• I acknowledge ways my symptoms are reinforced.

• Sometimes, whether I have been aware of it or not, symptoms have had payoffs. I do not need to to avoid or obtain things, protect myself, or deal with other people through them. I resolve to be assertive, courageous and honest in my dealings with the world.

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To ask the hard question is simple.

W.H. Auden

A touchy topic

It's not about malingering or making it up.

No one would say that they are sick or in pain in order to get something.  And there are already too many people out there saying "it's all in your head", or "you must be imagining it" or "having a nice holiday?" to people disabled from work. 

At the same time, we also know that behaviours get reinforced.  If there are payoffs, especially immediate ones (like reduced stress), for doing something, we are more likely to do it again.  See "the Human Dilemma"  for more on this.  Given the stress of living with a chronic condition, it is natural to try to minimize stress where possible. There are situations in which the condition itself creates the opportunity.

Can symptoms serve a purpose?

Yes, if we accept a few ideas:

1. Health is affected by many things, including our behaviour and beliefs
2. Human beings are complicated (see #1)
3. Any change has both positive and negative effects
4. We are not always consciously aware of what is reinforcing our behaviour.

Examples of reinforcers:

Bill hated his job but could not quit.  He thought that his chances of getting another job at his age were slim.  His back pain was a way out of an intolerable situation.  The pain was real, but he may not have realized that it was being reinforced.

Jill's marriage was not that close.  Her husband was often pre-occupied with his own things.  When her fibromyalgia flared up, and she had a major crash, he would become quite attentive.  Her flare-ups resulted in her getting what she needed and could not get any other way.  She does not like feeling so sick, and she may not know that the attention of her husband could play a role in her symptoms.

Theresa was forced into a marriage by her family.  After her two children were born, she could not handle having sex any more, but she did not want to suffer her husband's anger when she refused sex. She got sick and remained so for decades.  Doctors could never accurately diagnose her problem, and multiple surgeries did not help.  Her husband did not insist on making love to her when she was so frail.

Reinforcers confuse the issue and make it harder for people to recover.

There are usually many, many more losses than gains for being disabled, chronically ill or in pain.  This is obvious to those of us who have worked with clients with these problems. 

At the same time, there can barriers to recovery that people are not always aware of.  When symptoms have some kind of pay-off,  like reducing stress in one area of life, recovery is that much harder.  This is true even when there is more stress in another part of life.  People find themselves in a strange paradoxical situation:  what makes them feel better right now, will ultimately make them worse: the Human Dilemma again.

If a person has to rely on the condition to manage or reduce the stress of certain situations it will be even more difficult for them get better, or make the condition a smaller focus of life.

There are alternatives.

A symptom would not be reinforced if the person could manage another way.  If Jill can improve her marriage, her fibromyalgia will not serve a purpose.  She may still have it, but there would be one less thing to contribute to her flare-ups.  If Bill was able to make a clear decision to retire and live on his savings, his back pain would not be reinforced.  Then he might be able to relax, and this could help his back pain to some degree. If a symptom were used to deal with a marital problem, developing the courage to be assertive, and communicate will make the relationship, not the illness, the focus.  And this would be more appropriate. 

In general, having the courage to make tough choices, to speak up and deal with rather than avoid problems, will reduce any payoffs there might be for a symptom. Clear communication about what you want or need will make referring to your condition less necessary.

Questions to develop self awareness:  Ask yourself

• "Does my condition serve some larger purpose?"                       Examples
• "Are there things that I cannot get any other way that I can now get because of my condition?"
• "Could I obtain these things without referring to my condition?"

Cautions:  

1. Remember the principles of Holistic Health, and that our health can be affected by many things.  Don't think that just having a positive attitude or acknowledging that your condition has some reinforcers is going to magically cure it.  We are mind AND body, and we are affected by both our internal AND our external environments.   
2. Do not assume that you got this condition because of some character flaw.
3. Do not indulge in blaming yourself if you do see that your condition serves a purpose.

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