Having started yesterday’s post by discussing health anxiety, and pointing out that one of the things people do to cope with their anxiety about their pain is to seek reassurance, I thought it might be useful to go back to a paper published a couple of years ago by Linton, McCracken & Vlaeyen (2008). In this paper, the authors reviewed the concept of reassurance and see whether it is, in fact, reassuring.
What is reassurance anyway? We talk about it as if we know what we mean, and it’s even part of most guidelines for managing acute low back pain – but what is it? In this paper, the authors refer to the Oxford dictionary definition where reassurance is defined as ‘‘. . .removes the fears or doubts of (pain/illness); to comfort’’. As they point out,
“Reassurance always takes place within the dynamics of the interaction between the caregiver who has the intention to reduce worry, and the patient who is concerned. Ultimately, reassurance is achieved if the patient changes his/her behavior, understanding or thoughts.”
Reassurance is therefore a social act (once again, do you get the social theme?!) And the tools that health providers use are mainly verbal – information, persuasion and instruction.
When I think about what this actually means in a health care encounter, it usually looks like the provider gives information and recommends some sort of test or investigation. Hopefully the patient will make the link between his or her symptoms and the information the provider gives – and more hopefully, the results of the test or investigation come back showing that everything is A-OK.
Linton and colleagues discuss a study showing that “Only when doctors provided reassurance that included a relevant (to the patient’s concerns) explanation that linked physical and psychological factors was the explanation accepted.” Otherwise, the patient simply repeated or detailed his or her problems and asked for more tests. Sounds like it’s important for clinicians to demonstrate that they’re listening and really answering the specific concerns of the patient, rather than just giving general information. The interpretation these authors give to this response by patients suggests that “when patients experience the information as a lack of understanding of the legitimacy of the complaint, they responded by asserting the complaints more forcefully.”
I’m reminded of a quote attributed to the late Bill Fordyce ‘Information is to behaviour change as spaghetti is to a brick’ – just telling people things doesn’t seem to reduce their concern or change their behaviour. Maybe simple reassurance via information giving works fine for people with low health anxiety, but it doesn’t cut it for people who are anxious about their health. Our problem as clinicians is to work out whether the person we’re seeing is or is not health anxious and that’s not such an easy task.
Now another strategy that especially doctors use is acquiescing to the person’s desire for more investigations and sending him or her off for something like an MRI. Of course, the belief behind this is that there will be ‘nothing there’ and the patient will feel relieved and all is well.
A couple of things make this a problem – many MRI scans do show artifacts or changes that are unrelated to the pain problem, but because of the strong prevailing belief that these things ‘could’ be associated with the problem, these findings can send the person off on another round of medical consultations – sometimes ending up in unnecessary and invasive procedures or surgery. The second thing is less intuitive – Linton and colleagues discuss the findings from a study conducted in the Netherlands in which women with breast pain and women without breast pain were scanned – the results found that only transient positive effects were found in those in whom the scans were negative for cancer. So while it might temporarily relieve the worry, this is only a temporary effect.
A similar finding was obtained in a study of people receiving MRI for low back pain – all participants received the MRI but only half had their results released to them and their doctors. All of them received the same conservative care, but those who received information about their MRI findings actually felt less well in themselves. It had basically the opposite effect.
So far I’ve discussed the clinician’s responses and the overall effect on patients. Next I’ll look at the effect of reassurance on the patient. It makes sense to me as a clinician to want to reassure the person I’m seeing that their problem is mild, that they’ll recover and everything will be fine. Hmmm. Not so according to the findings discussed in Linton, McCracken and Vlaeyen’s paper. It seems that this actually increases the worry about future pain, so the patient hears ‘Your problem isn’t so bad – yet’.
Their recommendation? Expressing empathy, or in other words, reflecting to the patient that they are worried about their health, the meaning of the symptoms and that it must be very frightening. Just by doing this, clinicians can show that they are really hearing what the person says – and that’s in part what the person is looking for. It seems likely that the conclusion Linton and colleagues came to “while patients signaled psychosocial difficulties, GPs focused more on physical disease and that few GPs empathized with their patients. ..unnecessary physical interventions [are] associated with the GP’s responses rather than the patient’s demands.” That old adage ‘if all you have is a hammer, all you’ll see are nails’ comes to mind.
Just to put a spanner in the works, a study looking at parental reassurance is discussed in Linton et al’s paper – in this it was found that when parents reassured their children it actually increased verbal expressions of fear and worry. Some reasons this might occur are proposed – maybe by reassuring, parents are conveying that the kids actually do have something to worry about; maybe kids who are more anxious trigger reassurance from their parents more quickly; and finally by giving reassurance this could actually trigger release of negative emotions in the form of crying or pain behaviour. There is much to learn about interpersonal communication and pain, it seems!
So, to conclude. Even though reassurance is suggested as a mainstay for reducing the fear and worry associated with things like acute low back pain, it seems that the evidence is mixed in terms of how effective this can be. Giving advice without tempering this with what the patient actually wants to know about is not likely to be very effective. It looks like at the very least we’ll need to learn more about how to respond empathically to our patients, show them that we really are listening, and give individualised information that they’re ready to receive. We might also need to consider helping people ‘sit with’ or tolerate their anxiety about their pain – or should I say, we might need to help ourselves as health providers learn to tolerate our own anxiety about not suggesting things like investigations ‘to reassure’, because it doesn’t seem to actually do the trick.
And, as usual, there is so much more to learn.
LINTON, S., MCCRACKEN, L., & VLAEYEN, J. (2008). Reassurance: Help or hinder in the treatment of pain Pain, 134 (1-2), 5-8 DOI: 10.1016/j.pain.2007.10.002