Pain: The Problem with Secondary Gain

THE PROBLEM WITH SECONDARY GAIN

Secondary gain is a psychoanalytic term which refers to perceived advantages or ‘gains’ patients derive from their symptoms, such as sympathy, attention, avoiding responsibilities etc. Unfortunately, this concept has been turned against chronic pain sufferers with the result that they are often left feeling like failures at best and criminals at worst. May et al (1999) has observed that the disparity between expressed symptoms, pathological signs and perceived disability in CLBP has led to the moral character of the suffer forming a constant subtext to medical discourse about the condition. For example, Nicholas (1996) writes; “a person seeking help for chronic pain could be said to be inactive with secondary physical deconditioning, to hold unhelpful beliefs, to be overly passive or reliant on others for resolution of his/her problems..” Wow. In a recent study where women chronic pain sufferers were found to have greater levels of disability than men, it was speculated that perhaps they were using the pain as an excuse to stay at home, something the author described as “a powerful secondary gain.” (Gatchel 1995). Wasn’t there something called women’s liberation before 1995?

Unfortunately, and tragically, this concept appears to have been over-used with harmful effects for chronic pain sufferers. Eccleston et al (1997) noted that many pain patients are confused and angry at treatment which seemed to focus on their own behavior and of being blamed for their own suffering and misery. On the other hand, there seems to be some scant recognition that they might have gone too far with this concept. Pilowsky (1996) warned of the danger of an approach which emphasizes patients ‘taking responsibility’ for their pain becoming a basis for patients being blamed for poor treatment outcomes. The idea that pain sufferers are responsible for their pain is central to the CBT approach. It seems to fit in with an individualistic era where the role of family and community is in decline. Unfortunately, it ignores the reality that sick people need support and understanding. Such an idea would seem like pure madness in tribal societies and even some latin cultures where the idea that one person’s illness is their responsibility alone would seem inhumane and cruel.