Focusing on the “T” (Therapy) in CBT for Adult ADHD

Cognitive behavioral therapy (CBT) is an evidence-supported psychosocial treatment for adult ADHD. There are several available treatment manuals for clinicians, some with corresponding client workbooks. There is also a batch of other options tied to the credible, effective principles that guide treatments for adults with ADHD.

The most respected manuals have research support, chiefly via randomized controlled trials (RCTs), considered the ideal means to establish that a treatment works as promised.¹ A necessary facet of these RCTs is identifying participants who have ADHD without co-existing diagnoses to ensure the treatments are, in fact, directly addressing and improving the symptoms of ADHD.

When ADHD Gets Complicated—Which Is Usually

Here is where the discussion of the “T,” the “therapy in CBT, arises², and it's particularly relevant for adult ADHD. It’s well established that many things travel alongside ADHD, some of the most common being other psychiatric diagnoses, learning differences, and substance use issues.

However, these formal categories do not touch on the many life stressors that affect and are affected by ADHD, such as dealing with other health issues, such as diabetes, sensory or mobility ailments, reproductive health, caring for aging parents, pending divorce, or food scarcity. Even positive events can be stressful and difficult to navigate, such as marriage, raising children, a work promotion, or bringing home a puppy.

Adapting CBT for Adult ADHD

Some of the best RCT-based CBT manuals for adult ADHD present a series of 12 to 14 sessions or so, with session-by-session objectives and skill practice between sessions. This ensures that participants get an adequate “dose” of specialized psychosocial adult ADHD treatment. Thus, they are ready for use by clinicians in the community outside the structure of research.

However, their use with free-range adults with ADHD requires some “flexible rigor” by clinicians to adapt and personalize them to the individual needs of each client. The session-by-session approach provides guidance for the essential topics. You could think of the manuals as providing the piano keyboard and the notes, but clinical practice requires different tunes for different clients while still hitting all the keys.

Some manualized approaches draw on a conceptualization-based approach to adult ADHD, tailoring the presentation of the same CBT principles used in modular approaches at the outset and throughout treatment.³ Yet, there are no trade secrets about the necessary coping skills for managing and living well with adult ADHD.

Adapting CBT Requires Understanding ADHD

Basic familiarity with and understanding of the nature of ADHD and its effects is necessary. Unfortunately, very few practicing clinicians have received any formal training in the assessment and treatment of adult ADHD, either in the classroom or through supervised clinical experience in graduate and medical training programs.⁴ This lack of experience may contribute to rigid, inflexible administration of CBT for adult ADHD without adequate tailoring to individual clients, which has contributed to poor outcomes reported in a recent study. In the same study, a client who worked with an ADHD-familiar clinician described his positive experience as “transformative.”⁵

CBT for Adult ADHD Beyond Symptoms

A recent comprehensive meta-analysis of a batch of studies of CBT for adult ADHD yielded some encouraging results.⁶ The review focused on clinical research in which the outcome measures focused on improved overall functioning and quality of life, as well as functioning within specific domains of life, such as work, academics, and relationships.

The results showed that CBT for adult ADHD has many positive effects for overall life functioning, not just symptoms. Workplace functioning showed the strongest positive effects; social life, academics, and overall quality of life had more modest, sometimes inconsistent positive results. The modest results in these areas might reflect the great variability in social life and types of schooling.

Nevertheless, CBT for adult ADHD has some core principles that are beneficial and lend themselves to being adapted to the needs of individual clients. At the same time, future studies may examine CBT approaches specifically tailored to these different life domains as well as some of the other life stressors that complicate life with adult ADHD.

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