Philosophy, Psychiatry, & Psychology

In this paper, Professor Nordenfelt introduces the reader to the Stoic conception of mental disorder through the interpretations of Cicero in his Tusculan Disputations. Cognitive therapists trace their ancestry to the Stoic philosophers of the third century b.c. and to later stoical thinkers of the first and second centuries a.d., such as the slave Epictetus and the emperor Marcus Aurelius. Cicero was apparently most influenced by the greatest of the Stoics, Chrysippos, who lived in the third century b.c.

Are cognitive therapists latter day Stoics? Do they, for example, propose that indifference to every event (the Greek word is apatheia) is what we should aim for, and that strong emotions, be they positive or negative, are pathological? According to Cicero, joy (moderate positive emotion) is healthy, while delight (strong positive emotion) is unhealthy. Similarly, wish for something good in the future (moderate and positive) is healthy, while lust (strong and positive) is unhealthy. Caution (moderate and negative) is healthy, while fear (strong and negative) is unhealthy. Distress is, according to the Stoics, always unhealthy.

Cognitive therapy (CT) shares with the Stoics the proposition that emotions result from judgments and beliefs, but makes no explicit statements about strong, positive emotions. However, CT does consider strong, negative emotions as unhelpful and, therefore, unhealthy. As such, I believe that the implicit message of cognitive therapy is that strong positive emotions may be unhelpful, as they imply the possibility of the negative opposite. As cognitive therapists, when we attempt to decrease distress by inviting our patients to modify their interpretations and their beliefs through the consideration of less catastrophic or less negative alternatives, we are, by definition, not encouraging indifference or apathy, but are encouraging an active reconstruction of perceived reality. What if the reality cannot be reconstructed cognitively because it is inherently and consensually extremely negative? Do we then encourage indifference?

Epictetus and Marcus Aurelius made a distinction between things which are under our control and those which are not and recommended that, to avoid distress and unhappiness, we should only desire things which we can control. Cognitive therapists behave within a stoical tradition when they help their patients to change situations which are inherently negative by increasing their sense of control and of coping so they may make all changes that are possible. And yes, if alternative interpretations and beliefs are not possible [End Page 293] and situations cannot be changed, a certain indifference or forbearance is fostered. An analogy would be: “You cannot change a cold, wet summer day into a warm, sunny day. Strong negative emotions in such circumstances would be unhelpful. What would be helpful would be to look for ways of making such an eventuality tolerable—through alternative activities, looking forward to a better day, etc.”

With regard to the equivalence of mental health and virtue, I agree with Professor Nordenfelt that this is a somewhat fudged and implicit issue in modern psychiatry and clinical psychology. In cognitive therapy, the aim is to improve on mood and behaviors by modifying biased or dysfunctional perceptions, interpretations, and beliefs. Dysfunction in this context signifies relatively lasting states of strong, negative emotions which impede coping in several life areas. As such, there is no moral tone to these emotions; they do not constitute “vice” or sin and are not considered as blameworthy. Nonetheless, it is not unusual for cognitive therapy consumers to verbalize an implicit message that they appear to get from their therapists in terms such as, “It’s my fault if it’s the way I think. I can’t even think right.” Thus, somehow the idea of right and wrong is probably implicit in the way the model of cognitive therapy is portrayed and practiced.

To conclude, the spirit of the Stoics still pervades the theory of mental disorder in general and of cognitive therapy in particular to this day, although our approach is more complex and owes probably more to Kant than to Zeno, the founder of the Stoic school, and his followers.