Putting a Stop to Toxic Thoughts

Cognitive-behavioral therapy helps reverse the negativity that torments adults with ADHD – and prevents them from reaching goals.

Girl in doctors office to treat depression
Girl talking to therapist

Most adults with attention deficit disorder (ADHD) need medication, but that’s not always enough. That’s why many experts recommend meds and psychotherapy. But as Mark, a 30-something sales representative from New York City, discovered recently, not all forms of therapy work particularly well for 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. 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.

“I think of therapy as a partner in the recovery process,” says Lori, a 35-year-old secretary at a small college in Pennsylvania. “I used to feel that, as much as I tried, nothing would change. Now, when intense feelings come up, instead of reacting to them spontaneously and being devastated and discouraged, I take a step back and feel there’s hope.”

New Tricks for an Old Dog

The form of therapy that worked so well for Mark and Lori – and for countless others with ADHD – is called cognitive-behavioral therapy. CBT was developed 40 years ago, and since then it has proven highly effective in treating anxiety and depression. But only within the last decade has it been used for ADHD.

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There’s no evidence that CBT can replace drug therapy for ADHD, or even permit lower dosages. But research suggests that it works better for ADHD than do other forms of therapy. One recent study, from 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.”

Results come quickly. Traditional forms of therapy can go on for years, whereas cognitive-behavioral therapy typically yields its benefits in only 12 to 15 one-hour sessions.

What’s It All About?

Traditional therapy focuses on emotions and mines the past to find causes of current problems.

With cognitive-behavioral therapy, the focus is on thinking, and the way transient thoughts and enduring beliefs about oneself and the world influence how one feels and acts. It’s a tool for getting organized, staying focused, and improving one’s ability to control anger and get along with others.

This might sound a lot like what’s offered by ADHD coaches and self-help books. But knowing what to do is seldom enough – irrational thoughts and expectations stop you from doing it. CBT eliminates these roadblocks.

Distorted thinking

It turns out that the demoralizing thoughts and beliefs that keep us from doing what we want to do can’t stand up to the light of logic. As CBT reveals, they’re 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 are certain 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.

Once you learn to recognize these distorted thoughts, you’ll be able 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.”

Undoing a legacy of failure

Drug therapy is effective at fixing the errant neurochemistry that underlies ADD. But drugs are powerless to erase the legacy of bad feelings left by years of coping with ADD.

“Adults with the disorder have had a tougher time in school, a tougher time in the workplace and in relationships,” says Dr. Ramsay. “The end result of these frustrations is a negative view of themselves, the world, and their future. They’re quicker to assume the negative, and this can magnify symptoms and interfere with problem-solving. People with AD/HD avoid situations in which they’ve failed in the past, which keeps them from learning new skills.”

CBT aims to bring these beliefs into the open and facilitate changing them.

Finding a therapist

It’s easy to find a CBT therapist, but it can be harder to find one who specializes in ADD.

“My guess is that most cognitive therapists are generalists who don’t have specific training in ADHD, but can apply its principles to the disorder,” says Judith Beck, Ph.D., director of the Beck Institute for Cognitive Therapy and Research in Philadelphia.

When you interview a prospective therapist, ask about her training in CBT and experience in working with ADD.

For the names of therapists who use cognitive-behavioral therapy, contact the Association for the Advancement of Behavior Therapy or the Academy for Cognitive Therapy.

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