99: CBT for ADHD with Russell Ramsay

CBT for ADHD with Russell Ramsay | ADHD reWired

99: CBT for ADHD with Russell Ramsay

Dr. J. Russell Ramsay is a specialist in cognitive behavioral therapy (CBT) for those with ADHD, bringing a wealth of knowledge about strategies and mentalities regarding how to manage ADHD on the inside, with the mind. Discussing automatic thoughts, self-talk, the development of core beliefs, therapy, plenty of techniques for CBT, and more.

About Dr. J. Russell Ramsay:

  • At the University of Pennsylvania, Russell is the co-founder and co-director of their Adult ADHD Treatment and Research Program and an associate professor of clinical psychology in psychiatry in the Pearlman School of Medicine.

  • Author of numerous peer-reviewed scientific and professional articles, research abstracts, and book chapters in addition to his own four books related to ADHD, Russell is a member of the CHADD Hall of Fame and a member of the editorial board of the Journal of Attention Disorders.

  • One area where Dr. Ramsay specializes is in cognitive behavioral therapy for ADHD.

Adult ADHD Treatment and Research:

  • Working with his psychiatrist colleague Dr. Tony Rostain at the University of Pennsylvania, Tony observed how many of the patients he treated as children would return later as adolescents and adults, which ran contrary to supposed knowledge at the time saying that people grew out of it.

  • Dr. Rostain decided to create a program specifically oriented at adults. He would be able to handle the medication side, and brought on Dr. Ramsay to develop a psychosocial and cognitive therapy treatment, with both of them able to evaluate patients.

  • Since the program’s inception, they and other teams around the world have worked on adapting cognitive behavioral therapy (CBT) for ADHD applications.

  • In his book Nonmedication Treatments for ADHD, Dr. Ramsay begins with the statement: “Let me be crystal clear at the outset: this book is not an anti-medication book.”

  • Dr. Ramsay’s book on nonmedication treatments was based on the questions he would receive from people wondering how well CBT functions as a treatment in comparison to alternatives like neurofeedback, relationship treatments, coaching, and more; he assesses each option in relation to how supported it is with scientific evidence.

  • Alongside medication, CBT and psychosocial treatments rank as the next most viable treatment supported by evidence. Others, like coaching and couples therapy are evolving in their evidence.

  • In terms of couples therapy, Eric mentions Ari Tuckman’s recent survey-based study. Russell mentions the upcoming book Adult ADHD-Focused Couple Therapy, which includes a treatment model that can be tested.

What is Cognitive Behavioral Therapy?:

  • Similar to regular talk therapy, the patient sits in a room and talks with their therapist.

  • The focus of CBT is on how people think.

  • People will have automatic, reflexive thoughts and interpretations of events – catching those thoughts and analyzing what one is thinking at a particular moment.

  • If a friend doesn’t call you back, you may have any number of reflexive thoughts: the friend is mad at you, their cell phone died or was lost, they forgot, etc. Those thoughts can then build: wondering why the friend would be mad at you, thinking of how much of a jerk they are, etc.

  • If those automatic thoughts are working against our wellbeing or goals, they are considered mal-adapted.

Metahpors and Mal-Adapted Thoughts:

  • In order to make lessons and treatments more “portable” and able to stick with patients better, Dr. Ramsay uses a lot of metaphors to describe them.

  • Automatic thoughts are like a prosecuting attorney making a case to a judge about a particular task. The “prosecutor” makes the case that, for instance, organizing tax paperwork would be hard and should be delayed to a later time. Then, the judge rules in their favor without allowing a counter argument.

  • CBT would have a person imagine what a defense attorney would say to counter the prosecutor’s argument: that it’s only organization of documents, in the past it wasn’t as tedious once it was started, and the person can reward themselves afterward, for instance.

  • Automatic thoughts may sometime be based on a person’s history with a particular task being unpleasant, but that history doesn’t necessarily always apply to the task at hand.

  • Eric describes his experience in college with spending eight hours per day for nearly an entire semester to complete a three-page paper. That experience undoubtedly influenced how Eric thinks of himself as a writer.

  • Using the court metaphor, the prosecutor would seemingly have a lot of content with which to craft his argument. However, a good defense attorney could discuss the difference between the person’s ADHD management skills then and now, whether one could change their writing strategies and methods to make the experience of writing drastically different than it had been in the past, or comparing between assigned writing and personal writing, with the latter being more approachable.

  • If you can change the way you write, perhaps by organizing your topics before actually starting the writing, then the act of writing itself may become different enough that it’s not as stigmatized.

Core Beliefs and Exposure:

  • Another level of cognition is the level of core beliefs.

  • Core beliefs can be positive in the case of someone who is confident in their ability. They can also be negative in the case of someone thinking they’re bad at a particular task.

  • In overcoming negative core beliefs, one often has to confront their learned emotional response to the experiences that they have stigmatized over time.

  • Emotional exposure is also one potential strategy that’s traditionally associated with phobias and traumatic experiences. One tries to challenge the emotion and negative thoughts enough that they can bring it down to a manageable level.

  • Normalizing stressful and negative emotional tasks can make them more approachable.

  • You don’t have to feel anxiety free to manage taxes, write papers, etc. Being able to tolerate that feeling for just a few minutes can engage a person in the task; at least they’re moving forward.

  • Exposure and response prevention can play a part in dealing with negative core beliefs as well. It involves a specific situation resulting in a strong emotional response that leads to escape and avoidance. The strategy then becomes “the only way out is through”, which can be executed in progressive steps to build up tolerance to anxiety.

  • “In effect, you’re boring yourself out of the anxiety. You’re sitting […] with a task long enough that eventually it starts coming down.”


  • Eric and Russell bring up the point of obsessive compulsive personality disorder being close to a classic type-A personality: detail-oriented, perfectionistic, rigid, etc.

  • Sometimes OCPD simply co-exists with those who have ADHD as happenstance, but there is also the idea that coping and adaptation strategies for those with ADHD tend to reflect OCPD as a style. For instance, building consistency and patterns into one’s life for the sake of simplification could be an example of adaptation, despite it also relfecting OCPD tendencies.

  • Even if three percent of actions are excessive, the remaining 97% might just be a good way to manage ADHD.

Perfectionism and Emotional Reasoning:

  • Thinking that a person is what they feel emotionally is called “emotional reasoning”. “I feel stupid so I must be stupid.”

  • Emotional reasoning can hijack a normal line of reasoning that would otherwise see a person make rational decisions.

  • Dr. Ramsay and colleagues of his conducted a chart review study of patients who completed their program and a cognitive distortion questionnaire. They found that the number-one distortion by far was perfectionism, with emotional reasoning coming in second.

  • Russell highlights what is called “back-end perfectionism”, where one over-assesses their work after it’s completed because it’s not as good as it could be.

  • In comparison to back-end perfectionism, Russell and his colleagues currently hold a hypothesis that many adults with ADHD have front-end perfectionism, which would be the requirement of ideal conditions in order to start a task.

  • Front-end perfectionism is used as justification for people waiting on tasks “until they feel better”, which runs the risk of leading people into last-minute rushes or missed deadlines.


  • Eric points out that the mental dopamine boost most people receive upon completion of a task is largely absent in those with ADHD. Russell notes that setting up rewards for ourselves can be very important, though it’s one of those tasks that often becomes sidelined.

  • In Eric’s Coaching and Accountability Groups, one exercise involves having group members create star charts where they will give themselves stars upon completion of goals, no matter how incremental.

  • For instance, when trying to start working out, one could give themselves a star for simply visiting the gym without working out. Or, they could receive one for simply changing into workout clothes.

  • Those sort of incremental actions build scaffolding and prime the individual for future action.

  • Wearing his workout clothes to bed and placing his exercise bike in his living room are some steps Eric took in the past to remove barriers between himself and his goal of working out.

  • Different strategies will work for different people – personalize the strategy for the individual. For instance, some will respond well to a gradual, incremental approach to beginning a task, while others (Eric sees about 10–15% of clients) respond better to an all-at-once method, a more substantial change.

Dialectical Behavior Therapy (DBT) versus Cognitive Behavioral Therapy (CBT):

  • DBT is part of the CBT family. DBT was designed as a treatment for borderline personality disorder and suicidal behaviors and, as such, was modified to accommodate emotional regulation difficulties related to those conditions.

  • Emotional regulation exercises have a greater focus, with a goal on managing the emotions to bring them down to a level where one can cope with variable life endeavors.

  • DBT has specific skill modules, e.g. impulse control, emotional regulation, following through on tasks, etc.

  • Interestingly, DBT was modified by Alexandra Philipsen in Germany after she conducted a DBT program. Philipsen noticed how similar what was being treated was to what she saw in her separate adult ADHD patients and modified the existing modules to better suit them.

Studies and Research:

  • Philipsen continued to research that model, recently conducting the largest psychosocial treatment outcome study ever for adults with ADHD in Germany.

  • Dr. Ramsay compares Philipsen’s study with the MTA study conducted in the US on treatment for children with ADHD, the latter comparing medications with behavioral treatment.

  • The headline outcomes between the two studies ended up very similar: everyone seemed to function better on medications, whether alone or combined with psychosocial treatment.

  • Russell posits that in both studies, all of those monitored had some form of counseling, even if it wasn’t specifically CBT or psychosocial treatment, and any sort of counseling is likely to help at least a little, which may change the results slightly.

Products, Services, and Other Links:

Other information:

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