Expressing pain: which patients do we trust?

Trustworthiness is one of those instant judgements we automatically make about other people, affecting our behaviour towards them [1]. We wanted to know whether clinicians’ judgements of patients’ trustworthiness affected their estimation of patients’ pain [2]. There seem to be so many grounds on which the complaint and expression of pain is met with scepticism, or is discounted – being old, young, female, or from an ethnic minority, for starters – but also degree of attractiveness and likeability [3].

We used brief videos of male and female patients’ faces during a painful movement (a great resource annotated for pain by facial action coding [4]), selecting those with equivalent levels of pain expression but rated (by a panel of trainee clinical psychologists) at the higher and lower ends of trustworthiness. We embedded videos in an online study which we distributed to UK pain doctors and medical students in their clinical years, to vary extent of experience with treating pain. Each video (a randomly selected set across participants) had a brief vignette in the form of a referral letter that included a ‘back story’ on depression, but we were not confident that participants read it as we intended and understood depression either to precede pain onset or to follow it; we therefore did not analyse those data further.

We asked respondents to estimate pain for each video, to judge likelihood that the patient was exaggerating or minimising pain expression, and to rate options for treatment, from opioids to psychological referral. We quickly got responses from very experienced pain clinicians (predominantly male) but struggled to get enough from medical students (predominantly female) in their very busy clinical years.

There was no main effect of trustworthiness (rated by respondents consistently with our panel): the very marked main effect, shockingly, was of sex. Women’s pain was estimated almost 1 point in 10 lower than men’s, their expression was judged to be less authentic, and treatment recommendations involved fewer analgesics and more psychological treatment. I describe this gender effect as shocking, but it is consistent with very many studies that show that gender stereotypes are alive and well in pain medicine, with women’s pain more often discounted, disbelieved, and undertreated. However, this effect was largely produced by a strong interaction with trustworthiness: high trustworthy women were almost ‘honorary men’, while low trustworthy women (unlike low trustworthy men) were judged to have less pain and to be exaggerating it.

Although trustworthiness judgements were not related to pain estimates, they were related to the judged likelihood of exaggerating pain, and (retrospectively) this makes more sense than a direct relationship of trustworthiness with pain estimate. Curiously, though, even when men in the stimulus set were judged to be exaggerating pain, their pain was not discounted, while for women, the higher the estimate of likely exaggeration of the pain, the lower the pain estimate. This needs further testing to see if it is a robust effect, and exploration to see if it is a further expression of gender bias – men’s pain is real even if they hype it up a bit – or something else.

We also found – again, contrary to our expectations that pain estimates decline with experience [5] – that pain clinicians gave higher pain estimates than medical students did. Perhaps they were being careful about their pain estimates, but there was no relationship with empathy scores for them or for the medical students, and very few participants (in a free text entry) guessed our hypotheses.

What do we think is useful about the study? We strongly recommend using meaningful pain, real patients, and moving rather than static expression as stimuli, as in these videos (available from We learned not to try 3-way interactions (impossible to interpret), or to ask medical students to complete long surveys when they’re working all hours in demanding clinical settings.

More important, gender stereotypes pervade clinical care, whether the clinician is male or female. We should probably stop demonstrating the bias and start – as one of the authors, Ken Prkachin, has done in ethnic bias [6] – to try to find effective ways to counteract it. For this we should look outside the pain field. It is not a matter of education: lack of information is not the cause of gender bias. We need to find ways of challenging internalised gender stereotypes, and we need to grasp the implications of pain as a social communication [7], to enhance our empathy, and to listen to the patient in her or his context.

About Amanda C de C Williams

Dr Amanda WilliamsAmanda is an academic and clinical psychologist who has specialised in pain for thirty years; she now works at University College London, where she trains clinical psychologists, one of whom is the first author of this study. She also works clinically in the UCL Hospitals pain team, and in human rights. She is currently working on the evolution of pain behaviour, and how that behaviour is understood by others.


[1] Willis J, Todorov A. First impressions: making up your mind after a 100-ms exposure to a face. Psychol Sci 2006;17:592–8.

[2] Schäfer G, Prkachin KM, Kaseweter KA, Williams ACdeC. Health care providers’ judgments in chronic pain: the influence of gender and trustworthiness. Pain 2016 doi: 10.1097/j.pain.0000000000000536

[3] Tait RC, Chibnall JT, Kalauokalani D. Provider judgments of patients in pain: seeking symptom certainty. Pain Med 2009;10:11–34.

[4] Prkachin KM, Solomon PE. The structure, reliability and validity of pain expression: evidence from patients with shoulder pain. Pain 2008;139:267–74.

[5] Kappesser J, Williams ACdeC. Clinical judgement heuristics: methods and models. Eur J Pain 2013;17(10):1423-4.

[6] Drwecki BB, Moore CF, Ward SE, Prkachin KM. Reducing racial disparities in pain treatment: the role of empathy and perspective-taking. Pain 2011;152:1001–6.

[7] Hadjistavropoulos T, Craig KD. A theoretical framework for understanding self-report and observational measures of pain: a communications model. Behav Res Ther 2002;40(5):551-70.

Commissioning Editor:  Neil O’Connell


  1. You don’t want to answer my question? I think it would be a good test of whether your university educators taught you what to do in such a situation (prove my point, in other words).


    ^^ Skillfully handling a patient’s emotions is CRUCIAL to healing, and it’s obviously not even considered important enough to teach undergraduates. This paper shows [once again] how university educators are failing in their roles. On a par with politicians.

    John Quintner Reply:

    This posting reads like a typical ” motherhood” statement (“skillfully handling a patient’s emotions”) that is then followed by a sweeping generalization (“not even important enough to teach undergraduates”). I am sorry to be so critical but I cringe whenever I read stuff like this.

    EG Reply:

    Cringe: to draw back in fear, pain, or disgust. An emotional reaction, to be sure.

    So let’s use this. If you (as a doctor) had a patient who cringed when you mentioned the word “injection”, how would you handle that? What about if her emotional reaction was so severe that it caused illness on top of her presenting complaint? What do you do?

    John Quintner Reply:

    In the context of your post of October 16, I stand by my use of the word “cringe”. Where is your evidence that university educators are failing in their academic responsibilities towards their medical undergraduates?

  3. John Quintner says

    Kai, I have not come across any such quantitative research. However in the early 1990s I did attempt to explore the relevant and copious literature chronicling the so-called epidemic of “RSI” in Australia. The main-stream literature provided an example par excellence of the bidirectional invalidation of which you speak. Fortunately I was able to publish my findings: Quintner JL. The Australian RSI debate: stereotyping and medicine. Disability and Rehabilitation 1995; 5: 256-262.

  4. John Quintner says

    Amanda, in a chapter from a forthcoming book, Milton Cohen and I have attempted to tackle this very complex issue.

    A fundamental tenet of Western biomedicine is the validation of a patient’s predicament by the clinician through demonstration of a disease process underlying illness. For the person experiencing chronic pain, however, the absence of demonstrable pathophysiological evidence of disease is a challenge to the clinician’s ability to discharge that role. What may not have been appreciated is that the reverse situation can also hold true, insofar as the patient cannot validate the clinician as possessing sufficient knowledge and expertise to relieve their pain.

    In an effort to understand and remediate this impasse, this chapter explores the dynamics of the clinical encounter through the lens of the French sociologist Pierre Bourdieu, and examines the effects on the players when dealing with the aporia of pain. Then, in the novel approach of reframing the field of the clinical encounter through considerations of intersubjectivity, empathy and prospection, ethical possibilities for clinician and patient to achieve mutual validation of their predicaments are canvassed.

    Quintner JL, Cohen ML. The challenge of validating the experience of chronic pain: the importance of intersubjectivity and reframing. In: van Rysewyk S (ed). Meanings of Pain. Springer International Publishing, 2016 (in press).

    Kai Karos Reply:

    That seems like a very interesting point. I am wondering, is there any quantitative research investigating the invalidation of clinicians and their skill set when handling chronic pain? I think in this context it would be important to specify the profession and pathology involved but I can definitely see that stigmatization and invalidation and go both ways.

    On some level it still comes down to miscommunication and misunderstandings, especially regarding the non-dualistic nature of pain: Highlighting the enormous potential of biopsychosocial approaches to tackle pain (especially in absence of biomedical abnormalities) should be embraced rather than be seen with suspicion and the feeling of a patient that a therapist simply tries to “invalidate” their pain and has insufficient knowledge.

    I could imagine that this interchange of invalidation is especially prevalent with psychologists, at least I had a similar experience from patients regarding psychological pain research but I have no clinical experience myself. It would be very interesting to hear whether there is any quantitative data on this.

  5. I agree EG, control of emotions and the mind by the therapist is a skill that enhances all patient contact. Meditation is one of the ways to achieve this.

    The ‘unconscious reactions’ that John alludes to in response to the patient’s presentation will then be negated and the third space available to both parties.

  6. Amanda C de C Williams says

    Clinicians make the judgement that patients exaggerate, so I want to find out what makes them more likely to make that judgement. I would never use the term as it makes no sense: we cannot know another’s experience, nor is there any ‘right’ amount of pain to feel. But some – many – clinicians routinely discount pain, which means that they give too little or no analgesic, disregard the patient’s distress … all things that need to change, and it can’t be too soon. We won’t change these behaviours if we don’t understand them.

    Kai Karos Reply:

    Well said 🙂 Nice piece!

    John Quintner Reply:

    Amanda, one possible explanation is that when confronted by a patient in a state of existential distress, the clinician cannot avoid being similarly affected. This may be so embarassing to a clinician who is unaware of this unconscious reaction that he/she may tend to discount the experience of the patient. In our paper on the subject of stigmatisation we called this response “the negation of empathy”. Reference: Cohen ML, Quintner JL, Buchanan D, Nielsen M, Guy L. Stigmatization of patients with chronic pain: the extinction of empathy. Pain Medicine 2011; 12: 1637-1643.

    EG Reply:

    Yes, there’s three harmful responses which routinely appear when a therapist is met with a patient’s suffering:

    1– Blocking or distancing (which you refer to as ‘negation of empathy’).
    2– Overwhelm (‘oh no, another chronic pain patient… I can’t cope’).
    3– A desperate desire to fix the situation.

    It’s important to realize that numbers 1- and 3- are ego defense mechanisms against number 2- overwhelm. That being the case, we shouldn’t just suggest to therapists not to engage them. The idea – as you suggest – is to learn how to enter what you call the ‘3rd space’. In the 3rd space, the patient’s suffering is observed in its immediate fullness, but without judgment, and without overwhelm. This is why a practical understanding of meditation and congruence is absolutely vital to good practice. You can’t work at a high level without this skill.

    And as usual, none of the contents of this post will be taught at university. You have to figure it out on your own.

  7. Thank you John, I so enjoyed reading the post. I totally agree about this ‘Third Space’, it allows for both therapist and patient to communicate at a cellular level of remembering, both feeling and thinking awareness , away from any quantifiable paradigm. Utilisation of such a space by both parties allows for “validation’ and authenticity to ensue. Some may call this imaginary others ineffable and others a deep sense of trust.

  8. John Quintner says

    Yes, it is indeed timely for us to look outside the pain field. Earlier this year, Melanie Galbraith and I spent a day with distinguished philosopher Professor Horst Ruthrof, who kindly provided us with an opportunity to discuss these very issues in some depth. Readers of Body in Mind can read the summary of our discourse, which of necessity took place over a few bottles of wine:

  9. Isn’t it more about which therapists do the patients trust with their pain? Some patients are able to express well, others not and it will depend on who they are talking with. As pain is an expression of the whole then what they communicate is the true essence of their thinking -feeling. Who are we to judge if it is exaggerated or not.

    EG Reply:

    “Who are we to judge if it is exaggerated or not”.

    Yeh I feel the same way. It doesn’t assist the process in any way to judge a patient’s pain as an ‘8’ or a ‘6’, so why bother? Something hurts – that’s all I really need to know. There’s no advantage in ascribing a subjective numerical rating. It’s like measuring a joint ROM with a goniometer – there’s no advantage, so I never do it.

    Ali Reply:

    “Who are we to judge if it is exaggerated or not.” it is not completely related to the judgment. There are a number of studies (from Prkachin group, Vervoort, Singer, and Williams) showing that the observers perception of pain and his interpretation of pain can be influenced by his understanding of the trustworthiness, fairness, gender, and race of the patient. They suggest that biased interpretation of pain might influence the level of empathy and also level of care a health professional provides for a patient.