From the May/June 1994 issue
TONY AND NELLY CAME IN FOR COUPLES THERAPY BECAUSE Tony had grown so irrationally jealous of Nelly and so physically violent that she was frightened for her life. In their most recent fight, Tony admitted, he had choked Nelly nearly into unconsciousness. Even though she said she still loved him, she now wanted to separate. A 21-year-old graphic artist, Nelly was a beautiful and elegantly dressed young woman, spoke rapidly and fluently, and punctuated her sentences with graceful hand gestures. Tony was a construction worker, nearly twice her age 38, although he seemed older. A good-looking man in a rough-hewn, disheveled way, his hair uncombed and sporting a day’s growth of beard, Tony hunkered down in his chair and spoke in somewhat disjointed sentences, casting occasional sidelong glances at his wife or the therapist.
Tony said he knew his violence was out of control, but that when they fought, Nelly drove him to speechless fury with her torrents of verbal abuse. He couldn’t even follow what she was saying, let alone defend himself from her attacks. “It’s when I can’t understand what she’s saying, and I can’t find the words to answer her . . . that’s what starts it,” he said, his voice rising. Even while describing their last fight, he raised his hands as if silently shaking her. “When we fight, she calls me a loser, and I think she may be right.”
On the surface, this scenario sounds familiar. A seemingly macho, violence-prone man, more comfortable in the world of action than words, lashes out physically at his nagging wife, who uses her superior verbal skills to put him down. And yet, from the very beginning of the first session, there were clues that something else, something more subtle but important, might be a central factor in this marital struggle.
The first time Tony spotted the oneway mirror, for example, and saw the room and himself in reverse, he was clearly startled and reported experiencing a flashback to some painful memories of grade school. When he was 6 years old, he had been diagnosed as seriously dyslexic. “I used to read backwards, write backwards, speak backwards,” he said, his voice breaking, his eyes brimming with tears. “The words never came out right, and I could not follow what the teachers or other kids were saying.”
To help him learn to read, his teacher had built a special box with a mirror in it, which he was supposed to use while doing his reading assignments, both in class and at home. Not only was the box humiliating, it didn’t work. Tony failed second grade while everyone else, including his twin brother, moved on. That same summer, he was sexually abused by an older boy not an uncommon experience for learning-disabled children who feel like social pariahs among their peers. He admitted shamefully that he had liked the attention, the feeling that somebody had wanted him.
Despite his painful childhood, Tony was aware that he had assets that saved him: his competence in sports, his winning personality, and his popularity with girls. Unlike the depressed, shame-ridden man in the therapist’s office, Tony had been a classroom cut-up, amusing and engaging enough to make his teachers indulgent and to be genuinely liked by girls. Not only did they think he was good looking and funny, but also kind and gallant, in an old fashioned way. Indeed, he grew up priding himself on being able to take care of women. In fact, this appearance of strength and chivalry had drawn Nelly to him. A sexually abused child in a chaotic, disorganized family, she had run away at 12, living with one relative after another until she met Tony. In her eyes, he seemed to offer the protective, nurturant fathering she had never known.
But once again, the old demons surfaced, and the problems stemming from Tony’s learning disability which he, like most other people, assumed he had “outgrown,” now insinuated themselves into every nook and cranny of his life. Not only did he live with the deep feeling of personal inadequacy that often engulfs people who have been made to feel like failures as children, but the same crippling shortcomings seemed to dog him at every turn of his home and work life. Because he couldn’t fully absorb and process information, he literally did not understand what his wife was saying to him, while his struggle to find the right words kept him from the simplest expression of his fear that she would leave or betray him. Anxiously dependent upon a spouse who was better at negotiating the linguistic world, sorely frustrated by his own inability to communicate, he used the dangerous and self-destructive weapons of his hands when his fear and rage became desperate.
IN FACT, LEARNING DISABILITIES may play an unrecognized but substantial role in spouse abuse generally. A study by psychologist Neil Jacobson showed that poor communication skills in the husband and a difference in education and decision making power in favor of the wife were associated with husband-to-wife aggression. At the Ackerman Institute project on wife battering, we have found that approximately half the men who come for treatment suffer from a learning disability or Attention Deficit Hyperactivity Disorder (ADHD). [See Sidebar] In a society that demands a higher level of worldly achievement from men than from women, a man who fails because of one of these disorders suffers a double blow to his masculine self-esteem. Furthermore, because he is both dependent on his spouse and outclassed by her in verbal conflict, he may feel that she, too, is one of the enemy an intimate partner who makes him feel like nothing. It is hardly surprising he may compensate for his wounded pride and loss of mastery through a show of physical force against his “weaker” partner.
Tony is one among a vast number of adults whose diagnosed or undiagnosed learning disabilities have had a profoundly negative but largely unrecognized impact on their lives. Estimates suggest that approximately six million school-age children (about 10 percent of all school children) suffer from learning disabilities, two-thirds of whom are never diagnosed or receive remedial training. In addition, it is estimated that more than 10 percent of school-age children suffer from ADHD or ADD (attention deficit disorder without hyperactivity), associated disorders that may appear independently of LD or along with it. Unfortunately, because symptoms of these disorders may resemble each other, the diagnosis is often confused. In addition, these disorders generate secondary emotional difficulties that further confuse the diagnostic picture. As a result, the extent of the prevalence of LD and ADHD in the population is underestimated and their enormous personal and social costs are still largely unknown. But from thousands of diagnosed case histories, it is very clear that the effects of LD and ADHD radiate far beyond the immediate, concrete problems these children have with reading and writing and organizing their thoughts; they are well correlated with school failure, illiteracy, substance abuse and juvenile delinquency. Many children with unidentified learning disabilities steal, for example. One patient recalled compulsively taking her roommate’s sweaters because when she wore them, she could pretend magically that she was her roommate and not the stupid failure she felt herself really to be. Other children become withdrawn, shy and depressed. Some studies, in fact, have demonstrated the almost uniform presence of depression in learning-disabled children and adults.
Ironically, because it is widely regarded as better to be thought bad than stupid in our society, many learning-disabled children not formally categorized as “delinquent” conceal their difficulties behind a veil of bravado, defiance and misbehavior. Parents and teachers are likely to come down hard on these children, who, though obviously intelligent, are not only failing in school but creating havoc in the classroom, fomenting rebellion at home and encountering the rage and/or disappointment of every adult in their fallout zone.
To add to their misery, many of these children are vulnerable to abuse, as Tony was, not only because they are lonely and feel unlovable, but because they cannot adequately read and process the cues that signal danger from a potential abuser. Understandably, clinicians seeing Tony as an adult might assume that his present unhappiness and violence were connected to the trauma of his sexual abuse. Few, however, would understand that it was not the abuse per se that damaged him as much as the constantly repeated feelings of helplessness and inadequacy that both made him vulnerable to abuse in the first place and profoundly interfered with his intellectual and emotional development.
It seems like ordinary common sense to expect that learning-disabled children might grow up with an impaired sense of their own worth, and, as adults, might have difficulty functioning up to their true intellectual capacity. And yet few, including therapists, realize that a learning disability may be the central underlying factor in alcohol and drug abuse, violence, sexual abuse, depression, anxiety and chronic work-related problems. Similarly, it’s easy to imagine how lifelong failure at those skills our society most values literacy, verbal facility, logic might undermine the self-confidence a person needs to risk even rudimentary social overtures, let alone risk closer connections. But even therapists often have no idea how deeply embedded in the very fabric of a troubled marriage or family a learning disability or ADHD can be, how the original deficit in one spouse or child indirectly distorts the interactions between all family members, virtually creating the systemic problems that bring people into therapy. Marital problems that seem intractable and deeply rooted in a host of psychodynamic and family-of-origin issues, for example, may actually pivot around an undiagnosed learning disability or an undiagnosed attention deficit disorder.
Larry and his wife, Daisy, a nurse, came in for marital therapy because, according to Daisy, Larry had become increasingly distant, moody, preoccupied and emotionally unresponsive. Their social life was just about nil, she complained, because Larry was such a deadhead at parties and gatherings silent, uncommunicative, withdrawn that he drove people away. Furthermore, he nearly drove her crazy around the house, because he was so disorganized, forgetful, messy, undependable and sullen.
Larry, in his turn, admitted some of his shortcomings. He said he believed his tendency to put things off indefinitely, to refuse to make commitments, stemmed from his “passive aggressive” tendencies. He admitted his shyness in company, but said that Daisy abandoned him at parties, chattering away with ease while leaving him to stand silently nearby, feeling like an awkward, resentful outsider. After years of therapy, Larry attributed his social difficulties to his relationship with a domineering mother whom he could never please. Daisy, he said, reminded him of his mother.
All this sounded like a familiar combination of marital and family-of-origin issues until Larry described certain other symptoms a chronic sense of chaos and disorganization that made it almost impossible to set priorities in any areas of his life, difficulty organizing his thoughts when writing or speaking, constant trouble keeping to a schedule. Larry’s symptoms could be explained by depression or anxiety, or perhaps, as his wife believed, they might be weapons in his battle with her.
But the therapist suspected the possibility of a learning disability, an attention disorder or both. Did Larry have the same difficulties in childhood? When and how did he experience these problems now? How did they affect other aspects of his life besides his marriage?
With almost palpable relief, Larry said that he had been haunted by these symptoms all his life, and he poured out a history of struggle that his wife had never heard. He was always a very slow reader and a poor, badly organized student. He got through college and dental school by sheer force of will. Ironically, but not atypically for LD and ADHD/ADD patients, his parents and teachers attributed his poor performance to laziness or defiance. Larry accepted their explanation because he had no other way of understanding his difficulties. In short, as a child, his teachers made him feel stupid, while as an adult, his therapist made him feel deeply neurotic.
Getting through each day, he said, was an endlessly repeated, desperate struggle, like climbing the same steep mountain over and over. Not surprisingly, when he returned home at night exhausted, fuming with suppressed frustration, wound tight with tension, he avoided talking with his wife because he felt too tired to find the words and too afraid he might explode into helpless, inchoate rage all he wanted to do was collapse in front of the television. Yet, on weekends, this same silent, tense and morose man suddenly burst into explosive activity getting up noisily at six a.m. to go jogging, hustling his family off on day-long outings and to sporting events that exhausted them but left him still keyed up on Sunday night.
Daisy watched Larry’s unpleasant and oddly contradictory behavior his lugubrious silences during the week and his apparent disinterest in her, his frantic pursuit of action on the weekends, his boredom with their friends and could come to only one conclusion: he clearly didn’t love her anymore and wanted out of the marriage. The more silent and uncommunicative he was, the more frightened and angry she became. The harder she pressed him for a response to her increasingly distraught demands, the more anxious and ashamed of his own failures he felt, and the more deeply he retreated into his own shell.
Ironically, Larry was anything but a failure; in spite of a lifetime spent scrambling over massive hurdles, he had succeeded professionally and personally to an astonishing degree, making use of other talents besides the linguistic capacities usually rewarded in our society. Instead of academic facility and organizational skills, his abilities had taken other forms wisdom about people, manual dexterity (he was an unusually skilled and gentle dentist), empathy, courage and an almost unlimited fund of determination. It was a very important first step of therapy to make sure that Larry understood these very real gifts and the magnitude of his accomplishments given the shackles he had always worn. Only when the therapist had helped him see what he had achieved, did she suggest that his problems might, at root, have nothing to do with a failure of intelligence, creativity and moral character, or with vague, never fully understood childhood issues. Instead, they probably stemmed from neurobiological factors over which he had no control and which affected his ability to learn, particularly in areas of reading and writing, as well as his capacity to pay attention.
AT THIS SUGGESTION, LARRY WAS first astonished, then he slowly began to nod as if he were hearing, at last, something vital that he had always known, but never before had the words to describe even to himself. With obvious deep relief and emotion, he said that in all his years of therapy, the words never before really clicked, as they did now, with his felt experience of life. Now, as the jarring inconsistencies of his life began to assume a coherent pattern, he could imagine that he might not be the shameful failure he had always thought he was, but a strong, determined man who had triumphed over quite extraordinary odds.
Larry’s wife could now begin to look at Larry with new eyes, seeing somebody she had not really known before, a man who was not distant and secretive, not anti-social and self-centered, but struggling valiantly with difficulties she could hardly imagine. “I never knew what he has to go through every day,” she said tearfully. “It explains so much that I resented about him.” Once she understood that much of his behavior was caused by neurobiological factors that he could not help, a large part of her anger evaporated. As she became less critical and resentful, more supportive and understanding, he felt less defensive and demoralized, more confident and motivated to learn better strategies for dealing with the social occasions that she enjoyed.
Like Daisy, spouses often assume the worst about the behavior of their mates. They interpret symptoms of LD, such as long silences, difficulty with verbal expression, and forgetfulness, or symptoms of ADHD, such as inattention, messiness, chronic lateness, moodiness and restlessness, as signs of hostility, callousness or indifference. The responses of the spouse often contribute to highly dysfunctional interactions around the LD or ADHD, which then spread to all aspects of their interaction.
Many couples have had a long history of a complementarity in which the nonaffected spouse compensated for the functioning of the LD or ADHD partner, a pattern that though initially seeming benign, can become highly problematic. Tony, for example, depended upon Nelly’s facility with language, while she tended to lean upon him as an “older man” who gave her the parenting she never had; she was his voice, and he was her pillar of strength. As she matured and came to need are placement father less, however, she also became less willing to conduct him, step by step, through the world of written and spoken language. He, in turn, felt her defection to be an attack on his ability to care for women and a frightening abandonment to a hostile world in which he had no place.
Once the secret is out on the table, however, the diagnosis of LD or ADHD can come as kind of a revelation, fundamentally altering the meaning of behavior that has seemed to the other partner inexplicably perverse and destructive. Not only does the new explanation often dramatically reduce the reproach and blame, it frees up enormous energy that the spouse with LD or ADHD has formerly invested in covering up and concealing the shameful secret. Often, apparently intractable marital problems dissolve in an astonishingly short time. When Larry and Daisy came in for the fourth session, for example, they said they didn’t think they needed further marital therapy, because the knowledge of Larry’s learning disability and attention difficulties had so radically altered their interaction with each other. The assumed reason for Larry’s behavior, and thus the source of Daisy’s anger, had all but evaporated.
GIVEN THE PREVALENCE OF LD AND GADHD in the general population and the enormous suffering they entail, therapists should be as sensitive to their telltale signs and symptoms as those of depression, anxiety or any other diagnosis. And, like other clinical conditions, LD and ADHD may be recognized by the therapist before the patient is aware of them.
For example, Tony often responded to the therapist’s words with the phrase, “without a doubt,” at exactly those moments when he seemed to be having the hardest time following her. His confused and bewildered look signalled that he did in fact feel very serious “doubt” about what she was saying. Furthermore, he fumbled for words, often repeating a phrase, and sometimes answered a question as if he were still thinking about the previous question. Other LD patients sometimes seem very articulate when speaking voluntarily, but fall silent when they are asked even relatively neutral questions, as if they have problems processing the question or retrieving the words needed to answer. These clues, however, are subtle; most people with LD or ADHD are highly skilled at concealing their difficulties.
A patient with ADHD may have trouble sitting still and listening, and is likely to be jittery and restless, explosive and impulsive. For example, ADHD was identified in Michael, another violence-prone man who verbally and physically abused his girlfriend. Michael would become so agitated in joint sessions with her that, whatever the content of the discussion, he would have to pace up and down or leave the room. Like a small child trying painfully hard to sit still and be good, he nonetheless could not stop impulsively interrupting the therapist, or allow her attention to shift away from him and to his girlfriend even for a few seconds. When he was alone in sessions, he interminably and obsessively ruminated aloud about his girlfriend what she did, what she said, what he thought she was thinking and feeling and could not, however the therapist prodded him, refocus his attention on his own experiences and feelings. These qualities impulsivity, restlessness, perseveration and a history of drug abuse are all clues that the therapist should at least consider the possibility of ADHD.
Taking an educational history as part of the assessment can help the therapist determine whether or not LD or ADHD is present. Indeed, not only had Michael been chronically impulsive, agitated and subject to uncontrollable rages since childhood, he had been diagnosed as hyperactive in grade school. Another clear telltale symptom was Michael’s former drug abuse with cocaine, which he used, he said paradoxically, because “it mellowed me out.” That cocaine, an intense stimulant, had the same calming effect on Michael as Ritalin, a stimulant prescribed for hyperactive children, is highly suggestive of ADHD. But in all his years of drug abuse treatment, no clinician or counselor had ever considered ADHD as a possible factor in his condition; ironically, becoming “drug free” had robbed him of the one substance, however destructive, that had allowed him some control over his life.
Once a therapist suspects a learning disability or ADHD, he or she must carefully gauge the patient’s need to preserve secrecy, and broach the issue with great sensitivity, and only when the patient is able to hear it. While people with LD or ADHD can often feel enormous relief and gratitude to discover that they are not stupid, inadequate or lazy, timing of the information is important. These patients, already feeling inherently flawed when they come to therapy, may receive the premature suggestion of LD or ADHD as another body blow to their self-esteem; without proper preparation, they may feel, “so, there really is something terribly wrong with me, after all, and besides, it’s permanent. Thus, as important as it is for the therapist to make patients aware of the reason for their difficulties, it is at least as critical to help them recognize and accept, at the same time, the abilities and talents they do have. Perhaps the single most important gift of therapy for them is the dawning realization that they are undoubtedly far more intelligent and competent than they have ever believed, but according to different standards than those almost universally privileged in our society. It is, furthermore, the knowledge of this social component to their problem, the stark fact that the culture they call their own does not necessarily recognize or appreciate their particular abilities, that can be a powerful educational and therapeutic tool in their treatment.
FOR WELL OVER A CENTURY, western civilization (unlike many other historical and geographical societies and cultures) has prized just those so-called left-brain abilities linguistic, logical, mathematical capacities that, when they are areas of serious weakness, we refer to as learning disabilities. But cognitive psychologist and educator Howard Gardner argues that human beings are capable of a wide variety of intelligences other than those that are most easily quantified in the standardized tests that measure academic and professional success in our era. Unfortunately, astonishing gifts in music, art, psychology, spiritual awareness, athletics and dance fall outside the very narrow band of skills our society rewards most highly. As a result of this bias, a child who reads and writes up to par but can’t draw and has a tin ear for music would not be in any way learning impaired. On the other hand, if Leonardo da Vinci, Pablo Picasso,
Thomas Edison and Winston Churchill were tested today, they would, based on the historical evidence of their biographies, be considered learning disabled.
For LD and ADHD patients who have always felt stupid and incompetent, the discovery within themselves of undreamt-of capacities for music, spatial awareness, movement, sports, or interpersonal relationships, traditionally undervalued in the Western educational system, can be a revelation with the power to transform their lives. More prosaically, but just as important, simply placing the learning disability within a larger context of real and undeniably significant skills reduces the sense of limitation to more manageable, less destructive proportions. LD or ADHD becomes less shameful in their eyes, more an ordinary human imperfection, one easily outbalanced by the weight of their strengths.
If LD is suspected, the therapist can make a referral for a neuropsychological evaluation, which can help to pinpoint specific areas of weakness, locate areas of functioning amenable to remediation, and offer direction for vocational and professional development. To clarify a suspected diagnosis of ADHD, a therapist may administer a behavioral checklist, as well as carefully review a client’s history to determine whether symptoms of inattention, hyperactivity or impulsivity have been present from early childhood. It is important to remember that by adulthood, the hyperactivity associated with ADHD has often disappeared, leaving instead symptoms such as restlessness, distractibility, difficulty completing tasks, severe procrastination and impulsivity.
Once a therapist is reasonably sure that a patient has an attention disorder, it is helpful to consult a psychopharmacologist for possible medication. The psychopharmacologist must have specific knowledge of ADHD because the field is so new that even experts in psychotropic medications may not be familiar with ADHD. A short-term trial of a psychostimulant like Ritalin may actually confirm the diagnosis if it dramatically reduces the symptoms and improves the patient’s overall functioning.
Sally, for example, who had lost several jobs because of her failure to complete work assignments and her explosive temper, was motivated to try psycho-stimulants. Not only did the medication enable her to be more emotionally present less distracted and irritable in her relationships, but more effective at work.
But even without more specific diagnostic interventions, the recognition and acknowledgment of LD or ADHD as a plausible and convincing explanation for seemingly inexplicable difficulties, can in and of itself be therapeutic. For example, for Larry, the simple knowledge of his disability afforded much relief in his personal life, by reducing his wife’s hostility and his anxiety. Since he did not want to go on medication, he was not interested in an evaluation for ADHD. And because he had already worked out good enough strategies for meeting his professional responsibilities, the lengthy and costly process of a neuropsychological evaluation did not hold much attraction for him.
Just because a patient recognizes and accepts the diagnosis of LD or ADHD, however, does not necessarily mean that there is not emotional fallout from this new understanding. After the initial, and often dramatic, sense of relief from finally knowing an underlying cause of their own difficulties, many patients then experience an upwelling of long-buried grief and anger for their own lost years, as well as resentment at their partners for not understanding them, or even inadvertently contributing to their sense of humiliation. One man, for example, bitterly recalled his wife’s barely concealed impatience and disdain when he had to ask her to help him re-write his disjointed work-related reports, which he simply could not manage. She, on the other hand, had resented him for what she thought was manipulating her into covering for his carelessness and lack of perseverance.
Understanding the precise nature of a learning disability or attention deficit disorder helps clinicians both understand difficult or puzzling interactions with patients during sessions and adopt specific methods to improve communication with them. An adult with verbal processing problems, for example, may be unable to absorb detailed or extended interpretations from the therapist, just as he or she has always had a hard time taking in lengthy complaints and commentary from family members. For such patients, it is helpful for the therapist to deliver all comments briefly, clearly, pointedly, but in a slow, calm voice that reduces the anxiety already exacerbating the patient’s difficulty understanding what is being said. A person with memory problems may need to take notes during a session or the therapist may have to educate family members to break communications into chunks that can be remembered and answered.
A person with ADHD may require an active and structured clinical approach, organized around small, manageable pieces of concrete work. Mastering a strategy for establishing a morning routine, for example getting up, dressed, breakfasted and off to work with minimum chaos may itself be a significant therapeutic accomplishment for the patient.
The important point for the therapist to remember, whatever the intervention, is that most learning-disabled people grow up in our society believing that they have no worthwhile talents or abilities at all, that they are defective because they have failed the only intellectual tests our civilization really allows them to take. Their successes were often acquired by using alternative, socially invisible intelligences intellectual guerrilla tactics to burrow under the gates of achievement that otherwise remained closed to them. But in spite of quite formidable accomplishments, they generally do not know what they have done, nor what their disability has cost them. They live in shame and secrecy, crippled by an entirely false belief that they are impaired. Unhappily, their experiences of therapy have too often simply recapitulated their sense of failure, producing, along with elaborate new psychosocial diagnoses, even more frustration, disappointment and self-hatred.
To help people with LD and ADHD understand the neurobiological origins of their difficulties, to enable them to begin measuring themselves according to richer, more variegated, more universal criteria, and finally to teach them to recognize, often for the first time, the extent of their own accomplishments and gifts, should be the mainspring of their therapy. Once this key is turned, new doors will open for them, not only to a better understanding of their own natures, but to a world of relationship no longer mired in misunderstanding and pretense.
REFERENCES
Babcock, J.C., Waltz, J., Jacobson, N.S. and Gottman, J.M. (1993) Power and Violence: The relation between communication patterns, power discrepancies and domestic violence. Journal of Consulting and Clinical Psychology, 61, 1, 40-50.
Gardner, H. (1983) Frames of Mind: The Theory of Multiple Intelligence. New York: Basic Books.
Ratey, J.J., Greenberg, M.S., Bemporad, J.R. and Lindem, K.J. (1992) Unrecognized attention-deficit hyperactivity disorder in adults presenting for outpatient psychotherapy. Journal of Child and Adolescent Psychopharmacology, 2, 4, 267-275.
Silver L.B. (1984) The Misunderstood Child: A Guide For Parents of Learning Disabled Children. New York: McGraw-Hill.
Silver, L.B. (1992) Attention-Deficit Hyperactivity Disorder: A Clinical Guide to Diagnosis and Treatment. Washington, D.C.: American Psychiatric Press, Inc.
Gillian Walker, M.S.W., and Susan M. Shimmerlik, Ph.D., are founders, with Patricia Heller, of the Families, Learning Disabilities and Attention Disorders Program at the Ackerman Institute for Family Therapy.
