Therapy of the word and other psychotherapeutic approaches in Ancient Greek medicine

Abstract

One of the most distinctive aspects of contemporary psychiatry is its firm grounding in a neurological and biochemical framework for the interpretation of mental life and its disturbances. In the absence of any strong neurological understanding or systematic knowledge of active pharmaceutical substances, one might expect that early ancient medicine readily resorted to non-somatic approaches to healing mental suffering. Instead, what is usually labelled “therapy of the word” and other forms of what one may call psychotherapy emerge relatively late in Greek medicine, only in the first centuries of our era. This paper provides an overview and analysis of this development in ancient history of psychology, philosophy and medicine, covering a broad period of time from the fifth century BCE to the end of the late-antique period, the fifth century CE. The focus is on the very idea (or lack thereof) of the curability of mental disturbance, and on the particular branch of therapeutics which addresses the psychological and existential condition of the patient, rather than his or her physiological state.

Introduction

One of the most distinctive aspects of contemporary psychiatry, according to the usual narrative – or, at least, one of the narratives most visible in its opposition to pre-modern and ancient approaches to mental health – is its firm grounding in a neuro-centric, biomedical interpretation of mental life and its disturbances.¹ In its most extreme version, this biological reductionism is fundamentally at odds with the possibility of a psychotherapeutic approach to mental well-being. By the same token, in the absence of contemporary neurological models² or systematic knowledge of psychopharmaceutical substances, one might expect early ancient medicine to have more readily resorted to non-somatic approaches to healing mental suffering. Instead, what is usually labelled “therapy of the word,” and other forms of what one may call “psychotherapy,” emerge relatively late in Greek medicine, only in the first centuries of our era.³

In this paper, I aim to present an overview and analysis of precisely this development in ancient history of psychology, philosophy, and medicine. I shall examine a broad period (from the fifth century BCE to the end of the late-antique period, the fifth century CE) and focus on therapy: on the very idea of a curability of mental disturbance (or lack thereof),⁴ and on the particular branch of therapeutics which addresses the psychological and existential condition of the patient, rather than his or her physiological state.

It is important to point out that ancient medical measures aimed at curing disturbances of the mental sphere are never cast in opposition to, or isolated from, the standard repertoire of medical treatments – by which one means dietetic (food, drink, sleep, exercise, and the rest) and, to a limited extent, pharmacological and surgical methods. When therapeutic measures that influence the psychological sphere appear, at a later stage, they are juxtaposed and integrated with the more materialistic approach. This development speaks, among other things, to the influence of philosophy and ethics on the practice and theory of medicine. At the same time, it reaffirms the absence of any sharp dichotomy between the body and soul, physical and mental life, in ancient medicine as a whole.⁵

The expression “therapy of the word,” often used to indicate this departure from the strictly physiological approach, is restrictive and imprecise. In fact, the group of therapies I wish to discuss is not limited to forms of talking and communication, although these constitute a central part. Most importantly, this group of therapies has nothing to do with a confessional or intimate dialogue, like the ones imagined to be part of psychoanalytical settings.⁶ The ancient category is more well-rounded and comprehensive, and includes occupational aspects, travels and activities; distractions of the mind – emotional, artistic, intellectual, interpersonal diversions; and in general, any remedy acting within the personal and private sphere, rather than attempting to correct a physiological unbalance.

Antecedents: The power of words in ancient Greek culture

The spoken word – speech, hearing and responding to the verbalised thought of others, and in general, communication through discourse – is a particularly celebrated feature of Greek culture, from its very beginnings (Laín Entralgo, 1970). This is not only true in a general and well-known sense – the Greek logos was a gravitational centre of public life and key instrument of philosophical achievement; there is also a clear recognition of the impact words can have on the wellbeing of speakers and listeners – what we, and Greek physicians, call their “health.” Take, as first example, the famous passage from the Odyssey, Book 8. Here Odysseus has just reached the Phaeacians’ island. At this stage the hero is exhausted and desperate to finally be able to return home. The king of the island, Alkinoos, receives him and organises a banquet for the guest. During the feast, the singer Demodocus begins to sing the story of the fall of Troy, a story Odysseus of course knows very well as his own, as a dramatic first-person experience. Listening to the singer’s words, Odysseus is distressed by what he hears and begins to cry, in silence, with a “deep wailing” (baru stenachon) that escapes the notice of most, but not of the king. Alkinoos understands the mood of his guest and speaks as follows (Homer, trans. 1919, 8.516–46):

Hear me, leaders and counsellors of the Phaeacians, and let Demodocus now check his clear-toned lyre, for his song is not entirely pleasing to all alike. Ever since we began to eat and the divine singer was moved to sing, from that time the stranger has never ceased from sorrow and lamentation; grief, I think, has encompassed his heart. So, let the minstrel cease, that we may all be happy, hosts and guest alike, since it is better thus. For the sake of the honored guest this feast has been prepared, his sending and the gifts of friendship which we give him of our love. Dear as a brother is the guest and the suppliant to any man whose wits are capable of reason. Therefore, you too, do not longer hide with crafty thought whatever I shall ask you; to speak out plainly is the better course. Tell me the name by which they called you in your home, your mother and your father and the other people who lived around.

First of all, Alkinoos recommends that the painful words have to stop. Secondly, Odysseus is invited to tell his own story, a long account that will continue into book 12.⁷ This turning point in the poem is not only important as a narrative expedient – a switch from hearing the account from others to voicing one’s own experience – but also for how it illustrates an experience of deep grief, kept inside by Odysseus for a long time, whose outburst is triggered by words; and a healing, also carried out, at least in part, through words. When Odysseus finishes his story, six books later, the audience “remains still, in silence, as taken by a spell in the shady hall” (Homer, trans. 1919, 13.1–2).⁸ Words are recognised to have a soothing, magical power, a power to hurt, but also to heal. Of course, the Homeric poems are no medical text, and this episode is about the pacifying effect of words heard or spoken to friends in moments of suffering, of talking, and communication in a general sense – Odysseus is not sick, only deeply distressed; it is important, however, to stress that psychological, emotional power is assigned to words from early on in Greek culture.

Another non-medical reference, this time from the classical period, comes from a comedy by Aristophanes, Wasps. Here it is explicit that words are considered as a treatment for an individual considered as a mental patient. The “madman” of this play, Philocleon, is an old man obsessed with trials and law-courts, to the point of being unable to think of anything else. His appears to be a desperate case; his son Bdelycleon has tried everything, but in vain (Aristophanes, trans. 1938, 115–32):

At first he tried him with gentleness, wanted to persuade him to wear the cloak no longer, to go out no more; unable to convince him, he had him bathed and purified according to the ritual without any greater success,… As Cybele could do nothing with her rites, his son took him to Aegina and forcibly made him lie one night in the temple of Asclepius, the God of Healing, but before daylight there he was to be seen at the gate of the tribunal. Since then we let him go out no more, but he escaped us by the drains or by the skylight, so we stuffed up every opening with old rags and made all secure; then he drove short sticks into the wall and sprang from rung to rung like a magpie.

First, verbal persuasion is tried; then, religious purification; and then, a visit to the temple of Asclepius; finally, confinement is the only remaining option. Talk is the first step in attempting to deal with a disturbed behaviour.

These – Homer and Aristophanes – are just two, disconnected examples; one could go further exploring the motif of the enchantment through words or persuasion as attempted therapy, a central theme in classical thought, from Gorgias’ Encomium of Helen⁹ to Plato’s discussion of poetry as enchantment, or turning to the many places in tragedy in which suffering and heightened mental states are addressed, and possibly healed through words.¹⁰ All these have been scrutinised, in this respect, in much greater detail than the medical texts. By beginning with an archaic poem and a classical comedy, I hope to have shown how the idea that words, communication, and verbal exchange can impact on one’s mental well-being and even health is a traditional one in the wider Greek culture. To an extent, one could read what is happening in these two very different scenes or anecdotes as forms of “psychotherapy,” or at least attempts (with varying success) towards therapy that classical audiences understood, we may believe, pretty much the way we do.

Medicine: The early period (fifth century BCE)

But what about medicine? In medicine, therapies of the word – even if we extend the label to include not only talk, but also other therapies which might belong to a psychotherapeutic horizon – become part of medical discussions and medical therapy only late. Indeed, such practices are conspicuously absent in the fifth century BCE. The history of Graeco-Roman medicine can be so subdivided: a first classical phase (the Hippocratic Corpus and other coeval texts); a Hellenistic phase (fourth-first century BCE), of which little direct evidence survives; the imperial or late antique era (first-fifth century CE), dominated by important figures such as Galen, Aretaeus, Rufus and Soranus. We see clearly that forms of psychotherapy appear only in this last phase, after the Hellenistic period; in the Hippocratic corpus, i.e. classical medicine, we do not find anything of this kind. The impression is that the medicine of this early period programmatically excluded from its domain any aspect that might have to do with the emotions, with subjectivity, with the ethical and private – in short, whatever belongs to the personal sphere and comes to the fore in psychotherapy (See: Thumiger, 2017, pp. 335–45). In the whole Hippocratic corpus, with its hundreds of patient cases, we hardly find any comment about the psycho-social context as being relevant to the health or healing of an individual, despite the many occurrences of mental disturbance in that corpus.

There is, in fact, only one example from the earlier period, which is noteworthy for its uniqueness. This example comes from a text which does not represent the typical agenda and doctrine of Hippocratic clinics or nosology, although it belongs to the texts of the Hippocratic corpus. This text contains many philosophical suggestions and often displays a cryptic style, which makes its interpretation difficult. This is the treatise On Regimen, or “on the diet,” which discusses the kind of lifestyle one should follow to preserve one’s health. Instructions concerns not only nutrition, but also themes such as sleep, activities and exercise, work and travel, and bathing. Among these the author offers sometimes instructions for the health of the soul; in one case, at 2.61, we read that

Natural exercises are those of sight, hearing, voice and thought… By all the thoughts that come to a man the soul is warmed and dried; consuming the moisture it is exercised, it empties the flesh and it makes a man thin. Exercises of the voice, whether speech, reading or singing, all these move the soul.

Despite the ambiguous wording, we understand that stimulation of the senses has an effect on the soul, for this author. In particular, the reference to “exercises of the voice” brings us back to the Odyssean episode: speech – heard or spoken – moves the soul. What these exercises (which are not unique to this instance in ancient medicine) exactly entailed is difficult to determine, but we can imagine that they must have been oral performances, perhaps carried out in the company of others.¹¹

See also Hippocrates (trans. 1931), 2.89:

Whenever the heavenly bodies wander about [in dreams], some in one way and others in another, it indicates a disturbance of the soul arising from anxiety. Rest is beneficial in such a case. The soul should be turned to the contemplation of comic things, if possible, if not, to such other things as will bring most pleasure when looked at, for two or three days, and recovery will take place…

A distress of the soul (in this case, anxiety) can be cured through the contemplation of suitable spectacles, diverting and pleasing ones.

As we already stressed, this text is a unique one within the medicine of its time, and it possibly reflects stronger affiliations with philosophical reflections than any other Hippocratic text; hence, the reference to therapies for the soul that go beyond the attention paid to the physiology of the body.

To explore the medical approach to psychotherapy we should now concentrate on the authors of the later period.

Aulus Cornelius Celsus

The earliest reference to psychotherapy that is available to us is to be found after the Hellenistic period. Our first source is also one of the richest, the books De Medicina of the Roman author Caius Cornelius Celsus. This text dates to the 1st century CE, and originally belonged to an encyclopaedia which was not exclusively medical in content. We do not know much about the author. However, it seems evident from what he writes about medicine that he had specific competence in this field. In his treatise, Celsus preserves the first medical classification of mental disorders (book 3.18) for us, offering a definition of insania subdivided into three types. The first discussed by Celsus is phrenitis, an ancient acute disease localised in the head or chest that is preeminently mental; there follows a longer kind of insania, which he calls tristitia (and which corresponds to the Greek melancholy), and a longissimum genus, a longest type that seems to correspond to the Greek mania. Celsus expands especially on the first, phrenitis, and discusses it as if it were a paradigmatic mental disease, whose manifestation and treatment can be applied to all forms of mental disorder more generally.

What is relevant for us, in this text, is the long discussion Celsus offers of therapy, a total novelty compared to earlier medicine, where no specific therapeutics for mental disorder of any kind is to be found. Apart from the usual elements of diet, as well as pharmacological ones, Celsus emphasises the following: attention to the inclination of the individual patient; talk (communication with the patients through words); the devising of a kind of “cognitive therapy,” aimed at challenging and influencing the patients’ way of thinking; the emphasis on social and emotional aspects; and the enactment of a kind of “psychodrama” that also is part of this cognitive approach. The text reads:

But in dealing with the spirits of all patients suffering from this type of insanity, it is necessary to proceed according to the nature of each case. Some need to have empty fears relieved, as was done for a wealthy man in dread of starvation, to whom pretend legacies were from time to time announced. Others need to have their violence restrained as is done in the case of those who are controlled even by flogging. In some also untimely laughter has to be put a stop to by reproof and threats; in others, melancholy thoughts are to be dissipated, for which purpose music, cymbals, and noises are of use. More often, however, the patient is to be agreed with rather than opposed, and his mind slowly and imperceptibly is to be turned from the irrational talk to something better. At times also his interest should be awakened; as may be done in the case of men fond of literature, to whom a book may be read, correctly when they are pleased by it, or incorrectly if that very thing annoys them; for by making corrections they begin to divert their mind. Moreover, they should be pressed to recite anything they can remember. Some who did not want to eat were induced to do so, by being placed on couches between other diners. But certainly for in all so affected sleep is both difficult and especially necessary; for under it many get well. (Celsus, 3.18.9–12, my emphasis).

These balanced approaches to mental disease sound extraordinary in comparison with earlier sources;¹² they must, however, have been widespread at the time of Celsus, rather than being his original development: all other authors of the imperial age, in fact, incorporate similar measures into their nosological discussions when it comes to mental disorder. Anonymus Parisinus, for example, a first century CE nosological author, also discusses phrenitis and proposes similar remedies (Anonymus Parisinus, 1997, 1.1; 1.6):

First of all have the patients lie in a bright place; for most of them this is a good procedure. However, choose an appropriate milieu for those who are bothered by light. For some of them you should also adopt the light of a lamp.

And:

During delirious fantasies we shall calm them with the help of words, persuading them that those present are not enemies, but friends, and sometimes we shall rebuke them. We shall sometimes gratify some, then we shall surreptitiously suggest a fact they do not know, and we shall introduce to some of them their children for the purpose of comforting them, to others their wives (if they are fond of someone, this person could be helpful at the right moment), putting all hope of calm in this (my emphasis).

In the first passage, the anonymous author emphasises the modulation of light and darkness (an element already present among Celsus’ soothing remedies), that should be made to match the inclination of each patient; words are an important instrument to infuse calm and fend off fears; the stimulation of one’s cognitive capacities is also present (the use of more or less fictional situations to bring pleasure or challenge the mind), as is the importance of personal affections as element of healing – the company of one’s family.

Elsewhere, in his account of melancholy, Anonymus Parisinus lists in more detail the activities and diversions that might benefit these mentally ill patients: apart from baths and pharmacological measures – the usual – we find trips, entertainment, visual stimulations, the raising of appropriate emotions, and even sex (Anonymus Parisinus, trans. 1997, 1.7–9):

Let us employ also the help of words which exhort them, according to the type of attack, not to surrender to the causes producing the affection, but to fight them. During remission let them try to enjoy the pleasures of the eyes and the ears.

Loves, too, should be obtained in these cases: excite them to sex, but have them enjoy it at longer intervals.

A fragmentary, but especially remarkable example comes under the name of the physician Athenaeus of Attalia (first century CE), whose opinion about the care appropriate for old age is reported by Oribasius (trans. Libri incerti 39, 6.2.2). Commenting on the vulnerability of elderly bodies to illness and harm – the fact that their “psychic and physical capacities which hold us together and preserve us lose their strength,” he recommends that

one should strive after, in this age especially, gentleness and magnanimity. For such a person is not burdensome to everyone, but is longed for by all and cared for with a certain goodwill.

The point is not only opportunistic – the need to make the care for oneself as bearable as possible for relatives and others, but seems to be more general:

… and spend time in delightful places, and, in general, always live in good cheer. But, if this is not possible, for the most part [give yourself time] to be at leisure…¹³

A positive and joyful attitude is fundamental to health in general, and to be pursued by privileging entertaining and relaxing activities; even arguably moral traits such as gentleness and magnanimity are to be cultivated as capable of having a positive effect on psychological health. The point is specifically relevant to the elderly but is obviously presented as a general one (it is said to be valid “in this age especially,” but not exclusively).

The last great medical author we should consider is Caelius Aurelianus (fifth century CE). Caelius’s nosological treatise On Acute and Chronic Diseases is a wonderful text that stands out especially for the great clinical perceptiveness and attention to patients it shows, and the minute, detailed observation of patients’ symptoms. Caelius also recommends diversions, reading and other personalized measures to improve the state of the ill. Just like Celsus, he begins by discussing the disease phrenitis in depth. At Acute Diseases, 1.9, he discusses the variety of psychological measures that should be followed for the well-being of the deranged patients (from caring about the light, decoration, and state of his or her room, to the avoidance of unpleasant or disliked visitors, or the sound of loud voices), to more specific psychotherapeutic considerations. At 1.11 (97–98), he emphasises the efficacy of language on the psychological state of the patients, following an allopathic principle:

… during the whole period of recovery take measures that the patient may be restored from a condition of mental derangement to a state of complete sanity. For in most cases patients remain in a state of sadness, anger, or aberration right up to the return of physical health. It is necessary, therefore, to use grave and serious language to those whose state had been of hilarity. For thus the weakened condition of their mind and their childish and unrestrained raving are brought under control. But those who are in a state of sadness or anger must be soothed with gentle encouragement and pleasant and cheerful language. For tedium or sadness often has the effect, not only in this but in other diseases, of exciting the malady anew. For if healthy people in many instances incur bodily illnesses because of a troubled state of mind, it is not surprising that those who are not yet cured of a disease should suffer a relapse when their mental state has, so to speak, dealt a wound to their sickbed (Caelius, trans. 1950).

At Chronic Diseases, where mania is discussed at 1.5, he insists on finding the right balance between sympathy and intransigence in addressing patients and responding to them (156–7):

… instruct the servants to correct the patient’s aberrations while giving them a sympathetic hearing. That is, have the servants, on the one hand, avoid the mistake of agreeing with everything the patient says, corroborating all his fantasies, and thus increasing his mania; and, on the other hand, have them avoid the mistake of objecting to everything he says and thus aggravating the severity of the attack. Let them rather at times lead the patient on by yielding to him and agreeing with him, and at other times indirectly correct his illusions by pointing out the truth…

Exercises of the voice are mentioned here too, but with a special focus on the cognitive rather than emotional response of the individual.¹⁴ The patient with mania should be provoked with artful mistakes and questioning, reading and performances stimulating the emotions opposite to those afflicting him (1.5, 162–63):

When the patient’s body has gained strength, prescribe walking and also vocal exercise, as required by the case. Thus have the patient read aloud even from texts that are marred by false statements. In this way he will exercise his mind more thoroughly. And for the same reason he should also be kept busy answering questions. This will enable us both to detect malingering and to obtain the information we require. Then let him relax, giving him reading that is easy to understand; injury due to overexertion will thus be avoided. For if these mental exercises overtax the patient’s strength, they are no less harmful than passive exercise carried to excess. And so after the reading let him see a stage performance. A mime is suitable if the patient’s madness has manifested itself in dejection; on the other hand, a composition depicting sadness or tragic terror is suitable in cases of madness which involve playful childishness.

Even more intellectually engaged is the suggestion presented at 166–7, again for patients with mania:

… And if he is willing to hear discussions of philosophers, he should be afforded the opportunity. For by their words philosophers help to banish fear, sorrow, and wrath, and in so doing make no small contribution to the health of the body.

It is evident from these three authors, Celsus, Anonymus Parisinus and Caelius Aurelianus, that these methods have by now become part of the stock remedies to calm and balance a disordered mind. Other nosologies of the period follow similar lines. The reason for this development can be found, at least in part, in the influence of philosophy on medical approaches to the health of the soul. This last passage in Caelius Aurelianus points most clearly in this direction.¹⁵ Those we have mentioned so far are, however, nosological authors, the work of whom belongs to a rather well-defined genre in ancient medicine, that of treatises listing acute and chronic diseases in a catalogue and offering itemised discussions. Such works do not always elaborate extensively on therapeutic practices; especially, they do not explore closely the day by day routine of patients.

The best source to find more details and depth in this respect, and an extraordinary one at that, is offered to us by Galen (second-third century CE). The famous physician from Pergamon, who was active in Rome over a long period of time, among many things, developed in the fullest way the idea that mental illness (or rather, one type of mental pathology) can and should be addressed cognitively, “philosophically” rather than somatically, and through the practice of a daily exercise routine.

Galen

On several occasions Galen suggests that psychological states can influence the health of the body in important ways, and recognises this as a traditional doctrine in Greek medicine and culture. This principle has of course a therapeutic consequence. In his On Matters of Health (Galen, trans. (forthcoming),1.8.19–21), for instance, he remarks that

our ancestral god Asclepius¹⁶…prescribed for many patients [in emotional distress] to whom the motion of intense passions, having become more intense, had made the mixture of the body warmer than it should, to have odes written for them, as well as to compose mimes and certain kinds of song (my translation; my emphasis).

As in the example from Regimen, here, poetry and art (enjoyed and produced) can help the health of patients suffering under the pressure of unpleasant emotions; we are also reminded of our first example from the Odyssey.

On various other occasions, Galen contributes his own views about the importance of artistic and sporting activities in the care for one’s psychological health: for instance, in his On Matters of Health, 1.8, he states clearly that “the character of the soul is destroyed by bad habits in food, drink, physical exercise, things watched and heard, and music as a whole…,” and later goes on to mention various activities that are effective in this sense.¹⁷ Most importantly, elsewhere, Galen presents the design of a true and proper psychotherapeutic project about how to improve one’s soul and heal one’s ethical flaws and shortcomings (Singer, & Nutton et al., 2013, 2018). The first example I shall mention comes from Galen’s treatise where the Affections and Errors of the Soul are discussed. Galen speaks here as a physician, but from an ethical and philosophical standpoint, presenting the improvement of one’s soul and character as part of his medical project.

It is important (and interesting, as a reflection on the history of psychiatry) to emphasise here that what Galen discusses is not a matter of mental disorder in the way we would think of it,¹⁸ but rather a repertoire of moral flaws – typically, as examples, he lists proneness to “rage, anger, fear, distress, envy, vehement desire” and similar strong emotions that he considers morally despicable.¹⁹ As we might expect, the therapy for these is cognitively based and depends necessarily on the patient’s collaboration. One of the phases in the treatment that Galen prescribes includes relying on a figure of reference to improve one’s soul through constant training, the appointment of a kind of “supervisor” or “advisor.”²⁰ He suggests that one choose a reliable friend or acquaintance, a man of virtue and trustworthy, a person who is himself free from greed, desire to acquire fame and similar weaknesses; only such a person might be able to give sincere feedback. This figure can – in part at least – be compared to that of a psychotherapist in our modern sense: his main role, in fact, is to provide moral judgement on one’s behaviour, rather than offer any comfort or cure. He is a healer only in a metaphorical sense:

… ask him to make evident to you directly which of the above mentioned affections he sees in you, emphasising the gratitude you will feel towards him: he will be your saviour, even more so than the man who saves you when you have a body sickness (Affections and Errors of the Soul 3, Singer, & Nutton et al., 2013).

The introduction of a figure to assist the process of psychological therapy in a personal and bespoke way is a step towards a form of dialogical, interpersonal psychotherapy that in some aspects could be compared to the setting of modern psychoanalytical practices – though a moralised version of them: “from the very process of contemplating whether his criticism was correct or not, you will be conscious of a great benefit; and if you do this continually, on the basis of a genuine choice that you have made to become a decent human being, you will become one.” (Affections and Errors of the Soul 3, Singer, & Nutton et al., 2013).

Conversation and exchange are very important not only with this psychotherapeutic advisor figure, but also with one’s opponents. The antagonistic interlocutors are a relevant part in the psychological excesses Galen is discussing, such as envy or anger. He invites the reader to carry out a form of self-scrutiny, enacting the criticism from others and one’s own reaction to it as a test of endurance (Affections and Errors of the Soul 3, Singer, & Nutton et al., 2013):

In the initial period, even if after diligent investigation you find that a person has accused you insultingly and falsely, do not attempt to persuade yourself that you have committed no error; but let this be the first rudiment of your philosophy: to endure insult. At some later point, when you become conscious that your affections have been sufficiently reduced, you will try to justify yourself against such insults – but never in a shrill or argumentative way, nor displaying a quarrelsome spirit or desire to beat the person. Rather, you will do it for your own benefit, so that when he produces some plausible counter-reply to your rebuttal, too, you will either be persuaded that his assessment is superior, or find, on further examination, that you are free of his accusations.

This form of therapy is primarily directed at the interpersonal sphere, as the texts clearly show. Rather more introspective is the psychology applied in another text, the epistle On Avoiding Distress.²¹ Here Galen focuses specifically on another strong emotion that can pathologically affect the mind, grief. Here, too, he proposes a model of therapy, or self-training, based on words and imagination, the construction of “dramatic scenarios” that can help prepare oneself for adversities. We have already seen this exercise of imagination in a different application, as exercise for the mind aimed at distracting the individual and curbing extreme emotions (52–53):

… What Euripides put into the mouth of Theseus somewhere is true above all, as you will recognize when you hear:

As I once learned from a wise man, I fell to considering disasters constantly, Adding for myself exile from my native land,

Untimely deaths and other ways of misfortune,

So that, should I ever suffer any of what I was imagining,

It might not gnaw at my soul because it was a novel arrival.

The wise man constantly reminds himself of everything that he might possibly suffer, and someone who is not a wise man, provided that he does not live like an animal, is in some way also stimulated to a knowledge of the human condition by the realities of daily life.

And again:

The wise man reminds himself in all circumstances of the bad things that could happen… therefore… I urge you to exercise the imagination of your soul almost in every moment

What seems to be described in both examples is a kind of cognitive therapy, where the greatest importance is attached to talking and social communication (the first quote) and the projection of one’s life and one’s reactions to habituate one’s soul to loss and adversities (the second).

This is not really a kind of spiritual healing or improved self-knowledge of the sort one expects nowadays from a psychotherapeutic session. It is not primarily aimed at soothing the person; it does not necessarily promote a better understanding of or confidence in oneself; it does not aspire to foster the flourishing of the person as a whole, addressing all aspects of one’s life. Rather, it targets individual flaws, and a restricted selection of them – mainly flaws that involve a defect in one’s willpower and self-control. Also, as one might perhaps have noticed from the passages above, these therapies require robust reasoning capacities, philosophical attitudes and intellectual refinement, as well as quite some time for leisure. In conclusion, these recommendations are not intended for all, but speak directly to the wealthy, well-educated (and obviously male) urban elites.²² As such, this Galenic psychotherapy is also limited in its efficacy by what the nature of each allows, as the physician states clearly in several passages of his work. Most explicitly, at the end of his treatise The Dispositions of the Soul Depend on the Temperaments of the Body (QAM), which explores precisely the physiological determinants of one’s mental and ethical make-up, he states that some people are so bad that they cannot be improved by the “Muses” or by “Socrates” – by art or philosophy, important parts of the therapies we have surveyed. There is a limit to what philosophical therapy – Galen’s own brand of psychotherapy – can do (QAM 11):

Appropriately therefore we hate the wicked among men, without previously considering the reason that makes them so, and on the contrary we are attracted to the good ones and love them, regardless of whether they have become such by nature, because of the education they have received, or out of their own choice or customs. And we kill the irremediably bad for three good reasons: lest they do any harm, if they should live; so that they might instil fear in those similar to them, that they would be punished for the evil doings they will commit; and as a third reason, it is better for them to die, since they are so corrupt in their soul that they cannot be educated even by the Muses, nor can they receive any improvement from Socrates or Pythagoras.

Speaking to patients

In the case of Galen or our other examples so far, therapy of the word goes mainly in one direction: from the practitioner or the philosophical healer to the patient. For us modern readers, however, psychotherapy is especially, if not exclusively, about the opposite traffic, that from patient to interlocutor. This is the fundamental part of the process, especially in the psychoanalytical setting. Ancient medicine has on the whole been judged to score rather poorly in this respect – attention to the “voice” of the patient seems to be rarely advertised, and a generally authoritative perspective is the dominant structure of patient-doctor exchange.²³ For this reason, the one text that exposes this inverse traffic from ill person to doctor deserves to receive emphasis: Rufus of Ephesus’ Medical Questions, a treatise which explicitly teaches the technique of posing questions to patients, and, most of all, that theorises the clinical importance of this inquiry. This has to do, of course, primarily with a concern with the information that a patient can offer, the idea that certain aspects of pathology can only be extracted by engaging the subject involved. In addition, however, the argument in favour of interrogating and giving audience to patients has also a value in itself, from a psychological perspective. As Rufus emphasises, in fact, questioning is key in the first place for mental health cases (2–4):

That is my first principle: put your enquiries to the patient himself. From this source you can learn the extent of the person’s mental sickness or health, as well as his physical strength or weakness, and at the same time the type and location of the sickness he has been suffering. If he answers coherently, appropriately and with good recall, without stumbling either vocally or mentally, and in a way that corresponds to his own natural inclination – mildly and moderately if he is otherwise moderate, or again boldly if he is naturally bold or fearfully if he is naturally timid – then you should regard his mind at any rate as being in good order. But if you ask one question and he answers another, if in the middle of speaking he forgets what he is saying, if his speech is tremulous and unclear and there are shifts from the original mood to the opposite, all these are associated with derangement.

The way the patient speaks and articulates a reply is meaningful, especially as far as one’s mental health is concerned. A good physician is able to interpret the manner of talking of a patient and read it in its psychological significance (4–6):

You can comprehend the patient’s physical strength or weakness from how he tells you what has happened, whether coherently, in adequate voice, or with frequent pauses, for example, in a thin voice. [You can similarly discover] the type [and location] of disorder, [if he speaks rapidly, lisps, stammers from inability to control his tongue, and suffers the usual symptom of melancholy or, if there is no melancholy, hoarseness or paralysis of the tongue or some of the things that tend to arise in the chest and lungs. For the melancholy state is clearly indicated by over-boldness and uncalled-for sadness, both of which are particularly evident in the things the patient says (they are evident in other ways too, but the addition of this empirical test will allow the sickness to be clearly recognised); while an imminent case of lethargy is obvious if, when responding to questions, the patient forgets what he is saying and speaks without clarity.

In Galen most evidently (i.e., in his ethical writings; elsewhere he proposes a physiological interpretation of mental disturbance), but implicitly in other of our authors of the imperial age, one element springs into view: the fact that as they speak of mental health with a moral colouring, a judgement of the insane begins to emerge. Mad begins to equal bad and morally defective, and the mad patients must be antagonised (with strategies that are more or less aggressive, more or less radical) by the physician. Ethical flaws and bad behaviours are increasingly cast out as pathology in need of correction.

This moralizing direction goes in parallel, in the history we are considering, with the development of various forms of psychotherapy to address mental health, which makes sense, as these forms of psychotherapy engage precisely with the patient’s ability to reason and judge, appealing to his or her conscious mental life and voluntary choices. Judgement of value concerning patients, the ethical scrutiny of his or her actions and thoughts, seem to be the price to pay as this particular brand of more comprehensive methods is developed in Graeco-Roman medicine. A therapy addressing personality, emotions, human character itself, by means of talk and cognitive engagement, appears to be inseparable from the evaluative step. To illustrate this, we can conclude with a most explicit example: the passage in which the physician Caelius Aurelianus discusses, among his cases of Chronic Diseases, the Malthacoe or “passive homosexuals.” This is in many senses an extraordinary case – and a major example of a moralised conceptualisation of mental disease in ancient medicine (trans. 1950, 4.9, 131–37):

So the pathics, like the tribades,²⁴ are victims of an affliction of the mind. For there exists no bodily treatment which can be applied to overcome the disease; it is rather the mind that is affected in these disgraceful vices, and it is consequently the mind that must be controlled. For no man has ever overcome bodily lust by playing the woman’s sexual role, or gained relief by contact with a penis. In general, the relief of pain and disease is achieved by other means.

Here we have the extreme surrender of medicine to a “disease of the mind” so severe that no medical act can benefit it: “other means” altogether are needed as therapy – which ones, we do not learn from the text, but we can imagine them to be other than diet and pharmacology, and rather of the coercive or moral type. The “disease of the soul” par excellence is first and foremost a disgusting ethical deviation, impossible to cure for our medical author.²⁵

Concluding remarks

In conclusion, the history of ancient Graeco-roman medicine shows that, at least in this tradition, the incorporation of personality and psychology within therapy runs in parallel with the incorporation of another “softer” element, the engagement with value which the tendency towards normativity that value must bring. At first sight, this human-focussed turn in therapeutic practice appears to usher in undeniable positive progress (attention to the individual character as unique, the preference for lenient measures such as soothing, agreeing, diverting and socialising, the resort to communication); at the same time, it opens the door to an ideology of correction and allows greater subjective investment on the part of the psychiatric authority as far as therapy is concerned. The separation of talking therapies from the pitfall of subjective arbitrariness remains today, perhaps, one of the most challenging aspects of the psychotherapist’s profession.²⁶

Biography

Chiara Thumiger, Ph.D., is a Wellcome Trust research fellow in the Department of Classics at Warwick University, and a visiting research fellow at the Humboldt Universität zu Berlin. Dr. Thumiger researches the history of ancient medicine and the history of psychiatry more generally, with a specific focus on Greek and Roman antiquity. In addition, as a classicist, she has worked on ancient Greek literature, especially tragedy. She is working on a book on the ancient disease phrenitis and its place in the history of psychiatry, and she has recently published a monograph on mental health in the Hippocratic sources (A history of the mind and mental health in Classical Greek medical thought, 2017). Other recent published work includes the volume Mental illness in ancient medicine. From Celsus to Paul of Aegina, co-edited with P. Singer (Brill, 2018).