Foundation Metacognitive Therapy Skills

 

The effective implementation of MCT requires the use of several fundamental skills. There are four particular foundation skills that are important as a keel on which to build treatment. These skills are the focus of the present chapter.

The first skill concerns the therapist’s own ability to comprehend the different levels of cognition and to be able to shift between them, that is, to make a distinction between what is metacognition and what is “ordinary” cognition. The second skill is the ability to identify maladaptive cognitive processes that constitute the CAS in their different guises. The third skill is using metacognitive-focused Socratic dialogue. The fourth skill is learning to implement metacognitive-based exposure.

MCT is a skilled undertaking. Practice is the key to efficient and effective use of this approach. Supervision is a powerful ally in maintaining an appropriate focus on metacognitive factors in treatment and in developing greater levels of skill.

IDENTIFYING AND SHIFTING LEVELS

 

The natural tendency of the patient and the therapist is to conduct therapy at the cognitive level. Cognitive therapists usually engage the patient in reality testing of ideas in order to “encourage a more accurate description and analysis of the way things are” (Beck, Rush, Shaw, & Emery, 1979, p. 152). The focus is on examining the data against which to test the patient’s ideas. Reality testing also consists of identifying cognitive distortions in the patient’s thoughts and beliefs. It is likely that standard CBT procedures like this accomplish metacognitive changes—for instance, they certainly rely on fostering metacognitive awareness through the daily record of automatic thoughts. But patients are left evaluating thoughts against reality, a conceptual process, rather than simply choosing not to engage with their thoughts (a preferred goal of MCT).

If the therapist chooses the CBT approach, important aspects of MCT are missing because the work conducted is at the object level. The therapist joins with the patient in assuming that the thought or belief might be correct. Therefore great conceptual activity needs to be expended in evaluating the thought. If it is correct, then energy needs to be directed at problem solving. In part this is a form of conceptual processing and goal-directed coping that our patients are already engaged in. For example, a woman recently receiving treatment for generalized anxiety asked, “How do I decide which worries I need to respond to and which ones I can dismiss as distorted?” This person and the therapist were in cognitive mode. Unfortunately, they continued to discuss how it was possible to evaluate how realistic a worry was, and if it was realistic, then how to reasonably deal with it.

Although the therapist and the patient evaluate thoughts in CBT, which involves metacognitive awareness and metacognitive appraisals, treatment clearly operates at the cognitive (object-mode) level since the goal is to reality-test ordinary cognitions rather than to develop or test metacognitions. The metacognitive therapist must shift to a metacognitive level of working instead. For example, in the case of generalized anxiety disorder cited above, the therapist might say, “It seems as if you believe that you need to think about a worry in order to be able to cope. What would happen if you decided to do nothing with your worries?” This approach may elicit metacognitive beliefs about the need to engage in sustained conceptual activity and the possible negative consequences of not doing so, which can be tested. This line of questioning is firmly grounded in the metacognitive level of working and changes the way the patient experiences a worry (i.e., in a detached way) and explores and modifies metacognitive beliefs about worry. There is no attempt to work at the ordinary cognitive level of testing the reality of individual concerns.

The fundamental nature of the metacognitive level of working is that it should enable the patient to become aware of maladaptive thinking styles and processes, and to change the mental model of cognition and ways of experiencing thoughts. This entails more than simply reality testing the content of thoughts and beliefs and requires giving up maladaptive thinking styles (processes) and working at the higher level of testing the validity of beliefs about thinking.

As an example, let’s consider the case of a young man who believed that he was “defective.” He had suffered a history of abuse. This was his evidence of being defective or “spoiled.” A cognitive therapist would be likely to work at the cognitive level and to ask him to consider evidence against this idea, to examine the cognitive distortion in this belief, and to consider alternative conclusions. If the therapist used this approach, it migh well be effective, but it might not provide an alternative way of relating to negative self-beliefs and memories. CBT changes the level of conviction or the content of the belief but it does not help the patient to see that he is more than and separate from his beliefs and his memories. It would be useful to stand back from the belief and see it as an event in the mind rather than an essence of self, as one might with techniques such as detached mindfulness that are used in MCT.

A woman with obsessive–compulsive symptoms believed that she was contaminated with feces. She was concerned that she would become ill and would pass on diseases to her young daughter unless she scrubbed her hands in bleach. In CBT she might be asked to test her predictions that she was contaminated by refraining from washing in bleach and waiting to see if she or her child became ill. This approach would be a reasonable one to take in treatment, similar to exposure and response prevention. But her dysfunctional metacognitions might continue to operate because treatment has worked at the cognitive rather than at the metacognitive level.

If we were fortunate, this treatment might have enabled her to reality-test the belief that she is contaminated. In essence, we have removed the belief in contamination, just as washing removes that belief, albeit temporarily. In metacognitive therapy we aim to modify metacognitions rather than the lower-level thoughts and beliefs such as those concerned with contamination. Thus, the therapist shifts the focus of discussion in the session away from considering contamination (cognitive level) and explores beliefs about the importance of thoughts about contamination (metacognitive level). The patient does not simply learn that she is not contaminated. Instead she learns that her thoughts concerning feces are unimportant and need not be acted upon in any special way.

A 37-year-old man who had been traumatized in a robbery was continuously troubled by head pain, anxiety attacks, and intrusive memories of the event. When asked about the way he had been coping with these symptoms he said that he had been avoiding going out, using alcohol to “knock himself out,” and keeping himself alert to possible danger. He described how he had been going over the event to try and work out if there was anything he could have done differently in the situation. How can the therapist work at the metacognitive level in this case?

The traditional treatment approach might consist of imaginal reliving of the event and some reality testing of the patient’s distorted beliefs about himself and the nature of threat in the world. This would be an example of working at the cognitive level since we are changing the nature of his memory (cognition) and the content of his beliefs about himself and the world (cognition). Alternatively, the therapist could work at the metacognitive level by examining the way in which the patient controls his thinking about the trauma (metacognition), his beliefs about intrusive thoughts (metacognition), and his beliefs about the necessity to cope by going over events using rumination and worry (metacognition).

 

When the therapist and patient discuss the nature of problems in MCT, the therapist considers the patient’s negative thoughts and beliefs about the self and the world as symptoms or triggers of the problem because the true problem rests with how the patient implicitly or explicitly interprets and deals with these cognitive events. Keeping this in mind should allow the metacognitive therapist to make the necessary adjustments to focus therapeutic work at the metacognitive level.

The metacognitive level of working is one in which we ask the patient to step back from the thought or belief and see it as an internal event, as a symptom that does not require a conceptual or analytical response. In order to do that we do not simply appraise its validity but we try to engender a sense or mental model of what it is, an event in the mind, and we modify the metacognitions that give rise to the thinking styles that continuously support it. In contrast, reality testing an ordinary thought or belief to check its validity reinforces the mental model that some thoughts are facts and others are not. This obscures the situation that irrespective of validity, thoughts and beliefs are mental experiences that communicate information. It does not really matter if they are accurate or not, what is important is how we experience them and how we respond to them. The crucial factor is the nature of the metacognitive model that we have of our own cognitions.

DETECTING THE CAS

 

When starting out practicing MCT, therapists often fail to detect the CAS. Most prominent among these difficulties is the therapist’s failure to recognize worry and rumination either in the patient’s description of his or her thinking or as a process activated in session. It is essential that the therapist is and eventually the patient should become aware of and able to identify worry, rumination, threat monitoring, and counterproductive coping behaviors.

Periods of patient silence can be an indication that rumination and worry have been activated. Extended justifications of beliefs and repeated reflections on negative emotions are usually indicative of worrying or ruminating. A preoccupation with detail in verbal descriptions of events might be a marker for rumination or avoidant coping. In order to identify the process, the therapist must think beyond the content and validity of what the patient states and be aware of the activation of chains of negative processing. When these are observed they should be pinpointed and labeled to increase patient awareness, and the process interrupted rather than the content reality-tested.

Although these processes frequently play out spontaneously in the therapeutic encounter, a method of detecting them is to ask direct questions about their occurrence. The metacognitive therapist asks questions about dwelling on thoughts, worrying, ruminating, and brooding in response to stresses and emotions. The therapist aims to quantify in terms of frequency and duration the occurrence of these thinking styles. The therapist also asks if the patient has found that his or her attention has become “stuck” on any one thing in particular and what that is. This can be the basis for identifying threat monitoring. The therapist asks if the patient has tried to control thoughts or to cope with emotions or any perceived threat, and what form these responses take and how effective they have been.

The process of threat monitoring may also be observed in session. For example, an obsessional patient could be seen scanning the floor during treatment. This was apparent on the videotape of the session brought to supervision, but the student therapist had not observed this at the time of therapy. At the next session this floor scanning was noted and the therapist asked the patient about it. The patient stated that she was looking to see if there was any evidence that rat poison might have been spilt on the floor. This prompted a very useful discussion about the problem of trying to remain safe through threat-monitoring strategies. In other words, what effect does this strategy have on the frequency of thoughts about contamination and on learning that thoughts about contamination are unimportant?

In another example, a health-anxious patient repeatedly grasped his neck during the assessment interview. When asked about this action, he reported that he had to perform this action to feel his pulse to check whether his heart was beating normally. In this case, the threat-monitoring strategy had been detected by the therapist.

Some maladaptive coping behaviors are covert and readily overlooked by the therapist. The therapist must make a habit of asking about suppression, thought control strategies, emotional control, and avoidance strategies and exploring their idiosyncratic nature. For example, one patient stated that she was trying to stop her thoughts of a traumatic event. The therapist assumed that this meant she was suppressing them and failed to explore this statement in sufficient detail. Later the therapist discovered that the patient was trying to get rid of her thoughts by thinking as much as possible about the trauma because she had read that in order to overcome fear it must be confronted. When the patient was instructed to reduce this excessive thinking, she discovered that her thoughts about the trauma faded.

There are additional strategies for detecting the CAS, such as examining the idiosyncratic rating scales (e.g., CAS-1) and drawing the patient’s attention to the occurrence of individual components. The therapist can follow this strategy by instructing patients to record how often they notice themselves dwelling on negative thoughts or trying to suppress ideas that might trigger their concerns.

It should be expected that patients continue to engage in worry and rumination and other aspects of the CAS for some time during the early stages of treatment. It is important for the therapist to repeatedly draw the patient’s attention to these processes since they will be manifested in different ways. The demonstration that change in content and focus is not indicative of change in processes is useful in building greater meta-awareness and in arresting perseverative activity.

USING A METACOGNITIVE-FOCUSED SOCRATIC DIALOGUE

 

MCT uses Socratic dialogue to explore meanings, underlying processes, and beliefs. However, the focus of the dialogue differs from the focus that is typical of CBT. In CBT the therapist uses questioning to explore the content of thoughts and beliefs and to direct treatment to modifying beliefs. In MCT the therapist uses questioning to detect and arrest the CAS. When beliefs or assumptions are a focus, the Socratic dialogue is aimed at detecting and modifying beliefs about thoughts and emotions (metacognitions), rather than thoughts about the self and the world.

The two dialogues presented below first illustrate the traditional CBT approach and then the new MCT approach.

CBT Dialogue

THERAPIST: What led you to feel depressed?

PATIENT: When John didn’t want to see me.

THERAPIST: What did that mean to you?

PATIENT: I think no one likes me, I’m just boring.

THERAPIST: So it sounds as if you have negative thoughts when that happens. Do you think everyone gets depressed when this happens?

PATIENT: No, because they don’t think it’s as important.

THERAPIST: Right, so we need to examine what you think. What does it mean to you when people don’t want to meet up?

PATIENT: It means I’m boring, and they’re not interested in me.

THERAPIST: How much do you believe it’s because you’re boring?

PATIENT: I must be, otherwise people would invite me out.

THERAPIST: How does that thought make you feel?

PATIENT: Very sad and lonely.

THERAPIST: So it’s the meaning that you give to situations that makes you sad. It’s what you believe about them. You think people don’t see you because you are boring. What if there are alternative and more likely reasons why people can’t see you?

MCT Dialogue

THERAPIST: What led you to feel depressed?

PATIENT: When John didn’t want to see me.

THERAPIST: What did that make you think?

PATIENT: I think no one likes me, I’m just boring.

THERAPIST: So it sounds as if you have negative thoughts when that happens. What’s the first thought that starts you off?

PATIENT: I think, Why doesn’t he want to know me?

THERAPIST: Right. Let’s examine how you think in response to that initial thought. What do you go on to think?

PATIENT: I try to work out what’s wrong with me. Maybe it’s because I’m boring, maybe they don’t like me. I try and work out why it’s happening to me.

THERAPIST: How much time do you spend doing that?

PATIENT: It can last hours.

THERAPIST: How does that make you feel?

PATIENT: Very sad and lonely.

THERAPIST: So it’s the way you respond to the thought “Why doesn’t John want to know me?” that makes you sad. You’re trying to find an answer by analyzing what is wrong with you. Is that likely to make you feel happy or sad? What if there are better ways of responding to that thought?

The end question of each way of working is very different. In the CBT example the question is “What if there are alternative and more likely reasons why people can’t see you?” Compare this with the MCT question: “What if there are better ways of responding to that thought?” The MCT approach focuses on the impact of the rumination process that is triggered by a negative thought and shifts the patient to a metacognitive mode of working. In contrast, the CBT dialogue is operating in object mode in which thoughts are evaluated to determine if they are facts. Furthermore, the patient is encouraged to continue analyzing reasons for not being seen, perpetuating a conceptual process rather than terminating it.

As in the example above, the Socratic dialogue in MCT aims to identify instances of worry/rumination and other features of the CAS. The exploration of different components of the CAS using a metacognitive-focused Socratic dialogue is illustrated further in the following dialogues.

Exploring Worry

THERAPIST: When you had the thought “I could have failed,” what did you then go on to think about?

PATIENT: I thought of what I could have done and how I could deal with it next time.

THERAPIST: How long did you think like that?

PATIENT: For the rest of the evening. I couldn’t get it out of my mind.

THERAPIST: So you were worrying about the future and how to cope?

PATIENT: Yes, I’ve got to think about it or I’ll never get it out of my mind.

THERAPIST : Can you get it out of your mind so long as you think or worry about it?

Exploring Threat Monitoring

THERAPIST: Have you found that what you pay attention to has changed since you began feeling like this?

PATIENT: Yes, I’m aware of feeling tired and unwell most of the time.

THERAPIST: Is that something you check for?

PATIENT: When I get up in the morning I check to see how I feel, and then I know if it will be a good or a bad day.

THERAPIST: How do you expect to feel if it’s a good day?

PATIENT: I should feel relaxed and rested, but usually I feel tired and my mind is hazy.

THERAPIST: How much of the time are you monitoring your mind and feelings?

PATIENT: I’m aware of it most of the time.

THERAPIST: If you are looking for feelings of tiredness are you more or less likely to find them?

 

Exploring Coping Behaviors (e.g., Thought Suppression, Avoidance)

THERAPIST: When you have the thought “I’ve got a brain tumor,” what do you do to deal with it?

PATIENT: I reduce my activity because I don’t want to cause a stroke. I then ask my partner for reassurance. If I’m really worried I make an appointment to see my doctor.

THERAPIST: The ways you cope are to reduce your activities and seek reassurance from your partner or doctor. Has that enabled you to overcome your problem?

PATIENT: No, I still have the symptoms, and I think “What if the tumor is still growing and hasn’t been detected yet?”

THERAPIST: So what has happened to your worry since you’ve been coping like this? Has it stopped?

PATIENT: No, I’m still worried about my health.

THERAPIST: So perhaps we need to explore alternative ways of responding to your thought of a brain tumor. Perhaps you could choose to ban reassurance seeking, postpone your worries, and increase your activities.

Using Socratic Dialogue to Uncover Metacognitive Beliefs

 

While the examples above illustrate using Socratic dialogue to explore and weaken the CAS, it also serves in searching for metacognitive beliefs. Our patients show a response pattern consisting of the CAS because of the influence of metacognitive beliefs on processing. Uncovering these beliefs and changing them is an important feature of MCT. The following extracts from cases illustrate the use of the Socratic method in detecting metacognitive beliefs (the beliefs are italicized for ease of identification). The questions used typically ask about the advantages and disadvantages of using thinking styles, about the controllability of thoughts, and about the worst consequences of having them.

Detecting Positive Metacognitive Beliefs about Worry

THERAPIST: We identified that you worry about failure and the future. Are there any advantages to worrying?

PATIENT: I’m not sure what you mean by “advantages.”

THERAPIST: Does worrying help you in any way?

PATIENT: Yes, it’s important to try and anticipate problems so that I can be prepared.

THERAPIST: Do you believe that worrying makes you prepared?

PATIENT: Yes, if I worry, then I’ll be able to deal with problems effectively in the future.

THERAPIST: How much do you believe that on a scale of 0 to 100%?

PATIENT: Eighty percent. It wouldn’t be right not to think about problems.

THERAPIST: So it’s either worry or nothing in your mind?

PATIENT: Yes, now that you mention it, but what are the alternatives to worry?

Detecting Positive Metacognitive Beliefs about Threat Monitoring

PATIENT: I’ve made a complete fool of myself.

THERAPIST: How do you know?

PATIENT: I could see everyone looking at me.

THERAPIST: Do you normally check to see if people are looking at you?

PATIENT: No, it’s more like a feeling.

THERAPIST: On this occasion did you check other people or was it a feeling?

PATIENT: Now that you ask, I guess it was more of a feeling.

THERAPIST: What feeling do you use to determine if you’ve made a fool of yourself?

PATIENT: If I feel awkward and rigid, I’m afraid they can see that.

THERAPIST: So the thing you focus on is whether you feel awkward and rigid?

PATIENT: Yes, I don’t want to feel that.

THERAPIST: Are there any advantages to focusing your attention on those feelings?

PATIENT: It stops me from losing control.

THERAPIST: How much do you believe focusing on your feelings stops you from losing control?

PATIENT: If I didn’t do it things would be worse. I’m sure it helps.

 

Detecting Negative Metacognitive Beliefs

THERAPIST: It sounds as if you are spending a lot of time analyzing what is wrong and worrying about the future. Does that make you feel better?

PATIENT: Sometimes, but usually it makes me feel more depressed.

THERAPIST: That process of analyzing and excessive thinking is called rumination. Could you stop doing it if it makes you feel worse?

PATIENT: No, I don’t think it’s controllable.

THERAPIST: How much do you believe my rumination is uncontrollable?

PATIENT: One hundred percent.

THERAPIST: Could anything bad happen if you continued to ruminate in this way?

PATIENT: I’m not sure.

THERAPIST: What’s the worst that could happen?

PATIENT: I think it’s abnormal, it’s just further proof that I’m mentally ill, I’ll always be a depressive, I can’t control the way I think. (Note: What is the patient doing right now in this answer? Did you identify the start of a rumination sequence?)

Using Socratic Dialogue to Explore Maintenance Processes in Socialization

 

The therapist uses Socratic dialogue to communicate the metacognitive formulation and to engage the patient in the treatment process. This “socialization” of the patient to MCT is achieved by exploring maintenance processes as set out in the model. In particular, the therapist aims to show the impact of worry and rumination on anxiety or mood, the ineffectiveness of coping strategies such as thought suppression, and the consequences of threat monitoring on anxiety and appraisals. Some examples of these processes follow.

 

Threat Monitoring in a Case of Generalized Anxiety Disorder

THERAPIST: What do you think are the consequences of constantly paying attention to how your mind works?

PATIENT: I need to be sure that I’m not losing my mind.

THERAPIST: When you focus on your mind do you notice it is working how you want it to?

PATIENT: No, I usually find that it’s not working how I’d expect.

THERAPIST: Could focusing in that way interfere with how well you think it works?

PATIENT: Yes, I suppose it could.

THERAPIST: So you see how one of your coping strategies of monitoring your mind is contributing to your worries. That sounds like it could be a vicious cycle to me.

 

Thought Suppression in a Case of Obsessive–Compulsive Disorder

THERAPIST: You said you try to control your thoughts. What do you do?

PATIENT: I try not to think about murderers.

THERAPIST: Does that seem to be working?

PATIENT: No, I still get the thoughts.

THERAPIST: Is it possible to forget about something that you are trying not to think about?

PATIENT: No, I suppose you have to remind yourself of what it is.

THERAPIST: That’s right. Does pushing the thought away help you discover it is meaningless?

PATIENT: No, I suppose I’m scared of having the thought.

THERAPIST: So the way you deal with it can keep your anxiety going and make the thought more important than it really is.

Coping Behaviors in a Case of Panic Disorder

THERAPIST: How do you stop yourself from suffocating?

PATIENT: I slow down and take deep breaths. I have to get a special deep breath that clicks.

THERAPIST: Do you think there are any problems with doing that each time you think you’re suffocating?

PATIENT: Well, sometimes I’m aware that I hyperventilate.

THERAPIST: Yes, that could make your symptoms worse, and that’s one maintenance process. Let’s explore another one. If you save yourself each time, do you discover that these are simply thoughts about suffocating?

PATIENT: No, I keep thinking it could happen next time.

THERAPIST: That’s right. You don’t allow yourself to discover that it’s only a thought and that you are not going to suffocate. So the thought keeps its importance. (Note: The behavior prevents disconfirmation of belief in the thought. It also prevents the patient from relating to the thought as a thought, that is, from shifting from the cognitive level to the metacognitive level and becoming detached from it.)

Worrying in a Case of Hypochondriasis

THERAPIST: You said that worrying and analyzing your symptoms stops you from missing something that could be important and it could save your life. Do you think there are any problems with thinking like that as a way of coping?

PATIENT: Well, I don’t suppose it’s very positive.

THERAPIST: That’s right. So how does thinking that way influence what you believe?

PATIENT: Well, I’m going to end up believing the worst.

THERAPIST: So is your problem a brain tumor or is your problem that you keep thinking the worst?

PATIENT: It might be that I keep thinking the worst.

METACOGNITIVELY FOCUSED VERBAL REATTRIBUTION

 

The verbal reattribution techniques in MCT are similar to those of CBT, but they differ in focus. They are used to modify negative and positive metacognitive beliefs rather than the content of other thoughts and beliefs. Common types of questions used in both CBT and MCT are as follows:

 

1.      Questioning the evidence for and against the belief

What is the evidence supporting this belief?

What is the evidence against this belief?

2.      Presenting counterevidence?

Give information about the benign nature of anxiety.

Show how worry is different from stress.

3.      Identifying the cognitive distortion

Is this an example of catastrophizing, black-and-white thinking?

4.      Questioning the mechanism

“How can worry or anxiety harm you?”

“How can worrying keep you safe?”

5.      Questioning the advantages and disadvantages of the belief

“What are the advantages of controlling your thoughts?”

“What are the disadvantages of controlling your thoughts?”

6.      Evaluating the quality of the evidence supporting the belief

“Would this evidence convince someone else?”

7.      Rating and re-rating belief

“How much do you believe that?”

“How much do you believe that now that we’ve reviewed the evidence?”

The following examples illustrate this type of questioning to weaken a range of different metacognitive beliefs.

Negative Belief in Uncontrollability

THERAPIST: How much do you believe that your worry is uncontrollable?

PATIENT: Seventy percent.

THERAPIST: Have you tried to control it?

PATIENT: Yes, but it doesn’t work. That’s why I know I don’t have control.

THERAPIST: How does a worry ever stop if you can’t control it?

PATIENT: The problem is no longer there.

THERAPIST: So what happens to your worry if you have to answer the telephone?

PATIENT: Well, then it stops because I have to think about something else.

THERAPIST: So is that some evidence that you can control it?

PATIENT: Yes, a little evidence.

THERAPIST: Let’s test your belief in uncontrollability. I’d like to introduce an experiment….

Negative Belief in Danger

PATIENT: I don’t want to think these thoughts.

THERAPIST: What’s the worst that will happen if you allow yourself to have them?

PATIENT: I might act on them and harm someone.

THERAPIST: How much do you believe having a thought will make you act on it?

PATIENT: Ninety percent.

THERAPIST: What’s your evidence?

PATIENT: I don’t have any—I’m just worried it could happen.

THERAPIST: Maybe it’s just a worry then. Is there any counterevidence?

PATIENT: Well, I’ve never harmed anyone before.

THERAPIST: That’s a good point. How many bad thoughts have you had?

PATIENT: Too many to count.

THERAPIST: So is that evidence that thoughts have the power to make you do something or is it evidence they don’t?

PATIENT: Maybe some evidence they don’t have power.

THERAPIST: How much do you believe that they have power?

PATIENT: Seventy percent.

Positive Belief about Rumination

THERAPIST: How much do you believe that analyzing the past will help you feel better?

PATIENT: One hundred percent.

THERAPIST: Has it worked yet?

PATIENT: Sometimes I get the answer, so I think it does.

THERAPIST: Have you solved your problem of depression then?

PATIENT: No.

THERAPIST: So where’s the evidence that it’s working to help you overcome your depression?

PATIENT: Well, I don’t really know. But I can’t think about nothing.

THERAPIST: Sounds like you have a black-and-white view of your thinking. It’s either analyzing the past or nothing as a means of dealing with your low mood. What do you think are the consequences of that?

PATIENT: Well, I guess I’ll continue to analyze things.

THERAPIST: How often does that lead you to feel better?

PATIENT: Not always. I can get worse before getting better.

THERAPIST: So perhaps it makes you worse?

PATIENT: Yes, I think it does.

THERAPIST: So how much do you believe it’s helping in the long term?

PATIENT: I don’t know. Maybe I’m not doing it enough.

THERAPIST: Okay, should we get you to do it more and see if that helps?

PATIENT: No, I don’t think it’s going to make things better.

THERAPIST: How strong is your belief it helps then?

PATIENT: Less now, probably twenty percent.

METACOGNITIVELY DELIVERED EXPOSURE

 

Exposure is a component of MCT. However, treatment does not necessitate prolonged and repeated exposures as a means of producing emotional change. The goal of exposure in MCT varies: it is used both to modify beliefs and to strengthen alternative and more adaptive processing. Three types of metacognitively delivered exposure are used to (1) facilitate belief change in general, (2) specifically challenge metacognitive beliefs, and (3) promote adaptive processing of trauma.

General Belief Change

 

Any behavioral experiment that involves exposure to a feared stimulus with the aim of testing beliefs is an unspecified metacognitive technique since it is evoking the appraisal of cognition. Experiments of this kind can be improved by delivering them in more highly specified metacognitive terms. That is, the way in which a patient processes information during, before, and after exposure can be controlled to maximize belief change. This can be likened to writing a metacognitive script or plan for guiding processing.

For example, a patient suffering from social phobia typically avoided paying attention to other people’s faces during social interactions. She also ruminated about the impression she might have made for hours afterward. Despite the fact that she had been exposed daily to social situations, her belief that “people think I’m stupid” had been present for years. She had received psychological treatment several years earlier in which she had been exposed to social situations while learning to control her anxiety and to use self-assertiveness. This helped at the time, but she felt that her anxiety had continued to be a problem. During MCT she was exposed to social interactions under the instruction to focus attention on other peoples’ faces. Specifically she was asked to “try to form a complete impression of what the other person looks like, as if you will need to recognize him or her in a crowd.” In addition she was instructed to notice when she began to analyze her performance after the event and to ban this activity and apply detached mindfulness to her intrusive thoughts. This procedure of orchestrating her style of processing during and after exposure to situations enabled her to discover that her problem was one of negative thinking and not one of what people might think. For an experimental test of the effects of this type of approach, see Wells and Papageorgiou (1998b).

 

Challenging Metacognitive Beliefs

 

In MCT the therapist specifically targets positive and negative beliefs about thinking. Thus, exposure is presented with a rationale that is specifically intended to test metacognitive beliefs.

For example, a patient with obsessive–compulsive disorder was asked to touch a contaminant and postpone washing to test his belief that “thinking it is contaminated must mean it is contaminated.” This is very different from a habituation rationale (e.g., “Do not wash and your anxiety will subside”) or a cognitive rationale (e.g., “Do not wash and you will discover that nothing bad will happen”). In the MCT condition the focus is on challenging the belief about the importance of the intrusive thought, not the likelihood of danger actually occurring or responsibility for preventing it. For an experimental test of the effects of this type of approach, see Fisher and Wells (2005).

In another example of MCT in generalized anxiety disorder, the therapist exposed the patient to the worry process as an explicit test of beliefs that worry is harmful (e.g., “Try to worry more to see if you become psychotic”). This differs from standard CBT where exposure involves avoided situations in order to reality-test the content of worry or exposure involves the worry process itself to promote habituation.

 

Facilitate Adaptive Processing of Trauma

 

This type of metacognitively delivered exposure aims to remove aspects of maladaptive processing and those coping styles that interfere with self-regulation. It is most often used in MCT for trauma. Here the patient is instructed to respond to spontaneous intrusive thoughts in a particular way that facilitates built-in and automatic self-regulation processes. This is not presented as a test of beliefs but as a way of removing barriers to normal emotional processing. It is not assumed, as is the case in usual CBT practice, that there should be repeated exposure to and elaboration of trauma memories. Instead patients are instructed to acknowledge their intrusions and to refrain from engaging with them in any way such as by analyzing the event, pushing intrusions away, or worrying about future danger. This approach is presented with the rationale that emotional healing is a natural process that occurs spontaneously if it is not disrupted by certain unhelpful responses to thoughts and feelings.

For example, an individual traumatized by being stabbed in the street reported that he repeatedly had intrusive thoughts about the event and the feeling of heat in his abdomen at the site of the wound. Rather than going over his memory trying to defragment it and promote habituation, as might be practiced in CBT, the MCT therapist explored his typical response to the intrusion. The patient described normally trying to distract himself from the intrusion and analyzing what he could have done to fight off the attacker. The therapist instructed him to abandon these strategies and instead to keep a passive watch over the intrusion without pushing it away, without trying to distract from it, and without analyzing what he could have done. In this way the thought was deprived of its salience and influence and the patient began to notice that it faded on its own.

 

Using the P-E-T-S Protocol in Exposure

 

Exposure experiments in CBT have been conceptualized as consisting of four components—preparation, exposure, testing, and summarizing—which have been labeled the P-E-T-S protocol (Wells, 1997). They are normally used to test specific predictions based on the patient’s thoughts/ beliefs. Each element represents a stage in a sequence. These experiments are used in the treatment of anxiety disorders. Although they incorporate exposure, this is usually brief and is coupled with a specific rationale and a disconfirmatory strategy or test. The P-E-T-S system is depicted diagrammatically in Figure 3.1. This system is also normally used for testing metacognitive beliefs, such as the belief that rumination is uncontrollable, the belief that thoughts can be harmful, and the belief that worry is useful.

The first stage is preparation (P), which consists of focusing on the target metacognition to be challenged. It involves exploring the evidence for that metacognition and the coping behaviors that prevent its disconfirmation. A belief rating is made at this stage. Then a prediction is set up that specifies what should occur if the coping behaviors are modified. In doing so the therapist provides an explicit goal for the experiment as a means of evaluating a thought/belief.

The next phase is exposure (E). This refers to exposing the patient to the internal event that activates the metacognitive belief. For example, this could be exposure to bodily sensations or thoughts in obsessive–compulsive disorder (OCD), or avoided news items that normally lead to a thought that triggers worry in generalized anxiety disorder (GAD).

The third phase consists of the test (T). This is performing a change in behavior that acts as an unambiguous test of a patient’s prediction. For example, while reading news items about crime a patient with GAD might try to worry intensely to test the prediction that it is possible to lose control of his or her mind. (In the later stages of treatment the test phase is often replaced with a practice phase involving practicing the implementation of alternative plans for processing in order to strengthen alternative response styles.)

FIGURE 3.1. The P-E-T-S protocol for behavioral experiments. Adapted from Wells (1997). Copyright 1997 by John Wiley & Sons Limited. Adapted by permission.

The final phase is the summary (S). This involves summarizing the result of the experiment in relation to the original prediction and then rerating belief. The experiment is then refined and repeated in order to further lower the belief level.

An example of implementing an experiment using P-E-T-S can be seen in a patient with OCD who was concerned that he would molest children if he had thoughts of a sexual nature:

THERAPIST : What will happen if you have these thoughts?

PATIENT : Well, nothing will happen if I control them.

THERAPIST : What if you don’t control them?

PATIENT : I’m afraid that I could do something.

THERAPIST : So you believe that having the thought has the power to make you act on it?

PATIENT : Yes, and that disgusts me.

THERAPIST : How much do you believe the thought could make you do it?

PATIENT : Sixty percent.

THERAPIST : If I asked you to have those thoughts right now, would that make you act on them?

PATIENT : No, because I’m not in a risky situation.

THERAPIST : What would be a risky situation to expose you to?

PATIENT : If you asked me to drive past a school.

THERAPIST : Okay, so we’ve identified a belief you have about these thoughts and a situation in which you could have them to test it out. You must challenge your belief about these thoughts in order to overcome your anxiety. What I want you to do for homework is to drive past a school while deliberately repeating these thoughts. In this way you can learn that these are only thoughts and they are not important. Can you think of a school you could try?

PATIENT : Yes, I know where all the local schools are because I try to avoid them.

THERAPIST : At the next session we’ll review how the experiment went.

In this example we can identify the elements of P-E-T-S as follows:

P = Find a target metacognition: “The thoughts will make me act on
      them.”

Make a belief rating (60%).

Identify a situation.

Explore the usual coping behaviors as a source of an alternative
test strategy by reversing them (e.g., reverse controlling thoughts and avoidance). Set up a prediction (“Let’s see if you act on it”).

E = Drive past a school to elicit thoughts and activate belief.

T = Ban controlling thoughts and instead deliberately have more of
      them.

S = In the next session rerate belief and refine experiment as necessary.

Here the summarizing phase is carried over to the next treatment session because this experiment was set for homework. In other situations the whole experiment including the summary phase can be conducted during the treatment session. Some sessions contain several experiments of this kind.

CONCLUSION

 

In this chapter several foundation skills that are central to practicing MCT were described. Each of these skills represents an example of working at the metacognitive level in treatment, using Socratic dialogue, and implementing specific change strategies. These basic skills will be found reverberating in the material presented in the disorder-specific chapters throughout this book.

The therapist using MCT requires a clear understanding of metacognitive levels of working, and should be able to identify maladaptive processes and metacognitive beliefs. The ability to focus the therapeutic process on this level and away from ordinary cognition is crucial.

The therapist can use the basic techniques of cognitive therapy. However, he or she should implement them in a way that is parsimonious with the metacognitive model. Socratic dialogue should be utilized to explore the CAS, to examine maladaptive metacognitive beliefs, and to socialize to the metacognitive model. It should be used to challenge metacognitive beliefs and coupled with behavioral experiments in this regard.

The optimal use of exposure in MCT considers how exposure can be configured to change metacognitive beliefs or manipulate processing styles that support adaptive learning.

CHAPTER 4

Attention Training Techniques

 

This chapter introduces metacognitive treatment techniques that directly modify the control of attention. We saw in earlier chters how patients are conceptualized as “locked into” unhelpful thinking patterns that they find difficult to bring under control. The metacognitive model assumes that the control of attention in psychological disorder becomes inflexible as attention is bound up with perseverative, self-focused, worry-based processing and monitoring for threat. The redirection of attention away from such activity should provide a means of interrupting the CAS and of strengthening metacognitive plans for controlling cognition (improving flexible executive control).

In this chapter I present the treatment manual for one particular strategy called the attention training technique (ATT). Later in the chapter I broaden the discussion to briefly consider another strategy called situational attention refocusing (SAR). These two techniques have different aims within the metacognitive treatment approach. It is important to note that neither strategy is a means of distraction from internal events or a means of managing or avoiding emotion. The use of distraction in psychotherapy usually entails shifting attention onto neutral or positive stimuli as a means of attenuating attention to painful, emotional, or threatening stimuli and thereby reducing the intensity of reactions to them. The ATT and SAR do not involve shifting attention to neutral or positive stimuli to control or avoid subjective experiences. Instead they involve shifting attention in ways that are specifically designed to strengthen metacognitions that regulate thinking, remove unhelpful thinking styles that impede normal emotional processing, or modify beliefs.

OVERVIEW OF THE ATT

 

The aim in developing the ATT was to devise a procedure that could impact several dimensions of the CAS and the metacognitions driving it. The first published study reported its effects in the treatment of a panic disorder case (Wells, 1990). In that study the initial objective was to use a technique that could interrupt excessive and inflexible self-focused attention. Self-attention of this kind is a key ingredient in worry/rumination and threat monitoring (e.g., attending to bodily events in panic), which are central components of the CAS.

An important question in the development of the ATT concerned the aspect of attention that should be manipulated as a basis of interrupting the CAS and increasing metacognitive flexibility. Attention is multifaceted and can be divided into aspects of selectivity, switching, parallel processing, and capacity requirements. The ATT was devised with these dimensions in mind and how the technique might interface with the patient’s goals.

Several characteristics of the technique were theoretically grounded and specified at the development stage. It was important that it should be attentionally demanding and not become substantially less demanding with practice; otherwise it would not systematically strengthen control processes. It should involve external processing of non-self-relevant material so as to interrupt perseverative self-focused processing. It should not be employed by the patient as a distraction, avoidance, or symptom-management strategy because this could maintain dysfunctional self-focused control and erroneous beliefs about internal events.

Initial attempts to develop an effective technique explored the use of visual attention strategies, but the results were weak. A later attempt involved developing an auditory-based attention procedure that required the spatial allocation of attention. This procedure has remained the basis of the ATT.

The ATT consists of three components: (1) selective attention, (2) rapid attention switching, and (3) divided attention. Each component is practiced in a single seamless exercise. The procedure lasts approximately 12 minutes and is roughly partitioned as follows: 5 minutes for selective attention, 5 minutes for attention switching, and 2 minutes for divided attention.

Selective attention instructions consist of guiding the patient’s attention to individual sounds among an array of competing sounds at different spatial locations in the environment, with the instruction to give intense attention to specific individual sounds while resisting distraction by others.

Rapid attention switching consists of instructions to shift attention between individual sounds (and spatial locations) with increasing speed as this phase progresses. At the beginning of this phase approximately 10 seconds is devoted to different individual sounds. Subsequently, the speed of switching is increased to one sound every 5 seconds.

The ATT technique ends with a briefer (1–2 minutes) divided attention instruction in which the patient is asked to expand the breadth and depth of attention and attempt to process multiple sounds and locations simultaneously.

The procedure is configured so that it consistently loads attention. To this end multiple simultaneous sounds should be used in a training session. The pace of switching in the switching phase can be modulated. The procedure ends with divided attention so that the technique retains a resource-demanding character.

Between six and nine sounds, combined with spatial locations, are identified or introduced for the exercise depending on the level of demand required. Some but not all of these sounds are “potential sounds” and can be operationalized solely as locations in space. The sounds may not exist during the practice of a particular exercise. For example, the patient is asked to “focus on any sounds in the far distance that might be detected on the right-hand side.” In this way attention is allocated to a location in space irrespective of the occurrence of detectable sound events occurring in that space. Thus, the technique utilizes an inner metacognitive map for the spatial allocation, control, and intensity of attention.

Typically a minimum of three actual competing sounds are used at different spatial locations in the consulting room, a further two sounds are identified outside of the consulting room in the near distance, and two more sounds (or locations) are indicated in the far distance (these two “sounds” may consist of “spatial locations”—for example, one to the left and one to the right for focusing attention in the distance). The near distance is usually defined as outside the practice room but within the building and the far distance is defined as outside the building.

Given this range of parameters there is usually enormous scope for varying the precise nature of the technique between sessions, which offsets the effects of practice on task difficulty and provides sufficient flexibility so that the ATT can be implemented in most environments. Recorded versions of sounds have also been used in the implementation of ATT.

Patients are usually asked to focus on a visual fixation point and to maintain their visual focus throughout the exercise. The ATT is practiced when participants are not in a state of anxiety or acute worry. This underscores the point that the technique is not intended as an emotion management strategy. However, when used in the treatment of depression, the technique inevitably necessitates application during chronic low mood, but even in this case the technique is not intended or used as an immediate alleviation of sadness.

RATIONALE FOR THE ATT

 

A credible and acceptable rationale is an important component of the ATT. This increases compliance with the procedure and with homework practice. It also frames the technique in an appropriate way that counteracts the effects of some unhelpful processes. More specifically, the rationale emphasizes that the technique is not intended to lead to a “blank mind” free from intrusive inner experiences. Similarly, the rationale counteracts the use of active thought suppression.

Components of the rationale emphasize that inner events that intrude into consciousness should be treated as additional noise and should not be resisted. This facilitates the shift to a metacognitive mode and a state of detached mindfulness.

Unrealistic expectations and assumptions about the technique should be elicited and dealt with before practicing. A common misconception is that the procedure should “block out” unwanted thoughts and feelings. The therapist should emphasize that unwanted intrusive experiences should be regarded as additional noise. The therapist should indicate that it is desirable to be aware of these intrusions and continue to direct attention as instructed even in the presence of this awareness.

Slightly different rationales have been used across disorders that have been tailored to capture the specific nature of the CAS in each case (see Wells, 2000), but they are all based on a generic rationale that can be expressed as follows:

“Anxiety and depression are unpleasant emotional experiences that signal some kind of threat or loss. They become persistent and a problem when people respond to them by changing their pattern of attention and thinking. Most people don’t recognize that their attention has become locked onto dwelling on themselves, their thoughts, and their feelings. This process prolongs and increases negative feelings and negative beliefs about the self. Unfortunately, people are usually unaware of this process and it can be difficult to interrupt. You can see the unhelpful effects of dwelling on your symptoms and thoughts about yourself if you consider what happens when something interrupts this process. If you have to deal with an emergency affecting someone else, what happens to your anxiety/sadness? You will have noticed that you temporarily feel better, but your problem returns when your attention reverts back to your unhelpful pattern of self-focus.

“It is important to become more aware of your focus of attention and to strengthen your control over it. Then it will no longer be habitually locked onto unhelpful patterns of dwelling on yourself and your body. You will learn a technique called attention training that will make it easier for you to break free of old and unhelpful thinking patterns.

“The aim of the technique is not to distract you from upsetting thoughts or feelings. In fact, these are likely to occur as you practice. You must not try to stop them. The aim is to continue to follow the procedure while allowing these inner experiences to take care of themselves. You can simply think of these experiences as passing inner noises.”

 

CREDIBILITY CHECK

 

Following presentation of the rationale, the therapist runs a credibility check to determine the extent to which the patient anticipates that the technique will be helpful. The following question should be used:

“How helpful do you think it will be for you to practice this technique? Can you give me a number on a scale from 0, not at all helpful, to 100, representing very helpful?”

 

Low levels of credibility (i.e., less than 40) should be explored and the rationale for the ATT strengthened. The therapist enhances credibility by reviewing experiences that the patient has had in which he or she has focused more on him- or herself and drawing attention to the impact this has had on thoughts and beliefs. This can be contrasted with the positive effects of being absorbed in externally focused activities to illustrate the role of attention and the importance of strengthening control over it.

SELF-ATTENTION RATING

 

The self-attention rating is an important index of the effectiveness of the procedure in counteracting the CAS (recall that self-attention is a feature and marker for the CAS). A 7-point rating scale is used to measure level and change in self-attention. This scale is reproduced below and is available to be copied in Appendix 5.

“At this moment in time how much is your attention focused on yourself or on your external environment? Please indicate by giving me a number on the scale”:

 

 

The therapist administers the self-attention rating before the first in-session practice of the ATT and then immediately after practicing. Typically, a reduction of at least 2 points in self-focus is achieved after the first practice session. If this is not the case, the therapist explores the possible reasons for lack of positive change and focuses on dealing with them.

Causes of little change might include a lack of effort due to the low credibility of the rationale or the use of counterproductive strategies during practice, such as thought suppression, daydreaming, and diversion of attention to worry. In these cases the rationale should be reinforced and emphasis given to prioritizing the attention task rather than competing processes. The technique should then be practiced again.

BASIC INSTRUCTIONS FOR THE ATT

 

A set of instructions for implementing the ATT are given below. In the instructions different sounds are designated as S1, S2, S3, etc. While at least three of these sounds are discrete consistent sounds, some designated sounds are often spatial locations in which there is no predetermined consistent sound. These instructions are an updated version of those published earlier in Wells (2000, pp. 145–146):

“I would like you to focus your gaze on a dot that I have placed on the wall. Throughout the exercise try to keep your eyes fixed on the dot. I’m going to ask you to focus your attention on different sounds inside this room and outside of this room. I will ask you to focus your attention in different ways. It doesn’t matter if thoughts and feelings come into your mind. The aim is to practice focusing your attention no matter what you might become aware of.

“To begin with, focus on the sound of my voice (S1). Pay close attention to that sound. No other sound matters. Try to give all of your attention to the sound of my voice. Ignore all of the other sounds around you. You may hear them but try to give all of your attention to the sound of my voice. Focus only on the sound of my voice. No other sound matters. Focus on this one sound.

“Now turn your attention to the sound I am making as I tap on the desk (S2). Pay close attention to that sound, for no other sound matters (pause). Try to give all of your attention to the tapping sound (pause). Closely monitor the tapping sound (pause). If your attention begins to stray or is captured by another sound, refocus on the tapping sound (pause). No other sound matters. Give this one sound all of your attention (pause). Continue to monitor this sound and if you are distracted return your attention to it (pause).

“Now focus on the sound of (S3; e.g., the ticking of a wind-up timer) (pause). Pay close attention to that sound, for no other sound matters (pause). Try to give all of your attention to the sound of the timer (pause). Closely monitor the sound the timer makes (pause). If your attention begins to stray or is captured by another sound, refocus on the timer (pause). No other sound matters. Give this one sound all of your attention (pause). Continue to monitor this sound and if you are distracted return your attention to this sound as soon as you can (pause).

“Now focus your attention on sounds that you might hear outside of this room, but nearby. Focus on the space outside and behind you (S4). Pay close attention to that space and try to detect sounds that might occur there [if there are specific sounds, the therapist draws attention to them]. Even if there are no sounds keep your attention on that space. Try to give all of your attention to it (pause). Closely monitor for sounds there (pause). If your attention begins to stray or is captured by a sound elsewhere, refocus on that place. No other sound matters. Give all of your attention to that place and what you might hear there. Continue to monitor and if you are distracted return your attention to it (pause).”

 

The instructions in the above paragraph are repeated for additional sounds (S5-7) and/or spaces (e.g., on the left, on the right, and in the far distance).

“Now that you have identified and practiced focusing on individual sounds and locations I am going to ask you to quickly shift your attention between them as I call them out (pause). First, focus on the tapping sound (S2), no other sound matters (pause). Switch your attention and focus on what you might hear behind you in the near distance (S4) (pause). Pay close attention to (S4), no other sound matters. Now turn your attention to (S7), no other sound matters (pause). Turn your attention again this time to the sound of the timer (S3) (pause). Now switch and focus on the tapping sound (S2) (pause). Now focus on (S6) (pause), now on the sound of (S5) (pause), (S4) … (S2) … (S3) …, etc.

“Finally, I want you to expand your attention. Make it as broad and deep as possible. Try to absorb all of the sounds and all of the locations that you have identified at the same time. Try to focus on and be aware of all of the sounds both inside and outside of this room at the same time (pause). Covertly count the number of sounds that you can hear at the same time (pause). Try to hear everything simultaneously. Count the number of sounds you can hear this way.

“This concludes the exercise. How many sounds were you able to hear at the same time?”

 

PATIENT FEEDBACK

 

Following implementation of the above procedure the therapist asks the patient to rerate the intensity of self-focus using the bipolar rating scale. Reductions of 2 points are typical in the first sessions. Failure to achieve this level of change is a marker for possible difficulties that must be explored. The ATT should be repeated in these cases with the necessary adjustments made.

Failure to reduce self-focus can be caused by misunderstanding of the rationale for the ATT. In particular, patients might try to control or suppress thoughts, or they might be dividing their attention between continuing with worry/rumination while partially directing attention externally. Some patients are reluctant to relinquish their own mental control strategies which would be necessitated by fully engaging the ATT. In these circumstances fears concerning such a shift in strategy should be examined and challenged.

The therapist also asks about the general experiences that might have occurred as a result of the ATT. The technique can produce perceptual changes such as mild and temporary increased sensitivity to external stimuli and metacognitive experiences that are unusual for patients such as experiences of temporary mental quiescence that should be normalized.

Finally, the therapist should ask about the ease with which the patient could perform the technique. The therapist should state that the technique is intended to be demanding and requires practice. It is most important that the therapist is aware of statements that indicate unhelpful assumptions about the use of the ATT. For example, some patients assume that they were unable to practice effectively because they had intrusive thoughts or feelings during the procedure. Here, the therapist normally reemphasizes that the aim of the technique is not to remove awareness of inner events but to practice controlling attention in a particular way. One strategy is for the therapist to suggest that it is useful to experience intrusive thoughts and feelings during practice as these normally bind attention to them and the aim is to have flexible control even in the presence of these “inner noises.”

HOMEWORK

 

A crucial component of the ATT is consistent practice of the technique for homework. Usually, patients are asked to practice twice a day, but in reality most patients only manage to do this once a day. Practice should be scheduled for approximately 12 minutes and the sequence used in the session should be followed. The ATT Summary Sheet (see Appendix 4) is given as a reminder of how to practice and as a means of monitoring homework.

The ATT Summary Sheet acts as a focus of discussion in which three potential sources of sound can be identified or obtained and noted, thereby increasing compliance. For example, one patient decided to take a radio into a spare room in the house where he would practice, and he tuned this between channels to generate noise. He decided that he would play some music on his stereo that was located in an adjacent room, but he could not think of another type of sound he could use. After some discussion with the therapist he decided to buy a wind-up cooking timer as a further noise-generating device. He built the rest of the procedure around listening for incidental sounds at locations outside. The therapist normally works with the patient in completing the ATT Summary Sheet in the first ATT session.

TROUBLESHOOTING

 

Occasionally setbacks are encountered in administering the ATT. Some common setbacks and suggested solutions are as follows:

Failure to Practice

 

Use the ATT Summary Sheet to increase practice rates. Continued failure to practice may be due to poor socialization and lack of understanding of the reasons for using the technique. If this cause is suspected, the therapist should introduce further socialization.

Motivation to Continue the CAS

 

Some patients do practice ATT but they view it as something that interferes with their preferred strategy of ruminating/worrying. Thus, the motivation to continue the worry component of the CAS remains. There are two ways in which this occurs. First, worry or rumination can continue in parallel with practicing the ATT such that the person has long periods in which he or she has no active mental engagement with sounds because his or her resources are diverted to brooding. Second, the person can view the ATT as a chore that must be done quickly so that he or she can return to focusing on (dwelling on) thinking about problems.

In these circumstances it is necessary to review the disadvantages of worrying and ruminating and help the patient to see how these strategies have not solved problems and are unlikely to do so. The therapist should then introduce worry and rumination postponement strategies (see Chapters 6 and 9) in conjunction with the ATT.

Misuse as Avoidance or Symptom Management

 

The patient may apply the ATT as a direct means of avoiding emotions and erroneous threat. Some patients have been detected misusing the technique as a form of distraction from emotions, as a means of controlling anxiety or panic, or as a means of suppressing obsessional thoughts. The therapist must detect these instances and reinforce the concept that the technique should not be used as a coping strategy. It is useful in these circumstances to use metaphor to convey the idea that the ATT is a means of general “mental fitness training” and not a form of avoidance.

It is not desirable to use the ATT as a coping strategy because this transforms it into a form of cognitive or emotional avoidance, which is a problem because it may interfere with emotional processing and maintain erroneous negative beliefs about the danger and consequences of thoughts and feelings. Furthermore, the nonoccurrence of catastrophe (e.g., fainting due to anxiety) can be falsely attributed to the use of the ATT and not to the fact that anxiety does not cause catastrophe. By this mechanism false beliefs are more likely to persist. It is helpful for the therapist to explain the counterproductive effects of using the ATT as an active coping strategy.

OUTLINE OF THE FIRST ATT SESSION

 

The first ATT session should follow the structure and content outlined below:

 

1.      Review the nature of the patient’s problem, emphasizing the role of difficult-to-control self-processing in problem maintenance.

2.      Present the rationale for the ATT using idiosyncratic material.

3.      Socialize by illustrating the role of self-focus in the form of worry and self-monitoring. Use a self-attention socialization experiment if possible.

4.      Check the credibility of the rationale. Take steps to increase socialization if necessary.

5.      Rate current level of self-focus.

6.      Administer the therapist-guided ATT.

7.      Rerate the level of self-focus and elicit feedback.

8.      Review the ATT Summary Sheet with the patient (see Appendix 4) and complete the list of sounds.

9.      Set homework.

10.  Elicit feedback and ask the patient to summarize the session.

Subsequent ATT Sessions

 

Follow-up sessions should begin with a review of homework practice as recorded on the ATT Summary Sheet. Any problems arising should be discussed and resolved. Sessions then proceed with therapist-guided practice of the ATT.

The therapist explores competing demands on the ATT effects, such as engaging in checking of the self, worry and rumination, and any attempts to monitor and control inner experiences. The incompatibility of these processes with attention-training effects are highlighted. The patient is asked to ban these processes. For example, the therapist introduces the idea that bodily checking and worry interfere with developing effective levels of mental control and mental agility because they lock attention into familiar and old response patterns that emphasize threat rather than establish control over attention.

CASE EXAMPLE

 

In hypochondriasis the conceptual component of the CAS can be observed in the form of worry about symptoms and rumination concerning their possible significance and causes. Threat monitoring is evident in the form of mentally scanning the body for signs and symptoms, physically checking parts of the body (e.g., palpating the abdomen), checking bodily processes and mental functioning (e.g., checking memory for names), and searching for information about symptoms. Unhelpful coping behaviors such as excessive resting, avoidance of exercise, taking unnecessary medications that change bodily function, trying to control automatic physiological function (e.g., breathing), and avoidance of medical information can also be readily identified.

A 43-year-old man with hypochondriasis and panic attacks was treated with the ATT. The patient described a range of unexplained symptoms including abdominal pain, chest pain, arrhythmias, dizziness, and feelings of unreality (dissociation). His current main symptom of concern was feeling unreal and chest pain. His medical evaluations had been extensive and were unremarkable, but he was concerned (i.e., worrying) that the tests might have failed to detect a serious medical condition.

The therapist suggested that a technique called attention training be tried to determine if it could reduce his excessive body-focused processing.The therapist explained that the patient had become anxious about his health and preoccupied with his body. The therapist pointed out that this anxiety and preoccupation was an example of altered body awareness that could be adding additional layers of symptoms that needed to be managed before considering further medical testing. The role of these processes was illustrated by asking the patient what happened to his anxiety when he focused on his body (“Do you become more or less aware of your symptoms?”). The therapist also explored what happened to the patient’s symptoms when he became intensely worried about his health. This was contrasted with examining what happened to anxiety when the patient was absorbed in a work task. A useful discussion ensued of how the patient would run a mental check of his body when he became aware that he had not been focusing on his symptoms for a while, which was further useful information supporting the role of altered body awareness.

The therapist introduced a socialization experiment to show how alterations in body awareness produced by attention could influence subsequent perception. The patient was asked to focus on sensations in his fingertips to see if there were any feelings there. The patient described a feeling of tingling. The therapist then asked him to be aware of his fingertips but to shut out that feeling. The patient discovered that he was now unable to be aware of his fingertips and to shut out the tingling in them. In this way the therapist helped the patient to understand how turning attention toward the body and dwelling on sensations could lock attention onto them such that it changed his subsequent awareness.

A further socialization technique was also used in which the therapist illustrated the role that assigning personal importance to things has in locking attention onto them. The patient was asked if he had noticed a strange event after buying his most recent car: The fact that many more people now seemed to be driving the same model car. This observation was used as an illustration of how assigning personal significance to events such as cars—or in the patient’s case, symptoms—had the power to make someone witness more of them even if little had actually changed. The rationale for the ATT was presented with an emphasis on learning to regain control of attention and reduce worry and the significance given to symptoms so that body awareness could return to a normal state.

The ATT was practiced for eight treatment sessions. In the third session the therapist also introduced worry postponement and instructed the patient to ban his bodily checking at all times. This consisted of asking him to stop checking his pulse and to stop running a mind-check over his body which he was prone to do several times each day.

In later sessions the therapist worked on challenging the patient’s positive metacognitive beliefs about the importance of focusing on and worrying about bodily symptoms. In this case the ATT formed a substantive component of metacognitive treatment for hypochondriasis.

SITUATIONAL ATTENTIONAL REFOCUSING

SAR is an attentional modification technique used in metacognitive therapy that differs from the ATT in its aim and nature. Rather than retraining executive control and interrupting perseverative processing, SAR is intended to explicitly enhance the processing of information that is incompatible with the patient’s dysfunctional beliefs (e.g., in treating social phobia), or it is used to counteract external threat monitoring in the later stages of MCT for PTSD.

This is a technique that should be applied to stressful or problematic situations as a means of configuring processing in a way that is beneficial for developing adaptive appraisals and beliefs. It is not a coping strategy aimed at preventing emotion or removing threat, but it is applied as a means of disrupting unhelpful attention patterns that maintain an unrealistic sense of threat and as a means of increasing the flow of new information into consciousness to modify beliefs.

The technique has been incorporated in the treatment of social phobia (Clark & Wells, 1995; Wells & Papageorgiou, 1998a) and in the treatment of posttraumatic stress (Wells & Sembi, 2004b). For example, Wells and Papageorgiou (1998a) asked individuals with social phobia to engage in one session of exposure to a feared social situation while focusing attention externally on features of the social environment such as the color of other people’s hair and eyes. This condition was compared with one session of exposure alone using a standard habituation rationale. The exposure plus SAR condition was more effective at reducing negative beliefs, reducing anxiety, and changing the image that patients had of themselves afterward.

SAR can be used explicitly to modify beliefs and incorporated as a feature of behavioral experiments. For example, individuals with social phobia often believe that everyone is looking at them. While they claim to be very aware of this attention, their awareness does not stem from looking at other people, but from a sense of self-consciousness. (Note: The person’s processing configuration is inadequate for discovering the truth and therefore needs to be altered.)

In treatment it is very helpful to ask patients to enter feared social situations and to actively focus on other people to determine how many people are actually looking at them. The patient is further instructed to deliberately make a mistake (e.g., drop something) or to show signs of anxiety while focusing attention on others to determine the truth about the reaction of others even under negative conditions. In these instances showing signs of failed performance coupled with SAR are examples of disconfirmatory maneuvers or “tests” in behavioral experiments as described in Chapter 3 because they actively challenge predictions and beliefs.

In PTSD, patients become hypervigilant for threat and focus their attention on aspects of the environment that could be dangerous as an attempt to minimize danger. Unfortunately, this increases the patient’s sense of current danger and vulnerability, thereby maintaining his or her anxiety. SAR consists of asking patients to notice instances of threat monitoring and to ban it during situations that remind them of trauma. Processing is rebalanced and returned to a more normal state by asking individuals to focus on neutral or safety signals in the environment instead to counteract bias and retrain an adaptive attentional control plan. For example, one patient scanned for speeding cars whenever she approached a traffic intersection because she feared another collision. She was asked to look out for cars that were slowing down or were stationary instead. She quickly realized that her strategy of looking for danger led her to ignore the actual features of the situation and learned that traffic intersections were generally safe rather than generally dangerous.

CONCLUSION

 

In this chapter I have described the purpose and nature of direct attentional modification strategies that form a component of metacognitive therapy. While the ATT is generally considered a component of a wider MCT treatment package, evidence suggests that it can be very effective even when used alone (see Chapter 10).

The ATT and SAR have different purposes. While the ATT is designed to increase executive control and to interrupt perseverative self-focused processing, SAR is intended to increase access to disconfirmatory information and to correct attentional strategies that are counterproductive in situations (i.e., it modifies threat-monitoring aspects of the CAS).

Attentional modifications are powerful strategies that impact on metacognition. It is likely that they strengthen plans for controlling and guiding online processing and increase flexibility in cognitive control that is impaired in psychological disorder. The development and investigation of attentional strategies that are grounded in theory linking attention to causative and change mechanisms in psychopathology opens up a wide range of new therapeutic possibilities. As this chapter illustrates, changing attention processes can be developed beyond the use of simple distraction. In MCT it is aimed at modifying central control processes, reversing unhelpful processing styles, and improving the flow of more adaptive information into consciousness that can change the content of what we know. In SAR the manipulation of attention is a basis for implementing metacognitively delivered exposure. The aim is to control cognition in a way that facilitates the acquisition of processing strategies that support access to corrective information.

The metacognitive approach emphasizes the role of control functions in treating psychological disorder. It is proposed that these can be strengthened through the development of attentional technologies such as the ATT. Improved flexible control over attention allows the person to change his or her beliefs and to adaptively process threatening material (e.g., criticism, intrusive thoughts) and modulate emotional processing without triggering the full-blown CAS. (A recorded version of the ATT is available at www.mct-institute.com).

CHAPTER 5