Dealing with Chronic Pain

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Pain is not simply the cause of suffering. Suffering can also be a cause of pain.

We must reject Descartes's meaning-free model of pain causation.

The experience of pain must have causal force and survival value if it evolved and persisted in humans.

We should not abandon the distinction between pain and suffering, but consider pain a type of suffering.

There has been a lot of debate about our Pain Essay, "Questioning the Boundary Between Pain and Suffering." We argued that pain is not simply the cause of suffering, but that the two have a more complex, interdependent relationship. This arises partly from our decades of caring for patients with chronic pain. The standard view of many patients and clinicians is that these patients have one central problem, chronic pain, from which all their other problems flow. But these patients have many problems: medical problems, psychological problems, and social problems that feed off one another. They have both real pain and real suffering.

Modern pain medicine clinicians are accustomed to understanding suffering as a result of pain, with pain reduction as the principal means for addressing suffering. Once the relationship between pain and suffering is understood to be bidirectional, suffering can be understood as a cause as well as an effect of pain. Suffering and pain can be relieved through changes in meaning as well as reductions in sensation intensity. Over 300 years ago, René Descartes started modern mechanical understandings of pain with his image in Treatise On Man of a boy with his foot in some fire. This image created a scientific ideal of meaning-free pain mechanisms that must be rejected. We must put Descartes’s boy with his foot in the fire back into a context that helps explain why his foot is in the fire as well as how the flames produce pain. Years ago, pain pioneer Patrick Wall contrasted how one would feel after hitting one’s own thumb with a hammer with how one would feel after someone else hit one’s thumb with a hammer. This difference can't be explained with Descartes's model.

Some pain experts continue to insist that we can't explain pain without reference to tissue damage and nociception (nerve activation by tissue damage). This ignores some very common chronic pain syndromes like fibromyalgia. These are considered a type of "nociplastic" pain that arises from brain processes and may involve no tissue damage or nociception at all. This type of pain is thought to have especially weak links to tissue damage and strong links to psychological trauma.

These pain experts argue that both suffering and pain are experiences, not “things” that can cause other things, events, or experiences. This is a version of the philosophical doctrine of “epiphenomenalism” that recognizes mental experiences like pain as real, but denies them any causal force. On this view, the brain produces experiences which have no effect on brain processes or anything else, including voluntary actions (which are considered an illusion). This view considers only mechanical causes to be real causes, for only these operate like billiard balls striking one another. Furthermore, we must ask, if experiences like pain have no causal force, how did they evolve and persist? How can the evolution of pain be explained if pain has no causal force or survival value?

Our main argument is that we have too readily separated suffering from pain and understood suffering as the causal product of pain. In its purest form, this perspective portrays pain as the product of impersonal causes (like tissue damage and nociception) and suffering as the product of personal meanings (like threat, danger, and loss). But this is not consistent with modern pain neuroscience, nor with the complex interweaving of pain and suffering encountered in the clinical practice of pain medicine and pain psychology.

Perhaps we need to consider suffering as equally valid to nociception as a cause for pain. This shift would be easier to apply to chronic pain than to acute pain. But that is where the major unsolved problems in pain medicine are to be found. Indeed, some of the newer psychotherapies for pain, such as Pain Reprocessing Therapy (PRT) and Emotion Awareness and Expression Therapy (EAET), target experiences of threat, danger, and psychological trauma as a means of providing pain relief.

This subordination of pain to suffering would disrupt the medical model underlying most pain medicine. It would cease to prioritize pain as the bodily cause of suffering. It would instead subsume pain under suffering understood as an inescapable feature of human existence. This is similar to the understanding of suffering in Buddhist philosophy as portrayed in the Four Noble Truths. The first of these is the Truth of Suffering (Dukkha). This states that life inherently involves dissatisfaction, pain, and instability. This includes physical pain, emotional distress, and the impermanence of pleasure. The remaining truths explain that suffering is caused by craving, desire and attachment to transient things. And that it is possible to end suffering by letting go of craving and attachment.

Dealing with Chronic Pain

Take our Depression Test

Find a therapist to help with chronic pain

This is not meant as a proposal to turn pain medicine into a form of religion. It is only to suggest what might be involved if we move suffering from the periphery of our clinical and research concerns to the center.

Sullivan MD, de C Williams AC. Questioning the boundary between pain and suffering. Pain. 2026 Jan 1;167(1):1-7. doi: 10.1097/j.pain.0000000000003767. Epub 2025 Sep 12. PMID: 40952907.

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