In my work as a clinical psychologist, I’m often asked to provide an evaluation to determine if an adult client has ADHD. Clients come to me reporting that they can’t focus their attention long enough to complete a mundane task. They start several projects and complete none. They can’t manage their multiple responsibilities. Completing their work tasks is drudgery. They can’t keep up with the productivity expectations of their employer. They can’t slow their thoughts enough to focus on what’s in front of them. They are chronically distracted. Their minds race even as they try to sleep. (All client stories in this article are composite examples.)
Whether these problems are the result of ADHD or are due to some other diagnosis or are just part of life—this is what I try to figure out. But in recent years there is only one answer people want to hear, and it’s that they have ADHD.
I’m not talking about people who meet the diagnostic criteria, which includes clear evidence of significant attention problems beginning in childhood and causing verifiable impairment in work, school, or social functioning. Many of those who seek a diagnosis have no clear history of clinically significant attention problems. Still, they have begun to perceive themselves as having a disorder of some kind. (My evolving perspective is based on anecdotal experience and on my discussions with colleagues, not on any specific research.) They look to my assessment not to understand what’s really wrong but to get confirmation that what’s wrong is that they have ADHD. But why would people desire a clinical diagnosis that is defined by the DSM5 as a neurodevelopmental disorder?
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Some clients want medication, specifically Adderall, which they imagine will help them overcome their challenges. Students often want academic accomodations—support like extended time on testing, designated note takers, and flexible deadlines. And some just want to belong to an identifiable group. The sense of belonging, of not being alone in their struggles, can be a powerful driver in the quest for diagnosis.
Years ago, the mental health profession came to understand that some people have a diagnosable attention problem that can benefit from treatment. This helped destigmatize those previously considered lazy or inept. This destigmatization was good and necessary. Identifying ADHD as a problem affecting some children has clear positive effects. It helped us understand that kids who had a hard time settling their bodies and minds were not lazy or incompetent. We also came to understand that some kids don’t outgrow it and continue to struggle in adulthood. However, we have done such a good job of destigmatizing diagnosis that Jonathan Haidt, in his book The Anxious Generation, wonders if we are instead valorizing it.
Many clients seem to be coming to me for something like absolution. They want to hear that their inability to manage their lives is not their fault. Let me explain. In a technological, competitive, capitalistic society in which one’s worth is measured by productivity, a deep sense of inadequacy can result for those who struggle to compete. We internalize a sense of falling short. Our perceived insufficient productivity is experienced as a secular sin. Often, those seeking the diagnosis are driven by perfectionistic self-expectations. The internal script goes something like: “I should be able to handle all of the demands of my life with no difficulty, and if I struggle, then there is something wrong with me as an individual.” Receiving a diagnosis of ADHD means they have a diagnosable disorder that explains why they struggle. This can provide a profound sense of relief, whether the diagnosis is accurate or not.
What I see in my clinical practice is that many of us are trying to keep up with what Tricia Hersey refers to in Rest is Resistance as “grind culture.” As I borrow her term, I’m mindful of the fact that her strongest emphasis is on the enduring reverberations of chattel slavery on Black Americans. But I think there is a sense in which the idea of grind culture applies to the voluntary servitude we all take on in a productivity-oriented, capitalist economy. “We become rigid and impatient when our checklist isn’t completed to perfection,” Hersey says. “We become less human and less secure.”
There is a secular puritanism at work here, in that we are all, in Mary Oliver’s words, walking on our knees “for a hundred miles through the desert, repenting.” We are repenting of our imperfect productivity and our insufficient attention to the demands of grind culture. We seek absolution in the form of a clinical diagnosis that explains our deficiency and provides a solution in the form of a medication that molds us back into the image of productivity, efficiency, and autonomy.
What if we began to ask not only whether an individual has ADHD but also what assumptions, expectations, and cultural forces impinge upon people that make us struggle so much? We take it for granted that we should all be paying perfect attention all the time. But even medieval monks didn’t pay perfect attention all the time (or at least didn’t perceive themselves to be doing so). In The Wandering Mind, Jamie Kreiner argues that we have inherited distractibility from evolution, and from monastic traditions we have inherited the belief that distraction is a problem to be conquered.
Underlying much of this is what I call the self-expectation of omni-competence: One must be successful at whatever one undertakes, and it must be accomplished independently. We must be able to multitask efficiently, and failure to do so reveals a diagnosable mental health problem. Anything less than complete success reflects a flaw that resides within the individual. According to this way of thinking, we are all what psychologist Miriam Greenspan in Healing Through the Dark Emotions calls “narcissistic bubble selves,” sealed off from larger influences and determined only by our own biology and inherent temperament.
Since many physicians are rightfully cautious about prescribing stimulant medication, they seek a diagnosis of ADHD for their patients as a way of gatekeeping, sending their patients to a psychologist for an assessment. This, however, has not resulted in gatekeeping so much as it has opened the floodgates of diagnosis and stimulant prescriptions for those who may or may not meet the (admittedly imperfect) DSM5 diagnostic criteria for ADHD. This results in feedback loops in which an individual’s diagnosis, legitimate or not, leads to others identifying with their symptoms and seeking out a diagnosis for themselves, which in turn leads more people to identify with the diagnosis, creating greater and greater circles of identification and diagnosis.
Here is a representative case study: A primary care physician requests an assessment for a young man who works full time, attends graduate school, and serves as primary caregiver for elderly family members. He sleeps maybe three hours a night. He is overwhelmed and scattered. He wants a diagnosis of ADHD so he can access stimulant medication. He really believes there is something deficient in himself that the medication will correct.
But in his case, sleep deprivation, overwork, stress, and perfectionism are salient factors. A stimulant medication probably would help him get more stuff done—but at what cost? I tell him he is free to ask his physician for medication (it’s ultimately up to the physician anyway), but that in my opinion, this would only enable him to do even more of what he was already doing that is not good for him. I affirm his commitment to his responsibilities, but I also tell him that sleep is a necessity, not a luxury.
Which brings us to rest, or rather the lack thereof. I have begun to think of the human costs of grind culture in terms of sabbath consciousness. It is about limits and finitude: We all have limited energy, endurance, and aptitude. We are not independent agents free from the constraints of our biology and our individual limitations. We can’t do everything ourselves. We require rest—not only the restful sleep that is necessary for consolidation of memory, regulation of mood, and restoration of physical stamina, but the pause that aids contemplation, reflection, attentiveness, and deeper insight. Such reflection can help us understand what is most important, what our realistic capabilities are, and how we might rely on others to do that which we cannot do.
We would do well to realize that no one can be good at everything, and that we are not required to adhere to some platonic ideal of omni-competence. The failure to excel at all of one’s endeavors is not a diagnosable disorder. Struggling with a demanding job while juggling other life stressors is a life problem, not a mental disorder.
Walter Brueggemann addresses this in Sabbath as Resistance: “Multitasking is the drive to be more than we are, to control more than we do, to extend our power and our effectiveness. Such practice yields a divided self, with full attention given to nothing.”
Echoing Tricia Hersey’s tying together of the legacy of enslavement and our current grind culture, Brueggemann locates the nexus of sabbath resistance in the exodus, which provides the very basis of the sabbath concept: “Do you dream of more bricks you have to make yet, or of bricks you have made that were flawed? We dream so because we have forgotten the exodus!”
Notice how well the concept of ADHD fits with our individualist, capitalist, technological economy. If we cannot keep up with production and consumption, we must have a disorder that should be medicated in order to bring us back into line. The disorder is seen as residing in the individual’s inability to keep up with grind culture and therefore best addressed with a medication that helps meet grind culture’s demands.
Frequently, I have worked with mothers of young children who work full time and manage all of the household affairs, sometimes while attending school or holding additional responsibilities, such as caring for other family members. They struggle to juggle everything, sometimes in the absence of a support system. They tend to blame themselves for this. They come seeking a diagnosis to confirm their image of themselves as deficient. They undergo a full assessment involving review of their current circumstances and history, as well as standardized testing of attention, personality, and cognitive functioning. When the results do not support a diagnosis of ADHD, they often express frustration and say something like, “you’re just telling me I need to try harder.”
This is the exact opposite of what I’m saying. They are already trying much harder than is healthy for them. I am not going to label them with a neurodevelopmental disorder just because they are overextended and don’t have sufficient help—including, often, from their partners. Recent research shows that women still shoulder most of the load for maintaining the domestic sphere. In my experience, this is true even when they are working full time and even when the male partner is more supportive than most.
A large percentage of the referrals I have received in recent years are of women who have internalized the pressure to conform to the ideal of perfect productivity in all domains. This doesn’t mean they have ADHD. The inability to accomplish everything is not a sign of pathology.
Another client was a member of an evangelical group that places a strong emphasis on personal piety and confession of one’s shortcomings. She also came seeking a diagnosis. But my assessment revealed a strong history of exceptional academic performance, an advanced degree, a high level of professional attainment, a record of stellar reviews from her employer, and a glowing report from her husband about her meticulously kept home. She still measured herself as falling short. She was walking through the desert on her knees, repenting.
I’m trying to bring a sabbath consciousness into these assessments, not as an identifiable religious practice but as a way of reframing the problem. I almost never talk about these things explicitly with clients, but these thoughts undergird how I try to approach peoples’ concerns about attention and the lack of it.
First, a sabbath consciousness reminds us that we are valuable simply by virtue of being. That we are worthy from the very start, not because of anything we accomplish but rather simply because we are. To quote Abraham Joshua Heschel, “There is a realm of time where the goal is not to have but to be, not to own but to give, not to control but to share, not to subdue but to be in accord.”
Second, a sabbath consciousness reminds us of the importance of limits. We can only do so much. And because we’re not very good at calculating how much is enough, the equation is built into practices that override our sense of what is enough. As Wendell Berry’s “Sabbath Poem, 1985, V,” says, “To come in among these trees you must leave behind / the six days’ world, all of it, all of its plans and hopes.” We see this practice in other spiritual traditions as well, such as in Buddhist meditation or the Muslim pause for prayer at scheduled intervals throughout the day. I often recommend a mindfulness meditation practice to clients who struggle with attention. I think of this as observing a micro-sabbath.
Third, sabbath consciousness reinforces that the desire for a sense of enough-ness is universal. It applies to all of us. One of the gifts of the destigmatization of attention disorders was the grace it conferred on people who struggle with attention. An attitude of grace, however, should not depend upon a clinical diagnosis but should extend to all of us. We need to dispense the same grace to everyone, so that it is no longer necessary to seek a clinical diagnosis in order to experience that grace. We need to dwell in grace together while recognizing our mutual dependency. None of us can do it all alone, but together, we can help each other do what needs to be done.
Concerns about attention problems are real and often very distressing. Many people feel overwhelmed and defeated by the treadmill of their life, and they are seeking relief. But I have begun to wonder whether the search for relief via diagnosis only serves to obscure the question of what’s really going on here. What if we started to think in terms of our national “attunement” deficit disorder?
If we conceptualize the problem individualistically and mechanistically, we will seek solutions in a technological manner that ignores the human and communal element. If, however, we understand this as a larger cultural problem driven by the demands of a technological, consumerist society, then perhaps we can begin to imagine different solutions.
Client stories in this article are composite examples.
