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In treating individuals of all ages with ADHD, most clinicians have often wished they could check in with their patients daily to make sure they are on track, working toward their goals for that day. Children and adults with ADHD frequently have trouble prioritizing their activities so that they do not get lost in a thicket of insignificant tasks. They usually cannot stay focused long enough to plan an extended series of activities, which results in their leaving many projects incomplete. In addition, they can forget their goals from one day to the next, or fail to act on a goal even if they do remember it, which results in their dissipating their considerable energies ineffectually. While most of these patients want to succeed, their symptoms of ADHD keep tripping them up. Their problem lie not so much in assessing what they should do as in following through. Most individuals with ADHD can tell you what they would like to do, their problem lies in doing it. Their plight is like a starving man who is separated from a banquet table by an electrical field that deflects him every time he comes close to reaching food. The person with ADHD needs a guide to get through the electrical field. Sometimes a psychotherapist can act as that guide. Sometimes a teacher can, or a parent, or a spouse. Sometimes the guide is a medication. Sometimes the guide is a good administrative assistant or a tutor. Sometimes an organizational consultant helps, or a neighbor, or a friend. However, for many of my patients, what I can provide them is not quite enough. They need a daily check-in. It is not economically or temporally feasible for me to have daily telephone appointments with all my patients. The more I met with patients who were stumbling over daily details- and this included the vast majority of my adolescent and adult patients- the more I wanted to find some way to supplement my work with them with a daily phone call from a reliable outside person. The model that came to my mind was that of a coach. I was led to this model by my experience with a seventh-grade student who befriended the janitor at one of the schools where I consulted. This boy- let's call him Jake- had had a progressively more miserable school experience since first grade. At the start of his seventh-grade year, I diagnosed him with ADHD and started him on medication. The medication helped somewhat, and his work with me in therapy progressed satisfactorily, however, he was still floundering in school. Then, around late November, he made a quantum leap forward. He became much more enthusiastic, upbeat, and focused. His grades jumped dramatically. He approached every day with a plan. He began to take a positive attitude to all his activities instead of laboring under the defeatist feeling that had so plagued him. Why this dramatic change? I thought perhaps the medication had gained greater efficacy; but there was no reason for that, no change in dose or brand or schedule. I considered that my psychotherapy might be having a telling effect, but, in all honesty, I didn't think so. Then one day Jake began to mention Hank, one of the school's custodians. Hank and Jake had become friends. Hank had told Jake he ought to make more out of his experience at school. Jake asked Hank how. The next thing Jake knew he was meeting with Hank every day. Jake's mom brought him to school 20 minutes early each morning, and Jake helped Hank wheel out the trash barrels. While they wheeled out the barrels they planned Jake's day. "What have you got in history today?" Hank would ask. "And math? And English?" He'd ask about each class. And he would give bits of practical advice. "Watch out for Mrs. Jones in Science today. I saw her drive in and she is in a bad mood." With Hank's help, Jake changed from a marginal student to a major success. Hank taught me the value of a coach. I began to advise parents to find someone like Hank for their children. I called this person a coach for want of a better term, since the role is not exactly described by any term. I found that a parent could not be a good coach because of what I call the "nag factor," but that almost any other responsible adult could. And, in cases of my adult patients, I found that a spouse could not be an effective coach for the same reason, but that any other reliable adult could. While many of my patients- adolescent and adult alike- liked the idea of a coach and wanted to use one, they discovered that coaches are hard to find. Those patients who did find coaches got excellent results. I decided to coach some patients myself in an effort to perfect a method of coaching. I took on a few cases as experiments. We learned from each other. Over time I developed a basic method of coaching that proceeds as follows. The client and the coach agree to meet daily over the telephone. While in-person meetings have obvious advantages, the telephone overcomes many logistical problems and is more practical for most people. There simply are not many on-site "Hanks" out there. The coach and client can meet in person every now and then, but the bulk of the coaching must be done efficiently over the telephone. Once telephone contact is made, the coach talks the client through a four step procedure, summarized by the acronym HOPE, which stands for Hello, Objectives, Plans and Encouragement. First, the coach says a few words of hello to the client, simple chit-chat. This establishes initial rapport and gets the client focused. Next the coach asks the client to state his or her three most important objectives for that day. This requires the client to prioritize as well as to define specific goals. Then the coach asks the client to delineate his or her plans to reach the day's goals. The act of putting plans into words increases the likelihood the goals will be achieved. the coach ends the session by providing encouragement, pure, undiluted cheerleading. Most people with ADHD carry with them great slag heaps of negativity. The daily dose of encouragement counters this negativity head-on. The HOPE method combines practical assistance with emotional support. It combines practical assistance with emotional support. It combines the discipline of defining goals and plans with the pick-me-up of encouragement. It is brief, focused, and forward-thinking. Because it is a method that is used every day, the repetition gives it great impact. No single session is memorable, but the cumulative effect of all the sessions can be dramatic. Although there are no controlled clinical trials of this method, since I have devised it only recently, I have had good results from using coaching to supplement my treatment of ADHD in selected adolescents and adults. In no way does it replace the role of the psychiatrist, psychologist, or primary practitioner. A coach is only adjunctive. Properly used, the coach can make the primary practitioner's work more effective, while adding little to the cost of treatment. For example, Jean was a photographer who came to see me because she was unable to stay focused on her work. She was a skilled photographer, but she was not making time to do the work she needed to do in order to develop further. She had been diagnosed with ADHD, but the medication was not effectively helping her structure her time to work as well as she knew she could. In addition to our weekly psychotherapy sessions, I began to coach Jean myself. She would call me at home every evening, the time of day she felt most at loose ends. I would take her through the HOPE method in a few minutes over the telephone. After some fitful starts she started to work more productively that she had in years. It is intriguing to speculate exactly what this coaching intervention was doing; but whatever it was doing, it produced superb results. To take a second example, Louise was a medical secretary who was getting into trouble at work due to the great organizational demands of the office. She knew the technical details of what she was supposed to do; however, she became overwhelmed by the magnitude of the task each day. I referred her to a coach I had trained. Louise phoned the coach upon arriving at the office each morning. The few steps of the HOPE method provided just enough structure and reassurance to allow Louise to get going in a positive direction. It worked well for her, while I continued to see her in psychotherapy to work on other more complex emotional problems. A third example is Skip, a Methodist minister who came to me for treatment of depression. He instead had ADHD, and his depression was the result of his being unable to keep up with all the requirements of his highly demanding job. He was being pulled in too many different directions, and he was unable to make priorities or set limits. While I began to treat his ADHD with medication and develop in psychotherapy a dynamic understanding of why it was so difficult for him to say "No" to other people, I referred him to another coach I had trained. Once again, the daily check-in sessions and the systematic application of the HOPE method produced excellent results. Skip used his coach to help him set up his day. With the coach's support he was able to more easily prioritize and plan, rather than being pulled this way and that. The coach did not take the place of psychotherapy. Instead, the coach provided a valuable supplement. The method works well with adolescents as well. I have already mentioned Jake's case. Polly is another case where coaching worked well. She was a tenth-grader who came to see me from a boarding school. Her academic performance was totally erratic, as it so often is with kids who have ADHD. Some nights she would go to her room and study, while other nights she would get lost in other activities. No amount of lecturing from mom and dad had had any impact on her inconsistent study habits. Nor did medication or a tutor. However, when I set her up with a coach-a mom of another ADHD child I had trained in coaching-Polly made definite improvements. She set it up so that she called her coach every night after dinner, before study time. They went through the four steps of the HOPE method just before Polly sat down to work. This gave her a "running start" as she put it into her homework. Polly's grades bounced way up, and her teacher's comments improved markedly. Polly liked her coach-who never nagged or lectured her-and felt that she was her ally. Since I have found coaching to be so useful for such a wide variety of patients, and since most people find it difficult to find a coach on their own, I have started a coaching agency. I train coaches in the basic method outlined above and give them additional training as to what a coach is NOT, i.e., a psychotherapist, a boss, a parent, an advisor, or a savior. The coach is simply a person who asks what do you want to do and how are you going to do it, a human reminder and an encourager. The name of the coaching agency is LifeCoach. The coaches I have trained come from several groups: mothers who are at home and want some part-time, meaningful work; college students who relate well to adolescents; senior citizens who have extra time and loads of experience; and various others. The work is as enjoyable for the coach as it is helpful for the client. The fee for the service is ten dollars per day, and the client signs up for two weeks at a time. So far, coaching has worked well. It is a limited service, but one that I think has a definite place in the ADHD field, and in other fields as well. There are various problems to work out, but more clients are finding the service helpful, and more professionals are seeking the service for their patients. Coaching is not meant to take the place of any existing treatment modalities, from psychotherapy to tutoring to behavioral modification to medication. It is intended only to supplement the treatment of certain selected patients. Coaching may prove to be useful in treating elderly patients, depressed patients, or the harried and anxious who have no specific diagnosis. Coaching also represents a commonsense, economically feasible addition to the ADHD treatment armamentarium. Coaching Is For Everyone!
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Coaching: An Adjunct to the Treatment of ADHD