Given a human's inherent awareness that survival may hinge on maintaining their membership in the societal group, it is understandable that rejection by group members would cause stress. Lazarus and Folkman (38) purported that stress arises as a result of a perceived insufficiency of resources to cope with the challenges posed by one's environment, as appraised by the individual. Hobfoll (10) expanded on earlier stress theories, proposing the conservation of resources (COR) model which holds that stress arises from the threat to, or actual loss of resources, or from a lack of resource acquisition. Hobfoll's COR theory asserts that people work to build and maintain resources for coping with challenges. By Hobfoll's definition, resources consist of personal characteristics, objects, energies, and conditions that serve to increase the level of assets valued by the individual such as success, social status, and the accumulation of further resources. Thus, resources relevant to pain-coping include internal character traits such as self-esteem, optimism and goal pursuit; or other external conditions such as social support (10, 39, 40).

Further described within the COR model, Hobfoll (39) posited that resource gain becomes more important emotionally when the individual is faced with loss of resources. People with chronic pain may find it more difficult than most to acquire or retain personal resources. For example, individuals with pain conditions may experience a decline in functional mobility, employment capacity, optimism, and/or self-esteem (41). In the case of reduced employment, they may become financially depleted (8), a problem further compounded by the cost of medical treatment. Social status may decline with job loss as the individual forfeits the ranking associated with a particular job role; and personal status in the family home may be threatened if capacity as the main “breadwinner” or as the ideal “homemaker” is lost (42, 43). In addition, chronic pain is often accompanied by fatigue (32), hindering the individual's capacity to maintain social relationships that may otherwise serve as a support resource (43). For those with chronic pain, limited means of building a resource base, together with the cumulative taxing of current resources, creates major coping stresses under the paradigm of Hobfoll's (10) COR theory of stress.

The loss of resources through having pain comes, paradoxically, at a time when assets and reserves are needed more than ever. As other resources become depleted, people with chronic pain may rely on the social support of friends, family and community members. However, having one's pain invalidated indicates a denial of support (44), either moral or physical. As pain-validation incorporates belief and acceptability of reported experience, the invalidation of pain suggests that the individual's expressions of pain are, in fact, unacceptable. At best, the pain-invalidated person is left to manage alone in their suffering; at worst, the individual risks being ostracised by their social network if they maintain their claims of pain publicly.

Anxiety is an ongoing psychological stress common to many living with long-term pain. Numerous aspects of chronic pain may cause anxiety, with a large range attributable to psychosocial conflicts, particularly those related to pain-invalidation. To the extent that pain communications are invalidated by societal others, continued expressions of pain constitute non-conformity to the values or standards of the societal group. Within the framework of exclusion theory, Baumeister and Tice (3) suggest that social exclusion may occur if an individual fails to contribute sufficiently toward benefiting the group. Thus, in accordance with exclusion theory, loss of functional ability and employability are undesirable qualities since they may be viewed as evidence of limited contribution capacity, and may therefore be a major source of anxiety for individuals with pain. Non-conformists to the group risk alienation and social exclusion which represents a fundamental threat to the self (3). Given the functional limitations inherent in many chronic conditions, patients with chronic pain may experience a heightened degree of anxiety over the prospect of denied social acceptance, since social support represents an important resource for coping (45, 46).

Exclusion from group membership may also occur, as posited by Baumeister and Tice (3), when individuals contravene the rules and standards of behaviour expected by the group, since rule-breaking threatens disruption to the harmony and living dynamic of the group. As such, all members must behave in accordance with the group's moral norms. For those whose pain remains unsanctioned, the receipt of financial benefits, specialized services, or exemption from standard commitments, may be viewed by many as acting outside of the conventions and rules expected of society members. As such, pain-invalidated individuals may bear the stress of being condemned by others in society who do not recognize theirs as a case for special allowances.

The physiological effects of social validation stress have been demonstrated by Shenk and Fruzzetti (47) in an experiment showing that individuals who received invalidating responses to their emotions arising from a stressful task demonstrated higher emotional reactivity, negative affect, heart rate, and skin conductance levels than individuals who were validated when expressing their feelings about the same task. Results supported the enhancing effect of validation on the individual's ability to regulate emotional reactivity in stressful conditions. Current research showing that social stress and negative emotions exacerbate pain perception (48) lends support to Shenk and Fruzzetti's (47) suggestion that individuals in validating environments may enjoy better health in the long term, since emotional support may be protective to those experiencing prolonged exposure to stress accompanying chronic pain (49). These findings are also supported from a physiological standpoint by studies showing that increases in cortisol levels and proinflammatory immune processes occur in response to perceived threats to the social self (50).

Several other experimental studies lend support to the concept of social influence on the perception of physical pain. Brown, Sheffield, Leary, and Robinson (51) found that participants exposed to social support during a cold pressor task reported lower levels of pain than participants who were denied social support during the same task. Furthermore, support for social influence on pain perception was demonstrated in fMRI studies (52) in that the experience of social exclusion used similar neural processing pathways to those typically recruited in processing physical pain.

Conversely, support for the role of social connectedness in moderating stress has been well documented (53, 54). Social support is associated with lower pain ratings and higher levels of pain-coping (55), and better functional capacity (45) in those with chronic pain. A possible explanation for these effects is offered in the findings that social support reduced neuroendocrine responses to social stressors, suggesting a lowered sensitivity to potentially stressful experiences (such as critical judgement) (56). Studies also show that the presence of oxytocin, a hormone associated with social bonding (57), attenuates levels of cortisol in response to social stress (58). Further studies showed that a combination of social support and oxytocin was associated with the greatest reduction in cortisol levels following social stress, when compared to participants in control conditions (no support or oxytocin), a group with only social support, and those administered oxytocin alone (58). Figure 1 illustrates how a lack of pain-validation and social support may relate to psychological distress and the potential exacerbation of chronic pain.

Beyond the stress imposed on sufferers who are socially unsupported, the importance of validation becomes apparent through a broader understanding of chronic pain and its consequent effects. Examination of narrative literature reveals that “having chronic pain” can be understood as more than the ongoing experience of physical discomfort. For many, having pain results in a myriad of direct consequences such as functional limitations which impede the capacity to work, to continue as the financial provider, perform home or family duties, and socialize with friends (43, 59). In these ways, living with chronic pain may result in a loss of identity, declining independence, reduced self-esteem, breakdown of relationships, and the resulting array of negative emotions (43, 59, 60). The outcomes of having chronic pain, as seen in Figure 2, may collectively be more problematic than the pain itself.

Chronic pain often prevents sufferers from behaving in ways that are consistent with the self-script, a script determined by their values. For example, people who value independence may struggle mentally with perceptions of incompetence and loss of self-worth in having to rely on others for help with shopping, looking after children, or even getting dressed, during a flare up of the condition (43, 61). In other instances, those who normally oppose drug use may battle internally with contravening their values to obtain pain relief via medications (62), and may potentially encounter external “drug abuser” stereotyping and stigma (25). For many, a substantial sense of identity loss ensues following work reduction or termination of their former career (60).

The changes and loss brought about by chronic pain interrupt the patient's view of their capabilities, identity, and understanding of the self in relation to the world (63, 64). Such losses or breakdown of self-script are often distressing, creating a destabilization of the sufferer's internal world and upsetting the stability of the psyche (65, 66), though the process is often noted as a precursor to the rebuilding of the self (63, 66). Humans rely on the consensus and verification of socially relevant others in forming perceptions about their own identity (67) and in establishing attitude norms (68). Social validation of the pain experience may help buffer pain-induced loss and destabilization by allowing for social communion, unity, and highlighting aspects of shared identity (69). The ability to tell one's story is also an important mechanism for re-organisation and formation of the new self following chronic illness, and helps the sufferer create meaning in the experience (64). Allowing opportunities for this narrative process, together with healthcare professionals' validation of uncertainty and loss experienced by their pain clients may, therefore, be beneficial (64, 70, 71).

One of the limiting factors to the efficacy of therapeutic interventions is the level of patient compliance or adherence (73). Poorer relationships with healthcare professionals relate to lower adherence to treatment plans (73), while healthy alliances relate to higher treatment adherence (74). This points to the benefits of developing rapport and a high-quality relationship between patient and professional, such that the patient feels heard and understood (74, 75). By validating pain through acknowledging the experience, and demonstrating belief in, and understanding of the patient, the therapist shows that (s)he is mentalizing the client's experience. Mentalization is an ability to understand the feelings, motivations, and behaviours of the self or others from their subjective perspective or mental state (76). In terms of chronic pain, mentalizing involves understanding the cognitions and emotions held by the patient regarding their pain, allowing for comprehension of the broad impact of pain and its consequences on the patient. Within the therapeutic relationship, mentalizing indicates to the patient that their experience is worthy of active consideration, enabling them to feel safe to discuss their pain and difficulties without fear of reprisal or judgement (75). Pain-validation is an active means of communicating mentalization, and is central to establishing patient trust in the therapist.

Another way for the therapist to demonstrate their capacity to mentalize the patient's experience is by indicating an understanding of the deeper implications that having pain may hold for that patient. Those with chronic pain commonly feel a range of negative emotions including depression, fear, frustration and anger (77). Furthermore, experiences of injustice toward pain by social others are associated with adverse pain outcomes and resistance to change by individuals with pain (78). Pain-validation, then, offers a clear benefit in that it acts to create belief and acceptability, which can be demonstrated through the provision of pain education. For example, it may be helpful for the patient to hear that they are not alone in their suffering, nor abnormal in their condition, with many other people sharing similar symptoms or difficulties in achieving diagnoses. Rather than feeling defective, different and isolated, this form of validation allows the individual to maintain a sense of shared humanity, the importance of which is described as a core component of self-compassion (79).

A recently developed modality called Emotional Awareness and Expression Therapy (EAET) that gives focus to the role of emotional processing, has been successfully employed to reduce pain (80) and improve physical functioning (72). Therapists aim to educate patients about the role of stressful emotions in pain (71, 72). Patients are encouraged to face and express emotions that may have previously been unvoiced, particularly around trauma and conflicts, and techniques are taught to facilitate communication between the patient and close others (72).

Where appropriate, validation of pain symptoms may also be demonstrated by pain specialists providing pain education that offers alternative possible explanations for pain, particularly in the absence of scanning or laboratory-based evidence. Central sensitization is one such phenomenon theorised to account for continued stimulus sensitivity, and consequent pain signalling by neurons, even when injury and inflammation are no longer present (81). Sensitization may develop due to neural re-wiring at the site of injury, which may increase the excitability of neurons, or the number of neural synapses in the region (81, 82). Education about such mechanisms for pain is another core tenet of EAET with the aim of re-framing the patient's sense of pain as coming from the brain, and not necessarily due to further injurious movement (72). Learning about such possible reasons for otherwise unexplained pain may also provide validation regarding the “felt” experience, supporting patients who may have previously perceived practitioner judgements or disbelief regarding claims of pain.

Efforts made by the therapist to convey understanding of physical, psychological, and social difficulties (such as pain-invalidation in social circles) are fundamental to building the patient-provider relationship in the patient-centred approach (77). Sharing knowledge of general experiences reported in pain literature, potentially familiar to the patient, may provide further evidence of the therapist's ability to understand the complicated layers of distress associated with having a chronic condition. The therapist may choose to offer psychoeducation about the inability of social others to appreciate pain-related fatigue, the seemingly inconsistent appearance of pain symptoms in specific conditions, or the secondary effects of pain medications. This shared understanding may serve to enhance patient trust in the therapist and open the way for further communication and learning (75, 77).

Current pain management interventions often include modalities such as Cognitive Behavioural Therapy (CBT) and Acceptance and Commitment Therapy (ACT), that involve cognitive re-framing or behavioural modification and will, by definition, involve change (40). Re-framing and behavioural techniques are designed to arrest catastrophizing directions of thought, improve estimations of efficacy for pain-coping, increase general self-efficacy, build confidence for increasing functional mobility, and reduce pain-avoidance (30, 74). It is worth noting here that change may be difficult for several reasons. For example, both ACT and cognitive therapy techniques involve effortful and active practice of conscious awareness of thoughts and feelings, while remembering and applying newly learned strategies (83). Even more uncomfortably, change requires the mental exertion of pushing through boundaries of fear, deconstructing old realities, and disrupting maladaptive “scripts” or schemas, which once provided a sense of psychological stability (66). Hence, the prolonged effort and even discomfort necessary to instigate and adhere to change requires a degree of internal motivation. Such motivation may fail if the patient's fundamental struggle (having chronic pain) remains unacknowledged. Indeed, Linehan (16) warns of a client's need to feel validated prior to moving forward with interventions, underlining the problem that may occur if this need is unmet, whereby clients can remain “stuck” feeling invalidated, and resist treatment. Attempts to encourage change in clients at this stage may be experienced as dismissive of the client's feelings (16). Thus, pain-validation appears to be an important first step in pain management therapy by way of acknowledging the present experience of the client, and paying recognition to the difficulties in transitioning to life with chronic pain (70). Given the potential barriers to pain management interventions (84), the dual benefit of pain-validation in fortifying the therapeutic relationship and increasing patient motivation to embrace cognitive, behavioural, and affective change may go a long way toward improving treatment adherence (77, 84).

Having established a construct definition of pain-validation, researchers can operationalize the construct and develop means of measuring levels of pain-validation or invalidation for those with chronic conditions. The Pain-Invalidation Scale (Pain-IS) is one such instrument, designed to measure pain-invalidation by the self, immediate others, healthcare professionals, and over-attending others (85). The Pain-IS enables the identification of areas where pain-invalidation may be limiting patient progress in therapy, or in functional rehabilitation. High scores in any domain may indicate the need to employ or teach validating communications as a first step in pain management therapy. Whether this increases compliance to interventions needs to be assessed.