7
This chapter presents extended case examples to illustrate how cognitive interventions fit within a course of cognitive behavior therapy (CBT) for adults with attention-deficit/hyperactivity disorder (ADHD). All identifying information has been changed to protect privacy and confidentiality; the case examples presented here are drawn from actual clinical encounters but represent a hybrid of cases for illustrative purposes. All clients underwent a thorough diagnostic evaluation for ADHD. Therapist commentary is provided throughout the description of the cases.
Grace-Ann is a 42-year-old married mother of two, who sought CBT due to recently having been placed on a performance improvement plan at work. She works in an administrative support position within a large health care organization. She had previously worked part-time for a local medical practice but sought a full-time position once her children entered middle school.
Grace-Ann anticipated that she would struggle with the shift to a faster-paced position, but after 2 years her disappointing performance reviews could not be blamed on an adjustment issue. She had been diagnosed with ADHD in college after being placed on a 1-year academic leave. Although needing three extra semesters, she graduated college with a combination of a prescribed stimulant and regular meetings at the campus learning center. Grace-Ann still takes medication, which helps, but the problems in her current job have escalated to the point that she is concerned about potential dismissal.
Grace-Ann identified her primary goal for CBT as better organization and follow-through with tasks at work. When asked for a specific example of this, she cited a current delay on her supervisorʼs request for patient-visit data. She said that her boss requested it days ago, but she had not yet acted or even responded despite knowing it is a priority.
THERAPIST: Would it be fair to say that this is a relatively common example of the type of issue that you want to improve?
GRACE-ANN: Yes. Today itʼs the visit data, but I seem to put off tasks like this all the time when I know full well it doesnʼt make sense.
THERAPIST: We can use this as an example of how you can break down this sort of task and figure out how you do not do things to set the stage for better follow-through on this and other tasks. Would that be a good use of our time today?
GRACE-ANN: Yes. This is exactly what I need help with.
THERAPIST COMMENTARY: This is an example of starting small with a relevant problem that is likely representative of larger, more pervasive issues. In addition to clarification of broader therapy goals, this issue provides an opportunity to socialize Grace-Ann to the CBT approach using the structure of the How You Donʼt Do Things [HYDDT] form, including its cognitive elements [see Chapter 5, this volume]. This form and task also are a good initial homework task.
THERAPIST: First, what is your overarching goal for wanting to handle this task in a timelier manner? Why is this of value to you?
GRACE-ANN: Right now, I want to survive my next performance review and keep my job. But it would be nice to get things done and not have the stress of them hanging over my head. I want to know that I can rely on myself to do these things simply because I need to do them.
THERAPIST: Those are some good reasons. So, youʼre saying that follow-through on this and similar tasks would reflect well on your job performance and help you to feel less stressed and more confident in yourself, in general. Focusing on this project, what exactly do you have to do?
GRACE-ANN: There is a sorting feature in the electronic medical records system that allows me to organize and analyze data to give my boss.
THERAPIST: Even before getting to the sorting feature, what would be the smallest first step that you would need to take to get started, to actually “touch” the task?
GRACE-ANN: What do you mean?
THERAPIST: Are there steps you must do on the computer before even getting to the sorting step?
GRACE-ANN: I need to get the department identification numbers before I run the sorting features. It is only a couple of steps to make sure I have the right numbers.
THERAPIST: Okay, even though it is a small step, it is one to factor into your planning. On an even more basic level, though, when you walk into the office, what would have to do to even get access to these department numbers and patient data? If you were scripting this out in a series of instructions for a robot, what would the robot have to do once it entered the office doors?
GRACE-ANN: Well, the very first thing Iʼd have to do is go to my desk and log on to the computer.
THERAPIST: Once logged on, what is the next step directly related to the project?
GRACE-ANN: There is a drop-down menu for analytics which is what I use for data sorting. There is another drop-down menu that I can use to find the department numbers I need for the data search.
THERAPIST: Okay. What we are doing here in terms of a portable skill is one that we all know—break down a task into small steps. This sort of scripting helps lay out a sequence of steps like a recipe. Despite knowing this, it is the doing, the implementation where problems arise for most people.
GRACE-ANN: I know, I beat myself up at the end of each day when I look back at all the times when I could have taken care of this. It sounds so simple sitting here talking about it.
THERAPIST: This is a challenge for anyone with a human brain, but even more so when dealing with ADHD. By simply taking some time, as we are doing here, to lay out some actionable steps you can increase the likelihood you will start and follow through. There are a few more details that can help increase the odds. When will you do this? What is a specific day and time that you can commit to devoting to this task, an appointment for doing it?
THERAPIST COMMENTARY: This guided discussion provides Grace-Ann with a framework for understanding her procrastination and corresponding high-yield pivot points for engagement, which is the goal of the HYDDT form. This process reflects the prolongation of these moments and the personalization of strategies for better navigating them.
GRACE-ANN: I can do it first thing tomorrow morning when I arrive at the office.
THERAPIST: Specificity helps with follow-through because it gives an exact target. What time tomorrow?
GRACE-ANN: I get there at 8:30 a.m.
THERAPIST: Let me play devilʼs advocate—is that a realistic plan? It sounds feasible now but are there other things that might get in the way of this plan at 8:30 a.m. tomorrow?
GRACE-ANN: Well, I typically spend time taking care of pressing emails and simply settling in. Iʼm usually not up and running on things right at 8:30 a.m. I guess 9:00 a.m. is probably more realistic.
THERAPIST: Okay, 9:00 a.m. tomorrow morning. How long do you think it will take to sort through the data and be ready to give it to your boss? Can it be done in one sitting or will you need more time?
GRACE-ANN: It really should only take about 30 or 45 minutes, though sometimes these things take longer than expected because of missing data or other issues that come up.
THERAPIST: Focusing on tomorrow at 9:00 a.m., what is a realistic expectation for a minimum amount of time you can devote to this task, even if you encounter difficulties?
GRACE-ANN: Iʼd say 45 minutes should be more than adequate.
THERAPIST: Again, at 9:00 a.m. tomorrow will the prospect of working on this task until 9:45 a.m. look realistic? Would it be better to start with 30 minutes?
GRACE-ANN: I have a 10:00 a.m. meeting that includes my boss, so 45 minutes is realistic and gives me time to prepare for the meeting. It would be nice to tell her Iʼm done or at least update her.
THERAPIST: That sounds good. So, the plan is to start on the task at 9:00 a.m. tomorrow by logging on to your computer, accessing the drop-down menus, and working on the data until 9:45 a.m.
GRACE-ANN: Yes, that sounds good.
THERAPIST: Where will you do this?
GRACE-ANN: My desk.
THERAPIST: Iʼm going to again raise the question of whether this is the best place for this task because I would guess there are a lot of distractions and people looking for you.
GRACE-ANN: There are, but I should be able to make myself do it there. Itʼs my desk.
THERAPIST COMMENTARY: Grace-Annʼs use of a should statement in this case is an opportunity to shed light on the role of cognitions at various pivot points. This relatively innocuous should thought is an example of the influence of such thoughts for adults with ADHD in terms of choices that affect pivot points and moving from being off task to being on task.
THERAPIST: Fair point. Though, let me propose that even though you should be able to work at your desk, are there better options for limiting distractions, even as a back-up? This is one of the ways automatic thoughts, this one being a should statement, can arise and even subtly limit options.
GRACE-ANN: Well, people do stop by my desk and ask me for things, especially in the morning. There is a floating office with a desk and computer that I can use. I can close the door and hide out there.
THERAPIST: For this plan tomorrow, which do you think is the better option, desk or floating office?
GRACE-ANN: Iʼll give the floating office a try.
THERAPIST: So, at 9:00 a.m. tomorrow the first step of the plan is to go to the floating office, close the door, sit at the desk, log on to the computer, and click on the analytics tab.
GRACE-ANN: Yes.
THERAPIST: And the stop time of 9:45 a.m. still seems realistic? It gives you time before the meeting?
GRACE-ANN: Yes.
THERAPIST: With this plan in place, letʼs consider the barriers to follow-through. At 8:59 a.m. tomorrow, what could go through your mind, what thoughts might you have that would interfere with it?
THERAPIST COMMENTARY: Introduction of task-demoting thoughts using the HYDDT.
GRACE-ANN: I know myself, and it sounds good now, but when it comes time to work on it, I wonʼt feel like doing it and I might put it off and take care of other details.
THERAPIST: That is a great example. You have a very good action plan, but we are trying to ensure that your carry it out, itʼs all about the implementation. What other tasks will seem more important than the data sorting and how will you handle this impulse to keep to the plan?
GRACE-ANN: Iʼm not sure. These other tasks eventually must be done, too.
THERAPIST: Yes, thatʼs true. But how do you stick up for the importance of the data sorting? Another way to think about it is viewing justifications for putting off the data sorting as a thought or case against your plan made by a prosecuting attorney in court: “Your Honor, Grace-Ann should not work on the data task right now. She can accomplish many other tasks in those 45 minutes.” While there is some truth to this argument, it leaves out important information. This is the nature of the automatic thoughts we discussed in our first meeting. These thoughts are the case made by the prosecutor and the judge renders a decision not because the case is strong, but because only one side is argued. The cognitive element, the C in CBT, focuses on examining these thoughts and their effects on us and our options for handling things, which is like the role of a defense attorney on our side, but still bound by the evidence. Does this make sense?
GRACE-ANN: Yes, I like that example.
THERAPIST: So, how would your defense attorney respond to the prosecutorʼs claim that the small tasks you will likely encounter tomorrow should be done first?
GRACE-ANN: The data sorting is the priority. I only need to work on it for 45 minutes, and then I can update my boss, which is more important for my performance review. Iʼll do the other tasks later.
THERAPIST: Nice. I like the view that the task is only 45 minutes, which is why we try to specify bounded work blocks so that it is more manageable. To keep perspective, are there other things that you do for “only” 45 minutes that can remind you that it is a manageable length of time?
THERAPIST COMMENTARY: The various names of the coping strategies are used as part of the socialization to CBT for adult ADHD but also to personalize it. Such names serve as hooks and reframes that increase the likelihood that clients will remember and use skills, such as defense attorney, bounded task, and others. Grace-Annʼs use of “only 45 minutes” can be recruited as such.
GRACE-ANN: What do you mean?
THERAPIST: Thoughts about time required of a task affect our belief of our ability to carry it out. For example, if someone must do something for 5 minutes, we will reframe it as 300 seconds, which sounds more manageable and increases the likelihood of follow-through.
GRACE-ANN: My train ride to work is about 45 minutes and is not that bad. I can think about the data sorting as the length of the train ride I do every day. If nothing else, I know Iʼll be done at 9:45 a.m.
THERAPIST: Those are good ones. What about the thought that you wonʼt feel like doing the task?
GRACE-ANN: Thatʼs tougher. I worry a lot about not doing a good job or my boss pointing out something Iʼve missed, particularly now with being placed on probation.
THERAPIST: So, when facing the plan tomorrow morning you might have thoughts of uncertainty that you might not do a good job and might miss something, made worse by the performance plan.
GRACE-ANN: Yes, and these things have happened before to me. Even when I think Iʼve done a good job, I canʼt fully trust my work. It can make it hard to even start.
THERAPIST: Then it makes sense that part of you may not feel in the mood for the project, but this increases the likelihood of escape to easier tasks. Is there a mind-set to help you get started? Have you had experiences facing other challenges that might be helpful in this case?
GRACE-ANN: Well, if my boss keeps asking for the data, this will not help my standing with her. I can at least get to the point at which I run the analyses. I almost did not apply for this job in the first place, but I figured I had nothing to lose. I can do the same here and take my best shot.
THERAPIST: Nice. In effect what I hear you saying is that you do not yet know if you will have problems, so go ahead, face it, and trust the plan. How can you use these reminders tomorrow?
THERAPIST COMMENTARY: This section highlights the externalization of information, motivation, and coping plans to increase their use at the point of performance.
GRACE-ANN: Iʼm going to put a note in my planner right now to remind me.
THERAPIST: While youʼre doing that, Iʼd suggest making a task appointment in your planner for the 9:00 a.m. to 9:45 a.m. time. Recording plans and referring to them in a planner or elsewhere are prompts for engagement and follow-through. You mentioned that you might not feel like working on the sorting data project. How do you experience those sorts of feelings?
GRACE-ANN: I donʼt have panic attacks or anything, but I get a sinking feeling when Iʼm given a project and itʼs like, ugh, even for basic ones. Once I get started, though, it usually goes okay.
THERAPIST: That last part is a good defense attorney thought for managing your emotional reaction, the fact that once started, these feelings improve. Based on your past and recent frustrations, this not-in-the-mood reaction makes sense. You used a word that Iʼve heard used to describe discomfort about tasks, the ugh feeling. How might you handle your ugh tomorrow?
GRACE-ANN: Yes! Ugh is a good description! I know that once I start, it is not that bad and it will feel good to get it done but it is like I feel . . . ugh, just not wanting to do it.
THERAPIST: How long does it take to get to that point at which it is not so bad? Do you think you will be tense and uncomfortable the whole 45 minutes tomorrow or not that long?
GRACE-ANN: No, no, no, maybe a couple of minutes, if that. In fact, some days I feel stressed on the way to the office but by the time I get to my desk, Iʼm fine.
THERAPIST: Thatʼs a good reminder that facing discomfort is a good way to relieve it. In fact, it sounds as though the tension you describe some mornings before work gets relieved by facing it with your get-to-work plan or script.
GRACE-ANN: I never thought of it that way.
THERAPIST: Yes, exactly, that is what we are doing here—defining the data task in actionable, doable steps. Many clients learn that they can face a task while feeling discomfort and having negative thoughts, noticing them, rather than expecting to be discomfort-free. Any other reminders that might be helpful for managing the gut feelings?
GRACE-ANN: I think the idea that Iʼll feel better getting something done on it will be helpful.
THERAPIST: That is important—we underestimate the positive feeling of getting things done, even by getting started, through discomfort, and making headway. All this being said, what are some escape behaviors that you might anticipate—things that would signal that you got off task?
GRACE-ANN: As I mentioned, checking emails, returning phone calls or texts, or answering questions.
THERAPIST: These are signs that you are avoiding the task. What is a good reminder to help increase the likelihood you will get started on your plan?
GRACE-ANN: There is nothing that will be so important that it cannot wait until 9:45. I can put my phone in a pocket or in my purse. Iʼm feeling confident Iʼll get started.
THERAPIST: What about other people seeking you out for help?
GRACE-ANN: I just need to get to the other room and close the door. If I can do that, I can get started.
THERAPIST: So, if you go to that room and close the door, then you can log on to the computer and start.
GRACE-ANN: Yes.
THERAPIST: This sort of if-then statement is called an implementation intention strategy. It is part of an interesting line of research on turning intentions into actions. We boil down a goal or a difficulty with that goal into an if-X-then-Y reminder for a specific coping plan. What about recording your if-then reminder in your planner?
GRACE-ANN: Let me get it down now: “If I go to the floating office, then I can log on and start.”
After running through the scenario for her data entry, the therapist recorded the planned strategies on the HYDDT form and gave it to Grace-Ann as a reminder and a tool for facing the data task the next day. It also provided a template that Grace-Ann later used to good effect in other situations, including work, home, and personal endeavors.
Grace-Ann completed the data-sorting task as planned and over the next sessions made progress on the timelier performance of work duties, with some ups and downs. The ups were used to point out her skills and gains; the downs were used to focus on and hone coping skills (e.g., her planner as a tool) and interpersonal skills for self-advocacy and the clarification of details and expectations with her boss.
A cognitive theme across domains was Grace-Annʼs assumption that she let down others. First and foremost was her concern about meeting expectations at work, per her probationary status at work. At various times, though, she worried that her poor follow-through was a letdown to her family. This issue came to a head in an unexpectedly emotional session.
GRACE-ANN: It might seem silly, but I want to talk about Halloween today.
THERAPIST: Thatʼs right, itʼs today. Whatʼs going on?
GRACE-ANN: I need to stay late at work today because we process billing and other matters at the end of the month. As of now, Iʼll get home just in time to take my kids trick-or-treating. But I havenʼt gotten candy yet to give out to trick-or-treaters who come to our door, not to mention having no time to give my kids dinner before they go out.
At this point, Grace-Ann becomes genuinely upset and tearful.
THERAPIST: This is obviously important for you, Grace-Ann. Iʼm glad you chose to share this. Take your time, when youʼre ready, let me know whatʼs going on for you right now.
GRACE-ANN: (Sniffing back tears) This is stupid for me to take up therapy time with this, but I should have taken care of the candy before now. I canʼt believe I waited until today. I need to go to work right after the session, so I canʼt get the candy now. Even if I stop by the store on my way home, thereʼs only going to be crap candy left. Iʼll be one of “those people” who wait until the last minute. Then Iʼll be late and make the kids wait for me, or Iʼll have to catch up with them and explain what happened in front of their friends and other parents. Iʼm sure [my husband] Jim will give me that disappointed, not-again look. Iʼm sorry to be unloading all of this in here. I must be your most messed-up client.
THERAPIST COMMENTARY: There are a host of thoughts and assumptions voiced by Grace-Ann, but this sort of situation reflects the benefit of a case conceptualization. The strong emotions and theme of disappointing others suggests schema-activation. This emotional moment and related meanings of it were explored in detail after empathically witnessing Grace-Annʼs account of the full picture. Where needed, the therapist clarified various statements (or thoughts) and had Grace-Ann elaborate on feelings to better understand of how they fit together before intervening.
THERAPIST: Briefly, what do you mean when you said youʼd be one of “those people”?
GRACE-ANN: Someone whoʼs totally disorganized and wrecks things for other people—a loser.
THERAPIST: Grace-Ann, remember when during our first meeting I mentioned how we procrastinate on the little stuff the same way we do the big stuff?
GRACE-ANN: Yes.
THERAPIST: This is one of these times. Just because some matters may seem small this does not mean that they are trivial. The small stuff matters in big ways. I want to hear more but also make sure that we reserve time to come up with a plan for when you leave here today.
GRACE-ANN: But the fact of the matter is that I messed up and didnʼt get the candy! Thatʼs not a distorted thought. Itʼs a fact. I waited until the last minute and I might still wreck things, somehow.
THERAPIST: Youʼre right, it is Halloween and you did not get candy yet. That cannot be undone. How you handle this situation is within your control now and moving forward.
GRACE-ANN: I know but itʼs just frustrating. Itʼs candy today, but everything goes like this.
THERAPIST: There are many moving parts here. Let me ask whether you think that when you go to the store, no one will be anywhere near the candy section, and the only candy available will be, how did you put it, “crap candy?” What is a kind of crap candy, anyway?
GRACE-ANN: Those orangey circus peanut things.
THERAPIST: That the candy bins will only be filled with crappy, orangey, circus peanut things? Have you been in a store after Halloween, Valentineʼs Day, or other candy holiday? Whatʼs on sale?
GRACE-ANN: Candy.
THERAPIST: Right, my guess is others will need to buy candy tonight and the store will have some in stock, which is why so much is left over.
GRACE-ANN: Yes, but they probably have good reasons; I have no excuse.
THERAPIST: Grace-Ann, I want to be clear that this in no way minimizes the importance of this matter for you. I imagine it feels similar to your emotions about the work issues youʼve been facing. I hear your frustration at having to face this sort of thing.
GRACE-ANN: This comes everywhere in my life! I should have a shirt that says “Iʼm sorry” on the front and “Thanks for understanding” on the back to handle all the times Iʼve disappointed people.
THERAPIST COMMENTARY: At this point, the therapist acknowledges Grace-Annʼs desire to handle the immediate Halloween issue, but uses the collaborative approach to explore the strong emotions and self-criticisms in more detail to clarify hypothesized schema that may be operating and interfering with coping, specifically using the Downward Arrow technique (Burns, 1989).
THERAPIST: Like I said, I could not keep my CBT union card if we do not try to learn something from this situation and have a plan for handling it before you leave today. First, would it be okay if we take a moment to unpack this situation even more because it may be relevant to other situations.
GRACE-ANN: Yes, okay.
THERAPIST: For this exercise, we are going to take one of your thoughts and assume that it is true and accurate and look at what this means for you. Are you okay with doing this?
GRACE-ANN: Yes.
THERAPIST: One of the thoughts you mentioned was having to explain to Jim and your kids why you were late and seeing Jimʼs “not-again” look. If this thought is true, what does this mean for you or what does it say about you?
GRACE-ANN: Iʼm disorganized and unreliable at work and even to my family, way more disorganized than is normal.
THERAPIST: Assuming that this is true, what does this mean for you or say about you?
GRACE-ANN: It means that my family, my job, my friends . . . nobody can rely on me to do what I need to do. Jim and the kids will see again how much worse I am than their friendsʼ parents.
THERAPIST: Assuming then that this is true? What does this mean for you or say about you?
GRACE-ANN: That they shouldnʼt depend on me and I donʼt follow through on promises. I might lose my job, which affects them. They canʼt trust me, and I canʼt even trust myself to do things that I set out to do, even just for me. This is what happened in college, why Iʼll lose this job, and why my family is probably already fed up with me. Iʼve messed up and failed everyone and everything that is important in life. Why should they expect that I will change? I know I donʼt.
THERAPIST: Letʼs stop the exercise there. How are you feeling?
GRACE-ANN: (tearfully) Sad, angry at myself, rotten. Iʼm being hard on myself, but I deserve it.
THERAPIST: (waiting a few moments for Grace-Ann to sit with her feelings) This exercise is called a Downward Arrow. It takes a thought that seems plausible on the surface and digs down to see the deeper theme or core belief. If automatic thoughts are the weed, the core belief is the root of the weed. Based on what you said, underneath the candy issue, you believe that you failed and that no one in your life can trust you. In fact, you said you donʼt trust yourself.
GRACE-ANN: Hearing it like that it feels harsh, but itʼs justified and true in a lot of situations.
THERAPIST: You were diagnosed with ADHD in college when you were on academic leave, right?
GRACE-ANN: Yes.
THERAPIST: What happened after you resumed school?
GRACE-ANN: I struggled. I needed more than a year extra to finish, more than any of my friends.
THERAPIST: But you finished with your degree.
GRACE-ANN: Yes, but I had a good learning specialist at the learning center and I couldnʼt have done it without the medications.
THERAPIST: Yes, but you finished, right?
GRACE-ANN: Yes.
THERAPIST: What made you persist?
GRACE-ANN: Part of me knew that I was capable of doing the work and figured I needed a degree, but it wasnʼt easy and my grades were not great. I wanted to finish to show that I could.
THERAPIST COMMENTARY: This piece of the session highlights the therapistʼs role to point out incremental gains and the clientʼs strengths that may be minimized by the client, like with Grace-Annʼs yes-but thoughts. Within this context of eliciting and affirming the negative reactions but expanding and reframing them, seeds are dropped for the long-range goals of understanding and coping with this and other such situations to kindle hope and self-compassion along with the necessary strategies and skills.
THERAPIST: That last part sounds like one of the goals you had from Day 1, to know that you could finish things. Apart from the reality of any of your frustrations at college, you showed an ability to face them, make good use of supports, and move ahead, even if not in the way you planned. Iʼm not saying it was easy or even ideal but to point out that this part of your story is true too. Iʼm guessing you had harsh thoughts about yourself when you were put on academic leave.
GRACE-ANN: Yes, that was a low point. It was really embarrassing to tell my parents. I could tell they were disappointed.
THERAPIST: None of this is to dismiss your strong feelings and try to put a happy face on all this—they are valid but also show how much you care, for yourself and your family. It is to point out that you also were able to adapt, use resources, and do the work to finish college.
GRACE-ANN: Iʼm tired of having to go through all this and work so hard. It shouldnʼt be this hard.
THERAPIST: I can only imagine, especially right now when you are amid another frustration.
GRACE-ANN: This is nowhere near as bad a college, but it doesnʼt change the fact I messed up Halloween.
THERAPIST: Youʼre right that this is the most immediate matter. But, about tonight, do you think Jim and your children will be fed up with you and have nothing to do with you?
GRACE-ANN: No, not really. But Iʼll be asked why I didnʼt get candy earlier and I still need to deal with it.
THERAPIST: Yes, that is how we work through these deeper beliefs, changing moments at a time. About tonight, whenever you go to the store, if you see someone else in line buying candy, would your thought be “Loser,” “What an awful parent,” or “Oh, that poor family”?
GRACE-ANN: Other people probably have better reasons for being there.
THERAPIST: Such as?
GRACE-ANN: Maybe theyʼre divorced, a working parent. Maybe they donʼt have kids and donʼt worry about what candy they hand out to trick-or-treaters.
THERAPIST: Youʼre a working parent. Could Jim have gotten candy? You also mentioned guilt about crap candy. Iʼm not up with the particulars of candy giving but is there candy shaming on Halloween?
GRACE-ANN: Jim offered but he already does so much, I felt I should at least do this, but once Iʼm home and after making dinner itʼs hard to go back out, though that is what I should have done.
THERAPIST: So, even though there is some truth in your reactions, what you just said suggests there is more nuance. I hear you feeling guilt about Jim chipping in and offering to help, and you may discount how much you do at home. This is how schemas operate—they lay dormant but then a trigger like candy sets off a cascade of feelings and thoughts, like a hibernating bear getting hit on the head with a stick and awakening growling and attacking.
GRACE-ANN: (with a smile) I guess my bear got hit by Halloween candy.
THERAPIST: Yeah, maybe some crappy, orangey, circus peanuts. (Grace-Ann laughs) Kidding aside, it will be important to see how this failure-mistrust reaction is triggered in other situations and might undermine your many strengths as part of working on your follow-through and trust in yourself.
The session wrapped up with Grace-Annʼs plan to ask Jim to get candy on his way home. To address mind reading and comparative thoughts, she crafted some adaptive reminders, such as “Once home, I can focus on the children and our family time.” She took heart from her positive schema, that she strives to be a good parent and partner, even caring about Halloween candy.
Grace-Ann made a lot of progress in CBT and was an active collaborator. Although her probationary status at work was not lifted, she was not fired; instead, her performance plan was extended another 6 months, her boss noting improvements but there remained areas in need of improvement. Grace-Ann weighed the fit between her skills, weaknesses, and the ongoing demands and stresses of the job. She decided to look for a new job, eventually finding one as a practice manager for a small, local dental practice. The smaller, more personalized setting with a more manageable work pace offered a better fit for Grace-Ann and her skills.
Evan is a 24-year-old college student who is two courses shy of earning his degree. He was diagnosed with ADHD after his first semester of college, during which he failed or withdrew from all but one of his classes. Because his final two courses were offered online during the summer session, he decided to move back home rather than continue to pay for on-campus housing. He has two part-time jobs (found for him by his parents) to earn money and add structure to his schedule.
In addition to the problems in his first semester, Evan has ended up with a less than full-time course load most semesters because of dropped classes. He had his best academic year just prior to moving home, when he started both semesters with a part-time schedule by design. Evan passed his courses, did not violate attendance policies, and was on-time with assignments. He was helped by formal academic accommodations and a prescribed ADHD medication. As Evan was now focused on completing his degree and finding a postgraduation job, he was referred to a nearby therapist for CBT for adult ADHD.
At his first session, Evan said that he had initially resisted CBT because he felt as though he had turned a corner in the past year. The medication helped him focus and his online courses promised to be relatively easy. He resigned himself to a course of CBT to appease his parents, although he conceded their concerns were justified, and he admitted that he had struggled with an online course in past, which he eventually dropped. Evan now was preparing to face two such courses while working part-time and living at home.
THERAPIST COMMENTARY: Evanʼs case represents issues engaging in treatment [see Chapter 5, this volume] common for emerging adults with ADHD [see Chapter 6]. Normative adult transition issues are complicated by ADHD and changing dynamics with parents. Early sessions focused on Evanʼs “buy-in” for treatment and the goals he found useful and relevant to him.
When discussing therapy goals, Evan said that he felt behind his peers, as he would soon be 25 years old and was unsure of his “adulting” skills. As a first homework task, the therapist invited Evan to select examples of the kind skills he would like to develop as well as to look up the syllabus for the coming online course to sketch out his semester plan.
Evanʼs initial goal was to cultivate better money habits such as opening and using a savings account so he could eventually live on his own. He had two part-time jobs but wanted to start to look for a full-time job for after graduation. His primary goal, though, was to pass his online courses and, in doing so, earn his degree and take a big step toward independence.
Evan had never worked while taking a class. The concentrated summer schedule is fast paced compared with schedules for the fall and spring semesters. Evan and his therapist used an activity chart (e.g., a weekly calendar) to outline Evanʼs obligations over the first week or two of the summer session. The 168-hour week was reframed as a budget of $168, and Evanʼs schedule was a spending plan. This template was prepopulated with classes, work hours, meals, sleep needs, and other obligations such as CBT sessions and a dental visit. Slots tentatively earmarked for studying were logged as “appointments” as were those for time for hanging with friends, practicing guitar, or undedicated down time. The chart allowed Evan to see his week laid out in front of him.
Evanʼs first reaction to this external representation of his week was, “Wow, this looks really busy.” The therapist agreed that it was ambitious but pointed out ample pockets devoted to self-care, sleep, and down time. Taking a page out of motivational interviewing, the therapist asked Evan whether, in fact, he wanted to take on such a schedule. Evan was determined to finish school. As he reviewed the schedule, he saw that he could manage work around his study needs and each facet of the plan was within his capability to achieve.
The therapist asked Evan for positive examples of how he had handled the past academic year. Evan said that it was useful to keep in mind that he did not have to do everything all at once. The therapist used this observation to highlight the various key pivot points in Evanʼs schedule—plans for attending the online course, deadlines for uploading assignments, and arrival times for work. Plans for studying at a public library and navigating other transitions were pinpointed, including those for discretionary time.
Over the first couple weeks, Evan generally kept up with class and work. In addition to reinforcing these steps, initial examples of task delays, even minor ones, were reviewed using the HYDDT form to help Evan stay on track. Evan found the idea of bounded tasks useful, particularly for assignments. This coping tactic provided Evan with an alternative mind-set from his typical approach to schoolwork, which was to wing it and wait to be in the mood to study. He took to the idea of reframing time (e.g., study for 1 hour), which he tracked with a 60-minute study-music playlist he compiled. In fact, Evan noticed that he ended up with much more and higher quality down time by starting and keeping up with schoolwork.
THERAPIST COMMENTARY: Given Evanʼs initial ambivalence about CBT, many of these early successes resulted from his personalization of skills, which spurred his use of them. This was boosted by the therapistʼs recognition of them and highlighting where Evan exhibited skills that he doubted (e.g., to keep to a study plan), along with noting his other strengths.
At the end of the first summer session, Evan faced his only serious delay while working on his final paper. He already had a rough idea of main points but had not yet started a draft. Evan found himself distracted at the public library, which had been a good study space. He came up with the idea to use the libraryʼs separate conference room, which was unused most days. He was friendly with the library staff and has secured permission to use it.
Evan struggled to organize and record his ideas because he was trying to get the ideas “just right” the first time, which led to procrastination. The therapist reviewed the three writing modes (see Chapter 6) to help him get unstuck. Evan agreed to first jot down bullet points to touch an outline. This would be followed by generative or free writing, getting ideas down, though not necessarily in their final form. The final writing mode would be editing. Evan admitted that he often tried to free write and edit, simultaneously.
At the very end of the session, Evan offhandedly mentioned that his father had caught him smoking marijuana late one night. Evan mentioned that he smoked to help with sleep, which he had done while living on campus. He knew his parents did not approve, but they only asked that he not smoke at the house. Evan said that he wanted to cut down his use of marijuana apart from any social use out with friends. It was agreed to discuss this further after Evan returned from a between-semester beach trip with friends. In the interim, he had informed the therapist that he finished the final paper on time and easily passed the class.
Evanʼs next CBT session came just before the next summer semester began. After a review of Evanʼs progress, the agenda turned to his use of marijuana as a sleep aid. The therapist asked Evan whether he viewed it as a problem separate from being caught by his father—“If you had your own place and smoked when you had trouble sleeping, would this be something that you would want to change?” The therapist respected the rules and concerns from Evanʼs parents but wanted an honest account from Evan about his view on the matter.
THERAPIST COMMENTARY: The discussion of substance use in emerging adults with ADHD can be a sensitive one. There is a balance of maintaining the alliance with determining if there is evidence of use issues that require a higher level of treatment or an agenda item in CBT. CBT provides a forum to explore Evanʼs thoughts about his marijuana use (in the context of various negative effects and other clinical misgivings [see Chapter 6]). The spirit of informed decision making and an analysis of the clientʼs use pattern is a good starting point for collaboration, review of clinical data, and motivation and prospects for change.
Evan said that sleep was a longstanding issue that worsened in college. He had an erratic sleep schedule at school because he often stayed up late; he would put off sleep until he could not stay awake. He said that he had trouble waking up, getting out of bed, and starting his day after a night of smoking, and this was beyond his typical sleep inertia.
Evan shared a new wrinkle in his view of smoking after his beach vacation with friends. He said that his friends eschewed their old party mind-set and partook much more modestly than in the past; instead, they focused on work and other aspects of their lives. Evan said that he stayed up and slept in later than any of this other friends, and he had the sense that his friends did more before he got up than he did all day. Evan vacillated between envy of their adult lives and confusion about whether he wanted that life for himself, both sides were relevant to the question of whether he smokes too much marijuana. Evan and the therapist discussed that emerging adulthood is a daunting time devoted to defining what is important and meaningful for him. This was set out as a theme to explore while finishing his class, staring his job search, and facing other adulting issues.
The focus was on how Evan wanted to spend himself. He did not want to stop smoking; instead, he agreed to focus on times marijuana use seemed obligatory (i.e., for sleep). The goal was framed as improving his sleep patterns and making informed choices about smoking rather than it being the default option. Evan agreed to track his sleep.
The next few sessions focused on a combination of managing his new online course and reviewing his sleep habits. Evan said that the local public library was again his classroom and study station. He sat in the public area (though in a remote back corner) to view lectures using headphones with the conference room reserved for assignments requiring more focus. These go-to places were now habitual implementation targets (e.g., “If I go to the conference room, then I can spend 10 minutes on the assignment”). He said that the library staff showed an interest in his progress toward graduation and encouraged him, which he said helped him get on task.
Evan set a 12:00 a.m. get-in-bed target time and an 8:00 a.m. wake-up-and-get-out-of-bed time for most days. Although allowing for sufficient sleep, he still had difficulties winding down, often lying awake in bed for over an hour. The therapist reviewed with Evan his experience leading up to getting into bed. Even when working evenings, he was home by 10:30 p.m. and had ample down time. However, his lead up activities before getting into bed were all over the place, including sleep-disrupting distractions from being online.
Noting that Evan had been able to create routines to promote studying, the therapist wondered whether some sort of sleep script might help. Evan was initially resistant, claiming he should not have to put this much effort into sleep and waking up. Probing this thought revealed Evanʼs doubts about his ability to maintain the strategies and tactics once he had to do so on his own. He viewed them as “weird,” noting his beach friends did not seem to work as hard to be “normal.” Even though he was confident that he would pass his last class, he cited a series of yes-but thoughts about postcollege plans (e.g., “Yes, Iʼll have a degree, but Iʼm not qualified for most jobs”; “Yes, I may find a job, but then Iʼll have to do it every day, and itʼs not like school where they help you”; “Yes, I can perform a job like the ones I have now, but these are not careers and do not pay enough to live on my own”).
The understandable concerns about full-time work would be sorted out by ongoing coping with academics and adult skills, eventually adapted to specific job demands. The therapist pointed out that Evan had gained skills that he used habitually and had personalized, a fact that was leveraged to target his existing sleep habits and how he ends up in sleep-interfering patterns at night. The point was made that all the strategies and tactics for adult ADHD are tools meant to help him or anyone, including his beach friends, to make informed choices and to act with intention in accord with personally meaningful goals, including sleep.
THERAPIST COMMENTARY: This section illustrates the therapistʼs highlighting incremental coping improvements and client strengths, which implicitly focus on Evanʼs budding self-regulatory efficacy and residual mistrust. Although not identified as such, Evanʼs doubts about his sleep and finding work after college reflect a hypothesized overgeneralization of his self-mistrust. As it was more immediately relevant, sleep strategies were prioritized, which offer opportunities for modifying thoughts, behaviors, and beliefs that can be used in a job search.
Evanʼs sleep script for getting into a sleep mode focused on readying for the next day (e.g., laying out work clothes or study materials). He also made sure his electronics were charging before getting ready for bed as part of the wind-down routine. In fact, Evan recognized how tired he was once he finally got into bed but thoughts coursed through his mind, which were not racing or disturbing but still kept him awake. Some basic relaxation and meditation exercises were reviewed, though he found light stretching easier to do. Evanʼs use of his smartphone at night was reviewed to distinguish uses that were sleep promoting versus sleep interfering. He listened to recordings (podcasts or music), which quieted his thoughts. It was advised that he only listen to familiar works for sleep (e.g., comfort media) so as not to be kept awake by novel content.
Evan had periodic awakenings at night, during which he assumed his sleep was ruined, and this triggered his marijuana use. He was open to coping plans for such times (e.g., get up for a short time before returning to bed, write out distracting thoughts, cover clock to avoid sleep math) and, as important, modifying sleep thoughts (e.g., “Even if I wake up, I will still be rested enough for the day”). Evan was helped by psychoeducation about historical accounts of first and second sleep, which normalized middle of the night wakings. Various principles of CBT for insomnia were used to structure sleep, including the notion of getting up and out of bed at the appointed time regardless of the amount or quality of sleep, supported by the finding that individuals typically underestimate how much sleep they have had in comparison with awakenings (see Chapter 6).
Evan did not always fall asleep quickly but more often got into bed as planned and kept to his wake-up time. His use of marijuana as a sleep aid virtually stopped during the semester, though it remained an option. The therapist invited Evan to note his smoking at other times to discern when he smoked due to stress as opposed to when he smoked socially, in the spirit of informed decision making.
Evanʼs final online course turned out to be more straightforward than the previous one, with no written assignment other than a final reflection paper. This was a fortunate turn of events, as Evanʼs focus during the summer shifted to his job search, with graduation now guaranteed.
Evan faced the fact that his college struggles meant he was not as competitive a job candidate as other graduates with better grades and stronger resumés. He introduced a self-imposed abstinence from marijuana due to possible preemployment drug screenings, which led to a greater focus on skills for managing triggers, risk factors, and justifications for smoking.
Evan eventually found a job with a friendʼs local start-up company that promised interesting work and personalized mentorship and support. He shed one of his part-time jobs after a few months once the start-up provided paid hours. Evan continued to put money in his savings account while he lived at home and embarked on his unique, winding adult path.
I have all these things I have to do but I canʼt make myself focus! I sit down and try to do what we discuss in here but it doesnʼt work! My mind goes all over the place and then I get up and do something else and I know Iʼm not doing what I need to do! I have people asking me for the things I promised them, and I say Iʼll do them ASAP but my word means s*** because I still donʼt do it! They must be thinking Iʼm not trustworthy and not worth paying—and theyʼre right! The meds donʼt help, and I donʼt do what we talk about in here! I sometimes think this is a waste; Iʼm going to f*** up anyway, so why not just f****** give up?!
Kurt spewed these frustrations during his 10th session of CBT at sufficient volume that therapists in adjacent offices heard his tirade loud and clear. Kurt is in his mid-30s and lives in a rented house with four younger roommates. He grew up near Philadelphia but moved to Los Angeles when he was accepted to a prestigious college videography program. His high school academic record was unremarkable, but he had a singular talent for film and video. He said that his portfolio likely got him into the program, even though his high school grades included Cs and Ds due to procrastination and disorganization; he simply preferred A/V work to school.
Kurt said the college program was the best possible fit, as it was almost wholly based on hands-on learning and projects, but he was still overdue on deadlines and late to classes, meetings, and video shoots. He was nearly suspended during his first semester because he was late providing his final high school transcript. The videography program required a bare minimum of traditional classes; Kurt was granted extensions on all of them and barely passed, but he graduated.
Kurt stayed in Los Angeles, where the status of the program and recommendations from faculty helped him to get jobs. Initial projects were relatively low impact but allowed him to quickly build his body of work and reputation. He supplemented his income with part-time jobs, which he claimed were easy. However, he invariably quit or was fired because he would fail to show up for shifts when a competing video/film job came up; he was confident that he would soon support himself solely with paid work in his field.
Video/film work is very project based, providing interesting, time-limited ventures. Kurt had a defined role in each project, accountability to others, and a clear, final product at which point he could jump to a new project. The downside was that he had to be organized to find new projects and field inquiries for his services. It was difficult for him to respond to inquiries and set up his next job while hyperfocused on a project at hand.
Kurt was undiagnosed with ADHD and struggled with the organization and time management needed to arrive on time, meet deadlines, and keep up with administrative details (e.g., submitting invoices for payment). He also found it difficult to curb his frustrations with others and acted impetuous and ill-tempered when facing hassles involved in projects; he was similarly snarky when confronted on these matters, which also affected project schedules.
Over the next few years, Kurtʼs video/film work slowly declined, in part due to poor follow-through on inquiries, which forced him to devote more time to other jobs. This created a vicious loop of having less time to network and seek out projects, tasks already difficult for him. He eventually fell behind on rent, amassed substantial credit card debt, and was forced to move home with his parents before he turned 30 years old.
After moving back to Philadelphia and finding a room in a rented house, Kurt pieced together a couple of part-time jobs. His parents supported him financially as he tried to revive his career, hoping to return to Los Angeles but also seeking work in Philadelphia and New York. About a year ago, he was hired for a New York project on the recommendation a former classmate. Kurt did the work but never submitted an invoice for it. He grew increasingly depressed by what he viewed as self-sabotaging behavior.
Kurtʼs parents encouraged him to seek out help for his mood. After a few meetings, his therapist suggested that Kurtʼs mood issues and ongoing problems might be from undiagnosed ADHD. She prescribed an ADHD medication and recommended a thorough evaluation, which led to a diagnosis and referral for CBT for adult ADHD.
Apart from other executive function problems, emotional dyscontrol is a relevant factor in Kurtʼs case. Whereas his passion for film and video served him well, he had little patience for details that did not interest him and overreacted to various hassles he encountered. He recognized his reactions as over-the-top and he got over them relatively quickly, but this pattern had damaged relationships and his reputation with others.
During the session in which Kurt unloaded his frustrations, the therapist tried to summarize and steer the discussion toward problem management. The therapist settled back and absorbed the outpouring until Kurt paused, took a few breaths, and apologized for his outburst, and then Kurt noted his exasperation at his circumstances. The therapist said an apology was not necessary, recapped Kurtʼs aggravations, noted that it was likely only a snapshot of how frustrating his difficulties and their effects have been for him, and affirmed that behavior change is hard work.
THERAPIST COMMENTARY: Emotional dyscontrol seen in adult ADHD is often more restrained than in Kurtʼs case but may still manifest in relatively short, sharp outbursts that are disruptive and distracting to the clientʼs overarching objectives. Impulsivity and emotional dyscontrol likely overlap insofar as adults with ADHD often describe reaching a point of feeling overwhelmed by stressors or setbacks. In addition to an empathic summary, it is useful to explore whether there is anything else pertinent to the clientʼs emotional reactions in session.
The therapist inquired about any other feelings Kurt wanted to voice. Kurt said that his ongoing poor follow-through is the main difficulty that interferes with moving forward in his life outside of work (e.g., dating, health, finances). He felt shame each time he needed money from his parents, like when a piece of equipment recently stopped working and he needed to replace it. This was viewed by Kurt as further evidence he cannot catch a break. He described haste to catch up to how his life was in Los Angeles, but since he had been home now for several years, Kurt worried that he might turn 40 or 50 years old and still be mired in the same situation.
Kurt calmed down but was still antsy and distressed by all he had to do. As it was the end of the session, he quickly drew up a task plan with the therapist that involved logging into a weblink Kurt needed to review and sitting and looking at it, even if he could not focus as well as he would like; they lowered the bar as much as possible to foster Kurtʼs engagement. The purpose was to see if Kurt could marshal enough focus to make headway, albeit imperfectly. Kurt still doubted his ability to face even this single task but agreed to try.
Although he was calmer at the next session, Kurt had his typical bouncy leg and showed other signs of restlessness. He apologized again for the previous session and said he quickly got over it afterward. In fact, he used the homework plan to good effect and was somewhat productive at home after the session. The therapist noted the fact that Kurtʼs plans and his ability to implement them could be hijacked by his strong emotions. He agreed and noted that a roommate pointed out Kurtʼs defensiveness when he gave Kurt a reminder that rent was due; the roommate said that Kurt was very impatient and pushy when he needed something.
Kurt conceded that the roommateʼs observation was accurate. The therapist provided some psychoeducation about ADHD and emotions, including their role in procrastination. To this end, Kurt said that despite his productivity since last time, he continued to find pretexts to put off working on the long overdue invoice from the New York job, which was still a therapy goal. Although he could not argue if the employer did not want to pay him, Kurt still wanted to submit an invoice to close the loop on the project and reconnect with the contact person there.
Kurt and the therapist revisited the HYDDT form, which had been used before for this invoice, to recraft a plan for facing it. At the next session, Kurt said he still had not submitted the invoice, though he shared an interesting observation. When thinking about the invoice, he tried to touch the task by double checking some particulars of the project, including contact information for the agency. While sorting through digital files and emails, Kurt felt a wave of embarrassment and shame at the prospect of reaching out to someone whom he had presumably disappointed. He described anger at himself and a sense of sadness and regret at the loss of the opportunity the New York project had offered him and that he had, in fact, completed the job without being paid. Logic told him the worst outcome of sending a belated invoice was that it would be ignored or unpaid, but Kurt expected it to confirm his failure and ruined reputation. This flood of feelings and thoughts resulted in walking away from the task and created low spirits and morale for the rest of the afternoon.
Kurt and his therapist discussed how his emotions and corresponding beliefs added another layer of difficulty to managing ADHD. The interactions of these factors and his ongoing problems further eroded Kurtʼs sense of self and trust in his coping abilities. Kurt said that he felt like an impostor during the videography program. He was one of a few students from outside Los Angeles, New York, or San Francisco. Despite his strong work, he recalled “squeaking by” with low grades. Kurt saw his current plight as his comeuppance and a sign that he really was a fraud.
The therapist summarized back and illustrated a conceptualization of Kurtʼs description of how ADHD and past and current difficulties fit together. This included the beliefs he voiced and their link to his experiences and how these magnify his already strong emotional reactions. Finally, the avoidance of the invoice was outlined using this understanding.
THERAPIST COMMENTARY: The case conceptualization is a synopsis of the CBT model that has been modified for adult ADHD. It provides an opportunity to look at how different facets of the clientʼs experiences and subsequent cognitive, behavioral, and emotional patterns fit together. In the spirit of collaboration, Kurt and the therapist decided together how to best move forward toward Kurtʼs goals using this conceptualization in the here and now to guide coping plans and skill-based strategies.
The therapistʼs summary led Kurt to the “Okay, this makes sense but what do I do about it?” question. The therapist put it back on Kurt whether he still wanted to submit the invoice; if so, what was a realistic first step for him? Whatever his decision, it was framed as an opportunity to face the invoice or let it go, and work toward experiences with which to rebuild efficacy. They reviewed examples of Kurtʼs experiences and mind-sets when actively engaged in projects that provided evidence counter to his failure belief and illustrated his talents. These examples included the New York job, for which he said the product he delivered was great and admitted that the overdue invoice overshadowed this fact. Kurt spoke of the resilience he had in Los Angeles that allowed him to tolerate critiques of his work and use them to hone his skills and craft. The therapist pointed out that Kurt exhibited this trait recently by taking to heart his roommateʼs feedback, which was evidence of his ability to face and tolerate discomfort to grow and improve.
Kurt said that although he still wants to return to Los Angeles, he could do more to seek out work on the East coast, including smaller jobs, and he recognized that he has been avoiding steps he could take to improve his employability. He and the therapist discussed how Kurt might reach out to old contacts and friends to network. Kurt worried it would look weird and inappropriate to suddenly reach out after so much time has passed, but when asked whether he would view it as weird or inappropriate if they contacted him, Kurt smirked and said that he would be pleasantly surprised to hear from them.
Kurt decided that he still wanted to close the loop with the New York invoice, if nothing else to simply face it for his own sake. He realized what he had viewed as small first steps were still too big with respect to his shame reactions. Kurt agreed to view the video he sent to the New York agency to remind him of the quality of his work, like an exposure task. He later noted that after doing so, he posted some other video footage on his social media accounts.
Emotions played a prominent role in these experiments. Kurt gained practice noticing and tolerating feelings that arose but endured them to stay engaged in an endeavor, and found that his emotional fortitude slowly improved. As he took such steps, he observed mixed emotions that could be discerned and labelled, including positive feelings of pride in his work and pangs of remorse about lost opportunities. Cognitive defusion strategies added another layer to coping with strong thoughts and feelings. He found it helpful to view intrusive thoughts and feelings as critiques for which he could use his resilience to tolerate without abandoning a plan.
THERAPIST COMMENTARY: This phase of Kurtʼs CBT reflects the sufficiency reframes of being able to do enough and tolerate discomfort while engaging in endeavors. In addition to tolerating discomfort, Kurt was able to notice and discern adaptive, task-promoting emotions and mind-sets. He developed more trust in his abilities to face priority tasks that were the building blocks for higher order goals related to seeking projects as well as fostering more adaptive beliefs and schemas about himself.
By no means was Kurt a Zen master, but he coped better. He adopted a method acting approach living in Los Angeles, which was that he tried to act like someone who already possessed the emotional flexibility he was trying to muster. The baseball film Bull Durham was a favorite of Kurtʼs, in which a young pitcher was advised to play the game with “fear and arrogance” as he left his minor league team to play in the major leagues. Kurt used this as a reminder he could hold competing feelings. He often had to have such faith in his work and ideas during the editing process in past jobs, unsure of how the product would turn out but trusting his vision. He said he now viewed CBT as editing his outlooks, habits, and emotions.
Several weeks later, Kurt submitted the invoice by email. He received a notice that it was past the submission deadline and would not be paid. He was initially bothered by the impersonal response but ultimately gave himself credit for facing the task. In fact, he later sent a message to his contact in the agency and received a cordial response and an invitation to “keep in touch.” Kurt felt that he had not only closed the loop on the invoice, but also perhaps opened a line communication.
The fact that Kurtʼs therapeutic gains continue to outpace his functional gains is not uncommon. His difficulties reestablishing his career despite improved coping efforts are akin to improving spending behaviors while still paying down large credit card debts—it is progress but requires persistence to maintain, including facing periodic setbacks, and reach benchmarks on the way to an ultimate desired outcome.
Kurt is still prone to mood funks when faced with obstacles such as ongoing financial support or reading accounts on social media. When reviewing options for side jobs or prospects for steady income as he pursues video/film work, Kurt still rigidly insisted that he must be fully devoted to his field or he will be out of the loop, which limited some potential avenues. In the meantime, Kurt established a website through which he has secured some jobs, including a wedding (a prospect he would have viewed as an anathema, which reflects some flexibility in at least entertaining work options). Nevertheless, he has gained confidence enough to engage in and follow through on such tasks and to do what he sets out to do more consistently, although he may have more hurdles to face and endure as he moves forward.
These wide-ranging case examples reflect the clinical diversity in the psychosocial treatment of adult ADHD. CBT provides a flexible model for helping clients understand and recognize how features of ADHD unfold in daily life to create the functional difficulties for which they seek psychosocial treatment. This model also provides a therapeutic framework for fashioning personalized interventions targeting key pivot points in a clientʼs life at which the implementation of coping strategies can be most beneficial. Although the use of such behavioral skills is the main outcome goal, the cognitive component of CBT was highlighted in the cases reviewed in this chapter.
Grace-Ann faced difficulties following through on work endeavors that were informed by deeper schemas related to self-mistrust and belief that she had disappointed others. Evan faced similar self-doubts as he finished his degree requirements while navigating emerging adulthood. He dealt with self-comparisons with his peers who seemed better at being an adult and dealt with longstanding sleep problems managed with marijuana. Finally, Kurtʼs case reflected the role of emotional dyscontrol in adult ADHD. His emotions and other executive functioning difficulties magnified and were magnified by his frustrations with trying to reestablish his career and to establish newfound trust in his ability to consistently face endeavors. For each of these individuals, the cognitive domain of CBT for adult ADHD served to personalize their unique barriers to follow-through and foster engagement in more adaptive coping approaches that increased follow-through and led to some degree of progress.
As was noted in the Introduction, this book is the long-delayed answer to a question posed during the Q&A of a workshop in 2002 about the central cognitive theme in adult ADHD. The answer offered throughout the pages of this book is that impaired self-regulatory efficacy (and distrust thoughts and mistrust beliefs) is the central theme underlying the thoughts and beliefs of adults with ADHD, which has ripple effects on functioning, particularly attempts to transform intentions into actions.
The broader goal of this book was to outline the role of thoughts and beliefs in the lives of adults with ADHD and within psychosocial treatment. Its unique contribution is its emphasis on the role of cognitive change principles within a CBT approach modified for adult ADHD, chiefly to effect behavior change in settings in which adults with ADHD have coping and functional difficulties.
CBT for adult ADHD turns managing ADHD into managing pivot points, with cognitions representing an essential ligament or mediator between intention and action at these points. This approach serves the same function for therapists helping adults with ADHD by offering a way to frame and deliver tools, skills, tactics, and strategies in distinct and doable units of action that clients believe they can use. Treatment is personalized to the array of individuals and their unique life circumstances, histories, temperaments, roles, and personal goals, all of which influence and are influenced by their thoughts and beliefs. As reportedly said by Hall of Fame baseball player Yogi Berra, “If I hadnʼt believed it, I wouldnʼt have seen it.”