A Randomized Controlled Trial Comparing the Attention Training Technique and Mindful Self-Compassion for Students With Symptoms of Depression and Anxiety

Abstract

The Attention Training Technique (ATT) and Mindful Self-Compassion (MSC) are two promising psychological interventions. ATT is a 12-min auditory exercise designed to strengthen attentional control and promote external focus of attention, while MSC uses guided meditation and exercises designed to promote self-compassion. In this randomized controlled trial (RCT), a three-session intervention trial was conducted in which university students were randomly assigned to either an ATT-group (n = 40) or a MSC-group (n = 41). The students were not assessed with diagnostic interviews but had self-reported symptoms of depression, anxiety, or stress. Participants listened to audiotapes of ATT or MSC before discussing in groups how to apply these principles for their everyday struggles. Participants also listened to audiotapes of ATT and MSC as homework between sessions. Participants in both groups showed significant reductions in symptoms of anxiety and depression accompanied by significant increases in mindfulness, self-compassion, and attention flexibility post-intervention. These results were maintained at 6-month follow-up. Improvement in attention flexibility was the only significant unique predictor of treatment response. The study supports the use of both ATT and MSC for students with symptoms of depression and anxiety. Further, it suggests that symptom improvement is related to changes in attention flexibility across both theoretical frameworks. Future studies should focus on how to strengthen the ability for attention flexibility to optimize treatment for emotional disorder.

Full text

CLINICAL TRIAL
published: 25 May 2018
doi: 10.3389/fpsyg.2018.00827
Frontiers in Psychology | www.frontiersin.org 1May 2018 | Volume 9 | Article 827
Edited by:
Francesco Pagnini,
Università Cattolica del Sacro Cuore,
Italy
Reviewed by:
Michail Mantzios,
Birmingham City University,
United Kingdom
Michael Simons,
RWTH Aachen Universität, Germany
*Correspondence:
Stian Solem
stian.solem@svt.ntnu.no
Specialty section:
This article was submitted to
Clinical and Health Psychology,
a section of the journal
Frontiers in Psychology
Received: 13 November 2017
Accepted: 07 May 2018
Published: 25 May 2018
Citation:
Haukaas RB, Gjerde IB, Varting G,
Hallan HE and Solem S (2018) A
Randomized Controlled Trial
Comparing the Attention Training
Technique and Mindful
Self-Compassion for Students With
Symptoms of Depression and Anxiety.
Front. Psychol. 9:827.
doi: 10.3389/fpsyg.2018.00827
A Randomized Controlled Trial
Comparing the Attention Training
Technique and Mindful
Self-Compassion for Students With
Symptoms of Depression and Anxiety
Ragni B. Haukaas, Ingrid B. Gjerde, Grunde Varting, Håvard E. Hallan and Stian Solem*
Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway
The Attention Training Technique (ATT) and Mindful Self-Compassion (MSC) are two
promising psychological interventions. ATT is a 12-min auditory exercise designed to
strengthen attentional control and promote external focus of attention, while MSC
uses guided meditation and exercises designed to promote self-compassion. In this
randomized controlled trial (RCT), a three-session intervention trial was conducted in
which university students were randomly assigned to either an ATT-group (n=40) or
a MSC-group (n=41). The students were not assessed with diagnostic interviews but
had self-reported symptoms of depression, anxiety, or stress. Participants listened to
audiotapes of ATT or MSC before discussing in groups how to apply these principles
for their everyday struggles. Participants also listened to audiotapes of ATT and
MSC as homework between sessions. Participants in both groups showed significant
reductions in symptoms of anxiety and depression accompanied by significant increases
in mindfulness, self-compassion, and attention flexibility post-intervention. These results
were maintained at 6-month follow-up. Improvement in attention flexibility was the only
significant unique predictor of treatment response. The study supports the use of both
ATT and MSC for students with symptoms of depression and anxiety. Further, it suggests
that symptom improvement is related to changes in attention flexibility across both
theoretical frameworks. Future studies should focus on how to strengthen the ability
for attention flexibility to optimize treatment for emotional disorder.
Keywords: attention flexibility, attention training technique, mindful self-compassion, depression, anxiety,
mindfulness, metacognitive therapy, RCT
INTRODUCTION
Anxiety and depression are the most common psychological disorders, with a lifetime prevalence
of 28.8 and 16.6%, respectively (Kessler et al., 2005). Cognitive Behavioral Therapy (CBT; Beck,
1976) is often a recommended treatment for these disorders. However, meta-analyses indicate that
the effect of common psychotherapies including CBT has probably been overestimated (Cuijpers
et al., 2016). Thus, increased understanding for emotional disorder and further research on effective
treatment is needed. The “third wave” CBTs, including Metacognitive Therapy (MCT; Wells, 2009)

Haukaas et al. ATT and MSC
and mindfulness-based interventions, represent promising
perspectives for understanding and treating these disorders.
Attention Training Technique (ATT; Wells, 2009) is an auditory
task developed as part of MCT, aiming at increasing attention
flexibility. Mindful Self-Compassion (MSC; Germer and Neff,
2013; Neff and Germer, 2013) originates from the mindfulness
tradition, with an explicit focus on relating to oneself in a friendly
manner. Both ATT and MSC represent promising methods for
group-administered intervention, with the benefit of being cost
effective and easy to administer.
Metacognitive Therapy and Attention
Training Technique
MCT builds upon the self-regulatory executive function (S-REF)
model, which seeks to explain cognitive and metacognitive
factors involved in top-down control and maintenance of
psychological disorders (Wells and Matthews, 1996). According
to this model, cognitive processes are spread across three
interconnected levels: low-level automatic and reflexive
processing, cognitive style in the form of conscious processing of
thoughts and behaviors, and metacognitive knowledge or beliefs
stored in long-term memory. Metacognition refers to awareness
and cognition about cognitive processes and includes cognitive
factors that control, monitor, and appraise thinking (Wells,
2009).
According to the S-REF model, psychological disorder
is linked to a perseverative style of thinking called the
cognitive attentional syndrome (CAS; Wells, 2009). CAS
consists of prolonged worry or rumination, threat monitoring,
and different unhelpful coping styles accompanied by a
heightened self-focused attention. This may lead to sustained
dysfunctional processing, reduced attentional flexibility, and
an experience of uncontrollability of negative thoughts and
emotions. The aim in MCT is to eliminate the CAS and
to modify dysfunctional metacognitive beliefs about control,
appraisal, and cognitive and emotional processing, and thereby
strengthen the ability to react in a more flexible way to
negative internal stimuli. ATT is one method for achieving
this.
A meta-analysis of MCT for anxiety and depression including
16 studies demonstrated large effect sizes and suggested that
MCT might be superior to CBT (Normann et al., 2014).
Later randomized controlled trials (RCTs) also support the
effectiveness of MCT in treating depression (e.g., Jordan et al.,
2014; Hagen et al., 2017) and anxiety disorders (e.g., Johnson
et al., 2017), and preliminary results indicate that MCT may
be suited for group administration (Dammen et al., 2015;
Papageorgiou and Wells, 2015).
ATT is a component of MCT designed to strengthen
attentional control and promote external focus of attention, to
interrupt and break free of the CAS (Wells, 2009). The exercise
is auditory, and consists of three sections targeting different
attentional components: selective attention, attention switching,
and divided attention. The aim is not to distract oneself from
difficult thoughts or feelings, but rather to increase flexibility and
thus voluntarily being able to choose attentional focus.
Although originally a part of MCT, a growing number of
studies are examining the potential of ATT as a standalone
intervention. A systematic review with meta-analytic elements
summarizes findings from 10 ATT-studies including four studies
with a single case experimental design, four RCTs, and two case
studies (Knowles et al., 2016). Number of ATT-sessions ranged
from 1 to 11 sessions among the included studies. Although
still preliminary, the meta-analysis indicates that ATT may be
effective in treating a wide range of psychological problems.
Four of the included RCTs (Sharpe et al., 2010; Fergus et al.,
2014; Nassif and Wells, 2014; Callinan et al., 2015) involved
non-clinical samples and used one or two sessions, and are as
such comparable to the current study. Within-group effect sizes
pre- to post-intervention in these RCTs were medium to large:
negative affect (d=1.03), anxiety measures (range: d=0.32–
0.65), intrusive thoughts (range: d=1.06–1.33), hypervigilance
to pain (d=0.95), self-focused attention (range: d=0.55–
1.78), and attention flexibility (d=0.61). Effect sizes were also
large for differences between groups for symptom measures
in three of the RCTs. Further, the authors called for more
evaluations of ATT against comparable interventions, such as
mindfulness based interventions, including follow-up intervals
(Knowles et al., 2016).
A general goal of ATT is to increase attention flexibility,
often referred to as part of or similar to the concept of
attentional control (Callinan et al., 2015). Attentional control
can be described as the ability to direct and control attention
voluntarily (Derryberry and Reed, 2002). A study suggested
that poor attentional control limits the ability of emotion
regulation, whereas high attentional control allows the individual
to more flexibly disengage and orient attention away from
threatening information (Derryberry and Reed, 2002). Hence,
poor control may leave the individual vulnerable to emotional
disorder. Attentional control is also negatively correlated to state
anxiety (Spada et al., 2010) and a possible moderator of the
relationship between activation of the CAS and symptoms of
emotional disorder (Fergus et al., 2012). It has been demonstrated
that ATT can strengthen attentional control measured by self-
reported attention flexibility, with medium to large between-
group effect sizes (range: ηp2=0.12–0.15) (Nassif and Wells,
2014; Callinan et al., 2015). This was consistent with performance
on a more objective laboratory-based task of attentional control
(Callinan et al., 2015). It has thus been suggested that attentional
flexibility/control might be a transdiagnostic protective factor
and a putative change mechanism of ATT (Fergus and Bardeen,
2016).
Mindfulness and Self-Compassion
Originating in Buddhist traditions, mindfulness can be defined
as “the awareness that emerges through paying attention on
purpose, in the present moment, and non-judgmentally to the
unfolding of experience moment by moment” (Kabat-Zinn, 2003,
p. 145). Thus, mindfulness can be regarded as consisting of
two components: self-regulation of attention toward current
experiences, and relating to these experiences in an open,
curious, and accepting stance (Bishop et al., 2004). Attentional
processes are important in mindfulness, such as focusing on inner
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Haukaas et al. ATT and MSC
experiences of breathing and emotional sensations. Research also
indicates that mindfulness training has the potential to modify
and strengthen attention following regular training, such as
enhancing the ability to voluntarily shift focus of attention (Jha
et al., 2007; Zylowska et al., 2008; Hölzel et al., 2011).
There is increasing support for the beneficial effects of
mindfulness-based interventions and treatments. Different
programs have been developed and evaluated, such as
mindfulness-based cognitive therapy (MBCT; e.g., Segal
et al., 2002) and mindfulness-based stress reduction (MBSR; e.g.,
Kabat-Zinn, 1982, 1990). A meta-analysis including 39 studies
demonstrated that MBCT, MBSR, or similar interventions were
effective in reducing symptoms of depression and anxiety in
clinical and non-clinical samples, with medium to large effect
sizes (Hofmann et al., 2010).
Based on research indicating that self-compassion might be
one of several key mechanisms accounting for the positive
effects following mindfulness-interventions, a MSC-program has
been developed (Germer and Neff, 2013; Neff and Germer,
2013). According to Neff (2003b), self-compassion consists
of three interrelated components: self-kindness, a sense of
common humanity, and mindfulness. In these terms, being self-
compassionate means relating to oneself in a friendly and patient
manner, understanding that pain and suffering is experienced by
all humans, and being mindfully aware of painful experiences
without over-identifying with them. Mindfulness in the context
of self-compassion is described as awareness in a balanced way to
one’s negative thoughts and emotions, and is thus slightly more
specific than mindfulness in general (Neff, 2003b). The MSC-
program is originally designed as an intervention of eight weekly
group meetings, for both clinical and non-clinical populations,
aiming at enhancing self-compassion through informal (during
daily life) and formal (sitting meditation) exercises (Germer and
Neff, 2013; Neff and Germer, 2013).
Research indicates that self-compassion is inversely related
to psychopathology (Barnard and Curry, 2011), and a meta-
analysis summarizing 20 cross-sectional studies found large effect
sizes for the negative relationship between self-compassion and
stress, anxiety, and depression (MacBeth and Gumley, 2012).
Altogether, this indicates that self-compassion might increase
resilience against stress and be an important buffer against
psychopathology. One RCT evaluating the MSC-program with a
non-clinical sample, found the program to be effective compared
to a waitlist control (Neff and Germer, 2013). Between-group
effect sizes were large for self-compassion and depression,
small for stress, and medium for remaining measures such as
anxiety and mindfulness. Another study of particular relevance
for the current study found promising results with a briefer
self-compassion intervention with a non-clinical sample of 52
students (Smeets et al., 2014). The RCT compared a self-
compassion program of three weekly meetings to a time-
management control group and demonstrated large effect size
for self-compassion (d=1.19), medium effect sizes for optimism
(d=0.66), self-efficacy (d=0.52), and reduction in rumination
(d=0.70), and small effect size for worry (d=0.19). This
indicates that a three-session trial may be sufficient for a
therapeutic effect, such as improving well-being and resilience
(Smeets et al., 2014). However, this study did not include follow-
up assessment.
Comparisons of ATT and
Mindfulness-Based Interventions
As presented above, ATT and mindfulness originate from
different traditions and as such have several dissimilarities.
Meditation for instance, which is a core element of mindfulness-
based interventions, is not recommended in MCT (Wells,
2009). Furthermore, although attention is emphasized in both
mindfulness and ATT, they seem to differ in their perspectives
on the preferential locus or direction of attentional focus. Self-
focused attention can be defined as: “An awareness of self-
referent, internally generated information that stands in contrast
to an awareness of externally generated information derived
through sensory receptors” (Ingram, 1990, p. 156). Heightened
self-focused attention has traditionally been associated with
psychopathology, and is considered a core component shared by
several psychological disorders, such as anxiety and depression
(Ingram, 1990). ATT targets inflexible and excessive self-focused
attention, aiming to increase attention flexibility, and switch
to a more external attentional focus (e.g., Wells, 2009). In the
mindfulness tradition, however, increased internal attentional
focus has been suggested as an important change mechanism
for achieving the beneficial effects of mindfulness training
(Baer, 2009). Distinct functions of different types of self-
focused attention has been proposed (Trapnell and Campbell,
1999), and a ruminative, self-critical self-focus, as described in
MCT, is probably different from the reflective, experiential self-
focus associated with the mindfulness tradition (Baer, 2009).
Studies have also supported this notion (Watkins and Teasdale,
2004).
Despite the conceptual differences, both intervention
perspectives seem promising in reducing symptoms of anxiety
and depression, and may operate through related mechanisms
such as attentional processes. Therefore, the relationship
between them are of interest to explore. This was done in a
RCT with 76 students, comparing ATT to mindfulness-based
progressive muscle relaxation (MB-PMR) in a single-session
trial (Fergus et al., 2014). Symptoms of cognitive and somatic
anxiety were significantly reduced after one session, with
medium to large effect sizes in both the ATT-group (range:
d=0.32–0.65) and the MB-PMR-group (range: d=0.59–
1.04)1. Heightened self-focused attention was related to less
anxiety after MB-PMR, whereas heightened externally focused
attention was related to less anxiety after ATT. However, the
study was a single-session trail and lacked follow-up assessment.
Despite its limitations, this RCT indicates that both perspectives
are effective in reducing symptoms of anxiety, and that the
effect of self-focused attention might depend on whether it is
performed in a mindfulness-based context or not (Fergus et al.,
2014).
The effectiveness of these perspectives in reducing anxiety
symptoms via common processes has also been supported in
1As effect sizes were not given by Fergus et al. (2014), these were calculated using
Morris and DeShon’s (2002) Equation (8) with correlation coefficient 0.5.
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Haukaas et al. ATT and MSC
a recent RCT comparing ATT and MB-PMR to a thought
wandering control (TWC) with 81 high trait anxious individuals
(McEvoy et al., 2017). There was a significant reduction in state
anxiety after a single session, with large effect sizes in both
experimental groups (ATT: d=0.83; MB-PMR: d=0.85).
Contrary to previous findings (Fergus et al., 2014), the notion that
internal vs. external shifts in attention is associated with symptom
reduction was not supported in this study. Furthermore,
cognitive flexibility as measured by an emotional Stroop task
was not associated with anxiety reductions. This was inconsistent
with their hypothesis, previous studies (e.g., Nassif and Wells,
2014) and metacognitive theory (Wells, 2009). However, changes
in present-focused attention and metacognitive beliefs were
potent change mechanisms across ATT and MB-PMR. The
authors concluded that the two techniques are more similar than
different and may influence symptom reduction via common
mechanisms (McEvoy et al., 2017). A related study exploring
the theoretical basis of such interventions also found that
mindfulness and metacognitions share important elements,
although they are distinguishable constructs (Solem et al., 2015).
In summary, metacognitive and mindfulness-based traditions
offer viable treatment options and may contribute to increased
understanding of emotional disorder through different
theoretical perspectives on self-regulation and attentional
processes (e.g., Hofmann et al., 2010; Normann et al., 2014).
Specifically, both ATT and MSC can be considered promising
cost effective and easy-to-administer interventions for preventing
and reducing symptoms of anxiety and depression (Neff and
Germer, 2013; Knowles et al., 2016). Such interventions are
originally built upon separate constructs, but may be somewhat
overlapping (Solem et al., 2015; McEvoy et al., 2017). Thus,
comparing these perspectives is of interest, as well as exploring
how underlying mechanisms such as attentional control relates
to symptom reduction (Fergus and Bardeen, 2016). As few
controlled studies have evaluated these interventions, and only
two studies have compared ATT and a mindfulness-based
intervention (Fergus et al., 2014; McEvoy et al., 2017), more
RCTs are needed.
The current RCT therefore sets out to compare the efficacy
of ATT and MSC in a three-session trial over 3 weeks, thus
expanding results from Smeets et al. (2014),Fergus et al. (2014),
and McEvoy et al. (2017). However, the current RCT aims at
overcoming limitations in these studies. Fergus et al. (2014) and
McEvoy et al. (2017) did not include measures of depression or
mindfulness and Smeets et al. (2014) did not include measures
of anxiety and depression. Therefore, measures of both anxiety
and depression will be included in addition to theoretical
construct measures. Due to lacking information about long-term
effects in the previous studies, follow-up assessment will also be
included. The aim of the current RCT is to test the following
hypotheses:
H1: Both interventions will lead to a significant reduction
in symptoms of anxiety and depression. H2: Both interventions
will give a significant increase in mindfulness, attention
flexibility, and self-compassion and treatment-responders
will experience more change than non-responders on these
measures.
METHODS
Participants
A total of 94 participants showed interest in participation, of
which 81 showed up to intervention. The total sample therefore
consisted of 81 Norwegian undergraduate and graduate students
at the Norwegian University of Science and Technology (NTNU),
mean age 22.9 (SD =3.3, range =18–36). Participation was
open for everyone interested. The participants were not assessed
with diagnostic interviews, but had self-reported symptoms of
depression, anxiety, and stress. The majority of the participants
were female (75.3%) and 55.6% reported having a partner. In
total, 69 participants completed the three-session intervention.
A total of nine participants (22.0%) dropped out in the MSC
condition and three participants (7.5%) in ATT, no reasons were
reported. Participant flow is presented in Figure 1.
Procedure
The study was a RCT approved by the Regional Medical Ethics
Committee in Norway (ref.nr. 2015/470). Informed written
consent was given from all participants. Intervention was
implemented from 2015 to 2017. Participants were recruited at
two NTNU campuses with flyers, posters, and promotion in
lectures and social media. The study was presented as a course
in stress management based on either mindfulness or attention
training consisting of three group meetings. Participation was
open for everyone interested, but the information implied that
the course was suited for people experiencing excessive stress
and worry. Using the Research Randomize Program (www.
randomizer.org), the recruited participants were randomized to
either the ATT or MSC experimental group. Participants were
blind as to which experimental group they were allocated until
the first group meeting. All participants completed an online
questionnaire (described below) before, 1 week after, and at
6-month follow-up.
Measures
The questionnaire consisted of demographics and three 1-item
questions about level of test anxiety, self-esteem, and loneliness
using a 4-point scale; general symptom measures of anxiety and
depression used as primary outcome measures; and treatment-
specific measures for evaluation of the constructs of mindfulness,
self-compassion, and attention flexibility.
The Patient Health Questionnaire-9 (PHQ-9; Kroenke
et al., 2001)
PHQ-9 was used as a primary outcome measure in order to assess
symptoms of depression. PHQ-9 is a 9-item self-report inventory
based on DSM-criteria for depression. The items ask how often
the individual has been bothered by symptoms (e.g., “Feeling
down, depressed, or hopeless?”) over the last 2 weeks. Each item
is rated on a 4-point scale (0 =not at all, 3 =almost every day). In
the current study, PHQ-9 was used as a continuous measure with
total scores ranging from 0 to 27, in which scores of 5, 10, and
15 represent mild, moderate, and severe depressive symptoms.
Overall, the PHQ-9 has been shown to have good reliability and
validity (Kroenke et al., 2001, 2010). In the current study, the
PHQ-9 had a Cronbach’s alpha of 0.83.
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Haukaas et al. ATT and MSC
FIGURE 1 | Flow chart presenting participant flow from assessment to follow-up.
Generalized Anxiety Disorder-7 (GAD-7; Spitzer et al.,
2006)
In order to evaluate level of anxiety symptoms, GAD-7 was
used as a primary outcome measure. GAD-7 is a 7-item self-
report questionnaire based on the DSM-criteria for generalized
anxiety disorder. The items ask how often the individual has been
bothered by symptoms (e.g., “Feeling nervous, anxious, or on
edge?”) over the last 2 weeks. Each item is rated on a 4-point
scale (0 =not at all, 3 =almost every day). GAD-7 total scores
range from 0 to 21 wherein scores of 5, 10, and 15 may represent
mild, moderate, and severe anxiety symptoms. Research has
indicated good construct, criterion, factorial, and procedural
validity, as well as good reliability, for GAD-7 (Spitzer et al.,
2006). In the current study, the GAD-7 had a Cronbach’s alpha
of 0.82.
Self-Compassion Scale Short Form (SCS-SF; Raes
et al., 2011)
The construct of self-compassion was measured using a short
version of Neff’s (2003a) original 26-item Self-Compassion Scale
(SCS). The SCS-SF consists of 12 items being rated on a scale
from 1 to 5 (1 =almost never, 5 =almost always). Items include
e.g.: “I try to be understanding and patient toward those aspects
of my personality I don’t like,” and “When I feel inadequate in
some way, I try to remind myself that feelings of inadequacy
are shared by most people.” Total scores range from 12 to
60, in which higher score indicates higher self-compassion. As
the original SCS, the SCS-SF measures six components of self-
compassion: self-kindness, self-judgement, common humanity,
isolation, mindfulness, and overidentification. The total scores in
SCS-SF are almost perfect correlated with the original SCS, as well
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Haukaas et al. ATT and MSC
as having the same factor structure and good internal consistency
(Raes et al., 2011). Good reliability has been found in non-clinical
(Raes et al., 2011) and clinical (Lockard et al., 2014) samples. Raes
et al. (2011) recommend the full SCS when subscale information
is of interest. The current study uses total scores only. In the
current study, the SCS-SF had a Cronbach’s alpha of 0.86.
Detatched Mindfulness Questionnaire (DMQ; Nassif
and Wells, 2007)
DMQ is a 22-item self-report measure assessing participants’
different levels of awareness and how they respond to their
thoughts. The measure consists of five theoretically derived
constructs of detached mindfulness: attention flexibility, meta-
awareness, detachment/observing self, thought control, and
cognitive de-centering. These subscales are conceptualized
as adaptive or maladaptive in the metacognitive model of
psychological disorder. Each item is rated on a 5-point scale
(1 =disagree, 5 =agree). In the current study, the subscale of
particular interest was attention flexibility. This subscale has been
used to measure the construct of attentional control/flexibility in
previous ATT-studies (e.g., Nassif and Wells, 2014; Callinan et al.,
2015). The subscale consists of five items, including e.g., “I am
able to have a negative thought without worrying about it,” and “I
can usually let go of my thoughts even if I’m worried.” Scores on
this subscale can range from 5 to 25, with higher scores indicating
higher levels of attention flexibility. In the current study, the
DMQ flexibility subscale had a Cronbach’s alpha of 0.80.
The Five Facet Mindfulness Questionnaire (FFMQ;
Baer et al., 2006; Tran et al., 2013)
The FFMQ is a self-report measure assessing the following
five facets of mindfulness: observing, describing, acting with
awareness, non-judging of inner experience, and non-reactivity
to inner experience. This five-factor solution was developed
through factor analysis of combined items from five existing
mindfulness questionnaires. Each item is rated on a 5-point
Likert scale (1 =never or rarely true; 5 =very often or always
true). An example is: “I perceive my feelings and emotions
without having to react to them.” In the 39-item full form, the
facets of FFMQ have demonstrated good reliability and validity
(Baer et al., 2008; Christopher et al., 2012). The full FFMQ has
also been validated for use in Norway (Dundas et al., 2013). In
the current study, a 20-item short version (Tran et al., 2013) was
used and FFMQ was reported as a total score. Total scores can
range from 20 to 100, with higher scores indicating higher levels
of mindfulness. In the current study, the 20-item FFMQ had a
Cronbach’s alpha of 0.80.
Intervention
The intervention consisted of three group sessions 3 weeks in
a row, of either ATT or MSC, as well as instructions to listen
to certain audiotapes every day between sessions during the
intervention period. Each group consisted of 6–10 participants
sitting in a circle, being co-led by two therapists. All group
sessions were held in the afternoon at the university campus and
lasted for 45 min. The participants were instructed to take an
active part in the group discussions while the therapists mainly
were facilitating, asking socializing questions, and unraveling
misunderstandings.
The following structure was used in the first two sessions in all
groups:
1. Agenda-setting for the day.
2. Presenting the intervention condition: introducing the
participants to the technique and their respective rationales.
3. Practicing the technique using pre-recorded audiotapes.
4. Discussion of the technique: in order to understand the
exercise and how it can be useful and applied to everyday life.
5. Agreeing upon homework: listening to the audiotape between
meetings. Forms were handed out so that participants could
register practice frequency.
Session two and three in both conditions began by asking
about homework, feedback from the participants, summing up
the rationale, and unraveling possible misunderstandings. In
the second session, this was followed by step three to four, as
presented above.
In the third and last session, there was no practicing with
audiotapes. Most of the time went to group discussion on
the principles the participants had learned during the 3-week
intervention. Each participant described in turn how they had
experienced listening to the audiotapes and how they could
relate the principles to their everyday life. Finally, participants
provided evaluation feedback of the course. Differences between
the conditions are described below.
ATT-Intervention
After a brief discussion of self-focused attention and socialization
based on a rationale for ATT (Wells, 2009, p. 59), the
participants listened to a 12 min ATT audiotape together
(available at: http://www.mct-institute.com/attention-training-
technique). The exercise consists of six to nine sounds, in
addition to a voice guiding the listener through three sections:
5 min of selective attention, 5 min of rapid attention switching,
and 2 min of divided attention (Wells, 2009). The selective
attention section consists of instructions to focus on individual
sounds in an array of competing sounds at different spatial
locations. This is followed by rapid attention switching between
both spatial locations and the individual sounds with gradually
increasing speed. The exercise concludes with a section of
divided attention, in which the listener is instructed to expand
his or her attention to process multiple sounds and locations
simultaneously. The participants were instructed to focus on
a visual fixation point during the exercise and not to use
the audiotape as avoidance from uncomfortable thoughts and
feelings.
A further discussion of the principles of ATT and experiences
while listening to the audiotape followed. Using the Self-
Attention Rating Scale (Wells, 2009, p. 267), participants were
asked to rate their focus of attention before and after listening
to the audiotape by choosing a number from −3 (indicating
entirely externally focused) to +3 (entirely self-focused). Self-
focused attention vs. external focus of attention was then
discussed. Homework was ascribed in the form of listening to
the audiotape once a day for 2 weeks. The participants could
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Haukaas et al. ATT and MSC
choose freely between listening to the original audiotape or a
Norwegian translation. The last group session focused on use of
the principles from ATT and general elements of metacognitive
theory.
MSC-Intervention
In the first session, the concept of mindfulness was
introduced and general components such as moment-to-
moment experiences, a non-judging attitude, and breathing
were discussed. This was followed by listening to the first
10 min of a 20 min Affectionate Breathing-tape (available
at: http://self-compassion.org/wp-content/uploads/2016/11/
affectionatebreathing_cleaned.mp3), in which the listener is
guided through a breathing exercise. The audiotape instructs the
listener to keep an affectionate attitude and accept any arriving
thought and urge. A brief discussion of the experience and
principles in the exercise followed. As homework, participants
were asked to listen to the full audiotape once a day and try to be
mindful in their daily activities. The participants were instructed
not to use the audiotape as avoidance or coping strategy.
In the second session, self-compassion was introduced
for the first time after a short reminder of mindfulness.
Following a brief discussion of self-compassion, the participants
listened to the first 11.5 min of Neff ’s 20 min Loving Kindness
Meditation (available at: http://self-compassion.org/wp-content/
uploads/2016/11/LKM_cleaned.mp3). The aim is to generate
compassion for oneself and others, and the audiotape instructs
the listener e.g., to repeat compassionate phrases. After listening
to the tape, experiences during the exercise were shared, and
a further discussion followed on the differences between self-
compassion and self-pity and how to relate to oneself in a kinder
and more accepting manner. Homework was ascribed in the form
of listening to the new full audiotape once a day until the next
session and observing one’s inner critical dialogue. The third and
last session mainly focused on self-compassion and how to use
the principles in everyday life.
Therapists
The therapists were four clinical psychology students on their
fifth year, under supervision from a clinical psychologist. The
student therapists had no prior official training in ATT or
MSC. Training involved extensive literature reading on the two
conditions and receiving feedback on videotaped recordings of
training sessions before the experimental group interventions
started. Therapists also discussed and trained with the audiotapes
themselves. All therapists conducted both ATT and MSC equally.
The group leaders were supervised between the group sessions.
Data Analyses
To compare the two samples on demographics and measures pre-
intervention, one-way analysis of variance (ANOVA) was used.
Chi-square tests were used to compare the groups with respect to
dichotomous variables.
Repeated measures ANOVA was used to assess changes in
measures from pre- to post-intervention and follow-up, and
a split-plot ANOVA was used to compare the groups with
respect to changes in outcome measures. Pre-intervention,
2.5% values were missing on GAD-7, FFMQ, DMQ, and
SCS-SF. Missing data in these measures were replaced by
mean values. Last observation carried forward was used for
missing data post-intervention for dropouts (7.5% for ATT
and 22.0% for MSC) and missing follow-up data. To assess
whether homework frequency influenced outcome, a split-plot
ANOVA with number of homework exercises as a covariate
was conducted. Missing data on the homework-variable was
not replaced. Cohen’s dwith pooled SD and partial eta squared
was calculated and reported as effect sizes. Cohen’s dwas
calculated for each measure for each group, and correlations
between pre- and post-intervention values were included in
the calculation. This was done using Morris and DeShon’s
(2002) Equation (8), which corrects for dependence between
means. Cohen’s dis interpreted as small (0.2), moderate (0.5),
and large (0.8) effect size (Cohen, 1988). For main effects and
differences between groups, partial eta squared was used as
measure of effect size. Partial eta squared is interpreted as small
(0.01), medium (0.06), and large (0.14) effect size (Richardson,
2011).
It was of interest to examine differences between responders
and non-responders to intervention in order to find out
for whom the intervention worked and why. Response to
intervention was defined as at least 35.0% improvement
in primary outcome symptom measures (PHQ-9 and
GAD-7) pre- to post-intervention. ANOVAs were run
to compare non-responders and responders in the ATT-
and MSC-group on change scores in mindfulness, self-
compassion, and attention flexibility. For an easier to
interpret graphic presentation, individual change scores on
all theoretical measures were rescaled to a standardized 0–100
scale.
Finally, linear regression analyses were conducted
using the total sample to predict primary outcome
measures post-intervention, using primary outcome
measures pre-intervention, age, gender, and change in
mindfulness, self-compassion, and attention flexibility as
predictors. This was done in order to determine which of
these variables contributed to treatment response across
conditions.
RESULTS
Sample Characteristics
An overview of demographics, symptoms, and other measures
in the two experimental groups pre-intervention is presented in
Table 1. One-way ANOVA indicated no significant differences
between groups on any measures pre-intervention. None of the
participants reported no symptoms (scores of 0 on all measures).
Categorizing symptoms into none, mild, and moderate to severe
symptoms, 37.0% showed no symptoms of depression, while
63.0% scored in the mild to severe range. As for symptoms
of anxiety, 35.8% showed no symptoms, while 64.2% scored
in the mild to severe range. A total of 39.0% reported being
a little to very lonely, 21.9% reported having a little bad to
bad self-esteem, and 50.6% reported having some to a lot test
anxiety.
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Haukaas et al. ATT and MSC
TABLE 1 | Descriptive statistics and comparison between groups pre-treatment
(N=81).
ATT MSC Total F/x2Sig.
N40 41 81
Age 22.7 (3.2) 23.0 (3.4) 22.9 (3.3) 0.20 0.660
Female gender 75.0% (30) 75.6% (31) 75.3% (61) 0.00 0.949
Partner 55.0% (22) 56.1% (23) 55.6% (45) 0.01 0.921
PHQ-9 6.7 (4.3) 7.5 (5.2) 7.1 (4.7) 0.56 0.456
GAD-7 6.0 (2.9) 7.1 (4.1) 6.6 (3.6) 1.94 0.167
SCS-SF 34.5 (9.8) 34.3 (7.5) 34.4 (8.6) 0.02 0.899
DMQ flexibility 15.5 (4.8) 14.1 (4.3) 14.8 (4.6) 1.77 0.187
FFMQ 66.2 (10.4) 62.7 (8.2) 64.4 (9.5) 2.81 0.098
Test anxiety 2.6 (0.7) 2.5 (0.7) 2.5 (0.7) 0.06 0.812
Self-esteem 2.9 (0.8) 2.8 (0.7) 2.8 (0.8) 0.02 0.904
Loneliness 2.7 (0.7) 2.6 (0.6) 2.7 (0.7) 0.60 0.443
Parenthesis indicate standard deviations, except from female gender and partner, where
parenthesis indicate exact values. ATT, Attention Training Technique; MSC, Mindful
Self-Compassion; PHQ-9, The Patient Health Questionnaire 9 (range: 0–27); GAD-7,
Generalized Anxiety Disorder-7 (range: 0–21); SCS-SF, Self-Compassion Scale Short
Form (range: 12–60); DMQ flexibility, Attention Flexibility (range: 5–25); FFMQ, The Five
Facet Mindfulness Questionnaire (range: 20–100).
Treatment Response
Repeated measures ANOVAs indicated a significant reduction
in depressive symptoms (PHQ-9) and anxiety symptoms (GAD-
7) in both groups pre- to post-intervention, with medium effect
sizes (range: d=0.53–0.71) and no significant differences
between conditions (see Table 2). These results were stable,
with no significant differences in symptom level between post-
intervention and follow-up either for PHQ-9 (p=0.872)
or GAD-7 (p=0.934). As presented in Table 3, participants
reporting no symptoms increased in both groups for PHQ-
9 (ATT =40.0–55.0%; MSC =34.1–53.7%) and GAD-
7 (ATT =37.5–60.0%; MSC =34.1–51.2%), pre- to post-
intervention. There was also a substantial decrease in participants
scoring within the moderate to severe range. In general, these
results were maintained at follow-up, as depicted in Table 3.
However, there was a slight increase in participants scoring
within the mild range. Defining treatment response by minimum
35.0% reduction in symptoms measures, there was a treatment
response post-intervention of 33.3% (GAD-7) and 32.1% (PHQ-
9) across conditions. This was maintained at follow-up (GAD-
7=37.0%; PHQ-9 =35.8%).
As presented in Table 2, there was a significant increase in self-
compassion (SCS-SF), attention flexibility (DMQ flexibility), and
mindfulness (FFMQ) in both groups pre- to post-intervention,
with large effect sizes and no significant differences between
groups. With small to medium effect sizes, there was also a
significant increase in self-esteem and a significant decrease
in test anxiety, with no significant differences between groups.
For self-compassion, attention-flexibility, and self-esteem, these
results were maintained with no significant differences between
post-intervention and follow-up (SCS-SF: p=0.356; DMQ
flexibility: p=0.618; self-esteem: p=0.358). For mindfulness,
there was a significant increase (FFMQ: p=0.010) and for
test-anxiety there was a significant decrease (p=0.003) from
post-intervention to follow-up. The replacement of missing
follow-up data did not affect the results of the analysis as opposed
to analyses with completers only.
Homework
During the intervention period, the ATT-group listened to the
audiotape at home 10.6 times (SD =2.8), compared to the MSC-
group in which the participants practiced 7.3 times (SD =2.5).
Although this difference in homework is statistically significant
[t(66) =5.17, p<0.001], split-plot ANOVAs using homework as
a covariate indicated that number of exercises had no significant
effect on PHQ-9 (p=0.555) or GAD-7 (p=0.935). Note that
missing homework-data was not replaced.
Comparison of Responders and Non-responders
Figure 2 presents a comparison of the change scores (0–100) in
mindfulness (FFMQ), self-compassion (SCS-SF), and attention
flexibility (DMQflex) for responders and non-responders in
the ATT- and MSC-group pre- to post-intervention. ANOVAs
indicated significant differences in change scores between
responders and non-responders on most of these variables in
both the ATT- and the MSC-group, as illustrated in Figure 2.
Responders consistently showed higher change scores than
non-responders on self-compassion, attention flexibility, and
mindfulness.
Test of Theoretical Models
Regression analyses were run in order to determine which
variables contributed to explain symptoms post-intervention.
Table 4 summarizes results of regression analyses with
post-GAD-7 and post-PHQ-9 scores as outcome variables,
respectively. For post-PHQ-9 the total model explained a
significant proportion of variance, R2=0.696, F(6, 74) =31.58,
p<0.001. For post-GAD-7 the model explained a significant
proportion of the variance, R2=0.664, F(6, 74) =27.34,
p<0.001. Change in attention flexibility (DMQ flexibility) was
the only unique theoretical variable that significantly predicted
treatment outcome.
DISCUSSION
The aim of the present study was to examine the effectiveness
of a 3-week intervention trial based on either MSC or ATT for
symptoms of anxiety and depression among students, and to
investigate two theoretical models for emotional disorder. Both
interventions were associated with reduction in symptoms of
anxiety and depression, as predicted by the first hypothesis. In
support of the second hypothesis, both interventions significantly
increased mindfulness, attention flexibility, and self-compassion
pre- to post-intervention. The changes predicted by both
hypotheses were maintained when measured at 6-month follow-
up. A clear trend was found when comparing responders
and non-responders to intervention: responders showed larger
change-scores than non-responders on all theoretical measures
pre- to post-intervention. This might indicate that all of these
are possible change mechanisms. However, change in attention
flexibility was the only unique predictor of treatment outcome.
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Haukaas et al. ATT and MSC
TABLE 2 | Summary of means and standard deviations pre-intervention, post-intervention, and follow-up.
Pre- to post-intervention
Main effect Between groups
Variable Pre-score Post-score Follow-up dη2
pSig. η2
pSig.
Mean (SD) Mean (SD) Mean (SD)
PHQ-9 ATT 6.7 (4.3) 5.2 (3.7) 5.3 (0.7) 0.53 0.233 <0.001*** 0.001 0.803
PHQ-9 MSC 7.5 (5.2) 5.9 (5.2) 5.7 (0.7) 0.57
GAD-7 ATT 6.0 (2.9) 4.4 (2.9) 4.4 (0.5) 0.71 0.278 <0.001*** 0.001 0.732
GAD-7 MSC 7.1 (4.1) 5.7 (4.2) 5.8 (0.5) 0.54
SCS-SF ATT 34.5 (9.6) 39.2 (8.0) 39.9 (8.8) 0.82 0.313 <0.001*** 0.009 0.402
SCS-SF MSC 34.3 (7.4) 37.8 (8.1) 38.1 (8.5) 0.55
DMQ flexibility ATT 15.5 (4.8) 17.4 (3.9) 17.6 (4.2) 0.51 0.264 <0.001*** 0.001 0.844
DMQ flexibility MSC 14.1 (4.2) 16.2 (4.6) 16.3 (4.5) 0.73
FFMQ ATT 66.2 (10.3) 70.4 (9.8) 71.9 (10.8) 0.66 0.262 <0.001*** 0.004 0.571
FFMQ MSC 62.7 (8.1) 66.1 (9.4) 67.7 (9.3) 0.53
Self-esteem ATT 2.6 (0.8) 3.0 (0.8) 3.1 (0.8) 0.27 0.062 0.025* 0.000 0.978
Self-esteem MSC 2.8 (0.7) 3.0 (0.7) 3.0 (0.7) 0.24
Test anxiety ATT 2.6 (0.8) 2.4 (0.7) 2.3 (0.9) 0.24 0.048 0.050* 0.001 0.807
Test anxiety MSC 2.5 (0.7) 2.4 (0.6) 2.2 (0.6) 0.20
Loneliness ATT 2.7 (0.7) 2.8 (0.7) 3.0 (0.6) 0.12 0.001 0.757 0.010 0.370
Loneliness MSC 2.6 (0.6) 2.6 (0.6) 2.7 (0.5) 0.07
Effect sizes and repeated-measures analysis of variances (ANOVA) results showing effect of intervention and differences in effect between groups pre- to post-intervention.
***p<0.001, *p≤0.05. ATT, Attention Training Technique; MSC, Mindful Self-Compassion; PHQ-9, Patient Health Questionnaire 9; GAD-7, Generalized Anxiety Disorder-7; SCS-SF,
Self-Compassion Scale Short Form; DMQ flexibility, Attention Flexibility; FFMQ, Five Facet Mindfulness Questionnaire.
TABLE 3 | Frequencies of participants showing no, mild, and moderate to severe symptoms of depression and anxiety as measured with PHQ-9 and GAD-7
pre-intervention, post-intervention, and follow-up.
PHQ-9 (n/%) GAD-7 (n/%)
Cut-off Pre Post FU Pre Post FU
ATT
0–4 (No symptoms) 16/40.0 22/55.0 20/50.0 15/37.5 24/60.0 21/52.5
5–9 (Mild) 12/30.0 12/30.0 15/37.5 18/45.0 13/32.5 17/42.5
>10 (Moderate to severe) 12/30.0 6/15.0 5/12.5 7/17.5 3/7.5 2/5.0
MSC
0–4 (No symptoms) 14/34.1 22/53.7 21/51.2 14/34.1 21/51.2 20/48.8
5–9 (Mild) 16/39.1 13/31.7 14/34.2 17/41.5 14/34.2 16/39.0
>10 (Moderate to severe) 11/26.8 6/14.6 6/14.6 10/24.4 6/14.6 5/12.2
ATT, Attention Training Technique; MSC, Mindful Self-Compassion; PHQ-9, Patient Health Questionnaire 9; GAD-7, Generalized Anxiety Disorder-7; FU, 6-month follow-up.
In comparison with relevant previous studies (Fergus et al.,
2014; Nassif and Wells, 2014; Smeets et al., 2014; Callinan et al.,
2015; McEvoy et al., 2017), all effect sizes in the current study
were similar or even larger for primary outcome measures.
This indicates that the interventions were administered in a
satisfactory manner, and that both ATT and MSC performed
in groups were equally effective in reducing depressive and
anxiety symptoms among non-clinical individuals. Furthermore,
stability in this reduction 6 month later indicates that such
interventions may buffer against development of emotional
disorder. These results support the potential of ATT and
MSC as standalone interventions and imply that they are
suitable for group-administration. As for the optimal practice
dosage, six to nine sessions of ATT have previously been
proposed to attain long-term effects (Knowles et al., 2016).
The current study, however, found that three sessions might
be sufficient and that the amount of home practice between
sessions was not important for symptom reduction in either
the ATT- or MSC-group. Hence, understanding the rationale
is probably more important than the amount of practice, and
reaching this comprehension might be the main function of
practicing. However, this assumption needs further investigation.
Altogether, the support of the first hypothesis suggests that
MSC and ATT performed as 3-week group interventions might
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Haukaas et al. ATT and MSC
FIGURE 2 | Differences in change scores pre- to post-intervention for responders and non-responders for ATT (n=40) and MSC (n=41) classified by primary
outcome measures PHQ-9 and GAD-7. Change scores are reported using transformed scores (0–100). Significant differences between responders and
non-responders are highlighted (*p<0.05, **p<0.01). ATT, Attention Training Technique; MSC, Mindful Self-Compassion; PHQ-9, Patient Health Questionnaire 9;
GAD-7, Generalized Anxiety; FFMQ, Five Facet Mindfulness Questionnaire; SCS-SF, Self-Compassion Scale Short Form; DMQflex, Attention Flexibility.
produce beneficial and lasting effects for non-clinical student
samples.
In support of the second hypothesis, self-compassion
significantly increased in both groups. This indicates that both
interventions may strengthen the capability to relate to oneself
in a friendlier manner. The increase in self-compassion was
expected in the MSC-condition based on previous studies (Neff
and Germer, 2013; Smeets et al., 2014) and as this intervention
had an explicit focus on self-compassion. Self-compassion has
also been suggested a central change mechanism following
mindfulness interventions (Shapiro et al., 2005; Germer and Neff,
2013). As for the ATT-group, the increase in self-compassion
is particularly interesting, as this is not an explicit aim of this
technique. A possibility is that ATT may strengthen the ability to
voluntarily change the attentional focus away from self-criticism.
Mindfulness also increased significantly pre- to post-
intervention in both groups and was the only theoretical
measure that significantly increased from post-intervention to
follow-up. Even though increase in mindfulness is not originally
predicted following ATT, Wells (2002) acknowledges that
there are similarities between mindfulness and ATT. This is
plausible as both techniques support distancing from mental
and external events, allowing thoughts and feelings to come
and go, and promote present-moment focus through formal
exercises. The current study supports this notion and suggests
that although deriving from different conceptual frameworks,
both interventions affect related skills that keep developing
months after intervention. Increase in mindfulness in both
groups also supports previous statements that mindfulness and
metacognitions may share overlapping elements (Solem et al.,
2015).
Of all the theoretical measures included, change in attention
flexibility was the most unique predictor of symptom reduction
post-intervention. Enhanced attention flexibility was expected in
the ATT-group as this is an explicit goal of the technique, and the
results support previous studies (Nassif and Wells, 2014; Callinan
et al., 2015). This also yields support for the metacognitive model
of emotional disorder in that attentional control is important in
disrupting the CAS. The current results also expand previous
claims of the relative contribution of attention in mindfulness-
based interventions (e.g., Jha et al., 2007). Mindfulness-based
exercises might enhance attention flexibility by training the
ability to shift attentional focus between the breath and other
sensations, while inhibiting distractions. Altogether, the results
suggest that both ATT and MSC strengthen the capacity to
respond to one’s internal and external environment in a more
flexible manner.
This may at first glance seem inconsistent with the findings of
McEvoy et al. (2017), who found that reduction in anxiety was
independent of improvement in cognitive flexibility as measured
by emotional Stroop. However, this inconsistency is probably due
to methodological challenges already outlined by McEvoy et al.
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Haukaas et al. ATT and MSC
TABLE 4 | Multiple regression analyses with post-intervention PHQ-9 and GAD-7
regressed on pre-intervention PHQ-9 and GAD-7 respectively, as well as age,
female gender, and change in SCS-SF, change in DMQ flexibility, and change in
FFMQ across experimental groups.
Variable ß T Sig.
PHQ-9 POST
Age 0.009 0.140 0.889
Female gender −0.056 −0.860 0.393
PHQ-9 pre 0.805 12.824 0.000**
SCS-SF 10.000 −0.006 0.996
DMQ flexibility 10.193 2.582 0.012*
FFMQ 10.085 1.137 0.259
GAD-7 POST
Age −0.100 −1.465 0.147
Female gender −0.088 −1.280 0.205
GAD-7 pre 0.814 11.824 0.000**
SCS-SF 1−0.014 −0.161 0.872
DMQ flexibility 10.214 3.091 0.003**
FFMQ 10.050 0.639 0.525
**p<0.01, *p<0.05. PHQ-9, Patient Health Questionnaire 9; GAD-7, Generalized
Anxiety Disorder-7; SCS-SF, Self-Compassion Scale Short Form; DMQ flexibility,Attention
Flexibility; FFMQ, Five Facet Mindfulness Questionnaire.
(2017), that the emotional Stroop-task may have been unable
to detect changes in attention flexibility following intervention.
Therefore, the flexibility subscale of DMQ may be more suitable
than emotional Stroop in examining the contribution of attention
flexibility in symptom reduction.
One implication from the current study is that techniques
developed within different theoretical frameworks may decrease
symptoms of anxiety and depression via common mechanisms.
All theoretical measures increased similarly across both
conditions and scores were higher among responders than non-
responders to interventions. Several studies comparing different
psychotherapies has found equal symptom reduction and
improvements on both model-specific as well as common factors
(e.g., Warmerdam et al., 2010; Lemmens et al., 2017), indicating
that psychological processes necessary for symptom reduction
seems comparable across theoretical background. Although the
current study does not imply causality, it suggests attention
flexibility might be an efficacious underlying mechanism of
change across interventions and a potent common factor
between ATT and MSC.
It is further interesting to discuss the relationship between
direction of attentional focus and attention flexibility, as we
would argue that these constructs seem somewhat overlapping.
Fergus et al. (2014) found that the function of self-focused
attention may vary depending on the context in which it is
performed, thus supporting the differentiation between subtypes
of self-focused attention such as ruminative or self-critical, vs.
experiential or mindful self-focus (Baer, 2009). This notion was
not fully supported in a later study, where no relationship
between locus of attention and symptom reduction was found
(McEvoy et al., 2017). The authors concluded that locus of
attention may be less important than the ability to distance
oneself from one’s experiences, the capacity of present-moment
attention, and an experience of control over one’s attention
(McEvoy et al., 2017). Based on the unique role of attention
flexibility in the current study, it seems plausible that flexibility
in attention and voluntary control may be more important than
whether the focus is internal or external. This relationship should
be empirically investigated.
Limitations in this study should be considered. Participants
were not assessed with diagnostic interviews and therefore
diagnostic precision is lacking. There is also a possibility of
selection bias, as all participants actively signed up for the study
and might have a particular interest in the methods or topics. The
majority of the participants were also female psychology students.
Further, previous research complicated power calculations due
to incomparable measure instruments. The between group
comparisons suggested no clear trend that either intervention
should be superior to the other. Given these results, a sample
size of 400+would be needed for a significant difference to be
detected between the two interventions. Although the sample size
was not large, it was still designed to be appropriate for detecting
small differences (Whitehead et al., 2016).
Also, all outcome measures were based on self-report and
short forms were used for two out of five measures (FFMQ
and SCS-SF). Concerning therapist competence, a limitation
is that the group leaders had not previously been practicing
mindfulness or ATT on a regular basis. Further, the sessions
were not videotaped and thus cannot be evaluated. However,
administration was mainly automatized using pre-recorded
audiotapes and the results indicate that both conditions were
associated with significant symptom reduction. The lack of long
personal experience with either intervention may also have been
beneficial in that the therapists had no prior preference for ATT
or MSC and as such were unbiased. Due to the study design, it
remains unknown whether symptom reduction is caused mainly
by the specific intervention techniques or other therapeutic or
extra-therapeutic factors. Possible mechanisms include common
factors, pleasing, sharing experiences in a group, and expectancy
effects. These were not controlled for in the current study. An
improvement of the study design would therefore include a third
condition consisting of an attention placebo. Without such a
condition it is difficult to conclude as to the specific treatment
effects of the two conditions.
A possible limitation is that MSC could be biased toward
being attentive to suffering. Therefore, results could have been
different using other types of mindfulness interventions such
as mindful meditation. Several studies have supported use of
mindful meditation for improving attentional control, while few
studies have investigated this for MSC. However, as the results
showed, both MSC and ATT were equally efficient in improving
attention flexibility thereby demonstrating that also MSC is
associated with change in attention. It has been suggested that
self-compassion could be a better predictor of symptom severity
than mindfulness (Van Dam et al., 2011). However, other studies
have not reached the same conclusion (e.g., López et al., 2016).
Further research is therefore needed in order to discover whether
any specific type of intervention is more efficient than others in
improving attention flexibility.”
A practical implication from the current study is that attention
flexibility might be an important common factor in emotional
disorders and treatment. The importance of these findings
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Haukaas et al. ATT and MSC
is mirrored by observations that techniques enhancing skills
of attentional control (e.g., by mindfulness meditation) could
prevent relapse in depression (Teasdale et al., 1995). This
finding has considerable implications and provides an initial
step toward understanding how attention flexibility could be
a possible mechanism by which interventions may decrease
symptoms of depression and anxiety. Future studies should
investigate the most efficient ways of improving attentional
control. It is therefore important for future research to examine
how and why attention flexibility works, in order to optimize
treatment by specifically targeting this underlying mechanism.
Additional and more objective measures of attention flexibility
than self-report should be included, such as set-shifting tasks. The
relationship between attention flexibility and locus of attention is
also of interest to investigate. Future studies may also include an
additional control group such a wait-list or a talking condition.
CONCLUSION
This RCT supports both MSC and ATT as promising
perspectives for reducing symptoms of anxiety and depression
when administered in a brief group based intervention.
Symptom reduction was accompanied by significant increases
in mindfulness, self-compassion, and attention flexibility post-
intervention. These results were maintained at 6-month follow-
up and the level of mindfulness even kept increasing from
post-intervention to follow-up. Mechanisms of change may be
more similar across the techniques than different, and increase
in attention flexibility may be the most important underlying
psychological process in both models. Thus, targeting attention
flexibility specifically should be of interest in psychological
treatment and future research.
ETHICS STATEMENT
The study was a RCT approved by the Regional Medical Ethics
Committee in Norway (ref.nr. 2015/470). Informed written
consent was given from all participants.
AUTHOR CONTRIBUTIONS
SS initiated the project and was responsible for getting ethical
approval. HH and GV were group leaders for the first four
groups. IG and RH were group leaders for the last six groups.
SS supervised the group leaders. All authors contributed equally
to writing the manuscript and analyzing the data.
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Conflict of Interest Statement: The authors declare that the research was
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Frontiers in Psychology | www.frontiersin.org 13 May 2018 | Volume 9 | Article 827