The Clinical Uses of Stoic Acceptance

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Stoic philosophy seems to be having a revival. I’m guessing that’s because many well-meaning people are looking for a life philosophy with which to approach the current deluge of seemingly insurmountable social problems—global warming, systemic racism, political tribalism, oppressive religiosity—with a measure of realism and control that prevents them from becoming perpetually demoralized. The concept of “stoic acceptance” pivots on distinguishing between things that we have no control over whatsoever and things over which we have some, but not complete control, and marshalling our energies around the latter. In the political realm, this is akin to the ‘60s countercultural anthem, “think globally, act locally.” Or, centering your focus and remedial efforts on sources of injustice that are small, actionable, and achievable that present themselves in your everyday life.

A purple background, illustration of a Roman statue (bust), the word "STOICISM" printed across its eyesThese ideas can help in forming a therapeutic mindset, which psychotherapists can pass along to their clients. As a therapist myself, I have noticed that many clients frame their treatment goals in ways that readily set them up for disappointment: “My goal is to save our marriage; turn my teenage son into a successful student; get my wife to embrace and maintain a sober lifestyle; make my emotionally constricted husband more empathic; restore our sex life to what it was like before kids entered the picture; change my emotionally reactive girlfriend into a calm person.” Stating goals predicated on a desperately needed outcome—rather than as responsible steps to take that may or may not eventuate in that outcome—can be a recipe for disappointment.

The overly ambitious ways some clients define their treatment goals, mixed with the sense of urgency and demandingness in which their goals are asserted, can invite even the most well-intentioned therapist to collude with clients’ unrealistic aspirations. How do we reframe such clients’ treatment goals in more attainable ways without leaving them feeling dismissed and deflated? How do we stick with our own inner clinical wisdom around what’s possible given the limitations we perceive baked into a client’s psyche and life situation? How do we engage in the sort of stoic acceptance whereby we have a clearer sense of what we have some control over as regards client outcomes, and smartly concentrate our efforts there?

A clinical example will help. A couple recently sought me out to help them cope with the husband’s stage four cancer diagnosis. He was facing the harrowing dilemma of not knowing whether surgical removal of cancerous tissue and chemotherapy treatment would prolong his life. As someone who had toiled greatly to rise above relative poverty to become a successful real-estate investor, he was savoring his retirement years, expecting to make up for all the deferred enjoyment involved during those self-sacrificing work years. The prospect of dying before entering this yearned-for phase of life, naturally, caused him great anguish. His stated goal for couples therapy was: “I need my wife to be compassionate.” She struck me as ill-attuned during sad moments, naively optimistic—even characterologically cavalier—responding to her husband’s mortality concerns with comments like: “You’ve got to stay positive and battle the cancer with positivity….if you die I’ll just be a wealthy widow and have enough fun for the both of us!”

My stoic acceptance kicked in. The level of emotional foreclosure displayed by the wife rendered any in-depth, “analytical” work—uncovering past trauma, letdowns, abandonment that might undo her detachedness—a fool’s errand. What I could exercise some control over was prompting and cuing the wife to be silently attentive, rather than adding insult to injury with the aforementioned type of comments: “I suppose for now, Joanne, just listening to Mark’s horrible fears with a look of concern, without feeling any need to comment on them, would be a big help.”

Therapists often talk about “meeting the client where they’re at.” That happens to be a form of stoic acceptance. It involves a realistically minded assessment of a client’s limitations and intervening accordingly. It involves tailoring the therapy to the client, rather than the reverse. In this sense we could say that effective therapy requires an eclectic approach. I don’t necessarily mean eclectic in the sense of reaching for a grab-bag of clinical techniques and methods. I am referring to eclectic in the humanistic sense. A willingness to adapt and adjust our expectations as to what is possible, rather than what is expected, as far as therapy outcomes are concerned. Becoming more, or less interactive; more, or less directive; more, or less self-disclosing; more, or less overt with our genuine emotional reactions in the room, predicated on what clients need and can tolerate depending on their emotional thresholds and characterological idiosyncrasies.

One of the wholesome aspects of acquiring decades of clinical experience is that you can embody equanimity in the face of clients’ torturous and seemingly impossible life predicaments. That’s because you sharpen an awareness of what is and isn’t possible given the psychological make-up of a given client and the peculiarities of his or her life situation. You focus on the small, often imperceptible improvements clients can achieve with in-the-moment therapeutic input. You store them away so they can be articulated when clients need and want reassurance: “Over the past few months I’ve witnessed you talk less disparagingly about yourself…report fewer arguments with your husband…get better at saying “no” to your supervisor when she demands more of your time.”

Another feature of stoic acceptance pertains to using mortality awareness as a motivator to live life in the present with more urgency. There’s acceptance of the dreadful fact that our life could be cut short at any moment, impelling us to avoid squandering what time we have.

The Covid-19 pandemic and its aftermath pulled back the veil for all of us around how precarious life can be. Listening to clients in the aftermath of the Covid-19 pandemic, there has been a common theme: the need to live life with greater existential urgency. On many occasions during and after the pandemic, clients have confessed to me that death has been on their mind. A fear of their own premature demise, or that of a loved one. They cough up this disclosure, half believing I will automatically assume they are being morbid. As if such thoughts are tantamount to being depressed, demoralized, pessimistic, or plain unhappy.

As a therapist with stoic leanings, I actually view mortality awareness—recurring daily thoughts of my own premature death or that of a loved one—not as a morbid preoccupation, but as a salutary reminder to live more in the moment, let go of petty grievances, pursue sources of life enjoyment more vigorously, not let dormant creative projects go untapped and unfinished, be the most loving version of myself I can be with those that matter to me. There is an ancient tradition undergirding this mortality-awareness-motivational-mindset. The Roman Emperor and stoic philosopher Marcus Aurelius once remarked: “You may leave this life at any moment: have this possibility in your mind in all that you do, or say, or think.”

I have found that using clients’ thoughts about death can be a therapeutic inroad to coax them to zero in on and actualize the matters that matter most to them. As corny as it sounds, when the time is right, I am not shy about posing some version of the following question to them: “Fast forward to your final days; what will make you feel you have lived a good life, where you can die proud that you have achieved what you set out to do?” Holding clients’ feet to the fire about meaningful changes they know in their heart of hearts need to be made if they are to attain deeper fulfillment—personally, relationally, and professionally—can be galvanized in the dialogal context of anticipating their own death.

For many of my clients, these sorts of therapeutic conversations spur them to look more deeply at their work-home life balance; dormant passion projects that need to be revived; urgent diet and health issues that get perennially ignored; social justice concerns that need to move from the back burner to the front burner; friendships where they are being exploited due to over-giving and under-receiving; over-reactivity in dealing with their children that simply has to be dialed back; and core problems with their intimate partners/spouses that can no longer be sidestepped.

Training our minds on the precariousness of life and the inevitability of death can fuel deep, agentic engagement in important life pursuits—often perennially postponed—which frequently happens to be the real antidote to anxious and depressive mindsets.

In mid-life, the shrinking window of earthly time becomes more pronounced. Israeli psychologist Carlo Strenger sees this as a pivotal period in which people are driven to re-sort their priorities: “Life needs to be pared down to the essentials.” The temptation is to manage the dawning death anxiety with hedonistic pursuits, going for broke amusing ourselves to death with sex, drugs, or fancy material purchases. Ernest Becker, in his Pulitzer-Prize winning book, The Denial of Death, would say this life trajectory reflects mid-lifers managing their death anxiety by “tranquilizing themselves with the trivial.”

Ultimately, a more fulfilling way of dealing with death anxiety is to engage in what he calls “immortality projects,” meaningful pursuits that leave a lasting legacy to the special people in your life, and society as a whole. One such legacy is to exit the world leaving loved ones knowing they were loved, not in the abstract, but in the down-to-earth ways we treated them, day in and day out.

Nothing matters more than cultivating the most loving bond possible with those we love.  It’s deeply unpleasant to contemplate “death regrets” like our beloved, or family members, dying in the midst of our holding a grudge or nursing a petty grievance. But such unpleasant thoughts can help us get ahead of these death regrets and see the tragedy and ridiculousness in holding grudges and nursing petty grievances, goading us to mend our ways. Yale University scholar Martin Hagglund weighs in here: “The key to breaking habit is to recall that we can lose what we love.”

Befriending death reminds us to love our beloved, or family members, as if our relationship with them will not last. It makes us chase the profound consolation associated with knowing when that dreaded, but inescapable, day arrives (assuming we don’t go belly up first!) we can derive solace from the fact that we strove to love at our best, with our loved ones dying knowing with confidence they were truly loved.

As therapists, perhaps one of the greatest overlooked sources of countertransference is letting our own death anxiety prevent us from constructively engaging clients with their death anxiety. For me, that means accepting death as a part of life and being on an agentic path to living a life well lived—spurred on by the constant background awareness that my existence can be over at any time.

In summary, therapists of any stripe can borrow from aspects of stoic philosophy to help their clients wisely allocate time and energy to what they can and cannot change in their lives and see mortality awareness not as a morbid preoccupation, but as a wake-up call to avoid postponing the realization of what clients tacitly know has essential meaning and importance to them.

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16 COMMENTS

  1. One must behave in a “stoic” manner, when dealing with potentially deadly psychiatric neurotoxic poisonings, if one wants to escape the insanity of the psych system. At least that’s what I learned quite quickly from my former psychiatrist, the more one complains about the adverse effects of the psych drugs, the more psych drugs one is forced to take. But if one grins and bears the neurotoxic poisonings, and does not complain, it’s easier to get the psychiatrist to wean you off the neurotoxins. So “stoicism” works well for the patients, too.

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    • “clinical wisdom” basically amounts to a belief that the DSM “disorders” are real, and the DSM is a “bible.” Ordinary “wisdom,” albeit I only claim to be working towards wisdom, already knows the DSM is NOT a “bible.” And we already know the DSM was debunked as scientifically “invalid” over a decade ago.

      https://psychrights.org/2013/130429NIMHTransformingDiagnosis.htm

      So there is a chance that those of us ordinary people, who are merely working our way towards wisdom, may be more advanced in our quest for truth and wisdom, than those claiming to already have “clinical wisdom.”

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  2. “If you die I’ll just be a wealthy widow and have enough fun for the both of us” – to me that sounds like an unconscious death wish against the husband. Which is going to have some kind of emotional driver behind it. If he was “toiling away at work” all the time then she was probably a a housewife, and may resent not having had a career herself. If he is deprived of his deferred enjoyment by death, it’s a way for her to get even for *her* deferred enjoyment of always taking a back seat in their partnership. Or – since she mentions the issue of money – she may resent having to take handouts from the husband because she has no income. It may also be projection, in that she is the one “staying positive” – because he’s going to die. Nobody is too stupid to understand the seriousness of stage 4 cancer, so “naivete” about the outcome is almost certainly a defense.

    Of course I’m just speculating here. But since the husband’s stated goal for the therapy is “I need my wife to be compassionate”, her remarks, which are not compassionate, go right to the heart of the matter. After all, lack of compassion –> (passive) aggression –> death form a natural sequence. Telling her to keep those things to herself seems self-defeating to me, at least in the long term. If the therapist judges immediately that the wife is inaccessible and stoic acceptance ‘kicks in’, rather than arriving at that conclusion over time after some unsuccessful attempts to analyze her defenses, to me that points to unconscious collusion by the therapist based on some issue of his own. (End of armchair analysis, unfortunately I don’t have a solution)

    In general however I completely agree that death, and thinking about death, is a highly positive thing. If nothing ever died, there would be no evolution, and the Earth would still belong to primordial bacteria. Also, as some tradition (Buddhism I think) claims, death is the greatest teacher of enlightenment. I have derived great healing and mental health benefits from the suicide attempts I have made. Directly encountering the end of suffering, recovering a sense of agency, and encountering a way to be entirely myself, alone, independent of the traumatizing world of human beings and thus free of it. (Of course suicide is an extreme example.) By facing death consciously, self-delusions, defenses, trivialities, everything that is false in the mind is stripped away. Pure humanity remains. I recently read Elizabeth Kubler-Ross’s classic book ‘On Death and Dying’ where she portrays all of this much more skillfully. She also has a lot to say about doctors’ and nurses’ death anxiety hampering their interactions with dying patients. It seems not much has changed.

    By the way, Dr Gnaulati, I will check out your books, they sound very interesting.

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      • I disagree. Obviously you can’t “make” them compassionate in the sense of forcing them, but if one of my friends or loved ones told me that some behavior of mine bothered them or hurt their feelings, I would try to change it. Of course if the behavior is unconsciously determined and thus outside of the realm of free will, I wouldn’t be able to change it. That’s when you’d do therapy or self-analysis.

        What should his goal be though? “My wife is gloating over the fact that I’m dying of cancer, and I want to learn to accept it stoically”? Yuck! And if that’s the goal, why would she even need to be there?

        It would also be interesting to learn what her stated goal for the therapy was.

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        • It would indeed be interesting!

          My point is that having a goal over which you have no direct control is a setup for failure, in my experience. Empathy in particular is VERY difficult to teach, especially to an adult. Not saying it could not happen, but I’d be more likely to look at something more along the lines of not engaging when negative stuff is coming from her, drilling how to convey the necessary message most effectively, and how to set good boundaries when she becomes abusive. All things the person himself can control. I’ve seen way too many people spend way too much time trying to “get their viewpoint across” or “help him see how he’s hurting me,” etc., with absolutely no success and enormous frustration. I recommend setting goals that a person can accomplish, regardless of whether someone else chooses to “understand” or not!

          Hope that makes some sense.

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          • This reminds me of the “dear man” conversations I was pressured into having with people by DBT therapists. What an exercise in futility. First it was, “Do a dear man to your mother asking her not to offer you her Ativan when you’re at her house”. By the end of DBT that turned into, “cut off contact with your mother.”
            I can’t remember a single “dear man” conversation ever working. Usually, I wouldn’t get the thing I asked for, I’d feel humiliated (The idea of being a 40-something-year-old woman who is just now learning how to ask for something was excruciating), the DBT people would say, oh well, the “environment is too strong”, and then I’d have to practice distress tolerance/ radical acceptance.

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    • Here here KateL! I also am glad to be free of sanctimonious, self-righteous, defensive, obviously insecure, Ignorant, terribly wounded themselves people telling ME I lack insight and competence! Clinicians, “please! Clean your own house!”

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