By Antonia Dittner – co-author of CBT to Support Adults with ADHD
Many adult ADHD clients come to our specialist neurodivergent psychology service saying standard CBT ‘didn’t work’ for them. Cognitive-behavioural therapists also commonly report low confidence in supporting adults with ADHD. This is despite the fact that CBT is a NICE-recommended non-medication approach for adult ADHD and that there is growing evidence for its benefits in this condition.
When we started working with adults with ADHD almost two decades ago, we were struck by the high levels of psychological distress, often expressed in the form of negative self-beliefs, self-criticism and underlying feelings of shame. Existing evidence-based CBT for ADHD approaches had focused on skills-based and group approaches which, whilst helpful, did not directly target these elements of the ADHD experience. Furthermore, people attending mainstream mental health services for psychological help with common mental health conditions often say the ADHD itself can be a barrier to accessing support.
ADHD can have a significant impact on therapy. People with ADHD may forget to attend sessions or attend late, may be distractible, talk a lot, change topic or forget what has been talked about. They may find it hard to do the between-session or ‘homework’ tasks and to set goals, both standard elements of any cognitive-behavioural therapy. ADHD challenges may have impacted on previous therapies, so people may arrive with thoughts such as ‘therapy doesn’t work for me’ or ‘I’m a hopeless case’. This could affect their confidence or willingness to fully engage.
We consider that there are two important elements to CBT that supports adults with ADHD: making practical adaptations to increase accessibility and directly targeting the beliefs and coping that can worsen ADHD challenges, functioning and psychological distress.
In ADHD there may be differences in one or more ‘executive functions’. Executive functions are distinct from general verbal and non-verbal abilities and have been described as the ‘control room’ of the brain. They are essential for goal-directed behaviour and self-management and include planning, sequencing, inhibition, working memory (holding information in mind while thinking about it), staying focused despite distractions and they underpin emotion regulation. In our book we describe how to ‘scaffold’ and adapt therapy to support executive functioning differences. This includes discussing not only what the client may do differently but how, adapting communication to accommodate information-processing differences, co-creating written therapy records, structuring the session to allow for breaks and movement as well as offering support for missed sessions and late arrival.
The book explains how a formulation-driven approach can address the particular beliefs and coping associated with adult ADHD. A formulation is a shared hypothesis between therapist and client as to what contributes to and maintains challenges. In ADHD, we consider the individual’s predispositions (e.g. cognitive strengths and challenges, personality) and their experiences growing up with ADHD (e.g. negative feedback due to attentional or behavioural difficulties) and how these have led to understandable beliefs and coping. These beliefs and coping were perhaps inevitable given their experiences, and very often protective, but outlived their usefulness. For example, it is understandable that someone who struggles to complete tasks could have concluded that they are ‘lazy’. Many people with ADHD say they have experienced negative feedback or difficulties compared with their peers. It makes sense then that they would learn to cope by avoiding tasks. If they were not supported to learn the requisite skills for approaching and completing tasks or felt criticized for their efforts, then giving up is a natural consequence. These coping behaviours may help manage discomfort in the moment but can worsen challenges in the longer term.
Framing challenges in this way is inherently de-shaming. It also instils hope since it offers different ways to manage. Developing a shared formulation enables client and therapist to address the core challenges of ADHD. This may include providing psychoeducation, adjusting the client’s environment with appropriate supports and helping them develop adaptive skills to navigate executive functioning differences. At the same time, they can identify and address the thoughts (e.g. ‘I cannot concentrate so there is no point trying’), behaviours (e.g. procrastination) and emotion regulation difficulties that maintain challenges and distress.
We describe a step-by-step approach to this formulation-driven approach. It is based on the manual for a randomised controlled trial (Dittner et al 2018). We share the key components of this efficacious therapy as it was delivered. This book is intended to provide neuro-affirmative, concrete and practical guidance for cognitive-behavioural therapists at all stages. It focuses on how to tailor a CBT intervention to the client’s needs, whether focusing on the ADHD itself or adapting a therapy plan where ADHD-related challenges are present but not the primary focus of therapy.
Informed by almost twenty years of clinical experience and evidence-based practice, we are pleased to finally be able to share this with you. We hope this provides a much-needed framework and tools to share with your clients. We hope you find it helpful.