Monthly Archives: November 2015

Clinical News You Can Use

Adult ADHD: Medication Plus Cognitive Behavioral Therapy, Latest Research

An article by Sanjay Gupta*, “Talk Therapy Alone for ADHD Doesn’t Cut It,” reviews a recent multi-site study of treatment for Adult Attention Deficit Hyperactivity Disorder [ADHD]. In sum, “talk” therapy does have a significant benefit, but it doesn’t benefit ADHD symptoms quite as much as medication or the combination of medication plus therapy.

Treating ADHD means BOTH

adhd11) improving symptoms of concentration, focus, and memory with medications AND

2) developing skills for organization, social behavior, following-through, remembering responsibilities, and anticipating consequences.

The research addressed mainly the symptom domain.

We have known since the 1980s that “psychosocial” therapy, such as individual psychotherapy, group therapy, or social skills training, does not significantly reduce the symptoms of most children with ADHD unless medication is also used. The most common medications for children with ADHD are formulations of one of four drugs,

1) methylphenidate (e.g., Concerta, Daytrona, Focalin, Metadate, Methylin, Ritalin),

2) dextroamphetamine (Adderall, Desoxyn, Vyvanse),

3) atomoxetine (Strattera), or

4) guanfacine (Intuniv, Tenex).

A child may do well on the first drug chosen. But often, one drug may have unwanted side-effects or weak benefits for that child. So then a different one of these drugs needs to be selected. Sometimes, the child benefits more from taking the drug twice per day. Depending upon other behavioral symptoms besides those of ADHD, some children receive a second medication, such as Clonidine (catapres), riperidone, or an anti-depressant.

Adult ADHD Outcomes

The recent German study published by Alexandra Philipsen, et al, in JAMA Psychiatry shows the same is true for adults with ADHD, adding medication produces more benefit than therapy alone. The researchers adhd2analyzed data from 419 patients who had been randomly assigned to one of these four conditions: methylphenidate, individual therapy, structured cognitive behavioral group therapy, or placebo. Simply stated, the methylphenidate group experienced larger reductions in symptoms than patients in the two therapy conditions. The main measure was the ADHD Index of the Conners Adult ADHD Rating Scale.

The implications of these findings are of special importance for mental health professionals and ADHD patients.

  1. A reduction of 20-25% in symptoms can be achieved by a combination of therapy and medication.
  2. Medication should be added to the treatment regime in order to boost the improvement.
  3. Realistic expectations are important. The state-of-the-art approaches lead only to modest gains in ADHD symptoms.

The study only measured the overall ADHD Index on the Conners. (CAARS) Note that in addition to measuring how closely the patient’s symptoms match DSM-IV symptoms for ADHD, the Conners also measures various adhd3other symptom domains as well.   We present these in order to clarify that a person with ADHD has both SYMPTOMS, as measured in the study, and IMPAIRMENTS, that is, areas of functioning which are limited by ADHD symptoms.

1) Inattention-Memory Problems – Since Working Memory deficits are thought to be central to ADHD, many patients have problems with concentration, short-term memory, forgetfulness, absent-mindedness, disorganization, and planning.

2) Hyperactivity/Restlessness – Many, but by no means all, patients feel or appear restless and have trouble sitting still.

3) Impulsivity/Emotional Lability – Many experience rapid shifts in mood (not to be confused with Bipolar Disorder), irritability, making snap choices without stopping to think about consequences.

4) Problems with Self-Concept – Lifelong difficulties with relationships, academic performance, and choices lead to a loss of self-esteem, a poor sense of competence.

The study did not determine if the treatments led to improvements in the adhd4range of domains and impairments. Nor did the study look at long-term skill improvements specifically. However, since Conners scores did not go down much in the study overall, we see that, without medication, patients lagged in the acquisition of new skills.

 

In recent years, an industry has arisen using coaching as an intervention with adults with ADHD. Motivated individuals can benefit from coaching or working with a psychotherapist to improve follow-through, completing important tasks, social interaction and relationships, and self-concept. The Philipsen study suggests that medication may enhance the ability to learn these crucial skills.

Lastly, ADHD is a lifelong condition. A person with ADHD learns

*to manage the symptoms

*to overcome the impairments,

*to acquire skills for effective performance in school, work, partnering, family life, and in the community

The study should not be read to mean that medication alone if the answer. Therapy or coaching is essential to helping many ADHD patients to manage the social, occupational, and educational effects of their primary ADHD symptoms.

*Click here to read the Sanja Gupta article.

Click here to read the abstract of the Philipsen article. 

The entire article reference is:

Philipsen A, et al (2015). “Effects of group psychotherapy, individual counseling, methylphenidate, and placebo in the treatment of adult ADHD. JAMA Psychiatry, 2146.

If you have more interest in the Conners Adult ADHD Rating Scale (CAARS), here are two sites which give examples of scoring for the CAARS and a breakdown of the symptom domains measured by the Scale, which include the major areas of difficulty in adult ADHD. The scale itself is only available to trained mental health professionals.

CAARS: Long Version (CAARS-S:L)

CAARS: Short Version (CAARS-S:S)

If you want to dig deeper into the professional literature on Cognitive Behavioral Therapy for ADHD, a good place to start is this review:

Knouse, L.A., & Safren, S. (2010). Current Status of Cognitive Behavioral Therapy for Adult Attention-Deficit Hyperactivity Disorder. Psychiatric Clinics of North America, 33 #3, 497-50

This link to the Knouse and Safren article on PubMed brings the reader to a number of other articles on this subject:

Current Status of Cognitive Behavioral Therapy for Adult Attention-Deficit Hyperactivity Disorder

 

Therapy Gems: It’s Okay to Be Yourself in Progress Notes

I never knew myself as “Wr.”

I never referred to myself in written psychotherapy documents as “This Writer.”

The term “This Writer” has always felt to me to be discordant, as dissonant as screeching. sbh1

As it seemed to be a harmless practice, I did not tell my trainees to change the habit of referring to themselves in the third person, and I failed to examine my reaction in depth.

A few days ago, Lynn Godec and I were reading the notes of a client we needed to refer after her therapist decided to move out of the state. Reading this note, Lynn and I together grasped the deeper meaning of my displeasure at the terms “Writer,” “This Writer,” or “Wr.”  The therapist’s initials are LY.  The client is referred to by name, by her initials, JZ, or by Cl.

PROGRESS NOTE VERSION W

Cl came for the first of three final individual sessions. Wr. informed Cl at the end of last session that Wr. will be leaving at the end of the month.  Wr. and Cl spent most of the session processing this event, including Cl’s feelings of loss and disappointment, as well as Writer’s recommendation to transition to another therapist in the clinic.   Cl has hx of depression and SI, but reported no SI in this session.  She said she understood, and that she has had to change providers in the past.  Cl is open to Wr’s suggestions.  She reported since last session she was at the ER as a result of a bout of fear, tachycardia, and difficulty breathing which turned out to be one of her panic attacks. Wr. connected that event with the news imparted in last session.  Questioning uncovered her projections around why Wr. was leaving, which Cl had personalized.  Worked on a cognitive restructuring task and forecast other feelings about this transition would come up, to please bring that to the next session.

DR: For such an emotionally intense experience, doesn’t “WR” sound kind of distant.

LG: Yes, it seems too objective sbi2

DR: It’s odd.  It denies the intimate connection that Joy (meaning the client) feels, her anxiety, like there isn’t a relationship.

LG: The whole point of the note is the meaningfulness of a relationship and attachment for the client.  If the therapist wants it to sounds to objective all the time, that practice troubles me.

DR: Exactly.  Oh, if the therapist did it so much in this one session, more than in other notes, we could guess she is having a problem with clients’ feelings about her leaving, or is ambivalent about leaving.  It is a hard part of professional life to change jobs, to say goodbye to 30 clients and help that many new ones at a new job all in a couple of months.

As the conversation continued, I realized that in my job in business management before I went to graduate school, I followed the practice in business correspondence of using the first person. If I were giving my opinion, facts, or a promise, I referred to myself as “I.”  If I were referring to a process involving others at the company or a company commitment, I used the first person plural, “We” or the name of the company.

From day one of graduate school, I trained as a psychotherapist. My only jobs in the field over four decades, all three of them, were therapy jobs. The first was as a therapist on an inpatient unit.  The second was in a non-profit clinic. The last 25 years have been in a solo practice which morphed into a large private therapy clinic.  I had not trained in one of the many professions that therapists often do before becoming psychotherapists, especially, nurse, teacher, school social worker, protective service worker, case manager, discharge planner, residential treatment therapist, autism line therapist, psychometrician, and others.  Perhaps in some of those settings, therapists learned to speak of themselves in the third person.

On the other hand, I always referred to myself in notes as “I” or by my initials, “DR.”  For variety, I use “T” for therapist, but mainly to indicate a back and forth dialogue between Cl and T.

DR: Writing notes is almost more subjective than objective. We are not video recording the session.  We choose what to write, what’s salient, want we want to remember, how we will describe what happened.  We analyze the session and record what our clinical thinking tells us is important.

LG: It’s like trying to sound objective by using the third person, as if the therapist were watching the two parties interact and describing that from a step removed from being there.   S, that makes me wonder if therapists who write that way try to place themselves in that stance with the clients!

DR: That’s a scary thought.

sbh3

So I think we nailed it. Psychotherapy is a process in which the healing factors are a strong therapeutic relationship founded upon these factors:

  • genuineness
  • emotional honesty
  • positive regard
  • empathic attunement
  • instilling hope
  • a therapeutic alliance based upon rapport, the result of all these relational factors, and client-therapist agreement on the goals and methods

Interactional subjectivity, on the one hand, and self-observing objectivity on the other must be present together.  Client and Therapist are in an experiential relationship, the interactional, subjective side, and the therapist is paying attention to the process between them and the process inside each of them, the self-observing, objective side.  However, making the therapist an object also objectifies the client.   That does not seem to fit with the core healing factors.

DR: It feels like “Writer” is a violation of what therapy is about.   I wish our staff would write notes that show how well they are interacting, that they are connected with the client.

LG: Try re-writing that note. See if it makes a difference.

VERSION “I”

Joy came for the first of three final individual sessions. At the end of last session, I told her I will be leaving at the end of the month.  We spent most of this session processing this upcoming event, including Joy’s feelings of loss and disappointment, as well as my recommendation to transition to another therapist in the clinic.   Cl has hx of depression and SI, but reported no SI in this session.  She said she understood, that she has had to change therapists in the past.  Joy is open to LY’s suggestions.  She reported since last session she was at the ER as a result of a bout of fear, tachycardia, and difficulty breathing which turned out to be one of her panic attacks.   LY connected that event with the news imparted in last session.  Questioning uncovered her projections around why LY was leaving, which Cl had personalized.  Worked on a cognitive restructuring task and forecast other feelings about this transition would come up, to please bring that to the next session.

Reading version I, I feel closer to the interaction.  An important therapeutic byproduct is sensing I sbh4have a better grasp on the client’s process.

DR: I feel I sense Joy more, understand her better. Feeling her more directly in the first person makes it easier to see what is happening with her.

LG: So, as the author of the note, we aren’t writers; we should write like we are therapists.

Just to be sure it makes a meaningful difference, I read the two notes to a few non-therapists. Here is a sampling of some comments.

“The second one is comprehensible.”

“The first one is confusing.  I had to ask a lot of questions to grasp what she was saying.”

“The second one is more insightful.” I pointed out the content is the same.  “But it feels it has more insight.”

“The first is just inappropriate.”

“That writer is not a writer.  She’s a therapist.”

“It’s like putting the therapist four steps away from her place as therapist.”

“I would not want to see that therapist.  I don’t see she cares.”

So, I am not the only person finds the wording “This writer” to be incongruous with the role of therapist.

My recommendation is that therapists write notes in the first person and my hope is that no one causes me to read such dissonant notes anymore.

P.S. While I am discussing the use of “Writer,” I will add that the word “Provider” has troubled me since around 1988-1992 when the term came into common use.  Our status as Psychologist, Clinical Social Worker, Licensed Counselor, Marriage and Family Therapist, etc., was changed by Managed Care Organizations to “Provider.”   To the MCO, we are all roughly equivalent.  The first tier consideration for how referrals are doled out is by zip code.  Specialty areas are second-tier factors.  Actual profession is not a significant factor in the process.   Strikingly, professionals seem to have accepted the appellation of “Provider,” have signed “Provider contracts,” and, in the case of those companies for which is it difficult to  become a “Provider,” welcomed the opportunity to be on the “Provider panel.”  All that is necessary to survive in the profession; if we want to be paid for our work, we have to do this.  I am not suggesting we all rebel.  What I am suggesting is that we be proud of the arduous paths we have taken to get to be psychotherapists. I am also suggesting we attend to a larger subject, namely, care in the use of language.  Just as the connotative meaning of “writer” can be dissected and produces a different experience than “I,” so too “provider” produces a different experience than “psychotherapist.”  My hope is that therapists will become more conscious of the way in which they use language.