Cognitive Behavioral Therapy and the Treatment of ADHD

Read an interview about CBT with Dr. J. Russell Ramsay

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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 Therapy (CBT). I feel very fortunate to have had the opportunity to interview him about CBT.

What is Cognitive Behavioral Therapy (CBT)?

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.

What role does CBT play in a treatment plan for adult ADHD?

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 daily lives.

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.

How does CBT address some of the day-to-day problems caused by ADHD symptoms?

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 skills.

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.

Q: 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?

A: 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.

Q: How does one find a professional who is experienced in both CBT and ADHD?

A: This is the tricky part right now.

There are organizations devoted to the dissemination of CBT, such as the Association of Behavioral and Cognitive Therapies and the Academy of Cognitive Therapy that have therapist locator features on their websites. However, many practitioners who are quite skilled in CBT may not be familiar with issues faced by adults with ADHD. Likewise, there are organizations devoted to ADHD that have professional directories on their websites that include a variety of mental health professionals but these clinicians may not be familiar with CBT approaches. The National Resource Center (associated with Children and Adults with ADHD [CHADD]) has listings of adult ADHD providers and programs and the Attention Deficit Disorder Association (ADDA), which is an organization devoted to issues related to adult ADHD, also offers a listing of providers.

There are a growing number of adult ADHD specialty clinics around the United States and the world, including many that provide CBT-oriented treatment approaches. Harvard University/Massachusetts General Hospital and Mt. Sinai School of Medicine, NYU have active programs in the United States. There are excellent programs exploring psychosocial treatments for adult ADHD in Canada, Finland, and Germany.

Very often people find out about good therapists in their area by contacting these resources or clinics in their region and finding out if there are qualified therapists nearby who can be consulted. Unfortunately, because CBT for adult ADHD is a clinical specialty to which all clinicians are not exposed, there may be some locations without experienced therapists. However, there are increasing numbers of published treatment manuals and clinically-oriented professional books that can serve as useful resources to clinicians.

Source:

J. Russell Ramsay, Ph.D. Email correspondence/interview. February 4, 2011.

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