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.

 

Comments

  1. Great post Carolyn,
    Its definitely an interesting topic. We published a rather controversial qualitative research article on the topic where we analyzed comments on news websites to a prominent hostage-taking incident at a workers compensation board in Canada. You might find it interesting: http://www.ncbi.nlm.nih.gov/pubmed/22272685

    Geoff

  2. Hi Carolyn,
    thank you for your post/studies. As an injured worker I’ve lived all this and I think the most frustrating factor remains that my nueropathic injury can not be acknowledged in the guidelines WorkCover uses for assessing injured workers (yes, my 5.5 years of hellish chronic pain that completely took over my life and my husband’s was measured at 0% impairment). However even though this frustration has remained and I’ve had huge system battlies, I believe, it IS NOT the focus nor a factor in preventing me from seeking a cure or attempting to get myself the best I can given my pelvic injury. Isn’t our human nature tuned to wellness and wanting to ‘fix’ ourselves?

    I believe what affects the pain is the system requirements, the activities we must do in order to have our financial support, these being the dealing with the appointments that you know very well are not fair, that cannot assess or even understand your issue, these very activities that translate to being unheard, invisible, not understood, and worst of all that leave you without the correct treatment, often without support and in some cases looking ‘fraudelent’. try coping with that when you’re facing never possibly working again. So then what happens? You have the most motivating factor to find a way to get better, get your life back and ulitmately getting out of such an appalling system. I would never have accepted the pain, in fact I’ve made alot of progress avoiding that.

    I think its also really unfair that someone in a pain situation should be taught to accept the pain and deal with anger management. I hope the systems that infuriate injured workers are on this site because there is certainly a better solution and that’s updating the system and treating everyone as they require, correct treatment goes a long way. I mean imagine if the WorkCover system really used the learnings from BIM to help injured workers. I know I would have been better and back at work years ago.

    I understand your message, this new awareness might help some, but personally, injustice or not someone in pain doesn’t want to be that way, they ALWAYS want to be better and there’s nothing they’re thinking or can be frustrated about that can be preventing them from their attempts to get better. In a heated moment yes, there’s more pain but those moments are far fewer than the hunt for ‘betterness’. Well, that’s how it is for me anyway.

    Cheers

  3. Carolyn Berryman says:

    Hi Geoff,
    Thanks for alerting me to your article – I’ll take a look. It is certainly an interesting topic!
    Cheers Carolyn

  4. Carolyn Berryman says:

    Hi Soula,
    Many thanks for sharing your story. You have conveyed the sort of ordeal that a operating within a system such as WorkCover can often serve up. I like your point about trying to change the system and I hope that is what many of us strive to do in small ways where we can. Perhaps we all need to lobby harders in that direction whenever we get the opportunity.

    As for the notion of feeling angry or that the injury was not deserved, I hope the sentiment conveyed in this blog was not one of judgement, but of regard for the whole story, the holistic experience. I am sure that everyone wants to get better and hence as clinicians we need to continue to explore the range of strategies that might assist this, to travel a little further down the road. I do think that how you see the problem, will affect how it is dealt with. However, what will be useful for one person, may not be so for another.

    Best regards for a successful recovery,
    Carolyn

  5. Hi Carolyn-
    A colleague forwarded me this piece because of the work I do. Gotta say, I’m not feelin’ this piece. Even the term ‘perceived’ is really quite offensive. Justice and injustice are most of the time born out of very really life social and economic systemic disparities in life – and should be acknowledged as such. Injustice often leaves people angry, downtrodden or powerless – the trick is to mobilize the ‘perceived’ injustice towards justice. Deep resolution – inside and out. It’s organic, physiological and honest.

    Peace-
    Sage

  6. Carolyn Berryman says:

    Hi Sage,
    Thank you for your comments. I appreciate the view you have expressed that “…very real life social and economic systemic disparities lead to injustice” – there are examples everywhere one looks. These injustices form part of many stories and my aim in writing was to convey that they are just as valid as other parts of the stories we hear in clinic and need to be addressed. There are, of course, many other ways to address injustices than those particular methods I mentioned when reporting on the workshop. You have provided an opportunity here to mention such other methods as poetry, creative writing, meditation and meditative yoga. Techniques or methods that deal with the emotions and their physical expression may provide a path to recovery. To date, however, (and please feel free to correct me if I am wrong), I am not aware of any evidence for their effect in dealing with injustice. So, more work to do!
    I am sorry that you found the term ‘perceived’ offensive. I used this word in the context of its definition “to become aware of something by the use of senses”. It is probably tautological in the current context and should be omitted.
    Kind regards,
    Carolyn

  7. Yeah, I’d take ‘perceive’ to mean that what the person is feeling is not actually there. I know that you spend a lot of time talking about the brain but please don’t forget that there will be people who have conditions that will be lumped into ‘chronic pain’ where there is a very real poorly understood physiological mechanism. Understanding the accompanying pain helps somewhat but to think that the problem itself is ‘pain’ is truly missing the point. Then that truly creates a ‘perceived’ sense of isolation.

    It is unquestionable that my problem involves more than pain even though understanding of pain is central to recovery. I believe that there is a a lot to an ‘adaptive stress/pain response theory’. And a kind of ‘learnt’ physiological response to pain that comes with it ‘dysfunction’. But I assert strongly that there is ‘dysfunction’ that causes pain rather than ‘pain’ itself being the problem.

  8. Sorry: sometimes I convince myself that I know what I’m talking about. I clearly ‘don’t know’.

    If I’m honest I don’t think anyone really has anything much to add at the moment. I think that we should all just reserve judgement, listen to patients on their INDIVIDUAL basis. Intuitively it seems that a heap of DIFFERENT conditions are being lumped together under ‘chronic pain’. I’m not sure that this is helpful.

  9. Hi Carolyn
    Thanks for your interesting post. I too have been mulling these issues over and have recently added a 1-10 measure for Bitterness to the VAS scores I use for people attending my knitting group. We thought bitterness was more appropriate than anger. Interestingly those who are really having a hard time managing their pain have high bitterness scores (9 and 10/10) and those feelings (sometimes 20 years down the line) are preventing them from letting go and moving on to make the most of life now. These feelings of bitterness are often linked to a traumatic event – something that changed their lives forever which they had no control over. They don’t feel able to regain control until those issues are sorted. However, in most cases these are not ‘sortable’ particularly years down the line. They now have highly complex issues resulting from problems which have stacked up over the years. As far as treatments to address this, I HAVE noticed something interesting… touching something that feels good appears to reduce feelings of bitterness. It grounds you in the present and it’s my theory that it’s impossible to feel bitter at the same time as having a pleasant tactile experience!! So I’m doing a little experimentation on that theory in the knitting group.
    In the UK we’ve recently had a change in the benefits system. Many of those with chronic pain are being told they ‘can work’ so their benefits are changing. This has had a massive impact on their pain experience – they feel they have to justify their pain. Stress, anxiety and fear levels have risen massively and there is a huge feeling of bitterness, anger and injustice at this change. In reality there is such a shortage of jobs that even the fittest graduate finds it hard to find work so those who haven’t worked for years or who couldn’t guarantee being able to do a ‘day’s work’ don’t have much chance anyway so I’m not quite certain what the purpose of this change in benefits was. It has however had a detrimental effect on those living with chronic pain.