Working With Ananke: Epictetian Lessons From Community Mental Health
Eight years ago, I made the fateful leap from doctoral training into community mental health, jumping headfirst into a clinical internship at a hospital in one of Brooklyn’s most impoverished inner city neighborhoods. I didn’t know exactly what I was getting into at first, although I knew it would be tough, and I knew it would be real.
And it was real, all right. Little of my prior training prepared me for what I was to encounter. Traditional therapy was largely impossible. Clients wandered into my office starving and homeless, and I had to find them soup kitchens and shelters. Once, I turned my back on a hungry client to find some housing information for her, and when I turned back around, she was happily chewing on my half-eaten breakfast croissant—which she had fished out of the garbage. Prostitutes propositioned me, and addicts mandated to treatment by Parole tried to use my therapy groups as cover to sell drugs. Efforts at securing a conventional psychotherapeutic frame often came up short. The suffering, the deprivation, and the chaos, were humbling.
While working humanistically as a psychologist in challenging inner city environments, I have found Epictetus, the ancient Stoic philosopher, to be the most helpful of philosophical thinkers. Epictetus’s philosophical street cred is hard to top. Unlike other philosophers, many of whom are children of privilege (think Plato or Aristotle), Epictetus spent his childhood as a slave. His name, Epictetus, is a slave name that means only “acquired.” His given name, if he ever had one, is unknown. Although Epictetus obtained his freedom and became a popular orator, he lived in poverty by choice. He disdained possessions, never married, and never had children of his own, preferring to adopt a friend’s child who, if not for him, would have been abandoned. Epictetus didn’t just talk the talk, he walked the walk.
Epictetus’s philosophy, uttered with a voice grittily world-wise, shows an acute awareness of life’s limitations. As a former slave, Epictetus had intimate knowledge of what ancient philosophers conceived of as the goddess Ananke, the limiting or constraining aspects of fate. I think of Epictetus as a kind of intellectual antidote for our narcissistic culture. In the United States, we are bombarded with narratives and imagery that tell us we are special, we are important, we are exceptions: that the world will somehow make way for us. In popular action movies, lead characters possess superpowers, are able to defeat hundreds of enemies through sheer athletic skill, or are so brave that they are unstoppable.
For Epictetus, by contrast, there are no superheroes, no special exceptions. Nobody is entitled to bypass life’s limitations. Life is larger than us, we are not larger than life. We can control our thoughts and actions, to be sure, but our fates do not belong to us. We do the best we can to build lives for ourselves, but are not entitled to expect any particular destiny. Our material possessions can be lost or stolen, as can our power and reputation. Even our bodies are not truly our own, as they inevitably age and break down, like it or not.
To live in harmony with these facts of life, Epictetus argues, we must humbly accept that we cannot control them, and make our decisions accordingly. “Choose in conformity with nature,” Epictetus says. For example, I can decide to exercise regularly and eat well, but I cannot decide to be healthy: the latter is the purview of fate. In order to choose in accord with nature, Epictetus contends, we must learn to exert reflective control over what he calls our phantasia, our often-misleading imaginative impressions of life.
A client of mine, “Adam,” had spent his adult life preparing to be a chef de cuisine—the coveted culinary equivalent of being a rock star. After years of apprenticeship and toil, he finally made it, only to throw out his back. Unable to work because crippling back pain, he lost his job and his insurance coverage, falling into the public health system. We hoped, early in his therapy, that if he followed up with his medical doctors, his condition would improve and he could return to his dream career. However, as time went on, hope faded away over the distant horizon. After about a year, Adam had been poked, prodded, and tested by numerous specialists more than a hundred times, with no reduction in his back pain. He underwent back surgery, which was unsuccessful. On top of that, it was discovered that for some reason his kidneys were failing, and it was only a matter of time before he would require dialysis. There was nothing more he could do. He had done his absolute best, but the dream was dead. He was unable to cook even for himself. We looked hard for a silver lining, but were forced to accept that there wasn’t one.
As humanistic therapists who espouse self-actualization and following one’s bliss, we may not always fully appreciate the dream killing power of fate, as Epictetus did. Ananke can be a world-destroying tsunami. It can be a force or event, a literal disaster that sweeps one’s innermost hopes away forever, nothing personal. Many of the victims of Hurricane Sandy were busily going about following their respective blisses, only to find themselves suddenly shivering outside huddled in the cold, without homes or means of transportation.
Fate can also be a suffocating constriction of freedom to those who have no exit route from the ghetto. I have met numerous thwarted geniuses in the course of my work, inventive minds who simply did not have access to the resources needed to fully develop their abilities. Frustrated poets, unpatented inventors, painters without paints and musicians without instruments. One of most beautiful voices I ever heard was that of a middle age client of mine, a former lounge singer whose only pleasure was music. However, several years before I met her, she had gone deaf. Lacking insurance, she was unable to afford a hearing aide. In the absence of music, she had turned instead to crack cocaine. Not only can fate undercut the conditions of our bliss, but it can deliver responsibility in droves. There are many who can only follow their bliss in tiny slivers of time packed between layers of responsibility and obligation. It is disrespectful to these strugglers, and a falsely reassuring sort of phantasia, to assume that they could elect to drop everything and bolt for the fields of paradise. The world simmers with blocked creativity.
Therapists new to community settings often commiserate about their patients. The complaints vary, joined only by a thread of bitter frustration. “I can’t work with these clients the way I was trained to,” therapists grumble. Many new therapists beat the drum that their patients are not reflective enough, that they don’t keep appointments, that they are not motivated, or that they are too resistant to change. Methods are then devised, usually punitive and authoritarian ones, to force patients into the square holes of the therapist’s needs. Epictetus’s counsel regarding the Roman bathhouse is apropos:
If you are going to bathe, represent to yourself the incidents usual in the bath—some persons pouring out, others pushing in, others scolding, others pilfering…For thus, if any hindrance arises in bathing, you will have it ready to say, “It was not only to bathe that I desired, but to keep my mind in a state conformable to nature; and I will not keep it if I am bothered at things that happen.”
Similarly, therapists who practice in community settings might represent to themselves the Anankic challenges built into such settings, and endeavor to keep their own will in harmony with the nature of community mental health work. In my experience, therapists who learn to choose in conformity with the nature of this kind of work achieve a mellow and relaxed demeanor, as their attitude permits them to fluidly roll with challenging clients and situations with few problematic reactions. The client of this kind of therapist often perceives the therapy session as a welcome oasis of calm that provides a respite from a chaotic and frightening world.
On the other hand, therapists who try to control the uncontrollable become reactive and even explosive. These therapists balk at Ananke, fuming at missed appointments and railing at clients who do not wish to engage. They alienate their clients and burn out.
For clinicians in community mental health, it is well worth the effort to take up the practice of Epictetian humility. Let us conform our choices to the nature of the work. We might remember that no matter how hard we work, both we and our clients are subject to Ananke’s constraints. We can expect clients to be themselves, not whomever we may envision as ideal therapy clients. We can nourish our clients’ gifts, but cannot ensure that life will make room for these gifts to flourish.
To be sure, an Epictetian perspective does not require passivity in the face of community injustice or inadequate systems. Rather, when we advocate for our clients, we can do so strategically rather than reactively, and with the world-wise knowledge that we are not necessarily entitled to success even when our cause is eminently just. And when we think about our own lives, our own losses, setbacks, our own thwarted blisses, instead of ruminating over the fates we would have preferred, we might think with weary compassion of how we, our clients, our colleagues, our loved ones, our communities, are all siblings in the arms of Ananke.
Epictetus. (135 C.E./1758). All the works of Epictetus, which are now extant; consisting of his discourses, preserved by Arrian, in four books, the Enchiridion, and fragments (E. Carter, Trans.) London, UK: Richardson.
-- Kyle Arnold
Today's guest contributor, Kyle Arnold, PhD, is a Psychologist and Team Leader at Kings County Hospital in Brooklyn, NY, and Clinical Assistant Professor of Psychiatry at SUNY Downstate Medical Center.