Secondary Gain

Previously, we discussed primary gain, which is the tendency for people to seek reward and avoid pain. The ‘primary’ in primary gain refers to the fact that the behaviour, or the thing that person does or doesn’t do, is giving them a direct benefit. You eat chocolate because it tastes good. You avoid exercise because it’s uncomfortable. The reward or the avoidance is directly connected to the action.

Secondary gain is different. It’s when the benefit of a particular behaviour is indirect and comes from something external, like the response of others. You’re not getting the benefit from the behaviour itself. You’re getting the benefit from how other people respond to that behaviour.

A typical example of secondary gain could be when someone is sick, and whilst they’re unwell, they receive help, empathy, or support from others. They’re receiving an external benefit for being ill from those around them. The illness itself is obviously not pleasant. That’s not the gain. The gain is the attention, the care, the support that comes with the illness.

There’s nothing wrong with secondary gain on the surface. I’m guilty of giving secondary gain to people every day because it’s human nature to want to help and support others. We see someone struggling and we want to help. We see someone in pain and we want to comfort them. It’s what decent people do. The problem isn’t that people receive support when they need it. The problem is what happens when they start needing the support more than they need to solve the problem.

The Historical Context

Over a hundred years ago, the psychiatrist Sigmund Freud described patients who were ‘clinging on’ to their disease. It’s not uncommon to see a person hang onto their problems just to get some form of indirect benefit from others. This isn’t new. This isn’t a modern phenomenon created by social media or benefit systems or any of the usual suspects people like to blame for society’s problems. This is fundamental human psychology that’s been recognised for over a century.

Freud noticed that some patients improved right up to the point where their symptoms would normally disappear, then somehow their recovery would stall. They’d plateau just below fully recovered and stay there. Not sick enough to be completely incapacitated, but not well enough to lose the special consideration their illness afforded them. The illness had become comfortable. Or more accurately, the benefits of the illness had become more valuable than the benefits of recovery.

Research examining chronic pain patients has found evidence of secondary gain in a substantial minority of cases, with higher rates in contexts where compensation or disability benefits were available. That’s not a small minority. That’s a substantial proportion.

Imagine if you have so much support, sympathy, benefits, and help from others that even when your physical illness has gone, your illness behaviour remains so that you can continue to receive that secondary gain. The problem isn’t physical anymore. It’s behavioural. But the support continues, and so does the behaviour that attracts that support.

In medicine, there’s even a syndrome called Munchausen’s syndrome, where medical conditions are feigned or fabricated in order to gain attention or some other benefit from those around them. People will actually make themselves sick, or pretend to be sick, or exaggerate symptoms, purely for the attention it brings. That’s secondary gain taken to its extreme, and while most people don’t go that far, the principle is the same. The attention, the concern, the special treatment becomes more valuable than actually getting better.

The Subtle Nature

Because secondary gain is indirect, it may not be obvious to the patient nor the person giving help and support that the situation is getting out of control. Relationships are complicated. Some people need help, and some need to feel needed. So it’s easy to see how secondary gain can develop, especially as helping people is just as rewarding as receiving that support.

Let me give you an example from my practice. I had a patient, let’s call her Linda, who’d been signed off work with stress for about six months. Initially, there were legitimate reasons. She’d been through a difficult period. Work had been demanding. Home life had been challenging. She needed the time off.

But six months later, Linda was physically fine. The immediate stressors had resolved. Yet she kept coming back for sick notes. Because while she’d been off work, something interesting had happened. Her family had rallied around her. Her partner was doing all the housework. Her adult children were calling regularly. Her friends were checking in on her. She’d never felt so supported, so cared for, so central to everyone’s concern.

And going back to work meant losing all that. It meant returning to normal, where nobody gives you special consideration, where you’re expected to manage your own responsibilities, where you’re just another person getting on with life. The secondary gain from being unwell had become more valuable than the primary gain of being healthy and working.

The Support Problem

I have to say it, and it’s difficult to believe, but some people just don’t want to get better. Secondary gain is one of the causes. As Freud suggested, some people cling onto their diseases as well as their problems. An illness or a diagnosis gives that person a ‘why’, a reason to get help from others. Take away the problem and you also take away that help.

I’ve seen people continuously self-sabotage their recovery, again and again. Moving on in life can be difficult. Getting back to work is hard. Rehabilitation hurts. Change hurts. People close to you don’t want to see you in pain, and sometimes it’s easier not to try, easier not to get rid of that problem, and instead be surrounded by the comfort and warmth of secondary gain from others.

Let me be clear about what I’m saying here. I’m not suggesting that everyone who struggles with recovery is doing it deliberately. Most of the time, this process is unconscious. People aren’t sitting there thinking, “I’m going to stay sick so I get more attention.” They’re not consciously manipulating others. But unconsciously, they’re responding to the rewards they’re receiving, and those rewards are powerful enough to slow or stop their recovery.

Research on secondary gain in chronic pain populations has linked identified secondary gain factors to poorer treatment outcomes, independent of the objective severity of the underlying condition. The gain doesn’t have to be conscious to be powerful. It doesn’t have to be deliberate to be effective.

The Self-Examination

The answer is to look at whether there’s a behavioural element to what’s holding you back. Perhaps if you’re stuck in life or stuck in a problem, it’s because you’re getting some external benefit from having that problem too.

List down the benefits you’re getting from your problems. It’s a great exercise to do, and it may really shock you if you’re honest with yourself. What wouldn’t you have if you didn’t have this problem? What attention would you lose? What support would disappear? What responsibilities would you have to resume? What expectations would people have of you again?

What would you also have to give up if you gave up that problem? If you got better, if you moved on, if you solved this issue, what would change in your life? And I don’t just mean what would improve. I mean what would you lose? Because sometimes what you’d lose feels more significant than what you’d gain.

Ask yourself this as well. Is holding onto what’s wrong really fair on those around you? The people supporting you, caring for you, adjusting their lives to accommodate your problem — is it fair to them if you’re unconsciously prolonging your recovery to maintain their support? Is it fair to keep them in a support role indefinitely when you could move forward?

The Complexity

Secondary gain is complex. People hold onto the gain they’re receiving with a passion, and if they aren’t ready to change, then there’s absolutely no way they’re going to give away the benefits they’re receiving. Secondary gain is one of the reasons why change is so difficult. Add in primary gain (the direct benefits of avoiding discomfort), add in empathy, sympathy, and the excuses from others who just want to help and make you feel better, and you can’t fail to see why some people get stuck in their problems.

Let me give you another example. I had a patient, let’s call him Michael, who’d injured his back at work about two years before I met him. The physical injury had healed within a few months. Scans showed normal anatomy. Physiotherapy had restored full function. But Michael was still not working, still in “pain,” still disabled by his back.

Because Michael had discovered something interesting while he was injured. His wife, who’d been distant and critical for years, had become caring and attentive. His teenage children, who usually ignored him, were helping around the house. His employer, who’d been demanding and unsympathetic, was now bending over backwards to accommodate him. And he was receiving disability payments that weren’t much less than his salary, without having to deal with the stress of his job.

Going back to work meant losing all of that. It meant returning to a marriage where he felt unappreciated, to children who didn’t respect him, to a job that stressed him out, and to financial pressure without the cushion of disability payments. Consciously, Michael wanted to get better. Unconsciously, he had every incentive to stay exactly where he was.

The Enabler Dynamic

Here’s another uncomfortable truth. Secondary gain doesn’t exist in isolation. It requires enablers. It requires people who provide the benefits that maintain the problem. And those enablers often have their own reasons for maintaining the dynamic.

Some people need to feel needed. They derive their sense of purpose from caring for others, and if the person they’re caring for gets better, they lose that purpose. Some people feel guilty (maybe the problem occurred on their watch, maybe they feel responsible somehow), and providing support alleviates that guilt. Some people are conflict-averse and find it easier to keep providing support than to have difficult conversations about recovery expectations.

The point is, secondary gain is a two-way street. It’s a dynamic between the person with the problem and the people supporting them, and both sides have reasons (conscious or unconscious) for maintaining that dynamic. Breaking free requires both parties to recognise what’s happening and be willing to change their behaviour.

Research on pain behaviour in couples shows that solicitous partner responses — excessive attention and support — can meaningfully predict worse pain outcomes and disability over time. The support meant to help can actually make things worse.

The Honest Assessment

So let me ask you some difficult questions. Are you gaining benefit from your problems? Be honest. What support, attention, sympathy, or accommodation are you receiving because of your issue? What responsibilities are you avoiding? What difficult situations are you escaping?

What are you willing to give up to move on? Because moving on means giving up those benefits. It means returning to normal expectations, normal responsibilities, normal life without special consideration. Are you actually willing to do that? Or does the thought of losing that support scare you more than staying stuck?

Is your problem serving a purpose beyond the problem itself? Does it give you an excuse for not pursuing something? Does it protect you from having to face something difficult? Does it give you a way to express needs you don’t know how to express otherwise?

These aren’t comfortable questions. You probably don’t want to answer them. You might be getting angry right now, thinking, “My problem is real, how dare you suggest I’m benefiting from it.” And your problem probably is real. But that doesn’t mean you’re not also, unconsciously, receiving benefits that make recovery less appealing than you’d like to admit.

The Path Forward

Breaking free from secondary gain requires several things. First, you need to acknowledge honestly what benefits you’re receiving from your problem. You can’t address something you won’t admit exists. Write them down. All of them. No matter how uncomfortable that list makes you feel.

Second, you need to find alternative ways to meet those needs. If your problem is giving you attention and support, how else could you get that? If it’s protecting you from responsibilities you find overwhelming, how else could you address those? If it’s giving you permission to rest or prioritise yourself, how else could you create that permission?

Third, you need to communicate honestly with the people supporting you. Have explicit conversations about recovery expectations. Make it clear that you’re working towards getting better, and that getting better means gradually reducing the support rather than maintaining it indefinitely. This is hard. It feels ungrateful. But it’s necessary.

Fourth, you need to recognise that people who truly care about you want you to get better, even if that means they stop feeling needed as your supporter. The people enabling your secondary gain might resist your recovery (because they benefit from the dynamic too), but that resistance isn’t actually love. It’s their own need disguised as care.

The Reality

Secondary gain is real. It’s powerful. It’s often unconscious. And it keeps people stuck in problems they could otherwise solve. The benefits of having the problem become more valuable than the benefits of solving it, and so the problem persists.

But here’s what you need to understand. Those benefits are temporary. They’re unsustainable. Eventually, people’s sympathy runs out. Eventually, support systems get exhausted. Eventually, the costs of staying stuck outweigh the benefits of the attention you’re receiving. And at that point, you’ll be stuck twice over. Stuck with your original problem and stuck without the support that made the problem bearable.

The question is whether you’re going to address this now, while you still have support and options, or whether you’re going to wait until the secondary gain dries up and you’re left with just the problem and no benefits at all.

Are you gaining benefit from your problems? What are you willing to give up to move on? These questions might make you uncomfortable. They should. Because if you’re honest with the answers, you might discover that the main thing holding you back isn’t the problem itself. It’s the benefits you’re receiving from having it.

And once you see that, you can start making different choices. You can start pursuing recovery even though it means losing support. You can start moving forward even though it means facing responsibilities. You can start solving your problems even though it means giving up the benefits those problems bring.

Or you can keep clinging on, keep collecting your secondary gain, and keep wondering why you never quite manage to get better. The choice, as always, is yours.

Further Reading

• Freud, S. (1923). The Ego and the Id. W.W. Norton & Company.
• Fishbain, D.A., Rosomoff, H.L., Cutler, R.B., & Rosomoff, R.S. (1995). Secondary Gain Concept: A Review of the Scientific Evidence. Clinical Journal of Pain, 11(1), 6-21.
• Romano, J.M., Jensen, M.P., Turner, J.A., Good, A.B., & Hops, H. (2000). Chronic Pain Patient-Partner Interactions: Further Support for a Behavioral Model of Chronic Pain. Behavior Therapy, 31(3), 415-440.
• Pilowsky, I. (1997). Abnormal Illness Behaviour. Wiley.
• Fordyce, W.E. (1976). Behavioral Methods for Chronic Pain and Illness. Mosby.