i

Mastering Your Adult ADHD

ii

T R E AT M E N T S T H A T W O R K

Editor-In-Chief

David H. Barlow, PhD

Scientific Advisory Board

Anne Marie Albano, PhD

Gillian Butler, PhD

David M. Clark, PhD

Edna B. Foa, PhD

Paul J. Frick, PhD

Jack M. Gorman, MD

Kirk Heilbrun, PhD

Robert J. McMahon, PhD

Peter E. Nathan, PhD

Christine Maguth Nezu, PhD

Matthew K. Nock, PhD

Paul Salkovskis, PhD

Bonnie Spring, PhD

Gail Steketee, PhD

John R. Weisz, PhD

G. Terence Wilson, PhD

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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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1
Oxford University Press is a department of the University of Oxford. It furthers
the University’s objective of excellence in research, scholarship, and education
by publishing worldwide. Oxford is a registered trade mark of Oxford University
Press in the UK and certain other countries.
Published in the United States of America by Oxford University Press
198 Madison Avenue, New York, NY 10016, United States of America.
© Oxford University Press 2017
First Edition published in 2005
Second Edition published in 2017
All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
by law, by license, or under terms agreed with the appropriate reproduction
rights organization. Inquiries concerning reproduction outside the scope of the
above should be sent to the Rights Department, Oxford University Press, at the
address above.
You must not circulate this work in any other form
and you must impose this same condition on any acquirer.
CIP data is on file at the Library of Congress
ISBN 978– 0–19– 023558–1
9 8 7 6 5 4 3 2 1
Printed by WebCom, Inc., Canada
v

About T R E AT M E N T S T H A T W O R K

Stunning developments in healthcare have taken place over the

last several years, but many of our widely accepted interven-
tions and strategies in mental health and behavioral medicine
have been brought into question by research evidence as not
only lacking benefit, but perhaps, inducing harm (Barlow,
2010). Other strategies have been proven effective using the
best current standards of evidence, resulting in broad-based
recommendations to make these practices more available to
the public (McHugh & Barlow, 2010). Several recent develop-
ments are behind this revolution. First, we have arrived at a
much deeper understanding of pathology, both psychological
and physical, which has led to the development of new, more
precisely targeted interventions. Second, our research method-
ologies have improved substantially, such that we have reduced
threats to internal and external validity, making the outcomes
more directly applicable to clinical situations. Third, govern-
ments around the world and healthcare systems and policy-
makers have decided that the quality of care should improve,
that it should be evidence based, and that it is in the public’s
interest to ensure that this happens (Barlow, 2004; Institute of
Medicine, 2001; McHugh & Barlow, 2010).

Of course, the major stumbling block for clinicians everywhere

is the accessibility of newly developed evidence-based psycho-
logical interventions. Workshops and books can go only so far
in acquainting responsible and conscientious practitioners with
the latest behavioral healthcare practices and their applicability
to individual patients. This series, Treatments ThatWork, is
devoted to communicating these exciting new interventions to
clinicians on the frontlines of practice.

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The manuals and workbooks in this series contain step-by-step

detailed procedures for assessing and treating specific problems
and diagnoses. But this series also goes beyond the books and
manuals by providing ancillary materials that will approximate
the supervisory process in assisting practitioners in the imple-
mentation of these procedures in their practice.

In our emerging healthcare system, the growing consensus is

that evidence-based practice offers the most responsible course
of action for the mental health professional. All behavioral
healthcare clinicians deeply desire to provide the best possible
care for their patients. In this series, our aim is to close the
dissemination and information gap and make that possible.

This Therapist Guide and the companion Workbook for cli-

ents address the treatment of adult attention-deficit/hyperac-
tivity disorder (adult ADHD). ADHD is prevalent in adults
but under recognized and undertreated. With its characteristic
symptom picture of hyperactivity, impulsivity, and difficulties
focusing attention, adult ADHD can be as impairing as it is
in children. Mastering Your Adult ADHD was the first evi-
dence-based treatment for adult ADHD from a leading group
of clinical investigators. After years of research, and with sup-
port from the National Institute of Mental Health, this team
developed a treatment that directly attacks the symptoms of
ADHD in a collaborative framework with patients.

Now in its second edition, the clinical components of this pro-

gram have been updated based on the research team’s experi-
ences and on the most current strategies in cognitive behavioral
therapy (CBT). The intervention includes use of technology
(such as using smart phones), and optional strategies that help
with organization and planning. Optional sessions with a part-
ner or spouse of someone with adult ADHD have more focus
on providing education about ADHD, which can reduce dis-
harmony in the relationship. Either as a complement to medica-
tion, or for the cases where medication is relatively ineffective,

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every practitioner treating this very common disorder will want

to incorporate this intervention into their armamentarium.

David H. Barlow, Editor-in-Chief,

Treatments ThatWork
Boston, MA

References

Barlow, D. H. (2004). Psychological treatments. American Psychologist, 59,

869– 878.
Barlow, D. H. (2010). Negative effects from psychological treatments: A per-
spective. American Psychologist, 65(2), 13–20.
Institute of Medicine. (2001). Crossing the quality chasm: A new health system
for the 21st century. Washington, DC: National Academy Press.
McHugh, R. K. & Barlow, D. H. (2010). Dissemination and implementation
of evidence-based psychological interventions: A review of current efforts.
American Psychologist, 65(2), 73–84.

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Accessing Treatments ThatWork Forms and Worksheets Online

All forms and worksheets from books in the TTW series are made available dig-
itally shortly following print publication. You may download, print, save, and
digitally complete them as PDF’s. To access the forms and worksheets, please visit
http://www.oup.com/us/ttw.

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Contents

Introductory Information for Therapists xi

Module 1 Psychoeducation, Organizing, and Planning

Session 1 Psychoeducation and Introduction to

Organization and Planning 3
Session 2 Informational Session with Spouse, Partner,
or Family Member (if applicable) 15

Session 3 Organization of Multiple Tasks 21

Session 4 Problem-Solving and Managing

Overwhelming Tasks 29

Session 5 Organizational Systems 37

Module 2 Reducing Distractibility

Session 6 Gauging the Client’s Attention Span

and Teaching Distractibility Delay 47

Session 7 Modifying the Environment 55

Module 3 Adaptive Thinking

Session 8 Introducing a Cognitive Model

of ADHD 65

Session 9 Adaptive Thinking 83

Session 10 Rehearsal and Review of Adaptive

Thinking Skills 99

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Module 4 Additional Skills

Session 11 Application of Skills to

Procrastination (optional) 109

Session 12 Handling Slips 119

Appendix Forms and Worksheets 127

References 141

About the Authors 147

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Introductory Information for Therapists

This therapist manual is an accompaniment to the client work-

book for the second edition of Mastering Your Adult ADHD.
The treatment and manuals are designed for use by a thera-
pist who is familiar with cognitive-behavioral therapy (CBT).
The reason for both a therapist manual and a client workbook
is to help clients with attention-deficit/hyperactivity disorder
(ADHD) receive information in two different modalities—
verbally from the therapist, and in writing in the form of the
client workbook. We have found that presenting information in
multiple modalities can be helpful for adults with ADHD who
have low attention spans. Hence, we recommend that all of the
material presented in the client workbook also be presented in
the treatment sessions, and we recommend that clients have
their own copy of the client workbook so that they can refer
back to it for questions that may come up. You will notice that
the chapters and page numbers in the therapist manual and
client workbook do not always correspond because additional
information is provided in the therapist manual. However,
there is a note at the beginning of each session in the therapist
manual indicating which chapter in the client workbook coin-
cides with the chapter in the therapist manual.

Each of the treatment sessions builds on previous ones. Each

session begins with a review of skills learned in previous ses-
sions. Repetition is the key to helping adults with ADHD learn
new skills that will ultimately become more habitual. If neces-
sary, we recommend spending extra time on skills that have not
yet been mastered before moving on to additional skills. The
first skills module is on organizing and planning. We consider
this module to be the foundation for all additional modules,

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and therefore recommend spending as much time as it takes

for clients to learn these skills in order to maximize the chances
of the treatment being a success. We believe that all of these
modules are important and that the order in which the sessions
are presented in the manuals is the appropriate way to present
the information. However, if you are working with a client for
whom it seems to make sense to present the skills in a different
order (e.g., the client exhibits difficulties in some areas but not
others or experiences significant comorbidity), customizing the
approach in a way that makes sense to you and your client will
lead to successful treatment.

Background Information and Purpose of this Program

Information about the Validity of ADHD as

a Diagnosis in Adulthood

ADHD in childhood and adulthood is a valid, reliably diag-

nosed, neurobiological disorder. It can be reliably diagnosed
in adults; the diagnosis meets acceptable standards of diagnos-
tic validity; and the functional impairment caused by adult
ADHD includes impairment in employment, education, and
economic and social functioning (see Agarwal, Goldenberg,
Perry, & Ishak, 2012; Barkley, Murphy, & Fischer, 2008;
Biederman, Faraone, Spencer, et al., 1993; Biderman, Wilens,
Spencer, et al., 1996; Spencer, Biederman, Wilens, & Faraone,
1998). Psychopharmacological treatment studies (see Wilens,
Biederman, & Spencer, 1998), genetic studies, including
adoption (Cantwell, 1972; Morrison & Stewart, 1973; Sprich,
Biederman, Crawford, Mundy, & Faraone, 2000) and family
studies (Biederman, Faraone, Keenan, Steingard, & Tsuang,
1991; Biederman, Faraone, Keenan, et al., 1992; Biederman,
Munir, Knee, et al., 1986; Biederman, Munir, Knee, et
al., 1987; Faraone, Biederman, Keenan, & Tsuang, 1991;
Goodman, 1989; Goodman & Stevenson, 1989; Lahey,

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Piacentini, McBurnett, et al., 1988; Morrison, 1980; Safer,

1973; Stevenson, Pennington, Gilger, DeFries, & Gillis, 1993;
Szatmari, Boyle, & Offord, 1993), as well as neuroimaging and
neurochemistry research (e.g., Spencer, Biederman, Wilens,
& Faraone, 2002; Zametkin & Liotta, 1998) and molecular
genetic research (see Adler & Chua, 2002) all support that
ADHD as a diagnosis meets the guidelines for diagnostic va-
lidity standards (i.e., Spitzer & Williams, 1985).

Estimates of the prevalence of ADHD in adulthood range

from 1% to 5% (Bellak & Black, 1992; Biederman et al.,
1996; Kessler, 2006; Murphy & Barkley, 1996b). Generally,
the symptoms of ADHD in adulthood are similar to those
in children, and although the literature on women and girls
is limited, symptoms seem to be similar across both genders
(Barkley, 1998; Biederman, Faraone, Spencer, Wilens, Mick,
& Lapey, 1994; Biederman et al., 1996). Accordingly, core
symptoms in adulthood include the following:

■ 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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sexual behaviors (see Barkley, Murphy, & Fisher, 2008, for a

review). Our pilot work further details residual symptom pres-
entation in adult patients treated with medication.

Diagnostic Criteria for ADHD

Generally, a diagnosis of ADHD is made by a mental health

professional, using the definition set forth in the Diagnostic
and Statistical Manual of Mental Disorders, 5th edition (DSM-
5; American Psychiatric Association [APA], 2013). The DSM-5
lists the symptoms and other requirements needed for individ-
uals to qualify for all of the various psychiatric disorders.

To meet criteria for adult ADHD, individuals must have at

least five symptoms out of the nine possible inattention symp-
toms and/or five symptoms out of the nine possible symptoms
of hyperactivity/impulsivity. If an individual has five or more
symptoms in only the inattention category, we would say that
he has ADHD, predominantly inattentive presentation. If he
has five or more symptoms in the hyperactivity/impulsivity cat-
egory, we would say that he has ADHD, predominantly hyper-
active/impulsive presentation. If he has five or more symptoms
in both categories, we would say that he has ADHD, combined
presentation.

Inattentive symptoms include such things as failing to give

close attention to details, difficulty sustaining attention in
tasks, seeming not to listen when being spoken to directly, fail-
ure to follow through on instructions, difficulties with organi-
zation, avoidance of tasks that require sustained mental effort,
frequently losing things, getting distracted easily, and being
forgetful.

Hyperactive/impulsive symptoms include fidgeting, leaving

one’s seat frequently, feelings of restlessness, being unable to
engage in quiet activities, being “on the go,” talking excessively,

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blurting out answers, having difficulty waiting in lines, and

frequently interrupting.

In addition, the person needs to have had at least some of the

symptoms before the age of 12, the symptoms need to be pres-
ent in at least two different settings, the symptoms need to
clearly interfere with the individual’s ability to function, and it
must be clear that the symptoms are not better accounted for
by a different mental disorder (APA, 2013).

Distinguishing Between ADHD as

a Diagnosis and Normal Functioning

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.

Also, to be appropriate for the diagnosis, the distress and im-

pairment must be caused by ADHD and not by another disor-
der. It is important to conduct a thorough assessment in order
to rule out the possibility that symptoms reflect another psy-
chiatric disorder.

It is also important to note that ADHD in adults is still

relatively unstudied. There is recent evidence for a cohort
of adults who meet criteria for ADHD-related impair-
ment, but without documented difficulties with attention
in childhood (Moffitt, Houts, Asherson, et al., 2015). That
is, a recent longitudinal study of over 1,000 people found

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a 6% prevalence in childhood ADHD (most cases were

male) and a 3% prevalence of adults with impairing ADHD
symptoms (with equal numbers of women and men), but
almost no overlap between these two cohorts. As is com-
monly reported, those individuals with childhood ADHD
tended to outgrow the full syndrome over time but did have
some select impairments that continued into their 30s. In
contrast, the adults with ADHD symptoms had substan-
tial impairment, but this impairment did not represent a
continuation of a childhood- onset disorder. The authors of
the study suggested reconsideration of the requirement that
some symptoms of ADHD must be present before the age
of 12 years should these findings be replicated. Another in-
terpretation is that family support may mask ADHD symp-
toms in childhood, but when an adult has to take on sig-
nificantly more responsibilities, symptoms begin to appear.
Regardless of how these diagnostic issues are sorted out over
time, ADHD symptom impairment in adulthood is an issue
in clear need of effective treatment options.

Treatment of ADHD with Medications

Medications have been the most extensively studied treatment

for adult ADHD (for a review see Faraone & Glatt, 2010).
Although highly useful in the treatment of adult ADHD, it
appears that medications are only partially effective. In con-
trolled studies of stimulant medications, and open studies of
tricyclic antidepressants, monoamine oxidase inhibitors, and
atypical antidepressants, 20% to 50% of adults are considered
nonresponders due to insufficient symptom reduction or in-
ability to tolerate these medications (Wender, 1998; Wilens,
Spencer, & Biederman, 2002a). Moreover, adults who are con-
sidered responders typically show a reduction in only 50% or
fewer of the core symptoms of ADHD, and these response rates
are worse than the rates found in children (Wilens, Biederman,

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& Spencer, 1998a; Wilens, Morrison, & Prince, 2011; Wilens,

Spencer, & Biederman, 2002a). In other words, many resid-
ual symptoms often persist for adults with ADHD despite ad-
equate medication treatment.

Although psychopharmacology may ameliorate many of the

core symptoms of ADHD (attentional problems, high activ-
ity, impulsivity), it does not provide the client with concrete
strategies and skills for coping with associated functional
impairment. Quality-of-life impairments such as undera-
chievement, unemployment or underemployment, economic
problems, and relationship difficulties associated with ADHD
in adulthood (Agarwal et al., 2012; Biederman et al., 1993;
Murphy & Barkley, 1996a; Ratey, Greenberg, Bemporad, &
Lindem, 1992; Safren et al., 2010) require active problem-
solving, which can be achieved with skills training over
and above medication management. Recommendations for
the optimal treatment of adult ADHD call for the use of
concomitant psychosocial interventions with medications
(Biederman et al., 1996; Wender, 1998; Wilens, Biederman,
& Spencer, 1998a; Wilens, Spencer, & Biederman, 1998b;
Wilens et al., 2011).

Development of This Treatment Program

This program was developed and initially tested at the Cognitive

Behavioral Therapy Program at the Massachusetts General
Hospital (MGH)/Harvard Medical School, Department of
Psychiatry. Input for the treatment came from the psychiatrists
who run the Adult ADHD program at MGH (Drs. Joseph
Biederman, Timothy Wilens, and Thomas Spencer) and treat
large numbers of adults with ADHD using medications.
Through their clinical and research efforts, these providers no-
ticed that although medications do help, they do not fully treat
the problem.

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To help conceptualize the treatment, we also reviewed pub-

lished guidelines about therapy for adult ADHD, including
a chart review by Wilens, McDermott, Biederman, Abrantes,
Hahesy, and Spencer (1999) that reported on a CBT approach
developed by Stephen McDermott (2000). This treatment was
grounded heavily in cognitive therapy.

Secondly, members of our team met with medication-treated

adults with ADHD for their input about the types of problems
for which they would want help from a CBT. These individu-
als’ difficulties included organizing and planning; distractibil-
ity; anxiety and depression; and procrastination. Additional
issues included anger and frustration management, and com-
munication skills. Examples are discussed below.

Organizing and Planning

Problems with organizing and planning involve difficulties fig-

uring out the logical, specific steps to complete tasks that seem
overwhelming. For many clients, this difficulty leads to giving
up, procrastination, anxiety, and feelings of incompetence and
underachievement. For example, several of our clients who were
underemployed or unemployed had never completed thorough
job searches, resulting in not having a job, working in much
lower-paying positions than they could have, or not working at
a job that would lead to appropriate employment.

Distractibility

Problems with distractibility can occur at work or school.

Many of our clients have reported that they do not com-
plete tasks because other less important things get in the way.
Examples might include sitting down at one’s computer to
work on a project, but constantly going on the Internet to
look up certain websites, or browsing social networking sites.

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One student in our program lived alone, and whenever he sat

down to work on his thesis, he would find another place in his
apartment to clean (even though it was already basically clean
enough).

Mood Problems (Associated Anxiety and Depression)

Secondary to core ADHD symptoms, many of our clients have

mood problems. These problems involve worry about events
in their lives, and sadness regarding either real or perceived
underachievement. Many individuals with ADHD report a
strong sense of frustration about tasks that they do not finish,
or do not do as well as they feel they could have.

Research on This Treatment Program

In 2005, we completed an initial randomized controlled trial

of the intervention described in the first edition of this manual
(Safren, Otto, Sprich, Perlman, Wilens, & Biederman, 2005).
This study involved comparing the effect of the CBT inter-
vention plus continued medications to continued medications
alone. Thirty-one adults with ADHD and stable psychophar-
macology for ADHD were randomized. Assessments included
ADHD severity and associated anxiety and depression rated by
an independent evaluator and by self-report. At the outcome
assessment, those who were randomized to CBT had signif-
icantly lower independent evaluator-rated ADHD symptoms
and global severity, as well as self-reported ADHD symptoms,
than those randomized to continued psychopharmacology
alone. Those in the CBT group also had lower independent
evaluator-rated and self-reported anxiety, lower independ-
ent evaluator-rated depression, and a trend to have lower self-
reported depression. CBT continued to show superiority over
continued psychopharmacology alone when statistically con-
trolling for levels of depression in analyses of core ADHD

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symptoms. There were significantly more treatment responders

among clients who received CBT compared with those who
did not. These data support the hypothesis that CBT for adults
with ADHD with residual symptoms is a feasible, accepta-
ble, and potentially efficacious next-step treatment approach,
worthy of further testing.

In conducting our next study and treating more clients with

ADHD following our protocol, we made some refinements
to the initial treatment protocol and modules. We found that
many participants reported problems specific to organizing
papers (e.g., bills, paperwork) and other items in their homes,
and therefore a session was added on this issue. We added a
specific section on family member support because a large pro-
portion of participants requested this assistance.

We subsequently conducted a larger five-year full-scale efficacy

study funded by a grant from the National Institute of Mental
Health to Dr. Safren also using the first version of our treatment
manual. This study involved comparing the intervention in this
manual (CBT) plus continued medications to a comparison
treatment (relaxation plus educational support [RES]) plus con-
tinued medications (Safren, Sprich, Mimiaga, Surman, Knouse,
Groves, & Otto, 2010b). Eighty-six adults with ADHD par-
ticipated in this study. The participants were randomly assigned
to receive CBT (n = 43) or an active skills-based comparison
condition (RES; n = 43). We found that participants receiv-
ing CBT achieved lower independent evaluator-rated posttreat-
ment scores on the Clinical Global Impression (CGI) scale and
the ADHD rating scale compared with participants receiving
the RES condition, and there were more responders in the
CBT group than the RES condition based on both CGI and
ADHD rating scale results. These gains were maintained at six-
and 12-month follow-up. The results were published in one of
the top medical journals, the Journal of the American Medical
Association, and it is rare that psychosocial or behavioral treat-
ment trials are published in this medical venue.

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About the Treatment

Although this therapist manual is designed for therapists with

some experience with CBT, some important information is
presented here. Many of the clients with adult ADHD will
not have heard about CBT. A good proportion of clients may
have tried other types of therapy such as supportive therapy or
psychodynamic psychotherapy. To lay the groundwork for an
approach that is likely quite different from previous approaches
they have tried (e.g., the sessions have an agenda, the treatment
is modular, and the treatment requires active practice outside
of the session that is considered to be as important as or more
important than what is done in the session itself), we find it im-
portant to be able to answer questions about the model behind
the treatment approach. Some of this information is also pre-
sented in the client workbook.
■ The cognitive component of CBT: Cognitive components
include thoughts and beliefs that can exacerbate ADHD
symptoms. For example, a person who is facing something
that he will find overwhelming might shift his attention else-
where, or think things like, “I can’t do this,” “I don’t want to
do this,” or “I will do this later.” These thoughts contribute
to negative feelings, which can interfere with successful com-
pletion of the task. Part of this treatment involves restructur-
ing these types of thoughts so that thinking is more adaptive.
■ The behavioral component of CBT: Behavioral compo-
nents are behaviors, or things people do, that can exacerbate
ADHD symptoms. The actual behaviors can include things
like avoiding doing what you should be doing, and keep-
ing or not keeping an organizational system. CBT aims to
recognize unhelpful behaviors and to help the client iden-
tify and implement more effective behaviors that target a
problem area.
Repeated home practice of both cognitive and behavioral strat-
egies is essential for creating longstanding changes.

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Below is an explanation of each of the components of the model

in Figure 1:

■ Core neuropsychiatric impairments— starting in childhood—

that prevent effective coping: Adults with ADHD, by defi-
nition, have been suffering from this disorder chronically
since childhood. Specific symptoms such as distractibility,
disorganization, difficulty following through on tasks, and
impulsivity can prevent people with ADHD from learning
or using effective coping skills.
■ Lack of effective coping can lead to underachievement and fail-
ures: Because of this, clients with this disorder typically have
sustained underachievement, or things that they might label
as “failures.”
■ Underachievement and failures can lead to negative thoughts
and beliefs: This history of failures can result in developing

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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overly negative beliefs about oneself, as well as negative,

maladaptive thinking when approaching tasks. The negative
thoughts and beliefs that ensue can therefore add to avoid-
ance or distractibility.
■ Negative thoughts and beliefs can lead to mood problems and
can exacerbate avoidance: Therefore, people shift their atten-
tion even more when confronted with tasks or problems,
and related behavioral symptoms can also get worse.

Role of Medications

The treatment approach depicted in this manual was designed

for and tested on individuals who have already been diagnosed
with ADHD and who have been taking medications. In our
clinical practices, we have found, anecdotally, that delivering
the treatment to unmedicated clients, or clients who have not
taken their medications prior to the session, has been some-
what more difficult. Problems with inattention, distractibility,
and impulsivity can interfere with the didactic aspects of CBT.
Hence, we find it important to inquire about regular medica-
tion use, and to discuss the importance of adherence to the
medication regimen— especially in the case of stimulants,
which are typically short-acting agents.

Medications are currently the first-line treatment approach for

adult ADHD, and they are the most extensively studied. The
classes of these medications are stimulants, tricyclic antidepres-
sants, monoamine oxidase inhibitors (antidepressants), and
atypical antidepressants. However, a good number of individu-
als (approximately 20% to 50%) who take antidepressants are
considered nonresponders. A nonresponder is an individual
whose symptoms are not sufficiently reduced by the medica-
tions, or an individual who cannot tolerate the medications.
Additionally, adults who are considered responders typically
show a reduction in only 50% or fewer of the core symptoms
of ADHD.

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Because of these data, recommendations for the best treat-

ment of adult ADHD include using psychotherapy with med-
ications. Medications can reduce many of the core symptoms
of ADHD: attentional problems, high activity, and impulsiv-
ity. However, medications do not intrinsically provide clients
with concrete strategies and skills for coping. Furthermore,
disruptions in overall quality of life, such as underachieve-
ment, unemployment or underemployment, economic prob-
lems, and relationship difficulties associated with ADHD in
adulthood, call for the application of additional ameliorative
interventions.

Outline of Modules

The treatment involves three core modules: (1) psychoeduca-

tion/organizing and planning, (2) coping with distractibility,
and (3) cognitive restructuring (adaptive thinking). In addi-
tion, we include optional, one-session modules on (1) procras-
tination and (2) involving a spouse, partner, or family member
in the treatment.

Organization and Planning

The first part of the treatment involves organization and plan-

ning skills. This includes skills such as the following:

■ Learning to effectively and consistently use a calendar

■ Learning to effectively and consistently use a task list
■ Working on effective problem-solving skills, including
breaking down tasks into steps and choosing a best solution
for a problem when no solution is ideal
■ Developing a triage system for mail and papers
■ Developing organizational systems for papers, electronic
files, and other items

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Managing Distractibility

The second part of treatment involves managing distractibility.

Skills include the following:

■ Determining a reasonable length of time that one can

expect to focus on a boring or difficult task and breaking
tasks down into chunks that match this length of time
■ Using a timer, cues, and other techniques (e.g., distractibil-
ity delay)

Cognitive Restructuring (Adaptive Thinking)

The third part of treatment involves learning to think about

problems and stressors in the most adaptive way possible. This
includes the following:

■ 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

An optional additional module exists for procrastination. We

include this because most of the previous modules do relate
to procrastination, but some people require extra help in this
area. This module therefore specifically points to how to use
the above skills to help with procrastination.

Informational Session with Spouse, Partner, or Family Member

An optional additional module exists for providing information

on ADHD and this treatment program to a spouse, partner,

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or family member. We include this because many individuals

with ADHD report that they have conflicts with spouses, part-
ners, and family members because of their ADHD symptoms.
Through this session, we attempt to provide the family member
with information and make sure that he or she is “on the same
page” about what is happening in the treatment and is aware of
how he or she can facilitate behavioral changes.

Structure of Sessions

The following activities are included in each session.

Setting an Agenda

It is important to begin each session by setting an agenda. This

helps maintain a structured focus on treatment for ADHD and
also prepares the client for what lies ahead in the upcoming ses-
sion. One of the challenges in this treatment is to avoid getting
distracted by discussions of other problems that clients may be
facing. At times, these problems are pertinent to their ADHD
difficulties and can be addressed in the context of the session
topics. At other times, it is necessary to convey empathy regarding
a client’s difficulty and acknowledge that one of the limitations of
this treatment is the need to remain focused so that there will be
enough time to go over all of the skills to manage ADHD symp-
toms. Inevitably, this means not having time to go into other
topics. We recommend assisting clients to identify other people
to whom they can turn for support around other difficulties.

Monitoring of Progress

This treatment approach involves regularly monitoring im-

provement. By administering a measure of ADHD symptoms

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each week, you, as a therapist, can determine whether the skills

are helping. Items that do not change on the ADHD assess-
ment can be targets for further discussion. Highlighting symp-
tom reduction (no matter how small) also serves to enhance
clients’ motivation to continue therapy and engage in home
assignments. We recommend using the Adult ADHD Self-
Report Scale (ASRS) Symptom Checklist, which is a checklist
based on the 18 DSM-IV-TR symptoms of ADHD. This can
be accessed at https://www.hcp.med.harvard.edu/ncs/ftpdir/
adhd/18Q_ASRS_English.pdf. You should go to this link and
print out the most current version of the scale and make copies
so that you can have the client fill it out before each session. We
find it important to start each session with a discussion of the
current symptom score, as well as a review of the homework.

Review of Homework from the Previous Week

Each session will also begin with a review of clients’ progress

implementing the skills from each of the previous modules. It
is important to acknowledge successes and to try to resolve any
difficulties they may be having. Repetition of new skills is crit-
ical for individuals with ADHD and will maximize the gains
made in treatment and increase the likelihood of sustaining
improvement. In both the client workbook and the therapist
guide, we provide a checklist tool to assess which skills were
practiced and where future work is needed.

Additional Discussion Points Regarding the Treatment

Not every topic can be covered at once. Because the treatment

approach is modular, clients may have areas of difficulty that
will not be addressed until future sessions. The program typ-
ically starts with implementing a calendar and task list. This
module also involves learning organizing and planning skills.

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The next module is on distractibility. People sometimes have

problems with the first module because they get easily dis-
tracted, and this is not covered until the next module. This is
something that we discuss in the first module. We present it
here because it is a point that can come up in different sessions
as the treatment progresses.

Motivation Is Key

As part of the treatment program, it is important that for each

and every skill, your client understands how it will specifically
help him or her. We use aspects of a motivational interviewing
framework to help clients stay engaged and, potentially, resolve
their ambivalence about change. The balance here is that this
is a very structured treatment, and in the style of motivational
interviewing, it is important to enhance and help strengthen
the client’s intrinsic motivation for change. Taking such an ap-
proach involves trying to, as much as possible, elicit the client’s
own motivation for change as you guide him or her through
homework and didactic content. As with any CBT treatment,
if clients are not motivated or do not understand how each spe-
cific skill can benefit them, it will be extremely difficult to have
them do the work outside of the sessions. The exclusive focus
of this treatment is to help clients do things differently outside
of the treatment itself. In motivational interviewing (Miller
& Rollnick, 2013), for example, one important skill is the
“Ask, Tell, Ask” (ATA) framework. This involves the therapist
asking a question, eliciting a response, telling the didactic in-
formation, and then asking another question. For clients with
ADHD, this can be especially useful to keep them engaged.
Here is a sample dialog between therapist and client:
T: You were just telling me a lot about the difficulties that you have had
due to ADHD. Would it be okay if I provide some information about
the treatment? (ASK)
C: Yes, that would be great; I really need some help with this.

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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).

Use of the Client Workbook

The client workbook will aid you in delivering this interven-

tion. It is set up in a session-by-session format and, for the most
part, corresponds with the sessions in the therapist guide. You
will learn, however, that at times, variability in delivery of the
modules is required. In addition, page numbers at times may
differ between the two manuals.

We have planned the session content so that an optimal amount

of information is presented in each session. We have found that
some clients cannot take in a lot of new skills in any one session.
We have also found that it is important to leave enough time
for problem-solving regarding material from previous sessions,
provision of psychosocial support, and “coaching” around the
fact that, given the modular framework, not all skills can be
learned at once. Finally, limiting the amount of new informa-
tion in each session allows for practice of relatively few skills
per week, and allows you to present all of the information even
when client distractions emerge.

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In various points throughout the sessions, we reference work-

sheets for the client to complete. These worksheets are located
in the Appendix at the end of both the therapist guide and the
client workbook. The appendices are the same in both volumes,
but since the client workbook has larger pages, the worksheets
are larger and easier to complete.

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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

It is important to begin each session by setting an agenda. This helps

maintain a structured focus on treatment for ADHD and also prepares
the client for what lies ahead in the upcoming session. One of the chal-
lenges in this treatment is to avoid getting distracted by discussions
of other problems clients may be facing. At times, these other issues

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are pertinent to their ADHD difficulties and can be addressed in the

context of the session topics. Other times, it is necessary to convey em-
pathy regarding a client’s difficulties and acknowledge that one of the
limitations of this treatment is the need to remain focused so that there
will be time to present all of the skills to manage ADHD symptoms.
Inevitably, this means that there is not enough time to go into other
topics. Assist clients in identifying other people to whom they can turn
for support around other difficulties. Again, in the spirit of motiva-
tional interviewing, while giving information and setting the agenda
are necessary for CBT, engage the client in the process and make sure
that you are actively asking the client questions along the way. This
process helps to ensure that the client feels the treatment is being deliv-
ered in a collaborative way.

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.

Provide Information About ADHD

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.

The treatment therefore involves actively learning skills. These skills

need to be practiced regularly in order for the client to improve. The
point is to get a system started, and stay motivated to keep it going.
It is important to convey the point that people with ADHD do have
skills—but the issue is to stay motivated to develop a workable system,
and keep using it.

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Determine Client’s Goals for CBT for ADHD

We view this section as a discussion to maximize the fit between the

treatment approach and the client’s goals. Chapter 4 in the client work-
book lists similar questions and a grid for assisting the client with de-
termining how realistic each goal is. One of the columns in the grid is
for “controllability.” In determining the goals, it is essential to focus on
goals that are controllable. For example, a goal of “getting a new job”
depends on many things—including the economy, one’s education,
and other factors. A more controllable goal would be to do as much
as possible to maximize one’s chances of getting a new job. This can
be operationalized later in the problem-solving section by identifying
steps such as updating one’s résumé, applying for jobs, and arranging
interviews.

The following questions may be helpful in helping clients come up with

their treatment goals:

■ What made you decide to start this treatment now?

■ In what ways would you like to approach tasks differently?
■ What are some issues that others have noticed about how you
approach tasks?
■ If you did not have problems with ADHD, what do you think
would be different in your life?

Discuss the Structure of the Sessions

At this point in the session, we provide an overview of the structure of

the sessions, and provide some information about how clients can get
the most out of treatment. The following points should be addressed in
this discussion. After approximately each three or four sentences, stop
and ask clients how they feel about that point, if they understand, and/
or if they have any questions. This should be a general rule for you as a
therapist throughout the didactic parts of the treatment (few sentences,
check in with client, repeat if necessary, and/or move on and give a few
more sentences).

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The Therapy Will Be Directive—Almost Like Taking

a Course

Every session has an agenda, and specific topics will be followed in

each session. The topics are also covered in the workbook Mastering
Your Adult ADHD. We put the information in both places so that
clients can easily refer back to the workbook to look up answers to
questions that they may have forgotten, and so that they can get ad-
ditional practice. Although all of the sessions’ contents are included
in the client workbook, we recommend that you discuss the impor-
tance of not reading too far ahead and trying all of the new skills
at once.

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:

Additionally, though it is directive and like taking a course, at the

beginning of each session we will need to set an agenda. At that
point I will bring up what is usually done in this session, but also
will want to know from you if there are things that you feel are
important to discuss, and if the agenda seems to make sense. How
does this sound?

The Therapy Involves Home Practice

As discussed in the introductory materials, the therapy involves home

practice. We consider the home practice to be as important as, or even
more important than, attendance at the sessions. Hence, each session in-
volves a review of the previous week’s home practice and a review of the
skills that have already been presented in the therapy, as well as assign-
ments for the upcoming week. In this way, the treatment is similar to
taking a course. If clients know that home practice assignments will be
reviewed the following week, they will have more incentive to commit
time to completing the assignments at home.

When working on home practice, present it not as “assignments” but

instead as mutually agreed-upon skills to try and see if they work better
than what the client has been doing in the past.

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The Therapy Involves Regular Monitoring of Progress

We recommend administering an outcome measure at each session.

For adult ADHD, the most widely used measure is the Adult ADHD
Self-Report Scale (ASRS) Symptom Checklist. This can be accessed at
(https://www.hcp.med.harvard.edu/ncs/ftpdir/adhd/18Q_ASRS_
English.pdf ). Print out the most current version of the scale and make
copies so that you can have the client fill it out before each session. At
the beginning of each session, review the total score and compare it to
previous assessments so that progress can be measured. You can also
identify any target areas that have not been resolved. Problem-solving
any difficulty with homework assignments or skills learned will help
lead to improvement.

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.

Review the client’s progress in a collaborative way. If symptoms are

higher than the week before, ask why this was the case. If symptoms are
lower, point to whatever skills the client tried and see if using the skills
seems to have contributed to the improvement.

Potential Pitfall with the Modular Approach: Clients May

Have Areas of Difficulty That Will Not Be Addressed Until
Future Sessions

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.

Practice Is Highly Important

Explain that because ADHD is associated with difficulties with follow-

through, some or all of the skills may seem difficult at first. This is
the reason for doing the work both with a therapist and by oneself. As
a consequence, regular review and practice of skills will occur in the
session itself, as well as outside the session during the week. Although
these skills may seem difficult at first, with practice they become much
easier and eventually become “second nature.”

Ask About Potential Problems with the Treatment Itself

Some difficulties with following the treatment program include attend-

ance, attention, and adherence to the treatment. These problems are
part of the diagnosis of ADHD itself but can potentially interfere with
the treatment. Convey to the client that when difficulties with follow-
through with the therapy itself arise, it is important to discuss them
instead of missing a session. Also convey that we realize that difficulties
with follow-through can be part of the disorder itself. Discuss the impor-
tance of attending all sessions in order to achieve benefit. Research on
most cognitive-behavioral interventions suggests that the more effort
clients put into a treatment, in terms of completing homework and at-
tending sessions, the more they will benefit.

Discuss a Plan for Refocusing When You Think the Session May
Be Going Off Topic

One potential difficulty can include staying on topic and sustaining

attention. Therefore, you will need to aid in refocusing if and when the
topic of importance is no longer the focus of attention in the session.

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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.

Motivation for Change

The next section of this session is dedicated to increasing the client’s

motivation for making changes. Some of these sections can be repeated
on an as-needed basis as the treatment continues.

We provide an illustration of some of the difficulties involved in doing

treatment oriented toward behavior change. This metaphor is one used
in Dr. Marsha Linehan’s dialectical behavioral therapy treatment pro-
gram (DBT; Linehan, 1993). You can tell the client that negative habits
leave people feeling as if they are stuck in a hole, but the only tool they
have available is a shovel (e.g., the negative habit). CBT is like a ladder.
If you’re only used to working with a shovel, the ladder can feel very
strange and difficult to use. However, the ladder is a much more effec-
tive tool to use to get out of a hole than a shovel.

Discussion Point: Medications

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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history of medication use, and beliefs about the usefulness of medication.

Explain that the symptoms of ADHD, such as distractibility or poor or-
ganization, may interfere with medication use: The client may have trou-
ble taking all of the prescribed doses or may have difficulty developing a
structured routine for taking medication. This treatment will help clients
prioritize taking their medication and will provide opportunities to work
with a therapist and solve any problems involved in taking medications.
Each week factors leading to missed doses will be discussed.

Task List and Calendar Systems

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.

Despite the abundance of electronic options for creating organizational

systems, some clients may prefer to use paper planners and notebooks.
If clients are technologically challenged or feel that this option is more
palatable for them, this is perfectly acceptable. The one caveat is that it is
important for the client to have the system available at all times. For ex-
ample, a client who makes a dentist appointment over the telephone while
out doing errands must be able to enter that appointment into the calendar
right away so that he does not forget about it and miss the appointment.
Discuss this issue with the client to find a workable solution. Leave the
option open that eventually the client may want to move to an electronic
system once he has mastered the use of the paper organizational system.

Involvement of a Significant Other During Treatment

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.

This meeting is particularly useful for discussing organizational systems

that affect other family members. If the family does not know what the
client’s system is, they may interfere by using an alternative method. The
family session is optional but is designed to involve a significant other.
Discuss the pros and cons of having this optional session, and, if desired,
plan the logistics of scheduling a session with a significant other.

Potential Pitfalls

Clients may be reluctant to make significant changes that will decrease

the impact of ADHD on their lives. They may feel overwhelmed, pes-
simistic about their success, or worried that they will not have enough
time to practice skills at home. It can help to emphasize that you will be
guiding them to make changes gradually, and that you will work together
to make the new skills feel manageable. New behaviors will feel different,
perhaps uncomfortable, at first, and may not lead to success immediately.

Sometimes thinking about change in terms of an experiment can be

helpful. Encourage clients to try the new strategies for several months so
that they have a better chance of becoming more familiar and automatic.
In the end, clients can always go back to their old ways, but we fully be-
lieve that they will have success with this treatment. It can also be helpful
to emphasize the potential benefit of making small changes: Looking at a
calendar each day may only take three minutes but can have a tremendous
payoff in terms of improved organization and increased productivity.

Practice

■ Create an organizational system with a calendar and a task list.

■ Put all appointments on the calendar and start ONE master task
list.

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■ Read over the materials for the next session.

■ If agreed upon, ask a family member to attend the family session
and contact the therapist to arrange scheduling if necessary.

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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Informational Session with

SESSION 2 Spouse, Partner, or Family
Member (if applicable)
(Corresponds with Chapter 3 of the Client Workbook)

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

■ ASRS Symptom Checklist

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

It is important to begin each session by setting an agenda. Review the

session outline with the client and family member. It may be helpful to
review the rationale for agenda setting for the family member. Explain
that you will be setting an agenda so that everyone will know what to
expect in the session and to ensure that you remain focused on helping
the client and family member learn more about managing ADHD. You
will also address ways in which ADHD may impact the relationship
and discuss ways that the family member can be helpful in facilitating
use of skills. It is helpful to acknowledge that you probably won’t be
able to cover everything in this one session, but you will try to make
the best use of this time.

THERAPIST NOTE: (See Potential Difficulties section.) It is common

that significant others have been frustrated and fed up with their part-
ner for a long time due to symptoms of ADHD. When doing this ses-
sion, it is important to (1) be realistic about progress, (2) avoid having
it become a session about how awful it has been for the partner, and
(3) work on positive steps to try to alleviate symptoms.

Symptom Checklist

Give the client a copy of the ASRS Symptom Checklist (https://www.

hcp.med.harvard.edu/ncs/ftpdir/adhd/18Q_ASRS_English.pdf) to
complete at the start of the session. Briefly review the score and take
note of symptoms that have improved and those that are still problem-
atic. Note the score and the date in your chart note for future reference.

Review of Material from Session 1

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

Ask the family member to complete the ASRS Symptom Checklist

as a secondary way to report on progress. If the family member and
client are willing, instruct the family member to complete the ASRS
Symptom Checklist and then compare ratings to see if problematic
areas are similar.

Discuss the Family Member’s Role During Treatment

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.

Preview Treatment Modules

To enlist the support of the partner or spouse, and to continue to instill

credibility and confidence in the treatment, it can be useful to preview
the treatment modules, and discuss with the partner or spouse how he
or she can relate to the effect of ADHD on the relationship. Explain
each module and brainstorm ways the partner/spouse can help.

Module 1: Organization and Planning

The central goal of this first set of sessions is to develop a comprehen-

sive system for organizing and planning. This means consistently using
a calendar and task list system (looking at the task list and calendar
daily), learning problem-solving skills, and managing organization.
Areas in which the significant other can help can include the following:

■ 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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Module 2: Coping with Distractibility

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.

Module 3: Adaptive Thinking (Cognitive Restructuring)

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

■ The client and family member should continue to discuss ways in

which the family member can provide support while the client is in
treatment.
■ The client should read over the materials for the next session.

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Case Vignette

T: We have now reviewed the educational materials on ADHD and

discussed the outline of CBT for ADHD. Let’s spend some time
thinking about how FM [name of the family member] can support
you during treatment. C, what kind of support do you think will be
most helpful for you?
C: I think finding time to do homework. There are so many demands
between my job, our family, and taking care of the house. I’m lucky
if I can get those tasks done.
FM: Maybe we can think of a task that I could do for you so you have a
little more time to work on CBT skills at home.
T: That is a great idea! We don’t want you to feel too burdened, but
if there is one task you could be responsible for during this 12-week
treatment, that would be helpful. C, what do you think?
C: I feel bad that she’ d be doing more work than she already does.
I guess I would want to make sure she was really okay doing that.
FM: You can trust me on this, but if there are days when I need some
extra help, I promise I will let you know.
T: So what would be the task to hand over?
C: I think the best time for me to do homework is first thing in the
morning. If she could get breakfast together, it would give me 15
minutes to work on homework. Would that be okay?
FM: I could definitely try that out.
T: I think what you’ ll find is that if C takes those 15 minutes in the
morning, he will actually be more organized and productive during
the day, which will help out FM as well in the end.
C: That’s true.
FM: Yes.
T: This is a great start! Keep in mind that you can revise your strategies.
Sit down in a week or two and check in with each other to see how
things are going. Ask if either one of you feels more burdened. With
communication, these challenges can be addressed. Good luck!

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Organization
SESSION 3
of Multiple Tasks
(Corresponds with Chapter 5 of the Client Workbook)

MATERIALS NEEDED

■ ASRS Symptom Checklist

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

To maintain a structured focus on treatment for ADHD and to prepare

the client for what lies ahead in the upcoming session, it is important to
begin each session by setting an agenda. Use the session outline above
to set the agenda.

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Review of Symptom Checklist

Give the client a copy of the ASRS symptom checklist (https://www.

hcp.med.harvard.edu/ncs/ftpdir/adhd/18Q_ASRS_English.pdf) to com-
plete at the start of the session. Briefly review the score and take note of
symptoms that have improved and those that are still problematic. Note
the score and today’s date in your chart note for future reference.

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:

■ Client is attempting to use calendar and task list systems on a

daily basis.
■ Client is putting all tasks that need to be completed on the master
task list.
■ Client has identified a consistent time and place for looking at the
calendar and creating a daily task list.

Review of Previous Sessions

As always, this session includes a review of the client’s progress imple-

menting the skills from each of the previous sessions. Review the cli-
ent’s progress implementing skills from Sessions 1 and 2. Acknowledge
the successes the client has achieved, and discuss and try to resolve
any difficulties. Clients should be putting their appointments on their
calendar on a regular basis and should have a master task list on which
they put all tasks that need to be completed. The system does not need
to be working perfectly at this stage, but it is important for the client to
be attempting to use the systems consistently. It is also a positive sign if
the client has identified a consistent time and place to be selecting tasks
for the day and planning how the tasks will be completed. If the client
has not yet started using a calendar and task list system, try to resolve

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this issue, because the client cannot effectively proceed with the treat-
ment until these systems are in place.

Review the use of tools for organization and planning:

■ 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).

Managing Multiple Tasks

We often need to manage multiple tasks at one time, but individuals

with ADHD can find it extremely difficult to decide which task is most
important. Even once they have decided that a particular task is impor-
tant, it is often difficult for them to stick with it until it is completed.
Other less important tasks can become distracters (e.g., cleaning,
making phone calls, going online) and the critical task gets overlooked.

The following exercise teaches clients a concrete strategy to decide which

tasks are most important. This technique is one example of how indi-
viduals can force themselves to organize tasks even though it is difficult
for people with ADHD to process this type of information. It can be
helpful to ask how the client feels about being more strategic in ap-
proaching the day. Some clients discuss wanting freedom for creativity
or inspiration, or feeling stifled by the restrictions of a list. You can help
assess the pros and cons of an organized versus unorganized day with
regard to productivity, personal satisfaction, and relationship cohesion.

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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the client is actually hoping to complete on a particular day. The client

can divide the list up into different sections, such as home projects and
work projects, if desired.

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.

Skill: The A, B, C’s

■ “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.

It can be helpful to map them out in a daily schedule in between other

appointments already in the calendar. For example, if a client looks at
his calendar and sees that he has a block of time between 10 and 11:30
a.m., he may schedule one of his “A” tasks into that time block on his
calendar. He may then schedule another “A” task into another free block
of time later in the day and his third “A” task into the time block before
he leaves work at the end of 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

The client may become discouraged or feel overwhelmed when trying

to learn these new strategies. These strategies serve as an investment in
the future, but like a monetary investment, it takes effort to set aside
other agendas to invest in the future. Also remind the client that new
behaviors become comfortable with repetition. Talk about the fact that

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it takes time to change longstanding habits, and review the benefits

of becoming more organized and more effective at completing long-
term goals. Help clients resolve any specific difficulties they may be
encountering.

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

T: Let’s take a look at your task list.

C: Okay.
T: I see that you have three things on your list for today. Let’s figure out
if each item should be rated as an “A,” “B,” or “C” task.
C: This is going to be difficult.
T: Well, let’s just take one item at a time. The first one is “clean out the
cat’s litter box.” What rating should we give that one?
C: Well, it’s pretty messy and it smells bad. I think my kids will really
start to complain if that doesn’t get done today.
T: Okay. Let’s assign that an “A” rating. How about the next one, “call
hair salon for appointment”?
C: Well, I do need a hair appointment sometime soon, but I guess it
wouldn’t be the end of the world if I waited a few days on that one.
It would only take a few minutes to do it, though, and then I could
check it off my list.

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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

■ ASRS Symptom Checklist

■ Worksheet 1: Problem-Solving: Selection of Action Plan (in the
Appendix)

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

To maintain a structured focus on treatment for ADHD and to prepare

the client for what lies ahead in the upcoming session, it is important to
begin each session by setting an agenda. Use the session outline above
to set the agenda.

Review of Symptom Checklist

Give the client a copy of the ASRS Symptom Checklist (https://www.

hcp.med.harvard.edu/ncs/ftpdir/adhd/18Q_ASRS_English.pdf ) to
complete at the start of the session. Briefly review the score and take note
of symptoms that have improved and those that are still problematic.
Note the score and today’s date in your chart note for future reference.

Signposts of Change

For this session, the signposts of change would be as follows:

■ Client is attempting to use calendar and task list systems on a daily

basis.
■ Client is putting all tasks that need to be completed on master
task list.
■ Client has identified a consistent time and place for looking at the
calendar and creating daily task list.
■ Client is using priority ratings for daily task list.

Review of Previous Sessions

As always, this session includes a review of the client’s progress imple-

menting the skills from each of the previous sessions. It is important to
acknowledge the successes the client has achieved and to try to resolve
any difficulties.

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.

Review the tools for organization and planning:

■ Use of calendar for managing appointments

■ Use of task list system
■ Use of the “A,” “B,” and “C” priority ratings

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.

Worksheet 1: Problem-Solving: Selection of Action Plan (in the Appendix)

will be used to select an action plan. Explain to the client that devel-
oping an action plan can be helpful when it is difficult to determine
how to resolve a problem or when the possibility of numerous solutions
becomes overwhelming. Selecting an action plan involves five steps:

1. Articulate the problem.

2. List all possible solutions.
3. List the pros and cons of each solution.
4. Rate each solution.
5. Implement the best option.

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Skill: Five Steps in Problem-Solving

Use these instructions in conjunction with Worksheet 1. When teach-

ing these steps, emphasize to clients that the goal of this exercise is
for them to learn a strategy called “problem-solving.” Although we are
looking for a specific example here, and you are going to help with that
specific example, the goal here is for the client to take this skill and the
steps described below and apply them to other problems that come up
in the future.

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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Skill: Breaking Down Large Tasks into Manageable Steps

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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Again, a big potential pitfall has to do with implementing a calendar

and task list system. Any client who has not yet been able to find a good
system should be encouraged to start using one immediately after the
session (or you can use the next session to start setting up systems with
the client using what he has available at the time).

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?”

It may also be useful to troubleshoot barriers to homework completion.

Ask the client, “What is most likely to get in the way of sitting down to
do this?” and “What thought might go through your head that might
derail completion of the homework?” (e.g., “I can do this later”).

Practice

■ Continue to put all appointments on the calendar.

■ Put all tasks on the master task list.
■ Use and look at the task list and calendar EVERY DAY!
■ 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 to the next day’s daily
task list.
■ Practice using Worksheet 1: Problem-Solving: Selection of Action
Plan for at least one item on the task list.
■ Practice breaking down one large task from the task list into
smaller steps.

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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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SESSION 5 Organizational Systems

(Corresponds with Chapter 7 of the Client Workbook)

MATERIALS NEEDED

■ ASRS Symptom Checklist

■ Worksheet 2: Steps for Sorting Mail (in the Appendix)
■ Worksheet 3: Developing an Organizational System (in the Appendix)

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

To maintain a structured focus on treatment for ADHD and to prepare

the client for what lies ahead in the upcoming session, it is important to

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begin each session by setting an agenda. Use the session outline above
to set the agenda.

Review of Symptom Checklist

Give the client a copy of the ASRS Symptom Checklist (https://

www.hcp.med.harvard.edu/ncs/ftpdir/adhd/18Q_ASRS_English.
pdf ) to complete at the start of the session. Briefly review the score
and take note of symptoms that have improved and those that are
still problematic. Note the score and today’s date in your chart note
for future reference.

Signposts of Change

For this session, the signposts of change would be as follows:

■ Client is attempting to use calendar and task list systems on a

daily basis.
■ Client is putting all tasks that need to be completed on master
task list.
■ Client has identified a consistent time and place for looking at the
calendar and creating daily task list.
■ Client is using priority ratings for daily task list.
■ Client has noted instances where items on the task list were not
being completed and asked himself, “What is getting in my way?”
“Is the task too big?” “Am I not really sure how to approach the
problem?” Following this, he has either broken the task down into
smaller steps or completed a problem-solving worksheet.

Review of Previous Sessions

As always, this session includes a review of the client’s progress imple-

menting skills from each of the previous sessions. It is important to
acknowledge the successes the client has achieved and to try to resolve
any difficulties.

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If the client is not displaying the signposts of change as described above,

take some time to understand what is getting in the way. Often, clients
realize that they “should” take the time to plan out their days, but
then, in the moment, decide that it is more effective to just jump right
into work rather than “wasting” time planning. You can use Socratic
questioning to try to get clients to come around to the view that time
spent planning will set them up for a more productive day and will be
time well spent.

Review the tools for organization and planning:

■ Use of calendar for managing appointments

■ Use of task list
■ Use of the “A,” “B,” and “C” priority ratings
■ Use of problem-solving (selecting an action plan and breaking
down large tasks into small steps)

Skill: Developing a Sorting System for Mail

Responding to Mail and Email/Paying Bills on Time

Most people find it somewhat difficult to organize mail, important

papers, and bills. Now that so many things are delivered electroni-
cally, this problem can apply to emails and electronic files as well as
to actual papers. Individuals with ADHD can find it overwhelming
to deal with these issues. This can lead to arguments with roommates
or family members, failing to pay bills on time, misplacing important
documents, and failing to complete important tasks. This can be ex-
tremely frustrating and upsetting for the client as well as for the client’s
family members, friends, and coworkers.

Finding a Structured System

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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organizational system in the long-term (e.g., decreased feelings of being

overwhelmed, fewer late fees, not missing out on opportunities due to
lost paperwork or missed deadlines). We recommend involving the cli-
ent’s spouse, partner, or roommate to develop a system that is mutually
agreeable.

Steps to Sort Mail

Go over Worksheet 2: Steps for Sorting Mail to help the client develop a
system for handling mail.

Strategy for Paying Bills

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.

Even with many automatic payments in place, it is likely that there

will be occasions when bills come in that fall outside of the payment
system. For example, medical bills, utility bills (e.g., water bill), parking
violations, and tax bills may not easily lend themselves to the automatic
payment system. Thus, it is important that the client have a system for
dealing with these bills so that they do not “fall through the cracks”
and cause difficulties. It may help to have the client list all bills, includ-
ing recurring and less frequent ones, and make sure a plan is in place to
address each one (e.g., automatic payment, a reminder on the calendar,
or a triage time to go through mail and emails).

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.

Skill: Developing Organizational Systems

Another common struggle for people with ADHD is keeping papers,

electronic files, and other items organized. Without systems in place,
people lose items, leading to frustration when they need these articles
or missed deadlines because they can’t find important information.
Furthermore, many people find it difficult to throw things away, result-
ing in a cluttered environment that makes it even more difficult to find
important papers or other items. We recommend coming up with sys-
tems that are both simple and effective. If systems are too complicated,
they are time consuming to use and people stop using them.

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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

If the client thinks that everything is important, ask him or her to

discuss this issue with friends and family to get different perspectives
on what items or files really need to be saved. Encourage the client to
invest the time in the short-term to set up these systems. Talk about
the value of having these systems in place in the long-term. Coach the
client regarding breaking down the steps of setting up the systems into
smaller steps.

Suggest that the client discuss the proposed organizational systems

with family members before setting them up. Issues may arise with the
systems if this step is skipped: For instance, if the spouse is still putting
the mail in a big pile on the chair, and the client is trying to use the
triage system, it won’t work very well.

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Practice

■ Continue to use the calendar every day to record appointments, and

put new tasks on the task list every day.
■ Use and look at task list and calendar EVERY DAY!
■ 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 to the next day’s task list.
■ Practice using Worksheet 1: Problem-Solving: Selection of Action
Plan for at least one item on the task list.
■ Practice breaking down one large task from the task list into smaller
steps.
■ Set up and use the organizational systems developed in session.

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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4

T: Well, let’s think of an example. Let’s say you get an invitation to go

to an event and you want to go.
C: I would need to keep that.
T: Well, I am just wondering: Is that the kind of thing that you could
centralize? I mean, write down the important information (like the
location, the time, and a phone number) in your calendar, and thus
eliminate the need for an additional piece of paper that you would
need to keep track of? You could even take a photo of the invita-
tion with your phone so that you would have a picture of the actual
invitation.
C: Well, that would be totally radical!
T: This is the kind of thing I am talking about: the big, difficult goal of
really trying to reduce as much paper as possible, and really trying to
centralize EVERYTHING in your calendar and task list.
C: Umm … okay. Well, I guess I could try that out.
T: Okay, so what other things do you want to keep near your triage
center?
C: I think I should keep my computer, stamps, envelopes, pens, scissors,
and my phone in case I need a calculator.
T: What times do you want to choose to use your triage center?
Remember, you should choose times when you can actually deal with
the bills, phone calls, etc.
C: I think I could do it before work on Monday, Wednesday, and
Friday.
T: Do you have enough time then?
C: I think so. I have about an hour free between the time when the kids
leave for school and when I need to leave for work. I could just sit
down and do it as soon as the kids leave.
T: Let’s try it. Can you put the times down on your calendar?
C: Sure.
T: Why don’t you try to practice this at home? It might seem very difficult
at first because you aren’t used to doing things this way. Try to stick
with it, though. If you run into difficulties, try writing them down
and bring them to next week’s session. Does that sound good?
C: Sure. I’ ll give it a try.

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MODULE 2

Reducing
Distractibility
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47

Gauging the Client’s

SESSION 6 Attention Span and
Teaching Distractibility
Delay
(Corresponds with Chapter 8 of the Client Workbook)

MATERIALS NEEDED

■ ASRS Symptom Checklist

■ Clock or stopwatch (smartphone can be used)

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

To maintain a structured focus on treatment for ADHD and to prepare

the client for what lies ahead in the upcoming session, it is important to
begin each session by setting an agenda. Use the session outline above
to set the agenda.

47
48

Review of Symptom Checklist

Give the client a copy of the ASRS Symptom Checklist (https://www.

hcp.med.harvard.edu/ncs/ftpdir/adhd/18Q_ASRS_English.pdf ) to
complete at the start of the session. Briefly review the score and take note
of symptoms that have improved and those that are still problematic.
Note the score and today’s date in your chart note for future reference.

Signposts of Change

For this session, the signposts of change would be as follows:

■ Client is attempting to use calendar and task list systems on a

daily basis.
■ Client is putting all tasks that need to be completed on master
task list.
■ Client has identified a consistent time and place for looking at the
calendar and creating daily task list.
■ Client is using priority ratings for daily task list.
■ Client has noted instances where items on the task list were not
being completed and asked herself, “What is getting in my way?” “Is
the task too big?” “Am I not really sure how to approach the prob-
lem?” Following this, client has either broken the task down into
smaller steps or completed a problem-solving worksheet.
■ Client has started to implement a system for decreasing the amount
of mail (paper and electronic) that comes in.
■ Client has identified areas that require an organizational system
and has at least started to implement the system as agreed upon
with you.

Review of Previous Sessions

As always, this session includes a review of the client’s progress imple-

menting skills from each of the previous sessions. It is important to
acknowledge the successes the client has achieved and to try to resolve
any difficulties.

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49

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.

Review the tools for organizing and planning:

■ Use of calendar for managing appointments: Assess whether the

client has begun to use a calendar consistently. Discuss how fre-
quently the client uses the calendar, making sure that he looks at
the calendar daily. Finally, discuss any problems that the client is
having with using the calendar system.
■ Use of task list: Review any difficulties that the client is having
using the task list on a daily basis. Emphasize the importance of
looking at and using the task list each and every day.
■ Use of the “A,” “B,” and “C” priority ratings: If the client is having
any trouble with prioritizing tasks, discuss at this point.
■ 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
current task list.

Introduction to Attention Span and Distractibility

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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having a short attention span as being associated with low intelligence

or ability; rather, it means that people with ADHD need to use extra
skills in order to cope.

Skill: Gauging the Client’s Attention Span

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.

Explain to the client that there really is no such a thing as an exact

amount of time that represents each individual’s attention span—it
is different for everyone. The amount of time that one can work on a
particular task will depend on many factors, including those related
to the task (level of complexity) and those related to the individual
(fatigue, level of interest in the task, whether she has eaten recently,
etc.). What you are trying to gauge with this exercise is a reasonable
amount of time that the client can expect herself to work on a boring
task. Often, individuals with ADHD will set unrealistic goals for
themselves (e.g., “I am going to study for eight hours straight”), and
then they end up not wanting to start the task because the goal is so
overwhelming.

The next strategy is to help the client use problem-solving skills to

break down important tasks into small steps that he can do within
the allotted amount of time. You can discuss the fact that the client
will be learning additional skills to help gradually increase the length
of time that she can spend working on tasks. You should highlight
the importance of scheduling blocks of time in which the client can
work on tasks and also the importance of scheduling breaks in be-
tween tasks. The break should have a specific time allotment so that
the client does not end up having 30 minutes of work time followed
by a three-hour break!

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Skill: Implementing the Distractibility Delay

The distractibility delay is an exercise that can be done in addition to

the strategies described above. It is similar to an exercise used in anxiety-
disorder treatments (e.g., Craske & Barlow, 2006) and can be used as a
strategy for delaying attending to distractions while working on boring or
unattractive tasks. Clients with ADHD often report that when a thought
pops into their heads while they are working on a task, it is tempting to
simply stop working on their current task and shift to working on the new
task. They report that this is because they worry about forgetting the new
task and not completing it at all. The reality is that this has been the cli-
ent’s experience in the past. Thus, the distractibility delay can be described
as a tool for getting the distractions out of the client’s head and “parking”
them somewhere where they will not be forgotten, so that the client can
focus on the task at hand. Over time, the client will gain confidence that
these thoughts will not be forgotten and will actually get done.

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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Clients can be instructed to use the distractibility delay in a similar

fashion during meetings. For example, a client who tends to impul-
sively blurt out comments or questions can bring a notepad or tablet
to meetings, write down a cue word or phrase, and then try to refocus
his attention on the meeting. When there is a break in the conversation
or after the meeting, the client can bring up the question or comment.

Potential Pitfalls

Clients may become frustrated if they aren’t able to immediately im-

plement the distractibility delay and/or increase the length of time that
they can spend working on important or boring tasks. Clients should
be encouraged to look at this as a process that may take a while to im-
prove. They should be reminded that it took them many years to de-
velop their old habits, and it is not realistic to expect they will change
overnight.

Practice

■ Continue to use the calendar every day to record appointments, and

put new tasks on the task list every day.
■ Use and look at task list and calendar EVERY DAY!
■ 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 to the next day’s task list.
■ Practice using Worksheet 1: Problem-Solving: Selection of Action
Plan for at least one item on the task list.
■ Practice breaking down one large task from the task list into
smaller steps.
■ Use the organizational systems developed in this program.
■ Gauge attention span.
■ Use the distractibility delay when working on boring or unattrac-
tive tasks.

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Case Vignette

C: I’m not sure if I will be able to do the distractibility delay. I’m so

used to doing things as soon as the idea strikes me.
T: Well, does that usually work for you?
C: No, not really. I usually start things, and then I go off and start
doing other things, and I forget what I was even working on in the
first place.
T: So, do you think it makes sense to try a different strategy?
C: I guess so.
T: Well, what’s the worst thing that could happen if you try the dis-
tractibility delay technique?
C: I could feel really uncomfortable when I just write down the distrac-
tion but don’t do it right away.
T: Do you think you could tolerate this?
C: I guess so.
T: Do you want to give it a try?
C: Okay. It’s worth a shot.

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5

Modifying
SESSION 7
the Environment
(Corresponds with Chapter 9 of the Client Workbook)

MATERIALS NEEDED

■ ASRS Symptom Checklist

■ Worksheet 4: Strategies for Reducing Distractions (in the Appendix)
■ Alarm device

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

To maintain a structured focus on treatment for ADHD and to prepare

the client for what lies ahead in the upcoming session, it is important to
begin each session by setting an agenda. Use the session outline above
to set the agenda.

55
56

Review of Symptom Checklist

Give the client a copy of the ASRS Symptom Checklist (https://www.

hcp.med.harvard.edu/ncs/ftpdir/adhd/18Q_ASRS_English.pdf ) to
complete at the start of the session. Briefly review the score and take note
of symptoms that have improved and those that are still problematic.
Note the score and today’s date in your chart note for future reference.

Signposts of Change

For this session, the signposts of change would be as follows:

■ Client is attempting to use calendar and task list systems on a

daily basis.
■ Client is putting all tasks that need to be completed on master task list.
■ Client has identified a consistent time and place for looking at his
calendar and creating daily task list.
■ Client is using priority ratings for daily task list.
■ Client has noted instances where items on the task list were not
being completed and asked himself, “What is getting in my way?”
“Is the task too big?” “Am I not really sure how to approach the
problem?” Following this, the client has either broken the task down
into smaller steps or completed a problem-solving worksheet.
■ Client has started to implement a system for decreasing the amount
of mail (paper and electronic) that comes in.
■ Client has identified areas that require an organizational system and
has at least started to implement the system as agreed upon with you.
■ Client has encountered situations where he needed to concentrate
on a boring task and has attempted to use distractibility delay.

Review of Previous Sessions

As always, this session includes a review of the client’s progress imple-

menting skills from each of the previous sessions. It is important to
acknowledge the successes the client has achieved and to try to resolve
any difficulties.

56
57

It is important to focus on the fact that the client is attempting to use

these skills, even if the outcome is not 100% perfect. You should con-
tinue to emphasize that the ineffective behavior patterns probably de-
veloped over many years, and it is not realistic to expect that they will
completely change in just a few weeks. You can let clients know that
what is most important at this stage is that they are trying to notice
times when they are behaving in an ineffective manner and then are
using skills to become more effective.

Review the tools for organization and planning:

■ Use of calendar for managing appointments: Discuss any problems

the client is having using the calendar system.
■ Use of task list: Review any difficulties the client is having with re-
cording tasks and looking at the task list on a daily basis.
■ Use of the “A,” “B,” and “C” priority ratings: Discuss any difficul-
ties 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.

Review the tools for reducing distractibility:

■ Use of strategy for breaking boring tasks down into manageable

chunks: Discuss any problems the client is having breaking down
large and/or boring tasks into manageable chunks.
■ Use of the distractibility delay: Review any difficulties the client is
having with the distractibility delay technique.

Skill: Controlling the Work Environment

It is important for individuals with ADHD to work in an environ-

ment that has few distractions. Even with the coping with distract-
ibility skills discussed above, most people are somewhat distractible
when they are trying to concentrate. Sometimes distractions inter-
fere to the point where it is too difficult to get things done. When
conducting this session, refer back to the session on organizational
systems.

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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.

Individuals who work in an office setting may have fewer opportunities

to control distractions due to the limitations of the workplace. You can
discuss this with the client and explore things over which the client
does have control in the office environment (e.g., turning desk away
from window, closing office door at specific times, turning off ringer on
phone while working on a project).

Skill: Keeping Track of Important Items

One hallmark symptom of ADHD is frequently losing important

items. This can cause clients to be late and to feel frustrated. Ask the

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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.

Instruct the client to involve other family members in the process. If

everyone in the household is aware of where things belong, they can
be helpful in reminding the client to put her things away if they notice
that something is out of place. Also, emphasize the importance of plac-
ing the item in the appropriate place as soon as the client notices that
something is out of place.

Skill: Using Reminders

Another strategy for managing distractibility is to use reminders to

cue clients to use their skills. An alarm device can prompt clients to
check in with themselves on a regular basis about whether they are
on task. Most phones have alarms that can be used for this purpose.
Alternatively, the client can set up a task (or multiple repeating tasks
during the day) on an electronic calendar with a label “am I on task.”
Use an alarm to provide a reminder(s) on the device. When the alarm
sounds, the client should ask, “Am I doing what I am supposed to be
doing or did I get distracted?” If the client has become distracted, he
should immediately return to the task at hand.

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

■ Continue to use the calendar every day to record appointments and

put new tasks on the task list every day.
■ Use and look at the task list and calendar EVERY DAY!
■ 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 to the next day’s task list.
■ Practice using Worksheet 1: Problem-Solving: Selection of Action
Plan for at least one item on the task list.
■ Practice breaking down one large task from the task list into
smaller steps.
■ Use triage center to sort bills, papers, and mail.
■ Use the organizational systems developed in this program.
■ Use the distractibility delay when working on boring or
unattractive tasks.
■ Use skills in this module to reduce distraction in your work
environment.
■ Start putting important items in specific places.
■ Use reminders to check in to see if you have become distracted
when you are trying to focus on completing a task.

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

■ ASRS Symptom Checklist

■ Worksheet 5: 3- Column Thought Record (in the Appendix)
■ Worksheet 6: 4- Column Thought Record (in the Appendix)
■ “List of Common Thinking Errors” (in this session and in client
workbook Chapter 10)
■ “Preliminary Instructions for Adaptive Thinking” (in this session, in
client workbook Chapter 10, and in the Appendix [identified as a
handout])
■ Two completed sample thought records (in this session and in client
workbook Chapter 10)

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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■ Introduce the list of thinking errors.

■ Discuss labeling thinking errors using Worksheet 6: 4-Column
Thought Record.
■ Assign home practice.

Set Agenda

To maintain a structured focus on treatment for ADHD and to pre-

pare the client for what lies ahead in the upcoming session, it is impor-
tant to begin each session by setting an agenda. Use the session outline
above to set the agenda.

Review of Symptom Checklist

Give the client a copy of the ASRS Symptom Checklist (https://www.

hcp.med.harvard.edu/ncs/ftpdir/adhd/18Q_ASRS_English.pdf )
to complete at the start of the session. Briefly review the score and take
note of symptoms that have improved and those that are still problem-
atic. Note the score and the date in your chart note for future reference.

Signposts of Change

For this session, the signposts of change would be as follows:

■ Client is attempting to use calendar and task list systems on a daily

basis.
■ Client is putting all tasks that need to be completed on master
task list.
■ Client has identified a consistent time and place for looking at cal-
endar and creating daily task list.
■ Client is using priority ratings for daily task list.
■ Client has noted instances where items on the task list were not
being completed and asked, “What is getting in my way?” “Is the
task too big?” “Am I not really sure how to approach the problem?”
Following this, client has either broken the task down into smaller
steps or completed a problem-solving worksheet.

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■ Client has started to implement a system for decreasing the amount

of mail (paper and electronic) that comes in.
■ Client has identified areas that require an organizational system
and has at least started to implement the system as agreed upon
with you.
■ Client has encountered situations where he or she needed to con-
centrate on a boring task and has attempted to use distractibility
delay.
■ Client has identified a “home” for important items in his or her
living space and has started placing the important items in the des-
ignated spot on a regular basis.
■ Client has attempted to use strategies for reducing distractibility
that were identified in session.
■ Client has started using an alarm to check in and see if he or she has
become distracted when working on important or difficult tasks.

Review of Previous Sessions

As always, this session includes a review of the client’s progress imple-

menting skills from each of the previous sessions. It is important to
acknowledge the successes the client has achieved and to try to resolve
any difficulties.

It is important to focus on the fact that the client is attempting to

use these skills, even if the outcome is not 100% perfect. You should
continue to emphasize that the ineffective behavior patterns probably
developed over many years, and it is not realistic to expect that they
will completely change in just a few weeks. What is most important at
this point is that the client is trying to notice times when he or she is
behaving in an ineffective manner and is then using skills to become
more effective.

Review the tools for organization and planning:

■ Use of calendar for managing appointments: Discuss any problems

the client is having using the calendar system.
■ Use of task list: Review any difficulties the client is having with re-
cording tasks and looking at the task list on a daily basis.

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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.

Review the tools for reducing distractibility:

■ Use of strategy for breaking down boring tasks into manageable

chunks: Discuss any problems the client is having breaking down
large and/or boring tasks into manageable chunks.
■ Use of the distractibility delay: Review any difficulties the client is
having with the distractibility delay technique.
■ Use of strategy to remove distractions from the environment
■ Have a specific place for each important object
■ Use of cue control reminders: alarm, “Am I doing what I am sup-
posed to be doing?”

Introduce the Cognitive-Behavioral Model of ADHD

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.

This method of learning to think adaptively has been used in simi-

lar cognitive-behavioral treatments and has been effective in treating
many other psychological disorders, such as depression and anxiety dis-
orders.1 The major goal of learning to think about tasks and situations
adaptively is to reduce the frequency of times when negative and/or
unhelpful thoughts or moods interfere with tasks or follow-through or

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.

add to distress or distractibility. Your aim is to communicate the mes-

sage that previously learned strategies can be impeded by negative and/
or unhelpful thoughts. However, your client can learn strategies for
removing these barriers and thereby more effectively manage symptoms
of ADHD.

Adaptive thinking will enable clients to do the following:

■ Increase their awareness of negative, interfering thoughts

■ Increase their awareness of unhelpful thoughts
■ Develop strategies for keeping thoughts in check
■ Minimize symptoms

Adaptive thinking is important because of the interrelationship

among thoughts, feelings, and behaviors (Fig. 8.1). This model
emphasizes the important connection among thoughts, feelings,
and behaviors in a given situation. The cognitive part of cognitive-
behavioral therapy refers to the fact that thoughts contribute to how
people act and feel.

The Cognitive Component of Treatment: Automatic Thinking

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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be detrimental when they are characterized by negative content. You

might present this concept in the following manner:

In the course of a given day, numerous thoughts go through our

minds. What is surprising is that we often are not aware of these
thoughts. However, they play an important role in determining how
we are feeling in a situation, and how we may respond behaviorally.
When we are feeling overwhelmed or stressed or are anticipating
completing a task, the thoughts that go through our minds play a
critical role in determining the outcome of the situation.
These thoughts are “automatic”— they happen on their own. For
example, think about when you first learned to drive a car. In order
to coordinate many tasks at once, you had to be conscious of handling
the steering wheel, remembering to signal for turns, staying exactly in
your lane, avoiding other traffic, and trying to park. You were doing
many tasks at the same time that required your total attention.
Now, think about driving today. You probably know how to drive
without actively thinking about what you are doing. You likely don’t
even remember thinking about all of these steps because they have
become automatic. This can be a positive thing, in that it frees up
your attention to focus on other things, like what you will do when
you get to work, or what you need to pick up from the grocery store
later on. However, if the thoughts are negative in tone, this can be
problematic.

Less Helpful Automatic Thinking

In many situations, like the one we discussed above, automatic

thoughts enable us to complete a task more easily. Unfortunately, in
other situations, automatic thoughts interfere with accomplishing
goals. For example, imagine you have to do a task you will probably
not enjoy, such as preparing your tax return. Imagine the following
types of thoughts going through your mind:
“I am careless and am going to do this wrong.”
“This is going to take forever.”
“If I complete my return, I will realize I owe money.”

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“If I owe money, I won’t have enough for rent.”

If these thoughts are going through your head, then you can easily see
that this task will feel overwhelming and stressful. This will increase
the chance that you will procrastinate by doing any other possible task.

Thinking That Is Too Positive

So far, we have talked about NEGATIVE automatic thoughts. However,

researchers are now identifying another problematic way of thinking in
adults with ADHD that involves overly optimistic thinking (Knouse &
Mitchell, 2015). These authors claim that adults with ADHD often set
overly optimistic goals and verbalize overly positive thoughts. This pattern
can cause difficulties in that individuals feel good in the moment (e.g.,
“I don’t really need to do this today because I have plenty of time to do
it next weekend”). However, it causes problems when the thinking and
goal setting is unrealistic, and the person ends up failing to meet his or
her goals. Thus, we will be working on identifying these overly positive
thoughts in addition to helping you identify negative thoughts.

Relationship of Thoughts to Feelings and Behaviors

To help your client understand why it is important to identify and

change maladaptive thinking, discuss the relationship between auto-
matic thinking and behavioral outcome, usually some form of avoid-
ance. Negative automatic thoughts about a situation can cause a person
to avoid the situation because he or she (1) feels worse and (2) expects
the outcome of the situation to be negative. Avoidance can lead to more
anxiety, restlessness, and perhaps irritability or depression—because
the task doesn’t get done, and then the person feels worse about it.

Overly positive thinking can lead to avoidance as well. Even though

the accompanying affect is very different, the outcome is the same: The
individual with ADHD avoids the task and ultimately it does not get
done on time, does not get done well, or does not get done at all.

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.

Skill: Identifying Negative/Unhelpful Automatic Thoughts

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.

Ask clients to identify one distressing situation they experienced in the

past week or a time when they felt overwhelmed, stressed, sad, or upset.
You can also ask them to try to look for thoughts that are overly opti-
mistic yet unhelpful. These thoughts can be harder to identify in the
moment because there is not a negative affect associated with them.
After the fact, clients can identify these thoughts more easily.

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.

Ask the client to write a brief description of the situation in Column 1:

■ When did it take place?

■ Where were you?
■ With whom?
■ What was going on?

Ideally, the description of the situation should be a sentence or two at most.

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Then, instruct the client to write down all of his or her automatic
thoughts in Column 2:

■ What was going through your mind at the time?

■ What were you saying to yourself about the situation? To other people?
■ What was your role in the situation?
■ What were you afraid might happen?
■ What is the worst thing that could happen?
■ What does this mean about how the other person feels/thinks about
you?

THERAPIST NOTE: When coming up with automatic thoughts, it is

important to help clients separate thoughts from feelings. Gently instruct
clients that thoughts are ideas going through their minds during the sit-
uation; feelings go in the next column.

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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Introduce Thinking Errors

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.

Box 8.1 Common Thinking Errors

All-or-Nothing Thinking: You see things in black and white

categories. For example, ALL aspects of a project need to be
completed immediately, or if your performance falls short of
perfect, you see it as a total failure.

Overgeneralization: You see a single negative event as a never-

ending pattern.

Mental Filter: You pick out a single negative detail and dwell on it
exclusively, overlooking other positive aspects of the situation.

Disqualifying the Positive: You reject positive experiences by

insisting they “don’t count” for some reason or other. In this way,
you can maintain a negative belief that is contradicted by your
everyday experiences.

Jumping to Conclusions: You make a negative interpretation, even

though there are no definite facts that convincingly support your
conclusion.

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Mind Reading: You arbitrarily conclude that someone is reacting

negatively to you, and you don’t bother to check this out.

Fortune Telling: You anticipate that things will turn out badly,
and you feel that your prediction is a predetermined fact.

Magnification/Minimization: You exaggerate the importance of

things (such as your mistake, or someone else’s achievement), or
you inappropriately shrink things until they appear tiny (your own
desirable qualities or other people’s imperfections).

Catastrophizing: You attribute extreme and horrible consequences

to the outcomes of events. One mistake at work = being fired from
your job.

Emotional Reasoning: You assume that your negative emotions

necessarily reflect the way things really are: “I feel it, so it must be
true.”

“Should” Statements: You try to motivate yourself with “shoulds”

and “shouldn’ts,” as if you need to be punished before you could
be expected to do anything. When directed toward others, you
feel anger, frustration, and resentment.

Labeling and Mislabeling: This is an extreme form of

overgeneralization. Instead of describing an error, you attach a
negative label to yourself or others.

Personalization: You see negative events as indicative of

some negative characteristic of yourself or others, or you take
responsibility for events that were not your doing.

Maladaptive Thinking: You focus on a thought that may be true,

but over which you have no control. Excessively thinking about it
can be self-critical or can distract you from an important task or
from attempting new behaviors.

Overly Optimistic Thinking: You think about a situation in an

overly optimistic way that feels good in the moment but leads to
procrastination and/or avoidance and is not effective in the long run.
This list is adapted from Hope, Heimberg, Juster, & Turk (2000), with some
modifications. The list from Hope et al. (2000) was in turn based on Persons (1989).
Overly optimistic thinking is derived from Knouse & Mitchell (2015).

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Skill: Labeling Thinking Errors

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.

THERAPIST NOTE: As we emphasized in previous modules, instruct-

ing clients to practice new skills is vital so that they become familiar with
them, are able to easily use them, and begin to see the positive results that
can emerge when they consistently use these strategies. Remind clients
that when they are first learning a new skill, it may feel awkward, may
be confusing, and may require effort to implement. That’s okay! The
more they practice, the easier it will become.
In this session, try to anticipate which situations clients may want to
work on in the upcoming week. Anticipate any problems that may get
in the way of completing the homework. For example, having a busy
schedule, going out of town, or being uncertain about how to complete
an assignment may make it more difficult for clients to practice skills.
We have found that if clients can work with their therapist to anticipate
and problem solve in advance, these obstacles can become manageable,
and clients will be more likely to achieve success with the new skills.
Also, remind clients that they do not have to complete these home assign-
ments perfectly! The idea is for them to begin monitoring the thoughts
that arise in difficult situations and begin to practice identifying the
common types of thinking errors.

Preliminary Instructions for Adaptive Thinking

The purpose of using thought records is to identify and modify nega-

tive, automatic thoughts in situations that lead to feeling overwhelmed.
These instructions also appear in client workbook Chapter 10 and in
the Appendix (identified as a handout).

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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

■ Continue to use the calendar every day to record appointments and

put new tasks on the task list every day.
■ Use and look at task list and calendar EVERY DAY!
■ 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 to the next day’s task list.
■ Practice using Worksheet 1: Problem-Solving: Selection of Action
Plan for at least one item on the task list.

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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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T: If you think it will be difficult to have a paper form, you might

consider putting the thought record into your phone, tablet, or com-
puter, or using one of the available apps for this purpose. [Therapist
acknowledges client’s concerns, but gently encourages the client
to practice for a while and then determine if the feared outcome
is true.]
C: I guess that makes sense. Let’s just see what happens.
T: Good. Can you think of a situation in which you were experiencing
negative feelings from this past week?
C: Yes. I got a notice in the mail from my bank requesting copies of my
last six paystubs because there was an error with my direct deposit.
I have been really anxious and worried about it and haven’t been
able to respond to them all week.
T: Okay. So let’s write down the situation in the first column. Next,
can you identify some of the thoughts that were going through your
mind when you got the notice? [The therapist takes a matter- of-fact
approach and begins to break down the situation into the appropri-
ate columns.]
C: I really freaked out. I don’t want them to take back any money.
T: Then let’s write down your thought, “I don’t want them to take back
any money” in the next column. Were there any other thoughts run-
ning through your mind?
C: Yes. I don’t even know where my paystubs are. This is such a pain in
the neck. I shouldn’t have to spend time doing this stuff.
T: Okay. Let’s write all these thoughts down. You said you freaked out.
What were you feeling at the time? [The therapist assists the client in
distinguishing between thoughts and feelings.]
C: I was anxious, overwhelmed, annoyed, worried …
T: Good. You’re doing a great job breaking down this difficult situa-
tion. Can you rate those feelings on a scale of 0 to 100?
C: Umm, anxious 85, overwhelmed 100, annoyed 70, worried 90.
T: Okay, now let’s take a look at the list of thinking errors. Do you
think it makes sense to have these thoughts you described, or do any
of them fall under the categories listed here?
C: Well, I really don’t know where the paystubs are, this really is a pain
in the neck, and if it’s their error, I shouldn’t have to waste my time

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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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SESSION 9 Adaptive Thinking

(Corresponds with Chapter 11 of the Client Workbook)

MATERIALS NEEDED

■ ASRS Symptom Checklist

■ Worksheet 7: 5- Column Thought Record (in the Appendix)
■ Coaching story (in this session and in client workbook Chapter 11)
■ Instructions for completing the 5- Column Thought Record and de-
veloping a rational response (in this session, in client workbook
Chapter 11, and in the Appendix [identified as a handout])

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

To maintain a structured focus on treatment for ADHD and to prepare

the client for what lies ahead in the upcoming session, it is important to
begin each session by setting an agenda. Use the session outline above
to set the agenda.

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Review of Symptom Checklist

Give the client a copy of the ASRS Symptom Checklist (https://www.

hcp.med.harvard.edu/ncs/ftpdir/adhd/18Q_ASRS_English.pdf) to
complete at the start of the session. Briefly review the score and take
note of symptoms that have improved and those that are still problem-
atic. Note the score and the date in your chart note for future reference.

Signposts of Change

For this session, the signposts of change would be as follows:

■ Client is attempting to use calendar and task list systems on a daily

basis.
■ Client is putting all tasks that need to be completed on master
task list.
■ Client has identified a consistent time and place for looking at cal-
endar and creating daily task list.
■ Client is using priority ratings for daily task list.
■ Client has noted instances where items on the task list were not
being completed and asked, “What is getting in my way?” “Is the
task too big?” “Am I not really sure how to approach the problem?”
Following this, client has either broken the task down into smaller
steps or completed a problem-solving worksheet.
■ Client has started to implement a system for decreasing the amount
of mail (paper and electronic) that comes in.
■ Client has identified areas that require an organizational system
and has at least started to implement the system as agreed upon
with you.
■ Client has encountered situations where he needed to concentrate
on a boring task and has attempted to use distractibility delay.
■ Client has identified a “home” for important items in his living
space and has started placing important items in the designated
spot on a regular basis.
■ Client has attempted to use strategies for reducing distractibility
that were identified in session.
■ Client has started using an alarm to check in to see if he has become
distracted when working on important or difficult tasks.

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■ Client has completed a thought record with at least two examples

of thoughts that occurred during the week and brought it to the
session.

Review of Previous Sessions

As always, this session includes a review of the client’s progress imple-

menting skills from each of the previous sessions. It is important to
acknowledge the successes the client has achieved and to try to resolve
any difficulties. Remember, repetition of new skills is critical for indi-
viduals with ADHD and will maximize gains made in treatment.

At this stage, it is important to see that the client is attempting to com-

plete thought records. It may seem “silly” to some clients to go through
this exercise. However, you can emphasize the importance of getting
thoughts “out of your head” so that they can be evaluated more objec-
tively. If the client did not complete a thought record, this can be done
in session using examples of thoughts that the client recalls from the
previous week.

Review the tools for organization and planning:

■ Use of calendar for managing appointments: Discuss any problems

the client is having using the calendar system.
■ Use of task list: Review any difficulties the client is having with re-
cording tasks and looking at the task list on a daily basis.
■ 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.

Review the tools for reducing distractibility:

■ Use of strategy for breaking down boring tasks into managea-

ble chunks: Discuss any problems the client is having with this
strategy.
■ Use of the distractibility delay: Review any difficulties the client is
having with this technique.

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■ Use of strategy to remove distractions from the environment

■ Have a specific place for each important object
■ Use of cue control reminders: alarm, “Am I doing what I am sup-
posed to be doing?”

Review the tools for developing adaptive thinking:

■ Use of thought record (either on paper or electronically) to identify

and label automatic thoughts: Review any difficulties the client re-
ports with using this strategy.

Review the thought records the client completed at home. If no thought

records were completed, try to identify the obstacles that interfered and
use the problem-solving skills to determine the best way for the client
to work on automatic thinking. Did the client have difficulty making
time for home practice? Were the directions confusing? Was it diffi-
cult for the client to see his thoughts in writing? It is possible to try to
work with clients on “rethinking” the situation in their head versus on
paper. We have found that writing out the automatic thoughts helps
people “step back” from their thoughts and better identify the differ-
ence between thoughts and emotions, but in reality, it can sometimes
be difficult to get clients with ADHD to take the time to monitor their
thoughts.

If the client didn’t do any home practice, work on a thought record

together before moving on. Continue to emphasize the importance of
reviewing skills at home.

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.

Skill: Formulating a Rational Response

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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thoughts. To understand how powerful thoughts can be, we tell the

coaching story in Box 9.1. This story is meant to help the client rec-
ognize negative and/or unhelpful thoughts as they pop up (Coach
A thoughts) and to learn to develop more supportive, rational thinking
(Coach B thoughts).

Box 9.1 Coaching Story

This is a story about Little League baseball. I talk about Little

League baseball because of the amazing parents and coaches
involved. And by “amazing” I don’t mean good. I mean extreme.
You will see how it relates to ADHD and how you talk to yourself.

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.

Now there are a number of ways a coach can respond to this

situation. Let’s take Coach A first. Coach A is the type of coach
who will come out on the field and shout, “I can’t believe you
missed that ball! Anyone could have caught it! My dog could have
caught it! You screw up like that again and you’ll be sitting on the
bench! That was lousy!”

Coach A then storms off the field. At this point, if Johnny is

anything like I am, he is standing there, tense, tight, trying not
to cry, and praying that another ball is not hit to him. If a ball
does come to him, Johnny will probably miss it. After all, he is
tense tight, and may see four balls coming to him because of the
tears in his eyes. Also, if we are Johnny’s parents, we may see more
profound changes after the game: Johnny, who typically places his
baseball glove on the mantel, now throws it under his bed. And

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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.

Now let’s go back to the original event and play it differently.

Johnny has just missed the fly ball, and now Coach B comes out
on the field. Coach B says, “Well, you missed that one. Here is
what I want you to remember: fly balls always look like they are
farther away than they really are. Also, it is much easier to run
forward than to back up. Because of this, I want you to prepare for
the ball by taking a few extra steps backwards. Run forward if you
need to, but try to catch it at chest level, so you can adjust your
hand if you misjudge the ball. Let’s see how you do next time.”

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.

So, if we were the type of parent that eventually wants Johnny

to make the Major League, we would pick Coach B, because he
teaches Johnny how to be a more effective player. Johnny knows
what to do differently, may catch more balls, and may excel at
the game. But if we don’t care whether Johnny makes the Major
League—because baseball is a game, and one is supposed to be
able to enjoy a game—then we would still pick Coach B. We pick
Coach B because we care whether Johnny enjoys the game. With
Coach B, Johnny knows what to do differently; he is not tight,
tense, and ready to cry; he may catch a few balls; and he may
enjoy the game. And he may continue to place his glove on the
mantel.

Now, while we may all select Coach B for Johnny, we rarely

choose the view of Coach B for the way we talk to ourselves.

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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.

Keep in mind that we are not talking about how we coach

ourselves in a baseball game. We are talking about how we coach
ourselves in life, and our enjoyment of life. People with excessive
distress, and many with ADHD, tend to talk to themselves
this way.

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:

■ What is the evidence that this thought is true?

■ Is there an alternative explanation?
■ What is the worst thing that can happen?
■ Has this situation unreasonably grown in importance?
■ What would a good coach say about this situation?
■ Have I done what I can to control it?

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■ If I were to do anything else, would this help or hinder the situation?

■ Am I worrying excessively about this?
■ What would a good friend say to me about this situation?
■ What would I say to a good friend about this situation if he or she were
going through it?
■ Why is this statement a thinking error?

Sometimes a client can maintain a vehement belief that the negative

thought is true. One strategy is to acknowledge the part of it that
seems true, but be sure that the intensity is appropriate and that the
client is evaluating the worst-case scenario if it is true. Alternatively,
it can be helpful to suggest that you return to this thought another
time, as it is hard to work on it right now. You can also point out
that sometimes thoughts can be true (e.g., “I didn’t study as much as
I would have liked for that test”) and it is still not helpful to focus on
them in a particular situation (e.g., as one is walking into the class-
room to take the test in question). In that case, the strategy is not
necessarily to argue with oneself about whether or not the thought is
true, but simply to point out that it is unhelpful to focus on the thought
at this time.

We now introduce a new thought record containing an additional (fifth)

column for formulating a rational response (Figs. 9.1 and 9.2). The ra-
tional response is a statement that clients can say to themselves to try
to feel better about the situation. Keep in mind that we are not asking
clients to overlook ALL negative aspects of their thoughts; rather, the
idea is to come up with a more balanced, objective, and helpful way of
thinking about the situation.

For example, consider Johnny’s thoughts from the coaching story: “I

am so stupid! I missed that ball … I’ll never become a good base-
ball player … I’ll always be a failure.” The goal would be for him
to acknowledge that he missed the ball on this one occasion but has
caught others in the past (no magnification/minimization), to recog-
nize that there are additional skills he can learn to help him become
a better player (no fortune telling), and to see himself as having as
good a chance as the next boy to become a good baseball player (no
catastrophizing).

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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

We have discussed several different types of thinking errors that can

contribute to negative feelings. While it is important for clients to be
familiar with the types of errors they may be making, remind them not
to get stuck trying to find the exact type of error that corresponds with
the thought. Thoughts may fit into more than one category, and often
these categories of thinking errors overlap. The goal is for clients to rec-
ognize that the automatic thought might represent a thinking error, to
understand why this is true, and, most importantly, to come up with an
effective rational response.

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For many clients, identifying a rational response may be tricky at first.

Refer to the suggested questions above (e.g., What would you say to
a friend who said this?). Also, tell clients to keep in mind that their
thoughts and feelings about the situation may not completely change
immediately after identifying a rational response. However, if they
practice repeating the responses to themselves, over time they will
begin to replace the negative and/or unhelpful automatic thoughts with
more balanced and effective ones.

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.

Instructions for Completing the 5-Column Thought Record and Developing a

Rational Response

These instructions also appear in client workbook Chapter 11 and in

the Appendix (identified as a handout).

The purpose of adaptive thinking is to promote optimal thinking when

you are feeling 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 situation has already passed and you
find that you are thinking about it negatively, 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 you are
having and what your mood is like when thinking these thoughts
(e.g., depressed, sad, angry).

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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

In the last column, try to come up with a rational response to each

thought, or to the most important negative thought. The rational re-
sponse is a statement that you can say to yourself to try to feel better
about the situation. Questions to help come up with this rational
response can include the following:

■ What is the evidence that this thought is true?

■ Is there an alternative explanation?
■ What is the worst thing that can happen?
■ Has this situation unreasonably grown in importance?
■ What would a good coach say about this situation?
■ Have I done what I can do to control it?
■ If I were to do anything else, would this help or hinder the situation?
■ Am I worrying excessively about this?
■ What would a good friend say to me about this situation?
■ What would I say to a good friend about this situation if he/she were
going through it?
■ Why is this statement a cognitive distortion?
■ Is it helpful to focus on this thought at this moment?

Practice

■ Continue to use the calendar every day to record appointments and

put new tasks on the task list every day.
■ Use and look at task list and calendar EVERY DAY!

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■ 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 to the next day’s task list.
■ Practice using Worksheet 1: Problem-Solving: Selection of Action
Plan for at least one item on the task list.
■ 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 instructions for completing Worksheet 7: 5-Column
Thought Record.
■ Complete thought records for at least two situations during the week.

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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Rehearsal and Review

SESSION 10
of Adaptive Thinking Skills
(Corresponds with Chapter 12 of the Client Workbook)

MATERIALS NEEDED

■ ASRS Symptom Checklist

■ Worksheet 7: 5- Column Thought Record (in the Appendix)

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

To maintain a structured focus on treatment for ADHD and to prepare

the client for what lies ahead in the upcoming session, it is important to
begin each session by setting an agenda. Use the session outline above
to set the agenda.

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Review of Symptom Checklist

Give the client a copy of the ASRS Symptom Checklist (https://www.

hcp.med.harvard.edu/ncs/ftpdir/adhd/18Q_ASRS_English.pdf )
to complete at the start of the session. Briefly review the score and take
note of symptoms that have improved and those that are still problem-
atic. Note the score and the date in your chart note for future reference.

Signposts of Change

For this session, the signposts of change would be as follows:

■ Client is attempting to use calendar and task list systems on a

daily basis.
■ Client is putting all tasks that need to be completed on master
task list.
■ Client has identified a consistent time and place for looking at the
calendar and creating daily task list.
■ Client is using priority ratings for daily task list.
■ Client has noted instances where items on the task list were not
being completed and asked, “What is getting in my way?” “Is the
task too big?” “Am I not really sure how to approach the problem?”
Following this, client has either broken the task down into smaller
steps or completed a problem-solving worksheet.
■ Client has started to implement a system for decreasing the amount
of mail (paper and electronic) that comes in.
■ Client has identified areas that require an organizational system
and has at least started to implement the system as agreed upon
with you.
■ Client has encountered situations where she needed to concentrate
on a boring task and has attempted to use distractibility delay.
■ Client has identified a “home” for important items in her living
space and has started placing the important items in the designated
spot on a regular basis.
■ Client has attempted to use strategies for reducing distractibility
that were identified in session.
■ Client has started using an alarm to check in to see if she has become
distracted when working on important or difficult tasks.

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■ Client has completed a thought record with at least two examples

of thoughts that occurred during the week and brought it to the
session.
■ Client has attempted to develop rational responses for her thoughts.

Review of Previous Sessions

As always, this session includes a review of the client’s progress imple-

menting skills from each of the previous sessions. It is important to
acknowledge the successes the client has achieved and to try to resolve
any difficulties he may be having.

Repetition of new skills is critical for individuals with ADHD and

will maximize gains made in treatment and increase the likelihood
of sustaining improvement. Hopefully, at this point, the organiza-
tion, planning, and distractibility skills will have become automatic
for the client. If your client does not have workable systems es-
tablished, you should discuss and try to resolve this issue, possibly
even delaying this week’s agenda to the following session. It is un-
likely clients will achieve sustainable improvements in their ADHD
symptoms if they are not regularly using these skills. Clients do not
need to be using the skills perfectly, but they must at least attempt
to use them.

As we noted in the “signposts of change” section above, it is a positive

sign if the client has made an attempt to develop rational responses.
Even if the client did not come up with a helpful rational response,
reinforce his efforts, because it is the process of critically evaluating
one’s thoughts that is important. You can help the client to refine and
improve upon the rational responses during the session.

Review the tools for organization and planning:

■ Use of calendar for managing appointments: Discuss any problems

the client is having using the calendar system.
■ Use of task list: Review any difficulties the client is having with re-
cording tasks and looking at the task list on a daily basis.
■ Use of the “A,” “B,” and “C” priority ratings: Discuss any trouble
the client is having with prioritizing tasks.

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■ 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.

Review the tools for reducing distractibility:

■ Use of strategy for breaking boring tasks down into manageable

chunks: Discuss any problems the client is having with this strategy.
■ Use of the distractibility delay: Review any difficulties the client is
having with this technique.
■ Use of strategy to remove distractions from the environment
■ Have a specific place for each important object
■ Use of cue control reminders: alarm, “Am I doing what I am sup-
posed to be doing?”

Review the tools for developing adaptive thinking:

■ Use of thought record (either on paper or electronically) to identify

and label automatic thoughts: Review any difficulties the client re-
ports with using this strategy.
■ Use of thought record to develop rational responses: Assist the
client in developing rational responses if needed.

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.

We suggest using this session to review an additional problematic situa-

tion and to complete a thought record in full for this situation.

Planning for Future Treatment

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

■ Congratulations for completing the core treatment elements!

■ Continue practicing skills learned in previous sections.
■ Continue to use cognitive techniques for situations involving stress.
■ Remember to consider any anticipated problems completing the
homework.

Case Vignette

T: Congratulations! You’ve done a terrific job using the thought records

to break down difficult situations and understand how negative
thoughts can contribute to feeling distressed in the situation. Let’s
review the problem list that you completed at the beginning of treat-
ment and evaluate what would be helpful to work on next. It looks
like you were feeling really overwhelmed by paperwork and organi-
zation and that you had problems with procrastination.
C: Right. I could never keep my bills straight and would get so anxious
that I just couldn’t deal. I’ve had to pay a lot of late fees because
of this.
T: How are you doing with the organization strategies we’ve been
working on?
C: Much better. I now have a system for filing my current bills, and
I have set up automatic payments so that they get paid on time each
month. But I still sometimes try to avoid dealing with financial
issues when I get overwhelmed.
T: So you are still having some difficulties with procrastination. Perhaps
we should plan to do the optional session where we discuss how to
apply the skills from this program to procrastination.
C: I don’t know. I feel like I have done a lot of work already. I’ve been
coming here every week for several months now. I think that should
be enough.
T: You’re feeling like you’ve already put in your time to work on skills.
I’m really glad you mention that. Actually, a lot of people feel that
way. But here’s the catch. You’ve been struggling with ADHD for
many years, and have worked quite hard for three months, but it

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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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MODULE 4

Additional Skills
081
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Application of Skills
SESSION 11 to Procrastination
(optional)
(Corresponds with Chapter 13 of the Client Workbook)

MATERIALS NEEDED

■ ASRS Symptom Checklist

■ Worksheet 7: 5- Column Thought Record (if client is using paper
thought records)
■ Worksheet 8: Pros and Cons of Procrastination (in the Appendix)

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

To maintain a structured focus on treatment for ADHD and to prepare

the client for what lies ahead in the upcoming session, it is important to
begin each session by setting an agenda. Use the session outline above
to set the agenda.

Review of Symptom Checklist

Give the client a copy of the ASRS Symptom Checklist (https://www.hcp.

med.harvard.edu/ncs/ftpdir/adhd/18Q_ASRS_English.pdf) to complete
at the start of the session. Briefly review the score and take note of symp-
toms that have improved and those that are still problematic. Note the
score and the date in your chart note for future reference.

Signposts of Change

For this session, the signposts of change would be as follows:

■ Client is attempting to use calendar and task list systems on a

daily basis.
■ Client is putting all tasks that need to be completed on master
task list.
■ Client has identified a consistent time and place for looking at cal-
endar and creating daily task list.
■ Client is using priority ratings for daily task list.
■ Client has noted instances where items on the task list were not
being completed and asked, “What is getting in my way?” “Is the
task too big?” “Am I not really sure how to approach the problem?”
Following this, client has either broken the task down into smaller
steps or completed a problem-solving worksheet.
■ Client has started to implement a system for decreasing the amount
of mail (paper and electronic) that comes in.
■ Client has identified areas that require an organizational system
and has at least started to implement the system as agreed upon
with you.

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■ Client has encountered situations where he needed to concentrate

on a boring task and has attempted to use distractibility delay.
■ Client has identified a “home” for important items in his living
space and has started placing the important items in the designated
spot on a regular basis.
■ Client has attempted to use strategies for reducing distractibility
that were identified in session.
■ Client has started using an alarm to check in and see if he has
become distracted when working on important or difficult tasks.
■ Client has completed a thought record with at least two examples
of thoughts that occurred during the week and brought it to the
session.
■ Client has attempted to develop rational responses for his thoughts.

Review of Previous Sessions

As always, this session includes a review of the client’s progress imple-

menting skills from each of the previous sessions. It is important to
acknowledge successes and to try to resolve any difficulties.

Review tools for organization and planning:

■ Use of calendar for managing appointments: Discuss any problems

the client is having using the calendar system.
■ Use of task list: Review any difficulties the client is having with re-
cording tasks and looking at the task list on a daily basis.
■ 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.

Review tools for reducing distractibility:

■ Use of strategy for breaking boring tasks down into manageable

chunks: Discuss any problems the client is having with this strategy.
■ Use of the distractibility delay: Review any difficulties the client is
having with this technique.

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■ Use of strategy to remove distractions from the environment

■ Have a specific place for each important object
■ Use of cue control reminders: alarm, “Am I doing what I am sup-
posed to be doing?”

Review tools for developing adaptive thinking:

■ Use of thought record (either on paper or electronically) to identify

and label automatic thoughts: Review any difficulties the client re-
ports with using this strategy.
■ Use of thought record to develop rational responses: Assist the
client in developing rational responses if needed.

Introduction to Procrastination

Many individuals with ADHD have struggled with procrastination for

quite some time, although many do not realize that ADHD can con-
tribute to procrastination. In this session you will review your client’s
history with procrastination and try to identify the areas in which it has
been most problematic. Some examples might include making phone
calls, starting new tasks, applying for jobs, organizing papers, or get-
ting daily projects done. The goals in the session are (1) to help the
client identify especially difficult situations that lead to procrastination
and (2) to help the client understand the cognitive and emotional fac-
tors that contribute to procrastination. Once your client discovers these
reasons, she will be able to use more effective problem-solving strategies
and decrease the interference of procrastination.

The Attractiveness of 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:

■ Perfectionism or fear of negative evaluation for a less-than-perfect

product
■ The idea that it is difficult to get started unless the time pressure
is there

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■ The issue seems overwhelming.

■ It is difficult to find a starting point.
■ The tasks requiring sustained effort are not attractive.
■ The thought that it makes sense to wait for a period when there is
enough time (although this usually never comes)

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.

The Consequences of Procrastination

Procrastination can appear to be a good option for clients if it helps

them avoid a negative feeling or if they think that the time and envi-
ronment must be just right before they can begin a task. Unfortunately,
these potential benefits in the short-term are often outweighed by far
more negative consequences in the long-term. The goal of this section
is to point out the negative consequences so that they overpower the
seemingly attractive aspects of procrastination. Some examples of neg-
ative consequences are the following:

■ It is stressful waiting until the last minute to complete a task.

■ A task that is unattractive in the first place is even worse when it
is all-encompassing. Waiting until the last minute means that you
must sacrifice other activities as the deadline approaches.
■ Missing a deadline may incur a penalty (e.g., lower grade on a paper,
boss or client is angry at work).
■ You will feel worse about yourself later.
■ The final product is not as good as it could have been if you had had
more time to work on it.
■ Ignoring the problem usually makes it worse and even harder to
solve later.

Does your client recognize any of these consequences? Has he expe-

rienced them? Prompt clients to think about how procrastination has

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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.

Skill: Evaluating the Pros and Cons of Procrastination

Sometimes it can be useful to evaluate the pros and cons of an action

before making a decision. In this way, deciding to procrastinate on a
task can be seen as a decision that a client will be making. Accordingly,
a “decisional balance”-style worksheet can help the client decide
what to do.

Use Worksheet 8: Pros and Cons of Procrastination (in the Appendix)

with the client to objectively rate the pros and cons of procrastination.
Sometimes the short term pros and cons differ from the long term ones,
so be sure to evaluate both. Unfortunately, it is sometimes difficult for
clients to remember the pros and cons in the moment when they are
facing an overwhelming task. Explain that by taking the time now
to practice reviewing the pros and the cons, they will be better able
to remember the consequences in the moment when they are facing
procrastination.

Ask clients to think of a recent time when they procrastinated. Then

ask them to write down the pros and cons of procrastination in the
short-term. After this, ask them to write down the pros and cons
of procrastination in the long-term. Spend a few minutes discuss-
ing the answers. Generally, we see a pattern where there are more
pros for procrastination in the short-term and more cons for pro-
crastination in the long-term. Discuss how the client might bring
that long-term cons box into his decision-making process around
procrastination.

Skill: Adapting Problem-Solving to the Issue of Procrastination

In Session 4 of treatment, we introduced skills for problem-solving.

When a task feels overwhelming, or the client is uncertain about where

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to begin, she is more likely to procrastinate. Using the problem-solving

worksheet and/or breaking the task down into manageable steps will
help avoid this.

If the client is procrastinating around completing a specific task, have

him or her ask, “Am I procrastinating because I don’t know what to
do?” If the answer is “yes,” the client should complete the problem-
solving worksheet (from Session 4) to try to figure out the best solution
to the problem. If the answer is “no,” the client should ask, “Does the
task feel too overwhelming?” If the answer is “yes,” the client should
use the skill of breaking down large tasks into manageable steps, also
discussed in Chapter 4.

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.

Another trap is to set unreasonable goals. Remind the client that

each step should be realistic. The skills learned for managing dis-
tractibility will also be useful here. If your client knows that she
can typically work on unpleasant tasks for only 15 minutes, then
break down each step into goals that can be completed within this
timeframe.

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.

Skill: Using Adaptive Thinking to Help with Procrastination

In the Adaptive Thinking section (Sessions 8 through 10), clients learned

that their thoughts can play a powerful role in how they feel about situ-
ations, and that thoughts can influence their actions. Negative auto-
matic thoughts can also greatly contribute to procrastination. Using
thought records will help clients create balanced, helpful thoughts that
will decrease procrastination. The five steps for completing a thought
record (Fig. 11.1) can be applied to procrastination:

1. List the situation contributing to procrastination.

2. List the automatic thoughts regarding the task or goal.

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3. Identify the feelings connected to the thoughts.

4. Refer to the list of thinking errors to evaluate the thoughts.
5. Formulate rational responses to the thoughts.

As we’ve emphasized throughout the manual, practicing new skills is

essential for clients to ultimately be able to use them easily in a given
situation. Use these steps to teach your client this skill:

■ 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

Clients may have struggled with procrastination for many years, so it is

important to remind them that they CAN use the strategies they have
learned to decrease the interference of procrastination. Even if they are
unsure about whether the techniques will help, encourage them to do
an experiment! Instruct them to commit to using these skills each day
for one month and see how well they do. Chances are, they will see the
results quickly, and it will then be easier to practice the newly learned
techniques.

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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SESSION 12 Handling Slips

(Corresponds with Chapter 14 of the Client Workbook)

MATERIALS NEEDED

■ ASRS Symptom Checklist

■ Worksheet 9: Treatment Strategies and Usefulness (in the Appendix)
■ Worksheet 10: One-Month Review (in the Appendix)
■ Troubleshooting Difficulties Chart (in this session and in client
workbook Chapter 14)

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

To maintain a structured focus on treatment for ADHD and to prepare

the client for what lies ahead in the upcoming session, it is important to
begin each session by setting an agenda. Use the session outline above
to set the agenda.

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Review of Symptom Checklist

Give the client a copy of the ASRS Symptom Checklist (https://www.

hcp.med.harvard.edu/ncs/ftpdir/adhd/18Q_ASRS_English.pdf) to com-
plete at the start of the session. Briefly review the score and take note of
symptoms that have improved and those that are still problematic. Note
the score and the date in your chart note for future reference.

Signposts of Change

For this session, the signposts of change would be as follows:

■ Client is attempting to use calendar and task list systems on a daily

basis.
■ Client is putting all tasks that need to be completed on master
task list.
■ Client has identified a consistent time and place for looking at cal-
endar and creating daily task list.
■ Client is using priority ratings for daily task list.
■ Client has noted instances where items on the task list were not
being completed and asked, “What is getting in my way?” “Is the
task too big?” “Am I not really sure how to approach the problem?”
Following this, client has either broken the task down into smaller
steps or completed a problem-solving worksheet.
■ Client has started to implement a system for decreasing the amount
of mail (paper and electronic) that comes in.
■ Client has identified areas that require an organizational system
and has at least started to implement the system as agreed upon
with you.
■ Client has encountered situations where she needed to concentrate
on a boring task and has attempted to use distractibility delay.
■ Client has identified a “home” for important items in her living
space and has started placing the important items in the designated
spot on a regular basis.

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■ Client has attempted to use strategies for reducing distractibility

that were identified in session.
■ Client has started using an alarm to check in and see if she
has become distracted when working on important or difficult
tasks.
■ Client has completed a thought record with at least two examples
of thoughts that occurred during the week and brought it to the
session.
■ Client has attempted to develop rational responses for her
thoughts.

Ending Treatment and Maintaining Gains

The key to successful termination and relapse prevention for individu-

als with ADHD is persistent use of the skills. We recommend over-
emphasizing this point with clients. Most of our clients hear the follow-
ing phrase in almost every treatment session as well as in the follow-up
sessions: “The strategies and skills need to be practiced regularly so that
they become more automatic.” In other words, the end of regular sessions
of treatment signifies the starting point of the clients’ own program of
treatment, where they work to lock in and extend the skills and strate-
gies they have learned.

To help clients make the transition to this next phase of treatment—

where they take over the role as the therapist—it is important for
them to recognize the nature of any benefits they have achieved. One
way to look at progress is to graph or table the ADHD rating scale
scores from each week of the program with the client in the session
(Fig. 12.1). If there are sudden gains in treatment—dramatic or sig-
nificant reductions in a score on a given week—it is important to
discuss what occurred that week that caused the change (e.g., finally
started using a calendar to track appointments, finally started looking
at the task list daily).

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Figure 12.1
Symptom scores.

Examining What Was Valuable

In addition to attempting to recall which sessions had the most gains,

we review the treatment strategies and determine how useful they are.
Worksheet 9: Treatment Strategies and Usefulness (in the client’s work-
book and in the Appendix) can be done at home prior to this session
and discussed in the session, or it can be completed and discussed in
the session.

As the discussion progresses, you can provide positive feedback regard-

ing the approaches that worked, and emphasize the importance of con-
tinuing to use them. If there are strategies that have not worked, these
do not need to be continued. However, you should also discuss any

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difficulties the client encountered—for example, if any strategies are no

longer being used, or if any are not being used consistently.

Maintaining Gains

An important distinction for clients to be aware of is the difference

between a “setback” and a “relapse.” In a setback the client has some
difficulties with ADHD symptoms, whereas in a relapse the client is
back at baseline, as if he had not received any treatment at all. We con-
sider setbacks to be a normal and expected part of progress. Successful
treatment does not mean that clients will have no future difficulties
with ADHD symptoms. For most conditions, symptoms can wax and
wane over time.

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

It may also be helpful to match some of the symptoms the client is

experiencing with some of the specific strategies used in treatment. Use
the chart in Table 12.1.

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Table 12.1 Troubleshooting Difficulties Chart

Symptoms Skills to Consider

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.

Difficulty sustaining attention in tasks Check your management of your space. Is

your environment too distracting?

Difficulty organizing tasks in terms of Use your prioritization system.

importance
Use your triage and organizational systems.

Procrastination Use problem solving and adaptive thinking.

Break down large tasks into smaller steps.

Losing things necessary for tasks or Use a single work area.

activities
Use your triage and organizational systems.
Work with another person to reduce clutter.

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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Appendix

Forms and Worksheets

Accessing Treatments ThatWork Forms and Worksheets Online

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.

Worksheet 1: Problem-Solving: Selection of Action Plan

Worksheet 2: Steps for Sorting Mail

Worksheet 3: Developing an Organizational System

Worksheet 4: Strategies for Reducing Distractions

Worksheet 5: 3-Column Thought Record

Handout A: Preliminary Instructions for Adaptive Thinking

Worksheet 6: 4-Column Thought Record

Handout B: Instructions for Completing a 5-Column Thought Record and

Developing a Rational Response

Worksheet 7: 5-Column Thought Record

Worksheet 8: Pros and Cons of Procrastination

Worksheet 9: Treatment Strategies and Usefulness

Worksheet 10: One-Month Review

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Worksheet 1 Problem-Solving: Selection of Action Plan

Statement of the Problem:

Instructions for completing this chart:

1) List all of the possible solutions that you can think of for resolving the problem listed
above. List solutions even if you think they don’t make sense, or you don’t think you
would do them. The point is to come up with AS MANY solutions AS POSSIBLE.
2) Make sure that continuing what you are doing now (e.g., avoiding, or doing nothing, if
that is the case) is one of the possible solutions.
3) List the pros and cons of each solution.
4) After listing the pros and cons of each, give a rating to each solution on a 1–10 scale,
with 1 being the worst and 10 being the best, based on your assessment of the pros and
cons of each solution.
5) Use additional copies of this sheet as needed (even if it’s for the same problem).

Overall
Rating of
Possible Solution Pros of Solution Cons of Solution
Solution
(1–10)
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Worksheet 2 Steps for Sorting Mail

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.

Receptacle you will use for your triage center

Central location for your triage center

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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Worksheet 3 Developing an Organizational System

Organizational System for: ___________________________

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.

9. Reward yourself for using the system!

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Worksheet 4

Strategies for Reducing Distractions

Distraction Environmental Reduction Strategy

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Worksheet 5

3-Column Thought Record

Time and Situation Automatic Thoughts Mood and Intensity

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Handout A

Preliminary Instructions for Adaptive Thinking

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 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

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Worksheet 6

4-Column Thought Record

Time and Situation Automatic Thoughts Mood and Intensity Thinking Errors

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Handout B

Instructions for Completing the 5-Column Thought Record

and Developing a Rational Response

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 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 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:

■ What is the evidence that this thought is true?

■ Is there an alternative explanation?
■ What is the worst thing that can happen?
■ Has this situation unreasonably grown in importance?
■ What would a good coach say about this situation?
■ Have I done what I can do to control it?
■ If I were to do anything else, would this help or hinder the situation?
■ Am I worrying excessively about this?
■ What would a good friend say to me about this situation?
■ What would I say to a good friend about this situation if he or she were going through it?
■ Why is this statement a cognitive distortion?
■ Is it helpful to focus on this thought at this moment?

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Worksheet 7 5-Column Thought Record

Time and Automatic Thoughts Mood and Thinking Rational Response

Situation Intensity Errors

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 and Cons of Procrastination

Pros Cons

Short-term

Long-term

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Worksheet 9 Treatment Strategies and Usefulness

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.

Notes About Your

Usefulness
Treatment Strategies Application/Usefulness
Ratings
of the Strategy

Tools for Organization and Planning

■ Use of calendar for managing appointments

■ Use of task list

■ Use of strategy for breaking down tasks

into subtasks

■ Use of A-B-C ratings for prioritizing

multiple tasks

■ Use of problem-solving and developing an

action plan

■ Use of triage and organizational systems

Strategies for Managing Distractibility

■ Use of strategy for breaking down tasks

into duration of attention span and use of
breaks in between tasks

■ Using distractibility delay

■ Removing distractions from environment

■ Identifying specific places for important

objects

■ Use of reminders: alarm, “Am I doing

what I am supposed to be doing?”
Adaptive Thinking

■ Use of thought records to identify negative

thoughts

■ Reviewing list of thinking errors

■ Use of thought records to create balanced,

helpful thoughts
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Worksheet 10

One-Month Review

Date of review: _____________________

1. What skills have you been practicing well?

2. Where do you still have troubles?

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

Adler, L. A., & Chua, H. C. (2002). Management of ADHD in adults. Journal

of Clinical Psychiatry, 63(supp. 12), 29–35.
Agarwal, R., Goldenberg, M., Perry, R., & Ishak, W. W. (2012). The quality
of life of adults with attention deficit hyperactivity disorder; A systematic
review. Innovations in Clinical Neuroscience, 9(5–6), 10–21.
American Psychiatric Association. (2013). Diagnostic and statistical manual
of mental disorders (5th ed.). Washington, DC: American Psychiatric
Association.
Barkley, R. A. (1998). Attention-deficit hyperactivity disorder: A handbook for
diagnosis and treatment (2nd ed.). New York: Guilford Press.
Barkley, R. A., & Murphy, K. R. (1998). Attention-deficit hyperactivity disor-
der: A clinical workbook (2nd ed.). New York: Guilford Press.
Barkley, R. A., Murphy, K. R., & Fisher, M. (2008). ADHD in adults: What
the science says. New York: Guilford Press.
Bellak, L., & Black, R. B. (1992). Attention-deficit hyperactivity disorder in
adults. Clinical Therapeutics, 14, 138–147.
Biederman, J., Faraone, S. V., Keenan, K., Benjamin, J., Krifcher, B., Moore,
C., … Tsuang, M. T. (1992). Further evidence for family genetic risk
factors in attention deficit hyperactivity disorder: Patterns of comorbid-
ity in probands and relatives in psychiatrically and pediatrically referred
samples. Archives of General Psychiatry, 49, 728–738.
Biederman, J., Faraone, S. V., Keenan, K., Steingard, R., & Tsuang, M. T.
(1991). Familial association between attention deficit disorder and anxi-
ety disorders. American Journal of Psychiatry, 148, 251–256.Biederman, J.
Faraone, S. V., Spencer, T., Wilens, T., Mick, E., & Lapey, K. A. (1994).
Gender differences in a sample of adults with attention deficit hyperactiv-
ity disorder. Psychiatry Research, 53, 13–29.
Biederman, J., Faraone, S. V., Spencer, T., Wilens, T., Norman, D., Lapey,
K.A., … Doyle, A. (1993). Patterns of comorbidity, cognition, and psy-
chosocial functioning in adults with attention deficit hyperactivity disor-
der. American Journal of Psychiatry, 150, 1792–1798.
Biederman, J., Munir, K., Knee, D., Armentano, M., Autor, S., Waternaux,
C., & Tsuang, M. (1987). High rate of affective disorders in probands

141
421

with attention deficit disorder and in their relatives: A controlled family

study. American Journal of Psychiatry, 144, 330–333.
Biederman, J., Munir, K., Knee, D., Habelow, W., Armentano, M., Autor,
S., … Watermaux, C. (1986). A family study of patients with attention
deficit disorder and normal controls. Journal of Psychiatric Research, 20,
263–274.
Biederman, J., Wilens, T. E., Spencer, T. J., Faraone, S., Mick, E., Ablon, J. S., &
Keily, K. (1996). Diagnosis and treatment of adult attention-deficit/
hyperactivity disorder. In M. H. Pollack, M. W. Otto, & J. F. Rosenbaum
(Eds.), Challenges in clinical practice (pp. 380– 407). New York: Guilford
Press.
Cantwell, D. P. (1972). Psychiatric illness in the families of hyperactive chil-
dren. Archives of General Psychiatry, 27, 414– 417.
Craske, M. G., & Barlow, D. H. (2006). Mastery of your anxiety and
worry: Client workbook (2nd ed.). New York: Oxford.
Farone, S. V., Biederman, J., Keenan, K., & Tsuang, M. T. (1991). A family-
genetic study of girls with DSM-III attention deficit disorder. American
Journal of Psychiatry, 148, 112–117.
Faraone, S. V., & Glatt, S. J. (2010). A comparison of the efficacy of medica-
tions for adult attention-deficit/hyperactivity disorder using meta-analysis
of effect sizes. Journal of Clinical Psychiatry, 71(6), 754–763.
Goodman, R. (1989). Genetic factors in hyperactivity account for about half
of the explainable variance. British Medical Journal, 298, 1407–1408.
Goodman, R., & Stevenson, J. (1989). A twin study of hyperactivity: II. The
etiological role of genes, family relationships and perinatal adversity.
Journal of Child Psychology and Psychiatry, 30, 691–709.
Hope, D. A., Heimberg, R. H., Juster, H. R., & Turk, C. L. (2000). Managing
social anxiety: A cognitive behavioral therapy approach. Boulder, CO:
Graywind Publications.
Kessler, R. C., Adler, L., Barkley, R., Biederman, J., Conners, K. C., Demler, O.,
… Zaslavsky, A. M. (2006). The prevalence and correlates of adult
ADHD in the United States: Results from the national comorbidity
study replicaation. American Journal of Psychiatry, 163, 716–723.
Knouse, L. E., & Mitchell, J. T. (2015). Incautiously optimistic: Positively
valenced cognitive avoidance in adults with ADHD. Cognitive and
Behavioral Practice, 22(2), 192–202.
Lahey, B. B., Piacentini, J. C., McBurnett, K., Stone, P., Hartdagen, S., &
Hynd, G. (1988). Psychopathology in the parents of children with con-
duct disorder and hyperactivity. Journal of the American Academy of Child
and Adolescent Psychiatry, 27, 163–170.

142
431

Linehan, M. (1993). Cognitive-behavioral treatment of borderline personality

disorder. New York: Guilford Press.
McDermott, S. P. (2000). Cognitive therapy of adults with attention-deficit/
hyperactivity disorder. In T. Brown (ed.), Attention deficit disorders and co-
morbidity in children, adolescents, and adults. Washington, DC: American
Psychiatric Press.
Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people
change (3rd ed.). New York: Guilford.
Moffitt, T. E., Houts, R., Asherson, P., Belsky D. W., Corcoran, L., Hammerle,
M., … Caspi, A. (2015). Is adult ADHD a childhood-onset neurode-
velopmental disorder? Evidence from a four-decade longitudinal cohort
study. American Journal of Psychiatry, 172, 967–977.
Morrison, J. R. (1980). Adult psychiatric disorders in parents of hyperactive
children. American Journal of Psychiatry, 137, 825– 837.
Morrison, J. R., & Stewart, M. A. (1973). The psychiatric status of the legal
families of adopted hyperactive children. Archives of General Psychiatry,
28, 888– 891.
Murphy, K., & Barkley, R. A. (1996a). Attention deficit hyperactivity dis-
order in adults: Comorbidities and adaptive impairments. Comprehensive
Psychiatry, 37, 393– 401.
Murphy, K., & Barkley, R. A. (1996b). Prevalence of DSM-IV symptoms of
ADHD in adult licensed drivers: Implications for clinical practice. Journal
of Attention Disorders, 1, 147–161.
Naar-King, S., & Safren, S. A. (2016). Motivational Interviewing and CBT:
Combining Strategies for Maximum Effectiveness. New York: Guilford
Press.
Otto, M. (2000). Stories and metaphors in cognitive-behavior therapy.
Cognitive and Behavioral Practice, 7, 166–172.
Otto, M. W., Jones, J. C., Craske, M. G., & Barlow, D. H. (1996). Stopping
anxiety medication: Panic control therapy for benzodiazepine discontinua-
tion (therapist guide). San Antonio, TX: Psychological Corporation.
Ratey, J. J., Greenberg, M. S., Bemporad, J. R., & Lindem, K. J. (1992).
Unrecognized attention-deficit hyperactivity disorder in adults pre-
senting for outpatient psychotherapy. Journal of Child and Adolescent
Psychopharmacology, 2, 267–275.
Safer, D. (1973). A familial factor in minimal brain dysfunction. Behavior
Genetics, 3, 175–186.
Safren, S. A., Sprich, S., Chulvick, S., & Otto, M. W. (2004). Psychosocial
treatments for adults with ADHD. Psychiatric Clinics of North America,
27(2), 349–360.

143
41

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.
Journal of Attention Disorders, 13(5), 524–531.
Safren, S. A., Sprich, S., Mimiaga, M. J., Surman, C., Knouse, L., Groves,
M., & Otto, M. W. (2010b). Cognitive behavioral therapy vs. relaxa-
tion with educational support for medication-treated adults with ADHD
and persistent symptoms: A randomized controlled trial. JAMA, 304(8),
875– 880.
Spencer, T., Biederman, J., Wilens, T. E., & Faraone, S. V. (1998). Adults with
attention-deficit/hyperactivity disorder: A controversial diagnosis. Journal
of Clinical Psychiatry, 59(supp. 7), 59– 68.
Spencer, T. Biederman, J., Wilens, T. E., & Faraone, S. V. (2002). Overview
and neurobiology of attention-deficit/hyperactivity disorder. Journal of
Clinical Psychiatry, 63(supp. 12), 2–9.
Spitzer, R. L., & Williams, J. B. W. (1985). Classification in psychiatry. In H.
I. Kaplan & B. J. Sadock (Eds.), Comprehensive textbook of psychiatry (4th
ed., pp. 591– 613). Baltimore, MD: Williams & Wilkins.
Sprich, S., Biederman, J., Crawford, M. H., Mundy, E., & Faraone, S. V.
(2000). Adoptive and biological families of children and adolescents
with ADHD. Journal of the American Academy of Child and Adolescent
Psychiatry, 11, 1432–1437.
Stevenson, J., Pennington, B. F., Gilger, J. W. DeFries, J. C., & Gillis, J. J.
(1993). Hyperactivity and spelling disability: Testing for shared genetic
aetiology. Journal of Child Psychology and Psychiatry, 49, 728–738.
Szatmari, P., Boyle, M., & Offord, D. (1993). Familial aggregation of emo-
tional and behavioral problems of childhood in the general population.
American Journal of Psychiatry, 150, 1398–1403.
Wender, P. H. (1998). Pharmacotherapy of attention-deficit/hyperactivity dis-
order in adults. Journal of Clinical Psychiatry, 59(supp. 7), 76–79.
Wilens, T. E., Biederman, J., & Spencer, T. J. (1998a). Pharmacotherapy of
attention deficit hyperactivity disorder in adults. CNS Drugs, 9, 347–356.
Wilens, T. E., Biederman, J. & Spencer, T. J. (2002b). Attention deficit/hy-
peractivity disorder across the lifespan. Annual Review of Medicine, 53,
113–131.Wilens, T. E., McDermott, S. P., Biederman, J., Abrantes, A.,
Hahesy, A., & Spencer, T. J. (1999). Cognitive therapy in the treatment
of adults with ADHD: A systematic chart review of 26 cases. Journal of
Cognitive Psychotherapy, 13, 215–227.

144
451

Wilens, T., Morrison, N. R., & Prince, J. B. (2011). An update on the phar-
macotherapy of attention-deficit/hyperactivity disorder in adults. Expert
Review of Neurotherapeutics, 11(10), 1443–1465.
Wilens, T. E., Spencer, T. J., & Biederman, J. (1998b). Pharmacotherapy of
adult ADHD. In R. A. Barkley (Ed.), Attention deficit hyperactivity dis-
order: A handbook for diagnosis and treatment (2nd ed., pp. 592– 606).
New York: Guilford Press.
Wilens, T. E., Spencer, T. J., & Biederman, J. (2002a). A review of the pharma-
cotherapy of adults with attention-deficit/hyperactivity disorder. Journal
of Attentional Disorders, 5, 189–202.Zametkin, A. J., & Liotta, W. (1998).
The neurobiology of attention-deficit/hyperactivity disorder. Journal of
Clinical Psychiatry, 59(supp. 7), 17–23.

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About the Authors

Steven A. Safren, PhD, is currently a Professor of Psychology at the University

of Miami. His grant-funded work related to ADHD includes being the princi-
pal investigator (PI) of a five-year NIMH R01 to study the efficacy of cognitive-
behavioral therapy (CBT) for ADHD in adults, and the lead author of the
outcome of that trial published in JAMA— the Journal of the American Medical
Association. He was also the PI of a two-year NIMH R03 that studied the ini-
tial efficacy of CBT for ADHD in adults, and multiple PI (with Dr. Sprich)
of a three-year R34 to examine the efficacy of this approach with adolescents.
Before working at the University of Miami, Dr. Safren was, for 18 years, at
the Department of Psychiatry at Massachusetts General Hospital (MGH)/
Harvard Medical School, where he was a Professor of Psychology and Director
of Behavioral Medicine. There he served in a variety of other roles, such as
the Director for the Cognitive Behavioral Therapy and Behavioral Medicine
Clinical Psychology Internship tracks, and as the Associate Director of the
Cognitive Behavioral Therapy Program. Additionally, he maintained a clinical
practice treating clients with CBT at MGH. At the time of writing, Dr. Safren
has over 250 publications in the areas of CBT, psychopathology, and their ap-
plication to a variety of clinical problems in adults. In addition to his focus on
adult ADHD, Dr. Safren has a major focus working on the development and
testing of interventions related to medical problems such as HIV. This work is
also funded by the National Institutes of Health.

Susan E. Sprich, PhD, is the Director of the Cognitive Behavioral Therapy

Program at MGH and an Assistant Professor in Psychology at Harvard Medical
School. She also serves as the Director of Postgraduate Psychology Education
at the Psychiatry Academy at MGH. She was the Project Director of a five-year
study of CBT for adult ADHD and the co-PI of a three-year study of CBT for
adolescent ADHD, both funded by NIMH. She is also involved in clinical re-
search in the treatment of Obsessive-Compulsive Disorder, Autism Spectrum
Disorders, trichotillomania, and other anxiety and mood disorders. She has
authored over 20 publications in the areas of ADHD and anxiety disorders in
children and adults. Dr. Sprich conducts CBT with clients with mood disor-
ders, anxiety disorders, and ADHD through the Cognitive Behavioral Therapy

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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.

Carol A. Perlman, PhD, is a Cognitive Behavioral Therapist who special-

izes in the treatment of mood disorders, anxiety disorders, and adult ADHD.
Dr. Perlman was formerly a Clinical Assistant in Psychology at MGH,
Instructor in Psychology at Harvard Medical School, and Project Director
at the Harvard University Department of Psychology. She received her doc-
torate in clinical psychology from the University of Miami in Coral Gables,
Florida, and her postdoctoral training at MGH/Harvard Medical School. She
served as a therapist for the initial study of CBT for adult ADHD and a Co-
Investigator and therapist for the efficacy study. Dr. Perlman has published
over 20 articles in the area of mood disorders, posttraumatic stress disorder,
and adult ADHD. She is a national workshop presenter on CBT. Dr. Perlman
is the owner of Perlman Psychology Associates, LLC and maintains a private
practice in Medway, Massachusetts.

Michael W. Otto, PhD, is Professor of Psychological and Brain Sciences at

Boston University. He specializes in CBT of anxiety, mood, and substance
use disorders. He has had a major career focus on developing and validating
new psychosocial treatments, including treatments for ADHD. His research
includes a translational research agenda investigating brain–behavior relation-
ships in therapeutic learning, including the use of novel medications (e.g.,
D-cycloserine, yohimbine) and novel behavioral strategies to improve thera-
peutic learning/outcome. His focus on hard-to-treat conditions and principles
underlying behavior-change failures led him to an additional focus on health
behavior promotion, including investigations of addictive behaviors, medica-
tion adherence, sleep, smoking, and exercise. Across these health behaviors, he
has been concerned with cognitive, attention, and affective factors that derail
adaptive behaviors, and the factors that can rescue these processes. Dr. Otto
has over 370 publications spanning his research interests and was identified
as a “top producer” in the clinical empirical literature. Dr. Otto is a past
President of the Association for Behavioral and Cognitive Therapies, a member
of the Scientific Advisory Board for the Anxiety and Depression Association of
America, and President Elect of the Society for Clinical Psychology.

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