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Concept of secondary gain
Commentary
Concept of Secondary Gain How Valid Is It?
Steven A. King
S Dr. Fishbain aptly acknowledges in his focus article, the term secondary gain is commonly applied to patients with chronic pain though often those who utilize it have little understanding of its true meaning. Thus, his attempts to clarify what secondary gain actually is and to reconceptualize it are important for those involved in the care of these patients. What should be done about the term secondary gain? A redefinition, as proposed by Dr. Fishbain, may be helpful. However, one wonders about the validity of the term itself. The term gain implies something beneficial. Do patients really benefit from things considered to be secondary gains that are at the center of much of the debate regarding the concept, i.e., the loss of work and financial compensation? While patients may actively seek to retain these, when we examine the effect of the pain on their lives, we find that they are really suffering the secondary losses discussed by Dr. Fishbain. Unless malingering or Munchausen's syndrome is believed to be present, we accept that the pain. is real and that the person is actually suffering from this on a chronic basis, an unpleasant situation in itself. Furthermore, it is doubtful that many healthcare professionals who have had the opportunity to observe the effects of the worker's compensation and disability systems on our patients' lives would choose such a situation for ou rselves. If we believe that patients are truly gaining from the situation,then we would not be acting in their best interest to terminate the gain. The goal of programs that treat patients with chronic pain is to have
A
From the Department of Psychiatry,Temple UniversitySchool of Medicine, Philadelphia, PA. Reprint requests: Steven A. King, MD, Department of Psychiatry, Temple UniversitySchool of Medicine, 3401 North Broad Street, Philadelphia, PA 19140.
APS Journal 3(4): 279-281, 1994
them return to their prepain lifestyles. Most encourage patients to return to gainful employment if at all possible. We do this because we believe that this is in the best interest of our patients and that failure to do so will result in an exacerbation of the problems patients have, not their resolution. Injury and subsequent pain may be one way to leave a disliked job without losing financial compensation thus providing the time and resources to seek other more agreeable employment or retrain for another career. However, there is little evidence that this is what people do. Nor does it appear that there is any marked change in the condition of patients once their litigation is completed and the apparent financial secondary gain is terminated. 5 Even in situations where the outcome may be a financial windfall, such as when the injury and pain result from negligence, the degree of gain is again questionable. The wheels of justice in the American legal system grind slowly and years usually pass before money is received. Though, as Dr. Fishbain notes, there are many forms of secondary gain, those related to financial issues appear to have led to much of the abuse of the term. The major abuse is probably the widespread belief that it is synonymous with malingering. Because of the rising costs of worker's compensation and other forms of disability, there is a national concern that many who are receiving money, especially those who suffer problems that are subjective in nature such as pain, are doing so under false pretenses. The extent of malingering is still unclear though there is little evidence to support that it is pervasive. The Social Security Administration's Commission on the Evaluation of Pain concluded "that there are simply not very many malingerers in the Social Security disability applicant population" and "expressed confidence that trained professionals, medical and other, could identify malingerers. ''4 Throughout his article, Dr. Fishbain emphasizes 279
280
COMMENTARY/King
the issue of whether or not secondary gain is conscious or unconscious. While this may be of theoretical importance, it appears to be of less significance in clinical practice. One would have to lead a hermit's life to be unaware that injuries suffered at the workplace or resulting from other accidents outside of one's own home may result in financial compensation. We are constantly bombarded by this message in lawyers' advertisements. The recent Academy Award winning film Philadelphia poked fun at this in its depiction of the lawyer played by Denzel Washington who is constantly seeking clients through various forms of self-promotion and is willing to proceed with litigation no matter how fantastic a client's story may be. Thus, it is questionable whether issues regarding financial compensation can truly be out of anyone's conscious state. I therefore disagree with Dr. Fishbain's statement, "If patients respond to secondary gain issues in a conscious manner, then this behavior approaches the behavior in Munchausen's syndrome or malingering, or both." The etiology of Munchausen's syndrome, or factitious disorder with physical symptoms as it is named in the past and current editions of the Diagnostic and Statistical Manual of Mental Disorders is unclear. 1,2 These patients often flee when their illness is uncovered making research into what leads someone to consciously assume the sick role without any other apparent motivation quite difficult. However, it is possible to provide a simple, everyday example clarifying the difference between secondary gain whether conscious or unconscious and malingering. A person wakes up in the morning with a sore throat and a stuffy nose. The weather is cold and it is raining. The person feels he or she has been working very hard and, while if necessary could go to work, is also aware that there is nothing that needs to be done today that cannot be postponed. The person decides to take a sick day to rest. In contrast, is the example of the person who has bought tickets to a baseball game or a concert but has no vacation time to use to attend the event. On the day of the event, the person calls work and says "1 have a sore throat and a stuffy nose. I will use a sick day." The outcome is the same in both examples, e.g., not having to go to work, but the difference between the two is clear. Though the first person is achieving this as a secondary gain, there is no attempt to falsify the situation even though he or she is conscious of the behavior and the resultant outcome. What should we do when we believe those things that are considered secondary gains appear to be affecting patients' lives and their responses to treatment? Rather than using the term secondary gain, it
may be best if we simply identify those things we consider to be reinforcing patients' behaviors. The first step after this is to make patients aware of these reinforcers and their potential effect. Though they may be obvious to the outside observer, we cannot assume that they are as apparent to the person experiencing them. We must then determine to what degree they may be influencing patients' situations because, as Dr. Fishbain states, "patients' behavior is changed by the presence of secondary gain agendas." Whether these reinforcers result in a gain or a loss and are encouraged or discouraged depends a great deal on the viewpoint of each observer. The treating physician may view things one way, while patients, families, attorneys, employers, and insurance companies may have very different perspectives resulting from varying agendas. Patients with pain often face the paradox that while they want the pain to end, they do not wish to end the secondary gains that they are receiving. As Freud noted in his discussion of the case of a man injured at work, "If you could put an end to his injury you would make him, to begin with, without means of subsistence; the question would arise whether he was still capable of taking up his earlier work again. ''3 Therapeutic modalities that focus solely on ending the pain and pay scant attention to the secondary gains are generally doomed to failure. Unfortunately, one of the reasons healthcare professionals may not comment on the issue of secondary gain is the fear that this will indicate that they do not believe the pain is "real" and that patients might consider it an accusation that they do not want to get better. Those of us who treat these patients should identify this paradox and its affect on outcome and convey this to patients. Though it may be clear in our minds for many if not most patients, what is in their best interests, we cannot and should not judge them. We must be aware that they are in a confusing and often frightening predicament. Unlike other situations where it is accepted that it is in the patient's best interest to have illness terminated, when chronic pain is the problem the nature of the ideal outcome may be not be as clear. Furthermore, we must recognize that no matter how conscious patients may be of their situations, their health problems may limit their options. The case of Mrs. Y discussed by Dr. Fishbain illustrates this. Because of her mental health problems and pain, she is unable to return to work despite the palpable financial benefits of this. If such a patient claimed inability to work due to a general medical condition such as cancer or cardiovascular disease, we would probably simply accept this without providing a similar interpretation regarding the economy of gains and losses. The job situation may be as Mrs.
COMMENTARY/King Y describes and she may be truly incapable of returning to work. Dr. Fishbain demonstrates that secondary gain is a complex concept that has been much misunderstood and abused, often to the detriment of people who are already suffering. If his article results in a reconsideration of its meaning by those w h o apply it to patients with c h r o n i c pain, he will have done both groups a great service.
References 1. American Psychiatric Association: Diagnostic and statistical manual of mental disorders. 3rd ed., Revised. American Psychiatric Association, Washington, 1987
281
2. American Psychiatric Association: Diagnostic and statistical manual of mental disorders. 4th ed. American Psychiatric Association, Washington, 1994 3. Freud S: Introductory lectures on psycho-analysis (part 3). The standard edition of the complete psychological works of Sigmund Freud. Vol. 16. Hogarth Press, London, 1959 4. Social Security Administration: Report of the commission on the evaluation of pain (DHHS Publ No 64-031). Social Security Administration, Office of Disability, U.S. Department of Health and Human Services, 1987 5. Talc S, Hendler N, Brodie J: Effects of active and completed litigation on treatment results: workers' compensation patients compared with other litigation patients. J Occup Med 31:265-269, 1989
Concept of Secondary Gain How Valid Is It?
Steven A. King
S Dr. Fishbain aptly acknowledges in his focus article, the term secondary gain is commonly applied to patients with chronic pain though often those who utilize it have little understanding of its true meaning. Thus, his attempts to clarify what secondary gain actually is and to reconceptualize it are important for those involved in the care of these patients. What should be done about the term secondary gain? A redefinition, as proposed by Dr. Fishbain, may be helpful. However, one wonders about the validity of the term itself. The term gain implies something beneficial. Do patients really benefit from things considered to be secondary gains that are at the center of much of the debate regarding the concept, i.e., the loss of work and financial compensation? While patients may actively seek to retain these, when we examine the effect of the pain on their lives, we find that they are really suffering the secondary losses discussed by Dr. Fishbain. Unless malingering or Munchausen's syndrome is believed to be present, we accept that the pain. is real and that the person is actually suffering from this on a chronic basis, an unpleasant situation in itself. Furthermore, it is doubtful that many healthcare professionals who have had the opportunity to observe the effects of the worker's compensation and disability systems on our patients' lives would choose such a situation for ou rselves. If we believe that patients are truly gaining from the situation,then we would not be acting in their best interest to terminate the gain. The goal of programs that treat patients with chronic pain is to have
A
From the Department of Psychiatry,Temple UniversitySchool of Medicine, Philadelphia, PA. Reprint requests: Steven A. King, MD, Department of Psychiatry, Temple UniversitySchool of Medicine, 3401 North Broad Street, Philadelphia, PA 19140.
APS Journal 3(4): 279-281, 1994
them return to their prepain lifestyles. Most encourage patients to return to gainful employment if at all possible. We do this because we believe that this is in the best interest of our patients and that failure to do so will result in an exacerbation of the problems patients have, not their resolution. Injury and subsequent pain may be one way to leave a disliked job without losing financial compensation thus providing the time and resources to seek other more agreeable employment or retrain for another career. However, there is little evidence that this is what people do. Nor does it appear that there is any marked change in the condition of patients once their litigation is completed and the apparent financial secondary gain is terminated. 5 Even in situations where the outcome may be a financial windfall, such as when the injury and pain result from negligence, the degree of gain is again questionable. The wheels of justice in the American legal system grind slowly and years usually pass before money is received. Though, as Dr. Fishbain notes, there are many forms of secondary gain, those related to financial issues appear to have led to much of the abuse of the term. The major abuse is probably the widespread belief that it is synonymous with malingering. Because of the rising costs of worker's compensation and other forms of disability, there is a national concern that many who are receiving money, especially those who suffer problems that are subjective in nature such as pain, are doing so under false pretenses. The extent of malingering is still unclear though there is little evidence to support that it is pervasive. The Social Security Administration's Commission on the Evaluation of Pain concluded "that there are simply not very many malingerers in the Social Security disability applicant population" and "expressed confidence that trained professionals, medical and other, could identify malingerers. ''4 Throughout his article, Dr. Fishbain emphasizes 279
280
COMMENTARY/King
the issue of whether or not secondary gain is conscious or unconscious. While this may be of theoretical importance, it appears to be of less significance in clinical practice. One would have to lead a hermit's life to be unaware that injuries suffered at the workplace or resulting from other accidents outside of one's own home may result in financial compensation. We are constantly bombarded by this message in lawyers' advertisements. The recent Academy Award winning film Philadelphia poked fun at this in its depiction of the lawyer played by Denzel Washington who is constantly seeking clients through various forms of self-promotion and is willing to proceed with litigation no matter how fantastic a client's story may be. Thus, it is questionable whether issues regarding financial compensation can truly be out of anyone's conscious state. I therefore disagree with Dr. Fishbain's statement, "If patients respond to secondary gain issues in a conscious manner, then this behavior approaches the behavior in Munchausen's syndrome or malingering, or both." The etiology of Munchausen's syndrome, or factitious disorder with physical symptoms as it is named in the past and current editions of the Diagnostic and Statistical Manual of Mental Disorders is unclear. 1,2 These patients often flee when their illness is uncovered making research into what leads someone to consciously assume the sick role without any other apparent motivation quite difficult. However, it is possible to provide a simple, everyday example clarifying the difference between secondary gain whether conscious or unconscious and malingering. A person wakes up in the morning with a sore throat and a stuffy nose. The weather is cold and it is raining. The person feels he or she has been working very hard and, while if necessary could go to work, is also aware that there is nothing that needs to be done today that cannot be postponed. The person decides to take a sick day to rest. In contrast, is the example of the person who has bought tickets to a baseball game or a concert but has no vacation time to use to attend the event. On the day of the event, the person calls work and says "1 have a sore throat and a stuffy nose. I will use a sick day." The outcome is the same in both examples, e.g., not having to go to work, but the difference between the two is clear. Though the first person is achieving this as a secondary gain, there is no attempt to falsify the situation even though he or she is conscious of the behavior and the resultant outcome. What should we do when we believe those things that are considered secondary gains appear to be affecting patients' lives and their responses to treatment? Rather than using the term secondary gain, it
may be best if we simply identify those things we consider to be reinforcing patients' behaviors. The first step after this is to make patients aware of these reinforcers and their potential effect. Though they may be obvious to the outside observer, we cannot assume that they are as apparent to the person experiencing them. We must then determine to what degree they may be influencing patients' situations because, as Dr. Fishbain states, "patients' behavior is changed by the presence of secondary gain agendas." Whether these reinforcers result in a gain or a loss and are encouraged or discouraged depends a great deal on the viewpoint of each observer. The treating physician may view things one way, while patients, families, attorneys, employers, and insurance companies may have very different perspectives resulting from varying agendas. Patients with pain often face the paradox that while they want the pain to end, they do not wish to end the secondary gains that they are receiving. As Freud noted in his discussion of the case of a man injured at work, "If you could put an end to his injury you would make him, to begin with, without means of subsistence; the question would arise whether he was still capable of taking up his earlier work again. ''3 Therapeutic modalities that focus solely on ending the pain and pay scant attention to the secondary gains are generally doomed to failure. Unfortunately, one of the reasons healthcare professionals may not comment on the issue of secondary gain is the fear that this will indicate that they do not believe the pain is "real" and that patients might consider it an accusation that they do not want to get better. Those of us who treat these patients should identify this paradox and its affect on outcome and convey this to patients. Though it may be clear in our minds for many if not most patients, what is in their best interests, we cannot and should not judge them. We must be aware that they are in a confusing and often frightening predicament. Unlike other situations where it is accepted that it is in the patient's best interest to have illness terminated, when chronic pain is the problem the nature of the ideal outcome may be not be as clear. Furthermore, we must recognize that no matter how conscious patients may be of their situations, their health problems may limit their options. The case of Mrs. Y discussed by Dr. Fishbain illustrates this. Because of her mental health problems and pain, she is unable to return to work despite the palpable financial benefits of this. If such a patient claimed inability to work due to a general medical condition such as cancer or cardiovascular disease, we would probably simply accept this without providing a similar interpretation regarding the economy of gains and losses. The job situation may be as Mrs.
COMMENTARY/King Y describes and she may be truly incapable of returning to work. Dr. Fishbain demonstrates that secondary gain is a complex concept that has been much misunderstood and abused, often to the detriment of people who are already suffering. If his article results in a reconsideration of its meaning by those w h o apply it to patients with c h r o n i c pain, he will have done both groups a great service.
References 1. American Psychiatric Association: Diagnostic and statistical manual of mental disorders. 3rd ed., Revised. American Psychiatric Association, Washington, 1987
281
2. American Psychiatric Association: Diagnostic and statistical manual of mental disorders. 4th ed. American Psychiatric Association, Washington, 1994 3. Freud S: Introductory lectures on psycho-analysis (part 3). The standard edition of the complete psychological works of Sigmund Freud. Vol. 16. Hogarth Press, London, 1959 4. Social Security Administration: Report of the commission on the evaluation of pain (DHHS Publ No 64-031). Social Security Administration, Office of Disability, U.S. Department of Health and Human Services, 1987 5. Talc S, Hendler N, Brodie J: Effects of active and completed litigation on treatment results: workers' compensation patients compared with other litigation patients. J Occup Med 31:265-269, 1989