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Importance for patients of feeling accepted and understood by physicians before and after multimodal pain rehabilitation

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Published/Copyright: October 1, 2017
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Scandinavian Journal of Pain
From the journal Scandinavian Journal of Pain Volume 17 Issue 1

In this issue of Scandinavian Journal of Pain, Sara Edlund and her colleagues explore pain patients’ perceptions of validation and invalidation from their physicians pre- and post-treatment [1]. Validation/invalidation is a promising area of research in pain management, focusing on the importance of feeling accepted and understood. Whilst validating responses communicate understanding and acceptance to another (i.e. that their thoughts, feelings and/or behaviours are understandable and legitimate), invalidation communicates non-understanding and non-acceptance (i.e. that the individual’s experiences are somehow wrong or illegitimate) [2,3,4].

This study explores several important questions in validation research which have not yet been investigated; Can pain patients be clustered in terms of their perceptions of validation/invalidation from their physician? Are patients’ perceptions of validation/invalidation from their physician stable over time? How do perceptions of feeling understood and accepted (or not) by the physician affect patients’ experiences of pain (in terms of pain intensity and severity ratings, mood, pain catastrophizing, anxiety sensitivity and treatment outcome)?

1 High validation and low invalidation important for outcome of pain rehabilitation

Findings from this research suggest that most patients in this study felt understood by their physician pre- and post treatment. However, a small group of patients did not, rating their encounter with the physician as low in validation and heightened in invalidation. No link was observed between patients’ perceived validation/invalidation of their physician pre- and post-treatment, and treatment outcome. However, the heightened invalidation cluster reported greater negative affectivity post treatment (anxiety, anxiety sensitivity and negative affect) compared with the other two identified clusters (“moderate validation and invalidation” cluster, and “high validation and low invalidation” cluster) and reported greater levels of depression, pain interference and pain catastrophizing post treatment than the high validation cluster. Moreover, although patient perceptions of validation/invalidation were generally stable over time, some patients changed cluster. Interestingly, results suggested that patients scoring high on negative affectivity and pain interference ended up in the heightened invalidation cluster after treatment.

This study adds to the growing body of literature which implicates the value of validation in the context of chronic pain; validating feedback (or at least lack of invalidating feedback) has been found to increase emotional wellbeing [4], reduce physiological arousal [5,6], increase pain tolerance and adherence [7], reduce ratings of pain intensity and frustration [8] and counteract the interference caused by pain catastrophizing on individuals’ ability to recall information [9] compared with invalidating feedback. Thus, communicating understanding and acceptance in the context of pain, may have worthwhile and far-reaching consequences.

2 Importance of the patient’s own perception of invalidation

Whilst much of the research to date has been experimental, a strength of Edlund and colleagues’ study is in its ecological validity, situated within the clinical setting. Moreover, Edlund and her coworkers focus on patients’ perceptions ofvalidation and invalidation rather than objective ratings of patient-provider interactions. The researchers emphasize that given that invalidation is “in the eye of the beholder” (p. 1654) [10], it is important to consider how communication is received and interpreted by the patient. Regardless of whether a physician’s intention is to understand, or an interaction is objectively rated as “validating”, if the patient does not perceive that their thoughts, feelings, behaviours or experiences are being accepted and understood, it is likely that the potential benefits of validation will be lost.

Moreover, although ideas about the transactional model within validation research exist, there is still little clinically-based research exploring the links between perceived validation and the emotional experiences of patients in pain. Fruzzetti and Worrall’s transactional model [11] proposes that within a couple’s interaction, heightened emotional arousal is likely to lead to inaccurate expression of emotion, which in turn, leads to misunderstanding and invalidation from the other. Such invalidating feedback is expected to heighten emotional arousal further, feeding a cycle of unhealthy expression and misunderstanding. Moreover, one study suggests that feelings of invalidation can be felt by both parties [12]; within a pain consultation, both patients and providers can be left feeling that the other is not listening, understanding or accepting their responses, resulting in feelings of hopelessness, anger and/or withdrawal.

3 The negative power of the feeling of not being understood

Edlund and coworkers take important first steps in understanding this link between perceived validation/invalidation from the physician and the patient’s experiences of pain and negative emotion, in identifying a small cluster of patients who do not feel understood, and observing some significant differences in the ratings of this subgroup in terms of negative affectivity and pain interference. Whilst it is still unclear what the direction of this effect is, this work raises important ideas for future research looking at the effects of validating and invalidating transactional patterns in the pain setting. The researchers, in acknowledging the study’s limitations, suggest useful ways to extend upon this work; triangulating findings from objective ratings of interactions and patient ratings would be a helpful step in understanding the mechanisms through which validation/invalidation may be influencing pain patients’ experiences. Overall, this study, in exploring validation/invalidation from the patient’s perspective, emphasizes the importance of considering not just the value of validation, but for whom, and under what circumstances.

DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2017.07.007.

  1. Conflict of interest: None declared.

References

[1] Edlund SM, Wurm M, Hollandare F, Linton SJ, Fruzzetti AE, Tillfor M. Pain patients’ experiences of validation and invalidation from physicians before and after multimodal pain rehabilitation: associations with pain, negative affectivity, and treatment outcome. Scand J Pain 2017;17:77–86.Search in Google Scholar

[2] Fruzzetti AE, Shenk C, Hoffman PD. Family interaction and the development of borderline personality disorder: a transactional model. Dev Psychopathol 2005;17:1007–30.Search in Google Scholar

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[4] Edlund SM, Carlsson ML, Linton SJ, Fruzzetti AE, Tillfors M. I see you’re in pain – the effects of partner validation on emotions in people with chronic pain. Scand J Pain 2015;31:16–21.Search in Google Scholar

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[6] Greville-Harris M, Hempel R, Karl A, Dieppe P, Lynch TR. The power of invalidating communication: receiving invalidating feedback predicts threat-related emotional, physiological, and social responses. J Soc Clin Psychol 2016;35:471–93.Search in Google Scholar

[7] Linton SJ, Boersma K, Vangronsveld K, Fruzzetti A. Painfully reassuring? The effects of validation on emotions and adherence in a pain test. Eur J Pain 2012;16:592–9.Search in Google Scholar

[8] Vangronsveld KL, Linton SJ. The effect of validating and invalidating communication on satisfaction, pain and affect in nurse suffering from low back pain during a semi-structured interview. EurJ Pain 2012;16:239–46.Search in Google Scholar

[9] Carstens JKP, Boersma K, Schrooten MGS, Linton SJ. Effects ofvalidating communication on recall during a pain-task in healthy participants. Scand J Pain 2017;17:118–25.Search in Google Scholar

[10] Kool MB, van Middendorp H, Boeije HR, Geenen R. Understanding the lack of understanding: invalidation from the perspective of the patient with fibromyalgia. Arthritis Care Res 2009;61:1650–6.Search in Google Scholar

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Published Online: 2017-10-01
Published in Print: 2017-10-01

© 2017 Scandinavian Association for the Study of Pain

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  83. Editorial comment
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  86. Assessment and treatment at a pain clinic: A one-year follow-up of patients with chronic pain
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  130. Narratives of life with long-term low back pain: A follow up interview study
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  133. Clinical pain research
  134. Chronic pain disrupts ability to work by interfering with social function: A cross-sectional study
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  136. Evaluation of external vibratory stimulation as a treatment for chronic scrotal pain in adult men: A single center open label pilot study
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https://doi.org/10.1016/j.sjpain.2017.08.011

Articles in the same Issue

  1. Observational study
  2. Perceived sleep deficit is a strong predictor of RLS in multisite pain – A population based study in middle aged females
  3. Clinical pain research
  4. Prospective, double blind, randomized, controlled trial comparing vapocoolant spray versus placebo spray in adults undergoing intravenous cannulation
  5. Clinical pain research
  6. The Functional Barometer — An analysis of a self-assessment questionnaire with ICF-coding regarding functional/activity limitations and quality of life due to pain — Differences in age gender and origin of pain
  7. Clinical pain research
  8. Clinical outcome following anterior arthrodesis in patients with presumed sacroiliac joint pain
  9. Observational study
  10. Chronic disruptive pain in emerging adults with and without chronic health conditions and the moderating role of psychiatric disorders: Evidence from a population-based cross-sectional survey in Canada
  11. Educational case report
  12. Management of patients with pain and severe side effects while on intrathecal morphine therapy: A case study
  13. Clinical pain research
  14. Behavioral inhibition, maladaptive pain cognitions, and function in patients with chronic pain
  15. Observational study
  16. Comparison of patients diagnosed with “complex pain” and “somatoform pain”
  17. Original experimental
  18. Patient perspectives on wait times and the impact on their life: A waiting room survey in a chronic pain clinic
  19. Topical review
  20. New evidence for a pain personality? A critical review of the last 120 years of pain and personality
  21. Clinical pain research
  22. A multi-facet pain survey of psychosocial complaints among patients with long-standing non-malignant pain
  23. Clinical pain research
  24. Pain patients’ experiences of validation and invalidation from physicians before and after multimodal pain rehabilitation: Associations with pain, negative affectivity, and treatment outcome
  25. Observational study
  26. Long-term treatment in chronic noncancer pain: Results of an observational study comparing opioid and nonopioid therapy
  27. Clinical pain research
  28. COMBAT study – Computer based assessment and treatment – A clinical trial evaluating impact of a computerized clinical decision support tool on pain in cancer patients
  29. Original experimental
  30. Quantitative sensory tests fairly reflect immediate effects of oxycodone in chronic low-back pain
  31. Editorial comment
  32. Spatial summation of pain and its meaning to patients
  33. Original experimental
  34. Effects of validating communication on recall during a pain-task in healthy participants
  35. Original experimental
  36. Comparison of spatial summation properties at different body sites
  37. Editorial comment
  38. Behavioural inhibition in the context of pain: Measurement and conceptual issues
  39. Clinical pain research
  40. A randomized study to evaluate the analgesic efficacy of a single dose of the TRPV1 antagonist mavatrep in patients with osteoarthritis
  41. Editorial comment
  42. Quantitative sensory tests (QST) are promising tests for clinical relevance of anti–nociceptive effects of new analgesic treatments
  43. Educational case report
  44. Pregabalin as adjunct in a multimodal pain therapy after traumatic foot amputation — A case report of a 4-year-old girl
  45. Editorial comment
  46. Severe side effects from intrathecal morphine for chronic pain after repeated failed spinal operations
  47. Editorial comment
  48. Opioids in chronic pain – Primum non nocere
  49. Editorial comment
  50. Finally a promising analgesic signal in a long-awaited new class of drugs: TRPV1 antagonist mavatrep in patients with osteoarthritis (OA)
  51. Observational study
  52. The relationship between chronic musculoskeletal pain, anxiety and mindfulness: Adjustments to the Fear-Avoidance Model of Chronic Pain
  53. Clinical pain research
  54. Opioid tapering in patients with prescription opioid use disorder: A retrospective study
  55. Editorial comment
  56. Sleep, widespread pain and restless legs — What is the connection?
  57. Editorial comment
  58. Broadening the fear-avoidance model of chronic pain?
  59. Observational study
  60. Identifying characteristics of the most severely impaired chronic pain patients treated at a specialized inpatient pain clinic
  61. Editorial comment
  62. The burden of central anticholinergic drugs increases pain and cognitive dysfunction. More knowledge about drug-interactions needed
  63. Editorial comment
  64. A case-history illustrates importance of knowledge of drug-interactions when pain-patients are prescribed non-pain drugs for co-morbidities
  65. Editorial comment
  66. Why can multimodal, multidisciplinary pain clinics not help all chronic pain patients?
  67. Topical review
  68. Individual variability in clinical effect and tolerability of opioid analgesics – Importance of drug interactions and pharmacogenetics
  69. Editorial comment
  70. A new treatable chronic pain diagnosis? Flank pain caused by entrapment of posterior cutaneous branch of intercostal nerves, lateral ACNES coined LACNES
  71. Clinical pain research
  72. PhKv a toxin isolated from the spider venom induces antinociception by inhibition of cholinesterase activating cholinergic system
  73. Clinical pain research
  74. Lateral Cutaneous Nerve Entrapment Syndrome (LACNES): A previously unrecognized cause of intractable flank pain
  75. Editorial comment
  76. Towards a structured examination of contextual flexibility in persistent pain
  77. Clinical pain research
  78. Context sensitive regulation of pain and emotion: Development and initial validation of a scale for context insensitive avoidance
  79. Editorial comment
  80. Is the search for a “pain personality” of added value to the Fear-Avoidance-Model (FAM) of chronic pain?
  81. Editorial comment
  82. Importance for patients of feeling accepted and understood by physicians before and after multimodal pain rehabilitation
  83. Editorial comment
  84. A glimpse into a neglected population – Emerging adults
  85. Observational study
  86. Assessment and treatment at a pain clinic: A one-year follow-up of patients with chronic pain
  87. Clinical pain research
  88. Randomized, double-blind, placebo-controlled, dose-escalation study: Investigation of the safety, pharmacokinetics, and antihyperalgesic activity of L-4-chlorokynurenine in healthy volunteers
  89. Clinical pain research
  90. Prevalence and characteristics of chronic pain: Experience of Niger
  91. Observational study
  92. The use of rapid onset fentanyl in children and young people for breakthrough cancer pain
  93. Original experimental
  94. Acid-induced experimental muscle pain and hyperalgesia with single and repeated infusion in human forearm
  95. Original experimental
  96. Swearing as a response to pain: A cross-cultural comparison of British and Japanese participants
  97. Clinical pain research
  98. The cognitive impact of chronic low back pain: Positive effect of multidisciplinary pain therapy
  99. Clinical pain research
  100. Central sensitization associated with low fetal hemoglobin levels in adults with sickle cell anemia
  101. Topical review
  102. Targeting cytokines for treatment of neuropathic pain
  103. Original experimental
  104. What constitutes back pain flare? A cross sectional survey of individuals with low back pain
  105. Original experimental
  106. Coping with pain in intimate situations: Applying the avoidance-endurance model to women with vulvovaginal pain
  107. Clinical pain research
  108. Chronic low back pain and the transdiagnostic process: How do cognitive and emotional dysregulations contribute to the intensity of risk factors and pain?
  109. Original experimental
  110. The impact of the Standard American Diet in rats: Effects on behavior, physiology and recovery from inflammatory injury
  111. Educational case report
  112. Erector spinae plane (ESP) block in the management of post thoracotomy pain syndrome: A case series
  113. Original experimental
  114. Hyperbaric oxygenation alleviates chronic constriction injury (CCI)-induced neuropathic pain and inhibits GABAergic neuron apoptosis in the spinal cord
  115. Observational study
  116. Predictors of chronic neuropathic pain after scoliosis surgery in children
  117. Clinical pain research
  118. Hospitalization due to acute exacerbation of chronic pain: An intervention study in a university hospital
  119. Clinical pain research
  120. A novel miniature, wireless neurostimulator in the management of chronic craniofacial pain: Preliminary results from a prospective pilot study
  121. Clinical pain research
  122. Implicit evaluations and physiological threat responses in people with persistent low back pain and fear of bending
  123. Original experimental
  124. Unpredictable pain timings lead to greater pain when people are highly intolerant of uncertainty
  125. Original experimental
  126. Initial validation of the exercise chronic pain acceptance questionnaire
  127. Clinical pain research
  128. Exploring patient experiences of a pain management centre: A qualitative study
  129. Clinical pain research
  130. Narratives of life with long-term low back pain: A follow up interview study
  131. Observational study
  132. Pain catastrophizing, perceived injustice, and pain intensity impair life satisfaction through differential patterns of physical and psychological disruption
  133. Clinical pain research
  134. Chronic pain disrupts ability to work by interfering with social function: A cross-sectional study
  135. Original experimental
  136. Evaluation of external vibratory stimulation as a treatment for chronic scrotal pain in adult men: A single center open label pilot study
  137. Observational study
  138. Impact of analgesics on executive function and memory in the Alzheimer’s Disease Neuroimaging Initiative Database
  139. Clinical pain research
  140. Visualization of painful inflammation in patients with pain after traumatic ankle sprain using [11C]-D-deprenyl PET/CT
  141. Original experimental
  142. Developing a model for measuring fear of pain in Norwegian samples: The Fear of Pain Questionnaire Norway
  143. Topical review
  144. Psychoneuroimmunological approach to gastrointestinal related pain
  145. Letter to the Editor
  146. Do we need an updated definition of pain?
  147. Narrative review
  148. Is acetaminophen safe in pregnancy?
  149. Book Review
  150. Physical Diagnosis of Pain
  151. Book Review
  152. Advances in Anesthesia
  153. Book Review
  154. Atlas of Pain Management Injection Techniques
  155. Book Review
  156. Sedation: A Guide to Patient Management
  157. Book Review
  158. Basics of Anesthesia
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