Cognitive Behavioral Therapy (CBT) for ADHD in Adults

After the diagnosis I thought for a while: if the matter is attention, once attention is fixed the rest will come by itself.

It did not. Because my real problem was not only that my attention wandered. It was not knowing how to keep a calendar, never having learned to divide a job into steps and, most important, the sentence that played in my head at the start of every new job: "you'll leave it half done again."

No medication silences that sentence. Of the approaches that work in this gap, the most researched is cognitive behavioral therapy.

What it targets

CBT adapted to ADHD does not aim to make ADHD disappear. It works with two separate things.

Skills. Time management, planning, prioritizing, coping with procrastination, managing distractions. That is, the things that most neurotypical people pick up somewhere along the way by themselves and that nobody ever explains to anybody openly.

Thought patterns. Beliefs formed over the years: "if I start, I'll ruin it," "I can't keep up any system," "either it'll be perfect or not at all." These patterns directly stop behavior.

The second part is more important in my opinion, because teaching skills is not enough on its own. I often know what I need to do and how. What I do not know is what to do about the voice that does not let me do what I know. Perfectionism and all-or-nothing thinking stand exactly on this side.

The job of CBT in ADHD is not giving information. It is removing the obstacle in front of what is already known.

The state of the evidence and its limits

The randomized study by Safren and colleagues (2010), published in JAMA, shows that in adults whose symptoms continued despite taking medication, CBT provided significantly more improvement than the comparison group.

The study by Solanto and colleagues (2010) reports that a group-based approach called metacognitive therapy, which focuses on time management and planning, is effective on inattention symptoms.

Here we need to be honest. The Cochrane review by Lopez and colleagues (2018) brings together 14 randomized studies and 700 participants. The result is this: cognitive behavioral-based treatments can be useful in the short term in adult ADHD, but the quality of the evidence is low. Long-term follow-up data are scarce, the outcomes measured vary from study to study, and almost all the studies were done in the northern hemisphere and Australia. The same review also reports a low-quality benefit for secondary difficulties such as depression and anxiety.

The European consensus statement (Kooij et al., 2019) counts psychological support as one of the components of treating adult ADHD.

I want to separate two details. The first is that most of these studies were done in adults who take medication; there is no claim that CBT replaces medication. The second is that the sentence "low-quality evidence" does not mean "it doesn't work"; it means "the studies we have are enough to say this much and not enough to say more." Confusing these two cost me dearly; either believing fully in a method or sulking and leaving it entirely is itself an all-or-nothing move.

What happens in a session

CBT adapted to ADHD can be surprising for someone who comes with the expectation "I'll talk and feel relieved." Its structure is like this:

• Structured. Every session has an agenda.
• Focused on the present. The past is addressed, but the center is how you function now.
• With homework. Practice between sessions is at the center of the work.
• Time-limited. It is usually planned for between twelve and twenty sessions.
• Measured. Symptoms and goals are assessed regularly.

A typical session goes like this: last week's homework is reviewed, if it did not hold, why it did not hold is explored, a new skill is worked on, and a concrete practice is set for the week.

The "if it did not hold, why is explored" part is the heart of the work, in my opinion. Because in ADHD a system's collapsing does not come from a lack of knowledge; it comes from the system being too much for that person. A good therapist does not say there "so you're not willing," she says "so this step was too big."

What is worked on concretely

So that it does not stay abstract, let me list the typical topics.

A single system. A person working with several notebooks, several apps and several lists first brings all of them down to one place. Deciding where to look is also a decision, and that decision eats energy every time.

Breaking the job down to its first movement. "Write the report" is not a task, it is a heading. "Open the document and write the title" is a task.

Making time visible. A timer, a block in the calendar, a countdown. Where time is not felt, an object that shows time is needed.

Testing the thought. Taking the sentence "I'll ruin this job" and looking at its evidence. At first this felt a bit artificial to me; then I noticed this: I had never asked for the evidence of that sentence, I had accepted it as true for years.

Planning the return. The system will collapse. The question is not that it should not collapse but what will be done after it collapses. This section was the one that made the most difference for me; because in the past, a collapse was an excuse to rebuild everything from scratch.

For whom it works

• The therapist's experience with ADHD. A therapist who has general CBT training but does not know ADHD can misinterpret why the homework cannot be done and mistake it for resistance.
• A realistic homework load. Giving someone with ADHD long weekly homework leads to the homework not being done and producing shame. This becomes a reason to leave treatment.
• Symptoms being under some control. When symptoms are very heavy, skills work moves slowly; that is why it is often planned together with medication. Let me say once more that the decision on medication and therapy belongs to the doctor.
• Being able to keep going. Attending twelve sessions is in itself an executive function job. Putting the appointments on a fixed day and keeping them visible in the calendar is a matter that has to be solved before the therapy.

Three questions you can ask your therapist. "Do you work with adult ADHD?" "Is your approach structured?" "If you don't give homework, how do we move forward?" These three questions largely show in the first meeting whether there is a fit.

Other approaches and concepts that get mixed up

CBT is not the only option. If the emotional side weighs more, acceptance and commitment therapy and skills work derived from dialectical behavior therapy are also used. The place of mindfulness-based approaches is in the article on mindfulness practice.

Another thing that often gets mixed up is coaching. ADHD coaching is a form of support that focuses on building systems and is not mental health treatment; knowing that the two are not the same sets expectations correctly. I covered the choice between medication and therapy separately in the article on medication or therapy.

For my own part

If I come across a text that describes CBT as "the thing that cures ADHD," I now close it. The data we have do not say that.

What they say is this: there is a part that medication does not solve, and that part can be worked on. The idea that helped me most came from there. The reason I built systems and collapsed them for years was not a lack of willpower; it was that the systems I built were systems that do not work for me. Seeing this next to someone else was much easier than seeing it alone.