Diary Card Effect: Tracking Real Life, Real Skills, Real Change

DBT Clinician Sharon Ng and Jessica discuss the use of Diary Cards in therapy and how they are helpful for treatment.

Transcript

SPEAKER_00 0:04

Welcome to the Inner Solutions Podcast. I'm your host, Jessica Heil. I own and operate Inner Solutions, a private practice clinic located in Calgary, Canada. Inner Solutions seeks to understand and help our clients by providing empirically supported treatments and evidence-based practices with compassion and expertise. This podcast will provide you with information regarding complex psychological conditions as well as treatments that are available. It's called a diary card. Let's just jump right in. Sharon, how would you define what a diary card is?

SPEAKER_01 0:56

Yeah, so a diary card is a essentially a tool we use in DBT to help clients track their thoughts, emotions, urges, and behaviors, as well as skill uses that they use on a daily basis. So I'd say essentially how I break it down is there's the purpose behind it is kind of twofold. There is the usage for clients to help them build self-awareness, kind of giving them more of a detailed picture of what like a snapshot of what their life is on like the daily, and almost like a personal weather report. So kind of picturing how intense their emotions are, how often it shows up, and that pattern that emerges that we'll see in the long run. And then secondly, for myself as a therapist, a diary card does give me information that does help me knowingly how to tailor the sessions more effectively. So we also use a diary card almost like a roadmap, and I can help identify what key areas that I could suggest for clients to try out a strategy and if it's working or not, and then when to pivot. So it's pretty helpful throughout the course of therapy. That could be quite long term, like we're talking about close to a year, and having the diary card does help keep myself focused.

SPEAKER_00 2:12

I love that. Yeah, diary cards are something that we're going to use as, like I think about like DBT dialectical behavior therapy. It's such a behavioral tool that gets us to really think through what are the problem behaviors, is what we call them in DBT. What are the things that people are coming to therapy for, like the behaviors that they like to change? And because we get to target these on the diary card, it gives us the capacity to really watch for that progress throughout the time that they're in DBT. And as you mentioned, it's used for quite a few months. Like DBT is a long-term therapy. So oftentimes people are using these diary cards for months at a time. And it really gives this like wealth of data that we can look at to be able to track what those behaviors are looking like or like what those emotions and what those cognitions so that we can really see that change that's happening over time. Would you say that that's correct?

SPEAKER_01 3:05

Yeah, I'd say that's beautifully put, Jess. And I really like you hitting that it's really the data that kind of sells it for clients to start any kind of therapy. It does help to see how they're doing on the baseline, even at the outset of therapy, and being able to track these data points that as accurate as possible, they can really help them to see the tool that might work or not work. That's beyond just maybe myself saying, oh, it's working, or without really basing it just memory alone. Because I'd say being not great with memory. So having the diary card itself does make sure that we're as accurate to track what we're really helping the clients target.

SPEAKER_00 3:45

And I think it keeps us accountable as well. Like you said, that it's not only just for the clients, but it's also for us as therapists. Because when we get to use a diary card, it helps us figure out like what is it exactly that we are, like what are we actually targeting in therapy, which is so important in long-term therapy because as we get to know our clients and they get to know us, these are long-term relationships. And in any long-term therapeutic relationship, it's so easy for therapy to kind of go off track and kind of get used to like talking about whatever it might be, like the whatever's going on in the client's life, like week to week, and lose sight of like why are they actually here. So that diary card really gives us the ability to go, hold on a second. As much as I'm like, I'm so interested in everything that happened to you this week and I want to hear about that, I really want us to come back to what are these behaviors that we're tracking, because you said that this is the stuff that you want to be working on in order to make improvements in your life.

SPEAKER_01 4:41

Yeah, absolutely. It keeps us both aligned, uh, the client and myself to keep coming back to the diary card. And it does make the session, I find that more robust. So if I were to start off the session, the client and I to spend at least maybe 10 minutes to go through some of the targets for the session. It sets the agenda. And then we have like, you know, maybe about good 20 minutes the rest of the session to discuss maybe like more insights about what we're targeting and then problem solving. So it does seem like a good, even a good deal for the for the client to have a productive session. And essentially the other thing I wanted to mention is the entire course of therapy, having to track using a diary card seems kind of extensive. But what I think the building of the diary card itself is really building the constant self-awareness as a general life skill. So even past therapy for clients to instill maybe the idea of self-awareness even more through the diary card, whether or not they're still using it, I think it's a helpful life tool to bring throughout life, whatever they encounter.

SPEAKER_00 5:47

I think that makes sense too. Like there's there's so many, there's so many benefits to a diary card that are beyond just being able to see the progress. It is that that insight that people are able to gain and they can absolutely take that like from therapy and use it kind of forever and ever, right after therapy. Like once they gain that insight, it's not like they ever really lose it again. What would you say would be some of the other benefits that someone might get from tracking things like their thoughts, their emotions, and their behaviors?

SPEAKER_01 6:13

Yeah, good question. Some of the benefits that I've noticed, there's about three that stand out. As we mentioned, the self-awareness piece. That's one of the biggest benefits of tracking a diary card, I'd say. Most of us, I don't know about yourself, Jess, but uh, I go through autopilot quite a bit. But understandably, we can't be hyperaware of every little thing at all times, anyways, else we'll burn out. But when we do come to make meaningful changes in therapy and using the diary card to actually pause and notice what's actually going on inside of us, it does help us slow down and pay attention. So being like opposite of autopilot. So really noticing the unconscious patterns and bringing it to more conscious awareness. So it'd say when clients start noticing what they're feeling, when they're feeling it, what triggered it, they begin to connect the dots a bit more through their thoughts, emotions, and actions. So it's kind of like connecting the dots that forms a picture. So I'd say an example could be if someone notices they feel irritable almost every morning. By tracking, they can start realizing tendencies that if they were skipping lunch or maybe stuck in traffic, those are usually the events that happen before irritation. So that really does open the door to then now that's the areas we can problem solve. And the other areas that clients could benefit from is the triggers and patterns that they can identify. So over time, I'd say maybe I'd say three or more weeks of tracking, people can start noticing patterns. So maybe certain situations or people and even times of the day that regularly they might experience stresses and anxiety and stronger emotions than other times of the day. And also on the flip side, you can also highlight what is working. Perhaps their clients come in with their own skills and strategies. And I would sometimes ask, okay, what helped? I noticed a pattern here that during the day, perhaps anxiety is quite significantly lower. So what were you doing there that was different? And so you could see kind of on both sides that that kind of insight could help us build on what kind of strategies we can use later on. And then the third point that I've noticed that could benefit clients is even just writing things down. So whether it's your behaviors, thoughts, or emotions that you want to work on can have a pretty surprising powerful effect. In fact, there's research in areas in addictions treatment and even some health psychology, talking about some health and disordered eating programs that shows that even if we're tracking self-monitoring alone, it could lead to meaningful behavior change, even without necessarily talking to your therapist. So the rationale behind that could be tracking increases self-awareness, just the act of putting it down. It does force us to slow down, notice what's happening, you know, that name it to tame it approach. And it does spark that possibility of change. That might not be enough, but it's a first step.

SPEAKER_00 9:07

Lots of different benefits then to being able to do these diary cards. So that increase of insight for sure. I loved what you said about being able to see, like when there is progress, why there was progress rather than somebody feeling like it's kind of like, you know, it's just magic that all of a sudden things are changing. I love being able to pull up the diary card and be like, okay, hold on a second. No, it's it's like it's not magic. It didn't just suddenly change. Look at these things that you did that led to whatever it might be, right? This decrease of emotional intensity that you had on this particular day, or decrease in this behavior that we've been trying to shift for some time. It's because you use these skills, and this is why this is now impacted in this positive way. So I think that's cool that you were able to highlight that. And then for sure, the the third one that you said there, that self-monitoring, there's so much research behind self-monitoring that just having that awareness can be sufficient sometimes in being able to change a behavior on its own.

SPEAKER_01 10:04

Yeah, absolutely. And with the last point, as simple as it sounds, like even for things that we know that could be beneficial to us. So I'd like to use the metaphor of like even writing things down, kind of like putting your medication or your prescription on the counter instead of having it tucked away in the cupboard. If it's out of sight, it's out of mind. And honestly, there's many times I've forgotten to take my medication when it's behind a very disorganized cupboard. So I think that that's kind of similar to how our mind works the same way. If we don't know what's going on inside our mind and put it out there in front of us, in writing, in tracking in some form, then we're less likely to notice it, I'd say, and let alone like do anything about it. So definitely, diary card, as silly as it sounds, it's like kind of like our brain's prescription on on the counter and where like where you can't miss it, you can't just say, Oh, we didn't know about it. Um, but the fact that we wrote it down, it's like it forces us to later on do something about it.

SPEAKER_00 11:02

I actually think that's a brilliant metaphor because that isn't that so true, right? And I think that goes for anything. Like if it's out of sight, out of mind, we just don't think about something. Whereas if we are doing something to actively think about it, then all of a sudden it's at the forefront of our brain, right? And we're able to do something with it. So no, I love that. What sort of things might be tracked on a diary card? Like when you when you think about the clients that you see in any given week, what are some of the more common things that we might track? And I'm I'm gonna actually preface this because trigger warning, we are gonna probably here talk about some behaviors. So if anyone gets triggered by hearing about certain behaviors, you may want to just skip ahead for about um, I don't know, three to five minutes. But yeah, Sharon, generally, what are we tracking on a diary card?

SPEAKER_01 11:42

Yeah, excellent question. So it does sometimes, when I share what's on our diary card, it can seem daunting. But essentially, what it tracks is each diary card does look different from person to person, and especially if it's tailored to match the client's specific needs. So at our clinic at Inner Solutions, we've adapted the diary card to reflect certain patterns and concerns we're commonly see in the population we work at. So a few core things we have in our diary card is the target behaviors. So, like Jess did preface, some of the problem behaviors include self-harm urges, suicidal thoughts, plans, or behaviors just generally clients are coming to therapy to want to reduce or manage. So they're tracked daily to watch for any changes in frequency. And then we also track an intensity using either like a 10-point scale or a five-point scale. The other things that we do track are emotions and things like sadness, anger, shame, or if there's things that aren't shown on the diary card, we do have some empty spots for clients to add that's relevant to the emotions they want to work on, um, as well as the skills used for DBT. So, what's a cool thing we have on the back of the card is that we have all, I think it was 83 or more DBT skills, you know, ranging from mindfulness, distress tolerance, emotional regulation, interpersonal effectiveness. So they're all listed in the back for clients' turnover, check off to remind them that they have these on their back pocket when they need it most. What's else is tracked is other personalized items, like I've mentioned. It could be beyond other emotions that aren't listed. They could also track sleep, substance use, eating habits, or any kind of physical symptoms that they want to track. We have some clients that experience chronic pain. So having that to track as well can be personalized in. Yeah, so there's actually quite a bit of things we could track using a diary card. It can be adjusted as needed based on the client's needs and particular areas that they want to work on.

SPEAKER_00 13:42

And that's the cool thing about them, right? Is that as much as DBT, in many ways, DBT is it's a standardized treatment. We are told how to do DBT. And it does matter kind of the order that we do things and how we do things to make sure that we're being adherent to what DBT truly is based on the research that has shown DBT to be effective at treating what it does. And we also get to have some flexibility here to really truly tailor it to what each individual person would benefit from. So we get to put on the diary card like whatever we want to make sure that the person is able to target the behaviors or emotions or urges or whatever that is actually going to make a difference for them. Curious, Sharon, when it comes to like we talked a lot about how clients would use the diary card and what therapists might look for. How might a therapist use that information? Let's say that a client comes into session, they give you a diary card, they've got a bunch of, oh, one thing we didn't mention, I guess, is what the emotions would we do them on a rating scale. So zero to 10 with how intense did the emotion get throughout the day. Let's say that a client walks in and you can see that there's a series of emotions that were quite high for that client on any particular day, and they perhaps had a few different behaviors that showed up. Let's say that maybe they're targeting, I don't know, maybe we'll say their cannabis consumption and you notice that maybe their goal had been to abstain from cannabis and it showed up on a diary card. What would you do with that information?

SPEAKER_01 15:18

Excellent question. So with the diary card itself, I'd use it ongoing as a clinical compass to kind of keep going back over and over. So if it is that the cannabis usage is one of our targets, that would be a section that we could include to target from day one. So we could measure the baseline usage with the client from the very first diary card and moving forward. In fact, um, I do like the, and like you mentioned, the flexibility with the diary card. So sometimes we could, we do have a substance use section, but there are our understanding of substance use is based on urges and action. So sometimes I could break down the measure as how high the urge is and whether or not they acted out on it. So the client themselves could maybe be starting at maybe an eight out of 10 urge. And that's where we can discuss how that looks like. Maybe the client is feeling like maybe that high of an urge is when they are at social events and then having the act itself, whether or not they acted on it, might actually change depending on who was at the social event. So having that playfulness of these measures does help us know how to track it in a very concise manner to then know how to maybe play with some of the strategies thereafter. So once we've identified the baseline measure for the cannabis usage, we can use what's called a chain analysis that clinicians do use, especially in the beginning or when they notice that, let's say the targets, you know, there's a spike in usage of substances that we really want to figure out what happened leading up to that particular problem behavior, which is using the cannabis usage. So that helps us then inform us how to move forward on the particular strategies used, which is the next step to the chain analysis, which is the solution analysis. So that's where we can actually have the clients look at the back of the card and we can figure out which skills that we can use earlier on in that chain for when these problem behaviors happen for the next time. I say this for the next time because we understand that problem behaviors do come up as a pattern. So being able to use the chain and then follow up with a solution analysis on top of creating a plan and then with the diary card to then have the client be adherent to being reminded to follow those skills. That's kind of the beauty of how this all kind of wraps around in helping ensure that skills could be used when they need it the most. This time with the cannabis usage.

SPEAKER_00 17:55

Yeah. So with the like, and and yeah, we can like we use cannabis usage as just the example for this particular episode, but we could have used any other behavior as an example. Um, and one thing too, I thought that I'll caveat for everybody is that we're not necessarily like we don't have a bias around cannabis. So I'm just gonna say that allowed. I thought about that as I'm using this example of cannabis. If somebody was to come into our clinic and they want to work on reducing or abstaining, we would do that. But if they also came in and they said to us, yeah, I use it and I don't see it as a problem, we certainly wouldn't ever make anybody use it. So we we could have used any other example of a behavior just when talking about how we might track this on a diary card. So just so everybody knows. One thing that you brought up, Sharon, is is the the DBT skills. And I I really like that you brought that up because as we know, one of the core components of DBT is using the DBT skills. We talked about how on the diary card, on the back of it, they list all the different skills that are involved in DBT. How would you say that the diary card helps with learning and applying those skills?

SPEAKER_01 18:59

Yes, excellent question. And this is my favorite part. Yeah, so like you mentioned the DBT card at the back, where the skills are all laid out, it gives us a good overview refresher in case we forget what we're working on. And I'd say a lot of times, even myself, I do need to reference the back because there's some things that there's about 80, like I mentioned, there's about 83 different skills. So I can imagine when a client is maybe experiencing quite high emotional mind that they might forget. So having that in itself does give them a quick jolt of, like, oh yeah, I got this in my back pocket I can pull up maybe within mere seconds. As well, I'd say that is it an accountability tool for the clients to remember which skills that we've are working on for that particular week. So, say I'll just use a cannabis example. So there's an area in the diary card in the top right corner where there is targets to increase or decrease, and we can personalize those. So, say, let's say this week, my client and I had just had identified that we want to increase more mindfulness of perhaps thoughts for the week, just to kind of observe how that impacts their Canvas usage. So that could be the target of the skills to use that week. And there's that in the main chart, but also the client could have the flexibility of turning over the next page. And if they do feel that they need more, more skills that they've learned before, they can always mark off what they need beyond what we're targeting. And so just basically the diary card keeps therapy focused and then grounded and flexible as needed. And I'd say it's not about getting it right all the time. In fact, often I might work out with a client that the particular skill that we're working on that week might not be appropriate. Or maybe we find out that that particular skill isn't as strong enough for a different situation that they're in. So maybe being mindful in an environment that's really loud, like at a crowded gathering versus if it's like a gathering with two people, then we kind of know, like, okay, this skill might not be as useful for that situation. And then how can we adjust the plan to add in a different skill or how do we kind of tailor the plan? So essentially I do think of the cool part is overall using the skills using through the diary card as a tracker. It's like helping us also track how we're rebuilding our habits and rewiring our brain to kind of ditching the old and helpful habits with whatever that we're trying to lower and then kind of laying the tracks for more effective, helpful skill usage. So I think that's a that's a cool and more kind of a motivational point I explain to clients that they can be like, okay, yeah, there's some science behind this that can back up what they're doing. All the work is is efforts to helping them create more longstanding change.

SPEAKER_00 21:54

Yeah. And I think the really neat thing about DBT is that there is so much. research that supports that longstanding change really does happen. So diary cards are, yes, they're a lot of work. They're they're a lot of work for the clients. And they can sometimes, I don't know, sometimes they can feel cumbersome perhaps to be using them in each session because it does mean that we're focused more on again that target behavior in session rather than having kind of like a talk therapy approach where we're just sort of just chit-chatting and talking about whatever might be coming up week to week. We get moments to be able to do that still in DBT. So it's not that there isn't any of that. But really the diary card will always bring us back to what's the target. And if we can stay on the target, then our clients do make this beautiful progress and they go on to live these really just well functioning, lovely lives where they're they're feeling so much better than when they initially walked through our doors. And I think that's probably a good place for us to stop today, Sharon. Thank you so much for coming onto this podcast and talking to us about diary cards. I really appreciated this conversation.

SPEAKER_01 23:00

Yeah you're very welcome Jessica it was a pleasure and I hope this was helpful.

SPEAKER_00 23:04

Thanks everybody for listening and we will see you next episode. Thanks so much for listening. If you found today's episode helpful please go ahead and leave us a review and you can also follow the show so that you don't miss out on any future episodes. For more information about us you can check out our website www.innersolutions.ca