Why Cognitive Therapy for Women?

Hidden In Plain Sight: The Female ADHD Experience

Between 2020 and 2022, the population of adult women diagnosed with ADHD nearly doubled.  Often considered a “boys disorder,” girls are significantly less likely than boys to be diagnosed with ADHD. But this is by no means saying there is a lower prevalence of attention disorder in girls or women. Instead, girls with ADHD tend to present differently than boys and teachers and practitioners often overlook their symptoms. 

From a young age, women face difficulties receiving a diagnosis of ADHD. Disorders that go hand-in-hand with ADHD in girls, like anxiety and depression, can overshadow ADHD symptoms and lead physicians to misdiagnose their young female patients. Inward behaviors, like inattentiveness, are more common in girls with ADHD than outward behaviors, such as hyperactivity. In the classroom, hyperactive boys are noticed and dealt with by teachers, while inattentive female students remain ignored because their behavior is manageable. As a result, women learn strategic coping skills for their ADHD throughout their lives, further mitigating the external appearance of their disorder. Researchers Arcia and Conners (1998) determined that the self-perception of adult women with ADHD is poorer than that of men with ADHD or women without an ADHD diagnosis.  Learn more

Studies have shown differences in dopamine release, cognitive function, and sensation seeking between men and women in response to stimulant drugs like amphetamine, often used to treat ADHD (Quinn & Madhoo, 2014). The effects of amphetamine in women vary based on their menstrual cycle, with greater euphoric and stimulating effects observed during the follicular phase, when estrogen levels are higher, compared to the luteal phase. This research suggests that the response to ADHD medications might need to be adjusted throughout the menstrual cycle for better symptom control for women.

Cognitive therapy can be a helpful tool in your ADHD arsenal. Some cognitive therapists specialize in working behaviorally with clients to improve executive functioning skills which may be helpful for aspects of ADHD. While we here at CTWPS do not specialize in executive functioning coaching, we do support our clients in managing the anxiety and isolation that often surrounds their ADHD experience.  If that is something that you’d like to explore more in depth, reach out to us to learn more!

References

Arcia, E., & Conners, K. C. (1998). Gender Differences in ADHD? Journal of Developmental & Behavioral Pediatrics, 19(2), 77. https://journals.lww.com/jrnldbp/Abstract/1998/04000/Gender_Differences_in_ADHD_.3.aspx

Quinn, P. O., & Madhoo, M. (2014). A Review of Attention-Deficit/Hyperactivity Disorder in Women and Girls. The Primary Care Companion for CNS Disorders, 16(3). https://doi.org/10.4088/pcc.13r01596

Russell, J., Franklin, B., Piff, A., Allen, S., & Barkley , E. (2023). Number of ADHD Patients Rising, Especially Among Women. Epic Research.


The CTWPS Commitment to Women*:  Talking about hormones, periods and the full female experience 

The CTWPS practice has always been dedicated to addressing the specific mental health needs of women. Our clinicians are passionate about the need for increased understanding of, and compassion for the particular biological, psychological and socio-cultural experiences of women. In our psychotherapy work, we often support women in developing greater insight around the ways in which their womanhood impacts their thoughts, feelings and behavior on a daily basis; and ultimately, how aspects of their womanhood influences their mental health. 

Given my exposure to many women at many different stages of life (e.g. perinatally, postpartum, premenopausal, menopausal) ,over the years, I have developed a wealth of clinical experience that continuously reinforces my belief that there can be close ties between a woman’s reproductive cycle and her mental state. This is not to say that every woman experiences the same fluctuations in mood and mental state at similar points in the reproductive cycle; but simply, each woman responds to the rise and fall of estrogen and progesterone in her body at different points throughout her cycle, to differing degrees, in different ways. Furthermore, the multitude of changes I have observed and tracked with my patients over time are not limited only to the days leading up one’s menstrual period, as popular culture’s interpretation of “PMS” might suggest. A woman’s body, mind and mood is truly influenced by fluctuating hormones throughout the full reproductive cycle - all month long, month after month. Notably and thankfully, these hormonal fluctuations do not always have a negative impact on life! In fact, some women report feeling energized, experiencing greater clarity of thought, and having increased libido at certain points of their cycle. 

Just as I have become more convinced of how tightly woven reproductive hormones are in women’s daily lives, I have also become increasingly aware of how infrequently this topic is brought into the therapy room. As normal as it is, menstruation is, and always has been, stigmatized around the world. Historically, menarche and menstruation has symbolized religious impurity and contamination, been linked to witchcraft and evil, and been blamed as the cause of hysteria, disease and disorder. Unfortunately, to this day, playful words, disparaging metaphors and misogynistic themes persist when describing menstruation, (if it is mentioned at all). These tendencies undoubtedly perpetuate the embarrassment, shame and discomfort many women continue to feel about their body and its functions.

Thus, I and my colleagues at CTWPS make it our business to (gently!) inquire about the menstrual cycle with each of our female clients. We encourage exploration of how each woman experiences her cycle, and actively support the destigmatization of these topics. We help women track and assess changes in their mental state, mood and functioning alongside their monthly cycle, in order to better understand when interventions might be most beneficial to alleviate the negative impact of reproductive hormones. We assist women in developing (and following through with) plans for making lifestyle changes and/or medication changes to address difficulties they experience at different points in their cycle. And of course, we continuously educate our clients (male and female alike!), about the role of reproductive hormones in women’s lives, to encourage increased awareness, understanding and compassion for the full range of female experience.

As a female-focused psychotherapy practice, CTWPS is committed to honoring all that it means to be a woman in today’s world. If you or anyone you know would benefit from our expertise treating menstrually-related mood disorders (e.g. PMS, PMDD, Perimenopausal Depression) or mood disorders that tend to be exacerbated by hormonal fluctuations (e.g. depression, anxiety, OCD, and insomnia for example), please reach out to schedule a consultation. 


* A note about inclusivity: The aforementioned writing uses terms such as “woman” and “female” to reference individuals whose biological sex assigned at birth is female, and who possess female reproductive organs. We acknowledge that some cisgender women don’t have periods due to menopause, stress, disease or a hysterectomy. They may have never started menstruating due to a variety of medical conditions or they may be transgender or intersex. We also acknowledge there are people who menstruate who aren’t cisgender women. They might be trans men, intersex, genderqueer or nonbinary.

Why Cognitive Therapy for Women?

I am often asked how I came to work exclusively with women, whether I like it (I love it!), and why I use a CBT orientation specifically.  So I thought that I would share some of my background for our readers. I came to work with women exclusively after joining the Women's Mental Health Consortium in 2002, and meeting some pivotal reproductive psychiatrists who specialized in working exclusively with women (Catherine Birndorf, MD; Marty Altemus, MD; Karin Miller, MD to name just a few).  Meeting these esteemed colleagues let me know it was possible to build a practice working exclusively with women.   I found the idea of working exclusively with women very appealing as I had a feminist affinity for the issues women face, I tended to work predominantly with women already, and I believed that my CBT orientation would be especially helpful in the area of reproductive mental health.  

It's important to note that at that time in NYC, the therapy paradigm for reproductive mental health was still dominated by a psychodynamic therapy model.  However, many of the disorders that arise in the reproductive life cycle and for women overall - anxiety, depression, panic disorder, OCD, PMDD - have been shown to respond significantly to cognitive-behavioral interventions in the evidence-based research literature.   So while I knew no one personally who was specializing in using CBT for reproductive mood disorders at that time, it made clinical sense to specialize in this area.  And so I committed and founded Cognitive Therapy for Women.  I have never regretted that decision!

One of the surprising benefits of the CBT model has been that it "takes the shame out of the game" for mothers and prospective mothers.  So many of my patients have come to me frightened and ashamed of their symptoms in pregnancy and postpartum,  as if somehow their symptoms reflects their mothering ability or some deeper character flaw.  These patients did not make up this concept - this bias is sadly embedded in our culture. The CBT model challenges us to not make a bigger, or more nefarious story of the negative mood a women can experience during the reproductive phases of life.   So here at CTW it is important to us that we honor the complexity of women's mental health while striving to provide the most optimistic and effective treatment possible.