Q: I’m seeing more and more adults with attention deficit hyperactivity disorder (ADHD) in my psychotherapy practice. Too often, the skills and strategies we work on in our sessions don’t carry over into their daily lives. What can I do to make my work with ADHD clients more effective?
A: You’ve hit on a central issue that’s typically misunderstood about adult ADHD: the difficulties faced by adults (and children and teens, for that matter) with ADHD aren’t because they don’t know about coping skills or resist their use. Clients typically express their frustration with trying to implement the skills they’ve learned with statements such as “I know what I need to do. I could coach someone else about what to do. But I can’t do it for myself.”
As a cognitive behavioral therapist, I believe the key to improvement isn’t trying harder not to procrastinate, but seeing the components that lead to procrastination and then intervening to alter them. Of course, to achieve any behavioral change, clients must learn to do things differently. Thus, cognitive behavioral therapy (CBT) for adult ADHD emphasizes giving clients practice in developing tactics for overcoming procrastination. With practice, these coping skills become more habitual, and clients gain a sense of efficacy in managing their affairs, including managing inevitable slip-ups.
Although procrastination is at the core of many of the problems ADHD clients suffer from, each and every example need not be reviewed separately with them, as the pattern of procrastination on any task will be quite similar across the board. I typically begin by asking clients to choose a recent example of a task they couldn’t complete and ask, “When it came time to follow through on your initial plan, what thoughts went through your mind?” Probably the most common distorted thought characteristic of procrastinators is that of magnification/minimization. Clients magnify how difficult and uncomfortable completing a prospective task will be and, in turn, minimize the possibility that they’ll make at least some progress, that time spent on the task will be gratifying, and that any initial discomfort will be brief.
To get at clients’ negative emotional reactions when facing a troublesome task, a useful question to ask is “What was it like to be in your skin when you faced the task?” Although clients will identify specific emotional reactions—such as worry, stress, or sadness—that interfere with follow-through, the descriptions most often heard are “not in the mood” or simply “ugh.”
Escape behaviors are a defining feature of procrastination. These behaviors can be elicited by asking, “What did you end up doing instead of what you planned to do?” It can be illuminating to ask for an example of a permission-giving thought used to justify the escape behavior, such as “I’ll go through my emails, and then I’ll ‘be in the mood’ to get started on the task.” Of course, escape behaviors aren’t always recreational: individuals may end up doing productive tasks, such as a chore around the house or a different work duty, but these tasks function as a means to circumvent the high-priority task. Last, the therapist can ask about any other factors that interfered with the execution of the task plan. These factors may be external—such as environmental distractions—or internal—such as fatigue and hunger. But the CBT model for helping clients understand the effects of ADHD helps transform what previously seemed to be an invisible and irrepressible process into an observable sequence, providing a number of points at which to intervene.
My CBT-based model assimilates four domains of intervention: cognitive modification, behavioral modification (and use of coping skills), implementation strategies, and acceptance/mindfulness for emotional reactions.
Cognitive Interventions
Cognitive interventions involve changing the ratio of negative to positive (magnification to minimization) anticipations about the task. To facilitate this process, the metaphor of the defense attorney is useful. Clients usually decide to procrastinate not because the work isn’t worthwhile, but because only the evidence against doing it is deliberated—in other words, the prosecutor’s case. Making a case in favor of following through on the task—the defense attorney’s case—is another way to engage in cognitive modification of distorted thoughts. The result need not be that the client is now totally motivated for the task; rather, just enough motivation is required—which is akin to garnering enough votes to make the work seem doable.
For example, doing income taxes was a huge challenge for Jim, resulting in his not filing for three years. Whenever he considered filling out the forms, he had a rash of task-interfering thoughts, such as I’ll never be able to catch up, or I have to be in the right mood to do taxes, or I’ll mow the lawn now, so I can work on taxes later. In therapy, Jim learned to recognize his impulse to escape and consider how his internal defense attorney might object to his initial reactions with statements like Doing taxes is boring, but I can work on it a little bit now and make some headway, rather than avoiding the problem. It may seem to be a small step, but it helped Jim tremendously.
Behavioral Interventions
Adults with ADHD often have unrealistic expectations for facing tasks, such as having to complete them in one sitting over several hours. In Jim’s case, although he recognized the importance of catching up on his taxes, he got overwhelmed at the thought of tackling the task—which made him want to escape even more. However, breaking down the large, nonspecific task of “catching up on taxes” into achievable actionable steps, such as “first collect past W-2 forms and then organize them by tax year,” made the task seem clearer and less intimidating. In short, developing a specific action is akin to progressive behavioral exposure to an avoided task and can help ignite a launch sequence for getting on task.
Acceptance/Mindfulness Skills
Even after breaking down tasks into more manageable steps, the prospect of facing them may trigger uncomfortable feelings based on past frustrations. Acceptance/mindfulness skills for managing these negative feelings is a powerful intervention for balancing them out, as is reframing them as a tolerable and short-lived aspect of getting started.
The CBT model emphasizes that while clients need to recognize their negative feelings, these feelings need not dictate their actions. They can feel them and still follow the steps required to start an unwelcome task. Moreover, they can set more realistic expectations for how much time they’ll devote to a burdensome task, erring on the side of less time, rather than more. Part of their skill training involves scheduling realistic start and end times, thereby discovering that it’s easier to calibrate one’s emotions and efforts when a defined and reasonable end point is within sight. In Jim’s case, he reminded himself that no one is ever “in the mood” to do taxes, and the job can be stressful. Armed with a specific action plan and a clear finish line, which defined when he could stop, such as after 30 minutes or after organizing a certain number of receipts, he was increasingly able to chip away at his goal.
Implementation Strategies
Last, Jim’s overarching goal of “catching up on taxes” still triggered occasional worries, which resulted in his avoiding working on them. Implementation strategies represent a set of companion strategies that support working toward a goal and are framed as if–then statements. For Jim, these included “If I can sit down at the desk, then I can review my tax forms for at least 10 minutes.” Just moving his body to the desk was a small but essential step toward putting him in touch with the task, one likely to serve as a cue for other coping skills. A similar plan could be developed to handle likely distractions (“If I receive a text, then I’ll remind myself that I can wait to respond until after I review the forms”). The aim of the combination of these interventions is to make CBT “sticky,” helping individuals catch themselves as they start to fall into an old procrastination habit and instead to use more effective skills, which, over time, will become more habitual and easier to employ. Some clients have found it helpful to carry coping cards with prompts for working through the strategies, such as “What am I thinking? What would my internal defense attorney say? What’s the smallest step I can take? Can I handle the discomfort? What’s my implementation plan?”
Through the course of CBT, Jim became better able to “see” his ADHD in action and use coping strategies to get caught up on his taxes. Even when he procrastinated, he was better able to catch himself and get back on task—never perfectly, but certainly much improved.
Photo by Tara Winstead/Pexels
J. Russell Ramsay
J. Russell Ramsay, PhD, is cofounder and co-director of the University of Pennsylvania’s Adult ADHD Treatment and Research Program. He’s also an associate professor of clinical psychology in the University of Pennsylvania’s Perelman School of Medicine.
