Breaking Free from the ADHD Anxiety Generator with Dr. Russell Ramsay
In this episode of The ADHD Podcast, hosts Pete Wright and Nikki Kinzer welcome a special guest - Dr. Russell Ramsay, co-founder and former co-director of the University of Pennsylvania's Adult ADHD Treatment and Research Program.
Dr. Ramsay shares his insights into the complex interactions between ADHD and anxiety, two disorders that frequently coexist. He discusses how ADHD can be an "anxiety generator," with its intrinsic characteristics fueling feelings of uncertainty and perceived risk.
From a cognitive-behavioral therapy (CBT) perspective, Dr. Ramsay explores how thoughts, feelings, and behaviors intertwine in ADHD and anxiety. He highlights the importance of pausing, reflecting, and developing self-awareness to navigate these challenges.
Dr. Ramsay also addresses the concept of "procrastivity" - escaping high-priority tasks by doing other productive things. He offers strategies for breaking this cycle and turning intentions into actions.
With his extensive experience and new book, "The Adult ADHD and Anxiety Workbook," Dr. Ramsay provides valuable insights for those dealing with the challenging combination of ADHD and anxiety.
Links & Notes
-
Pete Wright:
Hello, everybody and welcome to Taking Control: The ADHD Podcast on TruStory FM. I'm Pete Wright, and I'm here with Nikki Kinzer.
Nikki Kinzer:
Hello, everyone. Hello, Pete. Right?
Pete Wright:
Oh, Nikki. We are continuing our conversation on ADHD and anxiety. It's like just a little tag, a coda on our series on comorbidities, and we've got a heavy hitter here to help us-
Nikki Kinzer:
Yes, we do.
Pete Wright:
... walk through this. It's absolutely fantastic. Before we dig in, head over to takecontroladhd.com to get to know us a little bit better. You can listen to the show right there on the website or subscribe to our mailing list, and we will send you an email each time a new episode is released. If you really want to connect with us, join the ADHD Discord community. It's super easy to jump into that general community chat channel. That's at takecontroladhd.com/discord. When you get in there, you'll find 1,000 of your dear friends that you've never met yet, best friends you've never met yet, and you'll see them talking about all sorts of things. If you want to support the show, if you've been a long time listener, you've never considered this, head over to patreon.com/theadhdpodcast.
For a few dollars a month, you can help guarantee that we continue to grow the show, add new features, invest more heavily in our community, and you can actually get access to a whole bunch of secret channels in Discord. You can listen to the show in the live stream and hear all of the mistakes and burps and stuff, and you get to ask our guests questions for a special members post-show that is not available in the public version of this show. So consider that, patreon.com/theadhdpodcast to learn more. Russell Ramsay is, was, I should say, the co-founder and co-director of University of Pennsylvania's Adult ADHD Treatment and Research Program and a professor of clinical psychology in the Department of Psychiatry in the Perelman School of Medicine at UPenn. But then he retired, and now he is living the dream with a solo virtual practice and coming to us spending lots more time podcasting all over the world. Russ, welcome to The ADHD Podcast.
Dr. Russell Ramsay:
Pete and Nikki, thanks for having me. It's an honor to be here.
Nikki Kinzer:
Well, thank you.
Pete Wright:
An honor for us to have you. I think, Nikki, you've been doing all the hard thinking about this this morning. Let's talk about why we're bringing this back to anxiety apart from the fact that you and I are both in an anxieties fan club.
Nikki Kinzer:
Oh, we are for sure. It's interesting 'cause we just finished the series with the comorbidities and the very first one we did was on depression and anxiety, and those are the two biggest ones, I think, that you see. We did a lot of other ones on OCD and eating disorders and some other things too, but anxiety and depression are definitely the top two that I see when I'm working with clients. So you have this new book that you wrote, which is fantastic. It's called The Adult ADHD and Anxiety Workbook, one of many books that you've written in the past. So I'm curious, there was a couple of things that really caught my attention. First, the approach of how you have this as a workbook and working through your anxiety and ADHD. Then there's another piece I really want to get to as well, and that's the procrastivity that you talk about.
Dr. Russell Ramsay:
Procrastivity, yeah.
Nikki Kinzer:
Yes. Yes. But first of all, let's talk about the ADHD and anxiety. So we know they're common. What are the interactions and struggles that you see people face between these two things?
Dr. Russell Ramsay:
You know what? I make the case in the book, but it's been something working in this field for 25 years, ADHD is an anxiety generator. If we think about, what is anxiety? It's the theme of anxiety is the perception of risk and increasingly a core feature of anxiety disorder, it's known as intolerance of uncertainty, the non-zero risk that goes in life. There's some preliminary research that that uncertainty goes hand-in-hand with anxiety. "I know I can do it, but I don't know if I will do it when I need to do it," due to procrastination, organization, forgetfulness. For many adults with ADHD, that's what brings up and not to create new things, but different types of anxiety like overwhelm anxiety. "I got so much to do, how am I going to get through everything?"
Peopling anxiety, I don't call it that, but there is an element of social anxiety, "What will other people think of me if I'm late, or I handed in something late, how will they judge me?" Even planning anxiety, "I know I'm supposed to make a plan, but isn't that a recipe of all the things I'm going to screw up on?" Now I'm putting words on what are very visceral feelings, the feelings of anxiety and working through the comorbidities. A lot of the comorbidities, they can be true comorbidities. Oh, I just happen to have depression or anxiety or OCD at the same time, but especially depression and anxiety can stem from ADHD. With depression, the main theme is loss, loss of opportunity, loss of relationships, loss of a sense of a future, "I won't be able to do this."
Pete Wright:
Right, that loss of agency, like loss of control.
Dr. Russell Ramsay:
Loss of agency, loss of control. That can also dovetail into the uncertainty that goes along with the anxiety and ADHD. So that intolerance of uncertainty and there's preliminary research evidence looking at that connection and like I said, *my blood line, ADHD is an anxiety and entropy generator because it can undo best laid plans due to the nature of ADHD. That was the appeal when I was approached about doing something about ADHD and anxiety because it's what I've seen in my practice for a long time.
Pete Wright:
It's so interesting to hear you talk about the anxiety generator. One of the things we've been talking a bunch about Nikki and I, is this idea of a budget for uncertainty and planning with ADHD. What you just connected for me is that living with anxiety means essentially you have a budget of uncertainty that is zero, and that is the deflationary spiral in efficacy over time.
Dr. Russell Ramsay:
Right. Right. A lot of the emotions and the cognitive piece of cognitive behavioral therapy, the negative mindsets, they often come from very real past experiences.
Nikki Kinzer:
Right.
Dr. Russell Ramsay:
The times that the uncertainty comes into play, "I didn't do what I set out to do, and I missed the deadline," and other emotions as well. Emotions, they're very helpful to have. They're signals for what's going on around us, and they do draw from our past experiences and help us predict things. Now, especially for people undiagnosed with ADHD going through all the uncertainties and the setbacks that can come with it, it makes sense that there's going to be... I'm a dyed in the wool cognitive behavioral therapist, and I've been doing presentations on this and I'll talk about we're feeling beings before we're thinking beings, and sometimes the cognitive work is putting words on the emotions and sometimes I get pushback. Well, classic cognitive therapy would say the thoughts come first. Even though I had occasion to ask Dr. Beck one time, Dr. Aaron Beck, what is still the biggest misunderstanding that's still out there about cognitive therapy? He said that thoughts always come first. We are meaning-making creatures, but sometimes it starts with the feelings and we layer the thoughts. Yes, thoughts can come first, but especially anxiety-
Nikki Kinzer:
Right.
Dr. Russell Ramsay:
... it is anticipating the uncertainty and the risk that can come with it. We'll get to the procrastivity, but procrastination in general, it's usually logically, our logical brain goes, "Yeah, it's really good. If I start doing my homework a little early. I start finishing the work project at work on Friday so I don't have to worry about it over the weekend." But if we go, "Yeah. But sometimes that doesn't work out so well, so we'll end up... You know what? I'll get it done over the weekend. Yeah, that's a good plan." If we do, that's fine, but then later on if we go, "Oh, yeah, but I forgot that kids have a soccer game this weekend or date night," or whatever the case may be, "and now I got to fit in work in there." So it's how the ADHD-based anticipations can, fueled by the understandable emotions, but how they can... It's like gasoline on fire sometimes.
Pete Wright:
Yeah. Well, and I just have to reinforce for people listening, when you say you might get it done on the weekend, which is great, the perils of ADHD lie deep in intermittent reinforcement, and we can snooker ourselves around every corner thinking, "Because I did it this last time, surely I'm capable of doing it again." Our memories do not work well around intermittent reinforcement.
Dr. Russell Ramsay:
Right, right, and that's also a little bit of self-medication, "I'll put it off later when I'll be in the mood to do it." This also, it's like the little octopus tentacles reaching out to other areas of life, but then, yeah, you might get the work done on the weekend, but what does that do to your relationships or things like that and the ripple effects that maybe we're not thinking of? I'm not saying, none of us dots the Is and crosses the Ts perfectly all the time, or the relapse rate for procrastination is 100% for anybody with a human brain. But we're just-
Pete Wright:
Right
Dr. Russell Ramsay:
... talking about trying to change the ratio so we're generally on top of things and those times and it can be an informed decision sometimes that we do, "Oh, my roommate from college, his flight got canceled, so he's in the city overnight. Sorry, I had plans with when I was going to see you. I'll see you next decade at the reunion." No, we can make an informed decision to say, "I'll push that off to the weekend 'cause I want to take advantage of this situation in the here and now."
Nikki Kinzer:
Yeah. So you're coming from a CBT point of view within this book and in your practice you are too. So tell our audience a little bit more about what that is and how it helps those with ADHD, just to be clear.
Dr. Russell Ramsay:
Cognitive behavioral therapy is a form of psychotherapy. People will ask, "How is it different from a talk therapy?" Well, it's a talk therapy. I sit in a virtual room now talking with people. What set it apart, at least at the outset, was the focus on cognitions. So it started as a treatment of depression, and Dr. Beck found that sitting across... He used to joke around that he was a trained psychoanalyst, and he did research on it. But as he would jokingly say, "I would break my psychoanalytic mode, and I saw a client, her face change when I said something. I asked her what she was thinking, and she said, 'Oh, I thought you'd be upset with what I was saying.'" He said, "No, I was just paying attention." But he started to wonder if his clients and other clients who are depressed, might have had these, what have come to be known as distorted thoughts, thinking errors for lack... depressive thinking errors.
Now, fast-forward several decades, it was very, and still is a successful treatment for depression, anxiety and a host of other things. It has been modified for adult ADHD and is considered an evidence-supported psychosocial treatment. Now, you don't think yourself into having ADHD. Part of the appeal at the outset, probably the mid-'90s is when some of the first work and more of the later '90s when it was taking hold modifying CBT for ADHD, and the initial appeal was the structure and the behavioral focus with the organization and whatnot. Now, living with ADHD, particularly if it's gone undiagnosed, it can lead to pessimistic negative anticipations, thinking yourself out of things.
So the cognitive behavioral therapy approach, yes, focused on problem solving, dealing with many of the issues of time management, organization, breaking tasks down, things like that, but also the emotions that go along with ADHD and how they are connected with the thoughts. So that braided cord of thoughts, feelings, and behaviors, I think CBT can be pretty good. Yes, it does focus on emotions. Even though it's not in the title, it has been shown to be effective both with the implementation of the coping strategies for dealing with ADHD. There's no trade secrets about what works, but also I think that is helped by dealing with the mindsets, thinking the thoughts and feelings associated with what we want to do and how our thoughts and feelings based on living with ADHD can sometimes undermine what we're trying to do, understandably, once we understand the nature of ADHD and how it plays a role in everything people set out to do.
Nikki Kinzer:
Well, and it's so interesting to me 'cause when you were talking about before how you'll get that push back around the feelings, the emotion piece of it, that's the first thing that stands out to me when you talk to someone with ADHD who's struggling is what they're feeling and the emotions that are coming up of shame and disappointment and frustration and hopelessness in a lot of ways. Why try again if it's never worked? It's always failed. So it's interesting to me that that gets pushed back 'cause its just [inaudible 00:14:42]
Dr. Russell Ramsay:
It was more like when I'm presenting on the CBT approach and I'll talk about putting words on feelings, and it's a good problem to have that people get-
Nikki Kinzer:
I'm sure.
Dr. Russell Ramsay:
... to talking bout that, the thoughts always come first. There is an element of that out there, but also if we broaden the notion of thoughts to what are our feelings telling us? I'm more of a lumper than a splitter when it comes to this stuff. I'm a dyed in the wool CBT therapist. But we're looking at what's it like being in your skin at that moment is another way I asked for the experience. Even sometimes the thoughts that we come up with, we're not necessarily thinking in these complete Elizabethan English sentences, but it's usually we have impressions and they're invisible, odorless, tasteless.
But these impressions, the meanings that we have for them are as powerful as any other physical things affecting us in the environment. So some of the pushback might be from some strict definitions of CBT, but it's usually when I just explain it like I just have, it usually makes sense that we're just trying to figure out, how am I reacting to the situation? How do my reactions maybe sometimes interfere with what I want to do, and how can I shape them and domesticate them and recruit them, and especially with feelings, change my relationships with these reactions so I can understand them and move them in the direction I want to go with?
Nikki Kinzer:
That's the essence of the workbook, is really working through these different domains and asking these questions to the reader.
Dr. Russell Ramsay:
Even in asking the questions, I think Russ Barkley would say the... well, the second executive function to emerge. First is self-awareness, that we are a separate self that requires self-regulation, but then there's inhibition, the pause. I love this quote that I use in one of my slides. "When you press a pause button on a machine it stops. But when you press a pause button on a human being, we start," because in that pause, now we can act with intention. So even running through some of the questions in this or any workbook, I know you've had Ari Tuchman on, and he has a wonderful workbook and other people do too, but very often what these questions serve or in a session, it's the stopping and thinking. It sounds simple, but it's hard to do. Then we reflect on, "What am I feeling?" Sometimes it is hard to label, and I'm not saying that there's a buzzer that if somebody puts the wrong label, it's just realizing, "What's it like being in my skin right now, and how is that tied in with what I'm doing or what I want to do?"
I know I'm just circling back on what you're saying, but the pause and running through some of the questions, it's a way to reflect. It doesn't mean we change right away, but hopefully the next time we encounter that, maybe this comes online a little bit, it's like, "Oh, this is one of these moments." That's usually working with a lot of clients, how the change happens. Procrastination is probably one of the number one, if not the number one problem I'm helping people with. Maybe after we're talking about it, they'll catch it after the fact, "Oh, I procrastinated. Yeah, I got off track over here." Then the next time they might catch themselves, "Oh, I'm moving off track now, but I still do it." But then they go, "Oh, I'm about to do this, oh, but I want to stay with this," and nothing's perfect. But that's the process with these pauses, hopefully we're eventually able to steer ourselves in the direction that we want to go in more often than not.
Pete Wright:
I think this makes it really challenging because, well, and specifically as we come off of the comorbidity discussion, you use the term braided cord, which really resonates with me of all these conditions that are living together. But so many of these discussions lead us to this conversation of where is our ADHD and where is our anxiety and how do we rationalize the differences between the two, how they relate to one another? Is that even useful when you, as you say, are a lumper? Thinking about the whole complex organism, is it useful to have that conversation of which is which?
Dr. Russell Ramsay:
You know what? It can be. I was well-trained in cognitive behavioral therapy. I went to Penn as a postdoctoral fellow at the Center for Cognitive Therapy, was there a couple of years, ADHD was not on my radar screen. The line I use, I had as much business of co-founding an ADHD program as I did joining the Blue Man Group or something like that. My resume was [inaudible 00:19:49]
Pete Wright:
Don't sell yourself so short, Russ.
Dr. Russell Ramsay:
Well, I did have a background in CBT. But in working through and talking about comorbidities, I think one point I also make is I think the executive functioning self-regulation model of ADHD, we all have executive function. So if you're depressed, your executive functioning will go down even if you don't have ADHD. So I think the executive function model, I'd like to see it more in medical psychiatry and psychology education 'cause I think it made me a better therapist in general, even for the clients I see without ADHD 'cause it does have relevance for depression and anxiety. So when I'm conceptualizing a case or working with somebody, it's not like, "Okay, today are we working on anxiety or ADHD?" Well, pretty often I'm drawing on, since we're talking about anxiety, the progressive exposure steps that go into treatment for anxiety, which are ultimately you're going to have to face your fears. So if it's about OCD, and I know OCD is in a different category from anxiety, but-
Nikki Kinzer:
We learned a lot from Dr. Oliveira-
Dr. Russell Ramsay:
Oliveira.
Nikki Kinzer:
... about that.
Dr. Russell Ramsay:
Yeah, he's good.
Nikki Kinzer:
Yes.
Dr. Russell Ramsay:
He's very good. He's excellent in that. So anyway, but eventually it is facing the feared exposure to the feared item, or if it's about dealing with panic attacks, it's going out and going farther away from home, well, there are many elements of that dealing with procrastination, "I really don't feel like doing homework. It's overwhelming. It's this, that or the other thing." So how I view it, and I'd certainly appreciate feedback to the contrary if people have different experiences, but in terms of the CBT for ADHD, I see it as being blended together because they're working, in terms of the outcome that somebody's trying to do behaviorally-
Pete Wright:
Right.
Dr. Russell Ramsay:
... it is the measure, changing thoughts, changing feelings. But usually the measure's going to be, "Am I doing what I set out to do? Am I functioning better?" Whatever words we want to put on it. If part of that is the exposure, if that gets double duty out of, "Okay, I'm less anxious because I learn... or I can domesticate my anxiety, I can feel anxiety at the same time I'm starting this task." But actually the starting of it and getting into it for a minute or two, it goes down because like Hitchcock the suspense director would say, "There's no fear in the bang, only the anticipation of the bang."
Pete Wright:
Right.
Dr. Russell Ramsay:
So once you're engaged in it, now you're doing it. Even if it's a little hard, it's probably not as hard as you were anticipating, or if it is hard, it's only hard in one way, not the 83 different ways you can think about it in anticipation. That's usually a fair fight where usually people can get farther along than they would have otherwise, and that's part of that progressive improvement. So I see it as a twofer. You can work on both at the same time. Yes, there might be things like panic attacks or other types of anxiety conditions that there may be a companion set of panic attack- specific coping.
But usually, the anxiety we're talking about that stems from ADHD, usually the more generalized anxiety and the task-related avoidance due to the discomfort of dealing with it in a broader term. Because sometimes the anxiety isn't necessarily a fear of the task, but it's the discomfort, the prospect of failure or getting stuck or that's the uncertainty. "I don't know what's going to happen, but something bad might happen." I've likened the feeling of ADHD to food poisoning, not literally the same thing, but what happens in food poisoning? We're presumably having a food we like-
Pete Wright:
Right.
Dr. Russell Ramsay:
... it's tainted and then our body does what it's supposed to do. It feels awful, but it gets rid of it. What happens the next time you're presented with that food? Are you gobbling it down, or does your body go into, "Ah, I remember that?"
Pete Wright:
Yeah, I'm not so sure.
Nikki Kinzer:
Yeah.
Dr. Russell Ramsay:
That's what tasks are like for folks with ADHD, school and work and other things, it's similar and maybe not the same visceral, but it's usually that felt physical sense of, "Oh, this isn't going to be good, but if I can do something else..." and what procrastivity is-
Nikki Kinzer:
Right yeah.
Dr. Russell Ramsay:
... is escaping the school or work by doing usually something maybe not necessarily fun but a household chore, or it's almost like a plea bargaining. "I'm not going to work on taxes, I'll mow the lawn because the lawn has to get done too." So we escape the priority task to do that thing, and it is productive. It is known in the procrastination literature as productive procrastination, but it's actually a subtle avoidance. We could always say it's like gateway procrastination if we want to put a jokey term on it because it sets the pathway for avoiding. I usually use doing income taxes and mowing the lawn versus taxes just as the illustration. But then it makes getting back to that priority task a little harder because it's getting built up in our head, and now we do have less time and energy or whatever to work on it, even though that's a self-handicapping because we're siphoning time away from doing it.
Nikki Kinzer:
So in one of your other books, Rethinking Adult ADHD, you talk about this and the subtitle of the book itself is Helping Clients Turn Intentions Into Actions. So how do we break this cycle of procrastivity?
Dr. Russell Ramsay:
I didn't come up with the term procrastivity, I got it from a client. When I looked it up, as much as you can trust Urban Dictionary online, it's been around for some time ago. But I always cite, I had a great dissertation chair, cite everything that you can. No, but what interested me about procrastivity was, well, what is it about mowing the lawn or doing these other chores around that or other things that themselves might've been put off, and are there some ways we can hack some of those? And reverse engineering procrastivity, this is just my take on it, some of the features that they generally have compared with the tasks we typically avoid, one, they tend to be more manual or hands-on, physical.
Nikki Kinzer:
Oh, that's interesting.
Dr. Russell Ramsay:
Mowing the lawn versus doing taxes or studying or writing a paper becomes-
Nikki Kinzer:
Cleaning the house.
Dr. Russell Ramsay:
Cleaning the house, something physical, running errands, washing the car, giving the dog a bath, whatever.
Pete Wright:
Also a clear done state.
Dr. Russell Ramsay:
Well, there's usually a clearer sense of onboarding, okay, mowing the lawn, go out, fill it up with gas, put in my playlist, do it. A clear sense of task progression, if you're mowing your own lawn, you know how long it's going to take you, and you can see the progress. Okay, quarter of the way done, halfway done, complete, done with the lawn, at least for this week. People, this is just anecdotal, but seemed like they'll spend more time on a procrastivity task. They'll spend an hour, hour-and-a-half mowing the lawn rather than 30 minutes on taxes or writing a paper.
Pete Wright:
Yeah.
Nikki Kinzer:
Totally.
Dr. Russell Ramsay:
Because there's a clear sense of achieving the outcome. There's a clear sense of efficacy. "I believe I can do this task more than the other one." So how that informed how you don't do things form and it's been upgraded in the new book with the anti-procrastination form, it's all right, how do we make these harder tasks, writing an essay, studying, doing taxes, how do we make it manual? Usually, it's breaking things down into getting to a work station. Can you get to the library to study? Or for me with writing, I got a local coffee shop that I go to as my go-to workplace for that where I think I wrote the last two books there.
Getting to the workstation, picking up the item, pick up all the envelopes that say Important Tax Document Enclosed and open them, you really haven't done your taxes yet, but you've just exponentially increase the likelihood that you'll go, "Okay, let me organize them, look at them. Let me reread the last two paragraphs I wrote last time. Let me log on. Even if it's starting an essay, let me just open a Word document and save as John's essay 5/22/24," something like that. You could stop right there, but you just exponentially... and the very least you could say, "I didn't procrastinate, I did something."
Nikki Kinzer:
Right.
Dr. Russell Ramsay:
But it's like Tom Hanks paddling out over the wave in the the Castaway. Now I guess the example breaks down 'cause then he's almost paddling out the certain death at that point. But let's not-
Pete Wright:
Right, let's-
Nikki Kinzer:
Let's not look at that.
Pete Wright:
... not look at that metaphor.
Dr. Russell Ramsay:
Let's not let that get in the way of an example. No, but it's making the task manual-
Pete Wright:
Right.
Dr. Russell Ramsay:
... also sequencing the first few steps, not the whole thing, not everything you have to do. But then your step of, "Let me get over here. Let me open it up. Let me fill in on the tax form, name, address, social security number," outlining a paper, but not any formal outline, just, "Hey, can you spend 10 minutes, 600 seconds?" That's like abounding a task, 600 seconds.
Nikki Kinzer:
I love that. I've never heard that before. 10 minutes, 600 seconds.
Dr. Russell Ramsay:
Well, but you know what? This is part of how we think about things. We think about the particles different than the whole. We'll think about-
Nikki Kinzer:
Right.
Dr. Russell Ramsay:
... how it's different than gravel, and all gravel is is a pile of pebbles.
Nikki Kinzer:
Right.
Dr. Russell Ramsay:
We know that $19.99 is really $20, but we gravitate to 19.99 'cause it's less, but it feels a lot less than it is. So there are these hacks about how our brain works. At 600 seconds and even other analogs from time, how long does it take you to walk across campus? 12 minutes. Are you willing to spend the amount of time it would take to walk across campus starting your paper, with the idea that once I get started, yeah, if you stop after 12 minutes, that's 12 more minutes than you did? But usually people say once I get started.
Nikki Kinzer:
They can go.
Dr. Russell Ramsay:
But even before portable timepieces, people would use these algorithms, not algorithms, analog for time "I'll be with you in the milking of a cow," because people knew roughly how long that meant in that day and age, so these felt senses... There's actually some researchers on time, that that's how they got into their research. One couple, they were a couple in research and this is old school, but they would pause their VCR, go make a snack and then start looking at each other 'cause, and I'm a Gen Xer, so if you knew after a while if you pause your VCR, the tape would start up again after a certain amount of time. But this is how we learn how long things last and get our sense of time by how long things take in the environment and that's how we get our felt sense of time. Nobody's done a study on this, but it would be an interesting study with the inattention of ADHD if this is part of time blindness, this is total-
Nikki Kinzer:
Right.
Dr. Russell Ramsay:
... total, total conjecture. 'Cause self-monitoring is impaired, well, what if other monitoring and just not being able to sequence and track how long things take if that goes into time blindness a little bit? So that was a far avenue, a crooked walk away from doing taxes, but how we try to balance we have to make it reasonable so we believe, "I can do it for 600 seconds," or, "I can do it-
Nikki Kinzer:
Absolutely.
Dr. Russell Ramsay:
... for these five problems." It's building that self-trust, the self-efficacy and our sense of enoughness. "Okay, even though this is hard for me, I'm enough that I can do this," and we want to build that up even more 'cause very often there's that thought about, "I'm less than."
Nikki Kinzer:
That's the CBT that you're talking about is being able to reframe that thought of, "This is-
Dr. Russell Ramsay:
Well, that's part of the reframing. Yes, yes.
Nikki Kinzer:
Yeah, "This is enough, this is good," and not going the other way.
Dr. Russell Ramsay:
In your own ADHD-friendly way-
Nikki Kinzer:
Right.
Dr. Russell Ramsay:
... so one person's reframe might look a little different. One person might be able to say, "I can sit down for 30 minutes and do this." Somebody else might say, "I can at least unload the bowls out of the top rack of the dishwasher." If that's all if I [inaudible 00:32:31]
Nikki Kinzer:
Yeah, I use that as an example too. Yeah, just open the door-
Pete Wright:
Yeah.
Dr. Russell Ramsay:
You know what?
Nikki Kinzer:
Like that, you know?
Dr. Russell Ramsay:
Yeah. Yeah.
Nikki Kinzer:
That's just one thing, opening the door-
Dr. Russell Ramsay:
Or when you're in the kitchen, because you know what? Get even the steps we do going there, that's like behavioral scripting, behavioral priming. You know what? I know interestingly this is something I've been more interested in since the book, it's called 4E Cognition, and I don't have the Es memorized. I'm just so happy that I've memorized cognitive disengagement syndrome from sluggish cognitive template 'cause I started with that. I finally committed it to memory, but 4E Cognition, it's more about how the brain evolved interacting with the environment.
There's a lot of things like managing the environment movement, how this can help foster cognition, and if we're moving towards the task, it is getting at some elements that will help us with the higher order things like writing the paper or even walking around saying to ourself, talking aloud what we're trying to type out. But saying to ourself or saying to our dog what we're trying to work out and write, that is a nice way to use our language system to get unstuck. The distanced self-talk that I talk about in a new book as a way it's both useful for task initiation and for managing emotions. Ethan Kross-
Nikki Kinzer:
So I think I missed that.
Dr. Russell Ramsay:
Okay.
Nikki Kinzer:
What is distant...
Dr. Russell Ramsay:
Distanced self-talk, and it is not specific to ADHD. Ethan Kross with a K, he's a neuroscientist at the University of Michigan. I was aware of his research before, and he has a good book on his approach called Chatter. I think it was published during the pandemic, '20 or '21, it was published, talking to yourself by name or as you.
Nikki Kinzer:
Oh.
Dr. Russell Ramsay:
So this would be, if I'm talking to myself, "Russ, you just need to get to the coffee shop on Saturday, get there, order your coffee and you can pick up where you left off." Or, "Russ, you know you're always anxious about what you're writing. You don't think you know anything, but you know once you get in there, you'll find something. You'll find your hook, just stick with it and you get through it for the stress emotions."
Kross' work found that in lab-based studies talking to ourself by name or as you for a task, "You just need to do this," or talking ourself through our feelings, I think some of the research, it was people who had gone through a relationship breakup and they were either asked to do I statements immersive self-talk, "I need to get over this. I need to not think about the person who dumped me," drawing from past personal experience there, or the task, "I have to get this done. I have to work harder," versus you just need to get out there. I'm illustrating for effect here-
Nikki Kinzer:
Right.
Dr. Russell Ramsay:
... but I found that the distance self-talk was helpful, and it's a very nice portable strategy. Bringing it up with a lot of folks with ADHD especially two things, task initiation and emotions that go with it, and the... Now, this goes beyond the data, but I think what it does, one, it makes us pause and think, we have to funnel the task or our emotions through the language system. Now, this is not saying we have the blunt emotions and no feeling. No, it's working with your feelings. It's changing your relationship with your feelings or with the task. Saying it aloud, which is action, speech is motor, it's behavioral.
Then we're also hearing it at the same time, so the auditory processing and very often hearing it, it's different than when it's bouncing around in our head. This goes way beyond the data, but a lot of people say, "I can come up with good plans or advise other people what to do. I could coach other people what to do, but I can't do it myself." Well, I don't know if there's anything to putting it in the language of speaking to somebody else where we're more compassionate using the you messages 'cause people will say, "I'm hard on myself, but maybe the language of you and putting it in the supportive language..." Now, this is, again, total conjecture, but there is evidence support, not specific to ADHD. To my knowledge it's not been studied in a ADHD, but it has been studied by Ethan Kross in the book Chatter and there's published research on that.
Nikki Kinzer:
Well, [inaudible 00:36:49]
Pete Wright:
But it's just so interesting [inaudible 00:36:49]
Dr. Russell Ramsay:
A lot of people say, "You know what? Now that you mentioned it, I do do that."
Pete Wright:
You do that, right.
Nikki Kinzer:
It's like the affirmations.
Pete Wright:
100%.
Nikki Kinzer:
It's affirming too-
Pete Wright:
I'm mot the handiest guy in the world. I'm putting together something from IKEA or not putting it together, but I'll say the instructions out loud to my... "Slot A goes into slot B."
Nikki Kinzer:
Right.
Dr. Russell Ramsay:
Not because it magically does anything, but it's like I'm trying to somehow-
Nikki Kinzer:
You're processing it-
Dr. Russell Ramsay:
... figure it out. Yeah. Yeah-
Nikki Kinzer:
Yeah.
Dr. Russell Ramsay:
... processing it.
Nikki Kinzer:
Yeah. Yeah. I love that.
Pete Wright:
It's fascinating to me because it connects directly back to this, first of all, I'm going to be referring to all of my time-related statements in the form of milking of a cow.
Dr. Russell Ramsay:
Right. Right.
Pete Wright:
But you know what? In all seriousness, there's a real physiological behavioral connection to time with ADHD. It's why I can't use really a digital clock. So my watch, my clock on the wall, they're all physical so I can see it.
Dr. Russell Ramsay:
Right.
Pete Wright:
But it's even better when I can refer to in my own head, I can get to this one thing in one unloading of the dishwasher. Maybe it takes me 10 minutes to put everything away, I understand that because I've lived it. That's my lived experience.
Dr. Russell Ramsay:
Right.
Pete Wright:
The same thing goes when hearing my own self talk out loud, not just meditating on it but thinking it then saying it at myself. That's a behavioral approach to understanding my relationship with my emotions and with time. I think that there's something, again, to your point about being total conjecture, I feel like my lived experience is my measure of time and accounting of emotion.
Dr. Russell Ramsay:
Right. Right. You know what? I always say probably the best analog time depiction is an old-fashioned hourglass.
Pete Wright:
Yes.
Dr. Russell Ramsay:
You see the sign draining from the top to the bottom chamber and that just captures time. Yes, the second hand could be 15 seconds away from being late, but, "Oh, I'm not late yet-
Pete Wright:
Yes.
Nikki Kinzer:
Right.
Pete Wright:
Right.
Dr. Russell Ramsay:
... 'cause that's an attraction. It's wonderful all these tools that we have, but sometimes it's that winding down, the countdown, the battery on our laptop, "Oh, I'm at 10%, I have to hurry." In fact, I think Nancy Rady might've mentioned that in her book, like unplugging your laptop or unplugging your device and then using the battery as a countdown clock.
Nikki Kinzer:
Oh, smart.
Pete Wright:
That's a pretty good one.
Nikki Kinzer:
Yeah.
Dr. Russell Ramsay:
Yeah, no, it's not bad. But other things, or it's sometimes people gamifying things, they'll try to make it a race to get through things. So these are all just different ways we deal with time and finding our personalized ways to engage with it, including, and this goes back to the avoidance of planning sometimes because winging it is a high cognitive load task for anybody figuring things out, and 'cause that presumes "Okay, at some point I'll wing it and feel like doing taxes or homework," and we probably won't. But going back to that, even with the planning, breaking things down into actionable steps and planning for down time-
Nikki Kinzer:
Right. Yeah.
Dr. Russell Ramsay:
... dedicated times that we go, "Okay, after this time either breaks," and me also having bounded breaks, because some breaks in the middle of the day might be bad breaks like going online or checking things. But at the end of the day they're fine if it's open-ended. But even things like bounded breaks, like a cup of coffee or a walk around the block, which, again, are physically based things like that, if we know we're going to get off track, but also just having, "Okay, after 7:00 I'm going to putter around," and like I said, making informed decisions.
"Okay, I thought I was going to do more," and sometimes it's because we're tired. We've been working really hard on a big project and we get to 4:00 and said, I" was going to do this at 4:00, but you know what? I'm giving myself a break. I'm making an informed decision, and I'm going to reschedule this. I'll do it first thing tomorrow," or something like that. Not all avoidance and not all avoidance is avoidance. Sometimes it is strategically changing the play at the line of scrimmage once you see what the defense is doing. Sorry for the sports analogy.
Nikki Kinzer:
Well, no-
Pete Wright:
Right.
Nikki Kinzer:
... I think it's so true 'cause when we talk about... 'cause the book that we have coming out is around planning, and I love that you use that as one of the examples in your... a lot of examples in your book.
Dr. Russell Ramsay:
Well, the planning anxiety because facing it-
Nikki Kinzer:
Yes.
Pete Wright:
Yeah.
Dr. Russell Ramsay:
... helps reduce the anxiety. Yes.
Nikki Kinzer:
It is.
Dr. Russell Ramsay:
[Inaudible 00:41:29] Yeah.
Nikki Kinzer:
Yeah, absolutely. But one of the things that I share with clients when they're time blocking and learning how to time block is that there's a difference between setting out the intention, putting it on your calendar, you see the alarm come up to remind you that, "Hey, it's time to transition into this," and you get to make the decision at that point, "Do I want to continue to go through the plan or is something else more important or whatever?" But there's a lot of empowerment with pausing for that moment and making that decision. Rather than thinking you're going to do it some time during the day and then at the end of the day you get to it or you never got to it, you feel terrible. You feel like, "There I go again, not following through with my plans." So there's this empowerment to it where you can change your mind. It's just a placeholder, it's nothing setting in stone, but yet you get to make that decision and there's so much power into trusting yourself again that, "I can do this. I can manage my time and decide."
Dr. Russell Ramsay:
Also, I hear the phrase out there more, talking about our future self. But even at that moment, let's just say it's 1:00 or something like that, and you go, "Think about how your 2:00 self will feel if you at least get a little of this task done." I think that's also useful, yeah, planners are set up where we can see, "Okay, I'm going to wrap this up at 3:00, and then I got a big blank spot there." It's like the next exit on a highway or something. "Okay, let's just get to that exit," it can help prime us and work us through. But you know what?
At the same time, thinking about our future self, how good will it feel at 2:00 to at least make some headway on this task? Rather than everything feeling like oh, it's projecting forward a little bit, and the thinking through, and it's part of the pause and the positive feeling for... It's also recalibrating the next hour, "Oh, my gosh, an hour?" But it's like, okay, but it's 1/24 of your day, or maybe it's 30 minutes or whatever it is, but thinking through, it's like, "Okay, 2:00 is not that far away now that I think about it that way."
Nikki Kinzer:
Right.
Pete Wright:
Right.
Nikki Kinzer:
Right. Right.
Dr. Russell Ramsay:
I've had people like that, that exact same increment of time, on one [inaudible 00:43:52] "Oh, my gosh, that's two hours," on another one, "Oh, it's only two hours."
Nikki Kinzer:
Right. Right.
Dr. Russell Ramsay:
But it's like something you like, "Oh, it's only two hours, this will be great," but they aren't.
Pete Wright:
Right.
Nikki Kinzer:
How long does it really take to milk a cow? How much time are we looking for that?
Dr. Russell Ramsay:
I don't know. I don't know. I could probably tell you how long it takes to run out to the store and back.
Nikki Kinzer:
Right, yeah.
Dr. Russell Ramsay:
No. No. Yeah. Yeah.
Nikki Kinzer:
This is great.
Dr. Russell Ramsay:
I don't have literally hands-on experience with that at all, so no.
Pete Wright:
It's 10 minutes.
Nikki Kinzer:
We still have to guess.
Pete Wright:
It's 10 minutes.
Nikki Kinzer:
10 minutes?
Pete Wright:
It's about 10 minutes.
Nikki Kinzer:
10 minutes.
Dr. Russell Ramsay:
Well, you know what?
Nikki Kinzer:
Okay.
Dr. Russell Ramsay:
You know what? One time I was bringing this up in a workshop and talking about a cup of coffee or something, even though you could have some huge... I said, "I would never advise this, but this is probably where the cigarette break came from, and I'm a lifetime smoker, and so I have no idea how long it takes," and somebody in the audience dead panned without missing a beat, "7 1/2 minutes," and it broke up [inaudible 00:44:44] I told him, I said, "I'll take your word for it." But that's the notion of these bounded tasks, 7 1/2 minutes, the length of time for a cup of coffee, for a cigarette, a walk around the block, whatever it is, walking across campus, how long would you...
When I was at Penn, I'd take the train in, and how long will you stay on the platform? If it's less than 10 minutes, I'll stay on the platform. Could you invest that much time in terms of at least starting this task to see how it goes? At least make an informed decision. If after eight minutes you go, "It's not happening today," great, that's an informed decision. You didn't procrastinate. That's an informed decision. That's the personalization of all the skills and tools. I think in the more recent book, I use the analogy a lot of the recipe. It's like, yeah, this is a recipe book, but if you go, "Yeah, I'm vegan, so I'm going to replace that, or I like salt on mine," that's the goal. It's not like, "No, you must do-
Nikki Kinzer:
"This, this, and this." Right.
Dr. Russell Ramsay:
... and you must do it this way."
Pete Wright:
Sure. Sure.
Dr. Russell Ramsay:
It's getting started.
Pete Wright:
Yeah.
Dr. Russell Ramsay:
Getting started, getting started, if you will.
Nikki Kinzer:
Yeah. Yeah. I love it. Thank you so much. This was so great.
Pete Wright:
Yes, absolutely. So the book just dropped as we record this, right? Just-
Dr. Russell Ramsay:
May 1st. May 1st.
Pete Wright:
... a couple of weeks ago?
Dr. Russell Ramsay:
Yeah, yeah, yeah.
Pete Wright:
Outstanding. How's it going so far? You getting some good feedback?
Dr. Russell Ramsay:
I don't know. Once it's done, it's out there.
Pete Wright:
You don't need to know.
Dr. Russell Ramsay:
So it's more like I climbed a mountain, so I'm just happy to be down. No, some colleagues are reaching out with compliments, but they're not going to tell you you're awful. So yeah, who knows? It's out there and [inaudible 00:46:19]
Nikki Kinzer:
What were you thinking?
Pete Wright:
Yeah, what were you thinking?
Nikki Kinzer:
Exactly.
Dr. Russell Ramsay:
"You got it all wrong." Probably many of your guests, like Ari Tuchman did the foreword for it, and you'll be like, "When I grow up, I want to be Ari Tuchman." No, I totally respect him, and he's too nice of a guy. He's a very highly competent, top-of-the-line therapist, and Roberto as well. I think you had Sharon Sweeney on?
Nikki Kinzer:
Yes.
Pete Wright:
She's many times.
Dr. Russell Ramsay:
She's one of my new friends in the ADHD world, and I respected her work from afar. But yeah, now you've got a great list there, so I hope I didn't bring it down too much.
Nikki Kinzer:
You have added to it.
Pete Wright:
Not at all.
Nikki Kinzer:
No, this is great.
Pete Wright:
Absolutely. No, we sure appreciate you hanging out with us. I'm going to send people, let's just make sure I get this right in the show notes, we're going to send them to cbtforadhd.com.
Dr. Russell Ramsay:
That's right.
Pete Wright:
Is that right?
Dr. Russell Ramsay:
That's right, yeah. Sometimes people hear CBD and they get really excited-
Pete Wright:
Yes.
Dr. Russell Ramsay:
... but it's cbtforadhd.com.
Nikki Kinzer:
That's funny.
Dr. Russell Ramsay:
I get some really disappointed sometimes coming up.
Pete Wright:
Yeah. I got to ask-
Nikki Kinzer:
Where's your store? I don't see the store.
Pete Wright:
Yeah.
Dr. Russell Ramsay:
Exactly. Exactly. "Where's your prescription?"
Pete Wright:
Cash only for Russell Ramsay. You're-
Dr. Russell Ramsay:
I got some cows in the back if you want to milk them [inaudible 00:47:29] that, yeah.
Pete Wright:
Links to the book and to Russ's work are in the show notes, everybody. Thank you so much for hanging out and listening to the show. We appreciate your time and your attention. Don't forget if you have something to contribute to the conversation, we're heading over to the show talk channel on our Discord server and you can join us right there by becoming a supporting member at the deluxe level or better. On behalf of Nikki Kinzer and Russell Ramsay, I'm Pete Wright, and we'll see you next week right here on Taking Control: The ADHD Podcast.
