Socratic Dialogue: How To Help The Patient Assess The Reality Of His Thoughts

2024 Author: Harry Day | [email protected]. Last modified: 2023-12-17 15:43

Author: Zaikovsky Pavel

psychologist, cognitive-behavioral therapist

From the author: One of the methods of correctly responding to dysfunctional automatic thoughts, negative images and deep beliefs is the "Socratic dialogue", which I will talk about today.

"Socratic dialogue" helps the patient to check the accuracy of his automatic thoughts … The therapist asks a number of questions in a certain form and sequence, answering which, the patient begins to realistically assess the situation.

In the last article I talked about Automatic Thought Detection Technique (AM)

In this article, you will learn how to:

• choose key AMs;
• evaluate AM using the Socratic Dialogue;
• check the effectiveness of the assessment process;
• the reasons why the patient is still convinced of AM;
• help the patient to self-assess AM

Focus on key AMs

When the therapist has identified AM, he tests how important it is to focus on it now and determines how the thought negatively affects the patient's behavior and emotions. In addition, the therapist predicts the likelihood of whether this thought will be repeated in the future and will cause negative reactions.

If the therapist notices that a thought is still important and causes distress, such a thought must be evaluated and worked out in detail.

An example of a dialogue with a patient from practice:

Therapist (summarizes): “When your teacher gave everyone the task to write a story about their favorite artist and speak with him in front of the class, you became very sad because you thought,“I can’t speak in front of everyone.” At that moment, how convinced were you of the realism of your thoughts and how sad were you?"

Patient: "I did not even doubt it and was very sad."

Therapist: "Now, what about your conviction and how sad are you?"

Patient"I'm sure it's too difficult for me to perform in front of a group."

Therapist: "And you still worry about it?"

Patient: "Yes strong. I only think about that."

When the guided discovery process is applied

The therapist helps patients to use their own negative emotions as a signal that automatic thoughts should be reevaluated and find an adaptive response. In the course of work, the therapist helps the patient to identify dysfunctional thoughts (AM, images, beliefs) that affect his emotions, physiology and behavior. After an important AM is found, the therapist helps to evaluate it.

Automatic thoughts are best assessed in an impartial and structured manner, so that the patient does not perceive the therapist's response unconvincingly and is not hurt.

"Socratic dialogue" helps to avoid such risks and consists of list of questions:

1. What does the situation look like?
2. What did I think or imagine?
3. What evidence is there that this thought is correct?
4. What evidence is there that it is wrong?
5. What alternative explanation can be given to what happened?
6. What's the worst that can happen and how will I deal with it?
7. What's the best thing that can happen?
8. What is most likely to happen? What is the most realistic scenario?
9. How will events develop if I keep repeating this thought to myself?
10. What happens if I change my mind?
11. If a friend got into a similar situation and reasoned the same way as I do now, what advice would I give him?
12. What should I do to resolve this situation?

Examples of application of the questions of the "Socratic dialogue"

It is important to inform patients that not every question is suitable for assessing AM and the list of questions is a useful guideline.

An example conversation illustrates how to assess dysfunctional thoughts and strategize further actions using the questions of the Socratic Dialogue.

Questions about evidence. Patients can find evidence of their AM, however, they ignore the evidence to the contrary. Therefore, it is important to identify evidence for and against the patient's AM, then summarize the information received.

Therapist: “Let's think about what evidence you will not be able to give a story in front of a group?»

Patient: “Well, I don’t remember the last time I performed in front of someone. I have no such experience at all. I am sure that I will be confused, forget everything and look stupid."

Therapist: "Is there anything else from the arguments?"

Patient: "Well, I'm not a public person at all and I usually listen when others are discussing something."

Therapist: "Is there something else?"

Patient (after thinking): "No, that's all."

Therapist: "Now let's think about what evidence exists to the contrary: that you will not be confused and will look confident?"

Patient: “Well, I will prepare every day and it will not be difficult for me to tell about Van Gogh. I read a lot about him and even wrote an essay on the theme of his life."

Therapist (helps the patient to find other answers): "Have there been cases when you told your friends about something and they listened to you attentively?"

Patient: “Well, ooh, yeah … When we discuss something interesting in class, I can also tell you something that I know. And they usually listen to me."

Therapist: "Clear. On the one hand, you don't remember when you spoke in public in front of everyone. But on the other hand, you participated in the general discussion of the class when something was interesting to you. Then you saw that others were listening to you and you did not feel stupid, on the contrary. And if you are prepared, you can tell a lot of fascinating things about Van Gogh. Right?"

Patient: "Yes indeed".

Alternative explanation questions offer to find the patient, how and what else can explain what happened, which made the patient upset.

Therapist: “Let's figure it out. If you’re really at a loss, what else can people think when they see you worry other than “she didn’t prepare well for the show”?"

Patient: "It is hard to say".

Therapist: "What can you think when you notice that the other person is worried when performing?"

Patient: Maybe, he is unaccustomed to performing in front of an audience, and he is worried ».

Questions on "decatastrophization" help when patients predict the worst-case scenario. In this case, it is important to ask the patient what his worst fears are and how he will act if this happens.

Therapist: "Tell us, what is the worst thing that can happen in this situation?"

Patient: “Probably the worst thing is that all the words will fly out of my head. I will stand and be silent. Everyone will think that I am not prepared."

Therapist: "And if this happened, how would you deal with it?"

Patient: "I would be upset and might even cry."

Therapist: “Have you seen when others are worried and worried? Did you think badly of such people?"

Patient: “Yes, I did. I didn't think badly, on the contrary, I wanted to support them."

Therapist: "So if you worry, people will see it and not judge you?"

Patient: "Yes".

Therapist: "So how would you handle?"

Patient: "I could say that I am worried and asked the group to support me."

Questions about the best and realistic options development help patients understand that their negative predictions are unlikely to come true.

Therapist: "What's the best thing that can happen?"

Patient: “I will prepare and share the most exciting moments of Van Gogh's life. Many will be interested"

Therapist: "What is most likely to happen?"

Patient: “I will prepare and tell. If I'm worried, I'll tell everyone that I'm worried. And if I forget the words, I will spy on the plan on paper."

Questions about the consequences of automatic thoughts help the patient to assess what emotions he experiences and how he behaves when he believes his AM. How his emotional and behavioral responses might change if he thought differently.

Therapist: "What are the consequences of the thought that you will not be able to speak with the story?"

Patient: "I will be sad and I will not have the desire to do anything."

Therapist: "What happens if you change your mindset?"

Patient: "I will feel better and it will be easier for me to prepare."

Questions about "distancing" offer to imagine that they would advise a loved one in a similar situation, then find out how much such advice is applicable in their life. This will help patients to distance themselves from the problem and broaden their view of the situation.

Therapist: “Let's imagine that your close friend was invited to speak in front of the group, and she was afraid that she would not succeed. What would you advise her?"

Patient: “I would advise you to do your best to prepare for the performance. And if it doesn't work out and she is worried, ask the class for support and tell about her excitement."

Therapist: "Is this advice applicable in your case?"

Patient: "I think yes".

Problem solving questions offer the patient to think about how to act now in order to resolve the situation that has arisen.

Therapist: “What do you think you can start doing today to solve a problem situation?

Patient: “I could write one paragraph for the story every day. It would take half an hour every day. This way I will be better prepared and will feel more confident."

Evaluate how the patient changed the AM score after answering the questions

After the work done, ask the patient to rate how much his initial AM score has changed (as a percentage or on a scale of strength: weak, medium, strong, very strong) and how his emotional state has changed. Clarify what contributed to the improvement.

Therapist: "Wonderful! Let's once again assess the veracity of your thought: "I will never be able to speak in front of everyone." How much do you rate its realism now?"

Patient: “Not very realistic. Probably 30 percent."

Therapist: "Wonderful. How sad are you?"

Patient: "Not at all sad."

Therapist: "Excellent. I'm glad the exercise was helpful. Let's think, what helped you to improve your condition?"

In a dialogue, the therapist helped the patient evaluate his dysfunctional AM using standard questions. However, many patients initially find it difficult to get involved in the response and assessment of AM. If the patient is having difficulty, you can ask them to summarize the discussion and then write coping cardbased on the patient's findings:

Reasons why the patient may still be convinced of the truth of the irrational AM

There are more important and undetected AMs. The patient named AM, which does not affect his mood and behavior, but behind it hides other thoughts or negative images, which he may not be aware of.

The AM assessment was superficial or inadequate. The patient noticed AM, but did not carefully evaluate or reject it - negative emotions did not decrease.

Not all evidence has been collected in favor of AM. The formulation of the adaptive response is reduced if the therapist did not elaborate enough about the details of the patient's situation and he did not give all the arguments in favor of AM. The patient can more effectively find an alternative explanation of the situation when the therapist helps him collect all the evidence in favor of AM.

Automatic thought is a deep conviction. In this case, a single attempt to overestimate AM will not lead to a change in the patient's perception and reactions. You will need techniques to adjust beliefs that are applied gradually.

The patient is aware that AM is distorted, but feels differently. Then it is necessary to find the belief underlying AM and examine it thoroughly.

How to help a patient cope with questions on their own

Make sure patients are able to use the Socratic Dialogue and understand that:

• an AM score will change their emotional state;
• they can handle questions on their own;
• not all questions apply to different AMs.
• an AM score will change their emotional state;
• they can handle questions on their own;
• not all questions apply to different AMs.

If the therapist assumes that the patient will judge himself harshly for the imperfect performance of the task, invite the patient to imagine a situation when it is difficult to complete the task and ask about his possible thoughts, emotions and feelings. Remind the patient that thought assessment is a skill that you will help them learn over the next sessions.

When the therapist and the patient have effectively dealt with the questions from the Socratic Dialogue, you can give him a list of questions for independent work. It is important to explain to the patient that the daily work on all questions and on each AM can be tedious, which is why the therapist suggests re-reading the notes throughout the day and they make up together coping card:

Checking dysfunctional AM for reliability makes it possible to see the situation from a different angle. As a result, the processes of reassessment of past experience are launched, new ideas appear and a new view is formed, which reflects the situation more realistically, which positively affects the quality of human life.

Checking dysfunctional AM for reliability makes it possible to see the situation from a different angle. As a result, the processes of reassessment of past experience are launched, new ideas appear and a new view is formed, which reflects the situation more realistically, which positively affects the quality of human life.

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