Validating pain communication: current state of the science
Open accessAbstract
Department of Psychology and Neuroscience, Duke University, Durham, NC, USA Corresponding author. Address: Department of Psychology and Neuroscience, Duke University, 2200 W Main Street, Suite 340 Durham, NC, USA 27705Tel: (919) 416-3400; fax: 919-416-345. E-mail address: [email protected] (F. J. Keefe). Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
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- Premisecitation§ Validating pain communication: Current state of the science
When patients receive social reinforcement, including validation, after disclosing pain-related thoughts and feelings, they may have worse outcomes, such as more pain.
“Despite the potential benefits of validation, some research suggests that receiving social reinforcement (including validation) after sharing pain-related thoughts and feelings may be associated with worse patient outcomes such as increased pain[22].”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [22]
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- Premisecitation§ Validating pain communication: Current state of the science
The amount of validation that recipients of pain communication provide is a potentially important factor that has been relatively understudied until recently.
“One potentially important factor that has been relatively understudied until recently is the level of validation that may or may not be provided by people who are the recipients of a pain communication [4].”
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- Premisecitation
Researchers increasingly consider whether a person feels validated by how a listener responds.
“A valuable addition to the conceptualization of validation has been the growing emphasis placed on considering whether or not a person feels validated by a listener’s response.[10; 15]”
Quote in the paperNot a substantial claim0 of 2 sources checked - Interpretationreasoning
When a pain patient feels understood and validated, this probably affects their emotions and actions differently than when they think others respond without understanding them.
“If a patient with pain feels understood and validated, it will likely influence their emotional state and their behaviors differently than if they perceive that others respond but do not understand them.”
Quote in the paperSubstantial claim - Premisecitation
When validation follows disclosure of pain-related thoughts or feelings, such disclosure probably increases.
“Alternatively, if validation occurs after someone discloses thoughts or feelings related to pain, this type of disclosure is likely to increase.”
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- Premisecitation§ Validating pain communication: Current state of the science
Responses from partners or healthcare providers to patients' pain-related disclosures may have significant consequences for pain-related outcomes.
“There is growing recognition that pain communication is important, and the way that people (e.g. partners, healthcare providers) respond to patients sharing their pain-related thoughts and feelings may have significant implications for pain-related outcomes[8].”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [8] source
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- Interpretationreasoning§ Validating pain communication: Current state of the science
These beliefs probably raise psychological distress and negative affect.
“beliefs which are likely to lead to increases in psychological distress and negative affect.”
Quote in the paperSubstantial claim - Premisecitation
When validation follows someone talking about pain or displaying other pain behaviors, those pain behaviors become more likely.
“Thus, if validation occurs after someone talks about their pain or shows other pain behaviors (see Figure 1, Panel A), then the likelihood of pain behaviors will increase.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [5] source
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- Interpretationreasoning
In the absence of intervention, some close others may validate immediately after patients describe their pain in detail, not realizing that such validation could reinforce maladaptive pain behaviors like focusing on pain, excessive reclining, or over-reliance on others.
“Without intervention, some significant others may engage in validating behaviors right after patients provide detailed descriptions of pain without realizing that these validating behaviors have the potential to reinforce maladaptive pain behaviors such as focusing on the pain, spending excessive time reclining, or over-reliance on others for assistance.”
Quote in the paperSubstantial claim- Rests on an assumption: People with ongoing pain probably discuss it with close others, and many of those others likely respond with attention or help.
- Premisecitation§ Validating pain communication: Current state of the science
A large number of chronic pain patients think that other people fail to understand their pain or regard it as legitimate.
“Many patients with chronic pain believe that others do not understand their pain or even consider their pain condition to be legitimate[9]”
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- Premisecitation
Several experiments support the notion that less negative affect can lead to less pain.
“Several experimental research studies have provided support for the idea that reductions in negative affect may lead to reductions in pain[18–20; 23]”
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- cites [19]
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- cites [20]
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- cites [23]
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- Premisecitation
The operant conditioning model emphasizes how social reinforcement shapes the development and maintenance of adaptive and maladaptive responses to ongoing pain.
“The operant conditioning model[5] focuses on the role that social reinforcement plays in the development and maintenance of maladaptive and adaptive responses to persistent pain.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [5] source
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- Premisenone given
Three models-operant conditioning, biosocial, and the interpersonal process model of intimacy-can predict how validating pain-related thoughts and feelings affects patient outcomes.
“Three theoretical models can be used to predict how validation of pain-related thoughts and feelings may influence patient outcomes: the operant conditioning model, the biosocial model, and the interpersonal process model of intimacy.”
Quote in the paperSubstantial claim - Premisecitation
In that study, validated participants were more satisfied with the interview than invalidated participants.
“Participants in the validation condition also reported greater satisfaction with the interview compared to participants in the invalidation condition.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [21]
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- Premiseown data
Neither experiment assessed participants' own perceptions of being validated or invalidated.
“Neither study measured perceived validation or invalidation from the perspective of the participant”
Quote in the paperNot a substantial claim - Premisecitation
More validation was unrelated to patients' pain reports or their anxiety or depression symptoms.
“Finally, higher levels of validation were not related to patient reports of pain or symptoms of anxiety or depression.”
Quote in the paperSubstantial claim0 of 3 sources checked - Premisecitation
Several studies have coded validation in chronic pain patient-partner interactions using the Validation and Invalidation Behavioral Coding System (VIBCS).
“A number of studies have used the Validation and Invalidation Behavioral Coding System (VIBCS[7]) to code validation occurring in interactions between patients with chronic pain and their partners.[1–3]”
Quote in the paperNot a substantial claim0 of 4 sources checked - Premisecitation
These behaviors were distinct from other spousal responses, including partner solicitousness.
“Second, these behaviors were found to be distinct from other spousal responses such as partner solicitousness.”
Quote in the paperSubstantial claim0 of 3 sources checked - Premisereasoning
Neither experiment measured pain-related factors beyond intensity, such as nonverbal pain behaviors, disability, or beliefs about the meaning of pain.
“Additionally, neither study measured aspects of the pain experience beyond pain intensity, such as non-verbal pain behaviors, pain-related disability, or interpretations about the meaning of the pain”
Quote in the paperSubstantial claim - Premisecitation
Observers reliably coded both validating and invalidating behaviors.
“First, observers were able to reliably code both validating behaviors and invalidating behaviors.”
Quote in the paperSubstantial claim0 of 3 sources checked - Premisecitation
That study found no difference in post-interview pain between validated and invalidated participants.
“Interestingly, participants exposed to validation, as opposed to invalidation, did not report differences in post-interview pain.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [21]
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- May combine two claims. 16
- Classified as probably not a substantial claim. 13
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PremisecitationThe biosocial model predicts that when patients are validated after disclosing pain-related thoughts and feelings, they will feel understood and accepted, have lower emotional arousal and negative affect, and may have less pain.
“According to the biosocial model, if patients receive validation after sharing pain-related thoughts and feelings, they will feel understood and accepted, will experience a reductions in emotional arousal and negative affect, and may experience a reduction in pain (see Figure 1, Panel B).”
Quote in the paperSubstantial claim0 of 2 sources checkedMay combine two claims.
PremisecitationThe biosocial model holds that validation soothes, lowers negative affect, and reduces tension in highly emotional interactions.
“According to the biosocial model[12; 13], validation has a soothing effect, reduces negative affect, and “takes the steam” out of interactions with high emotional arousal.[6]”
Quote in the paperSubstantial claim0 of 3 sources checkedMay combine two claims.
Premisecitation§ Validating pain communication: Current state of the scienceA romantic partner's validation may strengthen intimacy, which is associated with benefits like greater positive affect and better psychological well-being.
“Furthermore, validation from a romantic partner may enhance relationship intimacy, which is related to several positive benefits (e.g. increased positive affect, improved psychological well-being) [10; 11].”
Quote in the paperNot a substantial claim0 of 2 sources checkedProbably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationLinehan identifies six levels of validating behaviors that people like partners, friends, and health professionals can use.
“In the developing the construct of validation, Linehan describes six levels of validating behaviors that individuals (e.g. partners, friends, health professionals) may engage in (see Table 1).”
Quote in the paperNot a substantial claim0 of 2 sources checkedProbably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationIn the operant conditioning model, validation is a form of social reinforcement that raises the probability of the behavior it follows.
“This model views validation as a type of social reinforcement and predicts that validation increases the likelihood of whatever behavior it follows.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [5] source
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May combine two claims.
InterpretationreasoningBoth experimental studies had research assistants deliver validation or invalidation, which supports high internal validity but may reduce external validity.
“Both of these studies also used research assistants to deliver validation/invalidation, which contributes to high internal validity but may compromise external validity.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S4 (based). May combine two claims.
Premisenone givenAlthough some observational studies have coded validation and invalidation, none have yet compared observed validation with self-reported feelings of validation.
“Some observational studies have coded for validation and invalidation, but currently, no studies have compared observational reports of validation with self-reported feelings of validation.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
PremisecitationThe first experiment used healthy participants; the second used nurses with back pain in the previous six months.
“Lastly, the first study[14] used healthy participants while the second study[21] used nurses who reported back pain in past six months.”
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- cites [21]
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PremisecitationThat study found no differences between conditions in pain ratings or pain tolerance.
“No pain rating or pain tolerance differences were found between conditions.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [14]
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Classified as probably not a substantial claim. May combine two claims.
PremisecitationThe interpersonal process model predicts that when partners validate patients after they disclose pain-related thoughts and feelings, patients will report greater intimacy, positive affect, and relationship satisfaction, which in turn may reduce reported pain.
“The model (see Figure 1, Panel C) hypothesizes that when partners engage in validating behaviors after patients disclose pain-related thoughts and feelings, patients will report increased intimacy, positive affect, and relationship satisfaction; positive affective responses that in turn can lead to lower levels of reported pain.”
Quote in the paperSubstantial claim0 of 3 sources checkedClassified as probably not a substantial claim.
PremisecitationIn the interpersonal process model of intimacy, self-reported feelings of validation are a central construct.
“Self-reported feelings of validation are a key construct in the interpersonal process model of intimacy”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [10] source
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PremisecitationThe interpersonal process model proposes that intimacy arises when a speaker discloses personal information and a listener responds so that the speaker feels validated, understood, and cared for, which is called perceived partner responsiveness.
“This model hypothesizes that intimacy is a result of interactions where one person (the speaker) shares personally relevant information and another person (the listener) responds in a way that causes the speaker to feel validated, understood and cared for, which is referred to as “perceived partner responsiveness.”[10]”
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PremisecitationIn a second experiment with 28 nurses who had current back pain, validated participants felt less frustrated and angry, while invalidated participants felt more frustrated and angry.
“Participants who were assigned to the validation condition reported feeling less frustrated and less angry as compared to participants who received invalidation, who reported an increase in feelings of frustration and anger.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [21]
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PremisecitationIn an experiment with 59 healthy students, validated participants kept their positive affect, whereas invalidated participants reported less positive affect.
“Results showed that over the course of the experiment, participants in the validation condition maintained their positive affect, while patients in the invalidation condition reported a decline in positive affect.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [14]
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Interpretationown dataThe two experimental studies observed affect changes that match the biosocial model's predictions, but neither study found changes in pain intensity.
“These two experimental studies found changes in affect consistent with the hypotheses made by the biosocial model, while neither found changes in pain intensity over the course of the experiment.”
Quote in the paperSubstantial claimMay combine two claims.
PremisecitationIn that study, validated participants reported less worry, while invalidated participants reported more worry.
“Participants in the validation condition also reported a significant decrease in worry while participants in the invalidation group increased in worry.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [14]
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InterpretationreasoningPain intensity reports can be viewed as a pain behavior, and the absence of change in this behavior is inconsistent with both the biosocial and operant conditioning models.
“Reports of pain intensity may be considered a form of pain behavior, and the lack of change in this pain behavior does not fit with either the biosocial model or the operant conditioning model.”
Quote in the paperSubstantial claimClassified as probably not a substantial claim.
Premisenone givenIt remains unclear what validating responses actually reinforce.
“What exactly is being reinforced by validating responses (e.g. emotional disclosure, verbal reports of pain) has not been well-studied”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).
InterpretationreasoningThe way validation affects patients is probably more complex than any one model can explain.
“These models each make predictions about the influence of validation; however, it is likely that the mechanism by which validation influences patients is more nuanced than any single model captures.”
Quote in the paperNot a substantial claimClassified as probably not a substantial claim.
InterpretationreasoningA neutral comparison condition may be very difficult to include because most interactions give the patient some signal about whether they are understood.
“Including a neutral comparison condition, while desirable, may be very difficult since most interactions involve providing the patient with some indication that they are being understood or not.”
Quote in the paperSubstantial claim- Rests on an assumption: In most interactions, patients receive some signal about whether they are understood.
Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
PremisecitationThis model considers both the listener's actual response and how the speaker perceives that response.
“This model focuses on the speaker’s perception of the partner’s response in addition to the actual response of the listener.”
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May combine two claims.
PremisecitationWhen partners gave more validation, patients disclosed more and reported less support entitlement.
“Third, in couples where the partner provided higher levels of validation, patients were much more likely to engage in disclosure and much less likely to report a sense of support entitlement.”
Quote in the paperSubstantial claim0 of 3 sources checkedProbably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationThe interpersonal process model of intimacy treats intimacy as resulting from a transactional process.
“The interpersonal process model of intimacy[16; 17] views intimacy as the product of a transactional process.”
Quote in the paperNot a substantial claim0 of 2 sources checkedClassified as probably not a substantial claim. May combine two claims.
Premisenone givenSo far, validation has been compared only with invalidation and delivered only by research assistants.
“To date, validation has only been compared to invalidation and has only been delivered by a research assistant.”
Quote in the paperSubstantial claim
The paper relies on this without support.
People with ongoing pain probably discuss it with close others, and many of those others likely respond with attention or help.
“Patients having persistent pain are likely to talk about their pain with close others, and many of these people are likely to respond with attention or assistance.”
The paper relies on this without support.
In most interactions, patients receive some signal about whether they are understood.
“most interactions involve providing the patient with some indication that they are being understood or not.”
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
Each contradiction between two passages listed here was confirmed by an independent check.
Pain tolerance was measured despite a claim that only pain intensity was assessed
MinorThe paper says neither experimental study measured another aspect of pain beyond intensity, but it reports a pain-tolerance result for the first study.
“neither study measured aspects of the pain experience beyond pain intensity, such as non-verbal pain behaviors, pain-related disability, or interpretations about the meaning of the pain”
“No pain rating or pain tolerance differences were found between conditions.”
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“Despite the potential benefits of validation, some research suggests that receiving social reinforcement (including validation) after sharing pain-related thoughts and feelings may be associated with worse patient outcomes such as increased pain.(22) This article highlights studies examining the effects of validation…”
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- Authors
- Edmond, S. N., & Keefe, F. J.
- Affiliations
- Duke University (US)
- Venue
- Pain
- Published
- 2015-02
- Volume
- 156
- Issue
- 2
- Pages
- 215-219
- ISSN
- 0304-3959 (ISSN-L)
- PMC
- PMC4477266
- OpenAlex
- W1967177702
- Cited by
- 151
- References
- 19
- Citations by year
- 2026: 9 · 2025: 13 · 2024: 11 · 2023: 12 · 2022: 28 · 2021: 13 · 2020: 10 · 2019: 24 · 2018: 11 · 2017: 8 · 2016: 6 · 2015: 6
- FWCI
- 18.89
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Pain (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institutes of Health
- National Institute on Aging (AG041655, R01AG041655)
- National Cancer Institute (CA131148, CA173307, R21CA173307, R01CA131148)
- National Institute of Nursing Research (R01NR013910, NR013910)
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (UM1AR062800)
- National Center for Complementary and Integrative Health (UH2AT007788, R01AT007572, UH2 AT00788, AT007572)
- Topics
- Health Sciences › Health Professions › General Health Professions › Patient-Provider Communication in Healthcare
- Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Opioid Use
- Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
- Keywords
- pain communication, validation, pain assessment, patient-provider communication
- MeSH terms
- Communication, Emotions, Humans, Models, Theoretical, Pain, Pain Measurement
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