The management of secondary gain and loss in medicolegal settings: Strengths and weaknesses

Individuals with chronic illness and disability are among the most difficult patients to treat. The health-care provider is faced with an array of physical, psychological, and social factors, requiring adoption of a biopsychosocial approach to treatment. This approach necessitates consideration of the benefits for the patient of remaining ill and disabled. These benefits have been termed the "secondary gains" of illness, and they may serve to perpetuate disability and illness behavior. This paper focuses on secondary gain and loss issues in patients with chronic, nonprogressive illness associated with chronic disability, who are evaluated and treated in medicolegal settings. In working with this population of patients, the health-care provider is faced not only with the usual secondary gains of illness (e.g., escape from family responsibilities), but must also deal with the myriad of secondary gain issues unique to medicolegal settings (e.g., seeking financial compensation). Consequently, identifying and managing secondary gain issues can be quite challenging. A model for managing these issues is presented here, following a more general discussion of secondary gain and related concepts. This model has proven very useful when incorporated into an effective rehabilitation program, such as the functional restoration approach to treating chronic musculoskeletal disorders. However, shortcomings of this model for managing secondary gain have become apparent. These shortcomings, and methods for overcoming them, are discussed. The overall purpose of this paper is to improve the health-care provider's ability to identify and manage both simple and complex secondary gain issues.