A Clinical Argument for Stoicism: Stoicism & Addiction

“…just as no amount of fluid will satisfy one whose craving arises not from lack of water but from burning internal fever: for that is not a thirst but a disease.” Seneca - On The Shortness of Life: Life is Long if You Know how to Live it

As a Substance Use Clinician/Mental Health Counselor at a Medically Assisted Treatment (MAT)Clinic, I primarily treat amazing individuals that suffer from a brain disease called Opiate Use Disorder (OUD). One of the three pillars of the medical aspect of MAT with a Methadone prescription is that it addresses cravings to a recurrence of illicit use. In this Seneca quote, it’s hard for me not to see “fluid” as fentanyl/heroin (or any illicit substance at that including alcohol), “craving” as a biochemical response in the brain (often triggered by some form of a memory that once made us feel good) that drives an individual to crave illicit substance, and “disease” as brain diseases/mental health disorders.

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The Dichotomy of Control

“Of things, some are in our power, and others are not.” Epictetus - Enchiridion (Intro sentence)

Person Who Suffers from Mental Health Issues (What is Out of Control): Reputation, Treatment at their Primary Care Physician, Withdrawals, and Being Diagnosed with a Brain Disease/Disorder.

Benefit of Practice (What is Within Control - Focusing on Self, Reactions to Stuff, and Influence Upon the Cosmos): We approach acceptance (not to be confused with complacency and inaction) and spend more of our finite daily energy focussing on action steps that will more likely improve the overall quality of life.

Risk of Non Practice: We build resentment, engage in power struggles, become exhausted/overwhelmed/hopeless, increase risk to recurrence of illicit use, increases symptomatic behavior of mental health issue(s), and may become resistant to treatment.

Mental Health Care Worker (What is Out of Control): Outcome, Recurrence to Illicit Use, Suicide, and the Overall Responsiveness to Treatment.

Benefit of Practice (What is Within Control - Focusing on Self, Reactions to Stuff, and Influence Upon the Cosmos): Increased ability to focus on changing treatment and trying new interventions, as well as allowing us to remain engaged in our work as many clients still require our full attention, and increases the energy and time to spend on self-care and the separation of work life and personal life.

Risk of Non Practice: Increased risk of anger/sadness/depression, burn out and fatigue, quitting our job(s), and even changing careers entirely. This includes the loss of the passion that once drove us to this field as it increases the risk of personalizing the work and adding hero like burdens onto us. This can effect interventions and emotional regulation at work and can increase the risk of projecting this abnormally inappropriate sense of responsibilities through outbursts and frustration onto our clients and our loved ones at home; outward to our circles of care all the way to the cosmos.

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An Argument for the Clinical Benefits of Stoicism as Cognitive Behavioral Therapy for Both Preventative and Remedial Mental Health Care.

“Men are disturbed not by the things which happen, but by the opinions about the things.” Epictetus- Enchiridion (Passage 5)

Albert Ellis, one of the founding fathers of Cognitive Behavioral Therapy, uses this quote as a foundation to this psychological treatment.

Cognitive Behavioral Therapy (CBT) as defined is a psycho-social intervention that aims to improve mental health. CBT focuses on challenging and changing cognitive distortions (e.g. thoughts, beliefs, and attitudes) and behaviors, improving emotional regulation, and the development of personal coping strategies that target solving current problems.

This is remedial care. You have an identified problem. Typically, a behavioral problem. You need to “unlearn” this behavior and “learn” or “relearn” new behavior. It is meant to replace unhealthy decision making, especially cyclic behavior, with healthy decision making/behavior. This can take about 3 to 6 months of consistent therapy.

In this regard, some specific Stoic teachings and practices as a form of CBT can achieve multiple treatment goals of CBT such as Cognitive Distancing and the ability to challenge Cognitive Distortions.

Cognitive Distancing is the ability to contemplate both emotions and thoughts before choosing behavior, separating the impulsivity of acting based on how we feel, and allowing us time to choose and essentially “relearn” new behavior through repetitive and habitual decision making.

The ability to challenge a Cognitive Distortion is the ability to challenge your belief about a belief. There are many, but a common one is all-or-nothing thinking also called black-or-white thinking and polarized thinking. These are thoughts that allow no room for “grey”. Something is 100% this and 0% that. This can often sound like, “I’ll never be sober. I’ll never be normal. I’ll never get better. I’ll always be this way. My life will never be good. I will always be alone. No one loves me and no one will ever love me.” Cognitive Distortions cause psychological damage and can often leave us feeling stuck in a loop of poor mental health. It is important to note that everyone experiences cognitive distortions and this is one of many reasons as to why Stoicism can be used for both preventative and remedial mental health strengthening.

“Remember that it is not he who reviles you or strikes you, who insults you, but it is your opinion about these things as being insulted. When then a man irritates you, you must know that it is your own opinion which has irritated you. Therefore especially try not to be carried away by the appearance. For if you once gain time and delay, you will more easily master yourself.” Epictetus- Enchiridion (Passage 20)

“Opinion”: A thought that leads us to a feeling that influences our decision making.

“Appearance”: A Cognitive Distortion - Exaggerated or irrational thought pattern(s) that cause/can cause us to perceive reality inaccurately, reinforcing negative emotion and thoughts. These distorted thoughts have potential to contribute to an overall negative outlook on the world and perpetuate psychological harm.

“Gain Time and Delay”: Achieve Cognitive Distancing; the ability to think before acting.

“Master Yourself”: The ability to make the choices you want to; choices that are synthesized to your values and principles.

“In every act observe the things which come first, and those which follow; and so proceed to act… But observe both things which come first, and the things which follow; and then begin the act. You must do everything according to rule…” Epictetus- Enchiridion (Passage 29)

This, again, refers to the Cognitive Theory of Emotions; how our thoughts and perceptions influence our lives. Often, distress can distort people’s perceptions, and that, in turn, can lead to perpetually unhealthy emotional states and behaviors/decision making/patterns of thinking. CBT helps individuals learn to identify and evaluate their “automatic thoughts” and shift their thinking to be healthier. Simply put, our thoughts lead to emotions which lead to behavior and/or our emotions lead to thoughts which lead to behavior. This quote reminds me of a CBT practice for children: Red Light (STOP), Yellow Light (THINK), Green Light (GO/ACT).

“If you have received the impression of any pleasure, guard yourself against being carried away by it; but let the thing wait for you, and allow yourself a certain delay on your own part. Then think of both times, of the time you will enjoy the pleasure, and of the time after the enjoyment of the pleasure, when you will repent and will reproach yourself. And set against these things how you will rejoice, if you have abstained from the pleasure, and how you will commend yourself.” Epictetus- Enchiridion (Passage 34)

This quote may be some of the first evidence to the idea of creating what has been known in the field of addiction treatment as a “Recurrence to Illicit Use (Relapse) Prevention Plan”.

“Impression”- Cognitive Distortion and/or Craving. A Craving is a biochemical response in the brain that makes us want the very thing we do not need (often illicit substances). This is neurochemical and is “remembered” in the brain by a reward process attached to our sights, sounds, smells, tastes, memories, environments, and people.

“Pleasure”- The high of illicit use. The fleeting euphoric feeling.

“Guard Yourself”- Create a Recurrence to Illicit Use Prevention Plan. This is a prepared course of action that we commit to taking when we know we will have cravings for a recurrence to illicit use.

“Delay”- Cognitive Distancing: A Craving typically lasts not much longer than 15 minutes. If you can set a timer to delay your decision making by 15 minutes, you may survive your Craving.

“Think of Both Times”- Another example of Cognitive Distancing.

“Repent and Will Reproach Yourself”- Remind yourself that this behavior has historically brought us guilt, shame, and illness. Remind yourself of your goals, values, and principles. Yet another example of Cognitive Distancing and challenging Cognitive Distortions.

“Abstained From Pleasure”- If you have survived a Craving without returning to illicit substance use.

“Commend Yourself”- It is a large treatment goal and personal success to survive a Craving. Progress can often feel like regression. It is important to celebrate our victories through 1 of the 4 Stoic Virtues, Temperance (Balance/Moderation).

“In walking about, as you take care not to step on a nail, or to sprain your foot, so take care not to damage your own ruling faculty; and if we observe this rule in every act, we shall undertake this act with more security.” Epictetus- Enchiridion (Passage 38)

To “take care not to damage your own ruling faculty” means to not choose actions that are not synthesized with our values and principles.

“If We Observe this in Every Act”- Repetitive decision making creates habitual behavior which creates and reinforces pathways in our brains to make us quicker at choosing this behavior and more efficient at the actual practicing of this behavior. This is the primary function of CBT: to rewire and/or create brain pathways correlated to our senses/memories/thoughts/ and emotions that influence our behavior/decision making.

“Security”- This refers to both the ability to choose the behavior again in the future with more ease but also the ability to be more efficient at the behavior itself. We work hard today to secure whom we will become tomorrow.

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The Connection Between Rewiring/Reinforcing Brain Pathways and the Stoic Archer Metaphor as a CBT Practice with an Emphasis on Shooting Again.

The Stoic Philosopher, Antipater, and then later reiterated by the Stoic sympathizer, Cicero, use an archer metaphor to teach, primarily, The Dichotomy of Control.

A Stoic Archer focusses on what they can control by practicing their skill of archery as well as crafting the most efficient bow and arrows. They identify a target, draw the arrow back, and release. The wind blows and pushes the arrow ever so slightly off target. The Stoic Archer identifies the change in weather as something they can not control, so they do not focus energy at being upset and/or angry at the outcome. For it is in the act of shooting for a goal with your best tools, giving it your best aim and then best shot; honing the skill of “shooting straight” for goals to be straight just like an arrow shot, that is truly important.

This is often where the lesson ends. I’d like to reiterate a crucial conclusion for this lesson that aids us in creating and reinforcing brain pathways to “unlearn” unhealthy behavior and “learn/relearn” healthy behavior.

The Stoic Archer understands that they can not control the weather so they do not spend finite energy feeling frustrated about the outcome: not achieving the goal. So they reach back into their quiver, readjust their aim, and take their best shot again.

It is here where if we set specific CBT goals and apply the Stoic Archer lesson, we gain motivation to be resilient and insight into how Stoicism can aid us in preventing poor mental health, unwinding cyclic behavior, and making new healthy behaviors habitual. For example, if the goal is to use a positive coping skill when suffering from a craving to use illicit substances, then we begin practicing our positive coping skill, put forth our best effort into the goal, and if we don’t succeed, then readjust and try again. As we try again, we begin to “unlearn” the unhealthy response to a craving (to use) and “learn” that when we crave, we cope.

This is how it works: We choose a behavior that creates Endorphins (learning chemicals that feel great). That then triggers a response where Glutamate (neurotransmitter for memory) then retains what, where, when, who, and why you chose that response that felt good (this includes sights, emotions, smell, people, places, things, sound, and music). This is our brains way of teaching us that we want to choose the behavior that “feels great” again in similar circumstances. This “learning process” happens when we eat, sleep, and procreate. In other words, it’s a natural response about being human that likely evolved in this way for survival. The next time we encounter anything that triggers this memory again, we will crave whatever it was that we did that made us feel good the last time we did it. The more we choose it, the quicker we choose it (we loose the ability to consider consequences) and the more efficient at the actual behavior itself we become (this is a double edged sword- if we practice dancing we become great dancers, but if we practice illicit substance use we become great at that). To change this, we must replace this behavior with a healthier one and choose it over and over again to create new brain pathways and reinforce old/new brain pathways to make us better at wanting/choosing/doing the healthier behavior.

This is why it is important to highlight the Stoic Archers focus on reaching into the quiver and attempting their goal again, to the best of their ability. The benefits to these practices remain wether we are in clinical treatment or not. This lesson can also be used as preventative mental health care as well. This is how we change our unhealthy responses to emotions/thoughts. If we destroy property when we are angry, we must then replace destruction with something healthy, and choose that new behavior many times so that we begin to rewire our brains in a way that makes the new behavior a mastered and habitual skill, replacing the destructive behavior (unlearning it).

Another important note about the Stoic Archer metaphor as a CBT tool is that the less we focus on failed outcomes (something out of our control), the less self induced suffering we put ourselves through. Being an outcome based thinker can potentially lead to perpetual psychological harm. This type of displeasure/pain felt from focussing on the outcome or something that is out of our control actually engages our brains in a process that dampens endorphins. This means we are less likely to “learn” what we are trying to “learn”; less likely to rewire and create new brain pathways for our desired behavior change. It also means we are less likely to reach into our quiver of arrows and shoot again.

I like to use the image of a bendy road and a straight road (the roads are the brain pathways) with the time in between travel being the time we spend in the area of the brain where we contemplate consequences. Point A is our thought/emotion and point B is our behavior and the car is an Axon (neuron that carries information electrically in the brain). We start with a bendy road. When we choose a behavior based on our thoughts/emotions we begin to rework our road from the bendy road to the straight road (the brain pathways). The fastest route between point A and B is a straight line. This allows us to make this choice quicker and better but also eliminates time we spend contemplating our consequences (the travel time on the road). So, choose a CBT goal, try your best, and keep trying. Be The Stoic Archer!

Some CBT Therapists may suggest that after the new behavior has been learned then CBT has concluded. In truth, if we do not continue to make healthy choices we continue to risk rewiring our brain in unhealthy ways. When it comes to the field of addiction I often point out to my clients to consider how much they can gain with two years of sobriety and if I gave them two weeks to make choices to risk ruining all of that progress they often respond back to me with, “Give me one”. This is the main reason why, I believe, Stoicism is not only a powerful tool for CBT in a clinical and remedial setting; but a powerful tool that everyone can use for preventative mental health care as well.

“It is a mark of a mean capacity to spend much time on the things which concern the body, such as much exercise, much eating, much drinking, much easing of the body, much copulation. But these things should be done as subordinate things; and let all your care be directed to the mind.” Epictetus- Enchiridion (Passage 41)

Here we see Epictetus understand the value of Stoicism not only as remedial care, but preventative mental health care as well. This means that we should practice Stoicism (CBT practices/mind exercises) as much as we should eat well and exercise well: to be healthy and prevent illness. To practice Stoicism daily would be one way to exercise the mind against mental illness. To essentially strengthen/fortify our brains immunity and prevent it from becoming mentally ill. Epictetus understands that without the mind, you can not control the body. Therefore, the priority as far as the hierarchy of health needs is concerned are as followed: the mind is primary and the body is secondary.

…………………………………………………………………………………………………………… Closing Thoughts

In my work I have never had a client say to me, “I did CBT the other day!” but I have heard many say with great pride, “I was a Stoic today!” I believe one reason Stoicism reinvigorates my clients to be engaged in therapy is that Stoicism has “hero’s”. For example, many of my clients will say that they feel enslaved to addiction and/or a slave to their anger. When I teach clients about Epictetus, a born slave, they find many powerful comparisons and similarities between his strife and theirs along with this sense of trust that this person understood pain and therefore, had great wisdom as to how to overcome it.

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Recommended Reading and Resources

Stoicare.com - Brittany Polat and Eve Riches

Enchiridion - Epectitus

On the Shortness of Life: Life is Long if You Know How to Live it - Seneca

The Philosophy of Cognitive Behavioral Therapy - Donald Robertson