Does Couples Therapy Work for ADHD? What the Evidence Says

"If we went to couples therapy, would it get better?"

I hear this question often once ADHD begins to be talked about in a relationship. It is usually asked from a tired place. There are things that have been tried, conversations that did not work, and a hope that a third person can untangle this knot.

In this article I will try to give an honest answer to that question. The honest answer may be a little disappointing too: the short version is "it will probably help, but there are very few studies that show it for certain."

First the general picture: does couples therapy work

Yes, in general it works, and the evidence on this is quite solid.

A review that went through decades of research on the treatment of couple problems reports that about 70 percent of couples who receive couples therapy are positively affected by it, that this effect is comparable to the effect of individual therapies and that it gives markedly better results than control groups that receive no treatment at all. The same review also emphasizes that there is a two-way, circular relationship between relationship distress and individual mental health problems (Lebow et al., 2012).

This last point matters for ADHD. Tension in the relationship can make ADHD symptoms worse; ADHD symptoms can make the tension in the relationship worse. Which end of the cycle you enter at sometimes affects the whole cycle.

Where the ADHD-specific evidence stands

Here the picture is much weaker.

A comprehensive review of the writing on ADHD and romantic relationships notes that there are many findings that the relationships of adults with ADHD are shorter and more conflict-ridden, but that research examining what explains or eases these difficulties is still scarce. The authors note that there are still important gaps in the field in terms of prevention and intervention studies (Wymbs et al., 2021).

Let me give an example. For young adult couples, a group intervention was developed that combines cognitive behavioral therapy components aimed at ADHD with a program aimed at the couple relationship, and it was tried in a small pilot study (Wymbs & Molina, 2015). Pilot studies matter, because they show whether a method is feasible and whether couples stay with it. But proving that a method works requires large, controlled studies, and there is not yet that kind of accumulation in this area.

On the clinical side the situation is somewhat fuller. Guide books for clinicians have been written on ADHD-focused couples therapy; one of them offers clinical interventions for therapists working with couples in which one partner has ADHD (Pera & Robin, 2016). Books like this can be very instructive in practice, but a clinical guide and a randomized controlled study do not offer the same level of evidence.

We know that couples therapy works in general. We do not yet know well enough how and how much it works in couples with ADHD.

Not skipping the individual side

There is something that is often overlooked when couples therapy is discussed: treatment of the ADHD itself.

In a randomized controlled study of 86 adults with ADHD whose symptoms persisted despite medication, the group that received cognitive behavioral therapy showed greater improvement in ADHD symptoms than the group that received relaxation and educational support, and this improvement was maintained at 12 months (Safren et al., 2010). I described the details of the individual method in the article on cognitive behavioral therapy in ADHD.

What this means for a relationship: as long as the person with ADHD is not addressed individually, with forgotten promises, missed payments and days that cannot be organized, every agreement reached in couples therapy can run into the same wall the following week. Couples therapy and individual support are not alternatives to each other; most of the time they complement each other. The choice of treatment and the decision on medication are of course made together with the doctor.

What I look for in a therapist who knows ADHD

Even if the evidence base is limited, the outline of the clinical consensus on what couples work that takes ADHD into account should look like is clear. These are the things I find worth trying to look at in a first meeting with a therapist.

Do they know ADHD

A therapist who sets up a frame like "if only they paid a bit more attention" or "if they really cared they would remember" can shame the partner with ADHD even more. A simple question that can be asked: "Have you worked with couples where one partner has ADHD before? How do you approach the way ADHD shows up in the relationship?"

Do they give information to both sides

What the glossary calls psychoeducation, that is, explaining to both sides what ADHD is, what it explains and what it does not explain, is the cornerstone of this kind of work. When the partner without ADHD hears "this is not neglect, it is an executive function matter," and the partner with ADHD hears "this is understandable but it does not remove responsibility," the conversation goes somewhere else.

Do they avoid setting up one person as the problem

In a relationship where ADHD is being talked about it is very easy to load all the problems onto the person with ADHD. A good process recognizes the share of ADHD while also putting the behavior of the partner without ADHD, their tiredness and the relationship's own dynamics on the table. The parentification dynamic, in which one side is stuck in the position of constantly reminding and the other in the position of being constantly reminded, is the most familiar example; both sides have a share in reproducing that dynamic. I described this dynamic in the article on ADHD and relationships.

Do they work with concrete systems

In ADHD, talking only about feelings may not find its counterpart in the week's actual life. An approach that also works with practical tools, such as a shared calendar, sharing out space and a time rule for difficult conversations, is in my view more realistic. One form of support that focuses on building daily order is coaching; I talked about how it differs from therapy in the article on what ADHD coaching is.

Both of you write before the first session. Before the first session, each of you separately writes down these three questions and brings them along: What is the repeating situation in this relationship that tires me most? If this situation improves, what would I like to see differently in our daily life? How much of this situation is ADHD, in my view, and what is the rest? How different the answers are from each other tells a lot to the therapist and to you.

When couples therapy is not appropriate

If there is physical assault, threats or a situation in which one partner is afraid of the other in a relationship, couples therapy is generally not recommended as the first step. In that case safety and individual support come first. ADHD should not be seen as an explanation or an excuse for these behaviors.

If you do not feel safe, in Turkey you can call 112 in emergencies and ALO 183 for social support.

There is also this: couples therapy sometimes helps two people separate with less harm. That too is a legitimate outcome.

What can be done while waiting

Reaching a therapist may not be easy, either financially or in terms of time. A few things worth trying in the meantime:

• The partner without ADHD reads a reliable source on ADHD, and the partner with ADHD reads that source together with them and takes notes of the form "this is how it shows up in me."
• A short, blame-free relationship meeting once a week at a fixed time: what went well this week, what was hard, a single small change for the next week.
• Keeping difficult conversations away from the hours when tiredness is at its highest.

Talking about expectations beforehand can also help. Two people going to therapy sometimes quietly hope the therapist will take their side. When this hope is not met in the first sessions, the disappointment can grow and the therapy can be dropped early. Asking together before you start "What would we count as a good start if we saw it in the first few months?" gives both of you a more realistic line. Setting a trial period of a few sessions and assessing it together at the end is also a reasonable way.

These do not replace therapy, but they can let you start therapy from a more prepared place.

What I think today

I would like to be able to say a definite "yes" to the question of whether couples therapy works in ADHD. I cannot, because the studies that show it are not yet sufficient.

What I can say is this: couples therapy is generally a strong tool, and individual treatment of ADHD is a proven support in its own right. Setting up both together, and with someone who knows ADHD, is in my view the most sensible path with what we know today.