J. Russell Ramsay, Ph.D., is Associate Director and co-founder of the Adult ADHD Treatment and Research Program at the University of Pennsylvania School of Medicine, and a senior staff psychologist at Penn's Center for Cognitive Therapy. He is author of Cognitive Behavioral Therapy for Adult ADHD (Routledge, 2008) and Nonmedication Treatments for Adult ADHD: Evaluating Impact on Daily Functioning and Well-Being (American Psychological Association, 2010). Dr. Ramsay has lectured internationally to mental health professionals on adult ADHD and the principles of Cognitive Behavioral Therapy (CBT). I feel very fortunate to have had the opportunity to interview him about CBT.
Q: What is cognitive behavioral therapy?
A: What sets CBT apart from other forms of psychotherapy is the emphasis it places on the interactive role of cognitions -- automatic thoughts, images, belief systems -- and behaviors. CBT certainly does not ignore emotions, but rather targets problematic thinking and behavior patterns as the entry point to understanding and addressing the difficulties for which people seek treatment.
CBT was originally designed as a treatment for depression and research has consistently demonstrated that it is an effective therapy approach for mood problems. Subsequent studies have shown CBT to be helpful for other common problems, such as various types of anxiety, substance use, other mood problems, and some medical issues, such as dealing with sleep problems or headaches. The past decade has seen many clinical researchers who have worked on modifying CBT to address coping difficulties associated with adult ADHD.
Q: What role does CBT play in a treatment plan for adult ADHD?
A: Medications are considered the first line of treatment for ADHD in terms of treating the core symptoms of ADHD. There are a variety of medication treatments for ADHD whose benefits operate through their effects on brain functioning, generally producing improvements in sustained attention, managing distractions, and impulse control. For many people, these symptom improvements lead to functional improvements in their daily lives, such as being better able to keep track of items, experiencing less physical restlessness and greater impulse control, and being able to sustain focus on work or reading for reasonable lengths of time, to name a few.
However, many individuals may continue to struggle with the effects of ADHD despite adequate medication treatment. That is, individuals may continue to experience residual symptoms of ADHD and/or have ongoing difficulties implementing the coping strategies that they know would be helpful. Moreover, individuals with ADHD may struggle with difficulties managing their emotions in daily life, an increasingly recognized feature of ADHD, or may experience problematic levels of depressed mood, anxiety, substance use, or low self-confidence. These adults with ADHD require additional help to experience improved well being and functioning in their daily lives.
CBT has been found to be a useful adjunctive treatment that directly addresses the sorts of impairments and coping issues associated with adult ADHD that were described above. While the coping solutions may seem simple -- use a daily planner, start working on tasks well in advance of their deadline, break large tasks into smaller tasks -- they can be difficult to implement. Facing these longstanding challenges may also trigger negative thoughts, pessimism, self-criticism, and feelings of frustration that create additional barriers to follow through. There also may be a minority of individuals with ADHD who cannot take medications due to medical contraindications, intolerable side effects, non response, or who simply decline medications for whom CBT may be the central treatment approach. Hence, CBT may be recommended in cases in which medications alone are not sufficient to address problems associated with ADHD.
Q: How does CBT address some of the day-to-day problems caused by ADHD symptoms?
A: A common example is a patient who arrives late for the first session -- citing that addressing "poor time management" is a goal for CBT. Such events are used to "reverse engineer" the various component parts of the problem in order to provide increased understanding of how ADHD (and other factors) may contribute to the development and maintenance of their functional problems, in this case "poor time management," and to provide some initial ideas for coping strategies. This sort of review also allows treatment to be personalized to the individual's circumstances, thereby making it a relevant and salient opportunity to strategize for the implementation of coping skills.To continue with the aforementioned example, the issue of "time management" related to being late for an appointment could be the result of poor schedule-keeping (e.g., not having a daily planner with a record of the appointment), disorganization (e.g., not being able to find the piece of paper with the appointment date and time), poor problem-solving (e.g., not thinking through options for obtaining the appointment time, such as researching the number for the office and calling to confirm), poor planning (e.g., not setting a realistic time frame for leaving for the appointment, factoring in travel, parking, etc.), and becoming over focused on distracting tasks (e.g., working on the computer), to name but a few factors. Issues related to anticipations of the appointment may also create barriers to follow through, such as feelings of anxiety (which can be distracting and lead to avoidant behaviors) and task-interfering cognitions, either negative (e.g., "This doctor will not tell me anything I have not already heard") or positive (e.g., "I'm sure there will be plenty of parking" or "It won't matter much if I'm late").
Each of these components of "poor time management" offers an opportunity for change. As the various difficulties associated with ADHD are identified, there will be recurring themes that emerge and the various coping skills discussed can be applied to various situations to improve overall functioning. It is not a "quick fix" and skills must be implemented in a consistent fashion, but the combination of increased recognition of the effects of ADHD and a plan for handling them provides a template for making sense of what had previously been experienced as factors beyond one's control.
Interview continued on page 2.