Cognitive Behavioral Therapy is an evidenced-based
counseling treatment that is showing promise with clients facing ADHD. Below is
part of an excellent interview conducted with the author of a treatment
guideline for using CBT in this area, reprinted from About.com, by
J. Russell Ramsay, Ph.D., is Associate Director and co-founder of the Adult ADHD
Treatment and Research Program at the University of Pennsylvania School of
Medicine, and a senior staff psychologist at Penn’s Center for Cognitive
Therapy. He is author of Cognitive Behavioral Therapy for Adult ADHD
(Routledge, 2008) and Nonmedication Treatments for Adult ADHD:
Evaluating Impact on Daily Functioning and Well-Being (American Psychological
Association, 2010). Dr. Ramsay has lectured internationally to mental
health professionals on adult ADHD and the principles of Cognitive Behavioral
Q: What is cognitive behavioral therapy?
What sets CBT apart from other forms of psychotherapy is the emphasis it places
on the interactive role of cognitions — automatic thoughts, images, belief
systems — and behaviors. CBT certainly does not ignore emotions, but rather
targets problematic thinking and behavior patterns as the entry point to
understanding and addressing the difficulties for which people seek treatment.
CBT was originally designed as a treatment for depression
and research has consistently demonstrated that it is an effective therapy
approach for mood problems. Subsequent studies have shown CBT to be helpful for
other common problems, such as various types of anxiety, substance use, other
mood problems, and some medical issues, such as dealing with sleep problems or
headaches. The past decade has seen many clinical researchers who have worked
on modifying CBT to address coping difficulties associated with adult ADHD.
Q: What role does CBT play in a treatment plan for adult
A: Medications are considered the first line of treatment for ADHD in terms of
treating the core symptoms of ADHD. There are a variety of medication treatments for ADHD whose benefits operate through their effects on
brain functioning, generally producing improvements in sustained attention,
managing distractions, and impulse control. For many people, these symptom
improvements lead to functional improvements in their daily lives, such as
being better able to keep track of items, experiencing less physical restlessness
and greater impulse control, and being able to sustain focus on work or reading
for reasonable lengths of time, to name a few.
However, many individuals may continue to struggle with
the effects of ADHD despite adequate medication treatment. That is, individuals
may continue to experience residual symptoms of ADHD and/or have ongoing
difficulties implementing the coping strategies that they know would be
helpful. Moreover, individuals with ADHD may struggle with difficulties
managing their emotions in daily life, an increasingly recognized feature of
ADHD, or may experience problematic levels of depressed mood, anxiety,
substance use, or low self-confidence. These adults with ADHD require
additional help to experience improved well being and functioning in their
CBT has been found to be a useful adjunctive treatment
that directly addresses the sorts of impairments and coping issues associated
with adult ADHD that were described above. While the coping solutions may seem
simple — use a daily planner, start working on tasks well in advance of their
deadline, break large tasks into smaller tasks — they can be difficult to
implement. Facing these longstanding challenges may also trigger negative
thoughts, pessimism, self-criticism, and feelings of frustration that create
additional barriers to follow through. There also may be a minority of
individuals with ADHD who cannot take medications due to medical
contraindications, intolerable side effects, non response, or who simply
decline medications for whom CBT may be the central treatment approach. Hence,
CBT may be recommended in cases in which medications alone are not sufficient
to address problems associated with ADHD.
Q: How does CBT address some of the day-to-day problems
caused by ADHD symptoms?
A: A common example is a patient who arrives late for the first session — citing
that addressing “poor time management” is a goal for CBT. Such events
are used to “reverse engineer” the various component parts of the
problem in order to provide increased understanding of how ADHD (and other
factors) may contribute to the development and maintenance of their functional
problems, in this case “poor time management,” and to provide some
initial ideas for coping strategies. This sort of review also allows treatment
to be personalized to the individual’s circumstances, thereby making it a
relevant and salient opportunity to strategize for the implementation of coping
To continue with the aforementioned example, the issue of “time management” related to being late for an
appointment could be the result of poor schedule-keeping (e.g., not having a
daily planner with a record of the appointment), disorganization (e.g., not
being able to find the piece of paper with the appointment date and time), poor
problem-solving (e.g., not thinking through options for obtaining the
appointment time, such as researching the number for the office and calling to
confirm), poor planning (e.g., not setting a realistic time frame for leaving
for the appointment, factoring in travel, parking, etc.), and becoming over
focused on distracting tasks (e.g., working on the computer), to name but a few
factors. Issues related to anticipations of the appointment may also create
barriers to follow through, such as feelings of anxiety (which can be
distracting and lead to avoidant behaviors) and task-interfering cognitions,
either negative (e.g., “This doctor will not tell me anything I have not
already heard”) or positive (e.g., “I’m sure there will be plenty of
parking” or “It won’t matter much if I’m late”).
Each of these components of “poor time management” offers an opportunity for change. As the various difficulties
associated with ADHD are identified, there will be recurring themes that emerge
and the various coping skills discussed can be applied to various situations to
improve overall functioning. It is not a “quick fix” and skills must
be implemented in a consistent fashion, but the combination of increased
recognition of the effects of ADHD and a plan for handling them provides a
template for making sense of what had previously been experienced as factors
beyond one’s control.
Can you give an example of a negative
behavior pattern in which an adult with ADHD may find him or herself stuck and
walk us through how CBT may be used to change that maladaptive behavior into a
more productive and positive one?
Procrastination is one of the most common problems reported by adults with
ADHD. Although virtually every patient with ADHD cites procrastination as an
issue, every individual’s struggle is unique.
After having defined procrastination as a target for
treatment, the patient is encouraged to share specific examples, preferably
recent ones, of procrastination in his or her daily life. We slowly and
collaboratively review in specific terms the ultimate goal of the task, be it
simple, such as organizing a shopping list, or more complex, such as writing a
paper for a college class. We then review the individual’s relationship with
the task, either recent experiences of procrastination or the current
anticipation of the task. That is, we discuss the plan for the task, the
component parts of the task in order to break it down into steps (also known as
“chunking”), identifying any potential barriers or factors that could
influence followthrough. An important aspect of this process also is to
explicitly explore the individual’s cognitive and emotional reactions at the
prospect of this task. That is, asking “what thoughts go through your mind
about performing this task?” and “what emotions do you notice when
you think about this task?” Another question we commonly ask is “what
is it like to be in your skin when you are facing this task?” The purpose
of these questions is to uncover the role of negative thoughts and emotions
that may contribute to procrastination. We also want to identify the person’s
“escape behaviors” and rationalizations, such as “I’ll check my
e-mail first and then I’ll get right to work.”
The CBT interventions operate in the way executive
functions are designed to operate, to help individuals to be able to plan,
organize, and choreograph their time, energy, and effort in order to accomplish
tasks that may not be immediately rewarding (although the small rewards of
completing small steps is often minimized) but that are associated with larger,
more rewarding outcomes.
Individuals identify the specific plan for implementing
specific skills on a specific day and time on a specific task to increase the
likelihood of follow through (e.g., “When you walk in the door after work,
you may drift towards the television and rationalize that you need to ‘veg
out;’ what can you do differently to make sure that you get your mail before
you sit down? Where can you sort through the mail for that day? What will you
say back to those rationalizations for procrastination?”). The process is
not always an easy one and it is common that change occurs in a “two steps
forward, one step back” manner, but these sorts of skills delivered in the
context of a relationship with a therapist who understands adult ADHD can be
helpful for many people. The goal is to make the coping strategies “sticky”
so that they go with the patient and can be remembered and used in daily life.
J. Russell Ramsay, Ph.D. Email correspondence/interview.
February 4, 2011.
The holidays are often a time of great stress for those with mental health challenges. It’s the same for those with ADHD – this ultra busy time of year demands exceptional organizational ability, abilty to handle stress, willpower to withstand the influences of too many goodies….all the things that are hard for folks with ADHD.
Yes, it’s a demanding time when the pressure is on to finish work, enjoy the time off with family and friends, but not blow the budget! The holidays are particularly challenging for those with impulse control issues. Last minute shopping is the norm, but fast purchases, often bought on credit, leaves a bit of mess come January.
This might be the time to think about giving yourself a holiday gift: make 2012 a year to take charge of your ADHD symptoms! If you are one of many whose ADHD has got in the way of your work, your school grades, or your relationships, take the time to think about how you are going to make some changes in the new year.
Learn as much as you can about how ADHD affects your life: it plays out differently with everyone. Think about your core challenges, and what type of support might be used to address them. Do you need a coach? A therapist? A med review from your physician? A new workout buddy?
And if it’s your child that has ADHD, this is also a time to plan for the year ahead. Have you been keeping good contact with his or her teachers this year? Does your IEP reflect their true needs, strengths and challenges? Are they headed toward a great June report card, or another year of disappointment?
Over the holidays, when you have time to slow down and think about what you want in the coming year, do yourself a favour and plan for some support, either for yourself or your child.
Contact me now to set up some early counselling sessions, either by phone or email, to get you headed in the right direction!
Happy Holidays to All!
Congratulations – you have decided to get some help with your ADHD treatment, and managing your school/work life!
Now, how to do you go about finding someone?
Thanks for finding my website. I hope to provide some quick information about me, my services, and different aspects of ADHD that you might be interested in.
But it’s very, very hard to think about working with someone without ever meeting them! I realize making that first initial phone call can be intimidating.
In the field of human services. word of mouth is the best way to track down a helping professional that someone else has found to be professional, compassionate and ethical. As around at school, at information sessions and through friends. Find out why the person was satisfied with the counsellor’s services, and why the “fit” seemed to work.
Remember, when you initially call or email, you are hoping to learn some of the basics, such as the location of their office (it should be handy), their fees, their professional training and experience, and what others had to say about them.
I have published my references on this site: www.linkedin.com/marylynntrotter. Please check them out!
I offer a FREE telephone or email initial consultation, so please feel free to contact me.