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.

Author:
J. Russell Ramsay, Ph.D.

Associate Professor of Clinical Psychology in Psychiatry

Associate Director, ADHD Treatment and Research Program 

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.