Dr Patrick Jemmer
Secondary Gain: To Gainsay or Say Again
Dr Patrick Jemmer
BA (Hons) CertPgStud MA (Cantab) MA (Oxon) PhD (Birmingham) EurChem EurPhys MRSC MlnstP MIMA CChem
CPhys CMath CSci LNCP MNCH (Lie) FRSH
SoCEIS Northumbria University Newcastle UK NE1 8ST
Abstract:
In this article the historical background and modern manifestations of the phenomenon of secondary
gain are first presented. This is followed by a discussion of its cruciai roie in a therapeutic context,
whether this be physiological or psychological. Exemplary case studies are presented to illustrate
treatment methodologies, and it is emphasised that secondary gain must be treated tenderly, tentatively and with timeliness, if a resolution of the presenting probiem is to be achieved. Neuro-linguistic programming methodologies, which consider the intentions of aii behaviours to be positive, are
described, and it is shown how these can be used to resolve the inter-reiated probiems of conflicting
parts and secondary gain in a systematic and ecological way.
Keywords:
Secondary gain, neuro-iinguistic programming (NLP), hypnosis, hypnotherapy, case study, conflicting
carts; paranosic; epinosic; somatization; conversion; reframing; ecology; hoiism
"There was only one catch and that was Catch-22, which specified that a concern
for one's own safety in the face of dangers that were real and immediate was the
process of a rational mind. Orr was crazy and could be grounded. All he had to do
was ask; and as soon as he did, he would no longer be crazy and would have to fly
more missions. Orr would be crazy to fly more missions and sane if he didn't, but if
he was sane he had to fly them. If he flew them he was crazy and didn't have to; but
if he didn't want to he was sane and had to. Yossarian was moved very deeply by
the absolute simplicity of this clause of Catch-22 and let out a respectful whistle."
Joseph Heller, Catch-22, chapter 5, p. 46.
European Journal of Clinical Hypnosis: 2005 voiume 6 - issue 3
Secondary Gain
The phenomenon of 'secondary gain' was first
noted (although not named as such) during
World War I, and nowadays is colloquially conflated with the 'Catch-22' situation defined in
Heller's eponymous novel quoted above. The
following illustration taken from Hogan (1996)
demonstrates the nature of secondary gain in
such a 'theatre of war' setting. Consciously,
an injured soldier may well have wanted to
recover; however to go back to the front would
have pushed his subconscious mind to the limit. Despite a conscious knowledge that he was
forsaking his comrades, and deep conscious
resistance to this, the soldier would also have
experienced an incontrovertible subconscious
desire desperately to get home. Now, if the
soldier was 'lucky' and recovered sufficiently
he would be returned to the trenches and the
psychological conditions that led to his hospitalisation initially. On the other hand, if the
soldier did not recover, or worsened, he would
be shipped home. So, often, the soldier's presenting infliction did not resolve. This so-called
'secondary gain' was two-edged however,
as there would often be a deep psychological
counter-price to pay in this latter case. The
invalid soldier, although safe from shelling and
mortar-fire at home, could undergo an excruciating and seriously debilitating inner struggle
of guilt. It was impossible for many soldiers so
affected to return to battle; moreover, normal
civilian functioning often was found to have
been pathologically damaged as well.
Formally, psychologists and psychotherapists
define primary (paranosic) gain from a symptom is the freedom from anxiety and conflict
achieved by its formation. Freud in fact coined
the phrase 'secondary gain' to explain an important phenomenon in the treatment of phobia.
He noted that some people prefer to keep their
phobia since it serves a hidden purpose "the motive for the illness - i.e., the advantage derived
from it (the secondary gain of a neurosis)," as
discussed by Fonda (1995). The patient can be
quite disappointed if a therapist succeeds in
helping them to get rid of it. In any therapeutic
context, secondary (epinosic) gain describes
the positive practical advantages to be achieved
by using the seemingly negative or problematic symptom to influence or manipulate. For
example, illness results in attention and time
off from work; smoking may help a person to
34
relax or help them fit a particular self-image.
Ferraro (1999) notes that "secondary gain is a
standard psychoanalytic concept and is considered a reason that neurotic symptoms are so
difficult to give up." An excellent exposition
of primary and secondary gain in the context
of the psychopathology of body image (somatization disorders) is given in Frey (2004), and
discussed in more detail below.
Secondary gain is particularly evident in the
consideration of so-called 'conversion disorder.' Frey (2004) defines this as "a condition
in which the patient's senses or ability to walk
or move are impaired without a recognized
medical or neurological cause and in which
psychological factors (such as stress or trauma)
are judged to be temporarily related to onset or
exacerbation." The name 'conversion disorder'
arises from the idea that the sufferer 'converts'
a psychological conflict into a physiological
one, which manifests itself either as a breakdown in normal sensory operation, or as a specific motor problem. Physiological symptoms
can include blindness, convulsions, deafness,
double vision, hallucination, inability to swallow or speak, limb paralysis, loss of balance,
loss of tactile or pain sensation. Frey (2004)
quotes as an example a patient who loses his
voice in a public-speaking situation: "The
symptom simultaneously contains the anxiety
and serves to get the patient out of the threatening situation. The resolution of the emotion
that underlies the physical symptom is called
the patient's primary gain, and the change in
the patient's social, occupational, or family situation that results from the symptom is called
a secondary gain."
Hogan (2005) has investigated and reported
on the unusual feature of cultural influence
on an individual's reaction to pain and even
that person's subsequent level of suffering.
An example he quotes is the incidence of
whiplash in car accidents in Lithuania and the
USA. Whereas courts in the USA recognise
the condition, those in Lithuania do not: this
seems to 'encourage' claims for compensation
for the condition in the USA, whilst people
in Lithuania simply do not report incidence
of whiplash at all. Hogan's conclusion is that
within an enabling culture, secondary gain is
European Journal of Clinical Hypnosis: 2005 yolume 6 - issue 3
Dr Patrick Jemmer
often a sufficient motivator for the suffering of
specific pain. Exactly analogous subconscious
processes apply to self-defeat in sports, as Ferraro (1999) points out, since losing can generate great secondary gain. The example given
by Ferraro (1999) is when Greg Norman lost
a six-stroke lead in the 1996 Masters', resulting in humbling defeat which was witnessed
on television by millions. However, in the
weeks following this he received a great deal
of sympathy in the form of supportive articles
in major world newspapers and also through
letters from individuals. Ferraro (1999) concludes that "this sympathy can be quite reinforcing and gives defeat an unconscious appeal
to some individuals."
When a therapist works with a client presenting with a physiological condition, for whom
secondary gain is also a factor, this is often
evident from the pain which that client experiences. Recently, the intimate connection
between pain and emotion has been clearly
indicated. Thus a depressed person is much
more likely to report pain from an organic
disorder than someone who is not depressed.
Conversely, if we can reduce the symptoms of
emotional disorders like anxiety, depression,
panic and stress, then a client's tolerance to
physiological pain is likely to rise. Moreover,
as Spiegel (1999) observes: "The medically ill
have a great need for psychotherapeutic services. They experience considerable anxiety and
depression, undergo a series of stressors related to diagnosis and treatment, and experience
many social consequences of their disease...
including social anxiety, challenges to self-esteem, preoccupation with changes or losses in
physical function, and inappropriate guilt."
Let us now turn specifically to psychotherapy
with a metaphor taken from Hogan (1996).
As the client gains experience and learns, as
therapeutic journey progresses, the therapist's
pivotal role is often to uncover the root of a
specific problem. Once this uncovering has
taken place, the therapist-client team must
move steadily and peacefully towards a place
of understanding: a series of steps that the
client would not be able to make on her own.
And whereas before the client was previously
unable to distinguish the forest from the trees.
European Journal of Clinical Hypnosis: 2005 volume 6 - issue 3
the desired outcome is that the she will now
see both. This exploration and 'uncovering
of the eyes,' however, is one that must be accomplished congruently, sensitively, and at the
client's pace. Under the correct conditions,
such as those described by Viederman (1995),
"brief, active psychodynamic psychotherapy of
six sessions... led to the rapid disappearance of
symptoms. In particular, the metaphoric meanings of the physical symptoms were interpreted
and followed by an immediate disappearance
of symptoms."
However, even when therapy appears to be
progressing well, there can suddenly appear
resistance on the part of the client: various
cases are quoted by Hogan (1996) to illustrate
that "something else is in the way: this is the
secondary gain." The client can be consciously
aware of why she does not want to get better and
normally she will readily admit to this: indeed
she often proclaims that she wants to disavow
the problem state. We can imagine that there
exists an unconscious 'part' (or unconscious
'parts') of the client's psyche that benefit more
by maintaining the problem state than by allowing it to be released. The client is of course
unaware of these. There thus appears to be a
confiict in the client, which might be described
as a 'fragmentation' of parts. Neuro-linguistic
programming acts on the presupposition that
the part always has some positive intention in
maintaining the underlying problem state and
uses this fact in a proactive rather than reactive
way. Dilts (1996) makes the following insightful comments on this presupposition: "Actually, the principle of positive intention does not
come from religious or romantic idealism, but
rather from the scientific discipline of systems
theory. The fundamental premise of the principle of positive intent is that systems (especially self organizing or "cybernetic" systems)
are geared toward adaptation. That is, there is
a built in tendency to optimise some important
elements in the system or to keep the system in
balance. Thus, the ultimate purpose of all actions, responses or behaviours within a system
is 'adaptive' - or was adaptive given the context
in which those behaviours were initially established. " In fact, Neuro-linguistic programming
offers an array of tools for effecting the desired
changes based on this presupposition: amongst
these are the techniques of reframing or parts
therapy.
35
Secondary Gain
Let's take the example quoted in Merlevede
(2002): '"secondary gain' is the 'hidden', possibly unconscious, reason why a person acts in
a way that may, to an external observer, appear
to be self-defeating. For example, Joe Bloggs
frequently, and apparently sincerely, expresses
a desire to lose weight - but he never does..."
Hunter (2005) expands on this idea by illustrating how Mr Bloggs might describe how
he is experiencing an internal conflict, saying that "A part of me wants to get slim but
something else inside me keeps me starving
all the time!" That is, one facet or 'part' of the
personality desires to reduce the food intake;
this is in conflict with a second part, which
controls the desire to over eat. In general, there
are several common causes for such a conflict:
for example: authority imprint, overwork, past
programming, self-punishment, unresolved
past experience, personal or family problems,
and so on. Hunter (2005) also makes the point
that secondary gain could be important in a
case like this, and Merlevede (2002) reaches
the conclusion "... Why? Because Joe has an
unspoken belief that he will be safe from mugging so long as he looks big enough to wrestle
a bull."
One approach to resolving the conflict described above is to use ideomotor responses to
question the subconscious about the causes of
the problem and identify the conflicting parts.
Parts therapy can then be used to harness the
creative centre of the subconscious to synthesize the separate parts thus spawning a new
cooperative gestalt. Hunter (2005) tells us that
"appropriate use of parts therapy can help conflicting parts to achieve resolution. The process is much like conflict resolution, except that
the client is role-playing his/her various parts
with the therapist remaining objective in order
to facilitate inner dialogue. This process must
be handled appropriately, as it is extremely
important that such dialogue between the parts
be client-centred rather than therapist-centred.
Remember if you go looking for something,
the subconscious is fully capable of making
up a story to satisfy the therapist. (Example:
please note that excessive weight does NOT
normally indicate past sexual abuse!)." An alternative approach would be for the therapist
to use reframing techniques to transfer the
positive intention of the undesired behaviour
36
to achieve a more acceptable outcome as described by Setzer (2004). In the method of Sixstep reframing, the parts responsible for undesired behaviour are asked to form a collective
to choose more constructive outcomes. In all
these methods, an ecology check for the whole
system is essential prior to installation of the
new behaviour. These methods and their applications are elaborated in Hogan et al. (2001).
Let's now consider the importance of tackling
secondary gain in an integrated manner as part
of a holistic therapeutic process. A man scheduled to go on holiday abroad with his family,
presented to a therapist with a fear of flying.
This phobia had led in the past to an inability
to travel to holiday destinations, so that his
wife and children went alone. The phobia was
treated successfully: however, the therapist
was later berated by this client, for destroying
his marriage. The secondary gain inherent in
the phobia had provided an acceptable excuse
for the man to avoid spending holiday time
with his wife, with whom he was incompatible.
Once the phobia was cured, this convenient
excuse evaporated, and the prospect of a protracted period with his spouse was too much
for him, and he resorted to the extreme measure
of leaving her. So the therapy was successful
in part (in treating the phobia). However, the
side effect of this was that the resolution of the
secondary gain was sudden, and was not integrated, resulting in the possibility of long-term
damage. In some cases, the secondary gain is
so important that resolution and integration
are impossible. We can consider the case of a
young man who was afraid of travelling on the
Underground. Luckily, he had a wealthy uncle
who arranged for him to be chauffeur-driven
around the city. The man approached many
therapists for help with the fear: of course the
therapy proved fruitless since the lure of the
fancy transport was too great. As an aside we
note the comment of Middleton (1996) regarding the efficacy of hypnotherapy in such
cases: "Using hypnosis in conjunction with
behaviourist techniques such as systematic desensitisation makes more sense than using the
behaviourist technique alone. For example if a
patient wants help with a fear of travelling on
the London underground, or a fear of flying, in
order to work with the problem, it is necessary
to be in the place where the fear is. In this case.
European Journal of Clinical Hypnosis: 2005 volume 6 - issue 3
Dr Patrick Jemmer
the underground in London or some airport.
Not only is taking the patient to those places
time consuming, it is also very expensive. It
makes much more sense doing the work within
hypnosis and using the imagination alone. As
mentioned earlier, Wolpe says that the work
done within the imagination soon generalises
to real life." Other patients do not want to be
cured since they are receiving money from
medical insurance when phobias prevent them
from going to work. It is obvious here that
there is a strong personal motive not to get
well. These cases, however, represent only a
small minority.
Dilts, R. (1996). The article of the month: positive intention
- bringing light into the darkness: The principle of positive intention. URL: http://www.nlpu.com/Articles/article2.htm [Accessed
19 October 20051.
Ferraro, T. (1999). Athletic insight. The online journal of sport
psychology: A psychoanalytic perspective on anxiety in athletes.
URL: http://vvww.athleticinsight.com/Volllss2/Psychoanalytic_Anxiety.htm [Accessed 19 October 20051.
Fonda, M. (1995) quotes and discusses Freud, S. Two case
studies. In J. Strachey (Trans.),The Standard Edition (Vol. 10).
London: The Hogarth Press. 1955. URL: http://www.clas.ufl.
edu/users/gthursby/fonda/freudlO.html |Accessed 19 October
20051.
Frey, R. (2004). Health topics A-Z: Sqmatoform disorders. URL:
http://wvvw.ahealthyme.com/topic/topicl00587490 [Accessed 19
October 20051.
Grinder, J. and Bandler, R.The structure of magic II. A book
about communication and change. Palo Alto CA: Science and
Behavior Books. 1976.
Hall, L. M.The secrets of magic. Carmarthen UK: Crown House
Publishing Limited. 1998.
Hall, L. M. and Belnap, B. P. The sourcebook of magic:
Carmarthen UK: Crown House Publishing Limited. 2000.
In this article we have investigated the historical background and modern manifestations of
the phenomenon of secondary gain, and we
have seen how it is often crucial in a therapeutic context, whether physiological or psychological. We have presented case studies to
illustrate treatment methodologies, and shown
how it must be treated tenderly, tentatively and
with timeliness, if a resolution of the presenting problem is to be achieved. These methodologies are rooted in the toolkit of Neurolinguistic Programming, which considers the
intentions of all behaviours to be positive and
uses this fact to resolve the problem of conflicting parts and secondary gain in a systematic
and ecological way. As Andreas (2000) put it:
"There is an old joke that neurotics build castles in the air, psychotics live in them, and psychiatrists collect the rent. The task of NLP is to
build stairways, or transitions, so that people
can actually reach their desired outcomes easily (without becoming psychotic, and without
paying rent to psychiatrists!)".
Heller, J. Catch-22. New York NY: Simon and Schuster. 1961.
Hogan, K. (2005). IsleLife hypnotherapy: Relieving pain with
hypnotherapy. URL: http://ronstubbs.com/PainArticle.htm
I Accessed 19 October 20051.
Hogan, K., Nahum, E. J., Hastings, C. D., LaBay, M. L. and
Sumner, H. In Gray, K. H. (Ed.),The new hypnotherapy handbook: Hypnosis and mind/body healing. Eagan MN: Network
3000 Publishing. 2001.
Hunter, R.The art of hypnotherapy. Dubuque lA: Kendall/Hunt.
1995.
Hogan, K. (1996). Success dynamics corporation. Healing and
hypnosis IV: Motivation and secondary gain. URL: http://www.
kevinhogan.com/kevin4.btm [Accessed 19 October 20051.
Hunter, R. (2005). Parts therapy: Resolving inner conflict.
URL: http://vvvvw.translife.co.za/index.php?SubPage_ID= 145
[Accessed 19 October 2005].
McKay. M. and Fanning, P. Self-esteem. Oakland CA: New
Harbinger Publications. 2000.
Merlevede, P. E. C. (2002), Basic psychology for business
people: Did you ever hear of something called 'secondary gain'?
June 11 2002: Customer reviews of "How the way we talk can
change the way we work: Seven languages for transformation by
Robert Kegan, Lisa Laskovv Lahey". URL: http://vvwvv.amazon.
com/gp/product/customer-revievvs/078796378X/103-56112262639863 (Accessed 19 October 20051.
Middleton, J. (1996). Behaviour therapy: An explanation and
evaluation the bebaviorist approach to psychotherapy. URL:
http://www.hypnosis.demon.co.uk/old/behavior.htm [Accessed
19 October 20051.
Napier, N. J. recreating your self: Help for adult children
of dysfunctional families. New York NY: W W Norton and
Company. 1991.
Noble, J. (2001). Cedarfire: secondary gain: Keeping your reality
from manifesting. URL: http://wwvv.cedarfire.com/art.gains-jeri.
shtml [Accessed 19 October 2005].
Bibliography
Andreas, S. and Andreas, C. (2000). Selecting a resource to
anchor Anchor Point Magazine July 2000. URL: http://vvvvw.
nlpanchorpoint.com/Andrs2.htm | Accessed 19 October 20051.
Bandler, R. and Grinder, J. The structure of magic I: A book
about language and therapy. Palo Alto CA: Science and Behavior
Books. 1975.
Bandler, R. and Grinder, J. Frogs into Princes. London UK:
Eden Grove Editions. 1996.
Battino, R., and South, T. L. Ericksonian approaches: A comprehensive manual. Carmarthen UK: Crown House Publishing
Limited. 1999.
Beahrs, J. O. Unity and multiplicity: Multilevel consciousness of
self in hypnosis. New York NY: Brunner/Mazel. 1982.
Berkow, R. Psychiatric disorders: The neuroses. Chapter in R.
Berkow (Ed.), The Merck manual of diagnosis and therapy (16th
edition). Rahway NJ: Merck Research Laboratories. 1992.
European Journal of Clinical Hypnosis: 2005 volume 5 - issue 3
O'Connor, J. and Seymour, J. Introducing neuro-linguistic
programming. London UK: Thorsons. 1995.
Sangel, F. M. (2005). F M Sangel - articles: Primary losses and
secondary gains. URL: http://www.angelfire.com/zine/fmsangel/
articles/primary.html [Accessed 19 October 20051.
Setzer, L. (2004). 'Unlimited Power' by Anthony Robins,
sunimarized by Luke Setzer. URL: http://members.tripod.com/
AttitudeAdjustment/Books/Unlimited-Power.htm [Accessed 19
October 2005].
Spiegel, D. (Ed.), Efficacy and cost-effectiveness of psychotherapy. Arlington VA: American Psychiatric Publishing. 1999.
Viederman, M. Metaphor and meaning in conversion disorder: A
brief active therapy. Psycbosomatic Medicine, 1995, vol. 57(4),
pp. 403-409.
Watkins, J.G. and Watkins, H. H. Ego states: Theory and
therapy. New York NY: W W Norton and Company. 1997.