A Compassionate Approach to Care
This post addresses a difficult subject matter in regards to secondary gains in the treatment of chronic pain and illness. Hopefully, you will find that I bring a compassionate lens to the topic. A view that recognizes the frustrations that can arise when complex psychological factors are not addressed in trauma treatment and a perspective that does not blame the client.
Traditionally, the term secondary gain has been linked to clients who exaggerate physical symptoms of pain or illness or who fail to improve in treatment in order to receive certain advantages such a financial or housing support. However, clients who malinger or create factitious symptoms are actually quite rare. It is much more common that secondary gains aim to attend to deep unresolved attachment wounds or they are a way to achieve recognition of legitimate suffering. A concept closely related to secondary gains is the understanding that coupled with these gains are their related losses. Such losses are the genuine needs that are not being met in the client’s world currently.
“If you feel frustrated that your symptoms of pain or illness are not going away it can be valuable explore secondary gains sensitively and compassionately. This post attends to the importance of recognizing secondary gains in a way that does not blame you, the client. The goal of identifying secondary gains is to provide clarity about trauma targets that need to be addressed in order for treatment to be successful.”
-Dr. Arielle Schwartz
Understanding Secondary Gains
A secondary gain can be defined as any positive advantage that accompanies physical or psychological symptoms. Often, the reasons for secondary gains are deep and psychologically complex (Dersh, et al., 2004; Fishbain, 1994). As a result, you may be unaware of the psychological causes of your chronic physical pain or illness.
You may feel frustrated and trapped when symptoms are not going away despite all your efforts and attempts at treatment.
Ideally, you and your therapist can approach any discussion of secondary gains in a sensitive, compassionate, and non-blaming manner. Moreover, it should be understood that the underlying motivations of secondary gain are legitimate needs. You are genuinely suffering and are seeking to meet these needs in the best way possible. Blaming yourself or feeling blamed by your health care providers worsens the very problems that you are trying to heal.
The following list explores just a few secondary gains that can arise when working with chronic pain and illness:
- Physical symptoms legitimize psychological symptoms which may have been treated like an unacceptable form of pain by family members, caregivers, or physicians.
- Symptoms are a way to express unresolved attachment trauma. Relationships with healing professionals might meet the needs of a child part of self and you might fear that getting better means a loss of these relationships.
- Physical symptoms may arise after years of being inappropriately responsible. Being sick can provide an opportunity to rest and receive the care that was never possible.
- Similarly, symptoms can be a way to express unresolved revenge or anger toward a parent or spouse. If you were never recognized for the pain you endured, being sick might force them to be responsible for you.
- Being “sick” can provide a social identity that has a set of rules of engagement. This adopted role provides a way to relate to others. It can be frightening to let go of symptoms if you do not know who you would be without them.
Understanding Secondary Losses
A concept closely related to secondary gains is the understanding that closely coupled with these gains are their related losses. In other words, secondary gains are related to genuine needs that are not being met in your world currently.
The following list provides just some of the common secondary losses that can arise when working with chronic pain in illness:
- Financial loss
- Loss of social relationships and social support network
- Loss of respect from family and friends
- Loss of respect from physicians or therapists
- Loss of typical family life
- Loss of leisure or recreational activities
- Loss of meaning or purpose due to loss of work
- Loss of social role or identity
- Loss due to social stigmas related to being chronically disabled
- Guilt over disability
Implications for Treatment
There are several implications for treatment of secondary gains and losses. First, it is of upmost importance to address your legitimate needs. For example, if your need is to decrease isolation, focus on developing positive social connections as a goal of treatment. Or, you may need to attend to underlying attachment trauma or complex PTSD in therapy. In some cases, if you have felt a loss of respect from medical care providers, you may need your therapist to serve as a patient advocate. In general, collaborative treatment yields positive results.
It is common for symptoms of chronic pain and illness to be connected to early childhood attachment trauma. In these cases, physical symptoms may be related to emotional material that is connected to a young part of self. Here, we must recognize that we all have parts of ourselves that can sometimes be at odds with each other. For example, an adult part might be working toward self-care and symptom reduction; however, a young part might be sabotaging these efforts or unwilling to let go of pain symptoms. To work with this process, we aim to bring in support for the young part of self in the form of allies and resources. In general, I recommend EMDR Therapy and Somatic Psychology for chronic pain and illness with on “listening to symptoms” rather solely managing symptoms.
(This post is an adapted excerpt from the forthcoming book entitled EMDR Therapy and Somatic Psychology: Interventions to Enhance Embodiment in Trauma Treatment co-written by myself and Barb Maiberger, M.A.)
Dersh, J., Polatin, P. B., Leeman, G., Gatchel, R. J. (2004) The management of secondary gain and loss in medicolegal settings: strengths and weaknesses. Journal of Occupational Rehabilitation.14: 267-79.
Fishbain, D. A. (1994). Secondary gain concept: Definition problems and its abuse in medical practice. American Pain Society Journal, 3, 264-273.
Looking for a mind-body approach to healing C-PTSD?
Connect to this post? The Complex PTSD Workbook, is now available on Amazon! Click here to check it out and increase your toolbox for healing. Whether you are a client or a therapist this book will offer a guided approach to trauma recovery.
About Dr. Arielle Schwartz
Dr. Arielle Schwartz is a licensed clinical psychologist, wife, and mother in Boulder, CO. She offers trainings for therapists, maintains a private practice, has passions for the outdoors, yoga, and writing. Dr. Schwartz is the author of The Complex PTSD Workbook: A Mind-Body Approach to Regaining Emotional Control and Becoming Whole. She is the developer of Resilience-Informed Therapy which applies research on trauma recovery to form a strength-based, trauma treatment model that includes Eye Movement Desensitization and Reprocessing (EMDR), somatic (body-centered) psychology and time-tested relational psychotherapy. Like Dr. Arielle Schwartz on Facebook, follow her on Linkedin and sign up for email updates to stay up to date with all her posts.