When Suffering Is Not Pathology

Buddhism, predictive processing, and an integrated mechanistic account of suffering

Liam Baker is a psychiatrist in training in New Zealand and a Buddhist practitioner. He is fascinated by the intersection of modern neuroscience, contemplative wisdom, and clinical psychiatry. His writing considers how these fields, brought into close and respectful conversation, can deepen our understanding of the mind, suffering, and healing. His ongoing explorations of these themes can be found on his Substack.

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Modern medicine has inherited a form of suffering that was once more often held by community, spirituality, and shared relational meaning; a form of suffering for which we now have no clear label, no explanatory mechanism, and no cure. The problem is not that healthcare workers do not care about suffering, but that medicine often gives us a narrow language for recognising what suffering is. The Buddha’s diagnosis of this suffering, innate to human life and woven into existence itself, was his first noble truth: dukkha. His second noble truth identified its mechanism, the third revealed the possibility of freedom, and the fourth offered a path of treatment.

Predictive processing may help us understand the mechanism of non-pathological human suffering through an integration of Buddhist wisdom and scientific rigour. In doing so, it may make the Buddha’s diagnosis and response to suffering newly comprehensible through a scientific-clinical lens. This is not only a reinterpretation of old wisdom. A clearer mechanism may help us understand why existing practices work and point toward new ways of working with suffering. It may help recover a dimension of care that modern medicine has partly lost, beyond the treatment of disease alone: a way of meeting suffering itself with greater humanity, tenderness, and understanding.

A note before beginning:

This is a long essay, structured in three distinct parts. I have chosen to publish it as one piece because I think the full arc matters. However, each part offers a natural stopping point, and readers may wish to return to the essay in stages.

• Part 1 identifies the problem itself: a form of suffering that does not fit neatly into a diagnostic box.

• Part 2 considers that problem through a new combined lens: the predictive processing account of mind and ancient Buddhist wisdom.

• Part 3 explores the broader implications of this way of understanding suffering for medicine, healthcare, and those who work within it.

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Part 1 - The Problem Medicine Cannot Name

What is Healthcare for?

One of the first things we discussed at medical school was the definition of health itself. The World Health Organisation’s definition of health is as follows:

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”¹

This is clear: health is not simply the absence of disease. Yet in clinical medicine, and perhaps healthcare more broadly, the pressures of rising demand and dwindling resources, alongside, in my view, an overemphasis on the biomedical model, have led to a narrowing of scope. Medicine has thrived in its ability to understand the physical aspects of our being, its ailments, and the last century has brought about an untold revolution in how we meet that part of the equation. However, when we cannot name the disease or understand the pathology, we are less sure how to stay close to the suffering that is, and always has been, relevant to health.

Some may argue that medicine is about treating disease, and that should be our focus. However, the modern physician’s pledge, the modern version of the Hippocratic Oath created by the World Medical Association as an ethical compass for physicians, states:

“I SOLEMNLY PLEDGE to dedicate my life to the service of humanity;
THE HEALTH AND WELL-BEING OF MY PATIENT will be my first consideration;”²

Again, it is clear, particularly when read alongside the WHO definition of health, that medicine is not just about disease and its treatment, but about wellbeing, health, and care for the whole patient. Yet in practice, we are far more articulate when it comes to pathology and its cures, than suffering itself. It is not that we do not care; it is that we lack a mechanism for understanding the deeply human essence of suffering at its heart. When we do not know how to meet suffering, while our identity as clinicians remains so tightly bound to fixing it, compassion itself can begin to fatigue in the endless face of pain for which we have no clear answer.

The Limits of a Western View of Health

As a doctor in Aotearoa, a broader understanding of health is already integral to the healthcare system. Sir Mason Durie’s Te Whare Tapa Whā frames health through four dimensions, inseparable in shaping the wellbeing of not only the individual, but the whānau, communities, and wider society in which we co-exist:³

• Taha tinana — physical health

• Taha hinengaro — mental and emotional health

• Taha whānau — relational and social health

• Taha wairua — spiritual and existential wellbeing

When we consider taha wairua, we are not limited to religion. It concerns meaning, identity, connection, life force, ancestry, and our very sense of who, where, and when we are. The model is often portrayed through the image of a wharenui, a meeting house, with each of these dimensions forming one of its walls. If any one of them is neglected, the house becomes unstable.³

Of course, this way of thinking about healthcare is not limited to the Indigenous Māori context in Aotearoa. Many similar models of health and wellbeing exist throughout the world. Aboriginal and Torres Strait Islander and First Nations perspectives in Canada endorse similar models of health.^4,5 Across these traditions, health is recognised as far more than the absence of disease. It is relational, communal, and inseparable from meaning.

The Tibetan medical tradition of Sowa Rigpa offers another striking example. It understands health in terms of harmony across body, mind, behaviour, and environment. Particularly relevant here is that Tibetan medicine developed in deep conversation with Buddhist thought, rather than treating questions of suffering, meaning, and human flourishing as external to medicine altogether.⁶

The Clinical Problem: Suffering Medicine Encounters but Cannot Name

As a psychiatry registrar working in Consult-Liaison psychiatry, it is common to receive referrals from other medical specialties for patients in significant psychological distress. This distress is often related to illness, and often understood as ‘reality-based’ rather than pathological. The threats to meaning and identity are many: new disability after a traumatic amputation, loss of function and independence in old age, loss of an expected future in the face of a terminal diagnosis. The underlying currents, however, are familiar: loss, grief, confrontation with mortality, and radical shifts in identity, meaning, purpose, and relation to others.

None of this is ultimately separate from the illness or pathology. Yet treatment of the illness, or management of its symptoms, does not necessarily address this additional layer of suffering. Failing to meet that suffering is not only unsatisfactory from a human perspective; it can also shape the effectiveness of physical intervention itself.

This is not just an ethical omission. A person undergoing chemotherapy may struggle not because they misunderstand its purpose or cannot tolerate its side effects, but because they are frightened, grieving and isolated. They may no longer be sure what they are enduring it all for. If we attend only to the disease, we may miss the suffering that determines whether somebody can engage in treatment at all.

Consult-Liaison psychiatry stands at the edge of this tension. When suffering cannot be fixed by medical or surgical intervention, yet still needs to be met, we are asked to help. However, psychiatrists also work within the biomedical model: they diagnose pathology according to diagnostic manuals and treat according to the evidence base. Sometimes we use labels like ‘Adjustment Disorder’ or ‘Existential Crisis’ to capture forms of suffering related to an event that overwhelms a person’s capacity to cope. But these labels tell us little about the mechanism of the suffering itself. Nor is there a comprehensive evidence base that tells us how to meet this kind of suffering in a way that is genuinely helpful.

Labels Without a Mechanism

Adjustment disorder, existential distress, demoralisation, illness-related anxiety: these are all labels that attempt to name something real. They recognise suffering, link it to an identifiable stressor, distinguish it from more overt psychopathological syndromes, and justify attention and care. They do not, however, give us a satisfying account of exactly how or why this suffering arises.

They do not tell us why some people suffer profoundly in relation to a stressor while others do not, nor why suffering can amplify and perpetuate in certain individuals. We acknowledge that fear, grief, and pain are real. Yet we do not fully understand why, for some, they remain bearable, while for others they become overwhelming and incapacitating. The fact that this is the case suggests that something is being added to the initial insult itself: a further layer of suffering that cannot be explained by the event alone.

Of course, there are ways of working with this kind of suffering. Psychotherapy, the compassionate presence of a hospital chaplain, spiritual or contemplative practices, and even psychedelics in the case of existential end-of-life anxiety, all appear to offer benefit. But why? Without a mechanism, our ways of working with such suffering remain limited. Compared with pathology, our conceptual understanding of this deeper layer of suffering remains underdeveloped.

A Problem Medicine Has Long Recognised

Medicine has always encountered deeper layers of suffering in relation to illness, old age, and death. Grief, pain, loss, fear, and existential dread are aspects of life we confront on a daily basis. This encounter is inseparable from the work of a doctor, nurse, or allied health professional. Medicine’s triumph over the physical aspect of our being is undeniable. Historically, when medicine had little to offer regarding the physical, the doctor’s role as witness, comforter, and companion was harder to deny. Now that medicine has so much to offer, the suffering that cannot be fixed can stand out more easily as residual failure, psychological complication, or someone else’s problem. As Dr Edward Livingston Trudeau, a late nineteenth-century physician who founded a tuberculosis sanatorium in New York, is often quoted as saying in regard to the role of a physician:

“To cure sometimes, to relieve often, to comfort always.”⁷

He recognised that even when treatment options are limited, offering comfort remains a vital part of the doctor’s duty. In 1982, Dr Eric Cassell, in his article published in the New England Journal of Medicine titled “The Nature of Suffering and the Goals of Medicine,” wrote:

“Suffering is experienced by persons, not merely by bodies, and has its source in challenges that threaten the intactness of the person as a complex social and psychological entity.”

He then went on to say:

“The relief of suffering and the cure of disease must be seen as twin obligations of a medical profession that is truly dedicated to the care of the sick.”

And further:

“Physicians’ failure to understand the nature of suffering can result in medical intervention that (though technically adequate) not only fails to relieve suffering but becomes a source of suffering itself.”⁸

As doctors, we have a duty not only to diagnose and treat disease, but to understand the nature of human suffering and meet it with both wisdom and compassion. Cassell diagnosed medicine’s failure with remarkable clarity, although more than forty years later, the gap remains. We have become better at naming suffering as a clinical concern, but not necessarily at understanding the mechanism by which suffering takes hold, magnifies, and becomes bondage.

Palliative Care: Medicine Already Knows Pathology Is Not the Whole Story

The specialty of palliative care is grounded in the recognition that medicine, as an intervention to treat illness and ward off death, has limits. The shift from treating disease to managing symptoms acknowledges that medicine is not only about curing sickness, but also about alleviating suffering. This work remains profoundly important.

Dame Cicely Saunders, often considered the founder of modern palliative care, coined the term “total pain” to acknowledge that physical, psychological, social, and spiritual suffering are entangled.⁹ In palliative care, we find an existing example of medicine recognising that suffering cannot be reduced to pathology. Yet even here, we encounter the sense that we may still lack a deeper mechanistic understanding of how suffering becomes layered around pain, illness, and mortality.

Secular Modernity, Chaplaincy and Existential Distress

In an increasingly secular world, where scientific understanding often dominates what can be accepted as truth, inherited religious frameworks may no longer make sense to many people. Across many developed societies, formal religious affiliation has declined substantially. In England and Wales, for example, 37.2% of people reported having “no religion” in the 2021 census, up from 25.2% a decade earlier.¹⁰ This does not mean that meaning, ritual, or spirituality have disappeared. But it is not a stretch to imagine that shared communal frameworks around illness, death, grief, and existential meaning have weakened.

All human beings, at some point, will confront mortality, loss of control, collapse of identity, and failure of the physical body. Frameworks that once helped hold this existential form of suffering no longer dominate, particularly in secular developed societies. The scientific worldview that has risen in their place has transformed our understanding of the physical world, but it has relatively little to say about the forms of human suffering that cannot simply be understood through a microscope or an MRI scanner.

Hospital chaplains around the world have a visible presence and serve to meet what doctors don’t always have an answer for. Their compassionate, caring presence and ability to hold suffering within the relational space without ‘fixing’ may offer something medicine itself often struggles to provide. However, in an increasingly secular world, the religious connotations of chaplaincy, in my experience, appear to result in only a minority of patients reaching out for or accepting their support. Many younger or secular patients may not recognise their role and clinicians may dismiss their service as only for those with pre-existing religious affiliation. Yet, as we have already seen, human suffering extends beyond one’s individual religious or spiritual belief system.

Scientific, evidence-based healthcare remains one of the final institutions with broad social legitimacy to which many people turn in the face of distress. Yet when this distress cannot be easily categorised or explained, healthcare can struggle to meet it head-on. Some portion of what presents as the modern “mental health crisis” may not be reducible to an increase in discrete mental disorders alone. Psychological distress has clearly risen in some settings, including Aotearoa New Zealand, where the proportion of adults reporting high or very high psychological distress increased from 8.3% in 2018/19 to 13.0% in 2023/24.¹¹ But distress is not always well understood simply by assigning another diagnostic label.

It is not uncommon in psychiatry to encounter someone who has received several mental health diagnoses over time, each capturing something real, while the person continues to suffer immensely. Perhaps relational, existential, and meaning-laden suffering is the dimension that has not been adequately seen within a culture that has lost some of its shared ways of holding these aspects of human existence.

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Part 2 - A New Way of Understanding Suffering

It is important to be clear about what this essay is, and is not, referring to. We are not speaking here about pain, loss, grief, or death themselves; these are inevitable parts of life. Nor am I trying to draw a hard line between suffering and psychopathology. In mental illness especially, the boundary is often blurred. Biological and environmental vulnerabilities, life stressors, and existential suffering can compound one another until distress becomes dysregulating, impairing, or risk-laden. Clinical disorder is real, and often requires specific treatment. But even when pathology is present, there may still be an additional layer of suffering organised around fear, resistance, shame, identity, meaning, and uncertainty. This essay is concerned with that layer. The distinction matters not because these categories are cleanly separable, but because different aspects of suffering may require different kinds of understanding and care. The problem we are referring to is what the Buddha called dukkha.¹²

The Two Darts: The Buddhist Diagnosis of Suffering

The Buddha used the metaphor of two darts to distinguish between the inevitable pain associated with existence, and the mental suffering that we add in relation to it.¹³ The first dart relates to things such as physical pain, illness, and loss. The second dart refers to the reactions we have to the first.

Consider that you fall and break your leg. It is going to hurt. This is the first dart. A broken leg is obviously not a preference, and such an injury is typically met with a layer of mental resistance that says: “this can’t be happening”, “why me?”, “this is someone else’s fault for leaving the floor wet!”. The second dart involves not only this kind of conceptual, mental proliferation. It begins earlier, when pain is appraised as something that should not be happening: a subtle resistance to the fact that reality has not conformed to your preferred version of it.

The Buddha explained that this second dart manifests through craving and aversion. That is, craving a version of reality different from the one you are living in, or resisting a version of reality that is already here. This process of craving and resisting leads to clinging: a grasping at preferred ideas of the world, ourselves, and what we think should be happening. Clinging to the wished-for world in which the thing you did not want to happen never happened. Clinging to the idea of something that will finally bring lasting satisfaction, which you do not yet have. Clinging to the belief that you are right and they are wrong. Through clinging, our hopes and fears become bound up with our sense of identity, our sense of self. When the self is held in this way, we develop a compulsive insistence that reality be other than it is, in light of our hopes and fears.

In Buddhism, the self is not a fixed, inherently existing thing. It is a dynamic, unfolding process, shaped by biology, history, relationships, habits, and environment. Clinging reinforces this process as something more solid, fixed, and rigid than it really is. You become someone who likes this and not that, who believes this and not that, who needs this to happen and that not to happen. The world is increasingly encountered through the demands and defences of this self-model.

This is part of the deeper Buddhist insight of dependent origination: that no thing, and no person, exists inherently as something separate from everything else. Everything arises in dependence on other conditions. You are dependent on your parents, the sun’s energy, the earth’s water supply, your language, your culture, and countless experiences you did not choose. The self is no exception. Yet when this dependently arisen sense of self is held rigidly, it becomes a foundation for craving, aversion, and clinging. This leads to suffering: the suffering that lies in the gap between what you want the world and yourself to be, and the actual shared world in which you are living.

It is important to note that there is no blame, guilt, or shame involved in this process. If you are a human being, born into this world, this is part of how things are. The Buddha’s claim was not that he had somehow been exempt from the human condition, but that he had understood this process deeply enough to let go of the rigidity of self and of the self’s insistence that reality be a certain way.

The form of suffering outlined in the first part of this essay, to me, appears to align closely with the Buddha’s diagnosis. Illness, ageing, and death, realities clinicians encounter every day, were themselves the catalyst for his search for liberation. He recognised that they were inevitable aspects of being born into this world. The deeper point was that the mental resistance formed in relation to them was not inevitable.

Dukkha is the suffering that arises when deeply invested models of self and world resist updating in the face of unavoidable change, uncertainty, and loss.

Why Bring Science and Buddhism Together?

Science is extraordinary. Its power to investigate the external world has transformed human life beyond recognition. Yet when it comes to the human condition, and to suffering in particular, science alone has not provided a fully satisfying account.

One reason may be that science is, by design, primarily a third-person mode of investigation. It observes, measures, and explains phenomena from the outside. This is precisely its strength. But suffering is not only an object that can be observed externally; it is an experience lived from within. Brain scans, behavioural measures, and diagnostic categories may reveal important correlates of suffering, but they do not by themselves tell us what it is like to be caught inside craving, aversion, fear, or despair.

To understand suffering more fully, we may therefore need more than third-person observation alone. This is not to say we should replace science. However, we may also need a disciplined investigation of experience from the inside. This is where Buddhist contemplative traditions may become relevant, as a long-developed first-person inquiry into the mind and the nature of suffering.

When an ancient contemplative tradition developed through disciplined investigation of lived experience and a contemporary scientific account of the predictive mind appear to illuminate a similar structure of suffering, that convergence warrants serious consideration.

Suffering is something we live from the inside, but that does not mean it is without structure. A fuller account may require bringing first-person phenomenology and third-person cognitive science into disciplined conversation.

Predictive Processing: A Bridge Between Worlds

To understand how this account of dukkha might be brought into conversation with contemporary cognitive science, we need to briefly consider how predictive processing understands perception, prediction, and the mind’s relationship to uncertainty.

Most of us were taught a bottom-up model of perception. Light enters the eye, lands on the retina, becomes electrical signals, travels through the nervous system, and is then somehow turned into visual experience. In this sense, perception is built from the outside in.

Predictive processing turns this picture upside-down. It proposes that perception is primarily a top-down process. The brain does not simply wait for the world to impress itself upon it. Rather, it is constantly generating predictions about what is happening, based on prior experience. These prior expectations, or priors, shape what we perceive in the present.

These predictions are organised into what is sometimes called a generative model: the brain’s best current guess about what is going on. Sensory input still matters, but its role changes. Rather than fully constructing perception from scratch, sensory input is compared against the brain’s predictions. If the incoming data does not match the prediction, a prediction error is generated. This is the signal that something unexpected has occurred.

Once a prediction error is detected, the system must determine how much weight to give it. This is where the concept of precision weighting comes in. If confidence in the prior prediction is low, the incoming sensory information will be given more weight and the model will update to incorporate this surprising new information. If confidence in the prior prediction is high, surprising sensory data may be ignored or downplayed. Perception is therefore a constantly shifting negotiation between prior belief and incoming signal. This process of negotiation occurs across a number of hierarchical levels, and so is more complex than laid out here, but a full explanation of this is beyond the scope of this work.¹⁴

Predictive processing does not only apply to how we perceive the external world. What we take to be the self, this body, this personality, this history, this sense of “me” moving through time, can also be understood as a predictive model, shaped by past experience and continually used to make sense of what is happening now.¹⁵

Without going deeply into the mathematics of Bayesian modelling upon which the theory is based, the central point is this: we do not simply perceive the world as it is. We perceive through predictions shaped by the past. This includes not only the world of illness, loss, and mortality, but the self that must somehow make sense of them.

Predictive processing remains an evolving and debated framework, rather than a settled final account of mind. Even so, it has generated serious work across perception, action, and the brain’s modelling of the body, and offers a useful way of thinking about how models of self and world are maintained, challenged, and revised.¹⁶

Dukkha as Resistance to Uncertainty and Resistance to Updating

Through a predictive processing lens, dukkha, or suffering, can be understood in terms of resistance to uncertainty, and resistance to updating our models of self and world when reality no longer conforms to them. Living systems evolved to reduce uncertainty because uncertainty can threaten survival. We seek food, shelter, safety, and social inclusion partly because their absence makes the future less predictable. If we can reliably predict their presence, we are more likely to survive and reproduce. This is adaptive. The problem begins when the same uncertainty-reducing machinery becomes rigid: when the organism keeps defending a model of reality that reality itself is already disconfirming.

Take hunger as an example. Hunger itself is not necessarily the problem; it is a signal. But uncertainty quickly gathers around it. There is a more basic unease in not knowing when food will come, or whether the need will be met. Thought then compounds this: what if I never find food? What if this does not end? There is now not just sensation, but resistance to an uncertain future, elaborated into fear through conceptual proliferation. The mind reaches forward, imagines an intolerable possibility, and suffers in relation to the fact that this future cannot be guaranteed against.

Consider pain as another example. If you break your leg, something has changed in the body. Pain is the signal of that change. Almost immediately, the signal is appraised: good or bad, wanted or unwanted, safe or threatening. Depending on that appraisal, resistance can gather around the fact that reality has changed. The model says: my body is intact; today will unfold as expected. Reality says: your leg is broken. This mismatch is felt before it is fully thought. Then thought gathers around it: this cannot be happening, I do not want this, this should not be here in my experience. These thoughts are not the resistance itself, but its secondary elaboration. They give narrative form to the deeper refusal to release a preferred model of reality that has already been disconfirmed.

The suffering lies not only in unavoidable pain, but in the more basic resistance to reality being otherwise than expected, and in the conceptual proliferation that grows around that resistance. It also lies in resistance to a future that cannot be made certain or safe.

In predictive processing terms, one way of understanding suffering is as over-commitment to a prior in the face of either disconfirming reality or irreducible uncertainty. The model says: this should not be happening. Reality says: it is happening. The model says: I need to know that this feared future will not occur. Reality says: such certainty is not available. The more tightly the model is held, the more suffering is generated. Tightly holding the model, in Buddhist language, is clinging: the cause of suffering.

This also explains why acceptance is not passivity. Accepting reality does not mean you have to like what is happening. It means dropping the unnecessary struggle against the fact that it is already here, or against the fact that the future cannot be made fully certain. In many situations, this is what allows wise action to happen. Consider acceptance and commitment therapy. Experience that cannot be fixed is accepted, and energy is redirected towards valued, purposeful action. The sooner the broken leg is accepted, the sooner appropriate care can begin.

So from this perspective, unnecessary suffering is not simply pain. It is the suffering generated when deeply invested models of self and world resist updating in the face of present reality, or resist the uncertainty of a future that cannot be controlled.

Illness, Ageing, and Death

For someone diagnosed with a potentially life-limiting illness, some suffering is obviously inseparable from the reality they are living through. However, through the lens offered by both the Buddha’s language and that of predictive processing, there is an additional layer of suffering created by the mind’s intolerance of its changed reality. The self-world model that says, I have decades left to live, my body is healthy, the future is filled with possibilities, suddenly narrows. Instinctively, resistance to updating around the new information of a diagnosis arises, as does resistance to the uncertainty that the future now holds. Thought may then gather around this resistance, multiplying possible futures, losses, fears, and questions that cannot yet be answered.

Consider ageing. Our model, formed through our younger years, says: I am young, attractive, healthy, and full of vitality. Time continues, but our models do not necessarily update in a contemporaneous manner. Reality lands: wrinkles are noticed, joints ache with wear and tear, activities that were once simple become overwhelming efforts. If we cannot release our old models of who we are, the gap between who we think we are and who we have become grows, and resistance to reality beds in.

Death brings this tension into its starkest form. The uncertainty surrounding it, and the need to accept that the self we take ourselves to be will ultimately cease, is an obvious threat to the self-model. If that self-model is not held lightly, resistance to this reality can add untold layers of suffering to an entirely natural and inevitable process.

These are not abstract ideas. They are the realities that all of us face.

Why a Mechanism Matters

When medicine encounters non-pathological suffering of the kind outlined above, three typical responses may arise.

• Pathologise it: treat grief, fear, existential distress, or identity collapse primarily as disorder.

• Normalise it: “Of course they are distressed.” This may be true, but it can also risk abandoning the person to their suffering.

• Accompany it humanely, without understanding its structure: offer kindness and support, but without a clear account of what is occurring, how it is unfolding, or what might be the most effective way to help.

None of these responses are overtly wrong, but none of them are optimal. Medicine need not pathologise dukkha in order to care about it. But if it claims to care about health and wellbeing beyond pathology, it needs a richer understanding of suffering than pathology alone can provide.

Psychedelic-Assisted Therapy: A Tantalising Illustration

In recent years, interest in psychedelic therapy has grown. One influential model for how psychedelic therapy may function draws on the predictive processing account of mind. This theory is known as REBUS, or Relaxed Beliefs Under Psychedelics.¹⁷ The “beliefs” referred to here are not merely conscious opinions, but the largely unconscious priors that shape our experience. REBUS proposes that psychedelics may reduce the precision, or grip, of high-level priors, allowing previously rigid models of self and world to become more open to revision.

One of the most clinically compelling areas of psychedelic research has been in end-of-life existential distress. This is a form of suffering that is not easily reducible to pathology, but is real, potentially disabling, and can have a profound impact on quality of life. In trials involving patients with life-threatening cancer, psilocybin-assisted psychotherapy has been associated with substantial reductions in anxiety, depression, demoralisation, and hopelessness, alongside improvements in spiritual wellbeing and quality of life.¹⁸

If we consider the model described in this essay, one possibility is that such therapies work, at least in part, by loosening the priors that sustain a rigid self-world model in the face of mortality. When that model loosens, resistance may loosen with it. There may be less craving for another version of reality, less aversion to the reality already unfolding, and therefore less suffering.

In addition to this, psychedelics have long been associated with experiences of self-dissolution. If the self is understood as a predictive model shaped by prior experience, it follows that relaxing the grip of high-level priors may allow self-related beliefs to soften and update. This could include the belief that one is a fixed, permanent entity whose continued existence must be secured at all costs. In this sense, it is not difficult to see how clinging to the continued existence of the self might loosen, and how the suffering associated with confronting mortality might loosen with it.

What palliative psychedelics reveal dramatically at the edge of life, Buddhism suggests, is operating continuously in ordinary life: suffering is shaped not only by what happens, but by the rigidity of the models through which what happens is held.

Multiple Psychiatric Diagnoses, Exhausted Interventions, and Ongoing Suffering

The same principle may apply in psychiatry. A person may present repeatedly to services, accumulating diagnoses and exhausting interventions, yet continue to suffer immensely. Each diagnosis may capture something real. Each treatment may have been reasonable. Yet if we only see a cluster of disorders, we may miss the human suffering layered around them: shame, alienation, fear, identity collapse, and the struggle to live with a mind and life that feel increasingly unmanageable.

Instead of such people falling too quickly into the “treatment-resistant” bucket, what if a deeper understanding of their lived experience, and of the suffering threaded through it, could open another avenue for meaningful change?

If this account is right, then the problem for medicine is not only that it has overlooked a dimension of suffering. It is that, without understanding its structure, we may repeatedly fail to recognise what kind of help is actually needed. The question then becomes not only how suffering arises, but what it would mean for healthcare to meet it more wisely.

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Part 3 - What Would It Mean for Medicine to Meet Suffering Fully?

This final section is not an attempt to offer a comprehensive programme for clinical practice or healthcare reform. Rather, it considers some of the directions that become visible once suffering is understood in this way.

What Becomes Visible Once We Clarify the Mechanism?

This account of suffering offers not only a deeper way of understanding some of our existing interventions, but also opens doorways to evolving ways of working with suffering itself. If suffering involves, at its core, rigidity in belief systems, both conscious and unconscious, in relation to illness, uncertainty, loss, and the self that experiences all of these, then certain forms of care become understood in a different light. Ways of working that help people grieve, soften resistance, reorganise meaning, feel accompanied, and regain flexibility in their models of self and world may be more than simply ‘supportive’. They may target the very processes by which suffering compounds.

Palliative care already shows how medicine can meet suffering more wisely: continuing to treat what can be treated, while helping people grieve, orient towards what remains meaningful, and release some of the struggle against what cannot be changed.

Practitioners of ACT, or Acceptance and Commitment Therapy, will likely see strong parallels with what has been discussed here. Acceptance involves letting go of rigid resistance to what cannot be changed, and redirecting energy towards meaningful, purposeful engagement. It is no surprise that Stephen C. Hayes, the creator of ACT, drew explicit parallels between ACT and Buddhist ways of meeting suffering.¹⁹ Through the lens developed here, ACT may be understood as one of the clearest existing clinical responses to this mechanism: loosening rigid resistance to present reality and uncertain futures, and restoring flexibility where suffering has become organised around futile control. Psychotherapy more broadly can help make rigid, unconscious models visible, support the reorganisation of identity in the face of change, and restore flexibility in how one relates to oneself and the world.

Contemplative traditions, including but not limited to Buddhism, have long held ways of working with this kind of suffering. Perhaps they are worthy of serious investigation and incorporation into our scientific models of working with suffering. Practices such as meditation, of which many forms exist, can help redirect attention and cultivate greater non-reactivity to distressing events. Emerging predictive processing accounts suggest that some of these effects may be understood through altered precision weighting, with attention playing a central role in what the mind amplifies, sustains, or releases.²⁰ Compassion-based practices may also matter here. They may soften threat-driven ways of relating to the self and to experience, opening a different way of meeting suffering. These practices do not deny pain. Rather, they appear to alter our relationship to it, allowing less rigidity and greater ease amid the inevitable ups and downs of life.

This way of thinking may also help us understand certain trauma-focused interventions. MDMA-assisted psychotherapy, for example, may create a temporary state in which traumatic material can be approached with less fear, shame, and defensive constriction, and with greater self-compassion and trust.²¹ Through the lens developed here, one possibility is that it softens rigid threat-salience enough for painful memories to be reprocessed rather than reflexively avoided or re-experienced as overwhelming. EMDR may offer a different example. Its mechanisms remain debated, but we might tentatively wonder whether shifting attention while traumatic material is recalled reduces the grip of traumatic imagery enough for previously defended material to be approached and reorganised.²² These are pointers rather than settled claims, but they suggest that different therapies may converge on a similar principle: reducing the rigidity or overwhelming force of particular self-world models so that new processing becomes possible.

The role of chaplaincy similarly takes on renewed significance through this lens, as creating a relational space in which suffering can be held without immediately being fixed, explained away, or converted into pathology. Psychedelic-assisted therapy, as discussed earlier, may offer another emerging example of work that loosens rigid self-world modelling and opens greater flexibility in relation to life, meaning, and mortality.

The Relational Space as Healing Intervention

It may seem obvious that the relational space between doctor and patient, therapist and client, is an integral part of care. It has long been understood that one of the most important aspects of a psychotherapeutic intervention is the therapeutic alliance itself, rather than the specific modality used.²³ If suffering involves contraction around threat, uncertainty, shame, and loss, then a relationship that offers calmness, attunement, and non-abandonment may alter the field in which that suffering is held. When suffering is witnessed and held with tenderness, rather than discomfort or fear, it may become more bearable, less isolating, less defended against, and open the possibility for painful self-world models to soften and update.

In the busyness of the hospital ward, or the frantic space of an emergency department, this may be easily forgotten or disregarded. It is understandable that this relational space cannot be held as it might be in a long psychotherapeutic intervention, but even brief interactions matter. Done poorly, they can amplify threat, deepen shame, and confirm helplessness. Done with care and understanding, they can create steadiness, preserve dignity, and provide a sense of togetherness in what can otherwise be a lonely journey through illness.

How we meet suffering matters. It is not simply a problem to be rapidly eliminated or disregarded. To treat it that way may risk solidifying a sense of aloneness and exacerbating threat-based rigidity. Suffering may need to be held, accompanied, and understood, if a person is to move towards a different relationship with the inevitable pain of life.

The False Dichotomy of Disease and Suffering

Attending to suffering with understanding and compassion does not disregard the clinician’s role in treating illness, injury, and disease. In reality, pathology and the suffering formed around it are not cleanly separable in the lives of actual patients. A richer understanding of suffering may therefore improve the treatment of pathology itself.

A patient’s physical or psychiatric dysregulation may be real, and still be met through shame, alienation, fear, rigid identification, or collapse of meaning. When these dimensions are poorly understood, distress can intensify, coping can unravel, and engagement with care can become more difficult. Progress may stall, crisis presentations may increase, and suffering may amplify around the original condition.

A person is not first a disease, with meaning and suffering added later. These dimensions are already intertwined within the clinical space, shaping both the illness experience and the interventions we are trying to offer. Healthcare that better understands the multidimensional nature of suffering may therefore be more effective in treating pathology, not less.

Why Medicine Struggles to Offer This

Profound existential suffering cannot be adequately met in a ten-minute primary care appointment, when that same appointment must also include history-taking, clinical examination, diagnostic reasoning, and a treatment plan. Nor is it simple to offer in a packed emergency department, with assessments taking place in corridors and clinicians carrying responsibility for many acutely unwell patients at once. In such demanding environments, where resources are limited, the acute medical issue understandably takes priority.

Time pressure converts people into problems. This is not because clinicians stop caring. It is because many healthcare systems give them too little room to remain with suffering that needs presence and patience. Around the world, resource limitations often prevent us from spending the time we would like to spend meeting and addressing this deeper human dimension of care.

The failure to meet suffering in this way is not an individual moral failure of any one clinician. It is a systemic issue. In many health systems, an emphasis on acute, short-term intervention, measurable throughput, and statistically driven care leaves too little space to acknowledge the profundity of working with people during the most vulnerable and stressful periods of their lives.

This does not negate the importance of this aspect of our work. Instead, it strengthens the argument that, if healthcare is to be aligned with the WHO definition of health and the WMA physician’s pledge, greater allocation of resources is needed. It may be that, in the longer run, when suffering is met at the human level rather than treated as something beyond healthcare’s concern, illness and disease outcomes improve, and some of the demand driven by recurrent presentations begins to fall.

Clinicians Are Not Outside the Field of Suffering

Dukkha impacts clinicians too. In my own experience, and in that of those I have worked closely with, the suffering of the patient impacts clinicians deeply. Healthcare professionals face death, severe illness, traumatic injuries, and profound mental suffering on a daily basis. We are not detached observers of suffering, but intimately interacting with it, repeatedly, throughout our careers. This is not even to mention the suffering within our own lives, outside of the vocation.

When conditions limit our ability to respond to suffering in a way that we feel it deserves, moral injury can follow. When our own self-identity, bound up with fixing others, encounters suffering that cannot always be fixed, compassion can fatigue. Burnout, compassion fatigue, and moral distress are familiar terms, both intellectually and experientially, to most healthcare workers now.

Clinicians face high rates of mental health difficulty and an elevated risk of suicide.²⁴ When our identity is tied up with fixing, and we do not have the resources to heal as we feel we could, nor to meet the suffering that cannot be easily fixed, our own models of who we believe ourselves to be are threatened. Of course, we resist this, because we too are human. There is always more suffering to meet. In Buddhist cosmology, it is infinite.

Dukkha is contagious. Not in the sense that we can catch it through the air like an airborne virus, but in the sense that unheld suffering, both our own and our patients’, reverberates through relational systems. When clinicians are unable to meet the needs of those who come to us for help, we carry that with us. Over time, what cannot be metabolised can harden into detachment, exhaustion, despair, and sometimes the collapse of the very system that was able to care at all.

Can Medicine Afford to Care About This?

The obvious objection to meeting suffering in a way that is deeply understood, wisely responded to, and tenderly held, is that healthcare systems are already overstretched. In my view, this does not defeat the argument, but amplifies it. If suffering is clinically consequential and systemically reverberant, then providing the conditions for meeting it matters.

Failure to distinguish pathology from practical support needs, psychiatric disorder from non-pathological existential suffering and meaning collapse, may contribute to repeated presentations, fragmented care, partial diagnoses, escalating investigative demand, inappropriate medicalisation, and symptom management that never meets the deeper problem. If we cannot give suffering the attention it deserves, that suffering may return in forms that are more fragmented, more chronic, and more costly: for patients, clinicians, and society as a whole.

High-quality care needs time, continuity, better integration of interventions such as chaplaincy, psychologically and trauma-informed care throughout medical settings, and space to reflect on the most aligned approach in the face of deeply human issues that go beyond the usual protocol-driven care on offer. Clinicians also need working conditions that allow them to remain human in the presence of suffering, rather than being asked endlessly to absorb what the system has no space to hold.

Conclusion

This essay has argued that medicine encounters a form of suffering that is not always pathological, but remains inseparable from health, illness, and disease. Not every confrontation with pain, loss, or mortality requires clinical intervention, and ordinary human suffering should not be pathologised simply because it is difficult to bear. But neither can medicine pretend that such suffering lies wholly outside its concern.

Through the combined lens of Buddhist insight and predictive processing, I have suggested that we may be able to understand this suffering with greater mechanistic clarity: as the suffering that forms when deeply invested models of self and world resist updating in the face of change, uncertainty, and loss. This account does not resolve the problem, nor does it offer a complete clinical programme. It is a synthesis, and therefore necessarily provisional. But it may help clarify the territory: why certain forms of care matter, why the relational space itself matters, and where future clinical, empirical, and systems-level advances might lie. If we can better understand what we are trying to meet, we may become better able to investigate how it can be met. The aim is not simply to rename familiar suffering in mechanistic language, but to ask whether a clearer mechanism might help us work with it more precisely: through attention regulation, compassion and even neuromodulation; each offering ways of shifting how experience is weighted, held, and integrated.

If medicine is serious when it says that health and wellbeing are its first concern, then suffering of this kind deserves to be understood, not left at the margins of care.

This essay is dedicated to all those in healthcare who turn up, day after day, to meet suffering.

References can be found in the comments.

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