…and how The System, which wants to save its money, ends up paying more.
When you’re injured in a car accident in Ontario, the insurance provider has the right to request an assessment from a provider they have selected; these are called insurer examinations, and I used to do a lot of them. Typically, I was asked to see people who didn’t seem to be progressing fast enough, two years after the accident. Most had some combination of both physical injuries and psychological issues, including depression, anxiety, trauma, and pain disorders.
In 2008, I had done about 100 of these (almost none on injured passengers--apparently, not a lot of Ontarians carpool), when I began to notice a pattern…something that didn’t quite make sense.
Since most accidents involve two vehicles, if these drivers were randomly distributed, I’d expect there to be roughly a 50/50 split between the at-fault and not-at-fault drivers injured in accidents.
That was NOT what I found. What I saw was that the at-fault driver was assessed 5% of the time. That means that 95% of my sample was the driver who was in the wrong place at the wrong time. NINETY-FIVE PERCENT.
What was going on here? I began to go through the psychological research, but I couldn’t find the right keywords to answer my question…because I didn’t know how to ask it.
It was a year later that I found the paper I was looking for. Its author, Dr Michael Sullivan, had nailed the phrase for me: “Perceived Injustice.” And in his paper, he demonstrated that his simple little 12-item questionnaire on the sense of injustice following a physical injury did a remarkable job of predicting the persistence of post-traumatic symptoms. The more injustice the individual perceived, the more likely their PTSD was to last.
Bear in mind: The concept of “perceived injustice” is NOT about malingering or delusion. While perception can be inaccurate, that’s not automatically being implied here; all experience is perceived. It might just as easily be called “experienced injustice.” When a person feels that they have been treated unjustly, that’s what sets the wheels of this vicious cycle in place, regardless of whether they’re right or wrong.
There are two themes in Sullivan’s questionnaire: “Blame” (someone did this to me; I’m suffering, and it wasn’t even my fault) and “Severity” (no one gets how bad this is; I might never get better).
It’s a great start, and it’s been extended with some interesting work. But, with all due respect to Dr Sullivan and those who are exploring this idea further, there is so, so much more to this groundbreaking concept.
Some features of the event, I’ve found, enhance the perception of injustice: Being injured as a victim of a crime; betrayal of trust, as when a doctor abuses a patient; the mere presence of a child, even if the child wasn’t injured.
But one of the biggest ones has been written about under its own label: Sanctuary Trauma. That’s what happens when those who were supposed to support you following your injury failed to be there for you: The boss that dismissed your concerns; the failure of workplace insurance, long-term disability, or Veteran’s Affairs to accept the claim; the campus police who refused to take your sexual assault seriously; the service that tossed you aside like a broken toy…
In some cases, the failure of The System is worse than the injury caused by the original accident or crime. When the people who are supposed to help you turn you away, doubt your story, or drop the ball, the result can be devastating.
This is a concept that goes so much further than injuries in motor vehicle or industrial accidents. It speaks to a fundamental truth of human psychology: We get better when we feel heard and supported; if we feel invalidated and rejected, our bitterness, and the need to constantly prove that we’ve been injured, can cause us to double down on our symptoms. And that’s not just consciously inflating symptoms…it’s an unconscious process that can actually make the injury and impairment worse, like a placebo effect in reverse.
And this isn't just about the psychological injury. Perceived Injustice causes physical injuries to take longer to heal, and it's associated with longer periods of disability from employment. Perceived Injustice carries a huge cost, economically and in quality of life.
I’ve developed this theory of how Perceived Injustice seems to work.
Think of someone running a stop sign by mistake…a stupid thing that, admit it, we’ve pretty much all done.
There’s a variety of outcomes to this. Usually, there’s nothing at all; you look around, hope no one saw you, and drive away. There’s getting a ticket. There’s a close call, and subsequent embarrassment. There’s a minor accident; an accident causing injury; and worst of all, an accident causing death.
Clearly, it’s much worse to run a stop sign and kill someone than to run a stop sign and hit nothing, right? Bigger injury=bigger injustice.
Except, of course, that the error is the same in all those outcomes. The outcome is determined by physics, timing, and probability. Running a stop sign is a bad thing to do because it increases the probability of a bad outcome; but the driving error is the same whether that outcome is neutral or severe.
But that’s not what we feel! We feel that the greater the injury, the greater the injustice that’s been perpetrated. My life is ruined, and all that other guy got was a frickin’ ticket for running a stop sign!!
The greater the injury, the greater the injustice. And here we have the seeds of an unconscious, but potentially devastating conflict: If I were uninjured, there’d be no injustice. Which means: My injury is the proof of the injustice I’ve endured. I need to prove my injury in court, to the insurer, to VA, to worker’s comp. They keep screwing me over. But my injury is proof of the injustice I’ve endured. My suffering and impairment show them how wrong they are.
And even if there’s no legal battle, there’s a psychological battle. The anger and bitterness towards that other driver, perhaps, or towards the insurer who refuses to pay. My injury proves that what you did was horribly wrong. If I get better, it’s like I’m letting you off the hook!
So…how can I get better, when my injury is the proof of what’s been done to me, and my injury is proof that my anger and bitterness is justified?
And the deeper that sense of injustice, the more persistent the physical and psychological injuries will be, the greater the anger and bitterness…and the more ridiculous words like “acceptance” and “forgiveness” will sound. “Letting go” won’t seem like much of an option.
When the anger and bitterness of Perceived Injustice are added to the mix, the injury, whether it’s physical or psychological, is going to be a hell of a lot less likely to heal.
Psychologists can help people find their way out of Perceived Injustice, by helping them learn that "acceptance," "forgiveness" and "letting go" aren't something you do for the perpetrator or The System; they're something you do for yourself.
But it would be so much easier to achieve that if more people experienced more compassion when they seek the help they need.
The great irony is, The System usually treats people badly in an effort to save money. In reality, The System may be costing itself millions, by creating the conditions in which people are least likely to heal.
If only The System knew…Compassionate care saves money.
We get better when we feel heard and supported.
--Dr Jonathan Douglas