We are only beginning to explore psycho-therapeutic treatment methods that are helpful for individuals with ADHD. This article briefly presents a description of Neuro-cognitive Psychotherapy, a therapeutic model for the treatment of ADHD gradually developed over many years of clinical work with individuals with ADHD. Although this therapeutic approach is more appropriate for treating adolescents and adults, these concepts can also be very useful for working with children with ADHD (and their parents)
Neuro-cognitive treatment combines techniques borrowed from the field of cognitive rehabilitation as well as others used in cognitive-behavioral psychotherapy — thus the term “neuro-cognitive psychotherapy”. This therapeutic approach emphasizes the need for structure and goals — both in the individual therapy session as well as in the daily life of a person with ADHD. Neuro-cognitive psychotherapy involves helping an individual to move beyond self-defeating blame toward a more constructive, problem-solving approach to the challenges of ADHD. Developing better life-management tools, building a lifestyle that is more ADHD-friendly, and learning how to set and reach realistic long-term life goals are all part of the process.
Addressing the Neurobiological Aspects of ADHD
For treatment to be effective, a clinician must always keep in mind that ADHD is a neurobiological condition with challenges that must be addressed in concrete and practical ways. Too often, therapists focus on the psychological “baggage” of ADHD (depression, anxiety, low self-esteem) — while never addressing the ADHD issues that generate these feelings. Neurocognitive psychotherapy addresses both psychological distress and concrete problems in daily living in an integrated fashion, moving back and forth between the practical and the emotional, between the present and the past, between ADHD and related or coexisting conditions. Although neuro-cognitive psychotherapy involves a dynamic interweaving of focus — attending to the emotional and the cognitive, to the inner world of feelings and the outer world of life challenges, it is easier to discuss by deconstructing it into its component parts.
Cognitive behavioral therapy focuses on changing attitudes and thought patterns as well as behaviors. The beginning steps of the therapeutic journey start with learning to understand ADHD, what it is and how an individual is specifically affected by it. The therapist guides the client not only to better understand ADHD, but to “reframe” ADHD in a more balanced, constructive way that can lead to both acceptance and constructive problem-solving. As an individual develops a growing understanding of ADHD he or she can develop a more positive self-concept and realistic sense of potential. An effective therapist can help an individual identify traits related to ADHD that, while they may be detrimental in some environments, may actually serve a beneficial purpose in others. As a client moves from asking “what’s wrong with me” to asking “what are my strengths and weaknesses” the therapist can begin to guide him to find a good match between his interests, abilities, and traits that can help him reach his real potential at school or at work.
Cognitive Rehabilitation Aspects
The therapeutic effects of understanding, reframing, and accepting ADHD can set the stage for an individual to take charge of his ADHD through:
- Improving cognitive functions
- Developing compensatory strategies
- Restructuring the environment to be more ADHD-friendly
- Improvement of Cognitive Functions
Stimulant medication, at present, is the best understood approach to improving cognitive functioning in those with ADHD, however medication doesn’t work for everyone, and many individuals have a strong desire to find a non-medication approach to treatment. The clinician and her client should work together on many levels to identify and change factors that interfere with good cognitive functioning. Cognitive functioning is strongly affected by stress levels, hormonal fluctuations, sleep, exercise, health habits, and many other environmental factors. The therapist can work closely with her client to help identify healthy daily habits — such as improved diet, exercise, sleep patterns that can all help to improve cognitive functioning.
Even if medication is part of the treatment program, stimulant medication cannot magically solve all ADHD-related challenges. Adults with ADHD need to develop techniques to compensate for their difficulties — by developing new habits, using visual cues, and using programmable watches or time management software. Many therapists relegate this critical aspect of treatment to a coach or organizer, not realizing that formulating and consistently using compensatory strategies constitutes the heart of learning to “taking charge of ADHD.” A coach or organizer can provide increased support, but treatment is much less effective if the therapist is not also involved in helping to develop daily life management skills and strategies to reduce problematic ADHD patterns.
Creating Environmental Changes
Helping to bring about beneficial changes in the client’s environment is an essential part of neuro-cognitive psychotherapy. In neuro-cognitive psychotherapy, the therapist takes an active role in guiding his client as he works to develop an ADHD-friendly environment — at work, at home, and in his relationships with others. Together, they need to identify factors that increase stress and ADHD symptoms and then strategize to make changes — in the workplace, in the home, and in relationships with family, friends and co-workers. In this role, it is often appropriate and helpful to involve others in the treatment process — consulting with a supervisor at work about helpful accommodations and inviting significant others into the therapeutic process so that they can better understand ADHD and how it affects both them and their loved one.
ADHD rarely exists in a vacuum. To be effective in treating ADHD, the neuro-cognitive psychotherapist needs to be extremely familiar with the diagnosis and treatment of many commonly co-existing conditions such as anxiety disorders, depression, learning disabilities, bi-polar disorder, and substance abuse disorders. Treatment of these conditions must be interwoven with approaches designed to address ADHD challenges.
Structuring the Psychotherapy Session
Not only is it important to introduce structure into the living environment of an individual with ADHD, it is equally important to introduce structure into the therapy session itself. Structure, compensatory strategies, and reminders are needed in daily life as well as within the therapy session.
For example, just as unfocused activity rarely helps an individual with ADHD reach a goal, unfocused, rambling interaction during a psychotherapy session is rarely productive. A neuro-cognitive psychotherapy session should be structured to help a client review issues discussed in earlier sessions, review issues related to other treating professionals (medication issues, coaching issues, etc.), set priorities for the focus of the current session, and set goals or tasks to work on between sessions.
Memory difficulties are very common in adults with ADHD. There may be no real sense of continuity from session to session without added structure from the therapist. Audio-taping or note-taking during sessions can be extremely helpful, allowing the client to review issues and goals between sessions. Each session needs to involve setting goals and priorities and then establishing realistic steps to work toward those goals.
Because ADHD typically exists in a complex nest of several related conditions and affects many aspects of life, a number of professionals may become involved in the treatment process over the course of time. If the psychotherapist is not also the prescribing physician, the most basic and important care coordination needs to take place between the therapist and physician. An ADD coach, a professional organizer, a career counselor, or a marriage counselor may also be involved in the treatment of an individual with ADHD. The psychotherapist needs to take on the role of care coordinator — referring his client to other professionals, as needed, and communicating and coordinating treatment among the various professionals involved.
Bringing it all together
ADHD is a complex, but highly treatable disorder. To be effective, however, a psychotherapist must always be mindful that she is treating a condition that is both neurological and psychological in nature. In learning to work effectively with individuals with ADHD, a therapist may need to rethink and alter the less structured, non-directive treatment approaches that she has been taught. Directive structure, support, and strategies — in the therapy session and in daily life — form the foundation of neuro-cognitive psychotherapy, with a focus on feelings, attitudes, and coexisting conditions skillfully interwoven around this supporting foundation. After many years of clinical work, I am frequently reminded that each client is unique and complex, an individual who is challenged by, but not defined by his ADHD.