Attention - Self-Monitoring Record

Self-monitoring is a technique in which clients learn to systematically observe and record specific targets such as their own thoughts, body feelings, emotions, and behaviors. The aim is to improve clients’ awareness of their experiences and the contexts in which they occur, in order to help them gain insight into their symptoms and difficulties. Self-monitoring supports collaboration between the therapist and client, and creates opportunities to formulate and test hypotheses about these difficulties. Self-monitoring is usually introduced early in therapy, and provides an inexpensive and continuous measure of problem symptoms and behaviors throughout treatment. 

Psychology Tools self-monitoring records have been carefully designed to focus on particular targets. In most instances, there are:

• Regular versions of each form which focus on collecting essential data about the target.
• Extended versions of each form, which allow additional data to be collected about the consequences of client behaviors, and which can be used to form hypotheses about reinforcing factors.

What is self-monitoring? 

Self-monitoring functions as both an assessment method and an intervention (Korotitsch & Nelson-Gray, 1999; Proudfoot & Nicholas, 2010). Routinely used in cognitive behavioral therapy (CBT), it contributes to a wide variety of evidence-based treatments (Persons, 2008; Korotitsch & Nelson-Gray, 1999), and is comprised of two parts – discrimination and recording (Korotitsch & Nelson-Gray, 1999). 

Discrimination consists of identifying and noticing the target phenomena. 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 express concern about ‘doing it right’. Therapists can simplify the exercise by asking the client to record only whether the targets are present or absent, or by varying the questions they use to probe these thoughts and feelings. For example, instead of focusing on more difficult-to-capture thoughts and mental images, clients might be instructed to monitor more salient body sensations or behaviors (Kennerley, Kirk & Westbrook, 2017). 

Recording is the process of documenting occurrences, usually through some kind of written record. Using a record allows clients to self-monitor: to 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 review it (e.g., how often did it happen in a week, what was common across different episodes). 

Self-monitoring can be accomplished using many different tools:

• Diaries can be used to record information about when events occur, such as activity, sleep, or pain.
• Logs can be used to record the frequency of events, behaviors, thoughts, or emotions.
• Records can be used to record information about thoughts, memories, symptoms, or responses.

In practice, much of this terminology is interchangeable. For the purposes of this and other Psychology Tools resources, the term ‘Self-Monitoring Record’ will be used. 

Why practice self-monitoring? 

Clients are encouraged to actively participate in cognitive-behavioral treatment, so that they will develop the skills and knowledge to help them to address their difficulties. Introducing clients to self-monitoring is a straightforward way to begin this process. 

Self-monitoring supports client engagement and motivation by fostering a sense of self-control and autonomy (Bornstein, Hamilton & Bornstein, 1986; Proudfoot & Nicholas, 2010). It helps clients to understand how and why these difficulties developed, and how they are maintained. This lays the foundation for intervention. Self-monitoring records can also be invaluable in helping therapists and clients identify controlling or influential contextual factors, which may not be immediately apparent during therapy sessions, or in the therapy room (Korotitsch & Nelson-Gray, 1999). 

Data from self-monitoring records will often form the basis of case formulation and intervention planning (Cohen et al, 2013; Proudfoot & Nicholas, 2010). Different forms of self-monitoring provide different kinds of information, which can serve different purposes. For example:

• Self-monitoring data can help to define a problem hierarchy by identifying which problems occur most frequently, or which most severely affect a client’s wellbeing.
• Data from self-monitoring can be used to identify unhelpful patterns or styles of thinking (e.g., rumination, catastrophizing), or to examine the domains of a client’s preoccupation.
• Self-monitoring can be used to explore the context or triggers for a particular thought, feeling, or behavior.
• Self-monitoring can highlight specific coping or avoidance behaviors that the client uses to manage their feelings.

When should self-monitoring be practiced? 

Self-monitoring is often taught early, during the assessment stage of therapy. It can be particularly useful when the target phenomenon is covert and cannot be observed by anyone but the clients themselves (Cohen et al, 2013). Examples of covert targets include rumination, self-criticism, or self-harm. 

Early in therapy, clients may be asked to complete simple self-monitoring tasks, such as noting the frequency of particular behaviors or emotions. This can then develop into more sophisticated records that explore the triggers, thoughts, and consequences linked to specific events. As the intervention progresses, self-monitoring can be used to track adherence (e.g. how often a client uses a new strategy or adaptive coping technique) and the effectiveness of an intervention (e.g. how often the client now experiences problem symptoms, or implements new responses). 

How is self-monitoring conducted? 

Self-monitoring should be completed by the client during or shortly after an event. If the client finds it difficult to access their thoughts or emotions, self-monitoring can begin by focusing on more tangible experiences, such as body sensations or overt behaviors (Kennerley, Kirk & Westbrook, 2017). The target of self-monitoring should 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.

“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)

Effective training uses clear and simple instructions that can be easily revisited. It has been shown that 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 for monitoring, model and practice completion of the record, and emphasize the importance of repeated practice (Korotitsch & Nelson-Gray, 1999). 

Accuracy also improves when clients are aware that what they record will be compared with therapist observation or checked in some way (Korotitsch & Nelson-Gray, 1999). To support this, self-monitoring records should be reviewed in each session and the data should contribute to client-therapist collaboration, formulation and intervention planning. If a client experiences repeated difficulty with completing self-monitoring, the therapist should consider the following (Korotitsch & Nelson-Gray, 1999):

• What is the client’s understanding about why they are being asked to practice self-monitoring? Do they see value in self-monitoring?
• Is there anything about the client’s current situation and environment that could be interfering with self-monitoring?
• Are too many targets being monitored?
• Does the client need additional in-session practice?
• Would a different type of assessment or recording be more suitable for this client?
• Is the client avoidant of particular experiences?
• Does the client hold beliefs which might interfere with self-monitoring? (e.g. beliefs about doing things ‘perfectly’)?

The Attention – Self Monitoring Record worksheet is designed to help clients capture information about what they pay attention to in different situations. It includes columns to record information about: situational context; focus of attention (with additional prompts about an internal or external focus); emotional and physiological reactions; and coping responses. An additional ‘extended’ version of the form includes a column for recording the consequences of these coping responses, which may help therapists generate hypotheses about how the client’s existing coping strategies contribute to the maintenance of their difficulties.

“A great way of finding out more about your experiences of these difficult thoughts, feelings, and reactions is to use a Self-Monitoring Record. It’s like a diary that lets you record when a problem occurs, and any important details which could help us understand more about how it works. Would you be willing to go through one with me now?” 

Step 1: Choosing a focus, purpose, and prompt for data collection 

Self-monitoring records are best used to capture information about specific categories of event that are of interest to the client, or related to a presenting problem. The accuracy of self-monitoring decreases when individuals try to monitor for more than one target, so therapist and client should identify a single well-defined target (e.g., “Times when you notice yourself feeling anxious”, “Times when you notice a marked change in what you pay attention to”, “Times when you feel very self-conscious”). Self-monitoring is most helpful when it is completed as soon after the target event as possible, while the client’s memory is still clear. Consider asking:

• You’ve told me you’re really bothered by these feelings of <self-consciousness/anxiety/fear … > I wonder if you could fill in a self-monitoring record when you notice these feelings come on, so we can find out more about what’s happening in those moments?
• If we’re trying to understand more about times when you pay close attention to how you’re coming across to other people, what situations might it be helpful to collect some details about?
• When will you fill in this self-monitoring record? What will your prompt be?

Step 2: Situation 

Whenever the client notices their prompt for completing a self-monitoring record, they should be encouraged to start by recording information about the situation. Relevant contextual information might be factual (e.g. date, time, location), externally focused (e.g. things that they could see, hear, touch, smell, taste), or internally focused (e.g. thoughts, images, memories). Helpful questions to ask include:

• What caused you to start <thinking/feeling/experiencing> that?
• Were you aware of any triggers being present when you started to feel that way?
• Who were you with?
• What were you doing?
• What was happening?
• Where were you?
• When did this happen?

Step 3: Focus of attention 

Your focus of attention can change under conditions of perceived threat. Clark & Wells’ model of social anxiety proposes that when people with social anxiety enter feared situations, they become preoccupied with highly detailed monitoring and observation of themselves, and “use the internal information made accessible by self-monitoring to infer how they appear to others and what other people are thinking about them” (Clark, 2001). Similarly, people suffering from post-traumatic stress disorder are often hypervigilant for signs of threat and fail to attend adequately to signs of safety. Different therapeutic approaches for social anxiety and PTSD emphasize the importance of helping clients to bring awareness to their threat monitoring (e.g. Warnock-Parkes et al, 2020; Wells & Sembi, 2004). Helpful questions to ask include:

• What were you paying attention to in that situation?
• Were you scanning your body, your feelings, or your mind for anything?
• Could you rate how much of your attention was focused externally on the world around you, and how much of it was focused internally on your own thoughts, feelings, and body sensations?

Step 4: Emotions and body feelings 

Self-monitoring records provide opportunities to educate clients about the cognitive behavioral model, and specifically the links between thoughts, emotions, physiology, and behaviors. Clients can be helped to explore their emotional response to their focus of attention. Some clients may benefit from being shown an emotion wheel, or lists of emotions. Helpful questions might include:

• How strong was that feeling at that moment? Could you rate it on a scale from 0 to 100?
• Feeling are often best described with just one word, whereas thoughts often take a few words to described. What is the word that best describes how you felt in that moment?
• You said that you felt <mad/anxious/ashamed>. Were there any other feelings underneath that?

Step 5: Responses 

The final step is to explore how the individual responded to the situation, their focus of attention, and to their emotional and physiological responses. Behavior can be framed as ‘coping responses’ or ‘things that you did to help you cope with feeling that way’. Consider asking:

• What happened next?
• Was there anything you avoided?
• What did you do to cope or manage how you were feeling when you paid attention to that?
• How did you react to feeling that way?
• Have you ever coped differently when faced with a similar situation?

Step 6: Consequences (Optional) 

The extended version of the Attention – Self-Monitoring Record worksheet includes an additional column for clients and therapists to explore the consequences of the client’s coping strategies. This step is not recommended for clients in the early stages of practicing self-monitoring, as it introduces unnecessary complexity. However, exploring the consequences of an action can aid understanding of why particular patterns of behavior persist. Some behaviors might lead to positive feelings (e.g. vigilance for signs of danger can make you feel as though potential threat is being managed), some might lead to the removal of an unwanted feeling (e.g. escaping from a situation can lead to a reduction in fear), and some might have positive short-term consequences and negative long-term consequences (e.g. being extra careful to manage how you appear to others can make you feel safer in the short term, but may lead to you looking ‘unnatural’ or uncomfortable). Prompts could include:

• What was helpful or unhelpful about responding that way?
• How did you feel when you did that (emotionally and in your body)?
• How did people react when you did that?
• If you saw somebody else acting in that way, what would you think of them?
• How did you feel (a) at the time and (b) later?

• 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.
• Clark, D. M. (2001). A cognitive perspective on social phobia: In W. R. Crozier, L. E. Alden (Eds) International handbook of social anxiety: Concepts, research and interventions relating to the self and shyness. Chichester: John Wiley & Sons.
• 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.
• 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.
• Warnock-Parkes, E., Wild, J., Thew, G. R., Kerr, A., Grey, N., Stott, R., ... & Clark, D. M. (2020). Treating social anxiety disorder remotely with cognitive therapy. The Cognitive Behaviour Therapist, 13.
• Wells, A., & Sembi, S. (2004). Metacognitive therapy for PTSD: A core treatment manual. Cognitive and Behavioral Practice, 11(4), 365-377.