28 January 2010
Tracy Chotoo and Rita Woo
Understanding difficulties in
Developing an alternative perspective
- Socratic questioning and guided
- Consideration of the content and process
of automatic thoughts
The cognitive model of emotional disorders reviewed
Events, relationships, social and cultural circumstances
Core beliefs/ absolute assumptions
Conclusions drawn about the self, world, others etc. in light of experience
(I am…., the world is…., Others are…. Etc.)
Conditional assumptions and rules
Guidelines for living, standards, rules, which evolve from core beliefs (e.g. to compensate)
Contain moral, religious, cultural and social influences
(If….then…., Should or Must statements, Value judgements)
Events which impact on (e.g. activate/ shatter) pre-existing beliefs and assumptions
Activation of negative beliefs and assumptions
Negative automatic thoughts
Thoughts, images, meanings enter consciousness
Rapid, fleeting, generated by assumptions and beliefs in response to specific situations
Other aspects of functioning/ symptoms
Emotional state, behaviour, coping strategies, bodily state
Presenting the rationale for identifying NATs
Distressed response Response learned in CT
Affect, behaviour, (understanding the patterns/
Bodily reactions etc sequences so far)
search for alternatives
Coping/ adaptive behaviour
Homework Review: NAT Diaries
(groups of 4)
How did you get on?
Were you able to identify NATs?
What was it like recording these thoughts?
What did you learn about the process?
If you did not do the homework, or
encountered difficulties, what were the
How could you overcome these blocks? Try
to come up with specific and concrete
Large Group Discussion
How might doing this exercise help you when
working with clients?
What stumbling blocks or problems are you
aware of, and how might you prevent
problems arising, or overcome them?
What differences might there be for someone
who is anxious or depressed?
What are the pros and cons of identifying
NATs for clients?
Review - Common Difficulties Identifying NATs –
(see Westbrook et al, ‟07; Sanders and Wills)
The client avoids thoughts – focuses on feelings
The client has difficulty identifying or labeling
emotions (e.g. “I felt uncomfortable")
Client intellectualizes responses and avoids emotions
The client‟s thoughts are fleeting – meant to write
them down and then forget (Westbrook et al., 2007)
The client is avoiding triggers
Common Difficulties Identifying NATs II
The client writes pages and pages of thoughts and
Superficial thoughts provided
The client avoids discussing upsetting situations
(Moore and Garland, 2003)
Patient fears therapist responses
Thoughts and feelings don‟t match– client reports a
panic attack but described thoughts such as “It‟s
going to be OK”
“The goal of cognitive therapy is not simply to
make our clients think differently or feel better
today. Our goal as cognitive therapists is to teach
our clients a process of evaluating their goals,
thoughts, behaviours and mood so that they can
learn methods for improving their lives for many
years to come”
Socratic Questioning – (see Kennerley, 2007;
Padesky, 1993a; Westbrook et al., 2007)
“The cornerstone of cognitive therapy” (Padesky,
Socrates - would encourage young Athenians to
discover answers for themselves through a
process of guided discovery
Open ended questions about the client‟s internal
and external world, which they have the
knowledge to answer
Premise that answers have more emotional
salience if they are discovered by the client,
rather than told
Socratic Questioning can be helpful in:
Identifying cognitions, affect, behaviours
Exploring connections, consequences, patterns
Checking out therapist’s hypotheses
3. Challenging unhelpful cognitions
Looking for evidence for and against
Generating alternative ways of looking at things
4. Problem solving and arriving at solutions
Considering options, pros and cons, possibilities
5. Devising behavioural experiments
Working out ways of testing beliefs /assumptions
Socratic Questioning: Key features – I
You have asked a good Socratic question if:
The client can work out the answer to it
It reveals new perspectives
Assumes the client knows the answers and therapist is
expert at helping them discover
Draws attention to information and solutions relevant to
the problem, which may have been outside the client‟s
Guiding discovery rather than changing minds (Padesky,
this consists of asking the client questions which:
1. S/he has the knowledge to answer
2. draw the client‟s attention to information
relevant to the issue under discussion but outside
her/ his current focus, i.e. widens their
3. move from the concrete to more abstract so that the
patient can apply the new information to re-evaluate
a previous assumption or belief or construct a new one
Not positive thinking
Not a case of the therapist persuading the client to
see things from his/her point of view.
The goal is balanced and realistic thoughts
The question “What do you mean when you say
x?” can help to clarify idiosyncratic meanings
Try to avoid too many “why...” questions.
Alternatives include “what are some of the
reasons you think...” “in what ways do you
Brewin (2006):“CBT does not directly modify information
in memory, but produces changes in the relative
activation of positive and negative representations such
that the positive ones are assisted to win the retrieval
DTRs may help people to create new representations in
which –ve thoughts are associated with more positive
mood, positive memories, and realistic standards
In order for alternatives to enjoy retrieval advantage over
original thoughts important to ensure that no stone is left
unturned. Otherwise negative self-representations may
still be triggered by specific triggers
The 4 elements of Socratic questioning
(see Padesky, 1993a)
1. Ask concrete, informational questions
2. Empathic listening
3. Frequent summaries – check and clarify what has been said.
Give yourself time to think
4. Synthesising questions
So, how does this information fit together?
What sense do you make of that?
How might these ideas make a difference to you?
- What would your close friends say if they knew all this?
- Given what you have been telling me, what do you think will help?
Key Questions to facilitate the Socratic
Method – gathering information
What do you think/ feel about that?
What is going/ went through your mind?
What does that mean to you/ say about you/
others/ the world?
If that were true, what would that mean to you?
What’s the worst that could happen?
Downward arrow technique
(see Leahy, 2003, Westbrook et al, 2007)
Technique designed to help clients unpack or further analyse the
meaning of unhelpful cognitions
Can help identify client‟s fundamental belief system – the “bottom line”
(Fennell, 1999) or “bottom triangle” (Westbrook et al, 2007)
Beware „psycho-bulldozing‟ (Westbrook et al., 2007)
“Is it alright for me to continue with these questions?”
“Do you need a bit of a break?”
Tone is very important
Model the compassionate voice
“This may sound like a silly question, but….”
Try not to plough straight in with too much disputation
Death may not be the bottom – beware premature ending
Downward arrow – an example
T – What was going through your mind before going to the
P – I‟ll become anxious before talking to people
T – And if you did feel anxious, what could happen?
P – People wouldn‟t want to talk to me
T – And what would that mean?
P – That I‟m not worth talking to
T – What sort of a person is not worth talking to?
P – A loser
T – If you‟re a loser then that means….?
P – I‟ll never find anybody
T – And if that were to happen?
P – I‟ll always be alone and miserable
Downward arrow: some helpful questions (see
Burns, 1989; Leahy, 2003; Westbrook, 2007)
I wonder what seems so bad about that?
In your view, what does that mean?
What does that say about you / others /
What would that mean about your life /
What would others think of you?
How would you label that?
Can you describe the worst that could
happen? If that was true…
Exercise in pairs: Downward arrow
In pairs, each person to take turn as therapist and
Therapist to enquire about a recent example –
situation, emotion and cognitions
Use downward arrow questions to clarify the
cognitions your client reports
As a client, what was helpful about being
asked these questions? Anything that you
found difficult (be specific)?
As a therapist, what was useful / more
What was this like when working with
someone who is depressed / anxious?
What do you feel you need to work on?
Role play: in pairs, 20 mins each
Use Socratic questioning to ask the “client” about
their current problems (see cases)
Ask about the triggering situation, thoughts, feelings,
& coping, map out the vicious cycles
Try to identify key NATs and emotions, and ask
about intensity/ belief ratings from 0-100%
Use regular summaries and feedback
Encourage client to write this information on a
thought diary (columns 1-3) (will be used again later)
Role play: Feedback
Were you able to identify key feelings, thoughts and
What was it like to use Socratic questioning as the
therapist? What difficulties, if any, arose?
What did it feel like to be asked about your problem
in this way as a client?
Were there differences between depressed and
anxious clients? What difficulties might arise with
when identifying NATs and how can you deal with
Exploring the Content of Thoughts
Appraising / Evaluating NATs
Key aim decentring from thoughts : “thoughts
as mental events rather than expressions of
reality” (Beck 1979)
Socratic questioning is the key cognitive
technique in-session –guided discovery vs.
Evaluating NATs: how to do it
Identify situation, expand and clarify thoughts and
feelings – “it‟s no wonder….” “I can understand why…”
Target “hot” thoughts that have high affect.
Develop awareness of cognitive biases
Explore evidence for and against the NAT (current and
historical), then develop positive alternatives
Highlight any recurrent thought biases
Use NAT diary additional columns to summarise, and
generate new perspective
Aim is to reduce belief rating (0-100%) in original NAT,
and associated negative affect - need to be re-rated
Identifying cognitive biases
(see attached handout for examples)
Info-processing biases – normal and necessary
heuristics to process incoming stimuli
Exaggerations in information processing style –
likely to be more pronounced when affect is high
Can be problematic when bias is too extreme
Awareness of info-processing style can be a step
towards decentring from thoughts - rather than
focusing on content.
Aim is to identify information processing biases –
can open way to considering alternative views
Socratic Questions and appraising NATs
- “Consequence of” questions: Can elicit pros and
cons of current beliefs and act as a motivation to re-
- “Evidence for” questions: validating the client‟s
current reality –developing a “balanced view”; helps
understand why thoughts may have developed
- “Evidence against” questions: directing attention to
experiences / incidents that challenge the orig.
belief – can undermine their validity
- “Alternative view” questions – re-evaluating things
in light of all of the evidence, developing a new
conclusion / perspective
Socratic Questions: “consequence of”
How helpful or unhelpful is it to hold this
particular belief? (Elicit in detail)
What for you are the advantages of seeing
things this way?
Are there any disadvantages for you in
seeing things this way? (Consider both short
and longer term)
If you see the world this way, how do you feel
and behave? How do others react?
Socratic Questions: “Evidence for”
In your experience, what fits with this belief, what
makes it seem true?
When you think X, what evidence do you have
that supports this thought?
Why might any of us have that thought at some
Key Socratic Questions for Appraising NATs
(see Greenberger and Padesky, 2005)
Have I had any experiences that show that this thought
is not true all the time?
Is there anything that doesn’t seem to fit with this
If a friend or someone I love had this thought, what
would I tell them?
If a friend or someone I love knew that I was having this
thought, what would they say to me? What evidence
would they point out that my thoughts are not true 100%
of the time?
When I am not feeling this way, how do I view this type
When I have felt this way in the past, what did I think
about to help myself feel better?
If you fast-forwarded 5 years from now, how would you
view this situation?
Socratic Questions for Appraising NATs
(Greenberger and Padesky, 2005)
Have I been in this type of situation before? What
happened? Is there anything I learned from my
past experiences that I could use in this
Are there any small things that may contradict my
thoughts that I may be discounting as not
Are there any strengths or positives in me that I
Am I blaming myself for something over which I
do not have complete control?
Am I jumping to conclusions?
Socratic Questions: Developing an alternative /
balanced view (Greenberger and Padesky, 2005)
Based on the evidence listed, how would you now view
your original concern?
If someone I cared about was in this situation and had
these thoughts, what would be my advice to them? How
would I suggest they understand the situation?
If my hot thought is true, what is the worst outcome? What
is the best outcome? What is the most realistic outcome?
Given what you have just described, how likely is it that the
worst will happen?
If it did happen, what could I do to cope?
Can someone I trust think of another way of understanding
Socratic questions and problem solving
Define and identify the problem (clear and
Generate alternative solutions: “How would
a (respected) friend deal with this dilemma?”
“Given that you have identified X as an obstacle
to Y, how would you advise a friend to start to
resolve this?” “what are some possible ways of
managing this problem?”
Evaluate each solution: “What are the
advantages and disadvantages of that
approach?” “What might go well if you tried
this?/ What might be difficult?” “What would be
the worst-case scenario if that solution didn’t
work?” How could you prepare for that? What
could you do if it did happen?
challenging/ restructuring negative automatic
Role play: in pairs, 25 mins each way
Use Socratic questioning to challenge the “hot”
NATs identified in the last role play
Use the DTR columns to record evidence for and
against the thoughts
Be gentle but persistent – “Is there anything else
that makes you think X?...”
Re-rate intensity scores for belief in the NAT and
emotional intensity (0-100%) at the end of the
Feedback from evaluating NATs
Were you able to change the belief and
emotional intensity ratings?
What was it like to use Socratic questioning to
challenge NATs as the therapist?
What did it feel like as a client? Was it helpful?
What difficulties might arise in therapy and how
can you deal with them?
Appraising NATs – testing out new conclusions
Collaborative Empiricism – thoughts as hypotheses to
tested, data collected to generate new information and/or
evaluate beliefs, developing new beliefs
Learning theory suggests that we absorb
information most effectively if thinking is linked
Research – CBT interventions more effective
when combine both cognitive and behavioural
change (Bennett-Levy): consolidate learning,
and generalise from treatment everyday life
Discussion – in pairs
What sorts of things could your client (from
role play) think about doing to check out the
new perspective they have developed?
Working on the Process of Thinking
As well as working with the content of
thoughts it may also be helpful to work on the
Unhelpful thinking processes include thought
suppression, rumination and worry, and
meta-cognitive concerns (+ and -)
identified as transdiagnostic problems (Harvey et al.,
CBT intervention would focus on the
process, rather than specific content
Further Cognitive Techniques (see Leahy 2007)
Cost-benefit analyses / advantages-disadvantages
Useful as a motivational technique
Short-term vs. long term
Pie charts (see Greenberger & Padesky / Leahy)
Good for exploring a range of alternative perspectives
Aim of reducing probability estimates for catastrophic outcomes
Particularly useful for guilt and anxiety problems
Step 1: Belief rating in target thought (%)
Step 2: Develop list of alternative explanations (incl rating)
Step 3: Fill out the pie, starting with the most benign
Step 4: Review pie, reappraise original belief rating
NATs: using imagery and role play
Imaginal rehearsal – imagining self coping in a
Transforming problem images:
- developing a more positive ending
- manipulating distressing images
- updating problem images in PTSD (see Grey, Young and
Constructing an image of how client would like things
to be - can help clarify the thoughts and behaviours
associated with this way of being (Padesky & Mooney, 2005)
Role play - testing out new skills in safer context
Compassionate mind development ( - see Gilbert 2005)
Appraising NATs – common problems
Client cannot label emotions
Client cannot identify thoughts
Avoidance (affective or cognitive)
Client does not think it will be helpful
Client is scared that they will feel worse if
they focus on thoughts/ feelings
Aimless / meandering questions
There is no affective and/ or cognitive
change after challenging the NAT
Appraising NATs – common problems
Does the client understand and accept the CBT
model? Are they motivated to change?
Has a specific situation been described?
Has mood/ thought been clearly identified?
Is NAT being tested “hot”/ central for the client?
Are there multiple hot thoughts? Is there an even
hotter thought? Check with the client.
Has all the evidence for/ against the thought been
identified and challenged?
Is the alternative believable/ testable?
Is the NAT a core belief too?
Addressing difficulties: Points to
„Golden rule‟ - go back to the formulation –
does this predict any specific problems that
E.g. Avoidance, shame, skills deficits, core beliefs
Does the client require further
psychoeducation about thoughts/ feelings
and usefulness of focusing on them in
Use the downward arrow to identify and
challenge metacognitions e.g. “if I focus on
my thoughts I will go mad” or “if I tell my
thoughts to my therapist they will think I am
Consider the therapeutic alliance – does the
client feel safe to disclose and challenge
thoughts in the session?
What if the NAT is/ might be true?
Cost benefit analysis of thinking this way
Cognitive problem solving skills
Discriminate unpleasant emotion
Identify trigger (internal or external)
Identify NATs accompanying emotion
Search for more realistic/ helpful alternatives
Generate solutions/ coping strategies
Test out in action (behavioural experiments)
Reinforce changes in thinking by assessing
outcome of action (or return to 4)
Common problems with Socratic Questioning –
challenges for the therapist (Westbrook et al., 2007)
Aimless, meandering questions
Remember to ask questions pertinent to the formulation
Keep questions short, written summaries, tape
Self reflection, listen to tapes
Acknowledge and work on problems in the relationship
Exploration but no synthesis
Remember to synthesize information with accurate
summaries that can be linked to the formulation
Yes, but.... Do we need to challenge thoughts?
(Longmore and Worrell., 2007)
Component analysis suggests no additional
benefit of adding cognitive to behavioural
Across a range of disorders there seems to be
little difference between CT, BT and CBT
Limited evidence that cognitive change mediates
Different interventions may help people to switch
modes or schematic models.
Modes/schematic models contain multiple
representational elements. Targeting one aspect
of a system may lead to change in the others.
Reflective Practice – groups of 4
What have you learned about identifying and
From the client‟s point of view
As a therapist
How will this impact on your practice?
What do you need to do to develop these
Beck, J. (1995). Cognitive therapy: Basics and
beyond. New York: Guilford.
Kennerley, H. (2007). Socratic Method. Booklet
available from the Oxford Cognitive Therapy Centre -
Leahy, R.L. (2003). Cognitive therapy techniques: A
practitioners guide. New York, Guildford.
*Padesky, C.A. (1993a). Socratic questioning:
Changing minds or guiding discovery? Keynote
address delivered at the European Congress of
Behavioural and Cognitive Therapies, London. See
Westbrook, D., Kennerley, H., and Kirk, J. (2007). An
introduction to cognitive behavioural therapy: Skills
and applications. London: Sage.