Perceived injustice: a historical and clinical review of a useful concept for psychiatry

Abstract

Objective

Perceived injustice, a concept that arose in pain medicine, refers to an individual’s experiences and perceptions of victimisation from injuries resulting in chronic pain. Here, we have undertaken a historical and clinical review on the role of perceived injustice medicine in psychiatry and a systematic review on psychotherapeutic interventions for perceived injustice.

Method

For the systematic review, two studies were identified from a search of six databases.

Results

Though evidence is limited, psychotherapeutic interventions show promise in addressing perceived injustice and associated symptomatology.

Conclusion

Perceived injustice is a concept which may have great potential utility to psychiatry, particularly in occupational and medicolegal areas. Interventions addressing perceived injustice may help improve clinical outcomes.

In pain medicine, the concept of perceived injustice may be defined as individual experiences and perceptions of victimisation, either directly or indirectly, from injuries resulting in chronic pain. More formally, it has been thought of as ‘an appraisal cognition or set of cognitions comprising elements of attributions of blame, magnitude of loss and irreparability of loss’. ¹

Perceptions of injustice may arise when an injury has occurred due to the faults or omissions of others, and when an individual subsequently experiences loss or deprivation. ¹ Given psychiatrists’ roles in settings where chronic pain is commonly seen, such as consultation-liaison and addiction psychiatry settings, as well as in the workers’ compensation field, it is important that psychiatrists are familiar with this concept.

This paper will review the relationship between pain and justice in the cultural, religious and psychological spheres, along with the relationship between perceived injustice and outcomes relating to health, medicolegal and occupational functioning. This paper also reviews the literature around psychotherapeutic interventions for addressing perceived injustice.

Pain and justice in religion, culture and psychology

Religious traditions emphasise that pain aligns with spiritual or cosmic notions of justice. Jewish and Christian notions of pain may emphasise the notion that pain can be an opportunity for the sufferer to transcend the pain, or that pain can be either a punishment for transgressions or an opportunity for redemption. ² For example, Isaiah 53:4-5 (KJV) states, ‘Surely he hath borne our griefs, and carried our sorrows… but he was wounded for our transgressions, he was bruised for our iniquities… and with his stripes we are healed’. Similarly, Hindu notions of pain and suffering suggest its role as a karmic punishment, ³ and one of the Four Noble Truths of Buddhism is that life itself is full of pain. ⁴

Of course, an individual suffering with pain may not always perceive their suffering or the causal injury to be just. While the development of the concept of perceived injustice and a formal scale for its quantification are both relatively new, antecedents to the concept of perceived injustice can be found throughout the annals of the psychiatric literature. Freud ⁵ noted that individuals with melancholia ‘always seem as though they felt slighted and had been treated with great injustice’. In the 1960s, Merskey ⁶ noted that 30 out of 76 patients with persistent pain (compared with 5 out of 37 patients without pain) had ‘resentment’, which was defined as patients seeming ‘resentful’, along with blaming others for their pain or believing that they had been ill-treated. The idea of perceived injustice overlaps with the ideas behind another concept, post-traumatic embitterment disorder, wherein ‘embitterment and feelings of injustice’ predominate following a significant stressor, and may result in somatic complaints such as pain. ⁷

The phenomenon of pain and injustice has been noted outside of the psychiatric sphere. In Korean culture, haan is an emotion associated with ‘unresolved resentment against injustices suffered’ and ‘a feeling of acute pain in one’s guts and bowels, making the whole body writhe and squirm’. ⁸

Perceived injustice and chronic pain

A flurry of recent research has investigated perceived injustice and described its relationship to numerous pain-related factors. The Injustice Experience Questionnaire (IEQ), a 12-item scale, has been developed to assess perceived injustice. ¹ For example, as described in a recent systematic review investigating perceived injustice in individuals with musculoskeletal pain, perceived injustice has generally been associated with higher pain intensity, higher disability, poorer functional outcomes (such as decreased likelihood of an individual returning to work) and higher levels of psychological symptoms including depressive, post-traumatic stress and anxiety symptoms. ⁹ The IEQ is not currently included in the electronic Persistent Pain Outcomes Collaboration (ePPOC) measures used across Australia (see https://www.uow.edu.au/ahsri/eppoc/).

Perceived injustice in medicine

Perceived injustice has also been shown to be a useful construct beyond the field of pain medicine. For example, in women with cervical cancer who received false-negative smear results, perceived injustice was shown to be a significant predictor of symptoms of depression and anxiety. ¹⁰ In patients with advanced lung and prostate cancer, perceived injustice significantly affected symptoms of depression and anxiety along with anger towards the cancer and anger towards God. ¹¹ In patients with mild traumatic brain injury, significant correlations were reported between perceived injustice and self-reported depressive, post-traumatic stress, pain and post-concussion symptoms. ¹²

Perceived injustice in psychiatry

As Freud ⁵ noted, perceptions of injustice may play a role in psychiatric conditions. Like chronic pain, much psychiatric morbidity is a direct consequence of injury, either physical or emotional. It is not difficult to draw parallels between items in the IEQ relating to blame and unfairness (e.g. ‘Nothing will ever make up for what I have gone through’ or ‘I can’t believe this has happened to me’) and any number of traumatic disorders, or between those IEQ items relating to severity and irreparability (e.g. ‘I just want my life back’ or ‘I worry that my condition is not being taken seriously’) and nearly any psychiatric condition. In a recent contribution to understanding the role that perceived injustice may play in the phenomenology of depression, Sullivan and colleagues, ¹³ in a cohort of 253 individuals in an occupational rehabilitation service, showed that perceived injustice was a significant determinant of symptom outcomes in major depressive disorder. ¹³

Perceived injustice in medicolegal and occupational settings

Perceived injustice also plays an important role in the medicolegal sphere. The involvement of lawyers and litigation following injury has been associated with poorer psychological, functional and pain outcomes. One study showed that lawyer consultation was associated with perceived injustice. ¹⁴ Furthermore, perceived injustice has also been associated with intent to litigate. ¹⁵ The relationship between litigation and legal involvement and perceived injustice may be bidirectional. ‘Legal representatives have a vested interest in ensuring that their clients’ perceptions of injustice remain high’, as Sullivan and colleagues note. ¹⁶

Unsurprisingly, perceived injustice can also impact functioning. In a Victorian study, perceived injustice was found to mediate the relationship between eligibility for compensation and return to work. ¹⁷

Systematic review of literature

Despite the growing recognition of the importance of perceived injustice, there have been very few studies that have investigated the effect of psychotherapeutic interventions on perceived injustice. We conducted a systematic review (registered through PROSPERO, registration number: CRD42023386915) of Medline, Embase, Cochrane Library, PsycINFO, Epistemonikos, CINAHL and Mednar databases and identified only two such studies.

Chisari and colleagues, ¹⁸ in a cohort of seven women with vulvodynia, assessed a 6- to 7-week program of therapist-assisted online acceptance and commitment therapy in seven women with vulvodynia. Three of the seven women had an improvement on measures of perceived injustice. In a cohort of individuals with musculoskeletal back or neck injury associated with a current work absence (initial pre-dropout size of 66), Sullivan and colleagues ¹⁹ assessed a 10-week program of risk-targeted behavioural activation, supplemented by specific techniques to address perceived injustice and catastrophising. These techniques included problem solving, validation and identifying whence the perceptions of injustice may have arisen. A large reduction in IEQ scores was noted (25%, Cohen’s d = 1.0), with change in IEQ being positively correlated with changes in symptom severity for pain, pain catastrophising and depression.

Both of these studies, whilst indicating to the utility of psychotherapy in addressing perceived injustice, had methodological shortcomings. For example, neither utilised a control group, neither focused on perceived injustice alone as a primary outcome and both had only limited follow-up for measures of perceived injustice. More research is required to develop specific psychotherapeutic techniques to address perceived injustice in a time-limited and manualised format.

Summary

Perceived injustice may be a useful concept with applications beyond the field of pain medicine whence it originated and may have great potential utility to psychiatry as well as medicine more broadly and particularly in the occupational and medicolegal fields. We hope that this brief review of this important topic can provide a spur for further research, not only in investigating the role that perceived injustice plays in the phenomenology of various psychiatric conditions but also in developing treatment modalities that may help to address perceived injustice and, hopefully, lead to improved patient outcomes.