Eudaimonia, Cognitive-Behavioral Therapy, and the Promise of Rationality

Eudaemonia is having a moment in clinical psychology. For a long time, research on therapy for depression and anxiety has focused on reducing distress and managing symptoms. Happiness has always been the goal of therapy, of course, but in the early days of clinical research, it was usually defined simply as “the experience of positive emotions or pleasure”—a hedonic definition. This definition makes sense at first glance, especially since one devastating symptom of major depression is anhedonia, the inability to experience positive emotions. Reducing the symptoms of depression would therefore mean increasing a person’s capacity for hedonic pleasure.

The problem with the hedonic definition is that even after most individuals have successfully recovered from the symptoms of a mood disorder, persistent impacts on the individual’s well-being still remain. Some argue that reaching for hedonic pleasure alone misses another, more crucial component of a good life: eudaimonic pleasure. Aristotle originally defined eudaimonia as rational activity performed in accordance with human virtue. Meanwhile, positive psychologists have defined eudaimonia more broadly as “realization of one’s best self,” and operationalized it using a six-factor Ryff Scale of Well-Being that includes items like “self-acceptance,” “positive relationships with others,” “autonomy,” and “purpose in life.”

Many people benefit from therapy—some do not. Even those who do benefit often still experience impacts on their lives even after they find relief from symptoms. Maybe it’s a matter of finding the right therapist or sticking with the treatment long enough. Maybe some individuals are just more “treatment-resistant” than others. But a significant fraction of patients simply don’t respond to therapy. For example, cognitive-behavioral therapy (CBT) is the field’s gold standard of evidence-based practice. CBT can be effective for many different disorders, but it works best with anxiety-related disorders. How well? A 2015 meta-analysis from UCLA found that in published studies, on average, only 50% of clients with anxiety disorders respond at all.

The best-known evidence-based therapies for affective disorders were developed before eudaimonia was a relevant concept in clinical psychology. CBT and its close cousin dialectical behavior therapy (DBT) both emphasize distress reduction and symptom management through “skills” and coping mechanisms. A wave of new therapies has attempted to rectify this problem. The most famous is acceptance and commitment-based therapy (ACT), which focuses on “flourishing” and “living according to values.” Other new ideas like Well-Being Therapy (WBT) and Positive Affect Therapy (PAT) also incorporate eudaimonia into the client’s goals.

Here, I ask whether eudaimonia-focused therapy could close the gap for the 50% of clients who don’t respond to the field’s best methods. Can considering eudaimonia finally make therapy work for everyone?

This article does not intend to question the legitimacy of evidence-based therapies or attack psychology as a discipline. However, I hope to illustrate the categorical difference between treatments that are “evidence-based” and “universally effective.” For example, Ibuprofen is an evidence-based treatment for pain, but taking ibuprofen will not always make your pain go away. Sometimes your pain is worse than what the drug can handle; sometimes it appears to work, but the pain returns after the medication wears off. Right now, therapy is like ibuprofen: evidence-based, but far from universally effective. This article is about addressing the gap between the two.

To understand those who experience mental illness, especially with long journeys not immediately respondent to therapy, I draw from my significant lived experience and the friends I have made along the way. I also draw from online discourse about mental illness, where a curious association emerges. There are those who speak about the therapy tools that have helped them recover; there are those who have had negative experiences with it; and there are also those who simply seem as if what plagues them remains untouched by therapeutic ideas. The latter section is full of ironic memes, aesthetic montages, and bitterly self-reflective quotes from Camus, Dostoevsky, Kafka, and Plath—authors whose worldviews lean existential, absurd, and hard to understand. But if we look closer, they might actually hold an important key.

Dostoevsky’s Notes from Underground is a polemic against utilitarian ideas. If man truly possesses free will, the underground man argues, what use is that free will if it is always directed towards the most rational choice? There is something intrinsically satisfying in making the wrong choice, the one that hurts, because it is an assurance that you are still free. If there existed a tool—say, a skill or a therapy—that could reduce your distress, there is pleasure that comes from using it, but there is also a deeply life-affirming pleasure that comes from not using it, from choosing to exist in distress. Consciousness is an irrational thing, after all; pain is an irrational thing. To behave entirely rationally is to be reduced to a utilitarian “agent.” Behaving irrationally affirms the reality of one’s consciousness and the freedom of one’s will, what Dostoevsky called “that primary and most desirable good which is dearer to [man] than anything in the world.”

This argument might seem repugnant at first glance, and the character who advances it even more so. The underground man is not a happy person. He is full of self-hatred, cynicism, and despair. He traps himself so completely in overthinking his own actions that he withdraws from society, convinced that everyone else who values rational well-being (and, for that matter, their own eudaimonia) has constructed a society with no place left for him. And yet we begin to sympathize with him as the narrative continues. If you’ve ever decided to do something you’ll regret, for no benefit, no reason at all, a small part of the underground man lives in you. If you’ve ever clung to a self-destructive pattern without trying to solve it—worrying, smoking, oversleeping, distancing yourself from your friends—then a small part of the underground man lives in you. If you’ve ever come face to face with depression, or another mood disorder, then you and he could be well-acquainted. You might have even spent some of your own time underground.

I know from experience—and most clinical psychologists would probably agree—that mood and anxiety disorders involve certain patterns of irrational thought. These patterns usually involve debilitating emotional distress that makes everyday life a challenge. They can feel uncontrollable, inescapable; they can feel true and right even when you know they are false and destructive. Therapists hand patients tools to deal with their patterns of thought: you can challenge a thought on its rationality, distance yourself from it, or meditate on whether it reflects your values, for example. All of these tools assume that the patient wants to move towards rationality in their life. This is often the case, and these tools are often very helpful. After all, if something in your mind is holding you back and causing you pain, why wouldn’t you want to move away from it?

If this were true for everyone, then we would all be reaching toward eudaimonia all the time, and the underground man would be nothing more than a strange, sad caricature.

The resonance of irrationality also appears in the writing of Camus. In The Stranger, Meursault kills a man for reasons unknown even to himself. Imprisoned, he speaks with a chaplain who counsels him to accept a rational, religious worldview. Meursault refuses and holds onto his irrational worldview even though it means his certain execution. To Meursault, the universe is absurd and indifferent to reason, and his own indifference makes him feel like a part of this universe. To give that up would be another kind of death. Instead, he finds meaning within the absurdity and makes peace with his fate. In his own words: “I laid my heart open to the benign indifference of the universe. To feel it so like myself, indeed, so brotherly, made me realize that I’d been happy, and that I was happy still. For all to be accomplished, for me to feel less lonely, all that remained to hope was that on the day of my execution there should be a huge crowd of spectators and that they should greet me with howls of execration.”

Meursault’s last wish is a bleak thing to hope for, yet in some sense, hoping for his death as a criminal affirms the choices he made in life. Even after doing harm to others and harm to himself, even once caught in the machinery of justice, he continues to walk down his own irrational path. This is how he recognizes himself as alive and free. For both Camus and Dostoevsky, irrationality is a sort of freedom. It creates vital meaning and importance in our lives, even if it ends up causing harm.

This idea could help explain why people cling to self-destructive patterns instead of going to therapy. It could also explain resistance to evidence-based practice among both patients and providers. As long as therapy is a wholly rational endeavor, it rings false for that irrational part of us which provides meaning. This includes therapy which incorporates eudaimonia as a goal. Striving towards eudaimonia is inherently a rational endeavor; this is how Aristotle originally defined the term. The “good life” comes from a realization of one’s rational potential. And—again, I speak from experience—buying into the rational endeavor of therapy is not a trait, nor is it a one-time decision. It is a constant struggle. The rational part of us that wants to objectively improve is pitted against the irrational part that wants to make things worse. Is there a way to reconcile the two?

Camus’ absurdism may provide one possible answer. To him, an “absurd victory” entails finding purpose and joy in an irrational world; unlike Dostoevsky, he rejects despair and the contemplation of suicide. The Myth of Sisyphus does not consider illogical decision-making an integral part of the human condition like Dostoevsky does, but it does consider the absurd as a powerful, yet irrational answer to the world. If irrationality lends itself to humanity and to meaning-making, then Camus is right: that meaning can be positive as well as negative. Due to the nature of irrationality, it cannot always be positive, and by necessity it is sometimes hurtful. Camus embraces this complexity. To him, any joy you can find is a victory. If this sounds like a platitude, that’s because on some level it is one. Certainly it does not provide a satisfying answer for what one should do with debilitating thoughts and emotions. However, it is remarkable in that it manages to deal with the unreason of human consciousness and still come up with a positive.

The science of psychology attempts to address the stream of human consciousness in all its sense and nonsense. It is remarkable to see Aristotle’s ideas of eudaimonia adopted in this discipline centuries after his death. Psychologists have used it to create powerful tools for the measurement of human well-being and the development of new therapies. For those of us who live with mental illness, however, eudaimonia as an idea can fall flat because it makes too much sense. The writings of Dostoevsky and Camus are unique in that they address themselves to the nonsense of the human condition. Just as Aristotle’s ethics were folded into the psychology of happiness, if we are to reach out to people and care for them in all their irrational being, we would do well to take a cue from these authors’ irrational thoughts.