PODCAST. Stopping Negative Self-Talk with Cognitive Behavioral Therapy (CBT) with Dr. Laura Knouse, PhD.
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Dr. Laura Knouse is a clinical psychologist and Professor of Psychology at the University of Richmond. She is an expert in cognitive-behavioral therapy (CBT) for adult ADHD whose research focuses on how this treatment can be improved and implemented. She has published more than 40 peer-reviewed research articles and is the co-author of Thriving in College with ADHD: A Cognitive-Behavioral Skills Approach, and, most recently, Living Well with Adult ADHD: Practical Strategies for Improving Your Daily Life, co-authored with Dr. Russell Barkley.
Rebuilding Self-Trust & Mastering Executive Function with Dr. Laura Knouse
If you’ve ever felt like your brain is a "black box" that you can't quite trust to follow through on your intentions, this episode is for you. In this installment of the ADHD Wise Squirrels podcast, Dave Delaney sits down with Dr. Laura Knouse, a Professor of Psychology and a leading expert in Cognitive Behavioral Therapy (CBT) for adult ADHD.
From her early research in Russ Barkley’s lab to her fascinating work training rats to drive tiny cars (yes, really!), Dr. Knouse brings a wealth of clinical expertise and a refreshingly practical perspective on how to live well with a neurodivergent brain.
Key Highlights from the Conversation
Creative Empiricism: Dr. Knouse introduces a game-changing framework for dealing with "failure." Instead of viewing a missed deadline or a messy room as a moral failing, she encourages "creative empiricism," treating every setback as valuable data to help you tweak your systems.
The Rebuilding of Self-Trust: Wise Squirrels often carry a lifetime of "schema," suggesting they are unreliable. Dr. Knouse explains how CBT helps bridge the gap between knowing what to do and actually doing it, slowly rebuilding trust in your own agency.
Medication vs. Skills: It’s not an "either/or" situation. While medication can "turn down the volume" on symptoms, Dr. Knouse highlights why skills-based CBT is essential for managing the executive functioning gaps that pills don’t teach.
The "Scaffolding" of Relationships: We dive into the "parent-child dynamic" that often plagues ADHD-impacted couples and how to build external scaffolding (like shared digital systems) to take the pressure off the neurotypical partner.
Vetting Your Therapist: Not all CBT is created equal. Dr. Knouse provides a "litmus test" question you should ask any prospective therapist to ensure they actually understand the mechanics of the ADHD brain rather than just treating general anxiety or depression.
Why You Should Tune In
This isn't a dry academic discussion. It is a deep dive into the emotional architecture of ADHD. You should listen if:
You’re tired of the "Negative Narrative": Learn how "cognitive reappraisal" can help you stop the spiral of self-shame.
You’re a late-diagnosed adult: Dr. Knouse explains why the transition to adulthood often feels like "the scaffolding falling away" and how Wise Squirrels can build your own.
You want actionable tools: From "daily thought records" to "covert rehearsal" (mental visualization), this episode is packed with strategies you can start using today.
You want to hear about driving rats: Honestly, the "Rat-Controlled Vehicles" (ROVs) story is worth the price of admission alone.
Stop fighting your brain and start collaborating with it.
Tune in to hear Dr. Laura Knouse explain how to turn "I can't" into "Here is the data I need to try again."
When looking for a therapist, ask: "What can you tell me about the most effective psychotherapies for ADHD?" If they don't mention practical, skills-based strategies for executive functioning, they might not be the right fit for your ADHD.
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Welcome to Wise Squirrels, the podcast for late diagnosed adults with ADHD. I'm your host, Dave Delaney. Today I'm
speaking with Dr. Laura Nouse, a professor of psychology and expert in adult ADHD. I loved this conversation.
And you have to check out the show notes, by the way, at ysquirrels.com,
cuz that's where you can see the video of the rats driving tiny cars. It's crazy.
Some of the topics we discussed today include CBT, cognitive behavioral therapy for ADHD, and why high quality
therapy must focus on executive functioning and skill building, not just general talk therapy. We speak about a
framework for rebuilding self-rust by treating failures as valuable data points to adjust your strategies.
Relationship scaffolding, how to manage the parent child dynamic in couples and offload executive tasks onto shared
systems. Vetting therapists, uh the key questions to ask to ensure a provider actually understands adult ADHD
treatment. That's an important topic. We also speak about coorbidities in gender,
how untreated ADHD fuels anxiety and depression or can and why diagnostic
bias often leaves women overlooked or certainly has in the past and that's being corrected these days, but it's not
quite there yet. That's why typically women are diagnosed about 5 years after men. Laura is fantastic. So, you're
going to love this conversation that I will share with you in just a moment.
But before I do, uh, I would like to beg you, please beg you for a rating and a
review. I know, I know every podcast you hear this, but it is true that with your kind rating and review, it helps other
listeners discover this show. And really ultimately, my goal here is to help educate late diagnosed adults with ADHD,
help teach them, and teach myself as we go. So, please do me a favor now and just take a moment uh pause the podcast.
Go into your podcast app, assuming you're not driving, of course, and leave a fivestar review if you think it's worth five stars. I do get to see these
things. So, one reason, as I said, new listeners discovered the show. The second reason, Dave gets a little dopamine. That's right. When I see your
reviews, I get a little rush of dopamine. I'm like, "Oh, a new listener and somebody who loves the show." So, yeah. Would you do that for me, please?
And of course, if this is your first time listening to Wise Squirrels, you might be like, "Dave, we just met. What the heck? We can't go all the way." It's okay. I know I'm asking for a lot. So,
listen to the episode. If you like it, maybe leave a review afterwards. Okay,
deal. Is that cool? All right, let's listen to Laura. She's got a lot to share. Very excited to be here. I'm uh Dr.
Laura Nel. Um I am a professor of psychology at the University of Richmond in Virginia and that is a undergraduate
focused institution. So one of the cool things I do here is um train students in research and my students get to help me out with my research which is cool. I
have been involved in adult ADHD um research study and clinical work um since the very beginning actually. So, I
did a undergraduate honors thesis way back when on uh driving in ADHD in the
research lab of Russ Barkley at UMass Med Center at that time. Um, looking at people's beliefs about their driving efficacy. And it turns out we all think
we're above average drivers, but for people with ADHD, they also think they're above average drivers and we know there's some driving risk there.
So, um, I got the opportunity to get involved in that work from early on and then I went to graduate school and got
to learn more about assessment and treatment of ADHD. And then my uh, real
specialization began in um, at uh, the uh, Massachusetts General Hospital, Harvard Men School with Steve Saffron,
and that's where I got to work on one of the first randomized control trials of CVT for adult ADHD.
Yeah. um and which was such a great training experience and um really kind of set me on my way to where I am now.
Um so I do teaching, I do basic research studies, but I also really enjoy trying to take what we know from research that can be effective and help bring it to
actual people in the in the world and to clinicians. So I love that. Did you um did you fall into the topic or did you was it just
like right place, right time and then you're suddenly you're teaching rats to drive cars?
That was that was me my problem with being interested in everything regardless and having trouble editing with the rats and cars. But um the uh
the ADHD opportunity was sort of a at that time there weren't as many summer research opportunities available and
UMass had this fellowship and I kind of came to know Dr. Barkley like through some social connections and he was like
why don't you apply? Um, so that work in his lab was somewhat serendipitous. But then I I really it was a good fit for me
because if I were not a clinical psychologist, I would be a cognitive psychologist studying attention and memory. And so for me, it was always
just this wonderful fit in terms of research interest. And in fact, some of my research area is very cognitive, very
like what are ways that um we can enhance the kind of effective study strategies for students with ADHD, but
using some basic like lab studies to kind of investigate that. So yeah,
um that's cool. Um and and and just and maybe like a short uh summary because I know uh somebody out there is listening to this going,
Wait, did he just say something about rats driving cars?
Uh can you just briefly maybe summarize what what that was and just so people know?
So this happened um there's a fairly now kind of popularly well-known study at the University of Richmond where we in fact built tiny little rat control ROVs,
rat operated vehicles and behaviorally trained rats using um Froot Loops as reinforcers. It turns out they really
like Froot Loops and figured out how to incrementally reinforce little bits of behavior until we could get these rats over many, many training sessions to
steer these little cars around. And the reason I got involved was I had too much time on my hands. I was on sbatical and
two of my wonderful colleagues, one who's a neuroscientist, the other one who's the cognitive tinkerer who built the car were like, "Hey, we're doing
this project." And I was like, "Well, I teach the principles of behavior, like the operant conditioning class at U of R." I was like, I'd love to design the training protocol. And then here we are.
Um, check it out online. Just Google University of Richmond rat driving and you can see it.
Yeah. And I'll include links to all everything we tqurel.com in the in the show notes post. So, I'll find that video because that that sounds
I didn't see it, but that sounds hilarious.
It's funny because, you know, I think in the popular literature, the the message from that study was look how smart these rats are to drive cars. I think the
message is look how much work our students did to train these rats to drive cars and how yes like behavior is
flexible but like it takes a lot of work sometimes to learn new skills which perhaps is another theme we will touch on today.
Yeah. And maybe also the the my understanding at least is that in the US, the US is the only country that
uses, you know, the red dye and food or whatever and that and that. So Froot Loops in the US look way brighter than
they do in Canada, my home and native country. So maybe the maybe the rats have like superpowers now or they're all dead or whatever.
Well, that's that's fascinating, too.
and the stuff that you've done with Russ Barkley as well, you know, uh, co-
co-authoring a book with him, too. The the living well with adult ADHD,
practical strategies for improving your daily life. I mean, that's that's awesome. And and, you know, I'm pretty new to the to the wide wonderful world
of ADHD. Um, you know, having been diagnosed a handful of years ago and starting this podcast, you know, I was diagnosed at 50. And so right away as I
was learning about ADHD both through therapy and for myself um I came across
like you know two of the most popular people maybe three really uh Ned Hwell who I haven't to on our podcast I'd like
to at some point who seems like and and and then Russ Barkley and Tamara Rosier
or Russier um and and Tamara and I have spoken on the podcast and she's great um but I wanted to have Russ on Russ
Barkley and and had reached out several times and he was like, "I'm retired. I'm not doing it anymore." Oh, yeah. It's not just you. He's Dunzo. And he's totally dunzo. Yeah. Yeah.
Which is a shame because I was really enjoying his his video series of kind of debunking a lot of a lot of myths and disinformation out there and and soal
experts and all all the all the other stuff. Um, but when I was watching his like earliest videos and stuff from his
research, you know, I thought of him before I started seeing his YouTube channel, I thought of him as more of this like very clinical stero like, you
know, can uh kerun kind of guy and then Ned Howal was this like happy golucky guy. And then and then as I started
watching Russ Barkley's videos, I'm like, "Oh, he's hilarious. He's like drinking wine and wearing like, you know, Hawaiian shirts and has his dad jokes and stuff." So
there's some secret wackiness under there for sure.
Yeah. Yeah. And I and I I loved seeing that you've done work and obviously you do work with college kids, university students there, but I know a lot the
bulk of the work you do is is for adults with ADHD and we can obviously say that they also are adult adults albeit young adults.
Sure. Um but talk a little bit about scaffolding both from a a a student's perspective perhaps but also more you
know how late diagnosed adults work with their their partners and their families um and this what what can happen with a
a mixed couples where like your spouse perhaps is neurotypical and this parent sort of uh child dynamic I think Melissa
Orof calls it like parent child dynamic that happens. Can you talk a little bit about that and and about scaffolding and how we can maybe improve uh relations
and with our with our partners? Um yeah, let's let's talk a little bit about that that aspect.
And I think where this if I can also connect it to the college student area a little bit more. Um I think where you
sort of see the scaffolding or maybe um the rapid taking away of scaffolding happens between that high school college
transition sometimes for our students with ADHD. So maybe the parent um has been doing a lot of checking in a lot of
time management a lot of scheduling for the person. Um you know it could be that the school is more structured. You know,
I think for college students, one of the biggest things they have to get used to is that they don't have something scheduled every period of the day,
right? They have these big long swaths of time that just look endless and they have to figure out, you know, what to do in those swads of time. So, I think it
is relevant both to the college and maybe um more of the kind of romantic intimate partner family structure type of thing. Mhm.
I do think that there are ways that people who are in relationships with adults with ADHD sometimes will kind of take on some more of the executive
functioning um what we say executive functioning role or executive functioning system scaffolding, whatever you want to call it. Yeah.
Um and this this sure can work out. I mean, you know, every couple has strengths and weaknesses, but I think when I work clinically with people, it's when there's kind of that imbalance between the perceived division of labor.
So, so the general research on division of labor and relationships shows that there's no perfect division of labor.
It's all about like to what degree are the members of the couple satisfied with the current division of labor. Yeah.
Um so I think that there can be um situations where frankly resentments can build up between partners um if one partner feels like they're kind of
taking more of that um you know we hear the idea of like emotional labor too um the sort of management of the family. Um
and so in terms of scaffolding, you know, we might be thinking about one partner providing scaffolding to another partner in certain areas. I think one
way that you can approach working with that is to say, okay, what of this can we offload onto the scaffolding of
mutual systems like within the family that we all can engage with? Um you know, things like shared family
calendars, shared Google calendars are huge. Like in my family, again, this is anecdotal, but I'm trying to, you know,
I see a lot of my college students struggling because they've never had to manage their own calendars. So now with my 16-year-old, I'm like, "All right,
you got a Google calendar. I'm tagging you on events. Like, you're getting used to this." But frankly, like a thing Russ talks about a lot, Russ Barker, is the
for the tool to be useful, it needs to be in the time and at the point in space where it can be useful. And sometimes those electronic systems are a little
too like out in the cloud, right? So for us, we have this like wipeoff calendar every week that is like here are all the
activities happening. Here is when my picky eater son is packing versus buying. Like and we sit down once a week
and kind of co-create that so that we can find who's who's doing what. Um, so I don't know if that's an ADHD specific tip, but that's
an example I can think of of where how do we make it less about who's doing what they're supposed to and make it as Russy talks about a behavioral thing to engineer,
right? A thing that we're like constantly is that kind of along the lines of what you were Yeah. Yeah. totally. Yeah. And and it's funny too because you said like it it may not be like an ADHD specific thing.
And I find that a lot of times with like uh productivity hacks or organizational stuff so or or time management or what
have you. I sometimes feel like every productivity air quotes expert is like an ADHD whether they know it or not
and they're solving the problems for themselves. Sure.
And sharing those those solutions with the world. So, which probably accounts for why so many people with ADHD become entrepreneurs, like successful
entrepreneurs, by solving these problems. I I I've said it on the show before, but I sometimes wonder like what is it like after learning I have ADHD at
50? I'm like, what is it like to be neurotypical? Like, you know what I mean? Like how does does this the clock just work the way it's do you feel the
time the way like you know and I know there's no like you know black or white on or off like 100%
of anything amberverts like come on it's introvert or extrovert like you know leaning that way but yeah I find it really
as a neurotic person I feel the same way. What is what's that like to have a non-neurotic brain? How do you get anything done without anxiety?
Right. Right. Right. Yeah. And you mentioned I've seen that like ADC adults carry this core schema of self mistrust,
right? Because of lifetime of broken promises to themselves and things. So beyond just using like a planner, how does the cognitive part of CBT uh help an adult start to trust, you know,
really trust their own brain again, you know, especially after late diagnosis and you're like, wait, you know,
obviously we know we're not broken as as the titles of the book say. Um, yeah, how do we start trusting our our brains?
Hey, I'm not sure if you know about this, but I was a speaker and a trainer for Google for nearly six years. In
addition to this, I've been a coach through a lot of my career, helping small business owners and entrepreneurs
improve their businesses. But now with ADHD, I've learned a lot about helping other wise squirrels like me. Check out
the link at wisquirrels.com/coaching and book a free session with me to see
if I can help you. I have a feeling I can.
Yeah, it's a great question. It's a lifelong I often think every person we're born with these annoying bodies
that need things and brains that need that it really for anyone is this lifelong process of like how do I just like live in this like bag of bones that
I'm in, you know? Not to minimize the struggles of people with ADHD and in fact I think of course you know getting a high
quality diagnosis that really gives you some clarity about kind of what might be going on with you but then like good what we would call psycho education about like what are the executive
functionings what how what are the things that are the reasons that these particular um things that are hard for me are hard you know because the goals
are further away in time because there there are these distractions and then I think where kind of co the the spirit of
cognitive behavioral therapy has something to offer here is that part of part of one of the things with cognitive behavioral therapy is the whole point of
it is to not that you're going to fix things permanently but that you're going to learn skills that are going to help you better cope with daily life and to really take ownership of your own life.
And a big deal for a cognitive behavioral therapist is we are going to make sure that um as much as possible as
our as um our client like you are feeling ownership for those gains, you know, and you are not, you know, it's not like a sort of top down you're going
to lie on the couch and we're going to interpret your dreams and tell you what the right answer is, right?
But it's we're going to sit face to face and you're going to tell me some things about your life. We're going to gather some data about those specific things
that are problematic for you. We're going to tailor it to you and then we're going to come up with some stuff to try that may or may not work and that is a
matter of testing out in daily life and so that we can really tailor it as much as possible to what's going on with you.
So this this spirit of um creative empiricism to use some big words like we're going to try to tailor it given
everything we know about you everything we know you know from the research literature might be helpful but we're going to try things out we're going to observe the results of what we try and
then we're going to go back and tweak it again. So one attitude through that process is this attitude of like there are no bad data like a failure is not
you know doesn't mean something bad about you it's merely like okay now we have some more data to go back and sort of try it again and this idea also of
emphasizing small gains I think that is key to rebuilding that selfmistrust because
you know your brain evolved to help you survive not to make you happy and so the brain is going to default towards what
is the negative version of this story that's being told right now? Right?
So that mistrust is, you know, and you can talk about like it kind of in some ways it's your brain trying to help you by being like, hey, hey, hey, you know,
you should look out for that and to say like thank your thank you brain for, you know, helping me, but I'm actually like trying to just test out some things,
right? And the result may or not be maybe not be good in the moment, but I can kind of come back and try again. The other thing that when our brains are in
that mistrust mode is we tend to, and I see clients do this all the time, just totally miss these small gains and just be like, "Well, yes, that was good, but
that was good, but look at all this other stuff I did." And I, as the therapist, get like so worked up to the point of like I think my clients sometimes think I I don't know. I Sorry.
No, I think I I hear where you're going.
I think I think you're like the biggest for your client. Easy. Yes. Very wacky. I'm like, "No,
no, no. that thing that that thing right there that you just miss over and you want to this is the thing this is the thing right here and this is the seed that we're going to grow this from.
Yes.
So helping I mean you can use lots of uh kind of triedand-true cognitive therapy tricks of like okay you're and this is where some of my new research comes in.
You're coaching yourself to be like this like harsh coach that's like well it's not perfect so it's not worthwhile
right? Most people would not say that to a friend or let alone a child. You know,
think about especially if you're a parent or if you're somebody that mentors kids. Like, can you coach yourself internally the way you would coach um a kid or especially if you have
if you have taught people. We don't praise the outcome. When we're learning a new skill, if we praise only the outcome, we're never going to get there.
We've got to praise incremental pieces of that process, which is really hard to do, especially if you're a higher functioning person with big goals. But
like it's just not going to happen if we're not willing to get worked up about like our little successes.
That's fascinating. Yeah, because I'm you said a lot there, but I was thinking of like Yeah. how our brains are designed to help us survive. And so
every looming business for me, like working for myself, every looming thing that has that's coming up or every concern I have professionally or what
have you, are all these fires I need to put out. And yeah, so I like I just killed a caribou or whatever it was,
some woolly tooth mammoth or something and and I don't have time to like celebrate that I killed it and I'm and maybe not even time to eat it today because I've got I've got to get out and
put out those fires. Is it like cognitive uh what is it? reappraisal,
like reframing and slowing yourself down. Look at me sounding like an actual medical professional, which I'm not and I don't pretend to be.
But like, how can we like celebrate the wins? How can we recognize the wins?
Because I do this all the time. I don't like for clients, for example, I don't believe anything is a done deal until I see money in my account. And and and once it's in there, it's like, okay,
great. It's not like I'm some like greedy, you know, capitalistic must make all the money, right? Right. But but I
must make honey piece of feedback, right? It's it's the type of feedback that is helpful. Yeah. Yeah.
Yeah. So, how Yeah. What are some ways to kind of slow down and and celebrate the wins or recogni or or slow down long enough to even notice them?
Yeah. I mean, I think that when we think about the way the way that I think about you brought up a perfect term cognitive reappraisal, right? I think sometimes
Yes, exactly. Um, I use I've been using the term as I alluded to earlier, self- coaching.
So, we're always I see our thoughts as a behavior. There's there's neuroiming studies to show that we actually are talking to oursel. We're just
suppressing, you know, our tongue and lips. We are, you know, dying our behavior with what we say. First of all,
just I mean it's kind of basic, but just kind of noticing that internal dialogue,
trying to externalize it when you can talk out loud to yourself when you need to write out kind of in in uh CBT
sometimes we have this classic tool we call a daily thought record. you know,
at the end of the day, just sort of notice a couple moments where there was a large shift in mood either to the negative or um it could be to the
positive or in some cases, I've been applying this to the problem of procrastination. Like maybe you get to the end of the day and you're like,
what was it that I was avoiding in the moment in the moment of sort of a choice point? Like what was I thinking to myself? What was I feeling inside? And
then what did I do instead? And what was kind of the the connection that was that was going on there? M in some of my recent work, we've noticed
that a lot of times those thoughts that are happening in that moment are not our classic negative thoughts like oh my gosh like I'll do a terrible job so I
should just give up or um I can handle this and I'm feeling overwhelmed. A lot of times it's neutral or maybe even positive thoughts like I have much more
time to work on this later or I don't have to stop doing this thing right now like I have plenty of time to you know yeah or I can you know kind of
permission giving types of thoughts. And so the idea there isn't about necessarily like immediately changing that thought. Sometimes cognitive
therapy gets this um I think false idea that it's all about positive thinking that we're going to replace our bad thoughts with good thoughts. And first
of all we can't do that like thoughts a lot of times are quite like you know automatic. Um we also know if you try to suppress thoughts they come back even
stronger. So that's not a idea. The idea there is can you now be aware of that self- coaching and then stop and say but
is that going to get me where I want to go right now and that's super hard and that's the part that kind of requires practice. So I would say I'm going to wind this back
to the example you're giving. How to give credit for things that you know maybe you normally miss over. Can you identify times where you are having a
sort of it might and it might not always be like a like a wordy thought like even just sort of like a a feeling in your body somewhere where you're like uh
never mind or uh like it could even be something kind of non-verbal. Russ Ramsey and I both have kind of arrived at this like gh kind of feeling.
Yeah. And if you can start to clue into that and notice like I guess it was fine but I should have done that and be able
lie to say that that's not going to take some time but I think if you can figure out what for you are the signposts that
that thing is being missed or that that avoidance mode is sort of kicking in if it's a procrastination problem or that kind of overly negative coaching is
starting. You can use these as Russ calls them pivot points.
Okay, for me like that's the kind of red flag that I need to step back or I can step back and just kind of like reconsider a little bit.
And as you were alluding to earlier,
this is a lifetime of knowing ourselves to be able to catch ourselves like in those moments. But I think I found it can be helpful for people.
Yeah. And I like I do a lot of public speaking. So I like I love delivering keynote presentations and training and and and workshops working with people
and I sometimes do training on public speaking skills both presentation design but actually like speaking and I often
get comments about people being super scared of public speaking and what I've what I've started teaching folks is that
if you have if you've done all the work well first of all I'll say like what are the feelings of being fearful of
standing out on stage in front of hundreds people or whatever. The feelings are like butterflies in your stomach, sweats, shakes, maybe
goosebumps or chill bumps or what have you. Um, uh, shortness of breath perhaps a little like all these things kind of happen. sweats is if you are prepared
and yes it's it's nerve-wracking a little but if you're prepared and you're proud of what you're about to deliver like maybe you're delivering a
presentation about your latest findings and things and you're excite you're going to be sharing them you've done the work so you're you've done the research
in that case you've done the presentation like you've written the presentation you've designed the slides you've rehearsed and rehearsed and rehearsed and you feel great about it
the idea then is that when you stand out on stage So, pause long enough to consider that you're not scared, you're excited,
and that because you're about to share what you've learned in this case to like an audience, but but when you think about the the symptoms, air quotes, of excitement, what you feel, shakes,
goosebumps, sweats, shortness of breath,
right? Like you're excited, like butterflies in your stomach. It's like the same symptoms or feelings that you get when you're scared. And so it's just a matter of like slowing yourself down
enough to reframe those thoughts to realize no I don't I I no brain
100% of yeah that reappraisal or reframing is another word cognitive therapists love and as you know from
being human it's hard to do and I think one challenge there especially with a skill like public speaking that you're talking about is and this is true with
new skills to manage ADHD too is like we need practice opportunities like they're not going to you have to be patient with yourself because often I'll say like you
know and and people have high expectations and you know they'll be down on themselves if something doesn't work the first time and like we've been doing it the old way for like however
many years and it's it's not fair for you as your own coach to like expect that it's going to be perfect. Uh but I
think that um another thing related to that that this is more just uh my own thinking recently about like how do we use kind of some classic therapy tools and apply them in a novel way to ADHD.
Um I've been thinking a lot lately about the use of what uh you know in the field we would call covert rehearsal or visualization and how some of this might
be applied to um learning new thinking and feeling patterns with ADHD. So, um,
for your public speaking example, this might be something like, you know, the classic kind of close your eyes and kind of imagine, uh, what the audience looks
like. Kind of imagine yourself being on stage. What are you feeling in your body? And, you know, sports science tells us that this like visualization,
covert rehearsal stuff can be like super helpful and super effective. It's probably not as good as like practice, practice, but it's pretty darn good. Yeah.
And so, I've been thinking your question about how do we learn these new patterns? I've been um experimenting with sort of applying visualization. So
let's say you're trying to work on okay procrastination for example and it's a like take a specific task example and really like kind of go back to in your
mind visualizing everything you can about that scenario like where are you sitting at the desk when this happens.
What's kind of up on your computer screen? Like what are the sights, the sounds, all that stuff? Yeah.
And then when you're presented with the idea of the task, right? What do you feel in your body? Is it the gh? Is it the boredom? Is it anxiety? Like what is
it? Where is it? And what are the thoughts? And just like kind of mentally slow that tape down a little bit and practice saying something different to
yourself. You know, you're never going to like exactly match the reality of like what that looks like in real life.
But I wonder and I'd love to look into more in my research like whether we can leverage some of this to say like is this a strategy we can use? And then when that scenario pre presents itself,
not only might we more likely like recognize it, but we've already practiced the new response. I think that be helpful.
That's awesome. Yeah, I love that. Um,
you use the metaphor that like medication turns down the volume uh on symptoms, but it doesn't actually teach skills. Sure.
And um I would love to talk a little bit about that like as far as as far as how CBT can help and also like
you uh you've talked about how like in traditional talk therapy, especially if the the you know therapist or
psychologist or psychiatrist or whomever you're working with isn't familiar enough with ADHD that um talk a little bit about that
like how can we yeah how we can how can we tap into CBT in addition to or even because
medication is a challenging thing uh sometimes too. I just did an episode recently about um about
uh the the the quality or lack thereof sometimes of of medication. So like one batch isn't as strong as another and
things like that which can be problematic. But yeah, talk a little bit about the ski like teaching those skills that that CBT helps with.
Sure. Yeah. So um so one place that I start with that when I talk to clients or anybody is sort of like what is the
kind of CBT model of ADHD like why should we even use it to begin with right because what we do know is that the majority of the variation between
people is heritable that it it does have something to do with neurobiological functioning so first of all it's important to emphasize that like
thinking your style of thinking is not causing your ADHD so what the CBT model assumes which is in line with research
is neurobiological neurobiologically um related challenges in executive functioning is kind of at
the core. But the next step is that just by virtue of being a person that is coping with these challenges, you know,
throughout development, there often are some behavioral and cognitive consequences. So one branch is um many adults do develop great coping
strategies for their executive functioning problems, but other adults might not. And so you might have kind of skill gaps there. And then of course there's a good reason for the skill gap
because as one of my clients said, "How am I supposed to remember to use the skill that I'm that's supposed to help me remember, right? There's a little bit of circularity there."
Yeah. Yeah.
I will say that really good quality CBT for adult ADHD takes this as a given and says it's not about just educating you
that you need to do the skill. It's about implementation. It's about figuring out how do we get the reminders, whatever scaffolds that you
talked about earlier, we need to get this skill in the real world. So, we've got that behavioral side, but then of course the cognitive side as we think
about how the social environment is sort of reacting to people with ADHD throughout their development.
Unfortunately, still a lot of people with ADHD are getting negative feedback about their behavior or even backhanded negative feedback like, "Oh, you have so
much potential." you know and then you know feeling as though and then of course also being feeling blocked in getting to important goals in their
life. So this is where kind of some of the ne the um kind of negative emotions and negative thoughts the self-mistrust right that kind of builds up and where
it all comes to a head is that those negative thoughts and feelings or those patterns of thoughts and feelings can then get in the way of using the
strategies that could help. So you sort of have the the behavioral branch, the B and CBT, and then the C branch of CBT.
So when I think about medication, I'm thinking about the top of that model, it is when the medications are on board,
when they're working properly, it is kind of reducing um the impairment that can result from those symptoms. But what
we know from research is that even when an adult with ADHD is taking a medication that's effective, often they have residual symptoms and impairment.
And so this is where there's kind of room to grow even if you have a medication with the CBT skills. The other thing is uh my guess is you've had
other guests talk about you know meds aren't for everyone whether it's a side effect problem or history of cardiac issues or the person just simply that's
not something that they want to have in their toolbox.
And right now from the research evidence we don't um I did a study where we kind of did a little analysis on this.
Sometimes people will ask, "Well, does taking medication make it easier to learn the skills and therefore make the CBT more effective?"
What we know is if you're taking medications and you're doing CBT, like that's better than just doing CBT alone because you're taking the medications,
right?
But we don't have any evidence that CBT itself is less effective for someone who's not medicated, if that makes sense. So there's no evidence that like
you must be medicated in order to benefit from CBT, if that makes sense. I think is a message.
Yeah. And we talked I mean at the beginning we were talking a little bit about like ADHD and driving, right? And how CBT isn't going to teach you how to
be a better driver. However, it could teach you to slow down and be more mindful as you drive. And also the
medication can help like a stimulant can help you focus on the the task at hand so that you're not driving for an hour
and and getting to your destination and completely not realizing you drove for an hour and suddenly you're there or you drove past your exit.
I I love that example and I'll do you one better with that style of example. Yeah. Yeah.
Are you enjoying the conversation with Laura? Yeah. Me too. There's so much more. I'm excited to share it. I just wanted to mention very quickly that Why
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We have I have a lot of clients in CBT who have problems remembering to take their medication, right? And so there's a lot of CBT skills we can use to get
people more adherent to their medication. Yeah.
And then it's sort of like if we were a researcher, how is that a medication effect? Is that a CBT effect? I would say like it's both. And so, yeah,
I don't know. I get a little frustrated sometimes because I think some some clinicians maybe kind of make this false
dichotomy like the well pills don't teach skills. Like that's true, but I think sometimes there's subtly the
message there that somehow therapy or CBT is kind of like morally superior to medication in some way because it's more work. I don't know if people really mean
that, but I think there's a subtext there. And I just I want to send the message, at least in my opinion,
anything any tool in the toolbox. I don't think there's any, you know, it's not the Protestant work ethic that we're more moral because we're suffering. Right. Right.
It's like what is going to work for an individual person. Um and that's my view on kind of medications versus I wouldn't say versus medication in combination with uh the CBT.
Can I address your question uh you brought up about tailoring of CBT? Yeah. Yeah.
To ADHD. I think this is really really important and it's something I feel very passionate about and I'm a little
concerned about in some ways. Um because one challenge we have with CBT is a branding problem, right? If you go to your psychiatrist and you get
methylenadate, you kind of know that the methyl hopefully other than what you were saying with the kind of purity problems like hopefully the
methylenidate molecule is like inside of that pill and you know that you're getting methylinate.
Sure. When it comes to a specific type of psychotherapy like CBT, if you go out into the community and you ask, are you doing cognitive behavioral therapy,
there's no real guarantee about what version of cognitive behavioral therapy?
There have been some studies done on this use about CBT for anxiety disorders where they will survey people in the community, therapists, and say, "Do you
use CBT?" "Oh, yes, I practice CBT." and they'll say, "Okay, do you use exposure-based techniques which are the core active ingredient?" And they'll
say, "No." And it's like, "Okay, but are we really?" So, it's a challenge because it's like nobody regulates what CBT looks like. And so, for consumers, it's
like, "How do I identify whether this kind this flavor of CBT is the is is good or is the one that's right for me?" And
there was a study recently that came out um in the United Kingdom that sort of illustrated this. So, in the National Health Service, CBT, but kind of like
the flavor of CBT for depression and anxiety is the standard treatment. And it was a qualitative study that showed when adults with ADHD went to the
National Health Service and received this sort of generic CBT, maybe not surprising, like there was a lot of dissatisfaction and they felt like it
didn't work for them. So that just sort of illustrates that um and that CBT for adult ADHD just looks a lot different than it looks for uh depression and
anxiety because it really does focus on the skills to help with the executive functioning challenges. Yeah.
And we do talk about the thoughts and feelings which is really important but it's it's almost more in the service of like how do we use recognizing our
patterns of thoughts and feelings to help with the executive functioning problems. So is there a question then that a patient can use to ask their
therapist uh it it you know almost like something I always urge people to do before getting I mean assuming they
haven't been diagnosed yet is when you go to your say GP to to to talk about possibly exploring whether you may have
ADHD I think and this is the advice I give people so hopefully it's right is the the first question you should ask is what are your thoughts about ADHD
because my theory here is that if the doctor comes back and says ah you grow out of it as an adult or ah it doesn't really exist or it's overdiagnosed or or
what have you that is a red flag that or it doesn't it's not real that is a red flag that maybe your doctor doesn't believe in cancer as well right so so
maybe time to find it either way for sure yeah it's it's a big red flag so it's almost a good thing even regardless of whether you have any interest in ADHD it
it's a good question to ask your So, what is a good question to ask a a therapist before hiring them or or you
know engaging them in CBT specifically for ADHD?
What a great question and thank you for this question because I have been mulling over sort of like this this very question and my mind was going more to
very specific questions but I love the open-ended nature of the suggestion because it's like you know you want to see kind of where they go with it. Um I'm just off the top of my head I love
this idea. I think I might ask, what can you tell me about the most effective psychotherapies for ADHD?
I mean, and that right there answers I would be looking for would be skills-based treatments, uh, cognitive behavioral. I mean, obviously I'm biased
in this way, but that but I'm biased in the way that the science shows right now, at least now. Um, they should be talking about a lot of like practical
strategies to help you manage the functional impairment in daily life.
Yes, of course. And of course the CBT can can address your thoughts and feelings and um these are very important. I don't mean to discount them. They're essential in CBT.
Sure.
But it shouldn't primarily about like understanding your childhood.
It should be that that could be in the service of like what are we going to help you do on a daily basis that's going to change the way you structure
your environment like structure your life. And hopefully kind of the CBT moniker gets thrown in there. Yeah. And you could also follow up with saying
something like um you know if you like uh there are a lot of like treatment manuals out there of of things that have empirical support. So you could ask questions about that too.
Like what's your favorite CBT book or Yeah, that's good. And I mean Yep. And hope Well, I have biases about who I think they should say, but I guess I can give them I can give them my opinion.
Yeah.
Russ Ramsey, who you have on your podcast, awesome. His stuff um has great research support. Um Mastering Your Adult ADHD by Steve Saffron. He's the
person, full disclosure, I got to work with. Yeah.
And then, um, Mary Solanto has some great work more in like a group format, but hers also has been studied using,
um, kind of rigorous methods. There are others, too, but those are kind of three really solid ones.
Okay, that's that's helpful because Yeah, I'm thinking so you're you know,
you're on your blind date with your therapist and testing the waters. Yeah.
And uh and so the the question is, you know, what what are your what are what are the best uh treatments for ADHD like
therapeutic and and they say okay skills-based stuff and CBT is great and and then you can ask like hey what's
your favorite book on CBT or who are the thought leaders in CBT that you follow or something like that.
Yeah. So there are of course others but um yeah but just to get a Yeah. because I I think like yeah you know CBT is quite
popular at least in in the world we live in or certainly the the world you live in but um that along this journey for me as well. So um so
and we're just new we're the new kid on the block. I mean you know when I started that was one thing tough in my career when I first started wanting to study this there were no places to study
adult ADHD. Um and so CBT for depression and anxiety has like 60 years on us and we're kind of like you know the newest
one on the scene. And so we're trying to get the word out.
And it's weird too because anxiety and depression and correct me where I'm wrong are like the most common coorbidities that come along with ADHD.
And so if you're treating and this is my understanding from Russ Barkley with the line that if that with undiagnosed and untreated ADHD, your life expectancy can
be up to 13 years less. And so, and part of it is that if you are, and you can help me here on this, but like if if so,
like if somebody is an alcoholic and you're treating them for the alcohol abuse and and what have you, but they
don't have diagnosed with ADHD. So it's not to say um and so it may be a bad example but if you're tr
like I know a lot of women were missed traditionally and so they were treated for anxiety or depression or other coorbidities like OCD or bipolar or
whatever not just women but if you're not treating the root cause is that the right word is is ADHD a for those who
have ADHD because you can have clinical depression without ADHD but if you have if is ADHD
the root cause of the anxiety or the depression and eat.
Yeah, it's a great question and I think I'm going to give that hedgy researcher answer. It depends, but we do what we do know and can say for sure is it is a risk factor or a vulnerability factor,
right?
Um we know from research that um you know ADHD and it also appears earlier in development, right? It's a neurodedevelopmental disorder. So just
by virtue of the way things work, it's kind of on board before the onset of depression and anxiety. And so I think
it's very safe to say that if you have undiagnosed ADHD on board a and you have maybe depression, anxiety, substance
use, for most cases it's going to be very difficult to get real progress I think on those conditions if you're not
addressing the ADHD because the ADHD if it's ADHD it's causing functional impairment just by its very nature. Um
we also know a lot about the overlap now with ADHD and emotion regulation problems. Um, so I do think it's safe to say that and all the recommendations
that you see coming out of these coorbidity studies are like we should routinely be screening for ADHD in any of these populations and referring for
appropriate treatment because otherwise we're not going to be providing a good standard of care. Um yes,
another little bit of one thing your comment made me think of another little breadcrumb that we get related to the substance use piece is that um you know
I think a lot of times parents especially are worried like okay if I put my kid on a if my child starts taking a stimulant is that going to put them at risk for like later substance
abuse because they're taking a drug you know and what we find is um that either
there's no impact you know it doesn't increase the risk of later substance use. In some studies, it actually lowers the risk of substance use. Right? So,
appropriately treated ADHD. And I will say in a also in a small study I did with one of my students, data collected at Mass General, we found that one of
the best protective factors for depression in our sample for not developing depression was the number of years you had been receiving ADHD treatment earlier in life. And so,
that's a small study, but it supports how crucial maybe we could call it like a keystone diagnosis or something. Yeah. were there, you know.
Yeah. Yeah. Yeah. No, that's cool because Yeah. I think I think there's a lot there. And and and I always tell people that like if they're worried about again never pretending to be a
doctor or anything, but I always tell people that it's it's ADHDers who forget to take their meds all the time. And if they were that addictive for them, and I
I know there's some cases of that perhaps, but for the majority of people,
uh if they're forgetting to take their meds, like uh a drug addict does not forget to take their drugs. I assure you they do whatever the hell they can to get it.
An addicted person is living their life completely to take the drug. Right. Right. Exactly. Yeah. And I'd love to, if it's okay,
bring in a little bit of because I was talking about this um on another podcast recently. I feel like it's an area that like is so hard to wrap your head
around. This question of like the question that I was posed to me was like, well, aren't stimulant medications and like stimulant drugs of abuse sort of similar in mechanism of action? Um,
and there is some overlap there. But one thing that I think is important to understand, and I teach a very popular first year seminar at the University of Richmond called the psychology of drugs,
it fills up immediately. We talk about this a lot. Nice.
How you get the drug into your system matters a great deal. And so the medications for ADHD when you take them
at a slow method, which is like, you know, you have to take the pill, it goes into your um stomach, the acids chew it up, it gets in the bloodstream. That's a
very slow way to get a drug into your system or something like a patch, right? Yeah.
What we find with the ADHD medications in animal studies is that that creates the effect of upregulating dopamine in
the prefrontal cortex, which is the therapeutic effect we're looking for. Yeah.
But it doesn't create the kind of dop rapid dopamine spike in our kind of reward centers of the brain that are associated with addiction.
So this is one reason that like the way you take the medicine really matters to its addictive property. And in fact over the years the drug companies have
engineered their products in a way to prevent abuse. Like for example like Viviance. It's very very hard on purpose
to crunch crush off vivance. Um and it prevents abuse but also at the same time it solves the other problem we have with stimulants which is that they go in and out of your body really fast.
Yes.
And so what you want is it's slow and extended. And so, um, that's why I always think of, you know, when I was a kid in the 80s, there were kids that had
to like go to the nurse at lunch to get their medicines. And like, thank goodness kids don't have to do that anymore because that's very stigmatizing. But yeah. Yeah. And it sucks for those
So, I wanted to ask you a few quick things. Um, okay. this. So, I I made the mistake early on in the podcast and I'm always quick to like, you know, retract
or let people know that I'm an idiot and I don't know what I'm talking about. I So, originally, I used to say there are three types of ADHD. I now know there is
one type of ADHD with three presentations. And the first presentation is predominantly inattentive, which is the Lisa Simpson
analogy. I use the the predominantly hyperactive impulsive, which is the Bart Simpson aka Dave Delaney uh version at school. And then there's the combined
presentation which I use Calvin from Calvin and OBS as the example there.
What I don't know and what I've learned and in the little research I've done my understanding at least is that for the it's it's not one or the other but like
especially kids but like women or girls tend to be more ADHDI the inattentive
Lisa Simpson and and the boys tend to be more hyperactive impulsive. And my understanding at least is that it it was
the Bart Simpsons disrupting class like Dave Delaney um who were a problem and and thus the you know teachers are like get him the hell away from me where like
the the inattentive girl just playing with her hair getting straight A's maybe the boys are too has nothing to do with intelligence
but because she's not disrupting the class you know whatever and we could talk misogyny and sexism and things too but the question I have well first of
all if I'm right there but the other piece of this is the combined presentation which I'm really unclear on. Is it that as we mature we tend to
be we all tend to become more combined presentation? Can a kid be combined? Tell me what are your thoughts on that?
That's a great question. All right. So,
I think I'm going to start with the kind of and and I'm old on my presentation because they used to be called subtypes and now they're presentations. So, I
need to get used to that. TSM5. Um, so from my knowledge of sort of like the epidemiology epidemiology of ADHD,
it's really that predominantly hyperactive impulsive presentation that is kind of by adulthood. There's not a lot of those folks kicking around.
Usually you see that presentation like preschool, like early childhood, that's kind of when you see that presentation.
And then as kids move into more like school age, then the uh and maybe because they're in more of a school setting, the inattentive symptoms kind
of become more prominent. And that's where you see like the percentages sort of shift to where hyperactive impulsive subtype kind of like comes away to just
like the minimum, you know, number of kids. So really like a lot of times developmentally your hyperactive impulsive kids are just like precursor combined kids.
Okay. Um, but we do see much more of a kind of pure inattentive type that sort of persists across development.
So there are three presentations, but when I think of it, there's really kind of two presentations and one has two different flavors depending on where
you're at in development. That's not to say like there aren't hyperactive impulsive people, but like in terms of how represented they are in all people
with ADHD, like it's it's kind of a minority. So you become sort of combined as you mature in a sense even though like we're not putting labels on it
anyway. But I mean I always say like ADHD is an acronym at least for now it it's ADHD and not AD right which is just the original or not the original but the
last name. So it might be different in the next DSA. The other thing there the other thing that um I will say that
becomes complex about this though is that still I would make the argument that the criteria we have are not as sensitive to forms of adult
hyperactivity and impulsivity. They're still kind of based on like a kid maybe running around the classroom stereotype
idea but there is evidence that like kind of what impulsivity looks like in adults changes form developmentally. So
the question is are we like if so you do kind of see prevalence rates where it's like okay some of these combined type people will become inattentive type but
I'm always like are they really are they just sub threshold and we're not capturing the the ways impulsivity is showing up in their lives.
Yes. I had I had it's a great point because I had a mo I had a moment an aha moment as I was reading uh Tamara's uh
Rosier's book um your brain's not broken when I was first diagnosed and as I'm reading it I realized like and I don't know if the if I'm right I think I'm
right on the word stmming which I know like but but like I chew my lips and I do this crazy thing which like I've
always thought was nuts which is like I I I like if I'm wearing a soft t-shirt I'll just like do that like I'll touch. Oh, yeah. Sure.
Like if it's soft fabric and it's not like super weird like I don't do it like in front of people, but like under a table I might be. Um and and but as I
started reading about it and learning, I was like, "Oh, maybe this is me hyperactive now chewing my lips or playing with the the the the fabric of my shirt.
Maintaining that arousal in psychologist and girls play with their hair or like you know or what have you too or women.
Um yeah and say quickly we have a similar problem with gender and the criteria where it's like okay in order for a girl to
show up as you know being hyperactive impulsive she and and disruptive say in the classroom she's got to relative to
other girls because girls in general are less hyperactive that means that girls to get identified you know might have to
be even more severe relative to other girls than boys are to other boys. Yeah. Yeah. Yeah. I know that makes sense.
And while their source of kind of women getting missed over because if our like template is how much is this person
causing disruption, then as you were saying earlier, you know, yeah, it's going to lead to disparity.
Um, do you cover Madonna in the faculty lounge band?
Not yet. Yeah, we do. You know, the the latest song that I asked them to add to the repertoire for our gig this semester is Flagpole Sitter by Harvey Danger.
Okay. Yeah.
And uh I said any Green Day song off the album Dookie. So I think we're going to do Yeah. So that's that's the current favorite.
And I've heard you're a karaoke queen. Is that right?
Yes. We host many karaoke party in our home. The theme for next month is going to be screen time. Choose songs that are
associated with movies, television, or video games. So,
oh my god, that's amazing. That's awesome.
It's very fun. And I love it. It's been an It's been an intervention for some of our more socially anxious friends. Like,
we have friends that now would never have done it and now are planning, oh, this month I'm going to sing X. So,
Oh, that's great. That's great. Yeah. I I did the right and left.
I was convinced to do karaoke in Seattle once uh at a at a conference and I I happened upon old school punk rock. So I
did the KKK took my baby away by the Ramones, but I did it sitting on a stool as if I was Will Shatner. So I I did the
KKK took my baby away. They took her away from me.
Is epic as say it was fun.
Well, hopefully maybe we'll get to karaoke together someday.
I know. Or Jazzer size. We didn't even talk about Jazzer size. Or we we didn't talk about Dungeons and Dragons. We have so much more to talk about. I have too many hobbies.
I know that's that those are good hobbies though. They're healthy hobbies.
All right, this has been so much fun and I will make sure to uh include links and everything that we talked about. Laura,
how can people get a hold of you, learn more about everything you do, find your books and your over 40 peer-reviewed research articles?
Yeah, thanks. Um, well, I am a recovering academic and trying to put myself out there to people. And so, I finally have a website, laurann.com,
noun us, and you can see my stuff about my books, my public facing stuff, but like, yeah, a little buffet of some of my research studies if you're interested in that, too.
Awesome. Well, I will include everything in the show notes. And thank you again. This has been so much fun. Yeah, thank you.
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