Psychotherapy for Adult ADHD
Attention-deficit/hyperactivity disorder (ADHD) is a relatively common neurobiological disorder of childhood that often has long-term effects on behavior, learning, cognition, and emotional functioning (Brown, 2000). ADHD affects about 3-5% of school-aged children (APA, 2000), and the prevalence in adults is estimated to be around 4-5%. As many as 50-70% of children with ADHD continue to experience clinically significant symptoms in adulthood. By the time these individuals seek treatment, ADHD is usually not the only reason for which they need help. Often adults with ADHD also present with at least one other psychiatric disorder, such as anxiety (24-43%), depression (16-37%) and substance use disorders (32-53% alcohol use, 8-32% other substance use) (Barkley, 1998).
Adults with ADHD are more likely to experience functional problems in academic/work settings as well as relationships and daily living than the average population (Barkley, 2002). While female and male adults are considered similar in terms of difficulties in psychosocial functioning and the risk for developing comorbid diagnoses of depression and anxiety (Biederman et al., 1994), according to some studies women with ADHD actually have higher rates of anxiety and depression (Resnick, 2000) and they often experience difficulties fulfilling the traditional role expectations of mother, spouse, or homemaker (Ratey el al., 1995).
As a result of the emerging evidence that ADHD symptoms endure into adulthood, ADHD is now conceptualized as a developmental syndrome that affects an individual’s executive functioning and interactions with the environment throughout their lifespan (Brown et al., 2000). Problems with executive functioning underlie the specific difficulties with planning, self-control, and impulsivity, which are the hallmark issues in ADHD (Barkley, 1997).
Psychotherapy for ADHD
When an individual with ADHD finally decides to get help and is diagnosed for the first time, it can be quite an emotional and liberating experience to realize that one’s seemingly self-defeating behaviors and long-term problems do not stem from laziness or character flaws but are the result of a neurobiological condition. At the same time, getting diagnosed can also evoke grief and sadness over what life could have been for these individuals if they had been diagnosed and treated earlier in life.
Usually, the first line of treatment for ADHD is medication (psychostimulants). Many uncomplicated cases of adult ADHD respond very well to medication alone. However, with comorbid depression, anxiety or substance use or more complicated cases of ADHD, pharmacotherapy may be insufficient (Wilens et al., 2000). The most widely endorsed treatment for ADHD of all ages is multimodal treatment, which simply means creating a personalized combination of treatment approaches and support services to meet the patient’s particular needs (Resnick, 2000). Psychotherapy is a core component in most of these cases. Adults with ADHD often have two main goals in therapy – developing coping skills to manage their symptoms, and dealing with the emotional and functional effects that living with ADHD has had on their lives (Brown, 2000). Unfortunately, however, these very problems that individuals with ADHD face on a daily basis are also the challenges that often stand in the way of getting the most out of psychotherapy. The most common problems are being unable to concentrate in the session, having difficulty remembering insights and applying them to everyday life and poor follow-through on homework. These kinds of problems often lead to a negative experience in therapy or early termination. Therefore, therapists need to adapt their approaches for these clients to make therapy effective and successful.
Active Involvement of the Therapist
Therapists who can adopt a more interactive, directive role in therapy are most effective with adult ADHD patients, as they are able to actively refocus patients to the therapeutic agenda rather than getting carried away by the patient in the hopes of finding important emotional material (Hallowell & Ratey, 1994). While it is highly effective for the therapist to act as a coach, it is also important to adopt a humanistic stance to understand patients’ struggles of living with ADHD and to utilize the power of the therapeutic relationship.
Setting Reasonable Ground Rules for Therapy
Usually in therapy there are some attendance and performance expectations for the client such as getting charged for late cancelations or missed appointments and regular attendance. Therapists may need to tailor these rules to the individual circumstances of patients with ADHD. For instance, a patient who arrives late but was able to resist his urge to totally blow off the appointment like he typically would do, is actually making progress, which needs to be recognized by the therapist. It is important to always review behaviors that arise tactfully and constructively while processing the patient’s reactions to them as well.
The therapist is an important source of information about ADHD for the patient. Therapist can recommend books on the subject and periodically review the patient’s thoughts and feelings about what they have learned. Psychoeducation should be a core feature of treatment for ADHD.
Patients are encouraged to provide real-life examples of specific problems that illustrate their difficulties and work with the therapist to find suitable solutions. Since the problems that arise in therapy tend to mimic the problems patients face in the real world, any issue that comes up in therapy is a good problem to work on. It is also important for the therapist and patient to anticipate some problems that may arise and develop plans to solve or manage them. Active and collaborative problem-solving is key for success in therapy with ADHD patients.
Core Beliefs and Compensatory Strategies
Patients with ADHD often develop negative beliefs about themselves, the world and their future as a result of their daily frustrations over the course of their lives. Therapist and patient need to identify and challenge these core beliefs that exert significant influence on behavior and affect (Beck, 1995).
As a result of these deeply-rooted beliefs, clients can develop compensatory strategies that may seem helpful at first glance, but in the long-run end up maintaining the patient’s self-defeating behaviors and self-fulfilling prophecies. A common compensatory strategy for ADHD is avoidance. Since patients with ADHD often associate even the most basic tasks with feelings of incompetence and failure, they tend to experience painful emotions and negative predictions when faced with any kind of a challenge. So instead of dealing with the painful emotions and facing the challenge anyway, patients often escape the situation by avoiding it and as a result experience relief from the emotional discomfort in the short-run. In the long-run, however, deferring the task only creates more distress and negative consequences, which then lead back to feelings of incompetence and failure.
Therapy can help by identifying these compensatory strategies and developing behavioral alternatives as well as challenging the core beliefs that maintain these compensatory strategies.
Strategies for Living with ADHD
Depending on the specific difficulties a patient faces, adjunctive treatments such as academic support, career coaching, disability services or support group can be helpful. The patient can explore these options with the therapist and make educated decisions on what would benefit them the most. Therapy can be very helpful in looking at setbacks as predictable problems to be solved instead of treating them as evidence for the patient’s personal failure. Through therapy patients can transform from victims to proactive patients with ADHD and build self-awareness, coping skills, and problem-solving abilities into their lifestyles.
Adult ADHD Treatment References
Ramsay, J.R. & Rostain, A.L. (2005). Adapting psychotherapy to meet the needs of adults with Attention-Deficit/Hyperactivity Disorder. Psychotherapy: Theory, Research, Practice, Training, 42, 72-84.
BROWN, T. E. (Ed.). (2000). Attention deficit disorders and comorbidities in children, adolescents, and adults. Washington, DC: American Psychiatric Press
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
BARKLEY, R. A. (Ed.). (1998). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (2nd ed.). New York: Guilford Press.
BARKLEY, R. A. (2002a). Major life activity and health outcomes associated with attention-deficit/hyperactivity disorder. Journal of Clinical Psychiatry, 63(Suppl. 12), 10–15.
BIEDERMAN, J., FARAONE, S. V., SPENCER, T.,WILENS, T., MICK, E., & LAPEY, K. A. (1994). Gender differences in a sample of adults with attention deficit hyperactivity disorder. Psychiatry Research, 53, 13–29.
RESNICK, R. J. (2000). ADHD: The hidden disorder. Washington, DC: American Psychological Association.
RATEY, J. J., MILLER, A. C., & NADEAU, K. G. (1995). Special diagnostic and treatment considerations in women with attention deficit disorder. In K. G. Nadeau (Ed.), A comprehensive guide to attention deficit disorder in adults: Research, diagnosis, and treatment (pp. 260–283). New York: Brunner/Mazel.
BARKLEY, R. A. (1997). ADHD and the nature of self-control. New York: Guilford Press.
WILENS, T. E., SPENCER, T. J., & BIEDERMAN, J. (2000). Pharmacotherapy of attention-deficit/hyperactivity disorder. In T. E. Brown (Ed.), Attention deficit disorders and comorbidities in children, adolescents, and adults (pp. 509–535). Washington, DC: American Psychiatric Press.
HALLOWELL, E. M., & RATEY, J. J. (1994). Driven to distraction. New York: Touchstone.
BECK, J. S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford Press.