It is our pleasure to be able to catch up with some of our staff, alum, students and affiliates. Today we talk to Larry Maucieri, PhD, ABPP-CN about his practice and his new book, The Distracted Couple.
TFI: Tell us a bit about your career, and about your affiliation with The Family Institute.
LM: My undergraduate majors at University of Illinois were in music theory and economics (very math focused!) so I was not even involved in psychology until after college. I was introduced to psychological assessment and therapy methods when I worked at an insurance company and that prompted a career change for me. I earned a MA degree from NYU and a PhD in clinical psychology from Fordham University in the Bronx. My clinical internship was at Yale and then I did a neuropsychological postdoctoral fellowship at Northwestern Memorial Hospital with Drs. Sandra Weintraub and Robert Hanlon.
By training I am an adult clinical neuropsychologist, and I just recently completed my ABPP board certification in neuropsychology, which is the highest credential for the sub-specialty. Early on, my clinical work consisted of just assessments of adults for dementia, the effects of stroke, tumors and head trauma, and sometimes learning disabilities and ADHD. I first joined the Family Institute in 2008 and my early clinical work was focused in assessment of these areas. Within a few years though I took more of an interest in individual psychotherapy and in particular the applications of CBT within a relational context to help adults impacted by ADHD.
Simultaneous to my Family Institute position, I was a faculty member at the Adler School and as of 2011 a tenure track professor at Governors State. In recent years I have had a much more active – though still part time – therapy practice at Family Institute focused on adults who have ADHD or who are impacted directly or indirectly by neurological events, such as disabling strokes. I find the blending of neuropsychological knowledge and therapeutic techniques to be a really powerful combination. I love working with adults with ADHD for both assessment and therapy. I still do neuropsychological assessments regularly, but I am interested in developing more skills in cognitive rehabilitation as well to implement some of those tools in my work with adults and significant others impacted by ADHD, head trauma, stroke, or other neurological events.
TFI: The description of your book addresses how the focus of ADHD treatment and diagnosis has historically focused on children, and that adult ADHD and its impact on couples has not been sufficiently explored. Why do you think this has been the case? In what ways is adult ADHD different than that of children’s?
LM: Right, the concept of ADHD symptoms lingering on into adulthood is a relatively new one. The history of ADHD in America and other countries, by a number of different names and diagnostic criteria, has always been focused on the impact of the condition in children. And with good reason. It is first and foremost a neurodevelopmental disorder, and so there cannot be new onset for ADHD after age 12 or so by DSM-5 criteria. However, the previous wisdom was that ADHD only impacted children and adolescents, so that by adulthood the symptoms were significantly minimized if not gone. Part of the reason for this is because there was always so much focus on ADHD in childhood. If you skim the DSM-IV and DSM-IV-TR criteria for ADHD the behaviors described in the symptoms are obviously geared more toward childhood experiences. Also, the nature of ADHD in the adult lifespan is different than it is in children and adolescents. In some ways it is more subtle in adults than in children, and that is why the DSM-5 reduced the symptoms needed for each cluster of ADHD (inattentive and hyperactive-impulsive) from 6 to 5 for individuals over age 17.
A more accurate conceptualization of ADHD in adulthood is that it tends to manifest in a different way. It is more evident through symptoms of inattention, reduced focus, disorganization, and poor planning. Children are more likely to have the hyperactive elements of ADHD, but both children and adults can have impulsivity in their behaviors. Interestingly in adults ADHD commonly co-occurs with other problems, such as depression, anxiety, substance use, learning disabilities, and Tourette’s syndrome. The lack of impulse control and/or diminished self-esteem common in adults frequently may lead to problems with anger, and almost always relationship and/or work performance problems.
TFI: In addition to noticing the gap in exploration of adult ADHD (and its impact on relationships), how did you develop the topic of your book? Why did you decide to focus on couples as opposed to only individuals dealing with adult ADHD?
LM: Not long after I joined Governors State, Dr. Jon Carlson (who is a professor there) and I discussed a book that might overlap in both of our areas of interest. Most people know him through all of the APA videos that he hosted with well-known therapists who demonstrate therapeutic techniques in a specific modality. However, he has also published over 50 books primarily on couples and families and he works clinically with couples as well. My interests, as noted above, include ADHD.
So we conceptualized a book written specifically for therapists and counselors on unique problems and interventions for couples impacted by adult ADHD, and specifically where one partner or both had ADHD, rather than parenting children with ADHD. As we researched the literature we found that there were a few general public advice books on the topic but little if anything for clinicians. Certainly there was no handbook to address the topic. So we contacted several publishers with our ideas and ultimately decided to publish with Crown House.
The publisher and both of us realized that it was a sorely needed area to address. A few individuals were looking at the impact of ADHD on couples in articles, popular press books, and workshops, like Melissa Orlov, but it was a really under-represented area in the professional literature, and to have a book with a number of different contributors each providing their conceptualizations about the core problems and interventions for ADHD in couples was really something totally unique. So we were very hopeful it would be a very valuable contribution.
TFI: Editing a book of this nature is a big undertaking. Tell us a bit about the process of putting the book together—were there any surprising insights along the way? Any unexpected hiccups? Are there ways in which editing this book has impacted your practice and/or teaching?
LM: Yes, I had never edited or written a book before so it was all new to me. The Hollywood conceptualization of sending in a finished manuscript and it getting published immediately was challenged pretty early on, as we needed to provide a fairly detailed chapter by chapter account of each topic in the book, the authors associated with each chapter, and the justification for why this book should be accepted for publication right from the start. The publishers we talked with each used a peer-review process of sorts, not as rigorous as a journal article, but something similar to that approach. I find it incidentally kind of hilarious that the academic setting does not hold edited books in as high regard as peer-reviewed journal articles considering the work involved and the scrutiny at multiple levels, but that is a long-standing tradition that is not going to change.
Early on I contacted numerous authors who had published or were known to work with ADHD and/or couples. Interestingly, they tended to fall into one of these areas or the other, not both. At that point it was really all networking and explaining what our project was about. Responses were generally positive, and even the biggest names in ADHD, like Russell Barkley, while not available to write a chapter for us, was very encouraging of our project. After the project was completed Ned Hallowell, whom almost everyone knows from his best-selling book Driven to Distraction, loved our book and eagerly endorsed it very favorably. Despite his reputation he was extremely approachable and supportive.
In some ways I struck gold when I contacted Dr. Ari Tuckman who does a lot of work with ADHD in Philadelphia and who publishes on ADHD often as well. Ari was an absolute treasure trove of networking connections in ADHD and was so in support of our project that he used his own feelings about the book to help recruit a number of other authors as well. The other contributors we found through personal connection or scoping the literature on couples work and ADHD.
Editing was a fairly arduous process in terms of the volume of work (the book runs about 360 pages I think), the organization of the deadlines, providing feedback, and multiple revisions. Content was generally not a major problem as the contributors were all so well acquainted with the topics and had very well developed ideas. In some instances there were differences in opinion regarding editing but these were worked out easily. Ironically, a few contributors themselves had ADHD which impacted their meeting deadlines for the book, so they needed a little more support but all did fine with it.
I would not say that editing itself really altered the way I teach or practice, but one of the real perks of the editing process was how much I learned from the contributors of the book about couples work and ADHD! They are all so knowledgeable and skillful on the topic, and it was great to be part of a team that was working together to contribute something rather new to both ADHD and couples therapy. Also, several of us, including myself, now have a monthly blog we contribute on topics related to adult ADHD through the Psychology Today website.
TFI: In your expert opinion, what are a few of the ways an issue like ADHD can impact a relationship? Are there any pervasive misunderstandings/myths when it comes to adult ADHD, and/or about its impact on relationships?
LM: These sorts of questions are what really makes the book so useful for clinicians. As our contributors note there are a number of specific dynamics and interpersonal interactions that develop over time in a relationship in which one or both partners has ADHD. Each of the authors had a slightly different take on these concerns and how to best address them, from Ari Tuckman’s focus on executive impairments in relation to ADHD, to Melissa Orlov’s unique model for working with ADHD-impacted couples, to the contributors who examined the unique elements of ADHD in couples in certain socially marginalized groups. One contributor (Susan Tschudi) even shifted the focus in the relationship from the individual with ADHD to his/her partner who did not have ADHD but was nonetheless still impacted by.
In general though, the types of issues that tend to recur in relationships impacted by ADHD involve breakdowns in communication and compensatory behaviors that become untenable. Over time, the partner with ADHD almost always develops personal shame about his/her incapacity to meet the demands of the relationship, home life, or work. Nearly every individual I have worked with in a therapy or an assessment capacity with ADHD has some sense of deep personal shame or self-loathing about how ADHD has derailed them in a major aspect of their adult lives. Given the feedback they have received over time and society’s skepticism about the condition, there is almost always a question in their minds about whether they really have ADHD or if ADHD is even real. In my opinion this is actually fueled in part by some of the sloppy diagnostic practices of clinicians in not adequately assessing for ADHD and/or ruling out all other possible explanations when initially making the diagnosis of ADHD in children and adults.
So, the partner without ADHD may nor may not voice distress about missed chores and undone tasks immediately but it comes out eventually in some form. Another interesting component in this mix is that the partner without ADHD often begins to then compensate for the behaviors of the one with ADHD – completing the laundry when its left undone, picking up the kids forgotten at school – but this breeds resentment and over time the relationship begins to resemble more of a parent-child dynamic rather than a relationship of equals. Once that begins the cycle is further reinforced. There is really no way out of it at that point without intervention.
Finally, another interesting component of the ADHD-impacted couple is that much of the time the partner without ADHD also feels skeptical about ADHD or at least ADHD in his/her partner. This means that the interpretation of task failures becomes one of character rather than as a symptom of the disorder. Instead of procrastination, distraction and unfinished tasks seen as an inevitable consequence of ADHD that is not well controlled, it is interpreted as laziness, not caring, or selfishness. This of course leads to another set of problems for the couple.
Finally as you might guess, adult ADHD often has a devastating consequence at work as well. However, that is not always the case, particularly if the individual with ADHD is in a highly structured work environment, is in a work environment where there is not a lot of attention to detail required, or really enjoys the work and so it can draw his/her attention for long periods of time (what is sometimes referred to as hyperfocus). ADHD in the workplace is a whole different book but I mention it here because off concurrent with the relationship issues is difficulty maintaining or finding work, and so financial stress or at least difficulty managing money is often an additional stressor for couples already impacted by adult ADHD.
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