How does your client prefer to keep track of tasks?

Assessment Methods

Self-Monitoring: Influencing Effective Behavior Change in Your Clients,” article below

Select a health behavior other than exercise.

Write a 1,200 word paper including the following:

  • Develop your own self-monitoring scale for this health behavior.
  • Explain how you would use this scale as an assessment tool in a behavioral health intervention.
  • Summarize three current behavioral assessment techniques.

Include a minimum of three scholarly references. Use article below

 Format your paper consistent with APA guidelines.

Self-Monitoring: Influencing

 

 

 

Effective Behavior Change

 

in Your Clients

 

 

by Melissa Burgard, B.S., and Kara I. Gallagher, Ph.D., FACSM

Learning Objective

To understand how to effectively use self-monitoring to

 

assist clients with behavior change and improve client

 

outcomes.

 

 

Key words: Behavior Change, Self-Monitoring, Weight

 

 

 

Loss, Feedback, Clients.

 

 

Behavior change is a difficult process. As a health/

 

 

 

fitness professional, assisting clients with behavior

 

change can be particularly challenging because client

 

interaction is often limited. Many times, these meetings

 

are not sufficient to target both eating and exercise behaviors

 

and address the many barriers clients face. Because many

 

health behaviors need to be targeted outside of these

 

meetings, finding ways to track progress also is necessary

 

to successfully provide clients with appropriate feedback

 

and direction. Thus, teaching clients to self-monitor is

 

an effective strategy for targeting both eating and exercise

 

behavior change. Self-monitoring allows you to review

 

your clients’ current eating and exercise behaviors, identify

 

what needs to be modified so clients can reach their personal

 

health/fitness goals, and provide feedback.

 

By definition, self-monitoring is ‘‘the systematic

 

observation and recording of target behavior’’ (1) and

 

has been described as the most effective technique and

 

the ‘‘cornerstone’’ of behavioral treatments for weight loss

 

(2). Self-monitoring increases a client’s self-awareness, and

 

this has been shown to positively influence eating and

 

exercise behaviors (3). Several weight loss studies have

 

shown that the more consistent participants were at

 

self-monitoring and the more self-monitoring diaries were

 

completed, the greater was the weight loss (4–6). In a

 

review of studies, D.S. Kirschenbaum, Ph.D., determined

 

that consistency is best defined as recording at least 75%

 

of eating and exercise behaviors (7). This relationship

 

also has been found in high-risk situations. In a study

 

examining weight change during the holiday season, only

 

the most consistent self-monitors lost weight (8). Although

 

self-monitoring is considered to be a valuable tool for

 

behavior change, it does require the consideration of

 

several factors to be applied and used appropriately with

 

your clients.

 

Teaching your client to effectively and consistently

 

self-monitor is a process that is dependent upon the client’s

 

personality, goals, and knowledge regarding his or her

 

behavior. Taking individual differences into account, your

 

goal as the health/fitness professional should be to ‘‘help

 

clients be the best self-monitors they can be’’ (8). As a guide,

 

you can use the following ‘‘Four Ps of Self-Monitoring’’

 

to determine the best self-monitoring fit for your clients.

 

 

Purpose of Self-Monitoring

 

 

 

It is helpful to explain the benefits of self-monitoring to your

 

clients so they understand the value and importance it has

 

in promoting behavior change. Self-monitoring can lead to

 

self-awareness regarding behaviors and can help the client

 

regulate behavior more effectively by avoiding and coping

 

with situations that often lead to failure. Self-monitoring

 

records can help identify the specific nature of these situations

 

by answering questions of how, what, when, where, and why.

 

For example, self-monitoring can provide information

 

regarding specific details of client behavior such as:

 

 

How many calories do they eat?

 

How much activity do they perform?

 

 

 

Photo courtesy of Christopher R. Mohr

 

 

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What type of foods do they eat?

 

What foods do they tend to overeat?

 

What time of day are they most likely to exercise?

 

What types of exercise do they enjoy?

 

When do they eat the majority of their calories?

 

When are they most likely to miss a planned exercise

 

 

 

session?

 

 

Where do they make poor food choices?

 

Where do they have opportunities for exercise?

 

Why do they miss exercise sessions?

 

Why do they want to lose weight or begin an exercise

 

 

 

program?

 

By addressing the specific details of clients’ behaviors

 

that occur outside of in-person sessions, you can better assist

 

them with recognizing patterns of behavior that may

 

impact progress.

 

 

Personalized Approach

 

 

 

What to Monitor

 

 

Once you have explained to the client the underlying

 

purpose and benefits of self-monitoring, the next step is

 

to decide with the client what behaviors to monitor in

 

order to best reach their health/fitness goals. It is essential

 

to keep in mind that this should not be a one-size-fits-all

 

approach. Take a personalized approach to tracking

 

client behavior that is based upon personality, environment,

 

and individual characteristics and goals. For example, for

 

clients who wish to lose weight, monitoring both eating

 

and exercise information is the best way to determine

 

if they are on track. For other clients, eating behaviors may

 

be related to stressful situations, and thus, feelings of

 

stress may be an additional variable you may want to

 

monitor to assist with weight loss.

 

Collecting baseline data is an important component

 

of self-monitoring because it provides you with an

 

understanding of what your clients are currently doing,

 

which behaviors require minor modification, and which

 

behaviors you may need to target more heavily. More

 

information is helpful, but it is not necessary to have clients

 

heavily self-monitor at the beginning of a program. Rather,

 

collecting a typical weekday and a typical weekend day of

 

information may be sufficient to capture a snapshot of

 

current behaviors. Once this information is collected, it is

 

beneficial to discuss these initial self-monitoring records with

 

your clients. This will allow you to identify what areas or

 

behaviors they find to be most troublesome and to gain

 

greater insight into how they believe these behaviors can

 

be changed.

 

 

Amount of Detail

 

 

Some clients may prefer to keep highly detailed

 

self-monitoring records that include, for example, date,

 

time, place, mood, description of food, quantity of food,

 

calories, grams of fat, and hunger level (Figure 1). Others

 

will simply want to record whether they made healthy

 

eating choices at each meal. In determining the amount of

 

detail your clients should use, pay careful attention to

 

clients’ attitudes regarding monitoring, personalities, and

 

time constraints. For some, more will be better, and this

 

will provide you with ample information to offer feedback

 

and direction; others may become overwhelmed and

 

disheartened by trying to attend to too many variables.

 

There are pros and cons to having clients provide a large

 

amount of detail regarding behaviors. For example, although

 

measuring body weight can tell you whether a client is on

 

track, it does not provide you with any information on eating

 

and exercise behaviors. This type of self-monitoring may

 

work for an individual who is successfully losing weight. On

 

the other hand, for the individual who is struggling with

 

changing his or her body weight, you have very little

 

information to determine what is impacting weight loss and

 

will be limited in the amount of feedback you can provide.

 

 

Figure 1. Example of detailed self-monitoring.

 

 

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Thus, you need to discuss the optimal approach that allows

 

them to easily self-monitor, while still adequately describing

 

the behaviors at hand.

 

Regardless of the amount of detail provided, the

 

variables being monitored should be closely tied to the target

 

behavior of interest. For clients interested in weight loss, these

 

variables would include total food intake (including type,

 

calories, and quantity), fat intake, and amount of exercise

 

performed (5). If a client is unable or unwilling to provide

 

this amount of detail, monitoring fewer variables will still

 

increase awareness and serve to direct his or her attention

 

toward the targeted behavior. Abbreviated measures still

 

allow the client to track the behaviors he or she is interested in

 

changing. In addition, it also allows the client to modify the

 

type of recording to suit his or her personality and lifestyle.

 

Figure 2 provides examples of abbreviated types of selfmonitoring

 

that are based upon individual likes and needs.

 

Looking at the examples, ‘‘Sarah’’ prefers to keep track of

 

total calories but does not want to do so in an obvious way;

 

she simply tallies calories consumed throughout the day in

 

the margin of her day planner. ‘‘Jim,’’ on the other hand,

 

prefers to have an overall picture of how well he is doing; he

 

keeps track of his behaviors on a monthly calendar he posts

 

above his desk. Allowing your clients to determine the

 

optimal way they would like to monitor their eating

 

and exercise behaviors will improve compliance to the

 

self-monitoring process.

 

 

Frequency of Monitoring

 

 

Another factor that requires a personalized approach

 

when prescribing self-monitoring is how frequently

 

clients should record behavior. Unfortunately, there is no

 

clear formula for the optimal frequency of self-monitoring;

 

this will depend upon the client’s schedule and ability to

 

monitor, as well as the targeted behavior, how frequently

 

it occurs, and the degree of difficulty the client has

 

experienced while trying to change the behavior in the past.

 

For example, eating behaviors are best monitored every

 

time they occur. A client who chooses to self-monitor his

 

or her eating behaviors only at night will likely underestimate

 

this information because it is difficult to remember exactly

 

what and how much was eaten throughout the day. In

 

addition, the self-awareness that occurs at such a late hour

 

will do little good because the client cannot modify the

 

eating plan for that day if needed.

 

In general, the more frequently your clients monitor

 

behavior, the better. Frequency of monitoring, however,

 

should also be determined by how frequently the behavior

 

may change. For someone interested in weight loss,

 

weighing more than once per week is not necessary. In fact,

 

frequent weighing throughout the day or week may lead

 

to unrealistic expectations about how quickly weight loss

 

should occur and can ultimately lead to frustration and

 

disappointment. By selecting an appropriate frequency

 

of monitoring for the behavior at hand and discussing

 

individual preferences with your clients, you can maximize

 

the consistency and effectiveness of self-monitoring.

 

 

Pinpoint Method of Monitoring

 

 

 

Once you have discussed which behaviors to monitor,

 

the degree of detail, and monitoring frequency, the final

 

step is determining how the client should monitor his or

 

her behavior. With the increasing availability of health/

 

fitness information to the consumer, there are a number

 

of self-monitoring methods from which you can choose.

 

These vary from basic pen and paper methods such as

 

sticky notes, diaries, or calendars to more advanced

 

technologies such as pedometers, personal desk assistants

 

(PDAs), MP3 players, cell phones, and the Internet.

 

The most important determinant in which self-monitoring

 

method to recommend is that it is one the client is

 

willing and able to use.

 

The Internet is one avenue of self-monitoring that

 

is becoming increasingly popular and may be a viable

 

option for many clients. Many commercial Web sites offer

 

some form of self-monitoring for eating and exercise

 

behaviors, and many of these are free of charge. Using the

 

Internet for self-monitoring will depend upon the

 

 

Figure 2. Examples of abbreviated self-monitoring.

 

 

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availability and technologic expertise of your clients, but it

 

does allow for frequent and relatively easy monitoring of

 

eating and exercise behaviors. You also can have clients send

 

you electronic copies of these records and easily track

 

individual progress over time.

 

Not all clients will prefer to use technology. Some

 

individuals prefer to use a small notebook specifically for their

 

self-monitoring or will simply check off their behaviors as

 

they have met their goals (Figure 2). Whichever method is

 

decided upon should be matched to the client’s preference

 

for recording to enhance self-monitoring consistency.

 

To further determine which method is most

 

appropriate for your client, consider the following

 

questions:

 

 

1. Does monitoring the target behavior require

 

subjective or objective information? If you would

 

 

 

like your client to monitor moods, feelings, or ratings

 

of hunger or fatigue, then having the ability to record

 

more detailed information is important. Thus pen

 

and paper, e-mail, or a PDA may be good choices.

 

On the other hand, if you are only interested in objective

 

measures such as steps taken each day, a pedometer

 

can sufficiently provide the client with the information

 

he or she needs.

 

 

2. How does your client prefer to keep track of tasks?

 

 

 

Does your client prefer technology and the ease of modifying

 

entries by cutting, copying, and pasting, or does he or

 

she prefer writing things down using pen and paper?

 

 

3. What is the client’s technologic experience? Does

 

 

 

your client own a PDA or cellular telephone or have

 

Internet access? Do they have Internet access throughout

 

the day or only at limited times?

 

 

4. How frequently is your client willing to monitor?

 

 

 

If the behavior requires frequent monitoring, it is

 

important to find a tool that is readily available. If

 

your client does not have the self-monitoring tool

 

available at all times to record behaviors, determine a

 

method that is more appropriate.

 

 

Provide Feedback

 

 

 

Perhaps the biggest advantage of self-monitoring is that

 

it serves as an avenue for providing feedback to clients on

 

the behaviors they are attempting to change. Therefore, the

 

type and style of feedback you provide to clients is critical

 

for appropriately directing and supporting positive

 

behavior change. The feedback you provide will depend

 

upon the amount of detail the client has reported in his or

 

her self-monitoring records. For example, it is easier to

 

respond to clients if you have a clear and detailed

 

picture of the behaviors and choices they have made.

 

Nevertheless, even less detailed accounts can give you an

 

adequate indication of whether the client is on track.

 

When reviewing self-monitoring records, you should ask

 

the following questions:

 

 

What is the overall picture? If a goal was predetermined,

 

 

 

did the client meet his or her goal for the week?

 

 

What are some positive behaviors or changes the client

 

 

 

has made?

 

 

Are there any patterns of behavior? Do these patterns

 

 

 

support or interfere with the behavior change the client

 

would like to make?

 

 

Are there any additional factors to consider such as

 

 

 

vacation, family emergency, or odd work hours?

 

Once you have assessed the self-monitoring records,

 

you are then able to provide feedback to the client based

 

upon the previously outlined questions. Table 1 provides

 

step-by-step tips for providing feedback. In addition,

 

you also should consider the following strategies:

 

 

1. Use positive reinforcement. Positive reinforcement

 

 

 

refers to any factor that increases the probability that the

 

behavior will be repeated and can include encouraging

 

statements, recognition of progress, and celebration of

 

small yet meaningful changes. For example, if a client has

 

struggled with an afternoon snacking habit that has

 

 

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interfered with her weight loss, switching from cookies to

 

fruit is a meaningful change that should be encouraged

 

and rewarded.

 

 

2. Provide prompts for engaging in additional positive

 

behaviors and modifying negative behaviors. It is

 

 

 

important to try to determine challenging areas for

 

clients. This information can be learned from studying

 

patterns within self-monitoring records. Focus upon one

 

or two areas that the client can modify each week.

 

 

3. Modify the type of self-monitoring. Periodically,

 

 

 

you should modify self-monitoring assignments for

 

your clients based upon their progress, life events, and

 

personal health/fitness interests. As a client begins to

 

lose weight, for example, you may consider asking him

 

to record less information as he may already have a

 

certain amount of self-awareness regarding portion

 

sizes and calorie content. Other examples of situations

 

that require altering the type of self-monitoring

 

include a client who has decided to focus upon a

 

different health/fitness goal, a client whose schedule

 

will change drastically because of work schedule or

 

travel, or a client who begins to keep inconsistent

 

self-monitoring records.

 

Providing feedback to your clients allows you to extend

 

your personal interactions with them. As the client

 

begins to make (or not make) the necessary changes and

 

you begin to have a better understanding of the individual

 

personality type, you should modify your approach to

 

feedback so that it continues to remain interesting and

 

meaningful. Some clients will be driven by your feedback

 

to make the positive changes needed to be successful

 

and will enjoy receiving your comments. Others may

 

be more rebellious and will decide not to heed your

 

recommendations. By making proper adjustments to

 

monitoring assignments and the feedback you provide, you

 

can make self-monitoring a positive, effective tool to

 

promote the accomplishment of clients’ targeted goals.

 

 

Limitations of Self-Monitoring

 

 

 

As with any tool used to promote behavior change,

 

self-monitoring is not without limitations. First of all,

 

self-monitoring will not be an effective tool for your clients

 

unless they record honestly, frequently, and with enough

 

detail to become more self-aware to regulate the targeted

 

behavior. In addition, the mere act of recording behaviors

 

may not be enough to bring about behavior change. If a

 

client records eating and exercise behaviors but does not

 

understand the concept of energy balance and energy deficit,

 

then self-monitoring alone will not be a sufficient stimulus

 

to promote weight loss. Therefore, work with clients to

 

discuss areas that can be modified or targeted and educate

 

 

Table. Step-by-Step Tips for Providing Feedback

 

 

1. Start Positive. Regardless of how well your client managed the targeted behavior and/or kept self-monitoring records, your

 

first comment should be a positive one. This statement could be very general, (i.e. ‘‘Great job recording this week! I can see

 

 

 

you are trying to make changes in your diet.’’) or it may specifically refer to a behavior, such as ‘‘You did a fantastic

 

job reaching 150 minutes of physical activity this week!’’

 

 

2. Identify 1-2 Areas to Target. Next, provide 1 to 2 specific and meaningful recommendations or suggestions to help the client

 

make the necessary behavior changes. For instance, based on the self-monitoring records, you might suggest the client reduce

 

 

 

high fat/high calorie foods by substituting these foods with more fruits and vegetables. Or you may highlight situations

 

during the week where poor choices could have been linked to other factors (i.e. Friday dinner with out-of-town guest,

 

baseball game, etc.). Be sure to include at least one strategy for how the client can prepare for these situations in the future.

 

 

3. Offer Encouragement. Motivate your client by offering them words of encouragement. Although behavior change is highly

 

 

 

dependent on individual personalities, goals, personal barriers, etc., in general, clients respond more favorably to positive

 

comments than negative ones. Celebrate your clients’ small successes throughout the week by recognizing small changes in

 

an encouraging way. Offering a simple, ‘‘I know you can do this,’’ or ‘‘you are worth it’’ shows the client you understand

 

that behavior change requires effort.

 

 

4. Make it Meaningful. Try to avoid offering the same feedback to all clients or the similar feedback to the same client week

 

after week. The feedback you offer should be relevant to the target behavior and should offer clear direction for change.

 

 

 

If the client is unsuccessful, modify the feedback you provide as the client may simply have misunderstood the direction

 

you provided. When possible, discuss your feedback with the client in addition to giving them a written copy.

 

 

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them as to why these behavior modifications are important.

 

A common criticism of self-reporting is that clients often

 

underreport calories and food intake and overreport

 

behaviors such as physical activity or calories expended

 

(10, 11). Nonetheless, self-monitoring can still be a valid

 

tool for tracking behavior change as individuals most likely

 

under- or overreport such information on a consistent basis.

 

Self-monitoring is not for every client. Some clients

 

will feel burdened by tracking behaviors, and this may lead

 

to poor compliance to exercise and eating

 

recommendations. Thus, you need to be willing to modify

 

self-monitoring assignments or eliminate it altogether if

 

it begins to decrease, rather than promote adherence.

 

 

Summary

 

 

 

While the verdict may still be out on the ‘‘optimal’’ procedure

 

for self-monitoring, research does support consistency of

 

monitoring as a critical component of weight control and the

 

adoption and adherence of an exercise regimen. There are a

 

number of self-monitoring options available to you and your

 

client. Therefore, your goal should be to individualize the

 

assigned self-monitoring tasks to determine what works best

 

for the client to enhance consistency of self-monitoring and

 

promote favorable changes.

 

 

Melissa Burgard, B.S., is a Master’s candidate

 

and graduate research assistant in exercise

 

physiology at the University of Louisville

 

where her research focuses upon the role of

 

self-monitoring, feedback, and prompting

 

upon exercise adherence and weight loss.

 

Kara Gallagher, Ph.D., FACSM, is an

 

assistant professor in Exercise Physiology at

 

the University of Louisville where her research

 

focuses upon the role of exercise and behavior

 

change in weight control. She is a member

 

 

of the editorial board for ACSM’s Health &

 

Fitness Journal.1 She is ACSM Exercise

 

Specialist 1certified, ACE Group Exercise Instructor-certified,

 

 

 

and has worked in university and health/fitness settings for the

 

last 15 years.

 

 

References

 

 

1. Kanfer, F. H. Self-Monitoring: Methodological limitations and

 

 

clinical applications. Journal of Consulting and Clinical Psychology

 

 

 

35:148–152, 1970.

 

 

2. Wadden, T. A. The treatment of obesity: An overview. In: Obesity:

 

Theory and Therapy (2nd ed.), A. J. Stunkard and T. A. Wadden (Eds.).

 

 

 

New York: Raven Press, 1993, pp. 197–218.

 

3. Heesch, K. C., L. C. Masse, A. L. Dunn, et al. Does adherence

 

to a lifestyle physical activity intervention predict changes in physical

 

 

activity? Journal of Behavioral Medicine 26(4):333–348, 2003.

 

 

 

4. Boutelle, K. N., and D. S. Kirschenbaum. Further support for

 

consistent self-monitoring as a vital component of successful weight

 

 

control. Obesity Research 6(3):219–224, 1998.

 

 

 

5. Boutelle, K. N., D. S. Kirschenbaum, R. C. Baker, et al. How can

 

obese weight controllers minimize weight gain during the high

 

 

risk holiday season? By self-monitoring very consistently. Obesity

 

Research 6(3):219–224, 1998.

 

 

 

6. Tate, D. F., R. R. Wing, and R. A. Winett. Using internet technology

 

 

to deliver a behavioral weight loss program. Journal of the American

 

Medical Association 285(9):1172–1177, 2001.

 

7. Kirschenbaum, D. S. The Nine Truths about Weight Loss. New York:

 

 

 

Henry & Holt, 2000.

 

8. Baker, R. C., and D. S. Kirschenbaum. Weight control during the

 

holidays: The potentially critical role of self-monitoring. Presented

 

at the Meeting of the Association for Advancement of Behavior

 

Therapy, New York, November 1996.

 

9. Madden, M., America’s online pursuits: The changing picture of who’s

 

 

online and what they do. December 22, 2003. Available at http://

 

www.pewinternet.org/pfds/PIP_Online_Pursuits_Final.PDF. Accessed

 

 

 

Aug 8, 2005.

 

10. Horner, N. K., R. E. Patterson, M. L. Neuhouser, et. al. Participant

 

characteristics associated with errors in self-reported energy intake

 

from the Women’s Health Initiative food-frequency questionnaire.

 

 

American Journal of Nutrition 76:766–773, 2002.

 

 

 

11. Johansson, L.,K. Solvoll, G. E. Bjorneboe, et al.Under- and over- reporting

 

of energy intake related to weight status and lifestyle in a nationwide

 

 

sample. American Journal of Clinical Nutrition 68:266–274, 1998.

 

 

 

Condensed Version and

 

Bottom Line

 

 

Interactions between health/fitness professionals

 

and clients are often limited to face-to-face meetings

 

in the gym or health club. Many clients, however,

 

struggle with maintaining consistent healthy eating

 

and exercise behaviors outside of these interactions.

 

Self-monitoring allows you to monitor client progress

 

and identify areas that may hinder client success.

 

Self-monitoring also increases self-awareness of

 

behaviors and allows the client to become familiar with

 

other factors that are linked to the behaviors he or she

 

would like to change. By incorporating self-monitoring

 

into your interactions with clients and by providing

 

meaningful, directed feedback, you can increase the

 

likelihood that clients will successfully change eating

 

and exercise behaviors.

 

 

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