Stoic advice: I may develop full blown schizophrenia, what is a Stoic to do?

[Feel free to submit a question for this column, but please consider that it has become very popular and there now is a backlog, it may take me some time to get to yours.]

M. writes, “I consider myself to be a very unfortunate person. I have been afflicted with disease since the age of 15 (I am now 30) and went through war (Libyan civil war in 2011) during which my family and I lost relatives and friends, and also most of our material possessions; we now live as refugees. I managed to cope with all these misfortunes and more until a couple of years ago I was hit by the worst adversity I have ever had, a psychotic episode because of which I lost my mind in complete madness (delusions, hallucinations, etc.) for a few months. I was hospitalized against my will and forced to take antipsychotic medications.”

“I did however recover later on and gradually started gaining my self back. The doctors later told me about my condition and the worst news was that the likelihood of relapse is very high, just 15-20% of patients have only a one-off episode while the majority relapse and go on to develop a full-blown schizophrenia. So far through my reading of Stoic philosophers I find myself faced with a troubling issue. My problem is not with externalities that won’t affect my ability to lead a virtuous life. My problem is with the constant threat of losing my own mind on which the ability to exercise virtue depends. I fear losing the very thing that Stoics say is all you need to be self-sufficient. I feel hopeless in preparing for such an event as I will not have the means by which Stoicism (or anything else) would help me. I feel that my situation is beyond hope and that nothing can help me and see that the only way out of this is death. However, I can’t even kill myself because of my family and how hard it would be on them if I did. I am just trapped in this horrible nightmare. Please advise me on this as it is not something that I find ancient Stoics have dealt with.”

I truly feel awful about your situation, M.. I can hardly imagine what it would be like to experience one of the things you have endured, let alone the full set. Seems to me you have already demonstrated to be a Stoic in the best sense of the word. I will not address the war and consequent loss of friends and relatives, or your current status as a refugee, because those aren’t really the main question you are asking. And by comparison with the main question, they are actually easy, so to speak. The real issue is your mental condition, so let’s talk about that one.

The Stoics don’t refer to situations like yours, partly, I assume, because mental illness was of course far less understood then than it is now. But partly also because you are correct: mental illness strikes at the heart of the very thing that makes it possible to practice Stoicism — or any philosophy of life, really: what Marcus calls the ruling faculty.

“Different things delight different people. But it is my delight to keep the ruling faculty sound without turning away either from any man or from any of the things that happen to men, but looking at and receiving all with welcoming eyes and using everything according to its value.” (Meditations, VIII.43)

Indeed, Marcus famously said that the mind is an impregnable citadel, within which one can always retreat and bar the rest of the world, with its turmoil and lack of serenity:

“The mind that is free from passions is a citadel, for man has nothing more secure to which he can fly for refuge and repel every attack.” (Meditations, VIII.48)

But in your case the attack is from within, not from without, demonstrating that when Epictetus said that what is “up to us” includes our “opinion, motivation, desire, aversion, and, in a word, whatever is of our own doing” (Enchiridion, 1.1) he was being a bit optimistic, as there are situations when there is little that is our own doing, including some opinions, motivations, desires, and aversions.

I won’t lie to you. Stoicism is not a cure for mental illness. Indeed, it isn’t a cure for anything, it is a philosophy of life, not psychotherapy, and even less so, of course, psychiatry. My colleague Lou Marinoff, author of Plato, not Prozac!, a book about philosophical counseling, wrote in the Introduction to it that, despite the title, sometimes you do need Prozac, i.e., medication, in order to bring your mind back to more or less normal functioning. But once you manage that, you will still be faced by life’s problems, and that’s where philosophy kicks in.

This means that your initial preoccupation should be medical: get the best care you can, given the circumstances. I did a bit of research on this (which I’m sure you have too, so this is really for the benefit of other readers), and the first line of attack are antipsychotic drugs, probably of the kind you have already been administered. While they do have side effects, they commonly go away or are reduced significantly after a few days, and your doctor can work on finding the right dose.

After that, psychosocial treatments are helpful and often successful in order to learn coping skills and arrive at as normal a life as possible. People with schizophrenia can still manage to hold jobs and pursue a more or less normal life, with a combination of medications and learned skills. I hope you can achieve that much, your situation is not hopeless, even though it is very difficult.

What about Stoicism? Well, I think it enters the equation at two different levels: one is right now, the second one in case you really should develop full blown schizophrenia but will be able to manage the disease as sketched above.

First, the here and now. You are facing a situation that is clearly outside of your control. There is good reason to think that schizophrenia is actually a family of conditions sharing similar symptoms, not necessarily a single disease. There is evidence that suggests a genetic basis (which is obviously outside of your control), but people without a family history may develop it as well. Among the environmental causes listed by the NIHM web site are: exposure to a virus, malnutrition before birth, problems during birth, and a rather generic category labeled “psychosocial factors.” Again, hardly something under your control.

The Stoic practitioner, then, has to focus on how to handle the condition, both with regard to himself and to his loved ones. Seneca said:

“The wise man is sufficient unto himself for a happy existence, but not for mere existence. For he needs many helps towards mere existence; but for a happy existence he needs only a sound and upright soul, one that despises Fortune.” (Letter IX. On Philosophy and Friendship, 13)

Despising Fortune is something that is easy for someone like me to say, given the privileged life that I’ve lived so far, but your conditions — both what you have experienced in term of externals and your disease — really put your resolve to the test. Nobody is a Sage, but you should take comfort in the fact that you have been able to deal with your situation so far, and that your thoughts still go out to your family, clearly showing that your character is a good one, despite the incredible amount of “dispreferred indifferents” you have experienced thus far.

Indeed, I know few other people to whom this quote by Marcus clearly applies:

“The art of life is more like the wrestler’s art than the dancer’s, in respect of this, that it should stand ready and firm to meet onsets that are sudden and unexpected.” (Meditations, VII.61)

You have certainly met more than a fair share of sudden and unexpected onsets. And yet what you should do know, from a Stoic perspective, is clear: remind yourself that the universe isn’t after you, it is just that Fortune has dealt you a series of bad hands, not through malice, but by chance. It isn’t anyone’s fault, and certainly not your own. What is up to you is to play those hands to the best of your abilities, which means with integrity, concern for others (especially your family, who has been going through really hard times anyway), and by fighting the disease insofar as you can.

Which brings me to phase two, what happens if, in fact, the condition comes back. I have already mentioned that there are practical steps you can take, depending on what access you have to medical facilities (which I’m sure is limited, given your current life situation). You may also want to prepare yourself by reading a number of testimonies of Stoic practitioners who have dealt with mental illness, of a variety of kinds.

For instance: here is an article by Andrew Overby on depression; two articles (here and here) by Chris Peden on autism; and one by Zachary Augustine on diverse issues, including anxiety, obsession, depression, and chronic conditions. It may also help to talk to other prokoptontes afflicted by the same problem. For instance, here is a forum at PsychCentral initiated by someone who has schizophrenia and is interested in Stoicism. I’m sure there are others around, and you could probably find more people either with your same condition or who have something helpful to say about it at the now very large Facebook Stoicism community.

Let me stress again, that none of the above is a cure. Stoicism is a philosophy of life, not a kind of therapy or medical procedure. And yes, beyond a certain point, if our inner citadel has been severely damaged from within, then there is no talk of Stoicism or any other philosophy of life. However, I sincerely hope you will be able to fortify your defenses in such a manner that you will hold your citadel and live a life worth living within the human family.

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Categories: Stoic advice

17 replies

  1. Hello Massimo,
    do you not think this argument is weak without the divine aspect of stoic physics? I am not saying I agree with that aspect necessarily, however I do think it is essential for claiming these types of arguments as stoic ones. Without it is this not an empty command to try our best? Why would someone need stoicism to see that we should try not to be sad and get on with life? It seems an Epicurean could do exactly the same.

    Regards,

    Liked by 2 people

  2. Jasper,

    No, I don’t think so. And the ancient Stoics themselves recognize this, see for instance my post on Marcus’ take on “gods or atoms?” (http://tinyurl.com/l9sn89t)

    More generally, of course, I am a 21st century Stoic, so I am not bound by all the details of the ancient version, just like a Buddhist wouldn’t be.

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  3. You say a couple of times that Stoicism is a philosophy of life, not a therapy. But Albert Ellis consciously drew on Stoicism in developing Rational Emotive Behavioural Therapy. There seems to be a clear link between various cognitive therapies and Stoic insights. How exactly do you distinguish between a therapy and a practical philosophy of life?

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  4. I read the post and it was very insightful, I was under the impression that the ancient Stoics used Providence as some kind of reassurance of inherent meaning, but apparently that is not true. I do however still have one question left: which arguments or combinations of arguments here are exclusive to (21st century) Stoicism? Wouldn’t someone with nearly any (atheistic) view of life be able to make a similar blog post?

    I am not trying to discredit modern Stoicism as a whole, but in this instance it seems to offer little new insight.

    Liked by 1 person

  5. Alan,

    Yes, REBT was inspired by Stoicism. So was Frankl’s logotherapy, and the first wave of CBT. That’s because Stoic techniques are effective (evidence-based, as we say today) independently of the underlying philosophy.

    The difference between a philosophy and a therapy is that the latter is supposed to be a short-term intervention focused on a particular issue or set of issues, while a philosophy is a general framework for how to live one’s life.

    Of course the distinction is not quite that sharp. For instance, logotherapy is far more “philosophical” than CBT, with REBT somewhere in the middle.

    Jasper,

    The ancient Stoics did have a concept of Providence, though it was very different from the Christian one. They thought the whole universe was a living organism, of which we are parts. The universe doesn’t have a plan, but the parts make sense within the broad context. A famous metaphor used by Epictetus is that we are like the foot of a person: we don’t like to get into the mud, but if the person has to traverse a muddy terrain then we get muddy.

    Modern Stoics reject the ancient Stoic pantheism, but retain the idea of the Logos, the insight that the universe is (neutrally) organized according to rational principles — if that were not the case modern science wouldn’t be possible. (This is sometimes referred to as “Einstein’s God.”)

    Yes, an atheist would be able to write a similar blog post, but he would have no philosophical tradition to draw upon. Atheism, as far as I’m concerned, is not a philosophy, it’s simply a negative metaphysical position (to which I subscribe, by the way). There are philosophies similar to Stoicism, like Buddhism and Secular Humanism, that would draw similar conclusions.

    As for the insight being “new,” well, we tend to forget that the Stoics wrote this sort of thing two millennia ago, and then we have incorporated a lot of their notions without even realizing where they came from. I like to give credit to the original source.

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  6. As a psychiatrist, one of the best approaches to individual psychotherapy is to ask the identified patient what their theory of the problem is and discuss that – with the goal of modification. That can be done independently of the biological dimensions of the illness, but as Massimo has pointed out they also need to be addressed. The difference between an individual’s theory and the real probabilities of the Universe can be a very productive focus.

    Liked by 1 person

  7. I think one piece of advice missing about the here and now is that of planning ahead: make sure that the people that are close to you, your family and your friends, are aware that you can have a relapse of your condition and know what to do in such a case, so that they can help you regain your faculties.

    I think this is especially important in case M needs to be hospitalized against his will again. Giving a sort of “preemptive consent” to such an occurrence, maybe in the form of a written note, can help the people close to him take such a decision and ensure he gets the needed care in a timely manner.

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  8. Massimo,

    Absolutely. The Stoic injunction to act in the here and now is often misunderstood as not planning for the future, which is clearly not what Seneca or Marcus were doing. Rather, it should be understood as: make preparations for your hospitalization and legal aspects now (because it is under your control), but do not expect things necessarily to go as planned (because that’s not under your control).

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  9. Dear M: I think Massimo has given you very good advice. I have a number of friends and relatives who have mental health issues ranging from depression to bipolar disorder to schizoaffective disorder (the latter being the closest to your situation). Especially for schizoid type disorders, anti-psychotics are essential. And new ones are being developed every couple years. I would recommend if you can to see a psychiatrist that is a “Psychopharmacologist” i.e. highly certified in these meds. It is important that you have a doctor who is confident and knows how to adjust and switch the various meds – because the efficacy is very individual and frankly it is trial and error to get the exact right dose or cocktail. Not to mention that over time and in various situations or even seasons, the dose may need to change. Also, it is common to “quit” taking the meds – may be a symptom of the disorder itself or a dislike of side effects or “both” – very important to stay on the meds. As Massimo said, often the side effects lessen over time but you need to work with a Doctor to find an alternative if they don’t and stopping you from staying on them. So job one is finding the right med(s) and a doctor you trust and like.

    At the same time , meds work best generally with therapy. And here I believe Stoicism – especially the daily practice and discipline- can also help along with whatever therapy you seek. I think it can help you stay on the meds. If meds are working and you are lucid, can help further to clarify your mind and be aware of residual psychotic thoughts lurking (echoes etc), name them (“you are not what you claim to be”) and begin to have a few tools to augment the meds. It is even possible that daily mindfulness discipline may even create chemical brain change over time and a degree of healing (not my area of expertise but these general mind-body issues, so to speak, are being studied scientifically – massimo may be able to direct you to further reading to see if there is any evidence of this emerging). In any case, it can’t hurt. The idea is to use a combination of meds and these techniques to possibly minimize the amount of the meds you take over a long period of time. Again, not to quit taking them, but maybe lesser dose if possible (but be careful and don’t adjust down on your own).

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  10. On those last sentences I should have said the primary idea is to use therapy and Stoicism to augment the meds to minimize the effects of the disorder and to maximize your ability to flourish. The possibility of this also leading to a possible lower dose of the effective meds would be a nice extra benefit but may not happen and is not the primary goal of the therapy or use of stoic techniques.

    Liked by 1 person

  11. Actually — I think the Meditations of Marcus Aurelius does address this. I can’t find the exact quote at the moment, but I believe that the Emperor mentions the possibility of the infirmities of old age ending our time of opportunity to practice virtue ending before the time of physical death. I understood this to be a reference to dementia. Of course, dementia isn’t schizophrenia — but The prospect of either raise the same philosophical issues.

    The answer is in Stoicism’s relation to time. It’s been discussed a lot how it is your own decisions alone that are in your locus of control. But it’s not just any of your decisions. It is the decisions you make right now.

    Some day, you will certainly loose the ability to make rational decisions. Whether you are still moving about and breathing after that happens (as is with mind-robbing illnesses) or whether you are physically dead after losing it — it is inevitable that your faculty will eventually go.

    But how will you live UNTIL that happens?

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  12. @Jasper: “Which arguments or combinations of arguments here are exclusive to (21st century) Stoicism?”

    Here’s my 2 cents, FWIW.

    If you want to look for a distinctive signal in Stoic advice, IMO it’s usually more helpful to look at the idea of virtue than the divine (for the ancients, the latter supported the former, true, but often in an indirect or supplementary way).

    I think the original author make the conversation distinctively Stoic when he or she centered their question around “my ability to lead a virtuous life.”

    The “linchpin” that makes Stoic ethics hold together is its claim that being a morally excellent person is infinitely more important than anything else in life. Stoic advice about the “inner citadel” or focusing on “doing your best” all starts from that assumption. Whether you buy into that assumption for religious reasons or secular reasons is somewhat beside the point (the ancients used both kinds of reasoning simultaneously): contemporary Stoics are united by their distinctive virtue ethics.

    So, yeah, Massimo’s suggestions of what a prudent course of action might be are not particularly unique to Stoicism. Stoics don’t have a monopoly on wisdom!

    But beneath the whole question & post is a bigger question about Stoic ethics: if moral choice is the sum total of where our ethical thinking begins from (as Stoics), then what am I supposed to make of a situation in which my faculty of moral choice itself is damaged?

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  13. Sophia,

    You may be right, but a first search through my favorite quotes by Marcus didn’t turn out anything. I’ll look further, let me know if you find something specific.

    Jasper,

    I second E.O.’s comment about virtue rather than the divine.

    Two more things: (i) one of the things I like about modern Stoicism is precisely its ecumenic flavor. As I argued in the past (http://tinyurl.com/jfc8knq) metaphysics underdetermines ethics, which means the Logos can be taken on board by theists, pantheists (like the original Stoics) and atheists, with different connotations. (ii) Not only Stoicism doesn’t have a monopoly on good ethical counsel, I find it reassuring that other traditions, like Buddhism, or Secular Humanism, often come out with similar advice or perspective.

    Liked by 1 person

  14. Dear m. As for myself, massimo has given a compassionate response. Honestly this breaks my heart at many levels so maintaining rational thought is difficult. I think by even studying stoicism you are giving yourself a gift and good strategy to deal with your situation. Yes there are many excellent pharmaceutical products that side effects can be managed. I’ve worked in. MH many years. You fear not being rational. I challenge anyone to say they think rationally. Who’s to say psychosis is wrong? I’ve always seen it as different way of perceiving the world mediated by chemical changes in ones brain. By all means if it persecutes you or puts you at risk in any way pursue professional help but do not judge yourself please. You can continue to be virtuous. I have no doubt. By being realistic and honest you can set up supports and clearly provide direction to them for when you are not able. Many people I have worked with with schizophrenia have a philosophical depth I could never achieve. I’d hedge a bit that many ancient philosophers experienced mental poor health themselves so have great insight. I agree that joining groups that support your pursuit of stoicism would help. I’ve also found that groups that embrace critical reasoning (often embedded in philosophy) are very supportive for many of us that need support.
    And no, while philosophy is not therapy per se, I have found it very helpful as I process a life of depression, anxiety and now living with a terminal illness. It’s offering the missing elements of CBT, mindfulness , etc. I will hope for you that it’s manageable and you find the help you need and deserve.

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  15. Great article. Although you say that you are looking at it from an atheist perspective I don’t see what more a religious could say except prayer and meditation.

    Liked by 2 people

  16. Jbonni,

    To be precise, I’m saying that I myself am an atheist, but I’m trying to look at it from a religiously neutral Atoic perspective.

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  17. A thousand times, YES.

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