Is all validation equal? Evaluating sensory- and emotion-focused validation in the context of experimentally induced pain

Abstract

Validation has been examined in experimental and clinical settings, but examination of whether specific content of validation responses affect pain-related outcomes has not been considered. We examined the impact of sensory- or emotion-focused validation following a pain task. Participants (N = 140) were randomly assigned to one of three validation conditions (i.e. sensory, emotional, or neutral) and completed the cold pressor task (CPT). Participants provided self-report ratings of pain and affective-related variables. Subsequently, a researcher validated emotional, sensory, or no aspects of participants’ experience. The CPT was repeated, as were the self-report ratings. No significant differences were observed across conditions in pain or affective outcomes. All conditions reported an increase in pain intensity and pain unpleasantness across CPT trials. These findings suggest validation content may not impact pain outcomes during painful experiences. Future directions to understanding the nuances of validation across interactions and settings are discussed.

Observer responses to pain are known to impact pain experiences (Hadjistavropoulos et al., 2011). In operant models, bringing attention to pain behaviors can reinforce and increase pain in both acute and chronic pain (Fordyce et al., 1982). Contrastingly, empathy models of pain suggest validation can promote emotional closeness and enhance emotion regulation, which can positively affect one’s ability to cope (Cano et al., 2008).

Pain-related emotional disclosures of distress have been identified as a class of behaviors that differ from traditional “pain talk” and include affective aspects of the pain experience using emotion words. This distinct content may explain inconsistencies in pain research regarding observer responses to an individual’s pain experiences. Validation is a particular approach to responding to pain-related disclosures that involves recognizing an individual’s experience as valid in a judgment-free manner. Validating responses to an individual’s pain experiences can improve emotions and adherence during pain tasks (Linton et al., 2012), and in close relationships (Edlund et al., 2015). When employed by clinicians, validation improves patient satisfaction (Linton et al., 2017) and pain outcomes (Vangronsveld and Linton, 2012).

Research employing validation frequently compares validation and invalidation (Linton et al., 2012), without further parsing of the validation based on aspects of the pain experience. Given that validation relies on the individual’s experience, validation of any aspect of the pain experience—whether sensory or affective—could be warranted. We examined whether different types of validation (i.e. physical, emotional, or no validation) following a pain task led to different pain-related outcomes and experiences among participants. We hypothesized that participants who receive emotion-focused validation would report lower pain intensity and unpleasantness ratings (hypothesis one), have higher pain tolerance (hypothesis two), report less worry (hypothesis three), and less perceived threat of pain (hypothesis four) during a subsequent pain task.

Methods

Participants

Following receipt of Ethics Board (BEH 631) approval from the University of Saskatchewan Research, university students were recruited. Participants reporting contraindications to using the cold pressure task were excluded (e.g. cardiovascular disorder, Raynaud’s phenomenon, see von Baeyer et al., 2005). A priori power analysis suggested a sample of 138 was required to identify a medium-sized effect (repeated measures ANOVA; α = 0.05, 1 − β = 0.8, r among repeated measures = 0.75). Participants received 1% course credit for completing the study.

A total of 140 students participated. The majority were female (n = 95) with a mean age of 21.11 (3.83) years. Participants identified as Caucasian/White (60%); Asian/Pacific Islander (15%); African American/Black (9%); Aboriginal, First Nation, Indigenous, or Metis (6%); Middle Eastern (5%); or other ethnic origin (4%).

Measures and equipment

Cold Pressor Task (CPT)

The CPT is a widely used pain induction method (von Baeyer et al., 2005). Our CPT involved an 8L stainless steel tank filled with cold water circulated at 10 L/minute using an external pump attached to the tank and cooled using a dip cooler. Water temperature was set to 4°C (±1°) and kept stable through an electric thermoregulator. An uninformed maximum immersion time of 4 minutes was employed.

Demographic questionnaire

Participants’ age, gender, ethnicity, and marital status were queried through a demographics questionnaire.

Pain and Affective Rating Scale

Pain intensity and unpleasantness were rated with 11-point Numeric Rating Scales (NRS; 0 = “not at all intense/unpleasant”; 10 = “most intense/unpleasant possible” (Jensen et al., 1986), as were participants affective distress during the pain task and concern if they had to repeat the task (0 = “not at all worried/concerned”; 10 = “most worried/concerned possible”). The NRS is a reliable and valid measure of pain in studies examining acute pain procedures (Bahreini et al., 2015), and has been established as a valid and reliable tool to measure emotional variables such as anxiety (Fox et al., 2016; Knotkova et al., 2004).

The Perceived Threat of Pain Questionnaire (PTPQ)

The 4-item PTPQ was used to assess threat of pain in participants (Corley et al., 2016; Vlaeyen et al., 2009). Responses were rated from 0 to 10 (0 = “Not at all”, 10 = “Very much”), with items summed to represent perceived threat of pain. When used alongside the CPT, the PTPQ has demonstrated strong internal consistency (Clark et al., 2017). In the current investigation, Cronbach’s alpha was 0.88.

Cold Pressor Experience Interview (CPEI)

The CPEI was a 4-item, verbally administered interview, completed after participants completed their first CPT. These questions targeted both the emotional and physical aspects of the pain experience by asking participants to share what they felt physically and emotionally, before, during, and after completing the CPT.

Pain tolerance

Pain tolerance was measured by evaluating duration of hand submersion starting when the participant placed their hand in the cold water and ending when the participant removed their hand from the water.

Post-study questionnaire

This questionnaire assessed for biased responding that would occur had participants guessed the purpose of the study. Participants described their perception of the main goal of the study through one open-ended question.

Procedure

Randomization

Prior to data collection, participant IDs were generated. A research assistant conducted a simple computer-randomization procedure that assigned each participant into one of three conditions (physical validation, emotion validation, and neutral control). Condition assignment for each participant ID was written on a piece of paper in a sealed envelope labeled with the participant ID. The researcher running the study was blinded to participant condition until the participant had provided consent.

Protocol

Upon arriving at the laboratory and following receipt of informed consent, participants completed the demographic questionnaire. During the consent procedures, participants were told that the purpose of the study was to examine responses to pain and participants were not informed that there were different validation conditions until the end of the study. Using standardized instructions, the researcher informed participants on how to provide ratings on the NRSs and provided an overview of the CPT. The researcher then left the testing room and went to an adjacent room with a two-way mirror. The first CPT trial was completed and upon completion, participants provided ratings of the highest level of pain unpleasantness, pain intensity, and worry, and concern that they experienced during the task; and their concern to repeat the task. The researcher then returned to the room and administered the CPEI, then provided validation based on participant condition assignment. CPEI questions and responses were audio recorded. The researcher once again left the testing room. The participant completed the second trial of the CPT using the opposite hand, followed immediately by administration of the NRSs, the PTPQ, and the post-study questionnaire. The researcher then returned to the room and provided a debriefing to the participant in which they were informed of the purpose of the study and of their group assignment.

Each CPEI recording was reviewed by a member of the research team who was blind to the participant’s condition. The reviewer indicated which validation content was being attended to in the interaction. The classification of the audio files matched with the intended validation condition across all participants. A review of post-study questionnaire responses indicated that participants were unaware of their assigned condition and had not guessed the purpose of the study.

Validation intervention

Participants were randomly assigned to receive one of three validation interventions following the first CPT. Using standardized scripts, the researcher validated only the participants’ physical experience (e.g. numbness, tingling), emotional experience (e.g. anxious, apprehensive), or provided no validation (neutral group). The researcher used the descriptors provided from the participant in the CPEI to personalize the validation.

Data analysis

Preliminary analyses were conducted to compare demographic characteristics across conditions, with no significant differences identified. For pain outcomes, ANOVAs examined the impact of the between-subjects variable of validation type (emotion-validated, physical-validated, neutral) on the dependent variables of pain unpleasantness, pain intensity, and pain tolerance, across two time periods (post CPT 1 (time 1), post CPT 2 (time 2)). Perceived threat of pain was assessed using a one-way ANOVA examining whether differences in ratings on the PTPQ occurred between the three validation conditions. For affective outcomes, ANOVAs examined the impact of the between-subjects variable of validation type (emotion-validated, physical-validated, neutral) on the dependent variables of worry and concern to repeat the task across two time periods (post CPT 1 (time 1), post CPT 2 (time 2)).

Results

Pain outcomes

Means and standard deviations on all outcome variables across groups are summarized in the supplementary materials. For the dependent variable of pain unpleasantness, there was no significant interaction between validation type and time. There was a moderate main effect for time, Wilks’ Lambda = 0.95, F (1, 137) = 7.92, p = 0.006, η_p² = 0.055, with an increase in pain unpleasantness ratings from time 1 to time 2 in all conditions. The main effect of validation type was not significant.

There was no significant interaction between validation type and time on the dependent variable of pain intensity. There was a large main effect for time, Wilks’ Lambda = 0.90, F (1, 137) = 15.79, p < 0.005, η_p² = 0.10. In all conditions, pain intensity ratings increased from time 1 to time 2. The main effect of validation type was not significant for pain intensity ratings, F (2, 137) = 0.21, p = 0.81, η_p² = 0.003.

There was no significant interaction or main effects between validation type and time on participants’ pain tolerance measures. The one-way ANOVAs examining perceived threat of pain across conditions produced non-significant results.

Affective outcomes

There were no significant interactions between validation type and time on ratings of worry or concern for repeating the task. There were no main effects for either affective variable.

Discussion

This is the first investigation, to our knowledge, to compare the impact of sensory-specific and emotion-specific validation provided by an observer in a pain context. Contrary to expectations, validation of the sensory aspects did not lead to worsening pain outcomes or perceived threat among participants, as might be expected within an operant framework (Fordyce et al., 1982). We also saw no differences between the two validation conditions and, surprisingly, we found that both validation conditions did not lead to improved outcomes over the control condition.

It is unclear if worse outcomes would have occurred in an invalidation group (e.g. Edlund et al., 2015; Linton et al., 2012; Vangronsveld and Linton, 2012) and whether invalidation has a more powerful impact on pain outcomes than validation itself. Alternatively, all participants in our study may have felt validated due to being asked to share their pain experience, regardless of group assignment. As well, low worry/concern and threat ratings, along with the non-clinical nature of our sample could represent a group of participants who were not sufficiently distressed by the pain experience to gain value from validation of emotional aspects of their experience. Emotional disclosures are proposed to be functional and goal-directed (Cano and Goubert, 2017), and often are used to express distress related to loss of reward (e.g. inability to engage in valued activities) (Papini et al., 2015), or to reduce distress caused by pain by aiding in emotion regulation. Empathy models of pain have also illustrated that validation between individuals can promote empathic bonds and facilitate positive benefits, such as decreased pain (Cano et al., 2008; Leong et al., 2015; Vangronsveld and Linton, 2012). Consequently, the lack of condition effects in pain and affective outcomes observed in this study could also suggest that an empathic bond was not established.

There are limitations and future directions to be considered. Our study was conducted in a lab-based setting with a single researcher, potentially limiting the impacted pain responses and translation into natural settings. Second, our sample consisted of university students and thus results might not generalize to other populations. Third, while our investigation was novel in its inclusion of a neutral condition, the lack of an invalidation condition limits our ability to determine if the results would have been different had such a condition been incorporated. Further investigation with the inclusion of an invalidation condition would be valuable. Examining content of validation in more naturalistic pain settings (e.g. immunizations) may clarify the influence that different types of validation have on clinical pain versus laboratory-induced pain. Evaluations of behavioral markers of pain (e.g. facial expression) may also be valuable, as previous research has shown that verbal pain expression and behavioral pain expression do not always align when in the presence of an observer (Gagnon et al., 2017).

Overall, our findings provide indication that there is more work to be done to understand the nuances of validation. Our investigation contributes toward understanding theoretical models of pain and provide valuable evidence that focusing on sensory experiences and non-emotional pain talk may not lead to increased pain outcomes. This research supports further investigation of the function of emotional disclosures of pain-related distress and invites clarification of observer validation responses.

Research Data

sj-docx-1-hpq-10.1177_13591053231161065 – Supplemental material for Is all validation equal? Evaluating sensory- and emotion-focused validation in the context of experimentally induced pain

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sj-docx-1-hpq-10.1177_13591053231161065 for Is all validation equal? Evaluating sensory- and emotion-focused validation in the context of experimentally induced pain by Sadie Eskowich, Cayley Mackie, Kayla M Wall and Michelle M Gagnon in Journal of Health Psychology

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This article is distributed under the terms of the Creative Commons Attribution 4.0 License (http://www.creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).

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This article is distributed under the terms of the Creative Commons Attribution 4.0 License (http://www.creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).

sj-sps-4-hpq-10.1177_13591053231161065 for Is all validation equal? Evaluating sensory- and emotion-focused validation in the context of experimentally induced pain by Sadie Eskowich, Cayley Mackie, Kayla M Wall and Michelle M Gagnon in Journal of Health Psychology

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This article is distributed under the terms of the Creative Commons Attribution 4.0 License (http://www.creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).

sj-spv-3-hpq-10.1177_13591053231161065 for Is all validation equal? Evaluating sensory- and emotion-focused validation in the context of experimentally induced pain by Sadie Eskowich, Cayley Mackie, Kayla M Wall and Michelle M Gagnon in Journal of Health Psychology