Adults with ADHD increasingly report trouble finding a therapist who will treat ADHD as the primary concern. In this episode of Self Careapist Therapist: Expert Insights and Practical Therapy Skills, Dr. Maggie Sibley, professor of psychiatry and behavioral sciences at the University of Washington School of Medicine, explains where that gap comes from and how clinicians can close it. She draws on her team’s recent surveys of psychologists and ADHD coaches.

Guest: Margaret (Maggie) Sibley, PhD, clinical psychologist at Seattle Children’s Hospital

Host: Lorain Moorehead, LCSW, EMDR Certified Consultant, PMH-C

Aired: November 4, 2026

Listen: YouTube, Apple, Spotify

Key Takeaways for Clinicians

• Only 26.4% of PSYPACT psychologists advertise adult ADHD services. The figures for depression and anxiety are 69% and 74%.
• Most children with ADHD do not simply outgrow it. In a 16-year follow-up, 63.8% moved in and out of remission.
• The classic content of CBT for adult ADHD still matches what clients ask for. Dr. Sibley recommends updating the delivery with motivational interviewing and a slower pace.
• ADHD coaching has grown rapidly since 2020 and has no randomized controlled trials behind it yet.

Why Do So Many Therapists Hesitate to Treat Adult ADHD?

What the research shows: Dr. Sibley’s team coded the public directory of PSYPACT, the interstate telehealth compact for psychologists. Only 26.4% of providers advertised any adult ADHD services, and only 21.3% offered CBT for adult ADHD (Rout et al., 2026).

What she reported from her team’s follow-up survey: Of roughly 1,200 PSYPACT psychologists, more than half described themselves as hesitant to treat adults with ADHD. Fewer than one in three had received didactic training on adult ADHD. About half had never treated an adult with ADHD under supervision before finishing postdoctoral training.

Her interpretation: Confidence is the main barrier. A smaller group of psychologists reported an aversion to the population based on cancellations and incomplete homework, and she sees that as a secondary factor.

Do Adults Grow Out of ADHD?

Many clients arrive having read online that psychologists believe ADHD fades in adulthood. Dr. Sibley’s longitudinal research supports neither a clean recovery story nor a fixed lifelong one.

In the Multimodal Treatment Study of ADHD, her team followed children with ADHD for 16 years. Only 9.1% showed sustained recovery by young adulthood, and only 10.8% showed stable persistence at every assessment. The largest group, 63.8%, had fluctuating periods of remission and recurrence (Sibley et al., 2021). A 2024 follow-up found that during remission periods, people in this fluctuating group were successfully managing increased demands and responsibilities (Sibley et al., 2024).

For clinicians, that means expecting symptoms to rise and fall, and planning for clients to return to care when they do.

What Should CBT for Adult ADHD Look Like Now?

To modernize CBT for adult ADHD, Dr. Sibley’s team ran an innovation tournament, a method borrowed from business. They built a bank of ideas from existing CBT manuals and adolescent engagement research, then asked adults with ADHD to add their own. Adults with ADHD and ADHD-focused therapists rated each idea on importance and feasibility. The new protocol is being built from the ideas both groups endorsed, and it is still in development.

The content held up. Clients still want help with time management and with starting tasks they have been avoiding. Her clinical recommendations focus on delivery:

• Use motivational interviewing. Difficulty with self-motivation is part of ADHD, so attention to motivation and values does real work in session.
• Slow the pace. Cover two planned activities per session instead of four, and expect to revisit material several times.
• Treat missed homework as data. Confronting clients about incomplete homework tends to deepen shame. Ask what helped on the day it worked, then set one realistic next step.
• Build in an application phase. After teaching skills, give clients time to practice them in daily life and adjust what is not working.

How Should Therapists Respond When a Client Mentions Rejection Sensitive Dysphoria or Hyperfocus?

Rejection sensitive dysphoria spread widely through TikTok and is now often described online as a core feature of ADHD. Dr. Sibley notes it has not been studied as a research construct. Hyperfocus has been rebranded online as a superpower, and she notes there is no evidence that people with ADHD focus better at their peak than people without ADHD. The underlying difficulty, trouble disengaging from something absorbing, is well documented and can cause real harm, such as losing track of time and missing a school pickup.

Her recommended response is a functional analysis. Ask what the behavior looks like, then map its antecedents and consequences. Use the client’s own terms, the same way you would when working across cultures, and reserve correction for beliefs that could hurt the client. On the episode, Lorain offered assessment questions that fit this approach: How does that show up for you? How often did it show up this week? Where are you noticing it?

Should Therapists Charge No-Show Fees for Clients With ADHD?

Dr. Sibley supports keeping no-show fees. Private practitioners depend on a full schedule, and many have waitlists. Her focus is prevention:

• Explain the policy at intake and ask how confident the client feels about meeting it.
• If confidence is low, problem-solve the appointment time and reminder system together.
• For clients who are often late, check in about the next session before it arrives.
• Use case-by-case leniency when you can afford it.

She also cautions against too much hand-holding. Calling clients minutes before session, or having them complete tasks during the hour, shifts the therapist into a personal assistant role. The goal is self-management skills that generalize beyond therapy.

How Does Environment Affect ADHD Symptoms?

Dr. Sibley describes ADHD symptoms and impairment as waxing and waning with context. A job with novelty and frequent human contact may suit a client well, while hours of repetitive solo desk work may be very difficult for the same person. Major transitions, like a move or a new baby, often disrupt routines that were working.

Adults with ADHD in her study rated help with designing an optimal environment as a priority, while therapists rated it lower. Her suggestion is reflective listening. Clients already know a great deal about what works for them, and a therapist who organizes and reflects back a scattered narrative helps them see the pattern. Lorain uses a values alignment assessment for the same purpose, reviewing periods in a client’s life when they felt effective and periods when they did not.

Is ADHD Coaching Evidence-Based?

Not yet. Dr. Sibley’s national survey of 481 ADHD coaches, published in JAMA Network Open, found that 60.9% entered the field during or after the COVID-19 pandemic (Sibley et al., 2026). Most coaches (72.7%) have or suspect they have ADHD, and 44.5% previously received coaching themselves. Coaching is unregulated, has no geographic licensing limits, and has no randomized controlled trials of its efficacy or safety.

On the episode, Dr. Sibley also described two findings from her team’s ongoing work. Online searches for ADHD coaching now outpace searches for therapy or CBT for ADHD. And about 40% of licensed providers who treat ADHD refer clients to coaches.

If a client works with a coach alongside therapy, she recommends telling the client that the evidence base does not exist yet and encouraging them to ask about the coach’s training. Coordinating with the coach directly helps avoid redundant work.

Where Can Therapists Learn More About Adult ADHD?

• APSARD: The American Professional Society of ADHD and Related Disorders runs an annual multidisciplinary conference that Dr. Sibley recommends for science-based, practical training.
• CHADD: The national ADHD advocacy organization partners with the CDC on public information.
• Motivational interviewing training: Dr. Sibley tells adults seeking care to look for a therapist with solid training in both CBT and MI.
• Research participation: PSYPACT psychologists can sign up to pilot the new adult protocol at margaretsibley.com.

About Dr. Maggie Sibley

Margaret (Maggie) Sibley, PhD, is a professor of psychiatry and behavioral sciences at the University of Washington School of Medicine and a clinical psychologist at Seattle Children’s Hospital. She developed STAND (Supporting Teens’ Autonomy Daily), a motivational interviewing based treatment for adolescents with ADHD and their parents, and is a member of the Motivational Interviewing Network of Trainers. She is also an investigator on the Multimodal Treatment Study of ADHD (MTA) long-term follow-up.

About the Host

Lorain Moorehead, LCSW, is an EMDR Certified Consultant, PMH-C, and clinical supervisor licensed in Arizona, Texas, and Alaska. She hosts Self Careapist Therapist: Expert Insights and Practical Therapy Skills, a podcast for licensed mental health clinicians.

References

• Rout, M. R., Gaddis, A., Yeguez, C. E., Sibley, M. H., & Groves, N. B. (2026). Disparities in adult ADHD care delivery among U.S. telepsychology providers. Journal of Attention Disorders, 30(5), 571–576.
• Sibley, M. H., Graham, E. D., Holbrook, J. K., et al. (2026). Demographics, services, and practices in attention-deficit/hyperactivity disorder coaching in the US. JAMA Network Open, 9(1), e2552407.
• Sibley, M. H., Arnold, L. E., Swanson, J. M., et al. (2021). Variable patterns of remission from ADHD in the Multimodal Treatment Study of ADHD. American Journal of Psychiatry, 179(2), 142–151.
• Sibley, M. H., Kennedy, T. M., Swanson, J. M., et al. (2024). Characteristics and predictors of fluctuating ADHD in the Multimodal Treatment of ADHD (MTA) study. Journal of Clinical Psychiatry, 85(4), 24m15395.
• Sibley, M. H. (2016). Parent-teen therapy for executive function deficits and ADHD: Building skills and motivation. Guilford Press.

Related Episodes

• Navigate the Nuances of AuDHD (https://lorainmoorehead.com/audhd-a-deep-dive-of-autism-and-adhd/)
• Self Compassion for Shame (Publishing next)

If adult ADHD clients are part of your caseload and you want a second set of eyes on a case, see Clinical Consultation and Supervision for Therapists.

Full Episode Transcript

This transcript has been edited lightly for readability. Filler words and false starts were removed.

Introduction and How ADHD Is Treated (00:00)

Lorain Moorehead: Welcome back, Careapists, for an episode on enhancing engagement in therapy for adult ADHD. I’m joined by Dr. Maggie Sibley, a professor of psychiatry and behavioral sciences at the University of Washington School of Medicine. She has published more than 140 scholarly articles on the topic. Thank you for joining us, Maggie.

Dr. Maggie Sibley: Thanks for having me. I’m really happy to be here.

Lorain Moorehead: Will you start us off by giving an overview of what treatment of ADHD looks like?

Dr. Maggie Sibley: For the treatment of ADHD, we have guidelines globally in most major regions. The U.S. guidelines exist for children and adolescents, and they’re coming out for adults early in 2027. So we really look to those for how to best treat ADHD. We have two classes of treatments that have been found to be effective. One is medications, and the other is non-pharmacological treatments that are usually under the umbrella of cognitive behavioral therapy, or behavior therapy for younger children, where the cognitive piece isn’t yet relevant. For medications, there are stimulant medications and non-stimulant medications. Under the CBT umbrella, treatment is tailored to where someone is in the lifespan. For adults, we usually work directly with the adult in a CBT approach that is one-on-one and often structured like an anxiety or depression CBT would be. For adolescents, we often work with the adolescent and the parent together. There’s a piece that still relies on some of the parent training strategies you’d use with younger children, and also a piece where we’re trying to empower the youth to do more for themselves. In children, most of the evidence-based treatments work directly with the parent, focusing on modifying things about the home environment and the ways parents interact with their kids, to elicit behaviors that will hopefully help the kids be as happy and healthy as they can be in spite of their ADHD.

Why Psychologists Hesitate to Treat Adult ADHD (02:15)

Lorain Moorehead: You recently did some research with PSYPACT psychologists. What are you finding is the hesitation for a lot of our colleagues in treating ADHD?

Dr. Maggie Sibley: It’s interesting. We’ve been very interested in understanding why adults with ADHD have been coming to us, and coming into public forums, saying that psychologists don’t seem to be ADHD friendly. They’ve been saying it’s hard to get in with an ADHD specialist who’s a mental health provider, a non-pharmacological provider. That led us to wonder what is going on. I’m a psychologist, so I started with my own workforce as a beginning place. We thought it would be interesting to partner with the PSYPACT community. Because they’re interstate telehealth, they’re representative of how people want care nowadays, which is often through a virtual modality. They also represent most states. So we’ve been working with this group to understand what might be going on.

What we’ve seen is that compared to depression and anxiety, this provider workforce seems more hesitant to treat adults with ADHD. First of all, folks are willing to treat adults with co-occurring ADHD. Almost everyone is. And people are even willing on paper to see adults whose primary presenting problem is ADHD. But when you ask them if they prioritize those clients, if they directly advertise to those clients and try to attract them, it’s much lower numbers. We coded the PSYPACT profiles in the database, and I think only 25% of people who treat adults were listing ADHD as a condition they treated. On a survey we did with about 1,200 PSYPACT psychologists, over 50% said they were hesitant to treat that population. We also learned that less than a third of psychologists had received any didactics on adult ADHD in their training. That’s a huge number. Two thirds of psychologists never got lectures on adult ADHD in their training. And only about half had ever treated an adult with ADHD under supervision by the time they finished their postdoctoral training. So I think people just don’t have confidence in their ability to be effective with this group.

We had smaller numbers of psychologists reporting an aversion to the population: feeling like these clients cancel a lot, which isn’t great for business, or feeling like they don’t do their therapy homework, which makes it hard to progress. I think there’s an idea that that’s why people avoid ADHD. I don’t think it’s the main reason people have been hesitant, but it certainly was for some people.

Two Narratives About Adult ADHD (05:14)

Lorain Moorehead: It’s interesting. Does it seem to you like the understanding of what ADHD in adults looks like has changed over the past 10 or 20 years?

Dr. Maggie Sibley: I think we’re starting to have a split narrative on what adult ADHD looks like. One narrative comes out of the science, and one comes out of online discussion and information sharing. The truth is somewhere in between the two. But I think this split narrative is creating friction between what psychologists trained in adult ADHD think they should do, and have been told to do, and what people with ADHD want. There’s a popular viral Facebook post that maybe people saw where it says, my psychologist is basically saying that adults grow out of ADHD eventually, and everyone I know is saying my ADHD gets worse as I become an adult. To me that was a really good image of this almost us-versus-them thing going on in the ADHD community, where they feel like psychologists don’t even know what ADHD really is. They think you grow out of it. They think it’s something CBT can get rid of. I don’t think that’s what most psychologists think, but it is something the public is latching on to, and I think it’s something we need to address.

Lorain Moorehead: I think this is so interesting. The training folks are getting can be different from what a client, educated in the school of TikTok, comes in expecting or hoping for. That can lead to a provider feeling like they don’t have what it takes, or that they aren’t able to do what the client is requesting. And the client feels like, they don’t understand, they don’t know about this, they don’t know this terminology, so therapeutic services aren’t what I’m looking for.

Dr. Maggie Sibley: I feel like some of that gap is valid. Some of our existing tools do feel like they’re from a different decade. I think that leads people to start using their own ideas or trading ideas with other people. Some of those might be really good ideas, but as they take on a life of their own, we don’t have good information on whether they’re best practices or whether they help. Research is supposed to check all of that and give good information to people, but research can only move so fast. So I think the internet moving so fast is part of what’s contributing to this mismatch.

Staying Current With Patient Communities (08:07)

Lorain Moorehead: That’s so true. It feels to me like your research moves really fast. Some of the work you’re doing feels really modern and aimed at keeping up with these two schools of thought.

Dr. Maggie Sibley: Something my team does that I’d encourage everyone to do is immerse yourself in the patient communities and the advocacy communities. Read the Reddit. Go to the conferences that are about advocacy, so you have a pulse on what the people coming to you are seeing and thinking. I go to some conferences to learn and others to just listen and experience and get to know people. I think that’s a good way to stay current. It also helps you notice the places where good scientific information is needed, and that guides what my team decides to study.

Lorain Moorehead: I haven’t heard anyone put that into words that way before, but it’s so true. That can be a way to keep up with what people are saying, so we know where the research is needed.

Building a Modernized CBT Protocol (09:12)

Lorain Moorehead: Can you share about the focus group you conducted to generate ideas on how to bring these two schools of thought together?

Dr. Maggie Sibley: Basically, we looked at the existing CBT manuals for adult ADHD and took all of the content. If people have seen these, they have things like time management and executive function strategies. That’s the B part. There’s also the C part, which is cognitive restructuring around thoughts people may have about procrastination, or negative thoughts about the self that can emerge related to ADHD. Those are the classic things in those manuals. So question one is, do people with ADHD want to do those classic things? Do they feel it’s a fit for what they want help with? Question two is, does the ADHD community have additional ideas of things they’d like to do with a therapist? And then, are there things we can take from other places that are already known to be evidence-based? That includes adolescents with ADHD, where we’ve already done a lot of work on engagement, because that population was so obviously difficult to engage 20 years ago that we started there. It also includes other clinical populations that may share commonalities with ADHD, like the emotion dysregulation that people with ADHD also report struggling with.

So we took this pool of ideas, got adults with ADHD to help us brainstorm additional ideas, and put it all together in a big bank of things we could do with people in psychotherapy for ADHD. Then we designed a study called an innovation tournament. It’s used in business. Essentially, you give this bank of ideas to a sample of people with ADHD and ask them to rate the ones they think are best, both in terms of how important it feels to them to get help in those areas and how feasible it would be for them to implement the strategies. We also gave the same bank to mental health practitioners who specialized in ADHD clients or liked that population, and had them rate it as well. Then we looked for the intersection, where both the ADHD community and real-world practitioners found common ground. We said that would be a good place to refresh a CBT protocol for adults with ADHD, because I do think it needs modernization, and I do think we need to listen to the patient community about what they want to work on.

Sometimes they’re just using a different vocabulary for something. They got a vocabulary from TikTok, and they go to their therapist and say, hey, I want to work on this. I’ll give you an example: rejection sensitivity dysphoria. That came out of a psychiatrist’s thinking, but he got it really viral on TikTok. Now it’s being thrown around as a core feature of ADHD, even though there’s no research on it. Maybe some aspect of it is about rumination, and about the fear of rejection triggering emotional dysregulation, and that could be something that happens for people with ADHD a lot. But a therapist probably isn’t going to know that term. It’s not a technical term. If we break it down into something more familiar to therapists, maybe they would work on it with someone. I’ve gotten texts from friends who are mental health practitioners saying, what is this thing this person is trying to work on with me that they got off TikTok? So we’re trying to build those bridges with the common ground we’re finding. We’ve designed a protocol that works on some of this. Our next step is testing that protocol by giving it to real-world practitioners, having them try it with real clients, and getting their feedback on what’s good and what’s not. We get feedback from the clients too. We’re trying to build toward something everyone finds more acceptable.

How Therapists Can Get Involved (13:30)

Lorain Moorehead: How can therapists get access to that? How can they reach you to trial some of it?

Dr. Maggie Sibley: Right now, because it’s in the development phase, you can get involved through research, but we don’t have it out as a published thing yet, because we’re still changing it all the time. It’s still in revision, so we’re going to wait until the revisions are done before we launch it for the world. But if you’re a psychologist, especially if you have a PSYPACT credential, and you want to get involved with us, you can go to my website, margaretsibley.com, and sign up there to get involved by piloting it, being part of our research, or just giving feedback on it. We’re definitely partnered with the community in general on this work, because that’s how it’s going to become good.

Lorain Moorehead: That’s awesome. Maybe one day it can be opened to the other compacts coming through, like the counseling compact and the social work compact.

Dr. Maggie Sibley: It’ll be open to everyone. Once we get basic data on it with our first group of folks, through our grant from the National Institute of Mental Health… We chose psychologists in PSYPACT because they’re the only ones right now with a large-scale compact.

Lorain Moorehead: Very large. A lot of our compacts are still fighting in the legislature.

Dr. Maggie Sibley: I’ve been following the counseling one for a while, and I was hoping by the time we did this it would have more momentum. I did some of this work with adolescents with ADHD over the last 10 years, and we worked specifically with master’s level therapists in that trial, because that’s the front lines. That was really cool. We worked with community mental health agencies, and we have a similar treatment for teens with ADHD called STAND. We did this process 15 years ago with teens, and now we’re doing it with adults. Over time, that treatment evolved to be more in the hands of master’s level folks than psychologists, because that’s who’s working with these kids a lot of the time.

What Clients and Therapists Want From ADHD Treatment (15:50)

Lorain Moorehead: What were some of the top things everybody felt would be important in the treatment process?

Dr. Maggie Sibley: On the content side, it goes back to a lot of that classic executive functioning work. People want time management skills, task management skills, getting themselves started on work, and overcoming procrastination. The targets aren’t that different from what’s already in existing CBT protocols you could get from any online bookseller. So we got that right. I think it’s the way we work with people with ADHD as a mental health workforce that needs a refresh, to make people feel seen.

A lot of what I do is pull strategies from motivational interviewing, because it’s a patient empowerment approach where you let people tell their own story and help them spend time thinking about their motivation and their values. Part of this condition is difficulty with self-motivation. Motivational interviewing is really aligned with giving extra love and attention to that motivation piece, because that’s hard for folks.

There are other pieces of the process too, like slowing down. If kids with ADHD need more time on things like tests in school, and take a little longer to learn things but can learn just as well as their peers when the right things are in place, why wouldn’t we apply that in the therapy room? People with ADHD may need to see things multiple times. They may need a slower pace of therapy, where you only do two of the planned topics or activities or worksheets per session, instead of the four you might get away with for an anxiety patient who’s really on top of things. Understanding how to work with people that way is important.

Supporting Follow-Through (17:51)

Dr. Maggie Sibley: Knowing how to support follow-through is essentially the holy grail in working with someone with ADHD. People with ADHD come to therapy looking for help with follow-through, and we don’t always have the skills as therapists to help them follow through on homework assignments or on intentions to do things outside of session. That’s a place where there’s a toolkit we can train therapists in: adaptations of motivational interviewing specific to ADHD, which is how I describe it. I think those help a lot, but they aren’t in anyone’s hands, because almost no one even gets an adult ADHD lecture. And if you do, you’re probably getting the classic content from 20 years ago, not what we’re starting to do now. That’s the issue, I think.

Lorain Moorehead: That makes a lot of sense. It was highlighted that CBT, the classic 12-session group, is very class-like, and DBT is too. For someone who finds that difficult to engage in, burnout can happen along the way, especially because, to your point, they may need to see things multiple times for it to resonate. It might feel at a certain point like, wow, I’m not getting anything out of this. It’s really boring. It’s really hard to stick with. It’s not a service to them if it isn’t delivered in a way their brain responds to.

Dr. Maggie Sibley: And we don’t need them to feel shame about this, which they’re already feeling. I was trained around 20 years ago, and we were taught that you need to have serious confrontational conversations with clients who aren’t doing their therapy homework and tell them to get it together. That’s probably the worst thing you can do for a person with ADHD. They know they have issues in this area. They’re here to get help with it. So we need other ways of supporting people, being patient with them, and helping them take on a trial-and-error mindset.

A lot of what I train my folks on is this: if someone comes back and didn’t do what they were supposed to, okay, now let’s analyze that and look at what happened. We give them executive functioning support by debriefing. What did you learn about yourself? What did you figure out makes it hard for you to follow through? What do you know can help you follow through? What’s one little thing we could set as a realistic goal for you to try? Then we build on successes a little at a time, instead of jumping into what went wrong and problem-solving it. We look forward all the time. Okay, you did this thing. This is really good. Even though you did it one day, hey, you did it one day. That’s awesome. Let’s talk about that one day. Let’s talk about what went right that day. Why did it work that day? And then what do we need to do to make that happen for two days?

Lorain Moorehead: Two days.

Dr. Maggie Sibley: Exactly. I think people with ADHD feel more comfortable with that type of approach, so we’re really trying to help that spread.

No-Shows, Late Fees, and Accountability (21:16)

Lorain Moorehead: That makes a lot of sense. You mentioned something I wanted to bring up today. It’s possible a client with ADHD will be late. It’s possible there will be cancellations, and it’s possible there will be no-shows. To share my experience, it isn’t even that it feels frustrating. I typically have a no-show fee, and I’ve run into an ethical dilemma about whether it feels appropriate to attach one to a session when I know the client came to work on some of those strategies. Is there anything you’ve thought about there? What do you say to someone who says, I have a hard time working with ADHD because we end up with a lot of no-shows?

Dr. Maggie Sibley: I agree this is an issue. First of all, it’s not feasible for private practitioners who have to feed their families to go without no-show fees. It’s not fair to practitioners to have empty spots all over their schedule because people come to therapy when they feel like it, especially if you’ve got a waitlist. So I’m not an advocate for getting rid of the fees for these folks. I think it’s more about doing the things that promote their success. Explain the policy up front and make sure they understand it. Talk to them about their confidence level in being able to meet it. If confidence is low early on, then ask, what do we need to do to make you more confident that you’ll remember the sessions? What would make us confident that this is scheduled at a time you’ll get yourself to? There are little prevention things you can do.

I also think it’s case by case. If people want to be lenient sometimes with clients they feel are doing their best, and they feel financially that they can let one go, we should be flexible enough for that to happen. But I also think people with ADHD understand and want accountability, as long as it’s accountability with a lot of support and compassion. It’s important for us to balance those two things, accountability and compassion. Help them problem-solve up front each session. Even if you’ve got a chronic person who’s late all the time, check in about the next session before it happens. What’s your likelihood you’ll be able to make this? Do we need to move it? Keep that part of the conversation.

Lorain Moorehead: I like the idea that you’re building scaffolding from the beginning to support them, and ideally you’d see progress over time if the strategies are effective. Your work mentions appointment reminders, which could be helpful, but it could also help to encourage the client to imagine resources that would help them, even putting in their own reminders or timers, for this appointment and for the other things they’re engaged in.

Dr. Maggie Sibley: I love getting folks to do their own reminders and get themselves to do things. We’re in a world now where it’s pretty standard to have automated appointment reminders come by text message 24 hours before, and those are good for everyone. But I’ve been in situations where clinicians I’ve known wanted to call their client five minutes before to make sure they’re getting where they need to be. If you’re seeing people in person, it’s even harder than virtual. Virtual works really well for clients with ADHD, because if they forgot, you can often still get them on. I think clients with ADHD like virtual better too in some of the research, so that’s another solution.

In general, I don’t like too much hand-holding, because the point is for us to support their autonomy. There’s a little hand-holding that can be done, but ultimately we don’t want to become a personal assistant to them and spend sessions making them do the work they need to be doing. We want to do exercises that increase their life skills, their self-management skills, and their ability to self-regulate. Putting out the fire of the week, or making people sit down and do their work in your session, is probably less effective than big-picture work.

Lorain Moorehead: In terms of generalization, we want them to be able to leave our session and do it across the board.

Dr. Maggie Sibley: Yeah.

Hyperfocus and Functional Analysis (26:19)

Lorain Moorehead: That makes sense. There was a list in this paper of some of the barriers that were identified, and a lot of them were clinician awareness and clinician training. Hyperfocus was one of them. Can you speak to what we might need to know about hyperfocus and how it might show up with a client?

Dr. Maggie Sibley: This is another rebranding of something that has always been known. People with ADHD have trouble shifting gears in their day. They have trouble stopping something they’re enjoying and moving on to something else, whether or not they’ll enjoy that next thing. Just like they can have trouble getting their attention going on something, they can have trouble stopping their attention on something. It’s all part of the general difficulty with regulating attention that we’ve always known about. The term folks are using now is hyperfocus, and it’s being branded as a unique strength, that people with ADHD can jump in and focus better than anyone else at times. The research doesn’t necessarily support the idea that people with ADHD have better focus than anyone else at the right moment. I’m glad people with ADHD can focus well under the right circumstances, and maybe it’s a relative strength for them. But there isn’t evidence that a person without ADHD focusing at their peak does worse than a person with ADHD focusing at their peak. That’s the part that isn’t quite true, but it’s being spread on TikTok, so it’s something to be aware of.

We can help people with self-awareness of the difficulties that come when you get so locked in you don’t know what time it is, or so locked in that you decide not to move on to something important. I’ve worked with a client with ADHD who told a story of forgetting to pick her kids up from school because she got so sucked into something and had no idea how much time had gone by. Those are real issues.

Any time someone comes to you with a catchy term, like hyperfocus or rejection sensitivity dysphoria, do a functional analysis. What’s the behavior you’re talking about? What is the issue for you? Behaviorally, what are the antecedents, and what are the consequences? That should give you the assessment you need to pick the right tool to solve it. We don’t need to know whether the term is evidence-based. It’s a presenting problem. They’re coming to you with it. They’re telling you they’re struggling with it. Then you take that systematic approach. That’s what I would do.

Lorain Moorehead: I think that’s really interesting, and I hope it brings comfort as well. There can be a whole dialogue where the client feels supported when they come in and say, I need help with my rejection sensitivity dysphoria. We might ask, how does that show up for you? Describe your experience of that. Just like we would in any assessment. We’re not saying, I don’t know what that is, or that’s not a real thing. We’re saying, describe your experience. How often did it show up this week? How often did it show up today? Where are you having it? Just like any other element of assessment.

Dr. Maggie Sibley: Most of us have probably been trained to use the client’s language when working with them. Think about working across cultures. If you’re working with someone from a different culture, they’ll use different terms than you might to describe common psychological phenomena. You don’t need to say, oh, that’s called this. You use their words so they’re operating in a familiar space with what you’re doing. I’d say the same thing about the terms that have come out of TikTok. I don’t dispute what they’re saying. I tolerate it. If someone believes something that will harm them, I might give them some resources to look at. But that’s not usually what we’re encountering. We’re usually encountering creative takes on what ADHD is that may or may not be true, that came from social media, but that really resonate with people.

Shame and Feeling Understood (30:38)

Lorain Moorehead: I can see how being on the receiving end of some of that might evoke a negative thought in the clinician, like, oh gosh, other people know more about this, so obviously this isn’t something I can treat. Maybe that’s why you’re getting those reports from psychologists: there’s a whole vocabulary I don’t even know, so maybe this isn’t something I can ethically treat. But in reality, it’s a lot of things they’re probably already using and integrating with other client presentations.

Dr. Maggie Sibley: The other big thing that came out of our conversations and our work goes back to shame. A lot of people with ADHD experience shame because they’ve been getting negative feedback from their environment since they were kids. They’ve seen themselves not meet the standards of their peers in various areas: socially, academically, at work, even in hobbies or recreation. They feel like they’re not as good at things as other people. If you grow up always feeling that way, you develop shame about yourself and cognitions like, I’m not as good as other people, I shouldn’t even try. Then you go into therapy, and a lot of people want to unpack that.

I think they’re facing one of two things. Either they face a therapist who has some understanding of ADHD but hasn’t been socialized to that part of it, so the therapist wants to focus on fixing concrete behavioral problems and doesn’t acknowledge the shame piece people really want healing on. Or they see someone coming from more of an anxiety and depression lens, who hears the shame narrative, part of which is often folded up in anxiety, and thinks, this isn’t ADHD, this is anxiety. Then they miss the part related to the constant self-regulatory difficulties people have had their whole life. So people with ADHD feel like not a lot of people get them.

People with ADHD are often very lovable. If a therapist is comfortable with them, they should see them, even if they feel they don’t have the specific training. If you can be kind and curious and learn how to work with them, you’re probably doing better than a lot of others out there who dismiss what they’re experiencing. So I’d encourage people to get some training, but also not to be afraid to take these clients.

Lorain Moorehead: I think that’s great. The episode airing after this one is about self-compassion for shame, so these will work nicely together.

Designing an Optimal Environment (33:34)

Lorain Moorehead: Another topic that seemed to have clinicians concerned they’re not trained properly is modifying or designing an optimal environment. Can you speak to that?

Dr. Maggie Sibley: That surprised me. To get people on the same page, there’s an idea I personally buy into, which has origins in research but is bigger than research can easily comment on: ADHD symptoms and impairments can wax and wane. It’s not a fixed thing where you have this diagnosis at a clinical level every day of your life and that’s it for you. This collection of traits we call ADHD can flare up, or remit and become less problematic, depending on context, development, and environment.

For example, an adult with ADHD who finds a job with a lot of novelty, that interests them, gets them up and moving, and has them interacting with people they like, may do very well in that job. It’s engaging for them, and they’re able to succeed. But put that same person at a desk doing mundane work with almost no human interaction for eight hours straight, nine to five, and they may be unable to harness whatever they need to get that job done. In that case, it was the environment that let that person feel successful and be successful.

If we zoom out with our clients and help them take the time to understand themselves well enough to know what they need, and then be strategic about the environments they steer themselves into, everything I’ve seen in the research suggests that’s a great way to help someone’s ADHD flare down. Or, even if the symptoms are still there, it can mitigate the impact of those symptoms on their ability to meet regular adult milestones, like feeding your family, paying your bills, and living a healthy, balanced lifestyle. It extends beyond work to social relationships, how you exercise, where you live. If we zoomed out and made these big-picture decisions in ways that aligned with what someone does best, that could be really meaningful to a person.

That was on the list of strategies people with ADHD wanted help with, and surprisingly, the therapist sample didn’t seem to have high confidence or buy-in on that idea. I don’t know if we didn’t explain it well enough in the survey, but I think it’s a huge thing we should be doing with people and helping people do.

Lorain Moorehead: That’s really interesting. It reminds me of studies I’ve seen about a high number of entrepreneurs having ADHD, because switching gears, taking on many roles, making quick decisions, taking risks, and making connections with people feel good. That may help some of the symptoms flare down, and it’s also part of the entrepreneurial lifestyle.

Dr. Maggie Sibley: Totally. There are a lot of interesting professions that are a good fit for somebody with these traits. Going back to self-concept, if a person sees themselves being successful, that will help on the shame front, and with feeling confident enough to take more on and believing you are a person of value and worth. So there are multiple reasons it’s important to help people find their niche and get into the right environment. And when they’re not working with you anymore, they’ll have enough self-awareness about what makes them happiest and healthiest that they can avoid situations, or say no to things, that may put them in a less optimal environment and trigger their ADHD back up.

I hear a lot of people with ADHD talk about how a big change in their life, a big move, a job change, getting married, having a child, throws their world into chaos, because they have to learn a whole new set of self-regulatory strategies and routines to adjust to the new phase. When they know what they need and what’s best for them, they can enter new phases ready to put those things in place. Like you were mentioning with generalizability earlier, it can help with somebody’s long-term ability to steer their own life.

Reflective Listening and Motivational Interviewing (39:01)

Lorain Moorehead: This is really interesting. I do a values alignment assessment. Even stepping aside from the values language, it makes a lot of sense to explore times in somebody’s lifeline when their symptoms flared down, or when they felt really effective, and then examine what was going on and what elements of what they were engaged in helped them succeed. Someone’s hesitation might be that they don’t know every career or don’t do career-based assessment. But we might get a lot of data points just from examining times in somebody’s life when they felt really effective and when they didn’t.

Dr. Maggie Sibley: This might be the motivational interviewing trainer in me, but we’re not career counselors, and we don’t need to figure that out for people. People know about themselves and what they’re good at, but they need the space to reflect on those things. We can really help people who have disorganized thinking by listening to what they’re saying, organizing their thoughts, and reflecting it back to them. We’re a scaffold for them to hear their own thought process and notice things that have happened in their life. I think they can make the decisions.

That’s why I think reflective listening is a really good tool with people with ADHD in general. They’re often giving us disorganized conversations, jumping around in therapy based on the association of idea A with idea B. If we can stay organized, collect their thoughts, and give them back in a way that connects the dots, it helps move their thought process along, because we’re keeping it organized for them. That alone is a value of therapy for people with ADHD.

Lorain Moorehead: I think that’s so important. It’s really cool to hear the integration of motivational interviewing, because it’s a gentle, person-centered approach, and it’s a skill set a lot of people have been taught. It can build a sense of mastery for clinicians to know, I do have an approach I know really well. Hearing that it can be effective here might build some confidence.

Dr. Maggie Sibley: I agree. A lot of people with ADHD email me and say, I want to work with someone trained in the things you talk about. I tell them, if you can find someone with good training in CBT and good training in motivational interviewing, they can probably do these approaches. I’m mostly talking about the adolescent ADHD treatment, where there’s a book we wrote. Give them the book. They have the skills. As we move toward that with adult ADHD, it’ll be the same. We’ll have some sort of manual or workbook for clients. The book has all the content. You just need someone who’s good at the process. If people feel they’re good at the process, that’s the hard part. The easy part is learning different time management strategies to introduce. We can all get a quick study on that. The process is so important.

Building an Inventory of Coping Skills (42:33)

Lorain Moorehead: Another area where clinicians reported feeling less confident was an inventory of coping skills.

Dr. Maggie Sibley: That’s the big-picture work again. It’s zooming out: if I have these tools in my toolbox to manage my own ADHD, how do I build self-awareness of how to use them? What’s the map? What are the red flags that I’m heading into a tricky situation, and what do I do when it’s time to deploy some skills? Some treatments we’re familiar with do a better job of this than others. Some treatments are just a curriculum. You teach the skills, but you never step back and debrief. Now that we’ve learned these things, where are we going to use them? How are we going to use them? How do we know when we need them? I think that’s a forgotten phase, at least in a lot of protocolized therapies. Maybe our real-world practitioners who use the protocolized material for ideas are onto this: there’s a phase of therapy where you learn things, and I think the most successful therapy has a phase after where you watch yourself apply them, learn what’s easy and hard for you, and tweak, so you can come out of the therapeutic process feeling confident that you’ve got this.

Lorain Moorehead: That makes a lot of sense, and that part seems like it would be more enjoyable for some clients, beyond the learning, the vocabulary, or the basics.

What Therapists Can Learn From ADHD Coaching (44:16)

Lorain Moorehead: I’ve been eager to ask you about this. One segment of helping professionals that has marketed itself very well to ADHD clients is coaches. I was intrigued to hear you have a partnership to learn more about what they’re doing. Can you explain what you’ve learned from the coaches?

Dr. Maggie Sibley: This is so interesting. ADHD coaches have clearly been commanding a big presence online since the pandemic, and I’ve been aware of that, like a lot of people in the professional ADHD service field. If you look at the research on ADHD coaching, there really isn’t much. There are some focus groups with ADHD coaches where they describe what they do. Some coaches in private practice have taken a handful of clients and published before-and-after client satisfaction. But there are no randomized controlled trials of ADHD coaching as it exists in its modern form. I saw this as a public health issue, because when you look at and listen to ADHD coaching, they seem to be doing something that looks an awful lot like CBT for ADHD. I’m not sure about all of that yet, but I think it deserved study.

Here’s what we found, and what others have found too. First, workforce entry into ADHD coaching spiked astronomically starting in the COVID-19 pandemic, because the business model for coaching is basically teletherapy. With the changes the pandemic brought, you could reach the world from home as an ADHD coach, because coaches don’t have geographic restrictions on their practice like licensed mental health practitioners do. That led to the explosion. Then a survey by ADDitude Magazine in 2024 found that one in five adults with ADHD had received ADHD coaching. That’s pretty big for an unregulated modality with a grassroots origin that doesn’t have an evidence base, meaning evidence of efficacy and evidence of safety, which is important.

We’ve also done a Google Trends analysis of people searching online. People are now searching for ADHD coaching at higher rates than psychotherapy, therapy, CBT, or any of these terms for ADHD. So in the public sphere, ADHD coaching may be becoming more popular than going to a therapist for a formal, evidence-based, non-pharmacological therapy for ADHD. That’s where we are in terms of the public health landscape.

We did a survey that was published in JAMA Network Open at the beginning of this year. It’s open access, so anyone can read it. We learned that most ADHD coaches are adults who have ADHD themselves. About half are previous clients of an ADHD coach. Because there are no barriers to workforce entry, they’re generally using their lived experience to practice coaching with clients with ADHD. There are ADHD coaching schools, and there are people in the ADHD coaching community who are serious about getting certifications from those schools and not winging it. But there’s a lot of diversity in the workforce, ranging from a master life coach with many certifications who then got ADHD coaching certifications, to a person who woke up one day, turned on their computer, and posted on Instagram that they’re an ADHD coach now, with no attempt to get training.

When we ask coaches what they do, their report is that it looks a lot like CBT. So there are questions about scope of practice and boundaries with psychotherapy that have been difficult for coaches to answer. Their main answer is that therapy focuses on the past and coaching focuses on the present. Your audience will know most psychotherapists aren’t exclusively focused on the past, so that argument doesn’t hold up well with the professional community.

We’ve also surveyed practitioners in the licensed healthcare field in the U.S., prescribers and therapists who work with folks with ADHD, and 40% of them are referring to ADHD coaches. So this isn’t only a client issue. Much of this is advertised on social media, and that’s a big way coaches get clients. But I think med prescribers in particular may not be aware that therapists work with people with ADHD on these issues. They hear about coaching the same way anyone else does and think, oh, I can offer something psychosocial. That’s good. I don’t want to just offer meds. So that’s happening as well. That’s the whole primer on the landscape.

I’m not interested in destroying the ADHD coaching field. I’m interested in partnering with them. We’ve been partnering with their organizations to look at their scope of practice and how we can empower them to give safe care, because they’re here to stay. The question is how they can be a nice complement to what’s already formally in our healthcare systems, and how we make sure they’re doing it safely. I’d like to see research on ADHD coaching, both its safety and efficacy, so clients can make informed decisions about what form of care they want. There’s a lot of work and discussion to be had in this sphere.

If your clients say they’re getting an ADHD coach in addition to working with you, or if you’re thinking, I’ll handle the anxiety symptoms and send them to an ADHD coach for other things, I’m not discouraging that per se. But it’s important for the client to be informed that there isn’t evidence for this yet, and that most coaches’ training may not be much. Have them ask the coach questions about what they’re doing, and make sure you’re comfortable with it. It might also be good for the therapist and coach to talk to each other, so you’re not doing redundant things, the same reason you wouldn’t see two therapists at the same time. That’s basically the landscape.

Coaching, CBT, and How Therapists Describe Their Work (51:51)

Lorain Moorehead: That makes a lot of sense. Is executive functioning coaching the same as ADHD coaching, in your view?

Dr. Maggie Sibley: Functionally, I think it’s the same, but the people in those two communities like to differentiate themselves from each other.

Lorain Moorehead: That word differentiate is interesting, because I think it’s one thing coaches do really well. Some of it is because they don’t have anyone to report to in the same way we do about what we’re promising. You mentioned Google, and when you can state plainly what you’re doing, people know to go to you, or they resonate with your service. It’s been interesting to watch the coaching community do that. I see people resonate with the language, and I feel like we haven’t leaned into that yet.

Dr. Maggie Sibley: CBT has an image problem in the ADHD community, maybe beyond it too. I’m not as well positioned to comment on that, but it does have an image of being cold and teaching people to mask, things that go against the current ethos in the ADHD community. And yet I think we’re doing the same thing as ADHD coaches. I’d argue that psychologists and mental health therapists are in a better position to help with the tricky things, like follow-through, shame, and the emotion dysregulation that comes with ADHD. The nuts and bolts of ADHD don’t exist in a vacuum. As soon as you have comorbidities and other complexities, the mental health trained person can pivot and handle them. That’s one thing that differentiates us from ADHD coaching. But ADHD coaches are using more compassionate language to describe ADHD. And the fact that most have the diagnosis themselves may make them more appealing to clients, who feel they’ll be understood.

Lorain Moorehead: I think that’s really interesting. I don’t think many researchers have had the opportunity to explore coaching from the inside, because we’ve been dismissive of it. So it’s interesting that in your work you’ve been willing to explore it and build a partnership. There are elements that could be offered to make sure it’s a safe service, and also a chance to explore what they’re doing that’s been so effective and so appealing to people.

Dr. Maggie Sibley: Basically, I think we need more people helping people with ADHD. The number of people with a diagnosis is rising. A lot of formal practitioners are a little gun-shy about it, and we’re not even getting into prescribers who are scared to prescribe stimulants. So I think we want the ADHD coaching workforce. I think it’s a good thing. And it’s their decision as a workforce, not ours. But they need to figure out how to do it in a way that protects clients and coaches. It’s only going to take one lawsuit over something that happened with an ADHD coach, and suddenly everyone realizes the industry doesn’t have standards for training, accountability, or regulation. That could destroy their ability to practice, and we don’t want that either. Their field is having to grow up very fast. It’s not just your boutique person down the street anymore. They’re faced with these issues, and I think it helps to have people from other fields come have those conversations with them and be allies in that process.

Where Therapists Can Start (55:29)

Lorain Moorehead: That makes a lot of sense. As we wind down for today, is there one skill or one thing a mental health practitioner wanting to work with more ADHD clients could be left with to do a good job?

Dr. Maggie Sibley: I think they could do a few things. Immersing yourself in that world a little is helpful. Even if you don’t believe everything you see in online information sharing, know what it is. The best conference for good education on ADHD, I think, is the APSARD conference, from the American Professional Society of ADHD and Related Disorders. They have an annual conference with clinicians across disciplines who are interested in this population, and they safeguard their presentations to make sure they’re science-based but also practical, things clinicians can use. That’s a great resource. CHADD, the advocacy organization for ADHD, also partners with the CDC. Their information is good, and that’s another place to make sure you’re getting good information on ADHD. I’m an advocate of working with people with ADHD using approaches like motivational interviewing or other client-centered approaches, so getting training in that lens is helpful with this population as well. Those are my key tips.

I’ll give one more plug for the patient community. There are a lot of great, creative, really interesting people struggling to be their best selves. I think the mental health therapist community is the right group to help them, because there’s so much more under that onion than, I’m having trouble with executive functioning. I hope people will get more inspired and interested in working with these clients.

Lorain Moorehead: One last question. Do you detail your STAND approach in your book?

Dr. Maggie Sibley: Yes, that’s the adolescent approach, for people listening who are interested in adolescents. We didn’t talk about that as much today, but that’s what I worked really hard on from 2010 to around 2022, and you can see all of the work we did in that book. Like I said earlier, if you go to my website, you can see the new things we’re doing, get involved if you’re interested, and communicate with me. It’s an open invitation from us to the field to engage and do work together.

Lorain Moorehead: Perfect. I’ll make sure all those links are in the show notes. Thank you so much for your time. I think it’s really important work you’re doing, and I’m so happy you were able to come on and share it with us today.

Dr. Maggie Sibley: Thanks for the opportunity. I love being able to connect with the clinician community, so this is great.