Dialogues in Philosophy, Mental and Neuro Sciences ORIGINAL ARTICLE Crossing Dialogues

Association

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

www.crossingdialogues.com/journal.htm 10 Cavanna, 2019

“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)

THE RENAISSANCE OF STOICISM: PHILOSOPHY AS MEDICINE “It has not escaped our notice” (to borrow Mediterranean societies since Alexander the a famous incipit from world-class scientifi c Great (356-323 BCE) marked the end of the literature) that an unprecedented series of books stability of the Greek city-state (polis) and linking the ancient Greek philosophy of Stoicism exposed the citizens of his empire to diff erent with the modern science of well-being have cultures and worldviews. It was during the been published over the last decade. To quote Hellenistic age, an era of increasing uncertainty, but a few examples, the works of American that the main focus of philosophy shifted from philosophers William Irvine (‘A guide to the the study of universal nature to the understanding good life: The ancient art of Stoic joy’, 2009) of individual man (introspection). The rival and Massimo Pigliucci (‘How to be a Stoic’, Socratic schools of Stoicism, Epicureanism, 2017) have been widely read and discussed. Cynicism, and Skepticism started diff erent In the United Kingdom and Canada, Scottish traditions, and were indeed characterised psychologist Donald Robertson has focused his by inner debates and tensions, however it is excellent work on the key role of Stoicism as the important to note that they shared the view of conceptual foundation of modern psychotherapy the role of philosophy as practical guide for life (‘The philosophy of cognitive-behavioural and powerful therapy for psychological distress. therapy: Stoic philosophy as rational and In one of his surviving fragments (221 Usener), cognitive psychotherapy’, 2010; ‘Stoicism Epicurus (341-270 BCE) was quite clear about and the art of happiness’, 2013). During the the role of philosophy as medicine for the soul: last two decades of the XX Century, the late “A philosopher’s words are empty if they do not classics scholar Pierre Hadot in France and the heal the suff ering of mankind. For just as medicine infl uential philosopher Martha Nussbaum in is useless if it does not remove sickness from the United States paved the way for the present the body, so philosophy is useless if it does not Renaissance of applied philosophy based on the remove suff ering from the soul”2. Interestingly, Hellenistic tradition of philosophy as practical the surviving philosophical texts of the Roman wisdom providing psychological therapy or writers such as the eclectic Cicero (106-43 mind training (Hadot, 1981; Nussbaum, 1994). BCE) show evidence of medical terminology More recently, American philosopher Lawrence and suggest that the view of philosophy as Becker published the new edition of a daring therapy of the mind was widely endorsed. exposition of what Stoic philosophy would In his ‘Tusculanae disputationes’ (‘Tusculan look like today if it had enjoyed a continuous Disputations’), Cicero described philosophy as development from the Hellenistic age, through ‘Socratica medicina’ (‘Socratic medicine’) and the Renaissance, the Enlightenment, and modern ‘animi medicina’ (‘medicine for the soul’), and science, to the current trends of moral philosophy drew a compelling parallel between the role of (Becker, 2017). the philosopher in the treatment of mental disease The role of ancient philosophy as mind (‘animi morbum’) and the role of the physician therapy is acknowledged within the diverse in the treatment of physical disease. The traditions of Hellenistic philosophy, which therapeutic role of philosophy was particularly stemmed from the teaching of Socrates (470-399 evident within the Stoic tradition. Although it is BCE) in Athens, as recorded by Plato (428-347 appropriate to distinguish diff erent philosophical BCE), the founder of the Academy, and mediated movements and stages within Stoicism, it by his later disciples, especially Aristotle (384- appears that the analogy between philosophy 322 BCE), the founder of the Lyceum. The and medicine is a key theme across thinkers and Hellenistic philosophies fl ourished across the times. For example, in the fi fteenth letter of his

11 DIAL PHIL MENT NEURO SCI 2019; 12(1): 10-24 ‘Epistulae morales ad Lucilium’ (often translated transforms his vision of the world, and, fi nally, as ‘Letters from a Stoic’), Roman politician and his entire being. The analogy seems all the more philosopher Seneca (4 BCE - 65 CE) wrote self-evident in that the gymnasion, the place “Recte nos dicimus ‘si philosopharis, bene est’ where physical exercises were practiced, was […] Sine hoc aeger est animus” (“We rightly say the same place where philosophy lessons were ‘if you are studying philosophy, it is well’ […] given; in other words, it was also the place for Without wisdom the mind is sick”). Finally, the training in spiritual gymnastics”3 (Hadot, 1995). Socratic concept of philosophy as medicine for Crucially, Hadot showed that the Hellenistic the soul, that became commonplace throughout schools of philosophy shared the assumption the Hellenistic age, reverberated in the teaching that the consistent use of reason, combined with of another Stoic philosopher, Epictetus (50- eff ort and training, can allow human beings to 135 CE), as reported by his disciple Arrian at rise above their circumstances and conquer their the beginning of the II Century CE: “ἰατρεῖόν emotions and desires. This is hardly surprising, ἐστιν […] τὸ τοῦ φιλοσόφου σχολεῖον” (“the as Hellenistic philosophy, in all its derivations, philosopher’s school is […] a doctor’s clinic”) stems from the Socratic teaching and his attitude (‘Discourses’, III,23). Of note, the recent toward the centrality of reason: “for I am not discovery of the essay ‘Περὶ ἀλυπίας’ (‘Avoiding only now but always a man who follows nothing distress’) by the famous Roman physician Galen but the reasoning which on consideration seems (130-210 CE) suggests that the link between to me best”4 (Plato, ‘Crito’, 46b). philosophy and medicine was more than a philosophical metaphor. Galen’s engagement ASPECTS OF STOIC PHILOSOPHY with Stoic psychotherapy techniques locates his AND PSYCHOLOGY work within the tradition of practical ethics of Among the Hellenistic schools of philosophy, the Roman period (Xenophontos, 2014). Stoicism (especially in its late, Roman stage) The late French scholar Pierre Hadot arguably off ers the most obvious parallels provided the fi rst detailed analysis of the various with modern psychotherapeutic practices. exercises of a therapeutic nature to be found in Stoicism owes its name to the ‘ποικίλη στοά’ classical philosophy, with focus on ancient Stoic (‘painted porch’ in ancient Greek): a colonnade literature. Hadot’s account of the function of overlooking the central square of Athens most ancient philosophies as spiritual exercises where Zeno of Citium (334-262 BCE) taught (‘ἀσκήσεις’) is highly revealing and deserves his disciples from around 300 BCE. Zeno is to be quoted in full: “All schools agree that commonly regarded as the founder of Stoicism, man, before his philosophical conversion, is a philosophical school heavily infl uenced by in a state of unhappy disquiet. Consumed by the teachings of Socrates, mediated by the worries, torn by passions, he does not live a Cynic philosopher Antisthenes (444-365 BCE). genuine life, nor is he truly himself. All schools Stoicism is usually divided by scholars into three also agree that man can be delivered from this phases. The fi rst phase, or Early Stoa, featured state. He can accede to genuine life, improve Zeno and the philosophers who were heads of the himself, transform himself, and attain a state of Stoic school after him, including Cleanthes (262- perfection. It is precisely for this that spiritual 230 BCE) and Chrysippus (230-207 BCE). The exercises are intended. Their goal is a kind of introduction of the Stoic teachings to Rome by selff ormation, or paideia, which is to teach us to the philosophers Panaetius of Rhodes (180-110 live, not in conformity with human prejudices BCE, head of the Stoic school during the period and social conventions - for social life is itself 129-110 BCE) and Posidonius of Apameia (135- a product of the passions - but in conformity 51 BCE) marked the development of the Middle with the nature of man, which is none other than Stoa. Finally, the Late or Roman Stoa partially reason. Each in its own way, all schools believed overlapped with the early Christian era and in the freedom of the will, thanks to which man was characterised by the activity of three key has the possibility to modify, improve, and fi gures: the Roman philosopher and politician realize himself. Underlying this conviction is Lucius Annaeus Seneca (4 BCE - 65 CE), the the parallelism between physical and spiritual freed slave Epictetus (50-135 CE), and the exercises: just as, by dint of repeated physical philosopher-emperor Marcus Aurelius (121-180 exercises, athletes give new form and strength CE) (Figure 1). The only surviving texts from to their bodies, so the philosopher develops the Early Stoa and the Middle Stoa are scattered his strength of soul, modifi es his inner climate, fragments, whereas a few complete Roman texts www.crossingdialogues.com/journal.htm 12 Cavanna, 2019 in ancient Greek and Latin from the Late Stoa Aristotelian sense. The original sense of the have reached us. 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 Figure 1: A politician (Lucius Annaeus Seneca, 4 BCE - 65 CE), a use of reason) is the only evil (Figure 2). 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 Figure 2: Francisco Goya, 1799: ‘El sueño de la razón produce defi ned as the irrational expectation of something monstruos’ (‘The sleep of reason produces monsters’). bad or harmful, craving as the irrational striving The importance of rationality for the Stoic for something mistakenly judged as good, and concepts of human nature and virtue – as well pleasure as the irrational elation over something as well-being and mental health – cannot be that is actually not worth pursuing. Conversely, overestimated (Papadimos, 2004). Using mod- discretion, willing, and joy were regarded as ern terminology, for the Stoics cognition forms healthy emotions (‘εὐπάθειαι’) by the Stoics: the basis for the ability of the rational mind to a rational aversion of vice and harmful things free itself from unhealthy emotions (which are (discretion), a rational desire for virtue (willing), denied assent by rational judgement) and to pro- and a rational elation over virtue (delight). mote healthy emotions. It is clear that the Stoic Therefore the popular caricature of the Stoic approach relies heavily on the notion that rational sage as a grave fi gure, emotionally detached thinking or cognition (a uniquely human facul- and obsessed with the practice of endurance and ty) has overriding power over emotions (mental resignation is highly inaccurate. Although Stoic states shared with lower creatures). A formidable sages have developed their ability to endure rebuttal to the potential criticism of placing ex- pain to a remarkable extent, they do not have cessive faith into the positive power of reason, to sacrifi ce joy to have that ability, and rather was provided by Bertrand Russell in his popular than suppressing or hiding their feelings, they book ‘The conquest of happiness’ (1930), that is acknowledge emotions and redirect them for often quoted as one example of modern Stoicism their own good. (Robertson, 2010): The motto of the Stoic school was ‘follow nature’, which meant the human nature of a “There is in many people a dislike of rationality social animal capable of rational judgment. The […] There is an idea that rationality, if allowed free notion of mankind as a group of ‘quintessentially play, will kill all the deeper emotions. This belief rational animals’ is refl ected in the meaning appears to me to be due to an entirely erroneous of Stoic virtue, which follows the original conception of the function of reason in human life.

13 DIAL PHIL MENT NEURO SCI 2019; 12(1): 10-24 It is not the business of reason to generate emotions, in Rome, refused to acknowledge the insult and though it may be part of its function to discover replied to his off ender “I don’t remember being ways of preventing such emotions as are an hit”. Based on revealing ancient anecdotes such obstacle to well-being. To fi nd ways of minimizing as these, it would be tempting to argue that hatred and envy is no doubt part of the function of the Stoic attitude embodies a human trait that a rational psychology. But it is a mistake to suppose can be found, with minimal variations, across that in minimizing these passions we shall at the diff erent times and cultures. Unsurprisingly, the same time diminish the strength of those passions Stoic attitude has been celebrated in both poems which reason does not condemn. In passionate love, and novels that inspired generations and stood in parental aff ection, in friendship, in benevolence, the test of time. ‘Invictus’ is the title of a short in devotion to science or art, there is nothing that Victorian poem written in 1875 and published in reason should wish to diminish. The rational man, 1888 by the English poet William Ernest Henley when he feels any or all of these emotions, will be (1849-1903). Its celebrated verses encapsulate glad that he feels them and will do nothing to lessen the therapeutic power of inner rational resources their strength, for all these emotions are parts of the when dealing with life adversities: good life, the life, that is, that makes for happiness both in oneself and in others”. “Out of the night that covers me, Black as the pit from pole to pole, If virtue (i.e. living according to the rational I thank whatever gods may be nature of human beings) is the only good, it For my unconquerable soul. follows that, according to the Stoics, things that are commonly referred to as misfortunes In the fell clutch of circumstance (including disease and death) are nothing to I have not winced nor cried aloud. worry about, as it is possible to follow virtue Under the bludgeonings of chance even in such dire circumstances. In fact, My head is bloody, but unbowed. misfortunes are regarded as nothing more than ‘indiff erents’ (or ‘dispreferred indiff erents’): Beyond this place of wrath and tears the rational human being is naturally capable Looms but the Horror of the shade, of living in accordance to nature (‘virtuously’) And yet the menace of the years even when enduring illness or facing death. Both Finds, and shall fi nd me, unafraid. Socrates’ frugal lifestyle and Spartan education practices could be seen as important precursors It matters not how strait the gate, of this philosophy of life. The story of the How charged with punishments the scroll, Spartan boy who stole a fox and hid it under his I am the master of my fate: cloak, as reported by Plutarch (‘Moralia’, III, I am the captain of my soul.” 234), powerfully exemplifi es the Stoic attitude: not to be discovered, the young Spartan was able In his 1958 novel ‘Il Gattopardo’ (‘The to keep silent as the fox tore out his innards in an Leopard’), Italian writer Giuseppe Tomasi di attempt to break free. Even earlier, it has been Lampedusa wrote that Sicilian nobleman Don reported that when the pre-Socratic philosopher Fabrizio Corbera, Prince of Salina, “thought of Anaxagoras was told of the death of his son, a medicine recently discovered in the United he was able to bear the pain and control his States of America which could prevent suff ering emotional reaction by calmly stating “I knew even during the most serious operations and that I gave birth to a mortal son”. In the Roman produce serenity amid disaster. ‘Morphia’ was world (especially during the Republican era), the name given to this crude substitute for this attitude was deeply appreciated, as Stoicism the stoicism of the ancients”5. In addition to was seen as the Hellenistic philosophy most in literary masterpieces, Stoic words reverberate line with the traditional Roman values. History in personal accounts of real-life experiences, up books feature multiple examples of Roman until recent times. By explicitly adopting a Stoic fi gures who were regarded as Stoic role models or attitude and building on his acquaintance with sages. Mucius Scaevola allegedly impressed the Epictetus’ teaching, American Admiral James Etruscan king Porsena by thrusting his right hand Stockdale (1923-2005) was famously able to into a sacrifi ce fi re without giving any indication endure seven and a half years of isolation and of pain. Seneca reported that Cato the Younger, brutal torture as prisoner of war in Vietnam shortly after being shoved and struck at the baths without fl inching (Stockdale, 1993). Shot down www.crossingdialogues.com/journal.htm 14 Cavanna, 2019 over North Vietnam in September 1965, he was he replies, ‘or to death?’ ‘To banishment’. ‘What so badly beaten by a crowd when his parachute about my property?’ ‘It is not taken from you’. landed that his leg was broken and he walked ‘Let us go to Aricia then’, he said, ‘and dine’”6. with a limp for the rest of his life. After ejection Epictetus held this up as an excellent model of from his little A-4 airplane, he had about thirty Stoic behaviour: “This is what it means to have seconds to make his last statement in freedom rehearsed the lessons one ought to rehearse, to before he landed in enemy territory. Years later, have set desire and aversion free from every he reported that he had whispered to himself: hinderance and made them proof against chance. “Five years down there, at least. I’m leaving the I must die. If forthwith, I die; and if a little later, I world of technology and entering the world of will dine now, since the hour for dinner has come, Epictetus”. and afterwards I will die at the appointed time. How? Like a man who gives up what belongs STOIC INFLUENCES ON MODERN to another”7. Marcus Aurelius’ words were of a PSYCHOTHERAPY very similar tone: “He does not care in any way The therapeutic power of Stoic philosophy whether he will have his soul enclosed by his is perhaps most evident in Epictetus’ thought body for a longer or shorter time. Even if he (Xenakis, 1969; Long, 2004; Stephens, 2007; needs to leave right away, he departs as readily Pigliucci, 2017). Historically, the two surviving as if he were performing any of the other actions texts on Epictetus’ Stoicism by his disciple that can be done in a decent and orderly way, Arrian, the ‘Εγχειρίδιον’ (‘Handbook’) and the exercising care for this alone throughout his ‘Διατριβαί’ (‘Discourses’), proved formidable life, that his mind should never be in a state that sources of inspiration for self-help and is alien to that of a rational and social being”8. psychotherapy techniques. The opening line of By his own admission, Marcus Aurelius was Epictetus’ Handbook states that “τῶν ὄντων τὰ deeply infl uenced by Epictetus’ works, which μέν ἐστιν ἐφ’ἡμῖν, τὰ δὲ ούκ ἐφ’ἡμῖν” (“there are he borrowed from his teacher Rusticus when things which are within our power, and there are he was young (Hadot, 1992; Robertson, 2019). things which are beyond our power”). According In this passage (III,7) from ‘Τὰ εἰς ἑαυτόν’ (‘To to Epictetus, only our rational faculties (our himself’, more often translated as ‘Meditations’), judgements and opinions, resulting in voluntary the Roman emperor highlighted two key themes actions) are pre-eminently within our power of the Stoic thought: reason (rationality) and to control, whereas external events, including cosmopolitanism (philanthropy), as the pillars health, material wealth, and reputation, are of human nature. The famous Stoic injunction ultimately outside our control and in the hands to live ‘according to the nature’ can be fully of Fortune. The resulting ‘dichotomy of control’ understood only by taking into account their view (or ‘Stoic fork’) (Robertson, 2010) is a principle of human beings as social rational animals. Since of fundamental importance for Stoicism, with our own death is not subject to our control, it has practical implications in terms of healing nothing to do with the practice of virtue in the or therapeutic power: it limits considerably Stoic sense: therefore, it should be categorised the number of things and events we should as an ‘indiff erent’ and not be feared. realistically worry about, leaving everything The fundamental Stoic distinction between else within the realm of mere ‘indiff erents’. In what is in our power and what is not resonates an interesting historical anecdote, Epictetus in other famous texts inspired by Stoicism, until famously praised a Roman statesman and recent times. The Serenity Prayer is the common philosopher who was ordered by Nero into exile, name for a text written by American theologian Paconius Agrippinus, for showing a typical Stoic Reinhold Niebuhr (1892-1971), who wrote it attitude toward justice (Discourses, I,1): “What, in the 1930s and fi rst published it in 1951. The then, did Agrippinus say? He said, ‘I am not a prayer contains the following verses, which hindrance to myself’. When it was reported to make clear reference to the Stoics’ dichotomy of him that his trial was going on in the Senate, he control: 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 ‘God, grant me the serenity to accept the things used to exercise himself and then take the cold I cannot change, bath - ‘let us go and take our exercise’. After he Courage to change the things I can, had taken his exercise, one comes and tells him, And wisdom to know the diff erence.’ ‘You have been condemned’. ‘To banishment’,

15 DIAL PHIL MENT NEURO SCI 2019; 12(1): 10-24 ‘If’ is a poem by English Nobel laureate αὐτοῦ κρῖμα, τοῦτο δὲ ἤδη ἐξαλεῖψαι ἐπὶ σοί Rudyard Kipling (1865-1936), written around ἐστιν” (“If you are pained by any external thing, 1895 in the form of paternal advice to the poet’s it is not this thing that disturbs you, but your son, John, and fi rst published in 1910. It is often own judgment about it. And it is in your power quoted as a literary example of Victorian-era to wipe out this judgment now”). Once again, Stoicism. The following lines provide a good there appears to be an impressive convergence example of Stoic attitude toward what is not between Stoicism and modern psychotherapy: within our power: the essentially cognitive nature of emotions (‘cognitive theory of emotions’) (Montgomery, If you can meet with Triumph and Disaster, 1993; Moore Brookshire, 2007). And treat those two impostors just the same; […] STOIC PSYCHOTHERAPY AND Yours is the Earth and everything that’s in it, COGNITIVE BEHAVIOR THERAPY And - which is more - you’ll be a Man, my son! If the cause of emotional disturbance is of a cognitive nature, this naturally implies a The Stoics’ rational view of emotions fi nds cognitive (rational) therapy. Rational Emotive interesting parallels in the cognitive theories Behaviour Therapy (REBT) was developed of modern psychology. Epictetus clearly stated by American Psychologist Albert Ellis in the that “ταράσσει τοὺς ἀνθρώπους οὐ τὰ πράγματα, 1950s: the acknowledgment of the importance ἀλλὰ τὰ περὶ τῶν πραγμάτων δόγματα” (“men are of reason in emotional processing marked the disturbed not by things, but by the views which cognitive revolution that took place in the fi eld they take of things”) (Handbook, 5). These of psychology, moving from behaviourism to very words were carved in a beam of Michel de cognitivism. Therefore, REBT inaugurated the Montaigne’s library in Château de Montaigne, tradition of cognitive behavioural therapies the tower retreat of the French humanist (Figure (‘second wave’ of modern psychotherapy 3). In fact, the Stoic theme of the distinction interventions). Interestingly, it has been reported between things in themselves and the way we that prior to becoming a psychotherapist, perceive them resonates within Montaigne’s Albert Ellis read the Roman Stoics - Seneca, Essays (1580), with a clear allusion to Epictetus Epictetus, and Marcus Aurelius (Still and (Moriarty, 2016): “Men (says an ancient Greek Dryden, 2012). In his fi rst major publication on sentence) are tormented with the opinions they REBT, Ellis described the philosophical basis have of things and not by the things themselves”9. 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 Figure 3: Epictetus’ words (“men are disturbed not by things, but by truths of Stoicism were perhaps best set forth the views which they take of things”) in a carved beam in Michel de by Epictetus, who, in the fi rst century AD wrote Montaigne’s library (Château de Montaigne, France). in the Enchiridion: ‘Men are disturbed not by things, but by the views which they take of them’. The resulting shift in the locus of control Shakespeare, many centuries later, rephrased from external events (upon which we have this thought in Hamlet: ‘There’s nothing good little or no control) to internal attitude or or bad but thinking makes it so’” (Ellis, 1962). disposition towards such events is key to both According to Still and Dryden (1999), the Stoic philosophy and rational psychotherapy. saying of Epictetus quoted by Ellis has become In his ‘Meditations’ (VIII,47), Marcus Aurelius a “hallmark” of REBT and is “even given to is explicit about the implications of the Stoic clients during the early sessions, as a succinct approach to emotions: “Εἰ μὲν διά τι τῶν ἐκτὸς way of capturing the starting point”: there is a λυπῇ, οὐκ ἐκεῖνό σοι ἐνοχλεῖ, ἀλλὰ τὸ σὸν περὶ considerable overlap between the therapeutic www.crossingdialogues.com/journal.htm 16 Cavanna, 2019 remedies found in REBT and Stoicism, as catastrophes should not be perceived as ‘bad’ or they both emphasize the role of responsibility, ‘evil’ occurrences. In his ‘Meditations’ (VI,50), rationality, and self-disciplined observation of Marcus Aurelius made explicit reference to one’s mind as a means of modifying irrational the reserve clause technique: “μέμνησο ὅτι emotions and achieving psychological well- μεθ’ὑπεξαιρέσεως ὥρμας καὶ ὅτι τῶν ἀδυνάτων being. From his interest in the philosophical οὐκ ὠρέγου” (“Remember that your intention writings about human suff ering and the human was always to act ‘with a reserve clause’, for you condition by the ancient Stoics, Ellis surmised did not desire the impossible”). Seneca referred to that all individuals, are competent at disturbing the reserve clause as the ‘exceptio’ in his treatise themselves by irrational thinking patterns. ‘De benefi ciis’ (‘On benefi ts’, IV,34): “the wise In other words, it is not the thing itself that man considers both sides: he knows how great is disturbs us, rather we disturb ourselves about it. the power of errors, how uncertain human aff airs Therefore REBT holds that when people make are, how many obstacles there are to the success inferences about situations and events in their of plans. Without committing himself, he awaits lives, they go on to hold irrational beliefs about the doubtful and capricious issue of events, and those inferences and it is those irrational beliefs weighs certainty of purpose against uncertainty that lead to emotional distress and behavioural of result. Here also, however, he is protected by disturbances. that reserve clause, without which he decides REBT is particularly eff ective at fi ghting upon nothing, and begins nothing”10 unhealthy irrational beliefs and erroneous Another powerful Stoic spiritual exercise assumptions that lead to emotional distress, by is the use of mental imagery for the pre- employing specifi c psychological techniques. emptive visualisation of worst-case scenarios One of these techniques is the use of ‘reserve (‘praemeditatio malorum’ or ‘premeditation clauses’ - the letters DV, or ‘Deo Volente’ (‘God of adversity’, including the famous ‘meditatio willing’) added by Christian theologians to their mortis’ or ‘contemplation of death’) (Buzaré, correspondence are a familiar example of such 2012). In his ‘Letters from a Stoic’ (XCI), Seneca practice. The function of reserve clauses is to provided a clear account of this psychological remind us that the unfolding of events is not technique: “What is quite unlooked for is more within our power, and therefore even unpredicted crushing in its eff ect, and unexpectedness adds

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

Stoicism REBT Emotions are due primarily to our own beliefs Psychological distance from emotions Beliefs and emotions are two aspects of the Cognition and emotion are two aspects of the same mental process same mental process Constant attention to own faculty of judgement Monitoring of the relationship between thoughts, actions, and feelings Philosophical disputation of fundamental value Rational disputations of irrational demands judgments Replacement of irrational demands with ratio- Replacement of irrational demands with ﬂ ex- nal wishing and awareness that things may not ible desires (rational preferences and reserve turn out as we would prefer (exceptio) clauses) Use of mental imaging techniques (praemedi- Use of mental imaging techniques (rational- tatio malorum) emotive imagery) Acceptance of our body, other people, and Acceptance of oneself, others, and the world, external events, as “indiﬀ erent” as imperfect Opposition to judging adverse external events Opposition to judging adverse external events to be unconditionally “bad” or “evil” to be absolutely catastrophic Acknowledgment of healthy passions Acknowledgment of rational and healthy emotions

17 DIAL PHIL MENT NEURO SCI 2019; 12(1): 10-24 to the weight of a disaster. The fact that it Walter Mischel (Evans, 2013; Cavanna, 2018). was unforeseen has never failed to intensify a These studies showed that children aged 4 to person’s grief. This is a reason for ensuring that 6 years who were able to postpone immediate nothing ever takes us by surprise. We should gratifi cation when off ered a marshmallow would project our thoughts ahead of us at every turn and go on to have better life outcomes, according have in mind every possible eventuality instead to multiple physical, psychological and social of only the usual course of events. […] This is measures (Mischel et al., 1972). It has been shown why we need to envisage every possibility and to that the crucial factor in delaying gratifi cation strengthen the spirit to deal with the things which is the ability to change your perception of may conceivably come about. Rehearse them the action you want to resist or the event that in your mind: exile, torture, war, shipwreck”11. causes distressing emotions. Specifi cally, a well- In general, REBT and Stoic approaches share supported theory of self-regulation, called the a striking number of similarities (Table 1), as cognitive-aff ective personality system, suggests they both encourage the rational disputation of that delaying gratifi cation results from an ability irrational demands and their replacement with to use ‘cool’ regulatory strategies (i.e. calm, more fl exible desires or rational preferences controlled and cognitive strategies resembling (“I must recover from my illness by tomorrow” both cognitive behaiovural techniques and Stoic versus “I would prefer to recover from my illness exercises) over ‘hot’ regulatory strategies (i.e. as soon as possible”). emotional, impulsive, automatic reactions), In the fi rst major cognitive behavioural when faced with provocation (Mischel and therapy (CBT) manual, ‘Cognitive therapy Shoda, 1995). Interestingly, a brain imaging of depression’ (1979), Aaron Beck and his study conducted on a sample from the original colleagues stated that “the philosophical Stanford participants when they reached midlife, origins of cognitive therapy can be traced back showed that the prefrontal cortex (a brain region to the Stoic philosophers, particularly Zeno involved in cognitive judgments) was more of Citium (fourth century BC), Chrysippus, active in the gratifi cation delayers, when they Cicero, Seneca, Epictetus, and Marcus Aurelius. were trying to control their responses to alluring Epictetus wrote in The Enchiridion: ‘Men are temptations (Casey et al., 2011). Overall, there is disturbed not by things but by the views which a growing body of scientifi c literature showing they take of them’ […] Control of most intense that delayed (or deferred) gratifi cation, the feelings may be achieved by changing one’s process that the subject undergoes when the ideas”. Several CBT techniques are heavily temptation of an immediate reward is resisted in informed by the Stoic theory of emotions. For preference for a later reward, is linked to a host example, acknowledging that our emotions of other positive outcomes, including academic are due primarily to our own beliefs allows to success, physical health, psychological health, achieve psychological distance from emotions and social competence (Tobin and Graziano, (cognitive distancing) and prevents tendencies 2009; Peake, 2017). Self-control has been to judge adverse external events as absolutely referred to as the ‘master virtue’ by both social catastrophic (decatastrophising). and clinical psychologists, suggesting that the For the Stoics, emotions are not automatic, ability to delay gratifi cation plays a critical role instinctive reactions that we cannot avoid in a person’s overall psychological well-being. experiencing. Instead, they are the result of a Interestingly, it ahs been suggested that self- rational/cognitive judgment, called ‘προαίρεσις’. control is akin to a ‘moral muscle’ that can be According to the Stoics, it is within our power strengthened through exercise, thus validating to make a judgment (Marcus Aurelius’ ‘ruling the importance of regular practice, as emphasised faculty’: the executive function of the brain, in by both Stoic techniques and modern CBT-based modern cognitive science terminology) that gives interventions (Baumeister and Juola Exline, ‘assent’ to an initial ‘impression’, an automatic 1999). response or instinctive reaction to events that The ‘second wave’ of cognitive therapy is not under our control. Interestingly, the Stoic and other REBT-inspired psychotherapeutic theory of emotions found confi rmation in the approaches fl ourished during the fi nal decades results of the so-called ‘Stanford marshmallow of the XX century and was followed, at around experiment’, a series of studies on delayed the turn of the millennium, by a ‘third wave’ gratifi cation conducted in the late 1960s and of cognitive and behavioural therapies. The early 1970s by Austrian-American psychologist ‘third wave’ includes a range of therapeutic www.crossingdialogues.com/journal.htm 18 Cavanna, 2019 interventions encompassing mindfulness- “happiness is in the present moment, fi rstly based cognitive therapy and acceptance and for the simple reason that we live in the commitment therapy, among others (Hayes, present, secondly because the past and 2004; Hayes et al., 2011; Dimidjian et al., 2016; the future are almost always a source of Ruggiero et al., 2018). It has been observed that anguish […] each present moment off ers the practice of mindfulness can be traced back to us the possibility of happiness: if we adopt the Stoic exercise of attention (‘προσοχή’, which the stoic perspective, the present gives us can also be translated as ‘concentration on the the chance of fulfi lling our duty, of living present moment’ or ‘mindfulness’) (Robertson, according to reason”14. 2010). By encouraging concentration on our mental states at the present moment, both STOIC PSYCHOTHERAPY AND Stoicism and mindfulness-based therapies can NEUROPSYCHIATRY increase our self-vigilance and free us from Neuropsychiatric disorders result from distressing emotions. In Marcus Aurelius’ words common cerebral pathologies with diverse (‘Meditations’, II,8), (“Through not observing aetiologies and present clinically with a what is in the mind of another, a man has seldom combination of physical and psychological been seen to be unhappy; but those who do not symptoms. These conditions are traditionally observe the movements of their own minds must considered diffi cult to treat because of the of necessity be unhappy”12). By focusing our minimal endogenous capacity of the brain for attention on the present moment, we constantly repair. As a result of their overall intractability, guard our mind against unhealthy feelings, which most neuropsychiatric disorders tend to follow are rooted either in the past (depression) or in the a chronic course over time. Current therapeutic future (anxiety), two temporal domains that are interventions are largely limited to treatment of ultimately outside our control. Once again, this symptoms, with the goal of improving patients’ idea was clearly expressed by Marcus Aurelius health-related quality of life. Psychological in his ‘Meditations’ (XII,3): therapies, especially cognitive behavioural techniques, have proven highly eff ective fi rst-line “If […] you detach from your mind everything treatment interventions for aff ective and anxiety that clings to it by passionate experiences and disorders, that are often the main determinants everything that is in the past or in the future […] of health-related quality of life in patients with and if you practise living only in what you really neuropsychiatric conditions. In the United live, that is, the present - then you will be able to Kingdom, the National Institute for Health and live out the time that is left until you die in a manner Clinical Excellence has made recommendations that is free of upset and good-natured, at peace with for the use of CBT in the treatment pathways the divine spirit within you”13. of adult patients with depression in the context of a chronic physical health problem (National It has been observed that there are similarities Institute for Health and Clinical Excellence, between certain aspects of Stoicism and Eastern 2009), with relevant implications to a wide range doctrines (Macaro, 2018). Within the ancient of neuropsychiatric disorders. Clinical research Eastern tradition, Lao Tzu’s teaching (VI has provided solid evidence for the effi cacy and century BCE) was of a similar tone to the Stoic cost-eff ectiveness of what are ultimately Stoic- view on the importance of focusing attention to derived therapeutic approaches. Based on the the present moment: “If you are depressed you available evidence and informed by economic are living in the past. If you are anxious you are evaluations, the National Health Service (NHS) living in the future. If you are at peace you are developed and implemented a programme to living in the present”. However Hadot argued improve access to psychotherapy to the general that for the Stoics the exercise of attention to the population (Improving Access to Psychological present moment is, in a sense, the key to a wider Therapies, IAPT). The aim of the IAPT project range of spiritual exercises (Hadot, 1981). The is to increase the provision of evidence-based late French scholar was clear about the role of treatment interventions for common mental ancient philosophies as therapies for the burden health conditions such as anxiety and depression of the past and the uncertainty of the future, by primary care organisations. This programme aimed at allowing people to live within the has been active for over a decade and has present by practicing freedom and self-mastery: transformed treatment of anxiety and aff ective

19 DIAL PHIL MENT NEURO SCI 2019; 12(1): 10-24 disorders in adult patients. Cognitive behavioural or indeed about the likely impact of CBT-based therapies are therefore considered at the forefront interventions on tic expression. However, a recent of modern psychotherapy interventions, and review covering key fi ndings on the emotional have become the main approaches for dealing and behavioural aspects of Tourette syndrome eff ectively with a wide range of psychological proposed a more comprehensive, cognitively- disorders in patients with neuropsychiatric oriented conceptualisation of this condition conditions. (Gagné, 2019). Specifi cally, it was proposed Movement disorders are a prime example that maladaptive beliefs about discomfort and of neuropsychiatric conditions where cognitive about one’s ability to cope with discomfort behavioral therapy interventions can have a underlie negative appraisals of unpleasant signifi cant positive impact on patients’ health- sensory experiences in individuals with Tourette related quality of life (Cavanna, 2019). Basal syndrome. It was further suggested that these ganglia disorders like Tourette syndrome beliefs lead individuals to perceive premonitory and Parkinson disease have been referred urges to tic in a catastrophic manner and to as ‘paradigmatic’ or ‘quintessential’ thereby enhance tic frequency. Based on these neuropsychiatric disorders (Weintraub et al., observations, it is suggested that Stoic principles, 2011; Cavanna, 2018). In both conditions, it as applied to CBT-based interventions, could has consistently been shown that non-motor prove highly useful across a range of clinical manifestations such as aff ective symptoms can outcomes. bear a more signifi cant impact on health-related Parkinson disease, a hypokinetic quality of life than motor impairment itself movement disorder with neurodegenerative (Evans et al., 2016; Balestrino and Martinez- etiopathogenesis, is characterised by a Martin, 2017). combination of motor and non-motor features Tourette syndrome, a hyperkinetic sharing a chronic course (Kalia and Lang, movement disorder with neurodevelopmental 2015; Sauerbier et al., 2017). The classical etiopathogenesis, is characterised by a motor triad includes resting tremor, rigidity, combination of motor and vocal tics plus and bradykinesia, whereas anxiety and aff ective behavioural co-morbidities: obsessive- symptoms are among the non-motor symptoms compulsive symptoms and/or attention-defi cit with the deepest impact on patient’s wellbeing and hyperactivity symptoms, as well as anxiety, (Balestrino and Martinez-Martin, 2017). aff ective symptoms and impulse dyscontrol The most eff ective treatment interventions (Robertson and Cavanna, 2008; Cavanna and currently available consist in pharmacotherapy Seri, 2013). Tourette syndrome is chronic in enhancing dopaminergic pathways. Dopamine nature and available treatment interventions are replacement therapy can improve rigidity, not curative. Both alpha-2 adrenergic agonists bradykinesia, and, to a lesser extent, tremor, and antidopaminergic agents can decrease tic however neither pharmacological interventions frequency and severity, however a signifi cant nor more invasive approaches such as DBS are proportion of patients fail to respond to and/ curative (Sprenger and Poewe, 2013; Connolly or comply with the prescribed medications: in and Fox, 2017). Moreover, it is well recognized clinical practice, patients are frequently treated that dopaminergic agents can result in with serial agents in the search for effi cacy psychiatric/behavioral adverse eff ects (e.g. drug- and tolerability (Waldon et al., 2013; Farag et induced impulse dysregulation with reward- al., 2015). Likewise, behavioural interventions seeking behaviors, and psychotic symptoms) targeting tics (e.g. habit reversal training, (Chaudhuri and Schapira, 2009; Krack, 2015). exposure and response prevention) have a The catalogue of iatrogenic impulse control signifi cant degree of effi cacy only in a subgroup disorders encompasses pathological gambling, of patients (Frank and Cavanna, 2013; McGuire compulsive eating, hypersexuality; among the et al., 2014; Sukhodolsky et al., 2017). Finally, most commonly reported psychotic symptoms a few, selected patients with severe, treatment- are visual hallucinations and paranoid delusions refractory forms of Tourette syndrome have of theft or infi delity (Weintraub and Burn, 2011; undergone the surgical procedure of deep brain Voon et al. 2017). Again, there appears to be stimulation (DBS), with promising, albeit room for Stoic-derived cognitive behavioural somewhat inconsistent results. Very little is interventions to improve the subjective wellbeing known about specifi c management options for of both patients with Parkinson disease and their the non-motor aspects of Tourette syndrome, carers. The results of a recent review on CBT www.crossingdialogues.com/journal.htm 20 Cavanna, 2019 for the treatment of non-motor symptoms in Lucilius and illustrate the individual mentoring Parkinson disease found a growing evidence of a student, resembling the modern relationship base that this intervention (modified to account between therapist and his client (individual for disease-specific problems) is eff ective in the therapy sessions). Arrian’s transcripts of treatment of psychiatric symptoms (Koychev Epictetus’ teaching in the ‘Discourses’ record and Okai, 2017). Specifi cally, where controlled Socratic-type dialogues and discussions with study designs were used, moderate eff ect sizes students/visitors of his school that can be seen as were reported for the sustained efficacy of analogous to some modern forms of therapeutic CBT for depression, including with distance workshops (group therapy sessions). The other administration. The authors also found some major work based on Epictetus’ teaching, the initial data on the eff ects of CBT on impulse ‘Handbook’, is a compact distillation or aide- control disorders and insomnia, and highlighted mémoire of Stoic philosophy designed to the need for further studies to more precisely aid the student in the digestion of the studied determine the utility of CBT in Parkinson doctrines (self-help textbook). Marcus Aurelius’ disease. ‘Meditations’ contain the Roman emperor’s Overall, CBT-based interventions have been private journal records of his personal Stoic assessed in a number of large controlled clinical regime of contemplation and written exercises trials that have demonstrated an improvement (‘ὑπομνήματα’) and could be compared to the in both psychiatric co-morbidities and tics in modern practice of keeping a workbook for patients with Tourette syndrome (O’Connor self-help exercises (therapy journal). Therefore et al., 2009). Evidence from a randomised individual psychotherapy, group therapy controlled study and several uncontrolled workshops, self-help textbooks, and therapy studies on the effi cacy of CBT have also shown journals or workbooks could be considered as benefi cial eff ects on depression and anxiety in being distant descendants of the Stoics’ modes of patients with Parkinson disease (Koychev and philosophical therapy. It is tempting to speculate, Okai, 2017). Only a limited number of studies with Donald Robertson (2016), that “perhaps have evaluated the effi cacy of CBT in the modern psychology is only now rediscovering management of psychiatric symptoms in other obscure psychological mechanisms, which the movement disorders and there are no controlled ancient Stoics may have understood better than studies on the effi cacy of CBT in dystonia, their modern commentators”. Huntington disease, or essential tremor. A Among the many questions that remain review of primary data from clinical trials and unsolved when refl ecting on the relevance of case reports on the eff ects of CBT in the most Stoic philosophy beyond current neuropsychiatry common movement disorders confi rmed that practice, there is one that cannot be escaped: psychological symptoms are often misdiagnosed why now? What do our present time and the and left untreated, resulting in worse prognosis Hellenistic era have in common? It does not and lower health-related quality of life seem unreasonable to argue that the Stoic values (Berardelli et al., 2015). The authors concluded of inner freedom, equanimity, and self-mastery that evidence available suggests that CBT is could be especially meaningful and valuable useful in Tourette syndrome and probably useful when the external world becomes fraught or in Parkinson disease. Based on their fi ndings, turbulent. The present challenge of living in a they recommended planning of randomised state of constant anxiety about the dangers that controlled clinical trials to investigate the eff ects could strike unannounced at any moment in a of CBT-based interventions in the treatment of continuously changing environment is not new psychiatric disturbances in movement disorders. to mankind. Interestingly, the current lifestyle There is little doubt about the practical calls for the development of a frame of mind applications of Stoic psychological techniques that closely resembles the distinctive mind- and there seems to be increasing interest in set of the Hellenistic period, with its stress on testing such techniques across neuropsychiatric individualism, its preoccupation with inner life populations on a wider scale. It has been and inner liberty, its focus on the pursuit of observed that the four main surviving primary personal well-being, and its need to wrest our sources for Stoic philosophy loosely resemble mental health out of the most diffi cult turns of four distinct modalities of philosophical fortune. This picture of increasing uncertainty psychotherapy (Sellars, 2009; Robertson, 2016). caused by the ever-changing nature of the external Seneca’s ‘Letters from a Stoic’ are addressed to environment and our internal feelings mirrors an

21 DIAL PHIL MENT NEURO SCI 2019; 12(1): 10-24 all-too familiar human condition referred to as fi lm, Professor Levy’s voice is heard refl ecting ‘liquid modernity’ by Polish-British sociologist that “Events unfold so unpredictably, so unfairly Zygmunt Bauman (2000). The fi ctional character […] Human happiness does not seem to have of Professor Levy in Woody Allen’s 1989 movie been included in the design of creation. It is only ‘Crimes and misdemeanors’ described the we, with our capacity to love, that give meaning human condition of the modern era in a way that to the indiff erent universe. And yet, most human is strikingly reminiscent of the social, political, beings seem to have the ability to keep trying, cultural, and personal crisis that characterised and even to fi nd joy from simple things like their the Hellenistic age, when the philosophy of family, their work, and from the hope that future Stoicism fl ourished. In the fi nal scene of the generations might understand more”. Endnotes 1: “Venuta la sera, mi ritorno a casa ed entro nel mio scrit- operazioni più gravi, e di rimanere sereni tra le sventure. toio; e in sull’uscio mi spoglio quella veste cotidiana, pi- Morfi na lo avevano chiamato questo rozzo sostituto dello ena di fango e di loto, e mi metto panni reali e curiali; e stoicismo antico”. rivestito condecentemente, entro nelle antique corti delli 6: “διὰ τοῦτο γὰρ Ἀγριππῖνος τί ἔλεγεν; ὅτι ‘ἐγὼ ἐμαυτῷ antiqui huomini, dove, da loro ricevuto amorevolmente, ἐμπόδιος οὐ γίνομαι’. ἀπηγγέλη αὐτῷ ὅτι ‘κρίνῃ ἐν mi pasco di quel cibo che solum è mio e ch’io nacqui per συγκλήτῳ’. ‘ἀγαθῇ τύχῃ. ἀλλὰ ἦλθεν ἡ πέμπτη’ (ταύτῃ lui; dove io non mi vergogno parlare con loro e domandarli δ᾽εἰώθει γυμνασάμενος ψυχρολουτρεῖν): ‘ἀπέλθωμεν della ragione delle loro azioni; e quelli per loro humanità καὶ γυμνασθῶμεν’. γυμνασαμένῳ λέγει τις, αὐτῷ ἐλθὼν mi rispondono; e non sento per quattro hore di tempo al- ὅτι ‘Κατακέκρισαι’. ‘φυγῇ’, φησίν, ‘ἢ θανάτῳ;’ ‘φυγῇ’. cuna noia, sdimentico ogni aff anno, non temo la povertà, ‘τὰ ὑπάρχοντα τί;’ ‘οὐκ ἀφῃρέθη’. ‘εἰς Ἀρίκειαν οὖν non mi sbigottisce la morte […]” ἀπελθόντες ἀριστήσωμεν’”. 2: “κενὸς ἐκείνου φιλοσόφου λόγος, ὑφʼ οὗ μηδὲν πάθος 7: “τοῦτ᾽ἔστι μεμελετηκέναι ἃ δεῖ μελετᾶν, ὄρεξιν ἔκκλισιν ἀνθρώπου θεραπεύεται· ὥσπερ γὰρ ἰατρικῆς οὐδὲν ὄφελος ἀκώλυτα ἀπερίπτωτα παρεσκευακέναι. ἀποθανεῖν με δεῖ. μὴ τὰς νόσους τῶν σωμάτων ἐκβαλλούσης, οὕτως οὐδὲ εἰ ἤδη, ἀποθνῄσκω: κἂν μετ᾽ ὀλίγον, νῦν ἀριστῶ τῆς ὥρας φιλοσοφίας, εἰ μὴ τὸ τῆς ψυχῆς ἐκβάλλει πάθος”. ἐλθούσης, εἶτα τότε τεθνήξομαι. πῶς; ὡς προσήκει τὸν τὰ 3: “Toutes les écoles s’accordent pour admettre que ἀλλότρια ἀποδιδόντα”. l’homme, avant la conversion philosophique, se trouve 8: “πότερον δὲ ἐπὶ πλέον διάστημα χρόνου τῷ σώματι dans un état d’inquiétude malheureuse, qu’il est victime du περιεχομένῃ τῇ ψυχῇ ἢ ἐπ̓ ἔλασσον χρήσεται, οὐδ̓ ὁτιοῦν souci, déchiré par les passions, qu’il ne vit pas vraiment, αὐτῷ μέλει: κἂν γὰρ ἤδη ἀπαλλάσσεσθαι δέῃ, οὕτως qu’il n’est pas lui-même. Toutes les écoles s’accordent εὐλύτως ἄπεισιν, ὡς ἄλλο τι τῶν αἰδημόνως καὶ κοσμίως aussi pour croire que l’homme peut être délivré de cet état, ἐνεργεῖσθαι δυναμένων ἐνεργήσων, τοῦτο μόνον παῤ ὅλον qu’il peut accéder à la vraie vie, s’améliorer, se transform- τὸν βίον εὐλαβούμενος, τὸ τὴν διάνοιαν ἔν τινι ἀνοικείῳ er, viser à un état de perfection. Les exercices spirituels νοεροῦ καὶ πολιτικοῦ ζῴου τροπῇ γενέσθαι”. sont précisément destinés à cette formation de soi, à cette 9: “Les hommes (dit une sentence Grecque ancienne) sont paideia, qui nous apprendra à vivre, non pas conformé- tourmentez par les opinions qu’ils ont des choses, non par ment aux préjugés humains et aux conventions sociales, les choses mesmes”. mais conformément à la nature de l’homme. Toutes les écoles, chacune à sa manière, croient donc à la liberté de 10: “sapiens utramque partem eius cogitat; scit, quantum la volonté, grâce à laquelle l’homme a la possibilité de se liceat errori, quam incerta sint humana, quam multa con- modifi er lui-même, de s’améliorer, de se réaliser. Le par- siliis obstent; ancipitem rerum ac lubricam sortem sus- allélisme entre exercice physique et exercice spirituel est pensus sequitur, consiliis certis incertos eventus expendit. ici sous-jacent : de même que, par des exercices corpo- Exceptio autem, sine qua nihil destinat, nihil ingreditur, et rels répétés, l’athlète donne à son corps une forme et une hic illum tuetur”. force nouvelles, de même, par les exercices spirituels, le 11: “Inexpectata plus adgravant; novitas adicit calamita- philosophe développe sa force d’âme, modifi e son climat tibus pondus, nec quisquam mortalium non magis quod intérieur, transforme sa vision du monde et fi nalement tout etiam miratus est, doluit. Ideo nihil nobis inprovisum esse son être. L’analogie pouvait paraître d’autant plus évidente debet. In omnia praemittendus animus cogitandumque que c’est dans le gymnasion, c’est-à-dire dans le lieu où non quidquid solet, sed quicquid potest fi eri. […] Cogi- se pratiquaient les exercices physiques, que se donnaient tanda ergo sunt omnia et animus adversus ea, quae possunt aussi les leçons de philosophie, c’est-à-dire que se prati- evenire, fi rmandus. Exilia, tormenta morbi, bella, naufra- quait l’entraînement à la gymnastique spirituelle.” gia meditare”. 4: “ὡς ἐγὼ οὐ νῦν πρῶτον ἀλλὰ καὶ ἀεὶ τοιοῦτος οἷος 12: “παρὰ μὲν τὸ μὴ ἐφιστάνειν, τί ἐν τῇ ἄλλου ψυχῇ τῶν ἐμῶν μηδενὶ ἄλλῳ πείθεσθαι ἢ τῷ λόγῳ ὃς ἄν μοι γίνεται, οὐ ῥᾳδίως τις ὤφθη κακοδαιμονῶν: τοὺς δὲ τοῖς λογιζομένῳ βέλτιστος φαίνηται”. τῆς ἰδίας ψυχῆς κινήμασι μὴ παρακολουθοῦντας ἀνάγκη 5: “pensò ad una medicina scoperta da poco negli Stati κακοδαιμονεῖν”. Uniti d’America, che permetteva di non soff rire durante le 13: “ἐὰν χωρίσῃς […] τοῦ ἡγεμονικοῦ τούτου τὰ www.crossingdialogues.com/journal.htm 22 Cavanna, 2019

προσηρτημένα ἐκ προσπαθείας καὶ τοῦ χρόνου τὰ ἐπέκεινα Corresponding Author: ἢ τὰ παρῳχηκότα, ποιήσῃς τε σεαυτόν […] μόνον τε ζῆν ἐκμελετήσῃς ὃ ζῇς, τουτέστι τὸ παρόν: δυνήσῃ τό γε μέχρι Prof Andrea E. Cavanna τοῦ ἀποθανεῖν ὑπολειπόμενον ἀταράκτως καὶ εὐμενῶς καὶ ἵλεως τῷ σαυτοῦ δαίμονι διαβιῶναι”. Department of Neuropsychiatry, The National Centre for Mental Health, 25 Vincent Drive 14. “le bonheur est dans le moment présent, tout d’abord Birmingham B15 2FG pour la simple raison que nous ne vivons que le présent, United Kingdom ensuite parce que passé et avenir sont presque toujours source de souﬀ rance […] mais chaque moment présent email: [email protected] nous oﬀ re la possibilité du bonheur : si nous nous mettons dans la perspective stoïcienne, il nous donne l’occasion de Copyright © 2019 by Ass. Crossing Dialogues, Italy faire notre devoir, de vivre selon la raison”.

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