Abstract
Social justice appraisals refer to evaluations about fairness. These judgments are particularly pertinent in the experience of an undeserved fate, such as the suffering caused by a chronic health complaint. Published research examining the implications of these appraisals for adjustment to long-term painful conditions has emerged only recently, focused in two areas of investigation. One area shows that perceived injustice for pain may be a vulnerability factor that can block adjustment. The second area shows that maintaining some sense of justice in life, despite personal adversity, might protect psychological health when people are in pain. The review discusses this research and identifies key reactions to perceived injustice in the context of chronic pain. We call for investigations to synthesize this research, specifically to establish mediators and moderators of varied justice appraisals, to examine the relationships between core justice beliefs and injustice appraisals, and to identify drivers of responses to injustice. Finally, we consider interventions for those pain sufferers struggling to cope with perceived injustice.
The desire and ability to make sense of life is a core part of being human. Beliefs about the world, our worldviews, provide a framework for interpreting events. One omnipresent worldview entails social justice concerns about the fairness of the world. The fundamental belief in a just world provides a key basis for this deliberation. Based on just-world theory, the belief states that we need to believe that we live in a world in which each person gets what he or she deserves. The belief in a just world creates the illusion of a stable, orderly, and predictable world (Lerner, 1980) and guides social behavior. Perhaps to maintain this order, people with a strong belief in a just world are motivated to defend their belief when it is threatened by injustice, using techniques such as denial or rationalization of injustice that might enable them to perceive more fairness than unfairness in their misfortune (Hafer & Begue, 2005).
Social psychological definitions of perceived injustice often contend that it is typically wrought from social wrongdoing, such as unjustified externally inflicted harm, or from the violation or neglect of perceived rights. Prolonged suffering, such as experiencing a chronic health condition characterized by pain, can prompt perceived injustice that fluctuates throughout the trajectory of chronic pain, from the circumstances of onset, through the failed response to treatment, to an altered life of suffering. Along these lines, research has found that, among people with musculoskeletal pain disorders, injustice appraisals are often targeted at (a) significant losses incurred as a result of pain, (b) professionals, who are blamed for the inadequacy of health care interventions to remove pain, and (c) society, for stigmatizing the patient with chronic pain in his or her suffering (McParland, Eccleston, Osborn, & Hezseltine, 2011; McParland, Hezseltine, Serpell, Eccleston, & Stenner, 2011), an injustice particularly prominent among those suffering from “invisible” or “idiopathic” conditions. The reality of the injustice of chronic pain extends beyond these perceptions to encompass the inequitable distribution of medical treatment. A body of research reports that ethnic minority groups can receive significantly less medical treatment compared with their White counterparts with similar conditions (Green et al., 2003), leaving these groups vulnerable to poor health outcomes.
Despite the relevance of social justice cognitions among those suffering long-term painful conditions, published research overtly investigating the implications of these cognitions for adjustment to painful conditions has only relatively recently begun to emerge. We discuss this growing research, with findings from cognate fields, focusing on key reactions to appraisals of injustice. Finally, we suggest future research directions and clinical implications.
Social Justice Appraisals and Pain Outcomes
Research on the role of social justice cognitions in pain has followed two lines of investigation. The first line examined associations between perceived injustice and pain outcomes. Sullivan et al. (2008) developed a measure that characterized injustice in terms of severity/irreparability of loss and blame/unfairness. Across a sample of 226 people with musculoskeletal injuries sustained as a result of an occupational or motor vehicle accident, high perceived injustice for injury was associated with greater pain severity, depression, catastrophic thinking about pain, and fear of movement. It also predicted return-to-work status 1 year later. Subsequent work produced some similar results (Scott & Sullivan, 2012) and also found high perceived injustice to be associated with symptoms of posttraumatic stress and increased protective pain behavior after whiplash injury (Sullivan, Davidson, Garfinkel, Siriapaipant, & Scott, 2009; Sullivan, Thibault, et al., 2009) as well as less acceptance of pain among a group of fibromyalgia sufferers (Rodero et al., 2012). Overall, this negative pattern of findings supports a body of research, often from the organizational justice literature, that suggests perceived injustice may potentially be a risk factor for poor health (Robbins, Ford, & Tetrick, 2012), an effect that is theoretically attributed to the accumulated impact of perceived injustice on the physiological stress response (Jackson, Kubzansky, & Wright, 2006). Research in the organizational justice field has also found that perceiving justice might protect health. Supporting this, a second line of investigation found that the belief in a just world was associated with improved psychological and physical well-being among those suffering from chronic illness (Agrawal & Dalal, 1993; Bulman & Wortman, 1977). More recently, our own research found that perceiving justice in one’s own life, but particularly in the world in general, occupied a buffering moderator role among a sample of 95 attendees of arthritis and fibromyalgia support groups. The relationships of pain intensity and disability with psychological distress were significantly weakened by a strong general belief in a just world (McParland & Knussen, 2010). Thus, maintaining some sense of justice in life, despite personal adversity, may have benefited psychological health. Alternatively, given the correlational nature of the data, the reverse is also plausible (i.e., that strong psychological health increased the strength of the belief in a just world, boosted its effects, or both, in the sample). A second study supported the potentially adaptive role of just-world beliefs in pain, where a strong general just-world belief was associated with less self-reported anxiety, and a strong personal just-world belief was associated with less pain among healthy men exposed to an acutely painful cold-water task. For women, however, a stronger personal just-world belief was associated with higher self-reported pain (McParland, Knussen, Lawrie, & Brodie, 2013). These findings require replication, but we suggest that the task was more stressful for women than men, as indicated by lower pain tolerance and higher anxiety reported by the women in other findings in the study, a stressor that undermined the belief in a just world, making it detrimental to well-being for this group. This interpretation is consistent with research suggesting that the belief in a just world, particularly the personal just-world belief, is a partially experiential construct that may be weakened or rendered maladaptive by recurrent or intense injustice (see Dalbert, 2009) and indicates that the benefits of just-world beliefs in pain are dependent upon contextual factors.
Overall, although causality cannot be established from these data, we propose that beliefs about blame and loss in judging injustice may promote suffering or block adjustment to pain, whereas justice beliefs, in the form of the belief in a just world, may act as a personal resource that supports coping attempts in some circumstances of pain.
Responses to Injustice
Responses to injustice will be dictated by the type and gravity of the injustice, by reactions to previous injustices, and by the extent to which one cares about justice. The availability of personal resources will also dictate responses. For example, people of lower socioeconomic status are among those most likely to become victims of injustice and have fewer resources to cope with injustice (Hafer & Gosse, 2010). Although specific responses to injustice in chronic pain are currently unidentified, we know enough about this well-defined threat to suggest important reactions. We categorize responses as affective, cognitive, or behavioral strategies that either (a) may foster adaptation, facilitate management, or redress an injustice, restoring a threatened just-world belief or (b) may compound suffering and injustice.
Emotional responses
Appraisals of injustice can elicit emotional reactions, including depression and anger. Among people who suffer from musculoskeletal pain, these emotions have been found to be related to each other and to the severity/irreparability of loss and blame/unfairness components of perceived injustice (Scott, Trost, Bernier, & Sullivan, in press-a), although some empirical evidence indicates that loss might be a key cause of depression, whereas blame is predominantly at the root of anger. Okifuji, Turk, and Curran (1999) found that health care providers were the most common (62.4%) external target of anger among people who suffer from chronic pain, an attribution that is often made for perceived diagnostic ambiguity and treatment failure. Experiencing anger, whether expressed or not, is typically considered a maladaptive response to wrongdoing that can reinforce injustice and contribute to poor health in the suffering of injustice in chronic pain, in particular mediating the negative relationships that perceived injustice holds with pain intensity and depression (Scott et al., in press-a).
Cognitive responses
Strategies that can support attempts to cope with an experienced injustice include using cognitive reappraisal techniques, such as imagining the situation could be worse or taking meaning from injustice (Montada, 2003). One study found that for people with cancer, taking meaning from the situation restored a sense of justice and order in the world (Park, Edmondson, Fenster, & Blank, 2008). Making internal attributions for one’s outcomes can also be beneficial. For example, Hafer and Correy (1999) found that strong just-world believers who attributed a negative personal fate more to internal factors (their own behavior) than to external factors perceived more fairness in this fate than weak just-world believers, and they reported improved emotion, an effect potentially attributable to perceived control over one’s destiny (Dalbert, 2001). Maladaptive strategies include thoughts of retaliation or retribution, which are frequently accompanied by moral outrage, anger, and a desire for punishment (Darley & Pittman, 2003). Vengefulness can exacerbate rumination and the motivation to seek revenge, compromising well-being (McCullough, Bellah, Kilpatrick, & Johnson, 2001) and maintaining a focus on injustice.
Behavioral responses
Complaining is a frequent behavioral reaction to a perceived wrongdoing. Common complaints among patients experiencing pain involve medical encounters in which expectations are unmet, or they involve interpersonal grievances against medical staff (Mailis-Gagnon, Nicholson, & Chaparro, 2010). The function of complaining is often to remedy a situation through, for example, claiming an apology or securing compensation (Kowalski, 2002).
The award of financial compensation for injury can bring a sense of justice among claimants in the award received and in the process of making the decision to award (Franche et al., 2009). However, monetary gain alone may be insufficient to address psychological injustice (Darley & Pittman, 2003), and engaging with this process might compound suffering. For example, retaining an attorney in the Worker’s Compensation system because of dissatisfaction with medical treatment has been associated with poor well-being over time (Chibnall & Tait, 2010). Minority groups may be particularly disadvantaged in this system. Chibnall and Tait (2005) found that Blacks and those of lower socioeconomic status received less compensation and medical treatment in the Worker’s Compensation system than their better-off White counterparts, and this was associated with less satisfaction, which predicted higher postsettlement disability. Thus, for some people, compensation systems may reinforce perceived injustice and worsen health rather than improving outcomes.
Future Research Priorities and Clinical Implications
A first research priority is to merge research on social justice cognitions and reactions to perceived injustice to identify factors governing the maladaptive effects of perceived injustice and the strength and adaptability of just-world beliefs. A second priority is to study the relationship between prepain just-world beliefs and perceived injustice. The belief in a just world is a psychological resource for managing perceived injustice that may be compromised by severe circumstances of injustice. From this we can theorize an inverse association between the belief in a just world and perceived injustice in painful conditions that is most pertinent during single episodes of low-intensity injustice. A third priority is to study the differential effects of various types of justice on the pain experience. Some authors suggest that distributive justice (involving outcomes) has stronger implications for mental health (Robbins et al., 2012), whereas procedural justice (involving processes) has stronger implications for physical health (Lucas, Alexander, Firestone, & Lebreton, 2008). Knowledge about the effects of these types of justice might enable practitioners to forecast triggers of perceived injustice and to attempt to offset them before they become problematic. The consequences of inequity among cohabiting couples in the chronic pain milieu should also be investigated. Equity is important in personal relationships and is likely to be disrupted by long-term illness, perhaps bringing a sense of inequity and negative responses from the supporting partner that arises from one-sided support demands from the partner with chronic pain (Cano, Leong, Heller, & Lutz, 2009). Research should establish sources of perceived injustice in the potential guilt associated with unreciprocated help and in the social politics behind the struggle to be supported. Finally, establishing individual variability in the dispositional sensitivity to injustice (Mohiyeddini & Schmitt, 1997) will be essential to recognizing reactions to injustice; that is why for some people who suffer from pain, perceived injustice may be characterized by rumination, depression over loss, and ineffective complaining, whereas for others, an adaptation to pain and a psychological disengagement from a demand for justice is quickly achieved.
People who experience chronic pain with significantly high levels of perceived injustice (Scott, Trost, Milioto, & Sullivan, in press-b) who are struggling to cope may benefit from targeted intervention. Evidence for the efficacy of cognitive behavioral therapy for chronic pain is promising (Williams, Eccleston, & Morley, 2012), but guidance on subgroups and the tailoring of therapy remains a challenge (Morley, Williams, & Eccleston, in press). Specific support may come from compassion and forgiveness interventions, which have promising effects in reorienting negative thoughts, emotions, or actions toward an offender, specifically with a focus on empathy (Wade & Worthington, 2005). Forgiveness has been associated with reduced pain and anger in those who experience chronic pain (Carson et al., 2005). However, where forgiveness is unachievable, a focus on mitigating the effects of unforgiveness (e.g., revenge, anger) may be more appropriate. Anger-management interventions using cognitive behavioral therapy may be effective in treating perceived injustice that is accompanied by blame (Deffenbacher, 2011), but the evidence in chronic pain is lacking. A protocol for a cognitive behavioral intervention with explicit content aimed at social emotional experience is needed. Guilt, anger, shame, and embarrassment are rarely included as targets of therapy but are often characterized as expressions of poor emotional regulation or negative affect. They may also be a reflection of core beliefs challenged by chronic pain.
Conclusion
We learn that justice is important, but there is no universal consensus on what is just or unjust or guidance on how to respond to injustice. Many people with chronic pain interpret their experience in the context of injustice, which can impede successful adjustment to pain. Psychological interventions for chronic pain are often effective but need to evolve to take account of the effects on the pain experience of core justice beliefs and the violation of these beliefs.
Recommended Reading
Dalbert, C. (2001). (See References). A clearly written text for readers who wish to expand their knowledge of the belief in a just world as a personal resource.
Hafer, C.L., & Gosse, L. (2010). (See References). This chapter details factors that can influence responses to a perceived injustice.
Jackson, B., Kubzansky, L. D., & Wright, R. J. (2006). (See References). A thorough theoretical analysis of the effects of perceived injustice on physical health.
Sullivan, M. J., Scott, W., & Trost, Z. (2012). Perceived injustice: A risk factor for problematic pain outcomes. Clinical Journal of Pain, 28, 484–488. A comprehensive review of what is known about the effects of perceived injustice on painful conditions.
Footnotes
Declaration of Conflicting Interests
The authors declared that they had no conflicts of interest with respect to their authorship or the publication of this article.
Funding
The preparation of this article was funded in part by the Carnegie Trust for the Universities of Scotland.