In the Room

Begging the Question: Socratic Dialogue Part I

Ask any Cognitive Behaviour therapist do they use Socratic Dialogue as one of their techniques and they will all say “yes”. Move to a clarifying question such as what do you understand Socratic Questioning to be and the waters become murky very fast. This technique appears to be one of the most difficult ideas to learn in CBT partly because everybody suggests using it but very people can clarify exactly what the technique is.  The technique has been promoted by therapists from Adler and Winnicott through to Padesky and Beck.

For many therapists any type of open questioning gets called Socratic Dialogue. Maybe it sounds better saying I engaged in Socratic dialogue with the client compared to I questioned them about themselves for an hour.

Finding an agreed upon definition of Socratic questioning in psychotherapy or even within Cognitive Behavioural Therapy is next to impossible and it is pretty clear that Socrates has been hijacked as a brand name for all sorts of questioning techniques. Tim Carey and Richard Mullan in their paper: What is Socratic Questioning (no free access)are clearly totally gobsmacked by the lack of definition and outright contradiction surround this concept in psychotherapy. The range of conflicting definitions is quite remarkable and as Carey and Mullan remark somewhat ironically, Socrates often used his dialogue as way of reaching a clear definition.

Despite the stated importance of the Socratic Method for psychotherapy (A. T. Beck et al., 1993; J. S. Beck, 1995), clarity regarding this procedure is chimeric. Someone wishing to learn Socratic questioning could not discern from the literature what the procedure was, when it should be used, how it should be used, or what it should be used for. Indeed, a question as seemingly banal as the title of this article—“What Is Socratic Questioning?”—cannot be answered from existing descriptions. It seems that the term “Socratic method” can refer to almost anything at all. The discrepancy in the section describing the purpose of Socratic questioning is instructive. If Socratic questioning is concerned with changing minds, then a technique designed not to change clients’ minds could not legitimately be called Socratic questioning. It would seem inherently underhand and deceptive to advocate a process of self-discovery if it was the case that predetermined “discovery” was on the agenda. Currently, however, Socratic terms are used to refer to both changing minds and not changing minds.

Should one have the end point of the inquiry process in one’s mind or should it be an open ended go anywhere inquiry. Padesky in her paper: Socratic Questioning: Changing Minds or Guiding Discovery, for example would argue that using guided discovery should be utilised not to change a client’s mind but to allow the client to explore and reflect on their thoughts and behaviours. However even a brief reading of the old man himself indicates that Socrates had a pretty good idea where he was going on when he started out on his dialogue and his job was to make others come around to his way of thinking. There appears to be considerable debate about the degree to which one should have an end position in mind when one is using this technique.

The Angle of the Dangle: Facing Your Client

Every therapist has their own needs in the room. This may be the distance you need from your client to the angle your chairs face when sitting with your client. A lighter post today with a short questionnaire on your favourite seating arrangement. Look at the following  seating arrangements below and pick the one that is most comfortable for you. I am sure the more psychodynamic of the readers will be able to interpret what each of the chair angles means. Personally I am a fifteen degrees man myself.

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More Interesting Psychology and Psychotherapy Blogs

The more I am out in the blogosphere the more I am slowly becoming aware of other psychotherapy and psychology blogs out there. A few more to comment on that I have come across over the last two weeks and they are now listed on the blogroll. Psychotherapy Perspectives is a blog by an American private psychotherapist. The focus is mainly on psychotherapy treatment issues. One I particularly liked was on boundaries in psychotherapy.

 
Clinical Psychology and Psychiatry: A Closer Look is a blog by an academic and seems to focus mainly on critiquing drug trial research.. He certainly seems to know his stuff as he takes the studies a part in minute detail. PsychHealth is another Australian blog with a focus on health psychology. Good regular posts on health topics with a psychological focus.

The PsychotherapyBlog appears to focus on much wider issues than psychotherapy. In fact aside from a few good nuggets of psychological comments buried in the posts it is hard to find an article dedicated to pure psychotherapy. Nonetheless some enjoyable comment.

Psychoworld provides a newsy regular update of interesting research from mainly clinical and social psychology aspects. This has a nice layout that is easy to read but could do with the addition of an RSS feed or email update widget.  This blog is similair to the more well known Dr Deborah Serani which also provides a well informed and steady diet of interesting psychology research.

James Fennessy has a blog on modern psychoanalysis appropriately titled Modern Psychoanalysis. This is a serious blog with regular writing on aspects of psychodynamic treatment. His latest post provides some comments on initial engagement with a client.

 

Loose Lips Sink Ships: Therapist Self-Disclosure

Self disclosure in response to a question by the patient or as a technique to enhance therapy is a complex issue. Many of us utilise self disclosure as an empathic way  of normalizing patient behaviours, feelings or thoughts. Self disclosure may also be used as a way of enhancing empathy by saying “see I am like you”. This can be particularly important in groups that may feel marginalized in our culture such as by gender, orientation or culture.

So what do our clients think of our disclosures or for that matter our non-disclosures. An article in last years Counselling and Psychotherapy Research, looks at just this issue. The paper by Jean Hanson is called. Should your lips be zipped? How therapist self-disclosure and non-disclosure affects clients.

Albeit with a small sample she looked at qualitative themes in client narratives to uncover their views on their therapist instances of both disclosure and non-disclosure.

When participants reported disclosure as helpful, their reasons were similar to therapists’ rationales for disclosing. This supports both theory and empirical studies of therapists’ beliefs about the effects of disclosures. The greatest effect was on the alliance. The participants in this study valued their therapists’ disclosures because they contributed towards:

• a real relationship,
• a sense of connection, intimacy, closeness or warmth;
• trust, safety, or a decrease in alienation;
• a sense of being deeply understood, welcomed or cared about;
• an opportunity to identify with the therapist;
• a sense that the therapist would take responsibility for mistakes

Participants appreciated disclosures that made them feel their relationship was more egalitarian: the relationship seemed more balanced or mutual; the therapist appeared more human or fallible; or the disclosures helped them to be more autonomous.

Managing non-disclosure appears to be a more complex task in that on one level you are frustrating the client’s immediate need to attempt to meet what is perceived by the therapist as a more important need.

The most important element of skill that emerged from the few helpful nondisclosures in this study was that skilled therapists would frame their refusal to answer questions compassionately, in a way that clients could understand and accept as beneficial, even if they initially had negative feelings. For example, Lynn’s therapist would not comply when she begged him to give his opinion about decisions she was about to make. Although she felt frustrated in the moment, he had conveyed to her that he was refusing because he trusted her to make her own decisions. Ultimately, she felt validated by his ‘gentle firmness’.

The most often cited skill deficit in connection with non-disclosure was rigidity. Cardinal had a therapist who did not disclose as a matter of principle. Once she asked him casually where he was going for his vacation, and he replied that it was his policy not to disclose his personal business for safety reasons. Cardinal felt insulted that he did not take her character into account.

Skilled disclosures and non-disclosures tended to contribute toward the development of a positive alliance, while skills deficits were likely to slow or damage its development. However, a positive preexisting alliance mitigated the effects of skills deficits, while a negative or nonexistent alliance exacerbated the effects and could tip the scale towards termination.

Skilled disclosures and non-disclosures tended to contribute toward the development of a positive alliance, while skills deficits were likely to slow or damage its development. However, a positive preexisting alliance mitigated the effects of skills deficits, while a negative or nonexistent alliance exacerbated the effects and could tip the scale towards termination.

Responding to Client Questions II

There seem to be a number of questions that therapist’s get asked with some regularity.

Questions about shared experience

Questions about shared experience are common and include questions about the therapist’s personal life such as age, marriage, sexual orientation, race and children but also shared problems such as depression of anxiety. These questions often relfect concern that the therapist will not really understand or really empathise with the patient.

Are you concerned that because I don’t have children I may not understand what it is really like for you?

Questions about qualifications and experience

These questions often arise out of concern as to whether the client can be helped. At the base of these are often schemas around being defective, unlovable or too crazy. The difficulty is that questions about qualifications and experience often tap into the therapist’s incompetence schema and create anxiety in the therapist or a feeling of being attacked. Responding directly to the question may allay the therapist’s anxiety but does nothing about the client’s anxiety.

Part of you worries that I may not have enough experience to help you. Tell me more about that.

Questions about treatment

Most of us are likely to give some indication to the client about the probable length of treatment. However the degree that this is useful for the client is unclear.

…..describing the therapeutic process to a patient is similar to describing how something unusual tastes. It is difficult to capture the essence of the experience in words. Furthermore, many clinicians feel that the duration of treatment cannot be predicted ahead of time; much of it depends on the nature and extent of the patient’s difficulties, the degree to which the patient wishes to work on these difficulties, and external and internal obstacles that may arise along the way.

If treatment was to take a long time how would feel about that?

If treatment were to take a shorter time how would you feel about that?

Feldman suggests the following general responses for any questions that occur.

• Can you help me understand why that information is important for you to know?
• Can you help me understand how that information will help you?
• I have found that people ask questions that are really important to them. Perhaps you could help me understand why that question is important to you.
• I have found that the questions people ask are related to some of their difficulties. It might be helpful if you could tell me a bit more about your question.
• I am concerned that if I simply answer your question I would be robbing us of the opportunity to understand what might lie behind the question.

Responding to Client Questions

Questions from the client in psychotherapy usually always create some degree of anxiety in the therapist. If nothing else it puts the therapist momentarily on the spot while they think about their response. On another level it breaks one of the rules of therapy i.e. that client’s are there to talk about themselves.

This is an aspect of practice that is rarely written about in any of the psychology or psychotherapy journals or books for that matter. The only significant paper I have found on this is by Tamara Feldman in the Journal of Contemporary Psychotherapy. Fortunately Feldman’s paper is superb and probably obviates the need for further papers on the matter. For those of you that have the time, (access appears free) I highly recommend this paper. Much of this post is a summary of her ideas. While Feldman is clearly a psychodynamic therapist her article is relevant for any type of therapy. Ralph Greenson is his book The Technique and Practice of Psychoanalysis also has some discussion of client questions in his chapter on Technique of Analysing Transference.

Because a patient asking questions creates anxiety in the therapist we often attempt to minimise this by formulating blanket rules about patient posed questions. It is not uncommon to hear a therapist say, “always answer a question with a question”.

Two men are walking down a corridor together

The first turns to other and says, “…and what do you do for a living?”

The second replies, “What makes you ask?”

"Ah I see you are a psychologist", responds the first.

The other common rule is to try and answer the question factually unless it transgresses the therapist’s boundaries. Both these rules fail to accommodate the fact that questions can be asked by a client for a number of reasons. Responding to questions becomes all the more difficult when we may have only met the client for one or two sessions and have no clear formulation or intuition as to what may be driving the question. Does the client feel safe enough to explore the needs or fears underlying the question? Not knowing the client’s style may inhibit our sense of humour and make our response somewhat more formal. Will setting boundaries on the questions asked, hinder or enhance the therapeutic alliance. At these early stages we have to rely more on the art than the science of our practice and often the best we can do is guess and take a punt.

So why do clients ask questions?

• Client may simply want information.
• Client may want to focus away from themselves. The question serves as a defence against affect or anxiety.
• The client is attempting to meet a need through the question.
• The client may be wanting to strengthen the relationship by engaging more with the therapist.
• The client may be wanting to equalise or change the nature of the relationship with the therapist.

The Funnest Job: Working with Interpreters?

Working with sensitive or traumatic material with a person who speaks a foreign language is never easy.  A good interpreter makes all the difference

Here is a good set of suggestions on working with intrepreters. 

Hat tip:  The Relaxed Therapist

Problems with Homework?

At the end of the day all the talking and insight in the world is worth nothing if it does lead to a change in behaviour and a resulting change in outcomes for a client. At some point in time what is learnt, understood or acted out in the therapy room has to generalise to the client’s everyday world.

This translation from therapy room to real life is often done using homework exercises in cognitive behavioural therapy. A frequent complaint I hear in supervision is that the client turns up but hasn’t done their homework. This often generates a sense of frustration in the therapist leading to a label of being resistant used more pejoratively that psychologically.

If a client is not doing their homework but is turning up regularly for therapy it is not in my view useful or accurate to say the client is resistant to change. It is more useful to say the client has conflicting motivations about change. Clients may avoid working in therapy because they fear it will not work and this will reinforce their hopelessness. At the same time client may avoid working in therapy because it will work and then they will have to take responsibility for themselves and get on and have a life which can be scary stuff.

The very fact that they continue to come to therapy suggests that some aspect of them believes in or wants to change. Highlighting this as a conflict and exploring the mixed motivations using a cost benefit analysis technique frequently uncovers a way forward.

Calling it homework often casts in the frame of teacher and pupil with accompany memories of school, sometimes for the worse. It also puts it into a frame that this something the client is doing for somebody else i.e. the therapist rather than for themselves. At the same time I have never been totally comfortable with other descriptions such as activity scheduling or behavioural experiments.At the end of the day I usually come back to calling it homework.

There area number of good books and articles on using homework in a cognitive behavioural framework. Leahy’s great book; Overcoming Resistance in Cognitive Therapy covers homework problems in his chapter on process resistance. There has been a recent book published devoted entirely to homework in CBT whose authors include our own Professor Frank Deane. The book is called Using Homework Assignments in Cognitive Behavior Therapy. Judith Beck has some brief suggestion in her book: Cognitive Therapy: Basics and Beyond

Before exploring client resistance to homework it is useful to check that therapist or delivery issues are not interfering with homework completion. In my view it is always best to start with something small and simple and build on success. Far easier to be able to be positive about a success than it is to re-engage a client who feels like they have fialed you or themselves. Beginning therapists often carry beliefs about homework such as more is better. While compliant and compulsive clients may go off and complete all the homework given there will also be a feeling of resentment that may impact on the therapeutic alliance at a later stage.

Few Blogs for the Practicing Clinician

While there are 50 millions blogs out in the Internet few of them deal with the subject of being a psychologist or a therapist, particularly the day to day issues we face in our work. One of the few I have found is the Relaxed Therapist. This site is full of useful and controversial points to consider and worth a weekly look if you are practicing clinician. This lack of hands on blogging from clinicians is surprising to me. So many of my colleagues are practitioners in solo practice and blogging and the net seem natural ways to stay in touch with the profession.

There are also a number of blogs covering clinical and therapeutic research. Staff Psychologist has an almost daily posting on interesting psychology research. The British Psychological Society has a similar blog updating the latest research. One of the oldest and well known sites/blogs is PsychCentral with a wealth of psychological and psychiatric information.  PsychSplash is blog planning to provide links and highlights to psychology writing and blogging on the net.

Responding to Sexualised Comments: Option 3

I’ve had a few moments in therapy when personal boundaries have felt challenged – more earlier on and I’m not sure whether this is a function of loss of physical attractiveness due to ageing and/or clearer therapeutic boundaries due to experience.  I think I may have taken the ‘pretend it didn’t happen and hope it goes away’ approach early in my career – often my non-verbal responses may have alerted clients to the inappropriateness of their comments. Women are probably less likely to make such comments from my experience, and I think at least half of the comments I’ve dealt with have been from males.

For the vignette you’ve posted, my thoughts would be along the lines of:

• Name the process: “I’ve noticed that you tend to make comments about my appearance and the sound of my voice during our sessions”
• Raise the issue/dilemma: “I’m not sure what you intend by these comments, however they seem to me to be of a personal nature and therefore not appropriate within the context of our therapy sessions.  Can you tell me what is it that you mean by these comments?
• Explore further and delineate the differences between personal and professional boundaries, as well as the normal nature of personal attraction in relationships “how might our relationship in therapy be different from if we had met socially?”  “attraction is not unusual in relationships of all kinds, however it is important that we keep clear professional boundaries and continue to focus on the issues that you’ve brought to work on…how does this sound to you? “any questions about this?” etc.
• Agree/contract more appropriate boundaries: “I’m glad that we’ve been able to talk through this issue. Can we agree then that you’ll refrain from making personal comments during our therapy sessions, and that we’ll focus on the goals that you’ve come to work on”

I haven’t used the word ‘sexual’ in the above, and have used ‘personal comments’ & ‘attraction’ instead.  I prefer to use the client’s words/meanings. I would probably wait for the client to make clearer that the comments were of a sexual nature before constructing their communications as ‘sexual’. If their comments were very explicit, I would then of course be much readier to call them ‘sexual’.