Challenge Your Thoughts, Change Your Life

CBT is backed up by clinical results and research evidence showing that the therapy delivers real-world benefits for adults with ADHD — namely higher self-esteem, productivity, and happiness. Learn more about 'cognitive distortions' and how to unravel them with cognitive behavioral therapy.

An adult with ADHD, wondering to herself: "How does CBT work for my symptoms?"
   
 

CBT to the Rescue: How a Physician with ADHD Regained Her Confidence

Mary is a physician who was recently diagnosed with ADHD. At the start of her first CBT session, she sobbed as she unloaded her worries about her job, her marriage, and whether she was too disorganized to raise a child. She had felt like an “impostor” her whole life, having been told, “You’re too smart to have ADHD.” She said that she was embarrassed by the fact that she had to take a job at an Urgent Care facility after her contract with a group medical practice was not renewed, due to her disorganization and poor follow-through on work.

After a few minutes helping her to compose herself, the therapist asked Mary for an example of a task in her daily life that was tied to any of these worries. Mary said that she was already behind in her charting and had gotten an “unofficial warning” from the facility operations manager. As she headed to work after the session, she and the therapist reverse-engineered how she typically handled charting, and explored her mindset (“I hate charting”), emotions (“I’m stressed about everything I have to do”), and escape behaviors (“I end up doing ‘hands-on’ tasks I can get out of the way”) that result in avoiding charting.

Together, they developed an alternate action plan that included a specific implementation strategy (“If I get to a computer terminal, then I can complete the charting for my last patient and at least one overdue chart”), as well as for acknowledging and accepting her discomfort (“I can tolerate the stress and still open the electronic chart”). Mary also developed a realistic, task-oriented thought to normalize the hassle of charting (“No one likes charting. I don’t have to like it to start the next one”).

Although initial sessions focused on specific tasks, such as charting, the main outcome was that Mary had some immediate successes at work, and was more engaged in what she had to do. The difficulties she faced with charting were similar to those she faced in other parts of her life, so these initial skills were used to address other important matters. Mary was better able to face her worries and have a framework for catching herself when she was avoiding them. In the course of doing so, Mary’s view of herself shifted to that of being competent and confident in managing work, as well as other areas of her life.

 
   

Cognitive behavioral therapy, along with medication, has been one of the “go-to” treatments for adult ADHD. CBT is backed up by clinical results and research evidence showing that the therapy delivers real-world benefits for adults with ADHD.

CBT was originally a treatment for depression, based on the recognition that cognitions, or automatic thoughts, lead to emotional difficulties. Automatic thoughts are spontaneous interpretations of events. These impressions are susceptible to distortion, such as mistaken assumptions about yourself (or others), a situation, or the future. Say you’re getting ready to head to work or to an appointment and you think, “I have time to check my e-mail before I have to go.” This sort of poor time and task estimation is familiar to those with ADHD. Changing distorted thoughts, and the resulting change in behavior patterns, is effective in treating depression, anxiety, and other emotional problems.

Cognitive Distortions

Individuals who grow up with ADHD (particularly if it has gone undiagnosed) encounter more frequent and frustrating setbacks in life situations — at the job, in social interactions, and so on. Because of these many setbacks, adults with ADHD become self-critical and pessimistic. This, in turn, causes them to experience negative emotions (depression, stress, and so on), cognitive distortions, and, sometimes, negative self-beliefs. It is common for those living with ADHD to think that situations that don’t turn out well are their fault, when, in many cases, they aren’t. Those with ADHD bring the same pessimism to the future, imagining that tomorrow will go as badly as today.

Negative thoughts and beliefs get in the way of following through on strategies that might help, or cause a patient to avoid them altogether. CBT focuses on making sure that a patient consistently implements coping strategies that work for him or her.

CBT helps adults with ADHD to “see” their disorder in terms of its impact at specific, key moments. Consequently, CBT aims to help ADHD adults implement their coping skills to handle these moments or tipping points more effectively. Here are some frequently-asked questions about CBT.

What’s New with CBT?

Since 1999 there have been many studies done on the basic CBT approach for dealing with adult ADHD, in both individual and group formats, with a majority of the studies being published in the past five years or so. They support the key role that CBT plays in dealing with ADHD challenges. There have been ongoing modifications to the basic format of CBT to deal with a wider array of problems faced by adults with ADHD, such as comorbidities like depression and anxiety.

A recently published neuroimaging study of ADHD adults who completed a 12-session course of CBT showed improvements in ADHD symptom ratings and beneficial changes in the same brain regions that are typically monitored in studies of medication treatment. There is great interest in expanding the reach of CBT for adult ADHD to help those with more severe and complex problems.

How Exactly Does CBT Improve Adult ADHD?

While it is interesting that CBT may change the brain, most patients with ADHD just want to know how to get out the door in the morning without spending 20 minutes looking for their keys. CBT helps patients manage such everyday challenges.

CBT intervenes to lessen life impairments — procrastination, time management, and other common difficulties — not to treat the core symptoms of inattention, hyperactivity, and impulsivity. CBT sessions focus on identifying the situations in which poor planning, disorganization, and poor time and task management create challenges in one’s day-to-day life — dealing with obligations such as paying bills or completing work on time, and encouraging endeavors that provide personal fulfillment and well-being, such as sleep, exercise, or hobbies. Learning about ADHD is always a good starting point for patients, reinforcing that ADHD is not a character flaw, and showing how it interferes with carrying out good intentions.

The work of CBT focuses on proven coping strategies, including managing negative expectations, emotions, and behavioral patterns that interfere with the strategies. Most ADHD adults say, “I know what I need to do, I just don’t do it.”

The goals and session agendas of CBT center on scenarios and challenges that the patient has encountered and, more important, expects to encounter, particularly between sessions. The therapist uses take-away reminders, follow-up check-ins, and other ways of making coping skills “sticky,” so that they are used outside of the consulting room. Ultimately, the way that an ADHD patient functions in everyday life is the best measure of whether the therapy is helping.

What is a Typical CBT Session Like?

There are many formats for practicing CBT, and the therapist tailors sessions to a patient’s needs. Each session agenda provides a benchmark for identifying when the discussion is straying off course. Early sessions typically involve an introduction to CBT, the structure of sessions, and setting and refining therapy goals (making them specific, realistic, and actionable), as well as developing action plans for what the patient will do outside of the office. (See “CBT to the Rescue.”)

Subsequent sessions focus on the most important life situations affecting the patient, and developing coping skills to handle those situations. For each agenda item, the therapist and patient work together to reverse-engineer the challenge to better understand its nature, including a review of the impact of thoughts, feelings, behaviors, and other factors that have interfered with handling the situation.

Using the CBT framework breaks down the tough task of “managing ADHD” into specific tactics for navigating transition points in a day — getting up and off to work on time, starting a project that you’ve been avoiding, or setting a time to review a daily planner — which increases coping skills. These coping steps are strategized in a session (and written down as take-away reminders) to use between sessions.

CBT makes it easy to address other important issues that affect ADHD symptoms — co-existing mood and anxiety disorders, addictions to technology and gaming, a job search, or overall lifestyle habits — sleep, exercise, and one’s self-esteem.

How Do CBT and Medications Mix?

Quite well. For some individuals, using ADHD medications alone results in both symptom improvements and better management of adult roles and responsibilities. Most individuals, however, also need CBT to target ongoing struggles with disorganization and procrastination, despite being on ADHD stimulants. As has been said many times, “pills don’t teach skills.” The combination of medication and CBT is often the treatment of choice for dealing with the wide-ranging effects of ADHD.

When Can I Expect to See Results?

CBT brings immediate results in a patient’s life, and emphasizes long-term maintenance of coping skills and improvements. In fact, the length of time spent in treatment — over many months, say — is as important as the number of sessions a person undergoes. Some people ask whether they should take a month off from work or school and do a CBT “boot camp” for four or five weeks. The success CBT aims for, though, is to help individuals make sustained changes in their daily lives. Instead of having 20 daily sessions of CBT in a month, stretching out those sessions over six months allows a patient to turn his new skills into habits and to weave them into his lifestyle. This allows time and practice for mastering coping strategies for paying monthly bills, organizing work or school issues, and pursuing other tasks and endeavors in real time.

Some individuals return to CBT for “booster sessions” to address a challenge if they’ve fallen into old habits. Some resume CBT to adapt their coping skills to a major life change, such as having a child, losing a job, or other events.

How Do I Find a CBT Therapist Familiar with Adult ADHD?

This is the tricky part. There are many excellent CBT therapists, but relatively few of them specialize in adult ADHD. Competent therapists can use one of the many CBT treatment manuals for professionals to treat an ADHD patient. Existing technology raises the question of whether CBT can be done effectively by Skype or by phone. Licensed mental health professionals are bound by various health-care laws, at the state and national level, that may limit this option, but there are other possibilities for video sessions that comply with health-care privacy laws.

CHADD (and its National Resource Center), ADDA, the Academy of Cognitive Therapy (ACT), the Association for Behavioral and Cognitive Therapies (ABCT), and the ADDitude Directory have find-a-therapist features on their websites that offer good starting points. The American Professional Society of ADHD and Related Disorders (APSARD) is developing a listing of ADHD specialty clinics, some of which provide CBT or recommend clinicians in their area who do.


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TAGS: ADHD Therapy, Adult ADD: Late Diagnosis, Behavior Therapy for ADHD, Self Esteem

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