Tuesday, August 3, 2010

The "Invisible Ropes" of Adult ADHD, And How A Special Type of Therapy Can Help Set You Free

Introduction:  When I'm asked about the best kind of therapy for Adult ADHD, I explain that the research thus far points to cognitive-behavioral therapy (CBT), in combination with medication.  Then I emphasize a critical point: not just any CBT but that with a special focus on ADHD
      Standard CBT that does not acknowledge the neurobiological role of ADHD can be counter-productive, at best.  How do I know this?  Because I listen to the top experts who make this study and practice their life's work. 
      I'm pleased to offer a guest essay this month from one of these top experts: J. Russell Ramsay, psychologist and co-director at the Adult ADHD Clinic at the University of Pennsylvania. (Please see bio at the end of this post).  In preparing my talk for the upcoming CHADD 22nd International Conference on ADHD ("Adult ADHD Symptoms or Poor Coping Skills?"), I relied heavily on the book he co-authored with Dr. Anthony Rostain (see below).  
      The conference will be held in Atlanta this year, Nov. 11-13.  I cannot overemphasize the wealth of knowledge, validation, and support to be gained at this conference. If there's a possibility that you can attend, try your hardest to get there!  Sign up by September 15, and receive the early-bird discount!   --Gina Pera

By J. Russell Ramsay, Ph.D.

Circus elephants are trained while secured with ropes until they are subdued. Trainers then teach them to perform tricks for audiences without the use of restraints. No less powerful than when they were in the wild, these elephants are held back by the invisible ropes of their training.
      Growing up with ADHD, particularly when it has gone undiagnosed until adulthood, makes it very likely that adults with ADHD have encountered their own “ropes” in life, such as academic trauma, ongoing troubles handling the demands of daily life, or hurtful criticisms made by others. Although their circumstances may change in their adult lives, these experiences may have trained them to hold negative attitudes about themselves and their future.
      These negative attitudes, and the emotions and behaviors they bring about, are a central focus of cognitive-behavioral therapy (CBT) for adult ADHD.
      CBT was originally developed as a treatment for depression and has grown to be one of the best researched forms of psychotherapy and has emerged as the psychosocial treatment of choice for adult ADHD. CBT focuses on how we make sense of the world around us via the thought we have and the beliefs we hold.
      Negative thinking does not “cause” ADHD, but negative attitudes may create a general atmosphere of pessimism that interferes with follow through on the essential coping strategies needed to cope with ADHD. Even though changing behavior patterns is the ultimate goal of CBT for adult ADHD, focusing on attitudes is a crucial element of the process. Wht follows are descriptions of some common negative thought patterns heard from adults with ADHD.

Comparative Thinking: "I'm Not As ______ As"

Comparative thinking is a very common negative thought among adults with ADHD. Self-worth is based on how well (or poorly) a person matches up with others. Of course, being diagnosed with ADHD means the person might have to handle things differently than others do in some important ways. For example, Jane is a 46-year-old married woman with ADHD trying to balance work and family who commonly has the following comparative thoughts:
  1.  “I’m not a physically fit as Mary.” (Mary is her 29-year-old, single neighbor with no children who goes to the gym two hours each day.)
  2. “I am not as smart as my co-worker, David.” (Although Jane gets good evaluations at work, she processes information more slowly than David does.)
  3.  “My front yard is plain. The neighbors’ yards have colorful flowers.” (Jane has enough difficulty managing her affairs at work and at home without taking on a time- and labor-intensive project she does not really enjoy.)

Overgeneralization: All Or Nothing

The negative thought of overgeneralization refers to taking a single mistake and using it as evidence of a major character flaw that contaminates all areas of one’s life. For example, Joe forgot to pick up his wife’s dry cleaning, including the outfit she need for an important business meeting the next morning. “I really screwed up,” he thought. 
      What’s worse, he then started thinking of ways he was a “lousy husband” and, now that he thinks of it, he “must be a lousy father, too.” He started feeling down, did not exercise, and procrastinated on some paperwork he needed for work because he was too emotionally distracted. Joe certainly made a mistake, but the punishment imposed by his negative thoughts and his subsequent reactions far exceeded the evidence of his error.

"Should" Statements

A third common thinking error involves “should statements:” very strict, often unrealistic standards for personal performance. For example, Michael entered CBT after being recently diagnosed with ADHD. He made slow, steady progress over the first several sessions and was learning a lot about himself and ADHD. He showed up for his next session and made the shocking announcement that he was quitting therapy. He was frustrated after suffering some setbacks that week regarding some coping strategies he had been practicing. 
      We identified that his expectation for CBT was that he “should” be able to cure himself and not have any more ADHD-related difficulties. Thus, at the first sign of difficulty, he concluded he had failed therapy.
Loosing the Ropes 

Changing negative attitudes is hard work for adults with ADHD because these sorts of attitudes are often the end result of a lifetime’s worth of frustrations and heartache stemming from undiagnosed or under-treated ADHD. To catch these attitudes in action requires people to ask themselves, “What thoughts are going through my mind?” when facing problems or challenging situations in which they are trying to implement new coping skills. Considering the following questions can help to develop more constructive outlooks:

  1. If my best friend (particularly one with ADHD) had this thought, would I hold him or her to the same standards to which I am holding myself?
  2. On what evidence am I basing my thoughts? If I had a defense attorney, how would she or he defend me and then make a case in my favor?
  3. Is there another way to look at things? Am I ignoring any information? What could be the effect of changing my attitude now?
  4. CBT is not the power of positive thinking. It helps adults with ADHD to have more balanced thinking in order to be more resilient in their use of effective coping skills and, by doing so, to throw off the invisible ropes of negative attitudes.

Associate Professor of Clinical Psychology in Psychiatry
University of Pennsylvania School of Medicine

Note: The current article is a slightly modified version of an article first published as:
Ramsay, J. R. (2005). Cognitive behavioral therapy: The invisible ropes of adult AD/HD. Focus, Spring, 12.

For more information on comprehensive treatment of ADHD based on specific adaptations of traditional cognitive-behavioral-therapy read Cognitive-Behavioral Therapy for Adult ADHD, by
Ramsay and Anthony Rostain, MD, MS, co-director of UPenn's ADHD Treatment and Research Program.


  1. WOW...thank you for posting this, Gina!!! I know ALL about those "invisible ropes," everything except what to do about 'em. This is the first I've heard of CBT (ADD-specific or not) and it definitely sounds like something I should look into.

  2. Hi Raksha,

    I'm glad you enjoyed Dr. Ramsay's article. He knows this territory very well!


  3. The article sounds like it could be good -- but I just couldn't get past the invocations of cruelty in the accompanying photos. Even the "happy ending" photo is an elephant in a zoo - away from the vibrant social network of its kind. I would hope that my learning skills to hone my attention is not the same thing as internalizing the "ropes" and chains of the circus ringmaster. Metaphors matter.

  4. Sorry to hear that, Anonymous. It's good information.

    Maybe I should remove those three small photos; maybe it is too much.

    Then again, some people respond best to images, especially when they capture how they feel inside. When left unrecognized, ADHD can be cruel, too.

  5. I think this could be very helpfull in understanding the impact of psychologigal factors contributing to our cognitive behavior. The last sentences of my nueropsycholocigal evaluation a few yrs.ago> The patients self report inventory was similar to those patients who have limited insight of the impact of psychological factors...etc. Such patients typically are resistant to psychological interpretations to their problems. I've learned allot since then.

  6. This is a really helpful article, Gina! I see my family members who become "stuck" when an ADHD-related incident occurs. I do the best I can to provide other perspectives, but sometimes they think I'm just "saying that to be nice". It would be so much more meaningful if they could consider things from a much more balanced perspective themselves. I know they can't be totally objective; nobody can about their own life. I think the questions at the end of your post are very valuable. I'm looking forward to next month's blog!

  7. Thanks Marie. I'm glad you liked it.

    I am a fan of the work of Drs. Ramsay and Rostain, and was grateful to be able to share Dr. Ramsay's article with this blog's readers.

    There are many "experts" opining about ADHD, and it's really important to be selective.

  8. Hi Scott,

    You are a LEARNER, that's for sure! A veritable sponge! :-)


  9. I agree totally that cognitive behavioral therapy is one of the best treatments available nowadays. But it is always good to go for the best treatment possible. Some patients get well with just CBT while others with a combination of CBT and medication. But above all else, what they need is a strong support system from family and friends. Thanks a lot for this post.

  10. Hi there,

    Thanks for visiting.

    Just to be clear for this blog's readers: "straight" CBT that does not take into account ADHD's neurobiological underpinnings is not advised by Dr. Ramsay. It's CBT that incorporates a special focus on ADHD that has been shown helpful.


  11. Very interesting post...I think the part that has impacted me the most though, is those elephant photos. They're nauseating.

    As for therapy...I've certainly encountered this kind of "balancing of thinking" in my therapy experiences. One thing my therapist tells me to think about: "radical acceptance". She knows I spend a lot of time weighting my thinking in certain directions...so she asks me to counter that thinking, in those situations, with radical acceptance of the situation instead of wasting time analizing certain things. Very useful...and the more I do it, the easier it is.

    Still stuck on the elephant pics though...sigh...

  12. Okay, Katy, now that you've also weighed in, I'll delete all of the small pix (I already deleted one after the first commenter complained).

    But I'm thinking this is also a good topic for discussion in the future -- the hard time some pwADHD have in "tuning out" one thing in order to get to the larger thing. Filtering out.

    Maybe it also ties in with the topic of "emotional dysregulation" that's too-little talked about. It can be all-too-easy for some people with ADHD to downspiral into negativity or the opposite (over-optimism). In fact, I think this is one of the key reasons that ADHD is sometimes misdiagnosed as bi-polar disorder -- because of the extreme "in-the-moment" reactions to things positive or negative.

    This emotional reactivity often means that the person loses sight of the larger goals or issues.

    And yes, I know that people who do NOT have ADHD have their own issues. I have a best friend who is so "even-keeled" I suspect she might wait until the third hour of a three-hour visit to reveal to me that she'd won $100 million in a lottery (if she ever played, which is doubtful). And she would introduce it as just another tidbit of news. :-)

  13. Excellent post. I can relate to all those different trains of thought, especially the comparing and should thoughts. I really know much about CBT. I had bought a workbook on managing adult ADHD, not realizing that it should be used in conjunction with one's therapist. When I have my next appointment with my therapist I will bring the book, and see if it's something she can help me with.

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  15. Hi folks,

    @CBT -- One more thing..... Yes, most people will not be able to find a therapist who specializes in this kind of CBT for ADHD.

    I wanted to share the principles behind it, though, so that both consumers and therapists know what is truly helpful when dealing with the common "emotional baggage" to late-diagnosis ADHD. Some people will buy a few books for a therapist with whom they have rapport and trust. Or the therapist will study up independently.

    The important thing is both therapist and client giving the neurological underpinnings and late-diagnosis issues their due.

  16. Hi Polly,

    Yes, that's the idea! You're probably talking about "Mastering Your Adult ADHD" by Steve Safren? He is another researcher who has studied ADHD-focused CBT strategies.

  17. Upon a re-read, I can also see myself in the "Overgeneralization" portion. My initial reaction in my head usually involves ridiculous overgeneralizing of some kind. I am aware of it thought and often, when I feel myself reacting in that way, take it as a sign that I should wait to officially weigh in on a subject, until after I have taken the time to balance my cognitive baggage load on the issue...

    There has been a lot of chatter lately it seems about ADHD and CBT, it will be interesting to see if it continues to be seen as a helpful tool...

  18. Excellent article. CBT is a very effective therapy for adults coping not only with ADHD symptoms but also the frustrations, low self esteem and in many cases co-morbidities such as anxiety and depression that can develop with a late diagnosis of ADHD.
    And yes, ADHDers are challenged with issues of emotion dysregulation, and on that point, aspects of dialectical behavior therapy DBT can be useful: mindfulness meditation improves focus, self-monitoring and regulation and reduces rumination and other negative thought patterns because the mindful person is "in the moment," taking cues and evidence from their immediate environment rather than lapsing back into habitual distorted self-undermining assumptions and thought patterns. (I recommend mindfulness ala Jon Kabat Zinn or the work of Dr Lidia Zylowska (sp?) in LA.)
    The emotion regulation skills taught in DBT provide adults with ADHD a great framework for building assertiveness, a stronger sense of core values and motivation to follow through with commitments, engendering greater self-respect.
    DBT distress tolerance and mindfulness skills also are helpful tools for dealing with co-existing anxiety and depression.
    By the way, the blog post was so interesting I completely ignored the elephants altogether...

  19. Katy

    I can't imagine CBT/ADHD not continuing to be a useful tool. It's so foundational, at least for the late-diagnosis adult with ADHD, and makes so much practical sense.


    Thanks for that info. I'm a fan of Mindfulness Meditation, too.

    I'm less familiar with DBT, though I know it's often used in treating Borderline Personality Disorder (which some say is associated with ADHD that is undiagnosed in childhood and particularly exacerbated by trauma).

  20. I've heard a lot about Mindfulness Meditation but it's only started working for me when I got medicated. CBT looks promising but it's also irritating when those who implement it KNOW I have ADHD and when it doesn't work out, accuse of me not wanting to help myself.

  21. Hi Akania,

    Remember....it's CBT FOR ADHD. The standard CBT is NOT recommended for ADHD, says Dr. Ramsay. And for the very reason you describe -- because it doesn't factor in ADHD's neurobiological underpinnings. Best to stay away from any therapist who doesn't understand this about ADHD.

    I love Mindfulness Meditation, but I could see how many people with ADHD wouldn't find it helpful without medication on board. That's why when people say "Meditation or Medication?" I say sometimes both!


  22. Gina, I'm new to your blog. I believe a psychiatrist at Mt. Sinai Hospital in NYC is creating a CBT for ADHD group. I cannot remember her name but I was browsing the NYC ADHD group and it was mentioned. CBT is considered a "gold standard" of therapy.....but there are not a lot of clinically trained CBT providers.

  23. Hi JZ,

    Thanks for stopping in. Yes, psychologist Mary Solanto has done some research into CBT/ADHD effectiveness. Maybe she is starting such a group.

    At any rate. thanks for letting us know of such a group. Indeed they are hard to come by!


  24. I am very excited about this article. I recently got re-diagnosed as an adult with ADHD. I can't wait to find out if my therapist does CBT/ADHD. If not, i will deffinitly be buying this book.

    I think that understanding and researching this illness, makes a vast improvement on your outlook of the results. Dr.Russell Barkley really made a huge impact on my understanding of ADHD. It really makes sense that ADD is very different than ADHD. HE said that ADHD should be called Intention Deficit Disorder. This makes complete sense to me!

    I also fealt i was not ADHD because i was not physically hyper. I had no idea that there was such a thing as (what Dr. Barkley describes as) internally hyperactive. I thought perhaps I was just ADD. He talks about them not sharing the same symptoms, and they really don't! I was astonished to find my symptoms so perfectly put into words by someone else. Especially the impulse control and flashes of instant red-hot anger.
    I finally had that feeling of "someone finally understands me"
    Now that I have a greater understanding of this illness, i feel that i have regained a bit more control of my life.
    Thank you for posting this. I look forward to your next tid-bit :)

    1. Hi "more patient mother,"

      I'm glad you found the post helpful. Indeed, these two Drs. Russell -- Barkley and Ramsay -- have contributed a great deal to understanding ADHD and its treatment strategies. We are so lucky to have them.



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