Flashbacks – Self-Monitoring Record
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. The Flashbacks – Self-Monitoring Record worksheet is designed to help clients capture information about flashbacks and unwanted memories which they experience.
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 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 may 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 are 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 Flashbacks – Self-Monitoring Record worksheet is designed to help clients capture information about flashbacks and unwanted memories which they experience. It includes columns to record information about: triggers and situational context; the content of the flashbacks; 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 to generate hypotheses about how the client’s existing coping strategies contribute to the maintenance of their unwanted memories.
“A great way of finding out more about your flashbacks, and your other experiences of difficult thoughts, feelings, and reactions is to use a Self-Monitoring Record. It’s like a diary that lets you record when problems happen, and any important details which could help us understand more about how your flashbacks work. 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 have unwanted memories of what happened to you”, “Times when you notice a sudden change in how you are feeling”, “Times when you have a strong feeling in your body”). Self-monitoring is most helpful when it is completed as soon after the target event as possible, while the client’s memory of what happened is still clear. Consider asking:
- If we’re trying to understand more about your trauma, what kind of situations might it be helpful to collect some data about?
- When will you fill in this self-monitoring record? What will your prompt or cue be?
Step 2: Trigger
Whenever the client notices their individual prompt for completing a self-monitoring record, they should be encouraged to start by recording information about the trigger (situation) which has given rise to that experience. 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 might include:
- Who were you with? What were you doing? What was happening? Where were you? When did it happen?
- Were you aware of anything just before you noticed the flashback?
- What made you have that flashback?
- Were you aware of anything in that moment that reminded you of your trauma?
- Let’s think about your senses. Just before the flashback started, what could you: See? Hear? Touch? Smell? Taste?
Step 3: Flashback
Flashbacks are unwanted or involuntary memories. A core symptom of post-traumatic stress disorder (PTSD), unwanted memories are also present in other conditions, and can occur in any of the senses (sight, sound, touch, smell, taste, pain). An important property of flashbacks in PTSD, which can be experienced on a continuum, is their here-and-now quality: some people experience an unwanted memory but remain aware that it is an event from the past, whereas others lose touch with the present moment and feel as though the event is happening again ‘right now’ in the present moment. Helpful questions might include:
- What was your unwanted memory of?
- How much did it feel like the event was happening in the present moment? (0 = not at all, 100 = completely)
- What could you see, hear, touch, smell, or taste?
- How long did that flashback last? How long did it feel like it lasted?
- What did you think was happening? What did you think was going to happen?
Step 4: Emotions and body feelings
Clients can be helped to explore how they responded emotionally at the time of the original trauma, and how they responded during the flashback. Explore the client’s interpretation of what was happening, both during the original event and during the flashback, and whether their reactions were the same or different. Dissociation is common during trauma, and some individuals may report discontinuity between the events, their flashback or memory, and their emotional or physiological reactions. Similarly, some clients might report strong emotional or physiological reactions in the absence of a clear image or memory. In some circumstances, it can be helpful to enquire whether the client had any automatic thoughts about their emotional/physiological reactions. Helpful questions might include:
- How did you feel emotionally when you had that flashback?
- Was that the same feeling you had when the event originally happened?
- How strong was that feeling when you had the flashback? Could you rate it on a scale from 0 to 100?
- When you felt that, what was going through your mind?
Step 5: Responses
The final step is to explore how the individual responded to the situation, their appraisal of what was happening, and to their emotional and physiological responses. Behavior can often be helpfully framed as ‘coping responses’ or ‘things you did to cope with feeling that way’. Consider asking:
- What did you do to cope with that flashback?
- What did you do to manage how you were feeling?
- How did you react to feeling that way?
Step 6: Consequences (Optional)
The extended version of the Flashbacks – 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 when clients are 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. escape can lead to feelings of relief), some might lead to the removal of an unwanted feeling (e.g. self-harming or use of alcohol or other substances can lead to numbing), and others might have positive short-term consequences and negative long-term consequences (e.g. rumination about one’s actions can feel productive in the short-term, but may prevent change in unhelpful appraisals of trauma). Prompts could include:
- What was helpful or unhelpful about responding in that way?
- How did you feel when you did that? (emotionally and in your body)
- How did other people react when you did that?
- How did you feel (a) right away 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.
- 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.