Evidence-Based Coaching for Adult ADHD

by Lisa Joy Tuttle, MA, BCC, NBC-HWC

 Attention Magazine February 2021

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As a professional dedicated to helping adults with ADHD succeed in their lives, I am regularly on the alert for research-informed approaches that will benefit my clients. Curious to discover what a growing number of studies examining ADHD coaching might reveal, I joined colleagues Elizabeth Ahmann, Micah Saviet, and Sarah D. Wright in undertaking a descriptive review of the existing ADHD coaching outcomes literature.1 Our hope was that doing so might positively impact our work with clients and expand the knowledge base of our field. Along with the published literature, there exists another important kind of evidence that practitioners know well: the keen experience we cultivate over many years of facilitating our clients’ capacity to realize their meaningful aspirations.

Evidence-based coaching has been described as “the intelligent and conscientious use of best current knowledge integrated with practitioner expertise in making decisions about how to deliver coaching to individual clients… [providing] up-to-date information from relevant, valid research, theory, and practice.”2 Coaching draws upon existing knowledge from psychology, sport, organizational development, and other fields, and it encompasses a unique set of skills and perspectives.

Coaching is often a complement to our clients’ treatment with prescribed ADHD medications and supportive psychotherapy such as ADHD-focused cognitive behavioral therapy (CBT). Because psychiatrists, therapists, and coaches have non-overlapping areas of expertise, this three-pronged multimodal approach is gaining recognition and is recommended in recent professional consensus statements on the diagnosis and treatment of adult ADHD.3

Coaching:  view, scope of practice, and ethical conduct

Coaches hold the perspective that our clients are the expert in their own life and work, and that every client is “creative, resourceful, and whole”4 and view our role, as catalyst in evoking clients’ existing creativity, self-knowledge, and wisdom. Though the experience of ADHD indeed makes life more complicated, presenting many frustrations to be overcome, the people who have ADHD are nevertheless whole. Coaches convey to our clients the message, “our focus is not on what's wrong with you, but rather, what works for you!”

As with all professions, there are ethical standards and a universally accepted scope of practice, of which clients should be informed. “A coach should provide expert advice and teaching only in the areas in which he or she has nationally recognized credentials and follow evidence-based guidelines.”5 A key ethical mandate is to refer clients to another support professional when this is warranted.6 As mentioned above, many clients with ADHD benefit from engaging both a therapist and a coach. If, however, the coach is a trained mental health professional who also provides supportive psychotherapy, a clear distinction is to be made between the two modalities.

While as a coach it is outside my scope of practice to assess whether a client should take medication or what medication would be appropriate, for clients who have been prescribed medications, I encourage them to adhere to their doctor’s recommendations and to self-monitor the medication’s effects (on sleep, focus, appetite, etc.) as an important component of their self-care and to allow for fruitful conversations with their provider about a medication’s relative effectiveness. Additionally, I support them in developing a routine for regularly refilling their prescriptions.

Coachability: assessing motivation and readiness

Motivation is an important factor to assess in determining a potential client’s suitability for coaching. Coaches frequently receive inquiries from the parents and partners of people with ADHD in the hopes that we will inspire their loved ones to accept our help. Like that old therapy joke about the lightbulb wanting to change, those of us in the helping professions have long realized that our services are maximally effective when the potential client pursues the engagement, no matter how valuable the service or skillful the provider. The optimal candidate for coaching will be motivated to make changes and have some confidence in their ability to improve.

To assess readiness for change, coaches may employ the evidence-based Transtheoretical Model, an integrated “Stages of Change” framework conceptualized by James Prochaska and Carlo DiClimente.7 Its five stages are: pre-contemplation (not ready), contemplation (getting ready), preparation (ready), action, and maintenance (maintaining the new desired behavior). Wherever the client is in regard to their stage of change, our focus as coaches is to facilitate their readiness to progress to the next successive stage.

Since behavior change is rarely linear, it is crucial to normalize this dynamic. The words of psychologist-educator Dorothy Corkville Briggs eloquently describe the coaching process: “Growth is not steady, forward, upward progression. It is instead a switchback trail; three steps forward, two back, one around the bushes, and a few simply standing, before another forward leap.” This healthy perspective paves the way for exploration and learning.

The coaching partnership: co-creating a relationship of trust and rapport

“Research consistently finds that the ability to create a good relationship, collaboratively set goals, demonstrate effective empathy, and instill hope” are the major factors that lead to successful outcomes.8 Coaches provide an attentive, nonjudgmental sounding board and an incubator for our clients’ insights and wisdom. We engage in Socratic questioning to evoke our clients’ insights, and listen in three important ways: We listen to our client; we listen with our client for ideas and solutions generated through our conversation; and we listen for our client’s meaningful desires, concerns, and significant new awareness. I particularly am alert for when my clients say things like, “I wish…” “I love…” “I’m passionate about…” “If only…” Expressions such as these reveal emotional energy and interest. The safety and intimacy of the coaching relationship serves as a container for experimentation and growth.

Psychoeducation: understanding your brain and the vocabulary of ADHD

ADHD coaches provide accurate, up-to-date information about the neurobiological, genetic, and environmental contributors in ADHD and its most common comorbidities; we describe models of executive functioning in easy-to-understand terms; and clarify misconceptions and myths about ADHD that are promoted by critics and harbored among the general public. For clients who had previously attributed their difficulties to defects of character, such knowledge may liberate them from self-blame, and empower them to educate themselves and others in their lives about ADHD and embrace their strengths.

Individual and group coaching

Individual coaching is all about the client’s goals, agenda, pace for making changes. My client A.J. calls the essence of our coaching partnership the “we” aspect:

It’s that feeling of ‘We’ where you can get away from being trapped in your own head. It’s nowhere the same as when the coach is with you… somebody who can be with you for a while and follow along. This synergy with you is what has opened the way for so much of my growth.

Group coaching typically follows a curriculum with specific topics and a set pace. It offers an additional benefit of learning and practicing skills as part of a supportive community of fellow travelers. A member of one of my recent coaching groups shared her experience:

It’s really helpful to spend time with other neurodiverse people from a range of ages and backgrounds, to hear the things we have in common, share what’s working for us, what is still proving difficult, to validate each other and identify viable solutions. This approach to ADHD has made me feel like I finally have a guiding light in the tunnel of ADHD. The emotional support that this group has given has also been so beneficial. Hearing others express the same exact concerns and frustrations I have has been so emotionally healing as well.

Five clustered skills for adults with ADHD

A confounding issue for people with ADHD is that their challenges with motivation, organization, and working memory make it difficult to consistently apply the very strategies that could remedy these difficulties. For this reason, many of the skills ADHD coaches emphasize are geared to making actions more automatic and easier to start—and to re-start when interruptions and distractions strike, as they surely will. Concurrently, coaches help clients harness their own natural motivation and learn ways to manufacture motivation in order to meet the emotional and attentional requirements of the task at hand.

To pull far-away rewards in closer and make that ramp to getting started feel less steep, here are five evidence-based strategies, and how they have made a difference for some of my clients:

  1. Small steps in behavioral terms
    To make tasks and actions more manageable, coaches apply strategies from self-regulation and implementation science8 and ADHD-focused CBT,9,10,11 to help clients practice breaking them into smaller “chunks” and then defining each sub-task in behaviorally actionable language. Then we zero in to identify the smallest first step. As cognitive behavior therapist Mary Solanto teaches, “If you’re having trouble getting started, the first step is too big!”11Mike entered coaching hoping to overcome a pattern of chronic avoidance that was interfering with his marriage and his work. For several months in a row, Mike had avoided submitting his expense reports, rationalizing that his time would be better spent doing work. Over time, his not having been reimbursed to the tune of several thousand dollars led to fights with his partner about how his ADHD was hurting their financial security. Inviting a shift in perspective about the task, I asked, “Imagine you had to teach someone else how to create and submit an expense report… what are the specific behavioral steps you would advise them to take… and the smallest first step?While describing the process to me, Mike had an epiphany: His first impediment to his getting started was not having his receipts together in the first place. Dispersed in various places, due to his inattention and not having a system, the receipts were often found crumpled and unreadable. Mike’s new tactic was to snap a photo of each receipt the moment he receives it. This system cut his time on this task in half, and he felt the relief of avoiding avoidance!
  2. Realistic expectations and external supports
    My client Cecilia says, “One of the best strategies I have learned from coaching is to lower my expectations about what I can get done in a given period of time. I used to think that I could do a lot in a short period of time. Not true. I go too deep or I get distracted and end up going in too many different directions instead of focusing on a manageable short list of items. Keeping a timer nearby (an alarm, a clock) along with a notebook with a short, achievable list of tasks helps me to succeed by doing a few things well—instead of failing to do a lot of things (well or even at all.)”
  3. Do it now: the “hands-on” approach
    James’s overarching motivation for coaching was “to fulfill my potential—growing and improving,” with his goal of returning to college after a long absence to attain his bachelor’s degree. James frequently arrives with a list of actions he wants to take right in the session—such as emailing a professor with a question or scheduling a doctor’s appointment. He said to me, “Lisa, the hands-on approach has been the most useful thing for me about coaching. You give me the reins… just having you there as a human being who cares about me and my goals loosens some of my anxiety and makes it easier for me to take actions.”
  4. Between-session support and accountability
    Coaches often invite clients to do a brief check-in for no additional fee between regular weekly coaching sessions. These may be done via phone, text, email, or face-to-face, at regular intervals or on an as-needed basis to review an implementation plan or think through a decision. I additionally offer “book-end” check-ins—just before and after taking an emotionally challenging action.Keith is a medical student with ADHD who sought coaching to prepare well for his USMLE Step examinations. Since he wanted to avail himself of every scaffold possible, Keith scheduled check-ins with me between coaching sessions to review and refine his study plan, and requested a “book-end” before and after each of his Step exams. These book-ends greatly lessened Keith’s anxiety on the front end and helped him debrief the ups and downs of his experience afterwards. To those considering coaching, Keith says, “Make use of interim check-ins if your coach offers them!”
  5. From overwhelm to calm accomplishment
    Coaching clients often cite a desire “to be less overwhelmed” as a primary goal for their coaching. There is a fine but important line between how therapists and coaches address our clients’ emotions when these pose an obstacle to achieving goals. Coaches can help clients make a distinction between their “overwhelm”—which is emotional—and the likelihood of their being “overloaded” with commitments or “uncertain” about the steps to take—both of which are structural. Building greater certainty through external supports such as checklists and calendars, and having regular times to plan and reflect on priorities, are skills that can be cultivated to increase equanimity and feelings of accomplishment.

Learning to live well with ADHD is a lifelong pursuit. Though the road can be bumpy, coaching provides proven methods that can help pave the way for an enjoyable journey.

Lisa Joy Tuttle, MA, BCC, NBC-HWC, is the director of coaching and group programs at the Penn Adult ADHD Treatment and Research Program at the University of Pennsylvania’s Perelman School of Medicine, where she provides individual coaching and leads her popular Mindful Self-Management© executive skills coaching groups online for adults and young adults with ADHD. She is coauthor of a chapter on ADHD coaching outcomes research in The Guide to ADHD Coaching, and her t­­eam’s research is reported in the journals Pediatric Nursing (2017) and Journal of Postsecondary Education and Disability (2018). A board-certified coach and national board-certified health and wellness coach with a master’s in applied psychology, she is currently pursuing her PhD, researching stigma and empowerment in the context of ADHD.

Here are some trusted avenues to find a credentialed ADHD coach:

  1. Elizabeth Ahmann, Micah Saviet, and Lisa Joy Tuttle, “ADHD Coaching Outcomes: What Does the Research Say?” Chapter 5 in The Guide to ADHD Coaching: How to Find and ADHD Coach and What to Do When You Get One, Alan R. Graham, Ed., Motivational Press, 2018.
  2. Dianne R. Stober and Anthony M. Grant, Eds., Evidence-Based Coaching Handbook: Putting Best Practices to Work for Your Clients, Wiley, 2016.
  3. Sandra J. J. Kooij and colleagues, Updated European Consensus Statement on Diagnosis and Treatment of Adult ADHD: The European Network Adult ADHD. European Psychiatry, 56, 14–34, 2019; Sandra J. J. Kooij and colleagues, European Consensus Statement on Diagnosis and Treatment of Adult ADHD: The European Network Adult ADHD. BMC Psychiatry, 10:1, 67, 2010.
  4. International Coach Federation, The ICF Code of Ethics. ICF, 2003.
  5. Margaret Moore, Erika Jackson, and Bob Tschannen-Moran, Coaching Psychology Manual, second edition, Wolters Kluwer, 2016.
  6. James O. Prochaska and Carlo C. DiClemente, Stages and processes of self-change of smoking: toward an integrative model of change. Journal of Consulting and Clinical Psychology51:3, 390, 1983.
  7. Gregg Henriques, A New Unified Theory of Psychology. Springer, 2011.
  8. Kathleen D. Vohs and Roy F. Baumeister, Eds., Handbook of Self-Regulation: Research, Theory, and Applications. Guilford, 2016.
  9. J. Russell Ramsay, Rethinking Adult ADHD: Helping Clients Turn Intentions Into Actions. American Psychological Association, 2020.
  10. J. Russell Ramsay and Anthony L. Rostain, The Adult ADHD Tool Kit: Using CBT to Facilitate Coping Inside and Out. Routledge, 2015.
  11. Mary V. Solanto, Cognitive-Behavioral Therapy for Adult ADHD: Targeting Executive Dysfunction. Guilford, 2011.