www.elsevier.com/locate/cabpCognitive and Behavioral Practice 14 (2007) 134–138

The Attention Training Technique: Theory, Effects, and a MetacognitiveHypothesis on Auditory Hallucinations

Adrian Wells, University of Manchester

THE ATTENTION TRAINING TECHNIQUE (ATT; Wells,1990) is a treatment strategy developed out of a

metacognitive theory of psychological disorder. It has beenapplied in the treatment of several psychiatric disorders,and there is preliminary data suggesting that it may beeffective in panic disorder, social phobia, hypochondriasis,and recurrent major depression. Valmaggia, Bouman, andSchuurman (2007, this issue) have described an applicationof ATT to auditory hallucinations.

ATTwas originally devised as a potential component ofmetacognitive therapy rather than as a treatment methodin its own right. However, it appears to exert strongtherapeutic effects as a stand-alone treatment approach,but to date most of the data on treatment effects involvesmall samples of patients in uncontrolled evaluations.

Attention modifications of various types have beeninvestigated across a range of conditions. These includethe effects of distraction under painful stimulation(McCaul & Haugtuedt, 1982), under exposure to phobicobjects (Sartory, Rachman, & Grey, 1982), and the effectsof focusing on contaminants during exposure in obses-sive-compulsive individuals (Grayson, Foa, & Steketee,1986). In the field of schizophrenia research attentionmodifications have been used as a means of remediationof cognitive deficits (Suslow, Schonauer, & Arolt, 2001).Such studies are based on the idea that cognitiveimpairments involving early attentional processes areimportant components of neuropsychological vulnerabil-ity. The tasks utilized have varied, and included extensive(15 hour) vigilance training (Benedict et al., 1994), shapematching (Field, Galletly, Anderson, &Walker, 1997), andcombination strategies involving arithmetic, copyingvisual displays, and recalling of verbal and visual material(Olbrich & Mussgay, 1990). Studies of such cognitiveremediation reveal inconsistent results and their inter-pretation is impeded by the use of many different out-come measures of cognitive performance.

1077-7229/07/134–138$1.00/0© 2007 Association for Behavioral and Cognitive Therapies.Published by Elsevier Ltd. All rights reserved.

One of the conceptual limitations with earlier work onattention training in schizophrenia is that tasks have beendevised with the aim of improving low-level attentiondeficits, rather than with the goal of specifically treatingpositive symptoms and distress. It is conceivable that thedeficits reportedmight be a consequence of medication, aresult of distress, and/or arise from the metacognitiveprocesses giving rise to hallucinations.

ATT stands in contrast to the attentional strategiesreviewed above because it is a theory-based techniqueaimed at the modification of cognitive and metacognitivefactors considered to underlie psychological dysfunction.In this commentary I will provide an overview of thetheoretical underpinnings of ATT, and describe its natureand effects. I also offer a metacognitive hypothesisconcerning the development of distressing auditory hallu-cinations and consider how ATT may be beneficial intreating such symptoms.

Theoretical Basis: the Self-Regulatory ExecutiveFunction (S-REF)

Until recently, attention-based treatment strategieswere not founded on information-processing theorieslinking attention to other aspects of cognition—such asbeliefs, appraisals, and cognitive control—consideredimportant in psychological disorder. Theories of psycho-logical disorder and treatment have been rather vagueabout the regulation of information processing thatcontributes to cognitive vulnerability and the mainte-nance of psychological disorders. Taking a differentapproach, we (Wells, 2000; Wells & Matthews, 1994,1996) described how features of cognitive-attentionalcontrol are of special importance in the development andpersistence of psychological disorder. For example,attentional selectivity and attentional intensity governthe nature of an individual’s momentary experience, andthe control and availability of attentional resources caninfluence the efficiency of processing and belief change.

In S-REF theory a problematic pattern of thinkingcalled the Cognitive Attentional Syndrome (CAS) isresponsible for psychological disorder. When this pattern

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is activated it locks individuals into a spiral of psycholo-gical disturbance. The CAS consists of perseverativethought in the form of worry/rumination, attentionalstrategies of threat monitoring, loss of cognitive effi-ciency/capacity, and coping behaviors that fail to providecorrective learning experiences and contribute to failuresof self-regulation. Excessive and inflexible self-focusedattention is a surface marker of the activation of thissyndrome.

Central to the theory is the idea that coping strategiesin psychological disorder involve controlling thoughts in away that gives rise to the CAS and long-term difficulties inpsychological well-being. Metacognitive knowledge (i.e.,knowledge about thinking) is involved in controllingthinking and its presence can be expressed verbally asbeliefs. It influences the choice and implementation ofcoping strategy. It includes the belief that worrying/rumination is beneficial for coping and finding deeperunderstanding (“If I worry I’ll be prepared”), the beliefthat hypervigilance for danger is a way to remain safe(“Looking out for symptoms means I’ll get help in time”),and the belief that controlling certain thoughts isdesirable (“I must control my thoughts or I’ll go crazy”).It also consists of negative beliefs about the danger andmeaning of thoughts (“Bad thoughts have the power tomake bad things happen”). While I have representedthese ideas propositionally, in our theory such knowledgeor beliefs are linked to plans or programs (proceduralknowledge) that contribute to controlling cognition.

Like Beck’s (1976) theory the S-REF theory viewsnegative self-knowledge as important in generatingpathology, but it extends and modifies Beck’s theory inseveral respects. First, much of the knowledge ismetacognitive in nature (e.g., “Questioning my worthwill make me a better person”) rather than the familiarand more general explicit negative propositions (e.g.,“I’m worthless”). Second, beliefs (e.g. “I’m worthless”)and appraisals are seen as outputs of running programs(metacognitions) for processing, so modifying proposi-tional beliefs directly may be ineffective. The propertarget for therapy is the procedural knowledge orprograms (metacognitive beliefs) that give rise toconscious propositional beliefs and appraisals. It is there-fore necessary to modify the cognitive-computationalbasis for the more general propositional beliefs inproblematic situations. Third, metacognitive knowledgeis important in determining the problematic style ofthinking (the CAS) in pathology, and so it is important tofocus on metacognitions that give rise to worry/rumina-tion, threat monitoring, and unhelpful thought controlstrategies in particular. Fourth, the programs are mod-ified not by questioning the validity of beliefs but aremodified by running alternative strategies for thinking,attending, and behaving in distressing situations. Fifth,

the theory asserts that the individual’s scope for alter-native cognition and action is constrained by loss ofavailable processing resources. The person is poorlyequipped cognitively to deal with disorder and will haveproblems flexibly controlling cognitive processing andmodifying his or her knowledge base.

The implication of this is that attentional treatmentstrategies could be designed to counteract excessive self-focus, interrupt worry/rumination, provide increasedexecutive control over processing, and increase the flowof new corrective information into processing to facilitatebelief change. Training attention provides a means ofestablishing and strengthening replacement programs(metacognitions) and detached metacognitive awarenessthat can be called to guide cognition more adaptivelyunder conditions of stress.

Nature of ATT

ATTwas developed as a means of treating the CAS andmodifying associated metacognitions. A guide to using thetechnique is given in Wells (2000; Chapter 9).

ATT consists of three categories of auditory attentionalexercises, involving selective attention, attention switching,and divided attention. A single practice session lastsapproximately 12 minutes, with 5 minutes devoted toselective attention, 5 minutes to attention switching, and 2minutes to divided attention. Participants are asked tofocus on a visual fixation point and remain visuallyfocused throughout the exercise. A number of competingsounds are introduced and identified in the practiceenvironment. The number of sounds can vary but theimportant parameter is that there are sufficient sounds tomake the task difficult (i.e., it loads attention). A roughrule of thumb is to experiment with a minimum of 6sounds as a starting point.

The attentional demands imposed by the techniqueare intended to be incremental within and across eachsession. The level of difficulty can be adjusted byidentifying less distinct sounds in the selective attentionphase, gradually increasing the speed of attention switch-ing in the switching phase, and the introduction of agreater number of sounds across sessions. Audio- andcomputer-administered versions of ATT have been usedin some studies (Cavanagh & Franklin, 2000; Siegle,Ghinassi, & Thase, in press), but these strategies mayincrease the risk of practice effects, in which case theycould fail to load attention consistently.

ATT is presented with a rationale and instructions thatemphasize that the aim of the procedure is not tosuppress or avoid internal events (e.g., thoughts, sensa-tions) but to practice focusing attention flexibly in aparticular way. Intrusions should be viewed as additionalnoise and the central task is to apply attention asinstructed. This instruction emphasizes that ATT is not

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intended as a distraction strategy for reducing awarenessof internal events.

Effectiveness of ATT

ATT has been evaluated as a treatment for severalemotional disorders (panic disorder, social phobia,recurrent major depression, and hypochondriasis).These studies have consisted of single-case evaluationsusing a range of single-case methodologies, including truereversal designs, and systematic replication series. ATThas also been evaluated in a randomized controlled trialand a randomized trial comparing treatment as usual witha combination of treatment as usual and ATT. The effectsof modified ATT on neuropsychological responses indepressed patients undergoing fMRI has also beenexamined in a pilot study.

In the first study (Wells, 1990), ATT was used to treat apatient with panic disorder and relaxation-inducedanxiety. The patient showed a significant reduction andelimination of panic attacks during the first ATT phase, are-occurrence of panic during a subsequent autogenictraining phase, followed by elimination of panic in a finalATT phase. Treatment gains were maintained at 3-monthand 12-month follow-ups.

Subsequently, Wells, White, and Carter (1997) testedthe effects of ATT in a systematic replication series acrosstwo panic disorder cases and one social phobia case. A truereversal design was used in the social phobia case, whereATT instructions were followed by attention instructionsintended to reverse the effects of ATT by reinstating self-focus. In the panic disorder cases ATTwas associated with areduction in panic attacks, reductions in negative beliefsand anxiety, and gains were maintained at 3- and 6-monthfollow-ups. In the social phobia case ATT was associatedwith reductions in anxiety and negative beliefs, an effectthat was reversed with the self-focus manipulation, butreinstated following a reintroduction of ATT.

Single-case replication-series evaluations of ATT havealso been conducted for patients suffering from recurrentmajor depression (Papageorgiou & Wells, 2000) andhypochondriasis (Papageorgiou & Wells, 1998). Thesestudies produced results suggesting that the techniquewas effective in treating depression and health anxiety,respectively. Furthermore, the technique was associatedwith reductions in dysfunctional beliefs in each case.

Cavanagh and Franklin (2000) reported the results of arandomized controlled trial of ATT versus a no-treatmentcondition in hypochondriasis. They showed significantimprovement in a range of health-anxiety outcomes suchas degree of health worry, disease conviction, andbehavioral indices as a result of 6 sessions of ATT. Thesegains were maintained at 18-month follow-up. The authorsconcluded that ATT appears to be a clinically effectivetreatment for hypochondriasis.

Siegle et al. (in press) conducted a study of depressedpatients and examined the effects of a cognitive controltraining (CCT) package consisting chiefly of ATT whenadded to treatment as usual. Patients were randomlyallocated to treatment as usual or the treatment as usualplus the attention intervention. Outcome was assessed bymeasuring depressive symptoms, rumination, fMRI andpupil dilation. fMRI was collected on a small subsample ofthe participants. Participants who received 2 weeks ofCCT showed significantly greater improvements indepression and rumination than those receiving treat-ment as usual. Improvement after only 2 weeks of CCTwasgreater than the average change in depression scoresassociated with completion of the usual 6-week treatmentprogram. The preliminary fMRI data showed neuropsy-chological changes including decreased disruptions inamygdala activity on an emotion task. From pre- toposttreatment right amygdala responses increased inresponse to positive words, but decreased to negativeand neutral words.

In summary, much of the data are preliminary, butthere appears to be a consistent pattern of ATT effectswhen it is applied to a range of disorders. It is interestingto note that the procedure may lead to changes inthinking style (e.g., rumination) as well as beliefs, eventhough the content of thoughts/beliefs has not beentargeted directly. When ATT exerts an effect it appears todo so relatively quickly, and the gains appear to be stableacross follow-up. There is some preliminary indicationthat a cognitive control package built around ATT isassociated with changes in brain mechanisms, consistentwith the idea that the technique may increase executivecontrol over perturbations in lower-level emotionalprocessing, which is one of the mechanisms that the S-REF theory would predict. However, the use of multi-component packages incorporating ATT means that anyspecific effect of ATT cannot be isolated, limiting theconclusions that can be drawn at the present time.

Auditory Hallucinations: A MetacognitiveHypothesis

Applying the principles of the S-REF theory to under-standing and treating auditory hallucinations leads to astartling hypothesis concerning a cognitive pathwayunderpinning such symptoms. To recap briefly, the theoryholds that cognition is controlled, regulated, and syn-chronized by metacognitive processes drawing on meta-cognitive beliefs (programs). The concept of coping linksthe person’s beliefs to the development and maintenanceof pathology, and many of the coping strategies adoptedin psychological disorder are linked to monitoring andregulating thought in a way that gives rise to maladaption.

Application of the theory suggests that auditoryhallucinations are the products of metacognitions for

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the regulation and synchronization of thinking that giverise to the experience of thoughts as voices. Thus, hearingvoices, or perhaps more accurately “hearing thoughts,” isfor some individuals a coping strategy that has become askill—a strategy that is subsequently negatively appraised,leading to activation of the CAS and unhelpful combina-tions of control strategy, at which stage voices become adistressing symptom.

If auditory hallucinations arise from an acquiredmetacognitive program for creating voices, how mightsuch a program arise? Hearing voices is a relatively normaland common experience, and metacognitive beliefsabout the nature and significance of hearing internalthoughts as voices will play an important part in thechoice of strategy, such as focusing attention on andacting to enhance hallucinatory experiences, perhapsinitially as a coping strategy. Enhancement may beachieved through consciousness-altering strategies suchas use of recreational drugs, activation of auditorymemory, imagery, and subvocalization of soothingthoughts in conjunction with imaging them in the voiceof a trusted person. When voices are benevolent they arenegatively reinforced by their distress-reducing proper-ties, thereby strengthening their occurrence. However,the theory implies that at some stage, due to negativeinterpretation of voices, they become threatening and theindividual worries/ruminates about them, engages inmonitoring for bad voices, and engages other copingstrategies that are counterproductive (e.g., tries toenhance benevolent voices and suppress malevolentones). That is, the CAS is activated, which has the effectof constraining the person’s resources for flexiblecognitive control, and intensifies negative emotionsleading to a greater frequency of negative thoughtintrusions. Hallucinatory pathology is like a “skill” that isexperienced as out of control, is automatically primed byintensifying negative emotions, and increasingly activatesand reflects negative self-regulatory concerns.

This analysis implies that metacognitive therapy shouldbe a useful approach in the treatment of voices. ATT willbe helpful in treating voices if it can restore flexiblecognitive control (and knowledge of control) so that theperson can prevent the running of maladaptive hallucina-tion-inducing configurations, if it will allow the patient todevelop alternative plans for processing that counteractthe CAS, and if it helps to reestablish adaptive metacog-nitive beliefs about the nature of voices as benign innerexperiences.

Some Cautions and Future Directions in TreatingAuditory Hallucinations

Despite the fact that ATT should be advantageous inthe treatment of voices, it will only exert an effect if it ispracticed appropriately and consistently. Valmaggia et al.

(2007, this issue) have demonstrated in their case studythat the rationale and practice of the technique are viablein psychosis. However, I would like to emphasise that ATTwas intended originally as a technique to be used as partof a more complete metacognitive therapy. The metacog-nitive model predicts that strong positive beliefs aboutmaladaptive coping (e.g., the advantages of hearingvoices) will lead to difficulties in completely relinquishingunhelpful strategies of positively engaging with somevoices and suppression of other negative thoughts/voices.Thus, patients could remain in a state of ambivalenceconcerning the complete relinquishing of voices, perhapschoosing to retain some voices but to suppress others,representing a pattern of cognitive regulation prone toultimate failures of control and to negative self-appraisals.The inclusion of techniques for modifying positive andnegative metacognitive beliefs about thoughts and voicesis likely to comprise a more comprehensive overalltreatment package.

The Valmaggia et al. case study supports the potentialviability of ATT; the next step is single-case evaluationsusing no-treatment baselines demonstrating the effects ofATT on voices. If these are promising, then a randomizedcontrolled evaluation is warranted.

At its inception, my goal in developing ATT was not tocreate a strategy that patients could use as a form ofdistraction, or as anxiety management or active coping. Adanger if the technique is used in this way is that it acts as aform of avoidance of nonexistent threat. For example, apatient might use it as a means of controlling thoughts oremotions that are erroneously appraised as harmful. Insuch circumstances the technique can prevent thedisconfirmation of negative beliefs about symptoms, aseach practice of the technique supports a near-miss mind-set in which the nonoccurrence of catastrophe isattributed to using the strategy and not to the fact thatbeliefs about catastrophe are mistaken. Normally, askingindividuals to practice ATTwhen they are not in a state ofanxiety or current appraised threat reduces this risk. Inapplying the technique to auditory hallucinations, it willbe important to closely monitor the patient’s personalgoals in using the strategy. The technique may not beeffective if it is used solely as means of controllingmalevolent voices, as it could prevent the person fromdiscovering that voices are benign events in the mindrather than potentially dangerous entities. It might bebest to use the technique as a means of strengtheninggeneral control skills, for regaining knowledge of controland awareness of the nature of voices as internal events.Furthermore, if the person uses ATT to control malevo-lent voices while still attempting to engage with bene-volent voices as a means of personal support, a state ofsustained conflict in effective metacognitive regulation islikely.

138 Wells

Conclusion

ATT is a theory-based metacognitive control exercisethat appears to influence several dimension of cognitionin psychological disorder. It was designed to increaseflexible executive control over processing, disrupt perse-verative styles of thinking (worry/rumination), enhancedetached metacognitive awareness, and strengthen meta-cognitive programs for controlling cognition. There arepreliminary indications that it acts on some of theseprocesses, but it is premature to draw any confidentconclusions about the effects of the technique. Theapparent effectiveness of the technique as a simpletransdiagnostic treatment strategy is cause for its con-tinued evaluation in controlled studies, and furtherinvestigations might also focus on its cognitive andneurological effects.

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Addres correspondence to: Professor Adrian Wells, University ofManchester, Academic Division of Clinical Psychology, RawnsleyBuilding, Manchester Royal Infirmary, Manchester, M13 9WL, UK;e-mail: adrian.wells@manchester.ac.uk.

Received: December 22, 2005Accepted: January 9, 2006Available online 2 March 2007