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Perfectionism 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 Perfectionism – Self-Monitoring Record worksheet is designed to help clients capture information about their demanding standards, as well as the life domains in which they present.

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Description

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 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 Perfectionism – Self-Monitoring Record is a worksheet designed to help clients capture information about their demanding standards, as well as the life domains where they exist. It includes columns to record information about: the situational context; the content of negative perfectionistic thoughts and images; emotional and physiological reactions; coping responses, and the demanding or perfectionistic standards that may have contributed to them.

Instructions

“A great way of finding out more about your experience of perfectionism, and the difficult thoughts, feelings, reactions, and standards that go with it, is to use a Self-Monitoring Record. It’s like a diary that lets you record when your demanding standards are active, and any important details which could help us understand more about how your perfectionism 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 events 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., “Situations where you are perfectionistic.”, “Times when you think you must do things exceptionally well.”, “Times when you feel concerned about how well you are performing.”). Self-monitoring is most helpful when 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 perfectionism, 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?

Because perfectionism can be expressed in multiple areas of life (e.g., work, personal hygiene, appearance, social interactions, eating habits, time management, sport and fitness, orderliness, parenting), it is sometimes helpful to specify domains for self-monitoring (e.g., “Times when you think you must excel at work.”):

  • You mentioned that your perfectionism around your is an issue. I wonder if you could fill in a self-monitoring record whenever you notice yourself being a perfectionist in those situations, so we can find out more about what happens?

Step 2: Situation
Whenever the client notices their prompt to complete a self-monitoring record, they should be encouraged to start by recording information about the situation in which the prompt occurred. Relevant contextual information might be factual (e.g., date, time, location), externally focused (e.g., tasks they were doing, or interactions they were participating in), or internally focused (e.g., thoughts, images, memories). Helpful questions to ask might include:

  • Had you been particularly aware of anything just before you noticed?
  • 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: Thoughts
A core tenet of the cognitive behavioral approach is that people’s emotional and behavioral reactions to an event are driven by their appraisals of the situation (“What you think affects the way you feel.”). It is important to help clients notice and identify their automatic thoughts, interpretations, and predictions. Any automatic images or memories that clients experience can also be probed for meaning:

  • What thoughts were going through your mind in that situation?
  • When you noticed , what were you concerned about?
  • When occurred, what did you think would happen?
  • You said that when that happened, you had a picture in your mind of . What do you think that image meant?
  • Were there any thoughts, concerns, or criticisms that you went over and over in your mind?

Step 4: Emotions and bodily sensations
Self-monitoring records provide an opportunity to educate clients about the cognitive behavioral model, and specifically the links between thoughts, emotions, physiology, and behavior. Help clients to explore their emotional response to their interpretation of what happened, and to the events themselves. 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:

  • Feelings are often best described with just one word, whereas thoughts usually take a few words to describe. What word that best describes how you felt at that moment?
  • Did you notice any feelings or sensations in your body? Can you describe them?
  • How strong was that feeling at that moment? Could you rate it on a scale from 0 to 100?

Step 5: Responses
Next, explore how the client responded to the situation, to 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 manage your concerns about your performance’. Performance-related behaviors which often arise in perfectionism include performance checking (such as scrutinizing, comparison-making, and reassurance-seeking), procrastination, and avoidance. Consider asking:

  • How did you react when you thought or felt that?
  • What did you do to manage your concerns about your performance?
  • What did those thoughts and feelings lead you to do?
  • Did you avoid or postpone anything?
  • Are there times when you responded differently in a similar situation?

Step 6: Perfectionistic standard
The final step is to identify the perfectionistic standard or standards which might have contributed to the client’s response. Perfectionistic standards usually take the form of rigid rules expressed as ‘must’, ‘should’, or ‘ought’ statements (e.g., “I must impress my colleagues.”, “I shouldn’t make mistakes.”, “I ought to limit my calorie intake.”). Because the client may not have articulated their perfectionistic standards until this point, Socratic questioning may be required. Prompts include:

  • It sounds like you were trying to meet a standard in this situation. What do you think it might have been?
  • Were you concerned about breaking a rule you’ve set for yourself? Can you put that rule into words?
  • What were you expecting or demanding of yourself in this situation?
  • Can you finish this sentence: “When happens, I must or I should…?”
  • What rule did you break or were you in danger of breaking?

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, 419-428.
  • Kennerley, H., Kirk, J., & Westbrook, D. (2017). An Introduction to Cognitive Behaviour Therapy: Skills and 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, 415-425.
  • Persons, J. B. (2008). The case formulation approach to cognitive-behavior therapy. Guildford.
  • Proudfoot, J., & Nicholas, J. (2010). Monitoring and evaluation in low intensity CBT interventions. In J. Bennett-Levy, D. Richards, P. Farrand, H.
    Christensen, K. Griffiths, D. Kavanagh, B. Klein, M. Lau, J. Proudfoot, L. Ritterband, J. White, & C. Williams (Eds.), Oxford guide to low intensity CBT interventions (pp. 97–104). Oxford University Press.