This book provides an “existential positive psychology framework” (p. 3) for mental health clinicians whose clients are struggling with issues that have no solution or hope of resolve. The framework helps these clients learn to live positively, in spite of their suffering.
The husband-and-wife authors—a clinical psychologist and a clinical social worker—explain that their personal suffering catalyzed writing the book. One of the author’s brothers died of a genetic medical condition, and the doctors warned the author that he could also have inherited the disease. One more complication was the doctor’s warning that having kids was too risky. Years later, under medical advice, the authors planned a family but were infertile. “Our story was not a cognitive distortion; our suffering was not a set of irrational thoughts that needed to be corrected. No amount of therapeutic mental gymnastics could make us feel unbroken” (p. 4).
Mainstream psychological therapies, say the authors, offer little help to those suffering from irremediable conditions. “Boiled down to its most basic level, many clinical approaches view suffering as a problem to be fixed, and then, once the symptoms subside, disregard the effect of the event itself” (p. 5). The authors argue that we need another form of therapy, one focused on meaning.
Meaning, for the authors, is about coherence (making sense of one’s life), significance (feeling that my life matters), and purpose (choosing a direction). Yet for those plunged into life-altering conditions, a felt sense of meaningful living disappears. They suffer from “existential themes”: groundlessness (loss of control, burden of freedom), isolation (being alone), identity (determining who I am), and death (loss). How does one find direction in life when they struggle to answer Who am I? How does one feel their life is significant when they feel their lives are out of control? How does one make sense of one’s life when the ground under them feels marshy?
The clinical framework to help such clients is a five-phase plan, couched in a sunset to daylight metaphor:
- Sunset (“the sting of suffering”): Typically, clients feel senseless and out of control, and they develop a negative self-view. Their assumptions of who they are and what their world is like are shattered. The authors borrow the term depressive realism to describe this phase. The idea of depressive realism is that having a low mood enhances the ability to see the world (and one’s self) more objectively and accurately. The role of the therapist is to understand how clients make sense of things and help them stabilize.
- Dusk (“into the darkness”): The goal of this phase is acceptance of reality. Whatever coping skills clients have relied on—problem-focused, emotion-focused, or avoidance—no longer work for them. They feel the depth of their suffering but cannot name it and so cannot explore it. This is a difficult phase for clients, and the therapist helps them learn emotion self-regulation. Emotion regulation is required to face struggles and work through them, which the authors describe as “Pushing into the pain” (p. 66).
- Midnight (“the deconstruction process”): Most (mainstream) therapies end before this phase. Yet, it is precisely at this point that clients actively question many of their deeply held beliefs, which no longer resonate with their reality. Such reflection “will begin to rid themselves of whatever does not feel authentic” (p. 79). The therapist helps the client actively question how they have been making sense of their suffering, themselves, and the world around them.
- Dawn (“the reconstruction process”): The client reconstructs beliefs, but this time in ways that are authentic to their suffering. This process helps clients “revise their identity” (p. 14). This phase is essential for the client to develop autonomy, becoming the active authors of their lives. The therapist helps clients through this phase by guiding clients on revising their narratives.
- Daylight (“living authentically”): “Choosing a life that fits with their revised beliefs and identity” (p. 14). The therapist supports clients in their revised identities and realities.
This five-phase plan aims to help clients by “building meaning in life” (p. 12), and specifically finding meaning in their suffering. The authors tell us that meaning is so important because (1) research suggests it is integral to positive client outcomes; and (2) “meaning can transform already deeply painful experiences into something more without invalidating or excusing them” (p. 12). Essentially, if a client finds meaning in suffering, then they are able to transcend it.
As clinicians, the authors are more interested in practice than theory. This is not a book probing into the nature of meaning and purpose. To that end, many of the theories they cite are touched on only briefly, such as Dweck’s growth versus fixed mindset or Rotter’s locus of control. We don’t know why the authors looked to Dweck and Rotter, rather than others. Similarly, we don’t find much exploration into the nature of the research presented to support each of their therapeutic phases.
But the book’s purpose is not to deal with these issues. It’s intended to show therapists how to work with suffering at an existential level. And it regularly cautions therapists that existential issues are very human ones, which affect the therapist as much as they do the client. Working with clients whose problems are life-changing demands the clinicians, themselves, explore the meaning they give to these clients and their problems.
On a personal note, what is particularly fascinating about the phases of therapy is that they are similar to the program I developed at a residential facility for men suffering from addiction and other mental health issues. I have never met the authors or read their work before reading The Courage to Suffer. Yet the authors’ therapeutic direction—experiencing shattered assumptions about self and world, accepting reality no matter how bleak, deconstructing current narratives, reconstructing new life narratives, and supporting clients in their new ways of making sense of themselves and the world—are precisely how we help clients.