Perceptions of Injustice and Problematic Pain Outcomes

It is becoming increasingly clear that certain psychological factors will render some individuals more susceptible to problematic pain outcomes. Past research has pointed to psychological factors such as catastrophic thinking, fear of pain, and low self-efficacy as risk factors for heightened pain and disability. As summarized in the systematic review by Carriere and colleagues [1], emerging research suggests that individuals who experience high levels of “perceived injustice” in relation to their pain condition or injury are at high risk for a range of adverse pain outcomes including more severe pain, more pronounced or prolonged disability, more severe or persistent symptoms of mental health problems (e.g., depression, anxiety, post-traumatic stress disorder), and lower quality of life.

Carriere et al. [1] review 34 cross-sectional and prospective studies examining correlates of perceived injustice. Study samples include a wide range of pain conditions such as work injury, whiplash injury, fibromyalgia, chronic musculoskeletal pain, osteoarthritis, and spinal cord injury. The authors conclude that there is moderate evidence of a relationship between perceived injustice and pain severity, strong evidence of a relationship between perceived injustice and disability, and strong evidence of a relationship between perceived injustice and mental health problems. In a number of studies, perceived injustice has been shown to contribute to adverse pain outcomes independent of the variance associated with other pain-related psychosocial factors such as pain catastrophizing and fear of pain. Although the correlational design of many of the studies conducted to date limits the nature of the conclusions that can be drawn about direction of influence, Carriere et al. [1] note that the results of a number of prospective studies suggest that perceived injustice might be causally related to adverse pain outcomes.

There are important clinical implications of findings suggesting that perceived injustice is a risk factor for adverse pain outcomes. One implication is that measures of perceived injustice should be considered as part of assessment protocols used with individuals seeking treatment for pain conditions. High scores on measures of perceived injustice would alert clinicians to the possibility that clients might be at a heightened risk for delayed recovery or poor response to treatment.

Unfortunately, there are currently no intervention programs that have been developed specifically to modify perceptions of injustice associated with persistent pain. Furthermore, the current state of knowledge provides little guidance about the nature of interventions that would be required to effectively modify pain-related perceptions of injustice. Carriere et al. [1] point out that effective management of perceived injustice will require information about “how” perceived injustice impedes treatment response of the recovery process [1]. They summarize the results of a number of studies, addressing possible pathways by which perceived injustice might contribute to adverse pain outcomes (e.g., anger reactions, noncompliance, retribution motives, greater risk for mental health problems, expectancies, lack of acceptance). Greater understanding of the pathways through which perceived injustice impacts pain outcomes could provide critical information for developing interventions designed to reduce perceived injustice.

Carriere et al. [1] highlight that current approaches to the management of persistent pain might not be effective in modifying perceptions of injustice. They note that multidisciplinary approaches have a negligible impact on levels of perceived injustice. When a target variable or condition is resistant to change with available treatment options, it is worthwhile to reflect on possible preventive strategies or interventions. Important knowledge gaps, however, will need to be addressed about the factors that contribute to the emergence of perceptions of injustice before preventive interventions can be developed.

There are likely a multitude of factors that could give rise to perceptions of injustice. Scott et al. [2] reported that participants with whiplash injuries pointed to a wide range of sources of injustice, including the driver of the other vehicle, the health professional, the insurer, and family members. Interestingly, participants were more likely to identify the insurer and the health professional as the primary source of their sense of injustice than the person who was responsible for the accident. It is probably not the intention of insurers and health professionals to contribute to a psychosocial risk factor that will in turn impede recovery and contribute to higher claim costs. However, the findings of Scott et al. [2] invite reflection on the policies or procedures of insurers or health professionals that might be inadvertently contributing to the emergence of perceptions of injustice.

It is important to consider that perceptions of injustice are not merely mental constructions of the individual but might emerge from a reality that is characterized by justice violations. Reckless drivers and unsafe work environments do exist, as do unfair, disrespectful, or adversarial insurer practices. Individuals with debilitating pain might face legitimate and continuing inequities in access to services and resources in medical, insurer, and employment systems. If we accept that perceptions of injustice can emerge as a mental construction of the individual, and as a reaction to objective injustices characterizing the environments within which pain conditions occur, are adjudicated, and treated, then it follows that effective avenues of intervention will need to address factors within the individual (e.g., appraisals) as well as sources external to the individual that might be fueling the individual’s perceptions of injustice.

As noted by Carriere et al. [1], research in this area has proceeded in the relative absence of a guiding conceptual framework. This situation has, and will continue, to impede progress in the development of interventions aimed at preventing or modifying perceptions of injustice in individuals with persistent pain. The development of a viable conceptual model of perceived injustice will need to look beyond the context of pain as a forum for understanding the emergence and impact of injustice appraisals. The negative impact of injustice appraisals has been addressed in contexts unrelated to pain, such as organizational and procedural aspects of employment settings [3]. There is also a sizable literature on justice-related constructs such as entitlement, retribution [4], and forgiveness [5], again proceeding as independent avenues of enquiry without an overarching conceptual framework. Recent evidence suggests that the propensity to make injustice appraisals might be trait-like, influencing the perception of a wide range of stimuli [6]. Still, other research suggests that humans might be genetically prepared to evaluate their experiences in relation to principles of justice and that sensitivity to violations of justice principles (e.g., distributive justice) might be apparent in infants as young as six months of age [7, 8].

Conceptual elaboration and synthesis of models of justice-related constructs will be key to building a viable theoretical foundation from which to build intervention approaches that can either prevent or modify injustice appraisals. Interventions that can effectively prevent or modify injustice appraisals hold the promise of fostering more positive recovery outcomes in individuals suffering from debilitating pain conditions.

Funding sources: The author’s research is supported by grants from the Canadian Institutes of Health Research (CIHR), the Canada Research Chairs (CRC) Program, and the Institut de Recherche Robert-Sauvé en Santé et en Sécurité du Travail (IRSST).

Conflicts of interest: The author declares no conflicts of interest relevant to the material presented in this paper.