People seeking treatment for pain are often emotionally distressed. It is important that clinicians recognize and respond appropriately to this distress that can shape patients’ experiences and expectations of care, disrupt patient engagement in shared decision-making about management of their condition, and deter adherence to treatment advice. However, despite the potential for patient distress to derail pain management outcomes, many clinicians are not equipped with the required skills to identify and respond to patient distress.
A recent IASP Pain Research Forum virtual seminar, "The Heart of the Matter: Understanding and Responding to Patient Distress in Conversations About Pain and Pain Management," discussed evidence-based strategies for identifying and responding to patient distress in a manner that builds trust and empowers patients to participate more collaboratively in their care. The seminar was presented by Claire Ashton-James, PhD, University of Sydney, Australia, on February 18, 2021. A Q&A session moderated by Jessica Chen, PhD, University of Washington, Seattle, US, followed the presentation.
Ashton-James' take-home message was that the distress experienced by people in pain is normal, expected, and should not be feared or avoided. Understanding and responding to distress provides valuable opportunities for clinicians to show empathy, build trust, and connect with their patients. Clinicians who respond empathetically to their patients can also help reduce emotional distress and enhance patient outcomes. It is important that the clinician’s intentions reflect acknowledgement of, curiosity about, respect for, and support of the patient’s distress, and that clinicians regularly monitor the patient’s response to empathetic communication to ensure individualized care.
A recording of the webinar is freely available to IASP members here.
Pain can be distressing
Pain is an unpleasant experience associated with variable levels of emotional distress. Patients are often distressed when first seeking pain treatment, and experience several negative emotions such as fear and despair associated with their pain. Distress can pivot to feelings of hopelessness, helplessness, disappointment, and even anger after receiving pain management advice, particularly advice that is discordant with patients' beliefs and expectations about care, or when further investigations or specialist referrals are denied. Ashton-James emphasized that these “negative emotions are not inherently problematic but are a normal response to suffering and a predictable response to challenging circumstances.”
Responding empathically to distress matters a lot
Ashton-James highlighted the importance of appropriately responding to a patient’s distress. If the distress or concerns communicated by patients aren’t addressed or, even worse, are avoided, there is a risk that the patient will experience more distress, lose trust in the clinician, and ultimately reduce engagement with treatment. Patients who remain in a distressed state are more likely to have poorer treatment outcomes.
Responding to patient distress with empathy can help reduce distress, increase trust in the clinician, and increase the patient’s health-related self-efficacy – patients' belief in their capacity to engage in health-related behaviors required for management of their pain problem.
Ashton-James said that it “feels good to receive empathy.” Receiving empathic care from a trusted individual satisfies our most basic human desires such as belonging. Empathic communication also increases the production of endogenous opioids and prompts the release of oxytocin, both of which are involved in positive treatment expectations and placebo responses.
However, conversations about distress and the provision of empathetic responses are too often absent in clinical practice. Ashton-James noted that, on average, 70% of clinician conversations ignored or didn’t directly address patient distress.
Concerns about empathic responses
What are the barriers to responding to patients empathetically? Ashton-James described and addressed several concerns discussed in the literature, including concerns that you could “open Pandora’s box,” that there is “a lack of time,” and that clinicians will “burn out.” Most importantly, clinicians often report that they want to respond empathetically but don’t know how. This lack of confidence in responding to patient distress is a key predictor of clinician exhaustion, burnout, and their own distress.
How to respond with empathy
Ashton-James synthesized the literature on empathic responses into four categories of intentions. These four categories provide a framework for clinicians to deliver both verbal and nonverbal empathic responses.
The acronym ARCS represents the four categories of intentions: A, acknowledgment of the patient experience through nonverbal means such as eye gaze, or verbal means such as naming the emotion expressed; R, respect for the patient’s experience, indicated by listening without interrupting or providing validation, for instance; C, curiosity for understanding the patient experience, through body orientation or exploring causes, for example; and S, support for the patient’s goal attainment with treatment, which can take the form of touch or providing explicit commitment to give support, to name a couple.
Through ARCS, clinicians can engage in more empathic conversations with their patients. Ashton-James reiterated that providing empathy, like all components of care, needs to be individualized to each patient. Clinicians are encouraged to monitor the patient’s feedback during conversations to gauge the “amplitude of empathic responses” required.
For clinicians who work in pain management, exposure to patient distress is inevitable. It is important that patient distress not be feared or avoided but embraced empathetically. Through the ARCS of conversation, clinicians can be prepared to show empathy, build trust, and connect with their patients to ultimately improve the care provided to people in pain.
Aidan G. Cashin is a PhD student at the Centre for Pain IMPACT, Neuroscience Research Australia, University of New South Wales, Australia, and a PRF Correspondent.
Image credit: scyther5/123RF Stock Photo.