I remember the first time I heard the term “secondary gain.”
I was transcribing charts for a large hospital system. I had recently transitioned to a floating role, where I had a primary hospital account I worked for but had been considered flexible and capable enough to work basically anywhere. To cover other people’s time off.
It was a bit more stressful but came with a small pay increase and the promise of as much overtime as I wanted.
My first week I was thrown off the deep end, as I was suddenly covering a vacation for a coworker who normally typed up psych charts.
And while some of my experience with medical terminology carried over, there was a lot I had to learn when I started transcribing therapy notes and psychiatric consults.
Wasn’t easy at first. Almost like starting all over again. But as I worked, I studied. And I became fascinated. That time covering for my coworker (and others who worked on psych charts) would end up being a big factor in why I eventually went back to school to become a psychological researcher.
But on Day 1, I was pretty darn lost.
And I had no idea what to make of it when upon transcribing one of my very first psych charts I heard the dictating clinician say something to the effect of, “The patient has been noncompliant with treatment course. Upon speaking with them, their primary motivation appears to be secondary gain.”
What in the world does that mean? I wondered.
What’s Secondary Gain?
A quick Internet search gave me the technical definition. Essentially, secondary gain refers to benefits a patient gets secondary to being in a sick role. Examples can be being not having to work, being allowed to lighten their domestic responsibilities, getting prescriptions for certain drugs, etc.
Potentially, if they have an emotionally supportive partner, secondary gain can also result in sympathy and attention.
As I worked on the chart, it became clear to me that the clinician suspected that the patient was in a social environment that rewarded them for being sick — and so they really had no motivation to get well and every motivation to sabotage or impede treatment.
I really had no meaningful way to evaluate the clinician’s assessment of the patient’s course. At the time, I had no insight into psychological research and certainly no clinical experience. Not to mention all I had to go on was the clinician’s word.
I was a mere cog in the medical records wheel. My job was to type what the clinician had dictated into the phone system into the patient’s medical record, so that’s what I did.
But as I did, I thought to myself, That has to be nice, getting secondary gain when you’re sick.
I Hadn’t Experienced Secondary Gain With My Own Illness
Because in my own history, I had largely met with people who were largely un-sympathetic regarding my own psychiatric history and recovery. A boyfriend threatened to break up with me if I didn’t stop crying in front of him (I learned to cry in secret). A wide variety of people would give me a berth and worry that I could suddenly turn dangerous once they found out I’d been hospitalized in the past.
Basically no one said, “That’s awful. I’m sorry that happened to you.” And certainly no one took it a step further, adding, “Let me take care of you.”
It was about 11 years out from my last major trauma that I started to make friends who would respond in a neutral or positive way to the knowledge that I was a survivor, that I’d been in recovery, working on myself for over a decade.
After I learned about secondary gain (due to my job, I’d hear the term over and over again), I found myself wondering if the lack of it was why it took so long for me to get to a good place.
If a lack of support had stunted my recovery.
Can Support Backfire?
But then later on, I found myself wondering that if the fact that I didn’t really have anyone to support me — and certainly not anyone to enable my sickness or reward/offset any refusal to take care of myself — forced my hand. Maybe it forced me to get well.
It was painful, scary, and awful to feel alone and like I had to hide my past from everyone I knew.
But damn if it didn’t force me down a path that I might not have chosen otherwise (because healing was really hard but staying sick was even more uncomfortable).
Later on, I’d meet a friend of a friend who was awful to basically everyone she encountered, didn’t work or contribute much to her household, was medically noncompliant, didn’t seem to even attempt to manage any of her physical or mental illnesses (she would tell you proudly of all of her diagnoses almost in Modern Major General style), and spent large sums of money.
She had also basically manipulated her partner into a mono/poly situation in which she was allowed to date others and he wasn’t. She did this by being a hellish metamour that no one wanted to deal with.
Her husband was a dear. A catch himself, really. I don’t know why he put up with any of it.
But he did.
He took care of her. Doted on her. Gave her the world and asked for nothing from her. Even as she was pretty awful to him and everyone else around her in return, behaving like a petulant child, constantly making other people uncomfortable (it was a wonder she had any friends).
And as I watched her, I found myself making peace with my past. It could have been worse, I thought. True, you didn’t get support when you wanted or needed it, but maybe getting too much support would have been even more dangerous.
Are there situations where getting too much support can be worse than a lack of it?
I don’t know the answer to this question. But I spend a lot of time thinking about it.
This post is part of an ongoing Poly Land feature called Psyched for the Weekend, in which I geek out with brief takes about some of my favorite psychological studies and concepts. For the entire series, please see this link.