Therapy and ADHD Coaching
Similarities, Differences, and Collaboration
Peter Jaksa, Ph.D. and Nancy Ratey, Ed.M.
Treatment for ADD/ADHD in adults has typically been defined in terms of medication and therapy. Coaching is emerging as another form of help that can benefit many people with ADD. The very notion of "coaching" leaves many people scratching their heads in confusion, however. Most health care professionals have at best a vague idea of what coaching is, what the benefits are for the client, or how to work with a coach in a professional collaboration. Many physicians, some of whom are even reluctant to refer people with ADD for testing or therapy, are not likely to recommend to their patients something as esoteric sounding as "ADD coaching." Medication alone is seldom if ever sufficient treatment for ADD however. Many therapists who work diligently with their clients on emotional issues, relationship issues, and behavioral strategies to increase productivity, are perplexed to find that the therapeutic goals are simply not being implemented on any consistent basis. The client's failure to follow through may be interpreted, quite inaccurately, as "resistance" to treatment. A working knowledge of the benefits of ADD coaching would allow all these professionals to be more effective in treating their ADD clients.
Current therapies incorporate many types of cognitive, behavioral, and analytical approaches to help individuals gain insight and understanding, deal with painful emotional problems, and overcome self-defeating beliefs and destructive behaviors. Therapy focused on ADD behaviors typically needs to be quite pragmatic and behaviorally oriented. As many have pointed out, the problem with ADD is not one of desire or motivation but of follow-through and achievement. The struggle all too often is not doing those things which the person knows must get done! Insight by itself is practically useless if not accompanied by a behavioral treatment plan that addresses specific problems and provides specific strategies to deal with those problems. Even the behavior therapies have limits when it comes to helping individuals with ADD who live in the moment, respond to the immediate, having difficulty anticipating and looking ahead, or simply forget what the behavioral goals were from a few days ago. This is where effective ADD coaching can take planning, organization, pragmatism, and accountability to another level.
Essential Elements Of Coaching
What exactly is ADD coaching? At present the parameters of this emerging field, which is a specialty area within the broader field of personal and professional coaching, are still being defined. In a nutshell, coaching involves an ongoing relationship between a coach and client that is very goal-driven, structured, and focused on helping the clients actively create practical strategies to accomplish specific goals and also develop general skills to be more effective in their daily lives. The coaching relationship is highly individualized, focus on the particular needs of the client, and might encompass many areas of the client's life: work, exercise, nutrition, stress management, social and recreational needs, and so on. Unlike therapy, where the professional brings a particular orientation and set of therapeutic skills to apply to the problems at hand, the coach and coaching client mutually agree on what approach might work best for the particular client. As in therapy, a coaching relationship is safe, respectful, and supportive for the client, never coercive or punitive. A coach helps the client understand how ADD impacts behavior, rallies the client's motivation and active involvement in making changes, and elicits creative strategies to serve the needs of the client.
Very specific goal setting, planning, and strategies for organization and managing time are put into place early in the coaching process. The coach takes an active role in terms of offering suggestions, keeping in mind that goal completion is paramount along with skill building. Although there is no set model, contact between coach and client typically takes place a number of times during the week to allow for monitoring and encourage accountability on the client's part. A weekly meeting of 30 to 60 minutes, conducted in person or by phone, is supplemented by shorter phone calls and even e-mail messages to report on progress.
The coach takes on a very pragmatic, hands-on approach. He or she may collaborate with a professional organizer who goes into the client's home or office to help the person better organize and use physical space. Any ADDer who has lived with clutter and disorganization can appreciate the value of that! Coaches may help clients organize working areas, living areas, set up storage and filing systems, even organize bedroom closets. Setting priorities, clearly defining goals, and allocating time on a weekly planner for each required activity is a basic strategy that almost all ADDers benefit from. Keeping on top of one's schedule to the point that routines get established takes time and lots of effort. Again, having contact with a trusted ally several times during the week helps the client remember and follow through on planned activities. This is helpful for most people, but crucial for ADDers.
Similarities Between Coaching and Therapy
A therapist and a coach each establish a helping relationship with a client, with the general goal of helping the client to grow and to live a better life. The working relationships must be supportive, respectful of the client's needs, and free of manipulation or abuse. Confidentiality must be respected within the therapeutic or coaching relationship. Both therapist and coach get to know the client over time, help them assess priorities and goals, and help the client pursue those goals. Both approaches require a client who is open to change and willing to make changes in how things are done.
Both coaching and therapy deal with feelings and beliefs to some degree, but at very different levels. A therapist commonly helps the client work through very painful feelings and negative or self-defeating beliefs and behaviors. A coach does not get involved with emotional, cognitive, or behavioral problems of clinical intensity (depression, anxiety disorders, personality disorders, addictions, etc.) but must refer the person to a therapist to help deal with these issues. Feelings do play a part in the coaching relationship however, and may involve frustrations, fears of failure, avoidance behavior, and loss of confidence. These feelings can be dealt with in the course of the coaching, in terms of what motivates the client's behavior and helps or hinders goal achievement. The client's experience of overcoming past obstacles to success, and piling up a series of successes, may in itself produce some benefits in terms of heightened self-esteem and a reduction in stress, anxiety, and worry. Certainly these may be viewed as therapeutic benefits even though the intent was not to provide therapy.
Some Essential Differences
Therapy is by nature a mode of "treatment," involving the application of therapeutic techniques and remedies to relieve problems related to a disorder that fits within DSM-IV diagnostic categories, as well as to deal with problems of daily living. Licensed therapists earn an advanced degree in a formal training program, and must pass a licensing exam in their state.
Coaching is based more on a holistic or "wellness" model, intended to improve daily functioning and well-being for individuals without significant psychological impairment. This places coaching more in the realm of an educational process as opposed to a treatment process. There are no training programs for coaches in colleges or universities, no formal degrees, and no oversight by state licensing boards.
Coaching has limited benefit, and may be very inappropriate, for individuals with significant emotional or psychological problems. If those problems are evident at the start of coaching, or develop later on during the coaching process, the coach will refer the client to a therapist. This requires that a well trained coach has a general knowledge of psychopathology and is able to recognize when he or she is faced with a problem for which coaching is not appropriate. A close working relationship with a therapist helps to clarify diagnostic issues.
Coaching is more flexible. Much of the work may be done over the phone, since the emotional component of therapy that requires in-person meetings is not an issue with coaching. A coach in Boston may work with a client in Denver and never meet in person, yet the coaching can be very effective. The exception to this is when the coach works with children or adolescents, who do require in-person meetings. A coach-client contact may involve a five minute phone update, or an e-mail confirmation that a goal was accomplished. A coach is able to take a more holistic approach that takes into consideration any issue which effects daily living: productivity, the work and home environment, diet, exercise programs, managing time, basic financial management (are the bills getting paid?), sleep, and so on.
A very practical consideration for many people is that therapy is covered by health insurance, whereas coaching is not. Many coaches charge fees that are similar to what therapists charge.
When Collaboration Is The Solution
There are instances when it is in the client's best interests for a coach to refer the client for therapy, for a therapist to refer the client for coaching, and for coach and therapist to both work with the client in a collaborative and cooperative manner. As noted above, a coach will refer a client for therapy if the client is experiencing significant emotional problems related to depression, anxiety disorders, issues of abuse or trauma, personality disorders, angry or violent outbursts, rapid mood swings, addictions, and other such problems. Therapy may also be indicated during periods when outside life factors interfere with the client's ability to function and more psychological support is needed, for example during a divorce, separation, death in the family, serious illness, and so on.
As more and more awareness grows about the sometimes pervasive effects of ADD on the personal and professional lives of individuals, many therapists consider other approaches that help with managing ADD. Regular exercise is known to produce significant benefits. The services of a professional organizer can be very helpful with structuring the work and home environment to reduce clutter and reduce disorganization. Many therapists are referring to coaches so that they can help the client clear the behavioral "clutter" and allow the therapist to focus more on core therapeutic issues.
A therapist might consider referring a client to a coach for a number of reasons. When a client has difficulty following through on the goals set in therapy and the problem is not getting resolved in therapy, a coach can help therapy be more productive. The coach is able to provide more frequent contact with the client, set up more structure in the client's life to help address the therapeutic goals, and improve follow-through. Coaching can also be very helpful when the client needs to learn specific skills such as creating time lines, setting up more structures, and can benefit from the increased accountability that comes from frequent coach-client contacts. When a coach and therapist are both working with a client they need to maintain regular contact to monitor progress and ongoing problems. They must also work together to keep the boundaries clear, making sure that coaching issues are handled by the coach, and therapy issues by the therapist.
Some therapists have incorporated limited coaching techniques into their practice to better help the client with ADD. Some example might be to keep lists of issues to be worked on, give written homework assignments, and ask the client to check in during the week to report on progress and follow-through. It is more common for therapists to go into the coaching realm or use coaching tools, but this is not reciprocal. Coaches are not qualified, nor can legally adopt therapeutic tools or techniques in their coaching, unless the coach becomes a licensed therapist. The most useful combination of techniques occurs when the therapist and coach are separate individuals and have a solid, complementary working relationship. Both need a clear understanding of the goals each will pursue in working with a client.
This article was originally published in Focus, the newsletter of the Attention Deficit Disorder Association (www.add.org).
About The Authors
Peter Jaksa, Ph.D., is a licensed clinical psychologist with over 25 years experience working with children, adolescents, and adults with ADHD. Dr. Jaksa is the author of numerous articles and columns about ADHD, including articles published in ADDitude Magazine, Attention Magazine, Organize Magazine, and FOCUS. He has provided interviews to national publications and news organizations including the Wall Street Journal, CNN, Chicago Tribune, and Men's Health Magazine. He has presented at national conferences to health care professionals, educators, and the general public. Dr. Jaksa is a contributing writer for ADDitude Magazine and a member of the Scientific Advisory Board.
Nancy Ratey, Ed.M., is one of the founders of the ADD Coaching field. A personal and professional coach, consultant and trainer, Nancy runs a coaching practice in Wellesley, MA. Nancy may be reached at e-mail address: firstname.lastname@example.org