Who Would Want to Feel this Way?

The answer is, you’d be surprised….

Let’s begin this month with a vocabulary lesson. Sometimes people who presumably want medical treatment (which is the stated or “primary gain”) actually want disability benefits, money, time off work, attention, or any number of other less obvious results from treatment. This is called “secondary gain,” and is largely the reason that pain patients (especially those with more obscure disorders or less visible injuries) are so often looked at sideways by the medical community. We have all heard the stories of the “fakers,” looking for pills or a quick buck, or to avoid some responsibility.

However, this issue is important to you, too – the person with actual pain. Whether you realize it or not, you may at times use or exaggerate your pain to garner attention from loved ones, sympathy from strangers, or because some days you simply do not feel like getting out of the house. This doesn’t mean you’re faking, or manipulative, or even lying. Often times, such behavior is unconscious – but that doesn’t mean it is not occurring.

Think about it this way. No one wants to be in a wheelchair, right? Given the choice, everyone would pass. BUT, if you had to be in wheelchair due to illness or injury, why not get some benefit from it. So, you skip ahead in the line at Disney, or you ask your friend to spend extra time with you that day, and so on. Again, you didn’t want to be in the wheelchair in the first place, but why does it all have to be negative?

Now, I don’t mean to encourage people to cry out in pain in hopes of getting discounts at the car dealer or to simply cause a scene. I simply am asking you to consider two questions: a) Have all the changes from my pain/condition been negative? and b) Do I exaggerate or hold onto my pain some days, for some reason? The most telling tale I’ve experienced of “secondary gain” was a woman who found that her husband, who had been loving but not in an affectionate or outward fashion, became much more attentive and “into the relationship” once she needed greater caregiving assistance.

And this, while a nice end to a bad story, can also lead to what we call “tertiary gain.” (To reiterate, primary gain is getting what you asked for, secondary gain is getting what you wanted but didn’t ask for, and tertiary gain is when someone else benefits from your situation, without them asking for it.) Example: Consider the disgruntled older man whose family is not so fond of his bossiness and demanding nature. After pain onset and subsequent disability, his bark remains but his bite is gone. The family is thrilled (inwardly) to see that granddad has mellowed, or is more pliable. Do you think they want to see him get back to his old self again? Now, again, they didn’t cause the initial injury, or ask for harm to befall him. However, since it already happened, why shouldn’t they benefit from it? (And, yes, you may have heard of this as Munchausen’s by proxy, or secondary gain as Munchausen’s syndrome – these are not necessarily correct terms but they are similar enough.)

Just like secondary gain, tertiary gain may largely be unconscious or unstated. And, like secondary gain, those who benefit from tertiary gain (typically family, friends, caretakers) may at times exaggerate or maintain the illness or injury to maintain the benefits. So, sometimes family members may not push the patient toward physical therapy, may be happy to see the patient overmedicated or may not encourage attempts at returning to independent functioning.

You can choose to see these levels of secondary and tertiary gain as lies, or evil deeds, or manipulation. And they certainly can be. But they can also be the unintended positive result of a negative situation – family grows closer, we begin to appreciate our strengths, take time to “smell the roses,” and what have you.

In addition, I don’t mean this information to lead to questioning or resentment of family members. They may not be engaging in tertiary gain, or if they are it may be out of love and concern. Many people have the fantasy of wishing a loved one would open up more emotionally, ask you to be more involved in their life, or wish for a greater commitment. These aren’t uncommon or awful thoughts, and it doesn’t make them wrong for feeling that way. They are just making lemonade out of lemons.

Lastly, consider that these levels of gain may be occurring in or around you without your knowledge, and that is the point I wish to drive home here. Most pain specialists and physicians (and even we psychologists) have moments when we question the underlying thoughts or motives of people in our office. We have to ask “why?” sometimes. And, you should too. Rather than take offense at the nature of such questioning, consider that knowing the answer for yourself may change how you interact in relationships or how others perceive you. And, if you are more aware of how you or others are maintaining your pain status, you are more well-equipped to combat such issues and find greater improvement. So, though you’d love to be healthy and fit by tomorrow morning, do you or your family members get any benefit from your situation? Is there any reason to say that this bad set of symptoms has led to some positive outcomes (no matter how small or transient)?

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