218 ASSESSMENT AND INTERVENTION STRATEGIES
individual how to interrupt repetitive self- attentional processing that contributes to the
persistence of the anxious state. Wells (2000) suggests that ATT may be effective in alle-
viating emotional distress (e.g., anxiety) by weakening self- focused attention, disrupting
rumination and worry, increasing executive control over attention, and strengthening
metacognitive processing.
According to Wells (2000), ATT consists of auditory attentional exercises in which
clients are taught to selectively attend to neutral noises, rapidly switch their attention
between different sounds, and divide their attention among diverse sounds. The entire
procedure takes 10–15 minutes of therapy time and is practiced in a nonanxious state.
First clients are provided a rationale for ATT. The main point communicated to the
client is that ATT is a procedure for reducing self- focused attention which is known to
intensify anxious thoughts and feelings. The therapist can use specific demonstrations to
illustrate the negative effects of self- focused attention (e.g., have the client intensely focus
on an anxious thought or image and note any changes in mood state). After ensuring that
the rationale has been accepted, the therapist introduces a self- attention rating scale in
which clients use a –3 to +3 bipolar scale to indicate the extent to which their attention
is entirely focused on external stimuli (–3) to their attention is entirely self- focused (+3).
These ratings are administered before and after the ATT practice session to ensure that
the directed attention exercise resulted in a reduction in self- focused attention.
In the actual ATT procedure, the therapist instructs the client to focus on a dot on
the wall. Seating behind the client, the therapist first instructs the client to attend fully
and completely to her voice. Next the client is asked to attend to a tapping sound made
by the therapist. Again the instructions are to shift one’s attention so the client is fully
and completely refocusing on the tapping sound and not letting any other sounds dis-
tract him from this task. Then the client is asked to attend to a third sound in the room
such as a ticking clock. This procedure is then repeated for three different sounds in
the near distance (i.e., just outside the room) and three sounds in the far distance (i.e.,
sounds that are outside in the street).
After clients have practiced focusing attention on different sounds, the therapist
calls out the different sounds and they are asked to rapidly shift attention between the
different sounds. This rapid shifting of attention is practiced for a few minutes. Finally,
instructions are given to expand attention by trying to concentrate on all of the sounds
simultaneously and to count the number of sounds heard at the same time. After com-
pleting the training procedure, the therapist obtains client feedback. It is emphasized
that intentional direction of attention is difficult but with practice they will become
more proficient. Homework is assigned consisting of 10–15 minutes of ATT practice
twice a day. However, it is important to ensure that clients do not use ATT to avoid their
anxious thoughts or to control anxious symptoms (Wells, 2000).
A variant of ATT that is probably even more applicable to the anxiety disorders
is situational attentional refocusing (SAR). In SAR anxious clients are taught to shift
attention from an internal focus to external information that may disconfirm the
threat- related interpretation. Wells (2000) discusses the use of SAR in conjunction with
exposure in which an individual with social phobia is taught how to shift attention to
external information in the social situation which interrupts the deleterious self- focused
attention that is often seen in social anxiety. For example, when an individual with
social anxiety enters a feared social situation and becomes overly focused on herself