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The Benefits of Suffering and the Costs of Well Being: Secondary Gains and Losses

Will Joel Friedman, Ph.D. is a seasoned clinician with experience working with adults, couples, families, adolescents and older children since 1976. His aim ...Read More

The German poet Rainer Maria Rilke asserted, “Surely, life is right”. A provocative and powerful therapeutic stance is to affirm the “rightfulness” of all human behavior. The appropriateness of human actions need not imply a moral judgment like “right” or “wrong”, “good” or “bad”. To perceive the “rightfulness” of human conduct leads us to acknowledge that behavior does serve a purpose, meet a need, and that it is emotionally fitting somehow. This fittingness of human behavior rings true no matter how painful and destructive the behavior and its consequences are.

A delightful Sufi healing tale by Indries Shah chronicles the exploits of one Mulla Nasrudin and wonderfully captures the perspective of behavior being purposeful and persisting:

The Mulla was made a magistrate. During his first case the plaintiff argued so persuasively that he exclaimed, “I believe you are right! ” The Clerk of the court begged him to restrain himself, for the defendant had not been heard yet.

Nasrudin was so carried away by the eloquence of the defendant that he cried out as soon as the man had finished his evidence, “I believe you are right!”

The Clerk of the court could not allow this. “Your honour, they cannot both be right.”

“I believe you are right!”-said Nasrudin.” (1968, p. 67)

In a similar vein, deep acceptance of the labeled “problem”, along with a willingness to work within the metaphors of an individual’s mind, is a hallmark of Milton Erickson’s therapeutic approaches. One famous example is of Erickson approaching a young male schizophrenic patient at Worcester State Hospital who proclaimed himself Jesus. He said, “I understand you have had experience as a carpenter?” The patient had little choice other than to reply in the affirmative, and thereafter was involved in the project of building a bookcase and other productive activities (Haley, 1968, p. 28).

In working with a broad spectrum of clients demonstrating self-defeating behavior patterns, especially with complicating physical disorders and chronic pain issues, I have noticed that such clients often show little, if any, awareness of the purposes served for their self-defeating behavior. Almost without exception they discuss what is wrong in their lives. Thus it frequently appears that there is little, if anything, going “right” or adaptively in their world.

To illustrate this commonly shown “wrongfulness”, and unawareness of the “rightfulness” of human behavior, let us examine one interchange in the initial client assessment interview. Herein I often ask, “How do you need this (condition, problem, or disorder)?” I usually receive the reply, “I don’t need this!”, and often with some irritation to boot! I then rephrase my question as, “What purposes does this problem serve for you?”, and again receive the answers, “None”, “Nothing”, or “No purposes”.

What is remarkable is not that there is seemingly little self-awareness and inner reflection of the possible meanings of their disturbing challenge(s), but rather how these above-mentioned questions rarely seem to arise at all for a great majority of individuals facing troublesome problems in living. Although it is understandable that these hurting people are preoccupied with their particular problems, one might speculate that it is our very culture and socialization processes that do not teach individuals an appreciation of this “rightfulness” perspective.

This continuing observation in clinical assessments, as well as in psychotherapy, inspired the development of two lists of attitudes and behaviors that reflect motivational hidden agendas and perceptual blind spots of human endeavors. Table 1 is a list of benefits of suffering or “secondary gains”. Such gains can be thought of as “…the indirect, interpersonal advantages which the neurotic derives from his condition, e.g., compassion, increased attention, freedom from everyday responsibilities, and the like” (Watzlawick, 1967, p. 287). This list presents benefits or advantages which people often derive or receive from their physical, neurotic, and character disorders as well as life difficulties. It is theorized that the individual does not consciously and intentionally search for these benefits, but that there is a payoff (i.e., some enjoyment) in them. Refer to Table 1 for the specific items.

Freud termed these “secondary” advantages “epinosic”, meaning “on, or over, disease” (Goldenson, 1975, p. 750). In contrast to “primary gains that are tied to the original cause of the illness, “secondary” gains are the result of illness. Thus, secondary gains include the psychological benefits derived from the physical, neurotic, and character disorder symptoms. In practical terms, it can be quite difficult to make a clear demarcation between primary and secondary gains.

Table 2 presents a list of the costs or disadvantages of well being, what can be thought of as “secondary losses”. These are attitudes and behaviors people would need to give up or let go, in order to create the realistic possibility of addressing and resolving their difficulties. The above definition of “secondary gains” equally applies, but with a twist, i.e., these proposed “secondary losses” are avoided as disadvantages for making adaptive changes to remedy their disorder(s). These losses, once again, are beyond any hypothesized “primary losses” (e.g., old age physical limitations, death of loved ones, and material losses) related to the losses or disadvantages associated with the original source of the disorder.

Therefore, secondary losses include the broad spectrum of psychological disadvantages or costs derived from resolving the physical, neurotic, and character disorder. Again, in pragmatic clinical work, it is often difficult to accurately differentiate between primary and secondary losses. In short, both lists present tacit, secondary payoffs of illnesses and self-defeating, painful behavior. Refer to Table 2 for the specific items.

These lists have considerable utility. Each list can serve as a set of clinical hypotheses sensitizing the therapist, as well as client and possibly client’s family, to these issues and aiding each to have a clearer understanding of the clients’ true motives behind their attitude and behavior. Such information can prove enlightening not only to the therapist, but also to the client or their families, when this is deemed appropriate and prudent. Such hypotheses, once cross validated by testing, interview, or reportage of significant others, can serve to help design fitting healing interventions. Transference and counter-transference issues can be explored within this framework with profitable therapeutic returns.

Within a hypnoanalytic orientation, these lists can be useful diagnostically. As an adjunct to the Byran Hypnotic Word Association Test, the client’s unconscious / Higher Self can be asked the following questions concerning secondary gains: “The greatest advantage for having this difficulty is. . . ” and “Other things gained by this difficulty are. . . ” Similarly, the unconscious / Higher Self of the client can be asked the following questions concerning secondary losses: “The greatest disadvantage for giving up this difficulty is. . . ” and “Other things I might lose by giving up this difficulty are. . . ” The two lists of secondary gains and losses provide a helpful structure for accurately conceptualizing and synthesizing the clients’ answers.

It may further be helpful to offer these lists to selected clients at pivotal crossroads in therapy. One manner of utilization is for the client to identify attitudes and behaviors he/she thinks of as “wrong”, “bad”, or “shameful” in people, and ask, “What needs and purposes are served here?” The client can then look at secondary gains associated with these attitudes and behaviors. The same procedure is applicable in making alternative self- or other- attributions. Along the same lines, when a client is blocked in their progress, looking at the secondary losses can reveal what needs to be given up in order to get well.

Another way of using these lists is to request the client to carefully read through the list(s), and very candidly mark items he or she knows are operative and applicable to him or her and the challenges at hand. Thereafter, a clinically productive discussion can ensue that can reveal the underlying needs, motives, and purposes involved. Once these purposes are clarified, then the question “How can these needs and purposes be more constructively met for everyone’s benefit?” can be asked.

Within a hypnoanalytic context, these lists are fundamental in not only understanding the individual’s personality functioning and structure, and their constellation of functioning rewards to be gained and punishments to be avoided, but additionally to pinpoint the key resistances blocking therapeutic progress. Seasoned clinicians know the value of confronting, reframing, and otherwise defusing resistance in opening space for life transformation. Beyond evaluating the person’s ability for self-support as measured by ego strength, social support system, cognitive-behavioral adaptability, and the like, therapists do have a responsibility to not take away necessary crutches, or even do deeper hypnotic work to repair diagnosed hypnoanalytic syndromes, until the person is clearly ready and able to tolerate (1) giving up their secondary gain issues, (2) taking on the secondary loss issues, and (3) finding non-harmful, constructive means to meet the underlying unmet needs. Such determinations call upon therapists to make their very best clinical judgments.

Finally, the lists of secondary gains and secondary losses can be easily adapted to the clinician’s unique orientation, conceptual system, languaging, values, intentions, and clientele. In summary, knowing specifically the benefits of suffering and the costs of well-being can provide an important clinical distinction, workable diagnostic and therapeutic framework, and eminently practical tool to enhance our therapeutic tookbox and healing work.

List 1

The Benefits of Suffering: “Secondary Gains” Associated with Illness

1. (False) power and control

2. (False) self being built up by knocking another self down (e.g., domination, aggression, acting out, and passive-aggressive stratagems)

3. (Unhealthy) selfishness and greed

4. (Unhealthy) laziness and resigning oneself to helplessness

5. (Negative) attention, thinking oneself invisible, useless, or valueless

6. (Negative) acting out unrealistic fears (phobias) and anxieties, including being alone, unloved, unwanted, rejected, not good enough, worthless, undeserving, disliked, and stupid

7. Self-hatred and attacking oneself or another modeling unacceptable qualities

8. Punishing oneself or another, or setting up and even inviting another to punish you or punish them, to obtain relief from real or imagined guilt or shame

9. To degrade oneself, another, life, or God as a re-creation of abusive trauma, neglect, willful cruelty, degradation, and humiliation.

10. Misguided attachments (i.e., “have to’s”), tied to pleasing someone’s performance standard and obtaining love, or to avoid displeasing someone’s performance standard and losing love

11. To think oneself as important, “special”, indispensable, or irreplaceable

12. To “look good”, or at least not “look bad”, in one’s own eyes, in significant other’s eyes, and in the world’s eyes

13. Addictively, to obtain the mood change desired (i.e., obtain an adrenalin rush / “buzz” or create high drama/personal soap opera)

14. An overcompensation to “prove” oneself strong, competent, and confident, in the face of “believing” the exact opposite

15. To demonstrate love, loyalty, and honor to a significant other by taking on a characteristic malady, disorder, or dysfunctional attitude or behavior of theirs

16. Avoidance of conflict, yelling, domination, and aggression

17. To hide real feelings from oneself and/or others out of an earlier self-protective decision

18. To feel something / anything coming out of psychic and sensory numbness, emptiness, worthlessness, and deadness

19. Avoidance of unwanted or disliked responsibilities as well as unacceptable consequences of one’s irresponsible actions and unrealistic attitudes

20. Irresponsible ventilating, dumping, and displacing internalized tension / stress that he or she doesn’t know how else to let go of, channel, or transform

21. To justify acting out an old grudge, injustice, unfairness, or perceived wrong (i.e., revenge and “payback” motives)

22. Legitimize an invested belief in the unfairness and injustice of people, institutions, the world, God, etcetera

23. To justify and legitimize blaming, finding fault, complaining, criticizing, being snobbish, rude, uncaring, insensitive, and “laying on” guilt or shame

24. To obtain sympathy, pity, and others feeling sorry for him or her

25. Proves one “wrong”, “bad”, “a failure”, “incompetent”, and “a nothing” or proves one “right” about being so “wrong”

Table 2

The Costs of Well-Being: “Secondary Losses” Associated with Becoming Well

1. People will want something from you that you may not be willing to give

2. People, especially those who feed on offering pity, sympathy, misery, and suffering over another’s problems, lose interest in you and no longer spend time with you

3. People, especially those who habitually think themselves the downtrodden of the earth, will be jealous, envious, displeased, and angered

4. People, especially those who feel insecure, will think you are acting superior and elite due to your success

5. People, acting in accord with their own attachments, will misconstrue your values, intentions, commitments, attitudes, and actions by drawing erroneous conclusions

6. Tolerate losing so-called “friends” and associates who cannot accept, agree, approve, appreciate, or acknowledge your life functioning this well

7. The cost does mean to give up and release all of your best excuses, cop-outs, lies, half-truths, misleading omissions, justifications, intellectualizations, and “good reasons” for life not adaptively functioning

8. The cost does mean to give up and release petty grudges, past wrongs, injustices, and unfairness’s in triggering abused reactions

9. The cost does mean to give up and release the negative attention and agreement over your life and the world not functioning

10. The cost does mean to recognize and give up what does not function or serve in life adaptively working with reality

11. The cost does mean relinquishing special privileges at home and work, as well as with family members, friends, and associates

12. The cost does mean to give up and release significant anxieties, upsets, fears, frustrations, depression, and other unprocessed, somaticized, or behaviorally acted out emotions, by learning and consistently practicing constructive ways to help process feelings “through” one’s guts, body, mind, and spirit

13. The cost does mean to give up and release significant unrealistic, irrational ideas and beliefs

14. The cost does mean to recognize and give up what is basically irresponsible, including unenlightened selfishness, “special interests”, and the “seven deadly sins” of (false) pride, greed, lust, (acted out) anger, gluttony, envy, and sloth

15. The cost does mean to recognize and give up major sources of destructive distress along with unworkable attachments, animosities, and ignorance’s

16. The cost does mean to tolerate feeling awkward and uncomfortable with highly unfamiliar healthy, successful attitudes and behavior

17. The cost does mean to recognize and give up dysfunctional coping strategies such as doubt, denial, avoidance, escape attempts, going unconscious, suppression, not remembering, and not caring

18. The cost does mean to face oneself and find the means to resolve and complete remaining old problems as well as handle new challenges

19. Be willing to take responsibility for what you have control over in your life, including all of your words and actions (with rare exceptions) in addition to some of your thoughts

20. Be willing to take necessary actions to clean up unworkable aspects of your life, as well as transform your life into a state of being you are committed to live

21. The cost does mean to accept and learn to tolerate the realistic idea that nearly nothing can prevent you from taking the next scary, risky step in creating and claiming your True Self and taking your true power

22. Be willing to become tolerant and accepting of other peoples’ choices that are unworkable and destructive, without “carrying” them, rescuing them, or making their lives fundamentally “your business”

23. Learn and practice daily whatever verbal, assertive, limit-setting, emotional coping and environmental management skills needed

24. Be willing to become firmly intolerant of irresponsible / destructive attitudes and behaviors, abusive behavior, “injustice collecting”, and all forms of harm to any living thing

25. Be willing to tolerate genuine enthusiasm, zest, and exuberance in addition to stretch beyond your beliefs and attitudes in regard to how significant a contribution, service, and lasting gift you your beliefs and attitudes in regard to how significant a contribution, service, and lasting gift you can offer


Goldenson, R. M., The Encyclopedia of Human Behavior. New York: Dell Publishing Co., Inc., 1975.

Haley, J., Uncommon Therapy. New York: W. W. Norton & Co, 1963.

Shah, I., The Pleasantries of the Incredible Mulla Nasrudin. New York: E. P. Dutton, 1968.

Watzlawick, P., Beavin, J. & Jackson, D., Pragmatics of Human Communication. New York: W. W. Norton & Co., 1967.

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