Why people with ADHD quit therapy

Finding a therapist is hard. Finding one who actually understands ADHD? That’s a different problem entirely. Clinical psychologist Dr. Michelle Frank, who has ADHD herself, breaks down why people with ADHD struggle to stick with therapy. She looks at everything from the executive function demands of just getting there, to sensory issues, to the rejection sensitivity that makes you think “Does my therapist hate me?!” Plus: How to advocate for yourself in the room, even when your provider doesn’t specialize in ADHD.

• Listen: So... How does that make you feel about your therapist?

• Watch: Why people with ADHD can’t sleep (and what actually helps)

• Read: A Radical Guide for Women With ADHD, by Sari Solden and Michelle Frank

Rae Jacobson: It's complicated. ADHD is complicated and it feels complicated in every relationship, including with your therapist sometimes. One of the first things people ask when they learn what I do for a living is, "Could you recommend a good therapist for ADHD? Like, someone who actually gets it?"

It's a question it seems like I should have the answer to, and trust me, I really, really wish I did. But I don't. Because there are a ton of great therapists out there, but finding one who understands ADHD can be tough.

And it's really important because therapy can be tricky for people with ADHD in a bunch of ways. Holler if you've also missed a session, felt super bad about it, and instead of making a phone call like a human person would, just never went back.

So, today on "Hyperfocus", I'm asking: Why is it so hard for people with ADHD to find a therapist who gets it? And how do we make therapy actually work for us?

You asked about people with ADHD sticking with therapy. It's like, why would anyone stay in any relationship where they feel judged and misunderstood?

This is Michelle Frank. She's a clinical psychologist who focuses on ADHD. Michelle's mentors were legends — like, full-on legends — in the ADHD world, like Sari Solden and Ellen Littman. And by the way, you can hear from them and Michelle in an earlier episode of "Hyperfocus". Michelle found her way to this work partially because she has ADHD herself.

Michelle Frank: I started this journey saying I would never work with ADHD — too close to home, yada yada. Did a lot of my own work and just fell in love with working with this population. And it's my Roman Empire, as is all things ADHD.

Rae: Your Roman Empire, you mean like as in guy who listens to endless podcasts about the Roman Empire?

Michelle: Yeah, that's yeah. A type with which I'm familiar. Yeah, I will go to sleep thinking about these things. I will read "Attention Magazine" for fun.

Rae: Michelle has now taken her Roman Empire's worth of knowledge on ADHD and started a program that trains therapists in ADHD care. And this is kind of a big deal because one of the reasons it's so hard to find a therapist who gets it is because most aren't trained to work with ADHD clients. That translates to a real lack of therapists who understand the — let's call them — quirks of working with people who have ADHD.

Let me give you a scenario here, Michelle. One that I imagine will be somewhat familiar to you. A 17-year-old Rae goes to therapy.

Michelle: Oh, that's cute. That's a memoir title. Continue.

Rae: Sorry. I'm sure it was deeply adorable. I hadn't been diagnosed with ADHD. I was just a picture of disorganization and time blindness and not really knowing what was going on. And I felt like because I would do things like show up late to my sessions, be maybe all over the place in them, not really linear in the way that I was talking, screw up some of the billing stuff — all these things, right?

I remember thinking God, this woman hates me. Which is the process. When you're talking about judgment, yeah. But I wonder if that is something that a lot of people with ADHD go through where it wasn't just the therapy in the room that was an issue. It was all the other stuff you have to do to get to therapy.

So what are some of the reasons that you've found that people with ADHD tend to leave therapy or maybe not really form a strong bond with a therapist, which is really important for therapy? What are the things that are keeping people with ADHD out and why is that happening?

04:52 Therapy often places significant executive functioning demands on patients with ADHD.

Michelle: There's a lot of executive functioning demands, right? Like time management, follow-through. You can say I keep meaning to do this and then weeks and weeks can go by. The barriers to finding a provider that really gets ADHD, the barriers to the financial investment involved in therapy and finding someone who may or may not take insurance.

All of these issues do create one of those "Wall of Awful" situations for someone with ADHD. "Wall of Awful"? Right, it takes executive functioning to do the thing to get the help for your executive functioning.

And then I think some people are a little worried about being emotionally overwhelmed by the therapeutic process. And — no surprise to anyone — folks with ADHD can tend a little towards avoidant ways of coping with stress. And so sometimes it's kind of I'm just not ready. That might be too overwhelming emotionally, like I just don't feel I have that emotional space.

And then there are a lot of folks who unfortunately have worked with a therapist who does this kind of blank slate thing and doesn't give enough feedback, isn't actively involved in sessions.

Rae: This blank slate thing is something I think can really undermine therapy for folks with ADHD. A lot of therapists are listeners, which sure, is their job. They understandably see it as their role to create a safe space for their clients to express themselves. And that works really great for some people.

I, however, am not one of them. Like a lot of people with ADHD, when I'm being vulnerable and the other person is giving me nothing, my brain will helpfully fill that silence with every single horrible thing that person could be thinking about me. And then — and I'm fairly sure I'm not alone in this — anxiety takes over and I just fill the space with words.

Not helpful, therapeutic things either. Just words.

Michelle: Folks with ADHD really need that, like direct feedback. They need some conversations, not just building awareness, but the "but how" piece. Yeah. And so I've heard people say like, "Yeah, it was helpful in terms of like, I learned some things, but I didn't really know how to change some things."

Or they'll say, "I found that I was so tangential going off on my ADHD rabbit trails and it just became more of a conversation and then the hour was up and just rinse, repeat."

But the one that really breaks my heart is people feeling like ADHD isn't talked about at all or when it is, it's really dismissed or invalidated. Or you get this really kind of trite advice like, "Oh, have you tried using a planner and an alarm, you know, on your phone?" It's just my favorite thing. Where it's "Have you tried the things that everyone tells you to try? Did they not work? Oh. Oh, great. You should really talk to someone about that."

You know? As you're in therapy! Nothing feels worse than that.

Rae: When I think about why is it important for therapists to be trained in ADHD? Why is that something that we should want, right? Why isn't it just enough to walk in and be like, "I have ADHD," and they're like, "Oh, okay."

These things are the things I didn't think about. These everyday housekeeping things, like showing up on time, letting someone stand up during a session, feeling like you're able to say "I need a little more feedback from you because if you just stare at me, I have to insert what I think you're thinking and it's probably not going to be good."

Or — and this is something that comes up a lot and I think gets sort of swept under the rug — especially if you're seeing a provider who can prescribe and you're talking about ADHD, that you are a drug-seeker. And I wanted to get into that a little bit.

Michelle: Oh, that's such the fear, right? Like, can you break that down for me? The vast majority of people who take ADHD medication feel a lot of shame around taking ADHD medication. Need to be reminded that it's okay to take their ADHD medication, right? Like, need to deconstruct some of the ableism around "I'm broken or a bad person, I shouldn't need this store-bought dopamine agonist in order for my brain to work in the morning."

And so there's already such shame around having a neurotype that doesn't conform to these hyper-ideal standards. Yeah. And then you have all these hang-ups around getting meds on time or having going to a primary care and they ask you what meds you're on and then they kind of still screen you for ADHD every time you do it, even though you've been on these medications for your whole life.

Or start , you know,  you switch doctors and now we want to do a urine test on you and —.

Rae: "When was the last time you had an EKG?"

Michelle: Yeah, an EKG, right? And not saying that those things aren't necessary sometimes. It's just a lot of people with ADHD have already done the due diligence around these things and feel that they're not believed in their own story of their own body. And that's maddening.

And I think that's probably doubled down for women and particularly women of color who already aren't believed medically, but that's a different podcast.

Rae: Can I ask a question? And I know you are a therapist, so of course disclosure is completely at your behest. But, you know, therapists see therapists usually, right? And is it okay if I ask you: Have you been in therapy in your life?

Michelle: Yeah, I love therapy. Yes.

Rae: And you have ADHD.

Michelle: I love therapy, I love it.

Rae: Resounding advocacy for therapy. When you've, you know, you also at the top when I asked you about your background, you said, "I never wanted to work with this population. I told myself I'd never work with this population." And I'm curious about it. Like you have ADHD, you've been in therapy, you also had a hesitancy to work with people who have ADHD. Like, why?

Yeah, like just on a personal note. What is it for you that all these things bring up? Like as you're telling me all these very rational, very therapeutic things, you know, you've seen both sides. What's it like there?

08:40 Michelle shares her personal background with therapy and how she navigated her career with ADHD.

Michelle: I think a lot of people with ADHD, I felt insecure and I felt like if I don't have my own stuff together, how could I possibly be what somebody else needs in the room?

And then doing my own work deconstructed that entire argument in a lot of ways that: one — I did do my work and actually got to a place where I was feeling better in terms of my functioning and my overall level of satisfaction in my life, and that certainly helps.

And I also deconstructed that internalized ableism piece and this idea that there's some hierarchy of neurotypicality or hyper-productivity or that I needed to have it all figured out and fixed in order to be a witness and walk the path with someone else. I think we owe it to ourselves to embrace imperfection.

And that's a really hard journey when you have ADHD because, you know, your whole life you've received so many negative comments directly and indirectly that really impact your sense of worth in the world and make you feel like you are less than somehow. And really good ADHD work challenges that and helps you turn that on its head and say, instead of thinking about even as a therapy goal, how can I be more neurotypical or perform neurotypicality better, like how can I be the best version of who I am?

Rae: Well, that's a very good point. The idea that the goal of therapy is to just become a more neurotypical person is not the goal of therapy. The goal of therapy is you want to be more of yourself and more comfortable with yourself. I'm interested in, you know, we hear a lot about trauma-informed care. Like, understanding sort of where somebody is coming from and using that as a lens through which to do the therapeutic work.

Is there an argument for ADHD-informed care, would you say?

Michelle: Oh, absolutely. That's really what I aim to teach in my trainings.

Rae: What are the things that people with ADHD can do to advocate for good therapy if they don't have access to a specialized therapist?

Michelle: My hope is that one day all therapists know to ask questions like, "Tell me how you experience your sensory needs or your processing and communication needs, or tell me what ADHD means to you, how have you experienced that?"

And in the meantime, if you have someone who's otherwise a really good fit and they just don't have a ton of outside experience with ADHD, I think it's still worth pursuing that therapeutic relationship to see where it can go. And you might need to start those conversations.

Say, "I want to share with you a bit about what this has meant to me." And a good therapist is going to know how to roll with that and where to take that. And so it's really just saying your vulnerable truths. And then right in any relationship, making sure that they can hold that. And a really good therapist will be able to.

So it's usually I think having some courage to give a therapist a couple of sessions, it's being honest, it's sharing content that resonates with you. You know, if there's an "Understood" podcast you want to share.

Rae: Maybe one with a name like "Hyperfocus"? I don't know.

Michelle: I don't know, I don't know. Send it. Say, "Hey, can we talk about this in session?" I mean, therapists geek out on that stuff, you guys. Like, they love that. They love when — we love when clients show up and are like, "I've really want to talk about this," or "I'm really worried you don't understand me."

Oh my god, a therapist will eat that up. Are you kidding? Like, we love when you tell us when we're doing things wrong, when you bring stuff up. It's this beautiful opportunity for us to course correct, to repair, to model a healthy relationship where one person isn't going to understand you all the time.

And we can still be in relationship and talk about that and repair that. And that's where a lot of really good healing work happens.

Rae: See, I feel like I just want you to be the world's therapist. Like, how do we get that future? Many, many thanks to Dr. Michelle Frank. She's the best. If you want to hear more from her, you can check out our episode called "These Trailblazers Changed the Game for Women with ADHD". It's pretty cool. Thanks for listening, see you in two weeks.

"Hyperfocus" is hosted by me, Rae Jacobson. Our producer is Cody Nelson and Anna Rothschild is our senior podcast producer. Julie Subrin helps with booking. Our music comes from Blue Dot Sessions, our research correspondent is Dr. KJ Wynne.

Video is produced by Max McKenzie and edited by Alyssa Shea. Our associate director of content development is Calvin Knie. Briana Berry is our production director and Neil Drumming is our editorial director.

If you have any questions for us or ideas for future episodes, write me an email or send a voice memo to hyperfocus@understood.org. This show is brought to you by Understood.org. Our executive directors are Laura Key, Scott Cocchiere, and Jordan Davidson.

Understood is a nonprofit organization dedicated to empowering people with learning and thinking differences, like ADHD and dyslexia. If you want to help us continue this work, donate at Understood.org/give.