How Cognitive Behavioral Therapy Works

Cognitive Behavioral Therapy — or CBT — is an umbrella term for a group of interventions used to treat disorders like anxiety, PTSD, and more recently, ADHD. The way CBT is used to treat each condition varies, but all CBT focuses on cognitions — or thoughts — and behaviors, in the here and now. It's a short-term, goal-oriented form of psychotherapy that aims to change negative patterns of thinking with cognitive restructuring and change the way a patient feels about her self, her abilities, and her future. This ADHD therapy requires that the patient get in touch with her thoughts and feelings, and learn how to modify them when they’re dysfunctional.

Cognitive behavioral therapy is based on the recognition that cognitions, or automatic thoughts, lead to emotional difficulties. Automatic thoughts are spontaneous interpretations of events. These impressions are susceptible to distortion, such as unfounded assumptions about yourself (or others), a situation, or the future. An unhealthy internal dialog could prevent an individual from working toward an aggressive goal, working to develop productive new habits, or generally take calculated risks.

For adults with ADHD, the “cognitions” — or thoughts — addressed relate to the self-instructions we use when beginning a task. This includes our thoughts on how to organize, prioritize, and plan. The behaviors addressed are physical skills and habits — for example, learning how to use a planner.

“Oh that? I can do it later.” We're all guilty of procrastinating, but when we think this way consistently, we miss deadlines or create unnecessary stress. CBT trains the ADHD brain to instead think, “Let me look at what’s involved so I ensure I make the deadline.” Essentially, it replaces your dysfunctional thought patterns — which have gotten you into trouble before — with functional patterns that help you get the job done.

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No head-to-head studies have directly compared CBT to medication, but our clinical experience suggests that they accomplish different things. CBT intervenes to lessen life impairments — procrastination, time management, and other common executive functioning difficulties — not to treat the core symptoms of inattention, hyperactivity, and impulsivity. Medication is best for basic attention functions like reducing distractibility or prolonging your attention span. In other words, medication can help you focus, but CBT tells you what to focus on.

Most individuals find that they need CBT to target ongoing struggles with disorganization and procrastination, despite being on ADHD stimulants. As has been said many times, “pills don’t teach skills.” The combination of medication and CBT is often the treatment of choice for dealing with the wide-ranging effects of ADHD.

Many adults with ADHD, by virtue of their life experiences, also have coexisting anxiety or hypersensitivity. CBT makes it easy to address other important issues that affect ADHD symptoms — co-existing mood and anxiety disorders, hyperfocus on technology and gaming, a job search, or overall lifestyle habits — sleep, exercise, and one’s self-esteem. The techniques used to treat each condition are different, so it may be best for you and your therapist to focus on each one individually before moving to the next one. Remember, none of these conditions will go away overnight. They all require you to practice, develop awareness, and challenge negative beliefs. Don’t get discouraged!

CBT focuses on adopting coping strategies, managing negative expectations and emotions, and unwinding behavioral patterns that interfere with the strategies. So, what are some concrete skills you’ll learn in CBT? The first one I address with ADHD patients is how to use a planner to record not only your appointments, but also your day-to-day tasks. Whatever you intend to accomplish during the day should be in the planner. Remember, if it’s not in the planner, it doesn’t exist — and if it doesn’t exist, you won’t get it done.

1. Everything goes in one planner. Don’t have separate planners for home and office — you’ll just confuse yourself.

2. Have the planner with you all the time. Even if you’re just running out to lunch, you never know what thoughts are going to occur to you that you may need to write down.

3. Reference it regularly. Once in the morning, before you start your day, once at noon, to see how things have changed, and once before you go to bed, so you can start planning the next day. Or, link checking your planner to routine activities, like brushing your teeth, eating lunch, walking the dog, and so on. This helps someone with ADHD stay on task throughout the day, and prioritizes the things to get done. Instead of spending a lot of time putting out fires, think ahead to prevent them.

Adopt the simple mantra: "If it’s not in the planner, it doesn’t exist."

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If you’re having difficulty keeping up with the planner, it may not be the right system for you, and you may want to switch to another style of planner (from paper to digital, for example). This is fine every once in a while, but don’t blame every misstep and inefficiency on the planner! Entering your appointments into a planner is always going to be tedious — stick with it, and don’t chuck your planner every time you fall off the wagon.

Some of the in-session CBT exercises are based on simple ideas: Many people with ADHD don’t wear a watch. However, remembering to wear a watch, placing clocks all over the house, and keeping a detailed log of the day helps a lot with time management. How does someone with ADHD remember to do all that? Simple mantras ("If it’s not in the planner, it doesn’t exist") are basic forms of CBT. They serve as reminders to change one’s thought patterns.

If you are having trouble getting started on a project, the first step is too big. CBT also teaches patients how to break down complex tasks into manageable chunks. One way to do this is by time: If you think a task will take you five hours, start by working on it for one hour and then stopping. Then, when you’re ready, try another hour. Another option is breaking it down by amount, like, “I’m going to do half these papers now, and half later.” You’ll stop yourself from getting overwhelmed, and you’re more likely to finish the task.

CBT also addresses prioritization. Why is it important to prioritize? For all of us, time is limited. If you don’t do things in order of importance, there’s a good chance you’re going to neglect something critical. Prioritizing is especially important for people with ADHD, because they often follow their impulses. So if someone calls you with a new task, your impulse may be to shift right to that, even if there are more important things that need to be done first.

We teach prioritization using something called the “Urgency Importance Matrix,” which divides tasks into Important, Urgent, Non-Important, and Non-Urgent. Important and Urgent is easy — we know it needs to go first. But a lot of individuals with ADHD get tripped up by the second category, Important and Non-Urgent, which aren’t urgent now but will be eventually. CBT helps you tackle them by identifying your tasks, ranking them, and getting all the Important tasks done in a timely manner.

My mantra for avoiding distractions at your desk is, “Out of sight, out of mind. In sight, in mind.” This means you need to clear away the things you don’t want to be thinking about — like the latest People magazine — so you can focus on what’s important. If you need certain files for a project, make sure they’re on your desk, in sight, before you start working. Put them away when you’re done with them, so you can shift your focus to the next task.

Many adults with ADHD are perpetually running late — which can be bad for your career, your relationships, and your health. Individuals with ADHD are often reluctant to err on the side of being early, because they’re afraid they’ll be bored waiting around. A good CBT therapist will work to train your brain to be less stressed about getting somewhere early, in part by making sure you always have something — a book, a game on your phone — that you can turn to when you have time to spare.

People with ADHD are often very sensitive to criticism. This is often due to something we call “selective attention.” If your boss makes one negative comment about your work, for example, you ignore everything else he said and immediately jump to “I messed up. I’m worthless.” In CBT, we’ll examine the facts and determine if they really support this conclusion. In most cases, they don’t — and over time, you’ll learn to respond to criticism in a more helpful and self-encouraging way.

CBT has been shown to effectively treat anxiety in children. But so far no program has successfully treated ADHD in children. The most effective approach for ADHD children may be combining elements of CBT — like positive self-talk — with more traditional behavioral therapy, which involves interventions from parents and teachers.

CHADD (and its National Resource Center), ADDA, the Academy of Cognitive Therapy (ACT), the Association for Behavioral and Cognitive Therapies (ABCT), and the ADDitude Directory have find-a-therapist features on their websites that offer good starting points. You may have to work together with your therapist to address the specific issues faced by those with ADHD — if they want some direction, tell them to check out my book, Cognitive-Behavioral Therapy for Adults with ADHD.

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