Beha\
Res & Therapj.
1975. Vol
13. pp, 333-337.
CASE HISTORIES
Pergmon
Press, Printed
in Great Br~tsm
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 selfrecording 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 behavior 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; Kazdin. 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 selfrecording 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. suggested 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 present 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”. Fourteen 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 table (Table
of out Psychiatry
Department
and colleagues
around
Indianapolis
were sent the following
letter and
1):
faced by psychotherapists is the imprecision with which patients report 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: One of the continual
problems
frequency of symptoms. One way in which the accuracy
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
F
I
2
3
4*
5*
6
A
B
B
C
c
D
M
F
M
M
M
Sex
Client
Therapist
24
28
30
42
30
26
Age
of symptoms
or complaint
Not aware of feelings Not aware of feelings Trouble getting started or doing something that has to be done
Wishes to be more assertive Anxiety
Obsessions
Problem
Table 2. Clients, behavior
Behavior
counted
and outcome
Impulses to touch count and repeat acts Desires to assert self but unable to Feeling of impending doom or loss of control Feels angry but fails to express anger to spouse Number of times looked for source of anxiety Feelings of inertia or indolence
counted,
Feelings Anger Fear Guilt Inadequacy Being pleased (nonspecific) Being displeased (nonspecific) Urges (to eat, smoke, etc.)
any specific topic
that could be counted
Thoughts Obsessions Day dreams Thoughts about
or behavior
1. Table sent along with letter
Manifest behavior Eating Smoking Stuttering Drug use Sexual behavior Impulsive acts Compulsive acts Anger expressions (screaming, tantrums) Anxiety expressions (hyperventilation, sweating) Depression expressions (crying)
Examples
Table
X
X
X
X
X
K,A,U
X
X
B.M.
Outcome
X
N.D.E.
M
F
M
M
F
M
M
F
F
M
F
F
8
9
IO
Ilt
12
I.7
I4
15
I6
17
IK
19:
20
21
22
E
F
G
H
11
I
I
I
.I
K
L
M
N
N 1
N
tll
I’C~ISOIIS
40
understanding
gained
to
Trying to decide whether to leave husband of 20 yr Overweight and concerned about failure lose weight for a long time
58
21
31
Concerned ahout behavior towards children Wished to improve verbal and social behavior Concern about anxiety
Anger at wife following her filing for divorce Homosexualit).
IlCill
t‘oncern ;lhou t voluntary neck ‘.cracking!” Must stop smoking for
Uncomfortahlc feelings Discomforting sexual fantasies and acts Extreme marital disharmony Extreme marital disharmony Must quit smoking. In early stages of etnphysema
Preoccupied with fears of killing own infant Anxiety attacks
32
17
45
41
I7
31
40
47
23
2.5
34
.23
Code-- K.A.U: Knowledge. awareness, and;or No desirable effect was obtained. *Therapist C saw clients 4 and 5 together. ? Therapist H saw clients I I and I2 together. .-. __ .^
t
M
M
F
I
E
about
behavior
to physically
counted.
B.M.:
Behavior
Homosexual thoughts and urges Number of times angrily yelled and felt it to be unjustified later Negative statements and comments to others Number of felt fears and thoughts about fears Pleases and displeases which follow things husband says and does Urges to eat, and urges given in to by eating 3llegal” food
Impulses to smoke and cigarettes smoked Numhcr of times felt angry
modification
hurt infant son Feelings of apprehension, anxiety and panic Unexpressed feelings of anger towards self “Unacceptable” sexual thoughts and bntasics Pleases (good feelings) and displeases (bad feelings) which follow things spouse says or dots Numhcr of cigarettes smoked and urges to smoke Times cracked his neck
Wishes
reported
X
X
X
X
to have occurred.
X
X
X
X
X
X
N.D.E.:
X
X
336
CASE HISTORIES
AND
SHORTER
COMMUNICATIONS
If you are interested m collaborating with us in this investigation. will then send you: a. A wrist counter. b. A data sheet. c. Some guidelines to assist the patient in specifiying his behavior.
please
return
the enclosed
form. We
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 guidelines. 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 beginning 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
Some Pomters
PROJECT
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 themselves. 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,
337
CASEHISTORIESAND SHORTER COMMUNICATIONS Table.3.
Summary
of counter
project
results
Category Knowledge awareness or understanding (K.A,U)
No. of Clients
8 (3690
Behavior modification (B.M.) 2 (9”,“)
No desirable effects (N.D.E.)
Knowledge. awareness. or understanding and behavior modification (K.A.U + B.M.) 6 (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 confirms. 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 importance 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 selfrecording 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
ACKERMANP. D. (1972) Extinction of covert impulse responses through elimination of consummatory events. Psychol. Rec. 22,477-486. BARLOW D. H.. LEITENBERGH.. and AGRAS W. S. (1969) Experimental control of sexual deviation through manipulation 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, 541556. 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.) Sewcontrol: 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. BrooksCole, Monterey. ZIMMERMANJ. (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).
Res & Therapj.
1975. Vol
13. pp, 333-337.
CASE HISTORIES
Pergmon
Press, Printed
in Great Br~tsm
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 selfrecording 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 behavior 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; Kazdin. 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 selfrecording 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. suggested 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 present 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”. Fourteen 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 table (Table
of out Psychiatry
Department
and colleagues
around
Indianapolis
were sent the following
letter and
1):
faced by psychotherapists is the imprecision with which patients report 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: One of the continual
problems
frequency of symptoms. One way in which the accuracy
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
F
I
2
3
4*
5*
6
A
B
B
C
c
D
M
F
M
M
M
Sex
Client
Therapist
24
28
30
42
30
26
Age
of symptoms
or complaint
Not aware of feelings Not aware of feelings Trouble getting started or doing something that has to be done
Wishes to be more assertive Anxiety
Obsessions
Problem
Table 2. Clients, behavior
Behavior
counted
and outcome
Impulses to touch count and repeat acts Desires to assert self but unable to Feeling of impending doom or loss of control Feels angry but fails to express anger to spouse Number of times looked for source of anxiety Feelings of inertia or indolence
counted,
Feelings Anger Fear Guilt Inadequacy Being pleased (nonspecific) Being displeased (nonspecific) Urges (to eat, smoke, etc.)
any specific topic
that could be counted
Thoughts Obsessions Day dreams Thoughts about
or behavior
1. Table sent along with letter
Manifest behavior Eating Smoking Stuttering Drug use Sexual behavior Impulsive acts Compulsive acts Anger expressions (screaming, tantrums) Anxiety expressions (hyperventilation, sweating) Depression expressions (crying)
Examples
Table
X
X
X
X
X
K,A,U
X
X
B.M.
Outcome
X
N.D.E.
M
F
M
M
F
M
M
F
F
M
F
F
8
9
IO
Ilt
12
I.7
I4
15
I6
17
IK
19:
20
21
22
E
F
G
H
11
I
I
I
.I
K
L
M
N
N 1
N
tll
I’C~ISOIIS
40
understanding
gained
to
Trying to decide whether to leave husband of 20 yr Overweight and concerned about failure lose weight for a long time
58
21
31
Concerned ahout behavior towards children Wished to improve verbal and social behavior Concern about anxiety
Anger at wife following her filing for divorce Homosexualit).
IlCill
t‘oncern ;lhou t voluntary neck ‘.cracking!” Must stop smoking for
Uncomfortahlc feelings Discomforting sexual fantasies and acts Extreme marital disharmony Extreme marital disharmony Must quit smoking. In early stages of etnphysema
Preoccupied with fears of killing own infant Anxiety attacks
32
17
45
41
I7
31
40
47
23
2.5
34
.23
Code-- K.A.U: Knowledge. awareness, and;or No desirable effect was obtained. *Therapist C saw clients 4 and 5 together. ? Therapist H saw clients I I and I2 together. .-. __ .^
t
M
M
F
I
E
about
behavior
to physically
counted.
B.M.:
Behavior
Homosexual thoughts and urges Number of times angrily yelled and felt it to be unjustified later Negative statements and comments to others Number of felt fears and thoughts about fears Pleases and displeases which follow things husband says and does Urges to eat, and urges given in to by eating 3llegal” food
Impulses to smoke and cigarettes smoked Numhcr of times felt angry
modification
hurt infant son Feelings of apprehension, anxiety and panic Unexpressed feelings of anger towards self “Unacceptable” sexual thoughts and bntasics Pleases (good feelings) and displeases (bad feelings) which follow things spouse says or dots Numhcr of cigarettes smoked and urges to smoke Times cracked his neck
Wishes
reported
X
X
X
X
to have occurred.
X
X
X
X
X
X
N.D.E.:
X
X
336
CASE HISTORIES
AND
SHORTER
COMMUNICATIONS
If you are interested m collaborating with us in this investigation. will then send you: a. A wrist counter. b. A data sheet. c. Some guidelines to assist the patient in specifiying his behavior.
please
return
the enclosed
form. We
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 guidelines. 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 beginning 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
Some Pomters
PROJECT
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 themselves. 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,
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CASEHISTORIESAND SHORTER COMMUNICATIONS Table.3.
Summary
of counter
project
results
Category Knowledge awareness or understanding (K.A,U)
No. of Clients
8 (3690
Behavior modification (B.M.) 2 (9”,“)
No desirable effects (N.D.E.)
Knowledge. awareness. or understanding and behavior modification (K.A.U + B.M.) 6 (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 confirms. 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 importance 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 selfrecording 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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