Episode #138

Secondary gain is a powerful thing. It impacts behavior in ways that we wouldn’t think of, but when it comes to substance use it’s an important factor in making long lasting change. Behavior is so complex sometimes. So often people want to stop a behavior or change it, and despite a person’s best effort they can’t seem to make the changes stick. It turns into a cycle of trying to change, the period of actively working on change, the slide away from change and the period before the person tries again. It can feel maddening to keep trying over and over. So what is it that keeps people from making lasting change? Today, we’ll talk about the concept of secondary gain.



You’re listening to the All Things Substance podcast, the place for therapists to hear about substance use from a mental health perspective.  I’m your host, Betsy Byler and I’m a licensed therapist, clinical supervisor, and a substance abuse counselor.  It is my mission to help my fellow therapists gain the skills and competence needed to add substance use to their scope of practice.   So join me each week as we talk about All Things Substance.

Welcome back to the All Things Substance Podcast. This is episode 138. Last week we talked about willpower. The idea that a person should just be able to say no, that they should just be able to quit. That unless they’re an addict or an alcoholic, scaling back their problematic substance use should be a piece of cake, or at least doable. There are a lot of people who believe that even if you are an addict or an alcoholic, that you should be able to scale back your use or to just quit.

I can’t tell you the number of times I’ve had people say things to me like, well, my uncle used to drink all the time, and he just woke up one day and decided to stop. And he did. And the truth is that isn’t what happened. There’s way more to what happened with that uncle. There was a thought process beforehand. There were realizations they had, there were cravings they had after.

It is possible, of course, that somebody miraculously didn’t want to drink or use anything. It’s just not probable. Our brain isn’t wired like that. Our brain is wired to understand things that feel good. Things that take us away from stress or other things that bother us. If somebody’s been using alcohol or other drugs to manage that, the brain notices it and it’s gonna want that. It’s the same reason why they make hyper palatable food. 

Hyper palatable food. For those of you who aren’t familiar with it, it is the name for what they do to process food and fast food. It is the act of injecting more fat, sugar, and salt into foods than is necessary. The idea is to make them extra tasty so that we come back and it’s super effective. 

If you have ever tried to eat healthier, you’ve noticed this. At the beginning of an eating healthy time period, the healthy foods don’t seem as exciting. They seem kind of bland. They don’t sound tasty, and often it’s because our taste buds have been flooded with this fat, sugar, and salt. Well, two weeks later, if you manage  to stick with your eating healthy program, those foods sound good now and you look forward to it, and it doesn’t seem so bland anymore.

Well, that’s because our brain got away from the hyper palatable foods and we were able to see food and taste food  the way it is in a more natural state.

 It isn’t easy to just stop a behavior. If the behavior is new. It’s much easier. I don’t know whether it takes 20 days or three weeks or a month to establish a behavior because it completely depends on what it is, how often it’s being paired together and the person’s genetics among a myriad of other factors.

We just don’t know what we know. Habits get formed that they are hard to break, and that when we’re talking about chemicals and that when we are talking about substances, there are other complications so in the last couple weeks, I’ve been addressing some basic points because with Charting the Course coming up, I wanna make sure that we are ready to move to the heart of the course.

Charting the Course. If you don’t know, it is the six week live talk program that starts on July 11th. The doors for registration are open right now, and you can go over to betsy byler.com/course to check it out.  This course is designed to give you what you need in order to work with substance use as a mental health therapist without specializing and without having to refer out.

It is meant to give you what you need and not every single piece of information that exists about substance use. What I did was scale it down to what I have been teaching therapists for the last 12 years to help them be able to do this effectively and that they feel good about it.

So we’ve been addressing these topics. We started with the very reasons that we need to assess for substance use. We talked about harm reduction in abstinence. We talked about willpower. The thing we wanna talk about today, which is related to willpower, is the idea of secondary gain. 

So today I wanna talk about secondary gain, as though you’ve never heard of it. Because as I thought about it, I don’t know whether other therapists think or talk about this very much at all. But because it’s a psychoanalytic concept at its base, it’s something that I have really been aware of and worked with a lot over my career. But  I am someone who has a Master’s in clinical psych, And am not a social worker, and I’m not an LMFT.

I don’t know what the rest of you learned in school. That’s where we’re gonna be coming from today as we talk about how this concept relates to substance use and people’s ability to moderate or quit entirely.

The APA, the American Psychological Association, this is what they have to say about secondary gain. In psychoanalytic theory, secondary gain is the advantage derived from a neurosis in addition to the primary gain of relief from anxiety or internal conflict. Advantages may include extra attention, sympathy, avoidance of work, and domination of others. Such gains are secondary in that they’re derived from others’ reactions to the neurosis instead of from causal factors. They often prolong neurosis and create resistance to therapy. Also called advantage by illness.

When you look up secondary gain, there’s another word that tends to pop up and that is malingering. I’m not a huge fan of this word being tied to secondary gain because for me, secondary gain is something that happens to everyone and is vital in understanding people’s choices.

Last Friday, I reposted the podcast about stages of change because it’s super important and possibly the most important factor when talking about people’s choices around substance use. If you haven’t had a chance, head over to the podcast and check it out. It was originally episode 109.

So malingering is this idea that people would exaggerate or feign illness in order to escape something unpleasant, like a job or some other kind of obligation. It’s the idea. It’s the idea behind the eighties classic Ferris Bueller’s Day off.  Ferris Bueller, the main character fakes being sick in order to get a day off from school. That would be called malingering.

In the context of psychology. And in therapy, malingering is gonna be something that isn’t so temporary. It’s longer term. There are plenty of people who have experienced this with friends or family members where they feel like somebody’s physical or emotional issue pops up at convenient times so that they don’t have to be responsible for something.

It can be super frustrating. On the other side, there are plenty of folks that have illnesses that are undetectable, and they are often accused of things like malingering because they can’t quantify what’s going on with them. For instance, people with chronic pain. 

Pain is not something that can be measured objectively. It is purely subjective and we can’t see it. And so folks with chronic pain are often misunderstood and treated poorly because we can’t treat pain the way we treat other symptoms.

Over the years there has been discussion about the difference between malingering and feigning someone’s sickness. Malingering is said to be motivated by external incentives, whereas feigning is an individual’s deliberate fabrication or exaggeration without any assumption of goals. This feels to me kind of like a slippery slope, so I wanna be really clear.

Secondary gain is not good or bad. There is no judgment on it. It just is. We need to assume that all behavior has purpose. Certainly when it comes to children, I have this conversation with parents a lot. If we assume that behavior has purpose, then we can look for why a child might be doing a thing and rather than assuming intent in an emotional sense, we’re then looking for what the child is trying to communicate. As oftentimes adults will assign intent to children that they are far below a developmental level to have those kinds of thoughts. 

For instance, a two-year old doing something out of spite. That’s not something a two-year old’s thinking about. A two year old is thinking about, I’m angry, I want what I want, and they’re trying to get their needs met.

Trying to get a need met is super important. I’m not certain where it came from, but I know I grew up with this same phrase, and I’m certain you did too. The idea that someone is doing something, quote for attention. Well, the thing about it is, why is that bad? Why are we supposed to not want attention?

Attention is something that we need as humans. We need to be noticed. We need to be recognized. We need to be in relationship with others. It is a core feature of who we are. If you aren’t getting the attention you need, you need to find a way to get that need met. 

How many behaviors do we see in a day that are being done in order to get the need for attention met? There’s this ideal that we want people to do things without ulterior motive.  Work hard because they have a good work ethic and not because they want recognition. Do the right thing because that’s the right thing to do, and you shouldn’t want anyone to notice. Don’t care what other people think. 

There are times when I think that we can live in a place where we are more highly self-actualized; where we do things because it’s the right thing to do; where we work hard because that’s part of our integrity. At our base, though, we are social creatures who need each other.

So this idea that people are doing something and it being manipulative, which is often how this is phrased, is not where I’m coming from, and we wanna remove that today. Secondary gain is a fact of behavior. It is not good or bad, it simply is. And what we’re looking for are facts and patterns.

Here’s an example of how secondary gain works in the choices that somebody makes.  I recall a client of mine who was living with their  child who was a teenager, and it was fairly difficult. The client kept allowing their alcoholic ex to come into the home and to stay with them for a few weeks. Each time it ended up with the police being called and escorting the ex from the home.

As time would go by we would talk about what a bad choice that was for them, letting their ex in the home and how it ended up, and how they weren’t gonna do it again. It happened again. It went as predictably as we thought it would, and we had to come up with another plan to get the person out of the home.

I remember feeling really frustrated because this person, my client, was incredibly intelligent and knew, could tell me all of the ways that allowing their ex to stay in their home would go sideways. Yet they kept doing it. And it probably was five or six times in the space of the year that I had been working with this person. 

And so on I think the sixth time when they said, I need some help getting so-and-so out of the house, and I was like, no. And they said what? Said No. We need to figure out why you’re doing this because until we figure out why you’re doing it, It’s not going to change.  I went to find what they were getting out of having their ex in the house.

They weren’t having sex or any kind of romantic relationship. The person wasn’t overly helpful in the areas of the home. And initially my client was extremely resistant to the idea  that they could be gaining anything from having this ex in their home, and then we found it. 

My client had a very difficult child and no one to help. There wasn’t a single person that lived in our area that could tolerate their child. Because of this, my client had no help, no respite  from being with this child. Even the school had been threatening to kick them out. My client was exhausted and the only other person who had responsibility or an expectation  to manage the behavior of the child was the other parent.

And so when my client would get to the end of their rope, they would start entertaining thoughts about having a break. And that is how the ex came to be in their circle again. They even bought alcohol for the ex while they were in the home because this person was an alcoholic and couldn’t survive without alcohol, or they would be in withdrawal. What they finally said to me was, they’re not a lot of help, but at least it’s something

I wanna talk about that comment. They’re not a lot of help, but at least it’s something. That was the focus of our work. Until that very real need was met. There was no discussion about getting this person out of their house permanently. Now, If it was getting to a crisis place and things were getting violent and whatnot, then yes, of course. 

But knowing that it was going to be something that was going to happen again, and instead of feeling ashamed and beating themselves up for having this person in the home, they could just accept that it was going to happen and that at least they could have it happen on their terms.

What we had to do was work on getting supports in place. We had to talk about what it is that they needed and who they would be willing to trust with the information about what their child was like and how they were acting. I had explored the reasons why this person was allowing their ex around just to make sure that there wasn’t lingering feelings or some romantic notion that was still present, because if there had been, then we would’ve talked about that.

In this case, the secondary gain was the person was getting support. They were able to get a break, they were able to have some time alone, and that was enough to put up with the behavior of the ex until it wasn’t. 

So I wanna take this concept of secondary gain, and I want us to keep it in our minds as I talk about using behavior and what that is like. So in the beginning  if someone’s experimentation with drugs or alcohol, they wanna experience it. They wanna see what it’s like. They decide in those moments whether they like the feeling or not. 

The first time you drank alcohol, you experienced something and you decided whether or not you were going to drink again. Lots of people get really sick when they first drink and decide they’re never gonna touch it, and then time passes and, um, they end up deciding to give it another couple tries.

Generally people find out how much alcohol they can tolerate before they don’t like the feeling anymore, or they don’t like the outcome. That’s normal behavior as it relates to substances. People use it. They figure out what the line is, and then they stay to the side of the line. Occasionally they might drift over the line and be reminded of why they don’t like this and then not do it again.

Sometimes using substances in a normal way is a goal directed at helping people feel better. There are a lot of people who will talk about having a drink after work. And the insinuation here is I worked hard today and I deserve to relax, and in this case, alcohol equals relaxation. We know that it’s the alcohol content in it otherwise, mocktails would be just fine. But for folks who are using that after work in order to relax, that is not what they’re after. They’re after the alcohol content. 

What we know about alcohol is that it’s a depressant, that it slows the central nervous system down. So any activation that’s been there all day, whether it be from stress or from anxiety, or even depression will be impacted. The senses will get dulled a bit and things won’t seem quite as sharp.

So even when someone is drinking or smoking marijuana normally, meaning not in a daily fashion, they’re still using it to get something out of it. Where we start to cross the line, where we get into secondary gain in a problematic way, is if they are now using that substance to meet a specific need either, almost to exclusion or to exclusion of everything else. That makes it really challenging to change a behavior. Here’s another example. 

I met with a man in his twenties.  He had been painfully shy as a child all the way through high school. What he found when he went to college was that he was not prepared for the level of social interaction. Because he had grown up with the same people, he was able to manage the anxiety of being around them.

He had experimented some with alcohol in high school, as is pretty typical for at least kids in the United States. But at college, what he found was that it was simply too much.  He had to get used to a roommate, to floor mates, to classmates, to people he didn’t know, to professors, and he couldn’t. He had pretty significant social phobia, undiagnosed, and couldn’t manage it.

What he found was that when he drank, he was able to be himself, to be funny, to be witty, and to talk to women. He hadn’t been able to do that at all. Well, when you’re a freshman in college, there’s always a party to go to. You just have to know who’s throwing parties, and there’s usually someone who will buy alcohol for you.

And so what happened was they ended up figuring out relatively quickly that alcohol helped them manage social interactions. This worked so well that they would take a shot or two before they went to class. You can imagine that this didn’t last very long because it’s not adaptive and you can’t just stay still when it comes to substances, everything progresses. It is a guarantee of using substances, that the tolerance progresses, as does the risk for, and the experience of withdrawal. 

 So as this man was moving through his freshman year in college, continuing to drink his tolerance grew significantly. To the point that  he ended up having to come home in the middle of second semester because he could no longer tolerate it because he wasn’t going to any classes and doing anything other than drinking.

By the time I met this man, this was many years later, and he had found that alcohol was  helpful for him in terms of assisting him to be social, but he had developed a pretty significant alcohol problem. He had figured out  that he couldn’t drink during the day because of the nature of the work that he did. But once quitting time happened, then all bets were off. It was just a matter of keeping the drinking within enough space that he didn’t have the worst hangover tomorrow and could get up and go to work. Monday mornings were always really challenging because the weekend had happened.

As things progressed, there were other behaviors that came up. This landed him in trouble with the law and ended up in my office. As we started talking, he couldn’t tell me why he’d been drinking. He didn’t understand why  his drinking had gotten out of control.

He had seen people who had alcoholism when he was growing up and had made a promise to himself that he wouldn’t wind up there too. Yet here he was. It took about 45 minutes for me to find what caused him to drink. When we talked about where things went sideways and I asked him about certain parts of social phobia, I found that it was really severe.

And we talked about how that was present, and I asked him questions about being a much younger child and when he started noticing it and how separation anxiety had really morphed into social phobia. And how unacceptable it was in his family of origin to be shy, and what that was like for him. Here’s why that matters. Just because the person in my office had incentive to cut back or to quit didn’t mean he was going to be able to. Because the problem still existed and the problem in this case wasn’t even alcoholism. The problem was social phobia. 

He was managing to stay sober because he was terrified of going to jail and on probation you’re not allowed to drink. The problem was that it was not going to last. The thing that gets people sober initially is not the thing that’s going to keep them that way. It changes. 

In the beginning. It might be because probation made them go to treatment, or it might be because a spouse said they were gonna leave, or it might be because the doctor warned them about liver trouble or heart trouble or whatever the case is, that they got a warning and so they ended up cutting back or quitting. That only lasts for so long. 

Just like when people have gone to the doctor, found out they’ve gained weight, they’re middle aged, and now they need to cut back. Some people come out and they’re bound and determined to eat healthy. There’s a reason why the results of weight loss programs aren’t typical. Because there are other things holding up the behavior, and if those things aren’t addressed, the behavior returns. 

So on Friday when I re-released the podcast on stages of change, we talked about how precontemplation and contemplation were stages  that people occupy back and forth fairly often. People will often progress from precontemplation to contemplation to the planning stage and even to action sometimes, and then back down to pre-contemplation. The movement through those stages is natural and to be expected in most cases. What’s driving it a lot of times is secondary gain.

If we hadn’t addressed my client’s social phobia, they would still be drinking no matter that they’re on probation and no matter the consequences of getting a violation of their probation, if we hadn’t addressed my client’s need for respite care and outside support then their drunk ex would still be showing up at their door.

When we think about people’s behavior, we have to know what they’re getting from it. For some people, it is easier for them to talk about physical ailments rather than emotional ones.  I find that a lot with kids where they have headaches and stomach aches, and I believe they have those things, but when it’s emotional, we don’t find a biological cause. But these things pop up because it’s easier to say, my tummy hurts, or my head hurts. Then I feel sad and I don’t know why.

So when we talk to people about their substance use, there’s a lens here about secondary gain that I want you to be aware of. We need to know what they’re getting from the behavior. Even if it looks like there’s nothing, there is something. 

There is absolutely something that comes from this behavior. It could be very small. It could be that they don’t have to think for a couple hours or that they get to let off some steam. Or that it  helps them get through the week because they know they’re gonna be able to get hammered on the weekend. That’s enough. If the secondary gain, whatever it is, feels really small, I would look for what they’re getting relief from or what it’s accomplishing, because that might be where the big piece is.

So let’s take somebody who continues to drink, even though bad things happen all the time: they’re running out of money, their tolerance is up, and they always black out and end up doing things that they regret. Whether it’s waking up next to a stranger or driving home. The obvious thing is to quit drinking. They might tell me things like, but I like it. Okay. What do you like about it?  Is it the taste of it? Is it the feeling? What is it that they like? Okay, so perhaps they like the flavor. Okay. Is there a non-alcoholic version of what they’re really enjoying that they could have?

Then we take that obstacle and we say, all right, assuming that you can have this other beverage or whatever, now what? Why not give it up? It’s causing so many problems because I want to be able to relax. Okay. Tell me what relaxing means. We find out that relaxation means being free from stress or having less stress. So then while the secondary gain is  relief from stress, the thing we go after might not be how to relieve stress after work. It might be why are they so stressed? Is this level of stress above and beyond what is normal in a day? Because if it is, that’s the thing we need to address.

Very often when our clients are using substances in a problematic way, it has stopped being for fun. Yes, there are still fun times. Of course there are, but the reason they’re doing it, the primary reason isn’t for fun anymore. And this is usually seen when folks will start using the substance, whatever it is alone. Where if their friends bail on them, they’re still gonna drink, but they’re just gonna do it at home.

Because they want the other thing, it’s not about being social. It’s now become attached to something else. And that is conditioning where the person is stressed and they drink and they feel better, and the brain recognizes that. So when the brain recognizes that we have extra stress, it’s gonna send those signals to make that stress go away.

Our body wants us to get back to an equilibrium where we aren’t really anxious or stressed out or whatever.  That’s when the brain hopefully reminds us that alcohol would do that for us. We’re a grown adult, we work hard, we have our own money. We might as well get something to drink. And there’s really nothing wrong with that. 

The question is whether or not they’re using problematically. And if we’re talking about it with our clients, the chances are that there are now some unintended consequences from the use of the substance. So what we’re doing here is we’re not looking for a way to villainize substance use substances in and of themselves are just objects.  They are chemicals put together. They are a plant, they are liquid. What they do in our bodies can be problematic and some more than others.

The choice to use substances isn’t good or evil either. It just is. It’s normal human behavior. So what we’re looking at when we’re evaluating someone’s use and trying to figure out where we wanna intervene or start, is we wanna look at what’s holding up the behavior. 

If problematic drinking is what’s been identified, then we look at what the consequences are of that drinking, what consequences are neutral, what consequences are bad, what they wanna change about it. We look at the kind of drinking that they’re doing how often, how much, and when there are binge moments that weren’t planned, what is the thing that triggered them to do that?

Then in order to address the behavior, we find out what’s underneath it. It’s very psychoanalytic, and I have always known that about myself. I believe that the way that we heal from pain is that we make meaning from it. I also believe that the way we make behavior change is by understanding it and understanding ourselves.

There are certainly times and places where a very straightforward CBT approach is helpful, where we need to change a behavior immediately, and that the short term goal is what’s most important right now. For long lasting change, it is my bias that we need to understand what’s happening. 

So locking someone up and getting them sober is effective at the moment. However, putting them back in the environment they came from with no support, is. A waste of time. We gave them an experience of being sober for 30 or 45 days or whatever the time period is.  I think that is worth something. And typically when people are in a treatment program, they do learn some things about themselves. But if we don’t equip them to do that stuff in their regular life, then they’re not gonna be able to translate those skills from the treatment center to home. It’s really challenging for folks to do that. 

Even sober folks, it’s difficult for them to do that. In our office. They might be able to participate in breathing exercises and practicing coping skills. But doing it in the moment when they’re feeling panic, that’s really hard.

So here’s what I’m suggesting: when you are evaluating your client’s use of substances, You wanna know how much, how often, the outcome, and the impact. If someone is not able to curb their problematic substance use easily then we need to know more about it in order to help them achieve the goal that they want.

Sometimes bringing up substance use at all can feel really daunting. It’s one of those things that the idea of asking someone, so tell me how often you drink, puts people on the defensive really easily.  Cuz the insinuation is that they drink and that they might drink too much. We don’t wanna offend people and if they didn’t bring up substance use with us, or didn’t write it down on an intake packet, then should we really be talking about it? Is that our business? 

What I know to be true is that problematic substance use will get in the way of therapy. It doesn’t mean that someone’s gonna show up high or drunk or whatever  but the outcome will impact your work. If you are practicing coping skills and the person is telling you that they work or don’t work, would it change your mind if you knew that they were using them while having a few drinks, does that change whether those are effective or not? Can you really be certain that that’s working?

The need for us to look good to each other as humans is really, really powerful, and so we’re really used to trying to present ourselves in the best light. There’s nothing wrong with it. It just is how we’re built. And even with our clients, they don’t want us to be disappointed in them. They don’t want us to feel bad about the work that we somehow failed.

Can’t tell you all the times that I’ve heard clients talk about how they didn’t tell their therapists something cuz they didn’t want their therapists to feel bad. Because people don’t wanna hurt each other for the most part, at least not directly where other people can know about it.

So if you have ever wondered how to bring this topic up, I want to invite you to the live presentation that I’m doing on June 20th of my Five Steps webinar. The five steps to confidently ask your clients about substance use is something that I’ve presented before. There’s actually a recorded session of it from last fall that’s on my website that you can sign up to watch for free.

I wanted to present it live because I do think that it’s incredibly important information and that most of us struggle with figuring out how to bring up this sensitive topic. Doing it live means that you are able to interact with me and the time I chose means that our friends and listeners who are in the UK and Europe and in other time zones may be better able to attend. It’s on June 20th, which is a Tuesday at noon Eastern time, 9:00 AM Pacific time. June 20th, even though it doesn’t seem possible, is next Tuesday. 

I know for those of us who do therapy all day, every day, that those time periods can be difficult. So if you are not able to block out an hour or you don’t want to attend live, there will be a replay. I encourage you to go sign up for this webinar. It’s the Five steps to confidently and effectively ask your client about drug and alcohol use. You can head over to betsy byler.com/steps in order to sign up. 

I’m gonna share with you my five steps to bring up substance use in a way to bring up substance use with your clients in a way that is effective and will feel good to both you and your client. I’m excited to see you at the webinar next Tuesday and until then, have a great week. 

This podcast is designed to provide accurate and authoritative information in regards to the subject matter covered. It is given with the understanding that neither the host, the publisher or the guests are rendering legal, clinical or any other professional information.

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