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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.
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 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.
- 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.
- 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 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).
- 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.
- 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.
- 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.
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.
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.
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.
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.
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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