Chronic social exclusion and evidence for the resignation stage

Abstract

Experiences of social exclusion, including ostracism and rejection, can last anywhere from a few seconds to many years. Most research focused on short-term social exclusion, whereas virtually no empirical work has investigated the experiences of long-term social exclusion. Williams theorized that prolonged experiences of social exclusion (i.e., ostracism) would cause individuals to pass from the reflexive and reflective stages to the resignation stage characterized by the inability to recover threatened psychological needs and feelings of alienation, unworthiness, helplessness, and depression. Across two studies, we explored this prediction—and, in light of pain overlap theories, considered the possibility that chronic exclusion and chronic pain induce common psychological responses. Study 1 consisted of a quasi-experimental study involving five groups of participants: (1) those with chronic experiences of social exclusion (n = 82), (2) those with chronic physical pain (n = 82), (3) those with chronic hypertension (n = 69), (4) those with chronic kidney disease (n = 60), and (5) a group of healthy people (n = 83). Participants filled out a questionnaire including measures of need threat, negative emotions, and the four key outcomes linked to the resignation stage (i.e., alienation, unworthiness, helplessness, and depression). Although our data showed little evidence to support the psychological overlap between chronic exclusion and chronic physical pain, the results suggested that chronic experiences of social exclusion were associated with higher levels of negative emotions and resignation stage outcomes compared to participants in all the other groups. Furthermore, we found that threatened psychological needs mediated the effect of social exclusion on the resignation stage outcomes. Study 2 tested, but found no support for, the possibility that acute experiences of social exclusion could increase the resignation stage outcomes. Overall, our research indicates that when people are exposed to short-term exclusion, they recover their threatened psychological needs. However, when enduring chronic social exclusion, they do not, and enter the resignation stage.

Keywords

Chronic physical pain chronic social exclusion exclusion need threat ostracism rejection

In recent decades, hundreds of empirical studies found that various forms of social exclusion (e.g., ostracism, rejection, isolation, bullying, and discrimination¹) can cause a wide array of negative consequences, including—but not limited to—painful feelings (Eisenberger, Lieberman, & Williams, 2003), negative emotions (Gerber & Wheeler, 2009), a decline in cognitive abilities (Baumeister, Twenge, & Nuss, 2002), increased social susceptibility (Riva, Williams, Torstrick, & Montali, 2014), and aggressive responses (Twenge, Baumeister, Tice, & Stucke, 2001). Most of these previous research focused on short-term episodes of threats to social connections. For instance, Nezlek, Kowalski, Leary, Blevins, and Holgate (1997) randomly assigned participants to receive feedback that either everyone or no one wants to work with them on a group task. In another task, called Cyberball (Williams, Cheung, & Choi, 2000), participants believe they are playing with other players in an online ball tossing game (they are actually computer agents). Ostracized participants receive throws only at the beginning of the game but then never again. With both manipulations, and potentially others (Wirth, In press), participants do not know each other before the study and do not believe they will meet again with the others after it, which suggests the manipulations are particularly minimal. However, in real life, experiences of exclusion are likely to have consequences far more extreme than researchers can observe when participants are being kept apart in a minimal lab paradigm.

To examine chronic experiences of social exclusion, Zadro (2004) conducted interviews with individuals who were ostracized and excluded for years and even decades. In her interviews with over 50 long-term targets of ostracism, Zadro found chronically ostracized individuals were no longer looking for belonging, it appeared that they had become alienated; they were no longer looking for self-enhancement, they seemed resigned to accept their changeless low self-worth; they were no longer seeking a sense of personal control over their environment, they seemed to have embraced helplessness; and—finally—they were no longer looking for recognition of their existence by others, instead they appeared to have become depressed.

The insights gathered from these interviews helped Williams (2009) build his Temporal Need Threat Model of Ostracism in a way that considered different durations of ostracism experiences.

Three temporal stages of responses to ostracism

Williams’s (2009) Temporal Need Threat Model of Ostracism posits three stages of responses to ostracism: (1) reflexive (immediate), (2) reflective (coping), and (3) resignation (long-term). Williams (2001) argued that a single episode of ostracism immediately threatens four fundamental psychological needs: control, self-esteem, belonging, and meaningful existence. He called this the “reflexive stage,” that is, when the ostracized individual feels the immediate pain associated with a social threat. Currently, over 200 publications report short-term, experimentally induced instances of ostracism lead to threaten satisfaction of the four basic needs (effect sizes range from d = 1.0 to 2.0; Gerber & Wheeler, 2009; Hartgerink, van Beest, Wicherts, & Williams, 2015).

This first stage is followed by the “reflective stage,” when individuals assess, appraise, cope, and recover from the social threat episode. If individuals successfully cope in the reflective stage, their basic need satisfaction and affect will recover, which keeps ostracized individuals from entering the “resignation stage.” Thus, Williams’s model (2009) extended his predictions beyond reactions to acute social threats to include the third stage of ostracism or the resignation stage. During the resignation stage, social threats (e.g., ostracism) persist over time and the resources necessary for fortifying threatened needs become depleted—the individual becomes resigned to the outcomes of their exclusion. Belonging fortification could turn to alienation, self-esteem preservation could turn to constant feelings of low self-worth, reactance could turn to learned helplessness, and attempts to prove worthy of attention could turn to depression (Williams, 2009). In short, unlike an acute episode of social exclusion (e.g., ostracism during Cyberball) where individuals should recover, chronic social exclusion might persistently threaten the fundamental psychological needs, ultimately producing a downward spiral toward alienation, unworthiness, helplessness, and depression. Whereas qualitative interviews provide anecdotal support for the resignation stage (Williams, 2001; Williams & Zadro, 2001), empirical evidence is needed to support these predictions of the Williams’s model (2009).

The overlap between social and physical pain

During the last decade, researchers argued that acute social exclusion elicits a pain response (labeled social pain; see Eisenberger et al., 2003). This finding was accounted for by pain overlap theories (Eisenberger & Lieberman, 2005; MacDonald & Leary, 2005), according to which individuals process social exclusion similarly to experiences of physical pain.

Crucially, for the purposes of the present work, researchers recently found that the neural overlap between the pain types also implies an overlap in their psychological responses (Riva, Wirth, & Williams, 2011). Accordingly, researchers suggested that even a short-term experience of physical pain (i.e., hand submerged in cold water) can threaten need satisfaction (i.e., belonging, control, meaningful existence, and self-esteem) in way similar to what social pain does (i.e., ostracism during Cyberball; Riva et al., 2011, for similar results see Chen, Poon, & DeWall, 2015). Other results suggest an overlap between fear of social pain and fear of physical pain (Riva, Williams, & Gallucci, 2014), such that high fear for either type of pain intensifies the subjective experience of either type of pain. However, past research also showed that people can “relive” social pain more vividly and more painfully than they can physical pain (Chen & Williams, 2010; Chen, Williams, Fitness, & Newton, 2008). This research suggests that there may be departures between social and physical pain. For social exclusion, especially if the exclusion led to rumination, then the individuals will be more likely to continue feeling and experiencing the pain associated with it, even in moments when actual social exclusion is not occurring. Thus, it remains unclear whether the psychological overlap of the aversive consequences of a brief social exclusion experience and physical pain extend to chronic conditions as well, which leads us to the present research.

The present research

In the first study, we investigated whether chronic social exclusion produces outcomes associated with the outcomes of the resignation stage (e.g., alienation) and whether chronic exclusion and chronic pain induce common psychological responses. Building from these findings, the second study ruled out the possibility that even experiences of short-term social exclusion could increase resignation stage outcomes.

Study 1

The aim of Study 1 was twofold. Firstly, we tested—for the first time—the prediction made by the third stage of the Williams’s resignation stage (2009), that chronic experiences of social exclusion induce feelings of alienation, unworthiness, helplessness, and depression. In pursuing this aim, we also investigated whether experiences of chronic social exclusion are associated with high levels of negative emotions. Secondly, considering current theories on pain overlap (Eisenberger & Lieberman, 2004; MacDonald & Leary, 2005), we tested the possibility that experiences of chronic social exclusion and physical pain induce common psychological responses (i.e., negative emotions and resignation stage outcomes). To test our aims, we planned to conduct several group comparisons.

To test the first aim, we began our analyses by comparing the responses provided by a group of individuals who experienced chronic social exclusion with those of a group of healthy participants. However, we also compared the responses of the chronic social exclusion group against those provided by participants experiencing other chronic and distressful conditions, such as experiences of chronic physical pain, chronic hypertension, and chronic kidney disease. In doing so, we investigated whether the consequences potentially associated with chronic social exclusion are specifically linked to the experience of prolonged exclusion itself or to the mere chronicity (i.e., the temporal dimension) of a distressful (e.g., disease) condition.

In short, we tested the following comparisons in Hypothesis 1: We expected chronic social exclusion to be associated with the higher levels of negative emotions and negative outcomes of the resignation stage (i.e., alienation, unworthiness, helplessness, and depression) compared to individuals of all the other groups (i.e., healthy people and physical pain, chronic hypertension, and chronic kidney disease patients). Furthermore, we considered a potential mechanism that could account for such effect. Given that chronic social exclusion might persistently threaten the fundamental psychological needs, leading an individual into a downward spiral toward alienation, unworthiness, helplessness, and depression, we investigated the possibility that threatened psychological needs would meditate the effect of chronic social exclusion on the outcomes of the resignation stage.

To test our second aim, namely, the possibility that the experiences of chronic social exclusion and chronic physical pain induce common psychological responses, we contrasted the responses of chronic social exclusion and chronic physical pain groups against those reported by healthy participants and participants experiencing two other distressful conditions (i.e., illnesses) that are chronic but not painful (i.e., chronic hypertension and chronic kidney disease). In doing so, we investigated whether the consequences potentially associated with both chronic social exclusion and physical pain are linked to the presence of pain (both social and physical) rather than just to the chronicity (i.e., the temporal dimension) of a distressful condition (i.e., chronic hypertension and chronic kidney disease). This was meant to provide a conservative test of the possibility that experiences of chronic social exclusion and chronic physical pain induce common psychological responses.

This possibility led to Hypothesis 2: We predicted participants with chronic physical pain will have higher levels of negative emotions and negative outcomes associated with the resignation stage compared to healthy participants, to a group of patients with a mild chronic (but not painful) physical illness (i.e., chronic hypertension), and to a group of patients with a severe chronic (but not painful) illness (i.e., chronic kidney disease). In line with Hypothesis 1, we still predicted a difference between chronic social exclusion and chronic physical pain. However, the key prediction of Hypothesis 2 lies in the expected difference between chronic physical pain and two other chronic, but not painful, conditions (e.g., chronic hypertension and chronic kidney disease). Indeed, a difference between chronic physical pain and the two other chronic, but not painful, conditions would be needed to allow us to suggest that experiences of chronic social exclusion and chronic physical pain induce common psychological responses.

As a preliminary step, to check the appropriateness of our samples, we expected chronic social exclusion to be associated with the highest levels of social exclusion symptoms (i.e., need threat), whereas chronic physical pain to be associated with the highest levels of physical pain symptoms compared to all of the groups.

Method

Participants: Groups and recruitment procedures for each group

We conducted an a priori power analysis to estimate our sample size (using GPower 3.1; Faul, Erdfelder, Lang, & Buchner, 2007). With an α = .05 and power = .95, the projected sample size needed to detect a medium effect size (f = .25) was approximately N = 300 for a between-group comparison (analysis of variance [ANOVA], fixed effects, omnibus, one way). Overall, we recruited 379 participants (54% females; M _age = 51.78, SD = 15.45) in a quasi-experimental design that was subdivided into five groups. Thus, our sample size should be adequate for the objectives of this study. Table 1 contains the demographic data for each group.

Table 1.
Demographics (Study 1).

Group n Age (SD) Females Nationality, # of Italians

Chronic social exclusion 82 43.29 (9.45) 49 (59%) 82 (100%)

Chronic physical pain 82 56.13 (14.21) 49 (59%) 80 (98%)

Chronic hypertension 69 54.86 (13.97) 41 (54%) 67 (97%)

Chronic kidney disease 60 61.62 (16.27) 27 (43%) 57 (95%)

Healthy subjects 83 46.20 (15.83) 42 (50%) 83 (100%)

Chronic social exclusion

We recruited a group of people with experiences of chronic social exclusion, which we operationalized as exclusion that has lasted longer than 3 months. In doing so, we paralleled the International Association for the Study of Pain (IASP) (1979) operationalization of chronic physical pain (see below). Specifically, we recruited participants based on the question, “Recently, have you felt socially excluded for more than 3 months?” Participants in the chronic social exclusion group were recruited through a Facebook page, flyers, and advertisements in local newspapers; all of which included the screening question, an e-mail contact, and a link to an online survey.

For this group, we asked additional screening questions. Participants were asked first what form of social exclusion they were suffering from the most; participants chose from exclusion (4%), ostracism (11%), rejection (6%), betrayal (4%), humiliation (1%), abandonment (22%), bereavement (12%), loneliness (36%), and mobbing (4%). A second question assessed the duration of the instance of social exclusion participants experienced (M _months = 81.44, approximately 6 and ¾ years; SD = 96.90). A third question asked if they were taking any medications (if so, which ones) to cope with their situation of social exclusion.

Chronic physical pain

As our primary comparison group, we recruited a group of people who reported experiences of chronic physical pain. The IASP (1979) defined chronic physical pain as those that lasted longer than 3 months. Accordingly, patients were recruited from primary care offices, identified by their general practitioners based on the IASP-defined diagnosis of chronic physical pain, and then contacted. Those who agreed to participate were given a paper-and-pencil questionnaire packet.

For this chronic pain group, we also asked screening questions related to the specific form of chronic physical pain, its duration, the treatments options they were using, and the effectiveness of the pain treatment. Participants first indicated what form of physical pain they were suffering from; participants indicated osteoarthritis (32%), arthritis (4%), osteoporosis (4%), low back pain (17%), rheumatoid arthritis (4%), ankylosing spondylitis (1%), neuralgia (21%), neuropathy (10%), neurogenic arthropathy (2%), and other types of chronic pain (5%). We also assessed the duration (M _months = 12.69; SD = 27.05) and the treatments options they were using of these patients’ chronic physical pain. Finally, for this sample, we measured the subjective effectiveness of the pain medication: “Please rate the EFFECTIVENESS of your pain medication on your pain” on a scale from 1 (ineffective) to 10 (very effective).

Mild chronic, but not painful, physical illness—chronic hypertension

Chronic hypertension is a medical condition in which the blood pressure is chronically high. For the purposes of the current study, we considered this a “mild” form of physical illness based on the evidence that chronic hypertension per se usually produces no symptoms (including physical pain; Kottke, Tuomilehto, Puska, & Salonen, 1979). To recruit participants for this group, general practitioners contacted participants they diagnosed with chronic hypertension. Those who agreed to participate were given a questionnaire packet. Participants were also asked to indicate the duration of their condition (M _months = 59.32, approximately 5 years; SD = 49.39) and their treatment options for their chronic hypertension.

Severe chronic, but not painful, illness—chronic kidney disease

Chronic kidney disease is defined as the presence of kidney damage evidenced by specific laboratory findings, instrumental or pathological, or reduced renal function that persisted for at least 3 months (National Kidney Foundation, 2002). The severity of chronic kidney disease is described by six stages of increasing severity. Chronic kidney disease is a life-threatening disease, thus, for the purposes of the current study, we considered it as a severe form of physical illness. However, to try to avoid as much as possible the comorbidity between chronic kidney disease and physical pain symptoms, we considered only patients in the first three stages of the disease (pain symptoms are more likely to occur in the three last stages of the disease; de Zeeuw, 2008; National Kidney Foundation, 2002).

A researcher from a large hospital in Italy contacted patients who were eligible for the study. Those patients who agreed to take part in the study received a questionnaire packet. Participants were also asked to indicate the duration of their condition (M _months = 120.56, approximately 10 years; SD = 124.74) and their treatment options they were using for their chronic kidney disease. Causes of each participant’s chronic kidney disease varied (diabetes, hypertensions, glomerulonephritis, cardio renal syndromes, asymptomatic nephrolithiasis) as did the severities of the condition (however, patients were always within the first three stages of the disease).

Healthy people

Finally, we recruited a group of healthy participants who had (1) not felt socially excluded for more than 3 months in the last 6 months, (2) not felt physical chronic pain for more than 3 months in the last 6 months, and (3) not experienced any other chronic illnesses for more than 3 months in the last 6 months.

Dependent variables: Control measures

All participants who met the selected criteria for each group filled out several questionnaires related to their general characteristics and amount of social and physical pain they experienced.

General health measure: The Short Form for Health (SFH) survey

This survey assessed participant’s general health conditions. Specifically, the SFH-12 (Ware, Kosinski, & Keller, 1996) is a 12-item questionnaire designed to measure two key component of health: mental (α = .83) and physical (α = .84). Scale responses varied according to each of the 12 questions, with higher scores indicating a better level of general health.

Social exclusion symptoms: The Need-Threat Scale

The Need-Threat Scale (Williams, 2009) evaluated the prevalence of social exclusion and consisted of 20 items measuring satisfaction of four fundamental needs, that is, belonging (e.g., “I felt rejected”), self-esteem (e.g., “I felt liked”), control (e.g., “I felt powerful”), and meaningful existence (e.g., “I felt invisible”) during the past 6 months. Responses were rated on a 5-point scale (1 = not at all to 5 = very much). For the purpose of the present study, we created an average responses on the four basic needs (α = .93) scored, so that higher scores indicate that the basic needs are threatened (e.g., low sense of belonging to others).

Physical pain symptoms: The Neuropathic Pain Scale

We used this scale (adapted from Galer & Jensen, 1997) to assess physical pain symptoms over the past 6 months. This scale includes 2 items related to the intensity and unpleasantness of physical pain “In the last six months, how intense/unpleasant the pain has been?” Five items related to the qualities of pain (i.e., sharp, hot, dull, cold, and itchy), 1 item evaluated the patient’s pain reaction to light touch or clothing, and 2 final items captured the intensity of the deep and surface pain. All the items are rated on an 11-point scale (ranging from 0 = no pain to 10 = most intense/unpleasant pain imaginable). We averaged the 10 items to create an overall index of physical pain symptoms (α = .92), with higher scores indicating more physical pain symptoms.

Dependent variables: Negative emotions and resignation stage outcomes

Negative emotions: The Rejected-Related Emotions Scale

Based on the previous 6 months, participants completed 20 items assessing five clusters of negative emotions (adapted from Buckley, Winkel, & Leary, 2004): anger, anxiety, sadness, hurt, and rejection. Items were rated on a 5-point scale (ranging from 1 = not at all to 5 = very much), and we averaged them together to create an overall index of negative emotions (α = .96; higher scores indicating more negative emotions).

Resignation stage measures

All participants were asked to complete the following four scales, each of which were selected to correspond to a specific construct (e.g., alienation) predicted by the Williams’s (2009) resignation stage. Participants were instructed to respond to each of the following scales based on how they felt during the past 6 months.

Alienation: Sense of Belonging Instrument

This scale (Hagerty & Patusky, 1995) assesses stable feelings of the divorce between the self and others. We adopted it to assess participant’s feelings of alienation. In the short term, threats to social belonging have been generally measured as a psychological—temporary—state in which the individuals perceive a separation between self and others (e.g., “When the event happened, I felt excluded”). By contrast, the Sense of Belonging Instrument (SOBI) assesses stable feelings of the divorce between the self and others. From the general scale, we used the subscale called SOBI-P (psychological state). The scale consists of 18 items (e.g., “I feel like an outsider in most situations,” “I generally feel that people accept me” reversed-coded; α = .96). Items were rated on a 5-point scale (ranging from 1 = never true for me to 5 = always true for me), with higher scores indicating increased feelings of alienation.

Unworthiness: Self-Esteem Scale

Self-esteem has been conceptualized as a mechanism by which one assesses her/his own inclusionary status (Leary & Baumeister, 2000). The Rosenberg’s Self-Esteem Scale (Rosenberg, 1965) assesses global self-esteem, or trait self-esteem as it is relatively enduring, by focusing on people’s general feelings toward themselves both across time and situations. We adopted this scale as a proxy to assess feelings of unworthiness. The scale consisted of 10 items (e.g., “On the whole, I am satisfied with myself,” “All in all, I am inclined to feel that I am a failure,” reversed coded; α = .86) that were rated on a 5-point scale (ranging from 1 = totally disagree to 5 = totally agree). Higher scores indicate more feelings of unworthiness.

Helplessness: Beck Hopelessness Scale

We adopted the Beck Hopelessness Scale (Beck, Weissman, Lester, & Trexler, 1974) to measure helplessness, with the idea that the helplessness construct largely overlaps with that of hopelessness, as measured by the Beck’s Scale. This 20-item self-report scale was designed to measure three major aspects, that is, negative feelings about the future (e.g., “My future seems dark”), loss of motivation (e.g., “I could give up because I cannot make things better for me”), and negative expectations (e.g., “Things do not go as I want them to go”). Items were rated on a 5-point scale (1 = totally disagree to 5 = totally agree). For the purposes of the present study, an overall index was created (α = .89), with higher scores indicating more feelings of helplessness.

Depression: Beck Depression Inventory

We adopted this scale to assess depression (Beck, Steer, Ball, & Ranieri, 1996). Compared to the original version, we did not include the item related to suicidal thoughts (for ethics reasons), leaving 20 items that were rated on a 4-point scale that varied according to each item (e.g., “I feel sad much of the time”; “I am so sad or unhappy that I can’t stand it”). We averaged the items together to create an overall index (α = .97), with higher scores indicating increased feelings of depression.

Resignation overall index

We created an overall index by averaging together all of the 68 individual items from the four scales (e.g., alienation, unworthiness, helplessness, and depression; α = .98). Because items of one scale were rated on 4-point scales, whereas the others were rated on 5-point scales, each individual score was standardized prior to being averaged to create the overall index. This scoring is similar to previous procedures researchers used to create an overall index of need threat following exploring short-term social exclusion (e.g., Wirth, Sacco, Hugenberg, & Williams, 2010).

Demographics

We also asked participants to indicate their sociodemographic information, including age, gender, nationality, education, marital status, and job position.

Results and discussion

Statistical analysis

We performed one-way ANOVAs to test the overall differences between groups. Our specific hypotheses were tested using post hoc analysis with Bonferroni correction to control for multiple comparisons.

Preliminary analyses

Demographics

The distribution of male and female did not vary across groups (χ = 6.4; p = .171; see Table 1 for descriptive statistics) and neither did participant’s nationality (χ = 6.7; p = .154). However, groups did vary in terms of participant’s age as participants with chronic social exclusion were significantly younger than those with chronic physical pain, chronic hypertension, and chronic kidney disease, F(4, 375) = 20.95, p < .001. Because of this, we included age as a covariate in all the analyses.

Main analyses on control measures

Health condition

Firstly, the analyses showed significant group differences on the mental component summary scale (e.g., feeling nervous and depressed vs. happy and calm), F(4, 369) = 61.52, p < .001, η _p ² = .40. Post hoc analyses (see Table 2 for all the descriptive statistics) showed that the participants with chronic social exclusion experienced worse mental health than did healthy participants and those with chronic physical pain, chronic hypertension, and chronic kidney disease.

Table 2.
Means and standard deviations (in parenthesis) of the scores on the mental and physical component summary scales of SF-12, social exclusion and physical pain symptoms, and negative emotions (Study 1).^a

Group Chronic social exclusion Chronic physical pain Chronic hypertension Chronic kidney disease Healthy subjects

Mental component summary (0–4) 2.05 (0.56) 2.75 (0.60)^b 3.15 (0.58)^c,d 2.99 (0.71)^b,c 3.43 (0.58)^d

Physical component summary (0–4) 2.42 (0.79)^b 1.98 (0.48) 2.59 (0.59)^c 2.41 (0.62)^b,c 2.97 (0.26)

Social exclusion symptoms (1–5) 2.74 (0.65) 1.64 (0.54)^b 1.59 (0.55)^b 1.49 (0.49)^b,c 1.23 (0.54)^c

Physical pain symptoms (0–10) 3.39 (2.23)^b 5.45 (1.67) 1.89 (2.04)^c 3.05 (2.57)^b 1.56 (1.47)^c

Negative emotions (1–5) 3.94 (0.71) 2.85 (0.71) 2.52 (0.64)^b 2.47 (0.77)^b 2.23 (0.60)^b

Note: Means that have no superscript letters ^(b,c,d) in common in a given row are significantly different from each other at p < .05.

^aHigher scores indicate higher levels of each outcome.

We also found that participants with chronic physical pain experienced worse mental health compared to those reported by the healthy participants. Chronic physical pain was associated with lower levels of mental health than was chronic hypertension. However, the difference in this measure between chronic physical pain and chronic kidney disease was not significant.

Secondly, the analyses showed significant group differences on the physical component summary scale (e.g., limitations with work and other daily activities as a result of physical health), F(4, 369) = 38.86, p < .001, η _p ² = .30. Post hoc analyses showed that participants with chronic social exclusion experienced worse physical health than did healthy participants. As expected, we found that individuals with chronic social exclusion experienced better physical health than did those with chronic physical pain. However, we found that people with chronic social exclusion experienced worse physical health than did those with chronic hypertension, whereas the difference between chronic social exclusion and chronic kidney disease was not significant.

Finally, we found that the participants with chronic physical pain experienced worse physical health than did healthy participants, participants with chronic hypertension, and chronic kidney disease.

Social exclusion symptoms

The analyses showed significant group differences in the overall index of need threat, F(4, 367) = 84.56, p < .001, η _p ² = .48². Post hoc analyses showed that the participants with chronic social exclusion experienced more social exclusion symptoms than did healthy participants and participants with chronic physical pain, chronic hypertension, and chronic kidney disease.

Then, we found that participants with chronic physical pain felt more social exclusion symptoms compared to those reported by the healthy participants. By contrast, chronic physical pain did not differ in this measure compared to chronic hypertension and chronic kidney disease.

Physical pain symptoms

We found significant group differences also on the measure of physical pain symptoms, F(4, 366) = 46.29, p < .001, η _p ² = .33. Post hoc analyses showed that participants with chronic social exclusion felt more physical pain than did healthy participants. We then found that chronic social exclusion was associated with fewer physical pain symptoms than chronic physical pain. However, chronic social exclusion was still associated with worse physical pain symptoms compared to chronic hypertension, whereas the difference between chronic social exclusion and chronic kidney disease was not significant.

Then, we found that the participants with chronic physical pain reported higher levels of physical pain symptoms compared to healthy participants and compared to participants with chronic hypertension and chronic kidney disease.

Negative emotions and resignation stage outcomes

Negative emotions

A one-way ANOVA showed significant group differences in negative emotions, F(4, 367) = 75.21, p < .001, η _p ² = .45. In line with Hypothesis 1, post hoc analyses showed that participants with chronic social exclusion experienced more negative emotions than did healthy participants and those with chronic physical pain, chronic hypertension, and chronic kidney disease.

Then, we found that participants with chronic physical pain reported higher scores of negative emotions compared to those reported by the healthy participants. In line with Hypothesis 2, participants with chronic physical pain reported higher levels of negative emotions than did participants with chronic hypertension and chronic kidney disease.

Resignation stage

A series of one-way ANOVAs showed significant group differences in all the four key measures of the resignation stage, smallest F(4, 366) = 30.01, p < .001 η _p ² = .25, for unworthiness; see Table 3 for all the descriptive statistics. Post hoc analyses showed that the participants with chronic social exclusion reported higher levels of alienation, unworthiness, helplessness, and depression compared to those reported by the healthy participants. Further supporting Hypothesis 1, we found that participants experiencing chronic social exclusion reported higher levels of alienation, unworthiness, helplessness, and depression compared to those reported by the participants with chronic physical pain, chronic hypertension, and chronic kidney disease.

Table 3.
Means and standard deviations (in parenthesis) of the four outcomes associated with resignation stage (Study 1).^a

Group Chronic social exclusion Chronic physical pain Chronic hypertension Chronic kidney disease Healthy subjects

Alienation 3.39 (.79) 2.27 (.81)^b 2.16 (.88)^b 1.79 (.72)^c 1.54 (.51)^c

Unworthiness 3.08 (.82) 2.42 (.63)^b 2.51 (.69)^b 2.23 (.64)^b,c 1.96 (.59)^c

Helplessness 3.49 (.66) 2.81 (.53)^b 2.80 (.51)^b 2.77 (.65)^b,c 2.38 (.54)^c

Depression 2.41 (.54) 0.68 (.53)^b 0.47 (.47)^b,c 0.65 (.51)^b,c 0.40 (.45)^c

Resignation overall index 0.84 (.45) −0.08 (.43)^b −1.4 (.44)^b −0.22 (.42)^b,c −0.47 (.32)^c

Note: Means that have no superscript letters ^(b,c) in common in a given row are significantly different from each other at p < .05.

^aHigher scores indicate higher levels of each outcome.

Then, we found that participants with chronic physical pain reported higher scores of alienation, unworthiness, helplessness, and depression compared to those reported by the healthy participants. However, chronic physical pain did not differ on alienation, unworthiness, helplessness, and depression scores from the chronic hypertension group. Yet, providing mixed support for Hypothesis 2, participants with chronic physical pain did report higher levels of alienation compared to participants with chronic kidney disease. However, chronic physical pain did not differ on unworthiness, helplessness, and depression scores from the chronic kidney disease group.

Resignation overall index

Finally, the analyses showed significant group differences on the overall index of resignation, F(4, 370) = 119.83, p < .001, η _p ² = .56. Supporting Hypothesis 1, post hoc analyses showed that the participants experiencing chronic social exclusion reported more negative outcomes associated with the resignation stage compared to those reported by the healthy participants and those with chronic physical pain, chronic hypertension, and chronic kidney disease.

Then, we found that participants with chronic physical pain reported more negative outcomes associated with the resignation stage compared to those reported by the healthy participants. However, failing to provide support for Hypothesis 2, chronic physical pain did not differ on the overall index of resignation from chronic hypertension and chronic kidney disease.

Mediation analysis

According to Williams (2009), the resignation stage outcomes should be the result of the depletion of fortification resources due to prolonged need threat. We tested this possibility by considering that threatened psychological needs could mediate the link between chronic social exclusion and the outcomes of the resignation stage (i.e., alienation, unworthiness, helplessness, and depression).

We used a bootstrapping procedure (Hayes, 2013) estimating direct and indirect effects of potential mediators. The independent variable was the group (coded as chronic social exclusion = +4, control groups = −1 −1 −1 −1), the mediator was need threat, and the dependent variable was the overall index of resignation (see Figure 1). As expected, the group was associated with higher levels of the overall index of resignation (b = 0.21, SE = 0.01, t = 19.66, p < .001) and with higher levels of need threat (b = −0.25, SE = 0.01, t = −17.33, p < .001), and need threat was related with the overall index of resignation (b = −0.70, SE = 0.02, t = −35.93, p < .001). Supporting our mediation hypothesis, the indirect path from the group to the overall index of resignation through need threat was significant, ab = 0.15, 95% CI [0.12, 0.17].

Figure 1.
The mediational role of need threat on the link between chronic social exclusion and the resignation stage outcomes (Study 1).

Thus, in Study 1, providing evidence for the appropriateness of our samples, we first found that chronic social exclusion was associated with the highest levels of social exclusion symptoms (i.e., need threat), whereas chronic physical pain was associated with the highest levels of physical pain symptoms compared to all of the groups.

In support of Hypothesis 1, we found that chronic social exclusion was associated with higher levels of negative emotions, alienation, unworthiness, helplessness, and depression compared to healthy participants and patients with chronic physical pain, chronic hypertension, and chronic kidney disease. By doing so, we showed that the consequences associated with chronic social exclusion could be linked to the presence of prolonged experiences of exclusion rather than to the mere chronicity (i.e., the temporal dimension) or distressfulness (e.g., the severity of a disease) of a condition. Furthermore, we found that need threat mediated the effect of the group condition on the overall index of resignation, which suggests a potential mechanism that can lead individuals to the resignation stage.

However, Hypothesis 2 received only partial support. We did find that chronic physical pain was associated with higher levels of alienation, unworthiness, helplessness, and depression compared to healthy participants. Furthermore, we found that chronic physical pain was associated with higher levels of negative emotions compared to the two control groups, chronic hypertension and chronic kidney disease. Yet, the same results did not hold on resignation stage outcomes. We did not find consistent differences between chronic physical pain compared with chronic hypertension and compared with chronic kidney disease. These results suggest that chronic social exclusion and physical pain may not overlap entirely in their psychological outcomes as they do in acute forms (see Riva et al., 2011).

Nevertheless, it should be noted that the majority (i.e., 67 participants; 82%) of the participants with chronic physical pain were currently taking pain medication to treat their pain; this might (at least in part) explain the lack of differences between forms of chronic physical pain. Therefore, we examined those individuals in the chronic physical pain group whose treatment was perceived to be not adequate, inferred by both the report of higher levels of physical pain symptoms and the effectiveness of the pain therapy. First, we found that the report of physical pain symptoms was positively related with negative emotions (r = .41, p < .001), feelings of alienation (r = .37, p < .001), helplessness (r = .24, p = .027), and depression (r = .40, p < .001). Although the relationship between physical pain symptoms and feelings of unworthiness was in the expected direction, it did not reach the standard level of significance (r = .16, p = .15). However, overall, the report of physical pain symptoms was positively related with the global index of resignation stage (r = .37, p < .001).

Moreover, we found that that the self-reported effectiveness of the pain therapy (only for those who indicated they were taking medications for their physical pain; i.e., n = 67) was negatively associated with negative emotions (r = .33, p = .009), feelings of alienation (r = −.37, p = .002) and feelings of unworthiness (r = −.30, p = .016). The association was in the same (negative) direction also for helplessness and depression, even though it did not reach the standard level of significance (r = −.17, p = .16; r = −.20, p = .11, respectively). However, overall, the self-reported effectiveness of the pain therapy was negatively related with the global index of resignation stage (r = −.37, p = .002).

This pattern of correlations showed that higher levels of chronic physical pain symptoms and lower levels of self-reported effectiveness of the pain therapy were associated with more negative outcomes of the resignation stage, suggesting that when the pain medication does not adequately control the presence of physical pain symptoms, experiencing chronic physical pain might be associated with feelings of alienation, helplessness, depression, and unworthiness.

Study 2

Study 1 showed that chronic social exclusion is associated with the highest levels of resignation stage outcomes (e.g., alienation) compared to other distressful conditions. However, our data cannot speak to the possibility that even short-term experiences of social exclusion can be linked with a detectable increase in the resignation stage outcomes. If this possibility were true, we could not conclude that chronic social exclusion is associated with psychological outcomes that are different from those produced by short-term experiences of exclusion. Thus, in Study 2, we tested if levels of resignation stage outcomes could increase immediately following an acute experience of social exclusion, which, if they did not, would suggest resignation stage outcomes are unique to prolonged experiences of exclusion. We tested this prediction in Hypothesis 3, expecting that when people are exposed to short-term exclusion they recover and therefore they do not enter the resignation stage.

Moreover, considering the predictions of the temporal model of ostracism (Williams, 2009), we wanted to compare need threat due to acute exclusion with that resulting from chronic exclusion. Indeed, the theory argues that people exposed to short-term exclusion would recover, as indicated by an assessment of their reflective responses. Thus, on the reflective responses, the theory (Williams, 2009) would predict a difference between reflective responses caused by short-term exclusion and levels of need threat reported by participants enduring chronic experiences of exclusion. If individuals enduring chronic exclusion would have more threatened needs than those in the reflective stage, then we will have further evidence that chronic exclusion is uniquely related to resignation (see Hypothesis 1).

Method

Participants

One hundred and twenty-four participants (83 females; M _age = 24.60, SD = 9.60) volunteered to participate in an online experiment. We set a minimum of about 60 participants per group based on the sample sizes collected in the main study of this work (see Table 1).

Procedure

Short-term social exclusion

We induced short-term social exclusion using a typical manipulation of ostracism, Cyberball* (Williams et al., 2000) in which participants were randomly assigned to be ostracized, receiving a virtual ball from computer agents either once from each player at the beginning and then never again, or included, receiving the ball throughout the entire game (inclusion). We chose this manipulation of short-term exclusion because it has been widely adopted in past research (Hartgerink et al., 2015) and because it usually produces strong effects (d ranging from 1.0 to 2.0; Williams & Jarvis, 2006; see also Hartgerink et al., 2015).

Resignation stage measures

Right after the end of the game, all participants completed the same four scales adopted in the previous study aimed to assess the outcomes of the resignation stage; that is, the Sense of Belonging Instrument (α = .93; Hagerty & Patusky, 1995), the Self-Esteem Scale (α = .87; Rosenberg, 1965), the Beck Hopelessness Scale (α = .87; Beck et al., 1974), and the Beck Depression Inventory (α = .86; Beck et al., 1996). Considering the wording of these scales items (e.g., “I generally feel that people accept me”), participants were instructed to respond to them based on how they generally feel.

Reflexive stage measures

Next, as manipulation checks, we asked participants how often (0–100%) they received the ball and how ignored and excluded (from 1 = not at all to 5 = extremely) they felt during the game. Then, participants filled out the Need-Threat Scale (Williams et al., 2000) that assessed the participants’ feelings of belongingness, self-esteem, control, and meaningful existence. For the purpose of the present study, we created an overall index by averaging the responses on the four basic needs (α = .95), with higher scores indicating greater threat to basic needs. Finally, we used the Rejected-Related Emotions Scale (Buckley et al., 2004) to assessed how negative the participants felt (i.e., anger, anxiety, sadness, hurt, and rejection). We averaged the resulting 20 items to create an overall index of negative emotions (α = .95; increasing values indicated greater more negative emotions).

Reflective stage measures

Upon completion of reflexive stage measures, participants completed the same basic needs (overall index α = .94) and emotion (overall index α = .94) items as outlined earlier but responded based on how they felt right now rather than how they felt during the game.

Responses to all these measures were recorded on a 1 (not at all) to 5 (extremely) scale.

Results and discussion

Manipulation checks

Participants in the exclusion condition reported receiving the ball less often during the game than included participants, t(122) = 13.54, p < .001. Participants in the exclusion condition also reported that they felt more excluded and ignored than participants in the inclusion condition, t(122) = 13.54, p < .001.

Resignation stage outcomes

The analyses showed no significant group differences on all the four key measures of the resignation stage, largest t(122) = 0.96, p > .34, d = 0.17, for alienation; see Table 4 for all the descriptive statistics.

Table 4.
Means and standard deviations (in parenthesis) of the dependent variables of each dependent variable (Study 2).^a

Group Social inclusion, n = 66 Social exclusion, n = 58

Manipulation checks

I felt excluded and ignored 1.73 (1.01) 3.85 (1.38)

Percentage of throws received 31.44 (11.67) 7.84 (6.71)

Reflexive stage

Need threat 1.68 (0.71) 2.83 (0.74)

Negative emotions 1.53 (0.60) 2.39 (0.88)

Reflective stage

Need threat 1.74 (0.84)^b 1.69 (0.69)^b

Negative emotions 1.95 (0.82)^b 1.85 (0.71)^b

Resignation stage

Alienation 2.42 (0.87)^b 2.27 (0.74)^b

Unworthiness 2.69 (0.81)^b 2.69 (0.71)^b

Helplessness 2.55 (0.73)^b 2.53 (0.50)^b

Depression 1.71 (0.47)^b 1.71 (0.49)^b

Note: Means that have no superscript letter ^(b) in common in a given row are significantly different from each other at p < .05.

^aHigher scores indicate higher levels of each outcome.

Reflexive and reflective outcomes

We subjected the need-threat scores to a two-way mixed repeated measures ANOVA with inclusionary status (excluded vs. included) as between-participant factor and recovery stage (reflexive versus reflective) as within-participant factor. First, greater need threat was associated with the exclusion condition, F(1, 122) = 23.39, p < .001, η _p ² = .16, than the inclusion condition. There was also greater need threat in the reflexive stage than in the reflective stage, F(1, 122) = 57.94, p < .001, η _p ² = .32. These main effects were qualified by a significant interaction, F(1, 122) = 68.37, p < .001, η _p ² = .36. Pairwise comparisons showed that, at the reflexive stage, excluded participants reported higher need-threat levels than included participants (p < .001). However, such difference disappeared at the reflective stage (p = .795), suggesting that excluded participants had recovered.

The same analysis was conducted on negative emotions. Higher levels of negative emotions occurred in the exclusion condition, F(1, 122) = 11.44, p = .001, η _p ² = .09, whereas no main effect of recovery stage was found, F(1, 122) = .66, p = .416, η _p ² < .01. However, a significant interaction qualified these factors, F(1, 122) = 41.03, p < .001, η _p ² =. 25. In particular, at the reflexive stage, excluded participants reported higher levels of negative emotions than included participants (p < .001). However, such difference dissipated at the reflective stage (p = .493), suggesting again that excluded participants had fully recovered.

Overall, Study 2 tested whether acute social exclusion could be sufficient to increase the resignation stage outcomes. Our results showed that social exclusion increased need threat and negative emotions at the reflexive stage. However, excluded participants recovered, as indicated by the assessment of need threat and negative emotions at the reflective stage. Crucially, the resignation stage outcomes were not affected by such short-term manipulation. We measured resignation stage outcomes right after the manipulation; previous research showed that the effect of Cyberball are strongest immediately after the game and they tend to decrease within minutes of the end of the game (Hartgerink et al., 2015; see also Williams & Jarvis, 2006). Thus, by measuring the resignation stage outcomes first, we measured them in a position where the strongest effects following ostracism are generally found. Had we waited until later, a lack of differences may have occurred simply because participants recovered. Thus, supporting Hypothesis 3, our study suggested that short-term social exclusion is not sufficient to elicit feelings of alienation, unworthiness, helplessness, and depression; these are distinct outcomes associated with long-term social exclusion.

Moreover, as we mentioned early, the theory (Williams, 2009) would predict a difference between reflective responses linked with short-term exclusion and levels of need threat reported by participants enduring chronic experiences of exclusion. Accordingly, there is a significant difference between the need-threat levels of the reflective responses caused by experimentally induced exclusion (M = 1.69; SD = .69) and the need-threat levels reported by chronically excluded individuals (M = 2.74; SD = .65), t(138) = 9.18, p < .001. This difference suggests that participants exposed to short-term exclusion have their basic needs recovered, whereas those enduring long-term exclusion do not.

General discussion

Our findings provide the first empirical evidence that chronic experiences of social exclusion—compared to three other distressful conditions and a healthy control group—are uniquely associated with feelings of alienation, helplessness, depression, and unworthiness. These findings support Williams’s (2009) resignation stage. Whereas short-term responses to these need threats result in fortification, resources necessary to fortify become depleted over time for those experiencing chronic social exclusion (see Williams, 2009 for a review). This temporal prediction holds for all four needs, but originally the need for control was the first to be discussed in this fashion (Wortman & Brehm, 1975). Initially, the authors argue, threats to control result in an attempt to regain control: the experience of reactance (Brehm, 1966). However, over repeated exposures to control threat, learned helplessness develops (Seligman, 1975). Similarly, Williams (2009) argues that initial attempts to fortify belonging, self-esteem, and meaningful existence follow a temporal path of fortification (reflective stage), but a failure to fortify needs may lead to resignation. Thus, fortifying a threatened belonging need eventually gives way to alienation; self-esteem fortification gives way to unworthiness, reactance gives way to helplessness, and strengthening meaningful existence gives way to depression. In this sense, in Study 1 and in keeping with Hypothesis 1, we provided empirical support to Williams’s resignation stage (2009). We provided evidence that chronic experiences of social exclusion are associated with the highest self-reported levels of the outcomes Williams contended were part of the resignation stage: alienation, helplessness, depression, and unworthiness. Further, we found that prolonged basic need threat accounted for the effect of chronic social exclusion on the outcomes associated with the resignation stage. Finally, chronic experiences of social exclusion were also associated with worst levels of any psychological outcome we considered (e.g., negative emotions).

Our Hypothesis 2, investigating the possibility that social and physical chronic pain would induce common psychological responses, received less support. In Study 1, chronic physical pain was associated with higher levels of negative emotions compared to healthy participants, participants with chronic hypertension, and those with chronic kidney disease. However, chronic physical pain did not consistently differ on resignation stage outcomes from the chronic hypertension and the chronic kidney disease group. Overall, these three groups (chronic physical pain, chronic hypertension, and chronic kidney disease) were associated with similar levels of feelings of alienation, helplessness, depression, and unworthiness, failing to provide direct support for a chronic social exclusion and physical pain psychological overlap.

We noted, however, that the majority (i.e., 82%) of participants of Study 1 in the chronic physical pain group were receiving treatment for their physical pain. Among them, the average evaluations of the effectiveness of pain therapy was above the midpoint of the rating scale (M = 6.58; SD = 1.79; median [Mdn] = 7.00), suggesting an overall satisfaction of participants in our chronic physical pain sample with their pain therapy effectiveness. Therefore, it is possible that an effective pain medication could buffer the negative psychological consequences of chronic physical pain. Indeed, when we looked at the possible relationship between the presence of chronic physical pain symptoms and the outcomes of the resignation stage, we found a significant positive association. The pattern of correlations showed that higher levels of chronic physical pain symptoms were associated with higher levels of negative emotions and feelings of alienation, helplessness, depression, and unworthiness; whereas lower levels of drug therapy effectiveness (for physical pain) were associated with higher levels of negative emotions and feelings of alienation, helplessness, depression, and unworthiness. However, future studies are needed to explore cases in which inadequate pain medication in chronic physical pain conditions (e.g., intractable chronic pain conditions) might be linked to the resignation stage.

Previous research showed that an over-the-counter painkiller known to reduce acute physical pain could also reduce acute social pain (DeWall et al., 2010). As we already noted, only a handful of our participants (N = 14) in the chronic social exclusion group reported taking medications to deal with their experiences of social exclusion. Although this must be considered with extreme caution (given the unequal sample size and considering the variety of medications reported by the 14 participants), our data suggested that those who reported taking medication for their social exclusion did not differ on negative emotions and any of the resignation stage outcomes compared with those who reported taking no medication (largest t = 1.28, p = .20, for unworthiness).

Thus, it is possible that, in the case of chronic social exclusion and unlike chronic physical pain, removing the symptom (i.e., social pain) does not solve the problem. Chronically socially excluded people would, most likely, need to either work on the cause of their social exclusion (somehow addressing the source of social exclusion) or change the way they perceive it through the implementation of psychological strategies (e.g., reappraisal, mindfulness). When chronic physical pain participants did receive adequate treatment (according to their own evaluations), their conditions seem to improve, as they did not necessarily feel worse than other chronic conditions. If people with chronic social exclusion receive proper (e.g., psychological) treatment on a regular basis, they might also experience similar effects. However, individuals experiencing chronic social exclusion may avoid treatment because they do not want to feel stigmatized, similar to individuals with mental health issues avoiding treatment because they do not want the stigmatizing label of being mental ill (e.g., Corrigan, 2004). The discrepancy between how different types of chronic pain victims seek out help and support may be due to physical pain experiences being less stigmatizing than social exclusion experiences. Future research should address these issues.

Finally, Study 2 suggested that acute experiences of social exclusion are not sufficient to be associated with resignation stage outcomes (see Hypothesis 3). In particular, we found that individuals enduring experiences of chronic social exclusion have more threatened psychological needs compared with need-threat levels at the reflective stage for those recovering from a short-term episode of social exclusion. Williams’s (2009) temporal model of ostracism posits that exclusion that persists over extended time impairs an individual’s ability to fortify the threatened psychological needs, thus leading into the resignation stage. Thus, not only did we provided evidence that the resignation stage outcomes are linked to the presence of prolonged experiences of exclusion rather than to the mere chronicity or distressfulness of a condition, but we also provided a test that short-term exclusion does not increase the resignation stage outcomes. We believe that this constitutes important results that supported past theorizing (Williams, 2009) and are likely to generate future research.

Limitations and future research

Our study is among one of the first empirical investigations of the psychological correlates of long-term experiences of social exclusion. However, the results of this study should be interpreted with several pertinent limitations in mind. Being a correlational study on community samples, our findings come from individuals who sought to be part of the study, so they should be viewed with caution; these individuals may be unique in their pain experiences. Further, we cannot determine cause and effect with this study; it is possible that people who had higher levels of alienation, unworthiness, helplessness, and depression perceived themselves more readily on a call for experiences of social exclusion. Nevertheless, the current study is a first step toward understanding the consequences of experiencing continuous social exclusion from desired individuals and groups.

In this work, we mirrored research on chronic physical pain by asking participants the following question: “Recently, have you felt socially excluded for more than 3 months?” However, this question does not allow to distinguish between actual experiences of chronic social exclusion (e.g., being ostracized or rejected repeatedly or for prolonged time) and chronic social pain (e.g., pain associated with perceived social separation that persists even in absence of social threats; see Riva, Wesselmann, Wirth, Carter-Sowell, & Williams, 2014). The latter includes cases in which an individual who has experienced one of more instances of social exclusion (e.g., ostracism, social rejection) continues perceiving the painful feelings of social distance even if the direct causes of the social threat are no longer present. Accordingly, future research should try to disentangle between actual experiences of chronic social exclusion and chronic social pain.

Moreover, in Study 1, our chronic social exclusion group included a variety of social threats, ranging from ostracism, to loneliness to bereavement. The aim of our study was not to investigate the differences among these forms of social exclusion, but future studies are needed to explore this issue. Furthermore, to test Hypotheses 1 and 2, we considered two control groups with medical conditions that were known to be chronic but not associated with physical pain per se. Physical pain is a common symptom for a wide array of chronic illnesses, thus it is possible that its presence still contributed to some of the negative psychological consequences associated with our control groups (e.g., chronic kidney disease), as compared to healthy participants. Future studies should further try to disentangle the temporal dimension of a distressful condition (e.g., chronicity) from the presence of pain per se.

Conclusion

In the short term, social exclusion has a valuable function: By virtue of its aversiveness it protects the individual from engaging in behaviors (e.g., anti-normative behaviors) that might promote further ostracism and exclusion and it motivates the individual to regain social acceptance. Indeed, anthropologists argue that the threat and use of ostracism was critical in the formation of civil societies (Söderberg & Fry, In press). However, in some circumstances, instances of social exclusion (including feelings caused by ostracism, rejection, exclusion, bereavement, betrayal, humiliation, discrimination, and embarrassment) can extend over time and last for months and years. When this occurs, the adaptive function of perceiving social exclusion might cease and individual may feel resigned to their perpetual feelings of exclusion. Our present findings provide the first empirical support for the resignation stage, laying the foundation for studying the consequences of chronic experiences of social exclusion.

Group	n	Age (SD)	Females	Nationality, # of Italians
Chronic social exclusion	82	43.29 (9.45)	49 (59%)	82 (100%)
Chronic physical pain	82	56.13 (14.21)	49 (59%)	80 (98%)
Chronic hypertension	69	54.86 (13.97)	41 (54%)	67 (97%)
Chronic kidney disease	60	61.62 (16.27)	27 (43%)	57 (95%)
Healthy subjects	83	46.20 (15.83)	42 (50%)	83 (100%)

Group	Chronic social exclusion	Chronic physical pain	Chronic hypertension	Chronic kidney disease	Healthy subjects
Mental component summary (0–4)	2.05 (0.56)	2.75 (0.60)^b	3.15 (0.58)^c,d	2.99 (0.71)^b,c	3.43 (0.58)^d
Physical component summary (0–4)	2.42 (0.79)^b	1.98 (0.48)	2.59 (0.59)^c	2.41 (0.62)^b,c	2.97 (0.26)
Social exclusion symptoms (1–5)	2.74 (0.65)	1.64 (0.54)^b	1.59 (0.55)^b	1.49 (0.49)^b,c	1.23 (0.54)^c
Physical pain symptoms (0–10)	3.39 (2.23)^b	5.45 (1.67)	1.89 (2.04)^c	3.05 (2.57)^b	1.56 (1.47)^c
Negative emotions (1–5)	3.94 (0.71)	2.85 (0.71)	2.52 (0.64)^b	2.47 (0.77)^b	2.23 (0.60)^b

Group	Chronic social exclusion	Chronic physical pain	Chronic hypertension	Chronic kidney disease	Healthy subjects
Alienation	3.39 (.79)	2.27 (.81)^b	2.16 (.88)^b	1.79 (.72)^c	1.54 (.51)^c
Unworthiness	3.08 (.82)	2.42 (.63)^b	2.51 (.69)^b	2.23 (.64)^b,c	1.96 (.59)^c
Helplessness	3.49 (.66)	2.81 (.53)^b	2.80 (.51)^b	2.77 (.65)^b,c	2.38 (.54)^c
Depression	2.41 (.54)	0.68 (.53)^b	0.47 (.47)^b,c	0.65 (.51)^b,c	0.40 (.45)^c
Resignation overall index	0.84 (.45)	−0.08 (.43)^b	−1.4 (.44)^b	−0.22 (.42)^b,c	−0.47 (.32)^c

Group	Social inclusion, n = 66	Social exclusion, n = 58
Manipulation checks
I felt excluded and ignored	1.73 (1.01)	3.85 (1.38)
Percentage of throws received	31.44 (11.67)	7.84 (6.71)
Reflexive stage
Need threat	1.68 (0.71)	2.83 (0.74)
Negative emotions	1.53 (0.60)	2.39 (0.88)
Reflective stage
Need threat	1.74 (0.84)^b	1.69 (0.69)^b
Negative emotions	1.95 (0.82)^b	1.85 (0.71)^b
Resignation stage
Alienation	2.42 (0.87)^b	2.27 (0.74)^b
Unworthiness	2.69 (0.81)^b	2.69 (0.71)^b
Helplessness	2.55 (0.73)^b	2.53 (0.50)^b
Depression	1.71 (0.47)^b	1.71 (0.49)^b

Footnotes

Acknowledgment

We would like to thank Laura Ferris and Verena Graupmann for helpful comments on an earlier version of this article.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

References

Baumeister

R. F.

Twenge

J. M.

Nuss

C. K.

(2002). Effects of social exclusion on cognitive processes: anticipated aloneness reduces intelligent thought. Journal of Personality and Social Psychology, 83, 817.

Beck

A. T.

Steer

R. A.

Ball

Ranieri

W. F.

(1996). Comparison of Beck Depression Inventories-IA and-II in psychiatric outpatients. Journal of Personality Assessment, 67, 588–597.

Beck

A. T.

Weissman

Lester

Trexler

(1974). The measurement of pessimism: the hopelessness scale. Journal of Consulting and Clinical Psychology, 42, 861.

Brehm

J. W.

(1966). A theory of psychological reactance. New York, NY: Academic Press.

Buckley

K. E.

Winkel

R. E.

Leary

M. R.

(2004). Reactions to acceptance and rejection: Effects of level and sequence of relational evaluation. Journal of Experimental Social Psychology, 40, 14–28.

Chen

Williams

K. D.

(2010). Social pain is easily relived and prelived, but physical pain is not. In MacDonald

Jensen-Campbell

L. A.

(Eds.), Social pain: Neuropsychological and health implications of loss and exclusion (pp. 161–177). Washington, DC: APA.

Chen

Williams

K. D.

Fitness

Newton

(2008). When hurt won’t heal: Exploring the capacity to relive social and physical pain. Psychological Science, 19, 789–795.

Chen

Poon

K. T.

DeWall

C. N.

(2015). When do socially accepted people feel ostracized? Physical pain triggers social pain. Social Influence, 10, 68–76.

Corrigan

(2004). How stigma interferes with mental health care. American Psychologist, 59, 614–625.

10.

DeWall

C. N.

MacDonald

Webster

G. D.

Masten

Baumeister

R. F.

Powell

Eisenberger

N. I.

(2010). Acetaminophen reduces social pain: Behavioral and neural evidence. Psychological Science, 21, 931–937.

11.

de Zeeuw

(2008). Renal disease: A common and a silent killer. Nature Clinical Practice Cardiovascular Medicine, 5, S27–S35.

12.

Eisenberger

N. I.

Lieberman

M. D.

(2005). Why it hurts to be left out: The neurocognitive overlap between physical and social pain. In Williams

D. D.

Forgas

J. P.

von Hippel

(Eds.), The social outcast: Ostracism, social exclusion, rejection, and bullying (pp. 109–130). New York: Psychological Press.

13.

Eisenberger

N. I.

Lieberman

M. D.

Williams

K. D.

(2003). Does rejection hurt? An fMRI study of social exclusion. Science, 302, 290–292.

14.

Faul

Erdfelder

Lang

A.-G.

Buchner

(2007). G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods, 39, 175–191.

15.

Galer

B. S.

Jensen

M. P.

(1997). Development and preliminary validation of a pain measure specific to neuropathic pain The Neuropathic Pain Scale. Neurology, 48, 332–338.

16.

Gerber

Wheeler

(2009). On being rejected a meta-analysis of experimental research on rejection. Perspectives on Psychological Science, 4, 468–488.

17.

Hagerty

B. M.

Patusky

(1995). Developing a measure of sense of belonging. Nursing Research, 44, 9–13.

18.

Hartgerink

C. H.

van Beest

Wicherts

J. M.

Williams

K. D.

(2015). The ordinal effects of ostracism: a meta-analysis of 120 Cyberball studies. PloS one, 10, e0127002.

19.

Hayes

A. F.

(2013). An introduction to mediation, moderation, and conditional process analysis: A regression-based approach. New York, NY: Guilford Press.

20.

IASP Subcommittee on Taxonomy. (1979). Pain terms: A list with definitions and notes on usage. Pain, 6, 247–252.

21.

Kottke

Tuomilehto

Puska

Salonen

(1979). The relationship of symptoms and blood pressure in a population sample. International Journal of Epidemiology, 8, 355–359.

22.

Leary

M. R.

Baumeister

R. F.

(2000). The nature and function of self-esteem: Sociometer theory. Advances in Experimental Social Psychology, 32, 1–62.

23.

MacDonald

Leary

(2005). Why does social exclusion hurt? The relationship between social and physical pain. Psychological Bulletin, 131, 202–233.

24.

National Kidney Foundation. (2002). KDOQI clinical practice guidelines for chronic kidney disease: Evaluation, classification and stratification. American Journal of Kidney Diseases 39(2 suppl 1): S1–S266.

25.

Nezlek

J. B.

Kowalski

R. M.

Leary

M. R.

Blevins

Holgate

(1997). Personality moderators of reactions to interpersonal rejection: Depression and trait self-esteem. Personality and Social Psychology Bulletin, 23, 1235–1244.

26.

Riva

Eck

(Eds.) (2016). Social exclusion: Psychological approaches to understand and reduce its impact. Berlin, Germany: Springer-Verlag.

27.

Riva

Wesselmann

E. D.

Wirth

J. H.

Carter-Sowell

A. R.

Williams

K. D.

(2014). When pain does not heal: The common antecedents and consequences of chronic social and physical pain. Basic and Applied Social Psychology, 36, 329–346.

28.

Riva

Williams

K. D.

Gallucci

(2014). The relationship between fear of social and physical threat and their effects on social distress and physical pain perception. Pain, 155, 485–493.

29.

Riva

Williams

K. D.

Torstrick

Montali

(2014). Orders to shoot (a camera): Effects of ostracism on obedience. The Journal of Social Psychology, 154, 208–216.

30.

Riva

Wirth

J. H.

Williams

K. D.

(2011). The consequences of pain: The social and physical pain overlap on psychological responses. European Journal of Social Psychology, 41, 681–687.

31.

Rosenberg

(1965). Society and the adolescent self-image. Princeton, NJ: Princeton University Press.

32.

Seligman

M. E. P.

(1975). Helplessness: On depression, development, and death. San Francisco, CA: W. H. Freeman.

33.

Söderberg

Fry

D. P.

(In press). Anthropological aspects of ostracism. In Williams

Nida

(Eds.), Frontiers handbook of ostracism, exclusion, and rejection. New York, NY: Psychology Press.

34.

Twenge

J. M.

Baumeister

R. F.

Tice

D. M.

Stucke

T. S.

(2001). If you can’t join them, beat them: effects of social exclusion on aggressive behavior. Journal of Personality and Social Psychology, 81, 1058.

35.

Ware

J. E.

Jr Kosinski

Keller

S. D.

(1996). A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Medical Care, 34, 220–233.

36.

Williams

K. D.

(2001). Ostracism: The power of silence. New York, NY: Guilford Press.

37.

Williams

K. D.

(2009). Ostracism: A temporal need-threat model. Advances in Experimental Social Psychology, 41, 275–314.

38.

Williams

K. D.

Zadro

(2001). Ostracism: On being ignored, excluded and rejected. In Leary

M. R.

(Ed.), Interpersonal rejection (pp. 21–53). New York, NY: Oxford University Press.

39.

Williams

K. D.

Cheung

C. K.

Choi

(2000). Cyberostracism: Effects of being ignored over the Internet. Journal of Personality and Social Psychology, 79, 748.

40.

Williams

K. D.

Jarvis

(2006). Cyberball: A program for use in research on interpersonal ostracism and acceptance. Behavior Research Methods, 38, 174–180.

41.

Wirth

J. H.

(In press). Methods for investigating social exclusion. In Riva

Eck

(Eds.), Social exclusion: Psychological approaches to understanding and reducing its impact. Springer International Publishing Switzerland.

42.

Wirth

J. H.

Sacco

D. F.

Hugenberg

Williams

K. D.

(2010). Eye gaze as relational evaluation: Averted eye gaze leads to feelings of ostracism and relational devaluation. Personality and Social Psychology Bulletin, 117, 497–529.

43.

Wortman

C. B.

Brehm

J. W.

(1975). Response to uncontrollable outcomes: An integration of reactance theory and the learned helplessness model. In Berkowitz

(Ed.), Advances in experimental social psychology, Vol. 8. New York, NY: Academic Press.

44.

Zadro

(2004). Ostracism: Empirical studies inspired by real-world experiences of silence and exclusion (p. 294). PhD thesis. University New South Wales.