Quick and Dirty Therapist Guide: Working with ADHD and Anxiety in Adults and Couples
Friday, March 28, 2025.
Therapist Guide: Working with ADHD and Anxiety in Adults and Couples
Quick Clinical Overview
Co-occurrence: ADHD and Anxiety disorders co-occur in up to half of adults with either condition (Kessler et al., 2006).
Why it Matters: Anxiety can mask ADHD (especially in women); ADHD can exacerbate anxiety through chaos, failure, and rejection sensitivity.
Common Couple Dynamic: One partner overfunctions (to reduce anxiety); the other underfunctions (due to executive dysfunction)—leading to blame, resentment, and shame spirals.
Therapeutic Orientation Tips
Normalize the Overlap: “This isn’t you being lazy or high-strung—it’s your brain running two different operating systems at once.”
Shift from Blame to Pattern: “How does your ADHD feed the anxiety loop—or vice versa?”
Use Humor and Metaphor: The gas/brake metaphor (ADHD = gas, anxiety = brake) works for me with many clients.
Session Prompts and Interventions
🧠 Psychoeducation Prompt
“Can we try separating what’s ADHD and what’s anxiety?”
Goal: Distinguish behaviors and symptoms to reduce overgeneralized self-blame.
Use in Session:
Draw a quick two-column list on the board or shared screen:
“ADHD-driven behaviors” vs. “Anxiety-driven behaviors.”
Example:
Forgets bill = ADHD time blindness
Obsesses over bill = Anxiety rumination
Avoids bill = Combo
Therapist Note: Emphasize overlap without demanding clean lines.
🧱 Core Belief Reframe Prompt
“What story do you tell yourself when this happens?”
Goal: Identify internalized shame or perfectionism.
Use in Session:
“When you forget something, what does the anxious part of you say? What does the ADHD part want to say back?”
Common Belief Pairs:
“I’m a failure” ⇨ “I’m overwhelmed, not broken.”
“No one can count on me” ⇨ “I need external support systems.”
Therapist Note: Consider an IFS-informed reframe—help clients externalize these parts with compassion.
❤️ Couples Pattern Prompt
“What dance do you two get into around planning or follow-through?”
Goal: Surface the ADHD-anxiety polarity as a relational dynamic.
Use in Session:
Draw a circular loop on paper or whiteboard:
“Partner A worries about X → Partner B freezes → Partner A gets more controlling → Partner B gets defensive → Conflict escalates.”
Reframe:
“This isn’t bad intentions—it’s nervous systems triggering each other.”
Therapist Tool: Consider introducing a name for the loop ("The Tornado," "Crunchbrain," etc.) to de-escalate. Naming bestows power.
⏰ Executive Dysfunction Planning Prompt
“What’s one external support system we can experiment with this week?”
Goal: Treat executive dysfunction as a mechanical issue, not a moral one.
Suggestions:
Daily shared calendar
Task timers with rewards
“Body doubling” for chores
Therapist Note: Praise micro-successes loudly. Shame shuts down dopamine. Novelty and praise build it.
🌡️ Nervous System Awareness Prompt
“How does your body tell you this loop is happening?”
Goal: Increase somatic literacy for regulation.
Use in Session:
“Where does ADHD show up in your body?”
“Where does anxiety live?”
“What signals do you ignore until it’s too late?”
Intervention: Develop a simple “early warning system” cue list.
🪞 Reflection Prompt
“If you loved someone with this same brain, how would you treat them?”
Goal: Evoke compassion and de-shaming.
Use in Session:
This is especially useful when clients slip into harsh internal monologues about failure, lateness, or emotional flooding.
Bonus Prompt:
“What would your 9-year-old self need to hear after a hard day like this?” This question often yields pure gold in dyadic discussion.
For Couples: Weekly ADHD + Anxiety Check-In Template
What worked this week for our brains?
What overwhelmed us?
What one thing can we simplify next week?
Did we co-regulate or co-escalate this week?
One funny moment where ADHD or anxiety made a cameo?
Encourage couples to bring this back weekly—or turn it into a Sunday ritual.
Clinical Reminders
ADHD + Anxiety: often show up with rejection sensitivity, sleep disorders, sensory overwhelm, and disordered eating patterns.
High-IQ, high-masking Neurodiverse Clients: may appear calm but be in silent executive overload. Be on the lookout for this. Especially look for late-stage burnout signs.
Cultural Variables Can Deeply Matter: Many clients have learned to mask and reframe ADHD and Anxiety as productivity or perfectionism. This is especially true of many BIPOC women in professional spaces. These cultural adaptations may exacerbate anxiety, and this fact is sometimes missed by many privileged therapists.
Recommended Resources for Therapists
"More Attention, Less Deficit" by Ari Tuckman
"ADHD 2.0" by Hallowell & Ratey
"When the Body Says No" by Gabor Maté
"The Complex ADHD Workbook" by Kelli Miller (great handouts)
I hope this helps, gentle therapist readers.
Be Well, Stay Kind, and Godspeed.