Secondary gain: really?


One of my most popular posts ever is one I wrote many years ago on malingering. Secondary gain, like malingering or symptom magnification is one of those terms used by people who don’t live with persistent pain, and commonly used when a person with pain doesn’t seem to be progressing “as expected”. The term is an old one, originating in the psychoanalytic literature, brought into compensation and insurance environments but never really examined (Fishbain, Rosomoff, Cutler & Rosomoff, 1995) until well after it had become a popular label.

Freud first identified the potential for gains from being unwell – primary gains referred to the direct gains obtained from developing a psychiatric illness in the face of unresolved psychic conflict while secondary gains were considered to be “an interpersonal or social advantage attained by the patient as a consequence of his/her illness”.

The sick role, or illness behaviour, is a sociological phenomenon (Bradby, 2009). As a society we permit people who are unwell to take time off responsibilities of paid employment, caring for others, socialising and doing the everyday life activities that people do. We also, in some cases, pay people to stay away from work, both to undertake recovery and to protect others from the illness in the form of sick leave entitlements and compensation. To ensure “fairness” or a sort of moral agreement between the ill person and society, humans have used healers, shaman or religious authorities to ensure the person has an authentic problem: ie, that they are morally fit to receive our help.

To most of us, particularly people in Australia and New Zealand, UK, Canada with largely socialised healthcare systems, the idea of sharing the burden of ill health through socially sanctioned support seems natural. We allow people a period of time to get well and then, when recovered, the person can return to normal activities. If the person sustains some nasty event, like spinal cord injury or brain injury, leaving him or her with ongoing ill health, we support ongoing payments (some more than others, depending on the funding bucket used). It’s easy to justify this when the person’s problems are visible – but for people with less visible, or truly invisible disabilities, our moral compass starts going awry.

For example, we have Mobility Parking: but woe betide the person with an invisible disability such as irritable bowel disorder, or panic disorder, using the park even when displaying the appropriate sticker! Tut! tut! tut! It is even more difficult with an invisible problem such as persistent pain, and even more so when the person’s problem hangs around. Secondary gain is the word whispered in the wind as people judge whether this person really has a problem – or is it “secondary gain”?

Let’s unpack the notion of secondary gain. From a behavioural perspective, behaviour is repeated if (1) something introduced afterwards increases the likelihood of the behaviour being repeated, eg a tearful child is cuddled after tripping, meaning the next time the child trips, he will look for someone to cuddle him; (2) something unpleasant is removed as a result of the initial behaviour, eg the pain of a grazed knee reduces with some topical analgesia. In these situations, the child is not usually aware that the contingency offered changes what they do – they just do what makes sense.

It’s when we start looking at people who don’t fit the typical response curve after an injury, that commentators begin flinging the term “secondary gain” around as if the person deliberately chooses to remain ill. Of course, insurers who fund compensation received by the person have a vested interest in reducing their payments and, given persistent pain can’t be objectively measured either directly or indirectly (Tuck, Johnson & Bean, 2019), will question the motives of a person who doesn’t recover. And therein lies our problem.

In our societies, medical practitioners are pseudo priests in many ways. The word of a doctor holds a great deal of weight: medical certificates, death certificates, oh and judgements about diagnosis and recovery. When it comes to insurers, the opinion of a doctor is used to verify that a person really has the problem they say they have, and can then continue receiving payment. The problem with pain is, yet again, having no direct objective measure of pain. The doctor is assumed to have special powers to detect whether a person really has pain – and yet there is considerable evidence that many medical practitioners have very little training in pain and even less in persistent pain in their training (Shipton, Bate, Garrick, Steketee, Shipton & Visser, 2018).

How is the term “secondary gain” experienced by the person living with persistent pain? Lang, Igler, Defenderfer, Uihlein, Brimeye & Davies (2018) undertook an intriguing study of how the various ways pain in adolescents can be “dismissed” by clinicians. They report that 40% of adolescents indicate their pain was dismissed by others, with almost 30% of those individuals stating this was done by a physician (p. 664). It’s probably not surprising that this kind of dismissal happens more often to female adolescents! Their study established that no, the sense of being dismissed wasn’t an indication of adolescents being “too sensitive”, but rather, that being dismissed by either misbelief (you don’t really have this pain); minimising (you have pain but it’s not as bad as you think it is); secondary gain (you’re using this as a way to avoid something like school); and psychogenic (it’s your emotional state that’s the real problem and cause) – are all likely to lead adolescents to look for another opinion, and to feel stigmatised.

So – is secondary gain a real thing? I like to look at it through a different lens. Taking the moral judgement tone out of the equation (that belief that only people who truly ‘deserve’ help should get it), I like to look at the problem of delayed recovery through a lens of problem solving.

Yes, there can be some gains from being unwell – who doesn’t like a bit of fussing or to be excused from doing something you don’t enjoy. The question is whether these gains come at the expense of other things – and there’s pretty compelling evidence that the losses outweigh any possible gains (Worzer, Kishino & Gatchel, 2009). At the same time, telling someone “you’re just doing this because you don’t want to get better” or words to that effect is not likely to help them have any desire to change what they’re doing – it seems to shift the person towards resisting any change in how they’re coping. It’s counter-productive.

Let’s look at a few losses:

  • employment (and people DO value working for reasons other than money! – think self concept, identity, social interaction, daily routine…)
  • relationship loss (partners, family roles, friendships – some of the most profound stories I hear come from men saying they no longer have mates they spend time with)
  • emotional impact (depression, anxiety, anger, demoralisation, shame, guilt)
  • financial loss (with loss of employment and increased healthcare costs) (Worzer, Kishino & Gatchel, 2009)

What traps someone into these losses? What might maintain someone’s helplessness and demoralisation? Pain, of course, but so too does shame; stigma from time away from work (employers want to know if you have a “bad back” – then run a mile); lack of confidence about capabilities (am I reliable? can I be counted on?); disability (there are some things I cannot do); limited communication (how do I ask for help?) and a myriad of other things. For the avoidance of doubt, people do not magically “get better” once they obtain their insurance payout (Fishbain, Rosomoff, Goldberg, Cutler, Abdel-Moty, Khalil, et al, 1993).

What can we do?

  1. First do no harm, that means avoiding moral judgements about motives for ongoing disability. It doesn’t help and does harm.
  2. Second, begin working on the actual problems the person is experiencing – things like building consistency in activity levels; improving communication skills; increasing confidence.
  3. Third, start addressing the social stigma associated with persistent pain. This means taking a long, hard look at ourselves as clinicians, and at our workplaces and social scenes, and insurers or funders.

Why do we run from the conversation that yes, pain does persist for a good number of people? Why don’t we acknowledge that even the best treatment in the world may not reduce pain – and that this is not the person’s fault for not trying?

This doesn’t mean researchers and clinicians should stop searching for pain reduction approaches – it does mean giving those who are not helped the chance to view living well with pain as a viable option.

Bradby, H. (2009). Defining health, defining disease. In Medical sociology: An introduction (pp. 51-64). London: SAGE Publications Ltd doi: 10.4135/9781446211724.n4

Fishbain, D. A., Rosomoff, H. L., Cutler, R. B., & Rosomoff, R. S. (1995). Secondary gain concept: a review of the scientific evidence. The Clinical journal of pain.

Fishbain, D. A., Rosomoff, H. L., Goldberg, M., Cutler, R., Abdel-
Moty, E., Khalil, T. M., et al. (1993). The prediction of return to
the workplace after multidisciplinary pain center treatment.
Clinical Journal of Pain, 9, 3–15.

Shipton, Elspeth E, Bate, Frank, Garrick, Raymond, Steketee, Carole, Shipton, Edward A, & Visser, Eric J. (2018). Systematic review of pain medicine content, teaching, and assessment in medical school curricula internationally. Pain and therapy, 1-23.

Tuck, Natalie L., Johnson, Malcolm H., & Bean, Debbie J. (2019). You’d Better Believe It: The Conceptual and Practical Challenges of Assessing Malingering in Patients With Chronic Pain. Journal of Pain, 20(2), 133-145. doi: http://dx.doi.org/10.1016/j.jpain.2018.07.002

Worzer, W. E., Kishino, N. D., & Gatchel, R. J. (2009). Primary, secondary, and tertiary losses in chronic pain patients. Psychological Injury and Law, 2(3-4), 215-224.

10 comments

  1. Bronnie, in responding to your call that we take “a long hard look at ourselves as clinicians”, I am unsure as to what you would like us to look at.

    Nevertheless, in the interest of commencing what I hope will be a fruitful discussion, I offer my personal observations about the current “pain” landscape on social media:

    (i) There continues to be confusion between sensation and perception, with the consequence that theories of perception are being applied to the sensation of pain. Our perceptions can be changed whereas our sensations are given to us and can only be modulated.

    (ii) There are those who promote the viewpoint that pain is a “normal” experience when the opposite is the case;

    (iii) Some theorists believe pain is a learned experience and that it can be unlearned, rather like the way psychologists might go about removing an undesirable habit. The truth is that pain is a “given” and cannot be unlearned.

    (iv) Our experience of pain is said to rest upon a decision made by our brain, but only when it has concluded that tissue is in danger and in need of protection. This advice is not helpful to those with ongoing pain in whom no such threat is evident. This line of thinking suggests that a homunculus (“a little man”) resides with the brain and is responsible for making decisions.

    (v) Some theorists claim that pain is an “output” of the brain rather than a unique sensory experience (i.e. a sensation).

    We cannot hope to change workplaces, social scenes, and the attitude of insurers or funders until we recognise and correct any or all of our own misconceptions.

    1. Thank you for your thoughts John.
      I don’t agree with your observations, but that’s fine: we have many areas in pain and pain management in which we do agree. Some of the areas we do agree about are that people experiencing pain deserve empathic clinicians; that helping people develop new ways of relating to (perceiving, appraising, responding) their experience is fruitful for them; and that our understanding of pain mechanisms is incomplete.
      What I would like clinicians to look at in themselves is willingness to be OK with uncertainty and ambiguity – losing “control” and moving towards a relationship with the person with pain at the centre as an active agent, rather than thinking the “disease” is what must have most attention. I’d like clinicians to refrain from judging people for their response to their pain, and to help people draw from their own experiences to arrive at more helpful and workable conclusions about how they might affect their own experience. I’d love it if medical practitioners would recognise that the current approach to pain of repeated investigations, invasive procedures, multiple ineffective drugs and then abandonment is traumatic and unhelpful.
      We can take action to change how people with pain are viewed without necessarily agreeing on your “misconceptions” – we undertake actions all the time without having Truth underpinning them, and perhaps this is where our attentions might be fruitfully employed. Especially given that Truth may be a long time coming, and a pragmatic truth (ie workability in context) provides useful next best steps.

  2. Bronnie, when empathic clinicians do not correct any of their erroneous beliefs about pain. their well-intentioned actions are apt be misguided and fail to reach the goal of providing sensitive care.

    1. John do you have any research-based evidence of people being harmed by the ideas that you reject? As in, not opinion pieces, but primary research studies showing this? Because to date I have not identified any. Might be a piece of work you and/or your collaborators could put your energies to?

      1. Bronnie, I raised these issues in the interests of academic integrity.

        Because you are in an academic teaching position, would you please indicate with which of my observations you are not in agreement, as well as your reasons for opposing them?

        As for possible harm caused by these ideas, I am not in a position to conduct a primary research project along the lines you suggest. This is particularly so when dealing with a diverse group of people many of whom are already stigmatised.

  3. Here’s my response:
    1. The discrimination between sensation and perception is still complex and not fully settled. There are as many arguments for a distinction as there are against. Philosophers are not agreed on whether pain is sensation or perception or something combining both. Basic scientists are similarly not aligned on any single position.
    2. Your opinion is that pain is abnormal. My opinion is that pain is (typically) a normal response of an intact nociceptive system, and that like any bodily system, dysfunction can occur and result in an experience of pain.
    3. You already have heard my opinion regarding learning and unlearning pain – for the record, yet again, neurologically we cannot “unlearn” anything. We develop alternative neurological pathways.
    4. My interpretation of the “brain” deciding whether a pain is perceived or not lies in a pragmatic view of human “mind”. Mind is not equivalent to “brain”. As yet philosophers and researchers have not been able to determine how “mind” is produced.
    5. As taste/flavour and vision/sight are outputs of brain-based (nervous system-based) processes, so too is pain. The major distinction between taste or vision and pain is that pain is universally aversive: we don’t like it and want to avoid it.

    Until primary research is undertaken – and there is much research into stigmatisation amongst diverse groups – I’m not inclined to argue that the above opinions are more or less likely to harm or stigmatise people experiencing pain.

    I’m a pragmatist, I take a functional contextual view of how the world works. This means the notion of correspondence is unnecessary in the context of the kind of clinical work I do.
    Functional contextualism is recognising that events and actions occur within a context, and make sense in a context. The truthiness of any analysis lies in how well that analysis or response works to support the function for which it is being carried out. It’s ‘truth’ without a capital T. In the context of this individual, with whom I am working, and for the purpose of helping them with their distress and disability so they can flourish, I can draw on all manner of ways of communicating with them. I don’t look for Truth because that kind of stance argues that all people function in the same way. I don’t think that works outside of disease. It doesn’t work for the illness experience of an individual.

    I also hold a scientific realist perspective. We don’t know the full extent of anything much. Our current scientific models are always open to falsification, to being modified. We know as much as we know and we’ll likely know more in the future. All knowledge is provisional. That’s how I can hold on to a pragmatic approach of what works for this person in this context.

  4. Bronnie, thanks for your detailed response. Our main difference of opinion lies in what I see as the necessity for clinicians who work in the area to make a clear conceptual distinction between “pain as a sensation” and “pain as a perception”. As I have emphasized on many occasions, our perceptions can be changed whereas our sensations can only be modulated.

  5. Pragmatically I don’t think it makes a lot of difference JQ. Apparently pain perception exerts an influence at least partly via descending inhibition – thus rendering the distinction between sensation/perception somewhat moot. Personally I think that given philosophers, neuroscientists, neuropsychologists and others still are not in agreement about sensation/perception “division” and given that the majority of clinicians do not directly influence sensory input (unlike pharmacological and surgical/procedural treatments do), it doesn’t have a great deal of impact on the daily lived experience of people with pain.
    Perceptions, BTW, aren’t equivalent to cognitions, although cognitions may influence perception including attentional processes and emotional responses. In the case of pain experiences, emotion and attention strongly influence how much nociceptive activity reaches consciousness, and pain is a conscious experience so the perception/sensation divide really isn’t clear.

  6. Bronnie, I cannot agree with you that making the distinction between “pain as a sensation” and “pain as a perception” is a moot point.

    I maintain that making the distinction is of fundamental importance to our work as clinicians.

    Neurophysiological research has provided us with a good understanding of the process of nociception and of the nociceptive apparatus that we have inherited through evolutionary processes.

    The experience we call “pain” can therefore be justifiably interpreted as our awareness that the apparatus has been activated, by whatever means.

    But activation of the apparatus does not always reach the threshold of consciousness.

    On the other hand, according to my understanding, perceptions of pain (and of our other sensations), are totally reliant upon our mental processes of memory and imaginability.

    Neuroscientists are beginning to shed light on the neurobiology of these processes.

    Here are some recent references to support my argument:

    Buckner RL. The role of the Hippocampus in prediction and imagination. Annu Rev Psychol 2010;61:27–48. Doi:10.1146/annurev.psych.60.110707.163508

    Roberts RP, Wiebels K, Sumner RL, et al. An fMRI investigation of the relationship between future imagination and cognitive flexibility. Neurophysiologica 2017;95:156-172. doi: 10.1016/j.neuropsychologia.2016.11.019.

    Vyschedskiy A. Neuroscience of imagination and implications for human evolution. Curr Neurobiol 2019;10(2):89-109.

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