Meeting Your Goals When You Have ADHD

Meeting Your Goals When You Have ADHDAs someone with attention deficit hyperactivity disorder (ADHD), you probably know all too well the difficulty of accomplishing your goals. It can seem utterly daunting.

That’s because realizing goals taxes the executive functions in your brain, said Roberto Olivardia, Ph.D, a clinical psychologist and clinical instructor in the department of psychiatry at Harvard Medical School. These functions include everything from organizing to prioritizing to making decisions to managing time, he said.

Tedious tasks are especially tough. “Laundry, paying bills, attending business meetings — things that are not intrinsically interesting can put an adult with ADD into a tailspin of inaction,” said Terry Matlen, ACSW, a psychotherapist and author of Survival Tips for Women with AD/HD.

Lack of reward with long-term goals adds to the challenge.

“ADHD brains are low in dopamine, a neurotransmitter associated with reward, arousal and motivation. Because of this, ADHD brains are starving for instant stimulation and reward,” Olivardia said.

It can seem like the odds are stacked against you in meeting your goals. But while accomplishing goals might be more challenging if you have ADHD, the key is to find the best strategies for you.

That’s what Matlen and Olivardia have done. In addition to being successful practitioners and seasoned experts in ADHD, both Matlen and Olivardia have ADHD. Here, they share insights to help you accomplish your goals.

1. Brainstorm backward. First, write down your final goal, Matlen said, “then go backward from there, and write down [all] the steps needed to accomplish the goal.” While it might seem silly, do this for seemingly straightforward tasks, too, she said. Take laundry, for instance. It’s boring and repetitive, has many steps and no one pats you on the back when you’re finished, she said.

Matlen suggested breaking it down like this: Write down, “Do family laundry.” Next, write out each step, such as:

  1. Pick up laundry from every room, and put it in the basket.

  2. Take baskets to laundry room.
  3. Sort lights and darks.
  4. Sort cold water and warm water. And so on.

Write this list on a poster, and paste it in your laundry area. As Matlen said, writing out specific steps gives your brain a roadmap to follow.

Splitting your goals into steps also helps you realize that success is within reach. When you’re working on a big project, it can feel demoralizing to realize that you haven’t finished it yet, Olivardia said. But when you break your goal into steps, you’re able to say, “I completed 4 out of 10 steps,” he said.

2. Reward yourself for every step. “People with ADHD have a higher degree of motivation if they get rewards along the way,” Olivardia said. So consider how you can reward yourself for every step accomplished.

3. Just do it. People with ADHD struggle with procrastination, which becomes especially problematic when you think you need to be motivated to get started. You don’t, Olivardia said. “In fact, getting started can get you motivated,” he said. (Here’s more tips on getting motivated when you have ADHD.)

4. Set a timer for one hour. “Time is an amorphous concept to those with ADHD,” Olivardia said. Setting a timer gives you “concrete parameters to work from,” he said. Plus, after the hour, you might even want to do more work, he added.

5. Focus on the end feeling. Visualize yourself finishing the project – and how great you’ll feel once you do, according to both experts. “Sometimes we focus too much on the actual task, rather than how it will make us feel when it’s completed,” Matlen said. Focus, for instance, on how good you’ll feel after paying your taxes, she said.

“Since ADHD-ers can lose a sense of urgency or excitement around a task easily, you may need to keep that alive in your imagination,” Olivardia said.

6. Focus on self-care. Whenever people with ADHD hyper-focus on a task, they ditch healthy self-care, such as getting enough sleep or even drinking enough water, Olivardia said. You worry that stopping will sabotage your progress, he said. “However, being tired and hungry are the very things that will guarantee that you will lose steam,” he said. So make sure you’re taking care of your bare essentials, including sleeping and eating well.

7. Take breaks. If you’re getting distracted easily – also common in ADHD – Olivardia suggested taking a complete break for 10 minutes. Then return to your task.

8. Work with a partner. Partnering up is especially helpful for tedious tasks, Matlen said. “If bill paying is a horrifying experience, set up a time each month with a friend and do it together,” she said.

Having a friend who keeps you accountable for your goal also helps, Olivardia said. “Sometimes just knowing that you will be reporting your progress — or lack of progress — can provide you with the sense of focus to stick with it,” he said.

9. Get creative. Think of how you can make meeting your goals a more enjoyable or interesting experience. For instance, play music when you’re cleaning your house or use colorful stickers for filing, Matlen said.

10. Get help. Hiring outside help doesn’t just help you meet your goal; it might even save you money. For instance, if you hire a bookkeeper to pay your bills and balance your account once a month, you’ll likely save money on bank and other late fees in the long run, Matlen said.

11. Don’t assume that you can’t accomplish goals.  “Most importantly, never assume that you are not meant to accomplish great things because you have ADHD,” Olivardia said. “It can feel that way because you know that you are executing goals in a different manner from your non-ADHD counterparts,” he explained. But there’s nothing wrong with using a different strategy.

One size never fits all. The key is to find specific tactics that work well for you. And, again, don’t forget that even though meeting your goals might be challenging, as Olivardia said, you can absolutely accomplish great things.

Is Distance Treatment the Wave of the Future?

With advances in technology, distance learning on college campuses has exploded over the last decade.  And as time passes, the mental health community is taking note.

Students want to study when they want and how they want.  Distance learning makes education available to those who wouldn’t otherwise be able to get off of work, travel to class or spend hours in lectures.  

That same increase in convenience and availability could have a real impact for people seeking psychological treatment. Is distance treatment ready to take off?

People who must maintain jobs, care for children or aging parents, don’t have cars or access to public transportation or want to learn material that is not offered where they live can all benefit from distance learning. These are often the same reasons people struggle to access mental health services.

And there is a large body of research that suggests distance learning and traditional classroom learning provide the same quality of education. Distance learning is no longer considered a sub-standard educational option.

So, how can these benefits apply to receiving psychological treatment?

Treatment available online or at a distance could certainly help people with difficulties in getting to therapy sessions and incorporating treatment into a busy lifestyle. It would also enable people to access specific treatment modalities not otherwise available to them.

And, according to the American Psychological Association, psychologists have begun using electronic communication such as email, Skype and various forms of videoconferencing to augment treatment. But, while technology surges ahead, licensing laws and guidelines for providing safe and ethical distance treatment are still catching up.

A recent article reporting on the use of phone therapy in Monitor on Psychology suggests that talking on the phone with a therapist can provide the same, or even better, results for some.

In this study, conducted by University of Cambridge researchers, British adults with mild and moderate depression and anxiety disorders who received cognitive behavioral-based therapy via the phone benefited as much, if not more, than those who received face-to-face therapy. Those with severe symptoms did not see the same results.

This study also found that telephone therapy was less expensive than traditional therapy and was conducted as part of a national initiative in Britain aimed at increasing people’s access to therapy.

The telephone is only one of many options for providing distance treatment. The number of mental health tools available is rapidly increasing. And many in the field agree that it’s time for practitioners to embrace technology and what it has to offer in delivering interventions.

One-on-one treatment cannot be replaced.  Nor should it.  However, the need for treatment providers to meet the changing and growing mental health needs of the population has caused the ΑΡΑ Insurance Trust and the Association of State and Provincial Psychology Boards to launch a task force to develop guidelines for tele-psychology practice.

So what are some of the alternatives to one-on-one therapy?  According to a cover story in the APA Monitor they include the following:

  • Behavioral intervention technologies, such as those that deliver care via the Internet or mobile phones
  • Computer programs for depression and other disorders, which typically teach principles of cognitιve-behavioral therapy or some other evidence-based treatment

Although these treatment options are appealing and there is a growing body of research to suggest that many are effective, it is important to proceed with caution.  It is essential to ensure that individuals get the right treatment and that treatments offered have been studied and found effective.

Kaiser Permanente’s eCare for Moods Racks up Another ‘Win’

Kaiser Permanente's eCare for Moods Racks up Another 'Win'In the last decade, Kaiser Permanente launched a web-based service known as eCare for Moods, meant to help support patients within their health care system with bipolar disorder. Over the years, there’s been some research to support the use of this online tool to help improve patient outcomes.

In the November 2012 issue of Psychiatric Services, another study was published demonstrating the effectiveness of this free online tool for Kaiser Permanente customers. The study, by Hunkeler et al. (2012), found that depressed patients who had access to and used the eCare system had better outcomes — reduced depression and better overall health.

But although the research team clearly believes this is a “win” for eCare for Moods, after examining their data, I’m not so sure. If it’s a win, it’s more of a statistical win than a win for reducing a patient’s depression symptoms.

First, let’s get out of the way the fact that more than half of the study authors (out of 12) are affiliated with Kaiser, the publishers of the eCare system (parts of which Kaiser has also applied for patents, suggesting a potential revenue motive underlying some of this1 ). Obviously, when you work for an organization and are researching that organization’s tool for effectiveness — and possible later license or such — there might be some… ahem… incentives for a positive finding.

The study was designed to measure depression symptomology of participants who were divided into two groups. One group would have access to Kaiser’s proprietary eCare for Moods online web-based support and messaging system, in addition to their usual mental health care. The other would have just the usual mental health care provided by Kaiser. This design helps ensure that the primary difference between the two groups is the eCare for Moods program.

The program itself is comprised of a secure, password-protected website that provides personalized self-monitoring tools, secure messaging with the patient’s eCare manager — a trained psychiatric nurse — 8 depression psychoeducational modules, an appointment calendar, and a monitored discussion group (which you could only access after completing all 8 modules). eCare was only offered during the first year of the study. The second year of the study was just ongoing assessment of how the two groups were still doing, to see if the effects of eCare — if any — wore off over time.

How participants were doing was measured in telephone interviews after the initial interview was conducted in-person. The interviews included a number of different health surveys and questions designed to measure progress.

Which brings me to the second nitpick — why didn’t the study authors use a standardized and recognized measure for depression symptoms? Instead, these 12 researchers decided to make up their own, with no rationale for doing so (and no psychometrics provided on their made-up depression scale):

All interviews included an assessment of depressive symptoms experienced over the previous two weeks with questions adapted from the SCID. This provided a psychiatric status rating of the severity of current depression on a 6-point scale derived from the research diagnostic criteria2

Worse, the interviewers then had the subjects recreate a week-by-week blow of their mood for the previous 6 months. By memory. Could most people accurately recall how they were feeling three weeks ago — much less 3 months ago?

So the researchers were reliant on accurate memory recall to fill in the blanks every 6 months. It’s not clear why they didn’t simply have participants keep paper-and-pencil journal logs or use some other more frequent data recording method if they wanted weekly data tallies.3

Weird.

Depression Scores Decrease — for Everyone

The third problem is that the average depression score at the baseline of the study was 3.88 (eCare group) or 3.65 (usual care group). According to the researchers, depression is scored as: “3, moderate impairment; 4, marked impairment but below DSM-IV criteria for [a depression] episode.” In other words, the average of the participants was somewhere below the threshold to actually diagnose anything but the mildest of depression.

But if you think that’s bad, wait — it gets worse.

After a full year of treatment, the eCare group still averages a 3.00 — moderate impairment (technically, still depressed). They’ve dropped nearly a full point on the scale, but that’s it. According to the criteria, they’re still pretty much as depressed as they were when they started (as a group). The usual care group after one year looks pretty darned similar — a 3.10. While they’ve only dropped a half point (since the group wasn’t as severely depressed as the eCare group), their improvement is less impressive. But again, as a group, still depressed.

At the end of 2 years, no statistically significant change occurred in the eCare group — now it’s at a 2.95 average score. Same with the usual care group — now at a 3.11.4

Now, unfortunately, the clinical trials record doesn’t note what specific primary outcome measure they had planned to use. So we can’t know if they decided to change the primary outcome measure because it was even less impressive than what we’re seeing here.5

That’s okay — the researchers had another way to make these results look more impressive than they are. They also measured the “presence of depression” (as though depression was like an off/on switch). Any score less than 3 on the PSR means depression isn’t “present” any longer. Score 3 or higher and you’ve still got depression.

If this sounds arbitrary, that’s because it is. It is one of the ways researchers today get around the fact that a treatment isn’t really as effective as they hoped it would be. (Of course, the eCare group came out on top in this measure.)

Summary

The upshot? Here’s a study demonstrating the statistical effectiveness of a treatment intervention supplement — eCare for Moods — that likely had very little real world benefit for the patients who were using it. One of the areas that stand out in the data with a difference between the two groups — learning new coping skills — could be attributed to the psychoeducational modules the program offered.

These modules, of course, could be offered to the general public today and help potentially thousands learn new coping skills.

The eCare system itself has problems with keeping its audience. While 90 percent of patients logged into the system during the first 6 months, that dropped to under 50 percent in the next 6 months. Only 4.6 (on average) of the 8 educational modules were completed by participants — less than half of participants completed the full 8 (a problem common among virtually all online psychoeducational interactive learning modules).

While I appreciate that eCare for Moods can be a helpful supplement to people with mood disorders — such as depression or bipolar disorder — I feel like this research team may have overreached in extolling the benefits of the program. I’m not so sure that weekly depression severity was significantly different from the usual care group, given the data presented in this article alone.

 

References

Hunkeler, E.M. et al. (2012). A web-delivered care management and patient self-management program for recurrent depression: A randomized trial. Psychiatric Services, 63, 1063-1071.

 

Footnotes:

  1. Yes, even non-profits can have a revenue, if not profit, motive.
  2. Criteria, I should note, that were first proposed back in 1978 — long before the DSM-III-R made the scene. The researchers list no rationale for using this depression scoring method — as opposed to one of the well-researched and regularly-used depression measures. The researchers also fail to acknowledge this as a limitation in the article.
  3. The researchers make no note of this methodology concern in their limitations discussion. Ideally, the study would be designed to incorporate data directly from patients themselves, without retrospective memory coming into play, or the potential bias of the interviewer.
  4. p = 0.047 in a time-by-treatment repeated-measures design
  5. This study took a really long time — more so than usual — to make it into publication. This study was begun in 2002 (and was supposed to include bipolar patients too) with data collected primarily in 2003 and 2004. Its results were first presented at a conference in 2009, and it finally appeared in a journal in late 2012. Draw your own conclusions.

Responsibility for Treatment Compliance

Responsibility for Treatment ComplianceOne of the most difficult challenges to overcome when dealing with a mental illness is the temptation of the excuse.

With a psychiatric diagnosis comes an excuse for everything. Any bad behavior, lack of motivation, or failure can be passed off as a symptom or the result of an episode. The excuse is always available. Don’t take it.

No one’s asking you to take responsibility for having a mental illness. That’s not your fault.

But you have to take responsibility for your actions and for your recovery. Sure, unexpected things happen as a result of serious mental illness, but most of our behavior is within our control, or at least our influence. And the behavior that most influences our wellness is treatment compliance.

If you have a treatment regimen that works, stick with it. If you had one and left it, get back on it.

While many of us bemoan the fact that we’ll never be well, treatment success rates for mental illness are very high. The National Institute of Mental Health has shown success rate of treatment for schizophrenia of 60 percent, depression, 70 to 80 percent, and panic disorder, 70 to 90 percent.

Compare this to treatment success rates for heart disease of only 45 to 50 percent. But treatment only works if the patient complies with the doctor’s orders. So take your medicine as directed, stay away from non-prescribed drugs and alcohol, exercise, sleep, and eat well. Manage stress. Chances are you will get better. But you’ll lose your excuse. Then you’ll have to start taking responsibility for your actions.

Responsibility brings a sense of control. This is important because one who feels he has control over key aspects of his life is most destined for success and well-being. If all things that happen to me, or if my very own behavior, is beyond my control, why should I bother?

But if prescribed treatment brings me a measure of control over events and my behavior, then I can positively influence what happens to me and those I love. I’ll have to get out of bed, get off the disability insurance, go to work, and suffer the challenges that everyone faces. Life may even be a bit more boring. But I can contribute, connect with others, and work toward dreams I may have long ago abandoned. Yes, this can be very hard. I may have to deal with side effects and limitations. I may have to say no when I want to say yes. And compliance can be costly. But wellness is possible.

Unfortunately, access to treatment is not available to everyone. Finding a correct diagnosis and a successful treatment regimen can take years.

But if you have access to treatment, you have a responsibility to work with doctors, counselors, social workers, and any family and friends available to help you to find a successful treatment regimen. And then you have a responsibility to stick with it. Health can be more challenging than illness, but the life that results is always more satisfying.

 

Running shoe photo available from Shutterstock