Metacognitive therapy has a name for the thing it is trying to change, and it is not any particular worry. It is the cognitive attentional syndrome — the CAS: perseverative, self-focused, worry-based processing together with monitoring for threat[1].

The distinction is the whole idea. The CAS is a description of how attention is being spent, not of what it is being spent on.

The three moving parts

Read out of Wells’ description, the pattern has three components that reinforce each other:

  • Perseveration. Thinking that keeps going — the loop of worry or rumination that continues past any point of usefulness[1].
  • Threat monitoring. Attention scanning for signs of danger, which reliably finds candidates[1].
  • Self-focus. Attention turned inward onto your own state, thoughts and sensations[1].

The problem the model identifies is not that any one of these is present. It is that together they become the default setting, and attention loses the flexibility to be anywhere else.

Why this changes what a “fix” looks like

If the difficulty were the content of the thoughts, the sensible move would be to work on the thoughts: examine them, test them, argue with them. If the difficulty is the pattern, then engaging with the content is participating in it — you are still spending attention inward, just more skilfully.

That is why ATT is built the way it is. Wells describes the technique as interrupting the CAS and improving flexible executive control, and as interrupting excessive and inflexible self-focused attention[1]. Its stated aim is to directly modify the control of attention[1].

Hence an exercise made of external sounds and no content at all. There is nothing in a twelve-minute session to think about. The only thing being practised is where attention goes and how easily it can be moved.

What follows for how you practise

Three of the protocol’s odder-looking instructions make sense once the CAS is the target:

Thoughts are left alone. Intruding thoughts, images and feelings are treated as additional noise and not resisted; you must not try to stop them, and are asked to think of them as passing inner noises[1]. Fighting a thought is still attending to it.

A blank mind is not the goal. The manual states the exercise is not intended to lead to a blank mind, and that it counteracts the use of active thought suppression[1] — the aim is not to remove awareness of inner events but to practise controlling attention in a particular way[1].

It is not a coping move. ATT is practised when the person is not in a state of anxiety or acute worry[1], and is not to be used as a distraction, avoidance, or symptom-management strategy[1]. Deploying it against a spiral would make it one more thing attention does about the inner state — the pattern it is supposed to interrupt.

A caution about the model

The CAS is a theoretical account within metacognitive therapy, not a diagnosis and not an established mechanism. It explains why ATT is shaped as it is; it is not itself evidence that the exercise produces any particular result. What has been measured is covered in does attention training actually work?.

For the exercise this model produced, see the Attention Training Technique explained.

Questions and answers

What is the cognitive attentional syndrome?
In metacognitive therapy, the CAS is a pattern of perseverative, self-focused, worry-based processing combined with monitoring for threat. It describes a style of attending rather than the content of any particular thought.
How does ATT relate to the CAS?
Wells describes the technique as interrupting the CAS and improving flexible executive control — it works on the attentional pattern rather than on what the thoughts are about.
Is the CAS a diagnosis?
No. It is a model of a processing style described within metacognitive therapy, not a diagnostic category.

References

  1. Wells, A. (2009). Metacognitive Therapy for Anxiety and Depression. Guilford Press. Chapter 4: Attention Training Techniques.

Published by the makers of Heed, an app for practicing ATT-style sessions. iPhone · Android. Heed is a self-practice tool inspired by ATT research — not therapy, and not a medical device.