ADHD: Using therapy to support medication
A typical goal in sports psychology is for athletes to more readily achieve optimal mental states when engaging in their sport. “Optimal mental state” being the ability to maintain complete focus and respond to events as quickly and efficiently as one is capable of. Such a state is effectively synonymous with the concept of “flow” or antonymous to the concept of “choking.”
Obviously, the more an athlete can stay in an optimal mental state the better they’ll perform in their sport and so accessing such flow states has become a core pursuit of the sports psychology discipline(1). The basic idea is that by reflecting closely upon past flow states after they have occurred automatically, an athlete can improve their ability to enter them deliberately. Crucially, whatever reflections an athlete makes need to be distilled down into their purest form and associated with a ritual; some combination of a behavioural and cognitive mantra.
Commonly, athletes do this via journal reflections. Here is a typical template one might use:
Peak Moment: What was the single moment today where everything felt entirely effortless, automatic, or fully locked in?
Physiological State: Right before that moment, what did my body feel like (e.g., heart rate, breathing pattern, muscle tension, energy on a 1–10 scale)?
Attentional Focus: Where was my attention directed right before and during that movement (e.g., target, rhythm, opponent, external cue)?
Self-Talk & Internal Volume: What was going through my head? Was there any cognition, or just pure awareness?
Ritual: If I had to condense the exact mindset of that state into a physical position and a short command, what would it be?
Starting with self-awareness and eventually building into habit, an athlete improves their ability to deliberately enter optimal mental states.
Again, to revisit the definition of a flow state: an optimal psychological state characterized by complete absorption in an activity, in which attention is fully concentrated on the task and action feels relatively effortless(2).
This sounds similar to how I’ve heard people with ADHD describe the effects of medications:
“Everything was clearer; I had clarity.”
“I just knew how to do things and could focus on them until they were finished.”
“I could just get going; it was all suddenly easy.”
While I have precisely zero empirical evidence to support this, if athletes can improve their performance via journaling and ritual creation, I don’t see why ADHDers couldn’t improve their performance by similar means. If anything, athletes have the harder task of first having to dedicate hundreds of hours to their sport before enough skill has developed to enable anything resembling a flow state. Compare this to ADHD medications, with which people typically report immediate benefits.
I find it is often useful to first consider the way things go wrong to help provide contrast when we later try to consider how things can go optimally. An activity I might do with a client is to monologue our internal states at the peak of inattention:
“It was time to write the email… but first a coffee, then make sure I am optimally poised to write the email… milk… opening the fridge reminds me that fridges have lights that don’t turn on until the door is opened… when I was a kid I worked this out and found the switch… I remember finding it in Grandma’s fridge… when Grandma died, I wasn’t ready for how heavy the coffin was… I’m such a weakling…”
Like with the Catastrophizing Game, this exaggerates and effectively creates a caricature of one’s own inattentive self. But there will always be something quite true within the impersonation, which hopefully means that next time someone is stuck in the throes of mental paralysis, a small glint of self-awareness can activate, enabling the performance of the journal-developed ritual:
Peak Moment: Throughout 1–3 hours after taking my meds.
Physiological State: Light but strong, calm but alert, poised with no unnecessary tension.
Attentional Focus: Eyes were focused on the target, but peripheral vision was still available. Able to think and sense in perfect harmony.
Self-Talk & Internal Volume: Quiet, with steady reassurances and good leadership.
Ritual: Squint eyes while looking at the target; say “Lock-in.”
Working with a client prescribed ADHD medication, I set the above journal task for after the medication has worn off. This mirrors the approach in sports psychology where flow states are reflected upon from the vantage point of a mental baseline, thus building a metaphorical neural-bridge between "optimal" and "normal." Hopefully, with the development of an increasingly habitualised ritual, people can start to more readily access optimal states of concentration, both as a complement to medications and possibly as an alternative when medications aren’t available.
The vast majority of people I’ve known who have been prescribed medications report overall net benefits, and for some, life-changing improvements in work, academic, and social functioning. Many have also reported worrying immediate side effects, especially reduced appetite, itself highly impactful to executive functioning. There’s also the concern of growing tolerance and, at therefore at the very least, diminishing returns.
In late February, 60 Adelaide-based GPs completed the training to diagnose, treat, and prescribe medication for ADHD. Last month (July), I went through the list trying to make a referral and found an opening on my fifth attempt, the first four practices having closed their books due to an inundation of referrals. I am not sure why society has seen such a rapid uptake in ADHD presentations, but it’s not a situation that seems likely to decelerate. I hope this idea and ones like it might hint towards ways of enhancing our existing treatment approaches.
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Ned Dickeson is a clinical psychologist based in Adelaide, Australia.
This essay describes a personal hypothesis towards a treatment approach that has not been pressure-tested by empirical research and so should not be considered as evidence-based practice.
I have used AI for artwork and proofreading but not for ideas or prose.
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References
1. Weinberg, R. S., & Gould, D. (2019). Foundations of Sport and Exercise Psychology (7th ed.). Human Kinetics.
2. Csikszentmihalyi, M., & Csikszentmihalyi, M. (1990). Flow: The psychology of optimal experience (Vol. 1990, p. 1). New York: Harper & Row.
