Steven Watson | EdgeLab | Research and Scholarship | 19 September 2026
What makes therapy possible to stay with? For adults with ADHD, a treatment can be supported by trials yet still be difficult to enter, organise around or experience as relevant. Forgetting homework, struggling with appointments or encountering a therapist who misunderstands ADHD should not automatically be read as unwillingness to engage.
Asking people what would improve the fit
Margaret Sibley, Melisa Shafiee and Laura Knouse use an “innovation tournament” to identify ways of improving engagement in cognitive behavioural therapy (CBT) for adults with ADHD. An innovation tournament is a structured process in which people generate, rate and refine possible solutions. Here, adults with ADHD and practitioners considered both what therapy should address and how it should be delivered.
The study involved 69 adults with ADHD in the first two rounds and 16 practice experts. Sixteen adults generated ideas; a separate 53 rated their importance. Practitioners rated importance and feasibility. The researchers combined 42 participant-generated ideas with 41 items drawn from CBT and motivational-interviewing literature, producing an 83-item survey. A further 17-person group then “member checked” the recommendations.
Participants valued familiar CBT targets such as task management, planning, emotion regulation, responding to negative thoughts, reducing procrastination and setting longer-term goals. The strongest process recommendations included therapist knowledge of ADHD, empathy, collaboration, attention to strengths and autonomy, small pieces of didactic material and progress monitoring against individual goals rather than weekly symptom questionnaires.
The disagreements are as informative as the consensus. Adults rated several practices as important that practitioners saw as difficult to deliver: reducing shame, changing the environment, self-advocacy, adjusting treatment pace and exploring masking, identity or rejection sensitivity. Reported obstacles included limited practitioner knowledge and skill, time, insurance rules, the perceived boundary of clinical practice and the effort required.
The study’s real contribution
This is not an effectiveness trial, and the authors are clear about that. Its contribution is methodological and practical: it makes differences between treatment content, therapeutic process and implementation conditions visible. The finding that many adults valued core CBT content while criticising how therapy was delivered guards against a crude conclusion that the model itself should simply be abandoned.
The study also treats adults with ADHD as contributors to intervention design rather than only recipients whose adherence must be improved. Comparing importance with practitioner feasibility reveals where a seemingly personal engagement problem may arise from professional training or the organisation of care. Appointment reminders, slower pacing or environmental changes may be straightforward from the client’s perspective yet classified as excessive effort or outside scope by a service.
Preference is not evidence of benefit
The main limitation follows directly from the design. Ratings of importance and feasibility do not show that any recommendation increases attendance, reduces dropout, improves functioning or changes symptoms. The “go-zone” categories are relative to the sample’s mean ratings, and the 75 per cent threshold used during member checking is a design choice rather than a clinical boundary.
Some percentages also rest on very small numbers. Only nine of the sixteen idea-generating adults had previously received ADHD psychotherapy, so the headline barrier figures describe a handful of accounts. The samples were predominantly White, middle-aged and female, while member checking recruited willing attendees after a public presentation. Adults and practitioners were sometimes represented by the same people, which brings valuable combined experience but does not create independent confirmation.
Researchers supplied 41 of the 83 rated ideas. This usefully joined stakeholder suggestions to existing evidence, but it also shaped what could win. Several proposed de-implementation decisions—concerning mindfulness, interpersonal skills and distractibility training—did not reach the study’s own member-checking threshold. They should not be interpreted as evidence that these practices are ineffective.
A plausible alternative reading is that some standardisation and repeated measurement protect treatment quality, make deterioration visible and support shared decisions. Individual tailoring and evidence-based structure are not simple opposites. The relevant question is which measures help a particular therapeutic purpose and which become another obstacle to participation.
An AE interpretation: engagement depends on the arrangement
The following is my interpretation, not the authors’ framework. Autopoietic ecology asks what makes an activity possible and whether doing it renews the capacity to act again. Therapy engagement is therefore not a trait possessed by a client. It emerges through the relation between attention, memory, confidence, the therapist’s conduct, appointment systems, funding rules and the demands placed on life outside the session.
EdgeLab’s research programme follows how burdens move between people and institutions. When a service refuses reminders because the client should maintain “individual responsibility”, the work of making attendance possible is pushed back towards the person whose difficulties brought them to treatment. Likewise, naming shame reduction as important has little consequence if training, time and reimbursement never permit it.
The AE Concept Guide distinguishes recognising a problem from changing a later allocation. The practical test is whether stakeholder knowledge alters supervision, scheduling, session length, training or payment. The study does not prove an AE explanation, but its importance–feasibility gaps show exactly where to look.
From co-design to a fair test
The next stage should turn the strongest recommendations into a clearly specified, adaptable package and compare it with usual CBT. Evaluation should include attendance, continuation, individual goal progress, functioning, shame and confidence, alongside symptoms. It should record the additional time, training and administrative work required, and recruit people who are younger, older, male and from racially diverse communities.
Sibley and colleagues offer a promising map of what adults and practitioners think would help. Its value lies neither in declaring a new best treatment nor in blaming clinicians for constraints they do not control. It identifies the places where treatment, professional knowledge and service organisation must be tested together.
Reference
Sibley, M. H., Shafiee, M., and Knouse, L. E. (2026). “Strategies to enhance engagement in CBT for adult ADHD: an innovation tournament with stakeholders.” Frontiers in Psychiatry, 17, 1824100. Published 18 September 2026. https://doi.org/10.3389/fpsyt.2026.1824100.
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