dialogues in philosophy, mental and neuro sciences · good life: the ancient art of stoic joy’,...

www.crossingdialogues.com/journal.htm

Crossing Dialogues

Association

10

Dialogues in Philosophy, Mental and Neuro Sciences

Stoic philosophy and psychotherapy: Implications for neuropsychiatric conditions

A E. C 1,2,3

1: Department of Neuropsychiatry, BSMHFT & University of Birmingham, Birmingham (United Kingdom); 2: School of Life and Health Sciences, Aston Brain Centre, Aston University, Birmingham, (United Kingdom); 3: Sobell Depart-ment of Motor Neuroscience and Movement Disorders, Institute of Neurology and University College London, London, (United Kingdom).

Hellenistic philosophy has multiple parallels with modern psychotherapy and provides several theories, strategies, and techniques of practical value in clinical care, with particular reference to patients with neuropsychiatric conditions. The ancient therapeutic practices of Socratic philosophy, especially Roman Stoicism, reached us through the surviving texts of the three best-known Stoic authors: Seneca, Epictetus, and Marcus Aurelius. Both Albert Ellis and Aaron Beck, often regarded as the founders of rational emotive behaviour therapy and cognitive behavioural therapy, respectively, explicitly acknowledged the role of Stoicism as the philosophical precursor of their treatment approaches. The main analogy between Stoicism and modern psychotherapy is the assumption that cognitive activity (reasoning) aff ects emotions and behaviours: “men are disturbed not by things, but by the views which they take of things”, in Epictetus’ words. From the observation that cognitive activity can be monitored and altered, it follows that desired emotional and behavioural changes may be achieved through cognitive changes. Moreover, aspects of the ‘third wave’ of modern psychotherapy (mindfulness) closely resemble the ancient Stoic practice of attention or ‘concentration on the present moment’. Stoicism-derived psychological techniques can prove useful in the clinical management of patients with neuropsychiatric disorders. For example, movement disorders are chronic neuropsychiatric conditions characterised by the presence of both motor and non-motor symptoms, which are often psychological and aff ect patients’ health-related quality of life more deeply than motor features. Recent fi ndings have shown that cognitive behavioural therapies can be eff ective interventions for patients with movement disorders, especially Tourette syndrome and Parkinson disease. The benefi cial eff ects are not limited to anxiety and aff ective symptoms and prompt further research, across diff erent modalities. After providing a background on Stoicism as a Socratic philosophy based on practical techniques of mind therapy, the present paper highlights parallelisms between Stoicism and modern psychotherapy. Analysis of the texts of the Roman Stoics suggests that several types of psychotherapeutic practice currently in use in neuropsychiatry can be traced back to the Stoic tradition of philosophical therapy. Specifi cally, it has been argued that Seneca’s ‘Letters from a Stoic’ can be read as a precursor of individual psychotherapy, Epictetus’ ‘Discourses’ and ‘Handbook’ resemble recordings of group therapy sessions and self-help manuals, and Marcus Aurelius’ ‘Meditations’ can be regarded as an early example of therapy journal.

Keywords: cognitive behaviour therapy, Hellenistic philosophy, mindfulness, neuropsychiatry, psychotherapy, Stoicism.

DIAL PHIL MENT NEURO SCI 2019; 12(1): 10-24

ORIGINAL ARTICLE


Cavanna, 2019

THE RENAISSANCE OF STOICISM: PHILOSOPHY AS MEDICINE

“It has not escaped our notice” (to borrow a famous incipit from world-class scientifi c literature) that an unprecedented series of books linking the ancient Greek philosophy of Stoicism with the modern science of well-being have been published over the last decade. To quote but a few examples, the works of American philosophers William Irvine (‘A guide to the good life: The ancient art of Stoic joy’, 2009) and Massimo Pigliucci (‘How to be a Stoic’, 2017) have been widely read and discussed. In the United Kingdom and Canada, Scottish psychologist Donald Robertson has focused his excellent work on the key role of Stoicism as the conceptual foundation of modern psychotherapy (‘The philosophy of cognitive-behavioural therapy: Stoic philosophy as rational and cognitive psychotherapy’, 2010; ‘Stoicism and the art of happiness’, 2013). During the last two decades of the XX Century, the late classics scholar Pierre Hadot in France and the infl uential philosopher Martha Nussbaum in the United States paved the way for the present Renaissance of applied philosophy based on the Hellenistic tradition of philosophy as practical wisdom providing psychological therapy or mind training (Hadot, 1981; Nussbaum, 1994). More recently, American philosopher Lawrence Becker published the new edition of a daring exposition of what Stoic philosophy would look like today if it had enjoyed a continuous development from the Hellenistic age, through the Renaissance, the Enlightenment, and modern science, to the current trends of moral philosophy (Becker, 2017).

The role of ancient philosophy as mind therapy is acknowledged within the diverse traditions of Hellenistic philosophy, which stemmed from the teaching of Socrates (470-399 BCE) in Athens, as recorded by Plato (428-347 BCE), the founder of the Academy, and mediated by his later disciples, especially Aristotle (384-322 BCE), the founder of the Lyceum. The Hellenistic philosophies fl ourished across the

11

Mediterranean societies since Alexander the Great (356-323 BCE) marked the end of the stability of the Greek city-state (polis) and exposed the citizens of his empire to diff erent cultures and worldviews. It was during the Hellenistic age, an era of increasing uncertainty, that the main focus of philosophy shifted from the study of universal nature to the understanding of individual man (introspection). The rival Socratic schools of Stoicism, Epicureanism, Cynicism, and Skepticism started diff erent traditions, and were indeed characterised by inner debates and tensions, however it is important to note that they shared the view of the role of philosophy as practical guide for life and powerful therapy for psychological distress. In one of his surviving fragments (221 Usener), Epicurus (341-270 BCE) was quite clear about the role of philosophy as medicine for the soul: “A philosopher’s words are empty if they do not heal the suff ering of mankind. For just as medicine is useless if it does not remove sickness from the body, so philosophy is useless if it does not remove suff ering from the soul”2. Interestingly, the surviving philosophical texts of the Roman writers such as the eclectic Cicero (106-43 BCE) show evidence of medical terminology and suggest that the view of philosophy as therapy of the mind was widely endorsed. In his ‘Tusculanae disputationes’ (‘Tusculan Disputations’), Cicero described philosophy as ‘Socratica medicina’ (‘Socratic medicine’) and ‘animi medicina’ (‘medicine for the soul’), and drew a compelling parallel between the role of the philosopher in the treatment of mental disease (‘animi morbum’) and the role of the physician in the treatment of physical disease. The therapeutic role of philosophy was particularly evident within the Stoic tradition. Although it is appropriate to distinguish diff erent philosophical movements and stages within Stoicism, it appears that the analogy between philosophy and medicine is a key theme across thinkers and times. For example, in the fi fteenth letter of his

“When evening comes, I return home and enter my study; on the threshold I take off my workday clothes, covered with mud and dirt, and put on the garments of court and palace. Fitted out appropriately, I step inside the venerable courts of the ancients, where, solicitously received by them, I nourish myself on that food that alone is mine and for which I was born; where I am unashamed to converse with them and to question them about the motives for their actions, and they, out of their human kindness, answer me. And for four hours at a time I feel no boredom, I forget all my troubles, I do not dread poverty, and I am not terrifi ed by death […]” 1

Niccolò Machiavelli, Letter to Francesco Vettori (10 December 1513)


‘Epistulae morales ad Lucilium’ (often translated as ‘Letters from a Stoic’), Roman politician and philosopher Seneca (4 BCE - 65 CE) wrote “Recte nos dicimus ‘si philosopharis, bene est’ […] Sine hoc aeger est animus” (“We rightly say ‘if you are studying philosophy, it is well’ […] Without wisdom the mind is sick”). Finally, the Socratic concept of philosophy as medicine for the soul, that became commonplace throughout the Hellenistic age, reverberated in the teaching of another Stoic philosopher, Epictetus (50-135 CE), as reported by his disciple Arrian at the beginning of the II Century CE: “ἰατρεῖόν ἐστιν […] τὸ τοῦ φιλοσόφου σχολεῖον” (“the philosopher’s school is […] a doctor’s clinic”) (‘Discourses’, III,23). Of note, the recent discovery of the essay ‘Περὶ ἀλυπίας’ (‘Avoiding distress’) by the famous Roman physician Galen (130-210 CE) suggests that the link between philosophy and medicine was more than a philosophical metaphor. Galen’s engagement with Stoic psychotherapy techniques locates his work within the tradition of practical ethics of the Roman period (Xenophontos, 2014).

The late French scholar Pierre Hadot provided the fi rst detailed analysis of the various exercises of a therapeutic nature to be found in classical philosophy, with focus on ancient Stoic literature. Hadot’s account of the function of most ancient philosophies as spiritual exercises (‘ἀσκήσεις’) is highly revealing and deserves to be quoted in full: “All schools agree that man, before his philosophical conversion, is in a state of unhappy disquiet. Consumed by worries, torn by passions, he does not live a genuine life, nor is he truly himself. All schools also agree that man can be delivered from this state. He can accede to genuine life, improve himself, transform himself, and attain a state of perfection. It is precisely for this that spiritual exercises are intended. Their goal is a kind of selff ormation, or paideia, which is to teach us to live, not in conformity with human prejudices and social conventions - for social life is itself a product of the passions - but in conformity with the nature of man, which is none other than reason. Each in its own way, all schools believed in the freedom of the will, thanks to which man has the possibility to modify, improve, and realize himself. Underlying this conviction is the parallelism between physical and spiritual exercises: just as, by dint of repeated physical exercises, athletes give new form and strength to their bodies, so the philosopher develops his strength of soul, modifi es his inner climate,

transforms his vision of the world, and, fi nally, his entire being. The analogy seems all the more self-evident in that the gymnasion, the place where physical exercises were practiced, was the same place where philosophy lessons were given; in other words, it was also the place for training in spiritual gymnastics”3 (Hadot, 1995). Crucially, Hadot showed that the Hellenistic schools of philosophy shared the assumption that the consistent use of reason, combined with eff ort and training, can allow human beings to rise above their circumstances and conquer their emotions and desires. This is hardly surprising, as Hellenistic philosophy, in all its derivations, stems from the Socratic teaching and his attitude toward the centrality of reason: “for I am not only now but always a man who follows nothing but the reasoning which on consideration seems to me best”4 (Plato, ‘Crito’, 46b).

ASPECTS OF STOIC PHILOSOPHY AND PSYCHOLOGY

Among the Hellenistic schools of philosophy, Stoicism (especially in its late, Roman stage) arguably off ers the most obvious parallels with modern psychotherapeutic practices. Stoicism owes its name to the ‘ποικίλη στοά’ (‘painted porch’ in ancient Greek): a colonnade overlooking the central square of Athens where Zeno of Citium (334-262 BCE) taught his disciples from around 300 BCE. Zeno is commonly regarded as the founder of Stoicism, a philosophical school heavily infl uenced by the teachings of Socrates, mediated by the Cynic philosopher Antisthenes (444-365 BCE). Stoicism is usually divided by scholars into three phases. The fi rst phase, or Early Stoa, featured Zeno and the philosophers who were heads of the Stoic school after him, including Cleanthes (262-230 BCE) and Chrysippus (230-207 BCE). The introduction of the Stoic teachings to Rome by the philosophers Panaetius of Rhodes (180-110 BCE, head of the Stoic school during the period 129-110 BCE) and Posidonius of Apameia (135-51 BCE) marked the development of the Middle Stoa. Finally, the Late or Roman Stoa partially overlapped with the early Christian era and was characterised by the activity of three key fi gures: the Roman philosopher and politician Lucius Annaeus Seneca (4 BCE - 65 CE), the freed slave Epictetus (50-135 CE), and the philosopher-emperor Marcus Aurelius (121-180 CE) (Figure 1). The only surviving texts from the Early Stoa and the Middle Stoa are scattered fragments, whereas a few complete Roman texts

12


Cavanna, 2019

Aristotelian sense. The original sense of the Greek term ‘ἀρετή’ (often translated as ‘virtue’) is simply ‘excellence’: it did not involve any restricted or special sense of ‘morality’, as the term ‘virtue’ tends to do for us. To the eyes of the Stoic sage, virtue is the only good (leading to a happy life, or ‘εὐδαιμονία’ – sometimes translated as ‘well-being’, ‘fl ourishing’, or ‘meaningfulness’) and lack of virtue (i.e. poor use of reason) is the only evil (Figure 2).

Figure 2: Francisco Goya, 1799: ‘El sueño de la razón produce

monstruos’ (‘The sleep of reason produces monsters’).

The importance of rationality for the Stoic concepts of human nature and virtue – as well as well-being and mental health – cannot be overestimated (Papadimos, 2004). Using mod-ern terminology, for the Stoics cognition forms the basis for the ability of the rational mind to free itself from unhealthy emotions (which are denied assent by rational judgement) and to pro-mote healthy emotions. It is clear that the Stoic approach relies heavily on the notion that rational thinking or cognition (a uniquely human facul-ty) has overriding power over emotions (mental states shared with lower creatures). A formidable rebuttal to the potential criticism of placing ex-cessive faith into the positive power of reason, was provided by Bertrand Russell in his popular book ‘The conquest of happiness’ (1930), that is often quoted as one example of modern Stoicism (Robertson, 2010):

“There is in many people a dislike of rationality […] There is an idea that rationality, if allowed free play, will kill all the deeper emotions. This belief appears to me to be due to an entirely erroneous conception of the function of reason in human life.

in ancient Greek and Latin from the Late Stoa have reached us.

Figure 1: A politician (Lucius Annaeus Seneca, 4 BCE - 65 CE), a

slave-born philosopher (Epictetus, 50-135 CE), and an emperor

(Marcus Aurelius, 121-180 CE): the Roman Stoics with extant texts.

There is a curious resemblance between the two major Hellenistic philosophies, Stoicism and Epicureanism, in that historically they have both been prey to misconception. Just like the doctrine of Epicureanism is commonly misunderstood as shallow hedonism, it is often erroneously believed that Stoicism aims at a passionless life, or at the suppression of emotions. On the contrary, Stoic philosophers were careful in distinguishing between unhealthy and healthy emotions. Unhealthy emotions (‘πάθη’) included fear, craving, and pleasure (concepts that might arguably overlap with modern diagnostic categories in psychiatry, such as depression, anxiety, and impulse control disorders): fear was defi ned as the irrational expectation of something bad or harmful, craving as the irrational striving for something mistakenly judged as good, and pleasure as the irrational elation over something that is actually not worth pursuing. Conversely, discretion, willing, and joy were regarded as healthy emotions (‘εὐπάθειαι’) by the Stoics: a rational aversion of vice and harmful things (discretion), a rational desire for virtue (willing), and a rational elation over virtue (delight). Therefore the popular caricature of the Stoic sage as a grave fi gure, emotionally detached and obsessed with the practice of endurance and resignation is highly inaccurate. Although Stoic sages have developed their ability to endure pain to a remarkable extent, they do not have to sacrifi ce joy to have that ability, and rather than suppressing or hiding their feelings, they acknowledge emotions and redirect them for their own good.

The motto of the Stoic school was ‘follow nature’, which meant the human nature of a social animal capable of rational judgment. The notion of mankind as a group of ‘quintessentially rational animals’ is refl ected in the meaning of Stoic virtue, which follows the original

13


in Rome, refused to acknowledge the insult and replied to his off ender “I don’t remember being hit”. Based on revealing ancient anecdotes such as these, it would be tempting to argue that the Stoic attitude embodies a human trait that can be found, with minimal variations, across diff erent times and cultures. Unsurprisingly, the Stoic attitude has been celebrated in both poems and novels that inspired generations and stood the test of time. ‘Invictus’ is the title of a short Victorian poem written in 1875 and published in 1888 by the English poet William Ernest Henley (1849-1903). Its celebrated verses encapsulate the therapeutic power of inner rational resources when dealing with life adversities:

It is not the business of reason to generate emotions, though it may be part of its function to discover ways of preventing such emotions as are an obstacle to well-being. To fi nd ways of minimizing hatred and envy is no doubt part of the function of a rational psychology. But it is a mistake to suppose that in minimizing these passions we shall at the same time diminish the strength of those passions which reason does not condemn. In passionate love, in parental aff ection, in friendship, in benevolence, in devotion to science or art, there is nothing that reason should wish to diminish. The rational man, when he feels any or all of these emotions, will be glad that he feels them and will do nothing to lessen their strength, for all these emotions are parts of the good life, the life, that is, that makes for happiness both in oneself and in others”.

If virtue (i.e. living according to the rational nature of human beings) is the only good, it follows that, according to the Stoics, things that are commonly referred to as misfortunes (including disease and death) are nothing to worry about, as it is possible to follow virtue even in such dire circumstances. In fact, misfortunes are regarded as nothing more than ‘indiff erents’ (or ‘dispreferred indiff erents’): the rational human being is naturally capable of living in accordance to nature (‘virtuously’) even when enduring illness or facing death. Both Socrates’ frugal lifestyle and Spartan education practices could be seen as important precursors of this philosophy of life. The story of the Spartan boy who stole a fox and hid it under his cloak, as reported by Plutarch (‘Moralia’, III, 234), powerfully exemplifi es the Stoic attitude: not to be discovered, the young Spartan was able to keep silent as the fox tore out his innards in an attempt to break free. Even earlier, it has been reported that when the pre-Socratic philosopher Anaxagoras was told of the death of his son, he was able to bear the pain and control his emotional reaction by calmly stating “I knew that I gave birth to a mortal son”. In the Roman world (especially during the Republican era), this attitude was deeply appreciated, as Stoicism was seen as the Hellenistic philosophy most in line with the traditional Roman values. History books feature multiple examples of Roman fi gures who were regarded as Stoic role models or sages. Mucius Scaevola allegedly impressed the Etruscan king Porsena by thrusting his right hand into a sacrifi ce fi re without giving any indication of pain. Seneca reported that Cato the Younger, shortly after being shoved and struck at the baths

“Out of the night that covers me,Black as the pit from pole to pole,

I thank whatever gods may beFor my unconquerable soul.

In the fell clutch of circumstanceI have not winced nor cried aloud.Under the bludgeonings of chanceMy head is bloody, but unbowed.

Beyond this place of wrath and tearsLooms but the Horror of the shade,

And yet the menace of the yearsFinds, and shall fi nd me, unafraid.

It matters not how strait the gate,How charged with punishments the scroll,

I am the master of my fate:I am the captain of my soul.”

In his 1958 novel ‘Il Gattopardo’ (‘The Leopard’), Italian writer Giuseppe Tomasi di Lampedusa wrote that Sicilian nobleman Don Fabrizio Corbera, Prince of Salina, “thought of a medicine recently discovered in the United States of America which could prevent suff ering even during the most serious operations and produce serenity amid disaster. ‘Morphia’ was the name given to this crude substitute for the stoicism of the ancients”5. In addition to literary masterpieces, Stoic words reverberate in personal accounts of real-life experiences, up until recent times. By explicitly adopting a Stoic attitude and building on his acquaintance with Epictetus’ teaching, American Admiral James Stockdale (1923-2005) was famously able to endure seven and a half years of isolation and brutal torture as prisoner of war in Vietnam without fl inching (Stockdale, 1993). Shot down

14


Cavanna, 2019

over North Vietnam in September 1965, he was so badly beaten by a crowd when his parachute landed that his leg was broken and he walked with a limp for the rest of his life. After ejection from his little A-4 airplane, he had about thirty seconds to make his last statement in freedom before he landed in enemy territory. Years later, he reported that he had whispered to himself: “Five years down there, at least. I’m leaving the world of technology and entering the world of Epictetus”.

STOIC INFLUENCES ON MODERN PSYCHOTHERAPY

The therapeutic power of Stoic philosophy is perhaps most evident in Epictetus’ thought (Xenakis, 1969; Long, 2004; Stephens, 2007; Pigliucci, 2017). Historically, the two surviving texts on Epictetus’ Stoicism by his disciple Arrian, the ‘Εγχειρίδιον’ (‘Handbook’) and the ‘Διατριβαί’ (‘Discourses’), proved formidable sources of inspiration for self-help and psychotherapy techniques. The opening line of Epictetus’ Handbook states that “τῶν ὄντων τὰ μέν ἐστιν ἐφ’ἡμῖν, τὰ δὲ ούκ ἐφ’ἡμῖν” (“there are things which are within our power, and there are things which are beyond our power”). According to Epictetus, only our rational faculties (our judgements and opinions, resulting in voluntary actions) are pre-eminently within our power to control, whereas external events, including health, material wealth, and reputation, are ultimately outside our control and in the hands of Fortune. The resulting ‘dichotomy of control’ (or ‘Stoic fork’) (Robertson, 2010) is a principle of fundamental importance for Stoicism, with practical implications in terms of healing or therapeutic power: it limits considerably the number of things and events we should realistically worry about, leaving everything else within the realm of mere ‘indiff erents’. In an interesting historical anecdote, Epictetus famously praised a Roman statesman and philosopher who was ordered by Nero into exile, Paconius Agrippinus, for showing a typical Stoic attitude toward justice (Discourses, I,1): “What, then, did Agrippinus say? He said, ‘I am not a hindrance to myself’. When it was reported to him that his trial was going on in the Senate, he said, ‘I hope it may turn out well; but it is the fi fth hour of the day’ - this was the time when he was used to exercise himself and then take the cold bath - ‘let us go and take our exercise’. After he had taken his exercise, one comes and tells him, ‘You have been condemned’. ‘To banishment’,

15

he replies, ‘or to death?’ ‘To banishment’. ‘What about my property?’ ‘It is not taken from you’. ‘Let us go to Aricia then’, he said, ‘and dine’”6. Epictetus held this up as an excellent model of Stoic behaviour: “This is what it means to have rehearsed the lessons one ought to rehearse, to have set desire and aversion free from every hinderance and made them proof against chance. I must die. If forthwith, I die; and if a little later, I will dine now, since the hour for dinner has come, and afterwards I will die at the appointed time. How? Like a man who gives up what belongs to another”7. Marcus Aurelius’ words were of a very similar tone: “He does not care in any way whether he will have his soul enclosed by his body for a longer or shorter time. Even if he needs to leave right away, he departs as readily as if he were performing any of the other actions that can be done in a decent and orderly way, exercising care for this alone throughout his life, that his mind should never be in a state that is alien to that of a rational and social being”8. By his own admission, Marcus Aurelius was deeply infl uenced by Epictetus’ works, which he borrowed from his teacher Rusticus when he was young (Hadot, 1992; Robertson, 2019). In this passage (III,7) from ‘Τὰ εἰς ἑαυτόν’ (‘To himself’, more often translated as ‘Meditations’), the Roman emperor highlighted two key themes of the Stoic thought: reason (rationality) and cosmopolitanism (philanthropy), as the pillars of human nature. The famous Stoic injunction to live ‘according to the nature’ can be fully understood only by taking into account their view of human beings as social rational animals. Since our own death is not subject to our control, it has nothing to do with the practice of virtue in the Stoic sense: therefore, it should be categorised as an ‘indiff erent’ and not be feared.

The fundamental Stoic distinction between what is in our power and what is not resonates in other famous texts inspired by Stoicism, until recent times. The Serenity Prayer is the common name for a text written by American theologian Reinhold Niebuhr (1892-1971), who wrote it in the 1930s and fi rst published it in 1951. The prayer contains the following verses, which make clear reference to the Stoics’ dichotomy of control:

‘God, grant me the serenity to accept the things I cannot change,

Courage to change the things I can,And wisdom to know the diff erence.’


αὐτοῦ κρῖμα, τοῦτο δὲ ἤδη ἐξαλεῖψαι ἐπὶ σοί ἐστιν” (“If you are pained by any external thing, it is not this thing that disturbs you, but your own judgment about it. And it is in your power to wipe out this judgment now”). Once again, there appears to be an impressive convergence between Stoicism and modern psychotherapy: the essentially cognitive nature of emotions (‘cognitive theory of emotions’) (Montgomery, 1993; Moore Brookshire, 2007).

STOIC PSYCHOTHERAPY AND COGNITIVE BEHAVIOR THERAPY

If the cause of emotional disturbance is of a cognitive nature, this naturally implies a cognitive (rational) therapy. Rational Emotive Behaviour Therapy (REBT) was developed by American Psychologist Albert Ellis in the 1950s: the acknowledgment of the importance of reason in emotional processing marked the cognitive revolution that took place in the fi eld of psychology, moving from behaviourism to cognitivism. Therefore, REBT inaugurated the tradition of cognitive behavioural therapies (‘second wave’ of modern psychotherapy interventions). Interestingly, it has been reported that prior to becoming a psychotherapist, Albert Ellis read the Roman Stoics - Seneca, Epictetus, and Marcus Aurelius (Still and Dryden, 2012). In his fi rst major publication on REBT, Ellis described the philosophical basis of his approach as the principle that a person is rarely aff ected emotionally by outside things but, rather, “he is aff ected by his perceptions, attitudes, or internalized sentences about outside things and events […] This principle […] was originally discovered and stated by the ancient Stoic philosophers, especially Zeno of Citium (the founder of the school), Chrysippus (his most infl uential disciple), Panaetius of Rhodes (who introduced Stoicism into Rome), Cicero, Seneca, Epictetus, and Marcus Aurelius. The truths of Stoicism were perhaps best set forth by Epictetus, who, in the fi rst century AD wrote in the Enchiridion: ‘Men are disturbed not by things, but by the views which they take of them’. Shakespeare, many centuries later, rephrased this thought in Hamlet: ‘There’s nothing good or bad but thinking makes it so’” (Ellis, 1962). According to Still and Dryden (1999), the saying of Epictetus quoted by Ellis has become a “hallmark” of REBT and is “even given to clients during the early sessions, as a succinct way of capturing the starting point”: there is a considerable overlap between the therapeutic

‘If’ is a poem by English Nobel laureate Rudyard Kipling (1865-1936), written around 1895 in the form of paternal advice to the poet’s son, John, and fi rst published in 1910. It is often quoted as a literary example of Victorian-era Stoicism. The following lines provide a good example of Stoic attitude toward what is not within our power:

If you can meet with Triumph and Disaster,And treat those two impostors just the same;

[…]Yours is the Earth and everything that’s in it,

And - which is more - you’ll be a Man, my son!

The Stoics’ rational view of emotions fi nds interesting parallels in the cognitive theories of modern psychology. Epictetus clearly stated that “ταράσσει τοὺς ἀνθρώπους οὐ τὰ πράγματα, ἀλλὰ τὰ περὶ τῶν πραγμάτων δόγματα” (“men are disturbed not by things, but by the views which they take of things”) (Handbook, 5). These very words were carved in a beam of Michel de Montaigne’s library in Château de Montaigne, the tower retreat of the French humanist (Figure 3). In fact, the Stoic theme of the distinction between things in themselves and the way we perceive them resonates within Montaigne’s Essays (1580), with a clear allusion to Epictetus (Moriarty, 2016): “Men (says an ancient Greek sentence) are tormented with the opinions they have of things and not by the things themselves”9.

Figure 3: Epictetus’ words (“men are disturbed not by things, but by

the views which they take of things”) in a carved beam in Michel de Montaigne’s library (Château de Montaigne, France).

The resulting shift in the locus of control from external events (upon which we have little or no control) to internal attitude or disposition towards such events is key to both Stoic philosophy and rational psychotherapy. In his ‘Meditations’ (VIII,47), Marcus Aurelius is explicit about the implications of the Stoic approach to emotions: “Εἰ μὲν διά τι τῶν ἐκτὸς λυπῇ, οὐκ ἐκεῖνό σοι ἐνοχλεῖ, ἀλλὰ τὸ σὸν περὶ

16


Cavanna, 2019

catastrophes should not be perceived as ‘bad’ or ‘evil’ occurrences. In his ‘Meditations’ (VI,50), Marcus Aurelius made explicit reference to the reserve clause technique: “μέμνησο ὅτι μεθ’ὑπεξαιρέσεως ὥρμας καὶ ὅτι τῶν ἀδυνάτων οὐκ ὠρέγου” (“Remember that your intention was always to act ‘with a reserve clause’, for you did not desire the impossible”). Seneca referred to the reserve clause as the ‘exceptio’ in his treatise ‘De benefi ciis’ (‘On benefi ts’, IV,34): “the wise man considers both sides: he knows how great is the power of errors, how uncertain human aff airs are, how many obstacles there are to the success of plans. Without committing himself, he awaits the doubtful and capricious issue of events, and weighs certainty of purpose against uncertainty of result. Here also, however, he is protected by that reserve clause, without which he decides upon nothing, and begins nothing”10

Another powerful Stoic spiritual exercise is the use of mental imagery for the pre-emptive visualisation of worst-case scenarios (‘praemeditatio malorum’ or ‘premeditation of adversity’, including the famous ‘meditatio mortis’ or ‘contemplation of death’) (Buzaré, 2012). In his ‘Letters from a Stoic’ (XCI), Seneca provided a clear account of this psychological technique: “What is quite unlooked for is more crushing in its eff ect, and unexpectedness adds

remedies found in REBT and Stoicism, as they both emphasize the role of responsibility, rationality, and self-disciplined observation of one’s mind as a means of modifying irrational emotions and achieving psychological well-being. From his interest in the philosophical writings about human suff ering and the human condition by the ancient Stoics, Ellis surmised that all individuals, are competent at disturbing themselves by irrational thinking patterns. In other words, it is not the thing itself that disturbs us, rather we disturb ourselves about it. Therefore REBT holds that when people make inferences about situations and events in their lives, they go on to hold irrational beliefs about those inferences and it is those irrational beliefs that lead to emotional distress and behavioural disturbances.

REBT is particularly eff ective at fi ghting unhealthy irrational beliefs and erroneous assumptions that lead to emotional distress, by employing specifi c psychological techniques. One of these techniques is the use of ‘reserve clauses’ - the letters DV, or ‘Deo Volente’ (‘God willing’) added by Christian theologians to their correspondence are a familiar example of such practice. The function of reserve clauses is to remind us that the unfolding of events is not within our power, and therefore even unpredicted

Table 1. Parallels between Stoicism and Rational Emotive Behaviour Therapy (REBT).

Stoicism REBTEmotions are due primarily to our own beliefs Psychological distance from emotionsBeliefs and emotions are two aspects of the same mental process

Cognition and emotion are two aspects of the same mental process

Constant attention to own faculty of judgement Monitoring of the relationship between thoughts, actions, and feelings

Philosophical disputation of fundamental value judgments

Rational disputations of irrational demands

Replacement of irrational demands with ratio-nal wishing and awareness that things may not turn out as we would prefer (exceptio)

Replacement of irrational demands with fl ex-ible desires (rational preferences and reserve clauses)

Use of mental imaging techniques (praemedi-tatio malorum)

Use of mental imaging techniques (rational-emotive imagery)

Acceptance of our body, other people, and external events, as “indiff erent”

Acceptance of oneself, others, and the world, as imperfect

Opposition to judging adverse external events to be unconditionally “bad” or “evil”

Opposition to judging adverse external events to be absolutely catastrophic

Acknowledgment of healthy passions Acknowledgment of rational and healthy emo-tions

17


Walter Mischel (Evans, 2013; Cavanna, 2018). These studies showed that children aged 4 to 6 years who were able to postpone immediate gratifi cation when off ered a marshmallow would go on to have better life outcomes, according to multiple physical, psychological and social measures (Mischel et al., 1972). It has been shown that the crucial factor in delaying gratifi cation is the ability to change your perception of the action you want to resist or the event that causes distressing emotions. Specifi cally, a well-supported theory of self-regulation, called the cognitive-aff ective personality system, suggests that delaying gratifi cation results from an ability to use ‘cool’ regulatory strategies (i.e. calm, controlled and cognitive strategies resembling both cognitive behaiovural techniques and Stoic exercises) over ‘hot’ regulatory strategies (i.e. emotional, impulsive, automatic reactions), when faced with provocation (Mischel and Shoda, 1995). Interestingly, a brain imaging study conducted on a sample from the original Stanford participants when they reached midlife, showed that the prefrontal cortex (a brain region involved in cognitive judgments) was more active in the gratifi cation delayers, when they were trying to control their responses to alluring temptations (Casey et al., 2011). Overall, there is a growing body of scientifi c literature showing that delayed (or deferred) gratifi cation, the process that the subject undergoes when the temptation of an immediate reward is resisted in preference for a later reward, is linked to a host of other positive outcomes, including academic success, physical health, psychological health, and social competence (Tobin and Graziano, 2009; Peake, 2017). Self-control has been referred to as the ‘master virtue’ by both social and clinical psychologists, suggesting that the ability to delay gratifi cation plays a critical role in a person’s overall psychological well-being. Interestingly, it ahs been suggested that self-control is akin to a ‘moral muscle’ that can be strengthened through exercise, thus validating the importance of regular practice, as emphasised by both Stoic techniques and modern CBT-based interventions (Baumeister and Juola Exline, 1999).

The ‘second wave’ of cognitive therapy and other REBT-inspired psychotherapeutic approaches fl ourished during the fi nal decades of the XX century and was followed, at around the turn of the millennium, by a ‘third wave’ of cognitive and behavioural therapies. The ‘third wave’ includes a range of therapeutic

to the weight of a disaster. The fact that it was unforeseen has never failed to intensify a person’s grief. This is a reason for ensuring that nothing ever takes us by surprise. We should project our thoughts ahead of us at every turn and have in mind every possible eventuality instead of only the usual course of events. […] This is why we need to envisage every possibility and to strengthen the spirit to deal with the things which may conceivably come about. Rehearse them in your mind: exile, torture, war, shipwreck”11. In general, REBT and Stoic approaches share a striking number of similarities (Table 1), as they both encourage the rational disputation of irrational demands and their replacement with more fl exible desires or rational preferences (“I must recover from my illness by tomorrow” versus “I would prefer to recover from my illness as soon as possible”).

In the fi rst major cognitive behavioural therapy (CBT) manual, ‘Cognitive therapy of depression’ (1979), Aaron Beck and his colleagues stated that “the philosophical origins of cognitive therapy can be traced back to the Stoic philosophers, particularly Zeno of Citium (fourth century BC), Chrysippus, Cicero, Seneca, Epictetus, and Marcus Aurelius. Epictetus wrote in The Enchiridion: ‘Men are disturbed not by things but by the views which they take of them’ […] Control of most intense feelings may be achieved by changing one’s ideas”. Several CBT techniques are heavily informed by the Stoic theory of emotions. For example, acknowledging that our emotions are due primarily to our own beliefs allows to achieve psychological distance from emotions (cognitive distancing) and prevents tendencies to judge adverse external events as absolutely catastrophic (decatastrophising).

For the Stoics, emotions are not automatic, instinctive reactions that we cannot avoid experiencing. Instead, they are the result of a rational/cognitive judgment, called ‘προαίρεσις’. According to the Stoics, it is within our power to make a judgment (Marcus Aurelius’ ‘ruling faculty’: the executive function of the brain, in modern cognitive science terminology) that gives ‘assent’ to an initial ‘impression’, an automatic response or instinctive reaction to events that is not under our control. Interestingly, the Stoic theory of emotions found confi rmation in the results of the so-called ‘Stanford marshmallow experiment’, a series of studies on delayed gratifi cation conducted in the late 1960s and early 1970s by Austrian-American psychologist

18


Cavanna, 2019

“happiness is in the present moment, fi rstly for the simple reason that we live in the present, secondly because the past and the future are almost always a source of anguish […] each present moment off ers us the possibility of happiness: if we adopt the stoic perspective, the present gives us the chance of fulfi lling our duty, of living according to reason”14.

STOIC PSYCHOTHERAPY AND NEUROPSYCHIATRY

Neuropsychiatric disorders result from common cerebral pathologies with diverse aetiologies and present clinically with a combination of physical and psychological symptoms. These conditions are traditionally considered diffi cult to treat because of the minimal endogenous capacity of the brain for repair. As a result of their overall intractability, most neuropsychiatric disorders tend to follow a chronic course over time. Current therapeutic interventions are largely limited to treatment of symptoms, with the goal of improving patients’ health-related quality of life. Psychological therapies, especially cognitive behavioural techniques, have proven highly eff ective fi rst-line treatment interventions for aff ective and anxiety disorders, that are often the main determinants of health-related quality of life in patients with neuropsychiatric conditions. In the United Kingdom, the National Institute for Health and Clinical Excellence has made recommendations for the use of CBT in the treatment pathways of adult patients with depression in the context of a chronic physical health problem (National Institute for Health and Clinical Excellence, 2009), with relevant implications to a wide range of neuropsychiatric disorders. Clinical research has provided solid evidence for the effi cacy and cost-eff ectiveness of what are ultimately Stoic-derived therapeutic approaches. Based on the available evidence and informed by economic evaluations, the National Health Service (NHS) developed and implemented a programme to improve access to psychotherapy to the general population (Improving Access to Psychological Therapies, IAPT). The aim of the IAPT project is to increase the provision of evidence-based treatment interventions for common mental health conditions such as anxiety and depression by primary care organisations. This programme has been active for over a decade and has transformed treatment of anxiety and aff ective

interventions encompassing mindfulness-based cognitive therapy and acceptance and commitment therapy, among others (Hayes, 2004; Hayes et al., 2011; Dimidjian et al., 2016; Ruggiero et al., 2018). It has been observed that the practice of mindfulness can be traced back to the Stoic exercise of attention (‘προσοχή’, which can also be translated as ‘concentration on the present moment’ or ‘mindfulness’) (Robertson, 2010). By encouraging concentration on our mental states at the present moment, both Stoicism and mindfulness-based therapies can increase our self-vigilance and free us from distressing emotions. In Marcus Aurelius’ words (‘Meditations’, II,8), (“Through not observing what is in the mind of another, a man has seldom been seen to be unhappy; but those who do not observe the movements of their own minds must of necessity be unhappy”12). By focusing our attention on the present moment, we constantly guard our mind against unhealthy feelings, which are rooted either in the past (depression) or in the future (anxiety), two temporal domains that are ultimately outside our control. Once again, this idea was clearly expressed by Marcus Aurelius in his ‘Meditations’ (XII,3):

“If […] you detach from your mind everything that clings to it by passionate experiences and everything that is in the past or in the future […] and if you practise living only in what you really live, that is, the present - then you will be able to live out the time that is left until you die in a manner that is free of upset and good-natured, at peace with the divine spirit within you”13.

It has been observed that there are similarities between certain aspects of Stoicism and Eastern doctrines (Macaro, 2018). Within the ancient Eastern tradition, Lao Tzu’s teaching (VI century BCE) was of a similar tone to the Stoic view on the importance of focusing attention to the present moment: “If you are depressed you are living in the past. If you are anxious you are living in the future. If you are at peace you are living in the present”. However Hadot argued that for the Stoics the exercise of attention to the present moment is, in a sense, the key to a wider range of spiritual exercises (Hadot, 1981). The late French scholar was clear about the role of ancient philosophies as therapies for the burden of the past and the uncertainty of the future, aimed at allowing people to live within the present by practicing freedom and self-mastery:

19


or indeed about the likely impact of CBT-based interventions on tic expression. However, a recent review covering key fi ndings on the emotional and behavioural aspects of Tourette syndrome proposed a more comprehensive, cognitively-oriented conceptualisation of this condition (Gagné, 2019). Specifi cally, it was proposed that maladaptive beliefs about discomfort and about one’s ability to cope with discomfort underlie negative appraisals of unpleasant sensory experiences in individuals with Tourette syndrome. It was further suggested that these beliefs lead individuals to perceive premonitory urges to tic in a catastrophic manner and thereby enhance tic frequency. Based on these observations, it is suggested that Stoic principles, as applied to CBT-based interventions, could prove highly useful across a range of clinical outcomes.

Parkinson disease, a hypokinetic movement disorder with neurodegenerative etiopathogenesis, is characterised by a combination of motor and non-motor features sharing a chronic course (Kalia and Lang, 2015; Sauerbier et al., 2017). The classical motor triad includes resting tremor, rigidity, and bradykinesia, whereas anxiety and aff ective symptoms are among the non-motor symptoms with the deepest impact on patient’s wellbeing (Balestrino and Martinez-Martin, 2017). The most eff ective treatment interventions currently available consist in pharmacotherapy enhancing dopaminergic pathways. Dopamine replacement therapy can improve rigidity, bradykinesia, and, to a lesser extent, tremor, however neither pharmacological interventions nor more invasive approaches such as DBS are curative (Sprenger and Poewe, 2013; Connolly and Fox, 2017). Moreover, it is well recognized that dopaminergic agents can result in psychiatric/behavioral adverse eff ects (e.g. drug-induced impulse dysregulation with reward-seeking behaviors, and psychotic symptoms) (Chaudhuri and Schapira, 2009; Krack, 2015). The catalogue of iatrogenic impulse control disorders encompasses pathological gambling, compulsive eating, hypersexuality; among the most commonly reported psychotic symptoms are visual hallucinations and paranoid delusions of theft or infi delity (Weintraub and Burn, 2011; Voon et al. 2017). Again, there appears to be room for Stoic-derived cognitive behavioural interventions to improve the subjective wellbeing of both patients with Parkinson disease and their carers. The results of a recent review on CBT

disorders in adult patients. Cognitive behavioural therapies are therefore considered at the forefront of modern psychotherapy interventions, and have become the main approaches for dealing eff ectively with a wide range of psychological disorders in patients with neuropsychiatric conditions.

Movement disorders are a prime example of neuropsychiatric conditions where cognitive behavioral therapy interventions can have a signifi cant positive impact on patients’ health-related quality of life (Cavanna, 2019). Basal ganglia disorders like Tourette syndrome and Parkinson disease have been referred to as ‘paradigmatic’ or ‘quintessential’ neuropsychiatric disorders (Weintraub et al., 2011; Cavanna, 2018). In both conditions, it has consistently been shown that non-motor manifestations such as aff ective symptoms can bear a more signifi cant impact on health-related quality of life than motor impairment itself (Evans et al., 2016; Balestrino and Martinez-Martin, 2017).

Tourette syndrome, a hyperkinetic movement disorder with neurodevelopmental etiopathogenesis, is characterised by a combination of motor and vocal tics plus behavioural co-morbidities: obsessive-compulsive symptoms and/or attention-defi cit and hyperactivity symptoms, as well as anxiety, aff ective symptoms and impulse dyscontrol (Robertson and Cavanna, 2008; Cavanna and Seri, 2013). Tourette syndrome is chronic in nature and available treatment interventions are not curative. Both alpha-2 adrenergic agonists and antidopaminergic agents can decrease tic frequency and severity, however a signifi cant proportion of patients fail to respond to and/or comply with the prescribed medications: in clinical practice, patients are frequently treated with serial agents in the search for effi cacy and tolerability (Waldon et al., 2013; Farag et al., 2015). Likewise, behavioural interventions targeting tics (e.g. habit reversal training, exposure and response prevention) have a signifi cant degree of effi cacy only in a subgroup of patients (Frank and Cavanna, 2013; McGuire et al., 2014; Sukhodolsky et al., 2017). Finally, a few, selected patients with severe, treatment-refractory forms of Tourette syndrome have undergone the surgical procedure of deep brain stimulation (DBS), with promising, albeit somewhat inconsistent results. Very little is known about specifi c management options for the non-motor aspects of Tourette syndrome,

20


Cavanna, 2019

Lucilius and illustrate the individual mentoring of a student, resembling the modern relationship between therapist and his client (individual therapy sessions). Arrian’s transcripts of Epictetus’ teaching in the ‘Discourses’ record Socratic-type dialogues and discussions with students/visitors of his school that can be seen as analogous to some modern forms of therapeutic workshops (group therapy sessions). The other major work based on Epictetus’ teaching, the ‘Handbook’, is a compact distillation or aide-mémoire of Stoic philosophy designed to aid the student in the digestion of the studied doctrines (self-help textbook). Marcus Aurelius’ ‘Meditations’ contain the Roman emperor’s private journal records of his personal Stoic regime of contemplation and written exercises (‘ὑπομνήματα’) and could be compared to the modern practice of keeping a workbook for self-help exercises (therapy journal). Therefore individual psychotherapy, group therapy workshops, self-help textbooks, and therapy journals or workbooks could be considered as being distant descendants of the Stoics’ modes of philosophical therapy. It is tempting to speculate, with Donald Robertson (2016), that “perhaps modern psychology is only now rediscovering obscure psychological mechanisms, which the ancient Stoics may have understood better than their modern commentators”.

Among the many questions that remain unsolved when refl ecting on the relevance of Stoic philosophy beyond current neuropsychiatry practice, there is one that cannot be escaped: why now? What do our present time and the Hellenistic era have in common? It does not seem unreasonable to argue that the Stoic values of inner freedom, equanimity, and self-mastery could be especially meaningful and valuable when the external world becomes fraught or turbulent. The present challenge of living in a state of constant anxiety about the dangers that could strike unannounced at any moment in a continuously changing environment is not new to mankind. Interestingly, the current lifestyle calls for the development of a frame of mind that closely resembles the distinctive mind-set of the Hellenistic period, with its stress on individualism, its preoccupation with inner life and inner liberty, its focus on the pursuit of personal well-being, and its need to wrest our mental health out of the most diffi cult turns of fortune. This picture of increasing uncertainty caused by the ever-changing nature of the external environment and our internal feelings mirrors an

for the treatment of non-motor symptoms in Parkinson disease found a growing evidence base that this intervention (modified to account for disease-specific problems) is eff ective in the treatment of psychiatric symptoms (Koychev and Okai, 2017). Specifi cally, where controlled study designs were used, moderate eff ect sizes were reported for the sustained efficacy of CBT for depression, including with distance administration. The authors also found some initial data on the eff ects of CBT on impulse control disorders and insomnia, and highlighted the need for further studies to more precisely determine the utility of CBT in Parkinson disease.

Overall, CBT-based interventions have been assessed in a number of large controlled clinical trials that have demonstrated an improvement in both psychiatric co-morbidities and tics in patients with Tourette syndrome (O’Connor et al., 2009). Evidence from a randomised controlled study and several uncontrolled studies on the effi cacy of CBT have also shown benefi cial eff ects on depression and anxiety in patients with Parkinson disease (Koychev and Okai, 2017). Only a limited number of studies have evaluated the effi cacy of CBT in the management of psychiatric symptoms in other movement disorders and there are no controlled studies on the effi cacy of CBT in dystonia, Huntington disease, or essential tremor. A review of primary data from clinical trials and case reports on the eff ects of CBT in the most common movement disorders confi rmed that psychological symptoms are often misdiagnosed and left untreated, resulting in worse prognosis and lower health-related quality of life (Berardelli et al., 2015). The authors concluded that evidence available suggests that CBT is useful in Tourette syndrome and probably useful in Parkinson disease. Based on their fi ndings, they recommended planning of randomised controlled clinical trials to investigate the eff ects of CBT-based interventions in the treatment of psychiatric disturbances in movement disorders.

There is little doubt about the practical applications of Stoic psychological techniques and there seems to be increasing interest in testing such techniques across neuropsychiatric populations on a wider scale. It has been observed that the four main surviving primary sources for Stoic philosophy loosely resemble four distinct modalities of philosophical psychotherapy (Sellars, 2009; Robertson, 2016). Seneca’s ‘Letters from a Stoic’ are addressed to

21


all-too familiar human condition referred to as ‘liquid modernity’ by Polish-British sociologist Zygmunt Bauman (2000). The fi ctional character of Professor Levy in Woody Allen’s 1989 movie ‘Crimes and misdemeanors’ described the human condition of the modern era in a way that is strikingly reminiscent of the social, political, cultural, and personal crisis that characterised the Hellenistic age, when the philosophy of Stoicism fl ourished. In the fi nal scene of the

22

Endnotes1: “Venuta la sera, mi ritorno a casa ed entro nel mio scrit-toio; e in sull’uscio mi spoglio quella veste cotidiana, pi-ena di fango e di loto, e mi metto panni reali e curiali; e rivestito condecentemente, entro nelle antique corti delli antiqui huomini, dove, da loro ricevuto amorevolmente, mi pasco di quel cibo che solum è mio e ch’io nacqui per lui; dove io non mi vergogno parlare con loro e domandarli della ragione delle loro azioni; e quelli per loro humanità mi rispondono; e non sento per quattro hore di tempo al-cuna noia, sdimentico ogni aff anno, non temo la povertà, non mi sbigottisce la morte […]”2: “κενὸς ἐκείνου φιλοσόφου λόγος, ὑφʼ οὗ μηδὲν πάθος ἀνθρώπου θεραπεύεται· ὥσπερ γὰρ ἰατρικῆς οὐδὲν ὄφελος μὴ τὰς νόσους τῶν σωμάτων ἐκβαλλούσης, οὕτως οὐδὲ φιλοσοφίας, εἰ μὴ τὸ τῆς ψυχῆς ἐκβάλλει πάθος”.3: “Toutes les écoles s’accordent pour admettre que l’homme, avant la conversion philosophique, se trouve dans un état d’inquiétude malheureuse, qu’il est victime du souci, déchiré par les passions, qu’il ne vit pas vraiment, qu’il n’est pas lui-même. Toutes les écoles s’accordent aussi pour croire que l’homme peut être délivré de cet état, qu’il peut accéder à la vraie vie, s’améliorer, se transform-er, viser à un état de perfection. Les exercices spirituels sont précisément destinés à cette formation de soi, à cette paideia, qui nous apprendra à vivre, non pas conformé-ment aux préjugés humains et aux conventions sociales, mais conformément à la nature de l’homme. Toutes les écoles, chacune à sa manière, croient donc à la liberté de la volonté, grâce à laquelle l’homme a la possibilité de se modifi er lui-même, de s’améliorer, de se réaliser. Le par-allélisme entre exercice physique et exercice spirituel est ici sous-jacent : de même que, par des exercices corpo-rels répétés, l’athlète donne à son corps une forme et une force nouvelles, de même, par les exercices spirituels, le philosophe développe sa force d’âme, modifi e son climat intérieur, transforme sa vision du monde et fi nalement tout son être. L’analogie pouvait paraître d’autant plus évidente que c’est dans le gymnasion, c’est-à-dire dans le lieu où se pratiquaient les exercices physiques, que se donnaient aussi les leçons de philosophie, c’est-à-dire que se prati-quait l’entraînement à la gymnastique spirituelle.”4: “ὡς ἐγὼ οὐ νῦν πρῶτον ἀλλὰ καὶ ἀεὶ τοιοῦτος οἷος τῶν ἐμῶν μηδενὶ ἄλλῳ πείθεσθαι ἢ τῷ λόγῳ ὃς ἄν μοι λογιζομένῳ βέλτιστος φαίνηται”.5: “pensò ad una medicina scoperta da poco negli Stati Uniti d’America, che permetteva di non soff rire durante le

operazioni più gravi, e di rimanere sereni tra le sventure. Morfi na lo avevano chiamato questo rozzo sostituto dello stoicismo antico”.6: “διὰ τοῦτο γὰρ Ἀγριππῖνος τί ἔλεγεν; ὅτι ‘ἐγὼ ἐμαυτῷ ἐμπόδιος οὐ γίνομαι’. ἀπηγγέλη αὐτῷ ὅτι ‘κρίνῃ ἐν συγκλήτῳ’. ‘ἀγαθῇ τύχῃ. ἀλλὰ ἦλθεν ἡ πέμπτη’ (ταύτῃ δ᾽εἰώθει γυμνασάμενος ψυχρολουτρεῖν): ‘ἀπέλθωμεν καὶ γυμνασθῶμεν’. γυμνασαμένῳ λέγει τις, αὐτῷ ἐλθὼν ὅτι ‘Κατακέκρισαι’. ‘φυγῇ’, φησίν, ‘ἢ θανάτῳ;’ ‘φυγῇ’. ‘τὰ ὑπάρχοντα τί;’ ‘οὐκ ἀφῃρέθη’. ‘εἰς Ἀρίκειαν οὖν ἀπελθόντες ἀριστήσωμεν’”.

7: “τοῦτ᾽ἔστι μεμελετηκέναι ἃ δεῖ μελετᾶν, ὄρεξιν ἔκκλισιν ἀκώλυτα ἀπερίπτωτα παρεσκευακέναι. ἀποθανεῖν με δεῖ. εἰ ἤδη, ἀποθνῄσκω: κἂν μετ᾽ ὀλίγον, νῦν ἀριστῶ τῆς ὥρας ἐλθούσης, εἶτα τότε τεθνήξομαι. πῶς; ὡς προσήκει τὸν τὰ ἀλλότρια ἀποδιδόντα”.8: “πότερον δὲ ἐπὶ πλέον διάστημα χρόνου τῷ σώματι περιεχομένῃ τῇ ψυχῇ ἢ ἐπ̓ ἔλασσον χρήσεται, οὐδ̓ ὁτιοῦν αὐτῷ μέλει: κἂν γὰρ ἤδη ἀπαλλάσσεσθαι δέῃ, οὕτως εὐλύτως ἄπεισιν, ὡς ἄλλο τι τῶν αἰδημόνως καὶ κοσμίως ἐνεργεῖσθαι δυναμένων ἐνεργήσων, τοῦτο μόνον παῤ ὅλον τὸν βίον εὐλαβούμενος, τὸ τὴν διάνοιαν ἔν τινι ἀνοικείῳ νοεροῦ καὶ πολιτικοῦ ζῴου τροπῇ γενέσθαι”.9: “Les hommes (dit une sentence Grecque ancienne) sont tourmentez par les opinions qu’ils ont des choses, non par les choses mesmes”.10: “sapiens utramque partem eius cogitat; scit, quantum liceat errori, quam incerta sint humana, quam multa con-siliis obstent; ancipitem rerum ac lubricam sortem sus-pensus sequitur, consiliis certis incertos eventus expendit. Exceptio autem, sine qua nihil destinat, nihil ingreditur, et hic illum tuetur”.11: “Inexpectata plus adgravant; novitas adicit calamita-tibus pondus, nec quisquam mortalium non magis quod etiam miratus est, doluit. Ideo nihil nobis inprovisum esse debet. In omnia praemittendus animus cogitandumque non quidquid solet, sed quicquid potest fi eri. […] Cogi-tanda ergo sunt omnia et animus adversus ea, quae possunt evenire, fi rmandus. Exilia, tormenta morbi, bella, naufra-gia meditare”.12: “παρὰ μὲν τὸ μὴ ἐφιστάνειν, τί ἐν τῇ ἄλλου ψυχῇ γίνεται, οὐ ῥᾳδίως τις ὤφθη κακοδαιμονῶν: τοὺς δὲ τοῖς τῆς ἰδίας ψυχῆς κινήμασι μὴ παρακολουθοῦντας ἀνάγκη κακοδαιμονεῖν”.13: “ἐὰν χωρίσῃς […] τοῦ ἡγεμονικοῦ τούτου τὰ

fi lm, Professor Levy’s voice is heard refl ecting that “Events unfold so unpredictably, so unfairly […] Human happiness does not seem to have been included in the design of creation. It is only we, with our capacity to love, that give meaning to the indiff erent universe. And yet, most human beings seem to have the ability to keep trying, and even to fi nd joy from simple things like their family, their work, and from the hope that future generations might understand more”.


Cavanna, 2019

προσηρτημένα ἐκ προσπαθείας καὶ τοῦ χρόνου τὰ ἐπέκεινα ἢ τὰ παρῳχηκότα, ποιήσῃς τε σεαυτόν […] μόνον τε ζῆν ἐκμελετήσῃς ὃ ζῇς, τουτέστι τὸ παρόν: δυνήσῃ τό γε μέχρι τοῦ ἀποθανεῖν ὑπολειπόμενον ἀταράκτως καὶ εὐμενῶς καὶ ἵλεως τῷ σαυτοῦ δαίμονι διαβιῶναι”.

14. “le bonheur est dans le moment présent, tout d’abord pour la simple raison que nous ne vivons que le présent, ensuite parce que passé et avenir sont presque toujours source de souff rance […] mais chaque moment présent nous off re la possibilité du bonheur : si nous nous mettons dans la perspective stoïcienne, il nous donne l’occasion de faire notre devoir, de vivre selon la raison”.

examination of “third wave” cognitive and behavioral therapies. Behav Ther, 47:886-905.

Ellis, A. (1962) Reason and emotion in psychotherapy. Lyle Stuart, Oxford.

Evans J, Seri S, Cavanna AE. (2016) The eff ects of Gilles de la Tourette syndrome and other chronic tic disorders on quality of life across the lifespan: A systematic review. Eur Child Adolesc Psychiatry, 25:939-948.

Evans J. (2013) Philosophy for life and other dangerous situations. Rider, London.

Farag M, Stern JS, Simmons H, Robertson MM. (2015) Serial pharmacological prescribing practices for tic management in Tourette syndrome. Hum Psychopharmacol, 30:435-441.

Frank M, Cavanna AE. (2013) Behavioural treatments for Tourette syndrome: An evidence-based review. Behav Neurol, 27:105-117.

Gagné JP. (2019) The psychology of Tourette disorder: Revisiting the past and moving toward a cognitively-oriented future. Clin Psychol Rev, 67:11-21.

Hadot P. (1981) Exercices spirituels et philosophie antique. Etudes augustiniennes, Paris.

Hadot P. (1992) La citadelle intérieure: Introduction aux Pensées de Marc Aurèle. Fayard, Paris.

Hadot P. (1995) Qu’est-ce que la philosophie antique ? Gallimard, Paris.

Hayes SC, Villatte M, Levin ME, Hildebrandt M. (2011) Open, aware, and active: contextual approaches as an emerging trend in the behavioral and cognitive therapies. Annu Rev Clin Psychol, 7:141-168.

Hayes SC. (2004) Acceptance and commitment therapy, relational frame theory, and the third wave of behavior therapy. Behav Ther, 35:639-665.

Irvine WB. (2009) A guide to the good life: The ancient art of Stoic joy. Oxford University Press, New York NY.

Kalia LV, Lang AE. (2015) Parkinson’s disease. Lancet, 386:896-912.Koychev I, Okai D. (2017) Cognitive-behavioural therapy for non-motor symptoms of Parkinson’s disease: A clinical review. Evid Based Ment Health, 20:15-20.Long AA. (2004) Epictetus: A Stoic and Socratic Guide to Life. Oxford University Press, New York NY.

23

REFERENCESBalestrino R, Martinez-Martin P. (2017) Neuropsychiatric symptoms, behavioural disorders, and quality of life in Parkinson’s disease. J Neurol Sci, 373:173-178.

Bauman Z. (2000) Liquid modernity. Polity, Cambridge.

Baumeister RF, Juola Exline J. (1999) Virtue, personality, and social relations: Self-control as the moral muscle. J Personality, 67:1165-1194.

Beck AT, Rush AJ, Shaw BF, Emery G. (1979) Cognitive therapy of depression. Guilford Press, New York.

Becker LC. (2017) A New Stoicism (2nd Ed). Princeton University Press, Princeton NJ.

Berardelli I, Pasquini M, Roselli V, Biondi M, Berardelli A, Fabbrini G. (2015) Cognitive behavioral therapy in movement disorders: A review. Mov Disord Clin Pract, 2:107-115.

Buzaré E. (2012) Stoic spiritual exercises. Lulu Press, Morrisville NC.

Casey BJ, Somerville LH, Gotlib IH, Ayduk O, Franklin NT, Askren MK, Jonides J, Berman MG, Wilson NL, Teslovich T, Glover G, Zayas V, Mischel W, Shoda Y. (2011) Behavioral and neural correlates of delay of gratifi cation 40 years later. Proc Natl Acad Sci, 108:14998-15003.

Cavanna AE, Seri S. (2013) Tourette’s syndrome. Br Med J, 347:f4964.

Cavanna AE. (2018) Gilles de la Tourette syndrome as a paradigmatic neuropsychiatric disorder. CNS Spectr, 23:213-218.

Cavanna AE. (2018) Motion and emotion. Springer, New York NY.

Cavanna AE. (2019) Back to the future: Stoic wisdom and psychotherapy for neuropsychiatric conditions. Future Neurol, 14(1):FNL2.

Chaudhuri KR, Schapira AH. (2009) Non-motor symptoms of Parkinson’s disease: Dopaminergic pathophysiology and treatment. Lancet Neurol, 8:464-474.

Connolly B, Fox SH. (2014) Treatment of cognitive, psychiatric, and aff ective disorders associated with Parkinson’s disease. Neurotherapeutics, 11:78-91.

Dimidjian S, Arch JJ, Schneider RL, Desormeau P, Felder JN, Segal ZV. (2016) Considering meta-analysis, meaning, and metaphor: A systematic review and critical

Corresponding Author:

Prof Andrea E. Cavanna

Department of Neuropsychiatry, The National Centre for Mental Health, 25 Vincent DriveBirmingham B15 2FGUnited Kingdom

email: [email protected]

Copyright © 2019 by Ass. Crossing Dialogues, Italy


A historical and theoretical review of cognitive behavioral therapies: From structural self-knowledge to functional processes. J Ration Emot Cogn Behav Ther, 36:378-403.

Russell B. (1930) The conquest of happiness. Liveright, New York NY.

Sauerbier A, Rosa-Grilo M, Qamar MA, Chaudhuri KR. (2017) Nonmotor subtyping in Parkinson’s disease. Int Rev Neurobiol, 133:447-478.

Sellars J. (2009) The art of living: The Stoics on the nature and function of philosophy. Bloomsbury, London. 2nd Ed.

Sierra M, Carnicella S, Strafella AP, Bichon A, Lhommée E, Castrioto A, Chabardes S, Thobois S, Krack P. (2015) Apathy and impulse control disorders: Yin & Yang of dopamine dependent behaviors. J Parkinsons Dis, 5:625-636.

Sprenger F, Poewe W. (2013) Management of motor and non-motor symptoms in Parkinson’s disease. CNS Drugs, 27:259-272.

Stephens WO. (2007) Stoic ethics: Epictetus and happiness as freedom. Bloomsbury, London.

Still A, Dryden W. (1999) The place of rationality in Stoicism and REBT. J Rat-Emo Cognitive-Behav Ther, 17:143-164.

Still A, Dryden W. (2012) The historical and philosophical context of rational psychotherapy: The legacy of Epictetus. Karnac, London.

Stockdale JB. (1993) Courage under fi re: Testing Epictetus’s doctrines in a laboratory of human behavior. Hoover Institution, Stanford.

Sukhodolsky DG, Woods DW, Piacentini J, Wilhelm S, Peterson AL, Katsovich L, Dziura J, Walkup JT, Scahill L. (2017) Moderators and predictors of response to behavior therapy for tics in Tourette syndrome. Neurology, 88:1029-1036.

Tobin RM, Graziano WG. (2009) Delay of gratifi cation: A review of fi fty years of regulation research. In: Hoyle, RH (Ed) Handbook of personality and self-regulation. John Wiley & Sons, Hobiken, NJ:47-63.

Voon V, Napier TC, Frank MJ, Sgambato-Faure V, Grace AA, Rodriguez-Oroz M, Obeso J, Bezard E, Fernagut PO. (2017) Impulse control disorders and levodopa-induced dyskinesias in Parkinson’s disease: An update. Lancet Neurol, 16:238-250.

Waldon K, Hill J, Termine C, Balottin U, Cavanna AE. (2013) Trials of pharmacological interventions for Tourette syndrome: A systematic review. Behav Neurol, 26:265-273.

Weintraub D, Burn DJ. (2011) Parkinson’s disease: The quintessential neuropsychiatric disorder. Mov Disord, 26:1022-1031.

Xenakis I. (1969) Epictetus: philosopher-therapist. Martinus Jijhoff , The Hague.

Xenophontos S. (2014) Psychotherapy and moralising rhetoric in Galen’s newly discovered Avoiding Distress (Peri Alypias). Med Hist, 58:585-603.

Macaro A. (2018) More than happiness: Buddhist and Stoic wisdom for a skeptical age. Icon Books, London.

McGuire JF, Piacentini J, Brennan EA, Lewin AB, Murphy TK, Small BJ, Storch EA. (2014) A meta-analysis of behavior therapy for Tourette Syndrome. J Psychiatr Res, 50:106-112.

Mischel W, Ebbesen EB, Raskoff Zeiss A. (1972) Cognitive and attentional mechanisms in delay of gratifi cation. J Pers Soc Psychol, 21:204-218.

Mischel W, Shoda Y. (1995) A cognitive-aff ective system theory of personality: Reconceptualizing situations, dispositions, dynamics, and invariance in personality structure. Psychol Rev, 102:246-268.

Montgomery RW. (1993) The ancient origins of cognitive therapy: The reemergence of Stoicism. J Cogn Psychother, 7:5-19.

Moore Brookshire SA. (2007) Utilizing Stoic philosophy to improve cognitive behavioral therapy. NC Perspectives, 1:30-36.

Moriarty M. (2016) Stoic themes in early modern French thought. In: Sellars J (Ed) The Routledge Handbook of the Stoic tradition. Routledge, London: 204-217.

National Institute for Health and Clinical Excellence. (2009) Depression in adults with a chronic physical health problem: Treatment and management (Clinical Guideline 91). www.nice.org.uk/CG91.

Nussbaum MC. (1994) The therapy of desire: Theory and practice in Hellenistic ethics. Princeton University Press, Princeton NJ.

O’Connor KP, Laverdure A, Taillon A, Stip E, Borgeat F, Lavoie M. (2009) Cognitive behavioral management of Tourette’s syndrome and chronic tic disorder in medicated and unmedicated samples. Behav Res Ther, 47:1090-1095.

Papadimos TJ. (2004) Stoicism, the physician, and care of medical outliers. BMC Med Ethics, 5:E8.

Peake PK. (2017) Delay of gratifi cation: Explorations of how and why children wait and its linkages to outcomes over the life course. Nebr Symp Motiv, 64:7-60.

Pigliucci M. (2017) How to be a Stoic. Basic Books, New York NY.

Robertson D. (2010) The philosophy of cognitive-behavioural therapy (CBT): Stoic philosophy as rational and cognitive psychotherapy. Karnac, London.

Robertson D. (2013) Stoicism and the art of happiness. Hodder & Stoughton, London.

Robertson D. (2016) The Stoic infl uence on modern psychotherapy. In: Sellars J (Ed) The Routledge Handbook of the Stoic tradition. Routledge, London: 374-388.

Robertson D. (2019) How to think like a Roman emperor: The Stoic philosophy of Marcus Aurelius. St Martin’s Press, New York.

Robertson MM, Cavanna AE. (2008) Tourette syndrome: The facts. Oxford University Press, Oxford.

Ruggiero GM, Spada MM, Caselli G, Sassaroli S. (2018)

24

dialogues in philosophy, mental and neuro sciences · good life: the ancient art of stoic joy’,...

Documents