Urges – 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 Urges – Self-Monitoring Record worksheet is designed to help clients capture information about their urges and cravings. It includes columns to record information about: situational context; the focus and intensity of urges; cognitive, emotional, and physiological reactions accompanying urges; responses to the urges; and consequences of those actions.

"Many people struggle with urges and cravings. A great way of finding out more about your urges, and the situations and feelings that go with them, is to use a self-monitoring record. It’s like a diary that helps you record your urges or cravings, and other important details which could help us understand more about them. 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: those that are of interest to the client or related to their 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 have an urge to use drugs”, “Times when you crave alcohol”, “Moments when you want to look at pornography”).

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.

• "What tends to trigger your urge to <target behavior>?"
• "Where and when do you tend to crave <target behavior>?"
• "If we want to understand more about <target behavior>, 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: Situation

Whenever the client notices their prompt for completing a self-monitoring record, they should be encouraged to record information about the situation that has precipitated the urge. Antecedents for urges and addictive behaviors might include internal triggers (e.g., distressing emotions, physical discomfort, hunger, etc.) and external triggers (e.g., places, people, experiences, etc.) (Liese & Beck, 2022). Factual contextual information is also relevant (e.g., dates and times).

• "What triggered your urge to <target behavior>?"
• "What made you start craving <target behavior>?"
• "What was happening just before your urge to <target behavior>?"
• "Where were you?"
• "Who were you with?"
• "What were you doing?"
• "What was happening inside you?"

Step 3: Urge

According to the cognitive behavioral model of addictions, internal or external triggers lead to urges to engage in addictive behaviors (Beck et al., 1993). Urges and cravings are experienced as a pressing desire, hunger, pressure, impulse, or compulsion to engage in an addictive behavior (Liese & Beck, 2022). They also vary in intensity. For this reason, it is important to help clients notice the occurrence and relative strength of their urges.

• "What did you want to do in that moment?"
• "What were you longing for?"
• "What were you craving?"
• "How strong was the urge to <target behavior>?"
• "How badly did you want to <target behavior>?"
• "How intense was your craving for <target behavior>?"

Step 4: Thoughts, feelings, and sensations

Self-monitoring records provide opportunities to educate clients about the cognitive behavioral model, and specifically the links between thoughts, emotions, physiology, and behavior. For example, clients can be helped to explore the addiction-related thoughts that accompany their urges (such as anticipatory thoughts, where increased comfort or reduced discomfort are associated with the addictive behavior), as well as their emotional and physiological responses to cravings. In some circumstances, it can be helpful to enquire whether the client had any automatic thoughts about their emotional or physiological reactions (e.g., “I can’t stand feeling this way”).

• "What were you saying to yourself when you wanted to <target behavior>?"
• "What was running through your mind when you had the urge?"
• "What did you think about your urge to <target behavior>?"
• "How did you feel when you had the urge? Feelings are best described with just one word, while thoughts take a few words."
• "How strong was that feeling in that moment? Can you rate it on a scale from 0–100?"
• "How did you experience the urge inside your body? Can you describe it?"

Step 5: Responses

Explore how the individual responded to the urge. This might include whether they acted on the urge, did not act, or distracted themselves by doing something else.

• "What did you do?"
• "Did you resist the craving or act on it?"
• "How did you respond to the urge?"

Step 6: Consequences (Optional)

The extended version of the Urges – Self-Monitoring Record worksheet includes an additional column for clients and therapists to explore the consequences related to acting (or not acting) on urges. Exploring the perceived consequences of an action can aid understanding of why particular patterns of thought and behavior persist. For example, acting on urges might lead to positive feelings (e.g., excitement or satisfaction), the removal of unwanted feelings (e.g., anxiety or stress), or negative consequences that lead to more urges (e.g., regret or shame). Exploring instances where the client successfully manages an urge can also highlight useful resources and coping strategies. Finally, discussing the client’s attitudes toward the consequences of their responses provides insight into their level of motivation. For example, precontemplative clients are likely to deny or minimize the negative consequences of acting on their urges.

• "What was helpful or unhelpful about acting on your urge?"
• "After your <target behavior>, how did you feel (a) right away, and (b) later?"
• "Looking back, how do you feel about what happened?"
• "How did it feel to not act on this urge? How did you manage to do that?"

• Beck, A. T., Wright, F. D., Newman, C. F., & Liese, B. S. (1993). Cognitive therapy of substance use. Guilford Press.
• 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.
• Liese, B. S., & Beck, A. T. (2022). Cognitive-behavioral therapy of addictive disorders. Guilford Press.
• 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.