1. 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

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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

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

10. 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

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

12. 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

13. 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

14. “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

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

16. 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

17. 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

18. 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

19. 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:
Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008