Podcast Transcript
CBT for Adults with ADHD
Summary:
This podcast discusses cognitive behavioral therapy (CBT) for adults diagnosed with ADHD. The speakers, John Mitchell, PhD, and Laura Knouse, PhD, provide an overview of CBT and explain why it can be an effective treatment for ADHD, even though it does not directly address the core symptoms. They discuss the key components of CBT for ADHD, such as implementing organizational systems, tackling negative and avoidant thought patterns, and building behavioral skills. The speakers also address the importance of tailoring CBT to the unique needs of adults with ADHD, the growing evidence base supporting its efficacy, and some of the common challenges that clients may face in engaging with this form of therapy. Finally, they offer recommendations for resources and treatment manuals that clinicians and clients can reference.
John Mitchell, PhD
John Mitchell, PhD, is an associate professor of psychiatry and behavioral sciences at Duke University. He earned his PhD from the University of North Carolina at Greensboro in 2009 and completed his clinical internship and postdoctoral training at Duke University Medical Center. His research focuses on ADHD treatment development and ADHD-related outcomes into adulthood. Dr. Mitchell has authored or coauthored more than eighty scientific papers and book chapters, and he coauthored the book Mindfulness for Adult ADHD: A Clinician’s Guide. He has led grants funded by the National Institutes of Health. In addition to research, Dr. Mitchell is a practicing licensed psychologist in the Duke ADHD Program, working with adolescents and adults with ADHD.
Laura Knouse, PhD
Laura Knouse, PhD, is a clinical psychologist whose research and clinical expertise focus on the nature, assessment, and treatment of ADHD in adults, specializing in cognitive-behavioral therapy for adult ADHD. An associate professor of psychology at the University of Richmond, she earned her PhD from the University of North Carolina at Greensboro and completed her clinical internship and postdoctoral fellowships at Massachusetts General Hospital and Harvard Medical School. Her recent research aims to better understand the self-regulation and motivation difficulties of college students with ADHD through the lenses of cognitive and social psychology in order to develop effective interventions. Recent collaborative work with faculty in other disciplines focuses on how leaders can most effectively cope with personal crises and how growth mindsets are related to mental health and coping.
CHADD Podcast Series Overall Learning Objectives:
- Identify ADHD symptoms throughout the lifespan to improve diagnosis and treatment precision.
- Describe common coexisting conditions in people with ADHD to enhance care strategies.
- Explain effective principles of ADHD medication management for better outcomes.
- Discuss the importance of integrating behavioral and other interventions in managing ADHD for comprehensive care.
- Describe the role of interprofessional collaboration in delivering effective ADHD treatment.
Learning Objectives for This Podcast:
- Explain how cognitive behavioral therapy can help adults with ADHD.
- Learn how well CBT works to reduce ADHD symptoms in adults.
- Learn how to determine if a provider practices high-quality, specialized CBT for adult ADHD.
- Identify other interventions that could be integrated with CBT to increase treatment effectiveness for ADHD.
The following transcript has been edited for clarity.
Announcer (00:00): You are listening to Pocket MD training on ADHD in children and adults.
Dr. John Mitchell (00:07): Hi everybody, and welcome to another episode of Pocket MD. Today we're going to be focusing on cognitive behavioral therapy for adults diagnosed with ADHD. I am John Mitchell. I'm an associate professor in the department of psychiatry and behavioral sciences at Duke University and also a member of the Duke ADHD program and a clinical psychologist by training. [I am] here with a colleague and a good friend, Dr. Laura Knouse. And Dr. Knouse, would you like to introduce yourself to our podcast audience?
Dr. Laura Knouse (00:39): I'd love to, Dr. Mitchell. Thank you so much. I'm Dr. Laura Knouse. I am professor and currently chair of psychology at the University of Richmond. I'm also a licensed clinical psychologist in the state of Virginia and I did some specialized training throughout my career in research in cognitive behavioral therapy for ADHD. So, [I am] excited to talk about that today.
Dr. John Mitchell (01:01): Well, I'm looking forward to the discussion. Dr. Knouse, I was thinking to start, if we could just even say, what do we mean when we say cognitive behavioral therapy or CBT for short. What is CBT?
Dr. Laura Knouse (01:15): That's an excellent question, and maybe more complicated than you might think at first. CBT stands for cognitive behavioral therapy or cognitive behavioral treatment, and I like to describe CBT as really a big family of different specific types of interventions. This big family of interventions shares several common features or family traits, I guess I would say. The first important trait is that for CBT, we're really looking at the way that people's behaviors, emotions, and the way they're thinking about the world and viewing the world—the way these things interact to either help people move towards their important life goals, or how sometimes these things are interacting in ways that contribute to problems in living, or in some cases what we would call symptoms, depression, anxiety, difficulty coping, that sort of thing. But what the CBT looks like can really depend on the type of condition or problem that's being treated.
So, I think that for CBT for adult ADHD, we're really thinking a lot about how can we use or how can we teach people new skills, new ways of viewing the world, of viewing themselves, but also new skills and actions they're doing in their daily lives to help reduce the impact of ADHD symptoms and help improve quality of life. I think that another important thing about most CBTs is that a good thing about them is that a lot of them are tested scientifically using really high quality research designs to make sure that they actually do work for the people who have the condition in question. Now they won't work for everybody, but at least we should know that these treatments at least are a good place to start for the kinds of problems that people experience.
Dr. John Mitchell (03:09): Yeah, absolutely. I often refer people, when I'm doing evaluations for ADHD and talking about treatment options, to Division 12 of the APA, and it lists different treatments, psychosocial treatments, and non-medication treatments by different conditions. CBT is pretty prevalent throughout a lot of these, and I would just explain, off of what you're saying that yeah, it is a big tent. There's different cognitive behavioral therapy treatments, there's different waves of CBT. We went from behavioral therapy to cognitive behavioral therapy, and now the therapies that incorporate more mindfulness and acceptance, and then all the different CBTs for different things to focus on. It's funny we say CBT, [as though] it's one thing, but it's really a whole bunch of things, which kind of leads me into the next question. So, we're talking about CBT, but really what we're talking about is CBT for ADHD in adulthood—and what would you say is the idea of, why CBT for adult ADHD? Why do we even think that it should work?
Dr. Laura Knouse (04:14): That's such an important question to answer, because I think understanding the answer to that question feeds into a lot of, for both patients or clients and providers, how should they go about implementing this treatment? Because—let's be clear—your view of the world, your pessimism or optimism doesn't cause your ADHD symptoms. Thoughts don't cause ADHD symptoms. A lot of times specific behaviors don't cause ADHD symptoms. We know that these are for many people really based in neurobiology and genetics and traits that they carry with them. We think of the idea of neurodiversity that this is one variation on the spectrum of how human brains function. And so really the point here isn't that we should use cognitive behavioral treatment to get rid of ADHD symptoms. Really what we're trying to say is, are there more adaptive ways of thinking and acting and different skills and strategies that a person with ADHD can use to reduce the negative impact of their ADHD on their life?
And I think about this too, how it can work potentially hand in hand with medication treatments. The idea that one of these is not better than the other—the idea of many tools in the toolbox. And I think about medications, for example, working from the inside out, maybe turning down the volume on your symptoms for the amount of time that medication is in your body. But I think of CBT as working more from the outside in. So how can you structure your environment? How can you use different skills and strategies? How can you take a different view of your struggles that can help? Again, your symptoms might still be there, but you're getting to those meaningful outcomes in life even alongside your ADHD, rather than working against it. That's how I think about how CBT fits in with ADHD maybe a little differently than some other conditions.
Dr. John Mitchell (06:09): Yeah. Okay. So that's really helpful in thinking about what the idea is behind CBT for ADHD. Now, I know this about you because we were in grad school together a number of years ago; you got involved in some of the early trials of CBT for adult ADHD, and I believe the first big randomized controlled trial. Yeah. So, in your experience, what does CBT for adult ADHD look like?
Dr. Laura Knouse (06:33): Another really great question because we can say that even when we zero in on CBT for adult ADHD, even within that category, there's a lot of different, I would call it like flavors of CBT for adult ADHD. So, when I answer this question, I'm thinking about what I know are the common elements that I've seen across a lot of these approaches. And I just will say, as you mentioned, I got a chance to work on the randomized control trial by Steven Saffron at Mass General Hospital. And I will admit that is the bedrock of my training in CBT for adult ADHD. But when you look at treatment components, Dr. Mitchell, I would love to hear your opinion on this as well. The components I see are really common in core. The first ones, a lot of times, are putting in place some systems, what Russell Barkley would call environmental prostheses, things that can extend out into the environment and help people's planning, working memory, and these kind of boost these executive functions.
So, what this looks like a lot of times is a calendar system of some kind and some kind of task or task tracking system. Dr. Saffron used to say he would admit these are not rocket science, but a lot of times may be more difficult for an adult with ADHD to arrive at a system that they can use consistently. So, here's another theme I talk about a lot with CBT. It's not necessarily about what you do, it's how you can implement it consistently in daily life. And so it's really important to help your client find a calendar task list. This could be online, it could be paper, it could be whatever works for that client. And I bet you will know from experience too, and will concur with me, sometimes it takes a lot of trial and error to help the client find what's going to work for them.
I would say too, this is where the thinking piece comes in already, because a lot of adults will come in having tried a lot of systems and not found success, and may be thinking really negatively about their ability to even develop the skill at all. Is this something that they even believe is possible for them? And so right from the get-go, even though we're focusing on bedrock behavioral skills, we're trying to talk with clients about, what does it mean that you've had all of these in your mind, unsuccessful experiences, and how do we have sort-of a growth mindset about like, well, it's not that it can't work, it's that it just hasn't worked yet. And part of our job is to work together to find that solution that's going to work consistently for you.
Dr. John Mitchell (09:02): What we're going to do, is that we're going to refine what you know about it. We're going to make it work more given knowing what your behavioral tendencies are, and we're going to focus on the implementation. This is not a knowledge deficit, but this is an implementation issue. And I think that can be the challenging thing about therapy, is that it would be great if it was just a knowledge issue, say, oh, I just need to learn this one thing. And once I learn this, life is going to get better. As we're introducing these behavioral strategies, these self-talk strategies, ways to modify your environment, education about ADHD, they're all such important pieces. They take time. And so, I think when we do this therapy, it's important to remind people that it's such a long-term gain. When you have short-term gains, that's wonderful and celebrated, but it's really focusing on the long term.
Dr. Laura Knouse (09:49): And you've done a nice job there of winding me back to the question a bit, which is, of course, it's not just a calendar and task list. I probably should have started with psychoeducation just because I think it's so important. I think a lot of it is at the beginning is giving people good quality information about what ADHD is, what do we know about effective treatments, and then just listening to their story, and how do they view where their life has gone.
And honestly, with CBT, it's so important to focus on what their goals are for treatment. We shouldn't just be rattling through the skills in a formulaic manner, but saying, okay, how would your life be different if this treatment were successful? That's a wellspring I think you can go back to frequently with your client. It's not about what, because probably they, many of them, have had experiences where it is outside people like parents or teachers or whoever, being like, you need to do this differently and you need to change because of these external factors. But really tapping into what is their why for being in this treatment. So, that psychoeducation piece.
And then I'll just make sure to mention the other skills areas. So, definitely motivation, helping people to combat procrastination by the way that you set up the task, the way that you maybe build in some rewards, you break down the task, there's various strategies you can use for that, which can be effective.
And then like you said, a lot of it is, like, how do you set up your environment so it's prompting the kinds of behaviors that you want, whether that's reducing distractibility. So, I do a lot with my college students about, we go through this whole inventory of your study space and what is it that distracts you, and what kinds of ways do you need to, you're sort-of mise en place, right, when you talk about getting ready to cook something, how do you need to set up your environment so that you can get ready to pay attention or whatever. So that area.
And then we haven't talked too much yet about the cognitive piece, and I'm sure later we'll talk about that more. But, of course, giving people systematic ways to start to become more aware of—I like this metaphor of self-coaching. Become aware of the way that you're coaching yourself. Are you coaching yourself in a way that's going to lead to skill implementation and positive motivation, or is it going to lead more to “why should I even bother” kinds of avoidance-motivated strategies.
For a lot of that, we use some pretty standard, I guess I would say, like CBT for depression and anxiety types of approaches as well. And there's one last thing I wanted to say in response to this. Something that you said reminded me of it, the idea of implementation. That can of course be frustrating, right? Because genuinely it can be more difficult for adults with ADHD to implement some of these skills. But I also find it's an opportunity for creativity. And in CBT, we talk about creative empiricism, right? We're going to get curious about what works and what doesn't. And so, if the client comes back and is, like, oh, this didn't work. It's not like, oh, well we failed. It's interesting. So, let's unpack where did that, we do what we call chain analysis. It's like where in the chain did it break down and what little tweak could we try?
And I think I have had clients where if I can engage them in that curiosity-driven creative process, I'm thinking it can actually be quite fun. The idea that it puts therapist and client on a more level playing field. I'm not coming in being like, this is what you do, and if you do it right, it's going to work. I'm pretty sure that some version of this will help you, but we’ve got to work together to figure out what that actually looks like. And one of the coolest things about doing this work is that I've amassed all of these out-of-the-box solutions that some of my clients have found and can feed that forward. So, I don't know what you think about that last piece.
Dr. John Mitchell (13:36): Yeah, I know. I love that you mentioned that because I think about some of the trainees that I work with that are new to therapy, and informally, there is this perception that CBT is didactic, it's highly structured, highly formulaic, and therefore rigid. The good thing is we have these lovely treatment manuals from Steven Saffron, Mary Solanto, Russ Ramsay, and a whole bunch of others. And so, we can have fidelity to the treatments, but then also we have flexibility, and I love how you brought that up about treatment can be individualized. We can actually take a creative approach. And also modeling that when something doesn't seem to work and we're receptive to that, we don't say, you must use the skill this way, but instead, let's see if it works. And if it works, we celebrate. And if it doesn't, then we model how do we handle things when they don't go right? We don't throw up our hands and say, well, I did it by the manual and it's not working. Instead, we say, let's adapt it. Let's be curious here. And so, yeah, I love bringing that curious attitude towards the treatment.
Dr. Laura Knouse (14:37): And I would say your comment reminds me of another old adage about CBT, which is that as the CBT therapist, you're trying to make yourself obsolete. You're trying to get to the point where the client can engage with the process. And that's one of the ways that we do that by saying just this problem-solving approach to life is something that I think we're trying to encourage our clients to develop for their own selves and not be stuck in the cognitive piece, like the regret or it can't work because it hasn't worked, but be like, what are the positive qualities that I have and how can I work with this challenge that I have to bring those out,v I think is really important part of it.
Dr. John Mitchell (15:17): Yeah, and so, could you talk a little bit about what the evidence is for CBT?
Dr. Laura Knouse (15:23): Sure. So yeah, the past 20 years literally have been a watershed for now. Of course, caveat, we always need more research. I think one thing that would be good to have is more trials using exactly the same treatment manual. We have a lot of these different flavors of CBT. But all that’s to say that the most recent meta-analysis that I've seen really does show some nice effects in terms of these CBTs for adult ADHD, especially in particular on the inattentive symptoms. I would say if we're being specific about effects, that's kind of where you see the strongest effects. And it makes sense, because a lot of the skills that are traditionally in these approaches have to do with the inattentive symptoms, right? Distractibility, disorganization, procrastination, and whatnot. Although I will say, I meant to say earlier, of course, many CBTs incorporate mindfulness strategies. And I think there is some interesting possibility about the extent to which those skills might be maybe a little bit more helpful for the impulsivity piece, but maybe we can talk about that later.
But yeah, the number of trials that are out there, randomized controlled trials that are showing positive effects, more open studies pre to post. But yeah, without getting too much in the weeds, there have been, at least in the past couple of years, at least three really well done meta-analyses that show significant impact, moderate effects on inattentive symptoms, a little bit less impact on hyperactive impulsive. But also interestingly, many studies show effects on depression, anxiety symptoms, too, even if those aren't directly targeted by the treatment, which I think is an important result with respect to medications. It seems like they work well with medications, although at least in my study there wasn't. People often ask, does the CBT work better for people on medication? And at least in my study, we didn't find that. So, the message here is that whether your client wants to do the med thing or not, CBT probably could be helpful for them, is how I interpret that.
Dr. John Mitchell (17:21): I agree. I think that's a good take-home message, and treatment like we talked about can be individualized. And the nice thing is there's a lot of things that in the treatment literature, it's not just ADHD symptoms, the executive functioning difficulties, like difficulty with time management organization. You mentioned depression and anxiety symptoms that are so common in ADHD. So, there's a study that came out recently, it got to this issue of CBT for ADHD, but the importance of it being adapted for ADHD. And I was wondering if you could talk a little bit about that, because I could see that where if you're somebody out there and you're interested in this kind of treatment, what are you asking for? Are you just asking for CBT? Do you need something more specific than that?
Dr. Laura Knouse (18:07): Yeah, I was so glad, this is a study by William et al., 2024, and they used information they had collected from the National Health Service in the UK. Of course, they have centralized, socialized medicine, and so they have, I think, more standardized protocols for how, if you go to the NIHS for treatment for a particular condition, it's more algorithmic, you would receive X, Y, and Z is my understanding. And so, my understanding from the article is that the way that CBT is implemented in the National Health Service is much more like the CBT for depression and anxiety flavor of CBT that you and I discussed earlier. And what they found—they had some quantitative data, but it was also qualitative—they found that the adults with ADHD who had received this kind of non-tailored version of CBT did not seem to benefit very much.
They felt that it didn't really fit their needs, and that it was overall not a terribly helpful experience for most of the people in that study. And it's funny, when I read the headline of this study, first I thought it was saying, oh CBT for ADHD is not effective. But no, what it was saying is like CBT that is not for ADHD specifically might be barking up the wrong tree. So, I think what it really speaks to is the idea that not all CBTs are created equal and not all CBTs are just going to generically work for all conditions. And so, to your point, for the people out there who might be seeking out treatment, it can be really difficult. We don't have a good standardized way to say this person is practicing the certified version of CBT for ADHD. But I think there are some basic questions that people can ask. You can ask a provider, what has been your specialized training experience in CBT for adult ADHD? What kind have they used or do they use pieces at least from some of these manuals, Dr. Mitchell, that you mentioned earlier—Steve Saffron, Mary Solanto, others—where there is some research backing to why these particular components would be used for adult ADHD. Those are the things I think of. Do you have thoughts about that?
Dr. John Mitchell (20:14): I do something very similar. So, when I'm trying to guide people towards treatment, I name the particular manuals and I say it's a legit question to ask a potential therapist, Hey, do you know about this treatment manual? And if they do and they say they use it, I say, that's great. And if they don't, then I wouldn't say it's a lost cause. I would say, Can you ask them if they're willing to use something like that so that they can adapt it so they don't wind up with CBT? That's not really specific for ADHD. It's so funny, because when you're going up for medication, when you get a stimulant, you don't look at the pill and wonder, you're like, well, is this actually methylphenidate? No. But it's not that way with psychotherapy, and so, I think I find what I do in my own clinical practice to describe it to people, and really I wish it wasn't that way.
I wish I could look on a website and on the top right hand side, it's going to have that certification, and it's the same for everybody, and it's easy to check. But until we have that, I think of it as like, you're in a marketplace and buyer beware. It shouldn't be that way, but that's the way that it is right now. If you're going to be in the marketplace, we want you to be a well-informed consumer. And that gets back to that psychoeducation about not just what is ADHD, but what is the treatment? What is CBT and what should it look like?
Dr. Laura Knouse (21:29): Absolutely. Yeah. I think sometimes people don't feel, for whatever reason, that they can take ownership as the consumer in that way—but they can; they should. And any therapist should be so open to answering these questions. And if they're not, right from the beginning, that would be a little bit of a red flag.
Dr. John Mitchell (21:46): So, we were talking about cognitions earlier, and so a conversation that we've been having for over 20 years is this interesting thing in ADHD, where adults with ADHD—and there's research behind this, as you well know—there's certainly the negative thinking, right? The “I'm lazy” and the negative beliefs in self in the future and your ability to impact your future in a positive way. And at the same time, there's these positive beliefs, too. I remember this first coming up, and okay, first of all, what are these positive beliefs in ADHD? How can this coexist with negative beliefs? And then, also, how do we handle it? Because in a traditional cognitive therapy format and old school cognitive therapy was these cognitions are…
Dr. Laura Knouse (22:35): Just irrational.
Dr. John Mitchell (22:36): Irrational, yeah. And do you want your therapist saying you're irrational when you say that you do something well?
Dr. Laura Knouse (22:42): Or that things are just, when I use as a teaching example from actual client who is lovely was, “I'm a good person, so this is all going to work out for me,” which is a great thought, but the whole thing is the context he noticed. He would think that in situations where he really probably should have been dealing with a problem or planning ahead, but it was avoidance, right? But you're right. Are you going to be like, well, let's examine the evidence for and against the idea that you're a good person. That feels weird therapeutically.
Dr. John Mitchell (23:13): Instead, can we pivot to, What's the impact of this, and how does this fit in line with the presenting concerns that you have coming in and wanting to work on ADHD and these beliefs like what you said, “I'm a good person.” And that's a good thing to think. And also, in some situations where it does lead to maybe more putting things off and procrastination, and then in that case, How do you think we should best kind of approach these beliefs and kind of a cognitive approach?
Dr. Laura Knouse (23:43): Yeah, for sure. You've raised an important point that I always start with when I'm trying to educate a new audience about this, which is that absolutely the overly negative depressogenic, anxiolytic types of thinking are incredibly relevant to many adults with ADHD, right? There's high comorbidity between ADHD and anxiety and depression. These are people often who have had these perceived failure experiences and received a lot of frankly negative feedback from the environment. So, it makes sense that there might be a tendency to default pessimistically, [when you] think about your own capabilities and stuff. But as you pointed out—this is one of the cool things about being a clinical psychologist, a scientist practitioner—as people did this work, we started to notice, my clients sometimes have these overly positive or at least not negative thoughts that seem to come along with them, avoiding what maybe they should do, or the moment, that choice point, are you going to use the skill or not use the skill?
Oh, I don't need to write that down, I'll remember it. But there are just these moments of these thoughts that you're pointing out, we've done some work together and then I've done some other work trying to figure out what do we call these things—right now I'm calling them avoidant automatic thoughts. I think that's how they function and they're not always overly optimistic. They might be. And to your point about earlier about when are things like this problematic. I think a lot if it's not getting too in the weeds that it's about the context of a thought, it's not what the thought says it is, it's what the thought is doing in that moment. For example, me thinking, oh, I'm a good person in a moment that I'm feeling a little bit of low self-esteem and that boosts my mood, sure, that's functionally probably a good outcome.
But if it's occurring in the context of, okay, now I don't whatever, have a crucial conversation with somebody that I need to sort something out with, because I think it's all just going to all work out on its own—well, then, that thought's probably not terribly helpful for us. So, I think to your original question, I think a lot about what is the function of the thought as much as we can tell in the moment and helping, first of all, clients become aware of when they're having these, do they have ones that are common? In our article together, we call them red flag thoughts. So, if there's a constant one where I consistently have the spot noticing that it's linked with me not doing what's in my own best interest. And in some of my recent work, the problem of measuring these things is a real challenge because they're just fleeting.
And we can give people a questionnaire and say, How often are you having this thought? And they'll tell us something that correlates with other things they should correlate with. But I'm not convinced we're really capturing in reality how often is a person having a thought. So, in our lab, we've started using a research technique where instead of one questionnaire several times throughout the day, our participants will get pinged on their cell phone and fill out a little short questionnaire that says, How are you feeling right now? Have you had any of these thoughts in the last few minutes? And to what degree, if any, are you putting off something that you should be doing right now? And we've been able to measure, first of all, people are having these thoughts all the time. By the way, our college students about half the time are reporting them.
And I thought when we measured older community members, general adults, that would be lower. Now it's still like 43% of the time. So, these are not just negative thoughts, these aren't specific to ADHD by any means. But what we did find is that people with high ADHD symptoms or an ADHD diagnosis are having these more often and in some cases there's a tendency that they're even more predictive of avoiding things, being in avoidance mode as I would call it. But just the mere fact that they're having them more and they're associated with avoidance, it is sort of showing how potentially these thoughts might be having an influence on people's daily lives. So, that's some of the research.
And then to your question, what do we do about this clinically? I think, like I said earlier, just doing things to increase awareness, so good old self-monitoring. When you find that you've got into avoidance mode or you probably should have done something, as soon as you can use [it,] the CBT therapist out there will know about the daily thought record. It's a tool that we use to break down the situation, feelings, thoughts, behaviors. The goal there isn't to change it. The goal is just to become aware of when is it happening and what's the context, what kinds of feelings and behaviors is it linked to. And then, as you and I have written in our article, there's a lot of different things you could do to try to work with the thought. I'll name a couple, and I'm sure you have ideas too about how you might work with it.
Awareness, The client I was telling [you about] earlier, he wrote his thought on a bright colored Post-it note and stuck it to his computer screen. So it was like, okay, anytime I have this thought I like to use because I'm older now, the wise words of Ice Cube, “chickity-check yo' self before you wreck yo' self,” for basically that's a little ping to be like, Okay, do I need to stop and actually use a skill versus avoiding, just like in acceptance and commitment therapy (ACT), we think a lot, can we use metaphors? Can we use stories or physical kinds of stories? Metaphors, one that I actually credit. One of my former supervisors, she had a client who their problem was that they would take on too many commitments impulsively. They were sort of like a people pleaser. So, her idea was they talked about, okay, pretend you're at a potluck or if you come from central Pennsylvania, a covered dish supper, and you have the world's flimsiest paper plate and you're going through the buffet line and you're just putting more and more and more on this plate and this plate, the grease is soaking through the plate, the plate's piled too high and it slips out of your hand. So [they used] that very visceral image. And so [they] had the client be like, anytime you get a request, you’ve got to envision that plate. Can this really fit on your plate?
So, I think any way that you can bring that awareness to mind in the place that it's needed, so the client has a chance to do something different. That's the hardest piece of CBT—getting the skill out into the world. And those are just a couple of ideas. I actually did a version of this with college students, and I had to go on Amazon and order the lowest-rated paper plates that existed, and I made bats of Jello and I made them run around with plates full of Jello, to be, like, You can't hold everything on your plate, friend. I don't know if they remembered anything from it, but it was fun for me.
Dr. John Mitchell (29:55): There's something to be said for experiential learning, and the more that you can bring the behavior into the session, the better. I love how you put that and you use the term really focusing on avoidance because in the earlier iterations of this, we were talking about positive and negative, and then it's like, well, wait a minute. Those things are counter to each other. You can't have 'em because how can you be positive and negative?
Dr. Laura Knouse (30:18): And we find they're correlated. The positive and negative
Dr. John Mitchell (30:20): Thought positively correlated somehow. And it's because I think what you're talking about when they both contribute to avoidance. Yeah, I love that. Okay, so these are the things that people are, typically, this is what clients are encountering when they're doing CBT for adult ADHD. What would you say if you had to give them the most common challenge or one of the most common challenges they would expect to face in doing CBT?
Dr. Laura Knouse (30:46): The most common challenge, the thing that'll be hard about doing CBT, I think it's going to be that you have to practice, and this is actually, this is the same for the therapist. I think you can't just talk about skills. To your point earlier, the more you can actually be doing stuff in the session, like starting to make the task list right there. And, of course, then we know in CBT the infamous homework. So, these are the practice things that the practice exercises and assignments that the client's doing outside of the session, which we know in both generically. And there's a really nice paper that shows the importance of homework completion for CBT for adult ADHD, too. I think that's the biggest thing. Finding a way to commit to the practice piece of it and the implementation.
And even if it doesn't work, coming back, don't avoid sessions, don't not show up. You didn't do your homework. Come back and tell the therapist so we can work on it. And sometimes how to get the homework done becomes the thing you're working on, which is fine, because that's all grist for the mill. Following through in your commitments is a big thing that we're all trying to work on. So, I do think it's the practice piece of it.
I think for the therapist, it's the practice piece of it, making sure that you're really consistently following up on the homework, not allowing yourself or the client to engage in avoidance in that way of something's not working out. And then I think sometimes too, just keeping the session on track. I think using the agenda that CBT therapists are so famous for using, making sure that you have a direct conversation at the beginning with clients: ”You and I are both going to be tempted to go talk about other stuff that might not be directly related to where we really need to be,” and work [it] out with the person. “Is there a code word or a way that we can mutually agree upon [to] signal each other when we're getting a little bit off track,” and make it so that it's not just you calling out the client. I'm an extrovert.
Dr. John Mitchell (32:39): Okay, let me be a little bit of a downer here. Yeah, we've been all glass half full with CBT, but what about side effects? Are there any downsides to doing CBT?
Dr. Laura Knouse (32:50): I'm so glad you asked. I think this is a question we need to ask more when it comes to psychotherapy. First of all, the opportunity costs, meaning that there's going to be a time-intensive element to this, as we just talked about, iterative and practice and all that sort of thing. And you're talking about the time investment, but also as we know, the managed care environment here in the United States is very unfavorable, and so there is going to be a cost associated with the treatment. So, there's that. I do think that, especially early in therapy, it can be sometimes emotionally difficult for clients, especially if this is the first time they're coming fully face to face with the long-term impact of this disorder on their lives; especially when I worked more with middle-aged folks and older, there is, it's a bereavement process. I think that happens, and I think that's important to make space for. How would my life have been different if I had found this diagnosis or found these supports earlier? And I think that self-awareness always can be a double-edged sword, and I think that you as the clinician have to be really ready for that. Those are some things that I think of most immediately in terms of side effects.
Dr. John Mitchell (34:00): I think in general, when people are coming to work on something and with ADHD, this is by definition something that's been around their whole lives and it's the first time working on it, change can be hard. Learning to adapt can be challenging, and that doesn't mean that it's not worth it. It's analogous to anxiety. The way to get through anxiety is not to go over it, under it, or around it, but you’ve got to go through it. And I think when we're talking about avoidance of things, going back to what we were talking about earlier, avoidance of cognitions, avoiding behaviors that might feel aversive, like working on that thing that you really want to avoid right now and procrastinate on. It's not a pleasant thing, but there's a reason to do it. As we're talking about this, one thing that comes to mind is, okay, if somebody is listening to this and thinking like, Oh my gosh, they're talking about negative effects of CBT, maybe I shouldn't do it. I'd say, well, no, change could be challenging and that can be a good thing. And in some ways there can be short-term pain,
Dr. Laura Knouse (35:00): Which is true for medications. The idea that a lot of times those side effects—not always, but sometimes—can dissipate as you're getting used to the substance there.
Dr. John Mitchell (35:11): Yeah.
Dr. Laura Knouse (35:12): It's not cost–benefit analysis. But I'm glad you again asked the question because I think that any person who is getting involved in a treatment should be doing that cost–benefit analysis for themselves. I definitely think it's worth it, and I think that this is another reason that I think CBT sometimes has this incorrect stereotype that the therapeutic relationship is not as important as it is in other forms of therapy. And I just think that is completely off base, because we're asking people to become aware of things that are distressing to them at times, and to try on new things that are not going to be comfortable at first. And you have to have a high degree of trust with your client in order to help them to make those changes.
Dr. John Mitchell (35:56): What would be something like resources that you would recommend for people to learn more about CBT if they're interested?
Dr. Laura Knouse (36:04): Sure. You and I have both referred to several of the well-known treatment manuals, so I think especially if you're a clinician, that might be a really great place to start. So, we've mentioned Mastering Your Adult ADHD, Steve Saffron and colleagues, that has a therapist manual and a workbook for it so clients could look up the workbook if they were interested. You mentioned Mary Solanto's work on CBT; that is a really good resource, too, both of that. She has a treatment manual out there as well. I think the work of Russ Ramsey and Anthony Rostain, they're another great team; one of them is a psychiatrist and the other one's a psychologist, so, I think their stuff has even more about how the medication could be integrated in there. I think those are good resources. I would say those are kind of my top three for CBT.
Of course, if you're interested in the mindfulness work too, I would plug your work with Lydia Zylowska gives a really good research resource there. And I guess I can say for college students or maybe older high school students, the manual that we worked on is called Thriving in College with ADHD, and there's, like I said, the therapist manual, and then there's a workbook that can also function as self-help if you're a client and you just want to learn a little bit more about ADHD and what is CBT. I think Taking Charge of Adult ADHD is a good kind of research-supported general reference about ADHD that includes information of both meds and CBT.
Dr. John Mitchell (37:32): Yeah, you're naming some really great ones. I guess one that I would add to that list, including two authors that you mentioned, when clients ask, The [Adult] ADHD Toolkit by Russ Ramsay and Tony Rostain. I find that one very user-friendly. Awesome. I would add that to the list on top of some excellent ones that you already mentioned. So, I was going to make that kind of the last question, but I'm going to add in one more because you really piqued my interest. Your Desert Islands, if you had somebody coming in and you're going to teach them, you want to go over one skill.
Dr. Laura Knouse (38:06): Oh, just one. Okay.
Dr. John Mitchell (38:07): Yeah, and I don't know, maybe you have 1, 2, 3, 4, maybe five sessions, but you have one to drill down on.
Dr. Laura Knouse (38:14): I have five sessions and one skill.
Dr. John Mitchell (38:16): So, we have enough time to learn it, but then also enough time to try to figure out how to implement it.
Dr. Laura Knouse (38:22): Yes. Oh, it feels boring, but I’ve got to go with calendar task list, [which] I think that so many of the other skills are built upon. In one of my approaches, I talk about knowing what you need to do. When if you don't have that in place, it's hard to do all of the other stuff. So, I think, and can I cheat? I'm going to cheat a little bit and say that working on the task list also is going to include prioritizing and breaking big ugly tasks into smaller pieces. That one is huge. That's definitely a runner-up. I do this thing in my college student manual. I'm like, okay, look at this thing that says write history paper. When are you ever going to look at that on your task list and be like, well, gee whillikers, I feel like doing that right now. No, that feels horrible. I don't want to write history paper. But then going through the exercise of, like, I'm always step one, reread your professor's instructions, so breaking it down into those pieces and break it down so far that you don't look at it and have that, oh, I have plenty of time to do that later. You don't look at it and just feel gross. I guess maybe that would be, that's a little bit of a cheat, but that's a refinement on the check.
Dr. John Mitchell (39:31): I think that's fair, because I think that goes back to a lesson that for people to think of these skills not as totally separate, some of them are hierarchical, right? I'm going to learn about breaking things down after I've learned about a prioritized task force, maybe. Yeah, separate skills, but they actually work really well together, and you're not using them in isolation. So, either they're hierarchically related or they're going to be related somehow.
Dr. Laura Knouse (39:58): I think that framing helps people because it's normalizing it. There's nothing wrong with looking at, right, history paper, and being like, Oh, I don't want to do that. If I were not a person without ADHD, I would just do things. I think a lot of times our adults with ADHD think, If I were “normal,” whatever that means, I wouldn't have to use these quote unquote tricks to make myself do stuff. But the more you can talk about, no, everyone has to use these strategies to, maybe it's easier for people without ADHD, but the mere fact that you need to use these strategies does not mean there's something wrong with you. It in fact means you're highly skilled.
Dr. John Mitchell (40:34): I can't think of a better note to go out on, Dr. Laura Knouse. You are a gem to talk to about these things, and I always enjoy it. And thank you very much for being here on the Pocket MD podcast.
Dr. Laura Knouse (40:41): And thank you, Dr. Mitchell. It's been a pleasure.
Announcer (40:53): Pocket MD is brought to you by CHADD with funding from the US Centers for Disease Control and Prevention, and in partnership with the Rainbow Center at Rainbow Babies and Children's Hospital.