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10 CEUs Treating Locking In & Blocking Out: ADHD Adults

Section 22
Imago Relationship Therapy for Clients with Adult ADHD

Question 22 | Test | Table of Contents | ADHD CEU Courses
Social Worker CEUs, Counselor CEUs, Psychologist CEs, MFT CEUs

Little has been written about how to help individuals who have ADHD in relationships, but several authors have written about the application of Imago Relationship Therapy and similar communication strategies with couples affected by ADHD. My husband who has ADHD and I attended an intensive Imago Couples Weekend Workshop, in which I experienced the power of the process firsthand. I have now incorporated Imago Relationship Therapy into my ADHD clinical practice and find it extremely ADHD-friendly, although helping some clients calm their reactivity sufficiently to hear their partner fully can be quite challenging. However, once they learn the process, they too appreciate the benefits. Imago Relationship Therapy (IRT), a couples treatment, was originally developed by Harville Hendrix and popularized in his book Getting the Love You Want: A Guide for Couples. Those interested in a more comprehensive description of Imago Relationship Therapy can consult Brown’s book about the theory and practice of IRT and Luquet’s practical guide to short-term IRT, which includes handouts, session formats, and client exercises.

The primary tool used to teach couples to communicate more effectively is called The Couple’s Dialogue. It is a structured process that helps create the emotional safety required for people to communicate their needs or vulnerabilities to each other, without being defensive. It restores empathic connection, which allows people to relax their defenses. Most of us resort to angry criticism, loud repetition, outbursts, tears, or defensiveness when communicating to a loved one about a "hot topic." When we survey our environment and experience it as safe, we feel free to play, nurture, and mate. However, if our reptilian brain senses "danger" (a critical spouse/parent), we tend to respond in characteristic self protective patterns. Some people "hide" in a shell as a turtle does and withdraw, isolate, disengage, or avoid—these are the minimizers. Others maximize their energy outwardly and go after the loved one, demanding to be heard, yelling, lecturing, or becoming overly emotional. These instinctive reactive patterns exist in all dyads and tend to exacerbate conflict or power struggles. The goal of using the dialogue process is to help individuals learn to calm their reactivity and to listen to their partner in an attempt to understand, validate, and empathize. This internal reactivity is typically even stronger in relationships in which one or more of the individuals has ADHD.

The Couple’s Dialogue process is a brain-based approach compatible with the neurological challenges and relationship deficits involved in living with ADHD. It involves quieting the reactive old brain and engaging the reflective new brain. It is an ADHD-friendly process because it slows events, provides structure, reduces reactivity, and helps the receiver be fully present so that the sender can be fully heard. It facilitates understanding and problem solving. The dialogue procedure is quite simple, but it does require vigilance in monitoring its adherence. This dialogue procedure is best used when a member of a dyad wants to be listened to and understood, is upset about something and wants to discuss it, or would like to address a difficult or sensitive topic. When a therapist is present, the best format is to position the dyad facing one another (to maintain eye contact), in fairly close proximity, while the therapist sits perpendicularly to the couple and serves as a guide to facilitate the process. The overall dialogue process consists of three parts: mirroring, validating, and

Initiating a Dialogue
The person who wants to send a message would initiate the dialogue by asking the other person, "I would like to have a Couple’s Dialogue (or just a Dialogue, if it is with a teen). Are you available now?" It is the Receiver’s job to agree to have a dialogue as soon as possible, now optimally. If not now, the Receiver must set a time to do so and commit to it. If available, the Receiver replies, "I am available now." The Sender then begins to send the message, ideally by focusing on communicating the emotional impact of a situation/ behavior/event on him or her, rather than by attacking or criticizing the other.

After hearing the message, the Receiver then mirrors back what he or she heard by saying, "If I heard you correctly," or "If I’ve got it right, you said," and then paraphrasing the Sender’s message. It is important that the Receiver not be allowed to edit any of the material or react to it while mirroring it. The "mirror" must be neutral (accurate), not concave or convex; otherwise the reflection will be distorted, as in a fun house. The Receiver then asks, "Did I get it?" The Sender then says, "Yes," or corrects the Receiver as needed. The Receiver mirrors the correction and asks again whether that is correct. After accurately reflecting back the Sender’s material, the Receiver asks, "Is there more?" This question must be asked in a tone that conveys a genuine desire or willingness to know more, rather than an exasperated tone conveying that the Receiver cannot handle more. The Sender then continues sending the message until it is completed and the Receiver continues to mirror, check the accuracy of it, and invite the Sender to say more until the Sender says, "No, there is no more." At this point, the Receiver summarizes the Sender’s entire message—"Let me see whether I got all of that"—and then checks for accuracy: "Did I get it all?" The Sender listens to the summary and then gives the accuracy check (e.g., "Yes, you got it all," or, "You got most of it but you missed . . . ).

Once an accurate summary has been made, the Receiver goes on to validate the Sender’s point of view by saying, "You make sense, because . . . " and then briefly stating the logic of the Sender’s message. The Receiver is to make sense of the Sender’s message without necessarily liking it or agreeing with it or even making sense of all of it. It is important that the Receiver not ramble off on a lengthy discourse interjecting her or his own reaction or opinion at this stage. The Receiver merely states what part makes sense.

Last, the Receiver must empathize with the Sender by saying, "I imagine you might be feeling . . . " or "I can see that you are feeling . . . " if feelings are obvious. The Receiver chooses two or three feeling terms (i.e., angry, hurt, frustrated, not respected ) in guessing how the Sender feels or felt and then checks for accuracy. "Is that what you are feeling?" or "Did I get it right?" The Sender then confirms the guesses, adds to them, or corrects them. The Receiver mirrors this and, if appropriate, asks, "Is there more about that feeling?"

Exchanging Roles
When the Receiver has gone through all three parts (mirroring, validating, and empathizing), she or he would say, "I would like to respond now." The Receiver now becomes the Sender and vice versa. The process described is effective in helping dyads connect and understand one another in ways that typical "conversations" do not allow. It delights me to bear witness to the transformation in empathic connection that occurs when couples use this approach. What one moment seemed to be an insurmountable obstruction melts into a genuine understanding of the other’s perspective. When guiding couples and parent–teen dyads affected by ADHD through the dialogue process, it is important to keep in mind certain modifications that may be useful in accommodating ADHD behaviors. Inhibiting impulsivity and reactivity during the dialogue may be particularly challenging for many hyperactive and hyperemotional teens and adults. The therapist should offer support to the impulsive or reactive person to help him or her contain reactivity and maintain self-control. Afew reassuring words and praise for effort can help.

Many individuals who have ADHD struggle to retain lengthy messages from the sender in their short-term memory long enough to mirror them back accurately and may become overwhelmed by excessive information. Information overload can cause them to forget almost everything they just heard. To prevent this, I suggest that the therapist direct the sender to send only short messages, pausing between sections of longer material. At times it is necessary to remind the participants of this by gently requesting that the sender pause briefly, so as to allow the receiver to catch up.

Clinical Issues and Summary
Most individuals who have ADHD experience some relational challenges with partners, children, friends, and employers. However, there are effective strategies available for therapists to utilize with ADHD challenges to enhance good communication and strengthen relationships. Imago Relationship Therapy (IRT) is a brain-based approach that is highly compatible with ADHD. It facilitates healthy communication by slowing the process, providing structure, and containing reactivity, so that the participants can fully hear one another. It encourages the development of stronger listening skills and better self-control to enhance understanding and problem solving. However, there are no controlled outcome studies using IRT with clients who have ADHD. Other strategies include encouraging clients to perform caring/loving behaviors for their partner, such as calling at lunchtime, massaging their feet, or taking them coffee. Going on regular dates together and finding ways to laugh and have fun together are also very important. Giving each other surprises, such as flowers, goodies, love notes, or tickets to a favorite event, also enhances relationships. Couples, and parents, are encouraged to express appreciation daily, acknowledging the efforts of loved ones and thanking their spouse or child for performing certain task / behaviors and complimenting one another. Finally, it is important for individuals who have ADHD to take responsibility for managing their ADHD by taking prescribed medications faithfully, exercising regularly, and maintaining an ADHD-friendly lifestyle, in order to reduce the impact of the disorder on their loved ones when possible. Spouses of individuals who have ADHD must also educate themselves about the disorder to prevent misinterpreting their partner’s behavior or contributing to the creation of an ADHD-unfriendly environment. Keeping these strategies in mind, therapists can play an important role in assisting ADHD individuals in enhancing their relationships and building new communication skills for life.

-Robbins, CA; ADHD Couple And Family Relationships; Enhancing Communication And Understanding Through Imago Relationship Therapy; Journal of Clinical Psychology; May 2005; Vol. 61 Issue 5, p565

Personal Reflection Exercise #8
The preceding section contained information about imago relationship therapy for clients with adult ADHD.  Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article Reference:
Cohen, E., & Kalanthroff, E. (2019). Visuospatial processing bias in ADHD: A potential artifact in the Wechsler Adult Intelligence Scale and the Rorschach Inkblots Test. Psychological Assessment, 31(5), 699–706.

Kofler, M. J., Sarver, D. E., Austin, K. E., Schaefer, H. S., Holland, E., Aduen, P. A., Wells, E. L., Soto, E. F., Irwin, L. N., Schatschneider, C., & Lonigan, C. J. (2018). Can working memory training work for ADHD? Development of central executive training and comparison with behavioral parent training. Journal of Consulting and Clinical Psychology, 86(12), 964–979.

Stanton, K., Forbes, M. K., & Zimmerman, M. (2018). Distinct dimensions defining the Adult ADHD Self-Report Scale: Implications for assessing inattentive and hyperactive/impulsive symptoms. Psychological Assessment, 30(12), 1549–1559.

What are the five steps in a "Couple’s Dialogue"? Record the letter of the correct answer the Test.


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