actualisation becomes necessary to catch up with events. By multiplying these gaps, memories are not properly stored, life passes quickly and there is an alienation of the individual of the self-actualization process: the self becomes disconnected from experience.

A positive delusional bias (Owens, 2007, p.335-351) involving an unrealistic self-concept has been observed in children with ADHD. This bias appears to continue throughout adolescence (Steward, 2014, pp.316-322) into adulthood (Knouse et al, 2005, pp.221-234). This is the infamous "performance gap" specific to ADHD, in which the person never seems to manage as well as they should, or at least not as well as those close to them.

Thus, ADHD becomes a performance disorder, not a knowledge disorder: they know what to do, but they can't do it. As Dr Barclay puts it: "The back of your brain is knowledge, the front is performance. ADHD, like a meat cleaver, simply splits your brain in two. So it doesn't matter what you know, because you won't use it". Barclay (2009) also points out that Self-control cannot be taught in skills courses because it is an innate instinct.

Without an environment in which to feel safe and encouraged, the individual with ADHD is more likely to introject the values of significant others, both as a protective measure and as a way to feel a clearer sense of self. This might be reflected in the tendency of people with ADHD to seek to please, or to react to failures by constantly reinventing themselves, constantly changing schools, careers, relationships, cities.

The only alternative to this "chameleonic" self would seem to be a self that develops in accordance with the their basic organic values, but at the cost of blending in easily with others in any given setting. Rather than fitting in, the individual prefers to hold tightly to their core values, which are less adaptable to being approved by others.  He could become more disagreeable, demanding to be accepted for what he is, instead of being accepted for what he does (a game he can't play). This could explain much of what we see with oppositional defiance. This is also where we can see the struggle to break out of codependency, with codependent people having a deeply ingrained opposing belief: that they can only be loved for what they do, not for who they are.

In any case, the self suffers. Carl  Rogers observed that "the individual begins on a path that he later describes as "I don't really know myself" (Rogers, 1951/2015, p.501) People with ADHD have difficulty feeling understood, known and accepted - even by themselves, often quoting the phrase "I come from a different world" (Schrevel et al, 2014, pp.39-48).

The above analysis implies that people with ADHD could greatly benefit from a clearer sense of their bodily worth, but this perspective should be combined with an acceptance of their condition - after all, it is not easy to live with ADHD.

Proposal 8 (perceptual field differentiation):

If Executive Function provides a large part of the infrastructure of consciousness, any deficit of it may imply difficulties in differentiating the perceptual field in the self-concept. Carl Rogers asked: "Is the self simply the symbolized portion of experience?" (Rogers, 1951/2015, p.497).

If so, the ADHD self arises from deficiencies that can never be perceived; the person feels "normal", as whole as they ever were. This may help explain Krueger and Kendall's (2001) findings that adolescents with ADHD "were describing who they were in terms of ADHD symptoms, rather than distinguishing themselves from the disorder... They were ADHD and their ADHD was being translated through them... the study participants seemed to have difficulty sustaining a stable sense of self.".

Proposals 9 and 10 (self structure and assumed values):

Development Executive Function in children with ADHD is usually realized about 3 years later than in children of the same age without ADHD (Barkley, 2009). This could affect the individual's sense of "me" and "you" and "others" According to the development of theory of mind (Sabbagh et al., 2006, pp.74-81) In one study researchers concluded that subjects with ADHD had lower character scores than those with autism spectrum disorders, as the neurochemical deficits associated with ADHD may be barriers to character development that should not be neglected (Anckarsäter et al, 2006, pp.1239-1244).

Many professionals estimate that ADHD in the absence of treatment, decreases by approximately 30% of a person's executive age (Barkley, 2009) A child of younger mental age has a higher vulnerability to peer rejection (Barkley, 2014, p.102), social conflict and conditions associated with under-perception of self-worth. Such a child has also been found to be poorly equipped to maintain autonomy or respond resiliently to stressful situations. Thus, children with ADHD experience feelings of "divergence, disagreement and struggle in all areas of their lives" (Shattell et al., 2008, pp.49-57).

Children with ADHD also experience more tension in their interactions with parents (Krueger and Kendall, 2001). Therefore, the negative consequences of ADHD can appear early in life, and undiagnosed children often feel different from those without ADHD (Barber et al, 2005, pp.235-245). Feelings of loneliness, isolation are more often than not present (Shatell et al, 2008, pp.49-57). At the same time, young people with ADHD in general often suffer from a decrease in self-esteem as their time (Houck et al, 2011, pp.239-247). These feelings, left lingering and unaddressed, could have repercussions in adult life.

Proposals 11, 13, 14 and 16 (experiences are ignored, symbolised, denied or distorted: psychological maladjustment / rigidity of self structure)

Living a "normal," resilient and authentic life with ADHD is made difficult by the fact that behavioral impairments bring in recurring rejections and life management issues. Attention is important for self-realisation: "Without focused attention, elements are not explicitly coded. Implicit memory may be almost intact, but explicit memory is impaired for the stimulus or event.". (Siegel, 2012, p.63).

In people with ADHD, multiple intense experiences are processed, but the processing is carried out through certain unconventional, doubtful circuits in the context of a low executive age. Healthy processing requires the ability to effectively apply "the mind's attention flashlight" to allow focus on a particular part of the experience (Siegel, 2012, p.42). In the presence of ADHD, however, there is no flashlight, but rather a low-power bulb hanging from the ceiling that evenly illuminates the entire experience. In this way, the figure is not easily distinguished from the rest of the shadows. All this has the consequence that articulating/symbolising such experiences (self-actualisation) is slower and more emotionally difficult.

As Carl Rogers remarked, anxiety may result from ineffective or overloaded symbolization (Rogers, 1951/2015, p.507). Such generalized anxiety is closely associated with ADHD (more specifically the physical restlessness of the adult with ADHD), which however in adults is frequently diagnosed (incorrectly) as pure anxiety instead of ADHD (Barkley, 2009).

People with ADHD are also more likely to develop ADHD disorders. post-traumatic stress complex (Pliska, 2014, p.153; Biederman et al, 2012, pp.49-55). ADHD, however, is not considered a direct risk factor in dissociative identification disorder (Endo et al, 2006, pp.434-438), perhaps because, from the very beginning, the self-concept has not been very coherent (or because those who have the ability to live smoothly with their ADHD have become experts in dissociative responses).

In person-centred terms, ADHD obscures and impairs self-concept, increasing the likelihood of incongruent behaviour. Carl "organically expressed needs are denied admission into consciousness because they are incompatible with the concept of self".  Thus, ADHD may amplify the pressure exerted by valuing conditions, exiling the organismic valuing process and assigning the individual a strongly externalized locus of valuation.

In turn, stress exacerbates neurochemical deficiencies and ADHD symptoms. The result is often a person who needs lifelong support to organise their life and maintain their self-esteem. Adults with ADHD often feel they are leading a "double life", characterised by chaos and a perceived need to keep their disability secret for fear of stigma and discrimination (Toner et al, 2006).

Parents and other social factors play no causal role. whereas "all 40 twin studies published in the last 20 years have shown that the environment of growth has no influence" (Barkley, 2009) Parents with ADHD find their role very difficult, with more impulsivity, more expressed emotions, more discipline and less monitoring (Barkley, 2009). Understandably, this could contribute to both the parent's and the child's distress. Parents without ADHD may have difficulty accepting their child's ADHD and moderating their expectations of their child (Murphy, 2014, p.745).

The pressure exerted by conditions for recovery is causing difficulties in education and employment, with frustrated partners saying "you can't do anything right?" and "I wanted a partner, not a child" (Pera, 2014, p.797). It is easy to see how negative self-esteem, "failure" Constantly, self-blame, anxiety, depression, and addictive tendencies can come to seem normal.

Proposals 12 and 15 (behaviour consistent with self-concept / psychological adjustment):

There are, counter-intuitively, many people with ADHD who are free of psychological distress. Many will only demonstrate sub-clinical symptoms, but I wonder how fine the boundary of this condition is. Could the appearance major stressors in those people's lives trigger symptoms of clinical intensity? Further research into the 'positive psychology' aspects of person-centred theory in relation to ADHD could be valuable: what does the individual with ADHD need to develop?

Proposal 16 (the threat and rigidity of the self structure):

This proposal seems to be reflected in the development "armor": the personalities with which he or she is identified (such as the "class clown") and oppositional defiance disorder (ODD), in which the individual with ADHD learns to "reject the rejection" from other references, who don't seem to understand or empathetically accept it. Many adults with ADHD exhibit ODD symptoms at least at a sub-clinical level (Barkley, 2012b), with these demonstrating their power and influence in the context of their emergence in key relationships early in life.

Proposals 17, 18 and 19 (unconditional positive regard, integration of experiences, acceptance of others, increased body value):

If people with ADHD struggle to feel accepted and to be auto-update, unconditional positive regard would be in high demand, suggesting a useful role for person-centred therapy.

It can be hypothesised that Organic Valorisation Process (OVP) is less "available" for those with ADHD. Therefore, we can speculate that the motivational difficulties associated with ADHD-specific dopaminergic deficits might make it more difficult to feel any bodily appreciation, regardless of the presence or absence of an aggravating sense of distress.

Conclusion: In terms of person-centered therapy, ADHD is a delay in self-actualization

ADHD is an unseen condition, which is perceived at the behavioural level as a disruptive, disturbing attitude, thus discouraging compassion. The symptoms of ADHD act as a magnet for conditions of worthiness, and social support is too often limited to phrases approaching "Try harder, lazybones!". People with ADHD are usually expected to accept others' denial of the reality of their condition. If we were to generalize, imagine telling a person with autism that their condition is a fabrication, that "you don't really believe in autism".

Unlike visible disabilities, ADHD affects the structure, processes and content of the self. However, despite its powerful impact, even the sufferer of this disability is unaware of its presence unless diagnosed. Unlike visible disabilities, no one else will show it consideration unless the need to do so is realised.

The impact of ADHD on the mind and personality can be broadly interpreted in terms of person-centred:  from the earliest years of life, ADHD seems to be a powerful "force multiplier" for conditions for recovery, stress and psychological distress. Evidence suggests that ADHD impairs self-actualization, precipitating learning difficulties, poor performance and social isolation, producing envy a self-concept associated with low self-esteem.  

As mentioned earlier, people with ADHD are more susceptible to psychological stress. So, in relation to a therapist, they may take on the appearance of people suffering from anxiety, depression or the pressures of divorce, unemployment or addiction. They are likely to be far removed from their own process of self-worth, and their self-esteem is likely to be highly conditioned, biased towards the values of those who have felt the need to guide, punish, or ridicule them. This is why many people with ADHD, when they are finally diagnosed, most often in adulthood, they respond with a phrase similar to: "Are you saying I'm not stupid, lazy or crazy?" (Kelly and Ramundo, 2006).

For ADHD is usually recommended only Cognitive Behavioural Therapy (CBT), aimed at skills training. This is useful, but the fragility and complexity of the emotional and executive baggage of ADHD makes Person-Centred Therapy in many cases more comprehensive in treating it. 

Therefore, psychotherapists specialising in Person Centred Therapy who recognise ADHD as a condition real and have a basic knowledge of psychopathology and associated medication, they can help millions of ADHD patients. Person-centred therapy can work very well in conjunction with medication. Rogersians also have the opportunity to tailor their therapeutic approach to each patient's needs.