Medication or Therapy for ADHD? You Don't Have to Choose

After the diagnosis, the first practical question going around in my head was this: so what happens now, medication or therapy? The two stood there like two separate doors, and I thought I had to choose one.

As I read, I saw that the question itself was set up wrongly. Medication and psychological support are not two different roads to the same job. They do two different jobs.

Why the question is always asked this way

Part of what sets the question up this way is the assumption that treatment is a single thing. For the flu you take a medication and the matter is over; carrying the same logic over to ADHD feels natural.

Part of it is the sentences the sides say to each other. On one side there is a voice saying "no medication is needed, pull yourself together," on the other a voice saying "if you swallow a pill everything will be fine." Both see half of the matter, and both make the decision harder.

The framework that worked best for me was to separate two different questions. The first: "how severe are the symptoms?" The second: "what did twenty-some years with the symptoms leave behind?"

What medication works on and what it does not

Where it works: gathering attention, braking the impulsive reaction, quieting inner restlessness. That is, the intensity of the symptom itself.

Where it does not work: it does not teach keeping a calendar, it does not teach dividing a job into steps, it does not change the "I can't do it anyway" sentence that has hardened over the years. It does not tell you where to put your keys either.

There is an image in my head that makes this concrete: medication turns down the noise in the room. When the noise is turned down, the mess on the table is still there; it is just that now it can be seen.

How the medication is started, how the dose is adjusted and what should and should not be expected is a separate topic; I covered it in the article on ADHD medication treatment. In the glossary the name of this adjustment process is titration.

What therapy works on and what it does not

Where it works: building systems, coping with procrastination, loosening unhelpful thought patterns, working with shame.

Where it does not work: it does not change the biological ground of attention. A good therapy can make you a better planner, but your mind slipping in the fortieth minute of a meeting can continue.

There is something here that most people miss: ADHD therapy does not work like classic talk therapy. It is something structured, with homework and focused on skills. It is built not on talking and feeling relieved but on bringing out something to try during the week.

What the evidence says

The study in which this distinction is clearest is the research by Safren and colleagues (2010). The study was done with adults whose symptoms continued despite taking medication. The group receiving cognitive behavioral therapy showed significantly more improvement than the comparison group.

This design answers the question by itself: medication sorts out something, something is left, and therapy works on what is left.

The study by Solanto and colleagues (2010) shows that a group-based program targeting time management and planning is effective on inattention symptoms. So "teaching skills" here is not the name of an abstract good intention; it corresponds to a measured intervention.

Medication fixes the engine of the car. Therapy works on where to go and how to drive. You may need both.

What order the guidelines recommend

The European consensus statement (Kooij et al., 2019) recommends a multicomponent approach in adult ADHD:

1. Psychoeducation. Understanding what it is counts as the first step of treatment. In the glossary it appears as psychoeducation, and in my opinion it is the most underestimated step.
2. Medication treatment. If the symptoms noticeably affect functioning.
3. Psychological support. For skills and thought patterns.

The NICE guideline (NG87) likewise recommends adding psychological support in cases where medication alone is not sufficient.

The order varies by person. If the symptoms are very heavy, it is hard to make progress in therapy; in that case a ground is first created with medication and then skills work is done. If the symptoms are milder or the person does not want medication, one can start with therapy. This decision itself belongs to the doctor: which treatment is suitable, in what order and for whom is determined by an examination.

What the distinction looks like in daily life

When I divided my own daily struggles into two, the picture became clear.

Those related to intensity: not being able to hold the paragraph I am reading, the mind slipping in the middle of a long meeting, not being able to stay where I sit, jumping to somewhere else in the middle of a sentence while speaking.

Those related to accumulation: that indescribable resistance before starting a job, the "I wonder if it was bad" state that goes on for days after handing something in, the harshness of the sentences I say to myself when I forget something, not even thinking of asking for help.

None of the items in this second list has anything to do with the dose. They are what someone who got by for years without support has left behind, and they need to be worked on separately.

If you do not want medication

This is a legitimate preference and a subject that needs to be talked about; it is not a justification for quietly withdrawing from treatment. What is left on the path without medication:

• Cognitive behavioral therapy. The psychotherapy approach with the broadest evidence base in adult ADHD. The details are in the article on CBT in ADHD.
• Acceptance and commitment-based work. Especially if avoidance and shame weigh heavily. The details are in the article on acceptance and commitment therapy.
• Coaching. Structured support focused on daily functioning: ADHD coaching.
• Adjusting the environment. Adjustments made at the workplace and at school.
• Sleep, movement and routine. Not enough on their own, but they noticeably affect the picture.

To be honest: the effect size of medication treatment on the core symptoms is measured as higher than that of psychosocial approaches. Deciding while knowing this is better than deciding without knowing it.

Three questions to ask when looking for a therapist

Not every therapist works with ADHD, and this is not a matter of quality, it is a matter of area of expertise. Three things you can ask in the first meeting:

• Do you work with adult ADHD?
• Is your approach structured, do you give homework?
• How do you proceed when the homework cannot be done?

The third is the most distinguishing. An approach that reads the homework not being done as resistance produces nothing but shame in ADHD.

I explained in detail what medication does and does not do in the brain in the article on methylphenidate.

Three common mistakes

Changing nothing after trying the medication. Staying in the old lack of system once the symptoms ease means wasting the space that was gained.

Expecting from therapy the job of medication. A weekly meeting does not change the physiology of attention. When the expectation is set wrongly, therapy too is dropped with "it didn't work."

Dropping both and trying to build a system alone. This sometimes works. But when it does not, the bill is again paid by the person herself and the story ends up tied to "I couldn't manage it."

How I set the question now

I got the diagnosis at 23, met medication again at 28 and stopped again.

I no longer ask myself "medication or therapy." I ask two separate questions: how much do today's symptoms make my life harder, and who will work on the habits and thought patterns I have carried for years?

The addressee of the first question is a doctor. The addressee of the second is a process and time. The two can run at the same time, and most of the time they need to.