The Observation
When I first began practice in an orthopedic group, I saw roughly forty motor-vehicle injury cases each year. By my third year, I finally saw the strange pattern underneath it all: I never saw the person who caused the crash.
I met hundreds of patients who had been hitâoften rear-ended or struck at an intersectionâbut almost none who had done the hitting. Even in cases with no legal claim and no attorney, that pattern held true. I occasionally met the other driver by chance, and they nearly always said the same thing: "I was fine the next day."
The Victim-Perpetrator Difference
Research shows that being the victim (not at fault) predicts substantially worse outcomes than being the at-fault driver. This is not a coincidenceâit is a documented phenomenon.
The Victim (Not at Fault)
- Greater pain and bodily distress.
- Higher rates of PTSD, anxiety, and depression.
- Slower recovery and delayed return to work.
- Higher risk of chronic pain syndromes.
The At-Fault Driver
- Recovers significantly faster.
- Far less emotional distress.
- Rarely develops chronic pain from similar impact forces.
- Processes the event as "a mistake" rather than a violation.
Why the Victim Hurts More
The Amygdala & The Narrative
The difference is psychological as much as physical. Victims experience loss of control, unfairness, and fearâa combination that activates the brain's amygdala-centered threat circuits.
When this perception of injustice remains unresolved, it keeps the nervous system in a defensive mode, amplifying both muscle tension and pain. Those at fault resolve the trauma faster because guilt ("I made a mistake") allows the nervous system to stand down. Victims face an ambiguous story: they followed the rules and were hurt anyway.
The Hidden Cost of the Claims Process
Outcomes worsen further when compensation or legal claims are involved. Studies show that claimants under fault-based systems experience higher stress and slower recovery than comparable patients without claims.
The association does not mean that "lawyers make it worse." Most attorneys are helping patients navigate a complex system. The real problem is the system itself: slow pace, conflicting assessments, and constant scrutiny. That systemic stress keeps the body's threat response alive.
Clinical Implications: What Helps?
Validate the Context
Recovery is shaped by perceived injustice and loss of control, not only by tissue damage.
Screen Early
Identify psychological distress early and offer trauma-informed counseling.
Coordinate Care
Align physical treatment (chiropractic, PT) and medical input to deliver a single, reassuring narrative.
Pace Reactivation
Use time-based progression to avoid flare cycles; match intensity to physiologic readiness.
The goal isn't to minimize the injury. It's to reframe the experience from injustice to recovery and agency.
Key Takeaway: Victims consistently have worse pain outcomes than at-fault drivers due to loss of control and perceived injustice. Recognizing this biological reality allows us to treat the whole personârestoring safety and agency alongside physical rehabilitation.
References
- Gabbe BJ, et al. Association Between Perception of Fault... BMJ Open. 2015.
- Littleton SM, et al. The Influence of Fault on Health... Injury. 2012.
- Kovacevic J, et al. Predictors of Mental Health Outcomes... J Clin Med. 2020.
- Kovacevic J, et al. Different Patterns of Mental Health Outcomes... IJERPH. 2021.
- Giummarra MJ, et al. Chronic Pain Following Motor Vehicle Collision. Clin J Pain. 2016.
- Grant GM, et al. Stressfulness of Claiming Compensation... JAMA Psychiatry. 2014.
- Murgatroyd DF, et al. Seeking Financial Compensation... BMC Musculoskelet Disord. 2016.
- Elbers NA, et al. Factors That Challenge Health in the Compensation Process. BMC Public Health. 2015.