They have ADHD. They have anxiety, depression, OCD or trauma. Their relationship is toxic. They are on the spectrum.

When I try to understand what is troubling them, they sometimes hesitate to explain beyond simply naming their diagnosis. Many have relied heavily on social media, including Instagram, YouTube and TikTok, as well as conversations with their peers. They have spent hours comparing their private experiences with the public accounts of strangers and then discussing those comparisons with their friends.

I have come to think that much of the time, the use of clinical language is their way to summarize what they are feeling and experiencing. A way of compressing it into a single word or phrase. Since I am a doctor, perhaps they expect me to unpack that summary, to infer their feelings, experiences and difficulties contained within the diagnostic labels.

Often, their diagnosis is right on the nose. A young woman who believes she has ADHD may meet the clinical criteria, just as someone who describes herself as depressed may be experiencing a major depressive episode and need treatment.

In other cases, her diagnosis is providing a different, equally valuable function. It gives a label to distress that she cannot yet describe in ordinary language.

“I have ADHD” may mean, “I cannot keep up.”

“I have anxiety” may mean, “I am afraid of disappointing everyone.”

“I am depressed” may mean, “I feel alone, exhausted and unable to imagine that my future will improve.”

“My mother is toxic” may mean, “She repeatedly hurts me, and I do not know how to explain why it affects me so deeply.”

Her suffering is real, even if her words may be clinically off target.

Describing complex emotional experiences with short clinical terminology has been called “therapy-speak.” This is usually meant pejoratively. Though this is not entirely undeserved, therapy-speak can serve a real purpose. It provides a person with a vocabulary for experiences that previously felt private, confusing or illegitimate, gathering her fears, failures and painful contradictions under a recognizable label. Her diagnosis can organize an emotional mess. It can reassure her that other people feel the same way and allow her to feel connected by seeing herself in the stories of others.

Explanation can take the place of shame and confusion.

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A girl who believes she is lazy, disorganized or defective may feel enormous relief when she discovers ADHD, because her diagnosis tells her that her difficulties have a cause and gives her an account of herself that does not depend upon personal failure.

Her relief has psychological value even when her diagnosis might later prove misplaced. Her label has already revealed something significant. She needs an explanation for why ordinary life feels unusually difficult, and she fears that the explanation may be that she is fundamentally inadequate.

There is another reason young women may reach for psychiatric language. Their ordinary expressions of pain often fail to command attention.

A girl who says she is unhappy may be told that everyone feels unhappy sometimes. If she says she is tired, she may be told to sleep more. If she says her schoolwork feels overwhelming, an adult may remind her that she is intelligent, capable and earning good marks.

Then she says she has depression.

Her conversation with the adults around her changes. Her distress has acquired medical authority, and they become less able to dismiss what she is describing as moodiness, immaturity or adolescent exaggeration.

Her diagnosis becomes a claim to recognition.

Its meaning may be simple: “I need you to believe that this is serious.”

When our culture requires a diagnosis before it respects suffering, people might begin to describe every form of suffering as a diagnosis. Young women have learned that their clinical labels receive responses that their ordinary human pain often does not.

This creates a difficult clinical problem. Their diagnostic language can open a conversation, giving both patient and physician a place to begin. Yet there is a danger of oversimplification. The same language that begins the conversation risks narrowing it once a diagnosis has been accepted as the complete explanation.

A psychiatric label identifies a pattern but does not explain a whole person.

Her anxiety can arise from her temperament, family conflict, social pressures, perfectionism, uncertainty, grief, trauma or several of these at once. Her difficulty concentrating may reflect ADHD, though it may also arise from insomnia, depression, fear, chronic pain, loneliness or the cognitive demands of spending hours each day online.

Once her diagnosis becomes the entire explanation, her curiosity can stop. “I have anxiety” may replace her harder questions: What am I afraid of? Whose approval am I trying to secure? What anger am I suppressing? What do I imagine would happen if I disappointed someone?

Those questions are harder for a reason.

Her label can also become her identity during a period when that identity is still developing. Adolescence requires experimentation, as young people try different friendships, values, ambitions and versions of themselves, discarding some and keeping others as they gradually discover who they are.

Her diagnosis can become so central that she interprets every new experience through it.

A young person may cease to think of herself as someone who experiences anxiety. She becomes an anxious person, and before long she is interpreting her future, her relationships and her abilities through that single category.

Her description becomes her forecast.

My responsibility as her physician is to listen seriously without assuming that every diagnostic term is being used literally. I need to hear the message contained within her label and understand what she is trying to tell me through the language available to her.

When she tells me that she has ADHD, my first question does not have to be whether she meets the formal criteria. I can begin by asking, “What has been difficult for you?”

When she describes herself as depressed, I can invite her to tell me more about her feelings.

When she calls one of her relationships toxic, I can ask what happened, how often it happened and how it affected her.

These questions preserve the possibility of her having a clinical diagnosis while allowing her fuller account to emerge, one that includes her family, her relationships, her fears, her ambitions and her private understanding of herself. They communicate that I believe her experience without prematurely confirming her interpretation of it.

My curiosity gives her somewhere to go.

It allows her to move from her category towards her experience, from “I have anxiety” towards “I am terrified that everyone will discover I am not as capable as they think.” It turns her declaration into our conversation.

That translation is valuable. We need to hear about their sleepless nights and relentless self-criticism. We need to explore their friendships that feel humiliating, their parents whose approval is conditional, and expectations they cannot meet. We need to uncover the private fear that something inside them is fundamentally wrong.

Therapy-speak is often the imperfect attempt to make suffering intelligible. It is the language available to a generation raised online, where psychiatric concepts circulate freely and a diagnosis can provide explanation, legitimacy and community all at once.

My task is to understand what their language is trying to accomplish. Their label may be seeking recognition. It may be asking for protection, exchanging their self-blame for a medical explanation or expressing their need to belong somewhere.

Above all, it may be their request to be taken seriously.

I should answer that request.

Then I can help them find words for the full complexity of what they are experiencing, including the parts that cannot be compressed into a checklist or captured by a single clinical term. Their diagnosis may eventually become part of their account.

It should never be the end of their story.

I’m a family doctor in British Columbia, Canada. I write about the intersection of health, science, and belief. If this speaks to you, please consider subscribing or sharing.

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To help explain, let me share a typical conversation I have in my office, that has nothing to do with children or vaccines.

A middle-aged patient comes in to review the results of his latest blood tests. A few months earlier, we had started a statin medication for his high cholesterol. Now his numbers are looking good. His cholesterol has fallen substantially, and he has had no side effects. Together with improvements in diet and exercise, the medication has reduced his future risk of heart attack and stroke.

He is pleased with the results. Then he asks, “So, can I stop taking it now?”

I am confused. Did I somehow fail to explain why we were starting the medication? Did I inadvertently give the impression that lowering cholesterol was a temporary project, something we would complete and then move on from?

The treatment worked exactly as expected. Then, the success somehow made the treatment itself seem unnecessary.

Here we can see how providing preventive health faces an odd problem. When prevention works, the thing being prevented tends to fade from view. Eventually, people begin to wonder whether the treatment was needed in the first place.

This is especially true of perhaps the most successful medicines ever developed.

Vaccines.

Few medical interventions have prevented so much death and disability at so little cost.

The terrifying menace of smallpox has been entirely eliminated. The devastating disabilities from polio have been vanquished for most of the world.

Before vaccination, measles was so contagious that infection was practically universal in childhood. It killed roughly one child for every five hundred who caught it. When virtually every child eventually became infected, this translated into an enormous toll. And until this year, it was eradicated from North America.

Vaccination pushed these diseases so far out of everyday experience that we began to forget how many children they killed, paralysed, blinded or left with permanent neurological injury.

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The disappearance of these diseases changed the public’s perception of vaccination. While the disease became abstract, the vaccine remained visible.

A parent witnesses the needle entering their baby’s thigh and might see a fever that evening. They can read the list of possible side effects on an information sheet. What they cannot see is the case of meningitis that never had a chance to take their daughter’s life, or the polio that robbed their son of his mobility.

Preventive medicine produces invisible victories. And it turns out that invisible victories are surprisingly easy to doubt.

That is part of the context surrounding the US president’s latest attempt to rewrite childhood vaccination policy in the United States.

His executive order would reduce the number of vaccines routinely recommended for American children from seventeen to eleven. Vaccines against measles, mumps and whooping cough would remain on the standard schedule. Others would be restricted largely to children considered at higher risk. Vaccination against rotavirus, influenza and COVID-19 would become primarily a decision between parents and their doctors.

At first glance, that sounds reasonable. Parents already make medical decisions for their children in consultation with physicians. But changing a vaccine from a routine recommendation to something parents are expected to actively choose changes behaviour. Routine vaccines tend to get given. Optional vaccines require another decision, another conversation and often another appointment. Each extra decision creates an opportunity to postpone, forget or simply decline.

So the change is not merely administrative language. It will predictably reduce vaccination rates, even among parents who are not opposed to vaccines at all. Many would simply never get around to saying yes.

The proposal also calls for dismantling one of the most familiar vaccines in modern medicine. For decades, children have received a single injection with the wildly successful MMR vaccine, protecting them against measles, mumps and rubella.

Trump and his Secretary of Health, RFK Jr, want those vaccines separated and administered over several visits. His explanation during the Oval Office signing was revealing. He described children receiving “large amounts” of vaccine. He talked about “vats of vaccine” being “pumped” into their bodies and proposed giving smaller portions over multiple appointments so that the child’s body could “handle the amount of fluid.”

It is powerful imagery. A vat sounds industrial compared to a fragile, vulnerable baby. Put the two into the same sentence and an emotional conclusion almost writes itself.

The problem is that this is not how immunology works.

The danger of a vaccine cannot be inferred from the volume of liquid in the syringe. Nor does dividing an injection into smaller amounts necessarily make it safer. Vaccines work by presenting the immune system with specific biological signals, called antigens, that allow the body to recognize a true pathogen later.

A child’s immune system handles vastly more antigenic material during ordinary life than it encounters through routine vaccination. Every breath, meal, scraped knee and handful of playground dirt introduces the body to an enormous microbial world.

The immune system was built for this.

The childhood vaccine schedule is therefore based on a series of practical scientific facts. The schedule is not sacred scripture. It changes. New vaccines are added. Recommendations are revised. Some vaccines are restricted to certain populations. Doses are moved when evidence shows that another schedule works better.

That is medicine functioning normally.

The unsettling part of the current proposal is that the scientific evidence has not suddenly changed. Only the political instructions have changed. That discrepancy will generate uncertainty, and uncertainty has always been fertile ground for vaccine anxiety.

The anxiety itself deserves more sympathy than contempt.

Parents are being asked to make decisions for healthy children. The child in front of them does not have measles, tetanus or meningitis.

Then a clinician proposes an injection against a danger that the parent may never have witnessed. Any immediate reaction to the vaccine becomes tangible. The prevented disease remains hypothetical.

A hundred years ago, parents feared the disease. Today many parents fear the intervention. That change was produced partly by the extraordinary success of vaccination itself.

Consider measles again.

Before widespread vaccination, almost every child eventually caught it. Most recovered. Some developed pneumonia. Some developed encephalitis. Some died.

There was also a rare and particularly grim complication called subacute sclerosing panencephalitis, or SSPE, in which measles virus persisted in the brain and caused progressive neurological deterioration years after the original infection.

Parents once understood measles through experience - family, friends, neighbours. Now many understand it through memory, anecdotes or social media.

The same is true of polio.

Images of iron lungs once represented one of the great fears of childhood medicine. Thousands of children developed paralysis during major outbreaks. Vaccination transformed polio from a common public fear into a historical reference.

Then came a strange cultural inversion.

People began scrutinizing vaccines with greater intensity precisely because the diseases they prevented had become difficult to see. This is one reason vaccine misinformation can be so persuasive. Even when they are false, stories of adverse effects are vivid and visible. My child received a vaccine and three days later, something happened.

Human beings are exceptionally good at constructing causal stories from sequences.

If ten million children receive a vaccine, some will develop seizures afterward. Some will be diagnosed with autism. Some will develop diabetes. Some will develop cancer. Some will die. Those same events would also occur, at the same frequency, in a population of ten million unvaccinated children.

The vaccine-autism controversy remains perhaps the most famous example. A small 1998 paper suggested an association between the MMR vaccine and autism. The study was eventually retracted, when it was learned to have been based on fraudulent data and faulty methodology. Subsequent research involving enormous populations firmly disproved the claim.

Yet the idea survived. Bad information can acquire an afterlife.

Once a frightening possibility enters public consciousness, disproving it is much harder than introducing it. The new executive order exploits that psychological environment.

Separating MMR into several injections may sound cautious. It may feel gentler. It may reassure parents who worry that several vaccines at once somehow overwhelm the immune system. But there is currently no routine supply of separate vaccines that would allow the proposed system to function as described.

There is also a mundane logistical problem. Three visits create three opportunities to miss an appointment. Parents work, kids get colds, cars break down, and families move. Appointments are forgotten.

Public health programs succeed partly because they make the whole process easier.

One injection protecting against three diseases is easier to deliver than three injections administered on three different occasions. Every additional step creates another point where protection can fail.

Trump also seeks to weaken state requirements linking vaccination to school attendance. That raises a different question. How private is a vaccine decision? A person may reasonably argue that what enters their child’s body should remain a family decision.

But infectious disease does not respect the boundary of the family.

A child with measles will infect other children. One of those children may be too young to have been vaccinated. Another may be receiving chemotherapy. Another may have an immune disorder. Another may have received the vaccine but failed to develop sufficient immunity.

Vaccination policy therefore involves both individual medicine and population medicine. That tension has existed since vaccines were invented.

Smallpox vaccination produced fierce resistance in the nineteenth century. Anti-vaccination organizations flourished in Britain and North America. Protesters argued that compulsory vaccination violated bodily autonomy. Some believed the vaccine itself was dangerous. Others distrusted governments and medical authorities.

While the slogans have changed, the conflict is ancient.

Medical authorities should therefore resist the temptation to treat vaccine sceptics as stupid. Distrust is not cured by ridicule. People deserve clear explanations of benefits, risks and uncertainty. Vaccines do have adverse effects. Nothing biologically active is entirely without risk.

Medicine operates through probabilities. So does infectious disease. So the correct scientific claim is that vaccines’ risks can be measured, compared with the risks of the diseases they prevent, and incorporated into recommendations based on evidence.

The central question is therefore simple. What evidence justifies changing the schedule?

If separating vaccines reduces serious adverse events, demonstrate it. If spacing doses produces better immune responses, prove it. If a combined vaccine creates a significant danger, show us the evidence. If certain childhood vaccines provide too little benefit to justify routine use, tell us why.

That is how effective healthcare advances. This is the approach that has led to near elimination of previously devastating infections. Public health now faces a peculiar consequence of this enormous success. Several generations have grown up without seeing the staggering loss many vaccine-preventable diseases can inflict.

The suffering has faded from our cultural memory. That creates the perfect environment for a perverse logic that asks - perhaps we never needed all these vaccines after all ?

I’m a family doctor in British Columbia, Canada. I write about the intersection of health, science, and belief. If this speaks to you, please consider subscribing or sharing.

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When her sister called late at night, she answered. When a co-worker asked her to cover another shift, she agreed. When her partner became upset, she cancelled her own plans and stayed home to help him feel better. No single decision seemed serious on its own. She was being generous, dependable, and kind.

Over time, though, the requests became expectations. Her sister was offended when she did not answer her texts immediately. Her co-worker stopped asking whether she was available. Her partner treated any attempt to spend time alone as rejection.

She began waking with a tightness in her chest. The sound of her phone made her anxious. She rehearsed explanations for ordinary decisions and felt guilty whenever someone was disappointed. At work, she found it difficult to concentrate. At home, she became irritable and withdrawn. She stopped making plans because someone would probably need her.

There was no single event that explained why she felt so depleted. Gradually, her time, attention, and emotional energy no longer felt like they belonged to her. She felt anxious, resentful, exhausted, and increasingly helpless.

Each small accommodation had given other people greater access to parts of her life that she had never consciously agreed to surrender. What began as generosity had developed into a genuine mental-health problem.

Little by little, she had lost something she had never even known she needed: a clear sense of her own personal boundaries. That gap was at the centre of the problem.

Personal Boundaries

Personal boundaries are the limits that define what we will accept, what we will share, and how close another person is allowed to come.

They affect every kind of relationship. In intimate partnerships, boundaries govern privacy, sex, money, time, emotional responsibility, and conflict. With friends, they determine how much support we can give, how often we are available, and what kinds of behaviour we will tolerate. At work, they protect our time, role, dignity, and professional judgment. With customers, clients, or patients, they preserve the distinction between service and personal obligation. Within families, they help parents, adult children, siblings, and partners remain connected without treating one another as property.

The People Who Cross Boundaries

The difficulty with boundaries usually begins when another person fails to recognize or accept our limits. There may be many reasons for this.

Some people ignore boundaries because they are entitled, controlling, impulsive, or accustomed to getting their way. Others have such a strong need for reassurance, attention, closeness, or control that they lose sight of the burden they place on those around them. Some simply have poor awareness of boundaries and fail to recognize when their questions, demands, advice, or presence have become intrusive.

Manipulative people often challenge boundaries indirectly. They may use guilt, anger, flattery, withdrawal, urgency, helplessness, or accusations of selfishness. Instead of openly saying, “I do not respect your limit,” they pressure the other person to abandon it voluntarily.

People who cross boundaries because they have a poor awareness of social norms may be kind and well-meaning. Their behaviour may be unintentional, but the absence of malice does not erase its effect on others.

The People Who Struggle to Set Them

A person’s ability to recognize and defend a boundary also varies. There are many reasons someone may allow their boundaries to become blurred.

People who fear rejection often struggle to say no. Those raised in volatile, neglectful, or highly controlling families may have learned that safety depends on pleasing others. Caregivers may feel responsible for everyone around them. People who are lonely, anxious, financially dependent, disabled, exhausted, or recovering from abuse may tolerate treatment that they would readily identify as unacceptable for someone else.

Some highly capable people also have weak boundaries. They assume they can manage difficult personalities through patience, intelligence, or skill. They focus on whether they can survive the interaction and overlook what repeated exposure is doing to them emotionally.

Setting a boundary does not require proof that the other person is malicious or uncaring. It begins with recognizing how a relationship is affecting you, deciding what access remains acceptable, and communicating that decision openly but firmly.

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Recognizing When a Boundary Is Needed

Many people struggle to recognize when a boundary has been violated because they expect the violation to be overt or dramatic. Often, the first signs are felt internally. When boundaries are crossed, we may experience discomfort, resentment, tension, or dread. We may feel uneasy before seeing someone, drained afterward, resentful about requests we agreed to, or unusually anxious about disappointing them. We may rehearse conversations in advance, explain ordinary decisions at great length, or avoid checking our phone because we expect another demand.

These reactions often mean that some part of the relationship has exceeded our capacity or crossed into territory that no longer feels acceptable. We may not yet recognize that a boundary has been crossed, but our internal response is already telling us that the current arrangement has become emotionally and cognitively taxing.

This may indicate that we are agreeing to or permitting things that we genuinely do not want to accept.

When you feel this way, it can help to look at three things directly. First, pay attention to the interactions that regularly leave you feeling diminished, invaded, guilty, or angry. Then consider whether you have begun to feel responsible for the other person’s feelings or choices. Finally, notice whether you are tolerating unacceptable behaviour because you fear their reaction.

Another useful exercise is to consider what advice you would give someone else in the same situation.

It is also worth looking for patterns rather than treating every incident in isolation. Anyone can be inconsiderate, impatient, needy, or intrusive from time to time. The concern becomes clearer when the behaviour keeps repeating or the relationship depends on one person continually yielding.

Deciding What the Boundary Is

Once you recognize that something needs to change, the next step is to make the boundary concrete enough to act on. “I need more respect” expresses a genuine need, but it does not tell either person what will happen. “I will end the conversation if I am insulted” gives that need a practical form. Likewise, “I need space” may become, “I will respond when I am ready rather than immediately.”

A useful boundary focuses on your own actions. You cannot force another person to stop shouting, criticizing, borrowing money, arriving unannounced, or sending messages late at night. You can decide what you will do when that behaviour occurs.

In many situations, a practical boundary has three parts:

• the limit itself;

• the response if that limit is crossed; and

• a clear explanation of both.

You might say, “I am willing to discuss this, but I will leave if you begin insulting me,” or, “Please call before coming over. I will not answer the door to unplanned visits.” Other boundaries may be even simpler: “I cannot lend you money again,” or, “I will not discuss my parenting decisions with you.”

The wording will vary, but the principle remains the same. The boundary identifies what you will accept and what you will do if that limit is crossed.

Saying It Clearly

People often weaken a boundary by explaining it until it begins to sound negotiable. They anticipate objections, try to prevent hurt feelings, and offer so much background that the other person begins debating the reasons rather than hearing the decision.

Most boundaries need fewer words than the person setting them expects.

“I cannot do that.”

“That topic is private.”

“I will not continue this conversation while I am being shouted at.”

A brief explanation may be appropriate, especially in a valued relationship where both people generally act in good faith. Repeated justification is different. Difficult people often treat explanations as openings. They challenge each reason, propose exceptions, dispute your memory, or insist that the circumstances are different this time.

Consistency makes a boundary credible. A direct, calm, specific statement is usually enough. You are informing the other person of a decision. You are not asking them to approve it.

Following Through

For many people, stating the boundary is easier than enforcing it. The real difficulty begins when the other person becomes upset, disappointed, angry, or persistent. When a person states a limit and then abandons it as soon as there is resistance, the other person learns that pressure works.

Following through may mean ending the call, refusing to reopen the argument, reducing contact, or documenting workplace behaviour. In some circumstances, you may need to involve a supervisor, union representative, regulator, or lawyer. The response should be proportionate, realistic, and within your control.

Following through often feels uncomfortable because it interrupts an established pattern. You may feel guilty, anxious, or tempted to soften the limit immediately. That discomfort reflects the difficulty of changing the relationship. It does not indicate that the boundary itself is unreasonable.

Expecting Blowback

People who benefited from weak boundaries often react badly when the arrangement changes. They may accuse you of being selfish, cold, dramatic, controlling, disloyal, ungrateful, or cruel. They may remind you of everything they have done for you, withdraw affection, manufacture urgency, recruit other people into the dispute, or present themselves as the injured party.

This reaction can be powerful because it activates the very fears that made the boundary difficult to set in the first place. A person who fears rejection may panic when someone becomes angry. Someone who has spent years keeping the peace may interpret conflict as proof that they have done something wrong.

When blowback begins, it usually helps to avoid defending yourself point by point. You can acknowledge the reaction without reopening the decision: “I understand that you are upset, but my decision remains the same.”

With manipulative people, every additional explanation can become new material for pressure. Repetition is often more effective than persuasion. This is sometimes called the broken-record approach because you keep returning to the same brief position without being drawn into side arguments.

You are not trying to win an argument. You are refusing to reopen a decision you have already made.

Managing Guilt and Doubt

Guilt often appears after a boundary, even when no wrongdoing has occurred. People who have spent years accommodating others may interpret self-protection as selfishness, and they may feel a powerful urge to relieve the other person’s disappointment immediately.

It helps to separate guilt from responsibility. Guilt is an emotional response. It is not proof that you have done something wrong. You may feel guilty because someone is disappointed, but disappointment is not the same as harm. Their reaction does not make you responsible for changing your decision.

When doubt appears, consider whether you communicated the boundary respectfully. Ask whether the limit concerned your own time, body, money, privacy, or emotional capacity. It is also worth considering whether you were responding to a repeated pattern.

Getting Support

Boundary-setting becomes much harder when the other person is intimidating, financially controlling, emotionally abusive, professionally powerful, or capable of retaliation. In those situations, support may be essential.

Depending on the circumstances, a trusted friend, therapist, physician, union representative, manager, or lawyer can help you assess the risk and plan your response. Workplace boundaries may require careful documentation. Family boundaries may require reduced contact or communication through another person.

Intimate relationships involving threats, coercion, stalking, financial control, or violence require careful safety planning. A direct confrontation may place the person at greater risk. In these situations, an organization that supports people experiencing domestic violence can provide safe and informed guidance.

Learning Through Practice

Boundary-setting is a skill, and like any skill, it improves through repetition. It often helps to begin with smaller situations where the risk is limited. You might decline an invitation without inventing an excuse, allow a message to wait, ask someone to lower their voice, or end a conversation that has become intrusive.

Then notice what happens inside you before, during, and after. You may feel relief, guilt, anxiety, anger, or an urge to reverse the decision. These reactions are useful information. They help reveal which fears have been governing your behaviour and which relationships have been sustained by your lack of limits.

Over time, the rational self becomes a better representative of the whole person. It learns to treat discomfort as information, tolerate another person’s disappointment, and protect parts of the psyche that may not be able to argue their own case.

A boundary becomes real when the limit is recognized, stated, and defended. Awareness begins the process, language gives it form, and action gives it force.

I’m a family doctor in British Columbia, Canada. I write about the intersection of health, science, and belief. If this speaks to you, please consider subscribing or sharing.

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As he worked, he noticed that a fluorescent screen lying several feet away had begun to glow.

The observation made no sense. The tube was completely covered, yet something invisible had travelled across the room carrying enough energy to illuminate the screen.

Unsure what he had found, he gave the phenomenon a deliberately cautious name. In his first paper, published in his native German, he called them X-Strahlen, or X-rays in English. The X was the mathematical symbol for an unknown quantity, reflecting his uncertainty about the nature of this new phenomenon.

One evening he asked his wife, Anna, to place her hand on a photographic plate while the mysterious rays passed through it. When the plate was developed, the delicate outlines of the bones in her hand appeared beneath the shadow of her wedding ring. She gasped, “I have seen my death.” For the first time, a living person had looked beneath her own skin without a surgeon lifting a scalpel.

It did not take long for physicians to recognize the possibilities. Within months, doctors around the world were using the new rays to locate fractures, bullets and swallowed objects with a degree of certainty that previous generations could scarcely have imagined. Medicine had acquired an entirely new way of seeing.

That achievement alone would have secured Röntgen a place in history. Yet the story of radiation did not end with the discovery of X-rays. It was only beginning. Radiation would become one of medicine’s greatest diagnostic tools, one of its most effective cancer treatments, and one of its greatest ethical challenges.

What Is Radiation?

Radiation, simply put, is just energy travelling from one place to another.

Every day we encounter and appreciate radiation from many sources – the visible light from the sun that allows us to see, the infrared radiation delivering warmth from a flame, the radio waves carrying voices through the air, and the microwaves that reheat this morning’s coffee. The underlying phenomenon transmitting these varying effects is the same, only their energy levels differ.

These examples are all from the lower-energy part of the radiation spectrum. From the imperceptible passing of radio waves to the gentle breath of visible light, there is little lasting effect on the matter it touches.

But as the energy of radiation waves increases, so does its impact.

We are all very familiar with ultraviolet (UV) light. Although we can’t see UV radiation, as anyone who’s been to the beach knows, it still leaves its mark. Too much time in the sun’s UV light will damage skin cells, cause a sunburn and increase the risk of skin cancer. Its invisible energy is greater that the visible and infrared light we see and feel.

Ultraviolet waves occupy the boundary between familiar forms of radiation and the much higher-energy radiation such as X-rays and gamma rays. The energy carried by these more energetic types of radiation is capable of knocking electrons away from atoms and shattering chemical bonds. Physicists refer to radiation at these energy levels as ionizing radiation. This degree of energy easily damages DNA and alters the chemistry of living cells.

From radio waves and visible light to ultraviolet light, X-rays and gamma rays, it is all part of the electromagnetic wave spectrum. Radiation can also travel in another way. Sometimes the energy is carried by tiny particles, including electrons, protons and neutrons. They behave differently from X-rays or gamma rays, but they also can carry enough energy to damage living tissue, alter DNA and disrupt its biochemistry.

It is also worth recognizing that there are many sources of ionizing radiation that are a natural part of our environment. High-energy radiation routinely passes through our bodies as it rains down from outer space or emerges naturally from radioactive elements in the rocks beneath our feet. Each one of us will live our entire lives in the presence of ionizing radiation.

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One Discovery Begets Another

Röntgen’s discovery of X-rays spread through the scientific late nineteenth century world with astonishing speed as laboratories across Europe hurried to repeat his experiments. It was not long for physicians to recognize the practical importance. Within weeks they were producing X-ray images of broken bones, bullets and swallowed objects. Few scientific discoveries have travelled so quickly from the laboratory to the bedside.

Yet even as medicine was beginning to understand X-rays, another mystery emerged.

In 1896, the French physicist Henri Becquerel was exploring the properties of the element uranium when he made an unexpected discovery. He happened to leave some of uranium on top of covered photographic plates in a drawer. When he later developed the plates, he found that somehow the uranium had caused photographic exposure through their protective covering. Uranium, it seemed, was producing an invisible form of radiation all on its own.

Marie Curie immediately recognized the significance of Becquerel’s discovery. She suspected that uranium was not unique. Working through tonnes of uranium ore she eventually isolated two previously unknown elements, polonium and radium, that also emitted these mysterious rays.

Curie called the phenomenon radioactivity.

The Promise of Invisible Rays

It is difficult to overstate how revolutionary X-rays were for the practice of medicine at the turn of the twentieth century. For centuries, physicians had relied on what their own senses could tell them. They inspected the skin, listened to the chest, palpated the abdomen and inferred what might be happening beneath the surface. X-rays changed that almost overnight.

Imagine a child arriving after a fall from a horse, unable to move his arm. To detect a fracture before the arrival of X-rays, the physician would examine the limb, looking for deformity, tenderness and swelling before making what was, at best, an educated judgement. Now, for the first time, the doctor could simply look inside the arm. Guesswork gave way to direct observation. Physicians had acquired an entirely new sense.

Looking back, it is easy to imagine the excitement.

There was, however, a fundamental problem. While medicine had a remarkable new tool, it had not yet learned how powerful it really was.

The Cost of Discovery

Every powerful novel technology teaches two lessons. The first is understanding what the technology makes possible. The second is learning the costs. The first people to pay that cost were the scientists and physicians investigating this new phenomenon.

In the years following Röntgen’s discovery, X-ray tubes became common fixtures in hospitals and research laboratories. Physicians often demonstrated the new technology by repeatedly exposing their own hands, fascinated by the ability to watch the bones beneath the skin. Researchers handled radioactive materials directly, carrying small samples in their pockets, storing them in desk drawers and passing them from hand to hand. At the time, there was no reason to think these practices were dangerous.

The earliest signs seemed mild enough to explain away. After prolonged exposure skin would become red and inflamed, much like a sunburn. With continued exposure, however, the damage deepened. Hair fell out. Painful ulcers formed and failed to heal. Years later came an even more disturbing discovery. Some of those exposed developed leukaemia and other cancers.

Physicians gradually realized they were not dealing with a series of unrelated injuries, but with an entirely new form of disease. In the history of medicine, no physician had ever encountered chronic radiation injury. There were no textbooks to consult, no experienced mentors to ask and no established treatments to offer. The injuries themselves became the teachers.

Only gradually did a pattern emerge. The intensity of the exposure increased the injury as did repeated exposure. They also learned that different tissues responded differently. Bone marrow, skin, the gastrointestinal lining and the reproductive organs proved particularly vulnerable. While it might be tempting to judge these early pioneers by modern standards, that would miss the point. They were discovering dangers that no one had previously imagined.

By the middle of the twentieth century, medicine had begun to understand how to use radiation with increasing precision and respect. Just as that understanding was taking shape, the world discovered that radiation possessed another, far more destructive potential. The lessons learned in hospitals and laboratories were about to be tested on an unimaginable scale.

When Physics Became a Weapon

By the early 1940s, scientists understood enough about radioactive elements to appreciate that the enormous energy stored within the atomic nucleus might one day be released. What had begun as a scientific curiosity had become a military possibility.

The Manhattan Project brought together thousands of physicists, engineers and technicians in an unprecedented effort to build the first atomic weapons. Few fully understood what the detonation of such a weapon would ultimately mean for the human body.

When the atomic bombs were dropped on Hiroshima and Nagasaki in August 1945, the immediate devastation was unlike anything the world had witnessed. Entire neighbourhoods disappeared in seconds. Tens of thousands died instantly from the blast and intense heat. Then, something else followed. In the days and weeks after, those who survived the initial explosions soon began developing a baffling collection of symptoms. Their hair fell out. Their mouths ulcerated. Their skin peeled. Their immune systems failed. People who initially appeared unaffected by the blast were now dying.

Amid the human catastrophe, the physicians caring for survivors quickly realized they were witnessing radiation injury on a scale no one had imagined possible. Until then, doctors had learned about radiation one patient at a time. Hiroshima and Nagasaki exposed thousands of people within seconds, creating an unprecedented opportunity, born of unimaginable tragedy, to understand how massive doses of radiation affect the human body. Much of what we know today about radiation sickness, dose-response relationships and the long-term risk of cancer traces its origins to the survivors of Hiroshima and Nagasaki.

Medicine Learns to See More Clearly

By the middle of the twentieth century, radiation was no longer a mysterious force. Physicians and physicists had gradually learned how to measure it, control it and respect it. What had once been an invisible curiosity had become a carefully managed clinical tool.

By harnessing the power of radiation they developed two fundamentally different ways to look inside the body.

The first was simply to shine radiation straight through the body. Plain X-rays, fluoroscopy and CT scanning all work on this principle. A beam of X-rays passes through the body toward a detector on the opposite side. Denser tissues such as bones or tumours absorb more of the beam than soft tissues, creating the familiar images used every day in hospitals. With CT scanning, the X-ray source rotates around the patient while a computer reconstructs the hundreds of individual images into detailed cross-sectional views. Sometimes a contrast agent such as iodine is given beforehand. The contrast itself is not radioactive. It simply absorbs X-rays more readily than the surrounding tissues, making blood vessels, tumours and internal organs easier to distinguish.

The second approach works in the opposite direction. Instead of shining radiation into the body, physicians administer a minute amount of a radioactive chemical compound that travels to a particular organ or tissue. The radiation now comes from within the patient and is detected by the scanner. These studies reveal not only anatomy but also function. A nuclear stress test, for example, shows how well blood perfuses different parts of the heart muscle. PET scanning allows the tiniest, otherwise invisible tumours to reveal themselves by exploiting their sugar-hungry metabolism.

By the late twentieth century, physicians could look inside the body in ways that Röntgen could scarcely have imagined. Bones, blood vessels, organs, metabolism and even blood flow had all become visible. Yet from the beginning, many physicians had hoped radiation might do more than reveal disease.

They wondered whether it might also cure it.

Invisible Fire

In the early days of medical X-ray technology, an interesting question arose. If invisible rays could reveal a broken bone, locate a swallowed coin or pinpoint a bullet lodged deep within the body, physicians wondered, what else might they do?

Perhaps, instead of just detecting disease, these same invisible rays could also treat disease.

The first attempts focused on treating conditions close to the surface of the body, where the rays could penetrate most easily. Physicians found that repeated exposure sometimes helped skin cancers and other superficial tumours to shrink. Benign conditions ranging from enlarged lymph nodes to inflammatory skin disorders were also treated. The results were inconsistent but often encouraging enough to fuel even greater enthusiasm.

Yet, as the understanding of the physics of radiation evolved, no one really understood what radiation was doing to living tissue. Physicians could see that tumours sometimes shrank and skin sometimes ulcerated, but the underlying biology remained a mystery.

It would take decades to understand how radiation damages cells, why some tissues recover while others do not, and how a destructive dose could be concentrated inside a tumour without overwhelming the surrounding organs.

A century later, that knowledge has become part of an ordinary day in a modern cancer centre.

Consider a patient with breast cancer lying on a treatment table at the Cancer Agency. A machine slowly rotates around her delivering invisible beams through her body from several directions. She feels nothing. Where the beams intersect, her tumour receives enough radiation to shatter its DNA. The surrounding tissues receive only a fraction of that dose. Minutes later she stands, gets dressed and walks out of the treatment room.

Inside her body, changes have already begun. As the tumour cells are dying, some healthy tissue exposed along the way will also suffer. She will experience pain, skin irritation, and she will especially feel fatigue, as her body copes with the assault.

Despite the unwanted effects, modern radiotherapy represents one of medicine’s greatest triumphs. It took more than a century of physics, biology and engineering to transform a mysterious natural phenomenon into one of the most precise treatments in medicine.

While the technology is astonishingly complex, the underlying principle is surprisingly simple. Healthy cells, which generally divide more slowly, can often repair small amounts of DNA damage between treatments. Cancer cells, dividing rapidly and frequently lacking effective repair mechanisms, are much less likely to recover. By separating treatment into many carefully planned sessions, physicians exploit that biological difference.

Not every treatment works in the same way. Sometimes protons replace X-rays, depositing most of their energy at a precisely calculated depth before stopping. Sometimes tiny radioactive seeds are implanted directly within a tumour. Radioactive iodine can be swallowed, allowing the thyroid gland to concentrate the treatment exactly where it is needed. More recently, radioactive atoms have been attached to molecules that seek out specific cancers, carrying their invisible cargo directly to diseased cells.

Conclusion

When Wilhelm Röntgen noticed a fluorescent screen glowing across his laboratory, he could not have imagined where that simple observation would lead. It would change the way physicians see broken bones, guide surgeons, detect hidden disease, and help to treat cancer.

None of those possibilities existed in the glow of that screen. They emerged because one curious observation was pursued with patience, tested with rigour and gradually understood. That is how science usually advances. Curiosity comes first. Understanding takes longer.

Radiation itself is as ancient as the universe. Our understanding of its power is still very recent and continues to unfold.

I’m a family doctor in British Columbia, Canada. I write about the intersection of health, science, and belief. If this speaks to you, please consider subscribing or sharing.

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These were the years of Joseph Stalin, when terror, paranoia and authoritarian rule permeated every aspect of Soviet life. Scientists who challenged Lysenko were dismissed, imprisoned or killed. Despite decades of careful experimental work supporting Mendelian genetics, it was denounced as ideological heresy. Once Lysenko won Stalin’s confidence, his ideas became state doctrine, and ideology displaced scientific evidence. Winning the confidence of a dictator proved more powerful than the collective work of a generation of scientists.

The result was not merely bad science. Scientific progress was halted, harvests suffered, and policies built upon Lysenko’s theories contributed to years of agricultural failure and hunger. His name has since become shorthand for what happens when political power substitutes conviction for evidence.

That history came to mind when I heard the head of the U.S. military announce his ambition to create what he called a “High-T Department of War,” claiming that routine testosterone screening and hormonal “optimization” would produce a military that is “brutal and unrelenting.” Beneath the slogan lay a series of unscientific claims presented with remarkable confidence. These included the claim that testosterone deficiency is common among otherwise healthy service members; that routine screening will uncover this burden of previously unrecognised disease; that raising testosterone levels produces greater combat readiness, combat effectiveness and, in his words, increased “lethality”; and that healthy soldiers can be medically “optimized” through hormone therapy.

None of these claims has been established by credible scientific evidence. Rather, they represent a series of simplistic biological assumptions that either lack evidentiary support or contradict the findings of decades of careful research.

The appeal of this narrative has nothing to do with genuine clinical medicine. It draws its energy from a broader cultural story, one that portrays modern society as producing weaker, softer and less masculine men than previous generations. That story has been cultivated for years by podcast hosts, social media influencers, wellness entrepreneurs and, increasingly, senior political figures. It is therefore no coincidence that its latest expression comes not from an endocrinologist, a military physician or a panel of medical researchers, but from a former television personality now serving as the head of the U.S. military.

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Testosterone has become more than a hormone. It has become a cultural symbol. Declining testosterone is invoked to explain everything from falling birth rates and obesity to military preparedness, social cohesion and national decline. Complex economic, educational and cultural changes are compressed into a single biological story. Its seductive simplicity is obvious. Biology seems to offer certainty where sociology offers complexity.

That is precisely why such narratives deserve careful scrutiny. Hormones undoubtedly influence health, strength and behaviour. Yet no serious body of evidence suggests that the effectiveness of a modern military can be reduced to testosterone levels, or that routine hormone screening and treatment of healthy service members will produce a more capable fighting force. Wars are won through leadership, training, logistics, intelligence, discipline, technology and unit cohesion. Endocrinology has never occupied a prominent place on that list.

Nor has this story emerged from the scientific community. It has been advanced most enthusiastically by media personalities, wellness entrepreneurs and political figures with little or no background in endocrinology, epidemiology or military medicine. The Secretary of Defense is not even its most influential champion. A lawyer with a long history of marketing conspiracy theories and who has spent years promoting the false narrative of a testosterone crisis now oversees national health policy. Neither man built his reputation through scientific education, clinical training or biomedical research. Yet together they now influence both military and public health policy.

History offers many examples of medicine being recruited into the service of ideology. In Nazi Germany political leaders argued that decadence, intellectualism and declining masculinity had weakened the nation. Physical fitness, racial purity and military readiness became matters of state policy. Medicine, biology and public health were enlisted in service of that ideology. Scientific language was exploited to justify political objectives and cloak ideology in the authority of objective truth.

The Soviet Union reached the same conclusions through an entirely different political philosophy. One regime preached class struggle, the other racial supremacy. Yet both subordinated scientific inquiry to political conviction. Both reduced complex problems to simple biological explanations.

What united these otherwise irreconcilable regimes was not their ideology but their authoritarianism. Both concentrated power in the hands of political leaders who came to regard scientific evidence as something to be selected, directed or dismissed according to political need. Once governments begin subordinating scientific inquiry to political objectives, evidence quickly becomes secondary.

Democratic institutions provide safeguards against that process, but they do not eliminate the temptation. Whenever political leaders grow impatient with scientific uncertainty, dismiss independent expertise or reward loyalty over evidence, those safeguards begin to weaken. The institutions may remain democratic while the habits of decision-making become increasingly authoritarian. Science is especially vulnerable because it depends upon a culture that prizes evidence over certainty and expertise over political influence.

The testosterone initiative is therefore best understood not as an isolated policy but as one expression of a broader pattern. Once governments begin subordinating scientific evidence to political objectives, the same habit of mind rarely confines itself to a single subject.

Over the past several years, Americans have watched senior political leaders speculate publicly about disinfectant infusions, promote ivermectin as a treatment for COVID-19, alter official hurricane forecasts with a marker pen rather than revised meteorological data, dismiss the scientific consensus on climate change, and repeatedly reject the accumulated evidence across multiple scientific disciplines. None of these episodes stands alone. Together they reveal a style of governance in which political theatre and popular culture increasingly substitute for scientific evidence.

The history of medicine is not simply a history of discovery. It is also a history of failed ideas that ultimately succumbed when confronted by careful evidence. The scientific method does not promise certainty. It is merely a disciplined way of discovering when we are wrong. Every hypothesis must survive criticism, replication and the relentless pressure of new evidence. That process is slow, often frustrating and frequently untidy. It is also the reason modern medicine has achieved what previous generations could never have imagined.

Politics serves a different purpose. It rewards confidence, decisive action and compelling stories. Those qualities have their place in public life. They become dangerous when political power grows increasingly authoritarian. That tension has shaped some of history’s greatest scientific failures. It continues whenever governments allow ideology or popular narratives to outrun scientific evidence. When political leaders cloak policy preferences in the language of science, the scientific enterprise is no longer valued for discovering what is true, but for validating what governments already wish to believe.

Evidence gives way to narrative. Expertise yields to influence. Scientific uncertainty becomes a political inconvenience rather than an invitation to learn.

That is why this debate extends far beyond testosterone. It is about preserving the boundary between scientific inquiry and political conviction. Viruses do not recognise political parties. Hurricanes do not respond to campaign speeches. The climate remains indifferent to ideology. Nature does not take the slightest interest in our slogans, our tribal loyalties or our certainty.

Lysenko’s enduring legacy extends far beyond his failed theory of agriculture. It demonstrates the disastrous consequences of allowing political authority to determine which scientific conclusions prevail and which are suppressed. The implications extend far beyond Soviet genetics, beyond hormones and beyond any single administration. It is a warning for every society that values both scientific progress and political freedom.

I’m a family doctor in British Columbia, Canada. I write about the intersection of health, science, and belief. If this speaks to you, please consider subscribing or sharing.

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Last week, when in for a routine blood pressure review, she placed a paper bag on the counter with a small, defiant ceremony. Inside were seven supplements: collagen powder, high-dose vitamin C, “adrenal support” capsules, something called ‘Gut Harmony’, two different magnesium preparations, and a coral calcium tablet that cost, I later looked it up, sixty-two dollars for a month’s supply.

She wanted to know if I had any concerns.

I had several. But I began, carefully, with the coral calcium. There was no good clinical evidence it did anything a cheap store-brand calcium supplement couldn’t do. The “adrenal support” capsules, I explained contained licorice root at a dose that might interact with her antihypertensive. The collagen powder was being digested into amino acids like any other protein and was, at best, an expensive way to consume a small amount of glycine. I tried to be gentle. I tried to be precise. And I tried to be correct.

Margaret listened with the polite patience of someone waiting for you to finish being wrong. Then she told me about a woman from her walking group, Janet, who had been struggling with fatigue and joint pain for years before discovering the same collagen supplement. Janet now walked ten kilometres on Saturdays. She told me about a podcast she trusted, run by a former nurse, who had explained that mainstream medicine was decades behind the research. She told me about an account she followed on Instagram, a woman in Vancouver with a hundred thousand followers. She told me that her daughter, who worked in wellness, had done a lot of reading on this.

She left with her blood pressure medication adjusted and her supplement bag intact.

I thought about Margaret all week. Although her case was not unusual – in fact it is remarkable common – I thought about her because she unsettled my own certainties. Here was an intelligent, educated, critically-minded woman, and she was paying sixty-two dollars a month for ground-up coral. And she was not confused about it. She was ‘convinced’.

After thirty years of general practice, I have learned that facts are only part of the reason people believe what they believe. And changing a person’s mind requires more than simply giving them better information.

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I. The Stars Have Always Had Something to Say

Astrology is a useful starting point for exploring the enduring appeal of implausible beliefs systems. While it is one of the most familiar belief paradigms in modern culture, its central claims have been tested repeatedly and have not held up well. The position of the planets at birth does not appear to determine personality, predict relationships or explain the course of a human life.

Yet astrology continues to feel persuasive to millions of intelligent, educated people.

That makes it more than a harmless curiosity. Astrology provides a compact demonstration of the several cognitive biases that allow unrealistic beliefs to remain persuasive.

Yet every morning, millions of people read that Mercury is in retrograde, or that Scorpios should be cautious in matters of the heart this week, and they nod, and something in them feels recognised.

It would be easy – and it is a temptation I have had to consciously resist – to treat this as stupidity. It isn’t. It is something considerably more interesting.

The zodiac wheel has been refined over centuries into a masterwork of obfuscation. The statements astrology produces are carefully and exquisitely vague.

“You may find yourself re-evaluating a relationship….This is a time for patience…Your sensitivity could be both a strength and a source of tension.”

These are not predictions that can be falsified. They are mirrors, angled just so, in which almost any face will see itself reflected back with uncanny accuracy.

Astrology offers, at its core, a framework – a story about why things happen to you, about what you are, about where you fit. And human beings are, before we are anything else, story-seeking creatures. We are pattern engines. The cost of missing a pattern in our evolutionary past – that rustle in the grass, that change in a rival’s expression – was sometimes death. The cost of seeing a pattern that wasn’t there was almost nothing. We are, neurologically speaking, designed to find meaning whether it exists or not.

Rather than being a flaw in human cognition, it is the feature that built civilisation. It is also, under certain conditions, the feature that leads a perfectly rational teacher to spend sixty-two dollars a month on coral calcium.

II. The Man Who Tells You What You Want to Hear

Phineas Taylor “P.T.” Barnum was one of the great showmen of nineteenth-century America. From the 1830s until his death in 1891, he built a career out of museums, travelling exhibitions, circus acts, human curiosities and carefully staged hoaxes. He displayed a supposed mermaid assembled from the body of a monkey and the tail of a fish. He promoted performers as giants, dwarfs and medical marvels. He understood the power of publicity well.

Barnum’s genius was not simply that he deceived people. He gave them reasons to participate in the deception. His audiences wanted amazement, mystery and the delicious suspicion that the world contained more than ordinary experience revealed. Some knew they were being fooled and paid anyway. The performance worked because it offered everyone something they were already prepared to find compelling.

Twentieth Century psychologists later borrowed his name for our tendency to accept broad, general descriptions as being uniquely applicable to ourselves - they called it the Barnum Effect.

Online personality quizzes tell us that we are independent but value approval from people we respect. Mediums speak of unresolved tension with someone close to us. Populist political movements assure followers that they are the clear-eyed minority who can see what others cannot. Conspiracy theories offer hidden order behind confusing events. Wellness practitioners tell patients that they have been strong for too long, that their bodies are unusually sensitive, or that conventional medicine has failed to see the whole person.

Each belief offers a role: the misunderstood patient, the independent thinker, the spiritual seeker, the person awake to a concealed truth. Once the role feels accurate, the claims attached to it become easier to accept.

Barnum understood that people rarely pay merely to be informed. They pay to be astonished, reassured, flattered and recognised. The modern wellness industry has inherited the same insight. Tell someone that her fatigue is ordinary and multifactorial, and she may leave dissatisfied. Tell her that she has a hidden imbalance overlooked by conventional medicine, and she may feel understood for the first time.

Then show her the supplement designed to correct it.

III. The Particular Vulnerability of the Body

Medicine is, in one sense, uniquely positioned to be resistant to magical thinking. We have randomised controlled trials. We have meta-analyses and systematic reviews. We have regulators, and ethics committees, and peer review, and a culture – imperfect, contested, but real – that demands evidence before claims can be made and acted upon. We are, compared to almost any other domain of human knowledge, unusually good at being wrong and knowing it.

And yet.

The global wellness industry is currently valued at somewhere over five trillion dollars. Homeopathy posits that water retains the “memory” of substances diluted to concentrations at which not a single molecule of the original compound remains. Still, in 2026, purchased by millions of people who would describe themselves as science-literate. Detox regimens that the liver and kidneys perform automatically, continuously, and without assistance are sold in the form of teas and supplements and weekend retreats. Every year, people delay or abandon preventive therapies with solid evidence in favour of approaches that have none. Some die as a direct result.

Why is medicine so peculiarly susceptible?

The first reason is that the body is the most intimate territory there is. When we are ill, or afraid of becoming ill, the psychological stakes of uncertainty are enormous. Uncertainty is uncomfortable at the best of times. Uncertainty about your own mortality – or your child’s – is almost unbearable. A confident alternative practitioner who offers a clear explanation and a treatment plan exploits a void that science, with its carefully calibrated caveats and probabilistic language, struggles to fill. “We don’t fully understand the mechanism, but the evidence suggests this medication reduces your risk by around thirty percent” is true, and honest, and cold comfort at two in the morning.

The second reason is the power of anecdote. The human brain does not process “n=12,000 randomised controlled trial” with the same emotional weight as your friend Janet walking 10 K on Saturday. It never did. For most of human history, personal testimony from someone you trusted was the best available evidence. Today we give this a fancy name, “proximity bias.” But the machinery for intuiting credibility from a personal narrative is ancient, and fast and nearly unconscious. The machinery for critically evaluating a confidence interval is new, and slow and expensive in attention.

What is new is the scale. Janet is one person in a walking group. But the IG influencer in Vancouver is one person in front of a hundred thousand, and behind her are thousands of comments saying “this changed my life” and “I felt it within a week” and “my doctor never mentioned this.” The social proof is not just local anymore. It is a torrent, curated by an algorithm that has learned, with inhuman precision, that outrage and hope and the feeling of hidden knowledge are the emotions most likely to make you keep scrolling. The wellness influencer did not invent the appeal of anecdote. She just found a way to industrialise it. The power of anecdote, now turbocharged.

The third reason – and this one I find most troubling, because it implicates my profession directly – is that medicine has given people genuine reason to be suspicious. The Thalidomide debacle. The Tuskegee experiments. The opioid crisis, manufactured with explicit medical endorsement and the full confidence of prescribing physicians. The long dismissal of women’s pain as psychosomatic. The persistent disparities in how patients are treated depending on who they are. The long, embarrassing history of confidently-stated interventions that turned out to be wrong or harmful. Patients who are sceptical of pharmaceutical company claims are not paranoid. They are, in many cases, applying lessons that history taught them directly.

The tragedy is that this legitimate scepticism is not always aimed where it should. It slides, under pressure of anxiety and cognitive load and a persuasive podcast, from “be cautious about industry-funded research” to “coral calcium from a woman with a ring light and a detox programme.” The critical instinct is real. The target shifts.

IV. What Thirty Years Has Taught Me About Being Right

I am not immune to any of this. That is, I have come to understand, the beginning of being useful.

I believed, for the first decade of my career, that the path from ignorance to knowledge was essentially a problem of information transfer. Patients held false beliefs because they had not been given the correct facts. If I gave them the correct facts, clearly and patiently, the false beliefs would be replaced. This model was flattering to me, because it made my role straightforward. But it was almost entirely wrong.

What I know now – and the research broadly confirms this – is that people change health beliefs slowly, through relationships and experience rather than argument, and most reliably when the new belief is allowed to build on, rather than demolish, their existing sense of themselves. Margaret did not need to be told she was wrong. She needed to be understood well enough, over time, that she might eventually want to investigate her own assumptions.

I have learned to ask questions I don’t already know the answers to. What does the supplement make her feel? Not “do you think it works” – a question that raises the drawbridge immediately – but genuinely: what is the experience of taking it? Sometimes the answer reveals something about symptoms she hasn’t mentioned, or about anxiety, or about a sense of agency and control in a body that has started to feel unreliable. Sometimes the supplement is not really about the supplement at all. It is about fear. It is about her friend being well again. It is about a daughter who is paying attention.

I have also learned a harder lesson, which is that I do not always know I am right. The history of medicine is partly a history of confident doctors being confidently wrong, and there is no era in which that history ends – including this one, including me, today. Epistemic humility is not a counselling technique I deploy strategically with difficult patients. It is an accurate description of my situation. The correct response to a patient taking a supplement with no good evidence is not moral outrage but a genuine question: what am I missing about why this makes sense to them? And then: is there anything in what they’re telling me that I should take seriously?

The answer, occasionally, is yes. Folk knowledge is sometimes ahead of the published literature. Patient experience contains data that trials are too blunt to capture. I have been instructed, more than once, by a patient who came in with a paper bag full of supplements.

V. The Question That Truly Matters

Margaret still takes the collagen powder. She stopped the coral calcium – not because I argued her out of it, but because, about six months later, she looked it up herself, with fresh eyes, and decided it wasn’t worth the money. She mentioned it in passing, at a blood pressure review, in the same tone one might use to mention cancelling a gym membership you never used.

I marked it, privately, as a small victory. Then I wondered why.

The instinct to want our patients to believe correct things is not neutral. It contains within it an assumption that correctness is always what matters most, and that I am reliably the one in possession of it. Both assumptions deserve scrutiny. A patient who takes a harmless supplement and feels better – even if the mechanism is entirely placebo – and who therefore comes to trust me more, and agrees to the blood pressure medication that will actually reduce her risk of stroke – that patient is doing better in the ways that matter. Whether or not she is correct about collagen is, in the larger picture, quite a small question.

The larger question, the one that Margaret and horoscopes and populist politics and coral calcium are all circling, is this: what do we actually owe each other, as human beings trying to navigate a world that is genuinely uncertain, genuinely frightening, and genuinely too complex for any of us to fully grasp? We are all, always, working with incomplete information and evolutionary machinery that was not designed for the epistemological demands of the twenty-first century. I have a medical degree and access to the clinical literature and I still, sometimes, catch myself in motivated reasoning, telling myself that a finding I don’t like probably has a flaw I haven’t found yet.

The honest answer to why people believe things that aren’t real is that the distinction between what is real and what is not is harder, slower, and more uncomfortable to maintain than we like to admit. The comfortable lie is often not a lie about the world. It is a lie about how easy it is to know the truth.

What I can offer Margaret – what I can offer any patient – is not certainty. It is company in the uncertainty. It is thirty years of having been wrong in interesting ways, and the attention, and the willingness to keep asking. It is, I think, the most honest thing a doctor has to give.

I’m a family doctor in British Columbia, Canada. I write about the intersection of health, science, and belief. If this speaks to you, please consider subscribing or sharing.

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Even as a teenager, I found myself wondering how billions of human beings could be sorted into just two categories. The idea was appealing, but reality seemed more complicated than that.

What I didn’t discover until many years later was that the story had begun with a remarkable surgery, performed on a handful of desperately ill patients. Somewhere between the operating room and the public imagination, one of the most fascinating discoveries in neuroscience had been transformed into one of its most enduring myths.

In the early 1960s, a handful of patients with devastating epilepsy underwent one of the most extraordinary operations in the history of neuroscience.

For a small number of people with severe uncontrollable epilepsy, medications had failed. Their seizures, violent electrical storms, would often spread from one hemisphere of the brain to the other, sometimes many times a day.

In desperation, neurosurgeons attempted an radical solution. They reasoned that if the hemispheres could be isolated, the seizures might remain confined – instead of spreading to the opposite side of the brain – lessening the severity of the attacks. Their target was a thick bundle of nerve fibres buried deep between the cerebral hemispheres.

The treatment was simple in concept and radical in execution: sever the connection.

The structure is called the corpus callosum. While its Latin name translates rather prosaically as “hard body,” it scarcely captures its importance. Carrying two hundred million nerve fibres between the two hemispheres, it is the bridge through which two halves of the brain become something greater than either could be alone.

The operation to sever this bridge often worked. By sacrificing the brain’s principal connection, surgeons succeeded in containing the seizures. The seizures became less frequent, less severe, or both.

It also gave neuroscientists an rare opportunity.

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For the first time, they could investigate what each hemisphere knew and could do when communication between them had been interrupted. Researchers began testing these “split-brain” patients with a series of ingenious experiments. They placed familiar objects into a patient’s right hand and asked him to name them without looking. The patient could name the object without hesitation. When it was placed in his left hand, the very same object suddenly became impossible to name. They flashed images to one visual field, then the other, and discovered that the two hemispheres interpreted the same world in remarkably different ways.

Taken together, the experiments revealed genuine differences between the hemispheres. The left played a larger role in language and sequential reasoning. The right contributed more to spatial awareness, pattern recognition, music, and aspects of emotional expression. It was as though the brain, long assumed to function as a single mind, contained two specialists.

Then the findings escaped the laboratory and slammed into popular culture. Careful observations about the brain’s hemispheric specialisation, drawn from a handful of patients, soon became a sweeping theory of personality. The public version was irresistible. We were no longer simply accountants, musicians, engineers, or artists. We were different kinds of brains.

There was only one problem. It wasn’t true.

Where scientists had discovered specialization, popular culture inferred separation.

The mistake was subtle but profound. The healthy brain does not divide labour by surrendering creativity to one hemisphere and logic to the other. It is an integrated organ whose two hemispheres contribute continuously to almost everything we do.

When we recognize a friend’s face, solve a crossword, compose music, calculate a tip, comfort a grieving spouse, or fall in love, both hemispheres are at work. Nearly everything that makes us human emerges from networks spanning the entire brain, constantly exchanging information across the corpus callosum.

Yet labels often spare us from confronting a more complicated truth. Every one of us possesses analytical and creative abilities in different proportions. Some talents come more naturally. Others emerge only after years of practice. Our brains remain remarkably adaptable throughout life. Yet “I’m left-brained” is a much simpler story to tell than “I haven’t developed that skill yet.”

We humans have always preferred categories to complexity.

The story doesn’t end with neuroscience. It reveals a habit of thought that I encounter every day in the practice of medicine. We divide what is continuous into separate disciplines and then begin to mistake those useful distinctions for fundamental truths. Mind and body become separate domains. Neurology and psychiatry become separate specialties. Mental illness is separated from physical illness, as though biology itself recognizes those boundaries.

These distinctions help us organize knowledge, train specialists, and build hospitals. They are indispensable. They are also abstractions.

While boundaries exist in medicine, they do not necessarily exist in biology. A woman grieving the death of her husband develops insomnia, hypertension, and chronic pain. A man with Parkinson’s disease struggles as much with depression as with tremor. Living systems have no obligation to respect the categories we invent.

We became fascinated by the differences between the hemispheres. The greater wonder was the bridge between them.

Every thought, every memory, every conversation, every movement depends on an extraordinary dialogue across the corpus callosum. Hundreds of millions of nerve fibres carry information back and forth, allowing specialized regions to contribute their strengths while remaining part of a single mind. The miracle of our brains’ design was never specialization alone. It was the emergence of a single, unified experience of being human from countless specialized systems working in concert.

We inherited a myth that divided humanity into left-brained and right-brained people. The split-brain experiments revealed something far more profound. One’s sense of self is not hidden inside the left hemisphere or the right. Our thoughts, memories, emotions, imagination, aspirations, and sense of self emerge only through the continual collaboration of both.

The myth encouraged us to sort people into categories by exaggerating differences. The science revealed something quite different. The brain’s greatest achievement lies not in the specialization of its parts, but in their integration.

This is the broader truth we can glean from this story. The physiology of the brain echoes through society: specialized parts become powerful only when they remain in communication. Every one of us brings different strengths, different experiences, and diverse ways of seeing the world. Our greatest achievements emerge when those differences remain in conversation long enough to create something none could produce alone.

I’m a family doctor in British Columbia, Canada. I write about the intersection of health, science, and belief. If this speaks to you, please consider subscribing or sharing.

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But two blocks east, little had changed. Men with faces prematurely aged by vodka still hovered at the bus shelter outside the liquor store. Some of them found their way into his exam room when their stomachs bled or their legs swelled. His staff – two women in their thirties, brisk, efficient – had learned how to move easily between the patient carrying a MacBook and the one carrying a black garbage bag with all his belongings inside.

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It was Thursday, midafternoon. Colin’s head still throbbed from the wine he had drunk the night before. He had meant to stop at two glasses, but the bottle had vanished in stages, and then the sharp little fight with Melissa had flared. About nothing, really, and everything. She had left the kitchen with her lips pressed tight, and he had finished the wine standing at the sink, staring at the black window.

This morning, ibuprofen had dulled the edge but not erased it. Patients came and went in their usual blur. Coughs, referrals, minor rashes, the pale outlines of lives needing something from him. He had moved through them automatically, his smile thin but practiced.

He thought sometimes of when he had first started here, younger and earnest, determined to do the job properly. He remembered his first patient, an older woman with high blood pressure who brought him a tin of cookies in thanks for adjusting her pills. Back then, each case had felt like a problem to solve, a chance to set something right. He had told Melissa, still his new wife then, how gratifying it was, how he felt he was building something steady, useful. She had smiled at him from across their kitchen table, chin in her hand, and said, “I’m glad. I’m really glad.”

Now she said very little. Lately their silences had become longer, heavier. She often sat at the same table with her phone in her hand, scrolling while he poured another glass of wine.

The medical assistant’s voice broke into his thoughts. “Next is Mrs. MacKinnon. She’s here with her daughter.”

He remembered. Ellen. Seventy-two, diagnosed last week with primary lung cancer – small cell carcinoma. The referral had already gone in. Today would be about questions, preparation, reassurance.

He opened the exam room door.

Ellen sat quietly, her coat folded across her knees, hair soft and silver. Beside her was her daughter Margaret, dark-haired, in her forties, body angled forward, alert as a guard dog.

Colin greeted them. “Margaret? I’m Dr. Elder.” He extended his hand. Hers was firm, brief. Her smile polite.

He sat at his stool and clicked the laptop awake. “We’ve sent the referral to the Cancer Agency. They should be in touch within the week. They’ll talk to you about the options for therapy. Radiation and chemotherapy for example. For this type of cancer, these treatments can be very effective. The goal would be—”

Margaret cut in, her smile now taut. “Actually, Dr. Elder, mom won’t be needing the referral. We’re just here to get her records. We’re going to Edmonton. There’s a clinic there. They’re specialists in natural therapies. Much more aligned with what she wants.”

Colin blinked. He had heard this before, but it still struck like a hand to the chest.

He leaned back, measured his tone. “Small cell lung cancer is aggressive. It tends to spread quickly. With chemotherapy and radiation, there’s a real chance of adding years – good years. Without treatment—”

Margaret’s chin lifted. “We know, thanks. But your treatments are poison. They destroy the body. She doesn’t want that. We need to deal with the underlying problem.”

He turned to Ellen. She sat with a faint, smile, as though the whole conversation was happening at a distance.

“The treatments are toxic, yes,” Colin said, “but directed. And effective. Without them—” He stopped, feeling the ache behind his eyes, the weight of fatigue.

Melissa had said once, during an argument that had bled into silence, “You don’t fight for anything anymore.” He hadn’t known how to answer. He hadn’t even tried.

He softened his voice. “Ellen, how do you feel about all this?”

For the first time, Ellen’s lips parted, her throat working. But Margaret placed a hand on her mother’s knee and leaned in. “She’s clear. She doesn’t want chemo. Isn’t that right, mom?”

Ellen’s eyes flicked toward Colin, then down to her hands. She gave a small nod, her smile unchanged.

The silence felt familiar.

Colin exhaled through his nose. He tried once more, feebly. “Even meeting the oncologists doesn’t mean you have to commit. This is one of the cancers we can actually treat.”

Margaret stood, helping her mother to rise. “Thank you for your time, Doctor. But we know what’s best.”

Ellen allowed herself to be guided, her step careful, as though her daughter’s will carried her more than her own body did.

The door closed behind them.

Colin rubbed his temples, then his eyes, until sparks floated there. He thought of the patients he had seen that morning, of Melissa’s silence, of Ellen’s faint smile. He thought of the man he had once been, the one who believed in solving problems, in setting things right.

Finally, he looked at the glow of the laptop screen. The next name, ordinary, waiting.

I’m a family doctor in British Columbia, Canada. I write about the intersection of health, science, and belief. If this speaks to you, please consider subscribing or sharing.

Elijah Carter arrived wearing his Sunday jacket, though it was a weekday. He signed his name with an “X.” He could not read the consent forms placed before him, but he understood what he had been told: government doctors were offering free examinations, free medicine, and help for a condition people in Macon County called “bad blood.”

Bad blood could mean almost anything. Fatigue. Joint pain. Anemia. Infection. It was a phrase that carried more mystery than diagnosis.

Elijah trusted the doctors because there was little reason not to. They wore white coats. They carried clipboards. They spoke with confidence. They represented a government that claimed to care.

He did not know he had syphilis.

He did not know that the doctors already knew.

And he certainly did not know they had no intention of curing him.

Samuel Rivers came too.

His wife, Lottie, reminded him never to miss an appointment. Every few months he would travel into town, return with aspirin tablets, iron tonics, and a sense of reassurance. The doctors seemed attentive. They listened to his chest. They drew blood. They took notes.

Surely they were helping.

Yet each year Samuel seemed a little weaker. The headaches became more frequent. The aches settled deeper into his bones. His memory began to falter. Some days he struggled to complete work he had once done effortlessly.

Lottie noticed. “The medicine doesn’t seem to be helping,” she would say.

Samuel would shrug. “The doctors know what they’re doing.”

Most of us would have said the same.

The story began in 1932, in rural Macon County, Alabama.

The United States Public Health Service launched what became known as the Tuskegee Syphilis Study. Officially, researchers wanted to observe the natural course of untreated syphilis in Black men. More than six hundred men were recruited, most of them poor sharecroppers with limited education and almost no access to healthcare.

The researchers did not tell the men the true purpose of the study.

They did not explain that many of them had syphilis. They did not explain that the disease could damage the brain, heart, blood vessels, eyes, and nervous system.

Most importantly, they did not explain that treatment would be deliberately withheld.

The men believed they were patients. The government regarded them as research subjects.

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Modern readers often imagine syphilis as a rare infection confined to society’s margins, but that was not the reality of the early twentieth century. Before the arrival of penicillin, syphilis was one of the most common infectious diseases in North America. By the 1930s, millions of Americans had been infected, and in some communities prevalence rates reached astonishing levels.

It was not primarily a disease of sex workers, criminals, or social outcasts. It affected farmers, factory workers, teachers, businessmen, homemakers, and clergy. Few families were untouched. To many physicians of the era, syphilis was as familiar as diabetes or heart disease is today, a common and feared illness whose long-term consequences filled hospital wards and psychiatric institutions.

…

I first learned about Tuskegee in medical school. I had assumed the worst decisions must have occurred at the beginning. It was the 1930s, after all. Medical ethics were primitive. Racism was as explicit as it was pervasive. Scientific standards were crude.

But I was wrong.

The study did not end in the 1930s. Or the 1940s. Or the 1950s. It continued into the 1970s.

For forty years.

This changed the story from a historical curiosity into something far more malevolent. Because by the 1940s, penicillin had emerged as a highly effective treatment for syphilis. The disease was no longer a mystery. The cure was now available. The researchers simply chose not to provide it.

Internal documents revealed the perverse logic. The researchers wanted to continue observing the disease as it unfolded. They wanted more data. More pathology specimens. More publications. And treating the men would interfere with the study.

The scientific objective became more important than the human beings.

One physician wrote that treatment would “spoil” the experiment.

It is a particularly chilling phrase. Because it was spoken not by a monster. It was spoken by an ordinary professional who had become so absorbed in the machinery of research that he could no longer see the people standing in front of him.

As a physician, that possibility should unsettle me, or any doctor.

We like to imagine ethical failures are committed by obviously bad people. But the reality is usually more complicated.

The physicians involved in Tuskegee were not cartoon villains twirling their moustaches. Many were respected professionals. Many probably considered themselves decent men. They went home to families. They attended church and celebrated birthdays and graduations.

Yet year after year they participated in a system that allowed suffering to continue when it could have been prevented.

This contradiction, between the ordinary and the ghastly, is what makes Tuskegee so disturbing. Evil is often astonishingly mundane. It turns up disguised as routine paperwork, institutional loyalty, scientific ambition, or obedience to authority.

The study was sustained not by sadists or fanatics, but by ordinary people who gradually came to regard the unacceptable as routine.

Some doctors felt uneasy while few questioned the study. Others objected privately. But private discomfort is not the same as action. The machine kept moving. While lives were slowly destroyed, careers advanced, grants were awarded and papers were published.

Meanwhile, the consequences spread beyond the participants themselves. Syphilis is not a disease that remains contained. It devastates marriages and families. It alters future generations. Wives became infected. Children were born with congenital syphilis. Fathers died young.

Families watched loved ones decline without understanding why. Around kitchen tables throughout Macon County, people struggled to make sense of illnesses that seemed to worsen despite years of medical attention.

Imagine the confusion. Imagine watching your husband faithfully attend medical appointments for years and still deteriorate. Imagine trusting doctors enough to follow every recommendation while never realizing that the most important treatment was being intentionally withheld. Imagine discovering decades later that the people you trusted had known the truth all along.

By the late 1960s, the study might have continued indefinitely had it not been for individuals willing to challenge the institution from within.

Peter Buxtun, a young social worker employed by the Public Health Service, was one such man. When he learned the details of the study, he was horrified. Patients were dying while a cure was readily available.

Yet, nothing was being done.

He raised concerns through official channels. His objections were dismissed. Supervisors defended the study while colleagues rationalized it. The bureaucracy closed ranks around itself.

Buxtun refused to let it go.

After years of frustration, he leaked the story to a reporter. In 1972, the headlines exploded across America and the world. The public reaction was immediate. People who had never heard of Macon County suddenly learned that their own government had knowingly allowed Black men to suffer and die from a treatable disease.

The study was finally shut down.

Lawsuits ensued and Congressional investigations followed. Medical institutions scrambled to explain themselves.

Yet even then, the damage could not be undone. No settlement could restore lost eyesight. No hearing could reverse neurological injury. No report could resurrect the dead.

…

Twenty-five years later, in 1997, several surviving participants were invited to the White House. They arrived as elderly men. Some sat in wheelchairs. Some bore decades of grief and unanswered questions.

President Bill Clinton stood before them and issued a formal apology.

“What the United States government did was shameful, and I am sorry.”

While the words were necessary, they were also profoundly inadequate. How do you apologize for forty years? How do you apologize to wives who were infected? To children born with disease? To communities taught through experience that authority figures cannot always be trusted?

Some of the survivors cried. Others sat silently.

I often wonder what was passing through their minds.

Perhaps relief. Perhaps anger. Perhaps exhaustion. Perhaps the recognition that justice sometimes arrives long after it can change anything.

The story of Tuskegee did not end in 1972. Nor in 1997. Its consequences are still unfolding.

Today, when public health officials wonder why some communities remain suspicious of medical recommendations, Tuskegee is part of the answer. Trust is not built by scientific accuracy alone. Trust is built through honesty. Through transparency. Through treating people as human beings rather than data points.

When trust is violated by a doctor, a hospital, a university, or a government, the damage extends far beyond the immediate victims.

Stories travel. Families remember. Grandparents tell grandchildren. A wound becomes history, and history becomes culture.

I imagine a family gathered around a kitchen table in Atlanta during the COVID pandemic. The television is discussing vaccines. A grandmother shakes her head.

“No way I’m taking that shot.”

Her daughter, a nurse, gently pushes back.

The grandmother pauses. Maybe she remembers stories from her parents. Maybe she remembers stories from neighbours. Maybe she remembers hearing about men who trusted doctors and paid dearly for it. Her skepticism is not born from ignorance. It is born from memory.

And memory is powerful.

As physicians, we often think medicine is primarily about diagnoses, medications, procedures, and outcomes. Tuskegee reminds us that medicine rests on something even more fundamental.

Trust.

Every prescription depends on it. Every consent form depends on it. Every difficult conversation depends on it. Without trust, medicine becomes a technical exercise performed on unwilling strangers. With trust, it becomes a partnership.

The men of Tuskegee believed they were entering that partnership. Instead, they were betrayed. That betrayal echoes across generations because trust, once broken, is extraordinarily difficult to restore.

The Tuskegee Syphilis Study is therefore not merely a story about racism, although racism was central to it. It is not merely a story about scientific misconduct, although scientific misconduct was abundant. It is a story about what happens when human beings become less important than an institution’s goals.

The men came seeking care. They offered trust.

Medicine answered with deception.

And that remains one of the darkest chapters in the history of modern healthcare.

I’m a family doctor in British Columbia, Canada. I write about the intersection of health, science, and belief. If this speaks to you, please consider subscribing or sharing.

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In time, I realized that we were engaged in entirely different conversations.

I would raise a concern about something that had happened between us, expecting that we would try to understand it together. Instead, the discussion would quickly shift toward why I was wrong to feel that way. If I described feeling hurt, the focus would turn to how my words had hurt him. If I pointed to a specific event, we would somehow find ourselves discussing something that had happened years earlier.

I rarely left these conversations feeling heard. More often, I left feeling confused, exhausted, and increasingly uncertain of my own memory. Afterward, I would replay the discussion in my head, wondering whether I had misunderstood what had happened, expressed myself poorly, or simply gotten it wrong.

I began to wonder whether the problem was me.

What I came to understand was that we were not engaged in a shared search for understanding or a common account of reality.

The facts themselves were secondary.

What mattered was protecting a particular version of events, and a particular version of himself.

Everything else was negotiable.

Including reality.

Narcissistic Personality Disorder

Narcissistic personality disorder is one of the more misunderstood conditions in psychiatry. The term has become a cultural catch-all for selfishness, vanity, arrogance, entitlement, and bad behaviour.

Yet clinical narcissism is something deeper and more complex. It is often mistaken for excessive self-love. At its core, however, narcissism is better understood as a lifelong attempt to defend against feelings of shame, inadequacy, and insignificance.

Understanding that fact does not excuse the damage narcissistic people will inflict on others.

It does, however, help explain it.

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What Is a Personality Disorder?

Most mental health conditions represent a departure from a person’s usual way of functioning. Depression, panic disorder, and post-traumatic stress disorder typically develop after a period of relative stability.

Personality disorders are different. They emerge gradually over years and become woven into a person’s identity, relationships, and way of understanding the world. They are not simply conditions a person has. They become part of how a person thinks, feels, reacts, and relates to others.

Narcissistic personality disorder is one such condition, characterized by enduring patterns of behaviour that create distress, conflict, and impairment across multiple areas of life.

Narcissus and the Origins of Narcissism

The term narcissism originates from the ancient Greek myth of Narcissus.

Narcissus was a strikingly handsome young hunter who inspired desire wherever he went. Admirers pursued him. Yet he rejected them all.

As punishment for his arrogance, the gods condemned him to fall in love with his own reflection. One day, while drinking from a pool of water, Narcissus saw his image and became entranced. Unable to look away, he remained beside the water until he withered and died.

From our modern perspective, the tragedy of Narcissus was his inability to distinguish himself from the ideal beauty of his reflection. In this way, the narcissistic individual spends his life protecting a psychological reflection: an idealized but illusory version of who he believes he must be.

The Anatomy of Narcissism

When thinking of a narcissistic individual, we might picture someone vain, boastful, self-absorbed, and convinced of their own superiority. While the underlying reality is a bit more complicated, that description usually fits.

The narcissist carries an internal conviction that they must be exceptional, admired, respected, successful, attractive, intelligent, morally superior, or uniquely gifted.

These are not random set of traits. They form an interconnected system, designed to protect an idealized self-image from threats, particularly shame. Ordinary human imperfection becomes difficult to tolerate. Criticism, failure, or rejection feels threatening. Even minor slights can acquire outsized emotional significance because they jeopardize the image that holds the person’s psychological world together.

This helps explain why many narcissistic individuals appear unusually defensive.

Most people can acknowledge mistakes, absorb criticism, and eventually move on. For the narcissist, criticism often feels less like feedback than an attack on identity itself.

For many narcissistic individuals, accepting responsibility is not merely unpleasant. It feels dangerous. Shame is so difficult to tolerate that it is rapidly transformed into blame, justification, anger, victimhood, or counterattack.

Narcissistic individuals also display a powerful need for admiration and validation. Compliments provide temporary relief. Praise confirms the desired image. Recognition feels reassuring. The problem is that reassurance rarely lasts. External validation provides brief comfort but creates a need for more.

Relationships often become organized around this dynamic. Friends, spouses, children, colleagues, and employees gradually discover that while affirmation is welcomed, disagreement carries consequences.

Over time, genuine intimacy becomes difficult. Because intimacy requires vulnerability. And vulnerability requires imperfection. Imperfection threatens the image.

Another defining feature is an impairment, or absence, empathy.

This does not mean narcissistic individuals are incapable of understanding that other people have feelings. Many are perceptive, charming, and socially skilled.

The difficulty arises when another person’s emotional reality conflicts with the narcissist’s psychological needs. At those moments, empathy gives way to self-protection. The spouse’s hurt becomes criticism or a friend’s concern feels like disloyalty.

The conversation bends back toward the narcissist’s needs because preserving the self-image takes precedence over understanding someone else’s experience.

Over time, sadly, these patterns create a curious paradox.

The narcissistic individual spends enormous energy seeking admiration, love, loyalty, and connection. Yet the very strategies used to secure these things often drive them away.

Grandiose and Vulnerable Narcissism

Not all narcissists look alike. Some are overtly confident, attention-seeking, and status-conscious. Others appear anxious, wounded, misunderstood, or chronically overlooked.

Psychologists often describe these patterns as grandiose narcissism and vulnerable narcissism.

The grandiose narcissist says, “Look how extraordinary I am.”

The vulnerable narcissist says, “No one understands how extraordinary I am.”

Although they appear very different, the underlying psychology is remarkably similar. Both remain preoccupied with the self, struggle with criticism, react strongly to perceived rejection, and depend heavily on external validation.

The two forms are not separate disorders. They are different expressions of the same problem: a profound difficulty maintaining self-worth without constant reinforcement.

One seeks protection through superiority. The other seeks protection through victimhood.

Neither solution brings lasting peace.

The Suffering of the Narcissist

From the outside, the narcissist may appear confident, successful, charismatic, ambitious, attractive, influential, or unusually self-assured. Indeed, many will spend years cultivating precisely that impression.

Yet beneath the surface, life can be surprisingly precarious.

Imagine building your entire sense of worth upon a foundation that must constantly be defended. Every criticism becomes a threat. Every mistake becomes evidence of inadequacy. Every rejection becomes a referendum on your value as a human being.

For many narcissistic individuals, life becomes an exhausting cycle of achievement, validation, self-protection, and disappointment. This helps explain why some narcissistic individuals seem perpetually dissatisfied despite accomplishments that would leave others content.

Over time, the narcissist often becomes trapped inside the very system that was built to protect them. The armour grows thicker. The person inside becomes harder to reach.

My Life with a Narcissist

My interest in narcissism is not purely academic. I spent two decades married to a man whose behaviour eventually forced me to confront many of these dynamics firsthand.

I did not comprehend what was happening at the time. In fact, one of the defining features of such relationships is how difficult they are to understand from the inside. There were happy moments, shared accomplishments, and even brief periods that felt entirely normal. Yet between those moments there was persistent conflict. And even during the good times, tension and emotional turbulence were never far beneath the surface.

That complexity is precisely what makes these relationships so difficult to evaluate while living inside them. What slowly emerged was something harder to identify: self-doubt, confusion, the sense that ordinary disagreements somehow ended with me apologizing, the sense that my perceptions required external confirmation before they could be trusted, and the gradual narrowing of my own emotional world.

By the end, I felt less like a partner and more like a supporting character in someone else’s elaborate fiction.

When the marriage ended, I had powerful feelings of remorse mixed with relief. But what was most profound, was the degree of disorientation.

I felt like a shell of the person I had once been. Somewhere along the way, I had become so focused on managing another person’s emotions, expectations, and reactions that I had gradually lost touch with my own. I found myself wondering how I had drifted so far from the independent, confident person I remembered being, and how so much manipulation, control, and self-doubt had come to feel normal.

It took years to recognize how much energy had been devoted to managing another person’s emotional equilibrium while neglecting my own.

The details of every relationship are different. Not every difficult marriage involves narcissism. Not every narcissistic individual behaves in the same way. Yet when former partners tell their stories, the similarities are striking. The words differ but the experience does not.

When Reality Becomes Negotiable

While the primary experience of narcissistic relationships is conflict, many former partners describe something else as far more damaging.

The gradual erosion of trust in their own perceptions.

In healthy relationships, people disagree while maintaining a shared reality. Narcissistic relationships function differently. The narcissistic person experiences powerful pressure to preserve a particular self-image. They must remain justified, innocent, admirable, reasonable, generous, loyal, victimized, misunderstood, or morally superior.

When reality supports that image, everything proceeds smoothly. When reality threatens it, reality itself may become negotiable.

An argument that occurred yesterday is remembered differently today. A promise that was made is denied. A hurtful comment never happened. A betrayal becomes someone else’s fault. A criticism becomes an attack. An apology becomes evidence of victimization.

The issue is not always deliberate deception.

Often the narcissistic individual genuinely experiences events through a lens distorted by self-protection. The result, however, is the same. Conversations become exhausting and disagreements become circular. Resolution is impossible.

The partner enters the discussion hoping to understand what happened.

The narcissist enters the discussion needing to win, and to preserve who they are.

Over months and years, many partners begin to question their own judgment. They replay conversations repeatedly. They keep text messages. They write journal entries. They seek reassurance from friends.

Eventually the question is no longer, “What happened?” and instead becomes, “Can I trust myself?” That may be the deepest wound narcissistic relationships inflict. The destruction of confidence in one’s own experience.

And once that confidence has been eroded, rebuilding it can take years.

Children of Narcissists

An adult who enters a relationship with a narcissistic partner usually brings a pre-existing sense of self. They remembers who they were before the relationship began.

Children do not have that advantage.

For a child, the parent is reality. In healthy families, parents help children develop a sense of who they are and teach them that their feelings and perceptions can be trusted. In families organized around a narcissistic parent, children often learn something different. Instead of learning to understand themselves, they learn to understand the parent.

They become highly attuned to moods, disappointments, and grievances. Is Dad in a good mood today? Is Mom upset? Is this a safe moment to disagree? Over time, the child may learn that love is conditional, approval depends upon performance, and disagreement feels dangerous.

Many adapt remarkably well. They become responsible, helpful, agreeable, and successful. Yet beneath these strengths there is often a persistent belief that their worth depends upon what they can provide for others. Some become people-pleasers, perfectionists, or chronic caretakers. Others find themselves repeatedly drawn toward narcissistic partners because the dynamics feel familiar. The emotional atmosphere of childhood becomes the template for adulthood, not because it was healthy, but because it was home.

Probably, the deepest injury involves identity itself. In narcissistic households, feelings may be dismissed, minimized, mocked, ignored, or reinterpreted. The parent’s needs remain at the centre of the story, and the child gradually learns to occupy a supporting role.

Years later, many adult children of narcissists find themselves wrestling with the same question:

Who am I when nobody else is telling me who I should be?

For some, answering that question becomes the work of a lifetime.

Can Narcissists Change?

Like all personality disorders, narcissistic personality disorder exists along a spectrum. Some individuals never recognize the pattern. Others develop genuine insight and, through therapy, self-reflection, and painful honesty, learn to tolerate criticism, accept responsibility, and build more authentic relationships.

Change is possible, but it requires the very thing narcissism resists most: confronting the gap between the reflection and the self.

The Reflection

The more I have thought about narcissism, both as a physician and through my own personal experiences, the less convinced I have become that it is simply a disorder of arrogance, entitlement, or excessive self-love.

Beneath those traits often lies something far more fragile: an inability to tolerate shame, vulnerability, and the ordinary imperfections of being human. Much of the disorder can be understood as an attempt to construct and defend an idealized version of the self, until the defence becomes more important than the person it was meant to protect.

Relationships suffer. Families suffer. Organizations suffer.

The ancient Greeks captured this long before psychiatry existed. Narcissus did not fall in love with himself. He fell in love with a reflection.

In the end, the tragedy of Narcissus was not that he loved himself too much. It was that he spent his life staring at a reflection, and never truly met the person staring back.

Perhaps that is the tragedy for all narcissists.

I’m a family doctor in British Columbia, Canada. I write about the intersection of health, science, and belief. If this speaks to you, please consider subscribing or sharing.

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Many years ago, a patient came into my office twenty minutes late for an appointment that I had already squeezed into an overbooked day. She arrived visibly upset. Within a few minutes she was crying. A few moments later she was laughing. Then she was angry. Then complimentary. Then tearful again.

She told me about a conflict with a friend, a disagreement at work, concerns about her health, and frustration with another physician. Every event seemed dramatic. Every interaction felt urgent. Every relationship appeared to be hanging by a thread.

When the visit was over, I found myself thinking something odd.Although we had spent twenty minutes together, I still knew surprisingly little about her.

I knew how she felt. I knew how intensely she felt. I knew how everyone around her had reacted. But I had only the vaguest sense of who she actually was.

I still remember that experience because it was my first clinical encounter with something called Histrionic Personality Disorder.

With the histrionic personality, as the emotions take centre stage, the person behind them can become difficult to see. Sometimes that is true for the people around them. Sometimes it is true for the person themselves.

Before talking about histrionic personality disorder specifically, it helps to understand what we mean when we talk about a personality disorder.

Most people are familiar with conditions like depression, anxiety, panic disorder, or schizophrenia. These illnesses usually represent a change from a person’s baseline. Symptoms appear, worsen, improve, and occasionally disappear altogether.

Personality disorders are different.

They are not simply conditions that a person develops. They are enduring patterns through which a person experiences the world, interprets relationships, regulates emotions, and responds to stress.

Over years and decades, those patterns become woven into a person’s identity. They become so familiar that they stop feeling like patterns and simply feel like reality.

The distinction is important.

Most personality disorders begin as adaptations. A child learns certain ways of obtaining safety, attention, approval, affection, or protection. In the environment where those strategies first develop, they often make perfect sense.

The difficulty is that strategies that help a ten-year-old navigate the world do not always serve a forty-year-old particularly well.

Over time, the adaptation becomes the source of the problem.

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The word “histrionic” comes from the Latin histrio, meaning actor or performer.

Unfortunately, that etymology has probably done a disservice to many people who struggle with this condition because it suggests deception, manipulation, or deliberate theatrics.

Over many years of practice, I’ve learned the opposite. Most people with histrionic personality disorder are not pretending.

The emotions are authentic. The distress is genuine. The tears are real.

While it might seem that their emotions are fabricated, there is a better way to view it. One way I think about histrionic personality disorder is that attention functions almost like emotional oxygen. Most of us enjoy attention. We like being noticed. We like being appreciated. We like knowing that we matter to other people.

For someone with strong histrionic traits, however, attention often plays a much larger role in emotional stability. When attention is present, they may feel connected, valued, secure, and reassured. When attention fades, anxiety often begins to surface.

The challenge is that emotions become amplified and expressed in ways that can dominate relationships, conversations, and daily life. As a result, relationships can become organized around maintaining emotional engagement.

A disappointment becomes a crisis. A disagreement becomes a betrayal. A minor symptom becomes a medical emergency. A new friendship can feel intensely intimate after only a brief period of time.

None of this is usually conscious. The person is not sitting at home plotting ways to manipulate others. The amplification happens automatically. It is simply the language their emotional system has learned to speak.

One of the tragedies of the disorder is that the very strategies used to obtain connection often end up pushing connection away. Friends become exhausted. Partners become overwhelmed. Family members become wary of the next crisis. Coworkers begin to withdraw.

The result is a painful cycle.

The more abandoned a person feels, the more intensely they seek reassurance.

The more intensely they seek reassurance, the more likely other people are to pull back. And every withdrawal seems to confirm the fear that they were never truly valued in the first place.

As a family physician, I have often found these encounters surprisingly challenging.

Part of that challenge probably reflects my own personality.

I have always preferred precision over performance. I am interested in facts, timelines, mechanisms, probabilities, and causes. When someone tells me a story, my mind naturally begins sorting information into diagnostic categories.

Patients with strong histrionic traits are often communicating something entirely different.

I am trying to determine what happened. They are trying to communicate what it felt like. I am looking for diagnostic clarity. They are looking for emotional recognition.

For years I occasionally found myself becoming frustrated before I understood why. Then I realized that we were often participating in two different conversations.

I was listening for information.

They were asking for connection.

Once I learned to acknowledge the emotional experience first, the conversations became much easier. In fact, one of the paradoxes of medicine is that people often become more capable of describing what happened after they feel understood emotionally.

You can spend twenty minutes searching for facts. Sometimes two minutes of genuine empathy accomplishes more.

Like many personality disorders, histrionic personality disorder exists on a spectrum.

Many people have a few histrionic traits without having a disorder.

Most of us enjoy attention. Most of us want to feel attractive, valued, appreciated, or admired. Most of us occasionally exaggerate a story, seek reassurance, or become upset when we feel overlooked.

The diagnosis only becomes relevant when those patterns become pervasive enough to disrupt relationships, work, emotional stability, or a person’s ability to function.

The encouraging news is that people can and do change.

Personality disorders are not character flaws. They are not moral failings. They are not life sentences.

They are patterns.

Patterns can be understood. Patterns can be challenged. Patterns can evolve.

Psychotherapy remains the cornerstone of treatment. The goal is not to suppress emotion or transform someone into a stoic observer of life. The goal is to help people develop a more stable sense of themselves.

Over time, patients learn to tolerate ordinary levels of attention. They learn to express needs directly rather than dramatically. They learn to distinguish intimacy from intensity. They become less dependent on external validation and more anchored in an internal sense of worth.

That last point is the most important of all.

Many people with histrionic personality disorder become extraordinarily skilled at attracting attention. They know how to walk in and be seen. They know how to engage people. They know how to generate emotional energy around themselves. Yet beneath all that activity there is often a surprisingly fragile sense of identity.

Who am I when nobody is paying attention to me?

Who am I when I am not entertaining, attracting, charming, rescuing, seducing, or performing?

Who am I when I am simply myself?

Those questions lie much closer to the heart of the disorder than most diagnostic criteria. Every personality disorder can be understood as an attempt to solve a particular human problem.

Obsessive-compulsive personality disorder attempts to solve uncertainty through control. Narcissistic personality disorder attempts to solve shame through grandiosity. Borderline personality disorder attempts to solve abandonment through desperate attachment.

Histrionic personality disorder often appears to be attempting to solve invisibility. At its core lies a profoundly human fear.

Do I matter if nobody is looking?

Am I valuable without recognition?

Am I lovable when I am ordinary?

Those questions are not unique to people with histrionic personality disorder. In fact, they may be among the most universal questions human beings ever ask. The difference is one of degree.

Most of us wrestle with those questions from time to time. People with histrionic personality disorder wrestle with them every day. That is one reason I find personality disorders so fascinating.

The diagnoses themselves are useful. They help clinicians communicate. They guide treatment. They provide a framework for understanding behaviour. But the diagnosis is never the whole story. The diagnosis is simply a doorway into a deeper question about identity.

Who are we beneath our coping strategies?

Who are we beneath our fears?

Who are we when the audience leaves?

For people with histrionic personality disorder, that may be the central challenge. For the rest of us, it may be one of life’s most important questions as well.

I’m a family doctor in British Columbia, Canada. I write about the intersection of health, science, and belief. If this speaks to you, please consider subscribing or sharing.

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Anna was in her late twenties. She had done her hair carefully. She had chosen her clothes carefully. Most people in a waiting room would have described her as put together.

I have learned not to trust that impression too quickly.

Anna was not fine.

She drank most nights. She used cannabis to take the edge off her days. Her credit card debt kept growing because of her impulsive spending. Entire weekends disappeared under her covers. Her social life looked active from the outside, but most of her relationships were unstable and exhausting.

What was most revealing was how she spoke about her relationships.

Every story followed the same arc. She described intensity at the beginning. She described fast attachment and fast emotional investment. Then she described a rupture over something small. A delayed text message could trigger it. A change in tone could trigger it. A perceived slight could trigger it.

A disagreement would escalate within minutes. Anna would lash out and say things she later regretted. Sometimes she injured herself afterward. She did not injure herself because she wanted to die. She injured herself because she needed the emotional pressure to stop.

She described all of this in an almost matter-of-fact tone. She did not dramatize her experiences. She did not try to persuade me of anything.

I carefully observe the pattern developing gradually, over repeated visits. One visit looks like anxiety. Another visit looks like depression. Another visit looks impulsive or chaotic. Then the relationship history begins repeating itself and the picture becomes clearer.

Borderline personality disorder.

The term itself is old and awkward, but the clinical pattern is real. The disorder involves emotional instability, unstable relationships, a fragmented sense of self, impulsivity, self-harm, and a chronic sense of emptiness.

Anna described feeling as though she only knew who she was when another person reflected an identity back to her. If her relationship felt secure, she felt stable. If her relationship fractured, she fractured with it.

At one point she said, “I don’t know who I am when I’m by myself.”

That admisson by itself told me so much.

Personality disorders, broadly speaking, involve deeply ingrained patterns of perceiving, reacting, relating, and coping that become woven into a person’s identity and relationships over time. Unlike a depressive episode or a panic disorder, which usually feel like a change from a person’s usual baseline, a personality disorder is embedded in how a person experiences themself and other people across years and across settings.

In borderline personality disorder, the instability centres around emotional regulation, attachment, self-image, and fear of abandonment. Emotional reactions become amplified, rapid, and difficult to modulate once triggered. Minor interpersonal events can acquire enormous emotional significance.

A delayed text message, a subtle change in tone, a cancelled plan, or a perceived withdrawal of affection can provoke intense anger, panic, despair, or impulsive behaviour. The person’s sense of self destabilizes easily under relational stress. Their relationships can swing quickly from idealization to resentment, conflict, or desperation. The emotional response does not remain contained within the person. It spreads outward into their relationships, their decisions, their behaviour, and eventually into every interaction around them.

For the sufferer, and the people around them, borderline personality disorder is a cycle of attachment, rupture, repair, and repetition.

The overlap with other conditions can complicate the picture. We frequently diagnose these patients first with anxiety, depression, bipolar disorder, ADHD, substance use disorders, or some combination of all of them.

While often missed at the outset, the diagnosis of borderline personality disorder eventually emerges as the familiar pattern coalesces across multiple encounters.

But, the diagnosis is not even the most difficult part.

The difficult part is the interaction.

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Dealing with a patient who has borderline personality disorder requires a level of emotional discipline that our medical training barely touches.

The encounter stops feeling like a standard clinical exchange fairly quickly. The emotional intensity pulls us in. The conversation becomes harder to regulate. Our own reactions become part of the equation.

Psychiatry calls this countertransference.

Countertransference refers to our emotional response to a patient. Every physician experiences it to some degree. With borderline patients, it’s hard to ignore.

We often feel an urgency early in the visit. We feel a pressure to fix things quickly before they spiral. We start explaining more than usual. We start reassuring more than usual. We start trying harder than usual.

Then the plan begins to unravel.

A patient might test a boundary we set. A patient rejects a recommendation we make. A patient suddenly becomes angry, suspicious, hurt, or accusing over something that seemed minor moments earlier.

We feel the frustration immediately. Our jaws tighten. Our speech changes pace. We become more guarded. Sometimes we catch ourselves wanting to rescue the patient. Sometimes we catch ourselves wanting to end the visit as quickly as possible.

Then the opposite reaction appears.

We withdraw emotionally. Our tone becomes flatter. Our language becomes more formal and distant. The patient senses the change immediately. Patients with borderline personality disorder are exceptionally sensitive to emotional withdrawal, inconsistency, or rejection.

The cycle feeds itself.

This dynamic does not happen only in clinics.

Friends, partners, family members, and coworkers often describe relationships with borderline individuals as emotionally intense and difficult to sustain over time. So of course the same patterns happen with physicians too. We are not immune simply because we have medical degrees hanging on our walls.

The difference is that we are expected to remain stable inside the interaction. That expectation is simple in theory. It is not simple in practice.

We can feel our internal state changing during these visits. The pace changes. The emotional tone changes. What ought to be a straightforward appointment suddenly requires constant recalibration.

If we do not recognize our own countertransference, we start acting it out. We overextend or we withdraw. We become overly available or overly rigid. We rescue, then resent.

The patient reacts to every inconsistency.

My awareness of this dynamic was even more important once I considered my own history.

I grew up with a mother who had borderline traits. Volatility defined much of my childhood. Her affection could turn quickly. Her emotional reactions could become unpredictable without much warning.

Children adapt to that environment.

We learn to scan tone, posture, pacing, and facial expression. We learn to anticipate emotional weather before it fully develops. We learn how quickly a conversation can change direction.

That conditioning doesn’t disappear because we attend medical school. It follows us into our practices.

In some ways, my background helps me understand these patients more clearly. I understand the fear underneath their anger. I understand their hypersensitivity to rejection. I understand why reassurance rarely holds for long.

But my background also creates risk.

I can over-identify with a patient. I can work too hard to stabilize an interaction. I can tolerate behaviour that requires firmer boundaries. I can also detach too quickly once my frustration builds.

That is why self-awareness becomes part of the treatment.

I do not mean that as an abstract psychological exercise. I mean it as a practical clinical skill.

For intimate partners, howevere, the experience can become emotionally all-consuming.

Many will describe feeling as though they are constantly monitoring the emotional climate of the relationship. Small interactions acquire enormous significance. A delayed reply, a distracted tone, a cancelled dinner plan, or even a brief moment of emotional distance can trigger blowback. Panic, anger, despair, or accusations of abandonment are always just around the corner.

The relationship itself often becomes intensely close very quickly. Partners may initially experience the connection as unusually passionate, intimate, and emotionally open. But over time the instability becomes exhausting. Arguments escalate rapidly. Reassurance provides only temporary relief. Emotional crises repeat. The partner gradually shifts from companion to emotional regulator.

Many begin organizing their own behaviour around avoiding conflict. They need to choose words carefully. They will monitor tone carefully. They suppress their own frustrations to prevent escalation. Over months or years, some partners describe feeling emotionally depleted, hypervigilant, or unsure of their own footing inside the relationship.

The tragedy is that beneath much of the volatility lies profound fear. Fear of abandonment. Fear of rejection. Fear of emotional disappearance once attachment feels threatened.

That fear can generate enormous suffering for everyone involved.

Therapy is where our patients improve.

While medication helps at the margins - SSRIs, mood stabilizers, and low-dose antipsychotics can reduce selected symptoms - none can address the core pathology.

A type of talk therapy called Dialectical Behaviour Therapy remains the best-known approach. When done with a trained counsellor, this process allows a patient to learn emotional regulation, distress tolerance, and interpersonal skills. Some patients improve dramatically once they develop language and structure around their emotional reactions.

Other therapies help patients interpret relationships more realistically, understand their own emotional states more clearly, and build a more stable identity over time.

For my part, I usually give my patients a simpler framework.

Build routines. Build consistency. Slow down reactions. Learn to identify emotional escalation before it takes control of behaviour.

Anna did the work.

She did not progress perfectly or steadily. She experienced setbacks, which is common in this condition.

But gradually she became better at recognizing her own patterns before they fully detonated. She had fewer episodes of self-harm. She created less relational chaos. She developed better emotional regulation.

At one visit she told me, “I still feel everything. It just doesn’t take over the same way anymore.”

That is a reflection of real progress.

Borderline personality disorder has a difficult reputation among physicians. Part of that reputation comes from the emotional intensity these patients generate in us. Part of it comes from the fact that our training gives us very little preparation for managing our own emotional responses during these encounters.

But our patients do improve. I have seen it many times.

Our task as physicians is to remain steady enough for the treatment to continue working even when the interaction itself becomes emotionally difficult.

I’m a family doctor in British Columbia, Canada. I write about the intersection of health, science, and belief. If this speaks to you, please consider subscribing or sharing.

And yet life remains maddeningly capricious and persistently uncertain.

Our bodies age. Relationships change. Careers unravel. Illnesses appear without warning or reason. Even during periods of genuine happiness, most of us can feel a restless activity beneath the surface, searching for reassurance, meaning and control.

As a family physician, I witness this conflict play out routinely. Patients struggle with the seeming absence of purpose or reason when confronted with illness, or grave personal loss. Too often for these patients, a meaningful interpretation is elusive.

Over the past two weeks I have explored this tension from the perspectives of Buddhism and Carl Jung. Buddhism locates much of our suffering in craving, attachment, and resistance to impermanence. Jung approached suffering from another direction and focused on the tensions inside the psyche itself, particularly the hidden forces and contradictions that operate beneath conscious awareness.

This week I want to look at Stoicism.

Stoicism is a philosophical tradition that emerged in ancient Greece more than three centuries before Christianity and later matured through the lived realities of Roman political life, military life, slavery, illness, exile, grief, and public catastrophe.

One of the reasons Stoicism has survived this long is because it speaks directly to experiences that every generation eventually encounters. We all confront uncertainty, disappointment, desire, fear, conflict, aging, illness, rejection, and death.

The tenets of Stoic philosophy fit comfortably in the daily routine of my medical practice.

A common example is the anxious patient convinced that something catastrophic, yet undetected, is operating just beneath the surface.

Every skipped heartbeat becomes a warning. Every headache suggests hidden neurological disease. Every unfamiliar bodily sensation demands immediate interpretation.

At some point the patient will usually say something like, “I just need to know I’m okay.”

It is this apparently innocuous sentence that captures an enormous amount of human suffering in a remarkably compact form.

The Stoics understood this problem very clearly more than two thousand years ago.

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Stoicism began around 300 BCE in Athens with Zeno of Citium, who reportedly arrived there after surviving a shipwreck that destroyed much of his cargo as a merchant. According to one story, Zeno wandered into a bookseller’s shop after the disaster and became fascinated with philosophy after reading about Socrates. When he asked the bookseller where he could find people like that, a philosopher happened to walk by in the street. The bookseller reportedly pointed and said, “Follow that man.”

He did.

Eventually, Zeno himself began teaching. He lectured under a public colonnade called the Stoa Poikile, or “painted porch,” which is where Stoicism gets its name.

Most people encounter Stoicism merely as a philosophy of emotional endurance and psychological hardening in the face of adversity.

But ancient Stoicism was an entire philosophical system. Ethics was only one branch. The Stoics built frameworks for logic, physics, metaphysics, language, psychology, politics, and cosmology. They were trying to answer enormous questions about the nature of reality, how the universe functions, and how we should conduct ourselves within it.

Their philosophy rested on three major branches. Logic governed reasoning and judgment. Physics attempted to explain the structure and nature of reality itself. Ethics addressed how a person should live within that reality.

Importantly, ethics depended on the first two. The Stoics believed we could not know how to live until we understood what kind of universe we were living in.

The Stoics were materialists. That is, they believed everything that exists is physical. Even the soul. Even thought. Even reason.

For them, reality consisted of matter animated by an organizing principle called the Logos. The Logos represented a rational structure woven through nature itself. Not a personal god standing outside creation, but an ordering intelligence operating within it.

The universe, in Stoic thought, was rational, interconnected, and governed by cause and effect.

A tree grows according to its nature. A wolf hunts according to its nature. Humans possess reason, and therefore we fulfil our nature through rationality, cooperation, self-awareness, discipline, and virtue.

As the philosophy later spread into Roman culture, Stoicism became less abstract and more psychologically grounded in ordinary life.

Because it argued that virtue remained available to everyone, the philosophy appealed across social classes. The Stoics believed all people participate in reason and therefore belong to a single moral community. That idea was radical in the ancient world. A Roman emperor, a merchant, a labourer, an enslaved person, and a foreigner all possessed moral worth because all shared access to rational thought and ethical conduct.

Although the philosophy often gets reduced in modern culture to little more than emotional toughness and grit, the actual day-to-day teachings of Stoicism revolve around a remarkably sophisticated form of psychological discipline.

The Stoics believed that much of our suffering emerges from the meanings we attach to events rather than from the events themselves. They recognized that the human mind does not simply observe reality in a neutral way. The mind interprets constantly, predicts constantly, embellishes constantly, and very often mistakes its own interpretations for objective truth.

Consider a person who receives constructive feedback at work. Maybe a supervisor points out an error during a meeting or questions the quality of a report. The original event may be relatively contained. But within minutes the mind may begin constructing an elaborate internal narrative around the experience.

Stories about hidden motives may emerge, “He is trying to humiliate me.” Catastrophic predictions may rapidly follow, “I’m going to lose my job.” Broader conclusions about identity and worth may then crystallize around the event, “I’m incompetent. I always fail. Everyone else has their life together except me.”

At that point the suffering is no longer coming only from the criticism itself. The suffering expands dramatically once the mind begins layering prediction, catastrophizing, shame, memory and imagined future consequences onto the experience.

Stoics believed that emotional impressions arrive automatically, but they also believed that we possess some capacity to examine those impressions before surrendering entirely to them. In Stoic language, the goal involved learning to pause before granting full assent to the mind’s first interpretation of reality.

This moment of reflection is psychologically critical. The Stoic slows the process down and begins interrogating the mind’s first interpretation of events.

For a Stoic, we ought to begin by separating observable reality from the emotionally charged story rapidly forming around it. Most situations arrive in relatively simple form, but the mind almost immediately begins enlarging, interpreting, predicting, personalizing, and dramatizing the experience. Fear, ego, memory, shame, and imagination quickly distort the original event until the interpretation itself starts feeling indistinguishable from reality.

They also recognized how aggressively the mind fills gaps in knowledge with speculation that hardens into perceived truth. We assume malicious intent where none may exist. We predict catastrophe from limited information. We transform temporary discomfort into permanent identity. A criticism becomes evidence of worthlessness. An awkward interaction becomes social humiliation. A skipped heartbeat becomes impending death. The Stoics understood that our nervous system routinely escalates uncertainty into catastrophe, particularly when anxiety, insecurity, exhaustion, or fear are already operating beneath the surface.

Another critical Stoic tenet is that avoidance intensifies fear. This partly explains their deliberate contemplation of mortality. Consciously remembering impermanence sharpened our perspective and reduced unnecessary suffering. Marcus Aurelius repeatedly reminded himself that he, his loved ones, and everyone around him would eventually disappear. At first glance this can sound bleak, but the intended psychological effect is the reverse. Awareness of our mortality shrinks our many trivial resentments, and ordinary experiences regain their texture and immediacy.

Most importantly, the Stoics believed that much of our suffering emerges from arguing with the basic structure of reality itself. We demand certainty, permanence and fairness from and existence that is volatile, fleeting and unjust. We demand control from circumstances that were never fully controllable in the first place. Stoicism attempts to reduce suffering by encouraging us to stop negotiating with realities that no human has ever escaped.

Together these ideas create psychological breach between circumstances and the stories forming around the circumstances. That separation can be profoundly stabilizing.

This shift becomes extremely pertinent during adversity.

We often begin collapsing psychologically when we build our entire identity around maintaining control over things that are uncontrollable. Stoicism attempts to anchor stability somewhere less fragile.

The philosophy repeatedly redirects attention away from controlling circumstance and back toward the cultivation of character, conduct, restraint, honesty, courage, and steadiness during the inevitable difficulties of life. “How will I conduct myself when difficult things inevitably happen?”

The external circumstances may remain equally tragic, but the psychological posture changes profoundly.

At its best, Stoicism teaches steadiness without emotional numbness.

Modern caricatures often portray Stoics as emotionally frozen creatures, where wisdom is equated with emotional suppression. But the classical Stoics did not believe emotions should disappear. They simply believed powerful emotions should not completely dominate judgment and behaviour.

A Stoic still loves deeply, grieves deeply, fears deeply, and forms deep attachments to other people. In fact, the Stoics believed human flourishing depended heavily on friendship, duty, cooperation, and participation in community life. The goal was never emotional sterilization, but rather that learning how to experience intense emotions without becoming entirely governed by them.

That distinction remains enormously relevant clinically because modern culture tends to oscillate between two unhealthy extremes. Some people distrust emotion so thoroughly that they become rigid, detached, overcontrolled, and psychologically unreachable. Others treat every emotional state as unquestionable truth and become chronically reactive, impulsive, and destabilized by every fluctuation of mood or circumstance.

Stoicism attempts to chart a middle path between suppression and emotional surrender. The philosophy asks us to feel fully, observe carefully, interpret cautiously, and act deliberately rather than reflexively.

Of course, Stoicism also has limitations.

Some Stoic writing underestimates grief, dependency, vulnerability, trauma physiology, and unconscious psychological processes. We are not purely rational creatures. We are biological organisms with nervous systems, attachment histories, hormones, developmental injuries, and emotional needs.

A person in severe depression cannot simply reason themselves into serenity any more than someone can philosophically outthink sepsis.

Modern internet culture also frequently exploits Stoicism by turning it into a performance of masculine invulnerability, productivity obsession, or emotional detachment. That version strips away the philosophy’s humility, ethics, compassion, and communal responsibility while preserving only the hard outer shell.

Still, I continue to find Stoicism clinically useful because it repeatedly redirects attention toward the domains that remain partially within our influence. Our conduct, honesty, restraint, perspective, and ability to tolerate uncertainty without collapsing into panic all remain psychologically important long after certainty itself becomes unavailable. Most importantly, the Stoic philosophy encourages us to stop demanding guarantees that life was never designed to provide.

This becomes relevant whether we are confronting panic disorder, chronic illness, addiction, heartbreak, aging parents, divorce, cancer, grief, or simply the ordinary instability of modern life.

Stoicism does not promise permanent happiness. It offers something more restrained and probably more realistic.

Perspective. Emotional steadiness. Acceptance of uncertainty. A way to remain psychologically intact even when life becomes difficult.

That may explain why a philosophy born beneath a painted porch in ancient Greece still feels surprisingly alive inside a modern medical office.

I’m a family doctor in British Columbia, Canada. I write about the intersection of health, science, and belief. If this speaks to you, please consider subscribing or sharing.

That question sits underneath far more of human civilization than we usually acknowledge. Entire religions formed around it. Philosophical schools emerged to address it directly. Political systems, moral codes, rituals, meditation practices, myths, prayers, laws, and therapeutic traditions all grew, at least partly, from the same uncomfortable realization: human beings are psychologically unstable creatures. We are capable of extraordinary creativity and love, but also compulsive behaviour, self-deception, tribalism, resentment, panic, addiction, and endless dissatisfaction.

Material progress never solved this problem. Ancient Romans worried about status, ageing, uncertainty, and mortality as much as we do. While our landscapes change, our nervous system does not.

Every generation rediscovers the same patterns. We chase pleasure and become restless anyway. We obtain things we thought would finally calm us, then rapidly adapt and resume searching. We attempt to control uncertain futures and become anxious when reality refuses to cooperate. We compare ourselves constantly to other people and construct our identities around achievement, attractiveness, wealth, intelligence, productivity, morality, or belonging.

Then life destabilizes one of those identities and suffering follows immediately behind it.

Across centuries and cultures, some thinkers began noticing the same psychological patterns repeating over and over. Humans become attached to things that cannot last. We confuse control with safety. We chase status and approval. We build identities that fracture under pressure. Entire philosophical systems emerged from trying to understand these patterns and reduce the suffering they create.

Two systems stand out immediately. Buddhism and Stoicism.

Both systems developed more than two thousand years ago. Both continue to survive contact with modern neuroscience, psychology, and ordinary human experience remarkably well.

Buddhism understood very early that craving, attachment, and compulsive desire produce enormous psychological suffering. I discussed this last week.

Stoicism recognized that much of human distress comes from trying to control what cannot actually be controlled. I’ll explore this next week.

Today, I want to examine the psychological framework developed by Carl Jung, whose ideas continue to influence modern psychotherapy, spirituality, personality theory, and the way many people understand themselves. Specifically, I want to explore Jung’s framework for building a decent human life and examine how surprisingly well many of his ideas continue to hold up.

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Jung was a Swiss psychiatrist working in the early twentieth century, initially alongside Sigmund Freud before eventually breaking from him in one of the most (in)famous intellectual splits in psychology. He spent much of his professional life in Zurich, treating patients, writing obsessively, studying mythology, religion, dreams, symbolism, and the deeper patterns that seem to repeat across human cultures. He became one of the foundational figures of modern depth psychology.

Even people who have never read Jung still speak his language. Introvert. Extrovert. Archetype. Persona. Complex. These concepts leaked out of his system of psychiatry and into ordinary life.

Jung believed modern people often become psychologically stranded because they lose contact with meaning, ritual, purpose, community, and the unconscious forces driving their behaviour underneath conscious awareness.

He also believed happiness itself was misunderstood. Human flourishing did not emerge from permanent pleasure or emotional perfection. It emerged from integration, purpose, resilience, relationships, work, beauty, and the capacity to tolerate suffering without collapsing under it.

Jung, to be honest, was never especially sentimental about happiness. He distrusted the modern fantasy that somewhere out there exists a permanent emotional state called happiness, waiting to be unlocked with the right philosophical key.

He thought suffering was built into human existence. Anxiety. Grief. Fear. Regret. Jealousy. Loneliness. Rather than seeing these forms of suffering as glitches, he understood them for what they really are – ancient survival mechanisms. He saw that these experiences of discomfort and longing are purpose-built, baked into our being to keep us and our kin alive and safe.

A person who is incapable of fear does not become enlightened, he walks into traffic.

This is where a great deal of popular psychology goes off the rails. It treats unhappiness as evidence that something has gone wrong. Jung believed the opposite. Human beings are designed to experience conflict. The real question is whether your life can withstand it.

Near the end of his life, Jung outlined what he believed truly helped people build a decent existence. His list was improbably stark:

1. Take care of your body and mind.

2. Maintain close relationships.

3. Spend time around beauty and nature.

4. Do meaningful work.

5. Develop a philosophical or spiritual framework that helps you tolerate suffering.

That is basically it.

And frankly, modern research tends to offer the same conclusions. While an enormous industry has evolved pretending human flourishing is enormously complicated, the reality is as simple as these five simple precepts.

…

Take care of your body and mind

The first pillar was physical and mental health. This sounds obvious until you notice how many people attempt to construct a meaningful life while sleeping five hours a night, drinking too much, eating processed garbage, never exercising, and marinating themselves in cortisol from dawn until bedtime.

We too often treat our nervous system carelessly, like a disposable ornament, instead of the fragile miracle it is.

Sleep deprivation destabilizes emotional regulation. Alcohol worsens anxiety and depression in many people despite temporarily dulling both. Chronic stress changes cognition, impulse control, and memory.

The evidence is overwhelming.

And mental health drives suffering far more aggressively than many physical illnesses do. I have seen patients tolerate astonishing levels of physical pain while remaining psychologically intact. I have also seen relatively healthy people become imprisoned by anxiety, despair, obsessive rumination, or loneliness.

Maintain close relationships

Jung also emphasized relationships. This part is almost unavoidable because the evidence has become so repetitive that arguing against it is now indefensible.

People with strong marriages, deep friendships, stable family bonds, and genuine social connection generally do better across almost every metric we measure. Better mental health. Better physical health. Longer lifespan. Lower dementia risk. Lower depression risk. Better recovery from illness.

We regulate each other physiologically. Conversation alters stress hormones. Touch alters autonomic tone. While isolation and solitude are demonstrably destabilizing.

And despite endless cultural cynicism about marriage, long-term pair bonding still appears beneficial for many adults. Not universally of course. Some marriages are destructive. Indeed, for some of us it is undeniably healthier to remain alone. But in aggregate, stable intimate relationships correlate strongly with well-being.

None of this is especially fashionable to say because modern culture increasingly treats commitment as confinement. Yet people often can easily drift into another form of confinement instead: fragmented relationships, chronic ambiguity, emotional isolation, and the exhaustion of perpetual self-construction.

Spend time around beauty and nature

This one sounds softer until you consider how psychologically malnourished modern life has become.

People may spend ten hours a day staring into illuminated rectangles full of outrage, advertising, tribal warfare, pornography, vanity, algorithmic stimulation, and political hysteria.

Then they wonder why their inner life feels depleted.

Nature improves psychological well-being across cultures. This finding appears again and again in research. Forests, oceans, mountains, green space, sunlight, birdsong, open sky. Human physiology responds to these environments measurably. Blood pressure changes. Stress hormones change. Attention changes.

Exposure to art does something similar, although more unpredictably.

Music, literature, painting, film, architecture, poetry. These experiences organize emotion. They give language to internal states we might not otherwise be able to articulate.

Art interrupts psychic numbness. Sometimes it provokes grief that had been buried for years.

Anyone who has sat alone listening to a piece of music that suddenly exposed an entire emotional reality will understands this intuitively.

Do meaningful work

Jung also believed meaningful work was central to psychological stability. Again, modern evidence largely agrees.

Under circumstances of prolonged dormancy, we predictably deteriorate.

Research shows us that unemployment damages people psychologically, independent of the associated income loss. Work offers structure. It provides identity, social contact, competence. And, critically, it bestows purpose.

But Jung was careful here. He did not glorify endless ambition.

Meaningful work is not the same thing as status competition.

A corporate lawyer billing 90-hour weeks may possess status, money, and prestige while remaining psychologically stranded. Meanwhile, a carpenter, teacher, paramedic, nurse, mechanic, or small business owner may experience profound satisfaction because the work produces visible utility and earned competence.

We yearn to feel effective. We need evidence that our existence changes something concrete in the world around us.

Develop a philosophical or spiritual framework that helps you tolerate suffering

And finally, Jung argued that human beings require some larger framework for understanding suffering.

Traditionally, religion – and more recently spirituality – has filled this role. Philosophy often did as well. Stoicism. Buddhism. Existentialism. Secular humanism.

The framework itself varies. The underlying psychological appetite does not.

People break down when suffering appears random, meaningless, and endless.

I see this constantly in medical practice.

A cancer diagnosis becomes psychologically survivable for some patients once it can be integrated into a larger narrative about identity, family, faith, resilience, mortality, or purpose.

Others may spiral because the illness annihilates the explanatory structure they were relying on.

Modern secular culture often strips people of shared metaphysical frameworks while offering consumerism and self-expression as replacements. Those are thin psychological materials. They easily splinter under pressure.

Jung understood this decades ago.

…

The striking thing about Jung’s framework is how ordinary it sounds. That is exactly why people keep trying to reinvent happiness as something more exotic. Ordinary truths do not generate billion-dollar industries.

Sleep. Friendship. Marriage. Exercise. Nature. Meaningful work. Philosophy. Spiritual life. Purpose.

These are not modern “wellness strategies.” They are recurring human requirements that appear across cultures, religions, and centuries because human beings have never fundamentally changed. The technologies surrounding us evolved at extraordinary speed. Human psychology did not.

I’m a family doctor in British Columbia, Canada. I write about the intersection of health, science, and belief. If this speaks to you, please consider subscribing or sharing.

She had a successful career, a large house, a stable marriage, healthy children, financial security. The kind of life many people spend decades trying to build. Yet she woke up every morning with a dread already running in the background.

She exercised regularly. She travelled. She socialized. She pursued new goals, new projects, new purchases, and new forms of self-improvement. Each change produced a temporary improvement in mood.

Then the feeling returned.

Aching for control, she wondered whether the problem was physiologic. All the things she’d read about. Hormones. Perimenopause. Cortisol. Deficiencies. Inflammation. Some hidden imbalance that might finally explain why she felt perpetually unsettled.

For decades in my medical practice, I’ve seen versions of this same story, literally every day. While the details change, the underlying pattern does not.

Humans derive real pleasure and relief from improved circumstances, but our nervous system adjusts quickly. Then familiarity moves in. What once felt remarkable becomes normal, expected, woven into daily life. Our mind then resumes searching for the next thing that promises relief, fulfilment, excitement, certainty, or peace.

Buddhism identified this inescapable pattern more than two thousand years ago. The philosophy describes recurring features of human psychology with startling accuracy.

At its core, Buddhism attempts to answer two questions: why do human beings suffer, and how can they reduce unnecessary suffering over the course of a lifetime?

The system originated in northern India roughly 2,500 years ago through the teachings of Siddhartha Gautama.

According to tradition, Siddhartha was born into privilege. His father attempted to shield him from illness, ageing, suffering, and death. Eventually, Siddhartha encountered these realities directly. He saw sickness, poverty, old age, and mortality for the first time.

The experiences altered him profoundly.

He abandoned wealth and social status and spent years studying philosophy and religious practice. He experimented with severe asceticism and extreme self-denial before concluding that neither luxury nor self-punishment solved the problem of human suffering.

What emerged from that search became Buddhism.

Suffering is Certain

The Buddhist philosophy begins with a claim that many modern people still resist: suffering is inseparable from human existence.

People age. Our bodies inevitably deteriorate. Relationships fracture. Our parents die. Illness appears without warning and often persists. Eventually, grief enters every human life.

Buddhism does not treat these experiences as anomalies or cosmic mistakes. It treats them as inherent features of being human.

Modern culture often treats suffering as evidence that life has gone wrong. We are encouraged to believe that enough optimization, wealth, beauty, discipline, therapy, productivity, or medical intervention might finally eliminate distress altogether.

But reality keeps interrupting the fantasy.

Bodies fail. Plans collapse. People disappoint each other. Circumstances change. Loss enters every life eventually.

Buddhism begins by accepting this directly instead of arguing with it. The philosophy assumes that much human suffering intensifies the moment people begin demanding that reality behave differently than reality actually does.

Desire is the Source of All Suffering

The second major teaching states that much human suffering comes from attachment and craving.

People become psychologically attached to youth, status, identity, admiration, certainty, routines, relationships, and control. Then those things change, because everything changes.

This creates distress.

Aging becomes psychologically devastating when youth has become central to identity. Criticism becomes intolerable when self-worth depends on admiration. Financial loss becomes existential when status becomes fused to personal value.

Buddhism argues that human beings intensify their own suffering by demanding permanence from unstable conditions.

Modern life amplifies this tendency aggressively.

Social media platforms profit from envy and comparison. Advertising encourages chronic dissatisfaction. Consumer culture encourages people to construct identity through acquisition and display. Political systems reward outrage and emotional escalation.

The nervous system remains persistently activated.

One reason Buddhism continues to resonate is because the philosophy recognized very early that human attention is unstable, easily manipulated, and constantly pulled toward craving, fear, comparison, and emotional reactivity.

Adaptation

The philosophy also recognized another enduring feature of human behaviour: adaptation.

Humans rapidly become accustomed to improved circumstances that once felt exciting, meaningful, or life-changing. What initially produces relief, pleasure, pride, or gratitude gradually becomes psychologically normal.

The promotion becomes ordinary.
The larger house becomes ordinary.
The achievement becomes ordinary.
The relationship becomes familiar.

Then our desire regenerates.

Many people spend their entire lives chasing the feeling that the next achievement, purchase, experience, or transformation will finally produce durable fulfilment. The relief appears briefly, then the mind recalibrates and resumes searching again.

Buddhism argues that this cycle is not a personal failure. It is a built-in feature of the human mind itself.

Impermanence

Another central Buddhist teaching involves the critical idea of impermanence.

Everything changes.

Our bodies change. Our emotional states change. Our relationships, careers, beliefs - they all change.

People understand this intellectually while emotionally demanding stability anyway. That tension produces enormous psychological distress.

I see this constantly in medicine, often in paradoxical ways.

Patients will often tolerate terrible diagnoses more effectively than prolonged uncertainty. Humans crave stable ground. Buddhism argues that permanent stability does not exist in the form people might imagine.

That realization unsettles many people initially. But, over time, it can become psychologically stabilizing.

Once change becomes expected, people stop treating change itself as evidence that life has malfunctioned. Illness, loss, disappointment, emotional fluctuation, and uncertainty stop feeling like violations of how life was “supposed” to unfold.

Change and uncertainty become recognized as inherent features of being alive. That understanding alone can reduce an enormous amount of secondary suffering created by resistance, outrage, and the endless demand that reality behave differently than it does.

Mutability of the Self

Finally, Buddhism challenges one of the deepest assumptions people make about themselves. The philosophy argues that the self is far less fixed and permanent than most people believe.

Most people experience themselves as a stable, continuous entity moving through time. They speak about “who I really am” as though identity were a permanent object waiting to be discovered and preserved.

But human beings change constantly.

Identity changes across a lifetime. Personality changes. Priorities change. Memory changes. Political beliefs change. Relationships alter people. Trauma alters people. Ageing alters people. The body itself undergoes continuous biological turnover.

Even memory, which people often treat as proof of a stable self, is remarkably unreliable and reconstructive. People revise their own histories constantly without realizing it.

Yet despite all this, people cling fiercely to the idea of a fixed, permanent self that must be defended, validated, admired, protected, and made secure.

Buddhism argues that this attachment produces just another layer of suffering.

Insults feel existential because they threaten identity. Ageing feels terrifying because people become attached to earlier versions of themselves. Failure becomes psychologically crushing because self-worth fuses with achievement and status.

The philosophy does not argue that individuality is meaningless or that personality does not exist. It argues that human beings suffer when they mistake an evolving process for a permanent object.

Buddhism is not merely a set of observations about suffering and human behaviour. The philosophy first attempts to describe reality and the recurring tendencies of the human mind accurately, then builds a behavioural system designed to reduce unnecessary suffering and improve psychological stability over time.

The teachings were designed to be practised repeatedly over years and decades until they altered the way a person relates to thought, emotion, desire, and adversity.

In practical terms, Buddhism attempts to train three broad capacities.

First, it trains attention. The mind is impulsive, distractible, emotionally reactive, and constantly pulled toward fear, craving, memory, fantasy, and self-protection. Meditation was developed as a way to stabilize attention and reduce automatic reactivity.

Second, it trains behaviour. Buddhism places enormous emphasis on honesty, restraint, compassion, discipline, and awareness of how one’s actions affect other people. The philosophy assumes that chronically impulsive, selfish, deceitful, or aggressive behaviour destabilizes both relationships and the mind itself.

Third, it attempts to check craving. Buddhism recognized very early that human beings rarely stop wanting more. More status. More certainty. More stimulation. More admiration. More control. More pleasure. More reassurance. The system repeatedly asks whether endless desire actually produces peace or whether it keeps the nervous system trapped in chronic dissatisfaction.

These practices were never intended as abstract spiritual ideas. They were intended as repeated mental and behavioural exercises designed to alter how a person experiences ordinary life.

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Meditation

The first major tool is meditation.

Meditation, within Buddhism, functions as attentional training. The practice teaches people to observe thoughts and emotions without instantly reacting to them.

Most people never develop this capacity.

A fearful thought appears, and the body immediately behaves as though the threat is physically present. Rumination begins. Anxiety escalates. The mind spirals into prediction, interpretation, memory, fantasy, and self-criticism.

Meditation interrupts this reflexive chain.

A person learns to notice the thought without automatically obeying it. The thought still appears. The emotion still appears. But the individual gradually develops a small amount of psychological distance from the experience itself.

That distinction becomes powerful over time.

Modern neuroscience increasingly supports what Buddhist practitioners recognized centuries ago. Attention can be trained. Emotional reactivity can be reduced. The nervous system can become less volatile through repeated practice.

Buddhist meditation also exposes something many people never notice clearly: the human mind rarely remains in the present moment for very long.

People replay conversations from years ago. They rehearse arguments that have not happened yet. They catastrophize future outcomes. They mentally revisit humiliation, anger, regret, and fear over and over again.

Large portions of human suffering are internally generated this way.

Ethical Behaviour

Another major component of Buddhist practice involves ethical behaviour.

Buddhism places strong emphasis on honesty, restraint, compassion, discipline, and awareness of how personal conduct affects other people. These teachings are psychologically practical.

Chronically deceitful, impulsive, aggressive, selfish, or emotionally reactive people often create unstable social environments around themselves. Their relationships fracture repeatedly. Conflict follows them. Distrust follows them. Emotional chaos follows them.

Then they experience the consequences as though those consequences emerged randomly.

Buddhism argues that behaviour and psychological suffering are deeply connected.

A disciplined, compassionate, restrained person generally experiences a more stable internal life than a chronically reactive person. This is not mystical. It is behavioural psychology observed over centuries.

Taming Desire

The philosophy also encourages deliberate limits on craving and compulsive consumption.

Modern culture teaches people to intensify desire constantly. More status. More stimulation. More productivity. More visibility. More acquisition. But the craving extends far beyond material things. People also crave certainty, control, reassurance, predictability, validation, and the ability to prevent loss, rejection, illness, ageing, and disappointment.

Much of modern anxiety emerges from this endless attempt to force an unstable world into a stable arrangement.

Buddhism teaches the opposite discipline.

The philosophy argues that many forms of suffering intensify when people become psychologically dependent on conditions they cannot permanently secure or control. The practice asks whether endless wanting actually improves psychological well-being or simply destabilizes it further.

For many people, this becomes one of the hardest teachings to accept because modern economies are built around manufacturing dissatisfaction and reinforcing the idea that fulfilment remains one purchase, achievement, diagnosis, relationship, or transformation away.

Buddhism repeatedly asks the same uncomfortable question:

How much of your suffering comes from reality itself, and how much comes from your relationship to reality?

…

Buddhism has survived for more than two millennia because it speaks directly to conditions that have never disappeared from human life.

People still crave endlessly. People still compare themselves to others. People still fear ageing, rejection, illness, uncertainty, and death. People still build identities around unstable things and become psychologically shattered when those things inevitably change.

Despite modern technology, human psychology has remained remarkably similar.

I see this constantly in medicine. Patients often believe their suffering is unique because the details are unique. The diagnosis is unique. The marriage is unique. The betrayal is unique. The fear is unique.

But beneath those details, the emotional architecture is ancient.

We want permanence in a world built from impermanence.
We want certainty in a biological existence governed partly by randomness.
We want control over systems that were never fully controllable.

Buddhism does not promise escape from grief, fear, illness, heartbreak, or mortality. No serious philosophy can honestly promise that.

What it offers instead is a disciplined way of relating to suffering without becoming completely consumed by it.

That may be one of the most psychologically realistic goals ever proposed.

And perhaps the enduring question is not whether Buddhism is “true” in some abstract religious sense.

Perhaps the more useful question is simpler:

After two thousand years, are we actually any closer to solving the suffering it described so clearly?

I’m a family doctor in British Columbia, Canada. I write about the intersection of health, science, and belief. If this speaks to you, please consider subscribing or sharing.

I’d just started it on Friday. It’s short, not one of his long tomes.

The story is simple. Ivan Ilyich is a mid-level judge in late 19th-century Russia. He builds a life that looks right. He marries, advances his career, furnishes his home, and keeps the “right” company.

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Then he develops an inexplicable pain in his side. The pain lingers, then deepens, then takes over his days and nights. He sees doctors. They examine him and speak with confidence, but they don’t answer the question he is actually asking. His wife manages the household and her own frustrations. His colleagues think about promotions. A peasant servant is the only one who speaks honestly, and helps him through his nights. And while his young son senses what is happening, the adults decline to recognize it.

So Ivan is left to work it out on his own.

He is dying.

While it is written in late 19th-century Russia, it still feels close and recognizable. The world around Ivan is more formal and more rigid than we’re used to, but the core behaviour is familiar. People still can avoid saying what is happening when it counts.

As I read, I felt a steady pressure build. Ivan asks direct questions but gets answers that deflect rather than respond. He begins to doubt his own perception. He tries to keep things together for the sake of everyone else. His fear only sharpens. But it is not only fear of death. He starts to suspect that the life he built, which looked correct from the outside, may have missed some essential meaning.

Tolstoy writes him with restraint and compassion. Ivan is not an abridged two-dimensional character. He is a man who followed the rules and now finds himself inside a system that protects itself with politeness and leaves him alone with the truth.

He stops trying to keep everyone else comfortable. He stops pretending that things will turn. He sees what is happening and allows himself to face it directly. He begins to examine the life he built with a kind of urgency that only emerges at the end.

His people are physically present. They come and go. They speak, they adjust pillows, they ask pointless questions.

None of it reaches him. He is, ultimately, alone. Alone with the pain. Alone with his realization that his entire adult life had been frivolous and inconsequential. Alone with his now urgent need to reconcile that before time runs out.

The final stretch dips inward. His social world recedes. The roles he held no longer apply.

What remains is a private reckoning. He moves through fear, resistance, anger, and then something closer to acceptance. It is not tidy. It is not shared. It happens inside his own mind.

He dies.

We hope to do things differently now, and the difference starts, significantly, with language.

We speak more directly about illness and decline. Families will ask clearly about prognosis. Patients ask what the next months will look like, not only what the next test will show. They expect honesty and clarity.

Planning has moved out of the shadows. Wills, advance directives, conversations about thresholds and trade-offs.

The words that Ivan could not get anyone to say is now part of ordinary speech in many homes.

What changed?

Medical practice exists within, and arises from, the wider culture around it. This is where the change happened.

We stepped away from a single religious frame that once organized suffering and death. In its place we built a mixed vocabulary. Secular ethics gave us back our autonomy and consent. Psychology gave us a language for inner life.

Buddhism and other Eastern traditions entered the mainstream and normalized attention to impermanence, breath, and the mind under strain.

You can hear it in how we talk. We admit our fears. We acknowledge our boundaries. We accept that our control has limits.

We also learned to distrust polished surfaces. The twentieth century eroded trust in institutions and reshaped how people view authority. The idea that authority would tell the whole truth lost credibility. Plain speech gained ground. A person who speaks directly is now read as respectful. A person who hides behind formality is read as evasive.

Medical practice has followed the transition.

Today, I speak directly about illness and decline, without adornment. I bring families into the conversation. I help patients plan.

Medical assistance in dying is part of this broader change. It requires capacity, voluntariness, and informed consent. This is a process that could not function without direct language.

That is how we got here. A culture that accepts that life ends, that people want a say in how it ends, and that words should match reality.

But the older reflex is still active.

People can still protect each other from hard realities.

Sometimes, I will catch myself softening a prognosis. A family member will change the subject. A patient senses what is happening but decides not to force the issue because no one around them is ready.

The performance is subtler now. It often presents as kindness. It still leaves the central fact partially unsaid.

This impulse has a kind of internal logic.

Stating death forces a reordering of everything else. Plans collapse. Roles change. Time becomes finite in a way that cannot be ignored. Avoidance buys a little space.

Despite these understandable reservations, our culture has managed to achieve substantial progress for a more humane and practical approach to the end of life.

Yet, what we have built in the culture is ahead of what we have built in our systems.

People expect direct answers about decline. They expect time to talk through options. They expect continuity when decisions become hard. The structure does not always support that.

Appointments are short. Care is painfully fragmented. Responsibility moves from one provider to the next. The conversations that matter most often happen in small gaps and brief moments.

Support for end-of-life care remains uneven. Access to palliative care depends on geography and resources. Some patients receive careful symptom control and steady follow-up. Others rely on family members who are already stretched. Hospice beds are limited. Home care is inconsistent. The standard varies more than it should.

While training has improved, it is not uniform. Some clinicians speak plainly and stay present through the uncertainty. Others will still reach for the cover of technical language or defer the discussion altogether.

That is not a failure of intent. It’s a reflection how people were trained, what the system rewards and our lingering cultural sensitivities.

There is also a risk at the other end.

We have forms, checklists, and protocols. They can help. They can also reduce a hard conversation to a series of boxes. A patient can sign a document and still feel unheard. Clarity on paper is not the same as understanding or meaningful connection.

The future will be decided in these details.

We need time for real conversations. We need continuity so that a patient does not have to restate the same fears to a new face each week. We need broader access to palliative care at home and in the community. We need training that treats communication as a core skill, not an optional one.

And we need to keep the standard simple: say what is happening, listen for what matters to the patient, and act in line with that.

Tolstoy described a culture that protected itself with silence. We have moved past that in many ways. The next step is to build a system that can sustain the honesty we now expect.

I’m a family doctor in British Columbia, Canada. I write about the intersection of health, science, and belief. If this speaks to you, please consider subscribing or sharing.

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This was the age of antibiotics, of space rockets, of scientific breakthroughs.

Psychiatry too, it seemed, was on the brink of miracles. Inside, nurses moved briskly, their shoes whispering across polished floors, the air sharp with disinfectant and polish.

In the admitting office, a husband signed his name at the bottom of a form. His wife sat silently beside him, her dress neatly pressed, her eyes lowered. Dr. Donald Ewen Cameron leaned forward. His Scottish accent clipped each word.

“She is suffering from a profound disorder of mood,” he told the husband, not the wife. “We have a method here. Rest. Renewal. We will rebuild the mind.”

The husband exhaled in relief. The wife tried to smile, but the words clung to her like fog – rebuild the mind.

They led her upstairs. A nurse guided her to a narrow bed, pressing a cup into her hand. She drank obediently. The ceiling swam. Darkness rose up and carried her off.

Time slipped away. Sometimes she surfaced, a rubber bit between her teeth, straps at her wrists. A man adjusted knobs on a machine. A flash of white tore through her skull; her body bucked, then went slack. Later, in a dim room, she opened her eyes. A speaker beside her bed whispered endlessly: You are a good mother. You will feel calm. You are a good mother. You will feel calm. She pressed her palms to her ears. The voice seeped through her fingers, circling, circling.

In his office, Cameron scribbled furiously in his notebook. Subject demonstrates depatterning. Psychic driving proceeding as expected. He believed he was a pioneer. The Cold War was a contest not only of missiles but of minds. If the mind could be erased and rebuilt, whole diseases might vanish. Or whole identities. Patients were canvases.

And far away, in Langley, Virginia, a man in a gray suit bent over a stack of memos. He was not a doctor, not a healer. He worked for the Central Intelligence Agency. His pen scratched across the page: Subproject 68. Funding approved. Potential applications for interrogation and counter-espionage.

He initialed the bottom without hesitation. To him, Montreal was just a location, the patients just “subjects.” He had never set foot in the Allan Memorial Institute.

Months later, the young mother came home. She moved through her kitchen like a stranger, staring at pots and pans as though she had never seen them before. Her children tugged at her skirt, calling to her. She looked at their faces, uncertain. Their names would not come. Her husband stood in the doorway, helpless. She was alive, but emptied.

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Meanwhile Cameron lectured in Toronto, New York, London. He spoke of innovations in psychiatry, of bold new methods. He did not mention the patients who could no longer cook, no longer dress themselves, who forgot their own birthdays. Those were failures, and failures did not belong in a lecture hall.

In 1975, the story surfaced. U.S. Senate hearings revealed the existence of MKULTRA. Under television lights, a senator asked, “Were these experiments conducted on unwitting patients?” The answer was reluctant but clear: yes. Families recognized their own grief in the testimony. Survivors told of years lost, of memories stolen, of voices whispering in the dark.

Over nearly a decade, from the mid-1950s into the 1960s, patients at the Allan Memorial Institute were drawn into a program that few understood and none had agreed to in any meaningful sense.

The treatment itself followed a logic that, at the time, was presented as bold and scientific. Under Donald Ewen Cameron, patients were first “depatterned.” They were kept in prolonged, drug-induced sleep for weeks at a time, sometimes approaching two months, interrupted only for feeding, basic care, and repeated electroconvulsive shocks delivered at high intensity and frequency.

The goal was erasure. Memory, habit, identity, all reduced to a kind of blank state. What followed was “psychic driving.” Recorded messages, tailored to the patient, were played on a loop for hours, sometimes days, meant to imprint new patterns of thought and behaviour onto what remained. Admissions that began as brief stays stretched into months. Families were given little detail.

The theory promised renewal. In practice, many patients emerged not restored, but diminished, struggling to recover even the most basic threads of their former lives.

Funded in part through the Central Intelligence Agency under the umbrella of MKUltra, Cameron’s work reached well beyond conventional treatment. Dozens of patients, and likely more, were subjected to prolonged drug-induced sleep, repeated electroconvulsive shocks at intensities far beyond standard practice, and the relentless “psychic driving” of recorded messages played for hours or days.

Many entered with anxiety or depression. They left unable to recognize family, unable to care for themselves, some incontinent, some stripped of memory to a childlike state.

Cameron continued his career without sanction, lecturing internationally, his reputation largely intact. It would take years, and then decades, before compensation was offered to a small number of survivors. For most, the losses were permanent, carried quietly in the routines of daily life that no longer made sense.

The walls of the Institute still stand. Quiet now, but the silence is heavy. The Montreal Experiments remain a warning: when healing joins secrecy and power, the line between cure and cruelty can vanish. What is left are broken lives, scattered memories, and trust betrayed across generations.

We like to place this story in the past, to seal it off with the language of the Cold War and the authority of individual men like Donald Ewen Cameron. That is too easy. The instinct that drove those experiments has not vanished. It still appears whenever certainty outruns humility, whenever outcomes are prized more than the person experiencing them.

Every clinical encounter carries a test. Who is being centred. Who is being spoken to. Who is being asked to consent, and who is simply being moved along.

The lesson is not to distrust medicine. It is to insist that medicine earns trust, again and again, in plain sight.

I’m a family doctor in British Columbia, Canada. I write about the intersection of health, science, and belief. If this speaks to you, please consider subscribing or sharing.

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Saline first. Then the medication. Followed by more saline.

I watch the clock more than anything else. I have a full clinic starting in an hour. Back-to-back patients. Charts waiting.

I keep my head down when people pass by. There’s always that small question of recognition. Hospitals are tight networks. People know faces.

A nurse checks the line and asks how I’m doing. I smile and answer the way patients do. “I’m good.” It comes out easily.

This is my new perspective. As a patient.

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The shift began with my diagnosis of multiple sclerosis. From this side of the consultation table, different things stand out. Tone. Pacing. Where someone looks when you’re speaking. The small details that either steady you or leave you slightly off balance.

You start to pick up on it quickly as a patient. A small change in voice can shift the entire conversation. Eye contact can either open the door or close it. A passing comment can stay with you long after the facts are gone.

I noticed how easy it can be to dismiss things, even without meaning to. Maybe moving a bit too fast, or leaning on authority just enough to steer the interaction.

It doesn’t take much.

So, back at work, I made a point of doing the opposite. Slowing things down. Keeping space in the conversation. Addressing concerns directly instead of moving past them.

The difference was noticeable. Patients opened up. They asked more. The conversation felt more like something shared.

That’s what this is about. The small, repeated habits that end up defining how care feels on the other side. I’ve tried to distill these experiences into a handful of rules I come back to. Nothing complicated. Just the things that seem to make the difference in a busy clinic:

1. Be respectful. Check your ego at the door.

You hear it early in training. A senior physician speaks with a faint edge. A trainee watches, repeats, absorbs. Over time it becomes style. Confidence and authority are part of it. But, so is condescension.

The mechanism is straightforward. Patients come in looking for answers. Physicians feel pressure to provide them. Certainty becomes performance. Voice lowers. Language simplifies. The patient becomes a recipient rather than a participant.

Patients register this. Often later, when they replay the exchange and hear what was implied. The residue is real. They feel managed rather than understood.

Early in my own treatment, I raised a differential for a symptom I was experiencing. The physician interrupted with a smile that did not soften his words: “Knowing too much can be dangerous”

My professional and personal curiosity had crossed an invisible line and was corrected.

The reflex behind it is common. Re-establish hierarchy when it feels threatened. Guard the boundary.

There is a better move available in that moment. Walk through the reasoning. Test assumptions on both sides. Invite the patient into the analysis.

That change alters the entire encounter. Patients disclose more. They ask better questions. They follow through because they understand the plan and see themselves in it.

Medicine requires expertise. It does not require performance. Patients remember whether they were treated as capable.

2. It’s OK to say, “I don’t know.”

Every clinical encounter has a point where certainty runs out.

Many physicians fill that space with confidence. Not the grounded kind. But a thinner, improvised version. It sounds smooth. It keeps the visit moving even as it erodes credibility.

Our training rewards a projection of assurance. While not knowing might be seen as failure. The result can be overstatement. Guesses that are delivered as conclusions.

At an early treatment discussion, I asked whether I would need a permanent intravenous line. The resident answered immediately. A PICC line would be placed. The drugs required it. Standard practice.

Minutes later, the consultant reversed it. No. Your veins are fine.

The issue was not the initial uncertainty. It was the decision to guess and present it as settled knowledge. From that point, everything that followed carried doubt.

The same pattern shows up in risk discussions. I heard conflicting explanations from different consultants. Both confident. Neither accurate.

Patients recognise this. They may not challenge it in the moment. They remember it.

There is a simple alternative. State the limit. “I’m not sure. I’ll check. I’ll come back to you.” Then follow through.

That sentence builds more trust than a fluent guess.

3. Stay real. Let reassurance follow the facts.

Bad news often gets rounded off. Risks framed gently. Prognosis delivered in a tone that suggests things will likely be fine. The intent is kind, but the effect is distortion.

Patients do not start from neutral. They sense when something is wrong. They read faces, pauses, phrasing. When the words do not align with what they feel, the disconnect is immediate.

As an astute clinician myself, I already suspected a serious diagnosis. From my perspective, I either had a brain tumour or multiple sclerosis. But the first consultant stayed upbeat. “Most findings turn out to be benign. Try not to worry.”

Then, while waiting for imaging to clarify the diagnosis, my new neurologist was more direct: “It’s either a brain tumour or MS.” His clarity was welcome and refreshing.

The fix is straightforward. With diagnosis, honestly and clearly identify the likely range, including the serious end. Outline the next steps. Align the words with what the patient already suspects.

The same applies to side effects. Minimizing them trying to improve adherence will backfire. When side effects occur, patients feel blindsided.

Preparation steadies the course.

4. Don’t blame the patient. Even when stressed.

When the system is under strain, it can manifest in phrasing, tone and body language.

“Why did you wait till now to come in for this?” can sound like a reprimand. Patients hear the subtext. They withdraw. The interaction narrows.

The pressures are real. Overbooked clinics. Full corridors. Limited staff. That does not justify directing frustration at the person seeking care.

Careless language can turn a person into a problem.

A better approach gathers information without blame. “Tell me what brought you in today.” “Have you been able to see your GP?”

During a routine follow-up visit, I raised a concern about weakness in one arm. I play several sports requiring both arms.

“Everyone needs both arms,” the doctor said.

It erased the question. It closed the exchange.

These are small comments. They alter the relationship.

Precision in language prevents unnecessary harm. Address the question asked. Remove commentary.

5. Take every concern seriously.

Primary care and emergency settings see a steady flow of benign conditions. Those encounters build the relationship. Done well, they teach patients how to interpret symptoms and when to seek help. Done poorly, they leave patients isolated with the same fear.

There is a simple test. Would you use the same words if a colleague were present? The answer is often no.

Taking a patient seriously means granting that the concern has a basis. It means examining with care, explaining clearly, and providing a plan with a path back.

Patients calibrate future behaviour based on these interactions. They return earlier when they feel heard. They delay when they feel dismissed.

Reassurance requires attention, precision, and respect.

I’m aware reading this back that none of it is especially dramatic. No scandal. No single story that demands outrage. Just familiar moments, the kind most of us have either witnessed or taken part in.

That’s exactly the point.

This is the texture of everyday medicine. The tone we default to. The habits we inherit and rarely examine. The small decisions that shape how care is felt on the receiving end.

I don’t place myself outside of it. I’ve been part of this system for a long time. I’ve used the same shortcuts. I’ve felt the same pressures. I’ve likely missed some of these moments in my own practice.

Seeing it from the other side changed that. Not in a dramatic way, but in a steady, ongoing recalibration.

I’m trying to hold onto that.

If you work in healthcare, you’ll recognize pieces of this. You may disagree with some of it. You may have your own versions, your own examples that run deeper or cut sharper.

If you’ve been a patient, you’ll recognize it even more clearly.

I’d be interested in what you’ve noticed.

The moments that stayed with you. The things that helped. The things that didn’t.

I read every reply.

This isn’t about getting it perfect. It’s about paying attention to the parts of the interaction that rarely get named, but shape everything that follows.

If we’re going to improve how care is delivered, this is one place to start.

I’m a family doctor in British Columbia, Canada. I write about the intersection of health, science, and belief. If this speaks to you, please

consider subscribing or sharing.

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I knew the pattern.

She had been coming in every week or two for vitamin B12 injections. She believed they helped. Clinically, they were not indicated. The visits had taken on a different function. A brief procedure.

A few minutes of conversation about her recent separation and her daughter. Enough to acknowledge the problem without opening it fully.

Efficient. Contained.

The injection gave the visit a structure. It also gave me a way to avoid all the rest.

That afternoon, the pattern broke.

She described her ten-year-old daughter who had chosen to live with her father, a decision that, at first glance, suggested the usual explanations. Stability. Preference. The gravitational pull children often feel toward the less disrupted household.

Then the details flowed, slowly at first, then with force. Her ex-partner’s thinking had shifted over time, with a sudden inflection during the years of COVID-19.

Conspiracy frameworks. New Age language threaded with deep suspicion. A worldview that did not simply question institutions but rejected their legitimacy outright. He did not accept the authority of courts. He did not recognize the obligation to pay taxes. The structure of civic life, in his account, was optional, even adversarial.

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Her account was credible. Nothing in what she said required rescue or reinterpretation.

From a distance, the arrangement reads as a familiar outcome of separation.

One parent becomes the primary home. The child settles. The system records a decision and moves on.

Up close, a different set of forces is at work.

A household organized around rigid, paranoid beliefs does more than project opinions. It sets the terms of reality. It determines which sources are trusted and which are dismissed. In this environment, disagreement is equated with betrayal. The range of acceptable thought is narrowed. And that range is enforced through approval, withdrawal, or conflict.

For a child, this is not abstract. It is the environment in which language, judgment, and identity develop.

Children are adaptive. They learn quickly which responses preserve connection and which provoke tension. They adjust their speech. They filter what they report. They adopt the vocabulary that is rewarded. Over time, this becomes internal. The child may not experience or understand it as constraint.

It feels like alignment. It feels like loyalty.

The cognitive impact is cumulative. Critical thinking necessarily develops in relation to stable reference points. When outside authority is defined as hostile or illegitimate, external correction loses its sway. If evidence is continually reinterpreted to fit a fixed narrative, the distinction between belief and fact erodes. The child learns a rigid system that projects certainty, accounts for everything, and prohibits challenge from within.

There is also an enormous emotional cost. The child is placed in a divided field. One parent represents a closed framework. The other represents an alternative that may be harder to access or trust. Movement between those worlds requires constant adjustment. What is acceptable in one setting may provoke conflict in the other. Many children resolve this by choosing hardened consistency over conflict. They commit, outwardly or internally, to the system that demands it most strongly.

This is how a preference can take shape. It reflects adaptation to pressure, not a neutral evaluation of options.

As I listened, what I had missed in those earlier visits emerged. I had two reactions.

The first impulse was clinical and immediate. A ten-year-old is now embedded in a household organized around a belief system that does not recognize shared rules, that can distort judgment, that can turn ordinary authority into perceived threat. That raises concern about safety. About psychological development. About what becomes normalized.

The second turned inward. I had seen her story before. I had responded with sympathy, but I had not stayed long enough to hear the full account. The visits had been structured around the injection. The conversation had been secondary. I had allowed that structure to define the encounter. That was the error.

Cases like this move quickly past the limits of the medical visit and into the limits of the system at large.

In British Columbia, as in most jurisdictions, family disputes can be prolonged by one party with the will to extend them, and the system permits it. The process itself becomes leverage. Delay becomes strategy. The rules can be ignored without consequence. The person seeking resolution is drawn into a sequence that is slow, expensive, and uncertain.

The child remains in place while the process unfolds.

There is no concise solution to offer in that setting. Advice becomes procedural. Document carefully. Engage legal counsel. Maintain consistency. Protect the relationship with the child where contact is possible.

Each step is reasonable. Each step takes time.

None of it addresses the immediacy of what she is living through. The child remains where she is. The beliefs remain intact. The days pass without visible change.

Progress, when it comes, is measured in filings, in responses, in dates set months apart. In the meantime, the parent who is trying to act in good faith absorbs the cost. Financially. Emotionally. Structurally.

The system does not distinguish between those trying to resolve conflict and those who exploit it deliberately, to their advantage.

There is no intervention I can offer in a single visit that alters that trajectory. Only a set of steps that may, over time, shift it slightly.

The consultation ended where many of these encounters end. Not with resolution, but with a clearer account of what is happening, and a commitment to stay with it. While that has a value, it does not change the underlying conditions.

But it does keep someone from facing them alone.

It was a difficult way to end the week.

I’m a family doctor in British Columbia, Canada. I write about the intersection of health, science, and belief. If this speaks to you, consider subscribing or sharing.

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Dinner was easy. Laughter. Stories. Two old friends whose teenage sons now tower over the memory of their wedding. At some point my ex came up in conversation. I referred to him by a nickname I use privately. A dark, slightly theatrical shorthand.

Jennifer winced.

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“Don’t call him that,” she said. “We love you both.”

It was said kindly. Generously. As if she were preserving balance in the universe.

But something inside me tightened.

The tension was not irrational. It came from history. From a pattern of calculated cruelty that did not begin with the breakup and did not end there.

Years ago, after our separation, he told people grotesque accusations about me.

Some mutual acquaintances, as well as a close family member, had relayed the painful nature of the defamation. It was nightmarishly absurd. Not hyperboles, complete fabrications. The poisonous patter of an afflicted personality. But once words like that are released into a small community, they do not evaporate. They drift.

I didn’t knew who might have heard them.

For a couple of seasons, even though I had every right to be there, I felt uneasy walking through the village. I imagined glances. Whispered assessments. A kind of social exile that may not have existed outside my own head, but lived vividly in my body.

That is the part most won’t understand about smear campaigns. The damage is not only reputational. It is physiological. Humans are wired for belonging. Threaten that, even hypothetically, and our nervous system engages fear, apprehension and jeopardy.

So when someone says, “We love you both,” what they might mean is: I do not want to choose. I value harmony. I refuse to triangulate.

What the survivor hears is: “Your injury, and his aggression, are morally equivalent.”

That may not be fair. It is clearly not accurate. But the feeling is real.

Recovery from narcissistic abuse goes beyond leaving the relationship. It includes surviving the narrative that follows. It is learning to tolerate the fact that some people will remain neutral. It is managing the body’s reaction when an old accusation echoes in a familiar place.

You can be healed and yet still flinch. You can have rebuilt your life and still feel a surge of shame when you walk into a room weighted with history. You can understand why friends refuse to choose, and yet still feel the sting of their neutrality.

So last night, after a few drinks, I felt the old tightening. The scanning. The question: who knows what? Who believes what?

It surprised me. I had thought I was past it.

Relief came later, slowly. In a quiet room, by myself. With reflection and meditation. Not from vindication. Not from public correction. From quietly reaffirming that those accusations happened, that they affected me, and that they were false.

Sometimes recovery is not about clearing your name. It is about finding people who see you clearly, and accepting that other might not.

If you have been through something similar, you are not irrational for feeling activated years later. You are not dramatic for struggling with community neutrality. Your nervous system is responding to a threat it once experienced as existential.

Healing does not mean amnesia.

It means you can sit in the same village, order a drink, feel the tightening, and know that it will pass.

There is something else worth adding.

Many people who find themselves in relationships like this are not naïve. They are not foolish. They are not weak.

They are often generous and patient. They will try to see the best in others and be slow to assume malice. They are willing to self-reflect and take responsibility for more than their share.

These attributes are strengths. They are certainly not flaws.

But in the presence of someone who exploits empathy, those strengths can be used against you. Your instinct to understand becomes an opening. Your tolerance becomes an opportunity. Your capacity for forgiveness becomes a tool.

It can be deeply disorienting to realize that your kindness was not reciprocated, and instead harvested.

Even people who appear competent, accomplished, or professionally authoritative are not immune. You can run a clinic, manage crises, hold complex medical knowledge in your head, and still be gradually destabilized inside an intimate relationship. Intelligence does not vaccinate against manipulation. Success does not confer immunity from psychological coercion.

Abuse of this kind does not select for incompetence. It selects for decency.

If you were drawn into something like this, it does not mean you lack discernment. It may mean you were operating from trust in a world where someone else was operating from control.

And when it ends, it is common to feel embarrassed. Ashamed. As though you should have known better.

You did know better. You just assumed the other person was playing by the same rules.

There is no disgrace in being kind.

There is no contradiction in being capable and having been harmed.

You can be both strong and injured. Both accomplished and misled. Both discerning and, for a time, deceived.

None of that diminishes you.

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