I didn’t do anything to deserve this….

And now you’re going to pay! Perceptions of injustice can emerge from a variety of conditions such as injury as the result of another’s actions – or in the case of not installing appropriate safety procedures – inactions – the experience of undeserved or irreparable loss or if the individual is exposed to a situation that transgresses human rights, just world beliefs and/or equity norms. You’ve probably already made the connection to our client populations – people injured in work accidents, car accidents or at the hands of another may be prone to present a clinical story where a sense of injustice is central to their response to the injury. And as Michael Sullivan from McGill University said in his workshop at IASP (Milano) last week: “When you live with injustice, you just want to share it”.

Perceived injustice is related to persistent disability and although the mechanisms by which this impact occurs are yet to be clearly defined, Sullivan et al [2-4] have shown perceived injustice is related to high levels of catastrophic thought, increased pain, heightened levels of protective pain behaviour (but not communicative pain behaviour) and depression. There is also a relationship to anger.

Furthermore, perceptions of injustice beg the question of retribution. Thoughts such as “How am I going to get back at the person who is perceived to be delivering the injustice?” may become part of the unhelpful narrative driving the persistent disability. Sullivan et al [2-4] argue convincingly that protective pain behaviours or displays of disability may be the only “power” the client has in the battle against the perceived injustice perpetrator. Because observation of pain behaviours is one of the main clinical tools we use to determine another’s pain experience, these displays of pain behaviour may constitute an effective way to communicate the perceived loss, and exact some revenge.  For example, such displays of disability may lead clinicians to grant an extended period of sick leave or believe in an inability to meet  work capacity [3]. Who might be seen as the perpetrators of injustice? Not surprisingly the boss, the other driver and/or the insurer feature in this group.

Clinically, I often hoped the perceived injustice might be dealt with when the legal process had run its course and damages were awarded – a sort of compensation for the injustice, bringing the world back into balance. However, I noted in practice this resolution often did little for recovery, and in fact could impede it further if the settlement itself was seen to be unjust.

Well, help is on its way. Research by Sullivan’s group discusses the use of some potentially effective targeted cognitive behavioural intervention strategies to address perceived injustice.  First, forgiveness approaches – similar treatment interventions are used for victims of crime  [5] – may be useful.  Forgiveness approaches encourage clients to change negative thoughts and emotions and behaviour towards the perpetrator into positive concepts such as compassion or sympathy for the other person or gratitude for the client’s own ability to forgive. Second, encouraging pain acceptance has been shown to be a useful [1]. Acceptance of pain (perhaps through mindfulness techniques as well as other methods) has been shown to improve pain, disability, work capacity and depression. Third, anger management and injustice resolution strategies may assist in dealing with perceptions of blame, irreparability, severity and/or unfairness.

I suspect the use of these interventions may also require a bit of self-reflection as the desire to act as an advocate for the client can be strong in some clinicians (may the Force be with you!).  Never-the-less, further investigations to clearly identify what works and for whom are needed. But in the meanwhile, a willingness to clinically explore novel  interventions that specifically target perceptions of injustice may facilitate recovery from some conditions.

Carolyn Berryman

Carolyn Berryman, Body in MindCarolyn has been teaching with the Noisters (Neuro Orthopaedic Institute) for the last 10 years and finally got herself into research via a very competitive post-graduate scholarship. Not that she has every stopped studying – she already has a masters in physiotherapy and in pain science – good luck fitting PhD onto the business card!  What is Carolyn researching for her PhD?  Based at the University of South Australia in Adelaide Carolyn is looking at neurophysiological profiles between chronic pain and PTSD (post traumatic stress disorder) during working memory tasks.

What does Carolyn do day to day? She is under piles of papers doing a systematic review of working memory and cognitive impairment in chronic pain.  Carolyn will then be using EEG to evaluate what happens in people with pain.  When she is not in the office, she lives on an island 100 kms south of Adelaide (that’s a long commute!) and spends her off-time playing with family, sailing and walking. Here is Carolyn talking more about the research she is doing.

References

[1] McCracken LM, & Eccleston C (2005). A prospective study of acceptance of pain and patient functioning with chronic pain. Pain, 118 (1-2), 164-9 PMID: 16203093

[2] Sullivan MJ, Adams H, Horan S, Maher D, Boland D, & Gross R (2008). The role of perceived injustice in the experience of chronic pain and disability: scale development and validation. Journal of occupational rehabilitation, 18 (3), 249-61 PMID: 18536983

[3] Sullivan M, Davidson N, Garfinkel B, Siriapaipant N, Scott W. (2009). Perceived injustice is associated with heightened pain behavior and diability in individuals with whiplash injuries. Psychological Injury and Law, 2, 238 -247.

[4] Sullivan MJ, Thibault P, Simmonds MJ, Milioto M, Cantin AP, & Velly AM (2009). Pain, perceived injustice and the persistence of post-traumatic stress symptoms during the course of rehabilitation for whiplash injuries. Pain, 145 (3), 325-31 PMID: 19643543

[5] Wade N, Worthington E. (2005). In search of a common core: a content analysis of interventions to promote forgiveness. Psychotherapy: Theory, Reserach, Practice, Training, 42, 160 – 177.