Socratic questioning put into clinical practice

Summary

Socratic questioning is at the core of collaborative clinical communication, with a wide array of applications in behavioural medicine and psychotherapy. This brief article describes the process of therapeutic Socratic questioning, illustrates its clinical applications in therapy and provides a brief update on its recent developments.

In Plato's Dialogues, Socrates compared his questioning method to the job of his mother, who was a midwife. In fact, ‘maieutic’ etymologically means ‘the art of childbirth’ and is a term related to the Socratic method of eliciting new ideas from another. This process of drawing out ideas is known as Socratic dialogue and occurs in two stages: first, the person is invited to question held beliefs and to acknowledge contradictions in reasoning that are often embedded in social conventions and prejudices; and second, they are encouraged to think for themselves about alternative perspectives. Socratic questioning is a core method not only in cognitive–behavioural therapy (CBT) (Beck 1985), but also in motivational interviewing, which has a wide range of clinical applications.

Socratic questioning in psychotherapy

The primary goal of Socratic questioning in psychotherapy is not to change the patient's mind, but to guide them in discovering methods for improving their lives. This process of guiding discovery is not simply about fixing problems but mostly about developing ways of finding solutions. According to Padesky (1993), Socratic questioning is focused on asking questions that ‘(a) the client has the knowledge to answer; (b) draw the client's attention to information which is relevant to the issue being discussed but which may be outside the client's current focus; (c) generally move from the concrete to the more abstract, so that (d) the client can, in the end, apply the new information to either reevaluate a previous conclusion or construct a new idea’ (p. 4).

Collaborative empiricism as a therapeutic attitude

In CBT, the fundamental tenet for achieving these aims is collaborative empiricism – a therapeutic attitude where patient and therapist work ‘shoulder to shoulder’ to develop skills in sensible reasoning and hypothesis testing. Collaborative empiricism mitigates the therapist's preconceived ideas about the patient's problems, improves the therapist's accurate understanding of the patient's view and, notably, conveys the notion that every human has an ‘inner wisdom’ (Overholser 2011).

The collaborative process of Socratic questioning unfolds in four stages: (1) asking informational questions (i.e. the therapist brings into awareness potentially useful information); (2) listening (i.e. the therapist is open to discovering the unexpected); (3) summarising (i.e. the therapist looks at all the new information as a whole); and (4) synthesising (i.e. the therapist applies the new information to the patient's original concern through analytical questions) (Padesky 1993).

When applied across these four stages, Socratic questioning is customised to address the specific problem faced by the patient, and thus questions may assume various formats (Overholser 1993):

• • Memory questions, aimed at recalling and reviewing information (e.g. ‘When was the first/last time the problem happened?’, ‘What did you do then?’)

• • Translation questions, aimed at changing information into a different but parallel form (e.g. ‘What does it mean to you?’, ‘What would your friends say about this?’)

• • Interpretation questions, aimed at discovering values, skills or relationships between facts (e.g. ‘How are these two situations similar?’, ‘What can we learn from this?’)

• • Application questions, aimed at applying knowledge of skills to a specific problem (e.g. ‘What have you tried to correct this situation?’, ‘How will you feel about making these changes?’)

• • Analysis questions, aimed at developing awareness of thought processes used for reaching conclusions (e.g. ‘What do you think is causing the problem?’, ‘How could you tell if you are right or wrong?’)

• • Synthesis questions, aimed at encouraging the patient's creativity and divergent thinking (e.g. ‘What would you say to a friend in the same situation?’, ‘What does holding a PhD mean to you?’)

• • Evaluation questions, aimed at enabling value judgements in line with specified standards (e.g. ‘What do you look for in a long-term relationship?’, ‘How do you feel about yourself as a person?’).

In traditional CBT, use of these questions was targeted at problem-solving or changing irrational beliefs (Beck 1985; Overholser 1993). However, in more recent developments of the model, their use has been extended to elicit broader attitudinal shifts (e.g. moving from experiential avoidance to acceptance) and to increase willingness to change, as illustrated by the following examples (Ciarrochi 2008):

• • What have you been struggling with?

• • How have you tried to overcome that?

• • How did those efforts work out? (in the short term and in the long run)

• • What have you given up because of these difficulties?

• • Why is it so hard to change your thoughts and feelings?

• • If trying to change your thoughts and feelings does not work, then what can you do?

The evidence for Socratic questioning in psychotherapy

These extended applications of the Socratic method have recently been supported by research showing an association between the increased use of Socratic questioning in cognitive therapy and positive changes in depressive symptoms. Although the mechanisms through which Socratic questioning may lead to symptom improvement have not been ascertained, a reasonable inference is that it might improve symptoms by empowering the patient's active participation in treatment and/or fostering skill acquisition (Braun 2015). Many CBT experts agree that Socratic questioning has significant benefits within therapy and that its effective application needs to be tailored to individuals and therapeutic tasks (e.g. when modifying a patient's relationships with distressing psychological processes or giving information in a non-Socratic way might alienate patients and prevent those with more strongly held views from exploring multiple sides of an experience, forming a balanced view and tolerating uncertainty). However, while some experienced therapists regard the role of Socratic questioning as a central feature of CBT, others perceive it as a valuable (though non-essential) adjunct to treatment (Clark 2018). In fact, Socratic questioning is a therapy feature that appears to be marginally and non-linearly associated with increased odds of clinical improvement (Ewbank 2019), thus highlighting the need to better understand its mechanisms and conditions of change in psychotherapy.

Finally, it is worth noting that in therapy or counselling, the therapist's intentionality in using Socratic questioning is vital to the obtained outcomes. As Padesky (1993) incisively pointed out, if the therapist's goal is to change the patient's mind, then they will have the answer before the patient replies; if the therapist's goal is to guide discovery, they will have no anticipated answer – just genuine curiosity. Therefore, Socratic questioning is a core clinical skill that is simultaneously linked to the therapist's continuous development and to the therapeutic process of the patient's change and growth.