Learning Disabilities Research

Learning Disabilities Research & Practice, 24(4), 165–173


C 2009 The Division for Learning Disabilities of the Council for Exceptional Children

Do Problems with Information Processing Affect the Process of Psychotherapy

for Adults with Learning Disabilities or Attention Deficit/Hyperactivity
Disorder?
Merith Cosden, Sarah Patz, and Steven Smith
University of California, Santa Barbara

Problems in processing information can affect psychosocial functioning. Psychotherapy can be

used to address psychosocial problems; however, the same information-processing problems
that contribute to disabilities, such as learning disabilities (LD) or attention deficit/hyperactivity
disorder (ADHD), particularly deficits in auditory processing and attention, may also interfere
with the process of psychotherapy. Using a Web-based survey, data dealing with perceptions
of the effectiveness of psychotherapy were obtained from 52 adult patients with LD and/or
ADHD and 87 adults who did not have any diagnosed cognitive difficulties. While all re-
spondents reported psychotherapy was helpful, those with LD were less likely than others to
seek therapy again and reported a greater need for more accommodations. Respondents with
auditory processing problems were less likely than others to meet treatment goals. Overall, 44
percent of patients with a diagnosed disability indicated the condition affected therapy. Clients’
descriptions of the impact of their disabilities on psychotherapy, and need for accommodations,
are presented. Implications for both clients and therapists are discussed.

The social and emotional problems of adults with learning
disabilities (LD) and attention deficit/hyperactivity disorder
(ADHD) have been well documented. For adults with LD,
the inability to read social cues and poor pragmatic skills
can affect social interactions across the life span (Bryan,
Burstein, & Ergul, 2004). Similarly, for adults with ADHD,
inattention, poor impulse control, and emotional instability
have been associated with interpersonal problems (Barkley,
Murphy, & Fischer, 2008; Brown, 2005; Weiss, Murray, &
Weiss, 2002). For both groups, histories of school, work, and
social frustrations also contribute to maladaptive patterns of
functioning.
Given the lifelong impact of these disabilities, the pres-
ence of LD or ADHD are risk factors for psychologi-
cal problems including depression, anxiety, and substance
abuse (Cosden, 2001; Morrison & Cosden, 1997; Sharps,
Price-Sharps, Day, Villegas, & Nunes, 2005) and are over-
represented among those with these disorders (e.g., Bender,
Rosenkrans, & Crane, 1999; Jensen et al., 2001). Thus, adults
with either LD or ADHD are also more likely than adults
without these disabilities to experience a level of psycholog-
ical distress that warrants a psychotherapeutic intervention.
Requests for reprints should be sent to Merith Cosden, Department
of Counseling, Clinical and School Psychology, University of California,
Santa Barbara, CA 93106. Electronic inquiries may be sent to cosden@
education.ucsb.edu.
Research on Psychotherapy for Adults
with LD or ADHD
Psychotherapy, as discussed in this article, refers to a verbal
intervention offered by psychologists, psychiatrists, or other
trained mental health practitioners for a broad range of emo-
tional or cognitive disturbances or disorders, which include,
but are not limited to, low self-esteem, depression, anxi-
ety, and familial discord. Psychotherapy is used to provide
insight, correct distorted perceptions, ameliorate undue neg-
ative feelings, and promote personal well-being. Although
there are many models of psychotherapy, there are also a few
general factors that affect treatment regardless of theoretical
orientation (Wampold, 2005). Key among these is the estab-
lishment of a positive working relationship with one’s thera-
pist, which is based, in part, on the establishment of common
treatment goals and the client’s perception of the therapist’s
empathy and respect (e.g., Martin, Garske, & Davis, 2000).
The literature on psychotherapy for adults with either LD
or ADHD is surprisingly limited. Weiss et al. (2008), con-
ducted an electronic search of PUB MED for articles on
ADHD adult in conjunction with psychological treatment,
psychotherapy, cognitive behavioral therapy (CBT), or di-
alectical behavior therapy (DBT), and identified fewer than
a dozen studies, some of which were conference presenta-
tions, that used either pre- and postevaluations of clients
with ADHD, or compared them to clients on a waitlist or in
a control group. Published studies (e.g., Hesslinger, Tebartz
166 COSDEN, PATZ, AND SMITH: PROCESS OF PSYCHOTHERAPY
van Elst, Nyberg, & Dykierek, 2002; Rostain & Ramsay,
2006; Safren, Sprich, Chulvick, & Otto, 2004) typically
describe modifications of traditional psychotherapies (e.g.,
CBT, DBT) with a focus on reducing symptoms associated
with ADHD, such as impulsivity and limited attention span.
The literature on psychotherapy for adults with LD or comor-
bid LD/ADHD is even more sparse, with a search for arti-
cles on learning disabilities and counseling or psychotherapy
finding no comparison group or pre- and poststudies and few
empirical investigations of client outcomes (e.g., Cosden &
Greenwell, 2006), case studies (e.g., Wren & Einhorn, 2000),
and conceptual articles (e.g., Barton & Fuhrmann, 1994) on
how to best address the needs of this population. While a
few studies considered more distal outcome measures, such
as depression and anxiety, Weiss et al. (2008) noted the need
for greater consideration of the broader impact of psychother-
apy on symptoms outside of those directly associated with
the disability.
This study examines the possibility that the same
disability-related problems that increase the risk of individ-
uals with LD or ADHD experiencing psychosocial distress
may also interfere with the process of psychotherapy. Psy-
chotherapy relies on the ability of both client and therapist
to communicate effectively. Communication problems are
common among individuals with LD or ADHD. In partic-
ular, problems in auditory processing often experienced by
adults with LD or the limited attention span associated with
ADHD may interfere with the client’s communication with
their therapist during psychotherapy. In one study in this
area, Cosden and Greenwell (2006) interviewed adults with
LD (N = 31) and without LD (N = 103) who were receiving
both group and individual substance abuse treatment. They
found that participants who had LD, while indicating high
levels of satisfaction with all aspects of the treatment pro-
gram, also reported greater difficulty communicating with
counselors and less understanding of program requirements
than did clients without LD. Communication problems were
also noted in case studies of clients with LD and ADHD
described by Wren and Einhorn (2000). According to these
case studies, communication problems between clients with
LD or ADHD and their therapists and others arise due to
the clients’ difficulties in articulating their needs and under-
standing the verbal and nonverbal communications of others
(pp. 162–165). As one client stated, “I think most of us with
are LD float around from therapist to therapist our whole
lives, because the average therapist doesn’t understand about
us,” (p. 148). The authors also note that clients with LD
and/or ADHD often have high levels of anxiety associated
with the need to hide their disability, and that this stress needs
to be addressed in therapy in conjunction with the other prob-
lems for which the clients enter treatment.
Several studies have shown that, with adaptations, psy-
chotherapy can be helpful to adults with cognitive disorders.
In two studies, CBT was adapted for use with adults who
have ADHD (Hesslinger et al., 2002; Safren et al., 2004).
The goals of CBT are to reduce dysfunctional and distorted
thinking and increase problem-solving skills, with the ex-
pectation that changes in cognition will promote healthier
emotional and behavioral functioning. The therapy in each
study was modified to take into account the special needs
of adults with attention disorders. Hesslinger et al. modi-
fied a cognitive-based treatment, DBT, to help clients under-
stand the impact of ADHD on their emotional and behavioral
problems. Although their study had a small N (eight adults
at follow-up), the treatment was viewed positively by those
who completed it. Safren et al. provided CBT to address
both the symptoms of ADHD and dysfunctional thinking
and related problems in communication, anger management,
and relationship problems. The investigators modified their
intervention to accommodate client problems with organiza-
tion and follow-through by providing them with notebooks
and calendars to organize and maintain records of therapeu-
tic activities and by employing additional motivational tech-
niques to help them remain on task. Preliminary findings were
promising.
Although psychotherapeutic interventions adapted for
adults with disabilities seem to be effective, there are no pub-
lished studies on the extent to which these adaptations are
reflected in the mainstream psychotherapy typically available
for adults with LD or ADHD. Case studies on adults with LD
or ADHD who have obtained psychotherapy in community-
based settings indicate that a number of clients do not receive
disability-based treatment modifications. Often this is due to
a lack of awareness of the disability, because asking about
unseen cognitive disabilities is not part of many intake pro-
tocols and because clients are reluctant to disclose this infor-
mation (Wren & Einhorn, 2000). Clients may be reluctant to
self-disclose a disability to a therapist because of the stigma
of being labeled; it is also possible that the client does not
perceive his or her disability as relevant to the problem for
which help is being sought. However, even when the present-
ing problem is not directly related to having a disability (e.g.,
marital discord), the presence of a disability provides an im-
portant context for understanding the client’s needs. That is,
behaviors related to LD, such as poor understanding of so-
cial cues, or ADHD, such as limited attention to others, may
not be easily changed without recognition of the disability.
Clients are likely to benefit more from therapy if their dis-
ability is recognized and if they receive accommodations to
compensate for disability-related problems (Aviram, Rhum,
& Levin, 2001; Barton & Fuhrmann, 1994; Ramsay & Ros-
tain, 2005). This would require changes in standard intake
procedures to routinely include queries about the presence
of a cognitive disability, as well as client willingness to look
past the stigma of being labeled while recognizing the impor-
tance of their therapists’ understanding their special needs. In
addition, more knowledge is needed about how to effectively
accommodate clients with LD or ADHD in psychotherapy
when their identification is known.
Shared and Specific Concerns for Adults
with LD and/or ADHD
Although, as a group, adults with LD and ADHD have
different constellations of symptoms, they also share sev-
eral features pertinent to the experience of psychotherapy.
As noted, both groups are at increased risk for psychoso-
cial problems. Further, both groups are likely to experi-
ence disability-related problems inside of therapy in terms of

communication difficulties. Further, the invisibility of these
disorders increases the risk that disability-related prob-
lems in communication will be misconstrued as clinical
resistance to treatment.
The basis for these communication problems is likely to
differ as a function of disability, however. Adults with LD
are more likely to be hampered by problems in the auditory
processing of information while adults with ADHD are more
affected by deficits in attention as well as organization and
task completion (Bryon & Parker, 2002; Eisenmajer, Ross,
& Pratt, 2005). While distinctions have emerged in the pro-
cessing problems of individuals with LD and ADHD, there
is also significant within-group variation (Hendriksen et al.,
2007). In addition, the co-occurrence of LD and ADHD has
been found in a significant proportion of children and adults
diagnosed with either disorder. In a recent review of this
literature, Jakobson and Kikas (2007) found that the preva-
lence of this comorbidity ranged from 10–80 percent across
published studies. Common across studies, however, was that
individuals with comorbid LD and ADHD had more prob-
lems in processing information and in other psychosocial
arenas than did individuals with either disorder alone (e.g.,
Crawford, Kaplan, & Dewey, 2006; McNamara, Willoughby,
& Chalmers, 2005).
Purpose
The purpose of this study was to further understand the ex-
perience of psychotherapy for adults with LD and/or ADHD
by examining self-report responses to survey items dealing
with the topic. First, differences in the experiences of adults
with and without these disorders were examined. It was hy-
pothesized that adults with and without LD and/or ADHD
would utilize psychotherapy for the same types of problems,
such as depression, anxiety, or difficulties in social and fam-
ily functioning. However, given the literature suggesting that
LD and ADHD may be risk factors for substance abuse, it
was hypothesized that clients with either or both disabili-
ties would be more likely to seek treatment for this problem
than would clients without a cognitive disability. Regardless
of reason for psychotherapy, it was also hypothesized that
adults with LD and/or ADHD, compared to adults without
these difficulties, would be less likely to meet their treatment
goals and would report a poorer relationship with their ther-
apists, being less helped by therapy, and being less willing to
seek therapy again.
The second set of hypotheses addressed survey response
differences as a function of type of disability and certain types
of problems in processing information. Based on the nature
of verbal psychotherapy methods, the focus was placed on
problems in auditory processing and attention/concentration.
It was hypothesized the adults with LD would be more
likely to have problems with auditory processing while adults
with ADHD were more likely to report problems with at-
tention/concentration. Given the heterogeneity among adults
with LD or ADHD, however, it was hypothesized that there
would also be within-group variability in self-reported pro-
cessing problems. Thus, it was hypothesized that adults with
either LD and/or ADHD who had problems in these areas
LEARNING DISABILITIES RESEARCH 167
would be less likely to meet their treatment goals and would
have less positive ratings of therapy than would adults with
LD and/or ADHD without these problems.
Further, because other factors might also influence psy-
chotherapy, adults with LD and/or ADHD were asked
whether, from their perspective, their disorders affected the
process of psychotherapy. It was hypothesized that respon-
dents who stated that their disability affected the process
of psychotherapy would be less likely than other respon-
dents to have met their treatment goals and would have less
positive ratings on the psychotherapy measures. Given the
exploratory nature of this study, respondents were also asked
to describe the manner in which their disability affected their
therapy.
Finally, openness about one’s disability and the use of
disability-related accommodations within therapeutic ses-
sions were assessed. It was hypothesized that adults with
LD and/or ADHD would benefit more from psychotherapy
to the extent that they were able to talk about their disability
with their therapist and obtain accommodations in session.
Respondents were asked to describe accommodations they
received, as well as accommodations they wanted.
METHOD
Design
This study used an Internet-based survey developed through
software available at surveymonkey.com. Studies have found
that Internet surveys are cost effective and yield faster re-
sponse rates than do other techniques (Simsek & Viega,
2001). Further, Internet-survey sample data have been shown
to be comparable to data collected using other techniques,
including paper and pencil and automated touchtone tele-
phone response systems (Mathy, Kerr, & Haydin, 2003; Yun
& Trumbo, 2000). For example, in a survey of science writ-
ers, Yun and Trumbo found that a survey technique did not
significantly influence their findings, as their results were
similar for surveys executed by post, e-mail, and Web for-
mats. Representation of a population using Internet surveys
is less of a concern when an appropriate sampling frame
has been created and the target population has access to the
Internet.
To obtain responses from adults with and without LD
or ADHD who had completed at least one episode of psy-
chotherapy, links to the survey, titled “Quality of Psychother-
apy for Adults With and Without Disabilities,” were dis-
tributed to a national list serve for psychologists and college
faculty at universities with clinical training programs across
the country; it was also made available on several Web sites
(i.e., the Web pages of the first two authors and Psychologi-
cal Research on the Net sponsored by Hanover College). In
order to draw a large sample of adults with LD or ADHD
who had also completed an episode of psychotherapy, the
disabled students’ services programs at three colleges (two
within California and one in Colorado with which we had
prior affiliations) were specifically queried, as were adult
clients from the local Department of Rehabilitation.
168 COSDEN, PATZ, AND SMITH: PROCESS OF PSYCHOTHERAPY
The survey, with a face sheet requesting consent to partic-
ipate and explaining the requirements of the study, was sent
to agency representatives who, in turn, were asked to e-mail
the study request with a link to the survey to their student
and staff lists. Those who received the e-mail could choose
to respond anonymously to the survey. While a majority of
the lists to which the link was sent were college/university
domains, posting the link on public access sites allowed a
wider representation of adults to respond.
Participants
A total of 139 adults responded to the survey; 87 reported
no cognitive disabilities (NCD) and 52 reported having LD
and/or ADHD.1 Of the 52 participants with a disability,
16 identified as having LD only, 22 as having ADHD only,
and 14 as having both LD/ADHD. Mean age for participants
was 29 years with no significant difference among the groups.
There were no group differences with regard to ethnicity, with
a majority of participants identifying as European American
(74 percent), followed by Latina/o (11 percent), Asian Amer-
ican (7 percent), multiracial (4 percent), African American
(3 percent), and other (1 percent). Gender was primarily fe-
male (76 percent) and also did not significantly differ across
groups.
This high rate of female participation was surprising in
that a majority of individuals identified as having LD or
ADHD are male. One factor that might have contributed
to the overrepresentation of females in this sample is that
women tend to have more positive attitudes toward mental
health treatment than do men (e.g., Gonzalez, Alegria, &
Prihoda, 2005), and engagement in psychotherapy was a pre-
requisite for participation in this study. Further, studies find
that women are more likely than men to respond to surveys
in general (Cull, O’Connor, Sharp, & Tang, 2005) and Web-
based surveys in particular (Sax, Gilmartin, & Bryant, 2003).
As noted by Sax et al., this nonresponse bias, reflecting who
did and did not respond to the survey, does not reflect a re-
sponse bias, in terms of inaccuracies of responses to survey
items. Rather, disability status, participation in psychother-
apy, and willingness to respond to a survey are all likely to
have influenced the composition of the sample in this study,
and outcomes will need to be interpreted within this context.
Mean years of education differed among groups, F(3,
133) = 6.99, p < .001, with an average of 16.0 years for
the NCD group, 13.8 years for the LD group, 14.5 years for
the ADHD group, and 15.3 years for the LD/ADHD group.
This would be expected given the greater difficulties stu-
dents with LD and ADHD face throughout their schooling
relative to students without disabilities. In order to deter-
mine the validity of participants’ identification of LD and
ADHD, questions addressed their assessment and identifi-
cation process. Participants had been assessed by psychia-
trists (39 percent), clinical psychologists (38 percent), school
psychologists (35 percent), other physicians (19 percent),
neuropsychologists (7 percent), neurologists (6 percent), or
other specialists (4 percent). Respondents indicated problems
with one or more of the following: attention/concentration
(71 percent), organization (56 percent), reading compre-
hension (50 percent), memory/forgetfulness (48 percent),
writing (40 percent), reading/decoding (38 percent), auditory
processing (36 percent), mathematics (36 percent), process-
ing speed (29 percent), and visual processing (6 percent).2
Problems in attention/concentration and auditory processing
were the focus of this study.
Surveys
This survey was developed by the investigators for this
project in conjunction with a matched survey for therapists
(in progress). Items were created to address reasons for enter-
ing and leaving therapy for all clients, using prior research as a
basis for choices. In addition, items were created to attempt to
understand the impact of a disability on psychotherapy; given
the limited information in this area, both multiple selection
and open-ended questions were used. Finally, questions were
developed to assess and identify a disability, as well as needs
associated with the disability. These were designed to assure
that respondents had gone through a formal assessment pro-
cess for LD or ADHD and to understand better the nature of
their processing problems, with items selected for each based
on likely responses from the available literature.
Initial items were tested on a small sample (N = 10) of
graduate students, some with and some without cognitive dis-
abilities. Although items were answered anonymously using
the Web-based format, respondents also met with the investi-
gators to discuss the survey. Feedback from the respondents
led to changes in the wording for several items.
In the final survey, all participants were asked to respond
to a core set of 16 items describing their experiences during
their last completed episode of psychotherapy (see the Ap-
pendix for a review of domains). Participants were not asked
to reveal any specific information about the content of their
psychotherapy. Rather, they were asked to respond to check-
lists regarding their reasons for seeking and ending therapy.
Also, using 5-point Likert scales, they were asked to rate the
quality of the client–therapist relationship (1 = poor to 5 =
very good), the helpfulness of therapy (1 = not helpful to
5 = very helpful), and their likelihood of seeking therapy
again (1 = no/never to 5 = yes/absolutely).
Respondents who identified as having LD and/or ADHD
were sent to an additional section of the survey. The 12 items
on this page asked about the identification process for their
disability and their processing problems; participants were
also asked whether or not they had discussed their disability
with their therapists, believed their disability affected their
experience of psychotherapy, or had requested and received
special accommodations in psychotherapy. Participants who
indicated “yes” to the latter items were given the opportunity
to describe how their disability affected therapy, accommo-
dations they found helpful, or accommodations they thought
might be helpful. A list of items covered in the survey is ap-
pended, as is the URL for the survey, which is also available
from the authors on request.
RESULTS
The primary reasons for seeking psychotherapy for adults
with NCD, LD, ADHD, or LD/ADHD are noted in Table 1.

TABLE 1
Reasons for Entering Psychotherapy
NCD LD Only ADHD Only LD/ADHD
Reason n = 87 n = 16 n = 22 n = 14
Depression 63% 38% 68% 71%
Anxiety 59% 56% 64% 57%
Family problems 31% 50% 27% 43%
School-related 20% 69% 77% 64%
problems
Relationship 25% 25% 23% 21%
problems
Substance abuse 3% 0% 18% 14%
∗p < .05,∗∗ p< .001.
Note: Less frequently endorsed reasons for entering psychotherapy (N <
10) included eating disorder, bipolar disorder, bereavement, trauma, and
sexual dysfunction.
Other reasons, such as eating disorder, bipolar disorder, be-
reavement, trauma, and sexual dysfunction, were also noted,
but by fewer than 10 total respondents. As hypothesized,
there were no differences between the four groups on their
likelihood of entering treatment for depression, anxiety, or
family problems. Significant between-group differences were
found for entering psychotherapy due to school-based prob-
lems, x2 (N = 139) = 35.45, p < .001, and problems with
substance abuse, x2 (N = 139) = 8.83, p < .05. Differences
emerged between adults with and without disabilities, with
all disability groups similarly likely to have sought therapy
for school-related problems, either during their secondary or
postsecondary education. For substance abuse, partially sup-
porting the initial hypothesis, respondents with ADHD with
or without LD were the most likely to seek help.
It was hypothesized that the experience of psychother-
apy would be rated more negatively by respondents with LD,
ADHD, or LD/ADHD relative to adults with NCD and that
clients with LD and/or ADHD would also be less likely to
meet their treatment goals. Three of the dependent measures,
likelihood of seeking therapy again, quality of the therapeu-
tic relationship, and perceived helpfulness of therapy, were
rated on a 1–5-point scale (higher scores more positive).
Correlations among the three measures were significant, rais-
ing the question of whether or not they should be analyzed as
separate outcomes. As the correlations between likelihood of
seeking therapy again and the other two measures were only
moderate (r = .28 for helpfulness of therapy; r = .34 for
quality of the therapeutic relationship), ratings of the likeli-
hood of seeking therapy again were analyzed separately from
the other two. The correlation between helpfulness of ther-
apy and quality of the therapeutic relationship was higher
(r = .68), however, suggesting that these two variables were
measuring a similar outcome. Further, preliminary analysis
found problems with the equality of the error variance (Lev-
ene’s test) on the helpfulness of therapy variable. Thus, only
analyses of the quality of the therapeutic relationship and
likelihood of seeking therapy again are reported. There were
no significant differences between groups on the quality of
the therapeutic relationship, F(3, 135) = 1.36, ns. There were
significant between-group differences, however, with regard
LEARNING DISABILITIES RESEARCH 169
TABLE 2
Problems in Attention and Cognitive Processing Noted by Clients
with LD, ADHD, or LD/ADHD
x2 LD Only ADHD Only LD/ADHD
Problem n = 16 n = 22 n = 14 x2
6.16
.24 Auditory processing 25% 23% 71% 10.08∗
2.49 Attention/concentration 44% 86% 79% 8.71∗
35.45∗∗ ∗p < .05.
.17
8.83∗
to the likelihood of seeking therapy again, F(3, 135) = 2.72,
p < .05, η2 = .057. Respondents with LD reported a lower
likelihood of seeking therapy again than did respondents in
the other groups.
Respondents were asked whether or not they met their
treatment goals. Completion of goals was noted by 36 per-
cent of respondents. Respondents attributed leaving therapy
before all goals were met to practical problems, such as mov-
ing, not being able to afford treatment, or not having the time
to continue therapy (50 percent) or not feeling personally
ready to work on additional goals (15 percent). Only 14 per-
cent reported not meeting any goals. A chi-square analysis
on successful versus unsuccessful completion of psychothe-
rapy as a function of disability status was not significant,
x2 (N = 139) = 1.87, ns. There were no significant differ-
ences in the likelihood of success as a function of reason for
entering treatment for either group.
For the second set of hypotheses, the relationships of
disability type (LD, ADHD, and LD/ADHD) and spe-
cific processing deficits of interest (auditory and atten-
tion/concentration) were examined. Significant differences
among disability groups were found for problems in audi-
tory processing, x2 (N = 52) = 10.08, p < .05, and atten-
tion/concentration, x2 (N = 52) = 8.71, p < .05. Table 2
represents the likelihood of each group reporting these pro-
cessing problems. Not surprisingly, the directionality of the
differences indicated that adults with LD alone were less
likely than adults with ADHD or LD/ADHD to experience
problems with attention/concentration. Further, adults with
combined LD/ADHD were the most likely to report problems
in auditory processing. Despite these differences, the over-
lap of cognitive problems across disability groups supported
the examination of processing problems independently from
disability status.
The impact of problems in auditory processing and at-
tention/concentration was examined on the 53 adults with
disabilities. No differences were found for respondents with
and without auditory processing problems on the quality of
the therapeutic relationship, F(1, 51) = 3.43, ns, or likeli-
hood of seeking therapy again, F(1, 51) = 1.46, ns. Similarly,
there were no differences on these measures for respondents
with and without problems in attention/concentration, F(1,
51) = 1.59, ns, for the therapeutic relationship, and F(1,
51) = 1.89, ns, for willingness to seek therapy again.
Analyses were also conducted comparing respondents
with and without these problems in their successful com-
pletion of treatment goals. A two group (with or without
170 COSDEN, PATZ, AND SMITH: PROCESS OF PSYCHOTHERAPY
auditory processing problems) by two group (goal com-
pletion, no goal completion) chi-square was significant, x2
(N = 52) = 3.89, p < .05. That is, 16 percent of adults with
LD and/or ADHD who reported auditory processing prob-
lems completed their treatment goals compared to 42 percent
of adults with LD and/or ADHD who did not have this spe-
cific processing problem. Thus, while adults with problems
in auditory processing had similar perceptions of the value
of therapy as did other clients, they were less likely to have
completed treatment successfully. A similar analysis of goal
completion as a function of attention/concentration problems
was not significant.
When respondents with LD and/or ADHD were asked
whether or not they believed their disability had an impact of
therapy, 44 percent responded affirmatively. However, uni-
variate analyses found that respondents who stated their dis-
abilities affected psychotherapy did not differ from other
respondents in their ratings of the therapeutic relationship,
helpfulness of therapy, or likelihood of seeking therapy again.
There were also no differences in success rates for adults who
did and did not believe their disability affected psychother-
apy, x2 (N = 52) = .37, ns.
To understand how respondents saw their disability affect-
ing therapy, self-report data on the topic were examined in
relation to disability status and specific processing deficits.
Respondents who reported that their disability affected psy-
chotherapy did not differ, on the basis of chi square analyses,
as a function of disability type or problems with auditory
processing or attention. Open-ended questions were used to
further elucidate this issue. Information on how disabilities
affected psychotherapy was obtained from only 18 respon-
dents. Major themes were identified by the first two authors,
who coded responses independently and then met to discuss
them; most responses were short and consensus in coding
was reached. Four themes emerged: 8 respondents indicated
problems focusing in therapy or understanding the thera-
pist, 5 reported problems expressing themselves, 3 described
organizational problems interfering with their getting to ther-
apy or completing work outside of therapy, and 2 noted that
they had difficulty separating problems associated with their
disability from other psychological problems. There were no
clear patterns with regard to disability/processing problems
and open-ended responses to problems in therapy. Exemplary
responses are provided in Table 3.
TABLE 3
Themes for Responses on How Disabilities Affected Psychotherapy for Adults with LD and/or ADHD
Lack of focus/understanding in therapy
“I don’t listen at times to what the therapist is saying.”
“Sometimes I cannot fully understand until later.”
Difficulties in expressing ideas
“Making my points clear for the psychotherapist to understand. I knew what I wanted to say, but saying it out loud was difficult.”
“Articulating my thoughts to my therapist was sometimes difficult.”
Poor organization interference
“I have an extremely difficult time organizing and getting where I’m supposed to be or getting there on time. So I did miss a lot of appointments or
showed up late.”
“Forgot homework and time of session.”
Need to differentiate problems due to disability from other psychological problems
“It is hard to change my neurological disorder via will.”
“Sometimes my difficulties were not psychologically based.”
The final analyses examined the extent to which thera-
pists knew about their clients’ disabilities and made needed
accommodations. Almost all (97 percent) respondents indi-
cated that their therapist knew about their disability; 81 per-
cent told their therapist (as opposed to being asked about it).
When asked about accommodations, 29 percent of respon-
dents indicated that they had received an accommodation
in therapy, while 27 percent (including 40 percent of those
who received an accommodation) stated that they would have
liked an accommodation that they did not receive. There were
no differences in receiving accommodations across disabil-
ity groups or as a function of specific processing problems.
There was a difference among disability groups in terms of a
desire for accommodations, x2 (N = 52) = 6.32, p < .05; that
is, 50 percent of those with LD, compared to 18 percent of
those with ADHD and 14 percent of those with LD/ADHD,
wanted additional accommodations. There were no differ-
ences in need for additional accommodations in relation to
specific processing problems. However, adults who stated
that their disability affected therapy were also more likely to
receive accommodations (67 percent) than were those who
did not feel their disability affected therapy, 35 percent, x2 (N
= 52) = 4.30, p < .05. Further, those whose disability af-
fected therapy were more likely (86 percent) than others (29
percent) to want additional accommodations, x2 (N = 52) =
13.37, p < .001.
Participants were given the opportunity to describe ac-
commodations they received, and wanted, in psychotherapy.
Only six respondents described the accommodations they
received, while seven provided descriptions of accommoda-
tions they wanted. The first two investigators agreed on cate-
gories, classified the responses independently then discussed
the coding until they reached consensus. The respondents
who described accommodations varied in disability and pro-
cessing problem, with no pattern evident in relation to accom-
modations received. Three respondents described accommo-
dations that enhanced communication (e.g., “therapist wrote
down information,” “restated what I said and asked if that was
what I was thinking”), and three described therapist behav-
iors that reflected an understanding of their disabilities (e.g.,
using techniques to maintain attention or “tolerated my late-
ness”). Although more individuals with LD indicated that
they wanted accommodations they did not receive, five of
the six respondents who described desired accommodations

had ADHD. All respondents with ADHD reported attention
problems, and six of the seven noted problems in memory.
However, they still described different needs; three respon-
dents focused on enhancing communication (e.g., having pa-
per and pencil to write down ideas or books on tape), one
wanted more time to address issues (“without fees”), while
three respondents indicated a need to know more about how
their disability affected them (e.g., “I would like to find out
if my ADHD exacerbated my social anxiety”).
DISCUSSION
This study provides support for the use of psychotherapy
to address psychosocial problems by adults with LD and/or
ADHD. Respondents with and without cognitive disabilities
sought psychotherapy for many of the same reasons and were
equally likely to engage in treatment for depression, anxiety,
or family problems. However, in this study adults with LD or
ADHD were more likely than adults without these disabil-
ities to report the need for psychotherapy due to problems
at school. This may, in part, be an artifact of the oversam-
pling of university populations and the high expectation that
postsecondary students with LD and/or ADHD would con-
tinue to experience problems in this arena. Students with and
without disabilities were canvassed at the same universities,
suggesting that within that environmental context students
with disabilities have more need for psychosocial support.
This is consonant with research indicating that college stu-
dents with LD and ADHD experience more stress than do
students without these disabilities (Heiligenstein, Guenther,
Levy, Savino, & Fulwiler, 1999; Reiff, Harzes, Bramel, &
Gibbon, 2001).
Seeking help for substance abuse was noted by a higher
percentage of adults with ADHD and combined LD/ADHD
than by other respondents. Higher levels of substance abuse
among adults with LD and ADHD have been found in
other studies (Biederman, Wilens, Mick, Faraone, & Spencer,
1998; Cosden, 2001; National Center for Addiction and
Drug Abuse, 2000). This problem has been attributed to
self-medication to reduce discomfort due to the increased
stress associated with having a disability (Morrison &
Cosden, 1997). Although prior studies have suggested that
adults with LD or ADHD are at greater risk for substance
abuse, this study found more adults with ADHD seeking help
for that problem. Sharps et al. (2005) support this outcome,
as they found an association between substance abuse and an
inability of adults with ADHD to fully understand the impact
of risk behaviors on likely outcomes.
The hypotheses regarding differences in satisfaction with
therapy between adults with and without disabilities were
partially supported. Analyses identified within-group differ-
ences among adults with disabilities, indicating that some,
but not all, respondents had disability-related needs that in-
fluenced their therapeutic experiences. Adults with LD were
less willing than others to seek treatment again and were more
likely to want additional accommodations, while respondents
with auditory processing problems (which are most likely to
occur in adults with LD) were less likely to successfully
complete treatment. Thus, adults with LD and, in particu-
LEARNING DISABILITIES RESEARCH 171
lar, those with auditory processing problems, were the least
likely to have their needs met through the psychotherapy they
received.
In open-ended responses, problems with communication
(expressive and receptive) were the most commonly iden-
tified, with problems in organization and the need to under-
stand more about the manner in which their disability affected
therapy also noted. Although respondents with LD were the
most likely to report the need for additional accommodations,
adults with ADHD were more able to articulate the types of
accommodations they wanted. It is possible that the problems
experienced by clients with LD are more difficult to remedy,
or at least that clients with that disability are less able to de-
scribe the change that is needed. This suggests the need for
counselors at both college and community-based centers to
take a more active role in assessing the needs of their clients
with LD and in working with their clients to develop accom-
modations that would make therapy more effective for them.
While ideas for adaptations have been suggested in other
studies (e.g., Ramsay & Rostain, 2005; Wren & Einhorn,
2000), this is an area that warrants future research.
Methodologically, several measures were used to assess
respondents’ psychotherapy experiences, and these yielded
different responses. There were no between-group differ-
ences on ratings of the therapeutic relationship, with ratings
generally reflecting satisfaction. Greater within-group varia-
tion was noted in the more concrete questions such as why
one left psychotherapy and one’s likelihood of seeking ther-
apy again, making these more discriminating measures. A
similar pattern of results was noted by Cosden and Green-
well (2006), in that clients with LD reported high levels of
program satisfaction but also reported more problems under-
standing program requirements than did their non-LD peers.
The findings of these studies suggest that concrete mea-
sures of treatment effectiveness may be more useful when
obtaining consumer perspectives from adults with cognitive
disabilities.
It is important to note that many factors can affect the
process of psychotherapy, including the client’s presenting
problems and motivation, the therapist’s skill and treatment
plan, and the relationship between the client and therapist.
This study focused on one additional aspect of function-
ing that might affect psychotherapy for adults with LD or
ADHD, their challenges in terms of attention and cognitive
processing. In determining the utility and effectiveness of
psychotherapy for specific adults with LD or ADHD, the im-
pact of their cognitive processing problems is just one of the
many factors that need to be considered.
There are several limitations to this study. While drawing
from a broad sample, the findings are based on adults who
had access to the Web and were willing to respond to the
survey. For example, the low number of respondents with vi-
sual processing problems prohibited analysis of this type of
problem in relation to psychotherapy, even though it has been
associated with nonverbal LD and high rates of psychosocial
problems. There were more female than male respondents,
which is unusual for a study on adults with LD or ADHD.
This was likely a function of the greater likelihood for women
to participate in therapy and to respond to surveys. A major-
ity of respondents were also college educated. Further, the
172 COSDEN, PATZ, AND SMITH: PROCESS OF PSYCHOTHERAPY
small number of respondents relative to the complex nature
of these disabilities may have contributed to the failure to
find significance in the impact of these disabilities and pro-
cessing problems on psychotherapy needs. Future studies are
needed in which other methods of data collection are utilized
to obtain broader and larger samples of adults with LD and
ADHD.
Given the psychosocial needs of adults with LD and
ADHD, psychotherapy can be an important resource. Many
of the respondents in this study who had LD and/or ADHD
reported that they were able to use psychotherapy as effec-
tively as did adults without these disabilities. However, there
was considerable within-group variation in the reported im-
pact of their disabilities on psychotherapy, and some, particu-
larly those adults with LD and auditory processing problems,
needed additional modifications to make treatment success-
ful. Further understanding of how disabilities can affect psy-
chotherapy, and how modifications in treatment can facilitate
the effectiveness of psychotherapy, is needed.
NOTES
1. Seventeen respondents were excluded from this study,
14 of whom had not yet completed their first full expe-
rience of psychotherapy and thus were not able to re-
port its outcome. Additionally, three participants with
disabilities were excluded because they were “self-
diagnosed.” Although it is possible that these respon-
dents did have LD or ADHD, a conservative approach
to identification was adopted.
2. Although problems with visual processing have been
associated with nonverbal learning disabilities and a
greater likelihood of psychosocial problems than that
experienced by other adults with LD, the small num-
ber of respondents reporting that processing problem
prohibited analysis of it in relation to the experience of
psychotherapy.
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APPENDIX: SUMMARY OF KEY ITEMS
ON THE WEB-BASED SURVEY
Questions for participant with or without a cognitive disabil-
ity
Demographic characteristics (gender; ethnicity; marital sta-
tus; grade completed; age: check boxes).
Why did you seek psychotherapy? (options provided: check
all that apply).
Why did you leave psychotherapy? (options provided: check
all that apply).
Quality of client-therapist relationship (rate on 5-point scale).
Helpfulness of therapy (rate on 5-point scale).
Likelihood of seeking therapy again (rate on 5-point scale).
Questions only for participants with a cognitive
disability
Disability diagnosis (diagnosis; assessor; special education
received: check all that apply).
Areas of cognitive difficulties (options provided: check all
that apply).
How related was reason for seeking therapy to disability (rate
on 5-point scale).
Was disability talked about in therapy (Y/N).
Did disability affect work in therapy? (Y/N, If yes, how? free
response).
Were accommodations made in psychotherapy for your dis-
ability (Y/N, If yes, what? free response)
Would you have liked accommodations not made? (Y/N, If
yes, what? free response)
For survey, enter into your browser: http://www.survey
monkey.com/s.aspx?sm=T1bxECEktCt9bkw6XaZpaQ 3d
3d.

About the Authors

Merith Cosden, Ph.D. is a professor in the Department of Counseling, Clinical and School Psychology at the University of
California, Santa Barbara. Her research interests include the social/emotional functioning of adults with learning disabilities
and clinical interventions for individuals who have experienced trauma and/or who have substance abuse and co-occurring
disorders.
Sarah Patz, M.A. is a doctoral student in the Department of Counseling, Clinical, and School Psychology at the University of
California, Santa Barbara. Her areas of interest include assessment and accommodations for adults and children with learning
disabilities as well as understanding the effects of cognitive processing disorders on psychotherapy process and outcome.
Steven R. Smith, Ph.D. is an associate professor and director of clinical training in the Department of Counseling, Clinical,
and School Psychology at the University of California, Santa Barbara. His research interests include therapeutic personality
and neuropsychological assessment, use of performance-based assessment, and psychotherapy processes and outcome.