The elements of CBT that follow will be familiar to any clinician well-versed in the model. What differentiates CBT from being merely a collection of techniques is that, done rightly, it endeavors to enlighten the unique experience of a patient and to help her/him explore possibilities for making desired changes. What follows represents a cross-sectional summary of ongoing efforts to modify CBT to the clinical needs of adults with ADHD (see McDermott, 2000; Ramsay & Rostain, in press).
Receiving the diagnosis of ADHD is often a liberating experience and offers the first cognitive reframe of a patient's chronic difficulties. To this point, most patients have viewed their difficulties as confirming their maladap-tive core beliefs (e.g., "I'm lazy"). Many patients have communicated a sense of relief at finally having a coherent (and nonjudgmental) explanation of their difficulties, hearing that they are not alone in their struggles, and that there is indeed hope for change.
True to the CBT model, patients often have diverse personal notions of their difficulties and the steps they are willing to take in treatment. Some patients respond to the diagnosis with eagerness to explore new coping strategies and openness to making significant changes in their environments. Other patients, however, may be more suspect about the diagnosis and their abilities to change what seem to be uncontrollable cognitive and behavioral impulses. Spending time addressing these issues and matching CBT to the patient's therapeutic pace helps to increase treatment compliance and effectiveness.
The next step is providing psychoeducation about ADHD to the patient to demystify misconceptions about treatment and to shed light on the nature of this syndrome. To encourage further self-awareness we often encourage the patient to augment treatment with personal research, such as reading about adult ADHD or exploring reputable online resources. We caution that while these resources can be very helpful, they will not be as personalized to the patient's unique circumstances as would psychosocial treatment. We also encourage that patients share their impressions of these resources in treatment so that any potential misunderstandings or distortions can be addressed.
The therapeutic relationship provides a safe place for the adult with ADHD to explore the nature of his/her difficulties, to develop new coping skills, and to discuss the range of emotions involved in this personal undertaking.
Rather than being a blank slate, the therapist actively inquires about the patient's experience, keeps sessions focused, and helps the patient find a balance between accepting the reality of ADHD and making behavioral changes to minimize its negative impact.
A common therapeutic issue is managing what would typically be deemed "therapy-interfering" behaviors. Tardiness to sessions or failure to complete therapeutic homework, traditionally thought to be signs of hostility or resistance, are better understood as manifestations of the executive functioning deficits associated with ADHD. Framing them as opportunities to understand the effects of ADHD and to develop commensurate coping strategies gently addresses both the core symptoms of ADHD and the emotional frustration engendered by these sorts of recurring difficulties in a constructive, nonshaming way.
If patients have been prescribed a medication for their core symptoms, therapy can provide a regular opportunity to monitor both the patient's response and her/his attitudes that might interfere with compliance. Regular consultation between the therapist and prescribing physician, with the patient's expressed consent and input, helps to coordinate treatment.
The neurobiological and cognitive-emotional elements of the experiences of adults with ADHD are unavoidably intertwined. An ongoing case conceptualization allows the clinician and patient to understand how these various factors coalesce to influence that patient's automatic reactions. It also provides a therapeutic touchstone for assessing efforts to modify these reactions and to develop alternative options, particularly for maladaptive core beliefs and self-defeating compensatory strategies.
The most common core beliefs encountered in adults with ADHD cluster around notions of failure ("I've not fulfilled my potential"), defectiveness ("I'm inadequate"), social undesirability/exclusion ("I'm different and no one understands me"), and incompetence ("I cannot handle life"). These beliefs often stem from actual life circumstances and seem to "make perfect sense" based on the patient's described experience (e.g., "I frequently failed exams and classes and often had to attend summer school"). However, reexamining these events, simultaneously affirming the patient's affective experience and reexamining the accounts based on a retrospective understanding of ADHD, often opens up novel and/or expanded interpretations (e.g., "I did better when I had a teacher who answered my questions without making me feel that I was stupid").
The most compelling experience that prompts patients to reconsider their beliefs seems to come when they alter their default compensatory strategies that have maintained the maladaptive core beliefs. Of the many compensatory strategies associated with ADHD, anticipatory avoidance is the most ubiquitous. This is sometimes referred to as the "excessive procrastination technique" based on the patient's wish that the task will just "go away." This strategy involves putting off a necessary task because the patient anticipates that it will be unpleasant, the benefit for doing the task is too vague or distant in time, and/or the patient assumes his/her performance will ultimately be inadequate. The immediate relief gained whenever the task is avoided, often with the aid of a permission-giving cognition (e.g., "I'll do it later when I'm more up to it"), negatively reinforces avoidance as a default behavior and leads to an accumulation of disappointments. Behavioral experiments permitting the patient to stay on-task for a minimal time (even during a therapy session) provide immediate and positive (or at least less negative than predicted) emotional experiences associated with proactive behaviors.
Ultimately, the case conceptualization for the adult patient with ADHD aids her/him in making informed decisions. No treatment can guarantee that patients will be unaffected by ADHD. It is a neurodevelopmental disorder that requires ongoing coping in order to transcend the core symptoms. CBT helps patients to face challenging life decisions by considering all options without falling into impulsive avoidance patterns. Further, CBT aims to foster resilience, maintaining a focus on important overarching goals in one's life, even in the face of apparent setbacks and delays.
The next section will review preliminary clinical research on the effectiveness of this therapeutic approach.
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