In Buddhism, there is a tale of two arrows. The first flies our way when we experience a painful, undesirable or difficult event. This arrow is often unavoidable and unforeseen, as is the pain that it causes. The second arrow to fly is the suffering that arises from our reaction, judgements, and thoughts about the first. This arrow can lead to the creation of a story, which we deeply attach to, about our pain.
The tale is told of a man who is struck by a wayward arrow in the forest, he experiences immediate pain from the injury. What follows are the many thoughts and stories that arise from such an event, the second arrow. His worries plunge him into a deeper state of suffering, clouding his ability to see his way out of the woods. The Buddha asks “The first arrow hurts, why do we shoot the second arrow into us, ourselves?”
What this story tells us is that suffering and pain may not always be the same thing, the second arrow is optional, perhaps pain does not always need to lead to suffering.
In medicine we use treatments to reduce or alleviate pain, these can be quite effective. However, we may not always be aware of the suffering someone may be experiencing in relation to this event. Suffering may require a different kind of care and approach. There may be times where we wonder, why aren’t these symptoms improving? Why is this person behaving this way?
This past spring my son had a lengthy hospital admission. I was now, parent, patient and physician. Thrust into uncertainty, I did not know how to balance these roles. I was scared, angry, frustrated, this made it harder for me to be there with him. The first arrow of his illness was surprising and unavoidable, the second, of my suffering, was more malleable. Through practices of loving kindness, self compassion and acceptance, I was able to find some ease (emphasis on the some). Holding close to my heart that this time would pass, sitting in that hospital room, everything and nothing existed, all I could do was be present. 
His experience was of course different. As the days went on without the improvements I hoped for, I came to understand that indeed his physical symptoms were resolving, however he was now deeply afraid. The smallest interventions become harder, his suffering showing up as defiance, anger, anxiety. While we had addressed the physical illness, the second arrow was still blazing. Knowing this helped me to approach this stage in his healing differently. While he still required “medical” treatment, he also needed support to process his experience, for me to see and be with his fear and to not judge it.
Eventually he was able to release his fear, and move into acceptance and compassion (as much as a young child can). Once there he rapidly improved, later he would tell me “I didn’t think anyone could help me, I thought I would never get better” This was the story that kept him trapped in pain.
Recently I read “Suffering has more to do with our relationship to pain (and symptoms) than the pain (and symptoms) themselves” Suffering is not always something we can “fix” with our medical tools, however its recognition is an important part in the healing journey. Understanding the two arrows can help us see the whole, rather than just the part we are trying to cure.
With mindful acceptance, compassion and the wisdom of these practices, perhaps the second arrow doesn’t have to fly, and if it does maybe its effects can be softened. This may not be with medications or interventions, but rather with presence, compassion and bearing witness to a person's experience. Feeling heard can be incredibly therapeutic, from here we may know a person more deeply, and what a gift that is.
Sometimes suffering, in its many forms, can be very difficult to be with. This is where the strong back and soft front of compassion, which at its root means “being with” is important. While empathy, “being inside, or Feeling into” is an important gateway to compassion, staying in this state too long can leave us drained. While we need to be able to sense into another’s experience, in order to stay we need to add in the desire or intention to relieve suffering. This moves us out of direct experience to come alongside with an open heart and true wish to ease pain. Compassion has been shown to be protective for both patient and practitioner, while staying too long in empathy can lead to significant distress. Compassion does not fatigue the way empathy does, and the good news is, it is available to each and everyone of us.
About the Author
Dr. Alysha Mackenzie-Feder is a pediatrician living and working in Kelowna, BC. She is a student in the Soto Zen tradition of Buddhism, a mindfulness and meditation teacher and a mother to two young boys. She loves being close to nature and finds peace and meaning in the mountains. She runs the Platform “A Deeper Well” which seeks to create a community for health care professionals and runs in person and virtual events with a focus on compassion, mindfulness and supportive resilience in medicine. You can sign up for her monthly newsletter here if you wish: https://adeeperwell.substack.com/