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An explanation of Guided Discovery in Cognitive Behavioural Therapy
Neel Halder ST6 Psychiatrist, Medical Education Fellow, North Western Deanery
Cognitive Behavioural therapy (CBT) has come to be associated with a set of guiding principles. These are methodological assumptions, or defining characteristics of the approach. One of these focuses on collaboration; that is the therapist encourages the client to view therapy as teamwork. Another, which is somewhat linked to the first, focuses on the use of guided discovery. This is in contrast to some other forms of psychotherapy where communication via interpretations is the norm. This article aims to provide a clear explanation of what guided therapy is, and how it is incorporated in CBT, using examples and personal perspectives, as well as from noted therapists in the field. The technique can be used in many other settings including psychiatric consultations.
What is Guided Discovery?
Guided discovery is based on asking a series of questions that allows information to be brought into the client’s awareness. The client is therefore encouraged to discover things for herself. Guided discovery is sometimes also known interchangeably as Socratic questioning as it is derived from the method of teaching employed by Socrates, as recorded in the Socratic Dialogues (Cooper, 1997). This consisted of asking questions, which then promoted reflection, which in turn produced knowledge. These terms are often used interchangeably, which can be misleading. Socrates tended to know exactly where he was going with his questions, which is not a necessity for guided discovery, as detailed below. Originally, Socratic questioning involved a questioning style similar to that of a cross-examination (Sieple, 1985). Repetitive questioning was used to force people to admit their ignorance (Nelson, 1980). This would often result in humiliation of the client (Chessick, 1982).
Socratic questioning can be a component for guided discovery, but there are other factors that are required, like collaboration and genuine curiosity (Padesky, 1993). Padesky (1993) argues that using Socratic questioning as a method for changing beliefs is not necessarily the same as guiding discovery (see below).
Therapists need not necessarily know the endpoint at the start of the dialogue with the client. Padesky (1993) states that if therapists are too confident with where they are going, “you only look ahead and miss a detour that can lead you to a better place”. Wells (1997) writes “..a combination of knowing where to go, but allowing time to explore the patients’ evidence for thoughts and for the patient to generate solutions is desirable”. If a therapist asks a question with an answer already in mind, the client may perceive this as manipulation.
Guided discovery incorporates one of the other underlying principles of Cognitive therapy, namely its empirical nature. There is the data gathering element, looking at the data in different ways with the client, and inviting the client to devise her own plans for what to do with the data and information (Padesky, 1993). Beck, Rush, Shaw & Emery (1979) coined the term “collaborative empiricism” which encapsulates the idea of a joint approach where the client provides raw data to be investigated with the therapist’s guidance. This notion of the client and therapist working together via collaboration and negotiation comes from Kelly’s idea of both working as “personal scientists” (Kelly, 1955).
Beck, Wright, Newman, Liese (1993) point out that “questions should be phrased in such a way that they stimulate thought and increase awareness, rather than requiring a correct answer”.
Padesky (1993) suggests that Socratic questioning consists of 4 stages
1) asking informational questions
2) listening attentively and reflecting back
3) summarising newly acquired information
4) asking analytic or synthesising questions to apply the new information to the client’s original problem or thought
She goes on to state that for guided discovery to occur, then the questions asked should be within the client’s knowledge base, should draw attention to the relevant issue under discussion (but may be outside the client’s focus) and generally move from concrete questions to more abstract. By the end, the client should be able to apply new information to a previously held belief or generate a new one.
Overholser (1994) looked at the Socratic method itself, used for guiding discovery. He suggested the method uses three main elements; systematic questioning, inductive reasoning and universal definitions. Systematic questioning is used to guide the interview process and help the client seek answers independently. Inductive reasoning helps clients generate broad, logical conclusions based on limited experience. Universal definitions help clients develop abstract generalisations that remain the same over time and different situations.
Why is it used?
Cognitive therapists invest a lot of time in guided discovery. As well as eliciting negative automatic thoughts, this technique can be used to help client develop alternative interpretations of their problems. Guided discovery is a 2-way process, incorporating the principle of collaboration. This can aid the therapeutic relationship, by helping the client feel respected, accepted and valued as part of a team. Merely telling someone what to do would not have the same impact. Guided discovery would be more productive in therapy in that the client is more engaged to consider the problem under discussion, as well as the solution. For guided discovery to work there must be a genuine curiosity on the therapist’s part to understand the client’s viewpoint. If the curiosity feels false or manufactured, then the client may withhold important information.
The psychiatrist Beck (1993) makes the following observation about guided discovery: “questioning leads patients to consider options and solutions that they have not considered…this approach puts patients in the questioning mode (as opposed to the automatic impulse mode) so that they will start to evaluate more objectively their various attitudes and beliefs”. The client not only thinks about the problem at hand, but also possible solutions. The client is more likely to learn from, understand, and remember the interaction if she comes up with her own answers with the therapist’s help.
Piaget’s (1972) cognitive model involved the concept of hierarchical structuring of knowledge. Overholser (1995) incorporated this when discussing how knowledge typically requires first hand experience (direct observation) as opposed to information told by another person (second hand information). He argues that even when told by an expert, clients are less likely to understand, remember, value or use this information as it has been obtained by passively listening. Guided discovery involves the client working actively and therefore more likely to be effective. By doing this, clients learn a new way of examining problems and finding alternative coping strategies.
Dobson (2001) suggests a good way of practising guided discovery is to audiotape the sessions; to stop the tape each time the therapist has given a declarative statement or a closed-question, and then to think how it could be re-phrased into a Socratic question. Therapists should not be drawn into responding too quickly. Socratic questioning requires the client to think about the answers. It may seem like the client is struggling for the answer, but any premature intervention “interrupts the client’s thought processes and disrupts the purpose of the Socratic question (DiGiuseppe, 1991).
Guided discovery enables the client to provide her own answers instead of relying on the therapist for his interpretations that could be wrong. Conversely, the therapist may become convinced that the client’s thoughts or interpretations are mistaken, and tell her so, but this may well leave her with doubts and concerns. These doubts can be minimised and eliminated altogether if they were addressed in discussion between the therapist and client through guided discovery. This can put the client in a “compromising position- in that it is simpler to agree than disagree, or seem ungrateful or difficult” (Blackburn and Twaddle, 1996). So clients provide answers that they think the therapist wants to hear instead of learning to think independently. Also the therapist may only hear what he is expecting the answers to be. Assumptions can distract from the process of guided discovery as the therapist’s own cognitive distortions and thinking errors may be at play. Even if the interpretations are correct, it is the therapist doing the cognitive work and the client may not be learning how to identify patterns and use skills to solve similar problems in future. If the client perceives the interpretation as inaccurate, it can leave her feeling misunderstood and damage the therapeutic relationship. Overholser (1995) states that the “best insights come from the client, not the therapist”. Levy agrees that clients should be helped to arrive at their own interpretations (Levy, 1963). Direct advice can lead to the client blaming the therapist of the advice is ineffective.
There are different ways in which discovery can take place. The therapist may know the answer to the client’s problems, and direct her in the preferred direction in order to change her cognitions. Padesky (1994) makes the point that in circumstances where the therapist does not have all the answers, but rather genuine curiosity, then the discovery the client makes here is owned by the client and is more likely to lead to a successful outcome. This method may well take longer, but its effectiveness may well make the time spent pay off. She goes on to say, “in most cases, I think a direct challenge of beliefs is not as therapeutic as guided client discovery. If we lose the collaborative empiricism of cognitive therapy, we lose its long term benefits.”
There are limitations to the use of Socratic questioning to guide discovery. Overholser (1993) states there are some groups like young children, people with dementia or organic brain syndromes who may be too rigid or concrete in their thinking. Padesky (1993) talked about moving from concrete questioning to more abstract for guided discovery to occur. Those groups mentioned may lack the abstract abilities to benefit. Nevertheless, for those whom it is thought may benefit, it is important to spend time in the process of guided discovery. Merely telling them what to do will not promote self-initiated discovery. This is important because explicit instructions are thought to be counterproductive most of the time (Claiborn & Dixon, 1982).
One of the key processes in CBT is to enable the client to become his or her own therapist and eventually work through any problems without the therapist’s aid. The Socratic method used to guide discovery can promote autonomy (Overholser, 1987). Resistance towards the therapist and therapy is one potential for unsuccessful outcome. Telling clients what to do may well serve to increase the chances of resistance. Overholser (1991) showed that the using the Socratic method can reduce this effect. Guided discovery using the Socratic process can help clients identify and develop skills they lack, identify and self-correct illogical reasoning and learn to find answers independently (Seeskin, 1987). Learning by discovery produces better understanding and is more powerful than direct instruction (Legrenzi, 1971), because it emphasises the learning process instead of the specific content. It therefore promotes skill that can be generalised across different situations and strengthens the client’s ability to solve novel problems (McDaniel & Schlager, 1990).
Beck’s model of cognitive theory continues to be at the forefront of models used in clinical practice today (Beck, 1967). Guided discovery helps to identify and explore the client’s underlying assumptions without the therapist assuming the answers. Clients can then challenge their underlying beliefs, and guided discovery can facilitate client’s self-exploration. This can enhance rapport and therefore the therapeutic alliance. If the style was that of telling the client the answers, this would suggest inequality, with the therapist assuming a superior role. An attitude of “intellectual modesty” on part of the therapist would enhance the therapeutic relationship (Overholser, 1995).
Rational Emotive Behaviour Therapy employs a multi-dimensional approach which incorporates cognitive, emotive and behavioural techniques. Of these the major therapeutic tool used is a “logico-empirical method of scientific questioning, challenging and debating” to help clients with irrational beliefs (Ellis, 1979). Guided discovery incorporates many of these notions; the data gathering, looking at evidence, analysing information and collaboratively debating what it could mean.
Adler and Horney’s cognitive model involved a phenomenological approach and its contention that the view of one’s self and of the world is central to the determination of behaviour (Adler, 1936; Horney, 1950). However, the therapist never has direct access to the client’s phenomenological experiences, and remains dependent on the client for descriptions. Guided discovery blends the therapist’s professional theories with the client’s phenomenological experiences for effective therapy (Overholser, 1995).
The following is an extract about a fictitious client, which serves to illustrate the points made above. She was having episodes of anxiety at night and believed alcohol helped her. She questions why the therapist does not just tell her the answers.
C: If I’m drunk then I’ll be in a deep sleep and shouldn’t really wake in the middle of the night.
T: Do you think it’ll be useful to look at stages of sleep?
C: Yeah, I’d like to talk about that. Why don’t you just tell me and I’ll listen?
T: Well, you know one of the principles of CBT that we talked about in the beginning of our sessions was that I’d guide you to find your own answers. What do you think would happen if I were to tell you the answers, like in a lecture?
C: If it were interesting I would listen
T: What about the impact on your thoughts and beliefs?
C: Hmm, I’m not sure
T: For example you’ve been working hard in completing the monitoring form yourself. What did you learn from doing those?
C: That it makes no difference to your anxiety episodes whether there were other people in your flat or not.
T: What would have happened if I were to tell you that I thought this would be the outcome prior to you doing this work?
C: I wouldn’t have believed you
T: Hmm, so how does this fit with your initial wish for me to tell you the answers?
C: Yeah, it’s true, If you were just telling me the answers, I wouldn’t really take it on board and probably wouldn’t believe you. But if I do it myself I’m more likely to remember it and believe it.
T: So is the rationale clear to you about why it’s not like a one way process with me telling you things?
C: Yeah, I understand. It’s better I work it out myself with your help.
The reasons described above detail why guided discovery is such an important process rather than merely telling clients what to do. Overholser’s (1995) described guided discovery being analogous to a jigsaw puzzle. The therapist’s role is to make sure all the pieces are on the table. If the client attempts to force pieces that don’t fit together or is getting stuck, then the therapist can point out where the corner or edge pieces are likely to be found. Ultimately it is the client who fits the pieces together. If the therapist tells the client the answers (i.e. fits the jigsaw puzzle in front of the client), then the client will ultimately not gain the satisfaction of completing this herself.
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First Published December 2010