Buddhism, Suffering, and the Medical Model
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If you have ever suffered—and if you are a human being reading this, I suspect you have—you should consider suffering’s causes, lest you make things worse.
It is human nature to make sense out of everything. We can scarcely look at stones randomly thrown to the ground without seeing a pattern. It’s what our minds do, and it is a skill not to be scorned.
Our effort to make sense of the world certainly applies to mental or emotional suffering. Any explanation, even if it is frankly false—such as paranoid delusions—is superior to no explanation at all. The sense we make of things may make little sense, but nonsense is usually better than no sense. An explanation offers the possibility of control, however illusory.
Let’s say I’m utterly without energy, appetite, ambition, self-worth, libido, hope, or sleep. These are all elements of clinical depression. Or perhaps my inability to do anything is chalked up to a character flaw, like laziness. Or maybe we conclude that I am punishing myself for past sins, known or unknown, a penance I feel I must simply endure. These explanations may offer some comfort, but they offer little in the way of a positive path out.
People who are fortunate enough to find mental health treatment are offered an alternative explanation—that they suffer from a medical condition known as Depression. Receiving a diagnosis is enough to begin to lift some of the pernicious consequences of our home-grown explanations. “I’m not bad, I have a diagnosed condition.”
The medical model of psychological problems has offered the possibility of diminished stigma (a promise yet to be fulfilled). Further, it promotes research, encourages treatment, and replaces moralistic or theological accounts (blame, that is) with ostensibly empirically-based explanations. Those who were once punished, exorcised, or killed for erratic behavior are now more properly seen as suffering from an illness. Historically, seeing mental suffering through the lens of the medical model has been a great step forward, replacing punishment with treatment. The medical model is evidence of progress.
Mostly. Some mental suffering may not be best thought of as a medical condition, but rather as a human condition. This is the first tenet of Buddhist psychology: if you are born, you will not escape suffering, not because suffering is a disorder, but because it is our nature as humans. To be born is to experience things that will not always go as we wish. Suffering, in this view, may be a consequence of crushing loss, fear of a looming death, or living with an abusive partner. But even absent such enormous challenges, and even in the best of circumstances, we are not immune from a sense of restlessness and dissatisfaction. This is true even when we get what we thought we wanted (a partner, a good income, a nice house, grandchildren…). Buddhists claim that the underlying mechanism of suffering—whether vast or subtle—is always the same.
Abraham Maslow famously noted that if all you have is a hammer, everything looks like a nail. Psychotherapists are trained carpenters, and we’re proud of our hammer collections. But the hammers were all forged in the foundry of the medical model, which takes for granted that mental suffering is just another form of illness, profitably analogized to somatic illness, with symptoms (suffering) pointing to an underlying disorder in need of diagnosis and treatment. Our patient’s suffering is evidence that something is wrong, in need of caring, repairing attention. Nails everywhere.
Consequently, clinical practice has enthusiastically, if gradually, extended its reach from an early focus on debilitating conditions such as Dementia Praecox (as schizophrenia was once called) to other, less incapacitating forms of suffering. The proliferation of diagnoses from the original DSM (about 112 diagnoses) to its current version (over 250) are largely less disease-like and embrace nearly any unwanted behavior or emotion. If we believe we are supposed to be happy—a strange position perpetuated by advertisers and the popular press—we are more likely to regard ordinary human unhappiness as a disorder in need of treatment.
One unfortunate consequence of regarding all suffering as evidence of a psychological disorder is the risk of promising more than treatment can deliver; even the most blessed lives are eventually marked by loss and pain. As the medical model grows to embrace more forms of distress, what was once ordinary human unhappiness is cast as a disorder, adding to one’s sense of isolation. And many forms of treatment are simply not very effective. Those who fail to get adequate relief from conventional therapies will have the added burden of feeling like treatment failures.
The Buddhist response is not entirely at odds with this view. The Buddha was likened to a physician in his own time, and the four pillars of Buddhism, known as the Four Noble Truths, resemble the process of identifying symptoms, establishing etiology, forming a prognosis, and prescribing a treatment.
But Buddhist treatment differs from the medical model in understanding the causes of suffering and what is to be done about it. Rather than regarding our suffering as resulting from personal problems to be solved, Buddhism suggests that it is our relationship to experience—any and all experience—that gives rise to suffering. Our need for things to be different from how they are is a ubiquitous feature of every moment of mental suffering, subtle or catastrophic.
The solution, then, is less about fixing something, resolving a conflict, uncovering an unconscious truth, or adopting a better narrative. Rather, the “solution” is in changing our relationship to difficult experiences from resistance, rejection, avoidance, and escape in favor of deep acceptance, which comes from training the mind to turn wholeheartedly toward all experience, without regard for our opinions, preferences, or the dictates of the Pleasure Principle. Applied Buddhist psychology implies that our efforts to rid ourselves of our suffering are helping to drive it. Buddhist psychology invites us to let go of the need for things to be different from how they are. This, Buddhists claim, is the path to supreme well-being.
For Further Reading
For an expanded discussion of this topic, please see: Fulton, P. Contributions and Challenges to Clinical Practice from Buddhist Psychology, Clinical Social Work Journal, Vol. 42, No. 3, September 2014.
Fadiman, A. (1997). The spirit catches you and you fall down. New York: Farrar, Straus and Giroux. (This volume is a wonderful description of the clash between the medical model and a culturally-indigenous model of understanding epilepsy.)
Kroll, J., & Bachrach, B. (1984). Sin and mental illness in the middle ages. Psychological Medicine, 14, 507–514.
Paul R. Fulton is a psychologist who was a co-founder and former president of the Institute for Meditation and Psychotherapy. Paul is co-editor of the book Mindfulness and Psychotherapy, now in its second edition. He is course director for the Institute’s 9-month long Certificate Program in Mindfulness & Psychotherapy.