Tag: cognitive therapy

“Distancing” versus “Disputation” as the central process of Stoic psychotherapy

This article explores whether “distancing” from thoughts/impressions or “disputation” of underlying irrational beliefs is more integral to Stoic therapy.  If it were established that ancient Stoicism employed a focus on “cognitive distancing” strategies that would be important for several reasons.  Distancing is a simpler and more consistent procedure than verbal disputation, so analogies between Stoicism and CBT would be easier to make.  Moreover, large volumes of research now exist on distancing, which suggest that it may be one of the most important mechanisms in psychotherapy, and may serve both a preventative and remedial function.  Some groups of modern researchers also believe that disputation may interfere with distancing, which would be an important consideration for modern Stoics to assimilate.

The first major figure to notice the relevance of ancient Stoic philosophy for modern psychotherapy was Albert Ellis.  In the late 1950s, Ellis began developing what later became known as Rational-Emotive Behaviour Therapy (REBT).  REBT is the main precursor of modern cognitive-behavioural therapy (CBT), currently the approach to psychological therapy with by far the strongest evidence-base for most clinical problems.  Ellis had read the Stoics as a youth.  He later trained in and practiced psychoanalytic therapy.  However, after becoming disillusioned with psychoanalytic theory and practice he started looking for a radically different approach, and remembered Stoicism.  Hence, Ellis explicitly stated that Stoicism was the main philosophical inspiration for REBT.  Stoicism arguably stands in the same relation to subsequent CBT approaches in general, although these are really quite a diverse cluster of different therapies, rather than a single homogenous approach.

Ellis’ approach placed considerable emphasis on the systematic and vigorous verbal disputation of irrational beliefs – its characteristic feature.  However, he used to provide clients with a quotation from Epictetus to illustrate his basic premise that our beliefs are at the root of emotional disturbance: “It is not the things themselves that disturb people but their judgements about those things” (Enchiridion, 5).  This quotation highlights a basic assumption shared by all cognitive-behavioural therapies: that we should begin by separating our thoughts from external events.  Ellis and Beck (the founder of “cognitive therapy”) both saw this as an important therapeutic insight but mainly because it was a necessary precursor to the use of disputation techniques.  Typically, for example, REBT or CBT practitioners would ask their clients to evaluate the “pros and cons” of an irrational belief, or the evidence “for and against it”, and to identify alternative rational beliefs to replace it with.  This, combined with “behavioural experiments” designed to test out and challenge irrational beliefs in practice, form the bulk of what happens in most modern CBT sessions.

However, although the Stoics do appear to have sometimes challenged specific beliefs in ways that loosely resemble this, it was perhaps not their dominant or characteristic approach.  REBT and CBT might encourage clients to challenge underlying (“core”) irrational beliefs such as “I am worthless” or “Other people must like me otherwise it’s awful!”  When philosophically evaluating beliefs, Stoics tended to focus on defending underlying precepts of an even more  general nature from which individual judgements are derived, such as “the only good is moral good”, considering the possible criticisms, or arguments against these positions, and those in favour of them.  Whereas CBT and REBT often target “underlying” value judgements, Stoic disputation might be described as more “philosophical” or “meta-ethical” as it tends to concern the very nature of “the good” itself.  (And it may be closer to what modern researchers term disputation of “metacognitive” beliefs, beliefs about beliefs or cognitions about cognition.) The Stoics do appear to have challenged their judgements about specific situations but the focus in their writings is typically more on defending their core philosophical dogmas.  Moreover, when Stoics do examine particular situations they appear to place more emphasis on constructing  a positive mental representation of how the Sage might act, or what virtues Nature has granted that allow them to rise above adversity.  CBT places more emphasis on the identification and direct disputation of negative or irrational beliefs.

Since the 1990s, different researchers have introduced alternative approaches to CBT that are collectively known as the “third-wave” movement.  (The first wave was behaviour therapy in the 1950s and 1960s, the second the rise of cognitive therapy in the 1970s and 1980s.)  Although there are significant differences between these new forms of CBT, they all tend to place less emphasis on direct verbal disputation of beliefs and more on the initial step of gaining “cognitive distance”.  Beck defined “distancing” in cognitive therapy as a “metacognitive” process, a shift to a level of awareness involving “thinking about thinking”, which he defined succinctly as follows:

“Distancing” refers to the ability to view one’s own thoughts (or beliefs) as constructions of “reality” rather than as reality itself. (Alford & Beck, 1997, p. 142)

In CBT, clients are usually “socialised” or introduced to this notion through the use of simple diagrams or metaphors.  For example, they may be taught that when thoughts distort our perception of events it’s like we’re wearing coloured spectacles.  When we gain cognitive distance from our own thoughts, it’s as though we’re taking off the spectacles and looking at them, rather than looking through them.  A similar “distancing” mechanism has been seen as integral to mindfulness meditation practices which have been found effective in the treatment of depression, and were therefore integrated with some forms of CBT.  Therefore, the third-wave approaches are often described collectively as the new “mindfulness and acceptance-based” approaches.  For example, one of the most prominent of these, Acceptance and Commitment Therapy (ACT), was originally called “comprehensive distancing” because it explicitly aimed to test the hypothesis that the initial “cognitive distancing” strategy in conventional CBT was much more important than had previously been assumed.

Unlike REBT and Beck’s cognitive therapy, these recent forms of therapy do not explicitly claim to be influenced by Stoic philosophy.  However, perhaps by chance, they may have many similarities with aspects of Stoicism that were overlooked by the founders of CBT.  In particular, it might be argued that Stoicism itself placed more emphasis on a something akin to “cognitive distancing” than upon direct disputation of beliefs.  This may have been somewhat overlooked by scholars because “distancing” is a more subtle and elusive concept than disputation.  For that reason, sometimes it is difficult to tell if the Stoics are genuinely referring to the same mechanism, as this often turns on subtleties of translation and interpretation.

One of the passages that stands out most in this regard occurs right at the start of the Enchiridion of Epictetus, where he writes:

Train yourself, therefore, at the very outset to say to every harsh impression: “You are merely an impression [phantasia] and not at all what you appear to be [phainomenon].” (Enchiridion, 1)

Alternatively, perhaps more literally: “You are an appearance and not in any way the thing appearing” – you are merely the subjective impression and not the thing in-itself.

Epictetus, as is often the case, appears to be literally instructing his students to repeat this phrase to themselves as part of a general-purpose psychological strategy for managing disturbing thoughts or impressions.   The fact that this occurs in the first passage of the Enchiridion may also signal its importance.   It’s presented, as in cognitive therapy, as a prelude to other strategies, which involve “testing” the impression by applying the core precepts of Stoicism to it.  At this point, cognitive therapy might involve weighing up the evidence for and against the impression (or “automatic thought”), or identifying the types of distortion it contains, such as “over-generalisation” or “black and white thinking”, etc.  However, Epictetus says the most important response a Stoic can make is to question whether the impression has to do with things under our control or not.  If it refers to something external, the student is to say to it: “It is nothing to me.”  That is, this is completely indifferent with regard to happiness and the good life, the chief goal of Stoicism.  The Stoics appear to have realised, as modern CBT does, that any form of re-evaluation or disputation is impossible unless the initial step of gaining “psychological distance” takes place first.  I have to be able to view my judgements as hypothesis (merely impressions) rather than as facts (confusing them with the things they claim to represent), before I can begin to question them as such.

In relation to this, Epictetus also refers many times to the strategy of avoiding “being carried away” (sunarpasthêis) by impressions in general, and not letting them “seize the mind” prematurely.  He specifically refers to impressions that attribute good or bad to indifferent things, such as pleasure, other people’s happiness, insulting behaviour, or fearful prophecies, etc.

When you get an impression of some pleasure, guard yourself, as with impressions in general, against being carried away by it; nay, let the matter wait upon your leisure, and give yourself a little delay. (Enchiridion, 34)

And so make it your primary endeavour not to be carried away by the impression; for if once you gain time and delay, you will more easily become master of yourself. (Enchiridion, 20)

This delaying tactic was well-known in antiquity and can perhaps be traced to the early Pythagoreans.  It resembles time-out or postponement strategies used in modern CBT, which require cognitive distance from an automatic thought, and the ability to defer thinking any more about it or acting upon it until later.  Another reason this works well is clearly due to the fact that emotional disturbances (“passions”) tend to come and go naturally and so returning to a thought at a later time, in a different “frame of mind”, generally makes it easier to evaluate it more objectively.

Beck’s cognitive therapy writings only discuss “cognitive distancing” very briefly, although he does mention about half-a-dozen practical strategies, which are taught to clients in the initial stage of therapy.  For example:

1. Writing down negative automatic thoughts on a daily thought record, particularly fleeting automatic thoughts that might normally go unnoticed or get conflated with feelings
2. Writing thoughts on a blackboard and literally viewing them from a distance, as something objective and “over there”, by patiently describing the colour, size, and style of the writing, etc.
3. Viewing thoughts as inferences or hypotheses instead of facts, distinguishing between “I believe” and “I know”, discriminating carefully between thoughts and facts
4. Referring to your thoughts and feelings in the third-person (“Bill is having anxious feelings, he’s thinking that people are criticising him…”)
5. Using a counter to keep a tally of specific types of automatic thoughts, seeing them as habitual and repetitive, as just a meaningless side-effect of previous experience rather than something important and meaningful that deserves to be taken seriously
6. Self-observation, being aware of your own awareness, noticing how you observe your thoughts, maintaining a sense of yourself as conscious observer, separate from the contents of your stream of consciousness
7. Shifting perspectives and imagining being in the shoes of other people, who might disagree with your beliefs and view things differently, adopting a different perspective on things and identifying a range of alternative views, among which your current thought is just one of many

ACT and other third-wave therapies have added more techniques to this list and refined the existing ones.  In particular, they’ve introduced the use of mindfulness meditation techniques, derived from Buddhism, which are mean to train clients to develop greater detachment or psychological distance from their thoughts.  Beck himself never mentioned the use of meditation in this way, although it may seem an obvious adjunct to the techniques described above.

Moreover, a brief survey of the Stoic literature suggests that most of the psychological techniques employed can be seen as relating more to the mechanism of “distancing” than “disputation”.  For example, in the Enchiridion, Epictetus instructs students of Stoicism to do the following:

1. We should continually maintain attention (prosochê) to the leading faculty of the mind (hêgemonikon), watching our judgements as they happen; as if watching our steps, cautious of stepping on a sharp object, or as if looking out for an enemy in hiding
2. When upset, we should always remind ourselves that it is our judgment that harms us and not the external thing itself, and we should guard against being “swept away” by upsetting external impressions
3. When something appears to be upsetting, you should imagine the same thing befalling someone else, so that you can judge it from a distance
4. We should abandon value judgements and stick instead to a bare description of the facts of a situation, which forces us to see our value judgements as something we’re imposing on events rather than an intrinsic characteristic of external events themselves
5. We should remind ourselves how the wise man would judge the same thing differently because noting that different people view things differently helps us to distinguish our thoughts from external facts.  Epictetus’ favoured example: Death cannot be intrinsically evil otherwise Socrates would have judged it to be so.
6. We should postpone responding to impulses associated with powerful impressions until later, something which forces us to adopt a more detached perspective on them – modern therapists call this taking a “time-out” or simply “postponement”

These might be described as brief “shifts in perspective” rather than stepwise methods of disputation.  They are perhaps more experiential than verbal.  There’s no need to evaluate the evidence for these judgements, the Stoic simply reminds himself that they are judgements, peeling them away from the surface of reality, as it were, and viewing them as events within his own mind.  The Stoics referred to this process as “withholding assent” from initial impressions that mistakenly ascribe intrinsic value to indifferent things.  They assumed that impressions are outside of our control, being triggered by external events, like the “automatic thoughts” of cognitive therapy.  However, we do control what happens next: whether we accept the impression as reality or not, by giving our “assent” and saying “yes” to it.  Interestingly, the Stoics don’t seem to refer to saying “no” or exercising “dissent” toward impressions, merely suspending assent appears to be sufficient, at least at first.  Shortly after, attention may be shifted on to alternatives to the initial impression, such as “What would the Sage do?”

Some researchers, most notably the founders of ACT, have argued that verbal disputation techniques may interfere with psychological distance (which they call “cognitive defusion”).  The best way to illustrate this is perhaps by considering the example of Buddhist-style mindfulness meditation.  While meditating, if a distracting thought crosses the mind, mindfulness practitioners are taught to view it with detachment and resist the urge to respond to it by analysing its meaning or engaging in an internal dialogue about it.  They might view it as if it were like a cloud passing across the sky and “let it go”.  Engaging with the thought can simply make it more prominent, even if someone is attempting to challenge or dispute it.  One can easily be swept along with the thought this way and lose psychological distance from it.  The relative brevity of Stoic techniques arguably lends itself to maintaining psychological distance from upsetting impressions.  That could be lost again, though, if you “get into a debate with yourself” about the truth or falsehood of certain thoughts.  There’s a considerable body of modern research showing that attempts to suppress or distract oneself from distressing thoughts tend to be counter-productive.  Gaining psychological distance neatly circumvents this problem because it means neither assenting to (“buying into”) a thought nor trying to eliminate it, but rather viewing it from a detached perspective.  Rather than “I must not have this thought”, someone with psychological distance from their thoughts might say: “It’s okay to have this thought cross my mind but it’s just a thought, I don’t need to dwell on it or take it too seriously.”  There appear to be some references in the Stoic literature to suppressing automatic thoughts or feelings, though, which would be considered unhealthy and problematic from the perspective of modern research on psychotherapy.  However, the dubious strategies of thought-suppression or distraction do not seem to be an important or necessary part of Stoic therapeutics, and could easily be replaced with more consistent emphasis on “cognitive distancing” or merely withholding assent.