Sources of Injustice
Sources of injustice among individuals with persistent pain following musculoskeletal
injury
Whitney Scott, PhD
Institute of Psychiatry, Psychology, and Neuroscience
King’s College London
London, UK
Amanda McEvoy, BSc
Department of Psychology
Carlton University
Ottawa, Canada
Rosalind Garland, BSc
Ingram School of Nursing
McGill University
Montréal, Canada
Elena Bernier, BSc
Department of Psychology
McGill University
Montréal, Canada
Maria Milioto, PT
Centre d’ Évaluation et de Réadaptation de l’Est
Montréal, Canada
Zina Trost, PhD
Department of Psychology
University of Alabama
Tuscaloosa, USA
Michael Sullivan PhD
Department of Psychology
McGill University
Montréal, Canada
Corresponding Author:
Dr. Michael Sullivan. Department of Psychology, McGill University.
1205 Doctor Penfield Avenue, Montreal, Quebec, H3A1B1.
Phone: 514-398-5677; Fax: 514 398-4896; Email: michael.sullivan@mcgill.ca.
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Sources of Injustice
Acknowledgements:This research was supported by funds from the Canadian Institutes for
Health Research, le Fonds de la Recherche en Santé du Québec, and l’Institut de Recherche
Robert-Sauvé en Santé et en Sécurité du Travail. The authors thank Véronique Boulais and
Valérie Malette for their assistance in data collection. The authors declare no conflicts of
interest associated with this research.
Key Words: Chronic pain, perceived injustice, rehabilitation
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Sources of Injustice
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Abstract
Growing evidence supports the negative impact of perceived injustice on individuals’
recovery trajectory following injury. However, little is currently known about sources that
might contribute to individuals’ perceptions of injustice in this context. The purpose of this
study was to systematically investigate sources of injustice among individuals with persistent
pain following musculoskeletal injury. Following completion of the Injustice Experiences
Questionnaire (IEQ), participants completed a semi-structured interview during which they
were asked to explain reasons underlying their endorsement of IEQ items. Interviews were
transcribed verbatim and coded to categorize the individuals and groups identified as sources
of injustice and reasons underlying the identification of these sources. Participants frequently
identified employers/colleagues, insurers, healthcare providers, family, significant others,
friends, society, and other drivers as sources of injustice. Common reasons discussed by
participants for identifying these sources included the contribution of these sources to the
initial injury, inadequate assessment or treatment of pain and disability, and punitive
responses to participants’ expression of pain. Sex- and injury-related differences also
emerged in the identification of sources of injustice. The Discussion addresses strategies that
might be useful for preventing the emergence of perceptions of injusticein individuals who
have sustained debilitating injuries.
Sources of Injustice
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Introduction
Research suggests that individuals may experience feelings of injustice when they
suffer undeserved hardship or loss, particularly when this results from the negligent actions of
another person(Lind & Tyler 1988; Mikula 1993; Miller 2001). The experience of persistent
pain following accidental injury is a likely context within which individuals may experience
perceptions of injustice. In addition to ongoing pain, individuals may experience a number of
losses, including loss of employment, independence, and leisure activities(Harris, Morley, &
Barton 2003; Lyons & Sullivan 1998). To the extent that these losses violate principles of
distributive justice, perceptions of injustice are likely to emerge. External attributions of
blame for pain and related losses, for example, to the individual perceived as responsible for
the injury, may be common and mayfurther contribute to injustice perceptions(Ferrari &
Russell 2001; Mikula 2003).
A growing body of research suggests that some individuals with persistent pain
following injury experience their situation with a sense of injustice. In the context of
debilitating injury, perceived injustice has been defined as an appraisal of the severity and
irreparability of injury-related losses, unfairness, and external attribution of blame(Sullivan et
al. 2008). The Injustice Experiences Questionnaire (IEQ) is a self-report measure assessing
these facets of perceived injustice that has been shown to be reliable and valid among
individuals with persistent pain following musculoskeletal injury. In addition to items
reflecting loss, blame, and unfairness, several items reflect the perceived failure of others to
acknowledge the extent of one’s suffering(Sullivan et al. 2008).
A number of recent studies indicate that perceived injustice contributes to problematic
recovery outcomes following musculoskeletal injury. In both cross-sectional and prospective
studies, perceived injustice has been associated with greater chronicity and severity of pain,
heightened displays of pain behaviour, the persistence of symptoms of depression and post-
Sources of Injustice
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traumatic stress, reduced functioning, and prolonged work disability (Ferrari 2015; Scott,
Trost, Bernier, & Sullivan 2013; Scott, Trost, Milioto, & Sullivan 2013; Scott, Trost, Milioto,
& Sullivan 2015; Sullivan, Davidson, Garfinkel, Siriapaipant, & Scott 2009; Sullivan,
Thibault, et al. 2009). Perceived injustice predicts adverse pain outcomes even when
controlling for other pain-related psychosocial factors, such as pain catastrophizing and fear
of movement (Rodero et al. 2012; Scott & Sullivan 2012; Sullivan, Davidson, et al. 2009;
Sullivan, Thibault, et al. 2009; Yakobov et al. 2014). Perceived injustice has also been shown
to be more resistant to change than other pain-relatedpsychosocial variables (Sullivan et al.
2008).
The negative impact of perceived injustice on recovery outcomes and its apparent
resistance to change using current intervention approaches have led to questions surrounding
the most optimal way to intervene clinically. Several intervention strategies have been
suggested, including anger management, forgiveness-based interventions, and Acceptance
and Commitment Therapy(Sullivan, Scott, & Trost 2012). However, research is still needed
to test the efficacy of these interventions for mitigating the impact of perceived injustice.
An important consideration in the clinical management of perceived injustice is that
injustice perceptions may arise in the context of a social environment characterized by past
and ongoing negligence, loss, and unfairness(Sullivan et al. 2008). For example, it is possible
that the negligent actions of other drivers and employers may, in fact, have been causally
related to the individual’s painful injury. It is also possible that clinicians and insurers may
question the legitimacy of pain and suffering, and in turn, may fail to provide access to
resources necessary to foster recovery(Fernandez & Turk 1995). In addition, significant
others may fail to provide needed (or expected) support to the injured individual(Cano,
Barterian, & Heller 2008).
Sources of Injustice
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To date, systematic investigation into sources of perceived injustice has not been
undertaken. Greater knowledge of the range of sources that contribute to perceptions of
injustice may facilitate the implementation of strategies to prevent the development of
injustice perceptions following injury. Given evidence that injustice perceptions might be
resistant to change once formed, efforts to prevent perceived injustice in the first place may
be a more useful approach to promote recovery following injury.
The purpose of this study was to investigate the sources of perceived injustice among
individuals with persistent pain following musculoskeletal injury. Following completion of
the IEQ, participants completed a semi-structured interview in which they were asked to
discuss theirIEQ responses in greater detail, with a particular focus on their reasons for
endorsing items related to loss, blame, and unfairness. Interviews were transcribed verbatim
and coded to categorize the individuals and groups identified as sources of injustice andthe
reasons underlying the identification of these sources. Exploratory analyses also examined
sex and injury-related differences on the sources of injustice identified.
Methods
Participants
The sample consisted of 86 individuals with persistent musculoskeletal pain (43
women, 43 men). Forty-six participants had low back pain following an occupational injury,
while 40 had neck pain following a motor vehicle accident. The sample had a mean age of
39.35 years (range: 21-56 years) and a mean pain duration of 23.02 months (range: 3-249
months).The majority (95%) of the sample received a high school education or greater. The
majority (58.1%) of the sample was single or divorced. At the time of the study, all
participants were unemployed and receiving salary indemnity benefits from a provincial
insurance program. Further details on the characteristics of the sample appear in Table 1.
Sources of Injustice
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Procedure
Participants were recruited from the community and two rehabilitation centres in
Montreal, Canada. Inclusion criteria included the following: Individuals of at least 18 years
of age; musculoskeletal pain of at least 3 months duration in the back or neck following a
motor vehicle or occupational accident; unemployed at the time of the study; and, receiving
salary indemnity benefits from an injury insurer. Exclusion criteria included unemployment
prior to pain onset, inability to provide written informed consent, and inability to complete
the study procedures in English or French.
Participantsprovided demographic information and completed self-report measures of
pain intensity, disability, and symptoms of depression.Participants also completed the
Injustice Experiences Questionnaire after which they completed an in-depth semi-structured
interview aimed to explore in greater detail the reasons underlying their responses on this
questionnaire. All participants provided written informed consent as a condition of study
participation. The study was approved by the Research Ethics Board of McGill University.
Self-report measures
Pain Intensity
Participants reported their current pain intensity on an 11-point numerical rating scale with
the endpoints 0 (no pain) to 10 (excruciating).
Self-Reported Disability
The Pain Disability Index (PDI)(Gauthier, Thibault, Adams, & Sullivan 2008; Tait,
Chibnall, & Krause 1990) was used to as a self-report measure of disability.Participants were
asked to rate their level of disability in 7 different areas of daily living: home, social,
recreational, occupational, sexual, self-care, and life support. For each domain, participants
provide perceived disability ratings on an 11-point scale with the endpoints 0(no disability)
Sources of Injustice
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and 10(total disability). The PDI has been shown to be internally reliable and is significantly
correlated with more objective indices of disability (Gauthier et al. 2008).
Depression
The PHQ-9(Kroenke, Spitzer, & Williams 2001) was used to measure the severity of
participants’ symptoms of depression. On this measure,participants report on the frequency
with which they experience nine symptoms of depression from 0 (not at all) to 3 (nearly
every day). The total score of the nine items reflects the severity of depression symptoms,
with higher scores indicating more severe symptoms. The PHQ-9 has been well validated
among patients with chronic health conditions(Kroenke et al. 2001).
Perceived injustice
The Injustice Experiences Questionnaire (IEQ)_ENREF_9was used to measure injuryrelated perceptions of injustice (Sullivan et al. 2008). On this measure, participants are asked
to rate the frequency with which they experience 12 thoughts on a 5-point scale, ranging from
0 (never) to 4 (all the time). Previous findings suggest that the IEQ yields two correlated
factors reflecting components related to the ‘severity/irreparability of loss’ and
‘blame/unfairness’. Examples of items loading onto the first factor include, “Most people
don’t understand how severe my condition is”, and “I just want my life back”. Examples of
items loading onto the second factor include, “I am suffering because of someone else’s
negligence”, and “It all seems so unfair”._ENREF_9The IEQ has been shown to have high
internal reliability and to be valid for use among individuals with persistent musculoskeletal
pain following injury (Scott et al., 2013b; Sullivan et al., 2008).
Demographic Variables
Participants responded to questions concerning their age, sex, education, marital status, and
pain onset and duration.
Sources of Injustice
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Semi-structured interview
A semi-structured interview schedule was created for the purpose of the present study
to explore in greater depth participants’ experiences of injustice in the context of their
persistent pain following injury. Open-ended interview questions were created on the basis of
several IEQ items to explore the reasons underlying participants’ responses on these items in
greater detail. The questions included in the interview schedule covered aspects of both the
‘severity/irreparability of loss’ and ‘blame/unfairness’ facets identified in the original
development and validation of the IEQ(Sullivan et al. 2008).
During the interview, participants who rated IEQ items as a 1 or higher were asked to
identify the individual or group of individuals they were thinking of when they made their
ratings on specific items. Participants were also asked to discuss their reasons for identifying
specific individuals or groups during the interview. For example, participants who endorsed
the IEQ item, ‘I feel as though I’m suffering because of someone else’s negligence’ were
asked to identify the person they were thinking about when they rated this item, and in what
ways this person has been negligent.
Several additional questions were created to examine participants’ injustice-relevant
experiences with specific individuals that have been previously described in the literature as
potential targets of anger for individuals with chronic pain(Okifuji, Turk, & Curran 1999).
These additional questions were only asked if these sources had not already been identified
by the participant in the interview. An overview of the interview schedule is presented in
Appendix 1.
Participants recruited from the community (n = 11) were interviewed at McGill
University by a graduate student in clinical psychology or a research assistant. Participants
recruited from the rehabilitation centres were interviewed by clinicians at those centres (n =
75). These participants were paired with an interviewer who was not their treating clinician to
Sources of Injustice
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minimize the potential impact of issues surrounding the therapeutic relationship on interview
responses. All interviews were audiorecorded and transcribed verbatim. Interviews conducted
in French were translated by bilingual research assistants following transcription.
Coding of interview transcripts and data analysis
A coding system for analysing the transcribed interviews was developed specifically
for the purpose of this study. The first author (WS) developed a preliminary coding system
after reviewing the transcripts of the first 11 participants, at which point it appeared that a
sufficient number of common sources had been identified to inform development of the
coding system. The coding system produced was an exhaustive list of the sources of injustice
that emerged from the first 11 participant interviews which included individuals and groups
identified as sources of injustice and reasons for identifying these sources. The resulting
coding form was designed for raters to record the presence or absence (yes/no) of these
sources in each participant interview.
Two raters (AM and RG) were trained to use the coding system. The raters were
given a description of each code and examples of responses from the interview
transcriptsrelating to the codes.During a subsequent training period, the raters each coded the
transcripts of the first 11 participants. Their codes were compared during two follow-up
meetings facilitated by the first author where reasons for discrepant codes were discussed
andconsensus was reached regarding the most appropriate codes.
Following the training period, each rater coded approximately half of the 86interview
transcripts. During this process, the raters also identified any new sources of injustice that
were not captured in the initial coding system and brought this to the attention of the first
author. These sources were then discussed between the raters and the first author, and added
to the coding system as needed.Additionally, the two raters each coded a subsample of
9interviews(10% of the sample) to assess inter-rater reliability. A Kappa coefficient of 0.93
Sources of Injustice
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(p <0.001), 95% CI, (0.89-0.96) was obtained for all coded variables, reflecting ‘almost
perfect agreement’ according to established guidelines for interpreting Kappa (Landis &
Koch 1977).
For the purpose of sample description, mean scores and standard deviations were
computed for total scores on the measures of pain intensity, disability, symptoms of
depression, and perceived injustice. Frequencies were tabulated for each of the codes derived
from the coding system. Independent samples t-tests were used to compare mean scores on
pain, depression, disability, perceived injustice, and number of sources of injustice between
men and women and between individuals who had pain following a motor vehicle or
occupational accident. Chi squared tests were used to compare sex and injury-related
differences in terms of the frequencies of identifying specific sources of injustice.
Results
Participants’ means scores on pain intensity (M = 5.68; SD = 1.47) and symptoms of
depression (M = 13.33; SD = 5.88) indicate that, on average, the sample was experiencing
moderate levels of both pain and depression (Fejer, Jordan, & Hartvigsen 2005; Kroenke et
al. 2001). On average, participants’ scores on pain-related disability (M = 41.25; SD = 11.97)
were comparable to previous samples of individuals with long-standing musculoskeletal pain
(Scott, Trost, Bernier, et al. 2013). Participants’ mean score on the IEQ was 30.15 (SD =
9.50), which is comparable to previous studies using the IEQ in patients with persistent pain
following musculoskeletal injury(Sullivan et al. 2008). The mean score is above a previously
identified clinical cut-off on this measure(Scott et al., 2013b). Thus, participants in the study,
on average,appeared to experience clinically significant levels of perceived injustice.
Women (65.1%) were more likely than men (27.9%) to be injured in a motor vehicle
accident, whereas men (72.1%) were more likely than women (34.9%) to have sustained an
occupational injury, χ2 = 11.97, p = 0.001.Men and women did not significantly differ in
Sources of Injustice
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terms of their scores on pain intensity, depression, self-reported disability, or perceived
injustice. Likewise, there were no significant differences between participants with pain due
to a motor vehicle versus an occupational accident on these variables.
Individuals and groups identified as sources of injustice
Table 2 lists the individuals and groups identified by participants as sources of
injustice during the interviews. The majority of participants identified their employers and/or
colleagues, insurers, and healthcare providers as sources of injustice. Family, significant
others, friends, and strangers or society were also commonly identified. The other driver
involved in the accident was identified as a source of injustice among the majority of
participants with pain following a motor vehicle accident. Several sources were identified by
only a few participants:the participant him or herself, fate, the government, God, and science.
On average, participants identified approximately 4.17 (SD = 1.90;range = 0-9) individuals or
groups as sources of injustice.
Common reasons for identifying individuals and groups as sources of injustice
Table 3 summarizes the reasons discussed by participants for identifying specific
individuals and groups as sources of injustice. On average, participants discussed 4.94 (SD =
3.43; range = 0-19) reasons for identifying individuals and groups as sources of injustice
during the interviews. Generally speaking, there appeared to be commonalities in
participants’ reasons for identifying employers and colleagues, family, significant others,
friends, strangers, and society. The majority of participants who identified these sources
reported that they experienced punitive responses from them as a result of expressing their
pain. Lack of support was also frequently discussed as a reason for identifying these
sources.Among participants who identified the other driver, the most common reason given
was that the other driver caused the accident.
Sources of Injustice
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In contrast, reasons discussed by participants for identifying their insurers and
healthcare providers were highly varied and somewhat idiosyncratic. The most common
reasons provided for identifying insurers included the following: failure to provide access to
the proper treatment, inappropriate assessment of the participant’s pain and/or disability; and,
inadequate insurance coverage.A number of participants also reported that they had received
negative responses from their insurers as a result of expressing their pain.The most common
reasons for identifying healthcare providers were: inappropriate assessment of pain and/or
disability; punitive responses to the participant’s expression of pain; and, failure of the
provider to give the appropriate treatment.
Participants who reported that specificindividuals or groups do not understand or take
their condition seriously were also asked to identify aspects of their condition that are not
understood or taken seriously. The severity of pain and its impact on function and mood were
the most commonly identified sources of misunderstanding (Table 4). The chronicity and
variability of pain and side effects of medication were also identified as being misunderstood
by others.
Sex and injury-related differences on sources of injustice identified
Women (41.9%) were significantly more likely than men (14.0%) to identify the other
driver as a source of injustice, χ2 = 9.77, p < 0.01. Women (74.4%) also identified healthcare
providers significantly more than men (51.2%), χ2 = 4.98, p < 0.05. Lastly, women (58.1%)
were significantly more likely than men (32.6%) to identify family members as a source of
injustice, χ2 = 5.67, p < 0.05. In contrast, a greater proportion of men (76.7%) identified their
employer/colleagues as a source of injustice, as compared to women (55.8%), χ2 = 4.21, p <
0.05. Men and women did not differ significantly in terms of the average number of sources
of injustice identified.
Sources of Injustice
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For the purpose of descriptive comparison, Table 5 displays the relative rank ordering
of the frequency of identifying sources of injustice according to injury type. Healthcare
providers were the most frequently identified source among participants injured in motor
vehicle accidents, followed by insurers, other drivers, family members and employers and/or
colleagues. In contrast, employers and/or colleagues were identified most frequently,
followed by insurers and healthcare providers,among participants with work-related injuries.
Unsurprisingly, participants injured in a motor vehicle accident (60%) were
significantly more likely to identify other drivers as a source of injustice than those with
occupational injuries (0.0%), χ2 = 40.5, p <0.001. In comparison, those with work-related
injuries (80.4%) were significantly more likely to identify their employers and/or colleagues
as a source of injustice than those injured in a motor vehicle accident (50.0%), χ2 = 8.87, p <
0.01. Participants injured in a motor vehicle accident (75.0%) were significantly more likely
to identify healthcare providers than participants with work-related injuries (52.3%), χ2 =
4.77, p < 0.05. Motor vehicle injury participants (60.0%) also identified family members with
greater frequency than did those with work-related injuries (32.6%), χ2 = 6.48, p =0.01. On
average, participants with a motor vehicle injury (M = 4.90; SD = 1.96) identified
significantly more sources of injustice than those with a work-related injury (M = 3.54; SD =
1.62), t (84) = 3.52, p = 0.001.
Discussion
This was the first study to systematically explore sources of injustice among
individuals with persistent pain following musculoskeletal injury.The frequent identification
of employers and colleagues, insurers, healthcare providers, significant others, strangers and
society, and other driversas sources of injustice is consistent with the previous identification
of these groups as ‘targets of anger’ among individuals with chronic pain(Okifuji et al. 1999).
Sources of Injustice
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Participants also frequently identified family members and friends as sources of injustice,
suggesting that multiple relationships within an individual’s social network may be important
for pain-related adjustment. This study extends previous work byusing in-depth interviews to
explore reasons underlying the identification of these sources of injustice. This study is also
the first to explore sex- and injury-related differences in sources of injustice.
Other drivers, employers, and colleagues were frequently identified as sources of
injustice for contributing to the accident and pain onset. In contrast, healthcare providers and
insurers were frequently identified for failing to provide propoer assessment or treatment.
This is consistent with a previous study suggesting that patients differentially attribute blame
for the origin versus ongoing nature of pain (McParland & Whyte 2008). Future research
should examine whether injustice perceptions regarding pain onset versus maintenanceimpact
on individuals’ recovery through different mechanisms, including different emotional
responses.In the context of a no-fault legal system, individuals who perceive injustice
regarding pain onset may have little formal recourse to restore justice resulting from the
negligence of other drivers and employers. Consequently, feelings of helplessness and
depression may develop(Jackson, Kubzansky, & Wright 2006; Peterson & Seligman 1983).
In contrast,in the course of ongoing interactions between patients and their insurers and
healthcare providers, anger may be more likely, particularly if it serves torestore
justice(Mikula, Scherer, & Athenstaedt 1998; Miller 2001).
A common reason for identifying sources of injustice wasparticipants’ experience of
punitive responses from these sources as a result of expressing pain.Previous research has
shown that punitive and invalidating responsesfrom others and lack of social support
areassociated with greater pain, disability, and distressamong individuals with chronic
pain(Boothby, Thorn, Overduin, & Ward 2004; Ghavidel-Parsa et al. 2015; Kool & Geenen
2012; Leong, Cano, & Johansen 2011). The current data suggest that negativesocial
Sources of Injustice
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responses may impact pain-related adjustment by contributing to injustice perceptions.
Indeed, negative interpersonal responses toward the person in pain may violate social
contracts of respect and inclusion (Miller 2001; Skitka 2009). Therefore, understanding the
impact of social responses on pain from an interpersonal injustice perspective may be useful
for future research.
Sex and injury-related differences emerged in participants’ experience of injustice.
Women were more likely than men to identify other drivers, while men more frequently
identified their employer, likely due to the fact that women were more frequently injured in a
motor vehicle accident and men were more frequently injured at work. Interestingly, women
identified healthcare providers and family members more frequently than men. Following
injury, women may interact with the healthcare system more often and may be more
vulnerable to ‘psychogenic’ explanations of ongoing pain (Unruh 1996). This may increase
the likelihood thatwomen experience the treatment of healthcare providers as unjust.In the
family setting, women may be expected to continue to take primary responsibility for
childcare and household management following injury. Insofar as such responsibilities are
discrepant with women’s own expectations for their roles following injury, this may give rise
to women’s experiences of lack of support, invalidation, and injustice.
Participants injured in a motor vehicle accident identified significantly more sources
of injustice than those injured at work. The frequent identification of other drivers by these
participants, which is not a relevant source of injustice for those injured at work, is one
explanation for this difference. Healthcare providers and family members were also identified
more frequently by participants with motor vehicle accident injuries. It is plausible that
individuals with neck pain following a motor vehicle accident face greater scepticism
regarding the legitimacy of their ongoing pain and disability(Cassidy et al. 2000; Ferrari &
Sources of Injustice
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Shorter 2003; Malleson 2002). In turn, scepticism from healthcare providers and family
members may contribute to feelings unfair treatment among these patients.
The sources of injustice identified here provide insight into potentialstrategies to
prevent the development ofinjustice perceptions following injury. Greater training of
healthcare providers, insurers, employers, and family members in validating communication
strategies may reduce the frequency of negative interactions between these sources and
individuals with pain that contribute to injustice perceptions. Briefly, validation involves
communicating that another person’s experiences are legitimate and understandableby:
listening and observing; accurate reflection; articulating the unverbalized; validating feelings
in terms of sufficient causes and as reasonable in the moment; and, radical
genuineness(Edmond & Keefe 2015; Linehan 1997). One recent study suggests
trainingemployers in validating communication techniques may reduce work absence and
healthcare utilization (Linton, Boersma, Traczyk, Shaw, & Nicholas 2015). Involvement of
the employer in this way may be particularly important for individuals with work-related
injuries, as employers were the most frequently identified source of injustice for this group in
the present study.
Recovery expectations of the injured patient, healthcare providers, insurers,
employers, and family members could be comprehensively assessedand communicated
between parties in the early stages of rehabilitation. Such an assessment could facilitate early
identification and management of discrepant expectations between stakeholders. Likewise,
greater communication between relevant stakeholders on decisions related to treatment, the
allocation of rehabilitation resources, and workplace re-adaptation might increase the
transparency of these procedures, thus reducing the likelihood that they are perceived as
unfair in the future.
Sources of Injustice
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For individuals injured in motor vehicle accidents, the best way to involve the other
driver in the rehabilitation plan remains uncertain at present. One particular challenge is that
the other driver may not have the same degree of investment in the injured individual’s
recovery as other sources identified. Where possible, efforts to facilitate the injured
individual’scommunication of the impact of injury to the other driver may serve to reduce
injustice perceptions by ‘educating the offender’ (Miller 2001).Where it is not possible to
involve the other driver as such, forgiveness-based interventions (Wade, Worthington Jr, &
Meyer 2005)might help mitigate the impact of perceived injustice regarding the other driver.
The results of this study should be considered in light of several limitations.The
presence of the interviewer may have influenced participants’ identification ofcertain sources
of injustice for reasons of social desirability. As the majority of interviews were conducted
within rehabilitation settings, participants may have been less willing to discuss experiences
of injustice regarding healthcare professionals. Efforts to mitigate this included discussion of
the confidentiality of the interviews during informed consent and matching participants with
interviewers that were not involved in their treatment. Another point to consider is that
participants for this study had pain precipitated by an injury and were not working as a result.
Therefore, future research is needed to determine the generalizability of the results to
participants with pain of differing etiology and with varying levels of disability. The study
was conducted in the province of Quebec which operates under a no-fault insurance system.
Consequently, the sources of injustice identified here may not generalize to tort systems
where injured individuals are able to take legal action against the party responsible for the
injury-precipitating accident.
Despite these limitations, this is the first study to systematically identify sources of
injustice among individuals with persistent musculoskeletal pain following injury. The data
reveal the complex interpersonal context within which injustice perceptions may develop and
Sources of Injustice
19
be maintained. The data suggest that prevention and management of perceived injustice will
likely require interventions targeting the social context within which injustice perceptions
arise. Future research is needed to test the efficacy of interventions involving multiple
stakeholders for preventing perceptions of injustice following injury.
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Table 1. Sample characteristics
Age (years)
Variable
M (SD)or N (%)
39.35 (8.82)
Sex: Male
Female
43 (50.0%)
43 (50.0%)
Injury Type
Whiplash injury
Occupational injury
40 (46.5%)
46 (53.5%)
Pain Location*
Back
Neck
Upper limbs
Lower limbs
78 (90.7%)
54 (62.8%)
41 (46.7%)
39 (45.3%)
Time since injury (months)
23.02 (39.95)
Marital Status
Single
In a relationship/married
Divorced
Widowed
41 (47.7%)
35 (40.7%)
9 (10.5%)
1 (1.2%)
Education
<High School
High school
College
Undergraduate and above
Missing
3 (3.5%)
43 (50.0%)
22 (25.6%)
17 (19.8%)
1 (1.2%)
Pain Intensity
Disability
Depression
Perceived Injustice
Number of Sources of Injustice
5.68 (1.47)
41.25 (11.97)
13.33 (5.88)
30.15 (9.50)
4.17 (1.90)
Sources of Injustice
*Responses are not mutually exclusive.
Table 2. Individuals and groups identified as sources of
injustice
Source
n (%)
Employer and/or colleagues
60 (70.0%)
Insurer (incl. insurer physician)
57 (66.3%)
Any Healthcare Provider
54 (62.8%)
Physician
44 (51.2%)
14 (20.9%)
Physiotherapist
7 (8.1%)
Occupational Therapist
4 (4.6%)
Medical System
3 (3.5%)
Emergency personnel
Acupuncturist
1 (1.2%)
Family
39 (45.3%)
Significant Other
37 (43.0%)
Friends
29 (33.7%)
Other Driver
24 (27.9%)
Society/strangers
18 (20.9%)
Self
6 (7.0%)
Fate
4 (4.7%)
Government
3 (3.5%)
God
2 (2.3%)
Science
1 (1.2%)
*Note. Responses are not mutually exclusive
24
Sources of Injustice
25
Table 3. Reasons for identifying individuals and groups as sources of injustice
Source
Employer and/or colleagues
(n = 60)
Insurer, including insurance
physician (n = 57)
Health Care Providers (n = 54)
Family (n = 39)
Significant Other (n = 37)
Friends (n = 29)
Other driver (n = 24)
Society/strangers (n = 18)
Self (n = 6)
Fate (n = 4)
Reason for identifying source
-Punitive response to pain expression/work absence
-Caused accident/didn’t provide a safe workplace
-Not providing support after injury
-Poor communication after injury
-Appropriate treatment not given
-Inappropriate assessment of pain/disability
-Did not provide enough financial coverage
-Treated participant like a number
-Punitive response to pain expression
-Disorganized
-Participant has to pay for treatment up front
-Long wait for treatment/compensation
-Does not compensate for non-Western treatment
-Insurer blamed patient for accident/disability
-Harassed patient
-Insurer had a conflict of interest
-Inappropriate assessment of pain/disability
-Punitive response to pain expression
-Appropriate treatment not given
-Inappropriate treatment given
-Did not cure pain
-Long wait times
-Treated participant like a number
-Treatment not specialized/adapted to needs of participant
-Did not give participant adequate information
-Did not treat pain-related psychological problems
-Blamed pain on psychological aspects of participant
-Punitive response to pain expression
-Does not provide needed support
-Punitive response to pain expression
-Does not provide needed support
-Punitive response to pain expression
-Does not provide needed support
-Caused accident
-Did not apologize for accident
-Left scene after accident
-Punitive response to pain expression
-Caused accident
-Caused accident
-Equilibrium of life
n (%)
43 (50.0%)
21 (24.4%)
2 (2.3%)
1 (1.2%)
17 (19.8%)
16 (18.6%)
16 (18.6%)
13 (15.1%)
13 (15.1%)
11 (12.8%)
8 (9.3%)
6 (7.0%)
4 (4.6%)
4 (4.6%)
1 (1.2%)
1 (1.2%)
25 (29.1%)
20 (23.2%)
19 (22.1%)
9 (10.5%)
6 (7.0%)
6 (7.0%)
5 (5.8%)
4 (4.6%)
2 (2.3%)
2 (2.3%)
1 (1.2%)
34 (39.5%)
12 (13.9%)
31 (36.0%)
15 (17.4%)
26 (30.2%)
9 (10.5%)
24 (27.9%)
6 (7.0%)
4 (4.6%)
15 (17.4%)
3 (3.5%)
3 (3.5%)
2 (2.3%)
Sources of Injustice
Government (n = 3)
Science (n = 1)
-Things happen for a reason
-Did not prevent accident
-Has not impacted ordinary people
*Note. Responses are not mutually exclusive
Table 4. Sources of Misunderstanding
n (%)
Source
Severity of pain
29 (33.7%)
Impact of pain on function
26 (30.2%)
Impact of pain on mood
13 (15.1%)
Chronicity of pain
10 (11.6%)
Variability of pain
10 (11.6%)
Side effects of medication
3 (3.5%)
*Note. Responses are not mutually exclusive.
1 (1.2%)
2 (2.3%)
1 (1.2%)
26
Sources of Injustice
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Table 5.Ranking of sources of injustice identified according to injury type.
Motor Vehicle Accident
n (%)
Occupational Injury
n (%)
1. Any Healthcare Provider
30 (75.0%) 1. Employer and/or colleagues 39 (84.8%)
2. Insurer
29 (72.5%) 2. Insurer
28 (60.9%)
3. Other driver
24 (60.0%) 3. Any Healthcare Provider
24 (52.2%)
3. Family
24 (60.0%) 4. Significant others
19 (41.3%)
5.Employer and/or colleagues 21 (52.5%) 5. Family members
15 (32.6%)
6. Significant other
18 (45.0%) 5. Friends
15 (32.6%)
7. Friends
14 (35.0%) 7. Society/Strangers
6 (13.0%)
8. Society/strangers
12 (30.0%) 8. Self
3 (6.5%)
9. Government
3 (7.5%)
9. Fate
2 (4.3%)
9. Self
3 (7.5%)
9. God
2 (4.3%)
11. Fate
2 (5.0%)
10. Other Driver
0 (0.0%)
12. Science
1 (2.5%)
10. Government
0 (0.0%)
13. God
0 (0.0%)
10. Science
0 (0.0%)
*Note. Responses are not mutually exclusive
Sources of Injustice
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Appendix 1. Semi-structured interview schedule.
Follow-up
to IEQ
item 1
Follow-up
to IEQ
item 8
Follow-up
to IEQ
item 3
Additional
Questions
Questions and Probes
You endorsed the statement, ‘Most people don’t understand the severity of my condition’:
- Who specifically does not understand the severity of your condition?
- Why do you feel this individual (or group) does not understand?
-Are there specific aspects about your condition that are not understood?
You endorsed the statement, ‘I worry that my condition is not being taken seriously’:
- Who specifically is not taking your condition seriously?
- Why do you feel this individual (or group) is not taking your condition seriously?
-Are there specific aspects about your condition that are not taken seriously?
You endorsed the statement, ‘I am suffering because of someone else’s negligence’:
-Who specifically has been negligent?
-How has this individual/group been negligent or contributed to your suffering?
-Who was responsible for your initial injury?
-In the context of your pain condition, have you ever felt frustrated or angry in your
interactions with your healthcare providers, insurer, employer, or significant other?
-If yes (for all that apply), what has this person done to make you frustrated or angry? Have
you ever felt they did not understand your condition or were not giving you the treatment or
support you deserved? Why did you feel this way?
Note: IEQ, Injustice Experiences Questionnaire
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