23 Mar 2015
This essay will explore the role of guided discovery and associated techniques in helping clients understand the origin of their problems, their maintaining factors and the processes that will allow them to bring new perspective to the problems. The paper primarily discusses the role of Socratic dialogue and its facilitating role in the process of guided discovery, and subsequent cognitive and behavioural change. In this context, the role of 'telling' clients is also discussed, with a focus on how the didactic approach influences and impacts on the overall therapeutic relationship and patient outcome.
Guided discovery is fundamental to the discipline of Cognitive Behavioural Therapy (CBT) and has been described as the 'prime tool' in the cognitive therapist's range of skills, helping clients 'to explore evidence for and against their ideas, to search for an alternative perspective, and to examine how realistic and helpful these are by carrying out experiments in the real world and observing the results' (Fennell 1998; Padesky 1993). The process of guided discovery is underpinned by the principle of involvement and facilitation of the client, with the therapist guiding the client's exploration of their own circumstances, with an emphasis on facilitating rather than direct teaching (Overholster 2011). Guided discovery as a tool is based on the belief that clients are best placed to find answers to their own very specific problems, 'building personal resilience and fostering the ability in clients to ask pertinent and accurate questions of themselves in order to evaluate their cognitive biases independently' (Rutter & Friedberg 1999). As a term, guided discovery is often used correspondently with Socratic questioning, a questioning style through which the therapist facilitates the client's exploration of their thoughts, images, beliefs, behaviours and feelings (Calvert & Palmer, 2003). Socratic dialogue is essential in guided discovery due to the dynamic it creates between therapist and client, putting clients in the questioning mode as opposed to the automatic impulse mode, encouraging clients to consider their own circumstances more objectively (Beck, 1993). The role of the therapist in guided discovery is less autonomous than the didactic approach, with an emphasis on collaboration with the client and new ways of understanding with the aid of the learning cycle and active participation (Bishop & Fish, 1999; Westbrook, Kennerley & Kirk 2011).
Guided discovery works on the basis that learning is more powerful, and useful, when obtained through a process of discovery rather than passive listening. When learned by discovery, information that is acquired will more readily transfer to new situations in which the client needs to address other negative thoughts and behaviours, as the focus is on developing general skills rather than context-specific learning (Legrenzi, 1971; McDaniel & Schleger, 1990). The philosophy of guided discovery is encapsulated in the Confucian proverb 'Tell me and I will forget; Show me and I will remember; Involve me and I will understand'. Alternatively, didactic learning and telling clients what to do is geared towards specific problems or situations that does not encourage clients to develop the necessary skills for future challenges, nor does it encourage them. The didactic method does not make allowances for how well, or on what terms, a patient understands their problems. In a paper entitled 'They didn't tell us, they made us work it out ourselves', Dures et al(2003) conducted a comparative study involving a group of clients with chronic Rheumatoid Arthritis who considered the guided discovery process to significantly enhance their ability to manage their long term conditions compared to a more didactic approach. Involving clients in discovering and drawing their own conclusions are more likely to lead to conclusions that are both memorable and convincing (Westbrook et al 2011), and thus more likely to be both remembered and replicated when required. Research with clients and therapists supports the notion that guided discovery encourages a greater understanding on both sides of the relationship regarding the distressing experience of clients (Calvert & Palmer, 2003), assisting the development of an effective and complimentary therapeutic alliance.
The Socratic method of questioning consists of three main elements in relation to helping clients discover why they have their problems, what sustains them and how they can be changed. Overholster (1994) identified them as systematic questioning in the interview process, inductive reasoning generating logical conclusions based on limited experience and universal definitions that help clients develop abstract generalisations as key to this process. This is reinforced by Padesky (1993), focusing on the importance of looking at data in conjunction with the client and inviting the client to devise their own plan for what to do with the information. This forms the basis for guided discovery and the client-practitioner relationship. The process has been likened to an archaeological dig during which both the nurse and the client are discovering the bones of the problem (Calvert and Palmer, 2003), providing an accurate overview of the client's past to encourage a re-examination of experiences that may not previously have been acknowledged as significant. Simple questions can clarify and articulate the connection between feelings, thoughts and behaviours which would ultimately help them understand where their problems came from. This forms the basis for the formulation of the client's difficulties and helps both the therapist and client to build a coherent narrative of their previous experiences (Kennerley 2007), and provides the platform for discovering new ways of thinking. Socratic questioning allows clients to stand back and review and reflect the bigger picture. There are important attributes that a therapist must use whilst guiding discovery. They must be non-judgemental and ask open questions, ensuring the client does not feel encouraged to give specific answers through leading questions. Using the language of the client is particularly important to accurately reflect their own understanding and experiences, as the therapist and client must 'communicate and agree on a shared understanding of the problems being discussed' (Calvert & Palmer, 2003).
One of the most powerful components of the learning model of psychotherapy is the client beginning to incorporate some of the therapeutic techniques of the therapist (Beck et al, 1979). The process of guided discovery makes full use of the range of therapeutic tools and competencies, requiring empathy, listening, genuine curiosity and collaboration on the part of the therapist (Padesky, 1993). Involving a client in guided discovery requires greater dexterity on the part of the therapist than taking a didactic approach would. The therapist should be prepared to ask the client questions that they can answer, and to do so must develop an understanding of both the client and how the client understands and relates to their own problems. The process also demands a move away from absolute, concrete questioning to a more abstract form to gain further information. The tone of therapy is also important, as for guided discovery to work there must be a genuine curiosity on the therapist's part to understand the client's viewpoint (Westbrook, 2011; Padesky, 1993). The therapist's aim is to communicate warmth, empathy and a non-judgemental attitude, whilst minimising the client's angst, so as to facilitate engagement, lateral thinking and recall (Kennerley, 2007). This is essential whilst in pursuit of the final intention of the client taking a leading role in the therapeutic alliance.
The dialogue of guided discovery contrasts with the process of telling clients what their problems are and how to deal with them. This process also leaves the client's problems, and their experience of their problems, open to misinterpretation due to a more rigid, prescriptive approach. Telling patients what their problems are, and how they are to be fixed, also significantly alters the therapeutic dynamic. Without a fuller understanding of the client's background there is a possibility of the therapist acting incorrectly, and it also introduces an imbalance and inequality to the therapeutic relationship, with the therapist assuming a position of superiority. The therapeutic attitude of 'intellectual modesty' is called for in guided discovery in order to enhance the therapeutic relationship (Overholster, 1995). Beck et al (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'. The process of guided discovery avoids the absolutism of telling people what to do, encouraging a more diverse and varied approach to facilitating a wide range of clients into gaining a greater understanding of their current situation and of themselves. The more prescriptive, didactic approach can potentially deprive clients of a process through which they may acquire the knowledge to solve any problems encountered in the future. The process of telling clients what they should do may also leave them in a position of doubt regarding their own thought processes if it contradicts their own experience, or is not relayed in language that they can understand. Being overly-prescriptive can put the client in a difficult position, compromising them to a point where it is simpler to disagree rather than appear ungrateful, difficult, or wrong (Blackburn & Twaddle, 1996). Hoyt (2000) highlights the importance of practitioners making conscious efforts not to act as 'surrogate frontal lobes for clients', retaining the role of facilitator and guider only.
Socratic questioning is a useful tool for enabling clients to identify how specific psychological problems have been maintained through safety-seeking behaviours, reduction of activity, hyper-vigilance and catastrophic misinterpretation (Westbrook, 2011). When clients with anxiety disorders don't face their fears the maintaining cycle remains intact and prevents them from learning that their overestimated dangers are unrealistic. It is important that clients make the link through case conceptualisation that their safety seeking behaviours and catastrophic misinterpretations intensify their psychological problems. The therapist makes the use the CBT framework which incorporates a disorder specific or individualised formulation to illustrate to the client's awareness of what is maintaining their problems (Westbrook, 2011). Metaphorical Socratic questioning and analogies may also help the patient identify the maintaining factors for their psychological problems. The use of analogy can increase client cognitive flexibility, helping clients understand their problems from a different perspective which means that this allows the patient to see what maintains their problems without the therapist directly informing them (Overholster, 1993; Blenkiron, 2005). This is not something that is available to clients through a strictly didactic approach. In the process of guiding the client, the use of imagery techniques can assist the client in understanding that their anxieties are maintained because of the spontaneous imageries they hold of themselves which also further prevent them from discovering that nothing catastrophic will happen (Clark & Wells, 1995). This is evident in clients with social anxiety where they hold vivid mental picture of themselves as being incompetent in social situations. Use of the imagery technique will enableclients to identify how their perception of themselves in situations can intensify their anxieties whilst further preventing them from fully experiencing their anxiety symptoms (Hackmann, Bennett-Levy and Holmes ,2011). Hackmann stresses the importance of the therapist continuing as a non-intrusive facilitator of the image, using questioning to enhance the vividness and experience and explore links between thought and behaviour. Well structured Socratic questions can enable the client to reflect on past experience from a new perspective. The process of guided discovery is constantly concerned with the possibility of unlocking the powerful potential for self-healing within patients, and for patients to begin considering themselves as the person best placed to solve their own problems.
It is important that both the therapist and the client use an experimental approach to evaluate client's beliefs, behaviours, moods and plan for change (Padesky & Greenberger, 1995). Guided discovery facilitates this by encouraging the client to test their beliefs and thoughts through cognitive restructuring, looking at alternative interpretations for events and evaluating new behaviours. Cognitive restructuring and behavioural experiments are amongst the most powerful method for facilitating change and form a key component of treatment (Bennett-Levy et al 2004).The use of thought records in CBT can form the basis of encouraging the client to develop an alternative perspective through identifying the relevant emotions and cognition, exploring the validity of cognitions and then synthesizing a new perspective where appropriate. When working on automatic thoughts in CBT, the therapist's task is to teach the client how to critically assess their thoughts and view them as hypotheses that they may, but do not have to, find to be true (Vyskocilova and Pracsko (2012). Through getting to use a thought diary the client learns to stand back, review the situation and develop new perspectives. Furthermore, the client learns to identify their own emotions and key cognitions, exploring the validity of the thought and synthesizing new attitudes and approaches to old problems. Through the use of homework and rehearsal this procedure can be mastered which will ultimately help the client in overcoming future adversities (Calvert & Palmer, 2003). Thus, the ultimate aim is for the client to become both Socrates and his disciple (Vyskocilova and Pracsko, 2012). Zayfert and Becker (2007) suggested that cognitive restructuring is best method for facilitating this change, in which questions help the client discover new meanings and beliefs.
The use of imagery and role-play are invaluable techniques in manipulating unhelpful and detrimental cognitions. The process of guided discovery creates an environment where clients may replace disturbing, vivid images with more positive images.. Overholster (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). E Clients are less likely to understand, remember, value or use this information as it has been obtained by passively listening. The active search process brings the information more vividly to life as patients discover for themselves the answers to their questions in the context oftheir direct personal experience. Overholster (2011) stresses the importance of therapy promoting autonomy and independent decision making in patients. Most people do not like to be told what to do or what they should believe. When therapists pressure their clients to make specific changes, the therapy will inevitably suffer as a result. It works best when the therapist strives to promote an active alliance instead of passive compliance with therapy, astherapy facilitates change through greater self awareness and improved knowledge. Levy (1963) felt that patients should always be helped to arrive at their own interpretation and direct advice can lead to the patient blaming the therapist if the advice given is ineffective. Merely telling patients what to do will not promote self initiated discovery, nor lead to long-term satisfaction for both client and therapist.
It is crucial to the long-term success that clients are able to tackle setbacks productively through relapse management. In order to prevent relapse the clients need to ask themselves what they have learnt from therapy, and what they would subsequently do differently. Relapse management is an investment of time, but is worthwhile in order to prevent the 'revolving door' of patients constantly returning to services, as well as ongoing frustration on the part of patients as they struggle to manage their problems in the future. This also highlights the importance of building resilience.. The didactic model of teaching does little to facilitate students learning how to adapt creatively to the changing world in which they exist; in fact, a didactic approach can contribute to inappropriate, ineffective, and unhealthy coping responses (Stoner & Martin, 1993). Despite the importance of the ability of patients to manage their own problems successfully in the future, there is very little research on CBT interventions in terms of their long-term success, or the long term success of patients in managing their disturbing thoughts in the future. This is a gap in research that requires more urgent and rigorous evaluation.
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