Validation, Hope and Understanding

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    HI Everyone !!
    Just getting the conversation started following Workshop 3…..we talked about providing the patient with Validation, Hope and Understanding early in the process of evaluation and how this is the first step and a critical step in recovery. In fact, if we skip this, we will likely have a resistant patient who feels judged, misunderstood or that we are on the fringe of medicine and don’t know what we are talking about.
    I made this mistake just last week !!……a man came to me with decades of whole body pain….all the doctors, tests, treatments, etc. that one has. His ultimate diagnosis was chronic back pain from failed back syndrome and fibromyalgia. I thought he knew what I did and had come to see me to try a new path. In the first hour, I jumped in with this new approach to chronic pain and maybe it could help him – thinking he would be so relieved and excited. However, I had skipped the validation piece. I had read all of his medical records prior to his appointment, but from his perspective, I didn’t listen to his stories. He said I had not listened to him, that I had judged him, that I didn’t know the details of his pain and his experiences and how this had destroyed his life. I went too fast and didn’t listen enough. I had miscalculated how quickly I could go from Validation and Hope to Understanding…I felt really bad. He left my care, so I didn’t get a redo on that one. In hindsight, I should have seen how much pain he was in and been more sensitive to where he was in the first visit – I should have put more testers out there to explore how ready he was to hear the good news and developed the relationship more before diving into it.


    In fact, I think some patients aren’t really ready to hear there is even HOPE ! After all they have been through, how could there be? and if there were any hope at all, wouldn’t that mean that they had needlessly suffered? And, if they had needlessly suffered, that could, of course, be ENRAGING and too much to bare. I had a friend who had been in chronic neck pain for many years resulting in an early retirement and disability; after explaining the paradigm to her, her first question was, “What would I do about my disability?”. Sometimes, patients have gone so far down the rabbit hole of pain and it has become the whole focus of their lives, it is hard to even imagine extricating yourself out of that.


    Excellent points, Alicia.

    There are folks who have been dismissed and invalidated for a long time, by friends, family and doctors. They need validation, first and foremost. Often they have found that validation in an online support group of others who are also suffering. Those groups can be very helpful, but they also can act to imprint the ideas that their suffering will never end, that they have a disease that is completely incurable, and that they can only cope with it as best as they can and wait for a miracle medical treatment to emerge.

    Rocking that boat can be met with a lot of anger, understandably. We need to tread softly with these folks and recognize that they may never see things from our point of view.


    Thank you for sharing that experience Alicia. I have also leapt in too fast with my enthusiasm and hasn’t gone well. I had a patient today who fortunately was comfortable telling me she spent her whole childhood getting gas lighted by her parents with significant abuse and the information I was saying was starting to feel like that. Validating that and understanding this information can sound strange at first, but she is in control of where she wants to go with it and it’s not dangerous, was helpful to avoid her getting upset.

    David SchwarzDavid Schwarz

    Egocentricity is difficult to overcome. I am much more careful about this now compared to my earlier days in practice, but I can still get wrapped up in myself when time is a factor. I believe that these patients (and I guess all patients) need both our time and attention to feel validated. For example, I see doctors with a residency program partly to be able to be a helpful element to their training (and also because I couldn’t get a referral to a psychiatrist after mine quit outpatient practice…healthcare is such a mess at times). I started with another resident this last month and decided to read the notes as he seemed distracted and rushed in the appointment. He wrote one bit of information that made me feel like he doesn’t understand me: he wrote that I was working part time and left that job to start my PhD. The reality is that I not only am still working and have been doing my PhD even while part time, but I am now full time. Does this really matter? Probably not, but it feels like it does matter because of how meaningful being able to work full time is for me. The reason why I tell this story is that we never know what is meaningful to or patients or what will lead to their loss of a sense of validation and understanding. The funny thing is that the context of feeling like he was rushed and lacked attention led to the lack of understanding/invalidation interpretation of the error in history taking. This is part of why I generally spend substantially longer amounts of time in my initial evaluations compared to others in my profession. I do my best to set my clock aside and just listen, taking the necessary time. It would be great if we could all do that and have space to meet our patients needs without compromising our own needs.

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