CBT For Chronic Illness And Palliative Care: A Workbook and Toolkit Nigel Sage, Michelle Sowden, Liz Chorlton and Andrea Edeleanu Slide Set 4 Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Dealing with Difficult Questions Can Socrates Help? Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Socrates Philosopher Born 470 BC in Athens Died 399 BC by state ordered “suicide” using Hemlock Never wrote anything down Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Famous (attributed) Quotes One thing only I know, and that is that I know nothing. The unexamined life is not worth living. To find yourself, think for yourself. Wisdom begins in wonder. I cannot teach anybody anything, I can only make them think. Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Socratic questioning Why are you going back to bed? Because I want to. What is the reason you want to? Because I’ll feel better. For how long? A few minutes. And what will happen after that? I suppose I’ll feel worse again. How do you know? Because this happens every time. Have you ever found not giving in to the urge to return to bed has helped? When I get active I feel better. Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Purpose of SQ Tease out: Reframe the issues Clarify: False assumptions Inconsistencies of beliefs Contradictory views Double standards Faulty conclusions Reframe the issues Clarify: Alternative perspectives Choices Means by which to make choices Develop a way forward Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

SQ Method (Guided Discovery) Ask questions that: The patient has the answers to Draw attention to relevant issues and information Move from concrete to abstract Help patient learn to question Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Socratic Questions Ask questions that: Are simple and informal. Naïve Enable you and the patient to understand more fully what is being talked about identify what is not understood. Assume nothing Examine inferences being drawn by the patient from specific events. Non-judgemental Enable you and the patient to distinguish between fact, belief and opinion. Advice free Explore the possibility of alternative perspectives. Curious Encourage identification of the most helpful perspective. Focused Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Difficult theme: There is no point to life any more. Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Is that a change from before? Why do you say that? Because I can’t see any. Is that a change from before? Yes, I used to have a future to look forward to. Do you have no future at all? Not much of one because this cancer will kill me. So what will you do with the short future you do have? I don’t know. Have you got any plans? Not really, and that’s why life seems so pointless. Would making plans that fit with in a shortened future give life some more point? Well, it might do. Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Difficult theme: How long have I got to live? Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

My consultant says it’s impossible to predict. What have you been told? My consultant says it’s impossible to predict. Don’t you believe your consultant? I think she is just trying to avoid upsetting me. If she said you’d be dead in 6 weeks, would that upset you? Yes, of course it would, but I can’t bear this uncertainty. Would you be less upset if she said you would live for a year? Probably. I could do more with my life if I live that long. Amongst those things you would do, are there things you want to do even if your life is shorter than that? Yes, I can think of some. If we prioritise these and see what you could do about them, would that help you cope better with this uncertainty? Perhaps. But supposing I don’t have time to do them all. Do you always achieve everything you set out to do? No, that’s true, I don’t. Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Summarizing The Socratic Style Be naïve Assume nothing Stay Non-judgemental Resist giving advice Be curious Remain focused Allow true discovery Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

“I cannot teach anybody anything, I can only make them think.” The best guided discovery is a genuine collaborative effort between two people who do not know where the questions and answers will eventually lead. “Wisdom begins in wonder.” Curiosity and effort to understand are part of the guided discovery process for both participants. Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

A sequence of questions described by Padesky: Have you ever been in similar circumstances? What did you do? How did that turn out? What do you know that you didn’t know then? What would you advise a friend who told you something similar? Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Other useful questions could be: What do you mean when you say X? What is the evidence that X is true? What might be the worst that could happen? And if that happened, what then? What leads you to think that might happen? Can you think of anyone else who copes well with difficult situations? How do you think they would deal with this challenge? Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Other useful questions could be: How does thinking that make you feel? Is there another way of thinking about it that might make you feel differently? Is there any other way of seeing the situation? What do you think you could change to make things better for you? Is there something else you could say to yourself that might be more helpful? What might you tell a friend to do in this situation? Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

CBT For Chronic Illness And Palliative Care: A Workbook and Toolkit Nigel Sage, Michelle Sowden, Liz Chorlton and Andrea Edeleanu Publisher: John Wiley & Sons (2008) ISBN: 978-0470517079 Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008