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Secondary gain is bollocks

Paul Ingraham ARCHIVEDMicroblog posts are archived and rarely updated. In contrast, most long-form articles on PainScience.com are updated regularly over the years (see updates page).

“Secondary gain” is the idea that chronic pain and illness can have perks — like getting out of school or work — which may inspire patients to actually cultivate and dramatize their disability, consciously or unconsciously. If it’s deemed thought to be conscious, it’s a form of subtle malingering; if seen as unconscious, it’s psychosomatic illness.

Which is all mostly nonsense.

Psychosomatic illness does exist — huge can of worms there! — but it’s almost never the entire explanation for a patient’s problems, or even a major factor. And I think true malingering barely exists at all. The overwhelming majority of professionals who have ever referenced the concept of secondary gain are… well, let me hand it over to Jason Silvernail, Doctor of Physical Therapy:

“Secondary gain was a concept made up by us in medicine to cover our own failures. It never had anything to do with patients. It’s a crutch so we can avoid responsibility and accountability! #StopBlamingPatients”

Amen.

I am not prepared to say that no one has ever cultivated an illness because of some secondary benefits. I am actually quite sure I did a bit of that myself once upon a time. (That’s a long story, about being short — in the aftermath of being given growth hormone, I got quite sick with a puzzling illness for a few years, and it took me many, many years to stop blaming doctors for that and start honestly examining my own psychology.)

But I don’t think it ever helps to accuse anyone of it (directly or just by insinuation), mainly because it’s almost always wrong… and even when it’s technically correct it’s still not helpful. Clinicians should always err on the side of giving patients the benefit of the doubt.

 End of post. 
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