Felicia Heidebrecht * Psycholoog in Den Haag, Rijswijk & online @ Lifeinmymind

Along the years working with people using substances and/or having ADHD I heard ever so often accounts of the issues they encounter in their relationships. But the step to engage in couples therapy seemed often too scary. Substance use is often still an exclusion criterium from couples therapy, and an issue people themselves don’t want to bring up out of fear of being judged. Relatietherapy with someone with ADHD requires specialised knwoledge and experience. And many people with ADHD use substances too, so a combined approach is needed too.

I hope that with my approach I can offer a space where people feel comfortable to talk freely to me and to each other about their substance use and/or ADHD and make sustainable changes.

This is the story about a client I used to see in a special clinic for the “hard to engage” dual diagnosis clients using heroin and crack cocaine. Everyone in the service found her difficult to engage, and she was every time high on crack cocaine and under the influence of alcohol on top of heroin and methadone. She “wouldn’t listen”, and “wouldn’t want to sit and talk”. In one of my shifts in this clinic I took a different approach with her: I knew she liked painting and drawing, so I brought paint and paper into the therapy room together with her methadone prescription. My first question was not about her use, but about what she likes painting. She immediately took a paper and some paint and started painting a little house, trees, flowers and a cat. And she spoke about her dreams of coming off the streets and feeling safe, and her eyes watered at memories of so much trauma and abuse in her life. I have never seen her so focussed: drawing helped her channel her thoughts and her words despite her massive use of so many substances. Also, she gave me the cue: safety really matters to her, although her choices don’t help in the long-term and merely bring a fake safety in the moment. So I had then a brief conversation around creating some real safety that it was then in her hands: not mixing the alcohol with the heroin, not using alone, taking her prescription regularly. She sat down and listened.

Engagement is not always about sitting 20 minutes and working with a given structure. Engagement is speaking to the internal motivation and in the language that resonates with the other.

In my private practice I certainly can’t see anyone with this level of substance use, but nevertheless even manageable, low-level substance use can put a considerable strain on a relationship.

Among the biggest challenges provided by substance use in (couples) therapy are substance use-related mood patterns and the direct influence on the cognitive processes/way of thinking.

Similar challenges are true when working with people with ADHD. ADHD comes with different issues with the executive functions, and often also with strong emotions and difficulties in expressing and regulating them

People don’t always have to stop using to make changes towards their life goals. And certainly not before they are “allowed” or “able” to start therapy.

While certain patterns of substance use or certain characteristics of ADHD do indeed make (certain elements of) therapy more difficult or even impossible, I can think out of the box and work with what is possible to start creating change.