| SHORT-TERM OBJECTIVES | THERAPEUTIC INTERVENTIONS |
| Work cooperatively with the therapist toward agreed-upon therapeutic goals while being as open and honest as comfort and trust allow. (1, 2) | Establish rapport with the client toward building a strong therapeutic alliance; convey caring, support, warmth, and empathy; provide nonjudgmental support and develop a level of trust with the client toward him/her/their feeling safe to express his/her/their ADHD vulnerabilities and their impact on his/her/their life and addiction. |
| | Strengthen powerful relationship factors within the therapy process and foster the therapy alliance through paying special attention to these empirically supported factors: work collaboratively with the client in the treatment process; reach agreement on the goals and expectations of therapy; demonstrate consistent empathy toward the client's feelings and struggles; verbalize positive regard toward and affirmation of the client; and collect and deliver client feedback as to the client's perception of his/her/their progress in therapy (see Psychotherapy Relationships That Work: Vol. 1 by Norcross & Lambert and Psychotherapy Relationships That Work: Vol. 2 by Norcross & Wampold). |
| Describe past and present experiences with ADHD, including its effects on functioning. (3) | Conduct a thorough psychosocial assessment including past and present symptoms of ADHD and their effects on addiction, as well as educational, occupational, and social functioning. |
| Complete psychological testing or objective questionnaires for assessing ADHD and substance abuse. (4) | Conduct or arrange for psychological testing (e.g. Conners Adult ADHD Rating Scales, Substance Abuse Subtle Screening Inventory-4) to further assess ADHD, other possible psychopathology (e.g. anxiety, depression), and relevant rule-outs (e.g. learning disability/antisocial features); provide feedback of testing results; readminister as needed to assess response to treatment. |
| Implement remedial procedures for any learning disabilities that add to frustration. (5) | Refer the client to an educational specialist to design remedial procedures for any learning disabilities that may be present in addition to ADHD. |
| Cooperate with and complete a medical evaluation. (6) | Arrange for a medical evaluation to rule out nonpsychiatric medical and substance-induced etiologies (e.g. hypo/hyperthyroidism, stimulant use, thyroid replacement meds). |
| Comply with all recommendations based on the medical and/or psychological evaluations. (7, 8) | Process the results of the medical evaluation and/or psychological testing with the client and answer any questions that may arise. |
| | Conduct a conjoint session with significant others and the client to present the results of the psychological and medical evaluations; answer any questions they may have and solicit their support in dealing with the client's condition. |
| Disclose any history of substance use that may contribute to and complicate the treatment of ADHD. (9) | Arrange for a substance abuse evaluation and refer the client for treatment if the evaluation recommends it (see the Substance Use chapter in this Planner). |
| Provide behavioral, emotional, and attitudinal information toward an assessment of specifiers relevant to a DSM diagnosis, the efficacy of treatment, and the nature of the therapy relationship. (10 11, 12, 13) | Assess the client's level of insight (syntonic versus dystonic) toward the presenting problems (e.g. demonstrates good insight into the problematic nature of the described behavior, agrees with others' concern, and is motivated to work on change; demonstrates ambivalence regarding the problem described and is reluctant to address the issue as a concern; or demonstrates resistance regarding acknowledgment of the problem described, is not concerned, and has no motivation to change). |
| | Assess the client for evidence of research-based correlated disorders (e.g. oppositional defiant behavior with ADHD, depression secondary to an anxiety disorder) including vulnerability to suicide, if appropriate (e.g. increased suicide risk when comorbid depression is evident). |
| | Assess for any issues of age, gender, or culture that could help explain the client's currently defined “problem behavior” and factors that could offer a better understanding of the client's behavior. |
| | Assess for the severity of the level of impairment to the client's functioning to determine appropriate level of care (e.g. the behavior noted creates mild, moderate, severe, or very severe impairment in social, relational, vocational, or occupational endeavors); continuously assess this severity of impairment as well as the efficacy of treatment (e.g. the client no longer demonstrates severe impairment but the presenting problem now is causing mild or moderate impairment). |
| Identify the current, specific ADHD behaviors that cause the most difficulty. (14, 15, 16) | Assist the client in identifying the current, specific ADHD behaviors that cause him/her/them the most difficulty functioning as part of identifying treatment targets (i.e. a functional analysis). |
| | Review the results of psychological testing and/or psychiatric evaluation again with the client, assisting in identifying or in affirming his/her/their choice of the most problematic behavior(s) to address. |
| | Ask the client to have extended family members and close collaterals complete a ranking of the behaviors they see as interfering the most with his/her/their daily functioning (e.g. mood swings, temper outbursts, easily stressed, short attention span, never completes projects). |
| List the negative consequences of the ADHD problematic behavior. (17) | Assign the client to make a list of negative consequences of ADHD that he/she/they have experienced or that could result from a continuation of the problematic behavior; process the list (or supplement with “Impulsive Behavior Journal” in the Adult Psychotherapy Homework Planner by Jongsma & Bruce). |
| Verbalize the powerlessness and unmanageability that resulted from treating ADHD symptoms with addiction. (18) | Using a 12-step recovery program's Step 1 exercise, help the client to accept his/her/their powerlessness and unmanageability over ADHD symptoms and addiction (or supplement with the Step 1 exercise from The Alcoholism and Drug Abuse Client Workbook by Perkinson). |
| Verbalize the relationship between ADHD and addiction. (19) | Using a biopsychosocial approach, teach the client about the relationship between ADHD symptoms and the vulnerability to substance use. |
| Implement a program of recovery structured to bring ADHD and addiction under control. (20) | Help the client develop a program of recovery that includes the elements necessary to bring ADHD and addiction under control (e.g. medication, cognitive behavioral therapy, environmental controls, aftercare meetings, further therapy; or supplement with “Mastering Your Adult ADHD” exercise in Mastery of Your Adult ADHD – Client Workbook by Safren, et al.). |
| List five ways a higher power can be used to assist in recovery from ADHD and addiction. (21) | Teach the client about the Alcoholics Anonymous concept of a higher power and how this power can assist him/her/them in recovery. |
| Participate in a medication evaluation and take medication as prescribed, if prescribed. (22, 23) | Refer for a medication evaluation; if ambivalent, use motivational interviewing techniques to help the client explore pros and cons toward agreement to adhere to the prescription, if prescribed (or supplement with “Why I Dislike Taking My Medication” in the Adult Psychotherapy Homework Planner by Jongsma & Bruce). |
| | Monitor the client's psychotropic medication adherence, side effects, and effectiveness (or supplement with “Evaluating Medication Effects” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, McInnis, & Bruce); confer as indicated with the prescriber. |
| Increase knowledge about ADHD symptoms and their treatment. (24, 25, 26) | Educate the client about the signs and symptoms of ADHD and how they disrupt functioning through the influence of distractibility, poor planning and organization, maladaptive thinking, frustration, impulsivity, and possible procrastination (or supplement with “Symptoms and Fixes for ADD [now ADHD]” in the Adult Psychotherapy Homework Planner by Jongsma & Bruce). |
| | Discuss a rationale for treatment that accordingly targets improvement in organizational and planning skills, management of distractibility, cognitive restructuring, and overcoming procrastination (see Mastery of Your Adult ADHD: Therapist Guide by Safren, et al.). |
| | Teach the client how to monitor ADHD symptoms and assign monitoring tasks selectively for use in therapy. |
| Read self-help books about ADHD to improve understanding of the condition and its features. (27, 28) | Assign the client readings consistent with the treatment model to increase his/her/their knowledge of ADHD and its treatment (e.g. Mastery of Your Adult ADHD: Client Workbook by Safren et al., The Attention Deficit Disorder in Adults Workbook by Weiss). |
| | Assign the client self-help readings that help facilitate his/her/their understanding of ADHD (e.g. Driven to Distraction by Hallowell & Ratey; ADHD: Attention-Deficit Hyperactivity Disorder in Children, Adolescents, and Adults by Wender; Putting on the Brakes by Quinn & Stern; You Mean I'm Not Lazy, Stupid or Crazy!? by Kelly & Ramundo); process the material read to reinforce relevant therapeutic concepts. |
| Invite a significant other to join in the therapy to provide support throughout therapy. (29) | Allow the client to invite a significant other to participate in the therapy; teach the significant other throughout therapy how to help support change and overcome obstacles to therapeutic improvement. |
| Learn and implement organization, planning, and time management skills. (30, 31, 32, 33) | Teach the client organization and planning skills, including the routine use of a calendar and daily task list. |
| | Develop with the client a procedure for classifying and managing mail, other relevant paperwork and files, as well as scheduled appointments. |
| | Teach the client problem-solving skills (i.e. identify problem, brainstorm all possible options, evaluate the pros and cons of each option, select best option, implement a course of action, and evaluate results) as an approach to planning; for each plan, break it down into manageable time-limited steps to reduce the influence of distractibility (or supplement with “Getting Organized” in the Addiction Treatment Homework Planner by Lenz, Finley, & Jongsma). |
| | Assign homework asking the client to apply problem-solving skills to an everyday problem (i.e. impulse control, anger outbursts, mood swings, staying on task, attentiveness); review and provide corrective feedback toward improving the skill (or supplement with “Problem Solving: An Alternative to Impulsive Action” in the Adult Psychotherapy Homework Planner by Jongsma & Bruce). |
| Learn and implement skills to reduce the disruptive influence of distractibility. (34, 35, 36, 37) | Assess the client's typical attention span by having him/her/them do a few boring tasks (e.g. sorting bills, reading something uninteresting) to the point that he/she/they report distraction; use this as an approximate measure of his/her/their typical attention span. |
| | Teach the client stimulus control techniques that use external structure (e.g. lists, reminders, files, daily rituals) to improve on-task behavior; remove distracting stimuli in the environment; encourage the client to self-reward for successful focus and follow-through. |
| | Teach the client to break down tasks into meaningful smaller units that are likely to be completed without interruption by distraction based on his/her/their demonstrated attention span. |
| | Teach the client to use timers or other cues to remind him/her/them to cease a task before he/she/they become distracted, in an effort to reduce the frequency of distraction and off-task actions (see Mastery of Your Adult ADHD – Therapist Guide by Safren et al.). |
| Identify, challenge, and change self-talk that contributes to maladaptive feelings and actions. (38, 39, 40) | Use cognitive therapy techniques to help client identify maladaptive self-talk and/or underlying assumptions (e.g. “I must do this perfectly,” “I can do this later,” “I can't organize all these things”); challenge biases, generate alternatives, and do behavioral experiments to reinforce the validity of the alternatives (see Cognitive Behavior Therapy by Beck; or supplement with “Negative Thoughts Trigger Negative Feelings” in the Adult Psychotherapy Homework Planner by Jongsma & Bruce). |
| | Use Metacognitive Therapy to examine the client's “thinking about his/her/their thinking” (i.e. the meaning he/she/they place on his/her/their vulnerabilities associated with ADHD and his/her/their thoughts about how to respond to them accordingly) toward developing a more adaptive plan based on new, less maladaptive metacognitive appraisals (see Metacognitive Therapy for Anxiety and Depression by Wells). |
| | Assign homework asking the client to implement cognitive knowledge and skills in relevant tasks; review, reinforcing strengths and problem-solve obstacles toward sustained, effective use. |
| Acknowledge procrastination and the need to reduce it. (41) | Assist the client in identifying positives and negatives of procrastinating toward the goal of motivating him/her/them to work on staying goal-oriented and task-focused. |
| Learn and implement skills to reduce procrastination. (42, 43, 44, 45) | Teach the client to apply problem-solving skills to planning as a first step in overcoming procrastination; for each plan, break it down into manageable time-limited steps to reduce the influence of distractibility and increase the likelihood of successful completion. |
| | Teach the client to apply new cognitive restructuring skills to challenge thoughts that encourage the use of procrastination (e.g. “I can do this later” or “I'll finish this after I watch my TV show”) and embrace thoughts encouraging action. |
| | Assist the client in developing calendars or lists to record the details of scheduled activities and obligations; ask him/her/them to keep the list with him/her/them always and mark off each item as it is completed. |
| | Assign homework asking the client to accomplish identified tasks without procrastination using the techniques learned in therapy (or supplement with “Self-Monitoring/Self-Reward Program” in the Adult Psychotherapy Homework Planner by Jongsma & Bruce); review and provide corrective feedback toward improving the skill and decreasing procrastination. |
| Create and utilize an environment free from distracting stimuli that can be used for productive learning. (46) | Use a stimulus control approach to help the client design and implement an environment free of extraneous stimulation and serve as a place of study, concentration, and learning; explore the client's interest in using positive reinforcements after successful work sessions. |
| Combine skills learned in therapy into a new daily approach to managing ADHD. (47, 48, 49) | Teach the client mediational and self-control strategies (e.g. “stop, look, listen, and think”) to delay the need for instant gratification and inhibit impulses toward achieving more meaningful, longer-term goals (or supplement with “From Recklessness to Calculated Risks” in the Addiction Treatment Homework Planner by Lenz, Finley, & Jongsma). |
| | Select situations in which the client will be increasingly challenged to apply his/her/their new strategies for managing ADHD, starting with situations in which the client is highly likely to be successful (or supplement with “Problem Solving: An Alternative to Impulsive Action” in the Adult Psychotherapy Homework Planner by Jongsma & Bruce). |
| | Use techniques such as imagery, behavioral rehearsal, modeling, role-playing, and/or in vivo exposure/behavioral experiments to help the client consolidate the use of his/her/their new ADHD management skills. |
| Implement less impulsive social skills to minimize intrusions and offending others. (50, 51, 52, 53) | Use instruction, modeling, and role-playing to build the client's general social and/or communication skills (see What Does Everybody Else Know That I Don't? Social Skills Help for Adults with Attention Deficit/Hyperactivity Disorder by Novotni & Peterson). |
| | Assign the client to read about general social and/or communication skills in books or treatment manuals on building social skills (e.g. Your Perfect Right by Alberti & Emmons; Conversationally Speaking by Garner). |
| | Review social situations in which the client was intrusive or talked excessively without thoughtfulness; using modeling, role-playing, and instruction to teach alternatives that are more likely to be interpersonally effective. |
| | Teach the client problem-solving techniques that require thought before taking action and apply to simulated and actual interpersonal conflict situations (or supplement with “Applying Problem Solving to Interpersonal Conflict” in the Adult Psychotherapy Homework Planner by Jongsma & Bruce or “Staying Attentive and Other Negotiating Skills” in the Addiction Treatment Homework Planner by Lenz, Finley, & Jongsma). |
| Learn and implement calming skills to reduce tension, restlessness, and the risk of impulsive actions. (54) | Teach the client general and acute calming and relaxation skills; use modeling and behavior rehearsal toward decreasing tension and impulsive actions (or supplement with “Self-Soothing: Calm Down, Slow Down” in the Addiction Treatment Homework Planner by Lenz, Finley, & Jongsma). |
| List coping skills that will be used to manage ADHD symptoms. (55) | Review with the client the symptoms that have been problematic and the newly learned coping skills he/she/they will use to manage the symptoms (or supplement with “Symptoms and Fixes for ADD [now ADHD]” in the Adult Psychotherapy Homework Planner by Jongsma & Bruce). |
| Learn and practice mindful meditation to enhance attentional focus. (56) | Explain a rationale and teach the client mindful meditation to enhance attention regulation; apply the skill in other tasks requiring attentional focus within the client's limitations. |
| Develop an aftercare program that includes regular attendance at recovery group meetings, getting a sponsor, and continuing the therapy necessary to bring ADHD and addiction under control. (57) | Help the client develop an aftercare program that includes regular attendance at recovery group meetings, getting a sponsor, and continuing the therapy necessary to bring ADHD and addictive behavior under control. |
| Complete a survey to assess the degree of satisfaction with treatment. (58) | Administer a survey to assess the client's degree of satisfaction with treatment. |
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