Mastering Your Adult ADHD
Mastering Your Adult ADHD
T R E AT M E N T S T H A T W O R K
Editor-In-Chief
Jack M. Gorman, MD
T R E AT M E N T S T H AT W O R K
Mastering Your
Adult ADHD
A Cognitive-Behavioral Treatment Program
Second Edition
THERAPIST GUIDE
STEVEN A . SAFREN
SUSAN E. SPRICH
CAROL A . PERLMAN
M I C H A E L W. O T T O
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About T R E AT M E N T S T H A T W O R K
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References
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Contents
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References 141
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■ Impairments in attention
■ Impairments in inhibition
■ Impairments in self-regulation
These core symptoms yield associated impairments in major
life activities such as educational activities and occupational
functioning (e.g., trouble with organization and planning, be-
coming easily bored, deficient sustained attention for reading
and paperwork, procrastination, poor time management, im-
pulsive decision making), impaired interpersonal skills (prob-
lems with friendships, poor follow-through on commitments,
poor listening skills, difficulty with intimate relationships), and
other adaptive behavior problems (less educated compared to
ability, poor financial management, trouble organizing one’s
home, chaotic routine, leaving jobs or relationships even when
they are going well). Additionally, research suggests that adults
with ADHD have an elevated risk for substance abuse and en-
gagement in risky behaviors, including risky driving and risky
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Some of the symptoms listed above sound like they might apply
to almost anyone at certain times. For example, most people
would probably say that they are sometimes easily distracted or
sometimes have problems organizing. This is actually the case
with many of the psychiatric disorders. For example, everyone
gets sad sometimes, but not everyone suffers from a clinical di-
agnosis of depression. To consider ADHD a diagnosis for any
individual, that person must have significant difficulties with
some aspect of his or her life such as work, school, or relation-
ships. In DSM-5, there is more attention to impairment spe-
cific to adults, such as impairment in work situations.
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Distractibility
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Core
(Neuropsychiatric)
Impairments in
Attention
Inhibition
History of Self-Regulation Failure to Utilize
Failure (impulsivity) Compensatory Strategies
Underachievement –examples:
Relationship problems Organizing
Planning (i.e., task
list)
Managing
procrastination,
Mood avoidance,
Negative thoughts and Disturbance
beliefs (e.g., negative distractibility
Depression
self-statements, low
Guilt
self-esteem)
Anxiety
Anger
Functional
Impairment
Figure 1
Cognitive-behavioral model of adult ADHD.
Reprinted from S. A. Safren, S. Sprich, S. Chulvick, & M. W. Otto (2004). Psychosocial treatments for adults
with ADHD. Psychiatric Clinics of North America, 27(2), 349– 360, © 2004 Elsevier Inc., with permission from
Elsevier.
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Role of Medications
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Outline of Modules
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Managing Distractibility
■ Positive “self-coaching”
■ Learning how to identify and dispute negative, overly posi-
tive, and/or unhelpful thoughts
■ Learning how to look at situations rationally, and therefore
make rational choices about the best possible solutions
Application to Procrastination
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Structure of Sessions
Setting an Agenda
Monitoring of Progress
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Motivation Is Key
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T: Okay. So the first thing that we are going to do is help you or-
ganize where you need to be and when, as well as keep track
of your tasks. We’ ll need to come up with a good system for this
that we can continue to tweak as we go along. (TELL) How
does that sound? (ASK)
C: I think that would be useful. I have tried things like this in the
past but do think I could get back into this kind of thing.
Using a motivational interviewing framework as much as
possible brings the process of change as a product of the cli-
ent’s own desires, versus those of the therapist. Accordingly,
throughout the treatment, you should try to elicit verbaliza-
tions about change and help clients see the solutions rather
than prematurely solving problems for them, which would not
be as effective as having clients be more actively involved in the
treatment process (see Naar-King & Safren, 2016).
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MODULE 1
Psychoeducation,
Organizing, and
Planning
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Psychoeducation
SESSION 1 and Introduction to
Organization and Planning
(Corresponds with Chapters 1, 2, and 4 of the Client Workbook)
SESSION OUTLINE
■ Set agenda.
■ Provide information about ADHD.
■ Determine client’s goals for CBT for ADHD.
■ Discuss the structure of the sessions.
■ Explain modular format (some difficult areas will not be addressed
until future sessions).
■ Help client problem-solve potential difficulties with the treatment
itself.
■ Review motivation for change.
■ Discuss use of medications to treat ADHD.
■ Introduce the calendar and task list systems.
■ Discuss involvement of a significant other in treatment.
■ Identify potential pitfalls.
■ Assign home practice assignments.
■ Case vignette
Set Agenda
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For this session, the agenda involves providing an overview of the treat-
ment and psychoeducational information about ADHD, doing a moti-
vational exercise, and assigning homework.
You should provide information about the ADHD diagnosis here. This
involves a discussion of our view of ADHD in adulthood. Important
points to emphasize include the following:
■ It is a neurobiological disorder.
■ It is a valid diagnosis.
■ It is not related to laziness or lack of intelligence.
■ Evidence suggests that this type of structured approach can help
with symptoms.
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Check in with the client with questions such as, “How does this
sound?” and “What questions do you have?” You should also say some-
thing like this:
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Some clients doing CBT expect that their improvement will be linear.
For example, they expect that their symptoms will decrease by 10%
each week for 10 weeks, and then will be 100% improved. However,
this is rarely the case. Typically there are ups and downs along the
way—life events occur and skills take time to practice and master.
When there is a “down,” this is definitely not a time to quit; rather, it’s
a time to learn from the factors that led to the setback, and figure out
how to handle them in the future. This is extremely important with re-
spect to managing expectations. Setbacks that occur during treatment
can be viewed as important to treatment planning—they identify areas
that can be targeted for additional problem-solving and the develop-
ment of coping skills.
Discuss any potential problems with the approach, and plan how you
will address such problems. Emphasize that some of these skills may be
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familiar to the client, but they work only if they are continually used.
Therefore, for certain modules, the goal may be to start or restart using
these skills consistently in order to lay the groundwork for future mod-
ules and to lead to better functioning.
Discuss a Plan for Refocusing When You Think the Session May
Be Going Off Topic
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We discuss this upfront with clients so that they can agree with this
plan and not take this refocusing personally. Some potential aids may
include the following:
1. Ask the client to give you permission to use a hand signal when it’s
time to refocus.
2. Say to the client, “This is one of those times when I’m now going to
interrupt.”
3. Discuss ways that the client can communicate the need to take
a break.
4. Remind the client of how much more time is required and what fur-
ther topics need addressing.
Clients who are not taking medication for ADHD can still do this treat-
ment, but typically ADHD in adulthood is treated with medications. The
goal of therapy is to help clients function at their best level, using medica-
tions and the skills from this therapy. Discuss the idea that the medica-
tions can help the client actually achieve goals of behavioral therapy. If
you have not already done so, discuss the client’s current medications,
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Here we introduce the use of the task list and calendar systems. Because
these provide the essential foundation for systems the client will develop
throughout the treatment, it is critical to spend enough time on this
section so that client understands the rationale for these systems and is
ready to create her own system. Stress the importance of having a calen-
dar for appointments and explain that the rationale for the task list is to
record daily and overall goals by importance. As part of this discussion,
ask the client about past attempts at using organizational systems. Work
with the client to resolve any difficulties he or she had.
Next, try to come up with the best organizational system for the client
to start or restart using. The organizational system must have a calendar
and a task list. The discussion should focus on finding a single system
that is feasible for the client to start using. Some clients spend so much
time trying new systems that they never have a chance to make one
system work. There is no perfect system. Encourage clients to choose
one and commit to using it for three months. At that time they may
make a change if needed.
There are many systems that are available for use on smartphones, tab-
lets, computers, and laptops. We will not list specific brands or apps in
this book as the specific systems change and new options are becoming
available on a daily basis. The first goal is for the client to have a way of
keeping track of appointments so that one look at the calendar for the
day, week, or month will reveal all appointments. The second goal is for
the client to have a single system for keeping track of tasks, and to min-
imize the fear that there are unknown tasks to be addressed.
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If the client does not already have a workable calendar and task list system,
creating such a system is the principal home practice assignment for the
next session. Remind the client to bring a way of looking at the system to
every session as it will be used in most sessions. From this point forward,
the client should put ALL appointments on the calendar. If using an elec-
tronic system, the client should enter the appointment at the time that it
is made and should also set a reminder for the appointment as it is being
entered. You may need to discuss and resolve any concerns a client may
have about this. Many clients are reluctant to make others wait while
they enter an appointment or find their calendar to discuss a meeting
date. Assist clients in identifying and resolving these concerns.
The client should also begin to keep a master task list. Any task that
must be completed should be written in this list. The idea is to elimi-
nate the use of all alternative systems (e.g., sticky notes, multiple lists
on paper or stored electronically). The client should look at the task list
every day. Home practice this week includes finding all appointments
and tasks that may have been recorded in other places and entering
them into the master system. All other papers should be discarded.
Over the next several months, the client will be working to develop new
skills and habits for managing ADHD. In our experience, having the
support and involvement of a family member or significant other can be
extremely helpful. This provides an opportunity for the family member
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to learn more about ADHD and the skills that are taught in this treat-
ment for ADHD. This also enables the client and family member to
discuss how ADHD has affected their relationship. Finally, this enables
the client to enlist the support of another person to aid with home prac-
tice, resolve difficulties in the household related to ADHD, and so on.
Potential Pitfalls
Practice
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Case Vignette
T: I’ve now given you an overview of CBT for ADHD. Can you imag-
ine any difficulties you may have with the treatment?
C: Well, in theory it all sounds good, but I just don’t see how it will help
me. I’ve tried all those self-help books and they never work.
T: Why do you think they don’t work?
C: I can stick with it for a week or two, and then I just go back to my
old ways.
T: That is a really good point. For most people, change is hard, and
change takes time. With ADHD, it can be especially difficult to stay
motivated long enough to let the skills sink in and really work. Has
that been the case for you?
C: Yes.
T: Okay, well, this treatment was designed with that in mind. You will
not be alone in this! I will be working very closely with you to help you
stay motivated. In addition, we have broken all the skills down into
very manageable sections, so you will learn one piece at a time. What
we have also found to be helpful is that you and I will review these
skills over and over, so it will really help them become more familiar.
In the end, it won’t take as much effort; these skills will be automatic.
How does this sound?
C: Well, I guess I need to try and see.
T: Exactly. And that is a key point here. We only want you do to skills
that actually help. If we find that one strategy does not work, after you
have tried it for enough time, you do not have to do it anymore.
C: I guess I can give it a shot. I know nothing will get better unless I try
something new.
T: Exactly! I really believe you will benefit from this treatment. It gets
easier as you go along.
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THERAPIST NOTE: This session can take place at any time between
Sessions 2 and 6. The primary goals are to provide information about
the treatment to the family member/significant other and to make sure
that he or she is going to be supportive of the client. You can use your
clinical judgment and also work around the schedule of your client’s
family member in deciding when to schedule this session.
MATERIALS NEEDED
SESSION OUTLINE
■ Set agenda.
■ Review ASRS Symptom Checklist.
■ Provide education about ADHD from Session 1.
■ Provide overview of the CBT model of the continuation of ADHD
into adulthood.
■ Solicit feedback from the family member on the client’s symptom
severity.
■ Discuss the family member’s role during client’s treatment.
■ Discuss home practice assignments.
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Set Agenda
Symptom Checklist
The goal of this portion of the session is to provide the family member
with the educational information that was presented in the previous
session. Realistically, there will not be enough time to cover the mate-
rial in its entirety. Review the sections that dispel myths about ADHD,
and introduce the cognitive-behavioral model of ADHD. Finally,
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discuss some of the techniques that will be used during treatment, such
as the task list and calendar systems. In addition, it is important to dis-
cuss the role of home practice in the client’s success with the treatment.
This may be a critical area in which the family member may be able to
provide encouragement throughout the program.
Monitoring Progress
Having the support of a family member can enhance the client’s success
in CBT. Family members can remind clients to practice skills at home
each day, can assist in identifying locations for storing important items
(from the Distractibility module— Sessions 6 and 7 of this manual),
and can provide general support and encouragement. It is important
that both the client and family member agree on acceptable ways of
providing support. For example, it may not be effective for a family
member to nag the client multiple times a day about practicing skills.
However, the client may feel that a gentle daily reminder would be
helpful. It may be useful to have a discussion with the partner/spouse
about the difficulties of finding the balance between “parenting” the
partner/spouse with ADHD and letting the individual with ADHD do
things independently (running the risk that tasks might not get com-
pleted, etc.). Similarly, it is important that couples are on the same page
when it comes to scheduling and prioritizing tasks and appointments.
In this session, the client and family member can agree upon a regu-
lar time for a weekly meeting when such things can be discussed. The
couple can also discuss things such as syncing their calendars with one
another and sending each other electronic invitations to events so that
they will be aware of the other person’s time commitments.
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Potential Difficulties
In many cases, the client’s family member is highly frustrated with the
client for reasons related to ADHD. We have had many spouses come
in on the verge of wanting to dissolve the partnership, potentially after
years of frustration. As a therapist, it will be your job to strike this
balance of encouraging the partner to provide positive social support
but not engage in continued negative social interactions (e.g., nag-
ging) that might make it more difficult for the client to achieve his or
her goals.
■ Ensuring that important events that they would do together are put
into the calendar
■ Assisting with prioritization of tasks, and, if a mutually agreed-on
important task arises, making sure that it is put on the task list
■ Helping the client find a place for important items (keys, wallet,
phone)—if these items are seen in another place, moving them
back to the designated place or alerting the client that they are out
of place
■ Providing positive feedback
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The central goal of this set of sessions is to learn tools for coping with
distractibility. This entails learning about the length of one’s attention
span and breaking tasks into steps that take that amount of time. It also
involves skills like “distractibility delay” and modifying one’s environ-
ment so that work can be done efficiently.
The central goal of this set of sessions is to learn to think more adapt-
ively about situations or tasks. This involves learning to identify one’s
thoughts, look at the relationship between thoughts and mood, identify
evidence for or against the thought, and then developing an alternative
way of thinking about the situation or task.
Potential Pitfalls
A common concern among therapists is that the client will feel vic-
timized and attacked when problematic symptoms are identified. You
should set the stage for a constructive session by acknowledging that
ADHD does not mean that a person is lazy, stupid, or weak. Rather,
individuals with ADHD must use skills and strategies to cope with
symptoms effectively. In addition, you should control the session and
should not allow the family member to rant about his or her frustra-
tions with the client. This session is an opportunity for family members
to receive education about ADHD and CBT and to help to identify
strategies for providing support for the client during treatment.
Practice
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Case Vignette
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Organization
SESSION 3
of Multiple Tasks
(Corresponds with Chapter 5 of the Client Workbook)
MATERIALS NEEDED
SESSION OUTLINE
■ Set agenda.
■ Review ASRS Symptom Checklist.
■ Review client’s use of the calendar and task list.
■ Teach client how to manage multiple tasks.
■ Teach client how to prioritize tasks.
■ Problem-solve regarding any anticipated difficulties using these
skills.
■ Assign home practice.
Set Agenda
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Signposts of Change
In this section, we will highlight the client behaviors that serve as indi-
cators that the therapy is on track and progressing well. If your client is
not exhibiting these behaviors, uncover and discuss any obstacles that
might be preventing the client from using the skills. For this session,
the signposts of change would be as follows:
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this issue, because the client cannot effectively proceed with the treat-
ment until these systems are in place.
■ Discuss any problems the client is having with using the calendar
system or with writing down and using the task list on a daily basis.
Remind the client that having a good calendar and task list system
is NECESSARY (but not sufficient) to getting organized.
■ If the client has started these systems, review the specifics. Where
will the client keep the calendar and task list? How will the client
remember to look at the calendar and task list every day? The client
should pick a time or activity that already occurs every day to link
with looking at the calendar and task list (e.g., feeding dog, having
morning coffee, brushing teeth). Stress the importance of looking
at both the calendar and the task list every day.
■ Inquire about additional steps to communicate with others (e.g.,
sharing calendar entries with a spouse or boss/coworker).
It is important for clients to have both a master list that holds all of
the tasks that the client needs to complete and a daily list of tasks that
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All tasks should remain on the master list until they have been com-
pleted. If a task on the daily list does not get completed that day, it
should be moved to the next day’s list. Many electronic systems allow
items to be assigned a particular date, and the item will automatically
move to the following day if it has not been checked off as having been
completed. This can also be done using a paper system.
Skill: Prioritizing
When clients are faced with a number of tasks that must be completed,
it is important to have a clear strategy for prioritizing which tasks are
most important so that the most important tasks get completed. A useful
strategy is to develop a system for assigning a priority rating to each task.
Prioritizing can be used on the master list to help indicate which items ought
to be moved to the daily task lists (because these items are important and
need to be attended to right away), and it can also be used within the daily
list to help clients decide how to put the daily tasks in order of importance.
Talk with clients about the fact that people often like to complete the
tasks that are easier, but less important, first. This gives the impression
of getting things accomplished, but one never makes progress toward
important goals. So it seems to work in the short-term, but actually does
not work in the long-term. By adding “A,” “B,” and “C” ratings to the
task list, clients can address this issue. Instruct clients that it works best
to list all of the tasks first, and then assign the priority ratings.
■ “A” Tasks: These are the tasks of highest importance. This means that
they must be completed in the short-term (like today or tomorrow).
■ “B” Tasks: These are tasks of lower importance; some portions of
them should be completed in the short-term but other portions may
take longer.
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■ “C” Tasks: These are the tasks of lowest importance. They may be
more attractive and easier to do but are not as important.
A goal of this session is to help the client generate a task list and then
assign a rating of “A,” “B,” or “C” to each item. Pay attention to how
many items are being assigned to each category. If clients assign all items
an “A” rating, the strategy will be less useful; only three or four items
should have an “A” rating at a given time. “A” list items may be trans-
ferred to a daily list either on a separate piece of paper or on the daily
calendar. This way the client will not be distracted and overwhelmed by
the entire list; only the “A” list items need to be viewed during the day.
Make sure that the plan is reasonable. Some days may only allow for
one “A” list item due to multiple appointments, whereas other days may
be more open and therefore more tasks can be completed. Always start
with three or four “A” items. The client can complete “B” list items if
time allows. Talk with the client about making sure that all “A” items
are completed before moving on to the “B” items, and making sure
that all “B” items are completed before moving on to the “C” items.
Emphasize the importance of sticking to this rule in order for the strat-
egy to be effective. Tell the client to use this technique every day. Clients
using a paper system should copy over the “to-do” list when the old one
becomes too messy.
Potential Pitfalls
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Practice
■ Put all appointments on the calendar and review the task list on a
daily basis.
■ Use and look at task list and calendar EVERY DAY!
■ Select items from the master list to put on the daily task list.
■ Rate each task as an “A,” “B,” or “C” task.
■ Practice doing all of the “A” tasks before the “B” tasks and all of the
“B” tasks before the “C” tasks.
■ Carry over tasks that are not completed from the previous day to
the next day’s list.
Case Vignette
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T: I think that we should probably make that one a “C.” It is the type
of attractive task that people often want to complete because it is easy
and straightforward. The problem is that you can get so busy with
these small tasks that the more important ones never get completed.
How about if you complete this one after you have completed the
more important “A” and “B” tasks?
C: Sure. That makes sense.
T: The third item is “update résumé.” What rating should we give
that one?
C: Well, I have been out of work for a couple of months, and money
is really getting tight. I should really do that soon. I just get over-
whelmed whenever I think about working on my résumé.
T: It sounds like an important task, but maybe it is too large to tackle
all at once. Can you think of a way to break off a smaller piece of
the task?
C: How about printing out my résumé and proofreading it?
T: Okay. Let’s rewrite this as “print out résumé and proofread” and
rate that one as an “A.”
C: Sounds good.
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Problem-Solving
SESSION 4 and Managing
Overwhelming Tasks
(Corresponds with Chapter 6 of the Client Workbook)
MATERIALS NEEDED
SESSION OUTLINE
■ Set agenda.
■ Review ASRS Symptom Checklist.
■ Review client’s use of the calendar, task list, and “A,” “B,” “C” pri-
ority ratings.
■ Teach client to use problem-solving to overcome difficulties with
task completion and selection of a solution to a problem.
■ Teach client how to break a large task down into small, manageable
steps.
■ Problem-solve regarding any anticipated difficulties using these
skills.
■ Assign home practice.
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Set Agenda
Signposts of Change
The client must start implementing the calendar and task list systems,
if he or she has not already done so. Individuals with ADHD may
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postpone starting to use a system because they are searching for the
“perfect system.” Using a calendar and task list, however, will be critical
for all of the sessions to come. Encourage the client to make a decision
and pick a calendar system and a task list system, even though it may
not be the cheapest option, or the best option, or so forth. You can val-
idate that it is often tempting to keep looking for a better system, but
point out that this can interfere with actually approaching the tasks on
the task list that need to be completed.
Problem-Solving Strategies
This section involves helping clients learn to recognize when they are
having difficulty completing a task or are becoming overwhelmed and
cannot figure out exactly where to start. Explain that this situation
can lead to procrastination and other problems. One way to figure out
where the following skills should be applied is to look at the client’s
task list. If there are tasks that have been on the task list for many
days, weeks, or months and have not yet been started, the following
strategies should be considered. You will be teaching two key skills: se-
lecting an action plan, and breaking down an overwhelming task into
manageable steps.
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1. Articulate the problem: Try to get the client to describe the problem
in as few words as possible— one or two sentences at the most. An
example might be “I cannot decide whether I should quit my job”
or “I cannot decide what to do about a coworker I can’t stand.” In
many cases this can be the hardest part of the entire process. Clients
tend to mix a variety of problems into one, and the goal of the ther-
apist here is to help the client articulate one single problem that can
be described in a single sentence.
2. List all possible solutions: In this column the client should try to
come up with a number of solutions—regardless of how possible they
are, what the consequences may be, or whether or not they sound out-
rageous. The idea is to generate a list of as many solutions as possible.
3. List the pros and cons of each solution: Now is the time for the
client to realistically appraise each solution. In these columns the
client should figure out what he or she really thinks would happen
if he or she selected that solution. The pros (advantages) and cons
(disadvantages) of each should be listed.
4. Rate each solution: Using the final column, the client should rate
the pros and cons of the solution on a scale from 1 to 10 (with 1
being a terrible solution and 10 being the best possible solution).
This should be done as objectively as possible.
5. Implement the best option (see next skill of breaking down prob-
lem into manageable steps): Now that the client has rated each
option on a scale of 1 to 10, each rating should be reviewed. Look
at the one that is rated the highest. Determine if this is really the
solution that the client would like to pick. If so, help the client use
the other skills he or she has learned in this treatment program
(problem-solving, organizing, task list, calendar) to implement it.
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Explain to the client that learning how to break large tasks down into
smaller, more manageable steps will increase the likelihood that he or
she will actually start (and therefore eventually complete) important
tasks. Each task on the task list should feel absolutely “do-able.” If it
doesn’t, break it down into a smaller task. Here are instructions for how
to break down large tasks into manageable steps:
1. Choose a difficult or complex task from the “to do” list (or the so-
lution you identified in the problem-solving exercise earlier in this
session).
2. List the steps that must be completed: This can be done on a piece
of paper, a whiteboard, or a note app on a phone or other elec-
tronic device. You should ask questions such as, “What is the first
thing that you would need to do to make this happen?” and “What
is next?”
3. For each step, make sure that it is manageable: Have the client ask,
“Is this something that I could realistically complete in one day?”
and “Is this something that I would want to put off doing?” If the
step itself is overwhelming, break it down into smaller steps.
4. Add each individual step to the master list.
5. Move individual steps to the daily task lists one at a time as
needed.
6. Individual tasks can be placed on the client’s calendar in specific
time slots if the client finds this helpful.
Potential Pitfalls
Clients may find that their distractibility interferes with their ability to
use these skills. Reassure clients that they will be learning additional
skills to deal with distractibility in future sessions. Emphasize the im-
portance of focusing on one set of skills at a time in order to make
progress.
Also, clients may report difficulty with rating the pros, cons, and over-
all desirability of solutions. Again, reiterate that this is a new skill and
will take lots of practice until it feels comfortable for them.
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To help the client get into the habit of using the calendar system, it
may be helpful for the two of you to “rehearse” the scenario, using
imagery. For example, you can ask a client to imagine looking at her
calendar and then ask her, “What time is it?” “Where will you be sit-
ting?” “What will be in front of you?” “Will it be silent or will you have
music playing?”
Practice
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Case Vignette
T: Let’s look at your task list and see if there is anything that needs to be
broken down into smaller steps.
C: Okay. How about this one, “organize wife’s surprise birthday party”?
T: That sounds like a good one. What are the steps that you need to take
to do that?
C: I need to decide where I want to have it.
T: What would some other steps be?
C: I need to call and make sure that the place is available on the day
I need and make a reservation.
T: Sounds good. Then what do you need to do?
C: I need to make up a guest list.
T: How are you going to let the guests know about the party?
C: I was thinking of sending out invitations. I guess I need to send out
an email or an e-vite.
T: Put each of those steps down as separate items on your list. Can you
think of any other things that you need to do?
C: I need to speak with the restaurant about the menu, buy some deco-
rations, order a cake, and buy my wife a present.
T: You can put each of those down on your list as well.
C: Now I have a long list of things to do. What do I do next?
T: You can take that list and then move things onto your daily task list.
So, what do you want to do from that list tomorrow?
C: I guess I should start by deciding where I want to have the party and
making a reservation.
T: Okay, so put those two things down on tomorrow’s task list. What do
you want to do the following day?
C: I could make up the guest list and send out the invitations.
T: Sounds good. Do you think you can finish this process for homework?
C: Yes. I feel much better now. Instead of having this huge task hanging
over my head that is overwhelming, I can see how I might actually
be able to complete it by doing a couple of small tasks each day.
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MATERIALS NEEDED
SESSION OUTLINE
■ Set agenda.
■ Review ASRS Symptom Checklist.
■ Review client’s use of the calendar, task list, and “A,” “B,” “C” pri-
ority ratings, problem-solving, and breaking down large tasks into
small steps.
■ Teach client to develop a sorting system for mail.
■ Teach client how to develop organizational systems.
■ Problem-solve regarding any anticipated difficulties using these
skills.
■ Assign home practice.
Set Agenda
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begin each session by setting an agenda. Use the session outline above
to set the agenda.
Signposts of Change
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Explain to the client that putting a structured system in place can make
this issue feel less overwhelming and more manageable. Discuss how
the process may be difficult in the short-term but in the long-term will
make things much easier. Be sure to specify the benefits of having an
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Go over Worksheet 2: Steps for Sorting Mail to help the client develop a
system for handling mail.
As part of this process, talk with the client about his current strategy for
paying bills. One common concern of individuals with ADHD is that
they don’t want to pay the bill until the last minute. Some people feel
that this will save money as they won’t lose out on the interest that their
money earns in the bank. Other people feel that they want to wait be-
cause they want to have their money longer. Others just simply procras-
tinate. Typically, people who try this end up paying bills late, incurring
fees, and losing money. Suggest that it might actually be a more effec-
tive strategy for the client to deal with bills and other household tasks
right away. We suggest that clients use the triage system two or three
times a week, and deal with each piece of mail at that time. Talk about
the benefits of the OHIO (“Only Handle It Once”) technique with the
client. Point out that the technique will need to be used with email as
well as with paper mail, as many bills will likely be delivered via email.
Automatic Payments
At this point, you can suggest that the client consider setting up au-
tomatic payments for bills that she needs to pay on a regular basis.
For example, mortgage or rent payments, car payments, and student
loan payments are typically the same amount each month and are due
on the same day each month. The client can set up a payment system
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with the bank so that a check or electronic payment is sent out auto-
matically each month. For bills that vary in amount each month, such
as credit card bills, the client could set up an automatic payment to
cover the minimum payment (so the client will not incur late charges
or damage her credit score) and then set up reminders to make addi-
tional payments.
The client also needs a system for checking bank accounts to make sure
there is enough money to cover the automatic payments. Integrating
this into the client’s calendar system might be best, so that if a client has
a large automatic payment that goes out on a specific date, he can check
his account balance around that time. Additionally, many banks offer
text messaging or email alerts when balances become too low or when a
large payment is made. Using these techniques along with the problem-
solving skills training may be useful for individual clients.
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Before coming up with systems, assess where the client is having difficul-
ties with organization; email, paperwork, computer files, or areas of the
home can be common difficulties. Ask the client about difficulties that
may be caused by the organizational problems. These issues can often
cause relationship difficulties, and as noted above, disorganization can
lead to financial difficulties in the form of wasted money on late pay-
ment fees, poor credit scores, and so forth. It is helpful to start off with
an area that is causing impairment or distress for clients, as they may be
more motivated to make changes in this area than in an area that is not
causing much distress or impairment.
Ask the client about systems she has used in the past or is currently
using. Instruct the client that the system should be used for the MOST
IMPORTANT ITEMS ONLY. Anything the client does not need
should be discarded (or deleted, in the case of electronic files). The cli-
ent’s spouse or partner can help to develop the decision rules for this.
Many individuals with ADHD tend to save items, thinking they may
need them later. Review the guidelines in Worksheet 3: Developing an
Organizational System to help the client develop a system or improve
upon a system that is already in place.
Potential Pitfalls
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Practice
Case Vignette
T: What do you think you could use as your triage center for sorting mail?
C: I could use a wire basket that I have on my desk. Right now it is filled
with a random assortment of papers, but if I cleaned it out, I could
use it as a place to put all of my mail that needs to be sorted.
T: That sounds good. What will your rules be for sorting your mail?
C: I always feel like I need to keep things just in case I might need them
in the future, but I guess that’s not always helpful.
T: So what might be a more effective rule?
C: Well, I could ask myself what is the worst thing that would happen
if I didn’t save it.
T: How would that translate into a rule?
C: I could say that if I can’t think of a reason why I am definitely going
to need the paper or anything terrible that will happen if I don’t save
it, I will throw it away.
T: Okay, though I have a feeling that you will still find everything to be
important.
C: No, that’s not true!
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MODULE 2
Reducing
Distractibility
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MATERIALS NEEDED
SESSION OUTLINE
■ Set agenda.
■ Review ASRS Symptom Checklist.
■ Review progress.
■ Review use of calendar, task list, and work from previous module.
■ Teach client to gauge his attention span and develop a plan for
breaking tasks down into steps that take that length of time.
■ Teach client to implement the distractibility delay.
■ Assign home practice.
Set Agenda
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Signposts of Change
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A common issue that comes up at this point in the therapy is that cli-
ents are overwhelmed by implementing a new organizational system.
It is not uncommon for clients to have a HUGE backlog of mail and
other paperwork. At times, individuals will try to “clean up” by taking
all of the mail and paperwork that has accumulated on a surface (e.g.,
dining room table) and place it in a bag, bin, or box and put it in the
basement or spare room. Over time, this can lead to problems, such as
bills not being paid on time; also, this collection of bags, bins, or boxes
can feel like a huge burden to the client and family. Even though clients
are aware of what they need to do, it can be difficult to implement the
plan. You can help by validating the difficulty and reinforcing the idea
that the client only needs to focus on one small step at a time (e.g., go
through one small pile per day). If the client is limiting the influx of
paper at the same time, this will help him to be able to see progress in
terms of clearing out clutter more rapidly.
Clients with ADHD commonly report that they are unable to com-
plete tasks because other, less important, tasks or distractions get in the
way. Having a short attention span is part of ADHD. We do not view
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The purpose of this next exercise is to help clients estimate the length of
time that they can work on a boring or unattractive task without stop-
ping. In session, instruct the client to choose a boring or unattractive
task to work on for home practice. After starting the task, the client
should keep track of how long she can work before taking a break or
becoming distracted. The client should note this length of time and
repeat this exercise several times to see if a consistent “attention span”
emerges.
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Instruct the client to have a piece of paper or a note app open in a smart-
phone or other device when starting work on a boring or unattractive
task. Then the client should set a timer (can use smartphone for this
as well) for the agreed-upon length of time (e.g., 30 minutes). When a
distraction pops into the client’s head, he should write the distracting
thought down on the piece of paper or electronic note but should not
take action at that time. Rather, he should return to the task at hand.
When the timer goes off, the client can look at the list and decide if any
of the distracting tasks need to be completed at that time.
Instruct the client to repeat this process until the task is completed (or
the portion of the task that the client has set out to do for the day). The
client can then review the list of distractions and decide if (1) they need
to be completed at that time, (2) they should be added to the client’s
master or daily task list, or (3) they are unimportant tasks that do not
need to be completed. The piece of paper should then be discarded (or
the electronic note should be deleted) at the end of the exercise, so that
the client does not end up with multiple lists.
Also, explain to the client that he can use coping statements to help
return to the task at hand. These can include, “I will worry about this
later,” “This is not an A-priority task,” or “I will come back to this.”
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Potential Pitfalls
Practice
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Case Vignette
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5
Modifying
SESSION 7
the Environment
(Corresponds with Chapter 9 of the Client Workbook)
MATERIALS NEEDED
SESSION OUTLINE
■ Set agenda.
■ Review ASRS Symptom Checklist.
■ Review progress.
■ Review use of calendar, task list, and work from previous module.
■ Teach client strategies for controlling the work environment.
■ Teach client skills for keeping track of important items.
■ Teach client to use reminders to help with skill consolidation.
■ Instruct client in use of alarm device to help with staying on task.
■ Assign home practice.
Set Agenda
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Signposts of Change
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Instruct the client to think about things that typically are distracting
while working, such as ringing of the telephone, surfing the Internet,
replying to emails or texts, listening to the radio, watching television,
noticing other things on the desk that require attention, speaking with
other people in the room, or looking at something going on outside the
window. Using Worksheet 4: Strategies for Reducing Distractions, help
the client develop a plan for reducing the distractions that are prob-
lematic. Strategies can include turning off the phone, closing the web
browser and/or email, shutting off the sound that beeps when a new
email arrives, clearing off the desk or workspace, turning off the radio
and television, asking others not to come in while the client is working,
and turning the desk away from the window.
Interestingly, some clients with ADHD report that they do not concen-
trate as well when they are in a totally silent environment. If this is the
case for your client, try to help him or her articulate the circumstances
that are the most helpful in aiding concentration. For example, many
clients report that they concentrate better when a certain type of music
is playing in the background (often classical music or other music that
does not have lyrics that might be distracting).
Instruct the client to find one place at home where he can do impor-
tant tasks without distraction, perhaps a desk or a table or any other
“work space.” You can talk with the client about setting the stage for
success— setting up the work environment so that it is conducive for
the client to be as productive as possible.
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client to think of any difficulties that she has keeping track of impor-
tant items such as keys, wallet, or phone. The client should pay spe-
cial attention to those items that are needed each time that she leaves
the house.
Next instruct the client to think of a specific place in the house where
these items will be kept. This can include such strategies as leaving a
basket near the door and placing the important items in the basket each
time the client comes in the door, or installing a hanging rack next to
the door for keys. Encourage the client to think of one or more solu-
tions that are likely to be effective.
Potential Pitfalls
It is easy to get frustrated with these strategies if they don’t work right
away. Remind clients that they are trying to develop new work habits
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and that this takes time. Encourage them to think about the long-term
benefits of learning new work habits.
Practice
Case Vignette
T: I want you to try setting your alarm several times during the day
when you typically get distracted.
C: When should I do this?
T: Well, that depends. When do you think you experience the most dif-
ficulty with distractibility?
C: I have a lot of trouble when I am sitting at my computer at work. I get
very easily distracted by email, and sometimes when I really don’t
want to do work, I start playing solitaire or other computer games.
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T: Okay, then I would suggest that you set your alarm to go off at reg-
ular intervals when you are sitting at your computer at work. When
the alarm sounds, you should ask yourself, “Am I on task right now
or did I get distracted?” What other situations are difficult for you?
C: If something is going on outside my window, I have a hard time
ignoring it. Sometimes I will just stare out the window for 15 or
20 minutes before I catch myself.
T: In that case, maybe we should try to set up your work environment
in a different way. Is it possible for you to close your blinds or turn
your chair around when you are trying to get work done?
C: I never really thought about it, but I could close my blinds and bring
my computer over to the table and close my door. This would really
limit the distractions and probably make it easier for me to get work
done. I will try that this week.
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MODULE 3
Adaptive Thinking
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Introducing a Cognitive
SESSION 8
Model of ADHD
(Corresponds with Chapter 10 of the Client Workbook)
MATERIALS NEEDED
SESSION OUTLINE
■ Set agenda.
■ Review ASRS Symptom Checklist.
■ Review progress.
■ Introduce the cognitive component of the cognitive-behavioral
model of ADHD.
■ Discuss automatic thinking and the relationship of thoughts to be-
haviors and feelings.
■ Explain how to identify negative thoughts.
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Set Agenda
Signposts of Change
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■ Use of the “A,” “B,” and “C” priority ratings: Discuss any trouble
the client is having with prioritizing tasks.
■ Use of problem-solving (selecting an action plan) and breaking
down large tasks into small steps: Consider the client’s use of these
strategies and practice one or both skills using examples from his or
her current task list.
By now, you have worked with your client to develop systems for orga-
nizing, planning, and solving problems and to practice skills for man-
aging distractibility. The next section, adaptive thinking, will teach cli-
ents to increase their awareness of negative and/or unhelpful thoughts
that can cause stress and mood problems and can interfere with the
successful completion of tasks.
1
This method of implementing and teaching cognitive-restructuring skills is based on McDermott (2000), as
well as other cognitive-behavioral therapy manuals, including Hope et al.’s (2000) manuals for the treatment
of social phobia and Otto et al.’s (1996) manual for treatment of panic disorder in the context of medication
discontinuation.
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Thoughts Feelings
Behaviors
Figure 8.1
The cognitive-behavioral model.
The goal of this section is to highlight the role of negative and/or un-
helpful thoughts in ADHD symptoms. First discuss the automatic
nature of thoughts. Some thoughts happen so quickly that they are
not in one’s present awareness. Furthermore, automatic thoughts can
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Anxiety and depression may lead to more negative thinking, and around
and around the cycle goes, making the problem worse and worse. For
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people with ADHD, this cycle exacerbates other symptoms such as in-
attention, procrastination, frustration, and depression.
The first step in breaking this cycle is to identify and slow down negative or
ineffective, automatic thinking. Becoming more aware of situations when
this occurs is the first step in learning to think in more adaptive ways.
The thought record is a tool that was developed to help clients learn how
to identify, slow down, and restructure negative or unhelpful, automatic
thoughts. Clients may use the thought records provided in the Appendix
(Worksheets 5 and 6) or they can write the information in a notebook or
on their phone, tablet, or computer. Various apps can be purchased for
smartphones and tablets that can assist with the completion of thought
records. Complete one thought record in session with the client to make
sure he or she understands how it is done. You can refer to the “Preliminary
Instructions for Adaptive Thinking” included at the end of this chapter
and in Chapter 10 of the client workbook when completing the thought
record. Remind clients that they can refer back to these instructions if
needed when completing the thought records on their own.
It is important to have the client (not the therapist) write out the thought
records so that he or she becomes familiar with their format. The 3-
Column Thought Record should be completed by the client as follows.
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Then, instruct the client to write down all of his or her automatic
thoughts in Column 2:
Next, ask the client to list all of the feelings he or she experienced in
Column 3 (there may be several different feelings) and then rate the
intensity of each feeling on a scale of 0 to 100 (where 0 = the least in-
tense, 100 = the most intense). Examples of feelings include angry, upset,
happy, sad, depressed, anxious, and surprised. Figure 8.2 shows a sample
of a 3-Column Thought Record, if needed. Provide a blank 3-Column
Thought Record for in-session practice.
Figure 8.2
Sample completed 3-column thought record.
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Now that clients see how certain situations can trigger negative auto-
matic thoughts and subsequent negative feelings, our goal is to help
them understand why their thoughts are unhelpful and to recog-
nize errors in thinking. In our experience, and in the work of other
cognitive-behavioral therapists, common types of negative automatic
thoughts or “thinking errors” often emerge. These types of thoughts
may interfere with a client’s ability to complete tasks and also may con-
tribute to feelings of depression, anxiety, or frustration.
Box 8.1 lists common thinking errors. Review each one with the client
to make sure he understands them all. Help the client look for patterns
and determine which types of errors may be especially problematic for
him or her.
In addition to the thinking errors listed in Box 8.1, clients should also
be instructed to consider whether or not they might be engaging in
overly optimistic thinking.
Mental Filter: You pick out a single negative detail and dwell on it
exclusively, overlooking other positive aspects of the situation.
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Fortune Telling: You anticipate that things will turn out badly,
and you feel that your prediction is a predetermined fact.
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After the client has learned about common types of thinking errors, go
back to the thought record he or she filled out with you earlier. For each
of the automatic thoughts he or she listed, review the list of thinking
errors and help him or her identify the common patterns in his or her
thinking. Then, list the appropriate thinking error in Column 4 below.
Sometimes more than one thinking error is made, and there may be
some overlap among different types of errors.
THERAPIST NOTE: The goal of this exercise is for clients to see that
they are making thinking errors. Though it might be ideal for them to
pick the exact error, there is no real need to have them learn the exact
error they are making. If they pick one error for a thought, just ask them
to see that they are making thinking errors.
Remind clients that not all negative thoughts represent thinking errors;
sometimes it is realistic that a situation produces a negative thought,
which, in turn, contributes to a negative feeling. We offer the following
example to illustrate this:
Imagine you have been studying for an exam for many days and you
are driving to school to take the exam. Suddenly you encounter a
traffic jam due to a car accident that occurred earlier. Now, if your
thought was, “Oh no! I hope I won’t be late! I studied so hard for this
exam,” and you were feeling anxious and perhaps frustrated, that
would make sense! The challenge for you would be to problem solve: to
try and stay calm, perhaps to call the instructor to let her know that
you were going to be late, and to focus on driving safely.
However, if in addition to those thoughts you also said to yourself,
“Bad things always happen to me! I can never do anything right!
I am going to miss the exam and fail the class,” we can imagine that
your anxiety and despair would intensify, and you may be more likely
to drive dangerously, get in an accident, and not be able to take the
exam. Furthermore, if you did get to the exam in time, you most
likely would be distracted by these intense emotions and would be less
able to concentrate compared to when you were studying. Looking
closely, you can see that these thoughts could be classified respectively as
overgeneralization, personalization, and jumping to conclusions.
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Figure 8.3
Sample completed 4-column thought record.
Refer to the example in Figure 8.3 and then provide clients with copies
of the 4- Column Thought Record to complete on their own.
Potential Pitfalls
Often clients feel that it is impossible to change how they think. It is im-
portant for you to acknowledge that change does not occur overnight,
but clinical experience and research suggest that IT IS POSSIBLE!
Sometimes monitoring thoughts alone can begin the process of change.
For especially skeptical clients, it can be helpful to suggest they do an
experiment: For the next month they will commit to using thought
records to monitor their thoughts, label unhelpful thoughts, and at-
tempt to identify more rational responses. If, at the end of this one-
month experiment, they detect absolutely NO CHANGE, they may
consider returning to their dialog of negative thoughts. However, it is
likely that with consistent monitoring and practice, they will begin to
see improvement.
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For some people, writing out negative thoughts makes the thoughts
“seem more real” or more difficult to cope with, so they are reluctant to
use thought records. However, the thoughts are in their minds, inter-
fering, regardless of whether or not they write them down. Completing
the thought record will actually help them feel better about the situa-
tion, despite the initial difficulty of seeing their thoughts on paper.
Clients may also find that it is hard to label their feelings and may think
that they have to come up with the perfect words to describe their feel-
ings. Ask them to use the first word that comes to mind, even if it is not
perfect. Over time, it will become easier to label their feelings.
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The first step in learning to think in more useful ways is to become more
aware of these thoughts and their relationship to your feelings. If you
are anticipating a stressful situation, or a task that is making you feel
overwhelmed, write out your thoughts regarding this situation.
If a situation has already passed and you find that you are thinking
about it negatively or if, in retrospect, you realize that you were
having unhelpful thoughts, list your thoughts for this situation.
The first column is a description of the situation.
The second column is for you to list your thoughts during a stressful,
overwhelming, or uncontrollable situation.
The third column is for you to write down what emotions or feelings
you are having when thinking these thoughts (e.g., depressed, sad,
angry).
The fourth column is for you to see if your thoughts match the list of
“thinking errors.” These may include:
■ All-or-Nothing Thinking
■ Overgeneralizations
■ Jumping to Conclusions (Fortune Telling/Mind Reading)
■ Magnification/Minimization
■ Emotional Reasoning
■ “Should” Statements
■ Labeling and Mislabeling
■ Personalization
■ Maladaptive Thinking
■ Overly Optimistic Thinking
Practice
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■ Practice breaking down one large task from the task list into
smaller steps.
■ Use the organizational systems developed in this program.
■ Use the distractibility delay when working on boring or unattrac-
tive tasks.
■ Use your skills to reduce distraction in your work environment.
■ Start putting important items in specific places.
■ Use reminders to check in with yourself to see if you have become
distracted when you are trying to focus on completing a task.
■ Read the “Preliminary Instructions for Adaptive Thinking” about
completing a thought record.
■ Complete thought records for at least two situations during the week.
Case Vignette
T: Let’s practice completing a thought record together and then you will
be able to work on them at home this week.
C: To be honest, I really don’t see how writing down my thoughts is
going to change anything. I’m not always going to have a thought
record with me that I can complete when I run into problems. [An
example of resistance to completing assignments]
T: Those are really good points. Many people actually aren’t sure how
thought records can be helpful until they start practicing. What they
find is that seeing your thoughts written out helps you identify when
they are unrealistic and highlights the connection between unhelp-
ful, negative thoughts, and feelings like anxiety, which can lead to
procrastination. Does that seem to fit with you?
C: Yes, that happens to me a lot. I tend to think that way. But I am not
sure I see myself writing all this out all the time.
T: Okay, also, I don’t expect that you will always need to complete
thought records. Over time, with lots of practice, you will start to
catch yourself having negative thoughts and will restructure them in
your mind. The whole process will become automatic. But for now,
while you are learning, it is helpful to slow down the process and
write out a thought record. Does that sound manageable?
C: Well, I can try it and see.
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fixing it. And if they take back my money, I won’t be able to pay my
rent, and my landlord will evict me if I’m late one more time. [Here
the intensity of emotion increases and the client begins to feel worried
again.]
T: Now wait a minute: Do you think there is any “Jumping to
Conclusions” going on? You have no way of knowing for sure that
they are going to take your money back, and chances are that if there
is an error, it will not affect the entire amount you were paid. And
maybe there is some “Magnification/Minimization”—focusing on
the fact that you don’t know where the paystubs are, but minimizing
the fact that it is usually possible to get duplicate copies when you get
to work. I agree, it is a pain in the neck, and it makes sense that you
would be frustrated. [The therapist validates the client’s concerns
and calmly suggests thinking errors that may be contributing to the
client’s anxiety and worry.]
C: I guess that makes sense. When you break it down like that it doesn’t
seem so overwhelming, and I know it would just take a phone call to
get new copies sent right to the bank.
T: Exactly. You’ve done a terrific job. This is a great example of how
using the thought record can help you see a situation from a new
perspective, which can really have an impact on how you’re feel-
ing about it. Otherwise, your intense feelings may get in the way of
taking necessary action. [The therapist provides praise and reinforce-
ment for the client’s efforts.]
C: That was a lot of work, but I guess it will be worth practicing.
T: You will also find that it gets much easier the more you practice.
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MATERIALS NEEDED
SESSION OUTLINE
■ Set agenda.
■ Review ASRS Symptom Checklist.
■ Review progress.
■ Review thought records completed at home.
■ Discuss coaching styles and coaching story.
■ Discuss formulation of a rational response.
■ Assign home practice.
Set Agenda
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Signposts of Change
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If the client did complete thought records, review each one. Provide
feedback on successful completion, and assist the client in identify-
ing any patterns that are occurring with his negative thoughts. Often,
clients tend to engage in particular thinking errors. Once this is recog-
nized, they can begin to modify their thoughts.
In this session, the client will learn strategies to correct thinking errors
and develop more helpful thoughts. Our goal is to help transform
the unhelpful, interfering thoughts into more supportive, coaching
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But this story doesn’t start with the coaches or the parents; it starts
with Johnny, who is a Little League player in the outfield. His
job is to catch “fly balls” and return them to the infield players.
On this particular day of our story, Johnny is in the outfield.
And “crack!”— one of the players on the other team hits a fly ball.
The ball is coming to Johnny. Johnny raises his glove. The ball is
coming to him, it is coming to him … Johnny jumps up as high
as he can, but he is in the wrong place at the wrong time doing the
wrong strategy, so it goes over his head. Johnny misses the ball,
and the other team scores a run.
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before the next game, he may complain that his stomach hurts,
that perhaps he should not go to the game. This is the scenario
with Coach A.
Coach B leaves the field. How does Johnny feel? Well, he is not
happy. After all, he missed the ball—but there are a number of
important differences from the way he felt with Coach A. He is
not as tense or tight, and if a fly ball does come to him, he knows
what to do differently to catch it. And because he does not have
tears in his eyes, he may actually see the ball accurately. He may
catch the next one.
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Think about your last mistake. Did you say, “I can’t believe I did
that! I am so stupid! What a jerk!”? These are “Coach A” thoughts
and they have approximately the same effect on us as they do
on Johnny. They make us feel tense and tight, and sometimes
make us feel like crying. And this style of coaching rarely makes
us do better in the future. Even if you are only concerned about
productivity (making the Major League) you would still pick
Coach B. And if you were concerned with enjoying life, while
guiding yourself effectively for both joy and productivity, you
would still pick Coach B.
During the next week, I would like you to listen to see how you
are coaching yourself. And if you hear Coach A, remember this
story and see if you can replace Coach A with Coach B.
Reprinted from Otto, M. (2000). Stories and metaphors in cognitive-behavior
therapy. Cognitive and Behavioral Practice, 7(2), 166–172. Copyright 2000, with
permission from Elsevier.
After telling the coaching story, go back to one of the thought records
previously completed by the client at home or discuss one completed in
session together. Review the automatic thoughts and thinking errors
that were identified. The next step is to evaluate the helpfulness of each
thought. The following questions are suggested prompts to help clients
objectively evaluate these thoughts:
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Figure 9.1
Sample completed 5-column thought record.
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Figure 9.2
5-column thought record.
Potential Pitfalls
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THERAPIST NOTE: Remind clients that, with practice, they will feel
more comfortable using their new skills and will begin to notice improve-
ments. In session, identify situations to work on at home using the thought
records. Also ask clients to consider any difficulties they may have complet-
ing this assignment and work to resolve these problems to minimize the
chance that obstacles will stop them from completing their home practice.
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The fourth column is for you to see if your thoughts match the list of
“thinking errors.” These may include:
■ All-or-Nothing thinking
■ Overgeneralizations
■ Jumping to Conclusions (Fortune Telling/Mind Reading)
■ Magnification/Minimization
■ Emotional Reasoning
■ “Should” Statements
■ Labeling and Mislabeling
■ Personalization
■ Maladaptive Thinking
■ Overly Optimistic Thinking
Practice
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Case Vignette
T: Let’s take a look at one of the thought records you completed this
week and see if you can identify a rational response (Fig. 9.3).
T: Let’s start with the first thought: “He’s going to be so angry with me.”
What evidence do you have that supports or contradicts this thought?
C: Well, I know these calls were important. He had a really busy day
and asked me to do him a favor by calling, so he will be mad. But,
there have been other times when I forgot to do something and he
was a little frustrated, but not really mad at me. So it’s 50–50. He
might get mad, but there is a chance he won’t.
T: Good. Now, even if he is mad, is he going to break up with you?
What’s the evidence you have for that?
C: I get scared about this a lot. But, we have gotten into fights in the
past, and even when it’s a big one, he gets over it pretty quickly and
doesn’t hold a grudge. He tends to focus more on how to solve the
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problem. Plus, he does tell me all the time how much he loves me and
wants to be with me. So he probably won’t break up with me.
T: Great! So he may be mad, which will be hard for you, but it’s pretty
clear that he loves you and will stay with you. This is just a mistake
you made. What about the last thought?
C: I get so mad at myself when I forget to do things. It’s so humiliating.
T: Do these things happen every day, all day long?
C: Um, no. Maybe things like this happen once a month.
T: And you have been working extremely hard in this program so that
you can learn new skills for managing your ADHD!
C: I have. And I have seen some changes. So has my boyfriend. He tells
me how proud he is of me. He does know I’m trying hard.
T: Terrific. I understand it’s hard for you when these things happen, but
I think you can see now how these negative automatic thoughts can
really intensify your feelings and make it difficult to problem-solve
and cope with the situation.
C: It’s true. I can really see that now.
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Figure 9.3
Example completed thought record.
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9
MATERIALS NEEDED
SESSION OUTLINE
■ Set agenda.
■ Review ASRS Symptom Checklist.
■ Review progress.
■ Review thought records completed during the week.
■ Identify additional situations that might require adaptive thinking
for home practice.
■ Evaluate client’s need to complete the optional procrastination
module.
■ Assign home practice.
Set Agenda
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Signposts of Change
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In this session, review the thought records that the client completed
at home, and discuss any difficulties she may be having with adapt-
ive thinking. If necessary, complete a new thought record to review
these skills. If the client has not completed any thought records at
home, review the rationale for doing homework as a part of cognitive-
behavioral therapy. Emphasize that for this treatment, the whole pro-
gram revolves around doing things differently outside of the sessions.
Elicit reasons for resistance and discuss a possible way forward. Help
the client try to resolve any problems that he or she has been facing in
doing home practice.
Work with the client to identify any new situations that may require
adaptive thinking. Patterns of negative thoughts or important themes
may have emerged from examining completed thought records. It can
be very useful to discuss these patterns. If the themes have to do with
novelty seeking (e.g., “I can find a more interesting way to do this
task”) or a dislike for details (e.g., “It really stinks that I need to fill
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out all of this paperwork just to sign my son up for camp”), the client
can be instructed to come up with rational responses having to do with
the effectiveness of taking care of details or of doing things the more
“typical” way. Remind the client to refer to the materials on adaptive
thinking and sample thought records if he feels stuck.
We also reiterate that initially it is helpful to write out the five columns
in the thought record, but ultimately this process will take place in the
client’s mind. With practice, the client will learn to spot unhelpful auto-
matic thoughts as they emerge and will be able to come up with a more
realistic and/or helpful rational response that will help him or her feel
better about the situation. When necessary, the client can always write
out the thought record and review the materials on adaptive thinking.
Offer hearty congratulations to your client: She has now completed the
core elements of cognitive-behavioral treatment for ADHD. Review
the “problem list” that was completed at the beginning of the treat-
ment to determine whether to begin optional Session 11 (Application
of Skills to Procrastination), to do more review work on sessions that
were already completed, or to continue to Session 12 (Handling Slips).
Note that the skills that have already been taught can be easily applied
to the area of procrastination.
Potential Pitfalls
Your client has done a lot of work to get to this point. He may feel
like taking a break or may believe that he has done enough work and
will no longer have any difficulties related to ADHD. The most impor-
tant message to emphasize here is that the client needs to PRACTICE,
PRACTICE, PRACTICE to ensure that newly learned skills become
permanent. Your client’s effort will continue to pay off.
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Practice
Case Vignette
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takes consistent practice to maintain the gains that you have made.
You’ve mentioned a number of difficulties that have improved
during the program— remembering important appointments, get-
ting your work done on time, and being able to read without getting
distracted. You can continue to improve if you keep practicing your
CBT skills. When you think about it, it really only takes about 15
minutes a day at most to do homework, and the tradeoff is enormous!
C: Well, that is true. It just seems unfair. Other people don’t have to
worry about these things.
T: Others may not struggle with ADHD, but most people struggle in
some area. Remember we talked about the fact that you can’t change
that you have ADHD, which can be hard to accept, but you can
minimize the impact it has on your life by utilizing your CBT skills.
C: Yeah, I just have to remind myself of that.
T: You can. If you make it a habit to practice a little bit each day, it will
become much easier! I know you can do it.
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071
MODULE 4
Additional Skills
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Application of Skills
SESSION 11 to Procrastination
(optional)
(Corresponds with Chapter 13 of the Client Workbook)
MATERIALS NEEDED
SESSION OUTLINE
■ Set agenda.
■ Review ASRS Symptom Checklist.
■ Review progress.
■ Discuss the attractive aspects of procrastination.
■ Teach client to anticipate the negative consequences of
procrastination.
■ Use Worksheet 8: Pros and Cons of Procrastination to determine
whether or not to procrastinate.
■ Introduce techniques for trying to resolve procrastination problems.
■ Explain how to use adaptive thinking skills for managing
procrastination.
■ Assign home practice.
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Set Agenda
Signposts of Change
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Introduction to Procrastination
While procrastination can cause anxiety and anguish, there are also
reasons why it seems desirable or easier to postpone tasks. Some reasons
include the following:
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Ask clients if any of these reasons sound familiar and prompt them to
think about the reasons that seem to underlie their procrastination.
Determine if there any other reasons not listed above. The attractive-
ness of procrastination is not always clear at a conscious level, but if
clients think about it for a bit, they will recognize some of the common
reasons for procrastination.
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had negative consequences during their life. There may be other neg-
ative outcomes that are not listed above but have been significant for
the client.
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Remind your client that each step should feel completely “do-able.” Ask
the client to do a “gut check.” If the task doesn’t feel absolutely “do-
able,” have the client break the step down further. Alternatively, rather
than attempting to work on the whole problem, the client may want to
target only one or two sub-goals.
Here are the steps of breaking down large tasks into manageable steps:
1. Choose a difficult or complex task from the “to do” list. List the
steps that must be completed.
This can be done on paper or electronically. Ask questions such
as, “What is the first thing that I would need to do to make this
happen?”
2. For each step, make sure that it is manageable.
Ask, “Is this something that I could realistically complete in one
day?” and “Is this something that I would want to put off doing?”
If the step itself is overwhelming, then break it down into even
smaller steps.
3. List each individual step on the daily task list.
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Figure 11.1
Thought record.
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■ Ask your client to think about a specific task or issue about which
she has been procrastinating.
■ Assist the client in using each of the above-listed skills for this task
or issue.
■ Use problem-solving to help break the task into manageable steps.
■ Instruct the client to write down the steps on the task list.
■ Assist the client in listing the automatic thoughts she is having
about getting started.
■ Finally, prompt the client to identify the appropriate thinking errors
and come up with helpful, rational responses.
Potential Pitfalls
Practice
■ Select a reasonable goal or two from the list of steps outlined on the
task list.
■ Decide on rewards to use for completion of the goals.
■ Review skills from the previous sections of treatment. Note any
questions or difficulties.
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Case Vignette
T: Let’s think about how procrastination plays out for you and evaluate
the pros and cons. Let’s start with the short-term pros of procrastination.
C: Well, I don’t have to do the task I’m trying to avoid.
T: True. What else?
C: I can do something more fun, like go out with my friends or play videogames.
T: I see. There are more enjoyable, attractive activities that you’ d rather
be doing. What are some of the long-term pros?
C: Hmmm. I’m not sure I can think of any other than what I’ve already
mentioned. So the short-term pros are also the long-term pros.
T: Isn’t that interesting. How about the short-term cons?
C: I always feel guilty and anxious when I know there is something
I need to do and I am avoiding doing it. That makes me feel tense,
and then I usually get a migraine and get really irritable. My girl-
friend hates when I get like that, and sometimes says she won’t see me
until I finish whatever I need to do so I’ ll stop being so grouchy.
T: So even though it seems that you get to do more enjoyable activities
when you’re not doing the avoided tasks, you really suffer emotionally
and physically, and you aren’t able to spend as much time with your
girlfriend as you could. What about the long-term consequences?
C: One time a different girlfriend broke up with me because I was always
so irritable, and she knew it was because I was procrastinating. I guess
I’ve also had problems at school. I usually wait until a few days before
a paper is due to start working on it. By the time that I have an outline
or a rough draft, it is usually too late to go to the professor’s office hours
to get feedback and help. I’ve always been a C student, but if I started
papers and projects a little earlier, I’d easily get at least a B.
T: That’s too bad. Your relationships and school performance have really
suffered. What do you realize when you really examine the short- and
long-term pros and cons?
C: Of course it’s obvious! Procrastination creates more problems than it
solves. If I could make some small changes it could easily get better.
T: You’re exactly right! Using the problem-solving skills can make it so
much easier to complete tasks and avoid the cycle of procrastination.
Why don’t you do an experiment this week and see what happens
when you use these skills?
C: Okay.
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MATERIALS NEEDED
SESSION OUTLINE
■ Set agenda.
■ Review ASRS Symptom Checklist.
■ Review Worksheet 9: Treatment Strategies and Usefulness.
■ Discuss maintenance of gains and use of Worksheet 10: One-Month
Review.
■ Discussion of troubleshooting using the Troubleshooting Difficulties
Chart.
Set Agenda
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Signposts of Change
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Figure 12.1
Symptom scores.
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Maintaining Gains
Stress the idea that the key to maintaining treatment gains over the
long run is to be prepared for periods of increased difficulties. Explain
that these periods are not signs that the treatment has failed; instead,
they are signals that the client needs to apply the skills. The client can
use Worksheet 10: One-Month Review (in the Appendix) to refresh the
skills as needed. The purpose of the worksheet is to remind the client of
the importance of practicing skills, and to think through which strate-
gies might be important to practice.
Talk with the client about scheduling a review session on his own.
Discuss using the calendar to pick a time and date approximately one
month after the final treatment session. The client should sit down with
the One-Month Review worksheet and complete it as if he is having an
actual therapy session. Clients who cannot get back on track them-
selves may wish to schedule a “booster session” with you to review the
skills and get a “tune-up” to help with maintaining and generalizing
the skills.
Troubleshooting Difficulties
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Failing to give adequate attention to details, Recheck your attention span and your
making careless mistakes in work or other ability to break activities into units where
activities you can sustain attention.
Use your cues (alarm) to remind you of core
responsibilities at hand.
Easily distracted by things going on in the Manage your environment, and use your
environment distractibility delay.
Forgetful in daily activities Use your alarm system and your task list
along with your calendar.
Finally, you may want to suggest that the client use the problem-solving
worksheet in Chapter 4 to more carefully consider any difficulties with
symptoms. Suggest that the client enlist the help of family and friends
and/or schedule a booster session with you if the above strategies are not
effective in reducing his or her ADHD symptoms. Booster sessions are
common in cognitive-behavioral therapy and should be viewed not as
a sign of failure but rather as an opportunity to review skills and trou-
bleshoot difficulties. In our research trials, we did not include booster
sessions, but in clinical practice, it is common for us to see a client for a
course of cognitive-behavioral treatment and then continue to have in-
frequent booster sessions for a period of time. Many clients report that
they find the booster sessions helpful in maintaining the gains they have
made in treatment.
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Termination
As with any therapy, spend some time processing termination with the
client. Share your thoughts about how it was for you to work with the
client, noting aspects of the treatment that were especially enjoyable for
you (e.g., “I know you really had doubts about being able to track all of
your appointments in the calendar, and it was a pleasure for me to watch
you work through that and get to the point now where you can’t imagine
NOT using your calendar daily”).
Congratulate the client for all the hard work he or she put in to com-
pleting this treatment program. It was demanding! However, we truly
believe these skills can make a profound difference and help reduce the
severity of ADHD symptoms. Remind the client one final time that he
or she needs to PRACTICE, PRACTICE, PRACTICE the skills that
were learned. Improvements will not magically maintain themselves;
only through continued use will improvements become automatic
(refer to the Case Vignettes in Sessions 1 and 10 if necessary).
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271
Appendix
All forms and worksheets from books in the TTW series are made available digitally shortly
following print publication. You may download, print, save, and digitally complete them as
PDFs. To access the forms and worksheets, please visit http://www.oup.com/us/ttw.
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Overall
Rating of
Possible Solution Pros of Solution Cons of Solution
Solution
(1–10)
291
1. Identify a central location for your triage center: This is where you will open and sort all
incoming mail, bills, and paperwork. You can use a wicker basket, file tray, drawer, bowl, or
box for this purpose. The location should be close to your recycling bin and your shredder
so that you can recycle junk mail immediately and shred items, such as credit card offers,
that have personal information but do not need to be retained. Your goal is to keep only the
minimum amount of paper needed. It can be helpful to “unsubscribe” to email lists or opt
out of mailing lists to reduce the amount of electronic and paper mail that is coming in.
2. Figure out “rules” regarding keeping mail, bills, and paperwork (e.g., I will save copies
of all bills for six months after they have been paid; I will pay bills right away). If you
have a scanner, you may want to scan items and discard the originals to reduce clutter.
One item on your task list may be to purchase or set up a scanner and test out the proc-
ess. Alternatively, you may take a picture with your phone and transfer the photo to a
folder on your computer for important documents. Write in your rules below:
3. Gather all necessary items to keep with triage center: Most tasks can be completed on
the computer, so you should have your computer or tablet nearby when you are triaging.
If you cannot pay a bill or otherwise respond to an item online, you should keep your
checkbook, stamps, pens, calculator, address book, and so on nearby so that you don’t
need to go searching for these items when you need to pay a bill or respond to a letter.
4. Identify two or three times per week when you will go through the items in the triage
center and take any action that is required (pay bill, make phone call, respond to letter,
and so on). Use your calendar and task list to help with planning (e.g., put the task of
going through mail on your task list).
5. Write your “triage times” in your calendar. Choose times when you will have enough
time to deal with all of the items; avoid times when you will be too tired or stressed to
be effective at this task.
6. If you experience negative thoughts and you want to give up, try not to give in to this
impulse. You will learn how to cope with negative thoughts in the upcoming module
on adaptive thinking.
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1. Decide where you will keep your system. (Don’t spend too much time making this de-
cision.) If the system is for paper or objects, this can be an actual location. If it is for
computerized files, it can be a folder or drive on your computer.
2. Decide on categories. For example, if you are organizing tax information on your com-
puter, you may want to set up a folder for each year and then make sub-folders for vari-
ous deductions. If you are organizing your clothes in your closet, you may decide to put
all of your shirts together, your pants together, etc.
3. Buy any materials that you need for your system (file folders for a physical filing system,
hangers for your closet, baskets or bins if you are organizing smaller items, etc.).
4. Set up your main categories. You can always break down the categories further as you
go along if needed. Try to keep the system as simple as possible. As the system becomes
more complicated, the likelihood that you will use it becomes lower.
5. Start sorting your items into categories. It is important to use the OHIO (Only Handle
It Once) method. This means that when you pick up an item, you decide what to do
with it immediately (put it away in final destination—file, closet, or wherever, donate it,
shred it, recycle it, throw it away, or delete it). You should never have a category called
“decide what to do with this later.”
6. If it is too overwhelming to deal with everything at once, use the strategy of breaking
tasks down into smaller chunks described earlier. You can chunk it by either setting a
time goal (e.g., work on the organizational system for 20 minutes), an item goal (e.g.,
“I will deal with the first 20 pieces of paper I touch,” “I will sort through 50 emails”),
or a section goal (e.g., “I will sort all of my folded sweaters”). Once you complete this
“chunk,” you may feel a sense of accomplishment and/or you may realize that it is not
going to be as time-consuming as you imagined to set up your organizational system.
7. Plan specific times each week that you will use the system. Make sure you are not choos-
ing unrealistic times.
8. Remember that it is important to practice these skills for long enough that they become
a habit. Don’t give up too soon! It may have taken a long time for the current disorgan-
ized state to come into being, so don’t expect yourself to become perfectly organized
overnight.
Worksheet 4
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Worksheet 5
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Handout A
The purpose of using thought records is to identify and modify negative, automatic thoughts
in situations that lead to feeling overwhelmed.
The first step in learning to think in more useful ways is to become more aware of these
thoughts and their relationship to your feelings. If you are anticipating a stressful situa-
tion, or a task that is making you feel overwhelmed, write out your thoughts regarding this
situation.
If a situation has already passed and you find that you are thinking about it negatively or
if, in retrospect, you realize that you were having unhelpful thoughts, list your thoughts for
this situation.
The second column is for you to list your thoughts during a stressful, overwhelming, or
uncontrollable situation.
The third column is for you to write down what emotions or feelings you are having when
thinking these thoughts (e.g., depressed, sad, angry).
The fourth column is for you to see if your thoughts match the list of “thinking errors.”
These may include:
■ All-or-Nothing Thinking
■ Overgeneralizations
■ Jumping to Conclusions (Fortune Telling/Mind Reading)
■ Magnification/Minimization
■ Emotional Reasoning
■ “Should” Statements
■ Labeling and Mislabeling
■ Personalization
■ Maladaptive Thinking
■ Overly Optimistic Thinking
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Worksheet 6
Time and Situation Automatic Thoughts Mood and Intensity Thinking Errors
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Handout B
The purpose of adaptive thinking is to promote optimal thinking when you are feel-
ing stressed. The steps that are involved can be achieved using the rest of the worksheet.
Throughout the week when you are feeling stressed, sad, or overwhelmed, continue to list
your thoughts for each situation. If you are anticipating a stressful situation or a task that
is making you feel overwhelmed, write out your thoughts regarding this situation. If a sit-
uation has already passed and you find that you are thinking about it negatively, list your
thoughts for this situation.
The second column is for you to list your thoughts during a stressful, overwhelming, or
uncontrollable situation.
The third column is for you to write down what emotions you are having and what your
mood is like when thinking these thoughts (e.g., depressed, sad, angry).
The fourth column is for you to see if your thoughts match the list of “thinking errors”
These may include:
■ All-or-Nothing thinking
■ Overgeneralizations
■ Jumping to Conclusions (Fortune Telling/Mind Reading)
■ Magnification/Minimization
■ Emotional Reasoning
■ “Should” Statements
■ Labeling and Mislabeling
■ Personalization
■ Maladaptive Thinking
■ Overly Optimistic Thinking
In the last column, try to come up with a rational response to each thought, or to the most
important negative thought. The rational response is a statement that you can say to yourself
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to try to feel better about the situation. Questions to help come up with this rational re-
sponse can include the following:
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Worksheet 7 5-Column Thought Record
What is the evidence for the thought? Against the thought? Why is it the particular cognitive distortion? Is there an alternate explanation? What is
the worst thing that could happen? What would a good friend or good coach say? What would you say to a friend in a similar situation?
381
Worksheet 8
Pros Cons
Short-term
Long-term
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Please rate the usefulness of each strategy to you (“0” = Didn’t help at all to “100” = Was ex-
tremely important for me). Also, take some time to provide notes to yourself about why you think
each strategy worked or didn’t work to help you, and formulate a plan regarding which strategies
might be most helpful for you to practice over the next month.
Worksheet 10
One-Month Review
3. Can you place the troubles in one of the specific domains used in this treatment?
4. Have you reviewed the chapters most relevant to your difficulties? (Which chapters
are these?)
5. Have you reviewed Worksheet 9: Treatment Strategies and Usefulness, where you
wrote those skills that were most helpful to you in the first phase of this treatment?
Do you need to reapply these skills or strategies?
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References
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Safren, S. A., Otto, M. W., Sprich, S., Perlman, C. L., Wilens, T. E., &
Biederman, J. (2005). Cognitive behavioral therapy for ADHD in
medication-treated adults with continued symptoms. Behaviour Research
and Therapy, 43(7), 831– 842.
Safren, S. A., Sprich, S. E., Cooper-Vince, C., Knouse, L. E., & Lerner, J.
A. (2010a). Life impairments in adults with medication-treated ADHD.
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Safren, S. A., Sprich, S., Mimiaga, M. J., Surman, C., Knouse, L., Groves,
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and persistent symptoms: A randomized controlled trial. JAMA, 304(8),
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Program at MGH and in private practice. Dr. Sprich received her doctorate
in clinical psychology from the State University of New York at Albany, and
did her predoctoral and postdoctoral fellowships in CBT at MGH/Harvard
Medical School.
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