The CBT Technique That’s Overlooked, Undervalued, And Essential: Why Is Self-Monitoring So Important?

Self-monitoring is a core part of Cognitive Behavioral Therapy (CBT), but is often overlooked or underrated. In this article we look at the evidence behind self-monitoring, how best to help your clients to develop this skill, and how you can practice it yourself most effectively.

Why practice self-monitoring in CBT?

CBT is an open and accessible form of therapy which requires active participation from the client, and where the goal is to help clients develop skills to manage or overcome their difficulties. Effective CBT helps people to understand more about how their thoughts and actions affect how they feel, to assess the evidence for their assumptions, and to practice behaving in new ways.

This usually starts with an assessment.  Self-monitoring gives you the information you need to form tentative theories about what keeps the client’s difficulties going, and eventually develop a formulation – a shared understanding of the problem, how it might have developed, and why it might not be getting better. When carried out effectively self-monitoring creates a powerful springboard for many parts of the therapeutic process. (Bornstein, Hamilton & Bornstein, 1986; Proudfoot & Nicholas, 2010).

Self-monitoring is also a straightforward way to show clients how they can actively participate in therapy. Getting clients involved early in treatment can make them feel more engaged and motivated, because it fosters a sense of self-control and autonomy.

“Self-monitoring puts clients in charge of empirically examining their beliefs and behavior.” (Cohen et al, 2013)

What is self-monitoring?

Therapists almost always teach their clients to self-monitor. Developing self-monitoring skills teaches clients to systematically observe and record specific targets such as their own thoughts, body feelings, emotions, and behaviors. Though it’s usually introduced early in the therapy process, it can continue to provide an inexpensive and constant measure of problem symptoms and behaviors throughout treatment.

“Awareness is a logical first step of the change process” (Persons, 2008).

Self-monitoring is comprised of two parts – discrimination and recording (Korotitsch & Nelson-Gray, 1999):

• Discrimination is where the client identifies and notices the thought, feeling, or behavior that they have chosen to target. This can be challenging for clients. It may be the first time that they have brought attention and awareness to their symptoms, thoughts and emotions, and some clients may be concerned about ‘doing it right’. If the client finds this difficult, you can simplify the exercise by asking the client to record only whether the targets are present or absent, or you can vary the questions you use to probe these thoughts and feelings. For example, instead of focusing on more difficult-to-capture thoughts and mental images, clients can instead monitor more obvious body sensations or behaviors (Kennerley, Kirk & Westbrook, 2017).
• Recording is the process of documenting occurrences, usually in some kind of written record. Using a record allows individuals to self-monitor – that is, discriminate the target (e.g., a feeling of anxiety), record it (e.g., when it occurred, how long it lasted, where they were and what they were doing), and later review it (e.g., how often did it happen in a week, what was common across each episode).

Effective self-monitoring or self-recording helps clients to develop an insight into their difficulties, which lays the foundation for subsequent interventions. The client’s problems may be influenced by contextual factors that are not immediately apparent to them, and which may not be present during therapy sessions or in the therapy room (Korotitsch & Nelson-Gray, 1999). Self-monitoring records are often invaluable in helping the therapist and client identify these influential factors. Completing self-monitoring records between therapy sessions also gives clients additional feedback that serves to reinforce and consolidate the work completed in sessions (Bornstein, Hamilton & Bornstein, 1986).

“Formal monitoring is distinct from casual observation. It requires a commitment on the part of the therapist and the patient to think through what monitoring is needed and to consistently assess a variable or variables, collect the data, and use the data to inform the formulation and treatment plan” (Persons, 2008, p.183)

The advantages of monitoring thoughts, feelings, and behaviors

Monitoring and recording thoughts, feelings, and behavior in this way has many benefits:

Awareness can build motivation. Learning to self-monitor helps clients develop a critical awareness of their difficulties, which can prepare them for change. For example, self-monitoring the frequency of angry outbursts can help clients to see the true scale of the problem: perhaps they shout at their partner nearly every day, not once every fortnight as they had initially claimed. Similarly, self-monitoring the time taken to complete compulsive rituals can help a client with OCD to see how much time they lose each day, motivating them to engage with therapy.

Self-monitoring can shine a light on what is hidden. Self-monitoring can be particularly useful when the target is covert – it can’t be observed by anyone but the clients themselves (Cohen et al, 2013). Covert targets include rumination, self-criticism, or self-harm. We have developed problem specific records for each of these targets, so your client can use a record that feels targeted to their experience.

It’s difficult to argue with facts. Clients are more likely to change their underlying beliefs based on data that they have gathered themselves, rather than information asserted by a therapist (Hovarth and Greenberg, 1994). Additionally, examining this data together encourages therapists and clients to avoid relying on faulty assumptions or preconceived notions, and work collaboratively (Overholser and Silverman, 1998).

Self-monitoring can be beneficial by itself. In some circumstances, the act of self-monitoring has been shown to have a modest but beneficial treatment effect (Korotitsch & Nelson-Gray, 1999; Proudfoot & Nicholas, 2010). It has been shown to increase the frequency of positive behaviors and decrease the frequency of negative behaviors, and make a supplementary contribution to interventions (Korotitsch & Nelson-Gray, 1999).

Self-monitoring is a simple way to track client progress. For example, it can measure the frequency and intensity of intrusive thoughts over the course of therapy, and assess whether the client is ready for different stages of a treatment intervention, such as the introduction of cognitive restructuring or behavioral experiments.

Self-monitoring targets change as therapy progresses

Early in therapy, clients may be asked to complete simple self-monitoring tasks, such as noting the frequency of certain behaviors or emotions. As therapy progresses, this may develop into more sophisticated records that explore the consequences of particular coping responses. Following an intervention, self-monitoring can be used to track how often a client uses a new strategy or adaptive coping technique, and how often the client now experiences problem symptoms.

To understand the full potential of self-monitoring, consider ways in which it facilitates key mechanisms of change in CBT… self-monitoring appears to facilitate multiple processes that have been theorized to underlie change in therapy. At times self-monitoring can provide direct empirical evidence that helps to refute distorted cognitions. (Cohen et al, 2013)

Psychology Tools self-monitoring records have been carefully designed to focus on particular targets. In most instances there are Regular and Extended versions, so you can choose which to use depending on where the client is in the therapy process:

• Regular versions introduce your clients to self-monitoring, and focus on capturing the most essential data.
• Extended versions allow your clients to reflect on the consequences of their coping responses, which can deepen your shared understanding of what might be keeping the problem going.

How is self-monitoring conducted most effectively?

Self-monitoring is worth doing well. We’ve listed some elements of effective training below, which can set the groundwork for successful self-monitoring:

Focus. The target of self-monitoring should always be discussed and agreed with the client using specific definitions and examples, with discrimination and recording first practiced in-session until the client feels confident. The accuracy of self-monitoring decreases when people try to monitor for more than one behavior, or complete more than one task at the same time (Korotitsch & Nelson-Gray, 1999). Try to keep it simple. The therapist and client should identify a single, well-defined target for monitoring, learn how to complete the self-monitoring record, and emphasize the importance of repeated practice (Korotitsch & Nelson-Gray, 1999).

Timing. Self-monitoring should be completed by the client shortly after — or during — an event.  Some clients may find it very difficult to access thoughts or emotions, making discrimination and recording a challenge. In these cases, self-monitoring can begin by focusing on more tangible experiences, such as body sensations or noticeable behaviors (Kennerley, Kirk & Westbrook, 2017).

Review. Accuracy also improves when clients are aware that what they record will be compared with the therapist’s observations or checked in some way (Korotitsch & Nelson-Gray, 1999). Self-monitoring records should be routinely reviewed in each session and the data be used to help the client and therapist collaborate, develop formulations and plan interventions.

How can you help your clients get the most from self-monitoring?

Discrimination and recording are skills that need to be learned and honed with time, and your clients may need support to learn how to complete records accurately. Here are some key techniques therapists can use to help clients develop these skills:

• Select a relevant target for monitoring. Ensure the target is specific, clearly defined and agreed upon – does the client understand what they are monitoring and why? Will data about this influence clinical decision making?
• Record the right kind of information. Use a problem-specific record that feels targeted to your client’s experience. We have a wide range of self-monitoring records, and have thought carefully about the right language and most helpful prompts for each worksheet. You can see some examples here.
• Show how it can be done. Talking your clients through some similar case examples can enhance their understanding and engagement.
• Provide clear instructions. Does the client understand how to complete self-monitoring? Can they refer back to instructions without the therapist? Tailored case examples and instructions directly linked to the problem can be helpful here.
• Offer support for recording. How will recording be completed? Does the client have the necessary resources and materials?
• Provide modelling and training in how to record. Has the client practiced recording? Has the therapist observed the client practicing?
• Review the data that your clients collect. How would you feel if your hard work had been ignored? Subsequent sessions should always review self-monitoring data that you have asked your client to collect.

Practical steps to encouraging regular, accurate self-monitoring

It can be difficult to ensure that records are completed at the right times, but several techniques can be used to encourage regular, accurate self-monitoring. The method and format of self-monitoring can be adapted to suit each client’s preferences. If clients have literacy difficulties – prepared forms that can be easily marked or ticked are preferable. If they feel conspicuous using a printed sheet, they may be more comfortable filling out a form on a smartphone, or keeping the sheet tucked into a small notebook.

To make this easier, our new self-monitoring records are all available in multiple formats to support the way you and your clients work best:

• Professional version: Designed for clinicians, this comprehensive option includes everything you need to use the resource confidently. As well as the resource, each PDF contains useful information, including therapist guidance, theoretical context and background, instructions for delivering the resource, suggested prompts, and references. Some resources also include case examples and annotations where appropriate.
• Client version: Simpler and more focused, this version contains the blank resource PDF and ‘how to’ instructions where appropriate. It’s the best choice if you’re giving a resource directly to a client.
• Editable Word format: An editable Microsoft Word version of the resource.
• Editable PowerPoint format: An editable Microsoft PowerPoint version of the resource.
• Fillable PDF: A fillable version of the resource. This can be edited and saved in Adobe Acrobat, or other PDF editing software. Useful for clients who want to work online or for completing resources during teletherapy.

What can I try if my client is still struggling?

If your client experiences repeated difficulty with completing self-monitoring, work through the following checklist to make sure that you’re not falling into any of these common pitfalls:

• Understanding and motivation. Why does your client think they are being asked to practice self-monitoring? Do they see value in self-monitoring practice?
• Interference. Is there anything about your client’s current situation and environment that could be interfering with self-monitoring?
• Is your client being overloaded? Are too many targets are being monitored?
• Motivated but struggling. Does your client need some more in-session practice to really feel comfortable with that they are being asked to do?
• Practical obstacles. Would a different form of assessment and recording be more suitable for this client?
• Avoidance. Is the client avoidant of particular experiences?
• Blocking beliefs. Does your client hold any beliefs or assumptions which might interfere with self-monitoring (e.g., beliefs about doing things ‘perfectly’)?

Summary

Self-monitoring is an invaluable, versatile tool for therapists and clients, and it’s worth doing well. It can be a challenging skill to develop, but with time, practice, and the right self-monitoring tools, both therapist and client can get the most from this technique.

References

• Bornstein, P.H., Hamilton, S.B. & Bornstein, M.T. (1986) Self-monitoring procedures. In A.R. Ciminero, K.S. Calhoun, & H.E. Adams (Eds) Handbook of behavioral assessment (2nd ed). New York: Wiley.
• Cohen, J.S., Edmunds, J.M., Brodman, D.M., Benjamin, C.L., Kendall, P.C. (2013), Using self-monitoring: implementation of collaborative empiricism in cognitive-behavioral therapy. Cognitive and Behavioral Practice, 20(4), 419-428.
• Kennerley, H., Kirk, J., & Westbrook, D. (2017) An Introduction to Cognitive Behaviour Therapy: Skills & Applications. 3rd Edition. Sage, London.
• Korotitsch, W. J., & Nelson-Gray, R. O. (1999). An overview of self-monitoring research in assessment and treatment. Psychological Assessment, 11(4), 415.
• Overholser, J. C., & Silverman, E. (1998). Cognitive-behavioral treatment of depression: Part VIII. Development and utilization of the therapeutic relationship. Journal of Contemporary Psyhotherapy, 28, 199–214
• Persons, J.B. (2008) The Case Formulation Approach to Cognitive-Behavior Therapy. Guildford Press, London.
• Proudfoot, J., & Nicholas, J. (2010). Monitoring and evaluation in low intensity CBT interventions. Oxford guide to low intensity CBT interventions, 97-104.