CBT for Adult ADHD: From Intention to Action

That’s easy – I quote what clients have said to me over the years: “I know exactly what I need to do but I don’t do it,” or some variant of this theme. It’s not a knowledge problem but a performance problem.

But this frustration reflects what is still a misunderstanding and often a trivialization of ADHD. An “attention deficit” sounds quaint and may appear to be limited to running late, misplacing items, and waiting until the last minute to get things done.

Instead, there is increasing recognition of ADHD essentially as a neurodevelopmental syndrome related to the inefficient development and application of self-regulation capacities that are part of our human factory settings, also known as the executive functions. We all have executive functions but individuals with ADHD experience the effects of the delayed development of these skills and a chronic under-functioning in the areas of time management, organization, and emotional regulation, to name a few examples of how ADHD shows up in daily life. It is these issues that cause the significant difficulties and impairments in major life domains like education, work, relationships, and overall social functioning connected with a lifetime diagnosis of ADHD. There is also increased awareness and research on adult ADHD and poor health outcomes and risk for early mortality. ADHD is clearly not a trivial matter.

This is the insidious nature of ADHD as an implementation problem, not a knowledge problem. Clients will tell me that they know the skills and could teach them to others but still not use them themselves despite knowing they’d help them. A challenge in treatment is that the very nature of ADHD and executive dysfunction interferes with the behavior change and implementation processes.

There are no trade secrets about what helps adults with ADHD. The presentation of different skills, such as using a planner or overcoming procrastination requires a more granular approach. This means defining the skill in specific and actionable terms and in a sequence of steps that the client believes they can execute. These steps are what individuals without ADHD and with intact executive functioning do in their heads naturally and then execute them. 

The next level in adapting treatment for ADHD is anticipating where and when they will employ this strategy in their daily life. It involves accounting for potential barriers and distraction as well as thoughts and feelings that could either increase or decrease the likelihood of implementation. Ideally, there will be a written, tangible reminder of these plans, steps, and solutions – a behavioral prescription, if you will.

Working memory is what allows one to hold in mind an image of a task and goal, inhibit jumping to distracting matters in the environment, and then implement the first step of the behavioral script to get engaged. Managing emotions both deals with facing the discomfort, the “ugh” feeling of doing such tasks (instead of the hundreds of more immediately interesting options available to us – even if we really want the goal), and being able to use foresight to consider the later, “future self” benefits of following through on the task. It’s not lack of desire for or investment in the goal but being able to bring together these necessary facets to engage and follow through.

A history of ADHD and executive functioning difficulties, whether diagnosed in childhood or not until adulthood, can have wide-ranging effects. ADHD makes many roles and endeavors more challenging. There are also many public facing elements of symptoms, such as being called on in class while daydreaming, difficulties following the rules for games on the playground, as well as spending inordinate time devoted to assignments but not finishing them or failing to submit them on time. These slip ups can affect one’s sense of self as well as reputation and how others treat them, including a stream of critiques, corrections, and attempts at motivation – “You have so much potential - if only you applied yourself.

These experiences are central to the develop of self-mistrust beliefs – “I know I can do this, but I don’t trust I will do this when it needs to be done” – that are tied to strong feelings and thereby increase the likelihood of procrastination and avoidance of or escape from various assignments, social settings and relationships, and perhaps even sports, music, art, or other hobbies and interests.

Such thoughts are a ligament between intention and action. A facet of the cognitive domain of cognitive behavioral therapy (CBT) for adult ADHD is helping clients to recognize how such mindsets and related feelings and behavior patterns came to be and their influence. These automatic patterns make sense based on past experiences, but we are trying to focus on new options now. 

Consequently, clients develop their valued goals, roles, and other intentions for using the strategies and skills on their terms and seeing improved results. Through this process the aim is to modify and overcome mistrust and develop more self-trust, efficacy, and sense of competence in ways that are important to clients. 

For many rewarding goals and the implementation of the relevant actions required to achieve them, waiting for motivation is often a long wait. Procrastination on tasks is often justified by doing something else more immediately enjoyable or achievable to get “in the mood” for the task or waiting until tomorrow when it is assumed one will have the spark of motivation for the same task. These patterns usually only lead to more delays.

However, such a spark can be kindled, first, by the client selecting one thing they want to (or must) do, because there might be two or three things to do that create mental gridlock and task paralysis. Once a single task is identified, there is a pause to reflect on and even write down (externalizing motivation) why this task is personally relevant for the client, a personal valuation of it. Once there is a personal buy-in, it doesn’t guarantee follow-through but it’s a good start. 

One way I think about helping clients cross the synapse between “not doing” and “doing,” which can feel like crossing the Grand Canyon, is making the task real versus conceptual.

In my approach it’s followed by a sequencing of the smallest, first actionable step that represents moving from being off-task to being on-task, getting engaged. Strengthening this implementation step with a couple more actionable steps that the client believes, trusts they will do is an example of event segmentation and sequencing, the fancy way to follow our grandmother’s advice to break down a task into smaller steps. It is easier to trust one’s ability to do these specific, actionable steps, such as “sit at my desk” and then “opening the essay document and reading the last paragraph I wrote,” rather than the broad, vague, less specific task of “work on my paper.” Yes, it’s behavioral steps but it’s combined with a cognitive reframe of the task from conceptual to tangible and doable.

I’d say it’s twofold. When developing a between sessions plan, I ask the “Yes, but” question:

“Ok. The plan sounds good. But are you having any ‘yes, but’ thoughts: ‘Yes, this makes sense but here’s what’s going to happen when I try to do it this week.’”

This allows for some personalization of what will help the client with implementation and follow-through. It might be explicitly outlining the steps for dealing with motivation and getting unstuck mentioned in your previous questions. Externalization of information, writing out a sequence of steps that go into carrying out the plan is an effective way to set up a “first this, then that” sequence of steps, which is what intact working memory provides. Such granular matters are part of the tailoring strategies of CBT for adults with ADHD. Engaging in this sort of collaborative, pre-emptive problem-solving, often clients develop some solutions to try, which is how the approach is personalized. Treat the between sessions task plan as an experiment to see what happens that helps clients keep moving forward. 

The second aspect of this suggestion that is embedded in all the others and throughout my book is the importance of the therapeutic alliance in CBT. It is important that clients work with clinicians who understand the challenges and opportunities with adult ADHD, including pointing out authentic incremental improvements that adults with ADHD might dismiss. It also allows for the vulnerability clients often feel with sharing what have been longstanding sources of stress and even shame in a safe place where they bravely face their current roles and endeavors more effectively. During such safe conversations clients can discover and build on strengths and even pursue endeavors they never believed – or trusted – they could accomplish.