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Neurocognitive Psychotherapy for Adults with ADD (ADHD)

Kathleen G. Nadeau, Ph.D.

For psychotherapy to be effective in treating adults with ADD (ADHD), the therapist must take an approach that keeps in mind the neurological aspects of ADD (ADHD) as well as the psychological issues that develop from a lifetime of being impacted by ADD (ADHD). In addition, the therapist must address the comorbid conditions that typically accompany ADD (ADHD) in adults. Neurocognitive psychotherapy is a therapeutic model designed to help the clinician coordinate the treatment of these complex, interlocking needs. This model borrows some aspects of cognitive-behavioral psychotherapy such as "reframing," identifying and changing thought patterns that impede positive change and establishing concrete plans of action to reach realistic goals. Neurocognitive psychotherapy also borrows cognitive rehabilitation approaches such as 1) treatment focused on improving cognitive functioning, 2) the development of strategies to compensate for cognitive challenges, and 3) environmental modifications (of both the physical and social environment) to enhance daily functioning.

Psychological interpretations to a neurobiological disorder

Too often, the adult with ADD (ADHD) receives therapy from clinicians who are trained to psychologically "interpret" all behavior. Therapists with psychodynamic training may view an individual's chronic lateness as "resistance" to therapy rather than considering the possibility that this pattern is related to an ADD (ADHD) time-management problem that needs to be directly addressed on more practical terms. The therapist may over-focus on early childhood experiences that contribute to a client's anger, without considering that low frustration tolerance and anger outbursts are common ADD (ADHD) patterns that often improve with stimulant medication. The psychotherapist may interpret low motivation and disorganization as signs of depression, never considering that they might result from executive function problems associated with ADD (ADHD). While such psychological interpretations may be valid, the clinician who ignores the neurobiological underpinnings of behavior will not be successful in treating the client and may even contribute to the client's low self-esteem and demoralization by "blaming" the client for neurologically driven behavior patterns.

Cognitive/behavioral approaches to ADD (ADHD) in adults:

Cognitive/behavioral psychotherapy approaches are well-suited to treating adults with ADD (ADHD) because they are focused on changing attitudes and beliefs as well as upon setting and reaching defined goals.

  1. Changing cognitions. An important aspect of cognitive/behavioral treatment is to help change beliefs and attitudes that interfere with healthy functioning. Many adults with ADD (ADHD) have built-in expectations of failure. When an individual grows up feeling criticized, embarrassed, and ashamed; when he or she doesn't understand why their efforts to do well in school aren't as successful as their peers, then these individuals tend to grow up filled with self-doubts and self-accusations. "I'm lazy; I'm stupid; I just don't try hard enough." Messages from parents and teachers become internalized and are very damaging. Many adults give up on themselves, bouncing from job to job, relationship to relationship, or clinging to a job far below their level of ability, never reaching their potential. Cognitive/behavioral approaches can help the client to examine the damaging effect of such negative self-beliefs and then guide them in developing more positive, constructive thought patterns.

    The client needs to move from self-blame and expectation of failure, to an understanding of ADD (ADHD). The therapist needs to help the client move from a position of discouragement and despair to one of hope and efficacy. ADD (ADHD) is a highly treatable condition and many adults who have received effective treatment have been able to make very positive changes in their lives - as spouses, as parents, and in their careers.

  2. Setting goals and reaching them through taking concrete steps. A second very important aspect of cognitive/behavioral therapy is that it focuses on results, helping the client to identify concrete changes that he or she would like to make in their life, and then helping them commit themselves, with the support of therapy, to taking steps that will move them closer to their goals.

Cognitive Rehabilitation Approaches for Adults with ADD (ADHD)

Cognitive rehabilitation focuses on helping people with neurological problems to improve many aspects of cognitive functioning. Although most techniques were designed for people with more serious cognitive deficits, these approaches can be adapted very well to the needs of those with ADD (ADHD).

  1. Improving cognitive functioning. Cognitive functioning can be most rapidly and effectively improved in adults with ADD (ADHD) through the use of psychostimulant medication. In addition, there is growing, but inconclusive evidence that techniques such as neuro-feedback training may also help to increase focus and concentration.

    Cognitive functioning can also be enhanced or negatively impacted through daily lifestyle changes. Stress management is a crucial aspect of ADD (ADHD) management. Symptoms increase with stress level. Adequate sleep, good nutrition, and regular daily exercise can also have a very positive impact on cognitive functioning. For these reasons, the therapist should approach stress management techniques and daily life management habits as an integral part of the treatment program.

  2. Developing compensatory strategies - Cognitive rehabilitation emphasizes helping individuals with neurological deficits to develop ways to compensate in order to function better. In other words, those cognitive challenges that are not remediated by medication or lifestyle changes need to be compensated for through developing specific strategies. This approach can work well for adults with ADD (ADHD) to help them identify strategies to decrease problems with such issues as time management, money management, forgetfulness, and disorganization.

    Assistive technology - this term commonly used in the disability community is a useful concept when working with adults with ADD (ADHD). There is an increasing number of devices that can be very helpful to adults with ADD (ADHD) - timers, programmable watches, software programs, personal digital assistants. Through the use of such assistive technologies the client can learn to better manage their time and meet their commitments. It is important for the clinician who works with adults with ADD (ADHD) to become familiar with these devices and be able to recommend them to their clients, as appropriate.

  3. Environmental changes - Creating an ADD-friendly environment. The third critical cognitive rehabilitation concept that is extremely useful when working with adults with ADD (ADHD) is that of environmental modification - i.e., finding ways to alter the client's physical and social environment to enhance cognitive functioning. The therapist needs to be familiar with all aspects of the social, workplace and home environments that may either enhance or detract from the daily functioning of the adult with ADD (ADHD) and then help the client to find or create more ADD-friendly environments.
  • ADD-friendly home environment - de-cluttering, making easy, low maintenance choices

  • ADD-friendly work environment - helping the client to institute changes in the workplace that reduce distractions and disorder

  • ADD-friendly social environment - helping the client to develop relationships with others who will be more understanding and supportive of their ADD (ADHD) patterns.

Meeting the Challenge of ADD (ADHD)

One of the therapist's primary responsibilities in treating an adult with ADD (ADHD) is to help the client to approach the challenges of AD/HD from a responsible, positive, problem-solving point of view. Thus, the first and perhaps primary therapeutic task is to instill hope after many years of defeat, to think of ADD (ADHD) as a challenge, not a defeat, as a responsibility rather than an excuse - to take an active, problem-solving approach instead of a demoralized, defeatist attitude.

By starting with smaller, do-able goals, the therapist can help the client develop a better sense of how to learn to take charge of their ADD (ADHD) and learn strategies that will be successful.

Diagnosing and Treating Co-existing Conditions

As individuals with ADD (ADHD) become adults, the chances of their having one or more co-existing conditions increases. Common coexisting conditions include:

  • Anxiety
  • Posttraumatic Stress patterns
  • Obsessive-compulsive patterns
  • Depression
  • Bipolar disorder
  • Eating disorders
  • Substance abuse disorders
  • Sleep disorders
  • Learning disabilities

Many adults with ADD (ADHD) have been diagnosed with one or more of these coexisting conditions while ADD (ADHD) has been overlooked. Bipolar disorder and ADD (ADHD) can coexist and can be effectively treated together if the bipolar patterns are addressed first, with stimulant medication added later. When substance abuse and ADD (ADHD) coexist - a common situation - appropriate treatment with medication for ADD (ADHD) can increase the chances that a substance abuser can get into and remain in recovery, although careful monitoring of stimulant medication is important in such cases.

Successful treatment for ADD (ADHD) requires that the clinician make accurate diagnoses of both the ADD (ADHD) as well as of these coexisting conditions. Such coordinated treatment often requires multiple medications. It is essential for the psychotherapist and prescribing physician to work in a coordinated fashion, with regular periodic phone consultation to fine-tune the client's medication regime. It is essential for the therapist to convey to the treating physician that the presence of such conditions as depression, bipolar disorder, anxiety, panic attacks, or substance abuse do not rule out or override an ADD (ADHD) diagnosis. In fact, treatment will never be successful so long as co-morbid ADD (ADHD) is ignored while other conditions are treated.

Structuring the Neurocognitive Psychotherapy Session

The psychotherapy session should be conducted in a fashion that keeps in mind the neurocognitive challenges of ADD (ADHD). Issues of distractibility, shifts in focus and forgetfulness that affect the daily functioning of adults with ADD (ADHD) also affect them during the course of a psychotherapy session. Neurocognitive psychotherapy that always keeps such neurobiological issues in mind will greatly increase the effectiveness of each psychotherapy session. For example:

  • Helping the client to develop strategies to arrive on time for each session.
  • Encouraging the client to take notes during the session
  • Reviewing issues discussed in the previous session
  • Helping the client to stay on track if he or she is distracted by less important side-issues during the session
  • Interweaving a focus on both psychological and practical issues.
  • Helping the client set realistic goals and plan specific steps the client will take to reach these goals
  • Ending each session with a brief summary wrap-up and reminder of goals to focus on during the interval before the next session.

Other treatment approaches and supports

Treating adults with ADD (ADHD) requires creative problem-solving. At different points in the treatment, it may be important to bring other types of professional assistance into the therapeutic program.

  • ADD Coaching - The concept of ADD coaching is now well-established, however levels of training and experience can vary widely. Coaching can be used as an important adjunct to therapy. A coach can provide brief, frequent contact with the adult client to help them stay on track, working toward their goals between therapy sessions. It is important for the clinician and coach to communicate on a regular basis to compare notes and be sure to work toward the same goals with the client.

  • Professional Organizing - Disorganization is one of the biggest challenges faced by many adults with ADD (ADHD). Their homes may become so cluttered and disorganized that it becomes more and more difficult to function. Paperwork is often the greatest challenge of all. Often, an adult with ADD (ADHD) needs the hands-on help of a professional organizer to tackle the overwhelming task of getting their home and/or work environment de-cluttered and organized.

  • Adult ADD Support Groups - The opportunity to meet other adults with ADD (ADHD), to hear their stories and struggles, and to share resources and coping strategies can be highly therapeutic. There is a growing number of adult ADD (ADHD) support groups across the U.S., many of which are sponsored by CHADD, the national ADD (ADHD) advocacy group.

Summary

The clinician who wants to successfully treat adults with ADD (ADHD) in psychotherapy needs to develop many skills that are not commonly used in more traditional psychotherapy. Neurocognitive psychotherapy is a treatment model that has been developed, combining aspects of cognitive/behavioral therapy and cognitive rehabilitation that addresses both the neurocognitive and psychological aspects of ADD (ADHD). The astute clinician must always consider multiple factors - psychological issues that result from years of struggle with ADD (ADHD), problems of executive functioning related to ADD (ADHD), and the possibility of multiple comorbid conditions that are common in adults with ADD (ADHD) if treatment is to be really effective.

Each therapy session needs to address issues on many levels, with the therapist skillfully interweaving interventions that lead to self-awareness and understanding, that explore emotional and interpersonal issues, and that address the many aspects of daily living that become chronic challenges for adults with ADD (ADHD). Clinical experience shows that therapy sessions that provide structure, support, and practical strategies will be most effective in helping the adult with ADD (ADHD) to meet the daily challenges of his life and to move forward toward meeting his true potential and reaching his goals.

For more in-depth information on neurocognitive psychotherapy, the reader can consult:

Nadeau, K. The clinician's role in the treatment of ADD (ADHD). In Sal Goldstein and Anne Teeter Ellison, Eds. Clinician's guide to adult ADHD: Assessment and intervention. San Diego: Academic Press, 2002.

Nadeau, K. Neurocognitive psychotherapy. In P. Quinn & K. Nadeau (Eds.) (2002) Gender Issues and ADHD. Silver Spring, MD: Advantage Books.

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