Avoiding the Hemlock: Socratic Dialogue III

Socratic questioning is something that takes a lot of practice to do well. For many beginning therapists there is not enough time spent developing this technique particularly in getting observed feedback on what they are doing and not doing well. This skill cannot be developed without this feedback. Ideally it should be video feedback.

The second overarching problem that arises is not understanding what Socratic questioning is. Given the confusing array of definitions outlined in an earlier post this is not surprising. Without a model of what you are doing in your head it is very difficult to know whether you are actually delivering the product in a useful manner. Before you start using this technique define what it is for you. Are you going to use Padesky’s model or someone else’s?

On a more specific basis there are a vast number of ways that Socratic questioning can get derailed. So where do therapists go wrong?

Moving too quickly in general.

Sometimes a client may take some time to give up a cherished and long held dysfunctional belief. Not going at the client’s pace or slower usually leads to resistance. This is commonly seen by the use of the word “but” in the client’s responses. For me that first “but” is a sign I am going to fast and need to go back a stage or two. I observe for many clinicians that the first “but” leads to an increase in what I call “presenting the evidence” behaviour with a resulting argument/counterargument pattern that leaves both client and therapist frustrated.

In general I see moving too quickly as a reflection of the therapist’s need to control the process. To me it is important to remember that not only are we helping a client challenge and find news way to think about an aspect of themselves we are also teaching or modelling a critical thinking process.

Moving to the evidence to quickly

This is the most common mistake I see.  It is often compounded by the therapist presenting the evidence to counter a current belief rather than eliciting this from the client themselves.  In a worst case scenario the client states a dysfunctional belief that is then immediately countered by therapist.

But what about the following evidence? Therapist then proceeds to outline all the evidence against the belief.

Client either resentfully acquiesces or a but/counter but exchange follows. Our job is not to convince the client but enable a process where the client convinces themselves.

Framing the end goal as a question

This raises a general concept about the type of questions you should ask when doing Socratic questioning. In my view they should always be open ended. This is an exploratory process or a guided discovery. If a question can be answered with a “yes” or a “no” then it is not part of Socratic dialogue. The more extreme end of this is when the therapist's end goal is framed as a question:

Don’t you think you would feel less depressed if you said more positive things about yourself.

The client has little choice but to answer in the affirmative to such a question.

Not acknowledging the benefits of the clients current position

Nobody does nothing for no reason. If a client is holding a belief no matter how dysfunctional it appears it is also likely that they belief that it helps them in some way. Until a client understands how the belief helps them then it will be difficult to enable them to find a more functional substitute for that belief. For me this is a vital area of exploration to undertake in a Socratic dialogue. It sets up the opportunity to do a cost benefit analysis around the belief the client holds. It also allows for a genetic exploration of the development of the belief.

Not acknowledging the risk of entertaining new ideas

Taking on new ideas and behaviours is scary. Just look what happened to Galileo. From this perspective exploration of new ideas needs to go at a pace where the client does not feel too unsafe. Slowing down and normalising fears about change and newness enable the client to proceed.

Becoming frustrated when the client does not take on the new ideas

This comes back to the idea of pace. Think legato: a manner of playing that is smooth and connected and has a flowing effect. It is likely that if you are feeling frustrated the client is feeling frustrated. If this is not checked and addressed early on then the dialogue can develop into a battle of wills with the therapist feeling a need to dominate or convince the client of the value of a different position. The old psychologist joke is appropriate here.

How many psychologist does it take to change a light bulb?

Only one but the light bulb has got to want to change

The client may agree with you on the surface but is unlikely to be really convinced and the resentment they feel (expressed or not) is likely to impair the therapeutic alliance.

Not promoting the concept of choice

For me the concept of Socratic dialogue is about exploration rather than moving to some predetermined end point or belief. Even if the evidence is overwhelming for the new perspective we need to respect and empathise with the client if they are not ready to take this on board. It suggests we need to go back to some clarifying and exploring because we are missing something that means the client is not ready to take on these new ideas. Sometimes clients need time to go away and mull it over. Often the days in between sessions allows the new ideas to settle and they often return next session much more ready to take on these new ideas.

Forgetting the affect or failing to validate and empathise

Forgetting the affect or failing to validate and empathise Socratic questioning is a logical process and it can be easy to get caught up in the logic and forget the person sitting in front of you. Exploring a client’s feelings is an important part of the clarifying process. Validating and empathising with the client’s struggle to grapple with new ideas and evidence helps provide the motivation for the client to continue with the process.

Therapist dysfunctional thinking interfering with clarifying process

The most common therapist dysfunctional thinking is that thoughts are good and bad or right and wrong. This leads to labelling of client’s current position as bad or wrong. This can lead to the client feeling guilty or ashamed abut having these beliefs with resulting underlying feelings of resentment towards the therapist that will interfere with therapy.

I use the word legato because when this process is done well it can unfold in delightfully very smooth manner. Sensitising one’s self to the resistances (such as the “buts”) allows one to automatically self correct and adjust one’s tempo or move back to an earlier type of questioning (da capo).

Some general rules

• Open ended questions
• Slow down
• Make the client do the work and make the decisions
• Listen for the resistance
• Don’t forget to validate and empathise

Links

• Socratic Questioning I
• Socratic Questioning II

Comments

[Nikeroo]

Mine Own Executioner by Nigel Balchin
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Recommended reading for people wanting examples of different techniques. It is fiction but nonetheless very entertaining.

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