The Role of Tertiary Gain in Pain Disability
Some readers may be familiar with the concept of secondary gain, which has received increasing attention as a perpetuating factor in illness and pain disability.1-4 First conceptualized by Sigmund Freud, secondary gain refers to both the internal (i.e., intrapsychic) and external advantages attained by a sick person as a consequence of illness.5 Although originally conceived as an unconscious process, contemporary thinking is that secondary gains may be consciously and/or unconsciously motivated.3,5 In fact, there has been a recent tendency to incorrectly equate secondary gain with motivation for financial compensation and malingering.1-3,6 “Patient X has a secondary gain agenda” has become shorthand for the belief that the person is deceitfully trying to “game the system.” The authors’ previous work has focused on further elucidating the concept of secondary gain, and exploring complex secondary gain agendas, which are barriers to improved health and function. 3 An example demonstrates how secondary gain can serve as a perpetuating factor in illness and disability. An injured worker dislikes his supervisor because of previous experiences with this supervisor, and because the legitimacy of his injury is now being questioned. The worker’s desire to punish his supervisor (a secondary gain) may lead him to exaggerate symptoms of pain and disability, resulting in a more chronic and severe illness presentation, and perhaps adoption of the “sick role.”
Although the concept of secondary gain has received a great deal of attention, most are less familiar with tertiary gain, which can also be a significant perpetuating factor in illness and disability. Dansak7 first introduced the concept of tertiary gain, which he defined as those gains sought or attained from a patient’s illness by someone other than the patient, usually a family member. For example, the wife of an ill man may use her husband’s illness to gain more power in their relationship. Before his illness, he controlled the finances and did not allow her to work outside the home. After his illness develops, she takes over the finances, and takes a job to stabilize their financial status. Comfortable with this new arrangement-including her increased power in the relationship-she may consciously and/or unconsciously resist her husband’s attempts to regain his health and functional abilities.
It should be noted that illness and disability are also associated with ‘tertiary loss,’ especially among affected family members. The concept of tertiary loss, proposed by Kwan and colleagues,8 is defined as the limitations or losses experienced by individuals other than the patient, as a result of the patient’s illness (as opposed to secondary loss, which refers to the limitation or losses directly experienced by the ill individual). A significant amount of research has demonstrated that the patient’s close family members often experience poorer psychological well-being, decreased relationship quality with the patient, caregiver burden, and worse physical health.9 A specific example of tertiary loss is financial difficulties experienced by the patient’s family as a consequence of the illness. Common tertiary losses are listed in Table 1.
While secondary gain is seen as a perpetuating factor in illness and disability, tertiary gain is best conceptualized as a precipitating and/or a perpetuating factor. For example, a person who presents with benign and self-limiting symptoms, if exposed to an “overly solicitious spouse, “ or a “rule-out” physician, may eventually develop a chronic disability syndrome. These are examples of tertiary gain precipitating illness (perhaps a desire to control a wandering spouse in the first case; perhaps decreasing physician anxiety about being sued by “making sure” in the second case). For a person who is already ill, such as a person with chronic low back pain, tertiary gain may function to perpetuate disability. For example, a physician motivated by financial gain, as well as a desire to avoid conflicts with patients, may discourage appropriate levels of physical activity and over-prescribe narcotic medications.
As discussed above, secondary gain has often been equated with malingering. However, Kwan and colleagues8 point out that secondary gain is a neutral phenomenon, available and received by virtually all of those who are ill. Thus, it arises naturally out of the “sick role,” and should only be considered problematic when the desire for secondary gain is the primary motivation underlying and dictating one’s behavior. Moreover, Kwan and colleagues8 argue that tertiary gain is also a neutral phenomenon, arising from the social construct of the “caregiver role.” Several advantages accrue to caretakers of the ill and disabled, and may include monetary payment for services, special status and recognition in the community as a caregiver, and excuse from one’s responsibilities to some extent while helping the ill person. Tertiary gain becomes problematic when it is creates conflicts of interest in the caregiver between the personal interests of the caregiver and the interests of the ill person. If personal interests are put ahead of care giving duties, then the contract the caregiver has with society is breached.
The pursuit of tertiary gain may be consciously and/or unconsciously motivated.7 Tertiary losses typically outweigh tertiary gains, especially among family members, leading to attempts to help the patient become well. However, in a minority of cases, tertiary gains outweigh losses, resulting in the caretaker encouraging (i.e., reinforcing) continued illness and disability. The authors3 have previously proposed that secondary gain should be considered problematic when the ill person is more motivated to pursue secondary gain agendas than the agenda of improving health and function. Similarly, it is proposed that tertiary gain be considered malignant when the “caregiver” is motivated to pursue tertiary gain at the expense of what is in the best interest of the ill person, including what is most likely to help them recover or function at as high a level as possible.