When the analytic patient has attention deficit hyperactivity disorder

Most analysts are now treating or can expect to treat adult patients with cognitive deficits such as attention deficit hyperactivity disorder (ADHD), based on the prevalence of this syndrome in children and its continuation into adulthood. ADHD is a cognitive disorder considered by nonanalytic and analytic writers to be a dysfunction of affect regulation and behavioral inhibition. Analysis deals with these issues, and most analytic theories address affect regulation. Manifestations of ADHD can mimic the clinical expression of intrapsychic conflict, in which the cognitive deficits are embedded. If these symptoms are interpreted primarily as transference resistances without acknowledging the cognitive contribution, the patient may experience a resurgence of feeling misunderstood and shamed, helpless and defective. Confusion in the countertransference is a hallmark of analyses in which cognitive deficits are intertwined with psychic conflict, sometimes leading the analyst to compartmentalize the cognitive and the conflictual and to miss aspects of the patient and the process. Appropriate action within the analytic frame may be needed to help the patient seek information, specialists, or coaches to deal with limitations in executive functioning. A variety of technical considerations and confusions in the countertransference are illustrated.