The role of perceived injustice in chronic pain

It is increasingly recognized that the meaning individuals give to their chronic pain experience has an important influence on their pain-related adjustment. Recent research suggests that many patients with chronic pain experience their situation with a sense of injustice [1]. Patients with chronic pain often experience numerous losses, including loss of function, identity, and quality of life, and they may blame others for these losses. Research in patients with pain has defined perceived injustice as an evaluation of the severity of pain-related loss, blame, and a sense of unfairness [3]. Perceived injustice appears to influence recovery following painful injury. Studies have linked perceived injustice to greater pain intensity, disability, and mental health problems in patients with chronic pain [4]. Analogous findings have been shown in healthy individuals experiencing acute pain [5].

Despite these findings, it was not previously known how perceived injustice might influence pain outcomes. Therefore, we wanted to identify factors that might help explain this relationship [2]. Evidence from social psychology suggests that anger is the most likely emotional response to perceiving injustice. Additionally, research in patients with pain suggests that both the intensity of anger and the manner in which individuals regulate anger (e.g., by expressing or suppressing it) are associated with more negative pain outcomes. Taken together, we predicted that anger intensity and anger regulation style would help explain the relationship between perceived injustice and pain outcomes.

We asked patients with chronic musculoskeletal pain (primarily low back pain and fibromyalgia) to complete questionnaires measuring perceived injustice, anger, pain intensity, disability, and depressive symptoms. We found that anger intensity completely explained the relationship between perceived injustice and pain intensity. Anger intensity and anger suppression (i.e., the tendency keep anger “bottled up”) partially explained the link between perceived injustice and depressive symptoms. Anger did not explain the association between perceived injustice and pain-related disability.

The results suggest that anger management interventions might reduce the impact of perceived injustice on pain intensity and depressive symptoms. However, additional intervention strategies may be needed to reduce the impact of perceived injustice on pain-related disability.  Although speculative, interventions that validate patients’ pain and suffering (and, by association, the injustice experienced) may help reduce disability in patients who perceive injustice [3]. Future research is needed to test the usefulness of these interventions to mitigate the impact of perceived injustice in patients with pain. For further information on this research, please visit

About Whitney Scott

Whitney ScottWhitney is completing her doctoral degree in clinical psychology at McGill University. Under the supervision of Dr. Michael Sullivan, her thesis research examines the role of perceived injustice in chronic pain. She is also interested in clinical decision-making and clinically meaningful change in the chronic pain context. Whitney has also gained clinical experience working with patients with chronic pain through her predoctoral internship in psychology at the Alan Edwards Pain Management Unit.


1. McParland J, Hezseltine L, Serpell M, Eccleston C, & Stenner P (2011). An investigation of constructions of justice and injustice in chronic pain: a Q-methodology approach. J Health Psychol, 16 (6), 873-83 PMID: 21430131

2. Scott W, Trost Z, Bernier E, & Sullivan MJ (2013). Anger differentially mediates the relationship between perceived injustice and chronic pain outcomes. Pain, 154 (9), 1691-8 PMID: 23707294

3. Sullivan MJ, Adams H, Horan S, Maher D, Boland D, & Gross R (2008). The role of perceived injustice in the experience of chronic pain and disability: scale development and validation. J Occup Rehabil, 18 (3), 249-61 PMID: 18536983

4. Sullivan MJ, Scott W, & Trost Z (2012). Perceived injustice: a risk factor for problematic pain outcomes. The Clinical journal of pain, 28 (6), 484-8 PMID: 22673480

5. Trost Z, Scott W, Lange J, Manganelli L, Bernier E, Sullivan M. An experimental investigation of the effect of a justice violation on pain experience and expression among individuals with high and low just world beliefs. Eur J Pain 2013.



  1. Whitney Scott says

    Hi Stuart,

    Thank you for your comment and interest in our work. Yes, cognitive models highlight the importance of perpetrator intentionality on perceived injustice; the greater perceived intent, the more injustice and anger (Miller, 2001). That said, perceived intent is also a cognitive representation, which may or may not correspond to the offender’s actual intent. I agree that showing empathy and validating the patient in the early stages of pain may be useful, and may reduce the likelihood that you as a clinician are seen as a source of injustice.

    Forgiveness-based interventions may be useful in cases where the person is convinced of intent. In essence, forgiveness interventions focus on building empathy and compassion for the perpetrator by helping the patient see their shared humanity (Wade & Worthington, 2005). Although there are only a few studies on forgiveness in patients with chronic pain (see Carson et al., 2005), there are indications elsewhere supporting the utility of forgiveness-based interventions for perceived injustice and anger.

    Carson, J. W., Keefe, F. J., Goli, V., Fras, A. M., Lynch, T. R., Thorp, S. R., & Buechler, J. L. (2005). Forgiveness and chronic low back pain: A preliminary study examining the relationship of forgiveness to pain, anger, and psychological distress. The Journal of Pain, 6(2), 84-91.

    Miller, D. T. (2001). Disrespect and the experience of injustice. Annual Review of Psychology, 52, 527-553.

    Wade, N. G., & Worthington Jr, E. L. (2005). In Search of a Common Core: A Content Analysis of Interventions to Promote Forgiveness. Psychotherapy: Theory, Research, Practice, Training, 42(2), 160.

  2. stuart miller says

    My understanding might be a bit different. In the cognitive model of anger, I thought there was perceived injustice and a suggestion of intent on the part of the aggravator that was key. I haven’t reviewed the articles by Matt or the ER video but wondered if they were a way to provide empathy early in the process. When there is ambiguity of intent, some patients lean towards intent and have unresolved anger and others seem to cope better. I also like the idea of anger as a tragic representation of an unmet need (M Rosenberg). I am not sure of the best way to get resolution when there was intent (assaults) or where the person is convinced of intent. Please provide insight. Thanks for this research.

  3. The early bird gets the worm… it’s unfair to the worm, but we all cheer for the bird. Somehow we know that our ideas of fairness and justice don’t apply here.

    What does it say about a person if they get angry about some idea in their head? Does Kohlberg’s ‘moral development’ help?

    As Albert Ellis would say, it would be good if the world followed my rules. But it never does…

    By the way, I’m not against fighting for what you see as a fair go, preferably with the biggest opponent you can find. But we are talking here about people who believe that things really should be fair, as if there was a rule write in gold somewhere.

    So it is not the unfairness but the way we react against it.

  4. Alexander Technique teacher says

    My life changed when I stopped blaming whiplash for my 5 years of chronic back pain and took responsibility for my habits of movement. Using the patient assistance of an Alexander technique teacher over the course of about 3 months I was able to completely change my “story” and stop blaming outside factors on my painful body. 17 years later I’m still pain free and trying to spread this message to anyone who wants a new perspective. But that’s the key… they have to be open to change. I think I’m motivated most by seeing the glimmer of hope begin in their eyes as I explain some simple things about how they’re using their body…all day.

    Thankyou Whitney for bringing current science to this colossal challenge in our western society. I’m opinionated on this because my physical being is independent from my past. 9 years ago I almost chopped my leg off with a circular saw in the back yard. There is no hint of that debilitating trauma except for the massive shark bite (that I tell my kids) and certainly only positive ramifications have come from this incident. Without a mindset of self-responsibility AND a tool kit for managing myself I can only wonder what kind of mess I could have ended up in, emotionally and physically. The rehab offered by mainstream medical was rudimentary at best. I was shipped out as soon as I could bend my knee 90 degrees. (with the assurance that my leg will never be the same again)

    Anyhow… you’ve inspired me to write more about this at my blog, thanks for that!

    Whitney Scott Reply:

    Hi Alexander,

    Thank you for your interest in our work and for sharing your story.

  5. Thank you for a wonderful article. It is clinically useful, as I can think of several patients who have presented to me with these beliefs. It appears that my job as a therapist is to communicate to these patients that they need to find a way to move past the anger and feeling of injustice to help them recover, while at the same time not invalidating their feelings or appearing insensitive. What do you feel is the best way to approach this with the patient? To be very factual in nature (and risk coming off cold), or tip-toe around it empathetically (and risk not getting your point across). I feel like my phrasing and body language are the most important things when it comes to pain science education, and would love to hear what your opinion is when it comes to doing so. Thank you again!

    Whitney Scott Reply:

    Hi Wyatt,

    Thank you for your interest in our work. As limited research has examined interventions for perceived injustice, I will preface my response by saying that I am basing it mostly on my own clinical experience as a psychologist working with patients with pain.

    As perceived injustice entails feelings of not being understood, a crucial first step to intervention is likely going to be empathy and validation of the patient’s pain and suffering. At this point, as you say, phrasing, tone, and body language are key (e.g., warmth, openess, showing genuine interest in the patient’s point of view). As I said in response to an earlier comment, it may be useful to meet patients ‘where they are’ early on in the process. Therefore, it may not be useful to try to logically convince them that they need to ‘move on’. Instead, your initial expression of understanding and genuine compassion may be used to strengthen the therapeutic relationship. Once this relationship has a good foundation, this can be a solid place from which to collaboratively explore with patients the effect that focussing on or fighting against the injustice has had on their lives. Ultimately, the choice to change will come from the patient. However, this collaborative approach may reduce the likelihood of increasing resistance in the process.

  6. Thank you both. Patients pointing invisible weapons directly at the painful area that go on to develop a twitch are my biggest challenge. Your research certainly helps the less academically gifted therapists like me!

    Lesley Reply:

    thank you for this information that we do commonly see in MVA. i wonder how many people who come to the clinic would admit it was their fault. Is it only here in Quebec there is no fault although someone is at fault. I was thinking I wouild never know who really was at fault and likely the person would say they were not at fault. aside from this I would be willing to bet even if you were at fault there would be a lot of anger that it happened and you were injured anyway. It would be interesting to know if those who really were at fault let go of their anger earlier and did not need therapy as long.

    Whitney Scott Reply:

    Hi Lesley,

    Thank you for your comment. Indeed, the term “no-fault” is a bit of a misnomer, as fault is ultimately ascribed to one or more parties in this system. However, individuals deemed not to be at-fault are not able to sue for pain and suffering within this system. Similar to my response to Matt above, there are indications that individuals’ perceptions of injustice are more important for their well-being than their objective (i.e., legal) status as a victim. In some cases, it is plausible that a patients’ perceptions of injustice may not correspond to their level of responsibility deemed by the insurer . The paper by Ferrari and Russell (below) provides an interesting overview of different emotional responses of at-fault and not at-fault drivers, and how these may impact recovery.

    Ferrari R, Russell, AS. Why blame is a factor in recovery from whiplash injury. Medical Hypotheses. 2001, 56: 372-375.

  7. I am grateful that this type of research is being done, thank you, we need more and more support for addressing this aspect of central priming in pain.
    I do have to admit that I had a slight chuckle at the political appropriateness of the phrase “perceived injustice” – how about “victimized”… though of course in the clinic I avoid that term most of the time for a variety of reasons, instead preferring to talk about the “biology of disempowerment” – how is that for semantics!
    Kidding aside, this is a topic that we are all aware of, yet it seems to my experience most practitioners avoid for lack of skill in breeching the issue in a non-threatening way that doesn’t set off the shame button – of which I know no faster way of shutting down a therapeutic relationship than shame, which is largely unconscious for most.
    I have looked to see if there is research on this in relationship to how many people in motor vehicle accidents seek treatment based on whether they were at fault or were the victim – the reason being that I have yet to see a person at fault in an accident in my physiotherapy practice in nearly 15 years now (barring one time in a person with a pathological fracture), as opposed to the more common non-specific myofascial, musculoskeletal symptoms that present weekly.
    If anyone knows of a publication that has delineated these percentages (I’m sure auto insurers have the data and are fully aware of the discrepancy).
    I’m working on a presentation that is going to include material related to this topic, and I just finished some of the section on “whiplash as a model for psychophysiologic sensitization and procedural memory”… so here are some of the relevant publications to this discussion:

    I’m sure this study isn’t new to many, but it presents important insight:
    Castro WH, Meyer SJ, Becke ME, Nentwig CG, Hein MF, Ercan BI, Thomann S, Wessels U, Du Chesne AE. No stress–no whiplash? Prevalence of “whiplash” symptoms following exposure to a placebo rear-end collision. International Journal of Legal Medicine. 2001, 114: 316-22.
    (Up to 20% developed whiplash pain/symptoms, correlated to degree of stress history, and there was no physical movement or injury.)

    Also, these are good to review too:
    Oliveira A, Gevirtz R, Hubbard D. A Psycho-Educational Video Used in the Emergency Department Provides Effective Treatment for Whiplash Injuries, Spine, 2006 31(15):1652-57.

    Schrader H, Obelieniene D, Bovim G, Surkiene D, Mickeviciene D, Miseviciene I, Sand T. Natural evolution of late whiplash syndrome outside the medicolegal context. Lancet. 1996, 347: 1207-11.
    Schrader H, Stovner LJ, Obelieniene D, Surkiene D, Mickeviciene D, Bovim G, Sand T. Examination of the diagnostic validity of ‘headache attributed to whiplash injury’: a controlled, prospective study. European Journal of Neurology. 2006, 13: 1226-32.

    Finally, this is very interesting:
    Simotas AC, Shen T. Neck pain in demolition derby drivers. Archives of Physical Medicine and Rehabilitation. 2005, 86: 693-6.
    (Essentially, despite repeated “whiplash”, the incidence of neck pain is exceptionally low in demolition derby drivers because they enjoy it and don’t perceive it to be a threat to their well-being).

    Whitney Scott Reply:

    Hi Matt,

    Thank you for your interest in our work and all of the resources. As for semantics, research suggests that individuals’ subjective perception of injustice is more important for their health and well-being than “objective injustice” (i.e., injustice as legally or socially defined). That said, rather than attempting to determine the legitimacy of a patients’ injustice experiences, it may be more useful to ‘meet them where they are’, so to speak. From this place of empathic understanding, it may be easier to work with patients to see the unhelpfulness of ruminating on the injustice, or trying to find ways to ‘solve’ the injustice.

    Ferrari and Russell (citation below) provide an interesting biopsychosocial explanation of reasons underlying the differential presentation of at-fault vs. not at-fault drivers. They discuss differences in the physiological impact of the accident across the two groups, as well as different emotional responses (e.g., shame, guilt, and embarassment versus anger) that might account for different patterns of recovery.

    Ferrari R, Russell, AS. Why blame is a factor in recovery from whiplash injury. Medical Hypotheses. 2001, 56: 372-375.