Socratic Questioning for Therapists and Counselors

Learn How to Think and Intervene Like a Cognitive Behavior Therapist

Scott H. Waltman, R. Trent Codd, III, Lynn M. McFarr, Bret A. Moore

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781000169461
• Edition: 1
• Topic: Psychology
• Subtopic: Cognitive Behavioral Therapy (CBT)
• Index: Psychology

This book presents a framework for the use of Socratic strategies in psychotherapy and counseling.

The framework has been fine-tuned in multiple large-scale cognitive behavior therapy (CBT) training initiatives and is presented and demonstrated with applied case examples. The text is rich with case examples, tips, tricks, strategies, and methods for dealing with the most entrenched of beliefs. The authors draw from diverse therapies and theoretical orientation to present a framework that is flexible and broadly applicable. The book also contains extensive guidance on troubleshooting the Socratic process. Readers will learn how to apply this framework to specialty populations such as patients with borderline personality disorder who are receiving dialectical behavior therapy. Additional chapters contain explicit guidance on how to layer intervention to bring about change in core belief and schema.

This book is a must read for therapists in training, early career professionals, supervisors, trainers, and any clinician looking to refine and enhance their ability to use Socratic strategies to bring about lasting change.

Chapter 1

Introduction

Why Use Socratic Questioning?

Scott H. Waltman

Contents

How Does a Therapist Become Good at Socratic Questioning?

Promoting Change

Brief Example

Longer Example

What to Expect in the Rest of the Book

The notion that corrective learning is essential to psychological healing and growth stems back to the origins of psychotherapy (Alexander & French, 1946; Yalom, 1995), this phenomenon is commonly called the corrective emotional experience (Alexander & French, 1946; Yalom, 1995). From an integrative perspective, the nonbiological elements of a psychiatric disorder are often rooted in a pathogenic underlying belief (see Silberschatz, 2013; Weiss, 1993), and bringing about a change to that belief can alleviate suffering, leading to healthy changes in affect, thinking, and behavior. There are different routes to changing underlying beliefs, such as: interpersonal learning in a group setting (Yalom, 1995), the therapist providing a corrective experience that is counter to early learning (Alexander & French, 1946; Silberschatz, 2013; Weiss, 1993), use of questioning and Socratic Dialogue to help a client see things from a different perspective (Padesky, 1993), or using Socratic questioning to channel inborn knowledge, perhaps from a collective unconscious or spiritual realm (Peoples & Drozdek, 2017). This book focuses on using Socratic questioning to directly bring about change and using Socratic strategies to enhance experiential/interpersonal methods of change.

Of course, Socrates was not a therapist and a pure application of the Socratic method with a perfect fidelity would not be therapeutic (Kazantzis, Fairburn, Padesky, Reinecke, & Teesson, 2014). This book presents a more empathic and collaborative approach to using Socratic strategies in a clinical context; Socratic strategies are integrated with good clinical practices in a manner that is consistent with the evidence-base of what constitutes effective therapy. Collaborative empiricism appropriately describes this process of using collaborative strategies to join with the client in applying scientific curiosity to their thought processes (Tee & Kazantzis, 2011). Beckian Socratic Dialogue or Beckian Dialogue are also accurate descriptions of the process (see Kazantzis et al., 2018).

A wealth of proven cognitive change strategies can be found in the cognitive therapies. The basic principle underlying cognitive therapy and the broader cognitive and behavioral therapies is that the way people think and make meaning of their lives and situations affects what they do and in turn how they feel (Beck, 1979; Waltman & Sokol, 2017). Therefore, bringing about change in a person’s life is accomplished through bringing about changes in the way that they think. This process is called cognitive restructuring and it is typically more complicated than simply providing a reframe or alternate explanation. Socratic methods lead to a deeper, more lasting cognitive change and have been found to be predictive of symptom change (Braun, Strunk, Sasso, & Cooper, 2015)—this relationship remains significant even after controlling for the therapeutic alliance.

How Does a Therapist Become Good at Socratic Questioning?

If you are browsing or perusing this book, you likely have an interest in using Socratic strategies in clinical settings. You may be seeking to improve your own practice, or you may be seeking to find tools to help your students learn this valuable (yet complicated) skillset. This book is an excellent resource for either situation. Collectively, we have trained several thousand therapists in how to effectively utilize Socratic questioning in therapy to bring about lasting cognitive change that translates to emotional and behavioral changes. We have improved and refined our methods along the way, and this book represents a collection of the strategies we have found to be most effective in our own work and in the clinical practice of the clinicians we have trained.

So, how does a therapist become proficient at Socratic questioning? People learn well through experiential methods—learning through doing (Wenzel, 2019). In Chapter 3, “Getting Started,” we will review Kolb’s (1984) four phases of experiential learning: concrete experience, reflective observation, abstract conceptualization, and active experimentation. Like anything else, you must be able to persist at initially not being as good as you want to be, take risks, reflect, and get better.

It can be helpful to remember that Aaron Beck did not start out as Aaron Beck and Socrates did not start out as Socrates. You could be the next Aaron Beck or Socrates, or really your name could stand on its own, as you are the first you. As we learn from our predecessors, we learn about the value of curiosity and having an empirical mindset. Curiosity will take you quite far in this practice (Kazantzis et al., 2014), and cultivating a collaborative curiosity will help you and your client get further.

A common question from the therapists who are learning how to use Socratic strategies is what questions will be most effective for changing their clients’ minds. We will get there, but the first questions on which to focus are identifying what to evaluate, what the emotional meaning of the cognitive target is, and how the client sees it from their perspective. The best questions are based on having a thorough understanding of the client and the situation. If you can come to see the situation from their point of view, you can work to expand that viewpoint together.

Pragmaticism is another key attribute to cultivate. I have very fond memories of talking about this practice with Aaron Beck, when I used to worked for him. He was remarkably pragmatic in his views of Socratic methods and cognitive modification. In discussing cases, he had an uncanny ability to quickly grasp the essence of the situation and form a hypothesis of what he thought was the key cognitive content on which to focus. Depending on the complexity of the case, great creativity was often required. Consistent with research findings of how experts conduct psychotherapy (Solomonov, Kuprian, Zilcha-Mano, Gorman, & Barber, 2016), Beck was apt to integrate strategies that may have seemed to the observer to be beyond the bounds of traditional cognitive therapy—such as interpersonal, emotion-focused, mindfulness-based, and insight-focused strategies. Whenever this was pointed out, he would often smile and say, “If it works, it’s cognitive therapy.”

Similarly, this book represents an inclusive approach to Socratic strategies, with a focus on what works. Traditional cognitive strategies are enhanced with elements pulled from emotion-focused therapy, acceptance and commitment therapy, dialectical behavior therapy, functional analytic psychotherapy, schema therapy, and the existential and humanistic psychotherapy traditions. Additionally, strategies are pulled from philosophical, epistemological, formal logic, mathematical logic, business management, and legal realms to build a robust framework for using Socratic strategies to bring about lasting cognitive change.

Promoting Change

People typically have good reasons for believing what they believe—they have come by it honestly. Our tasks as therapists are to align with our clients, foster a relationship of trust, slow down and clarify cognitive and behavioral processes, and then jointly work to bring about change together. This can be more easily said than done. Over the past several decades, a wealth of effective strategies has been developed to help bring about cognitive and behavioral change. This book serves to present a framework for using Socratic strategies to bring about cognitive and behavioral change.

So how does a therapist go about promoting cognitive change? The trouble is that you cannot just tell someone how to think about a situation. I am sure we have all been there, and we can all remember a time that we have been trying to help someone see things from a different perspective by sharing the perspective that we thought was more accurate—typically our own perspective. Only what happens is that we have the same conversation week after week, and although we give people what we think may be the right answer, it does not seem to stick. So, the goal of Socratic questioning is to help people learn to see situations in a different way on their own. The thought being that if they can come to these new conclusions on their own, that the new perspective will be more impactful in their lives. In cognitive therapy, there is also a focus on helping clients learn to come to these new conclusions on their own; so that they can continue this process without us. Ultimately, we want them to learn to be their own therapist (Beck, 2011).

Brief Example

Sometimes, a single well-placed question can do a world of good and other times it is a much lengthier process. Consider the example of a young therapist who sought his own therapy after experiencing emotional burnout secondary to his experience of doing trauma work with adolescents in the foster care system. This therapist had an early experience of parentification and felt immense sadness at not being able to save the youth with whom he was working. His therapist saw a parallel between his early experiences and his current difficulties and wondered what beliefs or attitudes had been developed early on that might be exacerbating his current situation. The therapist’s therapist drew out a cognition related to having a responsibility for taking care of other people and used Socratic strategies to evaluate this cognition. A few targeted questions about why as a child his job had been to take care of the family and why the adult members of the family had not stepped up were enough to help the young therapist ask the questions he had never asked. This led to more reasonable attitudes about responsibility for others, decreased emotional burnout, and improved clinical effectiveness for the therapist.

Longer Example

Of course, it is not always that easy. Sometimes an exceptionally painful or unhelpful underlying belief can be like a great brick wall that was built brick-by-brick, that is, experience-by-experience; in these cases, disassembling the belief and building up a new belief can be an incremental and ongoing process. Consider the following example of a client with posttraumatic stress disorder (PTSD). This client grew up in an emotionally unpredictable environment. His mother had issues with alcohol and emotional dysregulation, and his father had been abusive. He reported that academically he did well in school, but he struggled socially. His life became significantly more difficult as a young teenager, when he decided to come out to his very religious family regarding his being gay. His father held some leadership role in the Christian church that they attended, and the client experienced several invalidations where several members of the congregation tried to preach and minister to him to “correct” him. These early efforts at a conversion therapy obviously did not change his sexual orientation, but they did cause him much distress and led to internalized heterosexism that he spent years working through. Soon after, his father became physically and emotionally abusive towards him, and the abuse went on for years.

He went on to get a degree in marketing and started a very successful company. He met a man with whom he fell in love and they were married. Approximately a year prior to my meeting with him, his partner experienced his first manic episode. During that time, his partner became increasingly paranoid and erratic; this culminated in his partner holding him captive and killing their beloved only child in front of him with a kitchen knife. His partner was later arrested and committed to a state-run psychiatric facility after being found not guilty by reason of insanity to charges related to the traumatic event. Undoubtedly, the killing of his daughter was extremely distressing to him, and he ultimately blamed himself for the occurrence. This horrific trauma was assimilated into his previous belief that the world was dangerous. He blamed himself for not being able to anticipate that this would happen, and for not being able to stop it.

He told himself that he knew that the world was unsafe and that he had been a fool for letting his guard down. Further, he saw this as a moral failure. He told himself that if he had been a better person, then he would have been able to stop this from happening; in other words, “My dad was right, and I really am bad.”

The most distressing of his trauma-related beliefs were related to the notion that he should have been able to anticipate what happened and that he should have been able to stop it. Through the use of thought logs and Socratic questioning, we relentlessly worked on these beliefs. The notion that he should have been able to anticipate the trauma was relatively easy for him to re-evaluate. His guilt and anxiety came down slightly afterward. The belief that he should have been able to do something to save his daughter was much more insidious. Consistent with the recent emphasis in the literature on attentional focus (Beck & Haigh, 2014), we used visual aids to facilitate guided discovery. He reported that the most impactful intervention that we used was the white board to map out the house and what he thought he would do differently. As he explained his hypothetical alternative courses of action, we looked at what his partner would have done differently. So, as he second-guessed himself and presented what, after months of rumination, emotionally felt like it would have been the “right answer,” we played through the revised scenarios to demonstrate that there had not been a realistic option that would have saved his daughter. He reported that this helped him to see that there was literally nothing he could have done in the situation and that in reality he was lucky to have escaped with his life. Following a dose of cognitive therapy, his symptoms decreased, he no longer met diagnostic criteria for PTSD, and his real-world functioning improved. This work of using Socratic strategies...