Nocebo Response

Validation and Invalidation: Your Patients and the “Nocebo Response”

No doubt you’ve heard of “the placebo response”. But how about “the nocebo response”? Much research has been done about now an inert pill, when presented with positive conditioning and expectations, can be as effective as the real thing, but not nearly as many studies have been conducted in regards to the nocebo effect, where the mere suggestion of negative association with a pill or procedure brings on negative side effects.

But the word “nocebo” doesn’t just refer to experiences with medications and treatments. Recently, a pair of doctors at the University of Southampton and University of Exeter Medical School in England penned a journal article entitled: “Bad is More Powerful than Good: The Nocebo Response in Medical Consultations”, which profiled how patients could get worse due to “sham interventions” and other interactions that elicit a negative response from them.

In particular, Drs. Maddy Greville-Harris, PhD, and Paul Dieppe, MDb, focused not on nocebo responses that came from negative information about medication side effects (about which some study has been completed) but, rather, the role of negative communication between doctor and patient in generating a nocebo response in a healthcare setting.

The researchers believe that doctor-patient communication and the way it plays out can significantly impact the outcome of a course of therapy. Based on their studies and on previous research, the authors concluded that the nocebo response can happen when the patient responds negatively to the conversation(s) they have with their healthcare provider.

Among the key components in the nocebo response are the concepts of validation and invalidation, the authors opine. Validation refers to the communication of understanding and acceptance while invalidation means the opposite, that is, non-acceptance and non-understanding. This is a bit different than empathy; a doctor can be empathetic and show feelings of warmth and kindness but may not portray acceptance and understanding on an intellectual plane (rather than an emotional one).

It’s important to note that, in this article and others similar to it, it’s often determined that while validation is wonderful and gives the patient confidence to move forward, the damaging effects of invalidation tend to be more powerful than the uplifting effects of validation. In other words, bad is more powerful than good, the authors note, or the power of bad human interactions are stronger than that of good human interactions.

Confused? It’s actually simple. The negative things you say to a patient will do more harm than the positive things will do good. Hence, Greville-Harris and Dieppe conclude that it is better for the medical professional to concentrate on NOT invalidating the patient rather than simply focusing on empathy, understanding, and validation.

In tests conducted to support this dissertation, consultations with patients at a pain management clinic were observed and then the observer’s observations were reported. After that was completed, semi-structured interviews were conducted with the patients (5 women with chronic pain issues) and the four consultants. The interviews were played back in order to discuss validation and invalidation.

In many cases, patients identified feelings of being “dismissed” by their physicians and “disbelieved” due to the comments by their healthcare providers. Many believed that the doctors did not “invest in them” nor did they “show insight into their condition”.

The authors described the scenario:

“Patients described feeling hopeless and angry after invalidating consultations, feeling an increased need to justify their condition or to avoid particular doctors or treatment altogether. Although the sample was small, these findings are in line with previous work. Thus, invalidation during consultations may elicit powerful nocebo responses in patients that have so far not been adequately researched.”

Furthermore, the researchers concluded the physicians think they are validating their patients by being empathetic and compassionate when, in fact, those reactions could be eliciting the wrong response from the patient. Many see such emotional responses as condescending or patronizing and lead the patient to believe that the doctor doesn’t take stock in the severity of their condition. In addition, a doctor who says “there is nothing wrong with you” when the patient is clearly experiencing pain makes the patient feel like their complaints are less than legitimate.

So, the question all medical professionals must ask themselves is if they are validating their patients or simply pacifying them during their conversations AND, more importantly, if their conversations are invalidating. Are you providing “lip service” or having a real, legitimate discussion with your patients? Do they leave your office knowing that you not only care about their condition and are sorry for their pain but also that you understand their concerns and can address them professionally and through proper patient education? Or do they walk away feeling belittle and confused?

Patient education is a huge part of the picture. For spine specialists, tools like Dynamic Disc Designs’ (ddd) many lumbar and cervical models demonstrate a true knowledge of your craft AND offer the chance for the patient to grasp some of that knowledge as well. After a consultation that includes a frank discussion and spine education using the fully-movable, highly-detailed spine models made by ddd, patients are satisfied that their concerns are validated and that you can offer more than a pat on the back and a “I hope you feel better soon”.

By educating patients with Dynamic Disc Design models, you can strive to eliminate the nocebo response, instead providing a consultation that “validates” your patient and prompts them to return to you for treatment.