An Introduction to Cognitive Behaviour Therapy, 2 edition

7

Socratic Method

Introduction

A cognitive therapist uses many types of question (see James, Morse & Howart, 2009 for a review). For example, we use direct, information-gathering questions, which can range from a simple ‘What is your address?’ to a far more challenging ‘Have you made plans to kill yourself?’ At other times we ask social questions to put our clients at ease (‘How was the trip to Wales at the weekend?’, ‘Did your son’s exams go well?’ etc.) or we make enquiries to clarify confusion: ‘Just what was it that she said to you?’ However, the single type of question most strongly associated with CBT is the Socratic question. Although there remains some dispute as to the precise definition (Carey & Mullan, 2004), it is generally accepted that, Socratic questioning is a ‘cornerstone of cognitive therapy’ (Padesky, 1993). In this chapter we will look at why this approach is considered so invaluable and how you can develop your skill in using it.

The Socratic method derives from Socrates, a philosopher living in Athens around 400 BC. He spent his time in the marketplace, encouraging the young men of Athens to question the truth of popular opinion. His unique approach was using questions to help his students reach a conclusion without directly instructing them. In this way, he supposedly elicited from a totally untutored slave-boy the basic principles of geometry.

A Socratic question was one that the student had the ability to answer – although he might not yet realise it. Socrates encouraged students to make use of their own knowledge base, to form their own opinions, and to see new possibilities, which they could act on. Socratic questions are not aimed at proving the questioner’s point – the intention is to encourage the other person to query their view and to develop new outlooks.

In CBT, Socratic questioning affords the therapist and client the same opportunities: revealing what clients already know but what they have not yet considered, or have forgotten. Through sensitive questioning, clients are encouraged to use what they know, to discover alternative views and solutions for themselves, rather than the therapist suggesting them.

The Socratic method can encompass more than enquiry. The primary aim of the therapist is to direct clients’ attention to possibilities that had previously been outside their attention, and there are means other than questioning to achieve this. For example, we can reflect dilemmas to help clients achieve a new perspective:

Therapist:

So it sounds as if you criticise yourself if you do X, and you give your-self a hard time if you do Y.

Client:

It is rather ‘no win’. I hadn’t though of it that way – no wonder I feel bad.

Also, we can offer information:

T:

I ran a clinic yesterday. Five of my five clients had been abused as children. How does that strike you?

C:

That I am not the only one – I am not so weird.

Although there are different ways to achieve the goal of encouraging new perspectives, the most commonly used Socratic technique in CBT is the Socratic question.

So, what is a good Socratic question? You have asked a ‘good’ Socratic question if:

 

  1. your client can work out an answer to it; and
  2. if the answer reveals new perspectives.

A ‘good’ question draws the client’s attention to information relevant to the issue being discussed but which might be outside his current focus. This can be helpful in clarifying the meanings of problems, and it can also be used to help the client make use of the new information in order to re-evaluate previous conclusions and to construct new plans.

However, what is a good Socratic question for one person at one time is not necessarily good for a different person, or at a different time. Take the question: ‘What is a good Socratic question?’ Clearly, this would not be useful if I asked it of a person who did not know the answer, but what if I asked it of a colleague who could come up with the answer? Would that make it good?

It would not be good if I asked a colleague who readily answered the question, but simply thought, ‘So what?’: she already knew the answer and so learnt nothing from the exercise. However, imagine that my colleague had lost confidence in her ability to teach CBT and had told me that she knew nothing of worth and could contribute very little to our training programme. In that context, answering the question might help her realise that she had specialist knowledge and could contribute to training. In this case, the enquiry provoked an answer that illuminated the issue.

Why choose Socratic questions?

Why do cognitive therapists strive to develop a repertoire of good Socratic questions? The answer lies in their effectiveness in encouraging a personal review of a situation and, where relevant, a shift in attitude, feeling and behaviour.

In his self-help book, David Burns (1980) wrote: ‘Through a process of thoughtful questions, you discover on your own the beliefs that defeat you. You unearth the origin of your problems by repeating the following questions over and over: “If that negative thought were true, what would it mean to me? Why would it upset me?” Without introducing some therapist’s subjective bias or personal beliefs or theoretical leanings, you can objectively and systematically go right to the root of your problems’ (p. 239; emphasis in the original).

Although didactic teaching has value in CBT, Socratic questions encourage clients to review data and draw their own conclusions – conclusions that are more likely to be memorable and convincing.

Socratic questions can be helpful in many areas of therapy, as we illustrate below.

1 Assessment and formulation

In identifying the cognitions, affect, behaviours and sensations pertinent to a client’s difficulties, Socratic dialogue can elaborate something that might ‘cross a client’s mind’ but was not previously fully acknowledged. Simple questions such as: ‘How do you feel?’ or ‘What went through your mind?’ can help clients clarify and articulate feelings and thoughts. Other examples of useful assessment questions are:

 

What did you do when that happened?
What did it mean to you when you thought/did that?
When was the first time that this thought occurred to you?
Did you have any other feelings?

You can also further inform the formulation by asking questions that help you check out hypotheses generated by the preliminary formulation, such as:

 

And when that happens, how do you feel?
What goes through your mind when you feel like that?
What do you tend to do at those times?

This encourages further exploration, thus building and revising the formulation.

2 Education

An essential part of cognitive therapy is teaching the client the skills of CBT. Some of this is best achieved didactically and experientially: for example, teaching assertiveness skills and breathing techniques. However, the links between thoughts and feelings, and their impact on motivation and behaviour, are often better explored collaboratively using a Socratic approach. A standard means of examining these links is to encourage the client to engage in a hypothetical exercise and imagine the consequences of different thoughts. For example:

Therapist:

Imagine that you believed that dogs were dangerous and you saw a dog: what would go through your mind?

Client:

That dog could bite me!

T:

How would you feel?

C:

Nervous, anxious.

T:

What would you do?

C:

I’d avoid the dog – I might even run away.

T:

Now imagine that you believed dogs were cuddly and safe: what would go through your mind?

C:

I suppose I’d think – Oh, he looks sweet.

T:

How would you feel?

C:

I imagine that I’d feel rather nice. I’d feel relaxed and pleased, especially if the dog was friendly.

T:

What would you do?

C:

In that case, I’d probably approach it and stroke it.

T:

What does that suggest about the links between thoughts and feelings, or thoughts and actions?

C:

Well, I guess that this shows me that my thoughts make a difference to my feelings. My attitude towards something affects the way I feel about it. I suppose it also shows that the way I feel about a situation can make a difference to how I respond. Is that what you wanted me to say?

T:

It’s not about what I wanted you to say, but rather about the conclusion you draw. What you just said – did you mean it? Did it seem true for you?

C:

Well, yes, I can see that it’s true – but it seems a bit simple, doesn’t it?

This particular technique can be elaborated if necessary. Further questions can be added, such as: ‘… and what might happen if you avoided/approached the dog? … what might you learn about dogs? … what might you learn about yourself?’ thus encouraging the development of further scenarios that can facilitate further exploration of the linkages.

3 Questioning unhelpful cognitions

The Socratic method is an ideal tool for prompting clients to consider a range of possibilities that lie outside their current perspective and so construct alternative views of a situation or event. Several types of question can be used for this purpose:

 

  • ‘evidence for’ questions
  • ‘evidence against’ questions
  • ‘alternative view’ questions
  • ‘consequences of’ questions.

Questions that elicit evidence supporting the problem cognition are important in building up a balanced view of a situation; they also enable the client to see that ‘it’s no wonder that I have this thought’ and therefore minimise the likelihood of self-criticism, such as ‘I am stupid for thinking like this’. Questions here include:

 

In your experience, what fits with this belief, what makes it seem true?
Why might any of us have that thought at some time?

In searching for evidence that is inconsistent with the problem cognition, you direct the client’s attention to incidents or experiences that provide alternative possibilities and challenge the original belief, thus questioning the validity of unhelpful cognitions. You might ask:

 

I’m just wondering, do you have any experience of this not being the case?
Is there anything that doesn’t seem to fit with that thought?
How might someone else view the situation?
Is that so all of the time, or are there occasions when things are different?

Once clients have reviewed why they hold a belief (even though it might be unhelpful) and have looked at ways in which the belief might not stand up to scrutiny, then they can be guided towards generating alternative possibilities by questions such as:

 

Now that you have looked at the bigger picture, how would you view your original concern?
Given what you’ve just described, how likely do you think it is that the worst will happen?

In this way, you encourage the client to stand back and review the situation, reflecting on the bigger picture that has emerged. This is essential training in CBT if your client is going to become his own CBT therapist (see Chapter 8).

Enquiry about the consequences of holding a current view (and an alternative view) will elicit the pros and cons of current beliefs and can provide a rationale for change that can motivate your client in taking the risk of changing their outlook and possibly their behaviours.

 

How helpful, or unhelpful, is it to hold this particular belief?
What good, if any, comes of holding this belief?
What is the downside of seeing things this way?
If you see the world this way, how do you feel, how do others react?

4 Problem-solving and working out solutions

You can guide your clients towards good problem-solving by using the Socratic approach to encourage first precision and then creativity.

 

So, just what is it that you fear will happen?
How might your friend try to deal with such a dilemma?
Given that you have identified avoidance as an obstacle to gaining confidence, how would you advise a friend to go about dealing with this obstacle?

This can then explore as many coping options as possible. You can also use the Socratic approach to tease out the pros and cons of a solution by asking your client to consider what might go well and what might go badly, and you can prompt him to devise back-up or reserve plans.

 

What is the worst-case scenario if this solution does not work?
How would you prepare for that?
How might you guard against it happening? What could you do if it did happen?

Thus, you can guide him through the stages of defining the problem, generating as many solutions as possible, planning to put a solution into action and devising contingency plans.

5 Devising behavioural tests

Once the client has a new perspective, he needs to take it forward and check its validity. Thus, the insights that Socratic questioning can generate often need to be followed by behavioural testing (seeChapter 9). For example, when working with a person with a phobia, we generally hypothesise that it will be helpful to face the fear. You can use the Socratic method to elicit the rationale for a behavioural experiment along these lines:

 

What do you think would happen if you held your ground and did not run away?
What would go through your mind?
And if you were able to remain in the situation, what would go through your mind?
How would you feel? What would this mean to you?

This can lead on to questions that shape the behavioural experiment, such as:

 

How might we set up a situation where this could happen?
What would make it easier for you to take on the challenge?
How will you gauge your success?

In this way, experiments can be evolved collaboratively. Similarly, trouble-shooting can become a collaborative venture, for example:

 

What could go wrong?
What is the worst-case scenario?
How might you prepare yourself/deal with this if it happened?
How might a friend prepare herself/deal with it if it happened?
What would we learn from that?

It is important that, as far as possible, experiments arise from the content of the session and are closely linked with the development of insight. Thus, if a client draws a new conclusion, for example: ‘If I could stay in that situation, like I used to do, then I’ll get back my confidence’, then you can ask, ‘How might you check that out?’ Similarly, discoveries in session can be linked with behavioural change by asking the question, ‘Given what we’ve covered today, how might you take things forward?

After experiments, Socratic enquiry can be used to prompt analysis of what happened, highlight problems and doubts and then move on to reconstruct new conceptualisations and further behavioural experiments.

6 In supervision

A final note regarding the Socratic method is that it can be as useful in supervision as it is in therapy, a point that has been strongly promoted by Overholser (1991). All the arguments for using it as a therapeutic tool stand when using it as a supervisory tool: it enhances learning, fosters collaboration and tests hypotheses. (See Chapter 19 on supervision and CBT.)

When do we use Socratic enquiry?

A Socratic question is not the only ‘good’ question in CBT. Therapists have many tasks: establishing a collaborative relationship, gathering information, deriving a formulation, skills training, and so on. Different forms of question can yield different results, which can be useful at various points in therapy in achieving a range of goals. For example, information gathering might sometimes be best achieved through direct questions (e.g. ‘Are you currently working?’), while establishing a warm and empathic relationship might merit a leading question (e.g. ‘You seem distressed – is this too upsetting for you?’).

Whatever type of question we choose, Beck et al. (1979, p. 71) advise that ‘Questions must be carefully timed and phrased so as to help the patient recognise and consider his notions reflectively – to weigh his thoughts with objectivity,’ and they warn that a client: ‘may feel he is being cross-examined or that he is being attacked if questions are used to “trap” him into contradicting himself’.

This reminds us that a good Socratic question is asked in the context of a good therapeutic relationship. Your aim is to communicate warmth, empathy and a non-judgemental attitude, whilst minimising client angst and hopelessness, so as to facilitate engagement, lateral thinking, creativity and recall. A client should feel that his perspective is interesting rather than ‘wrong’, and that his exploration of new possibilities will be valued and considered, rather than negatively judged. Clients need both the knowledge and the confidence to answer a question.

How is it done?

There is a common misconception that the effective cognitive therapist operates like a slick courtroom lawyer who never asks a question unless he knows the answer and, with two or three brilliant questions, reveals the ‘truth’. It is interesting, therefore, that Beck has described the television detective Columbo as his role model. The gentle inquisitive style of the television hero – never pushy or omniscient – reflects a respectful and genuine enquiry. This attitude is crucial to ‘good’ Socratic questioning.

The style and purpose of Socratic questioning in cognitive therapy was most thoughtfully reviewed by Padesky (1993). She highlighted the important difference between using Socratic questions tochange minds and using them to guide discovery. In summary, she argued that the therapist who ‘changes minds’ illustrates that the client’s thoughts are illogical, while the therapist who ‘guides discovery’ reveals new possibilities. She argued that genuine curiosity was key to achieving the latter. Teasdale (1996), commenting on Padesky’s view, has suggested that, at a psychological level, ‘changing minds’ invalidates specific thoughts or meanings, while ‘guiding discovery’ creates alternative mental frameworks. Consider the impact on your client: ‘You are wrong’ versus ‘There are other possibilities.’

The cognitive therapist should strive to guide discovery not only by adopting a position of curiosity but also one of humility. Humility enables us to anticipate that we might learn from the client, rather than assuming that we always have (or should have) the answer. In this way, we can avoid falling into the ‘changing minds’ trap.

Metaphor and analogy can aid Socratic questioning. Each encourages your client to imagine a parallel situation so that the focus is temporarily shifted from his original view. By doing so, the strong emotion of the personal situation is tempered and your client may be able to think more productively. Clients can be encouraged to develop their own metaphors to help them discover more about their problems and solutions. For example:

Therapist:

You say that it feels as if you have a pigeonhole in your mind that collects and stores all the hurt and betrayal from the past. What would it mean if you also had a pigeonhole that collected memories of good relationships?

Client:

I would be able to recall good times and positive relationships.

T:

How might we begin to build a pigeonhole for the positive memories?

C:

I have no idea!

T:

Well let’s think about it. If you were trying to help a friend hold on to memories of good times and positive relationships, how might you do it?

C:

I would encourage them to keep a notebook – or perhaps to keep a record on their mobile phone.

T:

Is that an idea which would work for you? And if so, how?

C:

Well – if I remember something, or if one of my friends recalls something positive, I could write it down so that I don’t forget quite so easily. Then I’d have a record.

T:

Yes, you would have created a pigeonhole. How might we try to ensure that you checked that pigeonhole regularly?

C:

I’d have to look at my notes regularly – I could try to review them at night before I go to bed. I could try to get into a routine of doing that.

Examining analogies can also prompt the client to stand aside from his own situation and consider a parallel one. For example, a question like: ‘How would you advise your son, if he faced a similar dilemma?’ can shift the client into a more hopeful and practical mindset which enables him to begin to generate new ideas for coping. Similarly, questions such as: ‘How might a friend view the situation?’ or ‘How might a detective go about collecting evidence?’ can help the client step into another ‘mindset’ and view things differently and more productively.

The skill of Socratic questioning is one that might come more naturally if you do not try too hard. In many social interactions you formulate hypotheses and ask questions that facilitate but don’t lead, and that permit flexibility and genuine responses. We use Socratic methods in our daily life without even realising it. Drew Westen, in his introductory psychology text (1996), gives the example of meeting someone at a party – a situation where there might be much Socratic enquiry. Imagine a man walking into a party and being greeted by an attractive, warm and friendly woman. He hypothesises: ‘She is interested in me’. It is very unlikely that he would just approach the woman and ask her out, it is more likely that he will use a line of questioning that will enable him to collect information to support or refute his hypothesis and will give the other person an opportunity to feed back her intentions in greeting him. He might begin with a friendly:

 

Hello, I’m Billy – a colleague of the host.

Depending on the responses that he gets, he might gauge the woman’s romantic interest and ask further questions to clarify her interest and intentions. For example, he might ask:

 

The band here is excellent and local – do you ever go out and listen to them?

If she continues to be friendly and replies that she often goes to listen to them and always enjoys the occasion, he then might maintain his hypothesis and continue with gentle questioning. However, at some point her response or behaviour might challenge his hypothesis and he would revise it without having jumped to a premature conclusion that could have resulted in embarrassment. For example, he might ultimately conclude:

 

She is a member of the host’s family and is helping the party run smoothly. She is polite and sociable rather than interested in a date with me. (Adapted from Westen, 1996.)

Downward arrowing

This refers to a type of systematic questioning that aims to help clients elaborate on, or ‘unpack’, their experience or NATs and perhaps identify the more fundamental meanings underlying an unwanted reaction. In some texts it is called ‘vertical arrow restructuring’.

Bea stated that she had to return to the house repeatedly to check that the door was locked. It was not immediately apparent to her why she needed to do this, but gentle, systematic questioning by her therapist gradually revealed that she felt rather incompetent and did not trust herself to lock the door properly. She feared that she would be burgled and would carry the blame for the loss to her family. This conclusion made sense of her drive to return again and again to make sure that the door was locked.

If you use the downward arrow technique, your questions should be paced and phrased so that your client never feels interrogated, but rather that you are taking a genuine interest. You might begin a line of enquiry with questions like:

Just how did you feel at the time?
… and what was going through your mind?
Any particular thoughts or pictures?

Such questions help clients re-activate the affect of the moment and focus on relevant cognitions. In the example above, Bea reported:

‘I felt anxious, really nervous and tense and I was sure that the only way I could deal with these feelings was to go back again and check. I was thinking: I’ve got to make sure, I’ve got to make sure.’

Your initial line of enquiry might be followed by further questions that help the client gently tease out or ‘unpack’ the personal relevance of a thought or an image – questions such as:

 

I wonder what seems so bad about that?
In your view, what does that mean?
What does that say about you?
What would that mean about your life/your future?
What would others think of you?
How would you label that?
Can you describe the worst thing that could happen?
And if that were true – then what?

Through such questions, you and your client can discover more about the belief system relating to a particular problem.

When first asked what would be so bad about being burgled and what it meant to her, Bea was reluctant to think about it and there was a period of silence. Her therapist acknowledged that this was difficult for her and suggested she take her time. Eventually, Bea revealed:

‘It would be terrible because it would be all my fault … It would prove how useless I am and no one would trust me again. They wouldn’t respect me within my own family. I would feel so ashamed and unworthy.’

Like many of our clients, Bea found downward arrowing an emotionally charged challenge. For this reason we need to be prepared to pace it sensitively, accept periods of silence, look for ways of making the task easier for our client and we must be prepared to stop the exploration if a client finds it too distressing.

Once the relevant beliefs have been identified, they can be examined and tested using cognitive testing and behavioural experiment. It is worth remembering that you can also discover more positive beliefs, such as: ‘On the whole, people seem to like me’, or ‘If I put in the effort, I can get things done’. Sometimes more positive beliefs are simply revealed as part of the course of questioning but we can increase the likelihood of uncovering them if we ask questions such as: ‘What would be so good about that? How might that help you? What positive things does that suggest?’ Positive beliefs can enhance progress – for example, someone who believes himself likeable and capable is likely to engage well with you, can probably take on quite challenging social assignments and would be motivated to engage in homework tasks – so it is useful to identify them.

Through downward arrowing, the client’s fundamental belief system is often revealed (as in Bea’s case). This is sometimes referred to as ‘the bottom line’ (Fennell, 1999), although it is often more akin to a ‘bottom triangle’, comprising the elements of Beck et al.’s (1979) cognitive triad: beliefs about the self, others and the world, and the future. These elements relate to each other, and finding yourself going round the triangle is often an indication that the ‘bottom line’ has been reached:

Therapist:

… and what might that say about you?

Client:

That I am bad. [Self]

T:

… and what would that mean to you?

C:

That no one is going to want to know me. [Others]

T:

… and if that were the case, what would that mean to you?

C:

That I will always be alone and miserable. [Future]

In trying to determine whether or not the bottom line has been reached, ask yourself: ‘Would anyone feel the way my client does if they held this view and believed it as much as he does?’ If your answer is ‘Yes’, then you have probably uncovered a core belief.

It can take several sessions before the core belief system is revealed, and sometimes it is simply not accessible. In fact, it is not always necessary to reach the bottom line (or triangle) in order to carry out effective CBT, and much productive work can be carried out at the level of a NAT or with the rules and assumptions associated with core beliefs. However, there can be advantages in uncovering core beliefs. First, an understanding of core beliefs can aid a client in understanding persistent vulnerabilities: ‘It’s no wonder that I have no social confidence and am depressed if I feel bad and undesirable’. Second, identifying core beliefs paves the way for schema-focused work, if necessary, as core beliefs are a key component of many schemata (see Chapter 17).

There is always a danger that if you have a strong belief in a hypothesis you may use the downward arrow technique simply to pursue its confirmation (to ‘change minds’). It is crucial to remember that however well informed we might be, we are sometimes wrong. A great strength of Socratic dialogue, provided that it is coupled with curiosity and humility, is that it can lead us to conclusions that we did not anticipate. A useful rule of thumb when using the technique is to devise questions that might refute your hypothesis. When you think that you have confirmed your hypothesis, ask another question or two that is designed to disprove your theory. This both helps you refute an incorrect hypothesis and also guards against your being too narrow in focus.

Stages in Socratic questioning

Padesky (1996a) has defined four stages in Socratic questioning. These are the stages of:

1

Concrete questioning: structured, information-gathering questions, which begin to inform your hypotheses about the client’s difficulties. For example:

 

·   How long have you felt low in your mood?

·   How often do you binge?

2

Empathic listening: careful, non-judgemental attention both to what the client is saying and to how it is said. The client can communicate a great deal through tone of voice or facial expression, which can further impact on your hypotheses and influence subsequent questions.

3

Summarising: feeding back a synopsis in order to check hypotheses, clarify information or reiterate a point. For example:

 

 

·   You say that you have felt depressed for the past three months, but that for several years you have felt rather low.

·   You seem to be saying that you probably binge every evening, but you are sometimes unsure whether or not you have actually binged.

4

Synthesising or analysing questions: these encourage either the development and expansion of an idea or a theme (synthesising), or the refinement of key information (analysing). For example:

 

 

·   When we review the past few years, your lowest points seem to be: when you split up from Paul; after the birth of Karen; when you feel that your marriage is not going well. Is there anything that links these events? [Synthesising]

·   Although there are many circumstances in which you binge, on what evenings are you most likely to? [Analysing]

Socratic enquiry helps the client review relevant evidence as widely as possible. You are more likely to obtain this ‘bigger picture’ by maintaining curiosity and not being too constrained by a hypothesis; and by continually asking ‘and is there anything else?’ If you get bound by rigid expectations, then you might terminate your enquiry before a wide enough data base has been uncovered. Consider the following example of different ways of approaching Jon, an anxious and miserable 14-year-old referred to the school psychologist because of poor performance in some subjects.

Approach 1: The psychologist asked about Jon’s schoolwork and concluded that the issue was indeed study-related. She hypothesised that Jon was experiencing specific academic difficulties and her questions were focused on this hypothesis:

 

Tell me more about the subjects that you’re not doing so well in …
Maths and physics: have you always struggled with these topics? …
So maths and physics have always been difficult for you, and now it’s even harder to keep up. [Summary] …
If a friend of yours was struggling with a subject, what would you suggest in order to help him out?

In this way, the therapist efficiently progressed to her target of developing more efficient studying strategies.

Approach 2: This time the psychologist developed the hypothesis that Jon was experiencing specific academic difficulties and initially asked similar questions. However, she followed these focused questions with an exploratory enquiry:

 

I can probably help you with your study technique, and we’ll talk through some of the strategies later – but first, I was wondering if there is anything else on your mind when you find yourself struggling in class.

It then transpired that Jon felt judged by the maths and physics teacher, Mr Smith. The psychologist focused her enquiry, finding out more about the relationship with the teacher. It became clear that Jon struggled in class because he felt especially anxious and self-conscious with this particular teacher. The psychologist then constructed a new hypothesis, that Jon had specific interpersonal difficulties with Mr Smith. Again she asked more exploratory questions, ascertaining the nature of their relationship:

 

How do you imagine Mr Smith views you? What goes through your mind?

Jon then revealed that he believed that this particularly conventional and religious teacher was blaming him for his parents’ impending separation. Jon blamed himself for his parents’ marital problems and felt guilty, even sinful.

The formulation was now quite different from the initial hypothesis. Jon was insecure and distressed because his parents were going to separate. Increasingly, he felt responsible for this, but he also felt isolated and could not discuss it with his parents. Shame inhibited him from sharing his troubles with his friends. He soldiered on. In lessons with Mr Smith, however, he felt judged and was reminded of his guilt. This interfered with his ability to perform in the class.

Having too narrow a focus is not necessarily a therapeutic disaster, as the limitations of the intervention will become apparent and you can reformulate. However, there are advantages to building the bigger picture as early as possible, as it communicates empathy – the therapist really ‘gets it’ – and this can inspire hope. Also, the formulation will be better informed and will lead to more relevant interventions or more sensitive prioritisation of issues.

Cautious and compassionate Socratic enquiry

A skilled therapist can become increasingly adept at ‘unpacking’ cognitions and identifying key, fundamental beliefs. However, this can become anti-therapeutic if you become overly focused on getting to the bottom of a problem without empathic pacing, a practice a colleague of ours calls ‘psycho-bulldozing’. It can leave clients feeling that you are insensitive and can result in your missing opportunities to teach them about the role and management of cognitions. There is useful material to be worked with en route to the ‘bottom line’, and it can help the therapeutic dialogue if exploration is sensitively paced and punctuated by summaries.

Maria is a depressed, 30-year-old divorced woman who, despite an impressive academic background, never remained employed for more than a few weeks. She tended to start jobs with great hope and enthusiasm but never sustained them. She was well defended emotionally and tended to minimise emotional responses, often appearing rather superior and arrogant. However, the downward arrow procedure distressed her unless it was paced very carefully. Because of this fragility, her therapist did not proceed directly to the bottom line but achieved this over several sessions. In such cases, it is helpful to ask:

 

Is it alright for me to continue with these questions?
Do you need a bit of a break? Let me know if you do.

Clients like Maria may have spent a long time trying to avoid the pain that is provoked by a core belief, and a therapist must not underestimate the fear and distress that uncovering it might elicit. In summary, this is the course that Maria’s therapist followed:

Therapist:

Why did you give up the project?

Client:

I was not good enough.

T:

And that means?

C:

There was no point. I have to be the best, or else I’ve achieved nothing.

T:

Can you tell me more about the importance of being the best?

C:

If I’m not superior, I’m wasting my time.

T:

What is so bad about wasting time?

C:

Time wasting is failure.

T:

Let’s imagine that you did waste time and you felt like a failure. What would that mean to you?

C:

If one is a failure, one is pathetic.

T:

Are you able to tell me what that means to you personally?

At this point, Maria revealed a core belief. Before this, however, many assumptions, ripe for further exploration, had been revealed. The assumptions that Maria disclosed gave opportunities to address thinking biases; to look at the pros and cons of holding a particular assumption; to construct vicious circles explaining the maintenance of the assumptions; to look at evidence for and against them; to challenge beliefs; to set up behavioural experiments; and to introduce techniques such as continuum work (see Chapter 8 for descriptions of cognitive techniques). For example, the statement: ‘There was no point. I have to be the best, or else I’ve achieved nothing’, gave an opportunity to highlight dichotomous thinking and unrelenting high standards and to explore the behavioural, emotional and occupational consequences of having such thoughts.

When Maria disclosed this painful core belief, she was tearful and it was clearly a brave and difficult thing for her to say. Her worst fear was that she would be revealed as the ‘candy floss’ that she believed she was. As it was not obvious why this might be so upsetting, the therapist asked her to describe a person who was ‘candy floss’. She reported that this was her family’s term for the most despicable sort of character: soft, vulnerable and sensitive. As she elaborated, she completed the triangle when she said that ‘candy floss’ people end up despised, rejected and lonely. Interestingly, as she said this, she became less upset. The words ‘soft, vulnerable, sensitive, despised, rejected and lonely’ did not provoke the emotion that was triggered by ‘candy floss’. This is a reminder of the importance of uncovering the idiosyncratic meaning for the client: the word or phrase that carries the distress and helps him make sense of the problem.

It might seem obvious, but the tone you use when posing Socratic questions will communicate messages to the client. Consider the commonly used downward arrow phrase: ‘What is so bad about that?’ If delivered in a brusque manner, a client might infer that you are suggesting that he is making a fuss about nothing, thus compromising the therapeutic relationship. If you pose the question in a gentle, inquisitive manner, perhaps prefaced with ‘This might sound like a silly question, but …’, then it is more likely that the client will feel able to respond without fear of being criticised or judged. Gilbert (2005) has studied the role of the ‘compassionate voice’ in cognitive therapy and argues for the advantages of clients developing a compassionate inner voice. You can be a good role model for promoting this voice. By using phrasing and a tone of voice that communicate support and non-judgement, you are leading by example.

Socratic questions and self-help

Ultimately, clients must become both Socrates and his pupil. They need to stand back, review and develop new perspectives. An invaluable aid in learning to do this is the daily thought record (DTR) (seeChapter 8). This record of key events guides the user through the stages of identifying key emotions/cognitions, exploring the validity of the cognitions and then synthesising a new perspective. With rehearsal, this procedure can become second nature.

Some authors have produced annotated DTRs that prompt the user with salient Socratic questions at each stage in the log’s completion (Greenberger & Padesky, 1995; Gilbert, 2005). For example:

 

What is going through my mind and how much do I believe it?
What supports this?
What contradicts my conclusions?
How might someone else view this situation?
What would I advise someone else?
What evidence is there to support alternatives?
What thinking biases can I identify?
How does my thinking help or hinder me achieving my goals?
What effect would believing an alternative have?
What’s the worst thing that could happen?
How would I cope?
Can the problem situation be changed?
What can I do differently?
How can I check this out?

Others have produced lists of key questions for clients to use as prompts (Fennell, 1989), and clients can be encouraged to keep their own log of questions that have been particularly productive for them, such as:

 

What line of enquiry has helped me in the past?
What do I imagine a therapist asking at this point?

Problems when using Socratic questions

Here are some of the more common difficulties in Socratic questioning, with suggestions for managing them.

The client cannot access the key thoughts or images in the session

Encourage clients to record relevant cognitions at or near the time of the problem occurring. It can also be useful to discuss a recent experience, using imagery or role play if necessary, in order to evoke the emotional state related to key cognitions: stronger emotions are likely to make relevant cognitions more accessible. As suggested in Chapter 8, it is also helpful to look out for clear changes in emotions within the session, as these can reflect ‘hot cognitions’ that might be relevant, and can be explored very close to the event. Encourage exploration of affect (‘How do you feel emotionally?’) and/or sensation (‘How are you feeling in your body?’) as this can give your client a more accessible starting point for exploring cognitive experiences.

The client invalidates distressing cognitions

Some clients might invalidate key cognitions as they emerge: ‘… but I know that is silly’, ‘… although I am sure that I’ll be fine’, ‘… but that doesn’t really upset me’. This is sometimes a means of avoiding distressing cognitions (see below), but this minimisation can reflect a failure to recognise the impact of a ‘hot cognition’ after the event. If this is the case, ask your client if the thought or the image felt true at the time it crossed their mind, stressing the importance of that moment.

The client is avoidant of distressing cognitions

A good starting point is working on your therapeutic relationship. Discover what your client needs in order to feel ‘safe’ and try to identify his fears. Take things slowly and make clear the rationale for unpacking potentially upsetting cognitions. Be aware that some clients might invalidate key cognitions as they emerge in order to avoid experiencing the ‘hot thought’: ‘… but I know that is silly’, ‘…although I am sure that I’ll be fine’, ‘… but that doesn’t upset me’. Acknowledge this pattern and try to uncover the client’s fears about staying with an emotionally laden thought or image. Such fears will have to be addressed before you can move on in therapy. Also remember that behavioural experiments (see Chapter 9) can help your client test out the negative predictions underlying the avoidance.

Key cognitions are fleeting in nature

Some clients find it difficult to identify important cognitions because they seem inaccessible or ‘slippery’ and easily forgotten (see Chapter 8 for a full description of the nature of cognitions). You can help by encouraging clients to carry a DTR or thought log so that they are better able to catch key cognitions as they arise. Again, attend to mood shifts in session, as these can give insights into thoughts and images relating to the problem. And again, try evoking a recent experience so that the relevant cognitions might be accessible in the session.

Crucial meanings are held in a non-verbal form

When clients seem to be unable to express key meanings verbally, try exploring sensations: ‘Where is it in your body, does it have a shape or texture? Colour? Temperature?’ ‘Can you picture it in your mind’s eye?’ This might provoke descriptions such as: ‘It’s red and it is a hard ball in the pit of my stomach’, and ‘It’s a soft, purple sensation, that gradually spreads throughout my body’. Accept that some non-verbal meanings are going to be metaphorical rather than literal, for example: ‘… my body is full of red, boiling jelly with metal shards cutting through my skin’ [pain] or ‘I feel nausea, and a black tidal wave inside me is pulling me away’ [disgust]. It is still possible to incorporate this information into a formulation and to work towards developing alternative meanings.

The client invalidates new perspectives

Some clients seem to collaborate with guided discovery only to dismiss new conclusions with a ‘yes but’. This might indicate that you have slipped into giving advice rather than posing Socratic questions: self-monitor to see if this is true. Alternatively, the client might need to substantiate his new perspective by engaging in behavioural change. Behavioural experiments are effective in achieving ‘gut-level’ changes in beliefs. ‘Yes but’s might also indicate that a robust belief system is at work, which can be revealed through further Socratic enquiry. Sometimes such a belief system reflects a problem schema and schema-change interventions might be appropriate (see Chapter 17).

The therapist questions without direction, or in an unfruitful direction

Although the importance of curiosity has been stressed, Socratic enquiry should remain hypothesis-led and guided by a formulation. Without this underpinning, you might well collect information but be unable to structure it, struggle to remain focused on the presenting problem or find yourself in blind alleys, hopping from one topic to another without getting closure on any. In each of these situations, referring back to a working formulation will provide the necessary structure to make sense of new information and to keep you on track. Having said that, apparent blind alleys can sometimes give useful further information about a problem, provided there exists a conceptualisation that can incorporate it.

The therapist lectures

It is possible to lapse into lecturing, particularly if you have a clear idea of where you want to lead the client or what you think the client should know. The need for collaboration, curiosity and humility have already been discussed, and session recordings can help you identify when you lose these qualities. It is important to identify a lecturing style early on, before the therapeutic relationship is put at risk. On occasion, you might find yourself unable to sustain a ‘good’ Socratic style because of tensions in the therapeutic alliance. It is important to keep the therapeutic relationship in mind and to address problems swiftly.

The therapist explores but does not synthesise and draw conclusions

Although the importance of curiosity has been stressed, Socratic enquiry should remain hypothesis-led and should aim to inform the formulation. Therapy should be regularly punctuated by summaries that draw together information and link it to the case conceptualisation. You might need to devise a reminder to summarise regularly, or to ask a client to synthesise new conclusions, say every 10 minutes. It can be helpful to ensure that a copy of the working formulation is always accessible for reference – better still, actually on view during the sessions, so that it is constantly there as a structure to help both you and your client.

The therapist asks questions only to validate a hypothesis

This can lead to a very biased ‘unpacking’ of information and, ultimately, a misleading conclusion. If you are exploring the hypothesis that your client has panic attacks, you need to ask questions that would allow for the possibility of your clinical hunch being wrong. After all, if you want to test the hypothesis that all swans are white, you need to look for a black swan. However, this is counter-intuitive for most of us so it does tend to require additional effort. Often, a little curiosity is helpful: ‘Can you tell me more? Is there anything else? Do you have any other thoughts/feelings/urges?’. Such questions will open up the field of exploration and prevent your enquiry from becoming too narrow.

The therapist limits Socratic enquiry to guided discovery

Although guided discovery is an invaluable tool it needs to be supplemented by other forms of Socratic method – curious debriefing of behavioural experiments and review of DTRs, for example. In addition, Socratic questions can be used in the wider practical context of, say, setting an agenda or planning a behavioural experiment. Try not to limit your use of Socratic method but rather think how it might help you and your clients get more out of a range of CBT approaches.

 

Summary

 

  • Socratic method is a technique fundamental to CBT which we can use to:

o    help clients discover things for themselves

o    get a better understanding of their problems

o    help them devise new ways of dealing with difficulties.

  • It is a skill that is versatile and can be used in all aspects of therapy and in supervision. Even so you should not strive to use Socratic questions exclusively – sometimes other forms of questioning are more appropriate. For example, when carrying out a risk assessment or simply collecting demographic information, you could ask direct questions.
  • Sometimes information-giving is a more effective means of teaching than Socratic methods. For example, informing someone of the physical dangers of self-starvation, or memory processes following psychological trauma. Remember, Socratic enquiry is only possible if a person has the knowledge to answer the question.
  • To be most effective in a therapy setting remember to be:

o    Curious and humble. You don’t have to know all the answers and you need to be prepared to learn from your client.

o    Cautious. Downward arrowing in particular can be a powerful technique.

o    Compassionate. This is not only a good stance for a therapist, but you are modelling an attitude for your clients to adopt.

o    Confident. You are an intuitive scientist so you know how to review, hypothesise and check out your hunches.

  • Remember also that Socratic methods are used in context. Make sure that you try to get the most out of them by creating a collaborative relationship and by respecting your clients’ needs.

Learning exercises

Review and reflection:

 

  • Consider what you have learnt from reading about Socratic method: what is new to you? What has been clarified for you? Are there aspects of Socratic method which still puzzle you?
  • Consider how Socratic methods fit with your practice: do you use this approach but could refine it? Do you need to start from scratch in improving your technique? Do you know the theory but are inconsistent in using Socratic method? If so, what patterns can you identify? Consider what parts of the chapter fitted particularly well with your way of working or your approach to CBT – you will find these easy to build on. Think about what parts of the chapter seemed less familiar or clashed with your current style – it will take more effort to remember and use these sections and you will need to put more effort into taking things forward.

Taking it forward:

 

  • Once you have decided what you want, or need, to build on, consider how this will be best achieved. Be realistic in your planning and take into account your resources – how much funding is available to support your further training? How much time do you have? How much experience in Socratic methods does your supervisor have?
  • Try to find workshops and literature that will help you develop your Socratic skills.
  • Recording sessions is essential for improving use of Socratic method: you can then review recordings yourself and/or ask your supervisor or a colleague to critically appraise your Socratic ability.
  • You need to think how you will evaluate your progress – this might require regular reviewing of session recordings and maintaining some form of rating.

Further reading

Kennerley, H. (2007). Socratic method. OCTC essential guides. Available from www.octc.co.uk

This is a brief text which considers how best we use Socratic methods in CBT. It is succinct, readable and covers the use of Socratic methods in assessment, testing beliefs, and problem-solving.

Padesky, C. (1993). ‘Socratic questioning: changing minds or guiding discovery?’.

This was a landmark keynote address delivered at the European Association for Behavioural and Cognitive Therapies conference in London. In it Padesky challenged some of the conventional thinking about Socratic questioning in CBT, and her views on optimising its use remain as relevant today as they were in 1993. The keynote is available from www.padesky.com