Is ADHD skills coaching just practicing CBT without a license?

[R. Matey]

I went to a training a while ago that featured an ADHD skills coach or "executive functioning" coach claiming that that they provide essentially boutique skills training for people diagnosed with ADHD, often as an adjunct to MPH. Casual googling tells me that there appears to be quite a market for it (one such example here). And patient facing material seems to draw a confusing and what seems like a really arbitrary distinction between CBT for ADHD and ADHD-coaching (ADHD Therapy Comparison: CBT vs. ADHD Coaching) since a lot of what is being described as coaching could be easily folded into a CBT treatment plan that would be covered by insurance (maybe with a little SFBT thrown in).

Casual research googling tells me (surprise, surprise) that there is little evidence that this actually works for people. This study from 2015 claims to study ADHD coaching, but admits that "coaching" entails some principles of CBT + psychoeducation (e.g., learning about ADHD, time management strategies). It sounds like the only difference is that the coach might be more available than your therapist, but is that the only difference?

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[biscuitsbiscuits]

I'm a postdoc trained in CBT and I do a lot of EF work (I don't call it "ADHD coaching" because I also do this kind of work with people who don't have ADHD). I pull in CBT with almost all of my EF clients because their thoughts and emotions are often part of what gets in the way for them, especially if we're working on procrastination, difficulties with task initiation, etc. I wouldn't get all that far with them if I neglected the entire cognitive/behavioral and emotion regulation part of the picture.

However, I have had some clients who really do actually just struggle with things like time management, planning, organization, etc., and there isn't a whole lot more to it. This doesn't happen that often (at least in the practice I work for), but I do see them, and they don't need to be seeing me for that. My thought has always been that these are the clients who should go to the pure "EF coaches." Those coaches are often former teachers or tutors, and they can be helpful in those areas... but they should not be doing CBT with them.

Anyway, I think two unfortunate things wind up happening: 1) a lot of clients who would benefit from CBT woven into their EF work aren't getting it and/or 2) untrained/unqualified folks are trying to weave in CBT. All of this obviously leads to further downstream effects. This is a long way of saying I agree with you that it's way too muddy right now and the average client is not going to be aware of these nuances.

 

[smalltownpsych]

A good coach can help people, a poor coach doesn’t and might make things worse. I hire people to help some of my patients with life skills as this can be a significant result of and a cause of mental health symptoms and part of the spice o provide is oversight of this process. A good coach, even in sports, will use principles that align with cognitive and behavioral principles. As far as treating mental illness, not too worried about the amateurs as I have plenty of people with significant symptoms that need trained professional help that keep finding me.

 

[PikminOC]

I'm a postdoc trained in CBT and I do a lot of EF work (I don't call it "ADHD coaching" because I also do this kind of work with people who don't have ADHD). I pull in CBT with almost all of my EF clients because their thoughts and emotions are often part of what gets in the way for them, especially if we're working on procrastination, difficulties with task initiation, etc. I wouldn't get all that far with them if I neglected the entire cognitive/behavioral and emotion regulation part of the picture.

However, I have had some clients who really do actually just struggle with things like time management, planning, organization, etc., and there isn't a whole lot more to it. This doesn't happen that often (at least in the practice I work for), but I do see them, and they don't need to be seeing me for that. My thought has always been that these are the clients who should go to the pure "EF coaches." Those coaches are often former teachers or tutors, and they can be helpful in those areas... but they should not be doing CBT with them.

Anyway, I think two unfortunate things wind up happening: 1) a lot of clients who would benefit from CBT woven into their EF work aren't getting it and/or 2) untrained/unqualified folks are trying to weave in CBT. All of this obviously leads to further downstream effects. This is a long way of saying I agree with you that it's way too muddy right now and the average client is not going to be aware of these nuances.

What's EF?

 

[WisNeuro]

What's EF?

Executive Function(ing)

 

[Ollie123]

I've wondered this myself.

The lines are blurry. There is a giant world of self-improvement/time management/organization/anti-procrastination stuff out there that I don't know we have any right to claim is our sole domain. A lot of it is relevant/beneficial for anyone, so mental health really has nothing to do with the equation. I didn't see many ADHD cases, but when I did we inevitably spent a decent chunk of time discussing these sorts of things. However, I think the broader CBT lens came in conceptualizing, managing emotional reactions and cognitive distortions related to implementation, etc. versus straight-up logistics around them (e.g., what app to download).

This is definitely one of the trickier "scope of practice" issues. When looking over a full course of treatment I hope differences would be apparent, I imagine an executive coach working with an overwhelmed CEO could have individual sessions that were virtually indistinguishable from an individual ADHD CBT session. That makes defining scope very difficult. What if the overwhelmed CEO also has ADHD, is that person than practicing without a license? What if its a presentation to a large audience and some of the members have ADHD?

These are the grey areas that make the therapy scope of practice so difficult to define (and our turf much more difficult to defend). Wish I knew the answer...

 

[cara susanna]

I'm kind of feeling the same way about Whole Health coaching at the VA. A lot of people I've seen in the role are not actually licensed mental health providers, yet they are delivering services that are awfully similar to mental health.

 

[smalltownpsych]

If we try to fight this type of encroachment purely from a scope of practice lens, we will probably just diminish our own influence as a field as it is too grey an area. In my mind, it is better for us to exert leadership and direction over this. I think of ABA as a better example of how we can use our expertise to lead. We don’t have to worry as much about trying to stop the individuals who are doing this type of coaching or practices as much as we should utilize and supervise these people ourselves and develop this as the model in systems such as the example of the VA above. While working both in residential and community mental health, the separation and resultant turf wars between ”clinical” and “non-clinical“ or therapist vs case worker or PSR staff was a problem that I saw and found that the best mitigation was to bring them together and let the clinical team support the non-clinical which most of the time they are hungry for anyway.

 

[R. Matey]

This is definitely one of the trickier "scope of practice" issues. When looking over a full course of treatment I hope differences would be apparent, I imagine an executive coach working with an overwhelmed CEO could have individual sessions that were virtually indistinguishable from an individual ADHD CBT session. That makes defining scope very difficult. What if the overwhelmed CEO also has ADHD, is that person than practicing without a license? What if its a presentation to a large audience and some of the members have ADHD?

Generally, I think you're right. It's probably not necessary to go to therapy if you need only time management help like @biscuitsbiscuits said and if an ADHD coach is giving a presentation about the pomodoro technique to 9 people and 3 of them have ADHD, it seems less like a scope of practice issue even though a therapist might mention it in a CBT session.

However, consider this excerpt from the article that I linked above:

ADHD Coaching​

ADHD coaching can help someone who struggles with rejection sensitive dysphoria.

RSD is extreme emotional hypersensitivity and pain triggered by the perception that a person has been rejected or criticized by important people in their life. It may also be triggered by a sense of failing to meet their own high standards or others’ expectations.

When an individual with ADHD comes to coaching without understanding their dominant “rejection/failure story,” they have created a mindset already predisposed to feeling rejected or unable to meet the unrealistic expectations forged in their brain.

People who struggle with both ADHD and RSD are generally not aware of the mechanisms that can trigger RSD and how it immobilizes their ability to function. A common focus of coaching would be a collaborative partnership of coach and client dedicated to improving the client’s self-awareness about specific situations, people, thoughts, and language that often trigger the negative emotions that spiral into ruminative episodes of RSD.

A good ADHD coach will listen to their client’s thoughts, feelings, and patterns — and reflect them back to verify their accuracy. This can lead to powerful questions from the coach and evoke new awareness that helps the client recognize the sources of their rejection

I'm having a hard time seeing what the difference between this and therapy is. I know I wouldn't be comfortable supervising a coach providing these services.