Some Initial Assessment Questions

Copyright © Donald Robertson, 2012. All rights reserved.

Instructions: The following questions are designed to help you describe a basic summary of any obsessive-compulsive symptoms.  OCD symptoms vary considerably from one person to another.  Some people have a wide variety of symptoms, whereas others only have one or two main symptoms.  Just ignore any examples or questions below that don’t seem relevant and focus on what you consider to be the most important aspects of your problem.

1. Are you bothered by recurring thoughts, images, or urges (obsessions) that are unwanted or seem unrealistic but are difficult to stop entering your mind?
2. Do you feel driven to use certain physical or mental behaviours (compulsion) excessively or repeatedly in order to reduce your internal distress or discomfort?

If you answered “yes” to either one of these questions then proceed to answer the questions below.

Obsessions

If you have intrusive thoughts (obsessions) that fall under any of the following headings, briefly describe them.  Rate each obsession in terms of its frequency, the intensity of distress caused, and the extent to which you try to resist the thought or control it.  Use the rating scales below:

• Doubting: Questioning whether you’ve locked doors, turned off appliances, made mistakes, completed tasks properly, etc.
• Contamination: Thoughts about contracting germs from doorknobs, toilets, money, etc.
• Inappropriate Behaviour: Thoughts about shouting obscenities aloud in public, undressing, acting strangely, etc.
• Aggressive Behaviour: Thoughts or urges about harming oneself or others intentionally, acting violently, etc.
• Sex: Obscene thoughts or images of a sexual nature, thoughts about violent or illegal sexual acts, etc.
• Religion: Blasphemous or religiously-themed disturbing thoughts, images, or urges, etc.
• Accidents: Thoughts or images about poisoning or injuring someone accidentally, etc.
• Horrific Images: Disturbing images of mutilated bodies, etc.
• Other (specify):

Describe your main obsessions:

Rate the frequency of each type of obsession (0-8), where 0 means “never” and 8 means “constantly”

Rate the distress associated with each type of obsession (0-8), where 0 means “none” and 8 means “extremely severe”

Rate your resistance to each type of obsession (0-8), where 0 means “never” and 8 means “constantly”

Compulsions

If you have any excessive or repetitive (compulsive) behaviours that fall under the following headings describe them below, and provide a rating of their frequency.

• Rule-following: Sticking to rigid rules or sequences, following rituals, routines, etc.
• Checking: Looking more than once to check locks, appliances, emails, etc.
• Washing/Cleaning: Washing your hands or body, cleaning your house or clothes, etc.
• Mental Rituals: Repeating words, prayers, mantras, counting, etc.
• Other (specify):

Describe your main compulsions:

Rate the frequency of each compulsion (0-8), where 0 means “never” and 8 means “constantly”.

Severity & Impact of Symptoms

1. What percentage of the day, on average over the last month, do you spend thinking about your obsessions (0-100%)?  (Is it more than one hour per day?)
2. When the obsession is at its peak, how strongly do you believe it to be true/accurate (0-100%)?
3. At other times, when not experiencing the obsession, how strongly do you believe it to be true/accurate (0-100%)?
4. What concerns you most about having these obsessions?  What do you worry that it might mean?  What’s the worst that might happen if the obsessions increased?
5. What percentage of the day, on average over the last month, do you spend engaging in your compulsions (0-100%)? (Is it more than one hour per day?)
6. Do you feel these compulsions are irrational or take up more time than necessary?
7. How strongly do you try to resist carrying out these compulsions (0-100%)?
8. How anxious would you feel if unable to carry out your compulsions (0-100%)?
9. What do you worry might happen if you were unable to carry out your compulsions?
10. In what ways have your obsessions and compulsions interfered with different domains of your life (work, relationships, daily routine, social life, etc.)?

US National Comorbidity Survey Replication (NCS-R)

The graph below shows the percentage of individuals who have a history of different diagnosable mental health conditions (lifetime prevalence of DSM-IV disorders), using data from a large US study involving nearly 10,000 participants.  You can see that the total percentage of individuals who have at some point met diagnostic criteria for some mental health disorder is extremely high, 57.4%, making these problems almost the norm.  The most common individual anxiety or mood disorder is clinical depression (major depressive disorder).  The most common anxiety disorders are specific phobias and social phobia.

A Metacognitive Model of Depression

Copyright © Donald Robertson, 2012.  All rights reserved.

This article briefly outlines the “metacognitive” model of depression employed in Metacognitive Therapy (MCT) and important “third-wave” approach to cognitive-behavioural therapy (CBT).  Metacognitive Therapy (MCT) for depression is quite different from traditional cognitive therapy and is based upon a different theoretical model.  Put simply, the structure of a depressive episode can be divided into the following sequence of events: 

1. Automatic negative thoughts, memories, or feelings of sadness trigger the cycle, sometimes these may be triggered by external events but often they may appear to more spontaneously – trigger thoughts often take the form of negative comments about the self (“I’m useless”, “I don’t feel normal”, etc.)
2. These activate implicit positive beliefs concerning the need to cope by ruminating about them, e.g., it’s often assumed that rumination will lead to improved understanding and thereby help to solve the problems associated with depression
3. Rumination is used as a coping response, which involves dwelling on negative thoughts and feelings for prolonged periods and analysing their personal meaning, perhaps even for most of the day
4. At some stage, negative beliefs about rumination typically become activated, these involve beliefs about the uncontrollability of rumination (“I can’t stop dwelling on how depressed I feel”, “There’s something wrong with the way my brain is working that I can’t control”).  Also, awareness of the process of rumination deteriorates so that a person may not fully realise how much time they’re spending engaged in unhelpful chains of thought, making it difficult to consciously decide to stop the process.
5. These beliefs exacerbate and maintain symptoms of depression, including behaviour like social withdrawal and avoidance, feelings of depressed mood, and typical depressive thoughts about deprivation (loss), deprecation (criticism), or defeat (hopelessness), etc.

The metacognitive model of depression is based on a basic distinction between automatic and deliberate thoughts.  Automatic thoughts are often fleeting and barely conscious and tend to “pop into the mind” spontaneously or in response to certain situations.  You can’t easily change automatic thoughts but you do have more control over what happens next, your voluntary response to them.  The main voluntary or deliberate thinking process in depression is called “rumination”.  Rumination typically consists of chains of questions such as “Why is this happening?  What does it mean?  Why me?  Will this go on forever?”  Sometimes this is described as over-analysing the meaning of events by asking “Why?” questions excessively, in a circular manner that goes on for long periods without arriving at any insights or conclusions of practical benefit.  One of the main drawbacks of social withdrawal and avoidance, another key feature of depression, is that it tends to increase self-preoccupation and provide more time to engage in morbid rumination.

Depressive Coping Style

The central factor maintaining depression can be viewed as a ruminative, self-focused style of coping with initial upsetting thoughts and feelings.  This way of responding to automatic thoughts and feelings is typically morbid and counter-productive.  However, especially with long-standing depression, unhelpful coping strategies such as rumination often become so familiar that the individual is barely conscious of engaging in them.  This makes it difficult for them to notice that they aren’t working, despite being used repeatedly, and to exert choice and control over them.

Rumination and Worry

Rumination involves prolonged thinking about the meaning of automatic thoughts and feelings.  As we’ve seen above, rumination often consists of chains of “Why?” questions about the meaning of events, tends to be focused on the past, and to generate depressed mood and low self-esteem.  However, some of the techniques recommended by traditional cognitive therapy are viewed by MCT as potentially fuelling rumination, such as keeping thought records or disputing the content of automatic thoughts and core beliefs about the self, etc.  Worry is also a common feature of depression and involves chains of thoughts such as “What if something bad happens?”, “How will I cope?”, which tend to culminate in catastrophic thinking about the future and escalating anxiety.  Worry about the return of future episodes of depression or the future worsening of symptoms may lead to mixed anxiety and depression.  Both worry and rumination often masquerade as problem-solving, although they can be distinguished, not least by the excessive amount of time spent on worry/rumination and lack of practical insights or solutions generated.

Threat-Monitoring

“Threat-monitoring” refers to being on the lookout excessively for problems or potential signs of danger.  In depression, threat-monitoring often involves increased self-preoccupation and focus on possible symptoms of depression such as mood changes, problems concentrating, or feelings of low energy, etc.  Paying more attention than normal to internal experiences, for prolonged periods, tends to amplify them and interferes with ordinary daily activity.  Threat-monitoring, like other aspects of coping, is to some extent driven by the assumption that it’s helpful or necessary, although it usually backfires by making the problem worse.  In particular, excessive self-focus may interfere with concentration and memory, thereby escalating these and other symptoms of depression.

Avoidance

In addition to these more internal strategies, people who are depressed often engage in behaviour or avoid activities as a way of trying to protect themselves against perceived threats or unpleasant feelings.  Most commonly, depressed individuals tend to withdraw from social life and spend more time alone or at home.  Some depressed individuals may even avoid activity specifically so that they have more time to “think over” their problems, although this typically makes things worse because their thinking becomes increasingly negatively biased and unhelpful.

Internal Struggle (Thought-Control)

In addition to avoiding external situations and activities, people often begin to struggle with their internal experiences, such as thoughts, feelings, and urges, etc.  This is sometimes referred to as “experiential avoidance” or “thought-control”.  In particular, when avoidance of external activities and other behaviour changes fail to alleviate depression, people often resort to more direct attempts to control or eliminate unpleasant thoughts and feelings.  There are many subtle strategies that people learn to employ, sometimes without even noticing that they are doing so.  However, attempts to suppress feelings, control thoughts, reassure yourself, relax your mind or body, distract yourself from unpleasant experiences, or use food or drugs to eliminate them, can backfire, especially if you become too dependent upon them or use them too frequently.  These strategies often make people “feel better” temporarily but can prevent them “getting better” in the long-run.  However, for that reason, they can become almost “addictive” and it may feel strange at first to abandon them completely, although this is usually an important step in therapy.  (You may notice that many of these are strategies recommended by older therapy approaches, which is because they sometimes do work, but they also often become “crutches” that fail to help properly.)  All attempts to control internal experiences tend to increase self-preoccupation and may lead to a “rebound effect” whereby the avoided thoughts or feelings keep returning more frequently.  These mental strategies can also take up a lot of attention and may interfere with your ability to function normally in life.

Detached Mindfulness

An alternative, more adaptive coping style consists in “doing nothing” in response to automatic thoughts and feelings associated with depression.  More specifically, it entails abandoning all of the maladaptive coping strategies above, ceasing rumination/worry, threat-monitoring, avoidance, and thought-control.  Instead, an attitude of “detached mindfulness” is prescribed by Metacognitive Therapy.  This involves acknowledging automatic thoughts and feelings, being mindful of them, but viewing them as normal, transient and harmless mental events, and accepting their presence while distancing oneself from them psychologically.  That means neither engaging with depressive thoughts through prolonged worry or rumination, nor trying to eliminate them by engaging in an internal struggle against them.  Detached mindfulness may appear like a subtle knack at first but it’s really the natural way that most people respond to passing thoughts and feelings. 

Metacognitive Conceptualisation of OCD

Copyright © Donald Robertson, 2012.  All rights reserved.

“Obsessions” take the form of automatic thoughts, urges, impulses, doubts, questions or images, which are usually experienced as unwanted, intrusive or inappropriate. Obsessions vary considerably but the most common types include thoughts about contamination, thoughts or urges about antisocial or violent acts, doubts about your own actions (e.g., whether you locked a door), etc. “Compulsions” are not always present but usually take the form of physical or mental attempts to cope with your anxiety or the perceived threat. Physical compulsions might include checking, seeking reassurance, performing rituals, etc. Mental compulsions can be quite subtle and are often overlooked at first but might involve trying to think positively, repeat a prayer, distract yourself, reassure yourself, or ruminating about the meaning of the initial thought.

The example questions below are used, in Metacognitive Therapy (MCT), to help understand (or “conceptualise”) the maintaining factors in obsessive-compulsive disorder (OCD). The first question, in bold, may be sufficient but additional examples are provided under each heading.

1. Initial Trigger

• When you felt anxious or upset, what initial thoughts, images, or urges went through your mind?
• What was the intrusive doubt or thought that triggered your response?

2. Emotions

• When you had the intrusion how did you feel emotionally (e.g., anxious, guilty, disgusted)?
• What bodily sensations, if any, do you experience at that time?

3. Appraisals of Intrusions

• What did having the intrusion mean to you?
• Did you have any worries or negative thoughts about the intrusion?
• Did you think that having these intrusions said something negative about you as a person?
• What would happen if you did nothing or couldn’t get rid of these intrusions?
• What’s the worst that could happen as a result of having the intrusion? How could that happen?
• Does the intrusion mean something bad has already happened? What? How does it mean that?
• What sense do you make out of having these intrusions? Do they tell you anything? What do they tell you about your actions or about events?
• Is it normal to have thoughts like this? What concerns you the most about them?

4. Underlying Beliefs about Intrusions

• What do these thoughts, images, or urges mean in general?
• Do you believe there’s something particularly special or important about this type of thoughts? How?
• Do unwanted thoughts mean you might be responsible for harm to yourself or others? How?
• Can unwanted thoughts cause unwanted actions? How?
• Can unwanted thoughts cause unwanted events? How?
• Can unwanted thoughts signify that something bad might have already happened? How?
• Do doubts or gaps in your memory signify that something bad has happened? How?
• Does this kind of thought say something bad about you or could they change you as a person? How?

5. Behaviour / Compulsions

• When the intrusion occurs, how do you respond or try to cope with it?
• Do you do anything to prevent the feared catastrophe from happening? What do you do?
• Do you do anything to stop yourself doubting or to control your thoughts? What do you do?
• Do you try to stop feeling anxious or upset? How?
• Do you engage in any ritualistic or repetitive behaviour? What do you do?
• Do you worry (keep thinking “What if something really bad happens?”) about your intrusions or try to think of solutions (“How will I cope?”)? How?
• Do you ruminate about your intrusions (over-analyse them and keep asking “Why?” questions) or try to understand their meaning? How?
• When you have an intrusion, what do you find yourself concentrating on or looking-out for?
• Do you avoid any situations or activities because of your intrusions?
• Do you do anything differently or in a special way because of your intrusions?
• How much time do you spend doing compulsive behaviours? How many times per day?

6. Appraisals of Behaviour

• What do you believe are the advantages and disadvantages of your behavioural response?
• Once you’ve started, how do you know when to stop your rituals or responses?
• What’s the worst that could happen if you continue to use this strategy?
• What’s the worst that could happen if you didn’t use the strategy?
• How much control do you have over your checking, neutralising or rumination?
• Have you tried to stop this behaviour? Is there a reason for not trying to stop?
• How does checking, ruminating or neutralising help?
• Do your compulsions keep you safe in some way? How does that work?
• How do you know whether your behaviour is helpful or not?
• What happens to your feelings/thoughts when you are prevented from checking or neutralising them?

The Philosophical Roots of Cognitive-Behavioural Therapy

Copyright © Donald Robertson, 2012.  All rights reserved.

[These are my notes from a talk given at Conway Hall on 9th May 2012.  You can find information on the talk and feedback from those who attended at the website of the London Philosophy Club.  The content below is largely based on my book The Philosophy of Cognitive-Behavioural Therapy (2010).  I departed significantly from the text below but it gives a flavour of the subjects covered.]

First of all, I should explain that ancient philosophy was very different from modern philosophy insofar as it involved a far greater practical orientation. Ancient philosophers often adopted a different lifestyle: they wore short grey cotton military-style cloaks, shaved or grew their hair and beards, slept on military camp beds, changed their diet, or observed vows of silence, in some cases, depending on the school they were aligned to. They changed their lifestyle and systematically rehearsed specific mental exercises, and meditation-like techniques, for explicitly therapeutic purposes. Whereas many ancient philosophers compared themselves to athletes, and trained in the open air of the gymnasia, modern philosophy became an increasingly bookish subject. Unfortunately, we all went from being warriors of the mind to something more like librarians of the mind. Among the ancient philosophies, Stoicism particularly sought to imitate the philosophical lifestyle of Socrates, the pre-eminent Greek sage, the ultimate role-model for later philosophers, and Stoicism was therefore the philosophical tradition that had the most explicit practical and therapeutic emphasis. So it’s been of special interest to modern psychotherapists for that reason and also because the founders of CBT made reference to it as a major inspiration for their overall approach.  I’m going to proceed therefore by considering the questions: “What is Stoicism?”, “What is CBT?”, and “What’s the relationship between them?”, and concluding with some practical examples of Stoic psychological exercises.

What is Stoicism?

So who were the Stoics? In a nutshell, Stoicism is an ancient Graeco-Roman school of philosophy, founded in Athens at the start of the 3^rd century BC by Zeno of Citium. The name Stoic”” comes from the stoa or covered street in the Athenian city centre where Zeno’s school met to do philosophy. So we might argue that, in a sense, “Stoicism” means urban philosophy or philosophy of the street. Its popularity continued for many centuries as leading Stoics introduced the philosophy to Rome, where it took root, was embraced, and developed an even greater therapeutic orientation. Historians record that the Stoics wrote hundreds, possibly thousands, of texts. However, we’ve lost most of the writings of Zeno and the other Greek founders of Stoicism. The three authors whose works we do have are Seneca, a wealthy Roman statesman, Epictetus a crippled slave, and Marcus Aurelius, one of the most-admired Roman Emperors. These three Stoics came from separate generations, which lived in Rome during the first two centuries AD.

So what did the Stoics actually believe? The famous Enchiridion or philosophical Handbook of Epictetus provides arguably the simplest outline of Stoic practices. It opens by stating the truism that some things are under our control and others are not. That’s arguably the core principle of Stoicism. Epictetus continues to say that, basically, our own actions are, by definition, under our control, whereas everything else that happens to us, is not under our control, at least not directly so. Of course, our actions may influence external events but we can’t absolutely guarantee the outcome, so we only have direct control over our own actions and everything else is, at least to some extent, in the hands of Fate. The Stoics believed that most human suffering is due to the basic error of confusing these two categories: taking too much responsibility for things outside our control and not enough responsibility for making our own actions accord with our own values or the virtues we aspire to possess. I’ve called this the “Stoic hypothesis” and it’s similar to certain concepts in modern therapy and also modern research on stress. The Stoic hypothesis is also pretty well captured by the famous Serenity Prayer used by Alcoholics Anonymous or “AA”, which is frequently-quoted by modern therapists:

Give me serenity to accept the things I cannot change;

Courage to change the things I can;

And wisdom to know the difference.

What is CBT?

So what is CBT? Cognitive-behavioural therapy or “CBT” is the most evidence-based form of modern psychological therapy. We should really say “therapies” in the plural because CBT is definitely not just one thing – it’s a broad movement consisting of dozens of different individual therapies. As the name implies, they mostly have in common the assumption that emotional suffering, and other problems, can be helped by learning to modify our cognitions and behaviour. By “cognitions” we just mean thoughts and beliefs. So CBT clients might typically be asked to keep a daily record of their distressing thoughts, to question the evidence for their underlying beliefs, and to engage in more fulfilling daily activities or to systematically face their fears without avoidance, etc.

What’s the relationship between ancient philosophy and modern CBT?

So what’s the relationship between CBT and Stoicism? The forerunner of CBT was Rational-Emotive Behaviour Therapy or “REBT”, founded in the 1950s and 1960s by Albert Ellis. Ellis was interested in philosophy and had read the Stoics in his youth before training as a psychoanalytic therapist. After becoming disillusioned with psychoanalysis, Ellis found himself returning to the Stoic principle that relatively “ordinary” irrational thoughts and beliefs cause emotional disturbance and this became the inspiration for the development of REBT, arguably the first major cognitive therapy. In the early 1960s, Ellis wrote:

This principle, which I have inducted from many psychotherapeutic sessions with scores of patients during the last several years, was originally discovered and stated by the ancient Stoic philosophers, especially Zeno of Citium (the founder of the school), Chrysippus [his most influential disciple], Panaetius of Rhodes (who introduced Stoicism into Rome), Cicero, Seneca, Epictetus, and Marcus Aurelius. The truths of Stoicism were perhaps best set forth by Epictetus, who in the first century A.D. wrote in the Enchiridion: “Men are disturbed not by things, but by the views which they take of them.” Shakespeare, many centuries later, rephrased this thought in Hamlet: “There’s nothing good or bad but thinking makes it so.” (Ellis, 1962, p. 54)

[By the way, there’s a small mistake in that passage. Cicero was a Platonist, not a Stoic but we’ll let Ellis off with that!] Anyway, Aaron T. Beck later developed “cognitive therapy”, which was at first heavily influenced by REBT and also cited Stoicism and particularly the quote from Epictetus as its inspiration and “philosophical origin”, as Beck put it. However, Beck’s treatment manual for depression was only published in 1979 and for anxiety in 1985. So cognitive therapy didn’t properly rise to prominence until the 1980s, by which time it was increasingly being combined with earlier approaches from behaviour therapy. Hence, Beck’s term “cognitive therapy” became gradually replaced by the more general term, which we all know and love, “Cognitive-Behavioural Therapy” or CBT. The story doesn’t stop there, though, because by the 1990s a number of “third wave” or “mindfulness and acceptance-based” approaches to CBT had already started to develop, which basically replaced Beck and Ellis’ emphasis on helping clients to directly question the evidence for their irrational beliefs with a greater emphasis on mindfulness and detachment from unhelpful thoughts. Recent “third wave” CBT puts more emphasis on gaining psychological distance from thoughts rather than disputing them, in other words.

So CBT has always been a broad church, composed of many different cognitive and behavioural theories and practices. Since the 1980s, Beck’s approach has been the most influential one, and following REBT it explicitly cites Stoicism as its philosophical origin. However, other forms of CBT may also have elements in common with Stoicism. For example, recently the emphasis in “third-wave” CBT has shifted on to the role of mindfulness and acting in accord with personal values. These are both key elements in Stoicism that were somewhat neglected by Beck and Ellis but which are emphasised in the new generation of CBT approaches, such as Acceptance and Commitment Therapy or “ACT”. I’ve argued in my book that mindfulness was one of the main aspects of Stoicism that Beck and Ellis failed to assimilate into their early cognitive-behavioural approaches. Mindfulness is all the rage now but it’s mainly associated with ideas from Buddhist meditation rather than Stoicism, even though Epictetus said, for instance, “Is there any activity that doesn’t benefit from being performed with true self-awareness?” Sleeping perhaps. But you might want to ponder how broad the beneficial applications of mindfulness and cultivating self-awareness might be in your own life? That’s a question perhaps to take away from this talk.

Example Philosophical Techniques

So we’ve talked about Stoicism, CBT, and the relationship between them. What about some practical examples of Stoic philosophical therapy?

1. First of all, “Dogmata” or precepts of Stoicism attempt to sum up rules of living as brief phrases, such as “Follow nature” or “Know thyself”, a bit like affirmations or coping statements in modern therapy. Stoics like Marcus Aurelius used to practice writing down short passages or phrases over and over that tried to express important philosophical maxims in many different ways. We have a clear record of this in his personal journal, called The Meditations.
2. Next, philosophical “katharsis”, not at all what Freud used the word to mean, but rather the knack of mindfulness, seeing thoughts as thoughts, distinct from external reality, as merely events in the mind and not confusing thoughts with the things they represent. This is very similar to the concept of psychological “distancing” we mentioned earlier as part of modern CBT.
3. “Objective representation” (phantasia kataleptike) was an important Stoic practice that involved carefully describing events in purely objective terms, without any rhetoric or value judgements. Similar techniques are used in modern mindfulness-based meditation techniques in CBT.
4. “Premeditatio malorum” involves imagining future catastrophes as if they’re happening right now and learning to cope with them better through mental rehearsal and Stoic acceptance. This is similar to a common CBT technique called “decatastrophising imagery”.
5. “Contemplation of the Sage” involved verbally describing or imagining the ideal wise man, or ideal Stoic, and how he would cope with different problems of living. Again, this resembles a modern CBT technique called “covert modelling” or modelling in imagination.
6. Finally, the technique scholars call “The View from Above”, which is found throughout classical literature. This involves picturing events from high above, as if from atop mount Olympus or looking down at the planet Earth from outer space. To the ancients this seemed like adopting the perspective of the gods on mortal events, trying to contemplate the place of the present moment within the vast totality of time and space. This technique creates a sense of psychological detachment that can be very useful but there aren’t many examples of the same type of visualisation being done in modern therapy.

So given the overlap, why would anyone, including modern therapists care about Stoicism? Well, the Stoics also provide a bigger philosophical system than modern therapy has to offer. They had their eye on the ideal way of life in general rather than just fire-fighting specific clinical problems such as anxiety or depression. The Stoics also had some strategies that modern therapy neglects or presents differently, including some of the ones mentioned a moment ago. However, an answer that’s very important to me, and to many other people, but not to everyone, is that the Stoics wrote some of the most beautiful and inspiring works in the history of European literature. Seneca, in particular, has always been revered as a great writer. Reading Seneca, or indeed Epictetus or Marcus Aurelius, is a very different experience from reading a modern clinical or self-help text on CBT. To some people it’s a much greater source of inspiration – the beauty of the writing and clarity of thinking often matters.

Philosophy is the love of wisdom. That’s what the word means and to the ancients that meant having the courage, integrity and persistence to live our lives wisely, even in the face of real adversity. As Plato famously wrote, philosophy is a battle of titanic proportions over the very nature of existence itself. It goes somewhat beyond what modern evidence-based psychological therapy can tell us. Philosophy demands that we ask even more penetrating questions. Quo vadis? Where are you going? What are we to do in life, more generally, with the specific pieces of knowledge that modern research on psychological wellbeing might give us?

Gaining Appropriate Psychological Distance

Distressing thoughts in social anxiety differ qualitatively from thoughts in most other forms of anxiety in that they are often attributed to other people, e.g., “He thinks I’m an idiot.”  Recent “mindfulness and acceptance-based” approaches to CBT place greater emphasis on viewing one’s own thoughts in a detached manner rather than trying to dispute or evaluate their content.  However, thoughts about others could be described as taking the convuluted form “I’m aware that… I’m having the thought… that he is having the thought… that I’m an idiot.”

The article below provides some ideas for adapting mindfulness and acceptance techniques for use in response to interpersonal problems such as social anxiety or relationship issues, etc.

Psychological Distance

Cognitive or psychological “distancing” is one of the most basic techniques in Beck’s original cognitive therapy approach.  More recently, it has been employed more comprehensively (and renamed “defusion”) in innovative mindfulness and acceptance-based approaches to CBT, such as Acceptance and Commitment Therapy (ACT).

Distancing can be considered a key component of “mindfulness” as it’s similar to the attitude adopted in various types of meditation practice.  Rather than disputing negative or unhelpful thoughts, distancing simply involves adopting a more detached attitude toward them.  Whereas in traditional cognitive therapy this was done as a prelude to challenging the content of thoughts, in modern mindfulness and acceptance-based approaches, it’s used as a radical alternative to challenging thoughts.  Because distancing is a simpler and more general-purpose skill, it can be used to address a range of problems at once and therefore also to build resilience to future sources of emotional disturbance.  Distancing essentially involves experiencing thoughts and images as psychological events rather than as the things they represent: as thoughts not facts.  In fact, psychological distance can involve both separating thoughts from external reality and also separating yourself from your thoughts.

Although distancing techniques are usually applied to your own thoughts, something similar can be done with thoughts attributed (rightly or wrongly) to others, even things they have explicitly said aloud.  For example, you might worry that someone thinks “You’re an idiot” or become distressed because they appear to snub you or actually said something that came across as a “put down” or an upsetting criticism.  Some basic strategies for gaining psychological distance from thoughts attributed to others might include:

1. Picture the words on their forehead or clothing, or projected on wall behind them, viewing the thoughts as objects at a distance and noting the properties of the writings, e.g., the colour, size, and style of the letters
2. Writing the thoughts down on a daily record or flipchart and viewing them from a distance physically, noting the properties of the writing again
3. Reminding yourself that other people’s thoughts are mere hypotheses rather than facts, just “their opinion”, and taking time to patiently view them as such
4. Picking a short word or phrase to summarise the thought or attitude attributed to the other person and repeating it quickly aloud, for about 30-40 seconds, while focusing on the audible properties of the words, the volume, accent and rate of speech, etc., rather than the meaning or content of the thought
5. Alternatively, label the thoughts as thoughts and quite slowly say aloud to yourself “I am aware that… I am having the thought… that she is having the thought… that xyz”, pausing between these words in this deliberately “clunky” and long-winded version.  This is done while being aware of the thought as a series of syllables you’re repeating, a mental activity, being aware of even the slightest muscles movements or changes to your breathing or facial expression as you speak
6. Imagine saying the thought several times in your mind, in a silly voice, like a cartoon character, or singing it along to an incongruous  tune like “Happy Birthday” or “Daisy, Daisy”, etc.
7. Imagining, metaphorically, that thoughts (e.g., criticisms) are like clouds in the sky or leaves on a stream, viewed from a distance like objects, and allow them to fade slowly into the distance, as you patiently let go of them, doing so repeatedly if necessary

Distancing techniques can be used before, during or after difficult encounters with other people.  Indeed, distancing strategies are often employed either in imagination (before or after an event) or “face-to-face” during real conversations.  It’s important they’re not used as a way of trying to avoid unpleasant feelings but merely to prevent yourself from becoming too absorbed in thoughts about other people’s opinions, and taking them more seriously or personally than necessary.  Fogging, negative assertion, and negative inquiry, described below, are common assertiveness techniques.  These can be used as ways to directly confront unpleasant experiences, during real conversations, in order to develop psychological distance from the thoughts and radical acceptance of uncomfortable feelings.

Fogging as Distancing

One of the central techniques of early behavioural assertiveness training was termed “fogging”.  It’s based on the metaphor of acting as if you were a bank of fog, through which sticks and stones pass without making an impact.  The psychologist Manuel J. Smith introduced the concept in his bestselling book on assertiveness, When I Say No, I Feel Guilty (1975).

A skill that teaches acceptance of manipulative criticism by calmly acknowledging to your critic the probability that there may be some truth in what he says, yet allows you to remain your own judge of what you do. […] Allows you to receive criticism comfortably without becoming anxious or defensive, while giving no reward to those using manipulative criticism. (1975, p. 323)

Fogging requires explicitly acknowledging critical comments made by the other person and agreeing with the “possibility” they might be true, without taking them too seriously.  Smith gives examples such as saying “That’s right”, “That’s probably true” or “You might be right”.  This is about changing your relationship with the ideas being expressed, accepting the fact that others are critical or disagreeable and even the possibility there may be some validity to their comments, without becoming too upset or entangled with their views.  The strategy of “fogging” therefore arguably resembles “distancing”, in some respects, except that it is applied to negative comments or thoughts attributed to others.

Negative Assertion & Negative Inquiry

Smith describes two other assertiveness strategies that are closely-related to fogging.  “Negative assertion” involves actively expressing self-criticisms before others have a chance to do so, without becoming too absorbed in them or overly-distressed.  “Negative inquiry” is a similar strategy but involves inviting the other person to express themselves honestly, even if this includes criticism.  Both of these strategies can be seen as resembling forms of “exposure therapy” in which negative comments and ideas are confronted directly.  However, like mindfulness and acceptance-based approaches to CBT, the exposure is accompanied by a certain type of detachment, remembering that these are just opinions held by certain individuals rather than objective facts agreed upon by everyone.

Decatastrophising Imagery

“Decatastrophising” is another common technique in cognitive therapy.  In interpersonal situations, it can involve creating a detailed mental image of the feared social catastrophe, so that you can patiently picture the worst-case scenario.  Your core underlying fear may well be quite unrealistic but it may help to imagine facing it anyway.  Picturing catastrophic events will typically cause a temporary rise in anxiety but if you patiently continue to “wait it out”, your anxiety should reduce over time, and with repetition this will become quicker and easier, until anxiety may eventually extinguish almost completely.  Exposure to feared events in imagination usually takes 15-30 minutes and is repeated daily for 1-2 weeks, although this can vary considerably.  The basic rule is that you should continue, at each sitting, to picture the feared event until your anxiety has reduced to at least half its original (or peak) level.  Stopping too soon, while anxiety is still high, is unlikely to be helpful and may even make your problem worse.  After having reduced anxiety through repeated, prolonged, exposure to the mental image of the worst-case scenario, it can be useful to plan how you could realistically cope with the feared event, perhaps even writing down and memorising a specific “coping plan”.  Likewise, it can be helpful to ask yourself what the worst-case scenario would be, what’s the best you can hope might happen, and finally what’s most likely to happen, the most realistic outcome.  You should then write down and repeatedly remind yourself of the most realistic outcome, and prepare to cope with that rather than focusing on possible, but unlikely, catastrophes.

Radical Acceptance of Feelings

Picture the other person doing or saying something that’s objectionable to you. Take your time to acknowledge how you feel emotionally and any associated bodily sensations or other automatic reactions that you experience. Allow yourself to let go completely of any attempt to control or avoid unpleasant experiences and instead let your feelings come and go naturally. Letting go of any internal struggle, radically accepting your feelings, and allowing yourself to process them naturally, will often reduce the amount of emotional suffering experienced and its impact on your ability to cope with the situation. However, this takes patience, and requires sufficient psychological distance from the thoughts encountered.  Radical acceptance differs from the use of decatastrophising imagery in that it is usually briefer and involves accepting anxiety rather than waiting for it to extinguish over time.

Valued Action

It’s important to emphasise that the strategies above are not to be used as forms of avoidance.  In fact, they’re intended as ways to more fully confront and endure unpleasant thoughts and feelings and to face situations and conversations that might be problematic.  Reflecting on your most important personal values and clarifying them can provide an important resource for interpersonal problems.  “Values clarification” exercises can be used to help do this, such as asking yourself what you’d like to be remembered for at the end of your life, or what virtues would be required to fulfil your main roles in life well.

Remembering your relevant values before, during, and after social encounters and remaining committed to acting in accord with them will help to guide you through things.  For example, you might value acting with “integrity”, “fairness”, or “assertiveness” in certain relationships.  Whether or not you actually succeed in acting this way, and living up to your values, may not always be 100% under your control but being committed to doing so is something you can always achieve, because it’s simply a matter of choice or intention.

How to turn unhelpful checking into helpful checking

Copyright © Donald Robertson, 2012.  All rights reserved.

Recently, a new cognitive therapy technique has been developed for individuals who suffer from compulsive checking behaviour, like repeatedly checking that doors or locked, cookers are switched off, or that emails have or haven’t been sent, etc.  As we’ll see below, the therapeutic strategy called “adaptive checking” involves shifting the focus away from checking whether your specific obsessive thoughts about having made a mistake or something bad having happened are true or false.  Instead  checking becomes focused on whether your underlying beliefs about how to interpret these thoughts are correct, i.e., your assumptions about how the meaning and importance of obsessive thoughts.  These “metacognitive” beliefs are often unspoken or implicit at first and you may not recognise them until you’ve spent some time exploring your attitudes toward your own thinking.

Individuals with obsessive-compulsive symptoms often feel compelled to repeatedly check things to reassure themselves that they are not going to be responsible, somehow, for causing harm to themselves or others.  That might be either because of something wrong they believe they’ve done (like sending an email to the wrong person) or failed to do (like not switching off electrical appliances).  The compulsion to check is often associated with “What if?” thoughts about some feared catastrophe that might result, such as going to prison or being burgled.  These are often described as obsessive doubts.  “What if I copied everyone in to a confidential email by mistake?  What if I end up getting sacked from my job?  What if they send me to prison?”  In the Victorian era, French psychiatrists called this folie du doute or “doubting madness”, although it’s really just a more distressing form of ordinary ways of thinking.  The perceived risk of this catastrophe happening is often greatly inflated during episodes of anxiety.  This may be because of the assumption that obsessive thoughts are meaningful and important rather than simply irrelevant side-effects of previous experiences.  Ordinarily, people might check something until they’ve obtained enough evidence to stop, which is often only once.  However, individuals with compulsive checking tend to check things repeatedly until their anxiety reduces, or for a fixed number of times or period of time, etc.  Hence, the “rules” that tell you how much time to spend checking and when to stop might be somewhat irrational and unrelated to the facts, the evidence revealed by your senses.

By repeatedly checking, moreover, you are assuming that the initial thought or doubt that triggered the behaviour is important and meaningful.  People who check repeatedly often doubt their memory and assume that the absence of a memory, or gaps in memory, are signs that something bad has happened or a mistake has been made.  This is an inversion of normal reasoning, though.  Less anxious people normally assume they’re safe unless there is evidence of danger and that they have done things as normal unless they actually remember something that suggests they made an error.  Doubts or “what if?” thoughts are not themselves evidence that a mistake has been made, especially when they occur obsessively, and are probably triggered automatically rather than reflecting true events.  Where there’s no other evidence of danger and you feel the urge to check that often means acting as if the occurrence of the thought itself were somehow sufficient evidence of danger.  However, other people probably have quite similar automatic thoughts or passing doubts but assume they’re relatively unimportant and meaningless, so they don’t particularly engage any further with them or struggle against them.  Indeed, research has consistently shown that intrusive thoughts, including doubts, are so common as to be the norm but that only a minority of people tend to become preoccupied with them and act in ways motivated by them.

Intrusive thoughts or doubts are experienced as particularly important and meaningful by some people because of the underlying assumptions they hold about them.  We call these “metacognitive beliefs” – which basically just means “beliefs about your own thoughts” here.  A recent variation of traditional cognitive therapy called “Metacognitive Therapy” (MCT) has been developed to address beliefs at this level, and involves innovative ways of treating obsessive-compulsive symptoms.  A common underlying belief about intrusive doubts is that if you have the thought that something has happened then it probably has.  For example, you might assume that if you have the thought “I’ve forgotten to lock the door” then you probably have forgotten, even if there’s no other reason or evidence to believe so.  These intrusive thoughts and doubts are automatic and may just “pop into your mind” in a reflex-like way because they’re triggered by being in certain situations or having certain feelings – they’re just habitual and not based on logic or facts.  When people assume that merely having an automatic thought about having done something wrong means they must be responsible for actually having done something wrong, psychologists call that retrospective “Thought-Event Fusion” (TAF).  The thought is treated as if it meant the event it portrays probably has happened, despite the lack of evidence or other reasons to thinks so, and this often leads to repeated checking for reassurance.

Initial Questions

You might find it helpful to ask yourself the following initial questions, loosely based on suggestions made by Adrian Wells (1997), the founder of Metacognitive Therapy:

• What is the initial thought (or doubt) that prompts you to engage in your checking behaviour?
• If you believed even more strongly that these thoughts were meaningful and important, how would that affect your problem?
• If you didn’t believe these thoughts were important or meaningful would you still feel compelled to check things?
• How anxious or responsible for potential harm would you feel if you knew for certain that these intrusive thoughts, in themselves, were completely meaningless and unimportant?  How would it affect your problem in general?
• So is your problem that you have thoughts about being responsible for making mistakes or causing harm?  Or is your problem that you’re over-estimating the importance of these intrusive thoughts and responding as if they were meaningful?
• You have thousands of other automatic thoughts every day, many of them are probably somewhat negative, but most of them barely catch your attention – how is it that these thoughts are more important or meaningful than the ones you ignore?
• Surveys show that most people have automatic thoughts about having made mistakes and similar doubts but only a small minority are obsessively anxious about those things – how can this be if your problem lies with the intrusive thoughts themselves rather than your interpretation of their meaning and importance?
• How does your checking behaviour affect your confidence in your memory?
• How does excessive checking affect your ability to distinguish between real memories and imagined events?

Finally, one of the most important questions to consider is: “How is your checking behaviour working out for you in the long-term?”  How’s it working out in terms of your anxiety and other symptoms?  How’s it working out in terms of your quality of life and ability to function at home and at work?  It’s useful to proceed to evaluate the evidence more systematically for the assumption that the doubt or “What if?” thought is typically important enough for you to act upon, by repeatedly checking, rather than simply doing nothing when it occurs.

Behavioural Experiments (Adaptive Checking)

Adaptive checking requires a subtle but important shift in emphasis, to what we call the “metacognitive” level, the level of beliefs about thoughts themselves.  Normally, people check to find out if there’s any evidence of danger or some problem having occurred.  For example, you might check repeatedly to see if you’ve locked your front door properly.  This type of checking often becomes repetitive and can occur every day, indefinitely.  The shift to more adaptive (metacognitive) checking involves using the same (or similar) behaviour to test out the assumption that the thoughts that trigger the checking are important.  For example, a common “thought-event fusion” assumption about obsessive doubts might be expressed as follows:

Intrusive thoughts or doubts about not having done something (e.g., locked the door) mean that I’ve probably not done it, even if there’s no evidence that’s the case.

An alternative belief might be:

Intrusive thoughts about not having done something are meaningless and unimportant in themselves.

To help test the importance of the obsessive thought itself, you should continue to hold it in mind throughout the checking.  For example, you might keep repeating the words “I’ve forgotten to switch off the lights” throughout the whole process of checking and for a short while afterwards.  You might also try to keep picturing the feared outcome while checking, e.g., continually visualising the house burning down.  While doing so, it helps to view these thoughts as just events in your mind that don’t necessarily correspond with reality.  This attitude is called “Detached Mindfulness” in Metacognitive Therapy.  You might want to learn more about this basic strategy first, before applying it during adaptive checking as it’s a bit of a knack and it can take a little practice to understand and acquire the skill.

Adaptive checking is one form of a more general technique called “Exposure and Response Commission” (ERC).  It can help to make you more aware of the thought as just being an idea or hypothesis in your mind, which may turn out to be meaningless and unimportant in itself, rather than seeing it as something that you need to struggle with.  The thought may also become boring with repetition, if you deliberately hold it in your mind continually for some time while checking.  Keeping the thought constant helps to ensure that you’re checking your interpretation of it or beliefs about its importance rather than simply trying to neutralise or remove it from your mind.  The key here is the shift to the “metacognitive” level of awareness during checking, which means shifting to a focus on testing your beliefs about these thoughts rather than the thoughts themselves.  For example, rather than compulsively checking to reassure yourself that the thought “I’ve sent the wrong email” is false, you would check whether the more general underlying belief “These thoughts are meaningful and important” is true or false – thereby shifting the focus onto your assumptions about how to interpret thoughts rather than the thoughts themselves.  It will help you keep your focus on the “metacognitive level”, the level of your underlying beliefs about your own thoughts, if you carefully rate the strength of your metacognitive beliefs (0-100%) immediately before and after each episode of adaptive checking.

On Hypnosis, CBT and Philosophy

Donald is the author of four books and many articles on psychotherapy, hypnosis, and philosophy in professional journals. His books on philosophy and resilience are recommended reading on several university courses in the UK and USA.

Build your Resilience: How to Survive and Thrive in any Situation (Hodder, 2012)

Part of Hodder’s popular Teach Yourself series, this self-help book on resilience-building combines traditional behaviour therapy with modern mindfulness and acceptance-based approaches to therapy.  Covers modern research on psychological resilience, Acceptance & Commitment Therapy (ACT), problem-solving, assertiveness and other social skills, progressive and applied relaxation training, worry postponement, and Stoic philosophical therapy.

The Philosophy of Cognitive-Behavioural Therapy (Karnac, 2010)

The first major text to explore in depth the philosophical origins of cognitive therapy and REBT.  Provides a detailed account of Stoic philosophy in relation to modern psychotherapy, including descriptions of many therapeutic techniques derived from classical literature.  Includes a transcript of the “View from Above” meditation exercise and detailed descriptions of other practical strategies from philosophical therapy.

The Practice of Cognitive-Behavioural Hypnotherapy (Karnac, 2012)

A comprehensive and up-to-date introduction to evidence-based clinical hypnosis, based on cognitive-behavioural theory and practice.  This book also examines the origin of hypnotism in the seminal research of James Braid and the relationship of his ideas to modern theories of hypnosis.  Chapters on the history and theory of cognitive-behavioural hypnotherapy, assessment, conceptualisation, and socialisation and hypnotic skills training, are followed by detailed accounts of self-hypnosis as a form of coping skills training, hypnotic exposure therapy, problem-solving hypnotherapy, and cognitive hypnotherapy.  This is an authentic cognitive-behavioural approach to hypnotherapy, based on the work of Aaron T. Beck and others in the field of CBT, and the cognitive-behavioural research of T.X. Barber, Irving Kirsch and others in the field of hypnosis.

The Discovery of Hypnosis: The Complete Writings of James Braid, edited by Donald Robertson (NCH, 2009)

The first complete edition of James Braid’s writings.  Braid was the founder of hypnotism and hypnotherapy, which he developed in opposition to Mesmer’s animal magnetism.  This collection also contains the first English edition of Braid’s “lost manuscript” On Hypnotism (1860), in which he summarised his life’s work.  It includes detailed editorial comments and introductory chapters providing the historical context and highlighting the contemporary relevance of Braid’s work.  A hypnotist who hasn’t read Braid is like a psychoanalyst who hasn’t read Freud – this book should be owned by everyone who calls themselves a “hypnotherapist” or uses hypnosis on a regular basis.  A return to the writings of Braid helps to dispel many misconceptions that have accrued around the subject of hypnosis.

You can find up-to-date information on Donald’s author pages on Goodreads and Amazon:

• Amazon UK Author Page
• Goodreads Author Page

Based on Excerpts from Resilience: Teach Yourself How to Survive & Thrive in any Situation (2012)

Copyright © Donald Robertson, 2012. All rights reserved.

ISBN: 1444168711 / Details on Google Books

My previous book The Philosophy of Cognitive-Behavioural Therapy (CBT): Stoic Philosophy as Rational and Cognitive Psychotherapy (2010) discussed the relationship between Stoic philosophy and modern cognitive-behavioural therapy in some detail, from an academic perspective. My new book, Resilience: Teach Yourself How to Survive and Thrive in any Situation (2012), is a self-help guide to psychological resilience-building, based on modern CBT.  However, it contains many references to Stoic philosophy.

The first few passages of the philosophical Handbook of Epictetus provide arguably the most authoritative summary of basic Stoic theory and practice. I’ve paraphrased the key statements below, to highlight the possible continuity with CBT and other modern psychological approaches to therapy, etc.

1. The Handbook begins with a very clear and simple “common sense” declaration: Some things are under our control and others are not.

2. Our own actions are, by definition, under our control, including our opinions and intentions (e.g., our commitment to doing what we believe is important), etc.

3. Everything other than our own actions is not under our direct control, particularly our health, wealth and reputation, etc. (Although, we can influence many external things through our actions we do not have complete or direct control over them, they do not happen simply as we will them to.)

4. Things directly under our control are, by definition, free and unimpeded, but everything else we might desire to control is hindered by external factors, i.e., partly down to fate.

5. The Stoic should continually remember that much emotional suffering is caused by mistakenly assuming, or acting as if, external things are directly under our control.

6. Assuming that external events are under our control also tends to mislead us into excessively blaming others and the world for our emotional suffering.

7. However, if you remember that only your own actions are truly under your control and external things are not, then you will become emotionally resilient as a result (“no one will harm you”) and you may achieve a kind of profound freedom and happiness, which is part of the ultimate goal of Stoicism.

8. To really succeed in living as a Stoic, you need to be highly committed, and may need to abandon or at least temporarily postpone the pursuit of external things such as wealth or reputation, etc. (Stoics like Epictetus lived in poverty while others, like Marcus Aurelius, tried to follow the principles while commanding great wealth and power – both were considered valid ways of living for a Stoic but Marcus perhaps believed his complex and privileged lifestyle made commitment to Stoicism more difficult at times.)

9. From the very outset, therefore, the Stoic novice should rehearse spotting unpleasant experiences (“impressions”) and saying in response to them: “You are an impression, and not at all the thing you appear to be.” (This resembles one of the early techniques used in CBT, called “distancing”.)

10. After doing this, ask yourself whether the impression involves thinking about what is under your control or not; if not, then say to yourself, “It is nothing to me.” (Meaning, it’s essentially indifferent to me if it’s not under my control – I just need to accept it; although the Stoics did admit that some external outcomes are naturally to be preferred, despite lacking true intrinsic value.)

The Greek word translated as “impression” in Stoic literature is phantasia, which refers to more or less anything that passes through your stream of consciousness, including thoughts, feelings, images, memories, and sense perceptions. The Stoics believed that thoughts, resembling statements, lurk behind every impression, e.g., when I see a tree, I simultaneously experience the verbal thought “That is a tree over there”, without necessarily being aware of the words and concepts being used.

Hence, these last two points, which clearly describe some of the most basic strategies of Stoicism, can be compared to modern “mindfulness and acceptance-based” psychological strategies and the early CBT technique called “cognitive distancing”.  Distancing in CBT sometimes uses verbal strategies such as prefacing a thought with the words: “I notice I am having the thought that…” This perhaps comes closest to the Stoic method above. Epictetus follows these remarks with this further advice:

11. When we experience desire or aversion toward certain (good or bad) things, we implicitly assume that they can be controlled (achieved or avoided), and failing to achieve our desires or avoid our aversions causes suffering.

12. Hence, if you attach desire or aversion to external events, outside of your control, and judge them to be inherently good or bad, by definition, you will make yourself vulnerable to suffering.

13. It is better (i.e., more resilient) to shift your efforts to controlling your own actions where you are more assured of success, although even doing this properly may require practice.

14. To help you reduce attachment to external events and therefore suffering, describe to yourself external things you desire in objective language, e.g., of your favourite cup say: “this is a cup I am fond of”, suspending any value-judgements. (A similar technique was touched upon earlier in the chapter on mindfulness of the present moment.)

15. When you engage in any action, therefore, do so with a “reserve clause”, reminding yourself in advance what to expect and preparing to accept external events, insofar as they are outside of your control. (We will return to the “reserve clause” but it’s like the saying, “Do what you must; let happen what may.”)

This final point, about Stoic acceptance, is described as keeping “your will in harmony with Nature.” In modern language, that simply means being willing to accept those things that happen outside of your control, including the outcome (success or failure) of your own actions.

Epictetus concludes this section with the famous saying, which is widely-quoted as a slogan of modern CBT: “It is not things themselves that disturb us but rather our judgements about things.” He suggests we remind ourselves that it is our judgements primarily that cause suffering by asking ourselves whether other people might respond differently to the same problems. However, it’s sometimes overlooked that Stoicism attributes suffering to a particular type of judgement, the cardinal error of judging external things outside of our direct control (health, wealth, reputation, etc.) to be of intrinsic value, leading to a rigid set of beliefs or assumptions, demanding that they absolutely must be pursued or avoided.

And clearly it must be hard when it is so seldom found.

For if freedom were close at hand and could be found without difficulty
how could it be that it is neglected by almost all?

But all excellent things are as difficult as they are rare.”

– Benedictus de Spinoza, Ethica, §5, Prop 42 n.

Review: Never Too Late to be Great

The Power of Thinking Long

by Tom Butler-Bowdon

www.butler-bowdon.com

In reading Tom’s new book I was reminded of the famous quotation above from Spinoza, one of the philosophers I most admire.  All excellent things are as difficult as they are rare – Rome wasn’t built in a day!  If personal success, in the form of freedom and happiness, was quick and easy, then more or less everyone would already have it.  When in fact, as a psychotherapist I’m acutely aware that most people’s lives are more unhappy than they tend to let on to others.  In the USA, the home of “positive thinking”, the prevalence of mental health problems is so high that almost 50% of the current population will have met criteria for a psychiatric diagnosis at some point so far in their lives.  There’s actually a lot more misery in the world than people realise.  I think the teachings of Buddhism are based on a similar observation: life is suffering.  Much self-help literature seems to gloss over the difficulty of life.  A notable exception is M. Scott Peck’s self-help classic The Road Less Travelled, which notoriously opens with the sentence: “Life is difficult.”  We have to recognise that a great many people in the world either live in great poverty and hardship or live lives of angst and quiet despair in the middle of apparent first-world abundance.  Personal success and happiness can take time and effort and sometimes only come later in life.  It’s easy to forget that in the legend of Buddha and many other great men, their journeys begin with a period of dissatisfaction.  Buddhist tradition claims that even Gautama Buddha only attained enlightenment around age 35; he spent years prior that searching and struggling. 

Tom gives many examples of great men and women who only flourished later in life, sometimes after many years of wandering, effort, or even personal suffering.  Spinoza’s philosophical masterpiece, the Ethica, was only completed a few years before his untimely death, aged 44 from lung disease.  Prior to that he had been expelled from the Jewish community as a heretic, having the most shocking curses placed upon his head.  His writings suggest great emotional turmoil and misery in his life before he finally achieved a kind of enlightenment, and “emotional remedy”, in the form of the imposing metaphysical system he developed.

I thus perceived that I was in a state of great peril, and I compelled myself to seek with all my strength for a remedy, however uncertain it might be; as a sick man struggling with a deadly disease, when he sees that death will surely be upon him […] is compelled to seek such a remedy with all his strength, inasmuch as his whole hope lies therein. (De Intellectus Emendatione, 4-5)

All excellent things are as difficult as they are rare, and sometimes take many years to achieve.  One more example…  Socrates, the pre-eminent philosopher-sage of antiquity, by some accounts, worked as a stonemason, following his father’s profession, until around middle age when he began to dedicate himself fully to the pursuit of wisdom.  He did not spring from the womb fully-armed with his philosophy but, rather, it appears it may have taken him half his life or more to begin developing into a philosopher, and his views were still a work-in-progress when he died.  Now at this point, it becomes apparent to me that I could probably go on offering up similar examples.  In fact, if I draw up a mental list of the people I most admire, it strikes me that virtually all of them took a long time to achieve things in life and often went through a period of initial hardship, setbacks, or emotional turmoil along the way.  I said that Socrates was my last example but I can’t hold back from mentioning another philosopher, discussed by Tom: Immanuel Kant.  Any first-year philosophy student will tell you that Kant was an intellectual titan, a giant of the European enlightenment.  I recall being acutely aware, when I was a young philosophy student, that Kant’s great work The Critique of Pure Reason was published when he was in his late fifties.  Somehow that knowledge comforted me.  It made me feel there was plenty of time to write a book or come up with a big idea myself.  As Tom points out, of course, we’re all living much longer nowadays so there’s that much more time to “succeed”, either personally or professionally, later in life.  We now live more than twice as long, on average, as people once did. 

Tom is someone I respect as a bona fide expert on self-help.  He has spent years immersing himself in the literature of personal development, studying the works of others in great depth, before developing his own contribution.  I think he’s right to believe that he spotted a gap, a problem that begged for an answer.  In writing this book, he did what seemed obvious to him but it only became so clear and obvious, as I understand it, after a long and patient journey.  In that respect, he is, of course, a living example of his own observations in this book.  We hear about people when they become successful.  For that reason, unless we take the time to delve a bit further into the lives of the people we admire, we’re prone to be duped by the illusion that success comes in an instant rather than slowly maturing over time as the result of a slow-burning process, often involving hard work and dedication for many years.  That illusion of instantaneous success can make people feel despondent.  Tom describes many strategies to help us take the long view.  Some of the exercises suggested in this book resemble techniques employed in cognitive-behavioural therapy, such as the method of “time projection” introduced by Arnold Lazarus, in which an individual is asked to jump ahead in time to a point in the distant future and look back on their life retrospectively.

Our relationship with time is one of the great neglected areas in psychotherapy, and personal development psychology.  It’s no secret that anxious individuals often seem to “run a fast clock”, time goes quickly for them.  In many of the clients I see in my therapy clinic, particularly those with Generalised Anxiety Disorder (GAD), the chronic worriers, there’s an overwhelming sense of urgency that goes hand-in-hand with fear of failure – a toxic recipe that creates intense anxiety, ruins sleep, escalates frustration, and leads to a permanent state of worry and apprehension.  Something is obviously wrong with this mind-set.  Indeed, recent research in cognitive therapy has found the sense of urgency in anxiety to be linked to what’s known as the “looming cognitive style” (LCS), a tendency to perceive risks as escalating more rapidly than they do in reality.  I think some of these anxious individuals would also benefit from reading Tom’s book because it would help them to question the type of time-pressure that they place themselves under: “to be a success by thirty”, etc.  As the calculations in the book show, by age 30 the average person still has 83% of their productive life remaining.  I’ll probably suggest reading it to some of my clients.  However, I think Tom’s book would be good for almost anyone else, young or old.  It’s a remedy perhaps to a defect in the existing literature.  I wish I’d been able to read it when I was young student, I’m sure it would have helped me ease the pressure off and relax into a more flexible long-term sense of direction, but my little anecdote about Kant served me well enough I suppose. 

For those interested in purchasing the book, the chapter headings are as follows:

1. Warming Up: Why what you’ve done so far may just have set the scene
2. Life isn’t Short: How increasing longevity is giving us multiple chances to succeed
3. The Long View: A simple way to join the elite
4. Lead Time: It’s the ‘time in between’ that matters
5. The 40 Factor: Why many people never do anything remarkable until their fifth decade
6. Mid-Century Magic: ‘Now for my next half-century’
7. The 30-Year Goldmine: How many, usually without intention, save their best for last
8. The Beauty of People: How background shapes us, but only to a certain point
9. Everything Big Begins Small: And often starts slowly

Tom’s a good writer and his style is very easy to follow and engaging.  “Once you start reading this book you won’t want to put it down” is a cliché but in this case it’s true.  You could probably read this book in a day or two because it flows so nicely, a bit like reading a novel.   Tom’s a trustworthy and knowledgeable guide in the self-help field and his distilled wisdom will potentially save you the job of reading hundreds of other books – thereby liberating another decade of your time to achieve personal goals in life!