Cognitive Behavioral Therapy, Invisible Fences, and Adult ADHD
by J. Russell Ramsay, PhD
WHEN TRAVELING THROUGH A RESIDENTIAL NEIGHBORHOOD it is not uncommon to see tell-tale signs of “invisible fences” used to keep dogs within the boundaries of their owners’ property. Visual cues (such as flags) mark the border and a “correction sensation” (a mild shock, reportedly akin to a static shock) train a dog to stay in the yard or, more specifically, that crossing the marked boundary is associated with an aversive physical experience. Once sufficiently trained, a dog will likely not test the system, having learned that venturing too far results in discomfort. Hence, even if the system delivering the shock is dismantled, the dog will be bound to the yard by this lesson unless it has the chance to “unlearn” its original training.
The notion of the “invisible fence” often elicits smiles and a few jokes, but the training process is firmly grounded in behavioral principles. Learning by the associations and contingencies (both reinforcements and punishments) encountered in life is a powerful form of “training” that we all undergo. Along the way, we figure out the “rules” of the world as well as our personal attitudes and beliefs about ourselves based on our experiences and vicarious observations of the experiences of others.
For adults with ADHD, experiences in school, work, relationships, and the myriad life situations that require good self-control to manage are often associated with various degrees of frustration, confusion, or disappointment. What is more, these frustrations may be magnified by the external and objective consequences of ADHD, such as recurring fines for overdue bill payments, low grades at school or poor performance reviews at work, as well as criticisms expressed by others. When these sorts of setbacks occur in isolation, they can be viewed as one-off mistakes or misjudgments that do not diminish one’s self-image. However, someone with ADHD who experiences regular “shocks” and in a variety of life domains may find it harder to view them as being unconnected. An “invisible fence” of negative thoughts, pessimism, and eroded sense of self-worth may develop. Similar to the dog within the yard, individuals learn to avoid situations that are viewed as being ripe for disappointment and failure, thereby limiting one’s options. These outlooks may be even more cemented for individuals who were not aware of the effects of ADHD, therefore being left to conclude that their repeated difficulties in life are evidence of an inherent character flaw.
Impaired executive functions
None of this is to suggest that ADHD is the result of “poor training,” “poor parenting,” or that people “negatively think” their way into ADHD. ADHD is understood as a developmental disorder of impaired executive functions. Drawing on the work of Russell Barkley, PhD, executive functions can be thought of as those behaviors that people use to help themselves organize and follow through on a plan that will improve their overall well-being in the future in the absence of an immediate payoff or perhaps even incurring a relatively mild inconvenience in the short-term. Rather than setting up fences, the executive functions allow people to set up guideposts, directing them to stay on track for personally relevant goals, such as tasks as routine as paying a monthly bill on time to those as inspiring as completing an academic program. The ability to stay focused on and to complete long-term projects or to keep up with obligations is commonly viewed as evidence of “good character” and “being responsible.”
It has been well documented that ADHD is associated with impairments in most domains of adult life, which makes sense considering that executive functioning problems will interfere with the ability to efficiently manage many “adult responsibilities.” Consequently, it can be assumed that the “training” of many of these individuals was replete with many “shocks” and setbacks, such as academic difficulties (sometimes bordering on being experienced as “traumatic”), repeated criticisms from others, and simply working harder than others to manage the typical demands of life—often with less productive outcomes despite the effort. Consequently, it is easy to see how individuals with ADHD arrive at the conclusion that their difficulties reflect a “character flaw” or “laziness” rather than being characteristics of a serious (though treatable) neurodevelopmental syndrome.
Although not a causal factor in the onset of ADHD, focusing on these negative outlooks and attitudes is an important component in the treatment for adult ADHD, particularly in Cognitive Behavioral Therapy. CBT is a form of psychotherapy originally developed as a psychosocial treatment for depression. Although the CBT model emphasizes the interplay of cognitions (i.e., thoughts, beliefs, images), emotions, and behaviors, the focus on the cognitions, or the interpretation of an event, serves as a useful entry point into an individual’s experience and as a first step in promoting change.
So, if ADHD is not the result of negative thinking, what is the importance of focusing on these thoughts in treatment? It is true that it is the “B” in CBT—behavioral change—that is the primary emphasis in the treatment of adult ADHD. The aim of various CBT-related treatment approaches for adult ADHD is to help individuals consistently implement skills and strategies to improve time management, organization, and planning and follow-through on tasks, as a means to compensate for executive functioning deficits in these areas. The specific coping strategies are usually familiar to individuals with ADHD, but the target of CBT is the consistent implementation of the strategies in daily life.
A common barrier to follow-through on coping strategies comes in the form of negative thoughts. For example, instituting a daily planner is a common first step in most CBT approaches for adult ADHD. However, this suggestion is often met with reactions, such as, “I’ve tried this before and it does not work for me,” “I put things in my cell phone but I still miss meetings,” or “I do not want to have to write down every single thing I have to do,” with each of these thoughts reducing the likelihood of using a planner. Further exploration of the basis for these thoughts or the “evidence” for these conclusions may reveal that, rather than a planner “not working,” the person often forgot to bring or misplaced the planner. Likewise, it turned out that the person who entered scheduled meetings in her cell phone did not did not use the alarm feature or regularly review her schedule each day for reminders—having the appointment in the cell phone that is in the pocket is the same as having the treadmill in the basement while the owner is upstairs. Finally, the person who was resistant to writing things down described feeling embarrassed to do so, concerned that he would appear “stupid” to others if he needed to record detailed reminders. Hence, his automatic reaction to an otherwise effective coping task was that, not only would it not work, it would result in his all too familiar experience of being “different” and “inadequate.”
As can be seen above, distorted negative thoughts can interfere with coping if not identified and challenged. This is not to say that positive thinking is the answer—gamblers represent a group of extremely positive thinkers. In fact, an excessive “positive bias” may be an issue for many individuals with ADHD insofar as it might undermine steps individuals can take to manage situations (for example, “It will all work out for the best, somehow”). The goal is to be able to recognize and assess automatic thoughts and conclusions in order to achieve balanced thinking.
The earlier example of the man worried about appearing “inadequate” when using a planner illustrates another benefit of paying attention to cognitions: managing emotions. One of the lesser appreciated executive functions and, therefore, a lesser appreciated aspect of ADHD, is the role of emotional regulation. Although the reported cognition related to using a planner focused on the notion that the individual would come across to others as incompetent, this reaction was associated with the emotional responses of embarrassment, low level anxiety, and shame. It is increasingly recognized that individuals with ADHD have greater difficulties effectively managing the typical emotional reactions encountered in day-to-day life. Thus, relatively minor frustrations will be more disruptive to an individual with ADHD, resulting in greater inward demoralization or outward expressions of emotions, often followed minutes later with the rhetorical question, “Why did I let that upset me so much?” On the other hand, there may be difficulties encountered with unbridled optimism or impulsive compliance that can lead to over-commitment at work or in one’s personal life (“Sure, I would love to organize that committee!”).
A focus on cognitions is a useful starting point to help individuals identify and disentangle their emotional reactions from the complex and rapid cascade of events, reactions, and predispositions that influence one’s experiences. In some situations there may not be reactive thoughts that are viewed as the culprit, such as in cases of impulsivity—defined as acting without forethought. Even so, adults with ADHD can learn to recognize their “risk factors” for impulsivity and make decisions and preparations that may pre-empt later frustrations (for example, “The line at the coffee shop is always long and slow moving first thing in the morning. Rather than setting myself up to be frustrated, I will go to the office first to arrive on time and will get coffee a little later.”).
Emotional management also involves “motivation.” Using the executive function view of ADHD, motivation is the ability to generate emotions about a task that promote follow-through. This definition provides the answer to the rhetorical question asked by most adults with ADHD: “Why do I always wait until the last minute to get things done?” In addition to having difficulties generating emotions that help someone with ADHD to engage in a task, there are likely many “barrier thoughts” that dampen the likelihood of activation (for example, “This is going to be difficult. I’m not good at this. It is pointless to even start.”). Again, these thoughts may be rooted in past frustrations. The insidious nature of negative thoughts is that they reactivate negative emotions, often leading to procrastination or other maladaptive patterns that end up seemingly reinforcing the negative thoughts, akin to a self-fulfilling prophecy. What is worse, with enough repetitions, these frustrating experiences and cognitions fuse into overarching negative core beliefs about oneself that create the ultimate invisible fence, leading individuals to give up on attempting reasonable pursuits in their lives.
Although the specific negative thoughts reported by adults with ADHD have not been studied in a systematic way, clinicians may observe some consistent themes. The specific categories may overlap insofar as different distorted thoughts may share some characteristics, but it can be beneficial to identify how thoughts can go askew. The following distorted thoughts represent some of the common issues that are relevant for the treatment of adult ADHD.
Comparative thinking. There is a natural human tendency to use comparisons with others as a means for judging one’s standing on a particular attribute, such as height, athletic or musical skill, or proclivity for an academic subject. However, taken too far, these sorts of comparisons may be used as an unfair and inherently biased measure of one’s self-worth. What is more, comparisons with others may interfere with one’s enjoyment of an activity (e.g., “History was not my best subject in school but I enjoy reading about it.”).
As was noted earlier, adults with ADHD have greater difficulties related to the executive functions and will likely require extra and/or different steps than their non-ADHD peers to cope with matters, such as time management; hence the consistent use of a daily planner is strongly recommended as a foundational coping step. However, if the adult with ADHD has the thought, “I do not see my co-workers carrying around their planners everywhere and referring to them throughout the day. I should be able to cope the way my peers do,” he is less likely to use it. There is likely the unspoken concern about appearing different and, more specifically, “flawed.” The individual may be so self-conscious about using the planner that he does not notice how diligently his colleagues actually use some sort of organizational system, not to mention the fact that whole aisles in office supply stores are devoted to paper and electronic planning systems, indicating their widespread use. The final consideration is whether the coping skill will make life easier for the individual.
Overgeneralization. The distorted thought of “overgeneralization” involves taking a single mistake and blowing its significance out of proportion. It does not mean that a mistake did not occur; rather, an individual’s reaction takes a problem and amplifies it into evidence of a major character flaw. For example, a woman with ADHD forgot to pay her credit card bill and received (yet another) late fee. Her disappointment at this mistake was understandable and her initial thought, “I messed up again and lost track of this bill,” was not distorted. However, her reaction to this setback mushroomed into conclusions that she is incompetent to handle the demands of life, has no hope for a stable career, and should abandon hope of ever being able to be a desirable partner in a relationship. What is more, she also skipped her exercise plan and was unable to focus on running some errands for herself, thereby increasing her task load for the next day. There was certainly the issue of disorganization around paying bills that needed to be addressed. However, her reaction was out of proportion to the problem itself.
Magnification/Minimization. This distortion tandem often contributes to procrastination and other difficulties with follow-through on challenging tasks, particularly those that require sustained effort across several work blocks, such as writing a paper for school, doing a project for work, home improvement task, etc. When planning to work on the task, the difficulty of the task is “magnified” (e.g., “This is going to be hard. I’m going to have to spend all day on this. I really have to be in the right mood to work on this. This will take a long time to figure out.”) as are, consequently, negative emotions associated with the task. However, the consequences for delaying the task are minimized in the form of rationalizations for avoidance (e.g., “I have plenty of time to work on this. I’ll wait until I am in the mood to work on it. I work best at the last minute.”). What also is minimized are the positive qualities of the individual and adaptive possibilities that increase the likelihood of success (e.g., “I usually get into the project after I get started. I can get a lot done in an hour and still have the rest of the day for other things. It will feel good to make some headway.”). A common scenario is that the task is completed under the duress of a looming deadline or, in the case of a project without an external deadline, it simply gets put off—again.
Changing negative attitudes
Changing negative attitudes is hard work because these sorts of distorted thoughts and beliefs are often the end result of a lifetime’s worth of frustrations and heartache stemming from undiagnosed or untreated ADHD. Moreover, the “evidence” in one’s life on which these negative outlooks are based may seem incontrovertible, though this evidence often does not support the magnitude of conclusions that are reached and may ignore evidence of good coping. However, these negative conclusions can feel as though they represent an open-and-shut case made by an unrelenting prosecuting attorney.
To catch these attitudes in action requires people to ask themselves, “What thoughts are going through my mind?” The evidence for the negative thoughts must be considered through the eyes of an assiduous “defense attorney” whose job is to ensure that your rights and well-being are protected. The following questions can help to develop more constructive outlooks:
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? How would I advise her/him?
On what evidence am I basing my thoughts? How would my defense attorney defend me and then make a case in my favor?
Is there another way to look at things? Am I ignoring any information? What could be the effect of changing my attitude?
Can I accept a degree of imperfection and discomfort in order to take steps to better manage ADHD? Do tasks usually end up being as bad as I think they will be?
What steps can I take to change my situation? What is the smallest first step to which I can commit? What are the skills that I possess that I may be underestimating?
In conclusion, CBT is not the power of positive thinking. It is a psychosocial treatment that helps adults with ADHD to have more balanced thinking in order to be more resilient and consistent in their use of effective coping skills. Although the primary source of change comes through the felt experience of making behavior changes and seeing positive results, being able to develop more constructive outlooks can help adults with ADHD take steps outside the invisible fences of their past experiences and explore new fields of opportunities.
J. Russell Ramsay, PhD, is a licensed psychologist and associate professor of clinical psychology in psychiatry at the Perelman School of Medicine at the University of Pennsylvania. He is the codirector of PENN’s Adult ADHD Treatment and Research Program. He is the coauthor of Cognitive Behavioral Therapy for Adult ADHD: An Integrative Psychosocial and Medical Approach (Routledge, 2007) and the author of Nonmedication Treatments for Adult ADHD (American Psychological Association, 2010). He serves on the professional advisory board of the Bucks County, Pennsylvania chapter of CHADD.
This article originally appeared in the December 2011 issue of Attention magazine, copyright © 2011 by Children and Adults with Attention Deficit/Hyperactivity Disorder (CHADD). All rights reserved. No portion of this article may be reprinted without written permission from CHADD.