Permissive Thinking – 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 Permissive Thinking – Self-Monitoring Record worksheet is designed to help clients capture information about their permissive thoughts or ‘justificational thinking’. It includes columns to record information about: situational context; the content of permissive thoughts and images; emotional and physiological reactions; responses; and consequences.

"Many people experience permissive thoughts that seem to justify doing things that are unhelpful or bad for them. A great way of finding out more about your permissive thinking, and the situations and feelings that go with it, is to use a Self-Monitoring Record. It’s like a diary that lets you record when you experience permissive thinking and other important details which could help us understand more about it. 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 behavior (e.g., “Situations where you allow yourself to binge eat”, “Times when you justify using drugs”, “Moments when you give yourself permission to drink too much”). Self-monitoring is most helpful when completed as soon after the target behavior as possible, while the client’s memory of what happened is still clear (Cooper, 2000). Consider asking:

• Where and when do you sometimes give yourself permission to <target behavior>?
• If we wanted to understand more about your permissive thoughts that come before <target behavior>, what kind of situations might we want to know more about?
• You’ve told me that you tend to drink too much on Friday nights after work. Could you fill in a self-monitoring record so we can understand the permissive thoughts that show up in that situation?
• When will you fill in this self-monitoring record? What will your prompt or cue 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 which has given rise to that experience. Relevant contextual information might be factual (e.g., date, time, location), externally focused (e.g., tasks they were engaged in, interactions they are participating in), or internally focused (e.g., thoughts, images, or memories). Helpful questions to ask might include:

• What happened just before you gave yourself permission to <target behavior>?
• Were you aware of any triggers which led you to start thinking permissively?
• Who were you with? What were you doing? Where were you?
• When did you start thinking this way?

Step 3: Permissive 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 that situation (“what you think affects the way you feel”). It is important to help clients notice and identify their automatic thoughts and interpretations. Automatic images or memories that clients experience can also be probed for meaning:

• What thoughts were going through your mind in that situation?
• What were you thinking to yourself?
• What were you saying to yourself that made it easier to <target behavior>?
• How were you justifying <target behavior> in that situation?
• What were the thoughts you had immediately before eating turned into a binge?

Step 4: Emotions and bodily sensations

Self-monitoring records provide opportunities to educate clients about the cognitive behavioral model, specifically the links between thoughts, emotions, physiology, and behavior. Clients can be helped to explore their emotional response to their interpretation of what happened, and to the events themselves. In some circumstances, it can be helpful to inquire 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 thought?
• Feelings are often best described with just one word, whereas thoughts usually take a few words to describe. What is the 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: Response

Next, explore how the individual responded to the situation, their appraisal of what was happening, and their emotional and physiological responses. Behavior can often be helpfully framed as ‘responses to your permissive thoughts’. Consider asking:

• How did you respond to your permissive thoughts?
• What did those thoughts and feelings lead you to do?
• How did you react to thinking that way?
• Are there times when you respond differently in similar situations?

Step 6: Consequences (Optional)

The extended version of the Permissive Thinking – Self-Monitoring Record worksheet includes an additional column for clients and therapists to explore the consequences of acting (or not acting) on permissive thoughts. Exploring the consequences of an action can aid understanding of why particular patterns of thought and behavior persist. For example, acting on permissive thoughts might lead to positive feelings (e.g., relief or satisfaction), some might lead to the removal of an unwanted feeling (e.g., anxiety or stress), and others might have negative consequences that lead to more permissive thinking (e.g., regret, shame, or disappointment). Exploring the consequences of resisting permissive thoughts can also highlight the benefits of these responses. Consider asking:

• How do you feel about what happened in this situation?
• What was helpful or unhelpful about responding to your permissive thoughts in that way?
• After you acted on your permissive thoughts, how did you feel (a) right away, and (b) later?
• How did it feel to not act on your permissive thoughts? How did you manage to do that?
• Looking back at this record, what do you make of permissive thoughts like those now?

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.

Cooper, M., Todd, G., & Wells, A. (2000). Bulimia nervosa: A cognitive therapy programme for clients. Jessica Kingsley Publishers.

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, London.

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 Press, London.

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.