Rethinking Adult ADHD

It came out in 2020 from the publishing house of the American Psychological Association (APA). Around two hundred and ten pages with the bibliography and index.

J. Russell Ramsay is a clinical psychologist. Together with the psychiatrist Anthony Rostain he is among the founders of the Adult ADHD Treatment and Research Program at the University of Pennsylvania. For years the two have been writing together on cognitive behavioral therapy for adult ADHD; I also reviewed separately on the site The Adult ADHD Tool Kit, which the same team wrote for the reader.

I could not find a verified Turkish edition; I write it under its English title.

First you need to know this: the book's main reader is the therapist. In the preface the author defines his main readers as mental health workers and clinicians in training, adding that he hopes the curious ordinary reader may find something too. I was that curious reader, and I found more than he hoped.

An answer given twenty years later

A small scene told in the book's introduction sets up the question of the whole book.

In the early 2000s at a conference in Sicily, Ramsay and Rostain give a workshop describing the approach they developed for adult ADHD. One of the participants, a specialist working on cognitive therapy for bipolar disorder, asks a simple question: just as depression and anxiety have distinct thought themes, what is the main thought theme of adult ADHD?

Ramsay tells how he could not give a good answer that day. This book is an answer given to that question about twenty years later.

I liked this scene. An expert putting at the center of the book a question he could not answer increased my trust in the rest of the book.

First he draws a limit

In the introduction Ramsay tells how he has added the same warning to every workshop he has given and every article he has written for years, and the whole book is built on this warning: negative thinking does not cause ADHD.

The order runs the other way. ADHD causes problems in life again and again. Missed deadlines, unfinished work, broken promises. Over time these problems produce certain thoughts and beliefs. And those thoughts prevent the coping skill from being used next time.

This distinction was important to me. When cognitive therapy is applied to ADHD it can sometimes read as "if you fix your thinking, your ADHD will go away." Ramsay cuts this off from the start. The neurodevelopmental picture stays where it is. The target of working with thoughts is the second layer that has piled up over it through the years.

A performance problem

The book's definition of ADHD is this: the gap between knowing what to do and doing it on time. Ramsay calls this a performance problem.

He says that telling someone who struggles with procrastination to "start early" is no different from telling someone depressed to "cheer up." When I read this comparison I laughed aloud, then got a bit angry; I remembered how many times I had been given this advice.

The book argues that thoughts sit right in the middle of this gap. The behavioral skills are known: lists, planners, breaking tasks up. According to Ramsay there is no secret to this. The problem is the mental events that step in at the moment the skill is to be used.

Ramsay calls these moments "pivot points": the moment the task is defined, the moment the plan is to be started, the moment the first discomfort is felt. These are the places where intervention is most productive.

The first chapter summarizes for therapists the present understanding of ADHD in adulthood, and stresses one point especially: cognitive behavioral therapy for adult ADHD should be understood as an approach aimed at the functional losses the symptoms cause in life. It should not be expected to treat the core symptoms directly. This is an important distinction for setting the expectation right. The aim of therapy is to lower the cost of living with ADHD.

For this reason Ramsay describes his own approach as a kind of extended-release therapy. The aim is for the skill talked about in the session to leave the session room and actually be used where and when it is needed; for the interventions to be "sticky." The clinical points at the end of the first six chapters do some of this work too: they show the therapist, by example, what the external reminders given to the client should look like.

A narrow kind of self-confidence

Here is the answer to the twenty-year-old question. Ramsay ties the central thought theme of adult ADHD to a little-discussed sub-dimension of psychologist Albert Bandura's concept of self-efficacy: self-regulation efficacy.

Roughly: believing you can do something is one thing, believing you can do it when needed, as much as needed, consistently, is another. Adults with ADHD often do not lack the first. They know they are intelligent, they know the work. What they do not trust themselves with is applying what they know on time.

Ramsay describes the source of this picture as "consistent inconsistency." Someone who works wonderfully one day cannot start the same work the next. As this fluctuation repeats over years, the person learns not to trust their own intention.

This is where I stopped most while reading. I rarely said "I can't" to myself. What I said was more like "I can, but I can't know that I will," and I had never thought this could have a name.

Here honesty is needed: Ramsay offers this theme as a proposal. In the book's second chapter he surveys research on cognitive distortions and schemas in adults with ADHD and shows that the model is consistent with these findings. But I did not come across a study in the book that directly tests whether a treatment centered on self-regulation efficacy is better than one that is not.

Escape and avoidance

The lack of trust turns into a behavior pattern: escape and avoidance.

A task causes discomfort. The discomfort lessens in the short term by moving on to something else. Because it lessens, that move is rewarded and becomes easier the next time. Meanwhile the task grows, the discomfort rises, avoidance becomes even more tempting.

To say that this cycle sounds familiar is an understatement. In the article procrastination or avoidance on the site I looked at the same mechanism from another place.

The trap of the optimistic thought

This was the idea of the book that surprised me most.

When people say cognitive therapy, negative thoughts come to mind. Ramsay says that in ADHD dysfunctional positive thoughts are at least as important as they are.

It was not hard to produce examples from my own life. Let me take care of this little thing first, then I will start comfortably. Tomorrow I will be more energetic. I work better under pressure. I will finish this in five minutes.

None of these sentences feels bad. On the contrary, they relieve at that moment. And it is this relief that lets avoidance in. The book takes these as a type of distortion and suggests testing them with the same seriousness as negative thoughts.

Seeing that some of the sentences I was trying to be kind to myself with were actually the voice of avoidance was not pleasant. But it worked.

The busy form of procrastination

In the fifth chapter there is a concept called "procrastivity." Being busy with other tasks that feel productive instead of doing the real task. Clearing the table, cleaning out emails, rewriting the to-do list.

What makes this type of procrastination dangerous is that it produces no guilt. At the end of the day you are tired, you have done lots of things, but the one thing that needed doing sits where it was.

The same chapter covers time management, attitudes about organization, emotion management, impulsivity, producing motivation and dealing with setbacks. One subheading is on tolerating discomfort: taming that reluctant "ugh" feeling that comes at the start of every task. The book names this in an everyday voice instead of a technical term, and it is good that it does.

Defense attorney

The fourth chapter adapts classic cognitive techniques to ADHD.

Noticing thoughts and seeing their effects. While trying to change a thought, hiring yourself a "defense attorney": a voice collecting evidence against the accusing inner voice. Cognitive defusion from acceptance and commitment therapy, that is, taking distance from a thought instead of arguing with it. Reframing the task.

The adaptation here is important. In classic cognitive therapy the truth of the thought is tested. In ADHD, a thought can block the next small step even if it is partly true, and that block is the real matter. For this reason the book uses the techniques in a way that makes starting and continuing the work easier.

How setbacks are explained is also part of this chapter. Instead of "I am a failure," saying "I had not broken this task into small enough pieces." The first is a verdict about character, the second a behavior that can be corrected.

Special cases and three long cases

The sixth chapter touches many subjects under short subheadings: attitudes about medication, young adulthood, co-occurring anxiety, depression and substance use, sleep, technology, relationships, older adults with ADHD, suicidal thoughts and therapists' misconceptions about ADHD.

The last subheading pleased me. The therapist's reactions to a client with ADHD and their misconceptions about ADHD are also handled as part of treatment. The thoughts of loved ones and the surroundings about ADHD are also in this chapter.

The part given to medication is a few pages and is concerned less with the medication itself than with the client's attitudes about medication. Ramsay and Rostain have for years advocated an approach that treats therapy together with medical treatment; the decision on medication is a decision always made with a doctor.

In the seventh chapter there are three long cases. The therapist's comments are scattered through the text. The seemingly scattered parts of the book come together here. Even if you cannot read the whole book, read this chapter.

The cost of being written for therapists

The book's language is a clinician's language. Case formulation, schema, the generic cognitive model. The first six chapters end with a list of "key clinical points," and these lists are written to the therapist.

Reading from the client's side you sometimes feel as if you are sitting in a room where you are being talked about. This did not bother me, but it could.

In the table of contents there is no heading given to women or hormonal periods. Emotional regulation is there but short. For these areas you need to look at other sources.

And one more thing: the book is not a method book. It does not offer a step-by-step program. If you are looking for a modular protocol of the kind tested in the study by Safren and colleagues published in JAMA in 2010, that is another book. Ramsay's book helps to understand why such protocols sometimes do not work.

Where it stands

There are randomized studies and meta-analyses showing that cognitive behavioral therapy is effective for adult ADHD. The book's second chapter summarizes these, and in the bibliography client books and therapy manuals are marked separately. The list of reliable information sources in the appendix is also useful.

The book's own contribution is narrower and more interesting: proposing a thought theme that explains why these effective techniques are not used in real life. That theme cannot yet be counted as a treatment tested on its own. It is a well-reasoned proposal resting on clinical observation and existing research.

If you have read the article cognitive behavioral therapy on the site, this book expands the "but why can't I do it" part of that article.

For whom, how

First of all for therapists working with clients with ADHD.

For the reader with ADHD, after a certain stage. It says a lot to someone who has tried cognitive behavioral therapy, learned the skills and still could not use them. For someone newly diagnosed it is early; it is better to read a more general book explaining what ADHD is first.

I first read the introduction, then the third and fourth chapters, then the cases in the seventh chapter. Then I used the fifth chapter like a reference section; going back to that subheading when procrastination, time or motivation got stuck. The first and second chapters can be skipped by someone who already knows ADHD and the research.