Helping Clients Get The Most Out Of Self-Monitoring In CBT

Self-monitoring is a key component of cognitive behavioral therapy (CBT), whereby clients learn to systematically observe and record specific targets such as their thoughts, body sensations, emotions, and behaviors. The aim is to improve clients’ awareness of their experiences and the contexts in which they occur, helping them understand their symptoms and difficulties. It supports collaboration between therapist and client and creates opportunities to formulate, guide treatment, and test hypotheses about those difficulties.

What is self-monitoring in CBT?

Self-monitoring can be used as both a tool for assessment method and intervention (Korotitsch & Nelson-Gray, 1999; Proudfoot & Nicholas, 2010). It is routinely used in several evidence-based therapies, including cognitive behavioral therapy (CBT), and usually comprises two parts: discrimination and recording.

Discrimination consists of identifying and noticing a target phenomenon. This can be challenging. For instance, it may be the first time a client has attended to their symptoms, thoughts, or emotions.

Recording is the process of documenting occurrences, usually using a written record. A record allows clients to discriminate and note down the target (e.g., moments of anxiety), including when and where it occurred, how long it lasted, and what they were doing.

Self-monitoring can take different forms, including diaries, logs, or records. These records can be used to capture a wealth of information in therapy, including daily activities, sleep, pain, distressing thoughts, problematic symptoms, food intake, or patterns of behavior.

Why self-monitoring matters

Clients are encouraged to participate in CBT so they can develop skills and knowledge they need to address their difficulties and become their own therapist. Self-monitoring is a straightforward way to begin this process. More specifically, it can help:

• Support client engagement and motivation by fostering a sense of autonomy and self-control (Bornstein, Hamilton, & Bornstein, 1986; Proudfoot & Nicholas, 2010).

• Provide insight into how and why difficulties developed and how they are maintained, laying a foundation for treatment.

• Identify important contextual factors that may not be immediately apparent during therapy sessions or in the therapy room (Korotitsch & Nelson-Gray, 1999).

• Inform case formulation and intervention planning (Cohen et al., 2013).

• Define a problem hierarchy by identifying which difficulties occur most frequently or most severely affect well-being.

Examples of self-monitoring in CBT include:

• Identifying unhelpful patterns or styles of thinking, such as rumination or catastrophizing.

• Exploring the contexts or triggers associated with particular thoughts, emotions, or behaviors.

• Recognizing problematic coping or avoidance behaviors that are used to (temporarily) reduce distress.

• Tracking adherence to new strategies and evaluate the effectiveness of an intervention.

Top tips for effective self-monitoring

1. Provide a clear rationale

Self-monitoring records are best used to capture information about a specific category of event that is relevant to the client or related to their difficulties. The therapist and client should understand why the information is being collected and how it will inform therapy. For instance, a therapist might introduce the task as a way to record when and where a problem occurs so everyone can understand how it works.

2. Use analogies

Analogies can highlight the purpose and value of self-monitoring. Waller and colleagues (2007), for example, describe a shopkeeper whose business is losing money.

“The shopkeeper could respond to this problem by making lots of sudden changes, such as raising prices or reducing stock. However, this would lots of guesswork and could be exhausting. Alternatively, they could try to remember what has worked in the past. However, the human memory is often incomplete or inaccurate. A third approach would be to keep a record of sales, costs, and other relevant factors. These records could help the shopkeeper identify patterns, make informed changes, and evaluate whether those changes are helping.”

3. Choose one well-defined target

The accuracy of self-monitoring decreases when individuals try to monitor more than one behavior or complete concurrent tasks (Korotitsch & Nelson-Gray, 1999). Therefore, the therapist and client should identify a single, well-defined target. Examples include:

• “Times when you notice you feel anxious.”

• “Times when you criticize yourself.”

• “Times when you binge-eat or purge.”

4. Encourage recording close to the event

Self-monitoring should be completed during or shortly after an event. It is most helpful when completed as soon after the target occurs, while the client’s memory is still clear.

5. Consider starting with simple targets

If clients find it difficult to notice their thoughts or emotions, therapists can simplify self-monitoring. For instance, clients might initially record when the target is present or absent, or focus on more salient experiences and overt behaviors (Kennerley et al., 2017).

6. Model and practice in session

It is often helpful to practice recording during the therapy session so clients feel confident doing this independently. Therapists should model self-monitoring and emphasize the importance of persistence and repeated practice.

7. Review records

Self-monitoring records should be reviewed in each session. Doing this consistently demonstrates that the task is clinically meaningful rather than an administrative exercise, and that the therapist takes an active interest in the work the client is doing. Moreover, the data can used to inform the client’s evolving formulation and intervention plan.

8. Explore non-completion

If self-monitoring is not completed, or the client encounters repeated difficulties, this should prompt collaborative troubleshooting. For example, it may be helpful to explore whether the client understands the purpose of the task, sees it as worthwhile, is avoiding particular experiences, or holds beliefs that make completion difficult (e.g., that self-monitoring should be done perfectly or not at all).

Frequently asked questions

1. When should self-monitoring be introduced?

Self-monitoring is often introduced early in CBT, such as during assessment. It can be particularly useful when the target is covert and cannot be directly observed by anyone other than the client, such as rumination or self-criticism.

2. How many targets should a client monitor?

A single, well-defined target is preferable. Monitoring multiple targets can reduce accuracy and make the exercise unnecessarily demanding.

3. What should therapists do with completed records?

Records should be reviewed during sessions and used to support collaboration, formulation, hypothesis testing, and intervention planning. Later in therapy, they can also help monitor progress and evaluate the effectiveness of treatment.

Key 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.). 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 ed.). Sage.

• Korotitsch, W. J., & Nelson-Gray, R. O. (1999). An overview of self-monitoring research in assessment and treatment. Psychological Assessment, 11(4), 415.

• Persons, J. B. (2008). The case formulation approach to cognitive-behavior therapy. Guilford Press.

• Proudfoot, J., & Nicholas, J. (2010). Monitoring and evaluation in low intensity CBT interventions. In Oxford guide to low intensity CBT interventions (pp. 97–104).