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SPECIAL ISSUE ON SOCRATIC DIALOGUE
Socratic Dialogue and Guided Discovery in Cognitive
Behavioral Therapy: A Modified Delphi Panel
Nikolaos Kazantzis
1
&Judith S. Beck
2
&
David A. Clark
3
&Keith S. Dobson
4
&
Stefan G. Hofmann
5
&Robert L. Leahy
6
&
C. Wing Wong
7
#International Association of Cognitive Psychotherapy 2018
Abstract Published guides for the practice of cognitive behavioral therapy (CBT)
include a range of recommendations for the use of Socratic dialogue (or Socratic
questioning) and guided discovery. While it is accepted that a specific dialogue process
can be useful to support the way a therapist develops a cognitive case conceptualization
(or case formulation), structures a session, or uses techniques, the stylistic aspects of
Socratic dialogue remain unclear. In particular, the role of collaboration in the dialogue
process has not been clearly articulated in the literature to date. Reaching expert
consensus on the ideal conditions for the use of Socratic dialogue can guide further
empirical study, including the design of a much needed complete and accurate assess-
ment of therapist skill in its use. This article summarizes the findings, conclusions, and
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https://doi.org/10.1007/s41811-018-0012-2
The authors acknowledge the scientific committee of the 8th International Congress of Cognitive
Psychotherapy held in Hong Kong June 24–27, 2014, who supported this second expert panel discussion.
The senior author also acknowledges the scholarly discussions of Frank Dattilio, Christine Padesky, and in
particular, Mathew E. Stuckey. Dr. Stuckey also provided feedback on a previous version of this manuscript.
*Nikolaos Kazantzis
Nikolaos.Kazantzis@monash.edu
1
Cognitive Behavior Therapy Research Unit, School of Psychological Sciences and Monash
Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne 3800, Australia
2
Beck Institute for Cognitive Behavior Therapy, University of Pennsylvania, Philadelphia, PA, USA
3
University of New Brunswick, Fredericton, Canada
4
University of Calgary, Calgary, Canada
5
Boston University, Boston, MA, USA
6
American Institute for Cognitive Therapy, New York, NY, USA
7
The Chinese University of Hong Kong, Hong Kong, Hong Kong
recommendations of a second expert panel on these specific features of Socratic
dialogue in order to guide further empirical study.
Keywords Cognitive behavioral therapy.Socratic dialogue .Socratic questioning .
Delphi panel
The use of a BDelphi method^in science represents a means of gathering expert opinion
and has been incorporated across a diverse range of fields of research using various
methodologies (e.g., Heyes et al. 2018; Petersen et al. 2018). This article presents the
second round of consultation with experts. The nature of the present panel enabled an
interactional exchange and allowed experts to expand upon earlier answers in the
context of what had been previously contributed on the topic. Specifically, panel I
had been focused on (a) the definition of Socratic dialogue in cognitive behavioral
therapy (CBT) and (b) whether the purpose of using guided discovery is primarily to
impart information, correct, or support the evaluation of client cognitions (i.e.,
Kazantzis et al. 2014).Here,inpanelII,expertswereagainquestionedonthe
following: (a) the definition of Socratic dialogue, but this was extended to (b) specific
guidance for its use in CBT, including specific case examples, and (c) advice for
supervision.
Socratic dialogue (SD), sometimes referred to as Socratic questioning, is a feature of
the therapeutic interaction in CBT (J. Beck 2011; Castonguay and Beutler 2006;
Kazantzis et al. 2017;Overholser2010; Padesky 1993). As with many other aspects
of the in-session processes of therapy, this brief statement hides the significant com-
plexity that exists at a technical and theoretical level (Dobson and Dobson 2016;Clark
and Beck. 2011;Hofmann2011). First, SD can be applied to any aspect of the session
(e.g., agenda, homework review, design, planning, summary, and feedback) or tech-
niques (e.g., considering pros and cons for a particular behavioral response or gathering
evidence that does not support clients’automatic thought).
Second, SD can be employed as a stand-alone technique designed to facilitate
cognitive reappraisal, information processing, emotion regulation, or indeed any of
the treatment processes in CBT (Hayes and Hofmann 2018). Further still, the informa-
tion gained in the use of SD can be used by the therapist to support case formulation
(e.g., identification and ongoing testing of hypotheses within techniques), as well as to
directly inform the clinician’s tailoring of generic and CBT-specific in-session process-
es—such as exploring the meaning to clients when therapists ask them to actively
participate (Kazantzis 2018; Wong 2013). Indeed, SD is the only relational element that
carries these wide-ranging applications and functions. Given that only preliminary
empirical support currently exists for SD (Braun et al. 2015; Froján-Parga et al.
2011), and current research has been focused on the content of the questions being
asked by the therapist (see review in Stuckey and Kazantzis 2018), there is a need for
further empirical work to support the theorized benefits of SD. Reaching expert
consensus on the ideal conditions for the use of SD can guide further empirical study,
including the design of a much needed complete and accurate assessment of therapist
skill in its use.
In panel II, experts were asked to respond to the same question as panel I regarding
(1) the definition of SD, but this was extended to include questions on (2) its use in
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sessions, and with specific case examples, as well as (3) the supervision of SD. Below
is a transcription of the dialogue, followed by an account of distilled themes and links
to the comments from panel I.
Question 1—Definition of SD
If You Were Talking to a Colleague Who Was Learning About CBT, How Would
You Define Socratic Dialogue?
JUDITH BECK
One of the things that I would tell the colleague or the student is that people tend
to learn much better when they draw conclusions for themselves. When they are
told things, they may be able to understand and accept that information at a
certain level. But if the therapist helps them evaluate their thinking rather than just
presenting a different side of reality, they get a deeper level of understanding. I
would say that the kind of Socratic questioning that therapists do varies quite a lot
from problem to problem, and from client to client. In general, we help clients
look for the evidence that their thought might be accurate, or that the thought
might be inaccurate. We help them look for alternative explanations; we ask them
if it logically follows the conclusion that they have derived. We help de-
catastrophize their thinking; we help them understand the effect of their thinking
and the effect of changing their thinking. We especially look for the meaning of
their thoughts and help them question the meaning as well. We might use
questioning to help them adopt another point of view such as asking the client
if someone else they cared about was in the situation and had this kind of thought,
what would he/she advise, how would they want the other person to think about
it.
KEITH DOBSON
The way I would help to define it would be as a process of guided discovery, and
a process that draws on the strength and knowledge of the client, with the idea
being that he or she knows their own life the best. We can certainly impose the
CBT structure to help clients to deal with negative thoughts, once they have been
identified, as well as problematic behavior, but we first need to understand what
the client’s worldview is.
ROBERT LEAHY
I would actually argue that Socratic dialogue as used in cognitive therapy is
not Socratic. If you look at Plato and Socrates’theory of knowledge it is that
the truth resides within the individual. So Socrates said in Plato’s model the
truth is known already and that the dialogue, the series of questions, is to
educate or to lead out of the mind and to articulate the truth that is already
known. That’s Plato’s theory of knowledge. That’s certainly part of what the
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Beckian Socratic dialogue is to help the individual identify contradictions that
are logically inconsistent. However, Plato’s theory of knowledge is complete-
ly anti-empiricism. You would never say let’s go out and collect the evidence
and let’s look at what other people think and do. So he would never have a
verifiability model. I would look at the Beckian model in combination with
Socratic questioning to educate or to lead out or to identify certain inconsis-
tencies along with a verifiability model that’s more part of logical positivism,
that the truth of something needs to be verified. So, it’s kind of a combination
of two things, and I think because of that it is more powerful than Plato’s
model. I think it actually transcends the Socratic model.
STEFAN HOFMANN
Philosophically we are rooted in logical positivism, following Popper’sfalsifica-
tion model. In other words, we encourage our clients to formulate testable
predictions and encourage them to falsify these predictions, rather than trying
to proof them to be right. I also think that the term BSocratic dialogue^is a bit
misleading. In a way we are trying to engage in an active process rather than
lecturing. We are engaging clients in an active discovery process. Yes, the media
often uses the term Btalk therapy.^We are not just talking, we are also engaging
clients in a process that leads them to discoveries, to evaluations, observations,
falsifications of misconceptions. So in a way it is not just talk therapy, it is also
Bquestioning therapy^and Bdoing therapy.^
KEITH DOBSON
So would you say that the term BSocratic dialogue^is sort of a metaphor for the
way that we approach clients, or do you think that it’s completely a misnomer?
STEFAN HOFMANN
I think it is a misnomer, because simply asking questions is not what Socrates
would do.
DAVID CLARK
I would agree with Stefan. When I use the term Socratic dialogue with my
students, I’m not really all that interested in whether it’sSocratesorwhatever.
Just to explain, in my classes I am training doctoral students. They have had no
CBT, the only previous course they have had is a basic therapy course where they
have been taught Rogerian reflection, let’s say. So I introduce the term BSocratic
dialogue^as a way of trying to describe a technique or a style. Which I think
helps the student to navigate between lecturing the client or the client versus this
reflection back or interrogating a client with questions. My students either do one
of two things: either they are peppering the client with questions, almost like a
police interrogation, or they are lecturing like we do as academics. So I say that
those are both really bad therapy styles, and Socratic dialogue is this nice
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interchange. So that is what I am looking for, and I use the term to more represent
a style of collaboration. I think that is what is critical when I use the term
BSocratic dialogue^. What I am looking for in my students when I rate their
therapy tapes and so forth, what I am looking for is that exchange back and forth,
the question, the answer, it could be the client is asking the questions or the other
way around. It represents a collaborative style, and that’s what I am trying to
communicate to my students.
WING WONG
Also, it is important first of all to try to convince your colleagues or the trainee
or the student why this Socratic style or questioning is important. I agree with
Stefan that it is not talk therapy, but your goal is to facilitate the thinking
process of the individual. Also I agree with Judy that people will remember the
conversation better if the messages come from themselves rather than the
therapist. But of course very often we do have clients coming to us asking us
specific questions.
ROBERT LEAHY
I just wanted to add a couple of other things here. I think if you look at the
Beckian model of Socratic dialogue, it has an underlying theory of knowledge.
And the theory of knowledge is partly based on what some people would call
Bfact.^You know that it is a discoverable fact that this is glass. Kind of a realist
model. Also in there is a pragmatic view of truth, which is completely different
from Plato, but in the pragmatic view of truth there is a Bhow useful^,Bwhat is the
consequence of this belief?^which I think is implicit in Beck’sSocraticdialogue.
There is also an implicit possibility of deconstruction, where you can
take—say—the concept of Bsuccess^, and rather than evaluate whether the person
is a success or not a success—rather you would deconstruct it to demonstrate that
the concept of Bsuccess^is totally meaningless. So, implicit in the Beckian model
the way I view it are concepts of knowledge in how to change thinking, in fact to
engage in behavioral experiments that test out your belief, that goes far beyond
the Socratic model, and is far more powerful and far more effective. So, I think
we should call it the BBeckian dialogue.^
JUDITH BECK
I also wanted to point out that much of the time when we hear clients’
automatic thoughts, we don’t know necessarily whether that automatic thought
is 100% true or 0% true or some place in the middle. This is why it is also very
important once we have identified the thought to have this period of collabo-
rative empiricism where together we’re going to try and figure out really what
the reality is. Just to echo what Bob said, there are many different ways of
changing cognitions. Not just Socratic dialogue, but for example through
storytelling, metaphors, through imagery, behavioural experiments, through
self-disclosure, things like that.
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Themes and Synthesis with Panel I
It is notable that the first response to question 1 (from Judith Beck) addressed how SD
could be used to facilitate treatment and how it would ideally be incorporated into
sessions. This led to further discussions among the panel regarding in-session processes
in SD and most specifically collaboration. (All panel members stressed this point.)
Panel members also reflected that knowledge acquisition, as it is conceptualized in
CBT (Dattilio and Hanna 2012), requires empiricism, collaborating in the selection,
testing, and gathering of new information to facilitate treatment (Leahy 2017). The
final exchange (Judith Beck) also clearly illustrates the general points that techniques
may be derived from any psychotherapeutic modality (Petrik et al. 2013) and that
clearly differentiating the various uses of a technique and how it facilitates different
treatment processes is important (Kazantzis et al. 2017).
In panel I, experts similarly identified the function of SD as a technique and conveyed
that the likely success of the SD would depend, in part, on elements of the therapist’s
interpersonal style. Indeed, both panels I and II commented that the use of the word
BSocratic^to refer to this process in CBT is a misnomer, since Socrates’style and intention
would not be consistent with the other principles that guide treatment and in-session
processes in CBT (i.e., collaboration and empiricism). Thus, while both panels placed a
similar amount of emphasis on SD as a feature of the therapeutic relationship that could
directly facilitate treatment processes, they differed in the level of specificity given to
relational elements. Panel I highlighted generic elements of the relationship, such as
curiosity, sensitivity, and non-verbal behavior, whereas panel II emphasized collaboration
and made a greater emphasis on the distinctive role of empiricism in SD.
Question 2—Use of Socratic Dialogue
If We Had the Opportunity to Watch Your Session Work, When Would We Most
Often See Your Use of Socratic Dialogue or Guided Discovery or Beckian
Dialogue, and in General, What Would Be an Example of an Undesirable
Application of This Dialogue Process?
ROBERT LEAHY
I think that if a client has a central core thought that seems to create some other
issues in their life, you might use this Socratic, or the Beckian dialogue, which I
think is more accurate. For example, I have a client whose central thought is that
BIf I am not a star, then I am nothing.^So looking at what the consequences are of
that and what the meanings are and so forth. The alternative is that if the client is
stuck with the idea that nobody understands them, so they have issues about
being invalidated, I would never use the Socratic dialogue because that might
seem invalidating. I would talk about how it must be difficult for them to feel as
though people don’t validate them, give me some examples of that in the past,
what did that feel like? What memories do you have? What images do you have?
What does it make you think and feel that people don’t validate you? I think that
sometimes observers from the outside who look at cognitive therapy think it’sjust
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going to be relentless inquiry by a ruthless prosecutor targeting every negative
thought. That’s a turn off. So there are times where I would shift the validation to
almost every session, because I have learned that if you are just relentlessly
questioning—even if you are trying to be gentle and understanding—the client is
suffering, thinking Bhe doesn’t understand what I am feeling, he’sfocusingmore
on what I think, not on my feelings.^
KEITH DOBSON
In the example that you just gave, would you not say that the questions such as
BHow did that feel for you?^or BWhat was that experience like?^arenotaform
of guided discovery as well?
ROBERT LEAHY
I guess the way I look at guided discovery is that the purpose of it is to discover
the truth, which reportedly may be different from the way the client is seeing it.
The purpose of validation is to share the experience with the truth. What it’slike
to feel alone, and feel misunderstood, not cared for, and humiliated. So I think
that there are times when I shift to focusing on discovering what the client…
There is a discovery part, but I guess the view that I have of Socratic dialogue is
that the client will state something and then you look at the meaning of it, and you
would look at the implications of it, deconstruct it to some extent, and in the
pragmatic model we would collect evidence and look at the consequence of it.
Validation I think is a very different kind of thing. But I think you are right, that
there is a discovery there.
STEFAN HOFMANN
I would argue that Socratic questioning and guided discovery are generally, but not
always, purposeful and successful in treatment. If it doesn’t seem to help, or if the
client is not responding to it then I wouldn’t continue. For example, if the client
simply wants specific information, these techniques are not necessary. If it helps the
client, then we need to use it. In most cases it does. Otherwise there is no need.
DAVID CLARK
This may reflect my behavioral background, but how important is this notion of
discovery? And one of the things that makes me a little uncomfortable is this
emphasis on discovery sounds a lot like an emphasis on insight. Sometimes you
have clients who come and they have a pretty good idea of what the issues are,
what some of the cognitions and beliefs they have to change, and its time to get to
work on it. I am not sure that guided discovery is necessarily going to add a
whole lot there. In fact, going back to this training issue, you have students where
you can actually see the client getting frustrated with all these questions. I am not
sure that we have any data that suggests that client or client discovery is
contributing significantly to behavioral change.
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ROBERT LEAHY
What about the research on sudden gains by Rob DeRubeis? There are some
studies relating symptoms to change in thought.
DAVID CLARK
But I don’tknowifthat’stheBclient discovery^of something about themselves,
or if that’s part of the work that the therapist and client are doing together.
JUDITH BECK
I think there are two kinds of guided discovery. The first kind of guided discovery
is: BYou’re upset. What was the situation? How did you feel? What was going
through y our mind?^Guided discovery helps clients figure out why they’re so
distressed and/or why they acted in a dysfunctional way. Another part of guided
discovery is to help clients discover to what degree their thoughts are accurate
and/or helpful.
KEITH DOBSON
What I was trying to imply was that if you saw a case of mine, you would see a
lot of questions in the work that I do. The major exception to that general rule is
around the assessment process; so when I am asking more direct questions about
history, or the diagnostic kind of information. Or if I need to do case formulation,
psychoeducation to provide information or facts, or insights to the client about
things that might be helpful to them, then I might be more didactic. If we are
doing skills training, then there may be less guided discovery and more explicit
training. Or, if the client him or herself does not want guided discovery or doesn’t
respond well to it, I might shift to more of a directive stance which is less focused
on guided discovery. I would always try to do these processes in a respectful way,
and allow the client to tell me that things aren’t working or that they don’tlike,so
that I can shift my pattern.
JUDITH BECK
It seems that guided discovery is not sufficient with clients with generalized
anxiety disorder when their thinking is part of an obsessive process. They need to
learn to accept their obsessive thoughts non-judgmentally and to shift their
attention away from them. Guided discovery is helpful in identifying underlying
beliefs, especially about their worries and about the process of worry.
WING WONG
It is also very important for us to be clear of when we use Socratic dialogue,
whether we are trying to facilitate the guided discovery of the client, or whether
we are using the Socratic dialogue to change certain cognitions or doing some
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cognitive restructuring. With the latter we do have the technique where we try to
steer our clients through the Socratic dialogue towards what we want them to
know or to say. If we are using it as a tool of guided discovery, then the questions
will be more open ended, and the therapist may not have the answer on the outset.
ROBERT LEAHY
I think that in real practice two things are important. One is that in cognitive
therapy, is that implicit in it, is that the therapist knows the right answer. We’re
not just sort of randomly inquiring and so forth, these is an implicit idea that we
know the thought we’re going after is extreme and possibly not based on fact. I
know it’s collaborative, but there really is an element of higher power in
knowledge that’s implicit in the person who asks the questions and directs the
dialogue. Which is fine. But I think that it is not as collaborative and equal as we
may think it is. The second thing, in terms of discovery, the question as the
therapist is BWhich thought is the most important to discover?^If the client has
the thought of BOther people don’tlikeme^I think that’s universal. Everybody is
disliked by a lot of people. So looking at the evidence where Bpeople don’tlike
you^might not actually be worth discovering. But the question is Bwhat is the
underlying assumptions, or rule books, or schema, or behaviors that follow from
that thought that need to be discovered?^That’s where the therapist can own up to
his or her sense of power or insight into where the problem is for the client. The
client thinks, BOther people don’t like me, and that’s the problem.^That’s not the
problem, the problem is the underlying assumptions or schemas.
STEFAN HOFMANN
It ties into identifying cognitive biases on a higher-level belief system versus on a
more automatic level. In most of the cases we do want to change cognitive biases
because they are maladaptive. But there may be some cases in which biases can
be quite adaptive. For example, there may be positive biases that keep people
from becoming depressed.
JUDITH BECK
An example of that is that most businesses in the U.S. fail. We would never have
modern technology if people didn’t have a positive bias that their company is
going to succeed.
KEITH DOBSON
Writers often toil for years, and they don’t know if they are ever going to publish.
ROBERT LEAHY
One thing we haven’t discussed is why should the client care about being logical
and factual. There is an implicit idea that there is this need to be logical and
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factual. And some clients will say, BLook, I know it’s illogical, but that’swhatI
feel, that’s what I believe.^The model of knowledge underlying the rationalist
model is that if you see the rational thing, you’ll be happy. You will have
fulfillment and flourish and you’ll want to pursue what is logical and rational.
What I like about the Beck model is that it’s not simply a rational model; it looks
at what is the pragmatic consequence of this belief. If you believe that you have to
be a star, like this particular individual, then the consequence is that when you are
not a star you are nothing and you feel humiliated, and you feel that everything
that you do is worthless. That’s why I think that looking at the consequences of
belief—affecting feeling and affecting behavior—this is very different from a
behavioral model that doesn’t really address beliefs or content, or in the ACT
model that doesn’t address content, and that actually views language and thinking
as impediments to experience and to a fulfilled life. There is an implicit idea here
that we can empower clients by changing the content and addressing their beliefs
about the consequences. Let’s say if we take the issue of worry, Judy Beck,
you’re right, if you dispute the facts—rational disputation of the facts about the
worry—the client says Byes, but…yes, but…yes, but…But there may be a more
fundamental metacognitive assumption that I need to know for sure in order to
feel secure^. And you can then work out what are the consequences of that,
what’s the evidence of that, which may be a more fundamental belief. So there is
a pragmatic link between thinking, feeling, and behaving.
JUDITH BECK
And something I think we haven’t quite made explicit is how important the case
conceptualization is to decide whether or not to focus on a particular cognition.
When there is an upsetting situation, are we going to focus on cognitions at all? If
we are, are we going to focus on the automatic thought level, are we going to do
guided discovery to figure out the meaning to the client? Are we going to work
on clients’underlying assumptions, rules, or their basic core beliefs? The con-
ceptualization helps therapists determine how to guide the session: how are they
conceptualizing the problem and how will they best help this client.
Themes and Synthesis with Panel I
The central theme in the panel’s response to question 2 was that the use of SD should
be carefully considered in terms of the comprehensive cognitive case conceptuali-
zation. Early comments were centered both in terms of how SD could be applied,
such as to validate emotional experience (Keith Dobson) and the perspective of the
client (Robert Leahy). The panel also addressed the capacity of the client, since some
clients will experience greater challenges with perspective taking (Stefan Hofmann),
though this may change over time (Keith Dobson), and may not be the focus of
therapy (David Clark and Wing Wong). The panel also considered specific disorders
(i.e., generalized anxiety disorder), in which automatic thoughts appear as unwanted
intrusive questions (Judith Beck), and such clinical presentations may be a contra-
indication for SD.
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In panel I, the panel made a clear distinction in the SD for guided discovery. The
panel differentiated among different kinds of discoveries: those suggested or interpreted
by the therapist, those guided by the therapist, and those independently discovered by
the client based on the synthesis of new information. These points were similarly
discussed and emphasized in panel II, and both panels emphasized the importance of
tailoring SD, based on the client’s presentation in any given session.
Question 2 (Contd.)—Case Examples
Two case scenarios were presented for the expert panel to consider in terms of how
Socratic dialogue can be integrated into therapeutic relationship elements and tech-
niques. In the first case, the client had the beliefs BI am unlovable^and BOther people
will evaluate me negatively.^The client often felt sad and fearful and had a prominent
interpersonal strategy of avoiding sharing and being intimate in her relationships. In the
second case, the client had the prominent beliefs BIamhelpless^and Other people
should take care of me.^He often feels guilt, shame, and fear and relied on other people
for support and nurturance. The panel members were asked to consider a number of
things in the context of the case scenarios, including (a) that these were the first
interactions in the first session and (b) that the process of guided discovery would be
useful. Panel members were asked how they would tailor their use of Socratic dialogue
and guided discovery when working with these individuals.
STEFAN HOFMANN
Socratic questioning, when used too early in treatment, can result in resistance,
defensiveness, and avoidant behaviors. So I think it is very important to let
collaboration guide you, and determine at what point you use Socratic
questioning. It cannot be used as a way to confront clients with insights they
were not ready to have yet. It is a powerful tool for people who are ready to
accept certain insights.
JUDITH BECK
In the first session, I might not know that the client is avoidant. With all clients, it
is important to be aware of the client’s emotional reactions as he/she is sitting in
the session. At the first session, the avoidant client might say things such as BI
don’tknow^quite a bit. If I press a little further and I say BWell, if you had to take
a guess about this?^,orBTell me a little more about that,^the client might start to
seem a little anxious. Then you can conceptualise. It looks like revealing some-
thing to me at this point doesn’t seem safe enough to the client. So I use his/her
emotional cues as a guide to decide when I am going to use guided discovery and
try to go a little bit deeper versus when to back off. The most important thing, of
course, is that the client comes back to the second session. So you want to make
sure that the client feels comfortable enough, when the therapeutic alliance is
stronger. I remember one client with avoidant personality disorder. At the start of
our fifth session, she looked very anxious. She was pulling her hair with her
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fingers and her knee was shaking. I said, BYou’re looking a little anxious today.
What’s going through your mind?^She whispered, BIcan’ttellyou.^Isaid,
BThat’sfine,youdon’t have to tell me. But will you tell me what you are afraid
will happen if you do tell me?^She said, BI’m afraid you won’twanttobemy
therapist anymore.^Isaid,BOh, that’s such an interesting thought. How much do
you believe that? And how does that thought make you feel?^After she an-
swered, I asked, BWould it be okay if we take a look at that thought?^So instead
of looking at the initial thought, which turned out to be BJudy’s going to reject me
because I didn’t do all my therapy homework, we first looked at her fears of
revealing to me. When she felt safe enough she told me her original automatic
thought. But I wouldn’tdothiswithanavoidantclientinthefirstsession.Inthe
first session, I would allow the avoidant client to use her coping strategies until
she felt safe enough.
KEITH DOBSON
I was going to say something similar, but about the other case—the dependent
helpless person. If it was during the first session that the client starting to ask me
more questions and look for reassurance, or to look for specific facts or figures
that I could help solve their problems with. Or if they told me about other
relationships in which they were clearly putting themselves in the one down role,
taking the dependent kind of a role, my response would probably be to notice
that. I probably wouldn’t name this process in the first session, but I would
probably note that they are being dependent or acting in a dependent way. I would
probably back away from providing reassurance too much. But I would try and
meet them at the level that they’re coming to therapy. So I would let them use
their natural coping skills, recognize these patterns, and use them to build the
therapeutic alliance. I would look for advantages and disadvantages associated
with that coping style with the client, so that over time they could make choices to
help themselves in the future.
ROBERT LEAHY
I think with the avoidant client, what I would focus on would be the discovery of
what it is for them to feel avoidant, what it is for them to feel like they are holding
back what they feel and what they think.
DAVID CLARK
In the first session?
ROBERT LEAHY
I would do it in the first session. Because they would be saying that they had
difficulties with intimacy and closeness and fears of being rejected. But I think
one of the most important things to do early on in therapy is to establish the
motivation to change. And one of the things we can do to establish the motivation
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is to have the client talk about how painful it is to be experiencing life the way
they do and how they try coping with it. People want to come back because they
feel like it might be worth changing. So having them talk about the idea of being
around other people, feeling like they can’tsharethings,orcan’ttalk,what’sthat
like for you? Let them feel a lot of validation, do a lot of labeling of that feeling,
let them explore other emotions that they have—fear, anger, resentment,
confusion—and explore and understand those kinds of emotions. Look for other
examples of where they felt left out. I wouldn’t be trying to change their belief in
any way, which is activating even their awareness of their Bspacing out^. A lot of
avoidant clients space out because they don’t want to experience what is going on
at the present time. So getting them to understand that I am understanding and
curious about their experience. And I’m talking about Bhow does it feel to be
experiencing that? Does it feel good or bad? Is that something that you have
thought of changing? How have you tried to change it?^Not promising it will
change, but activating the experience. It’s kind of like taking your pulse and
saying Byou have a pretty high pulse. It might be upsetting to you.^
JUDITH BECK
Another problem with avoidant clients, as you said in your keynote, is that they
often have very powerful negative emotional schemas. They may have a belief,
for example, BIf I start to feel upset, I’ll be overcome, I won’tbeabletotolerateit,
I’ll fall apart, I will lose control.^That’s why I think it’s really important to titrate
the therapy to avoid excessive distress. For example, asking a question such as,
BWhat’sitliketoberejectedbypeople?^may bring up to strong degrees of
emotion. The client may become frightened of her intense emotion and you run
the risk of her not coming back to treatment. Clients with avoidant personality
disorder are often frightened that the therapist will continue to say things or ask
questions that will make them feel very upset.
DAVID CLARK
I think it’s kind of interesting because you obviously can choose these two
personality types by accident. And I have agreed with previous comments of
my colleagues that with the avoidant and dependent probably the relationship
issues are going to emerge, therapeutic issues are going to emerge right from
that first session. Having said that, I would certainly start out that first session
in the same way. In other words, regardless of whether the client is dependent
or avoidant, I would be asking questions about their experience, what brought
them to therapy, experiences that are upsetting to them, and what are the
consequences of that. Getting them talking—and this is close to Socratic
dialogue and guided discovery—whydotheythinkthathappened,wasthere
anything that they contributed, what did other people contribute, and so on. As
you are doing that, yes the relationship and therapeutic issues are going to
come out about disclosure and having defensiveness and bit of resistance. It
might it might not. As a therapist you will have to choose am I going to deal
with this now and do the validation thing and move on, maybe not be too
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threatening as Keith said. You want to hook them into the therapeutic relation-
ship. But actually, the mechanics of it, I would probably start out exactly the
sameway.Andthegoalforbothwouldbethattheywouldfeelcomfortablein
therapy, that they would feel after that first session that they have been
validated, that they want to come back, and that they want to work with me
on some of their issues and problems.
JUDITH BECK
I agree with you. In general, I think it’s good to do standard cognitive therapy
unless proven otherwise, unless you get an indication that you need to modify it.
WING WONG
If the client comes to you feeling distressed and desperate, I don’t think the client
would have the energy for doing much self-exploratory and self-discovery, so it’s
a time that the client may need more help from the therapist, from a more
understanding point of view. And what Bob said this morning, is that do you
prefer to have a good CBT therapist or a good therapist? And of course the
answer is a good therapist.
Themes and Synthesis and Synthesis with Panel I
The central theme in the discussion here concerns the therapist’s attention to the case
conceptualization. A moment-to-moment case conceptualization takes into account the
client’s beliefs about change and the activities required for that change (Robert Leahy).
It considers beliefs about emotions (Judith Beck) and the personal resources of the
client early in the therapy process (Keith Dobson and Wing Wong). It also considers the
interpersonal strategies that are triggered by SD (Judith Beck, David Clark, Stefan
Hofmann, and Robert Leahy).
Question 3—Therapy and Supervision
What Advice Would You Give Those Wishing to Enhance the Use of Socratic
Dialogue and Guided Discovery in CBT? What Tips Would You Offer
Supervisors Who Strive to Support Therapists in This Aspect of Their Work?
JUDITH BECK
I always think it is a good idea for trainees to experience what the Socratic dialogue
is like–to put themselves in the shoes of the client. It’s useful for them to do role-
playing with a supervisor, colleague, or fellow trainee. Using the same case and the
same material, they can play the Bclient^in two roleplays. In the first, the Btherapist^
is very dogmatic, telling the client what to do, and what the right way to see reality
is. In the second roleplay, the Btherapist^covers the same material but uses Socratic
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questioning. It’s important for the trainee to experience the difference. And it will
probably motivate them to try to use guided discovery better.
STEFAN HOFMANN
We encourage our clients to become critical thinkers and to put some basic
assumptions to the test and re-examine the evidence, and so should therapists
also be critical thinkers and not get stuck on their preconceptions about the client
pretty early on. It is very difficult, especially for junior therapists, to let go of
some of these early hypotheses. So my advice would be to re-examine your
assumptions and strategies very frequently, especially if there does not seem to be
improvement in clients.
KEITH DOBSON
I would just add that trainers and supervisors also need to encourage trainees to
experiment, to do behavioral experiments with their clients and to test out their
assumptions about what is possible and what is not possible. For example, if the
trainee thinks that the client couldn’t tolerate certain kinds of emotional experi-
ences, you would actually test that out in therapy.
DAVID CLARK
I would add this, the other way you could try to enhance your therapeutic skills
for Socratic dialogue is to do it outside the therapy context. I have two daughters
who are now in their twenties, but when they were teenagers I tried some Socratic
dialogue as a parent. I soon found the limits of psychotherapy.
JUDITH BECK
You know, Dave, I always had this idea that I should definitely not bring home
any of my therapeutic techniques to my kids. One day, when my daughters were
eight and six, I overheard the older one saying to the younger one BCome on,
what’s the worst that will happen if you can’t find your homework?^
DAVID CLARK
Well, what I will say is lets say there was an issue that came up, kind of an
emotional issue or whatever, and I felt myself slipping into the parent role,
Bwhat am I going to do?^BThis is a catastrophe^things would probably not go
so well. And I would come back and I would say to myself Bif this was a
therapy situation, how would I try and communicate with this person?^And it
really did work, I must say. Draw back, take a breath and say Bnow start asking
some questions, try to discover their perspective and so on^and actually doing
some Socratic dialogue with myself andwithmydaughter.Theemotionallevel
would come down, and we could work it through. So it actually did work
outside the therapy context. It probably would make you a better therapist too, I
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thinkintheend,ifyoukindofdothat.SoIwouldsaytoatrainee,Bthese are
good communication skills. These are good problem solving skills. These are
probably some of the things in parenting courses. Why don’tyoutryitwith
your spouse, your partner, with your children, with your colleagues, with
yourself?^That would be one way to enhance those skills.
ROBERT LEAHY
I don’t think I agree with that. I think if my wife was using Socratic dialogue on me I
would find it condescending, because I don’t use it on her. I think in every day
interactions it does feel condescending like I know what the truth is and he or she
doesn’t know what the truth is. I think outside of therapy what works best is
validation and inquiry and discovery. People want to feel understood; they don’t
want to feel that their friend or their partner is trying to change their belief. You must
have extremely smart and sophisticated daughters. Which I think is a genetic thing.
DAVID CLARK
Here’s the thing. I don’t always know the answers, so that’s not true. When I use
Socratic dialogue with clients or whomever I’mtalkingto,I’maskingthem
questions I don’t necessarily know where we’re going with this. I don’thave
any truth. If I’m asking someone about their experience, or what they’re thinking,
Idon’t know what they are thinking; it’s a genuine question: Bwhat are you
thinking?^
ROBERT LEAHY
I think there are two parts. One is the discovery or the experience of the facts; no one
is really going to object to finding out what the facts are or what the experience is.
But I think that with the Socratic dialogue, even though you try to be Bgentle^or
Bdiplomatic^or Bcollaborative^there is a disputatious aspect, you know that the
thought that Byou’re an idiot^is irrational, which makes you feel like more of an
idiot. I guess my thought in terms of how I would go about teaching someone is to
have them identify five or ten automatic thoughts or negative beliefs the client has.
And then figure out what is the most central of those ten thoughts. The one that if
that client changed that thought there would be 10% progress, and other thoughts
would fall. Like for example the thought that Bpeople don’t like me. They think I am
an idiot. They think I’m talking too long^or something like that.
STEFAN HOFMANN
What a Socratic dialogue does is that it builds in a distance between your
emotions and thoughts are. And soon you develop a meta awareness where you
are able to examine alternative ideas, alternative perspectives, and you detach
yourself from the direct response to whatever beliefs you have. Thereby, it is
building distancing and flexibility.
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JUDITH BECK
Just on a practical level, when a student is learning cognitive behaviour therapy
for the first time, it’s useful to have a list of common Socratic questions about
examining the evidence, alternative explanations and so forth, that they can look
at between sessions. They can also have a copy for themselves and one for the
client to look at in session. The therapist might say, BAs we examine your
thinking today, we might ask some of these questions.^It’s difficult for beginning
therapists to remember what these common questions are.
WING WONG
I think that teaching Socratic dialogue with students, sometimes it’seasiersaid
than done. Sometimes they are so eager to get information from the client that it
makes it really difficult for them to be really Socratic. That is one of the things
that in training that is a big challenge for supervisors.
The central theme in the discussion here (all panel members) concerns the therapist’s
interpersonal style and how this likely reflects the therapist’s intention to direct, guide,
or facilitate a discovery. A distinction is also evident in separating the assessment and
intervention functions of SD (David Clark and Robert Leahy). There is also mention of
how SD can serve as an emotion regulation strategy, operating through distancing and
flexibility (Stefan Hofmann).
Overall Themes
It is clear that there is consensus in expert opinion about the range of applications in
SD’s use. Notable is the consistency between panels I and II regarding SD function as a
stand-alone assessment and intervention strategy. Experts convey that the information
gained from SD both informs and is informed by the evolving development of the case
conceptualization. The additional function of SD as an intervention to support the client
in the evaluation of their unhelpful and biased thoughts and beliefs makes SD a
uniquely flexible feature of CBT practice. No other stand-alone CBT-specific element
of the therapeutic relationship also has assessment and intervention functions.
Panel II offered a number of useful ideas about the methods of adapting SD for the
individual client. Experts agreed that SD involves the therapist collaborating with the
client to assess and evaluate their experiences. This is contrary to a directive or didactic
stylistic approach where a therapist may lecture or dispute with the client (e.g., based on
principles of logic) any distortions in the content or process of their thinking. Additionally,
the comments offered by experts conveyed that SD requires an active, rather than passive
therapist role (i.e., empathic listening might be part of a therapists use of SD, but by itself
would not warrant classification as SD). Thus, there is clear agreement that SD requires
both active client and therapist roles and has a degree of collaboration nested within it.
There are several implications from the ideas generated in panel II for future
research, not limited to the importance of considering the following: (a) the assessment
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function of SD (i.e., clarifying the nature of the client’s problem or concern), (b) the
intervention function of SD (i.e., discovery of a new perspective/ idea), and (c) the
nested role of collaboration within SD (e.g., seeking client feedback on the utility of the
discovery). Clearly, there is a high degree of expert consensus regarding the definition
of SD and its role in CBT practice, but there is a need for further empirical work to
accurately measure clinician’s skill in its use and evaluate SD outcome relations.
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