If you persist in throttling your impulses you end by becoming a clot of phlegm. You finally spit out a gob which completely drains you and which you only realize years later was not a gob of spit but your inmost self. If you lose that you will always race through dark streets like a madman pursued by phantoms. You will be able to say with perfect sincerity: "I don’t know what I want in life."

-- Henry Miller, Sexus

"I have wasted most of my life," said Andrea, a fifty-year old unemployed woman. "I have achieved nothing, I have no excuse for existence. I haven’t justified my existence yet."

Guilt, shame, and self-judgement are commonly heard when one interviews adults with attention deficit disorder. Low self-esteem and a merciless self-criticality are so much part and parcel of the ADD personality that it would be difficult to know where ADD ends and low self-esteem begins. Many of the traits thought to be caused by attention deficit disorder are, I am convinced, not the expressions of the specific neurophysiological impairments associated with ADD but of low self-esteem. Workaholism, drivenness, and inability to say ‘no’--all endemic in the adult ADD population--are some of the examples discussed in this chapter.

In the ADD child low self-esteem is manifested not just by the self-putdowns she may utter, such as "I’m stupid," or "I’m dumb." Above all, it is visible in the perfectionism and in the dejection and discouragement she experiences when she fails at a task or loses in a game. Nor can she accept not being in the right. The fragile and self-rejecting ego is unable to endure any reminders of its fallibility. Many people with attention deficit disorder retain that fragility into adulthood.

Where do self-judgement and lack of self-respect originate? The conventional view is that the low self-esteem of ADD adults is a natural consequence of the many failures, lost opportunities, and setbacks they have experienced since childhood, owing to their neurophysiological deficits. Plausible as it sounds, this explanation accounts only in small measure for why people with ADD think so very little of themselves.

Andrea, like so many others I have seen, would never hold anyone else under the severe judgement she imposes on herself. When asked, she rejects the idea that people should have to justify their existence. Life is its own justification. To demand that people earn the right to live and breathe is to reject the innate dignity of human life; nor can one logically insist on some arbitrary achievement level as a condition for self-respect.That people do judge themselves so harshly reflects low self-esteem, not low achievement.

Self-esteem, we must realize, is not what the individual consciously thinks about himself. It is the quality of self-respect that is evident in one’s emotional life and in one’s behaviours. By no means are a superficially positive self-image and true self-esteem necessarily identical. In some cases they are not even compatible. People who have a grandiose and inflated view of themselves on the conscious level are lacking true self-esteem at the core of their psyche. Their flattering and exaggerated self-evaluation is a defence against their deepest feelings of worthlessness. The professionally successful workaholic suffers from low self-esteem, no matter what his conscious self-image may be. Some years ago a hapless Toronto study purported to discover that men had higher self-esteem than women by asking people whether they ever felt despondent, or vulnerable, or lonely. Male respondents tended to deny such feelings, hence the study’s conclusions. It appears not to have occurred to the researchers that what they may have been measuring was not, in fact, self-esteem but the denial and suppression of negative emotions--hallmarks of low self-esteem!

There are some adults with attention deficit disorder who exhibit great self-confidence in specific areas of functioning and are high achievers according to social standards. Many others are low achievers who bring little confidence to any field of endeavour. What they share in common is that they all have low self-esteem. The low achievers may believe they would gain self-esteem if their ADD impairments could be eliminated and they could perform better in society’s eyes; the high achievers could tell them otherwise. The wide chasm that may yawn between success and self-acceptance is illustrated by a diary fragment shown to me by a forty-three year old professional with attention deficit disorder who enjoys a high income, the good opinion of his clients, and no lack of public recognition. The diary is typical of attention deficit disorder in the depth of self-laceration it reveals. It is typical, too, in its format, written on dog-eared scraps of paper filed in no particular order, months and years separating individual entries:

I have not achieved enough in life. I feel that my abilities exceed my attainments. I feel I could do more... I vegetate, my ambitions like rotting weeds around me. I want to paint. I want to study languages: French, German, Spanish... What else? I want to exercise. I want to meditate. I want to read. I want to see people. I want to take in more culture. I want to sleep enough. I don’t want to watch junk television any more. I want an end to the binge cramming of food into myself every evening... I want to live!

Characteristically, what this man did not think to write was: I want to learn to accept myself.

Self-esteem based on achievement has been called contingent self-esteem or acquired self-esteem. Unlike contingent self-esteem, true self-esteem has nothing to do with a self-evaluation regarding achievement or the lack of it. It doesn’t say "I am a worthy human being because I can do such and such." It says "I am a worthy human being whether or not I can do such and such." Contingent self-esteem evaluates, true self-esteem accepts. Contingent self-esteem is fickle, it goes up and down with one’s ability to produce this or that result. True self-esteem is steadfast, not subject to that kind of oscillation. Contingent self-esteem places great store by what others think. True self-esteem is independent of others’ opinions. Acquired self-esteem is a false imitation of true self-esteem: however good it makes one feel in the moment, it does not esteem the self. It esteems only the achievement, without which the self in its own right would be rejected. True self-esteem regards who one is, contingent self-esteem sees only what one does.

ADD adults don’t have low self-esteem because they are poor achievers, but it is due to their low self-esteem that they judge themselves and their achievements harshly. Much of the initial counselling I do is to help people recognize that in many ways the problem is not in what they have done in life, but in how they view themselves. There live human beings afflicted with far more debilitating impairments who do not necessarily hold the low opinion of the self prevalent among ADD adults.

The deep shame adults with attention deficit have carried all their lives predates any recollections of poor achievement. The association between low self-esteem and attention deficit disorder is not that the first arises from the second, but that they both arise from the same sources: stress on the parenting environment and disrupted attunement/attachment. In its earliest origins the core self is forged in the attunement contact with the parent. Its healthy development needs the atmosphere of what Carl Rogers had called "unconditional positive regard." It requires that the adult world understands and accepts as valid the child’s feelings, from which kernel the core self will grow. A child taught to still the voice of her innermost feelings and thoughts assumes automatically that there is something shameful about them, and therefore about her very self.

Absolutely universal in the stories of all adults with ADD is the memory of never being comfortable about expressing their emotions. When asked who they confided in when, as children, they were lonely or in psychic pain, almost none recall feeling invited and safe enough to bare their souls to their parents. They kept their deepest griefs to themselves. On the other hand, many recall being hyper-aware of the parents’ difficulties and struggles in the world, of not wanting to trouble them with their own petty and childish problems. The sensitive child, writes the Swiss psychotherapist Alice Miller, has "an amazing capacity to perceive and respond intuitively, that is unconsciously, to this need of the mother, or of both parents..." When I explore with my clients their childhood histories, emerging most often are patterns of relationships in which the child took care of the parent emotionally, if only by keeping her inmost feelings to herself so as not to burden the parent. ADD adults are convinced that their low self-esteem is a fair reflection of how poorly they have done in life only because they do not understand that their very first failure--their inability to win the full and unconditional acceptance of the adult world--was not their failure at all.

Although low self-esteem springs originally from the disrupted attunement/ attachment relationship with the parent, the belief that it is fed by poor achievement is not wrong. Only, the link is not a direct one. In the majority of adults I have interviewed it was evident that the inability to accept themselves was heavily reinforced throughout childhood by their parents’ expectations of better performance, and by their disappointment and disapproval at the absence of it. Superimposed on the parents’ anxieties were the contemptuous judgements and shaming that, throughout their childhoods, many of these ADD adults had experienced in school. Not performance as such but the attitudes of the adult world towards performance defined how many children learned to value themselves.

At our second session I asked Andrea, the fifty yearold self-confessed failure at the game of existence justification, if she had truly never done anything worthwhile in her life. She was silent for a while. "I have tried to be kind to people," she finally replied. "I have tried not to hurt people. I am creative in crafts, I teach people. I do a bit of gardening. But to me those things come easy. That’s just who I am. I didn’t have to work at them much. I mean, I’m not an accountant, I’m not a lawyer." "Would you want to be an accountant or a lawyer?" "It’s not that I feel like doing those things," Andrea said, again after a moment’s pause, "it’s that I think I should feel like doing them. I am still trying to get my father’s approval."

Andrea’s dismissal of her own talents resonated with me. In my undergraduate years and even beyond I had little respect for my ability to write. I could use it to advantage, for example by dressing some pretty thin essays in relatively elegant verbal garb to inflate their value, but I had little regard for it precisely because I felt it came naturally to me. "I don’t trust my words," I would say, "they come too easily." It never occurred to me that possessing a vein of talent did not mean that one could not work diligently at mining it. If I had a facility for something, or if I enjoyed it, it could not be worth much. Unless it was pure blood, sweat, and tears, it could not have value. A case of "I would never belong to any club that would have someone like me as a member." Much the same has been said to me by many adults with ADD. A few have even butted their heads against the wall trying to become accountants, which, in my estimation, must be the profession least suited for anyone with attention deficit disorder. So far as I could see, they were working to convince themselves of their own self-worth by striving to achieve something completely contrary to their nature.

Debra, a woman in her early thirties with a Bachelor of Science degree in Zoology, wanted help with her difficulties remembering and concentrating. "I feel so dumb," she said. "I can never keep up with discussions. People talk about politics and current affairs and I have no head for those things. I try hard to remember facts and names and dates from the newspaper, but it doesn’t stick. I tune out." What Debra does have a mind for is seeking the emotional truth in people’s lives, what their existence is like underneath the surface of social niceties. Her desire to be more adept at social conversation was not an unreasonable goal. It struck me though that she seemed to place a greater value on a facile awareness of peripheral facts, which she did not have, above insight, empathy, and understanding, with which she was gifted.

One of the barriers faced by adults with attention deficit disorder in their quest for self-esteem is that they do not really know who exactly that self to be esteemed is. "It drives me nuts when someone asks me what my feelings are," a student in his mid-twenties said. "I have no idea what my feelings are. I am lucky if figure out what my feelings were hours or days after something happens, but I never know what they are." Since having a strong core self relies on one’s acceptance of one’s feelings, being out of touch with one’s emotional side puts one out of touch with one’s self. What then remains to be esteemed? Only a false self, a concoction of what we would like to imagine ourselves to be and what we have divined others want us to be. Sooner or later people come to realize that this false self--wanting what they think they should want, feeling what they think they should feel--does not work for them. When they look inside themselves they discover a frightening emptiness, a vacuum, void of a true self or of intrinsic motivation. Many a time I have heard ADD adults say, "I don’t know who I am," or, "I don’t know what I want to do in my life."

Women with ADD are especially prone to give a higher priority to protecting the needs of others than on respecting their own. "I don’t know how to say ‘no.’ I’m always so worried about what the other person is feeling," said Catherine, a forty-three year old high school teacher. "I don’t know why. I guess it’s my second nature." As always, people’s language is revelatory. Catherine was uttering a deep truth when she spoke those words: suppressing her own feelings in preference to those of others was second nature to her. It had never been her first nature. It was acquired. Human infants are born with no capability whatsoever to hide or suppress feelings, be it hunger, fear, discomfort, or pain. Healthy newborns are skilled at communicating anger and have a superbly articulate talent for saying "no," as anyone can attest who has witnessed the rage of an frustrated infant or who has ever tried to feed some unwanted substance to a baby. She shouts out her responses to the world, loud and clear. Given the powerful survival value of emotional expression, Nature would not have us give up that capacity unless the suppression of emotion was demanded by the environment. When we forget how to say "no", we surrender self-esteem.

The adult with ADD is buried under the mound of yes’s, many of which are not true yes’s at all, only no’ s he dared not say. Life is one long exercise in trying to tunnel out from under them,a frustrating task since one keeps adding to the stack faster than one can take away from it. As busy as I ever was, I always found it almost impossible to refuse whenever anyone asked to become my patient. My addiction to serving the world got so out of hand that in one memorable month thirteen years ago, the very time we were to move to our new house, I ended up delivering fifteen babies. Most of these were first pregnancies, which meant that labour tended to be long and almost inevitably took up at least part of the night. I became more wan and bedraggled by the day, precisely when my wife, Rae, needed the most help with packing, organizing, and parenting. With the addict’s typical shiftiness, I had not told her what I had taken on. She just noticed me disappearing day in, day out. I was dutiful when at home, as dutiful as a person could be whose mind was buzzing with the self-imposed duties and responsibilities that kept me running day and night. I could feel myself becoming more and more hollow, a non-presence for my family. Behind the image of the busy, empathetic, and selfless physician was a person who, in his desperation to be needed, was willing to sacrifice his personal life. And, too, a person who felt so alienated from his own self that he had to keep running away from any awareness of it.

The need to be needed at all costs comes from one’s earliest experiences. If the child does not feel accepted unconditionally, she learns to work for acceptance and attention. When she is not doing this work he feels anxious, due to an unconscious fear of being cut off from the parent. Later--as an adult-- when not doing something specific, she has a vague unease, the feeling that he should somehow be working. The adult has no psychological rest because the infant and child had never known psychological rest. She has a dread of rejection and an insatiable need to have her desirability and value affirmed by others. Being wanted becomes one’s drug. Self-esteem is pre-empted by its false shadow, contingent self-esteem. What one does and what others think of it take precedence over who one is.

The driven and hyperfunctioning workaholic tries to delude himself that he must be very important, since so many people want him. His frenetic activity numbs him to emotional pain and keeps his sense of inadequacy out of sight, out of mind. During a group psychotherapy session a few years ago I heard one of the leaders say that a truly important person is one who considers himself worthy enough to grant himself at least one hour each day that he can call his own. I had to laugh. I realized I had worked so hard and made myself so "important" that I couldn’t beg, borrow, or steal a minute for myself.

There is one major respect in which the specific neurophysiological impairments of ADD do hinder the development of a core sense of self and the attainment of self-esteem. It is appropriate here to speak hereof a sense of self, because from the neurophysiological point of view the self simply does not exist. There is no neurobiological "self circuit" in the brain, no little gnome pulling all the levers. What we see as the self is really a construct, akin to the optical illusion that makes us believe that a series of photographic images projected onto a screen in rapid progression are people and objects in the real world. The "self" we experience is an unimaginably rapid series of firings of countless neurological circuits. "At each moment the state of self is constructed, from the ground up," writes Antonio Damasio. "It is an evanescent reference state, so continuously and consistently reconstructed that the owner never knows it is being remade unless something goes wrong with the remaking." It is the relative consistency of the repetitious neurological activities of the brain that convinces us there is a solid self. We might say that in ADD this consistency lacks consistency. The fluctuations are greater than most people experience. Thought patterns and emotional states pursue each other with an exaggerated rapidity and across a broader range. It seems there is less to hold on to. Too, self-esteem does require a degree of self-regulation, which the neurophysiology of ADD sabotages. The child or adult easily flung into extremes of emotion and behaviour does not acquire the mastery over impulses that self-esteem demands.

It is ironic, but despite her poor impulse control the ADD adult has persistently throttled her impulses, to use Henry Miller’s phrase. Submerged beneath a surface rippling with superficial and childish impulses are truer impulses for meaningful activity, the assertion of one’s autonomy, the pursuit of one’s own truth, and human connectedness. The deeper these have sunk, the less one knows who one is or in which direction one’s path lies. Attaining self-esteem begins with finding our true impulses and raising them to the light of day.

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