ADHD and Cognitive Therapy - What Makes Them a Good Match?
by Melinda White, MFT
Cognitive behavioral therapy is a form of treatment which helps people make concrete, observable changes in their lives. There is a focus on the ways a person's thoughts and attitudes affect his feelings and behavior. The premise is that some people develop negative and distorted beliefs about themselves which interfere with their functioning. This can lead to depression and anxiety, as well as the procrastination that affects so many adults with Attention Deficit Hyperactivity Disorder. Cognitive therapy helps people examine the beliefs that are holding them back and learn strategies to counteract those beliefs.
ADHD is considered a neurobiological condition. Yet the traits of ADHD are not the only problem for the adult with this condition. It is often the negative self-esteem and defeatist attitudes that develop as a result of the symptoms that are the most damaging. Cognitive behavioral therapy can be especially effective in addressing these issues.
Cognitive behavioral therapy is also a practical method of treatment that helps clients deal with the day to day issues that impede their success. Many adults with ADHD have difficulty with organization, prioritizing, and follow-through. Some adults with attentional difficulties tend to ramble, have trouble remaining on topic, and often forget what they've committed to do.
Cognitive behavioral therapists use a number of techniques that focus specifically on these issues. Choosing a specific topic or topics to work on each session is one goal of the cognitive session. Determining what the client will do about the issue discussed, how he can work on it, and how to evaluate its success are all topics for treatment. Clear-cut goals are developed and there are frequent check-ins on those goals. This can prevent rambling and jumping from one topic to another which can interfere with the treatment of the ADHD client.
The cognitive behavioral approach to therapy encourages therapists to bring up issues from previous weeks to continually evaluate progress. This can be extremely helpful for the adult with ADHD who easily loses track of her long term goals as she focuses on whatever seems most pressing at the moment. Working with a cognitive therapist, the client will be reminded to attend to areas of success while also refining strategies to help deal with those incomplete tasks.
In my private practice as a psychotherapist specializing in the treatment of Attention Deficit Hyperactivity Disorder, I use a number of cognitive techniques. One method I frequently use helps adults with ADHD deal with task completion. In session, we list the tasks the client wishes to complete that week. The client then chooses the task she will work on first. We break the task into small component parts to make it less overwhelming. I next ask her to estimate how long she expects the task to take. Since adults with ADHD are notorious for underestimating the time needed for a task, I then ask my client to add an additional thirty to sixty minutes to the time allotted. In addition, I ask her to record the actual length of time the job takes.
I next ask the client to predict the obstacles that might get in the way of task completion. We then discuss methods to cope with these obstacles. These cognitive methods help the client with ADHD be more realistic about her time commitments. Examining the obstacles helps someone with attention deficits preplan ways to deal with what might come up rather than impulsively allowing the obstacles to draw her
away from her task.
Since being on time has been a major issue for many of my clients, I am continually exploring techniques that will increase promptness for each individual. For one client I worked with, the usual datebooks, alarms, and phone call reminders did not work. We tried a system of picking one time of day to work on first. He chose getting out of the house on time in the morning. I asked him to keep a graph for two weeks of the time he actually left the house. Creating the graph increased his leaving on time dramatically. Tracking the times helped him focus on promptness. Having the visual record motivated him to leave early so he could record the mark on the graph where he wanted to see it. This type of record keeping is a part of the cognitive behavioral approach that can assist adults with ADHD in problem-solving.
Cognitive therapists also work with clients on examining their belief systems. When a client brings up an upsetting concern I ask him to list his automatic thoughts about the problem. It is quite often what the client tells himself about the dilemma that is the biggest issue.
Some typical negative thoughts that an adult with ADHD believes when he encounters difficulty are: "I am a loser." "I'll never make it."; "This only proves I can never be a _____."; "I'm just incompetent."
In session, we write down these thoughts. This gives the ADHD adult a place to put all the negative ideas swirling around in his head. It also gives him a chance to tune into those thoughts and how they are affecting him. It is not unusual for an adult with ADHD to avoid attending to his automatic thoughts while procrastinating on task completion because of a negative belief about himself. Making the thoughts explicit is the first step in counteracting such thoughts.
Other steps involve focusing on the distortions the client may be employing that continue to deflate his self-esteem. We also work on creating other healthier and realistic ways of viewing the event that's troubling him. These coping statements are also written down. I give the client a copy of these positive self-statements to take home with him. This is useful for any client. For the adult with ADHD who often has trouble remembering things, it is especially important to have a written record of the work to refer back to.
Adults with attention deficits tend to give up easily when barriers come up. This makes it harder for them to follow through on their commitments to others and to themselves. Cognitive therapy gives them tools to face the barriers by teaching them realistic, non-distorted ways to talk to themselves about the difficulties they encounter. This method of treatment helps an adult with ADHD learn to accept herself as she is rather than berate herself for her shortcomings. At the same time, it helps the client become more successful.
Melinda White is a licensed psychotherapist specializing in treatment of children and adults with Attention Deficit Hyperactivity Disorder. She served for two years as the Educational Coordinator for the U.C. Berkeley site of the National Institute of Mental Health's multimodal treatment study of ADHD. She has written several articles about coping with attention deficit disorder and has given workshops for parents, teachers, and adults with ADHD. She was a special education teacher for 15 years and has a life credential as a learning disability specialist. She is currently in private practice in Berkeley, CA.