Steady the Surge: A Therapist Guide to a Skills-First, Neuroaffirmative Protocol for Adults with ADHD and Emotional Surges

ADHD · Practice-informed · Practice-informed

A skills-first, neuroaffirmative protocol for adults with ADHD whose strong feelings arrive fast and leave a mess behind. It is built from five studies published in the last twelve months and four older robust ADHD trials, and it is delivered alongside medical care. Eight individual sessions and an optional booster run from a shared map of the surge through a one-minute log, body-first settling, the pause and check-the-facts skills, a compassion-focused session for the aftermath and a needs-based values session, ending in a surge plan. Each approach carries a colour-coded evidence rating and the guide says plainly what is supported and what is extrapolated.

Underlying mechanism: Skills-First, Neuroaffirmative Protocol for Adult ADHD and Emotional Surges: CBT-Informed Structure, DBT Skills, Body-First Settling, CFT and ACT

What it helps with

  • Giving clinicians a short, structured way to work on the fast feelings and the shame that follow, not only on core ADHD symptoms.
  • Helping a client notice a surge earlier, using the first body signal as the earliest point at which a pause is possible.
  • Offering grounding, movement or breathing as a choice, so a client who finds stillness hard is not set up to fail.
  • Softening the harsh voice of the aftermath before values work, so that goals are set from kindness and not from pressure.
  • Tracking function and surge counts across sessions, so change can be seen and the plan adjusted if nothing moves.

How clinicians use it

  • Confirm the ADHD assessment, screen for risk, mood episodes and trauma, and take baseline measures at Session 1.
  • Keep a steady four-part session shape: check-in and the log, review of practice, one new idea and one skill, then plan the week.
  • Keep the compassion-focused session (6) before the values session (7) by design. The order is clinical judgement and has not been tested.
  • Offer nose-low-slow breathing only as one choice beside grounding and movement. Resonance breathing is optional and later.
  • Repeat the measures at Session 8 and the booster, and say honestly if nothing has moved.

Clinical Implementation Guide

  1. Confirm the assessment, screen for risk and take baseline measures before starting.
  2. Run the sessions in order and keep the compassion-focused session before the values session.
  3. Repeat the same measures at Session 8 and the booster.

What the worksheet looks like

Therapist Guide: Steady the Surge — worked example
SessionFocusWorksheet(s)
1Assessment and a shared map of the surgeW1
2Make it visible: the one-minute logW2
3Body first: grounding, movement or breathingW3
4Noticing and the pause (STOP)W4
5Check the facts, opposite action and urge surfingW4, W3
6A kind coach for the aftermath (CFT), before the ACT session on purposeW5
7What matters and what helps (ACT with needs)W6
8Surge plan and review: repeat measuresW2, W6
BoosterFour to six weeks later: repeat measures and troubleshoot (optional)Any

Clinical cautions

The protocol assumes ADHD has been assessed. Surges also arise in bipolar disorder, borderline personality disorder, PTSD, autism and substance use, so assess or refer first if the picture is unclear. Stop and liaise with the prescriber if there are signs of mania or hypomania. Ask about self-harm and suicidal thoughts at the start and during treatment: this is not a comprehensive DBT programme. It is not a trauma treatment, so stabilise first where trauma symptoms are prominent. Medication decisions belong to the prescriber. Breathwork is optional: stop for dizziness, tingling, panic or a flashback, never use breath holds or fast deep breathing, and take extra care with asthma, panic disorder and breathing-linked trauma. Compassion work can briefly raise distress for people who fear kindness, so go slowly. Check licensing before using any named measure.

References

  1. López-Pinar, C., Selaskowski, B., Schulze, M., Oscarsson, M., Fenollar-Cortés, J., Sibley, M. H., Philipsen, A., & Hirvikoski, T. (2026). Cognitive behavioral therapy effects on global functioning, domain-specific functioning, and quality of life in adult ADHD: A comprehensive meta-analysis. Behaviour Research and Therapy, 201, 105026. https://doi.org/10.1016/j.brat.2026.105026
  2. Zhang, L.-Q., Pan, M.-R., Dong, M., Kong, X., Yu, Z.-Y., Zhang, S.-Y., Li, H.-M., Liu, L., Wang, Y.-F., & Qian, Q.-J. (2026). Group dialectical behavior therapy skills training versus group cognitive behavioral therapy for adults with ADHD: A randomized controlled trial. BMC Psychiatry, 26(1), 512. https://doi.org/10.1186/s12888-026-08130-w
  3. Kang, M. Y., Cheung, Y. C. H., & Wong, D. F. K. (2026). Mindfulness intervention reduced executive dysfunction, delay aversion, and ADHD symptoms: A randomized controlled trial based on the dual pathway model. Behavior Therapy, 57(4), 654-666. https://doi.org/10.1016/j.beth.2026.01.002
  4. Champ, R. E., Meneses, R. W., Adamou, M., Gillibrand, W., Arrey, S., & Tolchard, B. (2025). A neuroaffirmative, self-determination theory-based psychosocial intervention for adults with attention-deficit/hyperactivity disorder: Randomized feasibility study. JMIR Formative Research, 9, e69943. https://doi.org/10.2196/69943
  5. Tokumitsu, K., Sugawara, N., Tabuchi, T., & Yasui-Furukori, N. (2025). Adverse childhood experiences mediate the association between ADHD symptoms and severe psychological distress in the Japanese general population: A causal mediation analysis of 29,268 participants. BMC Psychiatry, 25(1), 1194. https://doi.org/10.1186/s12888-025-07656-9
  6. Pietruch, M., Kowalski, J., Browarczyk, W. M., Michałowski, J. M., & Wypych, M. (2026). Processes of change in cognitive-behavioral psychotherapy for procrastination: Moderation and longitudinal mediation analyses of randomized controlled trial data. Behaviour Research and Therapy, 204, 105106. https://doi.org/10.1016/j.brat.2026.105106
  7. Sumińska, S., Rynkiewicz, A., & Szulczewski, M. (2026). Resonance frequency versus fixed 0.1 Hz breathing in HRV biofeedback: A four-week randomized comparison. Scientific Reports, 16(1), 22630. https://doi.org/10.1038/s41598-026-53333-6
  8. Minjoz, S., Jeanne, R., Pellissier, S., & Hot, P. (2026). Psychophysiological effects of heart rate variability biofeedback versus sham biofeedback: A randomized controlled trial. Biological Psychology, 206, 109254. https://doi.org/10.1016/j.biopsycho.2026.109254
  9. Lehrer, P. M., & Gevirtz, R. (2014). Heart rate variability biofeedback: How and why does it work? Frontiers in Psychology, 5, 756. https://doi.org/10.3389/fpsyg.2014.00756
  10. Linehan, M. M. (2015). DBT skills training manual (2nd ed.). Guilford Press.
  11. Gilbert, P. (2014). The origins and nature of compassion focused therapy. British Journal of Clinical Psychology, 53(1), 6-41. https://doi.org/10.1111/bjc.12043
  12. Craig, C., Hiskey, S., & Spector, A. (2020). Compassion focused therapy: A systematic review of its effectiveness and acceptability in clinical populations. Expert Review of Neurotherapeutics, 20(4), 385-400. https://doi.org/10.1080/14737175.2020.1746184
  13. Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44(1), 1-25. https://doi.org/10.1016/j.brat.2005.06.006
  14. A-Tjak, J. G. L., Davis, M. L., Morina, N., Powers, M. B., Smits, J. A. J., & Emmelkamp, P. M. G. (2015). A meta-analysis of the efficacy of acceptance and commitment therapy for clinically relevant mental and physical health problems. Psychotherapy and Psychosomatics, 84(1), 30-36. https://doi.org/10.1159/000365764
  15. Ryan, R. M., & Deci, E. L. (2000). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist, 55(1), 68-78. https://doi.org/10.1037/0003-066X.55.1.68
  16. National Institute for Health and Care Excellence. (2019). Attention deficit hyperactivity disorder: Diagnosis and management (NICE guideline NG87; originally published 2018, last updated 2019). https://www.nice.org.uk/guidance/ng87
  17. Safren, S. A., Sprich, S., Mimiaga, M. J., Surman, C., Knouse, L., Groves, M., & Otto, M. W. (2010). Cognitive behavioral therapy vs relaxation with educational support for medication-treated adults with ADHD and persistent symptoms: A randomized controlled trial. JAMA, 304(8), 875-880. https://doi.org/10.1001/jama.2010.1192
  18. Solanto, M. V., Marks, D. J., Wasserstein, J., Mitchell, K., Abikoff, H., Alvir, J. M. J., & Kofman, M. D. (2010). Efficacy of meta-cognitive therapy for adult ADHD. American Journal of Psychiatry, 167(8), 958-968. https://doi.org/10.1176/appi.ajp.2009.09081123
  19. Philipsen, A., Jans, T., Graf, E., Matthies, S., Borel, P., Colla, M., Gentschow, L., Langner, D., Jacob, C., Groß-Lesch, S., Sobanski, E., Alm, B., Schumacher-Stien, M., Roesler, M., Retz, W., Retz-Junginger, P., Kis, B., Abdel-Hamid, M., Heinrich, V., … Tebartz van Elst, L. (2015). Effects of group psychotherapy, individual counseling, methylphenidate, and placebo in the treatment of adult attention-deficit/hyperactivity disorder: A randomized clinical trial. JAMA Psychiatry, 72(12), 1199-1210. https://doi.org/10.1001/jamapsychiatry.2015.2146
  20. Hirvikoski, T., Waaler, E., Lindström, T., Bölte, S., & Jokinen, J. (2015). Cognitive behavior therapy-based psychoeducational groups for adults with ADHD and their significant others (PEGASUS): An open clinical feasibility trial. ADHD Attention Deficit and Hyperactivity Disorders, 7(1), 89-99. https://doi.org/10.1007/s12402-014-0141-2

Copyright and use in research

© 2026 Dr Richard Pomfret and Third Wave Therapy Tools. May be used in research with the author and site cited. Version 1.0, approved 10 October 2026, revised as the evidence develops.

Suggested citation (APA 7th edition): Pomfret, R. (2026). Steady the Surge: A skills-first, neuroaffirmative protocol for adults with ADHD and emotional surges (Version 1.0) [Therapist guide and worksheets]. Third Wave Therapy Tools. https://thirdwavetherapytools.com/

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