Socratic Questioning - Guided Discovery

Two cornerstones of cognitive therapy have been identified by Padesky and Greenberger (1995). The first is the therapeutic relationship and the second is the use of ‘guided discovery’ – this phrase is often used interchangeably with ‘Socratic questioning’ although technically the latter is one particular technique employed to achieve guided discovery. This assignment critically evaluates the idea that Socratic questioning is a cornerstone of cognitive therapy.

The technique of Socratic questioning has been described by Padesky (1993) as involving four components. The first is using questions to uncover questions about a client’s awareness. The second is accurate listening, the third is summarising and the fourth is synthesising new information. When therapy begins, therapists are looking to the client for the raw materials of therapy, for example the eliciting of negative automatic thoughts (Neenan & Dryden, 2000). Socratic questioning allows therapists to adopt an attitude of collaborative empiricism (Beck, Rush, Shaw & Emery, 1979). Therapists aim to model this empirical approach towards thoughts, feelings and behaviours for the client, helping them to develop as self-therapists (Clark, 2006). Ultimately therapists aim to change constricted thinking and help motivate the client to change (Beck & Emery, 1985).

Socratic questioning, however, is more than just asking questions, listening and reflecting, underlying these basic principles are a number of very particular characteristics identified by Sage, Sowden, Chorlton and Edeleanu (2008). Central to Socratic questioning is taking a naïve approach, starting with basic questions and using an informal manner to illicit the client’s thoughts, beliefs and feelings. A component of this naïve approach is making no assumptions about the client’s experience. Further, Sage et al. (2008) point out that Socratic questioning should ideally be at once advice free as well as non-judgemental, but also curious-minded. Therapists aim to suggest and explore certain alternative worldviews but without directly telling the client what to do. One of the primary aims is for the client to distinguish between general opinion, their own personal beliefs and actual facts. The therapist, though, should specifically avoid taking a particular stance towards what these facts, opinions and beliefs should be. Finally, Sage et al. (2008) argue that the therapist must always have in mind a constructive outcome from Socratic questioning.

This last point, however, has proved controversial amongst practitioners of cognitive therapy. Some, like Padesky (1993) have argued that ‘changing patient beliefs’ may not be the best goal. Instead cognitive therapists may not be consciously aware of where the Socratic questioning is heading. Others, such as Wells (1997) argue more strongly that having some understanding of the destination of the questioning – while taking into account the client’s evidence – is important in accomplishing change (this point is echoed by Neenan (in press) in the context of coaching using cognitive techniques). Padesky’s (1993) argument has the advantage that it is more likely to result in alternative interpretations which are of the client’s own making. This increases the likelihood the client will accept these interpretations (Clark, 2006). Set against this is Sage et al.’s (2008) point that Socratic questioning must have a constructive outcome: this may be less likely to occur if the ultimate goal of the questioning is unclear.

Like any technique Socratic questioning can be applied poorly, for example by not allowing clients the time to formulate answers to the questions or by guiding the client to preconceived answers (Neenan & Dryden, 2004). Nevertheless Socratic questioning has proved an important component of therapies that empirical studies have shown to be effective (e.g. DeRubeis et al., 2005). In addition, although originally developed within cognitive therapy for depression, the use of Socratic questioning in guided discovery has been recommended in cognitive therapeutic approaches for a wide variety of disorders as diverse as substance misuse in psychosis (Graham et al., 2003), male sex offenders (Briggs & Kennington, 2006), posttraumatic stress disorder (Clark & Ehlers, 2004) and schizophrenia (Rector, 2004).

Although Socratic questioning is a cornerstone of cognitive therapies for many conditions, there are occasions when therapists have found its use needs to be either adjusted or redirected. Clark (2006) gives the example of clients who are wracked by obsessional doubt. These kinds of clients will often become very anxious in trying to identify the best possible answer to the questions. In these sorts of situations a less Socratic questioning style involving more summarising and suggestions can be beneficial. Similarly in couples therapy Baucom, Epstein and La Taillade (2002) point out that Socratic questioning can prove a self-defeating technique. When in the presence of their partner, couples are likely to be more defensive as information about their own thinking style may be used as ammunition against them. Consequently Socratic approaches may face considerable resistance and fail to move therapy forward successfully.

In conclusion, it is safer to say that ‘guided discovery’ is at the heart of cognitive therapy rather than Socratic questioning. While Socratic questioning is frequently adopted as the main method for guided discovery, there are occasions in which its use can prove counter-productive, such as with obsessional clients or in couples therapy. Despite this Socratic questioning has been employed in effective cognitive therapies for a wide range of conditions and clinicians continue to report its centrality in acquiring the raw materials of therapy, i.e. the client’s perspective. Like any technique it needs to be applied correctly and there are limits to its use but in general it is hard to refute the assertion that it is a cornerstone of cognitive therapy.

References

Baucom, D. H. Epstein, N., & La Taillade, J. J., (2002). Cognitive-behavioral couple therapy. In: A. S. Gurman (Ed.). Clinical handbook of couple therapy (pp. 26-58). New York: Guilford Press.

Beck, A. T., & Emery, G. (1985). Anxiety disorders and phobias: A cognitive perspective. New York: Basic Books.

Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy for depression. New York: Guildford Press.

Briggs, D., & Kennington, R. (2006). Managing men who sexually abuse. London: Jessica Kingsley.

Clark, D. A. (2006). Cognitive-behavioral therapy for OCD. New York: Guilford Publications.

Clark, D. M., & Ehlers, A. (2004). Posttraumatic stress disorder: from cognitive theory to therapy. In: R. L. Leahy (Ed.). Contemporary cognitive therapy: Theory, research, and practice (pp. 141-160). New York: Guilford Publications.

DeRubeis, R. J., Hollon, S. D., Amsterdam, J. D., Shelton, R. C., Young, P. R., Salomon, R. M., et al. (2005). Cognitive therapy vs medications in the treatment of moderate to severe depression. Archives of General Psychiatry, 62(4), 409-16.

Graham, H. L., Copello, A., Birchwood, M. J., Orford, J., McGovern, D., Maslin, J. & Georgiou, G. (2003). Cognitive-behavioural integrated treatment approach for psychosis and problem substance abuse. In: Graham, H. L., Copello, A., Birchwood, M., & Mueser, K. T. (Eds.). Substance misuse in psychosis: Approaches to treatment and service delivery (pp. 181-206). New York: J. Wiley.

Neenan, M. (in press). Using Socratic questioning in coaching. Journal of Rational-Emotive & Cognitive-Behavior Therapy.

Neenan, M., & Dryden, W. (2000). Essential cognitive therapy. London: Wiley.

Neenan, M., & Dryden, W. (2004). Cognitive therapy: 100 key points and techniques. Hove: Brunner-Routledge.

Padesky, C.A. (1993). Socratic questioning: Changing minds or guiding discovery? Keynote address presented at the meeting of the European Congress of Behavioural and Cognitive Therapies, London.

Padesky, C. A., & Greenberger, D. (1995). Clinician’s guide to mind over mood. New York: Guildford Press.

Rector, N. A. (2004). Cognitive theory and therapy of schizophrenia. In: R. L. Leahy (Ed.). Contemporary cognitive therapy: Theory, research, and practice (pp. 244-268). New York: Guilford Publications.

Sage, N., Sowden, M., Chorlton, E., & Edeleanu, A. (2008). CBT for chronic illness and palliative care: A workbook and toolkit. London: Wiley-Blackwell.

Wells, A. (1997). Cognitive therapy of anxiety disorders: A practical guide. London: Wiley-Blackwell.