The Art of Suffering Well

Finding meaning amidst medicalization

The other day, my friend went to buy a car. His goal, poor soul, was to find one that worked and fell within his budget.

In a typical modern twist, he soon found himself wondering how much he valued a heated steering wheel. Some of the new cars come with them, you see, for only a few hundred bucks more.

My friend described many other miseries that occurred at the dealership, but the heated steering wheel stuck with me for the following reason: a cold steering wheel had not been a problem before. It only became a problem once there was a solution. A solution that could be bought.

This led to me write Returning to Ivan Illich, but I want to explore the problem in a bit more detail here.

The Expanding Infrastructure of Mental Suffering

As I wrote in Illich, various mental health equivalents to cold steering wheels—from microaggressions and questions of identity, to dare-I-say “normal” levels of stress and anxiety—are becoming problems worth fixing. Why? Because just like car companies, clinical psychology and the pharmaceutical industry can offer solutions.

The most obvious example is The Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM is clinical psychology’s “bible.” Its list of disorders informs everything from case conceptualization and insurance reimbursement to medication prescription and individualized education plans in schools. Basically, the DSM establishes what “counts” as suffering in our society.

In the span of a lifetime, the DSM has ballooned from 128 disorders in the first edition (published in 1952) to over 300 in the latest edition (published in 2022). We can now expect, in America, nearly half of the adult population to meet the criteria for one of its diagnoses at some point in their life. Maybe we should start calling this “the book of everyday experience.”

Hold on a minute, you might say. Isn’t this what science does? It adds things as it discovers them? It would be absurd, for example, to fault biologists for increasing the number of known organisms.

To say that disorders are “discovered” in the same way as a new organism, though, is too much of a stretch. Consider what underlies the introduction of a new diagnosis to the DSM:

The process of determining a specific diagnosis, selecting diagnostic criteria, and evaluating the information is performed by a committee as opposed to using actual medical evidence or tests. For example, nearly all of the diagnostic criteria in all of the DSM editions are behavioral observations and not formal biological or medical test results.¹

There is no biological basis for most disorders listed in the DSM. As Tom Insel, former director of the National Institute of Mental Health, once said: “Biology never read that book.” As such, we cannot confirm the existence of a mental disorder in the same way that we can confirm diabetes. As Insel explains further, “Diagnosis for a mental illness is based exclusively on patient-reported symptoms and clinician-observed signs. There are no laboratory tests or biomarkers, except those used to exclude a medical cause.”² This leaves the whole process subject to…well, subjectivity.

this recently-discovered frog species underwent a much different process of discovery than the DSM 5-TR’s new Prolonged Grief Disorder; it’s existence can be confirmed by, uh, looking at it

Nevertheless, surely all the effort that has gone into describing more and more mental maladies has at least resulted in better solutions from the clinical and pharmaceutical industries? Not really.³ The recommended solutions are still therapy and medication. While plenty of new psychotherapies have been developed, none of them—new or old—significantly outperform the others.⁴ Although it might seem that new drugs routinely enter the market, most are the same old products with a fresh coat of marketing.⁵ In fact, as Harrington notes in Mind Fixers: Psychiatry's Troubled Search for the Biology of Mental Illness, most pharmaceutical companies are leaving the mental health space because they can’t improve on existing solutions.⁶

Because of all this, I find it hard to ignore the cynical read that clinical psychology and the pharmaceutical industry are pleased by the creation of more disorders because it gives them more to solve—for a price—without any real pressure to innovate. And as for those who are suffering, all they have been given is an expanded infrastructure in which to do so.

The Shrinking Infrastructure for Resilience

I worry that in lockstep with an expanding infrastructure of suffering, the infrastructure for resilience is shrinking. There are close to 200 more disorders, but not many new ways of addressing them.

I’m not here to cast aspersions on my colleagues or profession. (I think clinical psychology is way more innocent than the pharmaceutical industry, actually.) Most of the people I have worked with genuinely want to reduce human suffering. It’s just that not many have stepped back and considered the net effect of their efforts.

Let’s look more closely at the 1-2 punch of articulating a problem (by creating a diagnosis) and providing a solution (such as therapy). What’s so wrong with that? Well, for one, the solution is not resilient.

Resilience is one of those terms that gets bandied about endlessly in psychology circles. All I mean by it is a person’s ability to withstand or recover from adversity. Even to welcome it:

As I wrote in Illich, medication and therapy aren’t nearly as reliable as one’s family, community, or even oneself; they require money, a professional to administer the solution, and are subject to all sorts of fluctuations in coverage. For example, my colleague just moved across the country. What happened to all her clients? I took a few of them, but who knows about the rest. This independent aspect of reliance is important to keep in mind even if experts and institutions have the potential to provide better outcomes.

On a broader level, though, by expanding the DSM to its current ridiculous size, we are not only making more of mental experience into a problem requiring a solution—we are also suggesting that the model we have of mental illness is legitimate. Even, perhaps, close to complete. A layperson could be forgiven for thinking that between clinical psychology and psychiatry, humanity is close to solving for mental health. But nothing could be further from the truth. As Harrington (2019) says:

…current brain science still has little understanding of the biological foundations of many—indeed most—everyday mental activities. This being the case, how could current psychiatry possibly expect to have a mature understanding of how such activities become disordered—and may possibly be reordered?⁷

The impression of expertise, however, undermines individual and community agency in responding to mental health challenges. By huddling so many aspects of experience into DSM categories, we make more and more of daily life the purview of mental health professionals. The social worker walks in, flops her degree on the table, and everyone else scatters. Instead of encouraging people—along with their family, friends, and communities—to cope on their own, we are teaching them to outsource their issues to an expert. At an astonishing rate, we are giving people the framework and language for becoming mental health consumers.

All else being equal, clinical psychology’s work in describing more of the human psychic experience is a good thing. But the attitude with which these experiences are treated—diagnosed—has a significant effect on how they are further experienced. We have to ask what the net effect of a diagnostic outlook has been.

Diagnosis, Conversion, and Suggestion

I know firsthand how relieving a diagnosis can be. I once experienced dizziness every day for two straight years, mostly without knowing why. I spent the first 18 months on a carousel of new doctors, medications, and other potential solutions such as yoga, meditation, diet, and physical therapy. After a while, I got fed up and took matters into my own hands, which is what I should have done from the beginning. I soon discovered a diagnosis—Persistent Postural-Perceptual Dizziness (PPPD)—that led to a solution. Believe it or not, what solved the problem was a combination of exercise and sitting alone in a closet, breathing slowly and telling myself that I was safe.

Two months separated my finding a diagnosis and implementing this solution, though, and I remember this period particularly well because when I found the diagnosis, my dizziness went away for three days. The relief of knowing that I wasn’t crazy, or at fault, was so overwhelming that my symptoms magically disappeared for a while. I’ve had many clients report the same thing after being given a diagnosis by a psychiatrist, a personality report by a corporate coach, or an interpretation by me.

As Illich says: “The recognized healer transmits to individuals the social possibilities for acting sick.”⁸

Procuring an explanation for suffering is so powerful that it can eliminate the pain entirely, at least for a little while. Because of this, people often try to fit a square peg in a round hole. Through a subtle, often unconscious process, they adapt their experience to fit the definition of some proscribed—and accepted—form of misery. This is called conversion. It ranges from people intentionally manipulating systems of aid to genuinely believing in a proposed diagnosis. The human need to be seen and supported in times of distress is just that compelling.

An example I see in my practice all the time is attention-deficit/hyperactivity disorder (ADHD), a diagnosis that has surged over the past few decades. Occasionally, a client really does have an abnormally high level of distractibility and/or impulsivity, but other times, something else is causing them to be less successful or productive than they want. Perhaps their expectations are too high or their environment is too chaotic. Independent of whether ADHD is the right diagnosis, though, it remains an alluring explanation because of the social currency it presently holds. In claiming to have ADHD, a person can more reliably procure what every sufferer wants, at least in part: some acknowledgment that they are in pain.

In addition to conversion, there is suggestion. This is what happens when I tell you not to think of a pink elephant and you do. (Gotcha.) It also explains what is called “graduate student’s syndrome,” which is when students studying the DSM come to believe they have multiple diagnoses.

It’s funny, people usually shrug this off as a joke or meaningless occurrence, but I don’t know why the assumption wouldn’t be that this also happens all the time to non-graduate students. As soon as a doctor, psychiatrist, or therapist suggests to a client that they might have, say, obsessive-compulsive disorder, confirmation bias gets to work, often alongside the pressures of conversion. Before you know it, voila! The person is walking around, telling everyone that the reason they are who they are, is on account of their diagnosis.

My goal in exploring the topic of diagnosis isn’t to take away a source of solace and meaning for people. In many ways that would be purely mean-spirited, like slapping the ice-cream off someone’s cone. Instead, I want to step back and ask what we are trying to accomplish with the forms of suffering on offer. It would be one thing if they were legitimate forms, as most medical diagnoses are, because then they would lead to more targeted solutions, as with my PPPD. But as we’ve seen, diagnoses in the mental health space aren’t necessarily valid, which makes me wonder: beyond the relief a diagnosis provides, what is its value? Is it leading people to better solutions? If not, what are the opportunity costs? Are we foregoing different conceptualizations of suffering that would be better?

Keep in mind, any cultural explanation of pain is going to provide relief; that is not where value is determined. Value is determined by what else that explanation can do. If the answer is ever more medication and therapy, then I call foul.

The Art of Suffering Well

Until we have a firmer understanding of mental illness, I think we ought to pay more attention to the art of suffering well.

Suffering, odd as it sounds, needn’t be all that bad. Many of my friends know me, for example, as something of a glutton for punishment. (I mean, I spend my free time writing…) At any rate, I’ve come to recognize two central elements to artful suffering: expectation and meaning.

Expectation.

People respond to what they expect and what is expected of them. The meatless expansion of the DSM, along with dozens of medications and 70+ therapeutic orientations on Psychology Today, suggests that suffering is not necessary. That it is, in fact, avoidable—if only you take the requisite steps. (Have I mentioned we offer heated steering wheels?)

That suffering is avoidable is quite possibly the worst message to deliver to someone in pain. Instead, we should acknowledge the truth: suffering is universal and inevitable. Accepting this truth would at the very least prevent people from feeling stupid, blameworthy, or responsible for their misery. It would also cut down on the amount of time people waited, with bated breath, for salvation to arrive. Much of the time, it won’t, and a person is better served by learning how to suffer well.

Here's another expectation we should adopt immediately: people have resilience and agency. We should encourage, believe, and insist on this. You can’t avoid suffering, true, but you sure as hell can suffer better or worse. Instead of poor you, the attitude should be: I know you can do this. Often, the best gift we can give someone is the gift of high expectations.

Meaning.

A cousin to the idea that pain is avoidable is that it’s meaningless. This is the final, subtle impact of the DSM’s growth: that is has ushered more and more suffering under its medicalized, meaningless umbrella. Which is a shame, because meaning is the greatest salve to suffering that I’ve known.

Remember, much of what the DSM calls a disorder was once something without a name. But people still suffered from it. It’s just that without such a pervasive infrastructure of mental health services, terminology, and awareness, people would take these indistinct problems elsewhere: church, the bowling alley, friends and family, nature, art and the humanities, wherever. As discussed earlier, these were more resilient solutions because they required less. But I tend to think they were more meaningful, too.

I think we have mostly forgotten that suffering can be meaningful, that it can help define us:

An aged man is but a paltry thing,
A tattered coat upon a stick, unless
Soul clap its hands and sing, and louder sing
For every tatter in its mortal dress.

How to navigate suffering is a question as old as humanity itself, and has been the impetus for much of our most cherished art, philosophy, and religion. I owe much of my life’s meaning to my teachers in the humanities, whether literature, poetry, or classics:

Delicate Adonis is dying, Cytherea, what shall we do?
Rend your tunics, girls; beat your breasts.

In my opinion, it’s not only the mental health industry. Our culture, too, is losing its feel for how to guide people through suffering. Many cultures of the past relied on myths, ceremonies, and traditions to help make sense of individual or group hardship. Many had a distinct and unwavering sense of what to do with the experience of various forms of pain. In our increasingly medicalized world, though, suffering is becoming more and more unnecessary, meaningless, individual, and sterile. I mean, cognitive-behavioral therapy assigns homework, and when I went to get my inner ears checked out as a possible cause for dizziness, the technician didn’t even speak to me.

As Illich (2010) so brilliantly puts it:

Medical civilization, however, tends to turn pain into a technical matter and thereby deprives suffering of its inherent personal meaning. People unlearn the acceptance of suffering as an inevitable part of their conscious coping with reality and learn to interpret every ache as an indicator of their need for padding or pampering. Traditional cultures confront pain, impairment, and death by interpreting them as challenges soliciting a response from the individual under stress; medical civilization turns them into demands made by individuals on the economy, into problems that can be managed or produced out of existence.⁹

In a culture that has forgotten the value of resilience and is manufacturing more ways to suffer by the day—all while incentivizing the continuation of suffering—what is a person to do? Over half of the U.S. population will at some point in their lives qualify for what the clinical community has, with limited valid scientific justification, deemed a disorder.

Over the past few decades, we have created an incredible science of suffering. Has this in some way obscured the art of suffering well?

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REFERENCES

Harrington, A. (2019). Mind fixers: Psychiatry's troubled search for the biology of mental illness. WW Norton & Company.

Illich, I. (2010). Limits to Medicine. Marion Boyars.

Insel, T. (2022). Healing: Our path from mental illness to mental health. Penguin.

1. https://deserthopetreatment.com/co-occurring-disorders/history/

2. Insel, T. (2022), p. 126-127.

3. I recommend Tom Insel’s Healing, Anne Harrington’s Mind Fixers, and Abigail Shrier’s Bad Therapy for excellent accounts of the mental health industry’s various failures.

4. The idea that all therapies are roughly equally effective is sometimes called the “Dodo bird verdict.” As you would expect, there is significant controversy surrounding it. My take, which I’ll dive into in a future post, is that it’s largely true. Some techniques are better than others for specific issues—for example, exposure therapy is much more effective in treating panic disorders than psychodynamic therapy—but for the most part, I think common factors such as therapeutic alliance are more important than the differences various therapies squabble about (e.g. whether conversation follows an agenda or is free-associative).  

5. “In spite of all the…declarations of revolutionary science driving change…psychiatry had actually had no good new ideas about molecular targets for diagnoses and treatments since the 1950s.” – Harrington, A. (2019), p. 5-6. Emphasis original.

6. “For decades, [the pharmaceutical companies] had struggled to create novel drugs using molecular targets discovered in the 1950s and early '60s. They had then marketed what they had in their vaults, while innovating around the edges. But now the difficulties of meeting even the basic requirements of new clinical trial protocols were defeating them...One after another...the big companies abandoned the field of psychiatry." (p. 266)

7. p. 276, emphasis original.

8. Illich, I. (2010), p. 44.

9. p. 133-134.