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Aaron Beck

A brief history of IAPT: the mass provision of CBT on the NHS

I’ve a long article in Aeon magazine this week, looking at Improving Access for Psychological Therapy (IAPT), which is the first ever provision of talking therapy on a mass scale by a government. Before IAPT, the NHS spent just 3% of its mental health budget on talking therapy. IAPT has tripled that budget, and aims to train 6,000 new therapists in CBT by 2014, who will treat 900,000 people for depression and anxiety annually in England and Wales. It is, as one therapist put it, ‘the biggest expansion of mental health services anywhere in the world, ever’. Quite a feat.

In the piece, I tell the story of how IAPT occurred because of a chance meeting at a British Academy tea party:

In 2003, Lord Richard Layard was made a fellow of the British Academy. He’d made his reputation as an unemployment economist at the London School of Economics, but he’d always had an interest in depression and happiness. He inherited this interest, perhaps, from his father, the anthropologist John Layard, who suffered from depression, shot himself in the head, survived, was analysed by Carl Jung, and then re-trained as a Jungian psychologist. Layard junior was more interested in hard data than the collective unconscious, but he’d become interested in a new field in economics that tried to measure individuals’ happiness, and use the data to guide public policy. Layard wondered: what if governments started to take happiness data as seriously as they took unemployment or inflation? He tells me: ‘The most obvious policy implication was for mental health services.’

At the British Academy tea party, Layard struck up a conversation with the man standing next to him, who was called David Clark. ‘It was a fortuitous meeting’, Layard tells me. Synchronicity, his father might have said. Layard asked Clark if he happened to know anything about mental health. Clark replied that he did. He was, in fact, the leading British practitioner of CBT. He had helped to set up a trauma centre in Omagh after the Provisional IRA bombing of that town in 1998. The centre treated Omagh citizens for post-traumatic stress disorder, and kept careful measurements of the outcomes. The data showed that front-line provision of CBT in the field showed comparable recovery results as in clinical trials: roughly 50% of people recovered. Clark explained to Layard that trials of CBT showed similar results for depression, anxiety and other emotional disorders. He also explained that there was very little CBT (or any other talking therapy) available on the NHS for common problems like depression. Layard, who is nothing if not a doer, decided he wanted to ‘get something done about mental health’. So, at the age of 70, that is what he did.

With Clark’s help, Layard assembled a powerful argument for the British government to increase its spending on CBT. Depression and anxiety affect one in six of the population. Besides causing a lot of human suffering, this costs the economy around £4 billion a year in lost productivity and incapacity benefits. This problem has a solution, Layard argued: CBT. The government’s own National Institute for Health and Care Excellence (NICE), which evaluates evidence to guide NHS spending, recommended CBT for depression and anxiety in 2004. Yet for some reason, the NHS just £80 million a year on talking therapies, out of a total NHS annual budget of £100 billion. Layard and Clark recommended doubling the budget, so that 15% of adults with depression and anxiety would get access to psychological therapy. Some of them would get off incapacity benefits in the process, it was argued, so the service would pay for itself.

Layard and Clark presented their recommendations at a seminar at 10 Downing Street in January 2005. They managed to get IAPT into New Labour’s manifesto for the 2005 election, and were then faced with the task of turning it into a reality following Labour’s election victory. Clark designed the service. Firstly, and radically for the NHS, it allowed for self-referrals. Secondly, the service would have a ‘stepped-care’ approach: for mild cases of depression and anxiety, people would be treated by ‘Psychological Well-Being Practitioners’, who had a year’s training in CBT, and who provide ‘psycho-education’ and guided self-help, often over the phone. If that wasn’t adequate, people were encouraged to ‘step up’ to more intensive face-to-face therapy for a longer period of time, with a fully-trained therapist. Thirdly, IAPT would only offer NICE-recommended evidence-based therapies, which meant mainly CBT. Finally, IAPT centres would measure outcomes at every therapy session, and make this data available online, so both patients and politicians could see the results.

The reason Layard and Clark convinced politicians to put serious money into talking therapies is that CBT had built up a big evidence base to show it worked. I look at the origins of this evidence – the invention of the ‘Beck Depression Inventory':

Beck developed Cognitive Behavioural Therapy in the early 1960s. He tells me: “I was also influenced by the Stoics, who stated that it was the meaning of events rather than the events themselves that affected people. When this was articulated by Ellis, everything clicked into place.” While Ellis was content to be a free-wheeling rebel, Beck was more of an institution man. He wanted to transform clinical psychotherapy from within, by building up an empirical evidence base for cognitive therapy.

Before Beck, evidence for psychotherapy mainly consisted of therapists’ case studies. The reputation of psychoanalysis, for example, was built on a handful of canonical case studies written by Sigmund Freud, like ‘the Wolf-man’, ‘Dora’, and ‘Anna O’. The problem with that approach was the evidence was anecdotal, non-replicable, and relied strongly on the therapist’s own account of a patient’s progress. The therapist might exaggerate the success of a treatment, as Freud arguably did in the foundational case of Anna O.

Beck’s radical innovation was to develop a questionnaire which asked patients how they felt on a four-point scale. In 1961, he created the Beck Depression Inventory, a 21-question survey which measured a person’s beliefs and emotional state through questions like:

0 I do not feel like a failure.
1 I feel I have failed more than the average person.
2 As I look back on my life, all I can see is a lot of failures.
3 I feel I am a complete failure as a person.

By measuring the intensity of a person’s negative beliefs and feelings, Beck discovered a way to quantify emotions and turn them into data. Using the BDI, he could quantify how a person felt before a course of CBT, and after it. According to the BDI, after 10-20 weeks of CBT, around 50% of people with depression no longer met the diagnostic criteria for major depressive disorder. And, crucially, this result was replicable in randomised controlled trials by other therapists. CBT showed similar recovery rates for anxiety disorders like social anxiety and post-traumatic stress disorder.

Beck launched the era of ‘evidence-based therapy’. In doing so, however, he made some drastic alterations to the ancient philosophy that inspired him. He pruned out anything that was not scientifically measurable – including any mention of God or the Logos, virtue or vice, the good society, or our ethical obligations to other people. I once asked Beck if he agreed with Plato that certain forms of society encouraged particular emotional disorders. He replied: ‘I am loath to toss out an opinion that is not based on empirical evidence.’ There is much about which CBT is silent. It teaches you how to steer the self, but does not tell you where you should steer it to, nor what form of society might encourage us to flourish.

I wax lyrical about the place of IAPT in the history of ideas:

IAPT is an interesting moment not just in the history of psychotherapy, but in the history of philosophy. It is an attempt to teach Stoic – or ‘Stoic-lite’ – self-governance techniques to millions of people, an exercise in adult education as much as healthcare. The scale of it is beyond the dreams of the ancient Stoics, teaching on the street corners of Athens. Although the early Stoics wrote political works, they were all lost in antiquity, and later Roman Stoics viewed Stoicism more as a sort of individual self-help for the elite. Marcus Aurelius, the Stoic emperor of Rome, was in a position to spread Stoicism to the entire empire if he so wished, but he had a pessimistic sense of the limit of politics. ‘I must not expect Plato’s commonwealth’, he told himself. ‘[For] who can hope to alter men’s convictions, and without change of conviction what can there be but grudging subjection and feigned assent’.

Stoicism’s therapy of the emotions remained popular with intellectuals, but few believed it could be taught by the state to the masses. David Hume wrote that the majority of humanity is ‘effectually excluded from all pretensions of philosophy, and the medicine of the mind, so much boasted…The empire of philosophy extends over a few, and with regard to these, too, her authority is very weak and limited.’

The early results of IAPT have been better than Hume might have predicted, with recovery rates of 44.4%. IAPT is now being rolled out into child services, into the treatment of chronic physical conditions which have an emotional toll, and into the treatment of unexplained conditions like Chronic Fatigue Syndrome. An IAPT-style programme is also being piloted in Norway.

And finally I consider whether the state has any business providing therapy for our emotions. My position is basically that I’m all for the provision of CBT because it doesn’t try to tell people what ‘flourishing’ or the meaning of life is. But I’m wary of state support for Positive Psychology precisely because it does try to tell people what flourishing ‘is’. In place of Positive Psychology, I’d like to see something else – call it Positive Philosophy – which is more open-ended and Socratic when it comes to discussing the good life.

Once more, with feeling: the latest attempt to teach flourishing in schools

This week I’d like to examine the latest attempt to teach young people how to flourish in schools, via a new randomised controlled trial of a new Personal and Social Health Education curriculum, which is being launched in 30 English schools this autumn. As regular readers know, the attempt to teach people how to flourish is a subject close to my heart- indeed, my book, Philosophy for Life, imagines a ‘dream school’ that does just that.

Teaching flourishing has a long history. We could go back to the 19th century, when private schools tried to teach character through a combination of muscular Christianity and the classics, or all the way back to philosophy schools like Plato’s Acaedemy or Aristotle’s Lyceum. But let’s start more recently than that (I hear you breathe a collective sigh of relief) and begin in the late 1990s, when New Labour became interested in bringing psychotherapy into politics.

The idea of teaching well-being in schools took off in the UK after the publication of Daniel Goleman’s pop psychology book Emotional Intelligence in 1995. That book inspired a local education authority in Southampton to introduce EI classes in its schools, through a subject called Social and Emotional Aspects of Learning (SEAL). Other LEAs followed Southampton’s example, and in 2002, Ed Balls, the minister for education, made SEAL a non-statutory component in the national primary curriculum, as one part of a new subject called Personal and Social Health Education, or PSHE (sorry for all these acronyms). In 2007 it was introduced in the national curriculum for secondary schools. Although it was voluntary, around 80% of comprehensives taught SEAL in some form.

Despite the enormous, almost religious enthusiasm of LEAs and New Labour, SEAL rapidly attracted controversy. Some, like Kathryn Ecclestone at the University of Birmingham, criticised the ‘dangerous rise of therapeutic education’, where children were taught that a certain model of emotionality was ‘good’ and other models ‘bad’ or ‘sick’. Indeed, Goleman’s EI argues that the healthy child is socially-skilled and happy to publicly share their emotions – in other words, the healthy child is a girl. Boys or introverts, who may be reluctant to publicly discuss their emotions in circles, are immediately pathologised.

Schools were given a SEAL starter-pack and not much other guidance from Whitehall.

Another problem with SEAL was that schools were given very little guidance in how to teach it beyond a SEAL pack sent out from Whitehall. Only a fifth of teachers have any training in SEAL or PSHE. Many schools made it up as they went along, and SEAL classes included everything from CBT to rainbow rhythms. This, to some extent, reflected the intellectual incoherence of Goleman’s pop psychology book (Goleman wasn’t a trained psychologist, he was a journalist for the New York Times).

The big problem with SEAL, which a team at the University of Manchester discovered and reported in 2010, was that it didn’t do what it was meant to do. It had no impact either on children’s emotional well-being or their academic performance. Somehow, in all the enthusiasm, no one had thought to evaluate it until it had been in our schools and imposed on our children for a decade. I find that cavalier attitude pretty shocking, and a classic example of the policy risks of good intentions without good evidence.

The realisation that SEAL lacked any evidence base seriously undermined the idea of teaching flourishing in schools, and also undermined LEAs in the eyes of the new Coalition government. When Michael Gove became minister for education, he rolled back many of New Labour’s well-being initiatives in schools, abandoning Every Child Matter and insisting that OFSTED no longer try to evaluate the well-being of pupils. Gove also ordered a review of PSHE. That review is on-going – it was supposed to have published its results by now, but apparently the Department of Education has its hands full with its academy and free school programme. The government has at least made clear it doesn’t think much of SEAL.

The Penn Resilience Project

However, there was another attempt to teach young people how to flourish in a more evidence-based way. This was the Penn Resilience Project (PRP), which was designed by Karen Reivich, Martin Seligman and colleagues at the University of Pennsylvania. It was an attempt to introduce the basics of Cognitive Behavioural Therapy into classrooms, with the same evidence-based scrupulosity with which Penn’s Aaron Beck brought CBT into the mainstream of therapy.

In 2007, three local education authorities (Hertfordshire, Manchester and South Tyneside) paid to send around 100 teachers to Penn to be trained in the PRP, and then to teach it in 22 schools. The impact on students’ academic results and emotional well-being was then evaluated by a team at the London School of Economics. One of the driving forces behind the PRP was Richard Layard, professor at the LSE and the author of Happiness: Lessons From A New Science, who had also been instrumental in getting government support for the huge expansion of CBT services in the NHS.

The PRP was the great hope of enthusiasts for well-being education, because it was supposed to be carefully scientific and evidence-based compared to SEAL. Unfortunately, when project evaluation was published by the LSE in 2011, the results were not a home-run. Amy Challen, one of the project evaluators at the LSE, tells me:

There was a 0.1 standard deviation for participants on the Beck Depression Index, and that quickly tailed off after the project finished. That’s quite small. There are lots of possible reasons for that. Most young people don’t have depression in the first place. Also children were only taught 18 hours of the course in total – as Richard Layard said, you can’t learn French in 18 hours and it may be the same for well-being. There were problems with recruitment of teachers as well. Twenty of the teachers didn’t teach any PRP workshop, and some only taught one. And some teachers had excessive expectations – they thought you could teach the programme and everyone’s life would be transformed. They would focus on individual cases where they saw transformations, and not understand why that impact didn’t show up in the data. It’s because that was just one child among 30.

During the PRP pilot, Richard Layard and two colleagues decided to be more ambitious, and to try and gather together the best evidence-based programmes from around the world (well, the US, UK and Australia) not just for emotional well-being but for the entire PSHE curriculum, which also includes topics like sexual and physical health, media awareness, and also occasionally citizenship, environmental awareness, and even (shock horror) moral philosophy. Last year, they published a report outlining their new, evidence-based curriculum for PSHE, which brought together around 16 evidence-based programmes, including PRP and other CBT and mindfulness-based programmes. Layard wanted to test this curriculum out over a longer period, to give the children the time to really learn the cognitive and behavioural skills embedded in the course. James O’ Shaughnessy, former head of the Downing Street policy unit under David Cameron, who is a big enthusiast for teaching flourishing, told me: ‘One of the things we know from the evidence is the importance of habit formation. That takes time.’

Emma Judge, one of the two founders of How To Thrive

The new curriculum is now being road-tested in a randomised controlled trial at 30 schools around the South-East of England, starting in autumn of this year. The RCT is being funded through a £687,000 grant from the Education Endowment Fund, and is being evaluated by the LSE. The teaching and teacher-training is being organised by Emma Judge and Lucy Bailey, who helped to run the original PRP pilot for Hertfordshire local education authority, and who subsequently set up a not-for-profit called How To Thrive. Through that, they have trained 700 teachers to teach the resilience programme in 80 schools around the country. Emma Judge says: ‘The initial PRP pilot was just 18 hours. The research suggests that people can learn new habits but it’s hard work and takes practice.’ The new project will teach children an hour a week, over four years, and will cover all the topics of PSHE, including media / advertising awareness, drug awareness and sexual health, bringing together evidence-based programmes like the PRP, Mood Gym from Australia, and the Parents Under Construction programme from Houston.

Lucy Bailey says: ‘An important idea is that this is a proper subject, which is valued in schools, which teachers can talk about, which students see as valued by the school. In the initial project, some schools felt ‘don’t go into that classroom, they talk about feelings there’.’ Emma adds: ‘We used to get a lot of nervousness from teachers with the original PRP, who were worried they would be opening up a can of worms by venturing into the emotions. But that’s reduced now, because teachers realize it’s not about that. Some experiences would not be suitable for the classroom and would be handled differently, through the school’s counseling services.’

The tricky question of values

I ask Lucy and Emma if the new curriculum is trying to teach young people values. This seems to me the thorny question for both PSHE and Positive Psychology in schools. On the one hand, they are attempts to help young people to flourish. On the other hand, there is an understandable nervousness about state schools promoting a particular ethical vision of the good life (there’s much less nervousness about this in private schools, perhaps because they’re less multicultural in their pupil demographics, and because parents know what sort of ethical culture they’re paying for).

Emma says: ‘Positive Psychology does face that value question, and we’re involved in the designing of a Positive Psychology whole-school approach for Wellington College. But this PSHE curriculum is much more about skills and awareness than values. Of course, we don’t want kids to take drugs, or get drunk, or have unprotected sex, but there’s nothing more invasive than that.’ Lucy adds: ‘We want to strengthen young people’s capacity to make their own decisions. Of course at year 7 or 8 we say ‘it’s better not to take drugs’, but at year 9 or 10 we say ‘what’s your view?’ We want to help people develop their own value system. A Catholic school might have a very particular set of ideas about sex, for example, while we’re not trying to influence young people in any one way on that topic. We’re not saying how they should be.’

This is, of course, a tricky area. It’s one I grapple with in my book too. You can leave out values from the curriculum altogether and say you’re just teaching ‘life-skills’, but that risks leaving children in a moral vacuum, where you sacrifice children on the altar of your own liberal tolerance (wow, quite a melodramatic metaphor there). Or you can opt to include explicit values in the curriculum, but then you risk indoctrinating young people in your own unexamined dogma, drilled into them Madrasah-style, rather than enabling people to develop an autonomous and sceptical mind-set. The challenge is balancing indoctrination with skepticism, balancing inherited wisdom with a freedom to choose one’s own path. This is not an easy trick to pull off, and requires a great deal of skill, wisdom and humanity from the teacher.

I would still love to see more ethical discussion in PSHE, perhaps to combine it with Religious Education and moral philosophy, or at least to introduce more Socratic discussions about different models of the good life into the classroom – particularly in year 11, year 12, and at university. Life-skills are the means, but it’s useful also to think about the ends. I wish the new project the best of luck over the next four years. I’m not sure what the government plans to do with PSHE in the meantime.

*******

Here is a new brief collection of brief articles by Tory MPs on mental health. It’s interesting as an example of how mainstream mental health policy has now become. The MPs argue for new policies including greater provision of mental health services for soldiers and veterans, and greater choice of therapies for people besides CBT on the NHS.

Here is a new report from the World Economic Forum on creating a more evidence-based and quantifiable approach to well-being in the workplace.

Action for Happiness has published an interesting new report on the role of values in happiness and well-being.

A great article in Nature magazine on ritual and its role in societies.

The New York Times notes a new genre, the self-help memoire. The Guardian thinks that Sheila Heti’s new bestseller work of 20-something funny angst could be described as a self-help mash-up. And of course, Lena Dunham, creator of the HBO series Girls, is writing a sort of self-help mash-up too. Self-help is gradually becoming hip, mark my words…

I just read Jaron Lanier’s brilliant You Are Not A Gadget, which is a wonderful meditation on how the internet is not necessarily making us more free and authentic, and may be making us more conformist and enslaved to ‘Lords of the Cloud’ like Google and Facebook. In that somewhat dystopian vein, check out this interesting Aeon magazine long-read from Claire Evans about how the internet haunts us with the ghosts of past relationships.

Can autism be outgrown, asks Time Magazine.

My brother and another friend are both involved in the complex attempt to come up with new UN Millennium Development Goals. Not an easy task, as this Guardian editorial notes.

This week I have been mainly listening to new albums by Toro Y Moi (weird indie R&B) and Matthew E. White (sort of intelligent and quiet soul); I have been mainly reading Elijah Wald’s excellent book on the history of rock and roll; and mainly watching this wonderful documentary, also about the history of rock ‘n roll. Can’t wait to see Zero Dark Thirty this weekend.

See you next week,

Jules

In defence of Stoic Week

I was slightly surprised to see that Julian Baggini had used his column in the Independent to make some criticisms of ‘Stoic Week’, part of a project at Exeter University with which I’m involved. When you think of all the serious things happening in the world at the moment, from extreme weather to the war in Gaza, it seems odd to use your column in a national newspaper to criticise a project which, taken all together, is in my opinion a small but positive thing within the philosophical landscape.

Philosophy is so utterly marginal to British culture, so threatened with irrelevance at school and university level – is it really helpful for prominent philosophers to use what little public space they get to criticise initiatives aimed at broadening the public awareness of philosophy?

The project at Exeter brings together classicists, philosophers and psychologists to engage in a dialogue about the relationship between Stoic philosophy and cognitive behavioural therapy (CBT). As regular readers of this blog will know, CBT was directly inspired by Greek philosophies (not just Stoicism, also Socrates, Plato, the Sceptics and Epicureans…but mainly the Stoics). CBT is now the most scientifically credible and popular form of therapy for many emotional disorders. To my mind it is fascinating that CBT has built up an evidence base to show that the Stoics’ ideas and techniques for transforming the emotions genuinely work. It is extraordinary that ideas about the emotions conceived two millennia ago should still be our best guide for healing the emotions today.

I have written about this connection between Stoicism and CBT for five years or so, and all that time I could not understand why more philosophers did not write about it and see it as something really positive and interesting. The exception is Martha Nussbaum, whose 2001 book ‘Upheavals of Thought: The Intelligence of the Emotions’, explores the scientific evidence for the Stoics’ cognitive theory of the emotions (although Nussbaum does not accept the Stoics’ normative position, and characterises her own position as ‘neo-Stoic’).

Now, thanks to the Exeter project and to a series of books in the last two years on the relationship between Stoicism and CBT (including my own book), there is a lot more interest in how ancient philosophies can really help people cope with difficult situations and transform their emotions.

There have always been philosophers who criticise the modern use of Stoicism as a form of practical therapy. When I published an interview with Albert Ellis (the pioneer of CBT) back in 2007, Mark Vernon criticised my article for mistakenly conflating Stoicism with CBT, and ignoring the differences between the two. CBT was, at best, ‘Stoicism lite’, he wrote. I disagreed at the time, but now I think he makes a fair point – CBT does leave out a lot of Stoicism, not least its cosmology, its theism, and its ethical value system. It instrumentalises it, turning it into a set of techniques rather than a comprehensive moral system.

You can understand why CBT did that. To become a scientifically credible therapy, it had to drop any talk of God or providence, or even of the meaning of life. It teaches people how to transform their emotions, how to steer the self, without telling them where to steer the self to. It leaves people to decide for themselves what the meaning or goal of life is. You could develop a Marxist CBT, or an Islamic, Buddhist, Epicurean, capitalist or Aristotelian CBT. All it teaches you is how to transform the self and its emotions, not what the ideal self looks like.

Many people who have been helped by CBT go on, as I did, to explore the Greek philosophies from which it evolved – they get into ‘Stoic CBT’ or ‘philosophical CBT’. We fill in the bits that CBT left out – about God, society and the meaning of life. That is for us to do, not cognitive therapists working in the NHS. My book shows the different ethical directions that the Greeks took the cognitive theory of emotions, and leaves the reader to make up their own mind.

Baggini, in this latest salvo, suggests that the Exeter project is part of a mass ‘therapisation’ of our culture. He writes:

Not so long ago, therapy was widely seen as something only for the seriously disturbed or neurotic, overeducated Americans. Now, all that is good is being turned into therapy. Rather than seeking help on Dr Freud’s couch, people are turning to Monty Don’s allotment or Jamie Oliver’s kitchen to soothe their troubled psyches. Ancient philosophy is also undergoing this process of therapisation.

I’m not sure about the first sentence. ‘Not long ago’…as in when? Therapy and self-help have been pretty central to western culture since at least the Sixties. And I don’t think that people see Jamie Oliver as a particularly therapeutic figure, do they? And if people do find that gardening or cooking makes them feel good, what is wrong with that? I hardly think that finding gardening soothing to soul is a decadent modern invention.

Baggini’s on even shakier ground when he suggests that we are distorting ancient philosophy by trying to turn it into a form of therapy. I’m sure he’s read the Stoics, Epicureans, Cynics, Sceptics and so on – so he’ll know that they themselves very explicitly saw their philosophy as a form of therapy, which heals people of emotional problems. The Greeks’ view of philosophy as a form of therapy is explored at length in my book; or Martha Nussbaum’s Therapy of Desire: Theory and Practice in Hellenistic Ethics; or Richard Sorabji’s Emotion and Peace of Mind: From Stoic Agitation to Christian Temptation, or the Royal Institute of Philosophy essay collection, Philosophy as Therapeia. The therapy of the emotions is there on every page of Hellenistic philosophy.

Baggini may not be into this Hellenistic tradition. He might think it’s all a load of sap. He might prefer, I don’t know, the modern analytic tradition, or continental philosophy, or British empiricism. That’s absolutely fine. But the Hellenistic tradition is very much concerned with the emotions and how to transform them. It’s very much concerned with therapy or the art of being doctor to yourself. We’re not distorting it.

Baggini writes:

The only good reason to embrace a philosophical position is that you are convinced it is true or at least makes sense of the world better than the alternatives. I’m not a stoic because I do not agree that we are all fragments of an all-pervading divine rationality which is providentially organising the world, or that Epictetus was right to say you should not be disturbed if your wife or child dies or that “my father is nothing to me, only the good”. To become a stoic is to endorse the truthfulness of its world view and accept its prescription for how you ought to live, not just to like how it makes you feel.

Aaron Beck, the founder of cognitive-behaviour therapy, and Albert Ellis, founder of rational-emotive behaviour therapy, both appropriated Stoic ideas for their own ends, as does the philosopher Richard Sorabji, who says of Stoicism: “I choose the bits which I find helpful and I don’t take the full theory.” Such cherry-picking is perfectly legitimate. What’s objectionable is praising the joys of scrumping as though it were on a par with the care, dedication and understanding of growing an orchard.

This is the ‘all or nothing’ argument that I have sometimes been presented with. Don’t talk about Stoicism unless you are going to be a 100% Stoic, accepting all their ideas (including belief in the Logos, indifference to all external things, and faith in the periodic conflagration of the universe). Otherwise you’re just ‘pick n’ mixing’, not really seriously committing to a particular ethical path.

My response to this is that the ancients themselves pick n’ mixed. Marcus Aurelius pick n’ mixed from the Epicureans and Neo-Platonists. Posidonius pick n’ mixed from Plato and the Stoics. Augustine pick n’ mixed from Christianity and Platonism. Cicero pick n’ mixed from every philosophy out there. Baggini took some ideas from Hume in his book The Ego Trick. Does he agree with 100% of Hume’s ideas? No? Well that’s just pick n’ mixing! That’s just scrumping!

We all, to some extent, construct our own philosophies. What is important is whether our life-philosophies fit with human nature and the needs of our society at this particular time, and whether we actually live by them.

Most of the people I know who are into Stoicism today are fairly heterodox. But they make an effort to understand what the ancient Stoics really meant. They read not just Seneca and Aurelius, but also AA Long, Nussbaum, Hadot, Annas, Sorabji. They are serious about their philosophy of life, even though they’re not academics. And I also know a lot of people who have never read AA Long or Sorabji, but who have still read some Epictetus or Seneca, and found it really helpful – even a life-saver. Are they ‘pick n’ mixing’? Are they ‘scrumping’? Who the hell cares. Thank God, they have been helped by the Stoics through life’s many difficulties. I don’t care if they are a ‘proper Stoic’ or not. I care if they are suffering, and if they find something that helps them to cope with the suffering.

I personally am not a proper Stoic. I do not think externals are indifferent. I believe in reincarnation. I believe some passions are appropriate. However, I think the Stoics were unrivalled in their understanding of how emotions arise and how we can change them. They were unrivalled in some of their practical ideas for how to stay resilient in chaotic conditions, such as Epictetus’ idea of knowing the difference between what you can control and what you can’t. These ideas saved my life, and got me through depression and anxiety. I still use these Stoic ideas and techniques today, despite not accepting the Stoics’ normative position. I don’t think this is illegitimate, nor do I think Ellis and Beck’s ‘appropriation’ of Stoic ideas and techniques is illegitimate: CBT has helped millions of people to overcome suffering, which is more than can be said for most contemporary philosophers.

Baggini wants to keep therapy and philosophy safely apart, he says. Therapy (like CBT) is a set of instrumental techniques for ‘coping, not treating the whole person’, while philosophy helps us develop ‘a comprehensive outlook on life, along with a set of values’. I agree that, if you have an acute emotional disorder, you need immediate coping strategies, not total moral systems. But for the Greeks and Romans, these two things were on a continuum – first the immediate coping with crisis, and then the searching out of a more comprehensive philosophy of life. How can you draw a firm line between CBT and the philosophies from which it emerged…and why would you want to?

Philosophy and psychotherapy: no talking allowed!

I think therapists are increasingly learning that it is difficult to avoid normative questions of value and of what we mean by ‘flourishing’ etc. And philosophers are learning that it’s important to ground ethics in proper working theories of human nature and the emotions. As I put it in my book, ethics without psychology is a brain in a vat, while psychology without ethics is a chicken without a head. So I don’t think we can or should draw a hard line between psychotherapy and philosophy  – and I think it’s strange that Baggini should want to, considering he writes a weekly column with his psychotherapist partner called ‘The Shrink and the Sage’.

Finally, Baggini criticises ‘Stoic Week’s use of well-being questionnaires. Well, look, I think he is taking too seriously what started off as a small and fun project for Exeter classics undergrads. I know Baggini hates ‘happiness measurements’ and the attempt to try and use them to draw moral prescriptions (I have some sympathy with him here), and perhaps he sees this as an invidious example of that positivist trend. Of course the Stoic ethos is not about personal happiness – although I think these questionnaires try to measure flourishing or resilience rather than happiness. I personally am taking part in the week without religiously filling in the questionnaires.

In general, Stoic Week was the idea of a young post-grad at Exeter called Patrick, who is part of the Exeter project, and who wanted to give his students a sense that Stoicism wasn’t just something to study, but something you could practice each day. That is a fantastic idea, and his students have posted some YouTube videos of their experiences. No one, especially not Patrick, expected Stoic Week to gain international attention, or to attract the criticisms of a prominent British philosopher in the Independent! In general, though, I’d suggest that if the next generation of academics have half as fresh, engaging and practical an attitude to philosophy as Patrick does, then the future looks bright.

As to the questionnaires, no one is saying this is a serious scientific study. But the reason CBT has succeeded in reaching and helping millions of people, is it created an empirical evidence base to show it really worked. Likewise, the reason mindfulness therapy is now accepted in the NHS is it built up an evidence base to show it helped people overcome depression etc. Keeping evidence is not so out of kilter with the ancients’ tradition – they would also keep track of their ethical progress in journals. You don’t have to measure your daily happiness. You could measure your success at not losing your temper, for example. Epictetus said ‘count the days on which you were not angry’. So keeping track of your progress can be a useful part of the philosophical life.

I look at the utter marginalisation of philosophy in our culture today, and I think it is a pity. I personally believe philosophy is an extraordinary thing, something that can transform and even save lives. I wish more people knew that. Philosophy needs all the help it can get right now, so why knock initiatives that succeed in getting people involved and showing them the wonderful riches within our philosophical tradition?

Let me end with my favourite quote from Seneca, an exhortation to all philosophers great and small: “There is no time for playing around. You have been retained as counsel for the unhappy. You have promised to bring help to the shipwrecked, the imprisoned the sick, the needy, to those whose heads are under the poised axe. Where are you deflecting your attention? What are you doing?”

The re-birth of Stoicism

We’re coming to the end of Stoic Week. People all over the world have been practicing Stoic exercises and reflecting on Stoic ideas this week, thanks to this wonderful initiative, launched by a young post-grad at Exeter University called Patrick Ussher. Some of Patrick’s students have been sharing their thoughts on the exercises via YouTube. This is what studying philosophy at university should be like – experimenting, practicing, reflecting, sharing.

Of course, hardcore Stoics might say we shouldn’t share the fruits of our practice – we should ‘tell no one’, as Epictetus puts it. But I actually think it’s good to share your practice with other Stoics, as long as you’re not showing off. My own rather humble practice this week has been to knock off the booze for a week. Small steps, I know – but I’ve stuck to it out of the thought that it’s not just me practicing – there are lots of us out there, committing to this week. We’re stronger when bounded together.

It’s also been a good opportunity for people to say how they’ve been helped by Stoic writings in their life. People like Dorothea from Vancouver, who this week tweeted:

I went through an extremely difficult time a few years ago and one of the things that helped was Stoicism. Reading Epictetus was like having a wise friend sit with me in a situation that no one, not my friends or family, could understand.

Right on Dorothea! As I discovered when I was writing my book, there are loads of people out there who have been really helped by Stoic writings through difficult times, for whom Stoicism means a great deal to them. Everyone from Wen Jiabao, the prime minister of China, who says he has read Marcus Aurelius’ Meditations over 100 times, to Elle MacPherson, who named her son Aurelius, to Tom Wolfe, who got into Stoicism a decade ago and is still very into it today (he said he’d write a quote for my book – Tom, if you’re reading this, get in touch…I need your help!)

So here’s my question: is Stoicism really enjoying a revival or a rebirth now? Or is that a gross exaggeration? And if there is a revival happening, where could it go?

I think there is something of a revival taking place, in large part thanks to Albert Ellis and Cognitive Behavioural Therapy, but also thanks to the revival of the idea of philosophy as a therapy or way of life. And, finally, I think Stoicism fits quite well with our increasingly crisis-prone era. I’ll go through these three factors, quickly.

Stoicism and CBT

The biggest driver for the revival of Stoicism is its direct connection to Cognitive Behavioural Therapy. When I discovered this link, back in 2007, I couldn’t understand why it wasn’t more written about. I found it amazing that ideas and techniques from ancient Greek philosophy should be at the heart of western psychotherapy (2007 was the year the British government started putting hundreds of millions of pounds into CBT and also the year CBT started to be taught in British schools via the Penn Resilience Programme). And no one was writing about it. So I started to write about it. In 2009 I came across Donald Robertson, a cognitive therapist and scholar, who was also writing about it. I interviewed him for my first ever YouTube video.  Check it out and enjoy the trippy special effect at the end illustrating the Stoic idea of the ‘view from above’.

In 2010, Donald published the first ever book properly exploring the relationship between CBT and ancient philosophy. It’s a great book and helped me a lot.

Sam Sullivan, the Stoic mayor of Vancouver, accepting the Olympic flag in Turin

Then, this year, I brought out my book about ancient philosophies and CBT (not just Stoicism, also Epicureanism, Cynicism, Platonism, Scepticism etc),which featured interviews with lots of modern Stoics – Major Thomas Jarrett, who teaches Stoic warrior resilience in the US Army; Chris Brennan, who teaches Stoic resilience in the US Fire Service; Jesse Caban, who is a Stoic in the Chicago police force; Michael Perry, a Stoic Green Beret; Sam Sullivan, the Stoic former mayor of Vancouver, and others. I was helped a lot by the NewStoa community set up by Erik Wiegardt, which helped me get in touch with all these modern Stoics.

Since the book has come out, I’ve done a lot of talks about the connection between Stoicism and CBT, like this one on Radio 4. The book got a nice review in The Psychologist this week (behind a pay-wall alas), and I hope it has encouraged more of a dialogue between psychology and philosophy. The same month my book came out, Oliver Burkeman of the Guardian brought out his book, The Antidote, which also interviewed Albert Ellis and made the connection with Stoicism. We were both interviewed in this Guardian Books podcast talking about Stoicism and CBT.

Then, at the end of this year, Christopher Gill in Exeter’s classics department organised a seminar on Stoicism and CBT, which brought together Donald, me, Tim LeBon, a cognitive therapist and philosophical counsellor;  classicist John Sellars; Patrick Ussher, occupational therapist Gill Garratt and others. The Exeter Project has been a great help in making the connection between Stoicism and CBT a bit more explicit and academically credible.

The revival of philosophy as a practical way of life

Secondly, Stoicism has revived in the last few years thanks to a broader revival of ancient philosophy and the idea of philosophy as a way of life. When Alain de Botton brought out the Consolations of Philosophy in 2000, he was widely reviled by academics for dumbing down philosophy. A decade on, however, more and more academic philosophers have come round to the idea that philosophy can and should be an everyday practice, and even a form of self-help. That’s partly through the influence of de Botton and the School of Life network, but also through the work of academic philosophers like Pierre Hadot and Martha Nussbaum, who have pushed forward a more personal and emotional form of philosophy (by emotional, I don’t mean gushing and sentimental, I mean it works on the emotions, it tries to help people flourish). So academia has played its part in the revival, but I’d suggest self-help writers like De Botton, Eckhart Tolle and Tim Ferriss have been key in bringing Stoic ideas to a wider public.

Stoicism is popular in times of crisis

Exeter during Stoic Week

Finally, I think Stoicism is enjoying something of a revival because it fits with our crisis-prone era. It’s a good philosophy for coping with volatile and chaotic times. You wouldn’t expect it to be that popular during an age of affluence, for example  like we were in from 1955 to 1975, although it was popular then among some officers in Vietnam like James Stockdale. But you would expect it to be popular in times like now, an age of austerity and emergency, when our economies are crashing and our cities are being constantly buffeted by floods and hurricanes. It is appropriate that, in the very week Exeter University hosts ‘Stoic Week’, floods are coursing through the town. Our imagination has become more apocalyptic – whether that be in films like Deep Impact, books like The Road, or TV shows like Derren Brown’s Stoic-inspired Apocalypse. We’ve started to wonder how we’d fare if some of our affluent accoutrements were stripped from us. How would we, poor bare forked animals, cope upon the heath without our lendings?

There has been a growth in nostalgia for the Stoicism of our grandparents – the generation before the baby-boomers, who went through the war with a calm Stoic spirit (or so it seems to us). Hence the popularity of the old war poster, Keep Calm and Carry On. Hence the interest in the history of the ‘stiff upper lip’. Hence the call this week by a Tory MP and GP for a return to the values of ‘post-war Stoic Britain’, when people took care of themselves and didn’t burden the NHS with all their self-indulgent lifestyle illnesses. We are in the midst of an austere reaction to the consumer excesses of the baby-boomers, and Stoicism goes quite well with that reaction. Though of course, the baby-boomers are a part of the Stoic revival too – not least in the increased interest in assisted suicide. The baby-boomers want the freedom to choose their own death, as Seneca put it. If death became the ultimate lifestyle choice, that would be a huge cultural shift, away from Christianity, and back towards Stoicism (the word suicide, by the by, was invented by a 12-century theologian in a tract written against Seneca).

Where could the revival go?

So, there is something of a revival happening. But where could it go?  Well, I think we’re all learning how to take care of ourselves better, learning how to be the ‘doctors to ourselves’ as Cicero put it. I don’t think that necessarily means we’re all going to become card-carrying Stoics, but I do think and hope we’re becoming more intelligent about our emotions and how to heal them, and more DIY about our health in general and how to take care of ourselves.  I suspect and hope that this will involve a continued growth of interest in ancient philosophies – Greek, Buddhist, Taoist, Confucian, Sufi and so on. One of the most encouraging phenomena in this difficult era is the synthesis of ancient wisdom and modern empiricism – the Shamatha project in California is one of the great examples of it. I hope that my psychology colleagues in the Exeter project, Donald Robertson and Tim LeBon, can do more empirical work on Stoic ideas.

However, I personally think Stoicism itself is lacking some things. As Martha Nussbaum told me in this interview, it’s part of an ‘anti-compassion’ tradition. It lacks compassion, is too cold, too uncaring. I remember, on Stoic email lists, when someone has said that something terrible has happened to them, no one would say anything consolatory to them. They would just stiffly quote Epictetus – the philosophical equivalent of a punch on the shoulder. And I would feel like giving that person a hug and saying ‘yes, that’s pretty shit, but you’ll get through it’. The Stoic position of ‘nothing is fucked here, Dude’ seems to me too cold. We’re not Gods, we’re humans. I think we should be careful that the revival of Stoicism does not become too libertarian, part of a backlash against the welfare state. We also need to make clear that Stoicism does not mean repressing your emotions. Far from it. Nor should it mean coping entirely on your own with difficulties. Stoicism today should mean taking care of each other, not just of yourself.

A key contemporary challenge is that Stoicism lacks a proper sense of community, and if you look at modern attempts at building a Stoic community – the NewStoa group, or the Stoic Yahoo list, I don’t think either of them have been that successful, because they are too logical and not caring enough, so they end up with men bickering over terminology, rather than humans caring for each other.

Nonetheless, let me end on a positive note: the Stoics taught us some amazing stuff about how to transform the emotions, and how to take care of ourselves.  It’s just that, in my opinion, those lessons are best taught alongside other philosophies of the good life. Again, I come back to the same point I often ask myself: can we build philosophical communities that are genuinely caring, compassionate, nurturing?

*****

Tobias Jones

Next week, hopefully, I am off to meet a hero of mine, Tobias Jones, who runs a community like that in Dorset, for recovering addicts. Tobias wrote a fantastic book called Utopian Dreams, asking the same sort of communitarian questions that we are discussing. Do read it, it’s brilliant. I’ll hopefully be interviewing Tobias for a new podcast I’m putting together for Aeon magazine. Should be a really fun, exciting venture. Here’s a piece Tobias wrote for Aeon on his commune.

Next Tuesday, come to hear Angie Hobbs talking about the future of philosophy at the London Philosophy Club, at the Bethnal Green Working Men’s Club. She’s a fascinating speaker, and it’s a brilliant venue.

This week, my friend Sara Northey arranged a brilliant LPC evening, with a talk by clinical psychologist Peter Kinderman. Peter put forward a radical and (in my opinion) quite persuasive argument about why most psychiatric diagnoses and unscientific and deeply unhelpful, and we should instead switch to a problem-based analysis of emotional problems. Here’s an interesting write-up of the event by Natalie Banner, a philosopher at KCL’s Centre for Humanities and Health.

The accuracy of social psychology studies is under the microscope, after Dutch psychologist Diederik Stapel was found to have faked some of his studies, without being found out by the social psychology journals in which he published his results. A new report condemns not just him but the whole field of social psychology for its ‘sloppy’ research culture.

This New York Times article (forwarded to me by Matt Bishop) has been widely discussed in among therapists – it says business is declining for therapists, as people increasingly want problem-fixing rather than long-term counseling (Peter Kinderman would approve!). So therapists are having to hustle to get more business, which means putting more effort into branding. I’ve often thought that therapists should, at the least, put a video of themselves on their website explaining who they are and what sort of problems they can help with (in fact I considered setting up a business to help therapists do this).

Talking of therapists making videos, here is a video of Windy Dryden, a leading cognitive therapist in the UK, doing a song-and-dance version of CBT to the tune of ‘Moves Like Jagger’. Bizarre! Though it did make me think – perhaps I could put together some CBT songs..

Tomorrow, I’m speaking at this conference in Amsterdam along with Alain de Botton, Philippa Perry, Roman Krznaric, Stine Jensen and others. Still a few tickets left I think, if you’re in Holland and fancy coming along. My Dutch publisher, Regine, has been really amazing in promoting my book in Holland, and it’s got into the top 100. She is a force of nature.

The book is now out in Germany. One of my readers, Julia Kalmund, has arranged for me to come and speak at Munich University.  Nice one Julia! She wins this week’s awesomeness prize. It’s also just come out in Turkey….any Turkish readers of the newsletter??

A guy called Ahmad from Pakistan got in touch with the London Philosophy Club this week. He wrote:

Philosophy should be promoted in every community because it is usually above any caste and creed…Unfortunately there are not favorable conditions in Pakistan for such activity, London has a certain attitude for this,as it provided shelter to Volatire and Marx when Europe wasn’t ready to tolerate them…I want to become an active member of London Philosophy Club and to try to go to London for studies,it would be a pleasure for me to remain in the company of such creative social minds.

I find that great and inspiring – that’s why I love philosophy, because it connects us beyond any caste or creed. Good luck to you, Ahmad. Meanwhile the British government has succeeded in lowering immigration…by putting off foreign students from studying here. Doh!

See you next week,

Jules

PS, if you fancy some weekend reading, download my report on Grassroots Philosophy

Chief Rabbi Sacks is too harsh on Greek philosophy

It’s gratifying and heartening when the Chief Rabbi of your country writes a column responding to your book, and says some kind things about it – so thanks are in order to Chief Rabbi Lord Sacks for using my book as a springboard for his discussion in The Times on the deficiencies of Stoicism as a philosophy for life.

Nevertheless, I feel that Chief Rabbi Lord Sacks mischaracterises Stoicism and Hellenistic philosophy, and seeing as my book is designed to attract people to Hellenistic philosophy, rather than put them off it, permit me to say a few words in its defence.

Firstly, Chief Rabbi Lord Sacks conflates all the philosophies of the Socratic Tradition into one philosophy, and then sets it in opposition to the benevolent theism of Judeo-Christianity. He draws a sharp dividing line between Athens and Jerusalem, which is a surprising move from the author of How to avoid the clash of civilisation.  

Chief Rabbi Lord Sacks suggests that all the philosophies of the Socratic Tradition (as I call it in my book) agree that there “is no transcendent purpose to human existence”. In fact, they don’t agree.

Certainly, Epicureanism believes “there is no transcendent purpose to existence” and that the universe is “fundamentally indifferent” to us. But that’s not true at all of Stoicism, Platonism or Aristotelianism – all of which are theistic and have a teleological view of the universe.

The Stoics, for example, believe we are connected to the Logos, the divine intelligence pervading the cosmos, which orders the universe according to its benevolent plan. Stoics believe we are on Earth to develop our consciousness and reason and bring them into harmony with the Logos. As the Stoic philosopher Epictetus put it, “God has introduced man to be a spectator of his works, and not just a spectator, but an interpreter.”

Aristotle, likewise, thought the transcendent purpose of human existence was to develop our consciousness in order to know both the cosmos and God. And Plato had his own cosmic teleology of love. The father of all these movements, Socrates, also appeared to believe in God, and to think it his own personal mission from God to teach us to ‘take care of our souls’.

Chief Rabbi Lord Sacks then makes an old criticism of Stoicism (it’s also made by Sir Isaiah Berlin and Bertrand Russell), that it’s too pessimistic and introverted, the product of a particularly chaotic historical period, ie the 3rd century BC, when Athens was conquered by various marauding empires. He says ‘contemporary writers fail to remind us’ of this fact, which is not true – I do discuss the original historical context for Stoicism in chapter two of my book (page 28).

I agree with Chief Rabbi Lord Sacks that Stoicism may perhaps be too politically pessimistic and individualistic, which is why I only spent the first quarter of my book on the Stoics, before moving to other philosophies like Aristotelianism, which is more politically optimistic. Nonetheless, I think it’s unfair to call Stoicism introverted, withdrawn, ‘risk-averse’, or the product of cultural decline. It flourished in Rome in the first century BC and the first century AD, hardly periods of cultural decline. And it included among its ranks some of the most active and engaged politicians of the era – Cato the Younger, Cicero, Seneca – all of whom gave their lives for their country. Risk averse? Hardly.

Yes, Stoicism is an excellent philosophy for coping with crisis and chaos, which is why it is so popular with active soldiers today (including Israeli soldiers). It may not be the perfect philosophy for stabler and more comfortable periods of our life. Stoicism helped me a great deal in a very difficult period of my life, but I subsequently felt more drawn to other philosophies of the Socratic Tradition. But I can still recognise the great therapeutic value of the Socratic Tradition in general, and Stoicism in particular. So, I might add, can many Jewish scholars, from Philo of Alexandria all the way to Martha Nussbaum and Ronald Pies today.

The great value of the Socratic tradition, it seems to me, is that it rescued humanity from the tyranny of priests and taught us how to take care of ourselves. Before Socrates, if people were unhappy, they felt it necessary to bend their knee both to the gods and to their representatives on earth, the priests, to beg for forgiveness and mercy (usually through some sort of expensive material sacrifice, perhaps even the sacrifice of a member of your family).This tradition continues today, via psychoanalysis.

After Socrates and the Athenian Enlightenment of the 5th century BC, humanity learnt, in the words of Montaigne, ‘how much it can do of itself’. In psychotherapeutic terms, we learnt that our emotional problems are often self-caused, that they arise from our beliefs and attitudes, which we have the power to change. We can learn to ‘take care of our souls’ as Socrates put it (from whom the word ‘psychotherapy’ originates) and be ‘doctors to ourselves’ (in Cicero’s phrase). This is the Do-It-Yourself essence of both Socratic and Stoic therapy. We don’t need to kneel to the priests and beg for their benediction. Based on the priests I have met in my life, this strikes me as excellent news (although I have yet to meet Chief Rabbi Lord Sacks).

The Stoic / Socratic insight that we can to some extent heal ourselves of emotional suffering has since been tested out by modern empirical science, and has become the cornerstone of Cognitive Behavioural Therapy, which has helped thousands, if not millions, of people to overcome emotional disorders. (I should add that CBT was pioneered by two psychotherapists of Jewish descent – Albert Ellis and Aaron Beck – so the cross-fertilisation between Athens and Jerusalem is still yielding fruit). CBT has saved thousands of people from deep emotional suffering, including atheists, Jews, Christians, Muslims, Hindus and Buddhists. I personally think that Socrates and the Stoics deserve some credit for that, even if we don’t accept the Stoic goal of complete detachment from externals.

As for the advantages and disadvantages of believing in a ‘God with a human face’, well, the Chief Rabbi takes the discussion to theological levels well beyond my pay grade. I personally believe in God, and in a transcendent purpose to human existence, although I don’t believe in a personal afterlife or a personal God. The cosmos, alas, seems to me rather indifferent to the suffering of individual lives, although I cling to the hope that there is a benevolent general thrust to evolution.

What I like about the Socratic Tradition is it offers wisdom for both theists and atheists. It is a meeting place both for believers and unbelievers. In that sense, it seems to me a uniquely useful resource for those who want to avoid clashes of civilisation.