Philosophy of CBT – Page 2 – Donald J. Robertson

Excerpt: Ancient Social Anxiety

This is a brief excerpt from my book, The Philosophy of Cognitive-Behavioural Therapy: Stoic Philosophy as Rational and Cognitive Psychotherapy, which is now in its revised second edition, from Routledge.

Social Anxiety, Value Judgements, and Rigid Demands

[Albert Ellis was the founder of Rational-Emotive Behaviour Therapy, REBT, a precursor of modern CBT.] Ellis’ approach differs from other modes of cognitive-behavioural therapy in that he places most emphasis upon the role of irrational or “absolute” demands placed by the subject upon himself, other people, or his environment. According to Ellis, REBT is based on the assumption that the tendency to make “devout, absolutistic evaluations” of events in life is at the core of emotional disturbance and that these value judgements are typically framed in terms of dogmatic “must”, “should”, “have to”, “got to”, “ought to” statements, i.e., unconditional imperatives (Dryden & Ellis, 2001, p. 301). These are called “irrational beliefs” because they are viewed as cognitions, spoken or unspoken, which embody rigid and unrealistic demands and conflict with the goals of enlightened self-interest. By being “rational”, in other words, Ellis often appears to mean something akin to being pragmatic in our pursuit of long-term happiness.

Other types of irrational thought, such as over-generalisations, or unfounded assumptions, are emphasised throughout other schools of CBT, most notably Beck’s cognitive therapy. Ellis concedes that these can contribute to human suffering, and that it can be useful to target them in therapy. However, he insists that fundamentally rigid demands are the pre-eminent underlying cause of emotional disturbance, and even that they are a necessary condition of it. Even if I falsely concluded that everyone hated me, an irrational over-generalisation, in principle, I could still say “So what?” to myself and dismiss it without becoming upset. The unconditional demand that people must like me when combined with the belief that they do not, according to REBT, inevitably generates emotional distress. However, other people’s attitudes and behaviour, like other external events, are not under my direct control. Ellis makes this point, again by reference to Stoicism, when he advises those using REBT for self-help as follows,

As Epictetus pointed out two thousand years ago, although you do have considerable power to change and control yourself, you rarely can control the behavior of others. No matter how wisely you may counsel people, they are independent persons and may – and, indeed, have the right to – ignore you completely. If, therefore, you unduly arouse yourself over the way others act, instead of taking responsibility for how you respond to them, you often will upset yourself over an uncontrollable event. (Ellis & Harper, 1997, p. 198)

The irrationally rigid demands which REBT warns against, which are similar to the “rules” and “assumptions” in Beck’s cognitive therapy, also bear a striking resemblance to the unconditional value judgements which Stoics believe are at the root of emotional distress. For the Stoic, it is the tendency to judge things as being inherently or absolutely good or bad which leads to irrational craving (epithumia) or fear (phobos) respectively. In Stoic psychology, irrational desire, or craving, which places too much value on external things and other people’s opinions, is the root cause of anxiety. Believing that “I have to” have (or avoid) something, or that other people “must” behave (or not behave) in a certain way, as REBT would put it, is tantamount to saying that these things are of overriding importance in themselves, or absolute external values, as Stoicism would put it.

As is often the case, the Stoics give clear examples which would not seem out of place in a modern psychotherapy text, e.g., in this striking passage Epictetus describes the relationship between desire and social anxiety, or stage fright, as follows.

When I see somebody in a state of anxiety, I say, ‘What can this man want?’ Unless he wanted something or other which is not in his own power, how could he still be anxious? That is why a person who sings to the lyre feels no anxiety while he is singing by himself, but is anxious when he enters the theatre, even if he has a very fine voice and plays his instrument beautifully. For he wants not only to sing well, but to gain applause, and that lies beyond his control. […]

He does not understand what a crowd is, or the applause of a crowd. He has learned, indeed, how to strike the lowest and highest strings; but what the applause of the multitude is, and what force it has in life, he neither understands, nor has studied. Hence he must necessarily tremble and turn pale. […]

He does not know that he is wishing to have what is not allowed him, and wishing to avoid what he cannot escape; and he does not know what is his own and what is not his own [i.e., his value-judgements]; for if he did know, he would never feel hindered, never feel restrained, never feel anxious. […]

If, then, things outside the sphere of choice are neither good nor bad, and all things within the sphere of choice are in our power, and can neither be taken away from us, nor given to us, unless we please, what room is there left for anxiety? But we are anxious about this paltry body or estate of ours, or about what Caesar will think [i.e., about health, wealth, or reputation] and not at all about what is within us. Are we ever anxious not to take up a false opinion? No, for this is in our own power. Or about following an impulse, contrary to nature? No, nor this either. When, therefore, you see any one pale with anxiety, just as the physician pronounces from a person’s complexion that this patient is affected in his spleen, and that in his liver, so you likewise should say: this man is affected in his desires and aversions, he is out of sorts, he is feverish. For nothing else changes the complexion or makes a man tremble or sets his teeth a-chattering, or ‘Shift from leg to leg and squat on one foot then the other.’ (Discourses, 2.13.1-13)

Instead of attaching too much value to other people’s opinions, absolutely demanding their approval and fearing their rebuke, the musician should patiently train himself, over time, to put value primarily upon his own intentions and judgements and to take the audience’s praise or leave it with similar equanimity. For the Stoics, to value something positively or negatively is to try to control it, and we have more control over our own judgments and intentions than over external events or other people, so we should shift the focus of our value judgements inwards, within the here and now, and focus on the importance of our own mental activity and responses more than other people’s opinions. The example of stage fright is extended by Epictetus to oratory and any similar social anxiety. Anyone who anxiously demands, rather than merely preferring, that others praise him is being unphilosohical, and has failed to understand the nature of things in relation to his sphere of control. He blames his nerves on the situation, neglecting the importance of his own misplaced value judgements in determining his emotional disturbance.

Nor does he even know what anxiety itself is, whether it be our own responsibility or outside it, or whether it be possible to suppress it or not. Because of this, if he is praised, he leaves the stage puffed up with pride: but if he is laughed at, his poor bubble is pricked and collapses.

We too experience something of this kind. What do we admire? Externals. What do we strive for? Externals. Are we then at a loss to know how fear and anxiety overcome us? Why what else is possible when we regard impending events as evils? We cannot help being fearful we cannot help being anxious. (Discourses, 2.16.10)

Excerpt: Shame-Attacking Exercises

In certain concrete practical respects, REBT also contains therapy interventions that resemble techniques familiar within ancient philosophical therapy. Ellis was known for what he described as REBT’s “trademark” use of various “shame-attacking exercises”. In order to help clients overcome self-consciousness, social embarrassment and inhibition, Ellis would prescribe changes in behaviour which were designed to forcefully and directly challenge their sense of shame. For example, he refers to the technique of asking clients to repeatedly stop a bus without getting off, or asking strangers in the street to give them money, etc.

I realised, soon after I started REBT in 1955, that what we call “shame” is the essence of a great deal of our emotional disturbance. […] Seeing this, I created my now famous shame-attacking exercise in 1968; and perhaps millions of people, especially psychotherapy clients, have done this exercise and trained themselves to feel shamed or sorry about what they did, and about the public disapproval that often went with it, but not to put themselves down and not to feel humiliated about their personhood. (Ellis & MacLaren, 2005, p. 95)

Ellis further explains the exercise as follows,

Here clients deliberately seek to act “shamefully” in public in order to accept themselves and to tolerate the ensuing discomfort. Since clients do best to harm neither themselves nor other people, minor infractions of social rules often serve as suitable shame-attacking exercises (e.g., calling out the time in a crowded department store, wearing bizarre clothes designed to attract public attention, and going into a hardware store and asking the clerks whether they sell tobacco). (Dryden & Ellis, 2001, p. 329)

This aspect of Ellis’ work is strikingly reminiscent of the practices of the ancient Cynic philosophers who appear to have adopted, albeit in a more extreme manner, controversial lifestyles and behaviours in order to liberate themselves from social conventions.

The Cynics break with the world […] was radical. They rejected what most people considered the elementary rules and indispensible conditions for life in society: cleanliness, pleasant appearance, and courtesy. They practiced deliberate shamelessness – masturbating in public, like Diogenes, or making love in public, like Crates and Hipparchia. The Cynics were absolutely unconcerned with social proprieties and opinion; they despised money, did not hesitate to beg, and avoided seeking stable positions within the city. […] They did not fear the powerful, and always expressed themselves with provocative freedom of speech (parrhesia). (Hadot, 2002, p. 109)

Ellis seems unaware of this precursor to his “shame-attacking” exercises. However, the Cynics themselves specifically refer to the deliberate practice of “shamelessness” (anaideia) as a psychotherapeutic exercise. In the case of Diogenes, this was referred to metaphorically as his “defacing the coinage” of social conventions, which inevitably shocked others. So notorious were the shameless acts of Diogenes that Plato allegedly called him “Socrates gone mad”.

According to the Greek biographer Diogenes Laertius, the famous Cynic, Crates, who trained Zeno the founder of the Stoic school, was nicknamed “Door-opener” because of his habit of inviting himself into people’s houses to lecture them somewhat abrasively on philosophy(Laertius, 1853, p. 250). He also mentions another practice of Crates which sounds like an even more provocative version of Ellis’ shame attacking exercises, ‘He used to abuse prostitutes designedly, for the purpose of practising himself in enduring reproaches’(Laertius, 1853, p. 251). Epictetus seems to imply that Diogenes and the other Cynics, whom he greatly admired, deliberately broke wind in front of people, presumably also as part of their practice of shamelessness (Discourses, 3.22.80). Indeed, I am indebted to Still and Dryden for the following illustration drawn from Montaigne’s account of a quite surprising Stoic anecdote,

In the midst of a discussion, and in the presence of his followers, Metrocles let off a fart. To hide his embarrassment he stayed at home until, eventually, Crates came to pay him a visit; to his consolations and arguments Crates added the example of his own licence: he began a farting match with him, thereby removing his scruples and, into the bargain, converting him to the freer stoic school from the more socially oriented Peripatetics whom he had formerly followed. (Montaigne, in Still & Dryden, 1999, p. 157)

Crates’ exercises in shamelessness, or the overcoming of social anxiety and inhibition, can be seen as a practical training in his maxim, ‘That a man ought to study philosophy, up to the point of looking on generals and donkey-drivers in the same light’ (Laertius, 1853, p. 252). Zeno appears to have assimilated some aspects of his mentor’s philosophy into Stoic therapeutics, although moderated by a greater respect for society than the Cynics allegedly displayed.

Like Crates, Diogenes the Cynic, who was revered as a Sage by some Stoics, reputedly tested prospective students by instructing them to follow him around carrying a salted fish, or a piece of cheese, in their hands. When some refused, out of embarrassment, he would chide them: “See how a piece of salted fish was enough to dissolve our friendship!” (Laertius, 1853, p. 230). Notoriously insolent and iconoclastic, he once asked the Athenians to erect a statue to him, and when asked why he had done so, replied, “I am practising disappointment.” (Laertius, 1853, p. 235). These and many similar popular philosophical anecdotes illustrate the striking parallel between the ancient Cynics’ psychotherapeutic technique of anaideia, or shamelessness, and the “shame-attacking” exercises made famous by Albert Ellis within REBT, precursors of certain more modest “behavioural experiments” used to challenge social anxiety and inhibition in modern CBT. Beck and his colleagues also refer to “anti-shame exercises” and observe that cognitive therapy provides opportunities for clients to deliberately expose themselves to feelings of shame in order to conquer them (Beck, Emery, & Greenberg, 2005, p. 282). Indeed, there are many more parallels which can be drawn between the principles of REBT and those of Stoicism.

Addendum

I didn’t spot this quotation in time for the book but Diogenes Laertius writes:

Some one dropped a loaf of bread and was ashamed to pick it up; whereupon Diogenes, wishing to read him a lesson, tied a rope to the neck of a wine-jar and proceeded to drag it across the Ceramicus.

The Ceramicus was the busy potter’s district of Athens, as the name implies, but also the location of a major cemetery. This exercise in shamelessness clearly anticipates Ellis’ “trademark” REBT technique of taking a banana for a walk on a string through a shopping mall, as if it were a dog on a leash.

This is a brief excerpt from my book, The Philosophy of Cognitive-Behavioural Therapy, published by Routledge and available to order online from Amazon, and everywhere they sell books.