Dialectical Behavior Therapy in the Treatment of Adult ADHD
Many symptoms of ADHD persist into adulthood. Although hyperactivity tends to decrease with adulthood, emotional instability, disorganized behavior and disinhibition are prevalent in adult ADHD. Adults with ADHD often report trouble focusing and difficulty in selecting relevant stimuli, particularly when they are not motivated or in monotonous situations. These symptoms can lead to problems at work, school and in social situations. Low self-esteem and conflict are common consequences of difficulties with impulse control, emotional instability and difficulty recognizing social cues.
Dialectical Behavior Therapy
Dialectical Behavior Therapy (DBT) is a cognitive-behavioral therapy originally designed as an outpatient treatment for people diagnosed with borderline personality disorder. DBT was developed by Marsha Linehan and was originally aimed at reducing the high-risk, impulsive and treatment-interfering behaviors in women who self-injured. Clinical trials have found DBT to be effective in reducing self-injurious behavior and inpatient psychiatric days in women diagnosed with BPD. These trials also found it to be helpful in reducing anger and improving social adjustment. DBT has also been adapted and evaluated for other populations, including adult ADHD.
DBT’s approach balances a focus on behavioral change with acceptance, compassion, and validation for the individual receiving services. DBT strives to enhance an individual’s capability to manage psychological and emotional functioning, improve motivation, ensure that new behaviors are generalized to daily life, structure the environment to support adaptive behaviors and enhance treatment provider ability and motivation.
Core elements of DBT include the biosocial theory, stages of treatment, guidelines on identifying treatment targets, acceptance, change and dialectical treatment strategies and five specific modes of treatment, which includes a weekly skills group. In initial stages of treatment individuals often experience extreme behavioral dyscontrol and engage in problematic behaviors such as self-injury, suicide threats, severe eating disorders and substance use. The initial goals of treatment focus on stopping problematic behaviors and gaining behavioral skills to manage extreme emotion and impulsivity. Once greater behavioral control is achieved, focus in on improving quality of life, emotional experiencing and achieving ordinary happiness in ife.
Adaptations to DBT often focus on DBT skills training. Skills training group is generally a weekly group with half of group time structured to teach skills and half of group time spent reviewing homework and use of skills in daily life. The group is highly organized and focused on teaching and practicing new skills and improving motivation to use skills outside of group.
Although it was originally designed as an outpatient treatment for women diagnosed with borderline personality disorder, DBT has grown into an effective treatment for people with a wide variety of diagnoses and problems. Its effectiveness in modulating extreme emotions and reducing negative behaviors makes it an attractive treatment especially for people who struggle with impulse control and emotional instability. The emotional instability, disorganized behavior and impulse control problems make DBT a potentially good match for the treatment of adult ADHD.
In 2002 Hesslinger and colleagues developed a 13-week group as an adaptation of a DBT skills training group. The adapted group included trainings on 3 of the 4 skill modules taught in traditional DBT skills groups. The ADHD group focused on mindfulness, acceptance and tolerance of crisis and painful life events and managing emotions. The ADHD group added training on behavioral analysis, which is typically a part of DBT individual therapy. The purpose of each of these skills modules is to teach individuals to focus attention, accept and survive difficult life events without engaging in impulsive or dangerous behaviors and to reduce vulnerability to extreme emotions. Behavioral analysis teaches individuals to analyze their own behavior patterns and the thoughts, feelings and actions that contribute to impulsive and problematic behaviors.
Although the study size was small, the ADHD participants in the adapted DBT treatment experienced significant reductions in depression and ADHD symptoms. They also saw improvements in attention and ability to focus.