CBT Must Be Adapted for Adults With ADHD

Cognitive-behavior therapy (CBT) has achieved the status of an evidence-supported psychosocial treatment for adult ADHD as determined by Division 12 (Society of Clinical Psychology) of the American Psychological Association.¹ CBT is also the psychotherapy treatment of choice for adult ADHD in the UK per the National Institute for Health and Care Excellence (NICE), which also published treatment guidelines for the diagnosis and management of ADHD.²

These are positive developments for the treatment options for adults with ADHD, as CBT combined with effective medication treatment is a potent, effective one-two punch. The forthcoming inaugural US guidelines for the assessment and treatment of adult ADHD will provide yet another summary of the standing of CBT for adult ADHD in the overall treatment planning options for adult ADHD.

The Need For Access to ADHD-Adapted Care

But an ongoing stumbling block with all existing, research-supported treatments for adult ADHD is access to expert or at the very least ADHD-competent care. A recent study of the experience of adults with ADHD who received CBT in the UK through routine, community practices illustrate the importance of access to expert care and ensuring that treatment, in this case CBT, is adequately adapted to the needs of adults with ADHD.³

Problems When CBT Is Not ADHD-Adapted: Recent Research

Forty-six adults (33F/13M) were surveyed, and another ten adults (7F/3M) participated in semi-structured, in-depth interviews regarding their treatment in CBT for adult ADHD. Therapy was provided by either National Health Service (NHS) clinicians, independent providers, and a few participants were unsure of their therapist’s affiliation.

The three main themes that emerged from surveys and interviews were (1) difficulties with the general CBT approach, (2) difficulties with the therapists, and (3) the lingering consequences of their therapeutic experiences. When CBT was not adapted to ADHD and was conducted by a therapist inexperienced with adult ADHD, the generic approach was rated as not relevant to their needs and ineffective. Moreover, following a rigid structure in each session and having only a limited number of sessions was also unhelpful in terms of not being tailored to the needs of adults with ADHD for skill development. Core facets of adapted CBT for adult ADHD that make it effective⁴ were ignored, such as executive functions, working memory problems, and emotional dysregulation issues. The exclusion of these therapeutic elements meant that even the overarching goals for treatment did not seem relevant to the clients.

These disconnects between the therapists understanding of and experience working with adults with ADHD, which informs effective delivery of the adapted CBT approach, unsurprisingly led to less than ideal therapeutic relationships, which is an important part of CBT, generally, and especially for adults with ADHD who are so often misunderstood in their day-to-day lives.

Lastly, most participants reported that they gained extraordinarily little from treatment, including reports of feeling worse off and less hopeful about their prospects than before.

Conversely and importantly, one participant reported that effectively adapted CBT for adult ADHD delivered by a therapist who identified as having ADHD was a collaborative and helpful experience. This client found the well-adapted CBT to be “very transformational,” gaining a better understanding of how their mind works and how to collaborate with it.

Relevance of Problems with Non-Adapted CBT for Women with ADHD

If CBT is not adequately tailored to ADHD, results will be poor, especially for women with adult ADHD.

Source: Andrea Piacquadio/Pexels

It is important to note that of the 56 clients who either completed surveys or were interviewed, 40 were women. This is important because women with ADHD often get diagnosed later than males because their problems are often first identified as stemming from depression or anxiety, which often co-exists with ADHD, but because of ADHD.

Hence, most therapists are well-trained in identifying and treating depression and anxiety and not at all in identifying and treating adult ADHD, so they go with what they know to do. If all you have is a hammer, all you see is a nail. But these frustrations only further delay effective treatments for women with ADHD and might lead many to abandon hope, altogether.

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The Need for Adequate Clinical Training in Adult ADHD

An embedded issue in the results of this study and for all the excellent and forthcoming assessment and treatment of adult ADHD guidelines is that they will not magically make clinicians competent in the assessment and treatment of adult ADHD, especially for psychosocial clinicians delivering evidence-supported CBT for adult ADHD on a person-by-person basis.

Even the clinician-researchers who developed the CBT manuals for adult ADHD will say that their approaches should be used flexibly in clinical practice, tailoring the steps and the session order to the needs of clients, which requires an understanding of the experience of their clients.

None of this means that clinicians themselves must have ADHD to provide competent and collaborative care. Instead, the “accurate empathy” that is a cornerstone of CBT means experience and understanding that helps clinicians be able to see the world through their clients’ eyes in a way that make the treatment and the therapeutic relationship effective, empowering, and safe for doing the challenging bur rewarding work of coping with ADHD.