Beha\ Res & Therapj. 1975. Vol 13. pp, 333-337. Pergmon Press, Printed in Great Br~tsm

CASE HISTORIES AND SHORTER COMMUNICATIONS

Why not give your ciient a counter: A survey of what

happened when we did

(Received 21 Octoher 1974)

A perusal of the recent literature of behavior mod~~cat~on shows an increasing emphasis on the use of self- recording as a research tool (see for example, Bariow er ai., 1969: Duncan, 1969: McFall. 1970: Johnson and White, 1971; and Ackerman, 1972). In addition, self-recording is being more frequently utilized as a method of teaching students. clients and patients to (a) observe themselves more precisely. (b) assess the effects of treatments which they apply to themselves, with or without the guidance of a counsellor or therapist, and finally (c) provide the latter with objective information (see for example. Stuart, 1967; Lindsley. 1969; Kanfer. 1970: Duncan. 1971; Watson and Tharp. 1972; Mahoney and Thoresen, 1974; Thoresen and Mahoney, 1974; Zimmerman. 1975).

Several researchers have suggested and provided evidence for the notion that self-recording of one’s own be- havior can be a reactive measure which leads to behavior change on the part of the recorder without the addition of further treatment (see for example. McFall. 1970; Johnsonand White. 1971; McFall and Hammen, 1971; Kaz- din. 1974; and Lipinski and Nelson. 1974). Preliminary results which each of the present authors have observed with some self-recording clients confirms the above observation. Furthermore. we have also observed that self- recording can sometimes lead to unexpected. therapeutic side-effects. For example, the junior author recently gave a golf counter to a 17-year-old female patient who reported having many impulses to “go back and check” things before leaving her home. These impulses were usually acted upon and one of the consequences of this was that the patient usually kept her parents waiting when the three had to go out. This patient was asked to wear a golf counter, which was given to her. to count the number of times each day that she had an “impulse to check”. In an interview with her following a 7-day counting period. she reported that she had not been aware that she had so many impulses (103 the first day of counting); she actually felt revulsion with herself upon clearly seeing how frequently she had these impulses; she had more impulses when nervous and fewer when relaxed; and finally, both the number of impulses and the actual number of times she acted upon them were markedly reduced over the ‘I-day counting period. This set of results. together with other (albeit less dramatic) results. sug- gested to us that some clients can benefit merely by self-recording their own behavior. For some the benefit may be greater awareness or knowledge of the self-recorded behavior. for some it could be actual behavior change, and for some both benefits might be achieved.

To our knowledge. no study has been conducted which has surveyed such possible benefits of self-recording across a number ofclients and under conditions in which many therapists are involved. The purpose of the pres- ent study was to explore the effects of self-recording. per se. across many clients who were being seen by many different therapists. We did so by recruiting therapists who would be interested in trying out the procedure of having one or more clients self-record.

METHOD

Subjects were actually chosen by those therapists who volunteered to take part in our “Counter Project”. Four- teen therapists. including the present authors. selected one or more clients for the project. In all. 22 clients were selected. The 12 males varied in age from 17 to 47 with a median age of 30. The 10 females varied in age from 23 to 58 with a median age of 31f. Included in the population of clients who self-recorded were 2 persons diagnosed as being psychotic. 8 diagnosed as being neurotic (4 of whom were considered ob~ssive-compulsive). 5 who were working on marital problems. 2 who were dealmg with sexual problems. and 2 who were trying to eliminate smoking.

P,ocedure

Members of out Psychiatry Department and colleagues around Indianapolis were sent the following letter and table (Table 1):

One of the continual problems faced by psychotherapists is the imprecision with which patients report frequency of symptoms. One way in which the accuracy of reporting could be improved is by requiring the patient to actually count and record the occurrences of a symptom or behavior.

Preliminary results of this procedure suggest that this kind of self-monitoring sometimes has unexpected, therapeutic side-effects.

We want to examine these side-effects systematically. This project will require the cooperation of many therapists like yourself. Specifically, the procedure would be as follows:

1. You would select a patient wsho appears to have a symptom that could be monitored (See the table on the attached page). Preferably. but not essentially. this should be a new patient.

2. We will provide you with a wrist counter and a daily tabulation record sheet, which you will give to the patient, with instructions to record the frequency of the symptom each day.

3. At the end of a two-week interval, you collect the data sheet and the counter, and briefly interview the patient concerning his reactions to the monitoring experience.

333 H.R.T. I3 4-, I

Tab

le

1. T

able

se

nt

alon

g w

ith

lette

r

Exa

mpl

es

of s

ympt

oms

or

beha

vior

th

at

coul

d be

cou

nted

Man

ifes

t be

havi

or

Eat

ing

Smok

ing

Stut

teri

ng

Dru

g us

e Se

xual

be

havi

or

Impu

lsiv

e ac

ts

Com

puls

ive

acts

A

nger

ex

pres

sion

s (s

crea

min

g,

tant

rum

s)

Anx

iety

ex

pres

sion

s (h

yper

vent

ilatio

n,

swea

ting)

D

epre

ssio

n ex

pres

sion

s

(cry

ing)

Tho

ught

s O

bses

sion

s D

ay

drea

ms

Tho

ught

s ab

out

any

spec

ific

to

pic

Feel

ings

A

nger

Fe

ar

Gui

lt In

adeq

uacy

B

eing

pl

ease

d (n

onsp

ecif

ic)

Bei

ng

disp

leas

ed

(non

spec

ific

) U

rges

(t

o ea

t,

smok

e,

etc.

)

Tab

le

2.

Clie

nts,

be

havi

or

coun

ted,

an

d ou

tcom

e

Out

com

e

The

rapi

st

Clie

nt

Sex

Age

Pr

oble

m

or

com

plai

nt

Beh

avio

r co

unte

d K

,A,U

B

.M.

N.D

.E.

A

I F

26

Obs

essi

ons

Impu

lses

to

tou

ch

coun

t an

d re

peat

ac

ts

X

B

2 M

30

W

ishe

s to

be

mor

e D

esir

es

to a

sser

t as

sert

ive

self

but

un

able

to

X

X

B

3

M

42

Anx

iety

Fe

elin

g of

im

pend

ing

doom

or

lo

ss

of c

ontr

ol

C

4*

M

30

Not

aw

are

of

Feel

s an

gry

but

fails

to

fe

elin

gs

expr

ess

ange

r to

spo

use

X

c 5*

F

28

Not

aw

are

of

Num

ber

of t

imes

lo

oked

fe

elin

gs

for

sour

ce

of a

nxie

ty

X

D

6 M

24

T

roub

le

getti

ng

Feel

ings

of

ine

rtia

st

arte

d or

do

ing

or

indo

lenc

e X

X

so

met

hing

th

at

has

to b

e do

ne

X

E

E F

G

H

11

I I I .I K

L M

N

N 1 N

I 8 9 IO

Ilt

12

I.7

I4

15

I 6

17

IK

19:

20

21

22

F

M F

M

M

F

M

M t M

M F

F

M F F

.23 34

2.5

23

47

40

31

I7

41

45

17

32

31

21

58

40

Pre

occu

pied

w

ith

fear

s of

ki

lling

ow

n in

fant

Anx

iety

at

tack

s

Unc

omfo

rtah

lc

feel

ings

D

isco

mfo

rtin

g se

xual

fant

asie

s an

d ac

ts

Ext

rem

e m

arita

l di

shar

mon

y E

xtre

me

mar

ital

dish

arm

ony

Mus

t qu

it sm

okin

g.

In

early

st

ages

of

et

nphy

sem

a

t‘onc

ern

;lhou

t

volu

ntar

y

neck

‘.c

rack

ing!

”

Mus

t st

op

smok

ing

for

IlC

ill

tll

I’C

~IS

OII

S

Ang

er

at

wife

follo

win

g he

r fil

ing

for

divo

rce

Hom

osex

ualit

).

Con

cern

ed

ahou

t

beha

vior

to

war

ds

child

ren

Wis

hed

to

impr

ove

verb

al

and

soci

al

beha

vior

Con

cern

ab

out

anxi

ety

Try

ing

to

deci

de

whe

ther

to

le

ave

husb

and

of

20 y

r O

verw

eigh

t an

d co

ncer

ned

abou

t fa

ilure

to

lose

w

eigh

t fo

r a

long

tim

e

Wis

hes

to

phys

ical

ly

hurt

in

fant

so

n F

eelin

gs

of

appr

ehen

sion

, an

xiet

y an

d pa

nic

Une

xpre

ssed

fe

elin

gs

of

ange

r to

war

ds

self

“Una

ccep

tabl

e”

sexu

al

thou

ghts

an

d bn

tasi

cs

Ple

ases

(g

ood

feel

ings

) an

d di

sple

ases

(b

ad

feel

ings

) w

hich

fo

llow

thin

gs

spou

se

says

or

dots

N

umhc

r of

cig

aret

tes

smok

ed

and

urge

s to

sm

oke

Tim

es

crac

ked

his

neck

Impu

lses

to

sm

oke

and

ciga

rette

s sm

oked

Num

hcr

of

times

fe

lt an

gry

Hom

osex

ual

thou

ghts

an

d ur

ges

Num

ber

of

times

an

grily

yelle

d an

d fe

lt it

to

be

unju

stifi

ed

late

r

Neg

ativ

e st

atem

ents

an

d co

mm

ents

to

ot

hers

N

umbe

r of

fe

lt fe

ars

and

thou

ghts

ab

out

fear

s P

leas

es

and

disp

leas

es

whi

ch

follo

w

thin

gs

husb

and

says

and

do

es

Urg

es

to

eat,

and

urge

s gi

ven

in

to b

y ea

ting

3lle

gal”

food

X

X

X

X

X

X X

X

X

X

X

X

Cod

e--

K.A

.U:

Kno

wle

dge.

aw

aren

ess,

an

d;or

un

ders

tand

ing

gain

ed

abou

t be

havi

or

coun

ted.

B

.M.:

Beh

avio

r m

odifi

catio

n re

port

ed

to

have

oc

curr

ed.

N.D

.E.:

No

desi

rabl

e ef

fect

w

as

obta

ined

.

*The

rapi

st

C s

aw c

lient

s 4

and

5 to

geth

er.

? T

hera

pist

H

sa

w

clie

nts

I I a

nd

I2

toge

ther

. .-

. __

.^

336 CASE HISTORIES AND SHORTER COMMUNICATIONS

If you are interested m collaborating with us in this investigation. please return the enclosed form. We will then send you:

a. A wrist counter. b. A data sheet. c. Some guidelines to assist the patient in specifiying his behavior.

Those therapists who indicated an interest in taking part in the “Counter Project” by either returning a form to one of us, or contacting one of us personally, were sent a wrist (golf) counter. a data sheet and a set of guide- lines. The set of guidelines read as follows.

Some Guidelines for Counting Stgnificant Behavior

(I) In counting. it is important that the patient carefully PINPOINT what he will measure. Whether it is a feeling, thought. or overt behavior. it ninsr hare a hegimiy and m end. If you are counting elephants passing you by. you count O~P only after you see hot/~ the trunk and the tail pass by.

Thus, whether one is counting a feeling like fear or anger, a thought (about death. or ofa particular person, for example). or an expressed behavior like crying or stuttering. click the counter consistently either ar the heginning or end of the behavior or experience. Click only once for a complete cycle which must have a begin- ning and an end.

A given behavior may last only a second or it may last as long as an hour. It is only when it is over that one has the opportunity to behave again or experience again. In case of doubt. an arbitrary definition can be applied. For example. in the case of stuttering. one could say that an episode of stuttering is over when no stuttering has occurred for at least n seconds. An anxiety attack or fantasy is over and the next one can begin only after some minimal period of time has elapsed since the last one.

(2) Caution: it occurs to the patient upon simply looking at his counter, that he is supposed to be counting a phenomenon. In counting a thought. this aside thought SHOULD NOT BE COUNTED. It is merely an artifact of the labelling process. a reminder. It is not the same as the thought either “popping into the head”, being triggered by a different thought. being triggered by a feeling. or being triggered by an observable eqvironmental cue. All of these are okay to count.

(3) For most behavior, the time to be reported on the data sheet (“hours counted”) would be the number of hours awake. However, if what is counted has to do only with work behavior, then count working hours. Similarly, if it has to do only with being in contact with a given person, count only the contact hours. And so on.

(4) Data sheets should be returned to Joe Zimmerman. Please append the following patient information: sex. age, diagnosis.

The data sheet consisted of 14 rows (for the 14 self-recording days). On each row the client was to insert the date, number oftimes the given symptom or behavior was counted that day, the number of hours spent counting that day, and a space for any relevant comments about the day’s count.

A week later, each of the participant-therapists was sent a letter which gave some pointers on how to interview his client with respect to the counting experience. This letter read as follows:

COUNTER PROJECT

Some Pomters on the Post-Two Weeks Interview

The critical task is to obtain information about the impact of counting on the patient, about his reaction to it. if any, in a rotally non-directive tn~na~r.

Begin the interview by asking something like “Would you care to tell me what it was like to count your own behavior?” Or. “Teil me about the two weeks.” If this probe elicits a completely bland response (“It was all right.” “Nothing to it.” etc.), you may ask the patient. “Did you have any reactions to counting?“.

DO NOT ask specific questions like “How did it affect your behavior.” or “Did it do anything to you?” Specific questions may be asked ONLY to clarify a statement already made by the patient. Even then.

exercise care not to direct the patient’s response into a fresh channel. Of course, you should note anything that the patient volunteers spontaneously about his reactions to the

counter and counting. Write a brief summary of the interview: a paragraph will probablv suffice. Send II, along with the mlly

sheet and a statement of the patient‘s age. sex. and diagnosis. to Joe Zimmerman or Gene Levitt. If you wish to use the counter with additional patients. retain it. and we will send you more tally sheets.

Otherwise. piease return the counter with the written materials. We are sincerely grateful for your cooperation.

RESULTS

The results ofthis study are summarized in Tables 2 and 3. Table 2 presents the sex, age. problem or complaint. and behavior counted by each client. Tables 2 and 3 present results of the counting experience in terms of a set of outcome categories which the two authors independently agreed upon in 100 per cent of the cases. The categories employed were (a) Knowledge. awareness. or understanding gained about the behavior counted (K,A.U);(b) Behavior modification was reported to have occurred either immediately after putting on the counter and counting. or over the counting period (B.M.); (c) No desirable effect was obtained (N.D.E.); and (d) Both of the first two results were reported (K.A.U + B.M.).

Table 3 summarizes the overall results of the study in terms of the number of clients out of 22 whose results were placed in each of these categories.

Tabfe 3 shows that 16 of the 22 clients, or 73:,,. benefited in some way from the counting project. Of the 8 clients who reported that behavior actually changed. 6 indicated that they also learned something about them- selves. Indeed, of the 22 clients in the study. 14. or almost two-thirds. reported that they had achieved greater awareness and/or knowledge or understanding with respect to the self-recorded symptom or behavior,

CASE HISTORIES AND SHORTER COMMUNICATIONS 337

Table.3. Summary of counter project results

Knowledge awareness or

understanding

(K.A,U)

Category

Behavior modification

(B.M.)

No Knowledge. awareness.

desirable or understanding and effects behavior modification

(N.D.E.) (K.A.U + B.M.)

No. of Clients

8 2 6 (3690 (9”,“) (27”,,)

In addition to the above categorized results. 6 of the clients reported at least one additional benefit of counting. Clients 7, 9. 18, 19 reported that they gained substantial control over the behavior they were counting, by virtue of counting. Client 1 reported that each time she counted she felt relief from the symptom. Finally. client 17 reported that he felt relieved by the fact that the counts he took were not as high as those he had expected.

CONCLUSIONS

In 8 out of 22 clients who were given a counter to wear and use for the purpose of self-recording a symptom or behavior. behavior modification occurred merely by virtue of using the counter and counting. This result con- firms. at the clinical level. that self-recording can be a reactive measure. The generality of this result is suggested by the fact that seven different therapists were involved in those eight cases. What may be of even greater impor- tance is the fact that 14 of the 22 clients (10 different therapists) reported that they gained knowledge. awareness and/or understanding about the symptom or behavior which they monitored. This finding indicates that self- recording can be of value both to the monitor himself and also to the therapist who works with the monitor, at least with respect to achieving more knowledge. and more precise information. respectively. about problem behavior.

Two problems frequently faced by therapists are (a) the imprecision with which patients report the frequency of their symptoms, and (b) the failure of patients to take an active part in the therapeutic process. One way in which the accuracy of reporting could be improved and the part which the patient takes could be increased might be by requesting the patient to actually count and record the occurrences of a symptom or behavior. The results obtained in this study suggest that in addition to these two benefits. self-recording can help many clients gain more self-knowledge about problem behavior and can lead to behavioral change in the case of some clients.

Dept. of Psychiatry, Indiana University School of Medicine. Indianapolis. Indiana 46202. U.S.A.

JOSEPH ZIMMERMAN EUGENE E. LEVIT-T

REFERENCES

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BARLOW D. H.. LEITENBERG H.. and AGRAS W. S. (1969) Experimental control of sexual deviation through mani- pulation of the noxious scene in covert sensitization. J. ahnorm. Psychol. 5, 596-601.

DUNCAN A. D. (1969) Self-application of behavior modification techniques by teen-agers. Adolescence 16, 541- 556.

DUNCAN A. D. (1971)The view from the inner eye: Personal management of inner and outer behaviors. Teaching Exceprional Children 3, 152-l 56.

JOHNSON S. M. and WHITE G. (1971) Self-observation as an agent of behavioral change. Behav. Therapy 2, 48% 497.

KANFER F. H. (1970) Self-monitoring: Methodological limitations and clinical applications. J. cor7sult. c/in. PsJjchol. 35, 148-152.

KAZDIN A. E. (1974) Self-monitoring and behavior change. In M. 1. MAHONEY and C. E. THORESEN (Ed.) Sewcon- trol: Power fo the Person. Brooks-Cole. Monterey, Calif.

LINDSLEY 0. R. (1969) Should we decelerate urges or actions? Thou shall not covet. Paper presented at the Annual Convention of the American Psychological Association. Washington. D.C.

LIP~NSKI D. and NE~SQN R. (1974) The reactivity and unreliability of self-recording. J. counsel. clin. Psychol. 42, 118-123.

MAHONEY M. J. and THORESEN C. E. (1974) Sr!f-control: Power to the Person. Brooks-Cole, Monterey. Calif. MCFALL R. M. (1974) Effects of self-monitoring on normal smoking behavior. 1. consult. clirl. Psychol. 35, 13%

142. MCFALL R. M. and HAMMEN C. L. (1972) Motivation. structure. and self-monitoring: The role of nonspecific

factors in smoking reduction. J. cottsult cliil. Psycho/. 37, 8&86. STUART R. B. (1967) Behavioral control of overeating. Behac. Res. & Therapy 5, 357-365. THORESEN C. E. and MAHONEY M. J. (1974) Behavioral Se&ontrol. Holt. Rinehart & Winston. New York. WATSON D. L. and THARP R. G. (1972) Se!f’directed Behavior: Self-modification for Personal Adjustment. Brooks-

Cole, Monterey. ZIMMERMAN J. (1975) If it’s what’s inside that counts. why not count it? I: Self-recording of feelings and treatment

by “self-implosion”. Psychol. Rec. (In press).