Understanding Justice Beliefs in Chronic Pain

1. What is fair about pain? A quantitative and qualitative examination of justice beliefs in the context of chronic pain Dr Joanna McParland Division of Psychology Glasgow Caledonian University Glasgow Email: j.mcparland@gcal.ac.uk Tel: +44 (0) 141 331 3854

2. Belief in a Just World (BJW) “Individuals have a need to believe that they live in a world where people generally get what they deserve. The belief that the world is just enables the individual to confront his (/her) physical environments as though they were stable and orderly. Without such a belief it would be difficult to commit him(/her)self to the pursuit of long-range goals or even to the socially regulated behaviour of day-to-day life” (Lerner & Miller, 1978, p 1030 -1031)

3. Coping with threat to BJW Experience unjust suffering • Complain • Normalise (Lerner, 1998) • Make downward social comparisons • Cognitive assimilation • Seek compensation/apology • Self-blame (Hafer & Correy, 1999) • Make meaning (Park et al, 2008)

4. Application: Personal illness/injury • Bulman & Wortman (1977) - General just world beliefs positively correlated with happiness in sample of 29 predominantly male patients with spinal injuries (mean age = 23 years) • Agrawal & Dalal (1993) - General just world beliefs positively associated with recovery rate four days after myocardial infarction in a sample of males, although this relationship no longer significant one month later • Dalbert & Braun (1997) - Personal just world beliefs positively associated with positive mood & negatively associated with depression in sample of 64 mostly female breast cancer sufferers • Kiecolt-Glaser & Williams (1987) - General just world beliefs unrelated to mood, compliance with treatment, self-rated pain & pain-related behaviour in hospitalised acute burns patients • Sullivan et al (2008) - Perceived injustice associated with catastrophising, fear of movement/re-injury, depression and pain severity in samples if pain sufferers injured as a result of workplace or motor vehicle accidents. Also prospectively predictive of return to work and treatment outcomes. :

5. Jackson et al (2006)

7. Chronic Pain Definitions • “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” (IASP, 1994) • “..pain that persists beyond normal tissue healing time, which is taken to be three months” (IASP, 1986)

8. McParland & Knussen (in press) • Aim - to explore the potential coping function of just world beliefs in chronic pain. - specifically: to determine the ability of general and personal just world beliefs to moderate the relationship psychological distress holds with pain intensity and disability

9. Procedure • Chronic pain support group members • 405 questionnaire packs distributed to 15 chronic pain support groups in Central Scotland (4 fibromyalgia, 11 arthritis) • 107 packs returned; final sample N = 95

10. Sample Table 1. Descriptive statistics for the sample and pain condition variables ________________________________________________________ Demographic N(%) ________________________________________________________ *Gender: Female 86 (90.5) Male 8 (8.4) Marital status: Married 38 (40.0) Widowed 36 (37.9) **Other 21 (22.1) *Religious status: Religious 72 (75.8) Not religious 22 (23.2) ________________________________________________________ *Data missing for one participant; **Single, divorced, separated

11. Sample Table 1. Descriptive statistics for the sample and pain condition variables _____________________________________________________________________________________ Demographic N(%) Mean (SD) Range ________________________________________________________________________ *Employ status: Retired79 (83.2) Unemployed 9 (9.5) Homemaker 4 (4.2) Employed 2 (2.1) Type of pain: Arthritis (various) 43 (45.3) Fibromyalgia 15 (15.8) Joint/muscular 15 (15.8) Back 10 (10.5) ***Other 12 (12.6) ****Pain duration 16.21(14.66) .6-68 Age (years) 66.23(11.44) 43-93 _______________________________________________________________________ * Data missing for one participant ***Pain presented in terms of duration or intensity **** 18.9% of sample failed to record pain duration

12. Measures • Personal Belief in a Just World Scale (Dalbert, 1999) (α =.70) • General Belief in a Just World Scale (Dalbert et al, 1987) (α =.88) • General Health Questionnaire (GHQ-28) (Goldberg and Hillier, 1979) (α =.93) • Chronic Pain Grade (Von Korff, Ormel, Keefe and Dworkin, 1992) (PI α =.88; Disability α =.93) • Marlowe-Crowne Social Desirability Scale (Strahan and Gerbasi, 1972) (α =.68)

13. General Belief in a Just World Scale (Dalbert et al, 1987) I think basically the world is a just place I believe that, by and large, people get what they deserve I am confident that justice always prevails over injustice I am convinced that in the long run people will be compensated for injustices I firmly believe that injustices in all areas of life are the exception rather than the rule I think people try to be fair when making important decisions Personal Belief in a Just World Scale (Dalbert, 1999) I believe that, by and large, I deserve what happens to me I am usually treated fairly I believe that I usually get what I deserve Overall, events in my life are just In my life injustice is the exception rather than the rule I believe that most of the things that happen in my life are fair I think that most decisions that are made concerning me are usually just BJW Measures

14. Results

15. Results

16. Results • Simple slope analysis (Preacher, 2003) • Pain intensity – psychological distress relationship Low GJWB: B = 0.41; SE B = 0.09, β = .70, t = 4.72, p<0.001. High GJWB: B = 0.11, SE B = 0.06, β = .18, t = 1.66, p >0.05 • Disability-psychological distress relationship Low GJWB: B = 0.27, SE B = 0.05, β = 0.71, t = 5.71, p<0.001. High GJWB: B = 0.12, SE B = 0.04, β = 0.30, t = 2.67, p<0.01.

17. Key Conclusions • PBJW beneficial for psychological well-being in general • GBJW beneficial for psychological well-being when someone is suffering in some way (chronic pain) • But mediator/moderator variables require to be tested

18. Key study shortcomings • Limited generalisation of results • Uncertain what just world scales measure • Pre-pain just world beliefs not known

19. ESRC: Exploring justice issues in chronic pain: sufferer and partner perspectives (McParland & Eccleston) Phase 1 • Main aim: to examine the phenomenology of justice and injustice in chronic pain • Sample: chronic pain sufferers (from General Practice) and their spouses from different socioeconomic areas in Glasgow • Method: Focus group discussions examining issues of fairness, deservingness and entitlement

20. ESRC: Exploring justice issues in chronic pain: sufferer and partner perspectives (McParland & Eccleston) • Results - interpretative phenomenological analysis - Some key broad emergent themes - contested concepts - social comparison - stigma/judgement - challenge to self-identity

21. ESRC: Exploring justice issues in chronic pain: sufferer and partner perspectives (McParland & Eccleston) Phase 2 • Aim: to compare and contrast varied conceptions of justice and injustice in chronic pain within British culture using Q methodology • Sample: - chronic pain sufferers (GP, SG, Pain Clinic) (n = 33) - spouses (n = 9) - health professional lecturers (n = 15) - lay (members of the public) (n = 22) • Method: Participants sorted 47 diverse statements onto a grid ranging from -5 to +5 (in the shape of a quasi-normal distribution) in terms of how strongly they ‘agreed’ or ‘disagreed’ with each statement, whilst ‘adopting a chronic pain perspective’. An additional comments sheet was provided to allow any further thoughts or opinions to be recorded.

22. ESRC: Exploring justice issues in chronic pain: sufferer and partner perspectives (McParland & Eccleston) • Chronic pain participant analysis - PQmethod v2.11 (Schmolk, 2002) - Q factor analysis (PCA with varimax rotation) - six factors with eigenvalues >1 - factor loadings >.6 signify exemplificatory Q sorts. - focus on uniqueness of each account

24. ESRC: Exploring justice issues in chronic pain: sufferer and partner perspectives (McParland & Eccleston) • Factor 1 account. Pain is normal. It’s not about injustice (12 exem Q sorts) Any idea that pain and its experience are unjust is rejected. There is no basis for perceiving injustice. No one is to blame for pain. Pain isn’t something that happens to someone because of who they are or what they have done. Instead, pain can happen to anyone and is a stroke of bad luck. In other words, “shit happens”. In this regard pain is simply normal to the extent that suffering is part of life. When pain does happen one should be proactive in attempts to cope with it, whatever the challenge of this. • Factor 2 account. Pain is awful. It’s society’s fault (11 exem Q sorts) There is a theme of victimisation: primary victimisation at the hands of pain and secondary victimisation at the hands of society for furthering the injustice of pain with a failure to acknowledge and accommodate this experience. Embedded within this context is a “culture” of rights, specifically the entitlement to have ones medical needs met without conditions attached, by virtue of chronic pain membership. The right to treatment isn’t being met by the human need for this and that individuals suffer needlessly is a national disgrace.

25. ESRC: Exploring justice issues in chronic pain: sufferer and partner perspectives (McParland & Eccleston) • Factor 3 account. Chronic pain is not your fault, but it is your responsibility to address it (1 exem Q sort) There is an extreme, working class view of pain. Pain is attributable to working class, childhood roots. It is unfair that social class dictates who suffers pain and that individuals are treated unfairly because they suffer pain. However, pain eventually comes to us all. A sufferer is to blame if they do nothing to address their pain. There is a need to consider one’s life and, with the help of health professionals, revisit one’s childhood to address unresolved problems in order to facilitate recovery from the past. • Factor 4 account. It’s not fair. There should be a cure for pain (1 exem Q sort) That individuals suffer pain for any length of time is unfair. There is no need for this suffering. There is enough knowledge about how the body in pain works that medical science should be able to cure pain. However, this isn’t happening and the current medical system is unsatisfactory. Pain should not be accepted as part of life. A sufferer should always hope to be free of their pain, not because it is difficult to cope with, but because there should be no reason to suffer.

26. ESRC: Exploring justice issues in chronic pain: sufferer and partner perspectives (McParland & Eccleston) • Factor 5. If you are unlucky enough to suffer chronic pain, you deserve help (1 exem Q sort) Chronic pain sufferers deserve more than those who do not suffer chronic pain, because pain makes a sufferer different to others. Life is more challenging and sufferers are treated differently, creating greater needs for them. Pain sufferers also deserve something not least because they aren’t responsible for their predicament. There is a realistic perspective on pain and an appreciation that there are others worse off and more deserving. However, medical and particularly financial aid would help. • Factor 6. There is hope that the injustice of chronic pain will be rectified (1 exem Q sort) It is unjust that certain individuals are destined to suffer pain. Who is likely to suffer is unclear but those who have lived a “clean life” certainly do not deserve to suffer. Pain provides no useful function. It is an inhumane experience, but individuals should not lose faith that justice will prevail and their suffering will stop. There can be some temporary relief from suffering with pain medication that can help an individual to live a normal life and gain perspective on their situation.

27. ESRC: Exploring justice issues in chronic pain: sufferer and partner perspectives (McParland & Eccleston) • Discussion - not exhaustive of all possible justice accounts and restricted by items presented but common sense that: - pain is somehow “wrong” - injustice is the “abnormality” of pain - owed something as innocent victim of pain which can in some way restore injustice

28. Future Directions • Origins of justice beliefs • Develop measure of justice beliefs in chronic pain • Functions of justice beliefs in particular pain contexts • Justice decision-making processes • Reactions to injustice

29. Acknowledgements • Dr Christina Knussen • Glasgow Caledonian University • Economic and Social Research Council • Professor Chris Eccleston • Scottish Primary Care Research Network • Professor Paul Flowers • Dr Mike Osborn • Louisa Hezseltine • Dr Mick Serpell • Dr David Craig

30. Reference • McParland, J., Knussen, C . Just world beliefs moderate the relationship of pain intensity and disability with psychological distress in chronic pain support group members. European Journal of Pain, in press. Available online 05/01/09.