How CBT Dismantles ADHD Negativity: Cognitive Behavioral Therapy Overview
CBT is supported 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.
What Is CBT?
After a lifetime of mistakes, mishaps, and missed deadlines, is it any wonder that adults with attention deficit hyperactivity disorder (ADHD or ADD) suffer dangerously low self-esteem and perpetually negative thoughts? Cognitive behavioral therapy (CBT) is a short-term, goal-oriented form of psychotherapy that aims to change these negative patterns of thinking and change the way a patient feels about her self, her abilities, and her future. Consider it brain training for ADHD.
Originally a treatment for mood disorders, CBT is based on cognitive restructuring, or the recognition that cognitions lead to emotional difficulties. Automatic thoughts are spontaneous interpretations of events. These impressions are susceptible to distortion, such as unfounded assumptions about yourself (or others), a situation, or the future. Such unhealthy internal dialogs hinder an individual from working toward an intended goal, working to develop productive new habits, or generally take calculated risks.
CBT aims to change irrational thought patterns that prevent individuals from staying on task or getting things done. For an individual with ADHD who thinks, “This has to be perfect or it’s no good,” or “I never do anything right,” CBT challenges the truth of those cognitions. Changing distorted thoughts, and the resulting change in behavior patterns, is effective in treating anxiety, and other emotional problems.
How Does CBT Help People with ADHD?
ADHD is a chronic, persistent delay of self-regulation skills, including executive functioning skills. Delays in EFs create procrastination, disorganization, poor time management, emotional dysregulation, impulsivity, and inconsistent motivation. Although these problems are not included in the official diagnostic criteria for ADhD, they are common in adults with the condition, making it hard for them to regulate their emotions and behaviors.
Individuals who grow up with ADHD (particularly if it has gone undiagnosed) encounter more frequent and frustrating setbacks in life situations — on the job, in social interactions, and everyday organization. Because of these many setbacks, adults with ADHD become self-critical and pessimistic. This, in turn, sometimes causes them to experience negative emotions, cognitive distortions, and unhealthy self-beliefs. It is common for individuals living with ADHD to think they are at fault when situations don’t turn out well, when, in many cases, they aren’t. They may bring the same pessimism to the future, imagining that tomorrow will go as badly as today.
Demoralizing thoughts and beliefs that keep individuals from doing what they want to do actually can’t stand up to the light of logic. As CBT reveals, these thought processes are distorted in certain characteristic ways:
- All-or-nothing thinking. You view everything as entirely good or entirely bad: If you don’t do something perfectly, you’ve failed.
- Overgeneralization. You see a single negative event as part of a pattern: For example, you always forget to pay your bills.
- Mind reading. You think you know what people think about you or something you’ve done — and it’s bad.
- Fortune telling. You predict that things will turn out badly.
- Magnification and minimization. You exaggerate the significance of minor problems while trivializing your accomplishments.
- “Should” statements. You focus on how things should be, leading to severe self-criticism as well as feelings of resentment toward others.
- Personalization. You blame yourself for negative events and downplay the responsibility of others.
- Mental filtering. You see only the negative aspects of any experience.
- Emotional reasoning. You assume that your negative feelings reflect reality: Feeling bad about your job means “I’m doing badly and will probably get fired.”
- Comparative thinking. You measure yourself against others and feel inferior, even though the comparison may be unrealistic.
Learning to recognize these distorted thoughts helps you to replace them with realistic thinking.
“Understanding how you think is an effective start to making changes in your life,” says J. Russell Ramsay, Ph.D., assistant professor of psychology at the University of Pennsylvania. “Changing thoughts and changing behavior work hand in hand. Widening your view of a situation makes it possible to expand the ways you can deal with it.”
How Has CBT for ADHD Changed?
Since 1999, various research initiatives have studied the impact of CBT on the symptoms of ADHD in adults, in both individual and group formats, with a majority of the studies being published in the past 5-10 years. By and large, this research supports the assertion that CBT can help adults better address their ADHD-related challenges. For example, a 2016 neuroimaging study of adults with ADHD 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.
Still, some in the scientific community would like to see more rigorous research conducted with carefully constructed controls. In its 2011 report titled, “Current Status of Cognitive Behavioral Therapy for Adults Attention-Deficit Hyperactivity Disorder,” researchers from Massachusetts General Hospital and Harvard Medical School wrote: “The conceptual and empirical basis for CBT approaches in adult ADHD is growing and suggests that targeted, skills-based interventions have a role in effectively treating this disorder. At this stage of development, however, subsequent studies must progress in terms of methodological rigor. Additional randomized controlled trials with active control groups are needed and intervention packages must be tested across multiple trials by more than one research group.”
How Exactly Does CBT Improve ADHD in Adults?
While it is fascinating to learn how CBT may change the brain, most patients with ADHD just want to get out the door without wasting 20 minutes looking for their keys. CBT helps patients manage such everyday challenges.
CBT intervenes to improve daily life struggles — 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 a patient’s day-to-day life. Sessions may help an individual deal with obligations such as paying bills or completing work on time, and encourage endeavors that provide personal fulfillment and well-being, such as sleep, exercise, or hobbies. Learning about ADHD is always a good starting point, as it reinforces the message that ADHD is not a character flaw and demonstrates the neurological underpinnings of daily challenges.
Most adults with ADHD say, “I know what I need to do, I just don’t do it.” Despite having plans for what they want or need to do, they do not carry them out. CBT focuses on adopting coping strategies, managing negative expectations and emotions, and unwinding behavioral patterns that interfere with the strategies.
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 applying new coping skills so they are used outside of the consulting room. Ultimately, the way that a patient with ADHD functions in everyday life is the best measure of whether the therapy is helping.
What Is a Typical CBT Session Like?
CBT is administered in many different formats, and each therapist tailors sessions to a patient’s individual needs. Each session’s 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 Success Stories.”)
Subsequent sessions focus on identifying the most important life situations affecting the patient, and developing coping skills to handle those situations. One of the myths about CBT is that it ignores childhood and the past. These early-life experiences are the raw materials from which people develop deep-rooted, non-conscious beliefs and rules for “how the world is” and our role in it. This stems from human ability to categorize experiences to learn, understand, and predict and manage new situations. The patient’s understanding of his or her “rules for the world” is an essential goal in CBT. Uncovering the roots of the “rule book” helps adults with ADHD understand the patterns in their self-criticisms (or criticisms of others), avoidance patterns, and self-defeating behaviors. Ultimately, the main goals of CBT are to overcome impairments and to implement coping strategies. CBT helps in processing new experiences and finding new ways to handle setbacks. It adjusts the old rules to align with present-day life.
For each agenda item, the therapist and patient work together to reverse-engineer the challenge. They try 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.
Some of the in-session CBT exercises are based on simple ideas: “Many people with ADHD don’t wear a watch,” says Dr. Mary Solanto, Ph.D., associate professor of psychiatry at the Mt. Sinai School of Medicine. However, remembering to wear a watch, placing clocks all over the house, and keeping a detailed log of the day helps a lot with time management. How does someone with ADHD remember to do all that? Simple mantras (“If it’s not in the planner, it doesn’t exist”) are basic forms of CBT. They serve as reminders to change one’s thought patterns.
“We teach them that, if they are having trouble getting started on a project, the first step is too big,” Solanto says.
Solanto advises her patients to write down in their ADHD-friendly planners every task they have to do in a given day — from important appointments to everyday errands. She asks clients to link checking the planner to routine activities, like brushing your teeth, eating lunch, walking the dog, and so on. This helps someone with ADHD stay on task throughout the day, and prioritizes the things to get done. “People with ADHD spend a lot of time putting out fires, instead of thinking ahead to prevent those fires,” says Solanto, who has recently outlined her work in Cognitive-Behavioral Therapy for Adult ADHD: Targeting Executive Dysfunction. The book teaches therapists how to apply and use Solanto’s brand of CBT in their own practices.
CBT makes it easy to address other important issues that affect ADHD symptoms — co-existing mood and anxiety disorders, dependence on 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 responsibilities. Most individuals, however, find that they 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.
There’s no evidence that CBT can replace drug therapy for ADHD, or even permit lower dosages, but research does suggest that it works better for ADHD than do other forms of therapy. A 2010 study by Boston’s Massachusetts General Hospital found that a combination of drug therapy and CBT was more effective at controlling ADHD symptoms than was drug therapy alone.
“CBT picks up where medication leaves off,” says Steven A. Safren, Ph.D., leader of the study and assistant professor of psychology at Harvard University. “Even after optimal treatment with medication, most adults have residual symptoms, and this treatment appears to make them better.”
When Can I Expect to See Results?
Results come quickly. CBT typically yields benefits after only 12 to 15 one-hour sessions. However, most patients continue with CBT much longer, as it 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. This is generally not recommended. CBT aims to help individuals make sustained changes in their daily lives. Instead of attending 20 daily sessions of CBT in a month, a patient should stretch out those sessions over six months 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 or losing a job.
How Do I Find a CBT Therapist Familiar with ADHD in Adults?
There are many excellent CBT therapists, but relatively few of them specialize in ADHD. Competent therapists can use one of the many CBT treatment manuals for professionals to treat a patient with ADHD. 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.
CBT Success Stories:
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 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 at work.
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. Then, 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”), and a formula 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.
A Guy with ADHD Feels Better About Himself
Mark, a 30-something sales representative from New York City, discovered that not all forms of therapy work particularly well for helping him manage his ADHD. Since being diagnosed with ADHD 10 years ago, Mark has been on, off, and finally back on medication. He also worked with several psychotherapists — to no avail. “They either didn’t know much about ADHD, or they wanted me to deal with the ’emotional issues’ behind it,” he says. “That wasn’t helpful.”
Eight months ago, Mark started to work with a new therapist using CBT. Now things are looking up. He says he feels much better about himself and his marriage.
“A lot of stuff I did got on my wife’s nerves — forgetting things she asked me to do, or getting them wrong because I didn’t really hear her,” Mark says. “I still make mistakes, but they’re fewer and farther between. And she knows that I’m really working on it.”
For many years, Mark’s to-do lists remained mostly undone. Now he’s able to cross off 80 percent of the items. Even the tasks that used to seem overwhelming — filing receipts, clearing his desk of clutter — get done without difficulty.
A Journalist Finally Finishes Graduate School, and Regains Hope for His Future
Josh, a 35-year-old journalist, struggled with undiagnosed ADHD for most of his life. He had trouble managing personal commitments and organizing his time at school. “I was hopeless,” he said. “My education, employment, and finances were in jeopardy.”
Early last year, however, Josh discovered that he had inattentive-type ADHD and began to take stimulant medication to control his symptoms. A few months later, he also began a new style of CBT, which was developed for those with ADHD.
In the program that Josh entered, which was created by Dr. Mary Solanto, Ph.D., adults with ADHD learn in small group settings.
For Josh, it wasn’t so much the specific strategies that were taught that helped him, but the other people in the class giving him the motivation to change. “You hear from others with problems like yours, and it helps you make your own strategies for managing those problems,” he says.
Solanto believes that CBT is most effective when combined with other forms of treatment, and Josh agrees. Josh says that stimulant medication allowed him to benefit from the class, because it helped him stop and think about how ADHD affected him day to day. “In order to change, you have to be able to learn from experience,” he says.
“Our goal is to help people develop good habits and maintain them,” Solanto says. “And, just as important, to give support to encourage their use.”
Josh certainly sees the method’s impact. After starting graduate classes 15 years ago, he finally completed his graduate degree last year. He feels more productive in his career, and says that he has read and written more in the last year than ever before.
“I’m more hopeful,” says Josh. “I’m more confident.”
Carl Sherman, Ph.D., and J. Russell Ramsay, Ph.D., are members of ADDitude’s ADHD Medical Review Panel.