The relationship between perceived injustice and the working alliance: a cross-sectional study of patients with persistent pain attending multidisciplinary rehabilitation.

PURPOSE Accumulating research suggests that perceived injustice is a risk factor for adverse recovery following painful injury. Presently, however, little is known about the processes by which perceived injustice influences rehabilitation outcomes. It is plausible that perceived injustice and associated anger impact rehabilitation outcomes by compromising the quality of the therapeutic working alliance; however, research has not previously examined the relationship between perceived injustice and the working alliance. Therefore, the present study investigated the association between perceived injustice, anger, and the working alliance. METHODS Sixty-six patients with persistent pain following musculoskeletal injury participated in this study. All participants were enrolled in a standardized multidisciplinary rehabilitation programme. Participants completed self-report measures of perceived injustice, pain intensity, disability, anger intensity and regulation style, depressive symptoms, and a measure of the working alliance with their principal rehabilitation clinician. Each participant's principal clinician also completed the working alliance measure. RESULTS Greater perceptions of injustice were associated with poorer client ratings of the working alliance. Results also showed that anger expression mediated the association between perceived injustice and the working alliance. CONCLUSION Strategies to enhance the working alliance between rehabilitation professionals and clients with elevated levels of perceived injustice are needed. Implications for Rehabilitation Perceived injustice is associated with poor progress in rehabilitation programmes for people with musculoskeletal pain following injury. Perceived injustice is negatively associated with the quality of the therapeutic working alliance. Strategies to enhance the working alliance between rehabilitation professionals and clients with elevated levels of perceived injustice are needed.