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CBT for AD/HD Cognitive behavior therapy, or CBT has it has come to be called, has been around for more than 30 years. Originally it was based on the idea that thoughts could be treated like behaviors and modified using behavioral techniques. Through subsequent research it has become very apparent that this was a correct hypothesis. CBT has been further developed by such pioneers as Dr. Aaron Beck and his daughter Dr. Judith Beck. CBT has been found to be extremely helpful in reducing symptoms of depression and anxiety, and to be helpful in a wide range of other applications as well such as anger management. In recent years, several researchers have investigated the use of CBT specifically for ADHD. It has been found that CBT can be used successfully to teach coping strategies for managing the symptoms of ADHD. In addition self esteem improved among some participants and many reported an increased sense of self-efficacy. Improvement was also noted in some of the research in reports of mood and anxiety. In addition CBT was used to work on changing core beliefs that had developed due to the participants having grown up with ADHD. These core beliefs were especially problematic for people first diagnosed as adults. Many of these people had a lifelong history of difficulties that they did not understand that led to negative beliefs about themselves. Ramsay and Rostain (2008) reported that many adults with ADHD believe that they can’t trust themselves because they have always let themselves down. Many view themselves as failures due to past histories of significant underachievement. Many of the adolescents and young adults that I work with have come to really dislike the term “potential,” as in “You are not working up to your potential.” One young man referred to it as the “p” word. This sentiment is particularly true among the gifted/ADHD population. Many people with ADHD see themselves as flawed, or lazy or incompetent, adjectives that they may have heard their entire lives by teachers and parents who did not understand. In addition, Ramsay and Rostain (2008) have identified that fact that many adults with ADHD have developed coping strategies that are not effective. One of the most common in my experience is procrastination. Many people with ADHD develop procrastination to a fine art, perhaps because the immediacy of a deadline changes brain chemistry in a way that improves concentration. People with ADHD also tend to put off tasks because they seem too difficult or overwhelming. They may also engage in many lower priority activities while not attending to those of higher priority. They feel busy in this way, but necessary work does not get done either because it is seen as too overwhelming or requires more in the way of sustained mental effort than the tasks they do accomplish. These kinds of coping strategies can lead people to feel they are living on the edge, in a state of chaos, where nothing important gets accomplished. CBT has been used in the research studies to focus on these strategies, identify the maladaptive thoughts they maintain them, and to learn more adaptive ways of thinking as well as more adaptive coping strategies. People with ADHD use all of the cognitive distortions that are common to all of us. However Ramsay and Rostain (2008) report some that seem particularly common among adults with ADHD. For example they may overgeneralize from a single mistake to draw general, usually negative, conclusions about themselves (i.e. how can I expect to earn a living if I keep losing my keys?). They may also engage in blaming of others for their problems or expecting others to forgive them for their failures due to their ADHD. They may have unrealistic expectations about the role medication can play in their lives. In CBT we uncover these unrealistic ways of thinking and refute them using techniques developed by Beck among others such as the Socratic method in which the therapist asks questions to uncover the distorted thinking and the evidence the person has for their thinking. Additional evidence is then requested about other ways of seeing the problem. Another such technique is the downward arrow technique in which the therapist asks repeatedly and how would it be if their belief was true. The goal of these techniques is the assist the person to see other ways of viewing a situation and to find evidence for these possibilities instead of for the maladaptive ways they have been viewing the situation. By changing how they think about things a person is then able to change how they feel about them and therefore how they might act differently. Since many of the common core beliefs that develop over time are quite negative, it is not surprising that many people with ADHD often develop depression and anxiety. These symptoms are often successfully addressed with CBT as well. A fundamental change can occur when people begin to see that the way they have been their whole lives has been due to an underlying neurobiological problem rather than to a character flaw. Modifying and improving the symptoms then can become the focus of treatment, just a problem to be solved rather than a moral failure. In CBT we focus on changing the maladaptive thoughts to their adaptive or rational counterparts. Focusing on adaptive thoughts can lead to problem solving and self directed speech to guide behavior. For example let’s imagine a person who has the maladaptive thought "I'll never hold a job because I’m always late." We can assist the person to modify this thought to the adaptive thought "First of all I’m not always late. That is an exaggeration. However I am late more often than I want to be. I can solve this problem. I'm sure I can figure out a way to be on time. I've solved harder problems than this." Then the next step is what do I need to do to solve the problem? This could mean that the self directed speech becomes something like this: “Ok so what changes do I need to make so I can get to work on time? Let me brainstorm ways where I am getting stuck and try to figure out some other ways to handle this problem.” Sometimes the person will have made environmental changes but continue to have difficulty. This may be due to the fact that the person is engaging in some behaviors that have become habits that are counterproductive, such as not getting up on time in the example above. I know of someone who had two alarm clocks, one across the room. He would get up out of bed and turn off both alarms, then climb back in and go back to sleep resulting in more lateness. The trick then is to work on bringing into conscious awareness the choice that is being made at this point. We can encourage this person to say to himself when he climbs back into bed, “By doing this I am choosing to be late again. Do I really want to make this choice?” First we have to identify where the stuck spot is, then make environmental changes. In addition we can use inner directed speech to guide behavior by realizing where we are making choices. Some of these choices may be immediately gratifying, but they are not what we have set as goals for ourselves. In conclusion CBT can be very beneficial to adults with ADHD. It can be used to address specific symptoms and to re-frame how the person thinks about their symptoms and themselves. With a combination of medication to address the underlying neurochemical deficit as well as therapy to teach new strategies to manage symptoms and learning more adaptive ways of thinking, adults with ADHD have more hope of building on their strengths while learning to forgive their weaknesses. |
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