“My golden retriever has a better sense of time that I do!” my new client explained when I asked about her ADD. As I listened to her other concerns, I decided that metacognitive coaching would work well for this client. Coaching metacognition, teaching clients to be aware of and to manage their own thinking processes, has been successfully applied to coaching for years. This present study is interesting because, unlike much of the previous research, this study used a large sample size and statistical techniques to control for effects unrelated to the focus (nonspecifics) of the study (such as therapist support).
This rigorous study was designed to assess the efficacy of metacognitive therapy, a cognitive-behavioral intervention, for the treatment of adult ADHD. Participants randomly assigned to receive meta-cognitive therapy showed greater improvement on standardized measures of inattention symptoms, whether self-rated, observer-rated, or rated by a blind evaluator, than did those in a supportive therapy condition.
Metacognitive Therapy Group. Participants assigned to meta-cognitive therapy group were taught to 1) provide contingent self-reward; (e.g., for completing an aversive task); 2) dismantle complex tasks into manageable parts; and 3) sustain motivation toward distant goals by visualizing long-term rewards; 4) traditional cognitive-behavioral methods that challenge anxiety and depressive cognitions. Support from, modeling of, and reinforcement by other group members and the therapist were important components of the treatment that serve to stimulate, enhance, and maintain positive gains. The treatment began with training in specific skills (e.g., mechanics of planner use) and progressing to higher-order skills that encompass both time management and organization (i.e., planning).
Participants heard cues to promote generalization and maintenance of their new thinking habits. The program also makes use of self-instruction using phrases that link a problematic situation (cue) with a cognitive response that provides a solution to that problem. An example is “If I am having trouble getting started (cue), then the first step is too big (solution is to break task down into parts).” Another example, designed to cue individuals to minimize distracters in their organizational space, is “Out of sight, out of mind.”
The first hour of each 2-hour session is devoted to a roundtable review of each participant’s experience with the most recent home exercise to ascertain and address cognitive, situational, and emotional obstacles to implementation; suggest additional or alternative strategies; and address counterproductive emotional responses. The second half of each session begins with a presentation of the new topic and corresponding strategies, followed by an in-session exercise to illustrate or model each technique. Sessions conclude with an explanation of the next home exercise and anticipatory troubleshooting.
Supportive therapy Group. The supportive therapy groups were designed to control for nonspecific elements of the meta-cognitive therapy program, including session and treatment duration (2 hours per week for 12 weeks), group support and validation, therapist attention, and psychoeducation, Participants assigned to the supportive therapy group Following a manual delineating the techniques and strategies that were prohibited and permitted to them during supportive therapy sessions, therapist asked participants during the initial session, to identify a specific goal to address during the program. Each subsequent session was subdivided into two segments, with the initial half devoted to a review of events that transpired during the preceding week, including challenges or positive accomplishments; the second portion, when time permitted, involved a therapist-led discussion of a specific psychoeducational theme, elicited from group members at the outset of the session. Although the specific topics varied somewhat across groups, the most typical areas covered included primary symptoms of ADHD; everyday manifestations of ADHD symptoms; and psychopharmacological treatment. Throughout the various sessions, each therapist responded by providing psychoeducation, offering support and encouragement (e.g., highlighting positive changes and effort), and/or referring the problem to the group for alternative solutions.
Results. The robust results of this study indicate that metacognitive therapy provides significant benefit to patients with ADHD with respect to inattention symptoms that reflect the specific functions of time management, organization, and planning. General linear models comparing change from baseline between treatments revealed statistically significant effects for self-report, collateral report, and independent evaluator ratings of DSM-IV inattention symptoms. In dichotomous indices of therapeutic response, a significantly greater proportion of members of the metacognitive therapy group demonstrated improvement compared with members of the supportive therapy group. Logistic regression examining group differences in operationally de- fined response (controlling for baseline ADHD severity) revealed a robust effect of treatment group (odds ratio=5.41; 95% CI=1.77–16.55).
Although the magnitude of change on the metacognition group measures strongly favored metacognitive therapy, participants in the supportive therapy group also reported improvement. It may be that the support in the group reduced demoralization and improved hopefulness, which in turn motivated participants to tackle their own difficulties or discover solutions through reading, talking to others, or trial and error.
Metacognitive therapy yielded significantly greater improvements in dimensional and categorical estimates of severity of ADHD symptoms compared with supportive therapy. These findings support the efficacy of metacognitive therapy as a viable psychosocial intervention.
Implications for Coaches. When clients discuss their problems with time management and organizational issues, coaches can respond with metacognition coaching. Metacognition involves understanding and appreciating the strategies, processes, and factors that make personal growth possible. Two basic processes occurring simultaneously: 1) monitoring one’s progress in the moment; 2) making changes and adapting strategies if one perceives confusion. As clients become more skilled at using metacognitive strategies, they gain confidence and become more independent as learners. Coaches have the opportunity help their clients cultivate, engage, and enhance their metacognitive capabilities. Specifically, coaches can prompt their clients to —
- Analyze tasks
- Check assumptions
- Know weaknesses
- Know when to adapt
- Be strategic in their thinking
Tamara Rosier, PhD, has been an administrator, professor, leadership consultant, public speaker, and high school teacher. Now she is a passionate Leadership and ADHD Coach who helps her clients develop more confidence, smoother communication, closer relationships, and increased success. Contact her at 616-648-1969 and firstname.lastname@example.org.