Integrative CBT case formulation and intervention, while obviously making room for all five levels, are primarily based on the Beck/Ellis theoretical perspective of Level 3, namely that mental health problems are mainly cognitive in their nature and their roots, and are most effectively helped by achieving relevant cognitive change.
This means that we need to help the client get to the cognitive heart of the matter, which is often not all that obvious. In many anxiety problems, for instance, the client is not actually clear what it is precisely that they find threatening. A common example is fear of flying. To be afraid of flying can mean different things: fear of crashing, fear of dying, fear of not being in control (this is one reason why many who fear flying are not nearly so afraid of crashing in their car, even though the latter is much more likely), fear of panicking, of feeling enclosed (so in fact a form of claustrophobia), fear of leaving their children without a parent (this is why many people are more afraid, rather than less afraid, when they are flying in the company of their spouse).
The primary CBT process which is used in this regard is called Socratic Questioning or Socratic Dialogue. This is a cognitive/empathic process which tries to tease out what the client has learnt from their experiences, in other words to help them become clearer about some of their crucial beliefs, which are based on relevant experiential learning. This leads on to a process where the basis of beliefs are examined and questioned, not just in relation to their truth, but also their current relevance, value, importance, meaning, usefulness etc. So Socratic Questioning starts out as an exploratory process, and gradually becomes a more challenging, change-oriented process, fostering more functional, adaptive ways of interpreting the important aspects of our lives.
Therapeutic change may take place not just in the content of beliefs, but also in the way they are held, i.e. they may be held more provisionally, more flexibly. In this sense, Socratic Questioning is a philosophical method, an educational method, a part of critical thinking. Its function is to probe & test assumptions, viewpoints, ways of seeing things. It is not just a therapeutic tool; the following list, for instance, has been adapted from Paul, Richard - "Critical Thinking: How to Prepare Students for a Rapidly Changing World" (1993), and yet is very relevant to the therapeutic setting.
• Let me see if I understand you; do you mean _____ or _____?
• Could you give me an example?
• Could you explain that further?
• Do I understand you correctly? You seem to be assuming ____.
• What could we assume instead?
• Why would someone make this assumption?
• Is it always the case?
• Why do you think that is true?
• Do you have any evidence for that?
• What would change your mind?
• What would you say to someone who said ____?
• How could we find out whether that is true?
• Where did you learn this?
• Have you always felt this way?
• When you say ____, are you implying ____?
• Would that necessarily happen or only probably happen?
• You seem to be approaching this issue from ____ perspective.
• What might someone who believed ____ think?
• What would someone who disagrees say?
• What is an alternative way of seeing this?
In the therapeutic setting, this method can lead on to other forms of Guided Discovery, especially Behavioural Experiments (which will be explored in next week’s blog).
The Socratic Method goes back, as the name suggests, to the Ancient Greek philosopher Socrates (who was executed for his persistent questioning of widely-held beliefs), but does not necessarily fully reflect the style and philosophy of the original Socratic dialogues of Plato, which personally I never much took to. But I’ve always been fascinated by the nature of beliefs, where we get them from, why we keep them, why we change them. I love critical thinking, and the process of examining views from every possible angle; and a bit like Socrates, what I’ve discovered personally is that once you start doing this in a committed way, it may lead anywhere...