By Donald Robertson, author of How to Think Like a Roman Emperor: The Stoic Philosophy of Marcus Aurelius, discusses strategies for coping with pain derived from the ancient wisdom of Stoicism.

The physical frailty of Roman emperor Marcus Aurelius was notorious, and of great concern to his subjects. Around 174-175 AD, he was in such poor health that false rumours that he was dying, or already dead, actually spread throughout the empire. These were taken seriously enough for his most senior general in the eastern provinces, Avidius Cassius, to have himself acclaimed emperor, leading to a short-lived civil war in which Marcus and his loyalist army were victorious.

We know that Marcus suffered from chronic chest and stomach pains, problems sleeping, and poor appetite, among other symptoms. While it’s not clear what illness he suffered from, modern scholars have speculated he may have been describing the symptoms of stomach ulcers, among other things. Curiously, the historian Cassius Dio praises Marcus Aurelius for the remarkable physical resilience that he showed despite being “extremely frail in body”.

To be sure, he could not display many feats of physical prowess; yet he had developed his body from a very weak one to one capable of the greatest endurance.

He concludes his account of Marcus’ reign as follows:

He did not meet with the good fortune that he deserved, for he was not strong in body and was involved in a multitude of troubles throughout practically his entire reign. But for my part, I admire him all the more for this very reason, that amid unusual and extraordinary difficulties he both survived himself and preserved the empire.

Indeed, Marcus lived to be nearly sixty, at a time when war or plague claimed many of his contemporaries at a younger age. For example, his adoptive brother Lucius Verus, despite being a stronger, fitter man, dropped dead aged thirty-eight, and Marcus’ son Commodus was assassinated at thirty-one.

So how is it possible that Marcus Aurelius could both be renowned for poor health and yet praised for his endurance? We can find an answer in his personal notes practicing Stoic philosophy, The Meditations, where he refers many times to psychological strategies for coping with pain and illness.

Stoic philosophy had a sophisticated repertoire of psychological therapy techniques at its disposal. Indeed, it was the inspiration for modern cognitive-behavioral therapy (CBT), which first appeared in the 1950s. CBT is currently the dominant evidence-based form of psychotherapy, and provides some surprisingly robust techniques for coping psychologically with chronic pain and illness.

However, one of the best illustrations of the basic Stoic approach to pain actually comes from an early 20th century psychotherapist called Paul Dubois. Dubois used to assign his patients homework that involved reading the letters of the Stoic philosopher Seneca. One day when Dubois was explaining to a young patient how Stoic philosophy could help him cope better with illness, the man interrupted, saying: “I understand, doctor; let me show you.”

And taking a pencil he drew a large black spot on a piece of paper. “This,” said he, “is the disease, in its most general sense, the physical trouble – rheumatism, toothache, what you will – moral trouble, sadness, discouragement, melancholy.

“If I acknowledge it by fixing my attention upon it, I already trace a circle to the periphery of the black spot, and it has become larger. If I affirm it with acerbity the spot is increased by a new circle. There I am, busied with my pain, hunting for means to get rid of it, and the spot only becomes larger.

“If I preoccupy myself with it, if I fear the consequences, if I see the future gloomily, I have doubled or trebled the original spot.” And, showing me the central point of the circle, the trouble reduced to its simplest expression, he said with a smile, “Should I not have done better to leave it as it was?”

Dubois adds:

“One exaggerates, imagines, anticipates affliction,” wrote Seneca . For a long time, I have told my discouraged patients and have repeated to myself, “Do not let us build a second storey to our sorrow by being sorry for our sorrow.”

He says this diagram illustrates the Stoic doctrine that “He who knows how to suffer suffers less.” The burden of physical pain or illness is lightened when we are able to look at it objectively, without drawing concentric circles around it and multiplying our suffering by adding layers of fear.

Here is a rough outline of some of the key Stoic psychological techniques that Marcus describes using to cope with his own chronic pain and illness:

Carefully distinguish what’s directly under your control from what isn’t. This is really the basis of the Stoic approach. The Stoic philosopher Epictetus said: “What, then, is to be done? To make the best of what is in our power, and take the rest as it naturally happens.” That became the basis of the Serenity Prayer made famous by Alcoholics Anonymous: “God grant me the serenity to accept the things I cannot change; courage to change the things I can; and wisdom to know the difference.” Marcus likewise tells himself, “It is necessary that those who wish to follow Nature and be of one mind with her should also adopt a neutral attitude” toward things like pain and illness, by accepting the sensations and focusing instead on their own response to suffering (9.1).

Compare the consequences of struggling versus acceptance. The Stoics liked to say that it’s not really pain that’s our problem but rather the fear of pain. Struggling against things we can’t change can add to our emotional suffering. They want us to learn a healthy and rational attitude of acceptance instead. Of course, if there are practical steps that could potentially help your condition then take them. However, Marcus reminds himself, in vivid terms, of the futility of struggling against suffering that is beyond our direct control: “Imagine every man who is grieved at anything or discontented to be like a pig which is sacrificed and kicks and screams” (10.28). We commonly intensify our emotional suffering by struggling against events in futile ways and growing frustrated with life.

Remember that it’s not events that upset us but our judgements about them. This ancient Stoic doctrine became the fundamental premise of modern cognitive therapy. Pain and illness are unpleasant but you add another layer of suffering when you allow yourself to indulge too much in negative thinking about your condition. We can learn a great deal from those admirable individuals who are able to view physical illness more constructively. Marcus says that we should remember that unpleasant physical sensations, such as pain, are natural and inevitable in life, but that our conscious mind should not, “add to the sensation the opinion that it is either good or bad” (5.26). Take away thy opinion, and then there is taken away the complaint, “I have been harmed.” Take away the complaint, “I have been harmed,” and the harm is taken away. (4.7)

Practice letting go of the inner struggle and actively accepting painful sensations. The Stoics compared life to a dog tied to a moving cart. If the dog tries to struggle and resist it will be pulled along roughly by the cart anyway. However, if it chooses to run behind at the same speed as the cart, things will go smoothly. If we struggle against unpleasant experiences such as pain and try to resist them or become frustrated or resentful toward them then we often just make our lives worse.

Contemplate how others cope well with pain and illness and model their attitude and behavior. Marcus must have seen countless examples of others coping with pain and illness throughout his life during the plague and wars that afflicted the empire. Some people cope with such adversity better than others, of course. The Stoics advise us to learn from the example of those who face adversity with wisdom and courage, and emulate their behavior.

Nothing happens to any man which he is not formed by nature to bear. The same things happen to another person, and either because he does not notice that they have happened, or because he wants to show off his strength of character, he is firm and remains unharmed. (5.18) One of the Stoics’ favorite strategies is to ask what virtue, or resource, nature has given us to cope with a challenge such as facing chronic pain or illness. Contemplating the example set by others is one way of reminding ourselves of potential strengths and coping resources that we already possess.

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If you want to learn more about the life and Stoic philosophy of Marcus Aurelius, and how techniques from Stoicism can help you to deal with bad habits, manage anger, overcome worry and anxiety, cope with pain and illness, and even come to terms with your own mortality, check out How to Think Like a Roman Emperor.