(p. 113) Session 9: Self-Coaching
■ Attention-deficit/hyperactivity disorder (ADHD) symptom checklist
■ Worksheet 9: Five-Column Thought Record
■ Set agenda
■ Review ADHD symptom checklist
■ Review progress from previous sessions
■ Review thought records completed since last session
■ Discuss coaching styles and coaching story
■ Discuss formulation of more helpful alternative thoughts
■ Agree on home practice activities and anticipate difficulties using these techniques
It is important to begin each session by setting an agenda to maintain a structured focus on treatment for ADHD and to prepare the client for what lies ahead in the upcoming session. Use the preceding session outline to set the agenda.
Review of Symptom Checklist
Give the client a copy of the ADHD symptom checklist to complete at the start of the session. Briefly review the score and take note of (p. 114) symptoms that have improved and those that are still problematic. Note the score and today’s date in your chart note for future reference.
Signposts of Change
For this session, the signposts of change are:
■ Client is attempting to use calendar and task list systems on a daily basis.
(p. 115) ■ Client is putting all tasks that need to be completed on master task list.
■ Client has identified a consistent time and place for looking at their calendar and creating a daily task list.
■ Client is using priority ratings for daily task list.
■ Client has noted instances where items on the task list were not being completed and asked themselves, “What is getting in my way?” “Is the task too big?” “Am I not really sure how to approach the problem?” Following this, they have either broken the task down into smaller steps or completed a problem-solving worksheet.
■ Client has started to implement a system for decreasing the amount of e-mail and paper that comes in and needs to be dealt with.
■ Client has identified areas that require an organizational system and has started to implement the system as agreed upon with you.
■ Client has encountered situations where they needed to concentrate on a boring task and has attempted to use the distractibility delay.
■ Client has identified a home for important items and has started placing the important items in the designated spot on a regular basis. They have shared information about their system with family members.
■ Client has attempted to use strategies for reducing distractibility that were identified in session.
■ Client has started using an alarm to check in with themselves to see if they have become distracted when working on important or difficult tasks.
■ Client has completed a thought record with at least one example of thoughts that occurred during the week and brought it to the session.
Review of Previous Sessions
As always, this session includes a review of the client’s progress in implementing skills from each of the previous sessions. It is important to acknowledge the successes the client has achieved and to problem-solve around any difficulties.
Remember, repetition of new skills is critical for individuals with ADHD and will maximize gains made in treatment.
(p. 116) At this stage, it is important to see that the client is attempting to complete thought records. It may seem “silly” to some clients to go through this exercise. However, you can emphasize the importance of getting thoughts “out of one’s head” so that they can be evaluated more objectively. If the client did not complete a thought record, this can be done in session using examples of thoughts that the client recalls from the previous week.
Review: Tools for Organization and Planning
■ Use of calendar for managing appointments, meetings, and other commitments: At this point, you should discuss any problems that the adolescent is having using the calendar system.
■ Use of task list: Review any difficulties that the client is having with recording tasks and looking at the task list on a daily basis.
■ Use of the “A,” “B,” and “C” priority ratings: If the adolescent is having any trouble with prioritizing tasks, discuss the difficulties at this point.
■ Use of problem-solving (selecting an action plan) and breaking down large tasks into small steps: Consider the client’s use of these strategies and practice one or both skills using examples from their current task list.
Review: Tools for Reducing Distractibility
■ Use of strategy for breaking down boring tasks into manageable chunks: At this point, you should discuss any problems that the adolescent is having breaking down large and/or boring tasks into manageable chunks.
■ Use of the distractibility delay: Review any difficulties that the client is having with the distractibility delay technique.
■ Use of strategy to remove distractions from the environment.
■ Use of strategy to have a specific place for each important object.
■ Use of reminders and alarms: “Am I doing what I am supposed to be doing?”
(p. 117) Review: Tools for Developing Adaptive Thinking
■ Use of thought records (either on paper or electronically) to identify and label automatic thoughts. Review any difficulties that the adolescent reports with using this strategy.
Review the thought records that the client completed at home. If the adolescent was not able to complete any thought records, try to identify the obstacles that may have interfered and utilize the problem-solving skills to determine the best way for them to work on automatic thinking. Did they have difficulty making time for home practice? Were the directions confusing? Was it difficult for the client to see their thoughts in writing? It is possible to work with the client on rethinking the situation in their head versus on paper. We have found that writing out automatic thoughts helps people step back from their thoughts and better identify the difference between thoughts and emotions. However, in reality, it can sometimes be difficult to get clients with ADHD to take the time to monitor their thoughts.
If the adolescent didn’t do any home practice, work on a thought record together before moving on. Continue to emphasize the importance of reviewing skills in between sessions.
If the client did complete thought records, review each one. Provide feedback on successful completion and assist the adolescent in identifying any patterns that are occurring with their negative thoughts. Often clients have a tendency to engage in particular thinking errors. Once this is recognized, the adolescent can begin to modify their thoughts. (p. 118) (p. 119) (p. 120)
(p. 121) Potential Pitfalls
We have discussed several different types of thinking traps that can contribute to negative feelings. While it is important for the client to be familiar with the types of thinking traps they may be falling into, remind them not to get stuck trying to find the exact type of thinking trap that corresponds with the thought. Thoughts may fit into more than one (p. 122) category, and often these categories of thinking traps overlap. The goal is for the client to recognize that the automatic thought might represent a thinking trap, to understand why this is true, and, most importantly, to come up with an effective alternative thought.
For many adolescents, identifying effective alternative thoughts may be tricky at first. Refer to the previous suggested questions (i.e., What would you say to a good friend about this situation if they were going through it?). Also, tell your clients to keep in mind that thoughts and feelings about the situation may not completely change immediately after identifying an alternative thought. However, if they practice repeating the alternative thoughts to themselves, over time they will begin to replace the negative and/or unhelpful automatic thoughts with more balanced and effective ones. (p. 123)
Therapist Note: Remind clients that, with practice, they will feel more comfortable using their new skills and will begin to notice improvements. In session, identify situations to work on at home using the thought records. Also ask the adolescent to consider any difficulties they may have in completing this assignment and problem-solve to minimize the chance that obstacles will stop them from completing home practice.
Instructions for Completing a Five-Column Thought Record
The purpose of adaptive thinking is to help promote optimal thinking when we are feeling stressed. Throughout the week, whenever your client is feeling stressed, sad, or overwhelmed, they should continue to list their thoughts in each situation. If they anticipate a stressful situation or a task that is making them feel overwhelmed, they should write out their thoughts regarding this situation. If a situation has already passed, and they find themselves thinking about it negatively, they should list their thoughts for this situation.
■ The first column is for writing a description of the situation.
■ The second column is for listing thoughts during a stressful, overwhelming, or uncontrollable situation.
■ The third column is for writing down what emotions the client is having and what their mood is like when thinking these thoughts (e.g., depressed, sad, angry).
■ The fourth column is for examining if the client’s thoughts match the list of “thinking traps” and, if so, to write down the “thinking traps”. These may include:
■ All or nothing thinking
■ Mental filter
■ Disqualifying the positive
■ Jumping to conclusions
■ Mind reading
■ Fortune telling
■ Emotional reasoning
■ “Should” statements
(p. 124) ■ Labeling and mislabeling
■ Maladaptive thinking
■ Overly optimistic thinking
■ The last column is for the client to try to come up with an alternative thought to replace each negative automatic thought—or the most important negative automatic thought. The alternative thought is a statement that the client can say to themselves to try to feel better about the situation. Questions to help come up with this alternative thought can include:
■ What is the evidence that this thought is true?
■ Is there an alternate explanation?
■ What is the worst thing that can happen?
■ Has this situation unreasonably grown in importance?
■ What would a good coach say about this situation?
■ Have I done what I can do to control it?
■ If I were to do anything else, would this help or hinder the situation?
■ Am I worrying excessively about this?
■ What would a good friend say to me about this situation?
■ What would I say to a good friend about this situation if they were going through it?
■ Why is this statement a thinking error?
■ Is it helpful to focus on this thought at this moment?
The adolescent should:
■ Continue to use the calendar every day to keep track of their schedule and put new tasks on the task list every day.
■ Use and look at the task list and calendar every day!
■ Use priority ratings.
■ Practice doing tasks according to the priority ratings.
■ Carry over tasks that are not completed to the next day’s task list.
(p. 125) ■ Practice breaking down one large task from the task list into smaller steps.
■ Use the organizational systems developed in this program.
■ Use the distractibility delay when working on boring or unattractive tasks.
■ Use skills to reduce distraction in the homework environment.
■ Put important items in specific places.
■ Use reminders to check in with themselves to see if they have become distracted when trying to focus on completing a task.
■ Read the preceding “Instructions for Completing a Five-Column Thought Record.”
■ Write out examples of thoughts on Worksheet 9 for at least two situations during the week.
therapist: Let’s take a look at one of the thought records you completed this week and see if you can identify a more helpful alternative thought instead of one of your negative thoughts.
(p. 126) therapist: Let’s start with the first thought—I’m going to fail the test. What evidence do you have that supports or contradicts this thought?
client: Well, I’m worried about this test. I don’t really feel that confident that I know the material.
therapist: Good. Now, even if you don’t get a perfect score on the test, what is the likelihood that you are going to fail it? What’s the evidence you have for that? How many tests have you failed in high school?
client: I don’t think it is really likely that I will fail the test. I actually haven’t failed any tests since I’ve been in high school, and I get worried about failing tests a lot. I’ve been doing pretty well overall this year.
therapist: Great! So the test is likely to be challenging and you might not get a perfect score, but you really don’t have any evidence that you are likely to fail. What about the next thought that you haven’t learned anything this year?
client: As I said, I have been doing pretty well this year. I must have learned some stuff.
therapist: Do you think you might learn more if you study tonight?
client: Probably. That usually works out for me. I often get really upset before tests but then I end up doing fine.
therapist: How about the last thought that you will never graduate from high school? What would you say to a friend if she was having similar thoughts?
client: I would tell her that she always gets worried before tests but there is literally no chance that she won’t graduate. Even if she doesn’t do well on this test, she has a good GPA and she can do some makeup work to bring her average up in this class.
therapist: How would you construct an alternate thought from that?
client: I would say something like—I will graduate from high school if I do my best.
therapist: Terrific. I understand it’s hard for you when these types of thoughts come up, but I think you can see now how these negative thoughts can really intensify your feelings and make it difficult to problem-solve and cope with the situation.
client: It’s true. I can really see that now.
Time and situation
Automatic thought (Coach A)
Mood and intensity
Alternative thought (Coach B)
Studying for English test
I’m going to fail the test.
Jumping to Conclusions
I don’t have any evidence that I am going to fail the test. I have actually been doing pretty well this year.
I haven’t learned anything at all this year.
Devastated, Sad (100)
All or Nothing Thinking
I have learned some things and if I study tonight, I will learn more in time for the test tomorrow.
I will never graduate from high school.
I will graduate from high school if I do my best.