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Attention Training Experiment

Self-focused attention can make people less likely to see their social performance in a positive light, and contributes to the maintenance of social anxiety. The Attention Training Experiment is an exercise designed to help your clients learn to direct their attention outwards, so that they are more able to benefit from social experiments, and able to feel less anxious in social situations.

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Description

Self-consciousness refers to a tendency to direct attention inwards (Fenigstein et al., 1975), and appears to be a shared experience in several emotional disorders, most notably in social anxiety disorder (Stein, 2015). Closely related to self-consciousness is self-focused attention (SFA): a transdiagnostic cognitive process involving selective attention to self-referent information, including thoughts, feelings, memories, and bodily sensations, rather than external stimuli (Harvey et al., 2004; Ingram, 1990).

While self-consciousness and SFA are not always pathological, Ingram (1990) suggests that SFA becomes maladaptive when it results in ‘self-absorption’: an excessive, sustained, and inflexible attention to internal states. In other words, SFA is problematic when it is rigid and cannot shift according to situational demands (Mor & Winquist, 2002). Furthermore, SFA is often habitual and automatic (Warnock-Parkes, 2020).

According to the Clark and Wells (1995) cognitive model of social anxiety, SFA is a key maintenance process in this disorder. Social situations cause socially anxious individuals to direct their attention inwards to manage how they present themselves (such as by closely monitoring and observing their performance during interactions). Unfortunately, this has several deleterious consequences which perpetuate social anxiety, including:

  • Heightened awareness of distressing feelings and images that reinforce negative thoughts about one’s social performance.
  • The construction of distorted self-impressions (e.g., visual images or ‘felt senses’ about oneself) based on internally generated
    information (e.g., “I feel anxious so I must appear anxious to others”).
  • Reduced processing of external social cues (e.g., positive non-verbal feedback from others).
  • Biased processing of external social cues favoring rejection or disapproval (e.g., interpreting a brief loss of eye contact as a sign that the other person is bored).
  • Impaired social performance (e.g., difficulties tracking conversations due to self-focus).

It should be noted that the Clark and Wells (1995) model highlights several other factors that play a role in social anxiety. These include safety behaviors, problematic cognitive processes (e.g., anticipatory anxiety and post-event processing), and maladaptive cognitions (e.g., negative core beliefs and dysfunctional assumptions about social interactions).

Research has confirmed that SFA is pronounced among individuals with social anxiety and has many detrimental effects (Spurr & Stopa, 2002). For example, Hope and Heimberg (1988) found that individuals with social anxiety who scored high in public self-consciousness reported more negative thoughts, felt more anxious, appeared more anxious, and performed worse in a role-play task. Other research also suggests that SFA increases the likelihood of negative interpretations of social feedback (Pozo et al., 1991) and can obstruct disconfirmatory information processing (Wells, 2000). It follows that reductions in SFA are linked to improvements in social anxiety (Hoffmann, 2000). Furthermore, shifting the focus of attention from the self to external stimuli can augment the effects of exposure for social anxiety (Wells & Papageorgiou, 1998).

Cognitive therapy for social anxiety disorder (CT-SAD) is based on the Clark and Wells (1995) model and has proved effective (e.g., Clark et al., 2003). Attention training is a key intervention in CT-SAD and is introduced during the earlier stages of treatment (Warnock-Parkes et al., 2020). Following assessment and formulation, a behavioral experiment involving video-recorded social interactions is devised. The aim of video-feedback is to update clients’ negative self-images (“I don’t look as anxious as I thought I did”) and highlight how safety behaviors and self-focused attention make social anxiety worse. Attention training is introduced in the following session.

Attention training takes place during one meeting and is the focus of the session. Training aims to help clients focus their attention externally so that they can gather more accurate information during subsequent behavioral experiments (e.g., noticing how others respond to them during social interactions). In addition to reducing problematic self-monitoring, attention training can also reduce anxiety and make social interactions feel less threatening (OxCADAT, 2022).

Instructions

“People with social anxiety often feel self-conscious in social situations. Do you feel that way sometimes? One of the reasons why people feel so self-conscious is because they become self-focused. They pay close attention to how they are feeling, how they are performing, and how they appear in social situations, and pay much less attention to what’s going on in the world around them. Unfortunately, self-
focused attention can make social anxiety worse.

I’d like to spend this session doing some attention training with you. It involves us doing some exercises where we practice shifting your attention. Training your attention can help you feel less anxious in social situations and find out how you really come across to others. You could think of it as going to the ‘attention gym’. Do you think it could be useful to work through these exercises together?”

Attention training involves the client absorbing themselves in a series of in-session activities, which involve directing their attention outwards. It can be illuminating to compare this against the client’s experience of doing the same activity while focusing on their thoughts and feelings (directing their attention inwards) as well.

Warnock-Parkes and colleagues (2020) outline the following exercises, although the therapist determines the exact order. They recommend ending attention training with the therapist reading aloud as this is most similar to social interactions.

  • Task 1: Listening to sounds (e.g., the ambient noises inside and outside the consulting room).
  • Task 2: Looking at colors (e.g., the different shades of color in a series of vivid photographs).
  • Task 3: Listening to music (e.g., the different instruments in a piece of music).
  • Task 4: Noticing shadows and reflections (e.g., the different light textures in the consulting room).
  • Task 5: Listening to the therapist read a passage from a book. The client can also perform the exercise alone by listening to a podcast, or similar audio media.

Following each task, the therapist explores the client’s experience. Topics for discussion might include:

  • The degree to which the client could absorb themselves in each task.
  • How the client felt while they were absorbed in the task.
  • How threatening the world seemed while they were absorbed in the task.
  • How being externally focused compares to being internally focused (e.g., during social interactions).

For homework, clients might practice externalizing their attention in non-social situations, and whenever they feel self-conscious during interactions with others (OxCADAT, 2022). Clients are also reminded that externalizing one’s attention can be challenging (particularly in social situations) and requires practice.

References

  • Clark, D. M., Ehlers, A., McManus, F., Hackmann, A., Fennell, M., Campbell, H., Flower, T., Davenport, C., & Louis, B. (2003). Cognitive Therapy Versus Fluoxetine in Generalized Social Phobia: A Randomized Placebo-Controlled Trial. Journal of Consulting and Clinical Psychology, 71, 1058–1067. https://doi.org/10.1037/0022-006X.71.6.1058.
  • Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In G. Heimberg, M. R. M. R. Liebowitz, D. Hope & F. Scheier (eds), Social Phobia: Diagnosis, Assessment, and Treatment (pp. 69-93). Guilford Press.
  • Fenigstein, A., Scheier, M. R., & Buss, A. H. (1975). Public and private self-consciousness: Assessment and theory. Journal of Consulting and Clinical Psychology, 43, 522–527. doi:10.1037/h0076760.
  • Harvey, A., Watkins, E., Mansell, W., & Shafran, R. (2004). Cognitive behavioural processes across psychological disorders: A transdiagnostic approach to research and treatment. Oxford University Press.
  • Hoffmann, S. G. (2000). Self-focused attention before and after treatment of social phobia. Behavior Research and Therapy, 38, 1123-1132. DOI: 10.1016/s0005-7967(99)00105-9.
  • Hope, D. A., & Heimberg, R. G. (1988). Public and private self-consciousness and social phobia. Journal of Personality Assessment, 52, 626-639. DOI: 10.1207/s15327752jpa5204_3.
  • Ingram, R. E. (1990). Self-focused attention in clinical disorders: Review and a conceptual model. Psychological Bulletin, 107, 156–176. DOI: 10.1037/0033-2909.107.2.156.
  • Mor, N., & Winquist, J. (2002). Self-focused attention and negative affect: a meta-analysis. Psychological Bulletin, 128, 638-662. DOI: 10.1037/0033-2909.128.4.638.
  • OxCADAT (2022). Attention training. OxCADAT Resouces. https://oxcadatresources.com/.
  • Pozo, C., Carver, C. S., Wellens, A. R., & Scheier, M. F. (1991). Social anxiety and social perception: construing others’ reactions to the self. Personality and Social Psychology Bulletin, 17, 355-362. DOI: 10.1177/0146167291174001.
  • Spurr, J. M., & Stopa, L. (2002). Self-focused attention in social phobia and social anxiety. Clinical Psychology Review, 22, 947-975. DOI: 10.1016/S0272-7358(02)00107-1.
  • Stein, D. J. (2015). Social anxiety disorder and the psychobiology of self-consciousness. Frontiers in Human Neuroscience, 9, 489. DOI: 0.3389/fnhum.2015.00489.
  • Warnock-Parkes, E., Wild, J., Thew, G. R., Kerr, A., Grey, N., Stott, R., … & Clark, D. M. (2020). Treating social anxiety disorder remotely with cognitive therapy. The Cognitive Behaviour Therapist, 13, e30. DOI: 10.1017/S1754470X2000032X.
  • Wells, A. (2000). Emotional disorders and metacognition: Innovative cognitive therapy. John Wiley and Sons.