Attention Training Practice Record
When people struggle to control the focus of their attention, they find it much harder to interrupt cycles of worry, rumination, and other forms of self-focused attention. This can contribute to problems such as social anxiety. The Attention Training Practice Record helps clients learn to direct their attention, using a series of listening exercises.
Self-focused attention (SFA) is a transdiagnostic cognitive process that has been associated with multiple disorders (Woodruff-Borden et al., 2001). SFA involves selective (and often automatic) attention to self-referent information – bodily sensations, thoughts, emotions, beliefs, or memories – rather than external information (Ingram, 1990). While it is not always maladaptive, Ingram (1990) suggests SFA becomes problematic when it results in ‘self-absorption’: an excessive, sustained, and inflexible attention to internal states.
The attention training technique (ATT) aims to reduce SFA (Wells, 1990). It is a key component of metacognitive therapy (Wells, 2009) and is sometimes used as a standalone technique (e.g., Papageorgiou & Wells, 2000).
“Attention training… is based on the principle that intense and adhesive self attention contributes to maintenance of anxiety and other disorders and represents an emotional vulnerability factor.” (Wells, 2000).
ATT and metacognitive therapy are grounded in the self-regulatory executive function (S-REF) model, also developed by Wells (Wells & Matthews, 1994). The model suggests that psychological disorders result from self-regulatory strategies that “backfire”, and result in increased distress (Fergus & Bardeen, 2016). S-REF emphasizes a maladaptive style of thinking called the cognitive-attentional syndrome (CAS), wherein individuals engage in excessive conceptual processing of information in the form of worry and rumination (Wells, 2009). CAS also includes other problematic self-regulatory strategies, such as threat monitoring and thought suppression.
CAS is believed to arise from metacognitive beliefs (i.e., beliefs about one’s thinking). These include beliefs related to coping (e.g., “If I worry, I will be better prepared”) and cognition (e.g., “I am unable to control my worry”). Attentional control also plays a role in CAS in that it enables individuals to disengage from conceptual processing and perseverative self-focused attention (Reinholdt-Dunne et al., 2019). In other words, when individuals struggle to control the focus of their attention, they find it much harder to interrupt cycles of worry, rumination, and other forms of self-focused attention.
ATT aims to enhance attentional control. It achieves this using a series of auditory monitoring exercises “requiring progressively greater involvement of attentional resources” (Wells, 2000, p.88). By increasing control over attention, ATT can help clients:
- Be less influenced by metacognitive beliefs.
- Interrupt perseverative patterns of thinking (e.g., worry, rumination).
- Increase their ability to engage in disconfirmatory information processing.
- Reduce self-focused attention.
Research indicates that ATT is effective. In a recent systematic review, Knowles and colleagues (2016) conclude that ATT is an effective intervention for anxiety and depression, as well as some symptoms of psychosis. Wells (2000) has presented a recommended sequence for facilitating ATT:
- Psychoeducation: The therapist presents a rationale for using ATT.
- Attention ratings: The client’s SFA is measured before and after ATT.
- Phase one – selective attention: The client focuses their attention on a series of sounds while ignoring all others.
- Phase two – switching attention: The client moves their attention between the different sounds at a faster pace.
- Phase three – divided attention: The client focuses on all the sounds simultaneously.
- Post-training feedback and homework: The client is asked to practice ATT for homework.
“When people focus on their thoughts, feelings, physical sensations, or performance too much or too often, it can make them more distressed. Do you ever become very self-focused or self-conscious, or notice your attention gets ‘stuck’ on upsetting internal experiences? One way to address this is attention training, which aims to give you more choice and control over what you pay attention to. You could think of it as strengthening your attention ‘muscles’, but like any kind of training, it requires practice. Do you think training your attention could be helpful? This form will guide us through the process. You can also use it to record training you do on your own”.
- Step 1: Present a rationale. Discuss the ways self-focused attention can intensify and increase the detection of internal reactions, which contribute to negative beliefs and emotions. Disorder-specific rationales can also be provided. For example:
- Panic disorder: Focusing on physical symptoms can intensify them and make them seem more alarming.
- Health anxiety: Focusing on the body can exacerbate normal body sensations, increase awareness of them, and trigger health worries.
- Social anxiety: Self-focused attention can contribute to distorted inner images of the self and exacerbate negative thoughts and feelings.
- Depression: Dwelling on negative thoughts and feelings can make them more intense and worsen one’s mood.
- Step 2: Check the credibility of ATT. Check whether the client thinks ATT will be helpful (e.g., “On a scale of 0 – 100, how helpful do you think this training will be in overcoming your difficulties?”). If the client does not think ATT is credible, explore why and highlight its potential utility (e.g., repeat the rationale).
- Step 3: Obtain a self-attention rating. Before ATT, ask the client to rate the intensity of their self-focus. Wells (2000) recommends using a seven-point Likert scale ranging from -3 (“I am entirely externally focused”) to +3 (“I am entirely self-focused”).
- Step 4: Training. ATT is practiced with the therapist first. The client focuses their gaze on a spot on the wall and keeps their eyes open throughout the exercise. In the first phase (selective attention), the client listens to nine sounds in sequence (e.g., the therapist’s voice, tapping on a table, ticking of a clock) while ignoring all other sounds. Wells (2000) recommends incorporating three sounds within the consulting room and six sounds outside. In the second phase (switching attention), the client rapidly shifts the focus of their attention between these sounds. Finally, in the third phase (divided attention), the client focuses on all the sounds simultaneously. ATT usually lasts around 10 – 15 minutes (Fergus & Bardeen, 2016; Wells, 2000).
- Step 5: Feedback. Explore how the client found ATT, including any difficulties. Normalize how difficult ATT can be at first, and correct any misunderstandings that may have emerged (e.g., the client believes that distracting thoughts mean that they didn’t do ATT correctly). Remind the client that the aim is not to get rid of distracting thoughts or feelings, but to direct attention in a particular way (Wells, 2000).
- Step 6: Obtain a self-attention rating. Obtain a second rating of self-focus after ATT. A 2-point change on the scale mentioned earlier (towards being more externally focused) is typical. If this has not been the case, explore any difficulties that may have arisen during the exercise and repeat it if necessary. Limited change may indicate the client is attempting to control unwanted internal experiences or dividing their attention with worry or rumination during ATT (Wells, 2009). These issues should be addressed before attempting ATT again.
- Step 7: Homework. Remind the client that practicing ATT will strengthen their ‘attention muscle’ (Veale, 2007). Wells (2009) suggests practicing ATT twice a day for 10-15 minutes (Wells, 2000). However, the recommended length of self-practice sessions appears to vary, and training once per day is often more feasible for individuals (Fergus & Bardeen, 2016). Explore what sounds the client might incorporate into their training.
- Fergus, T. A., & Bardeen, J. R. (2016). The attention training technique: a review of a neurobehavioral therapy for emotional disorders. Cognitive and Behavioral Practice, 23, 502-516. DOI: 10.1016/j.cbpra.2015.11.001.
- 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.
- Knowles, M. M., Foden, P., El-Deredy, W., & Wells, A. (2016). A systematic review of efficacy of the attention training technique in clinical and nonclinical samples. Journal of Clinical Psychology, 72, 999-1025. DOI: 10.1002/jclp.22312.
- Papageorgiou, C., & Wells, A. (2000). Treatment of recurrent major depression with attention training. Cognitive and Behavioral Practice, 7, 407-413. DOI: 10.1016/S1077-7229(00)80051-6.
- Reinholdt-Dunne, M. L., Blicher, A., Nordahl, H., Normann, N., Esbjørn, B. H., & Wells, A. (2019). Modeling the relationships between metacognitive beliefs, attention control and symptoms in children with and without anxiety disorders: A test of the S-REF model. Frontiers in Psychology, 10, 1205. DOI: 10.3389/fpsyg.2019.01205.
- Veale, D., Willson, R., & Clarke, A. (2009). Overcoming body image problems including body dysmorphic disorder. Robinson.
- Wells, A. (1990). Panic disorder in association with relaxation induced anxiety: An attentional training approach to treatment. Behavior Therapy, 21, 273-280. DOI:10.1016/S0005-7894(05)80330-2.
- Wells, A. (2000). Emotional disorders and metacognition: Innovative cognitive therapy. John Wiley and Sons.
- Wells, A. (2009). Metacognitive therapy for anxiety and depression. Guilford.
- Wells, A., & Matthews, G. (1994). Attention and emotion: A clinical perspective. Erlbaum.