Philosophical Psychological Therapy: Did It Have Any Impact on Medical Practice?*

in Mental Illness in Ancient Medicine

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Introduction

At the start of Mike Leigh’s 2010 film, Another Year, a woman patient goes to her doctor asking for a repeat prescription of sleeping tablets and is encouraged to have some counselling sessions instead, an offer she accepts with reluctance. Could this kind of encounter have taken place in antiquity, in the age of Galen, for instance? By his time, the philosophical therapy of the emotions constituted a well-established genre of writings, to which Galen himself contributed in two surviving essays.1 Presumably, these writings also reflect, at some level, social practice. Is there any evidence that doctors, including Galen, made use of these philosophical therapeutic techniques as part of their medical practice, as in the Mike Leigh film, offering a patient therapeutic discourse rather than drugs or some other medical intervention? If we have little or no evidence that doctors actually did use philosophical therapy for this purpose, as I think is the case, why was this so? What features of ancient medical practice or the philosophical therapy of emotions made this an unlikely scenario, by contrast with contemporary Britain?

Before pursuing this question, let me specify it further by distinguishing it from lines of enquiry not pursued here. I am not asking whether ancient doctors set out to treat mental illness in general: they had well-established procedures of diagnosis and treatment and these are central topics for this volume.2 Nor am I asking whether ancient doctors, if they detected that an illness was, in some sense, psychological, rather than physical, responded appropriately to this fact. There are some well-known incidents in which Galen, for instance, or another doctor, used psychological insight—or common sense—to deal with cases which were brought to him as requiring medical attention.3 Nor am I asking whether ancient doctors ever used what one might call (broadly) psychological means to help treat patients in states of mental illness, though this question is closer to my concerns. There is some useful evidence on this point in Celsus (14–37 ce),4 Aretaeus (c. 150–200 ce),5 and Caelius Aurelianus (fifth century ce), who may be drawing on Soranus (98–138 ce). Caelius, in fact, suggests allowing mentally ill patients to listen to philosophical discussions if this helps to calm them down, which is virtually the only such evidence for this idea I have found.6 It is striking that there is almost no evidence of this kind in the Hippocratic corpus or, indeed, before Celsus, which indicates some more general change of approach in the later period.7 However, my initial question is whether ancient doctors in later Graeco-Roman antiquity ever saw it as appropriate to respond to cases of illness by deploying the methods we find in works of philosophical therapy or by referring the patient to someone who would apply such methods. More precisely again, I ask whether they ever did so as doctors, rather than as philosophers, since Galen, for one, seems to have played both roles.

The answer to this question seems to be ‘no’, with the single exception of the Caelius Aurelianus passage just noted and, perhaps, some indications in ancient writings on diaita discussed later. In the absence of evidence that ancient doctors did, indeed, draw on philosophical therapy of the emotions, I proceed to the next question: why not? I explore two main relevant factors: first, the nature of ancient philosophical therapy and, second, the scope for alternatives to philosophical therapy that fell within the ancient doctor’s normal repertoire of practices.

Ancient Philosophical Therapy and Its Relevance for Medical Practice

Was ancient philosophical therapy the kind of practice that could readily be applied by a doctor in response to a patient who presented herself in a distressed state, or whose physical state, when closely examined, seemed to be the result of emotional distress or disturbance? To address this point, we need to review key features of this philosophical practice, and also to consider certain preliminary questions raised by this material. The philosophical therapy of emotions, as a distinct genre of writings, became well-established in Graeco-Roman culture in the course of the Hellenistic and post-Hellenistic periods, though it was prefigured in some earlier thought, especially in Plato. The Stoics and Epicureans took the lead in developing this genre, which was subsequently adopted by Platonic thinkers, notably Cicero, Plutarch and Galen (who adopts an independent or eclectic approach).8 An initial question raised by this material is this. Most of our relevant evidence consists of literary versions of philosophical therapy, directed towards a wide variety of types of addressee, mostly individuals but sometimes groups. We do not have factual or anecdotal evidence about oral, one-to-one meetings, where such therapy was applied, or reports about its effectiveness, except in so far as such reports are built into the literary versions of therapy themselves. Can we be confident that, underlying these writings, there was also a well-developed body of social practice, on which the literary versions are based? Or is it possible that philosophical therapy was, instead, a literary genre, rather than a social practice? Although the evidence relevant for answering this question is indirect, and derives from the therapeutic writings themselves, it strongly suggests that there was, indeed, a social practice, which is reflected, and elaborated, in the writings.9 Even though we lack the equivalent of the reports of medical cases in Hippocrates’ Epidemics or Galen’s Prognosis,10 describing in some detail the effect of philosophical therapy, I think we can reasonably posit a significant body of such activities, which fed into, and were in turn informed by, writings in this genre.

Assuming that we are, indeed, dealing with an established social practice, another question arises. Was ancient philosophical therapy too theory-laden, specialised or revisionist in its approach—in a word, too philosophical—to be readily integrated into practically focused medical treatment? This question raises quite complex issues, and different considerations point to an affirmative or negative answer to it.

On the one hand, philosophical therapy depended, for its effectiveness, on at least some degree of philosophical expertise in the person offering the therapy. Although philosophy was a more widespread expertise in the ancient world than the modern world, at least among the educated Graeco-Roman élite,11 this fact alone sets limits on the scope of the practitioners. Apart from Galen, whose range of knowledge, exceptionally, spanned medicine and philosophy, I am not aware of other ancient doctors who were able to undertake this type of therapy for themselves (though they could, of course, hand patients on to those who could). Also, and more importantly, most forms of philosophical therapy incorporated a number of intellectual ideas and commitments, which were not necessarily widely shared in the culture as a whole, even by other members of the educated élite. For instance, Stoic and Epicurean therapy, typically, depends on adopting a certain conception of happiness (eudaimonia), and the therapy works towards producing this state in the recipient of therapy. Stoicism presupposes that happiness consists in virtue (aretē), whether or not one also has ‘external goods’, such as health, property or a flourishing family, and Epicureanism identifies happiness with pleasure, conceived (unusually) in negative terms as absence of physical pain (aponia) or psychological distress (ataraxia).12 Also, both Stoicism and Epicureanism, in different ways, assume that all human beings are, in principle, capable of achieving virtue and happiness, and also of being helped by philosophical therapy to achieve these goals. A more typical ancient view, reflecting ideas in Plato and Aristotle, is that the achievement of complete virtue and happiness depends on a combination of inborn nature, social habituation and intellectual education. Galen, for instance, normally assumes this Platonic-Aristotelian view, and rejects the Stoic position as unrealistic.13

A further potential problem is that Stoics and Epicureans adopt a strongly revisionist stance on emotions, presenting as misguided or diseased a wide range of emotions and desires which would not usually be regarded in this way in ancient culture. In fact, the adoption by Stoics and Epicureans of the terminology of philosophical ‘therapy’ was directly related to this revisionist approach. These philosophical schools proposed to diagnose and treat or cure emotions or emotional tendencies presented as ‘diseases’, which were not necessarily so regarded by those experiencing them. For related reasons, those to whom philosophical therapy was offered or recommended were not necessarily people who were actively seeking for therapeutic help because of emotional distress or disturbance (though they might be). Stoics and Epicureans saw most people as, in some degree, psychologically ‘sick’ and in need of therapy, regardless of whether those involved saw things that way. To this extent, their use of the language of sickness and therapy constituted a deliberate, and to some degree, provocative appropriation of medical terminology and the medical stance.14 Galen, in his role as medical practitioner and writer (rather than in his role as philosopher), reacted strongly against this adoption by Stoic thinkers and against what he saw as an abuse of medical language.15

The points made so far might suggest that philosophical therapy was too remote from conventional views and from standard medical attitudes to be incorporated into medical practice, and indeed that it was of limited practice use. However, the latter conclusion, certainly, goes too far, and the former one needs to be qualified and placed in a broader context. The pervasiveness and persistence of the practice of philosophical therapy attests to the view that it offered practical benefits. The kind of philosophical therapy outlined here lasted at least until the second century ce. The fact that it was adopted not only by Stoics and Epicureans but by thinkers of other schools (or no school) such as Cicero, Plutarch and Galen16 is a strong indicator that it was regarded as effective. It is clear from a variety of sources that, for instance, Stoic therapy was, in practice, successful in instilling in those who employed it qualities such as consistency of purpose and emotional resilience in the face of difficulties and disasters.17 As well as propagating ideas and attitudes designed to promote psychological strength and equanimity, philosophical schools advocated methods of self-therapy such as ‘mental preparation for future evils’ or ‘averting your mind from evils’ which enabled people to embed these ideas more effectively into the fabric of their lives. Hence, despite the specialised or revisionist framework of thought promoted by the philosophical schools, the guidance offered seems to have been highly effective at least for their adherents.18 Indeed, Stoic and other philosophical therapies have been found useful for psychological support in many subsequent periods of history, and are being actively deployed under modern conditions as a mode of life-guidance and for the purpose of enhancing psychotherapy.19 Also, although the philosophers, controversially, adopted medical language for their own practices, this adoption was not wholly unjustified. Although Stoics and Epicureans held revisionist views on emotions and cure, they attempted to prevent or to counteract psychological states, such as self-destructive anger or hatred and vengefulness that people in general might well have regarded as, in some sense, diseased and in any case worth avoiding.20 Also, the adoption of medical language by philosophers was partly justified by the fact that the thinkers aimed to promote what could reasonably be seen as a kind of ‘preventive’ therapy, helping people to build up over time attitudes that would counteract emotional distress.21 In this respect, philosophical therapy was comparable in its aims with the medical practice of regimen or diaita discussed later.

Further features of philosophical therapy need to be noted, which render the practice and its literary expression closer to conventional attitudes and practical application than might otherwise be apparent. Stoic thinkers, as well as addressing psychological problems that might arise in the course of applying their mode of therapy, also considered what was needed to make their approach more acceptable to those who did not share their ideas.22 Also, thinkers such as Cicero, Plutarch and Galen, in different ways, adopt a more selective or eclectic therapeutic approach, which includes deploying ideas and methods which they take to be widely applicable to a range of types of people.23 In certain works, notably Seneca’s On Peace of Mind and Galen’s Affections, we find explicit reference to the importance of addressing the psychological needs of people who are distressed or disturbed, and not just offering generalised or impersonal therapeutic guidance. Significantly, we find in those writings something closer to the one-to-one responsive guidance that we now associate with the practice of psychotherapy.24 In these later, and less philosophically doctrinaire, writings, we encounter representation of ways of treating disturbed people that we could more easily envisage being incorporated into medical practice.25 The emergence of this more pragmatic strand in philosophical therapy, in Plutarch especially, may have encouraged Galen to write in this genre, despite his explicit reservations about the Stoic appropriation of the language of therapy.26

The features of philosophical therapy just noted might suggest that this could, indeed, have been incorporated into medical practice or at least used as a supplement to it (as in the Mike Leigh film noted earlier). However, although Galen wrote in this genre, and presents himself as someone who offered philosophical therapy, there is nothing to indicate that he saw this as an extension of his medical practice. In the summary of his own writings made towards the end of his life, the two works of philosophical therapy are included under the heading of ‘ethical works’; and there is no suggestion that they were seen as forming part of Galen’s writings on medical practice.27 So, for Galen, the doctor who goes further than anyone in bridging the two areas, the borderlines seem to remain distinct. Some of the points already made about philosophical therapy explain why this should be so, and two further considerations can be added. One is that the effectiveness of this method depends, even in the more pragmatic approach deployed by Plutarch and Galen, on willingness to engage in reflection on rather major or demanding ethical questions. These include the question of the nature and basis of happiness, the range and type of emotions that can form part of a well-lived human life, and the minimum level of physical or mental resources needed to make life bearable.28 Ancient doctors, even if (like Galen) they had competence in this area or were at least familiar with it, might be cautious about recommending this kind of reflection as a treatment for highly distressed or disturbed patients. Secondly, and going along with the first point, there was widespread acceptance that the kind of change of beliefs, attitudes and emotions recommended in philosophical therapy is, necessarily, a long-term process and not something that can be achieved quickly. Galen, in fact, especially emphasises this point in his works of philosophical therapy;29 but it is also implied in other writings in this genre.30 This marks a point of contrast with normal ancient—or modern—medical interventions, in which the expectation is that the treatment undertaken will achieve results, if it does, in the shortest possible time. It also highlights the unlikelihood of shifting from medical to psychological treatment in the way exemplified in the Mike Leigh film. Modern counselling or cbt (cognitive behavioural therapy) psychotherapy tend to form a relatively short series of sessions (often six weekly, one-hour, sessions);31 but this is not a format that matches anything we know of in ancient philosophical therapy. There is a closer parallel between ancient philosophical therapy and ancient regimen or diaita, which also usually aims at long-term life-style management, and is also often integrated with the overall life-cycle. However, this similarity highlights the contrast, again, with other kinds of ancient (or modern) medical interventions and thus reinforces the difference in approach I am highlighting.

Medical Methods for Psychological Support: Regimen/Diaita

The second factor explored here is the question whether ancient doctors already had (medical) methods which offered at least some psychological support, so that recourse to philosophical approaches might have seemed unnecessary, or to go beyond what was feasible in most cases. The kind of support I have in view falls in the area of diaita or regimen, that is, in modern terms, preventive medicine or lifestyle management conducted with a view to healthcare. From a modern perspective, what is striking is the wide range of factors that fall under this branch of ancient medical practice. It embraces not only diet (broadly understood) and exercise or bodily care, including massage and bathing, but also sleep, work-patterns (in so far as these were subject to modification) as well as state of mind or emotions.32 Also, significantly, these were not treated as distinct or isolated topics; in Galen’s hands, at least, they formed part of an integrated method, whose overall aim was to coordinate these factors, and to apply them appropriately to specific individuals, bearing in mind variables such as age, social status and psycho-physical type.33 As in the case of Galenic philosophical therapy, the management of diaita is located in the context of the whole life-cycle.34 The breadth of approach of ancient diaita gives it a special interest in the modern context, where medicine is now often criticised for being practised in an unhelpfully piecemeal fashion. In addition, the prominence given to this branch of ancient medicine is also suggestive for modern concerns. Preventive medicine or lifestyle management has played a very minor part in modern medicine, compared with the central role played by drugs and surgery; but current medical problems, especially those linked with obesity, stress and aging, have given a new urgency to this dimension of healthcare.35 However, the breadth of diaita is also relevant for the current question. As Peter Singer has brought out, Galen accentuates in a number of contexts (including, but not limited to, diaita) the extent to which emotional factors can generate physical problems that fall centrally within the doctor’s concerns.36 Also, in qam, Galen makes bold claims about the extent to which diaita, if properly managed, can bring about improvements in patients’ psycho-ethical state and, indeed, their intellectual capacities.37 Implicit here is the view that diaita offers scope for a type of ‘whole-person’ care that could in principle include at least some of the guidance that might otherwise have figured in the philosophical therapy of the emotions, and which overlaps with the content of modern counselling and cbt therapy.

How far does ancient writing on diaita bear out the suggestion that this was seen as providing at least some of the psychological guidance that might otherwise have led doctors to extend their treatment to include philosophical therapy? I think the evidence supports this view, though it has to be admitted that the comments on the psychological content of diaita are often quite generalised. Galen, for instance, in Ars medica, includes “psychological events” or “emotions” (pathē) in the six factors which necessarily affect health. He comments further: “Obviously, one must refrain from excess of all emotions of the psyche: anger, grief, pride, envy, and worry; for these will change the constitution of the body”.38 A similar comment is made in one of his commentaries on Hippocrates, Epidemics vi, in connection with a passage where Hippocrates refers to the significance for health of “state of mind” (gnōmē), as one of the six factors affecting health.39 Galen’s interest here, as elsewhere, seems to be in cases where someone’s psychological state, for instance an obsession or idée fixe, seems to be undermining his or her health. He comments that the person’s health can only be improved in such cases if the doctor can help the person to alter the state of mind. But how is this to be achieved? Presumably, this is by some kind of dialogue, and perhaps, indeed, by the kind of dialogue that forms part of philosophical therapy, whether provided by the doctor or by a philosophical specialist, as envisaged in the passage of Caelius Aurelianus cited earlier.40

In De sanitate tuenda also, Galen seems to envisage some measure of psychological management falling within the scope of diaita, though again the comments are limited in detail. Early in the work, he makes the point that the psychological state is something that (because it affects bodily health too) falls within the remit of the medical doctor.41 He then discusses the scope for influencing the psychological state “by well-balanced exercise that takes place in the body, but also in the psyche”, specifically, by a combination of musical or artistic activities and athletics or hunting. Here, he seems mainly to have in mind moulding the character of young men, which is his central topic in this part of the work.42 However, he also says: “And in a considerable number of cases, we have restored health to people who were suffering for many years because of the character of their psyche, by correcting the imbalance of the motions”. Subsequently, he discusses correcting the shortcomings of those who have habituated themselves by “a daily regime which is too undisciplined or lazy”, by inducing them to adopt “a self-controlled life and … well-timed exercise”. Here, he clearly has in mind modifying the character of adults, presumably by advice and persuasion. However, in general, most of Galen’s more psychological comments are focused on the upbringing of children (reflecting his ‘life-cycle’ framework in the work),43 rather than offering advice or insights that could help adults manage their lives in a more balanced or less stressful way. Galen also seems keen in this work to show that diaita reflects more general features of his medical method and is firmly grounded in an understanding of the physical basis of health and disease,44 rather than being concerned to extend the boundaries of healthcare management towards those of psychological therapy. However, the scope of diaita in the hands of Galen is a reminder of the potentially inclusive and integrated approach that an ancient doctor could deploy within his standard methods.

Similar conclusions could be drawn from the writings on diaita by the first-century ce Pneumatist doctor, Athenaeus, discussed by Sean Coughlin.45 Here, as in Galen, diaita is conceived broadly, embraces management of psychological as well as physical dimensions of daily life, and is correlated either with specific types of people (for instance, women or children) and with the overall life-cycle. Athenaeus’ advice on how best to handle old age is particularly interesting in this connection.

… one should strive, in this age especially, for gentleness (praotēs) and magnanimity (megalopsychia). For such a person is not burdensome to everyone, but is longed for by all and cared for with a certain goodwill and sympathy. Endeavour to have people living with you who are pleasing and not irksome, with whom it is the sweetest custom to engage in desirable conversation … Best is the old age of those who carry on in culture and rational studies, because of diligence and the self-control (nēpsis) of this way of life, and because of their psychological stability (eustatheia) …46

This kind of advice does not match the kind of person-specific, responsive guidance that we associate with modern counselling or psychotherapy. But it comes close to the more generalised advice about the management of emotions we find in ancient works of philosophical therapy, though the context is clearly that of diaita.

A further point emerges if we consider another treatise on diaita in this period, that of Plutarch. Plutarch’s essay has an explicitly broader remit than most treatises on healthcare. He is concerned not only with managing health but doing so in a way that will enable his readers both to handle their consumption of food and drink sensibly and to play a significant role in the wining and dining that formed an integral part of the elite Graeco-Roman lifestyle.47 To an extent, at least, his advice edges into the areas covered by his own (rather practically directed) philosophical therapy: the importance of ‘moderation’ (sōphrosynē), for instance, figures in both contexts, though not in quite the same sense.48 Also, taken as a whole, Plutarch’s healthcare advice has a broadly psychological aim in view: namely that of enabling people to combine healthcare and social engagement in a way that forms part of a full and balanced life that is not stressful at the physical or emotional level. Although Plutarch’s essay is explicitly situated (by its prologue, Mor. 122b–e) as distinct in its overall aim from that of most treatises on diaita, there are areas of overlap with them. For instance, Galen’s advice on healthcare also has in view the social obligations and pressures that affect his readership, and may harm their health, and makes recommendations about how to deal with these competing demands.49 In this respect, both Plutarch’s work and Galen’s provide access to a zone of advice that embraces bodily management and social relations in a way that enables us to see its relevance for what are, in modern terms, ‘coping strategies’ in one’s mode of life.

A similar point could be made about Galen’s writings: observations are made which could figure in either type of work and comments are sometimes made which seem to underline the parallels between them.50 If this occurs in the relatively formalised context of writings, one may well imagine that is yet more likely in actual practice. If someone such as Galen encountered someone emotionally distressed or disturbed, in his professional or personal life (if these can be separated in this period), he might in practice have responded with advice that we might associate either with diaita or with philosophical therapy. As Susan Mattern’s biography of Galen underlines, advice on matters of health, including physical illness, was far from being solely the province of medical practitioners in antiquity, who were in any case a rather diverse group,51 and a similar point could be made about advice on the management of emotions.

If we pursue this line of thought, we might conclude that my whole inquiry has been based on an over-rigid distinction between the kind of treatment offered by doctors and by philosophers. Galen and Plutarch, to some extent, aimed to play both roles, in their writings at least; and we have no special reason to think that they maintained a strict distinction between the advice offered from these standpoints. The convergence of approach we find in these authors is interesting, and, like some other features of ancient practice noted, might be suggestive in its implications for modern practice, in which, for the most part, a rather rigid distinction has generally been maintained. However, Plutarch and, still more, Galen seem to have been rather exceptional in their range of interests; and, on the whole, it seems right to treat the two genres (philosophical therapy and medical practice, including diaita) as distinct and generally practised by people working quite independently. To this degree, it remains difficult to imagine an ancient situation quite like the Mike Leigh case with which this essay began, even though the points of convergence between medical and philosophical approaches are closer than we might initially have expected.

I am very grateful for the acute and helpful comments made on the first version of this paper by participants at the Berlin conference, and to the editors for their careful work in finalising the paper for publication.

See refs. in n. 8.

On ancient philosophers’ understanding of mental illness (including Galen), see Ahonen, M. (2014) Mental Disorders in Ancient Philosophy. This is a very useful review but it does not address directly the question raised here.

Main examples are these. The wife of Justus, in love with a dancer called ‘Pylades’, caught out by her irregular pulse; a slave steward detected as fearing for his life after some dubious accounting (Galen reassured him about this): both cases in Gal., Praen. 6 (xiv.631–34 K. = 100,15–104,8 Nutton). Boethus’ son, hiding his consumption of food and also caught out by his pulse: Gal., Praen. 7 (xiv.635–40 K. = 104,27–110,4 Nutton). A patient of Erasistratus who believed he was being called by a ghost (the doctor pretended he had called the patient’s name): Gal., Hipp. Epid. II 2 (207,45–208,35 Pfaff). A woman who thought she had swallowed a snake (the doctor produced one and convinced her she had vomited it up) (ibid). See also Mattern, S. M. (2013) The Prince of Medicine: Galen in the Roman Empire, 250–53 and id. ‘Galen’s Anxious Patients: Lypē as Anxiety Disorder’, in Petridou, G. and Thumiger, C. (2016) Homo Patiens—Approaches to the Patient in the Ancient World, 203–23; Nutton, V. ‘Galenic Madness’, in Harris, W. (2013) Mental Disorders in the Classical World, 121–22, 125–26; Singer, P. N. (2013) Galen: Psychological Writings, general introduction, 28 n. 59.

Celsus 3.18, 10–12 (124,11–23 Marx) speaks of methods of relieving fears, e.g. by readings, and proposes letting the patients engage critically with the reading to divert their minds; at 3.18 (126,8–10 Marx), he advises correcting depressing thoughts in mental patients.

Aretaeus, Th. Acut. Dis. 1.1, ‘The cure of phrenitics’: he recommends telling unexciting stories to patients, especially in cases of uncontrolled anger (92,1 Hude), or providing activities familiar to each person to get the patient to sleep (94–95 Hude).

Caelius Aurelianus, Acut. Dis. 1.11, on phrenitis: at 99 he recommends using ‘alloeopathic methods’ to control the patient’s emotions (76,12–21 Bendz); in Chr. Dis. 1.5, De furore sive insania, at 156–57 (522,25–26 Bendz) he recommends showing sympathy for, and agreeing with, the patient; at 163 (526,22–25 Bendz) he recommends offering readings and performances that may counteract their emotional tendencies; at 166–67 (528,22–25 Bendz) he recommends, if one wants (si audire voluerint), the reading of philosophers who ‘help banish with their words anger, fear, sorrow …’ (suis amputant dictis); at 170 (530,22–24 Bendz) he suggests trips and diversions of the mind. I am most grateful to Chiara Thumiger for highlighting these passages. See Pigeaud, J. (1981) La maladie de l’âme, 105–21, esp. 108–11; and on humane treatment of mental illness in later ancient practice, Clark, P. A. (1993) The Balance of the Mind, 373–89. See also, on Galen, Nutton, ‘Madness’, 126, referring to Gal. Hipp. Epid. VI 8 (494–95 Pfaff).

Hipp., Regimen 4 (iv.79 l. = 432–33 Jones) is exceptional in suggesting that the doctor should turn the attention of the patient to contemplation (theōria) of “comic things” (geloias), if possible, or at any rate to things whose contemplation brings pleasure. On the early history of philosophical therapy, see Laín Entralgo, P. (1970) The Therapy of the Word in Classical Antiquity; Gill, C. (1985) ‘Ancient Psychotherapy’, Journal of the History of Ideas 46.3, 307–25, esp. 320–25; Bartoš, H. (2015) Philosophy and Dietetics in the Hippocratic On Regimen. A Delicate Balance of Health, 165–229.

A brief overview of the genre: Chrysippus (third century bce, Stoic), ‘therapeutic book’ (Book 4 of Peri pathōn); Philodemus (first century bce, Epicurean), many works of this kind including those on avoiding fear of death and anger; Lucretius (first century bce, Epicurean), De rerum natura book 3 on confronting fear of death; Cicero (first century bce), Tusculanae disputationes; Seneca (first century ce, Stoic), De ira, De tranquillitate animi; Plutarch (first-second century ce, Platonist), various works including those on avoiding anger and on peace of mind (Peri aorgēsias, Peri euthumias); Galen (second century ce): Freedom from Distress (Peri alupias = De Indolentia =Ind.), Affections and Errors of the Soul; Stoic writings combining protreptic, therapy and advice: Epictetus (first century ce, Stoic teacher), Discourses; Marcus Aurelius (second-century ce emperor influenced by Stoicism), Meditations. See also Hadot, I. (1994) Seneca und die griechische-römische Tradition der Seelenleitung; Nussbaum, M. C. (1994) The Therapy of Desire; Gill, C. (2010) Naturalistic Psychology in Galen and Stoicism, ch. 5. On Galen as independent or eclectic, see Gal., Aff. Pecc. Dig. 1.8 (v.42–3 K = 28,25–29,16 de Boer).

There has not, I think, been a sustained attempt to reconstruct therapy as a social practice from the literary evidence, nor am I sure how effectively this could be done. For some suggestive moves in this direction, see (on Epicurean therapeutic discourse), Nussbaum, Therapy, 117–36, Tsouna, V. (2007) The Ethics of Philodemus, chs. 4–5; (on Epictetus’ discourses to students and visitors to his school), Long, A. A. (2002) Epictetus: A Stoic and Socratic Guide to Life, 43–64.

On the different styles of medical reporting found in these two works, see Lloyd, G. E. R. ‘Galen’s Un-Hippocratic Case-Studies’, in Gill, C. et al. (2009) Galen and the World of Knowledge, 115–31.

See Trapp, M. (2007) Philosophy in the Roman Empire, chs. 1, 8–9.

See Long, A. A. and Sedley, D. N. (1987) The Hellenistic Philosophers: sections 21, 58, 63.

On this difference, see Gill, C. (2006) The Structured Self in Hellenistic and Roman Thought, 131–45, 177–83, 231–32, 260–61, 414–15; Gill, Naturalistic Psychology, 160–7, 221–29 (on Galen). On the significance of these two points (conceptions of happiness and development) for philosophical therapy, see Gill, C. ‘Philosophical Therapy as Preventive Psychological Medicine’, in Harris, W. (2013) Mental Disorders in the Classical World, 339–60, esp. 348–51.

See Nussbaum, Therapy, chs. 4, 8–9, Tsouna, Ethics, chs. 2, 4, Gill, Structured Self, 113–26, Naturalistic Psychology, 246–50, 280–300.

On Galen’s reservations about the use of medical language by Stoics, see Gill, Naturalistic Psychology, 308–13, and on the contrast between philosophical and medical approaches to psychological illness, see Gill, Naturalistic Psychology, 300–14. M. Ahonen, in this volume, argues that the Stoics recognised explicitly the difference between their conception of ‘madness’ or ‘mental illness’ and that presupposed by medicine and conventional opinion. However, Tieleman, T. (2003) Chrysippus’ On Affections: Reconstruction and Interpretation, ch. 4, sees the Stoic and medical approaches as conceptually closer than is suggested here.

See Gill, Naturalistic Psychology, 250–52; also refs. in n. 8.

See e.g., on Epictetus, Long, Epictetus, ch. 8; on Marcus Aurelius, Gill, C. (2013) Marcus Aurelius: Meditations Books 1–6, xxxiv–lii.

For a review of philosophical techniques of this kind, see Cic., Tusc. 3.32–60; also Sorabji, R. Emotion and Peace of Mind (2000), chs. 14–15.

See Evans, J. (2012) Philosophy for Life (on a range of ancient philosophies as a source of modern life-guidance); Robertson, D. (2010) The Philosophy of Cognitive-Behavioural Therapy; (2013) Stoicism and the Art of Happiness (on Stoicism as enhancing modern psychotherapy). See also ‘Modern Stoicism: Home of Stoic Week, Stoicism Today and Stoicon’ (http//:modernstoicism.com).

A favourite Stoic example of passion was Medea (who murdered her own children to take revenge on an unfaithful husband). Seneca’s treatment of anger underlines the violent and self-destructive effects of this emotion. See Gill, Structured Self, 249–60, Naturalistic Psychology, 285–8, 297–300; also Nussbaum, Therapy, chs. 11–12, Graver, M. (2007) Stoicism and Emotion, ch. 5.

See Gill, ‘Philosophical Therapy’, 342–48.

See Cic., Tusc. 3.77; 4.59–62, Origen, Cels. 8.51; see also Tieleman, Chrysippus, 166–70, Gill, Naturalistic Psychology, 291–93.

See e.g. Cic., Tusc. 3 (review of therapeutic strategies); Plutarch, On Contentment, on whose eclectic or pragmatic approach, see Gill, C, (1994) ‘Peace of Mind and Being Yourself: Panaetius to Plutarch’, in Haase, W and Temporini, H. Aufstieg und Niedergang der römischen Welt ii.36.7, 4599–4640, esp. 4624–31; Van Hoof, L. (2010) Plutarch’s Practical Ethics, ch. 4. See also Gill, Naturalistic Psychology, 250–51.

See Sen., Tranq. 1: man seeking treatment for instability of purpose; Gal., Aff. Pecc. Dig. 1.7 (v.37 K. = 25,15–24 de Boer) and 1.9 (v.47–51 K. = 32,11–34,19 de Boer): young man troubled by anxiety by potential loss of wealth; also 1.4 (v.18–21 K. = 13,19–15,15 de Boer): man from Gortyn wanting to be cured of impetuous anger; 1.10 (v. 54–55 K. = 35,27–36,13 de Boer): man eager to be cured of his failings. On Galen’s use of addressees in Aff. Pecc. Dig., see Singer, Galen, 218–19.

See further discussion of Sen., Tranq. and Gal., Ind., from this standpoint, Gill, ‘Philosophical Therapy’, 352–57; also on Sen., Tranq. as a quasi-medical ‘consultation’, see Pigeaud, Maladie, 503–12. On Galen’s repertoire of therapeutic strategies, see Singer’s chapter in this volume.

Gal., Ind. indicates familiarity with Plutarch’s On Contentment; see Boudon-Millot, V. and Jouanna, J., with Pietrobelli, A. (2010) Galien tome IV: Ne pas se chagriner (= bjp), x–xi; Nutton, V., introduction to translation of Ind. in Singer, Galen, 62–63. On Galen’s reservations, see the references in n. 15.

They are listed among 23 works of ‘ethical philosophy’ (which are largely lost but which seem to be what we would call ‘practical ethics’), in Lib. Prop. 15 [12] (xix.45–46 K. = 169–70 bm). See Singer, Galen, 12–13, who points out that these works are marked as distinct from Galen’s ‘core curriculum’ of writings directed at expounding the techniques needed for medical practice.

On these themes, see Gal., Ind. 58–82 (21–25 bjp), Plu., Mor. 475b–477c, See also Gill, Naturalistic Psychology, 263–6; ‘Philosophical Therapy’; 349–57; ‘Peace of Mind’, 4624–31.

See Aff. Pecc. Dig. 1.4 (v.14–16 K. = 11,15–12,10 de Boer: life-long training possible, even at age 50); 1.4 (v.20–21 K. = 15,6–15 de Boer: improvement possible over five years); 1.10 (v.54 K. = 35,25–36,12 de Boer: correction takes many years and is not possible over age 40 or at most 50). Galen’s views about gradual development can be linked with his Platonic-Aristotelian approach to ethical development (seen as based on a combination of inborn nature, social habituation and education); see Gill, Naturalistic Psychology, 221–27, 249–50, 257–58, 261–62.

For the idea that change of beliefs and attitudes requires sustained, perhaps life-long, commitment, see Epictetus, Diss. 3.15, 3.21; this idea underlies Marcus Aurelius’ review of his life-long progress in philosophical understanding (Med. 1.7–9), see also Gill, Marcus Aurelius, lxxv–lxxvi, 57–63.

On cbt, see e.g. Hawton, K. et al. (1989) Cognitive Behaviour Therapy for Psychiatric Problems; Herbert, J. D. and Forman, E (2011) Acceptance and Mindfulness in Cognitive Behaviour Therapy.

See van der Eijk, P. ‘Therapeutics’, in Hankinson, R. J. (2009) The Cambridge Companion to Galen, Cambridge, 283–303, esp. 297–98; Van Hoof, Plutarch, 212. In Gal., Ars Med. 23 (i.367–68 K. = 346,8–347,12 Boudon, trans. Singer, Galen: Selected Works, 374), six factors are specified as especially relevant for healthcare: surrounding air, motion and rest of body, sleep, diet, and emotions.

See van der Eijk, P., ‘Therapeutics’, 298–300.

A parallel between the two practices in this respect is implied by Aff. Pecc. Dig. 1.4 (v.14–16 K. = 11,15–12,10 de Boer); 1.6 (v.31–33 K. = 21,15–22,22 de Boer); also v.47–48 K. = 32,11–33,2 de Boer): two people with a similar diaita but a different psycho-ethical state. See also Gal. Ind. 74–76 (22–23 bjp).

See Dieppe, P. et al. (2014) ‘Galen and Wellbeing: Whole Person Care’, International Journal of Whole Person Care 1.2, 76–78. This is the main focus of an Exeter-based public engagement project: ‘Ancient Healthcare and Modern Wellbeing’: see http://blogs.exeter.ac.uk/ancienthealthcare/.

Singer, P. N. ‘The Essence of Rage: Galen on Emotional Disturbances and their Physical Correlates’, in Seaford, R. et al. (2017) Selfhood and the Soul, 161–96, esp. App. 2.

See Gal., qam 9 (iv.807–8 K. = 67,2–16 Müller). See also Jouanna, J. ‘Does Galen have a Medical Programme for Intellectuals and the Faculties of the Intellect?’, in Gill, C. et al. (2009) Galen and the World of Knowledge, 190–205, esp. 200–5; Gill, Naturalistic Psychology, 319.

Gal., Ars Med. 24 (i.371 K. = 351,2–6 Boudon), trans. Singer, P. N. (1997) Galen: Selected Works, 376, slightly modified.

Hipp., Epid. 6.8.20–26 (v.352 l. = 286–87 Smith); on the Hippocrates passage, see Laín Entralgo, Therapy, 162–63. Galen’s commentary: health is based on diet, living conditions, efforts, sleep, sexual activity, mental activity, Gal., Hipp. Epid. vi 8 (484,1–485,25 Pfaff).

Gal., Hipp. Epid. VI 8 (487,18–23 Pfaff). See also Ballester, L. G. ‘Soul and Body: Disease of the Soul and Disease of the Body in Galen’s Medical Thought’, in Manuli, P. and Vegetti, M. (1988), Le Opere Psichologiche di Galeno, 117–52, esp. 151–52; Gill, Naturalistic Psychology, 318–19. For the Caelius Aurelianus passage, see n. 6.

Gal., San. Tu. 1.8 (vi.40 K. = 19,21–30 Koch).

Gal., San. Tu. 1.8 (vi.41–42 K. = 20,3–30 Koch).

San. Tu. 1.7 (vi.31–32 K. = 16,1–5 Koch); 1.8 (37–45 K. =18,19–21,33 Koch); 1.12 (vi.60–61 K. = 28,22–29,5 Koch): I am very grateful to Peter Singer for drawing my attention to these passages and allowing me to use his draft translation.

See van der Eijk, P., ‘Therapeutics’, 298–300.

See this volume, 109–42.

Oribasius, Libri incerti 39 (140,26–141,2 Raeder), trans. Coughlin, slightly modified.

See Van Hoof, Plutarch, 214–48; also Swain. ‘Social Stress and Political Pressure: On Melancholy in Context’, in Pormann, P. E. (2008) Rufus of Ephesus: On Melancholy, 113–38, esp. 128–30.

In Precepts on Healthcare, moderation (sōphrosynē) enables the person concerned to look after his health and also meet his social obligations (Van Hoof, Plutarch, 240–43); in On Contentment, moderation promotes a contented (euthumos) state of mind (469c–f, 474d), cf. Gill, ‘Peace of Mind’, 4624–31.

See Swain, ‘Social Stress’, 133–35.

See Galen refs in n. 34; on similarities between Plutarch and Galen on healthcare, see Swain, ‘Social Stress’, 133–35.

Mattern, Prince, 225–26.

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Mental Illness in Ancient Medicine

From Celsus to Paul of Aegina

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