The Philosophy of Cognitive-Behavioural Therapy (CBT)

Stoic Philosophy as Rational and Cognitive Psychotherapy

Donald Robertson

• Publisher: Routledge
• Year: 2019
• ISBN:
  9781000752618
• Edition: 2
• Topic: Psychologie
• Subtopic: Santé mentale en psychologie

This exciting new edition of The Philosophy of Cognitive-Behavioural Therapy (CBT) demonstrates how techniques and concepts from Socratic philosophy, especially Stoicism, can be integrated into the practise of CBT and other forms of psychotherapy. What can we learn about psychological therapy from ancient philosophers? Psychotherapy and philosophy were not always separate disciplines. Here, Donald Robertson explores the relationship between ancient Greek philosophy and modern cognitive-behavioural psychotherapy.

The founders of CBT described Stoicism as providing the "philosophical origins" of their approach and many parallels can be found between Stoicism and CBT, in terms of both theory and practise. Starting with hypnotism and early twentieth century rational psychotherapy and continuing through early behaviour therapy, rational-emotive behaviour therapy (REBT), and cognitive-behavioural therapy (CBT), the links between Stoic philosophy and modern psychotherapy are identified and explained. This book is the first detailed account of the influence of Stoic philosophy upon modern psychotherapy. It provides a fascinating insight into the revival of interest in ancient Western philosophy as a guide to modern living. It includes many concepts and techniques, which can be readily applied in modern psychotherapy or self-help.

This new edition, covering the growth in third-wave CBT, including mindfulness and acceptance-based therapies, will appeal to any mental health practitioner working in this area, as well as students and scholars of these fields.

Part I

Philosophy and cognitive-behavioural therapy

Chapter 1

The “philosophical origins” of CBT

Cognitive-behavioural therapy (CBT) is the predominant school of modern evidence-based psychological therapy. As the name implies, it employs both cognitive and behavioural interventions. Unfortunately, this name belies the fact that CBT is concerned with helping clients to deal with irrational or disturbing emotions and to cultivate rational, healthy, and proportionate ones in their stead. The terms “cognitive” and “rational” also suggest to some people’s minds that CBT must be a form of rationalization, or that it neglects emotion, intuition, or practical experience. However, CBT is actually anti-rationalist, in this sense, given its emphasis upon the value of behavioural experiments and empirical observation. In other words, CBT emphasizes that, insofar as it is reasonable to do so, beliefs should be tested out in practice, in the laboratory of our personal experience.

Professor Keith Dobson, one of the leading authorities in the field of CBT, offers the following account of its “philosophical bases”, that is, the common assumptions shared by variations of cognitive-behavioural therapy.

1. 1 Cognitive activity affects behavior.
2. 2 Cognitive activity may be monitored and altered.
3. 3 Desired behavior change may be affected through cognitive change.
   (Dobson & Dozois, 2001, p. 4)

Moreover:

A number of current approaches to therapy fall within the scope of cognitive-behavioral therapy as it is defined above. These approaches all share a theoretical perspective assuming that internal covert processes called “thinking” or “cognition” occur, and that cognitive events may mediate behavior change.

(ibid., p. 6)

If we accept this definition, there are several different forms of therapy that potentially fall within the “broad church” of CBT. The two most influential and commonly cited ones are the rational emotive behaviour therapy (REBT) of Albert Ellis and the cognitive therapy (CT) of Aaron Beck. Dobson includes a number of other approaches that combine cognitive interventions, which modify the clients’ thinking or internal dialogue with elements of earlier behaviour therapy. However, the philosophical bases of CBT described by Dobson are actually shared with several schools of ancient Greek philosophy. Stoicism, in particular, would certainly meet the criteria cited previously for classification as a species of CBT.

Moreover, as Beck’s approach is probably the most influential one in the current field of CBT, it may be helpful to delineate the components of which his seminal cognitive therapy of depression is comprised (Beck, Rush, Shaw, & Emery, 1979, p. 4). The client is helped by the cognitive therapist to do the following:

1. 1 To monitor his negative automatic thoughts, or cognitions.
2. 2 To evaluate the relationship between his thoughts, feelings, and actions.
3. 3 To carefully evaluate the evidence for and against his distorted or maladaptive cognitions.
4. 4 To generate alternative cognitions and to substitute them for the negative ones.
5. 5 To identify and modify underlying dysfunctional assumptions and beliefs which predispose him to negative automatic thoughts.

Once again, though, these and other strategies employed in cognitive therapy can be identified easily in the practices of various schools of classical philosophy, as we shall see, especially Stoicism.

Stoicism as the philosophy of REBT and CBT

Albert Ellis and Aaron T. Beck, the main pioneers of CBT, have both stressed the role of Stoicism as a philosophical precursor of their approaches. There is only a vague appreciation of this fact among many therapists today, however, so it is worth drawing attention to the key passages in their writings.

Ellis openly admitted that “much of the theory of REBT was derived from philosophy rather than psychology” (Ellis & MacLaren, 2005, p. 16). His first major publication on rational therapy, Reason & Emotion in Psychotherapy (1962), describes the philosophical basis of the approach as the principle that a person is rarely affected emotionally by outside things but, rather, “by his perceptions, attitudes, or internalized sentences about outside things and events” (Ellis, 1962, p. 54).

This principle, which I have inducted from many psychotherapeutic sessions with scores of patients during the last several years, was originally discovered and stated by the ancient Stoic philosophers, especially Zeno of Citium (the founder of the school), Chrysippus (his most influential 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 first century AD wrote in the Encheiridion: “Men are disturbed not by things, but by the views which they take of them”.

(ibid.)

Ellis adds that Shakespeare “rephrased” this idea centuries later when he portrays Hamlet saying “There’s nothing good or bad but thinking makes it so”. (This well-known quotation may stem from Shakespeare’s own reading of the Stoics, incidentally, particularly Seneca.) Moreover, earlier in the same book, Ellis states:

Many of the principles incorporated in the theory of rational emotive psychotherapy are not new; some of them, in fact, were originally stated several thousand years ago, especially by the Greek and Roman Stoic philosophers (such as Epictetus and Marcus Aurelius) and by some of the ancient Taoist and Buddhist thinkers. What probably is new is the application to psychotherapy of viewpoints [such as these] that were first propounded in radically different contexts.

(ibid., p. 35)

However, as we’ll see, Ellis was mistaken with regard to this latter point. Ancient Greek and Roman philosophers did consider themselves to be applying these principles as a form of psychological therapy. From Socrates onward, a “medical model” was commonly used to interpret philosophy as analogous to a talking cure, a form of medicine for the soul. The term “therapy” (therapeia) was used by Greek philosophers to describe the use of philosophical doctrines and practices to alleviate psychological suffering. For instance, the third head of the Stoic school, Chrysippus, wrote a four volume work titled On Passions, about pathological desires and emotions, which concludes with a volume titled Therapeutics, on the Stoic therapy of the psyche. Psychotherapy, in other words, is not a modern concept. The ancient Greeks developed philosophical approaches to psychotherapy and even employed similar terminology to describe their approach.

In a later article specifically examining the relationship between REBT and Stoicism, Still and Dryden note that the saying of Epictetus quoted previously 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” (Still & Dryden, 1999, p. 146). They go on to say that although the specific therapeutic remedies found in REBT and Stoicism may differ in some respects, 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 (ibid., p. 149).

Likewise, in his popular self-help book, A Guide to Rational Living, co-authored with Robert A. Harper, Ellis advised his lay readers of the relevance of Stoic philosophers for REBT,

History gives us several outstanding instances of people who changed themselves and helped change others by hardheaded thinking: Zeno of Citium, for example, who flourished in the third century B.C., and founded the Greek Stoic school of philosophy; the Greek philosopher Epicurus; the Phrygian Epictetus; the Roman emperor Marcus Aurelius; and the Dutch Jew Baruch Spinoza. These and other outstanding rational thinkers, after reading about the teaching of still earlier thinkers (Heraclitus and Democritus among others), and after doing some deep thinking of their own, enthusiastically adopted philosophies radically different from their original beliefs. More to the point for the purposes of our present discussion, they actually began to live these philosophies and to act in accordance with them.

(Ellis & Harper, 1997, p. 5)

As we shall see, the Dutch philosopher Spinoza, though not a Stoic himself, was heavily influenced by the therapeutic concepts found in Hellenistic philosophy, particularly Stoicism.

Moreover, at the beginning of Cognitive Therapy of Depression (1979), taking their cue from Ellis, Beck and his colleagues explicitly claimed that the “philosophical origins” of their own approach also lay in the ancient Stoic tradition.

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 Encheiridion, “Men are disturbed not by things but by the views which they take of them”. Like Stoicism, Eastern philosophies such as Taoism and Buddhism have emphasized that human emotions are based on ideas. Control of most intense feelings may be achieved by changing one’s ideas.

(Beck, Rush, Shaw, & Emery, 1979, p. 8)

There are obvious similarities between these two passages from Beck and Ellis. Both happen to employ the same translation of a quote from Epictetus. They could have chosen from an enormous wealth of similar passages written by Epictetus or, indeed, the other Stoic authors, which communicate the same basic idea. Both Ellis and Beck, incidentally, make a small error in listing Cicero as a Stoic. Cicero was a follower of the Academic school of philosophy, founded by Plato. Nevertheless, he was highly educated in Greek philosophy and his surviving writings are among our most important sources for the teachings of Stoicism.

These quotations from Ellis and Beck are typical of the somewhat cursory manner in which Stoicism is acknowledged by proponents of CBT as the major philosophical precursor of their approach. Nevertheless, what seems clear is that Ellis, and subsequently Beck, attributed the philosophical bases of REBT and CBT primarily to the ancient Stoics and, to a lesser extent, to similar themes in Oriental literature. Little more can be drawn from these brief remarks except that Stoicism is very relevant to CBT and that this importance stems from the shared emphasis upon cognition (ideas, judgements, opinions, etc.) as both the cause and cure of emotional disturbance. There are, however, a handful of other references made by important figures in the field of CBT regarding ancient philosophies that may help to further illustrate the nature of the historical relationship between the two traditions.

Stoic philosophy in Beck’s cognitive therapy

As Beck and his colleagues acknowledged, Ellis’ REBT “provided a major impetus” to the historical development of cognitive-behavioural therapies in general (Beck, Rush, Shaw, & Emery, 1979, p. 10). Moreover, as we have seen, they clearly state that cognitive therapy shared exactly the same philosophical origins as REBT. In addition, Beck had opened his earlier book, Cognitive Therapy and the Emotional Disorders (1976), with the claim that:

These assumptions converge on a relatively new approach to emotional disorders. Nevertheless, the philosophical underpinnings go back thousands of years, certainly to the time of the Stoics, who considered man’s conceptions (or misconceptions) of events rather than the events themselves as the key to his emotional upsets.

(Beck, 1976, p. 3)

Although Beck does not seem to have engaged any further with the Stoics’ philosophical views, he scattered additional quotations from Stoic and Stoic-influenced authors throughout this book, his first on cognitive therapy. Beck used the famous quotation from Epictetus mentioned previously as the epigraph of his chapter on Meaning and Emotions. He likewise quoted Marcus Aurelius, saying the same thing: “If thou are pained by any external thing, it is not the thing that disturbs thee, but thine own judgement about it. And it is in thy power to wipe out this judgement now” (Marcus Aurelius, quoted in Beck, 1976, p. 263).

Beck introduced his chapter on phobias in this book with the following Stoic-sounding quotation from Spinoza: “I saw that all the things I feared, and which feared me had nothing good or bad in them save insofar as the mind was affected by them” (Spinoza, quoted in Beck, 1976, p. 156). However, apart from these few references, Beck does not appear to have had much more to say regarding the “philosophical origins”, as he puts it, of cognitive therapy.

This is more surprising than it might seem at first. The Stoics do not merely present abstract philosophical theories loosely related to the clinical applications of cognitive therapy. They were the most practical and therapeutic in orientation of all the ancient philosophical schools. Their writings contain many specific psychological techniques or exercises, most of which are consistent with modern CBT, and some of which have been forgotten or neglected by modern psychotherapists, though still potentially relevant today. Indeed, A.A. Long, a leading scholar of Stoic philosophy, writes:

Epictetus scarcely needs updating as an analyst of the psyche’s strengths or weaknesses, and as a spokesman for human dignity, autonomy, and integrity. His principal project is to assure his listeners that nothing lies completely in their power except their judgements and desires and goals. Even our bodily frame and its movements are not entirely ours or up to us. The corollary is that nothing outside the mind or volition can, of its own nature, constrain or frustrate us unless we choose to let it do so. Happiness and a praiseworthy life require us to monitor our mental selves at every waking moment, making them and nothing external or material responsible for all the goodness or badness we experience. In the final analysis, everything that affects us for good or ill depends on our own judgements and on how we respond to the circumstances that befall us.

(Long, 2002, p. 1)

Long is undoubtedly correct. What he and other classical scholars find in Epictetus is, self-evidently, a therapeutic system very similar in its assumptions to modern CBT, and certainly one that meets the criteria quoted at the start of this section. Both Stoicism and CBT place central emphasis upon the role of cognition in determining the cause and cure of emotional disturbance, as the previous quotations amply illustrate. However, although this is one of the most fundamental principles of Stoicism, there are others that logically precede it. Moreover, the philosophical core of Stoicism is also consistent with the theory and practice of CBT, as we shall now see.

The Serenity Prayer and Stoicism

The most fundamental principle of Stoic psychotherapy can be found in the very first sentence of the famous Encheiridion or Stoic “handbook” of Epictetus: “Some things are up to us and others are not” (Handbook, 1). The importance of this maxim and the wider implications of absorbing its meaning and implications are explored in detail throughout the ancient Stoic literature.

The Encheiridion is a condensed guidebook to Stoic life that draws upon the more lengthy Discourses of Epictetus, which claim to record discussions held between the Stoic teacher and groups of students. Just like the Encheiridio...