Empathy and validation in chronic pain a systematic review

Authors: Karolin Teichmüller, Hripsime Galstyan, Lisa M. Bas, Gudrun Kindl, Philipp Kanske, Heike L. Rittner, Andrea M.F. Reiter

Abstract

Supplemental Digital Content is Available in the Text.

Spousal empathy and validation were associated with beneficial pain-related and relationship outcomes in chronic pain couples across most studies. The opposite was true for invalidation.

1. Introduction

Chronic pain is a debilitating condition defined as pain that persists or recurs for more than 3 months.^61^ It has a multifactorial origin,^42^ making a biopsychosocial framework necessary to understand the development and maintenance of chronic pain. This review focuses on the social aspect of this model by summarizing the current knowledge on the impact of empathic or validating behavior on pain-related and relationship outcomes in adult romantic couples. Indeed, as an individual with chronic pain (ICP) navigates his or her daily life, pain influences and is influenced by interactions with others, particularly by those closest to them, such as their significant others.^2,17^

According to the social communication model of pain,^14^ verbal or nonverbal expressions of pain inform others about the ICP's pain experience and encourage observers to provide support and care. The other's responses can, in turn, shape the ICP's pain experience. Thus, social interactions can affect both the expression and management of pain.^14^ To understand these effects, different frameworks have been A classical operant model of pain^21^ suggests that pain behaviors, ie, the expression or display of pain, can either be reinforced or punished by a significant other's response, influencing the likelihood of their occurrence. Within this framework, solicitousness, ie, “the provision of instrumental support and expression of emotional concern,”^41^ is assumed to reinforce pain behavior, with potentially detrimental effects on patient functioning. Dismissive or negative partner reactions should, in turn, lead to a reduction of patient pain behavior.^32^ However, a subset of verbal pain behaviors seems to deviate from operant theory predictions, specifically emotional disclosures of pain-related distress.^10^ These verbal expressions of feelings such as anger, sadness, or worry about pain have been conceptualized as controlled and goal-directed communication,^10^ to which social interaction partners should ideally respond in an empathic or validating manner.^36^ When we validate, we communicate to another that their experiences, including their pain, are real and legitimate.^63^ Newer models suggest that validation plays a beneficial role in the coping processes for ICPs. For instance, intimacy might develop particularly in situations where one person responds in an empathic and validating manner to another person's disclosure of personal experiences.^52^ Similarly, Linehan's biosocial model^35^ proposes that empathic responding or validation soothes an individual and reduces negative emotional arousal, which might positively affect pain adjustment (ie, decreased pain intensity and behavior). In a chronic pain context, a partner's empathic or validating response to an ICP's self-disclosure of pain-related thoughts and feelings could foster affection and decrease pain intensity and pain behavior.^18^ By contrast, invalidating interactions, such as hostile or dismissive partner responses, may interfere with emotion and pain regulation.^9^

In sum, empathy emerges as an important element that can deepen intimacy, support emotion regulation, and facilitate coping efforts within relationships.^3^ However, reaching a unified definition and conceptualization of empathy has proven challenging.^51^ Narrow approaches view empathy as the sharing of the affective experience of others.^16^ Here, we adopt a broader conceptualization of empathy as a multidimensional construct including both cognitive and affective processes and their combination.^55^ Cognitive components reflect the ability to accurately infer another's psychological state^29^ or adopt their point of view (perspective-taking).^15^ Affective branches of empathy include the sharing of others' emotions or pain, empathic concern or compassion (ie, a feeling of warmth and concern for others),^50^ and empathic distress (ie, self-oriented feelings of anxiety or unease).^15^ The concept of validation involves accepting and understanding responses to others' experiences,^7^ as opposed to invalidation, which consists of disrespectful, contemptuous, or nonaccepting responses. Transferred to the chronic pain context, pain-validation, described as “communicating belief and acceptability of the sufferer's expressions of pain,”^43^ serves to acknowledge the sufferer's experience.

Taken together, social interactions with close others can either enhance coping and facilitate optimal adjustment or contribute to the maintenance or even exacerbation of chronic pain. In addition, partners of ICPs must engage appropriately without becoming emotionally overwhelmed. They need to maintain this balance over an extended period because of the persistent nature of chronic pain, while excessive empathy is considered a risk factor for the development of empathic distress and also mental health issues.^28^ While acute pain is a prominent model for studying empathy,^19,31,57^ the scientific literature still lacks a comprehensive discussion of empathy's impact on chronic pain. An open question is whether the assumed positive effect of empathy in romantic relationships is consistent across studies. Therefore, this systematic review addresses this gap by evaluating the impact of empathic partner responses and behaviors on pain-related outcomes for the affected partner and relationship outcomes for couples managing chronic pain. It aims to provide insights for future research directions and implications for therapeutic approaches.

2. Methods

This systematic review was pre-registered with PROSPERO (Registration Number CRD42024600201, https://www.crd.york.ac.uk/PROSPERO/view/CRD42024600201) and was conducted following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).^47^ Eligibility criteria were defined based on the following PICO The population (P) comprised adult couples in a romantic relationship where one partner deals with a chronic noncancer pain condition. Cancer pain was excluded because of its specific characteristics and management. Mainly, noninterventional studies (I) were expected to be included, focusing on observing empathic or validating responses between partners. Nevertheless, interventional studies promoting these behaviors between partners would also have been eligible. Valid comparisons (C) could be against solicitous (overprotective, reinforcing), nonempathic or invalidating (dismissive, hostile), or neutral responses from the partner. Studies including healthy controls, ie, couples without chronic pain, would also have been eligible. However, studies without any comparison group (eg, with a purely correlative design) were also included. The outcome measures (O) were restricted to pain-related outcomes (ie, reduced pain intensity, pain-related disability, pain medication, improved pain coping strategies, and decreased pain behaviors in the affected partner) or relationship outcomes (ie, increased relationship satisfaction, emotional intimacy, and marital functioning) or both.

Only peer-reviewed and published original studies written in English or German were considered. There were no restrictions regarding publication year or study design.

2.1. Search strategy

A systematic literature search was conducted through 3 major electronic databases (APA PsycInfo, Web of Science, and PubMed) on October 2, 2024, using the following search terms in English and German: (“empath*” OR “validat*” OR “empathic respon*” OR “validating respon*”) AND (“chronic pain” OR “chronic illness” OR “long-term pain”) AND (“partner” OR “couple*” OR “spouse*” OR “marital relationship” OR “romantic relationship” OR “dyad*”) NOT “cancer pain.” As an additional search strategy, an ascendancy approach was used to identify further studies by screening the references of included studies (Fig. 1). The search procedure was repeated on July 2, 2025, to identify any newly eligible studies.

2.2. Screening process

All search results were imported into the Rayyan tool,^46^ and duplicates were removed before screening. During the first screening round, studies were screened by title and abstract. During the second round, studies were screened by full text and selected for data extraction according to our PICO framework. Owing to pragmatic reasons, only 1 reviewer (October H.G., July K.T.) was involved in the entire screening process. In case of uncertainty, H.G. and K.T. resolved ambiguity through discussion. If consensus could not be reached, input from A.M.F.R. was sought to make a final decision. The screening process was not blinded.

2.3. Data extraction and synthesis

Data were systematically extracted from each included study using a predesigned extraction template specific to the objectives of this review, which was slightly adjusted during the extraction process. The extracted data encompassed the following key (1) study characteristics, including author names, publication year, study design, and sample size; (2) participant demographics, such as age (M, SD), gender distribution, and health status (if possible with a specified chronic pain condition); (3) empathy, including its conceptualization and operationalization; (4) other variables as well as the tools used for measurement; (5) results, specifically the main findings and statistical significance (ie, P-values, confidence intervals, and effect sizes if reported); and (6) an assessment of the study quality (see below). The extracted data are summarized in Table 1.

In the pre-registered protocol, it was planned to divide the included studies between 2 researchers for independent extraction. However, to improve the reliability of the extraction process, the process was modified as One reviewer (H.G.) conducted data extraction for all studies. In addition, a second reviewer (K.T.) randomly selected 50% of the studies for independent data extraction and risk-of-bias assessment. H.G. and K.T. compared their results and resolved discrepancies through discussion. For the remaining half of the studies, K.T. double-checked the initial extraction. This was the only deviation from the pre-registration. The data from the included studies were synthesized narratively. The size of correlation coefficients is evaluated according to Cohen^13^: small (r ≈ 0.1), medium (r ≈ 0.3), and large (r ≈ 0.5).

2.4. Risk-of-bias assessment

The Risk of Bias Utilized for Surveys Tool (ROBUST)^44^ was applied to assess the methodological quality of the included studies. The ROBUST tool evaluates 8 key domains of bias using dichotomous criteria, such as adequacy of sample size or transparency in data management. Each criterion can either be met, receiving a score of 1 (indicating a low risk of bias), or not met, receiving a score of 0 (indicating a high risk of bias). A final score for each study is calculated, ranging from 0 to 8, with higher scores indicating a lower risk of bias. H.G. and K.T. resolved ambiguities in risk-of-bias assessment through consensus.

3. Results

A total of 434 published articles were initially identified from the database searches with the English search terms. No results could be found in any of the databases using the German search terms. After removing 110 duplicate articles, 324 studies underwent title and abstract screening, and 36 underwent full-text review. During the full-text screening, 26 studies were excluded for different reasons listed in the flowchart (Fig. 1). A list of the respective studies and a detailed description of the specific reason for their exclusion is provided in the supplementary material, http://links.lww.com/PR9/A349. Three additional studies were identified through citation searching; however, one was excluded because it was a conference proceeding, and another study was excluded for measuring empathy as an outcome variable, which is inconsistent with our PICO model (see Supplements, http://links.lww.com/PR9/A349). Finally, a total of 11 articles were included in our systematic review.

3.1. Study characteristics

Included studies were conducted between 2008 and 2019. Five studies used observational designs, where interactions between partners were observed and systematically coded. One study used a purely correlational design. Another 5 studies used longitudinal designs, using either daily diary methods or assessments taken at multiple distinct time points. Notably, 4 of these 5 studies reported different data from the same sample of patients with knee osteoarthritis and their spouses. To facilitate the tracking of this information, references to the 4 studies from the same sample are marked with an asterisk (*) in the following.

The sample sizes of the included studies varied considerably, ranging from 8 couples to 145 couples. Demographic data reported across studies also show inconsistencies. Aligning with epidemiological studies on the prevalence of chronic pain,^48^ most studies (n = 8, although 4 analyzed the same sample) included middle-aged adults with the mean ages between 50 and 65 years. The remaining 3 studies investigated younger samples. Regarding ethnic diversity, 4 studies included African American, Caucasian, and other racial backgrounds. However, several studies did not report ethnicity (n = 2 studies) or only specified percentages for White and Black participants (n = 1 study). Four of the studies mentioned only the percentage of White participants.

Regarding health status, the most common diagnosis for the ICPs in the included studies was knee osteoarthritis (n = 4 studies, but on the same sample). Apart from that, several studies included patients with various forms of chronic musculoskeletal pain. One study included patients who had chronic musculoskeletal pain with unspecified details, while 3 studies described more specific musculoskeletal pain conditions, such as low back pain, neck, and shoulder pain. Two studies examined pain conditions that specifically affected female one study focused on provoked vestibulodynia and another on vulvodynia. One study included participants with rheumatoid arthritis. Table 1 summarizes an overview of all data extracted from the included studies.

3.2. Study quality

Of the 11 studies included, 10 received a score of 4/8 or 5/8 on the ROBUST scale, reflecting a uniformly moderate risk of bias. With a score of 6, the lowest risk of bias was found in the study by Leong et al.^34^ Please refer to the Supplementary material, http://links.lww.com/PR9/A349 to review our risk-of-bias scoring for each study.

3.3. Conceptualization and measurement of empathy

Empathy was conceptualized and measured in various ways across the included studies. The most common conceptualization was defining empathic behavior from the spouse as validation. In 3 studies, validation was considered a response, which included acceptance of the partner and an attempted understanding of their thoughts, feelings, and experiences.^7,11,34^ Couples were invited to the laboratory and instructed to discuss a specific topic. In 2 studies,^7,11^ the interactions focused on the partner's pain experience and its impact on their lives, while 1 study^34^ instructed participants to discuss a topic of disagreement. No specific instructions were given regarding empathy or validation. Spousal interactions were videotaped and systematically coded by trained observers. Although all 3 studies aimed to identify validating and invalidating behaviors, each used different coding systems (Table 1).

Two other studies also assessed empathic responses by observing and coding in-lab spousal interactions, although the theoretical framework Gauvin et al.^23^ defined empathy as acceptance behaviors, such as perspective-taking and positive physical touch, and used the Rapid Marital Interaction Coding System,^27^ for coding verbal and nonverbal behaviors from the couples' interactions. Rosen et al.^53^ understood empathy as a response involving understanding, validation, and caring. They took a dual approach by developing and incorporating both observational and self-reported measures of empathy. Specifically, an observer rated the couples‘ videotaped interaction using the Empathic Response Card-Sort, while participants answered 3 items referring to the degree to which they felt understood, accepted, and cared for by their partner during the discussion.

Hemphill et al.^26^* asked patients’ spouses to indicate the extent of empathic spousal responses on a scale from Stephens et al.^59^ The original 7 items assess supportive partner communication and empathic understanding regarding the partner's pain in the past month, eg, “tried to put yourself in [the patient's] situation,” “showed [the patient] affection to comfort him/her.” In their daily diary survey, Martire et al.^40^* and Wilson et al.^65^* used 3 items from this scale to assess empathy from the patients' and/or spouses' perspective at the end of each day.

A solely cognitive approach was taken by Gauthier et al.,^22^ who measured pain-related empathic accuracy, ie, the ability of the spouse to accurately infer the partner's internal pain states from videotaped sequences of the patient performing a lifting task. Accuracy was operationalized through a Discrepancy Index, which measured the difference between self-reported pain and the spouse's estimation, and a Covariation Index, which assessed the spouse's sensitivity to fluctuations in the patient's pain over different trials of the lifting task.

Martire et al.^39^* took a different approach by conceptualizing empathy through autonomy support, defined as actions demonstrating empathy and understanding for the partner's situation and providing choices for health behavior changes. This aspect of empathy was measured by 3 items assessing the extent to which the spouse (1) showed understanding for how physically active the partner wanted to be, (2) respected the partner's decisions about physical activity, and (3) listened to the partner's preferences regarding physical activity.

Finally, Stephenson et al.^60^ used a 10-item self-report scale by O'Brien and DeLongis^45^ to measure empathic responding by capturing cognitive-affective aspects (eg, “Imagined myself in the other person's shoes”) and behavioral strategies (eg, “Tried to comfort the other person by showing my positive feelings for him/her”).

3.4. Association between empathy and pain-related outcomes

Four studies demonstrated a positive effect of empathy on pain-related outcomes, specifically physical functioning. For example, during 22 days of daily diary assessment, activity-related autonomy support was associated with more moderate-intensity physical activity and an increased step count for patients. By contrast, persuasion and pressure from the spouse did not relate to the level of physical activity in the patients.^39^* Male ICPs were even less active on days when they reported more activity-related pressure from their spouses. Longitudinally, Wilson et al.^65^* reported that ICPs, whose spouses exhibited greater empathic responsivity to changes in the ICPs' verbal expression of pain at baseline, showed steeper improvements in their physical function over the following 18 months. Similarly, Hemphill et al.^26^* longitudinally examined the mediating role of spouse responses to pain. Specifically, spouse confidence in patients' disease management at baseline was indirectly linked to improvements in patients' functional limitations and activity levels after 6 months, mediated through greater empathic responses to the patients' pain. This effect, however, was not observed over a twelve-month follow-up Although higher spousal confidence was still related to better patient functioning and physical activity, this effect was mediated through a decrease in solicitous responses, potentially implicating a gain in independence in those patients whose spouses trusted the disease management abilities of their partners. These 3 studies^26^^,^^39^^,^^65^* must be interpreted in light of the fact that they all analyzed data from the same sample. In a longitudinal design with a different sample, Stephenson et al.^60^ observed that spouses' empathic responding at baseline reduced the impact of spousal depressive symptoms on patients' disability 1 year later.

However, 3 studies showed nonsignificant or even disadvantageous associations of empathy with pain-related Martire et al.^40^* examined the association between ICPs' pain catastrophizing in the morning and spouses' responses throughout the day over a 22-day diary assessment period. While ICPs' pain catastrophizing in the morning and spouses' negative affect and punishing responses (ie, ignoring the patient, acting frustrated, or seeming irritated) throughout the day were related, there was no evidence that spouses' empathic or solicitous responses preceded or followed patients' catastrophizing. Similarly, Leong et al.^34^ found no significant cross-sectional association between observed validation and self-reported pain severity in their study. However, a moderation effect of sex Higher rates of spouse validation correlated moderately with greater pain, specifically in male patient couples. Gauthier et al.^22^ observed small-to-medium–sized negative correlations of higher pain-related empathic accuracy with different pain- and health-related variables. That is, the more accurately spouses inferred their partners' pain, the higher the degree of interference of pain, affective distress, and reduction of social activities in the patients. As a possible explanation, the authors propose that empathic accuracy could sometimes lead to adverse outcomes by overwhelming the spouse's emotional resources and impairing their ability to provide support. However, other explanations are possible (see discussion). In sum, most studies confirmed an association between spouse empathy or validation and ICPs' pain and functioning. However, the evidence remains inconclusive due to null results and contradictory findings, particularly from the study with the lowest risk of bias.^34^

3.5. Empathy and relationship outcomes

Similarly to pain-related outcomes, several studies showed a positive association between empathy and relationship outcomes. Cross-sectionally, observed validating and empathic responses were positively correlated with self-reported marital satisfaction in the studies by Cano et al.^7^ and Gauvin et al.,^23^ who also found that the effect of one's partner's level of empathy on relationship satisfaction was moderated by sex, being stronger for men than women. Similarly, Rosen et al.^53^ reported that perceived and observed empathic responses correlated with higher relationship adjustment reported by ICPs and their partners to a medium extent. Regarding empathy's moderating role, the study by Stephenson et al.^60^ demonstrated that higher perceived empathic responding at baseline attenuated the effects of ICPs' and spouses' depressive symptoms on marital quality at a one-year follow-up.

In contrast to expectations, a study that reported a link between spouse validation with greater patient pain (see above) also revealed a negative small-to-medium effect of frequent spouse validation on marital satisfaction. However, both effects were observed in male patient couples only.^34^ Similarly, Cano et al.^11^ found no significant correlation between observed validation and relationship outcomes. Gauthier et al.^22^ also did not report any significant associations between pain-related empathic accuracy and relational outcomes, such as dyadic adjustment and length of the relationship.

Only 1 study specifically assessed sexual satisfaction within the domain of relationship satisfaction. In this study, which included female patients with provoked vestibulodynia, a recurrent vulvovaginal pain condition, a greater number of observed empathic responses was associated with higher sexual satisfaction, whereas greater observed self-disclosures were associated with lower sexual satisfaction. No effects of partner empathy or partners' self-disclosure on sexual satisfaction were found.^23^

In sum, most studies linked spouse empathy or validation to marital functioning, although some ambiguity remains.

3.6. Invalidation

Eight studies also examined the effects of invalidating or nonempathic interactions on various outcomes for patients and spouses. Invalidating reactions could include, for instance, inattentiveness, telling the spouse what they should think or feel, or putting them down.^7^ To a small-to-medium extent, observed invalidation by both partners was associated with lower marital satisfaction^7,34^ and reduced perceived spousal support.^7^ In female patient couples, higher rates of invalidation by both partners were also significantly moderately related to higher spouse depression.^34^ In addition, Stephenson et al.^60^ identified a moderating role of empathy in the longitudinal association between depression and marital patient and spouse depression at baseline were linked to poorer marital quality at follow-up when spouses' empathic responding was low. The same study also reported that spouse depression was linked to greater patient functional impairment 1 year later in cases when the spouse showed low empathic responding. The results of another repeated-measurement study demonstrated that punishing spouse responses on 1 day predicted greater patient catastrophizing the next morning.^40^* Cross-sectionally, Cano et al.^11^ also observed that invalidation was moderately associated with helplessness catastrophizing in both partners, as well as with increased distress-related pain behaviors reported by the ICP and heightened anxiety in the spouse.

On the other hand, Hemphill et al.^26^* observed no adverse effect of punishing responses (eg, getting angry with or ignoring the partner) on the trajectory of the patient's functional limitations over 6 and 12 months. Analyzing the same sample, Wilson et al.^65^* also found no significant effect of solicitous or punishing responsiveness, ie, the degree to which spouses' solicitous or punishing reactions calibrate to changes in the ICPs' pain expression, on changes in ICPs' physical function over time.

4. Discussion

This systematic review reveals the important role of empathy in couples dealing with chronic pain. Several reviewed studies demonstrated that empathic or validating interactions positively affected pain-related outcomes, such as improved physical functionality and activity^26^^,^^39^^,^^60,65^* as well as relationship outcomes, including improved relationship satisfaction and quality.^7,23,53,60^ These results were evident for self-reported and observed measures of empathy and validation and could be found in cross-sectional and longitudinal study designs. The findings align with theoretical frameworks such as the interpersonal process model of intimacy,^52^ which posits that empathic responses deepen relational bonds and foster greater emotional intimacy. Contrary to the predictions of the operant model of pain,^21^ empathic responses do not reinforce pain behavior and instead relate to adaptive patient outcomes.^18^ In particular, we found no evidence of a disadvantageous effect of solicitousness on chronic pain or functioning.

However, not all findings supported the positive effects of empathy. In male patient couples, Leong et al.^34^ found that higher levels of spouse validation were related to greater pain and lower marital satisfaction. Another negative effect was reported by Gauvin et al.,^23^ who found an association between self-disclosures and sexual dissatisfaction. The authors suggest several explanations for their findings, such as a reduction of sexual desire and pleasure due to self-disclosures about negative emotions. Individuals who frequently self-disclose might also report their sexual dissatisfaction more openly.^23^ Surprisingly, this study was the only one explicitly addressing sexual functioning, although sexual difficulty among patients with chronic pain (also beyond genital pain) is common and burdensome.^20^ While reasons such as exacerbating pain, physical limitations, or medication are discussed in the literature,^1^ future studies should shed more light on socio-affective factors that influence sexual satisfaction in chronic pain couples.

The study by Gauthier et al.^22^ contradicted the expectation that empathic understanding would lead to more adaptive outcomes. According to their findings, higher pain-related empathic accuracy was linked to greater interference of pain in the patient's life, increased affective distress, and reduced social activity. The authors propose an indirect association between higher empathic accuracy and patients' dysfunction driven by empathic distress of the spouses and, consequently, less spousal support.^22^ Alternatively, patients with more severe pain conditions could express their pain and disability more strongly and thereby facilitate estimation, resulting in increased accuracy for patients with more pronounced symptoms. However, other findings suggest that the association between accuracy and pain severity reverses when the patient's pain persists over time,^33^ indicating that, in the long term, spouses of ICPs with high pain severity may become less empathically accurate to reduce their emotional burden. In addition, empathic accuracy alone does not guarantee beneficial In healthy couples, higher accuracy was linked to declines in subjective closeness when they expressed relationship-threatening thoughts or feelings during an in-lab discussion.^56^

Although 2 studies found no significant effects, 6 studies consistently showed the detrimental effects of invalidating or nonempathic responses on marital or relationship quality,^7,34,60^ along with various affective and cognitive aspects^11,34,40^* and physical functioning.^60^ Similarly, previous research has shown that a lack of empathy or validation in social relationships is associated with a wide range of negative outcomes, such as reduced mental well-being,^12^ poorer physical health,^30^ and reduced social functioning.^24^ These negative effects may be explained by an impaired ability to regulate emotions when an individual encounters an invalidating environment.^4^ Invalidating communication could also signal a lack of social safety,^24^ whereas feeling supported, accepted, and connected is essential for maintaining health and well-being.^58^

4.1. Limitations

This systematic review has several limitations that should be considered when interpreting its findings. First, the studies included vary in their measurement and conceptualization of empathy in couples coping with chronic pain. While some share overlapping components, such as validation, they also differ in key aspects. Some studies relied on self-reported measures, while others used observational coding systems to assess empathic behaviors. These diverse methodologies make it difficult to compare results across studies and impede meta-analytical calculations, which would have added value to this narrative summary. Second, the samples lacked diversity in age, sexual orientation, and ethnicity, with most participants being middle-aged, heterosexual Caucasian couples. Four studies even reported different data from the same study cohort, leading to an overrepresentation of older patients with knee osteoarthritis and their spouses in this review. This lack of sample diversity restricts the applicability of the findings to broader populations, including younger couples or those from different ethnic backgrounds. Furthermore, the participants in the included studies represent a small scope of chronic pain conditions, with musculoskeletal disorders and vulvovaginal pain being particularly prevalent. Future research should include a wider variety of chronic pain conditions, eg, neuropathic pain or fibromyalgia, to explore whether empathy has similar effects across different pain syndromes.

The review process itself also has limitations. The literature search did not include grey literature, and only 1 reviewer conducted the screening process in an unblinded manner. This could have introduced selection bias or reduced the reliability of study selection. Future reviews may also benefit from using a broader range of search terms to capture different facets of empathy, potentially enabling comparisons between affective and cognitive approaches.

4.2. Implications

Given the importance of social influences on chronic pain, interventions might benefit from involving relatives in the therapeutic process. Moreover, specific treatments for couples, including empathic responding exercises, are available.^8^ Martire et al.^38^ indeed demonstrated that couple-based interventions provide greater benefits for managing chronic pain than individual approaches alone. Based on insights from this systematic review, specifically incorporating empathy and validation training into interventions for couples coping with chronic pain could prove effective. For example, Edlund et al.^17^ found that a brief training session in validation increased validating behaviors in couples coping with chronic pain, as well as in sibling and parent–child pairs. In the context of children's pain, validation is even discussed as a mechanism for preventing the development of chronic pain.^63^

One study reported negative outcomes of spousal validation specifically for male patient couples,^34^ and another study found that one's partner's level of empathy affected relationship satisfaction more strongly for men than women.^23^ In addition, social support seems to affect men and women differently.^64^ Thus, tailoring interventions to account for gender differences seems necessary. Finally, addressing invalidating behavior within relationships of chronic pain couples is essential. Interventions should aim to reduce these behaviors actively, as studies in healthy individuals demonstrated that invalidating feedback predicts increased threat-related emotional and physiological arousal and reduced social engagement behaviors.^24^ Avoiding invalidation is also crucial for healthcare professionals, who interact with ICPs, to maximize patient satisfaction and foster good communication.^36,62^

Future studies should work to refine and standardize the ways empathic or validating responses are measured in couples coping with chronic pain. Specifically, adding subjective and objective measurement tools would allow exploring whether the mere perception of empathy is sufficient to produce positive outcomes or if objectively empathic responses are necessary. Relatedly, some researchers suggest that the pain patient's perception of their partner's support and responsiveness may be more important than their actual behavior.^37,52^ Only 2 studies in this review^53,60^ examined spouses' perception of empathic responding and found positive effects. Included studies also mainly focused on the spouse's empathic responses toward the pain patient. Nevertheless, understanding others in a relationship is a mutual process, indicating that a comprehensive view of empathy in relationships also needs to account for reciprocity. Future research should expand on this.

It may also be valuable to differentiate between state and trait empathy in the context of chronic pain. Although the spouse of a partner dealing with chronic pain might generally be an empathic individual, they may still react less empathically to their partner's pain-related expressions in certain situations. As empathy and compassion are cognitively costly, people might avoid these responses in situations in which they perceive empathy as effortful and aversive.^5,54^ Considering empathy as a motivated decision^6^ provides an interesting perspective on the reported associations of empathy and pain or relationship satisfaction, Partners could more likely choose to respond in an empathic or validating manner if marital functioning is high and/or their partners are less limited by their pain. The correlational design of the included studies, however, precludes conclusions on the direction of associations.

Most of the included studies in this review captured a momentary state of empathy. Future research could offer valuable insights by comparing momentary assessments of empathy^49^ with spouses' trait levels of empathy, thereby enhancing our understanding of potential deviations and their underlying causes.

Another key area for future investigation is the need for more longitudinal studies to better understand how empathic behaviors evolve over time and their lasting impact on relationships and health outcomes. In addition, such studies could examine phenomena such as empathic distress or caregiver burnout^28,66^ and include various social interaction partners, eg, friends or family members, such as parents, children, or siblings.^25^

5. Conclusion

The findings from this systematic review suggest that empathy and validation generally have a positive impact on patients´ physical function, physical activity, relationship satisfaction, and relationship quality in couples with chronic pain. Conversely, the review also revealed that nonempathic and invalidating spouse behavior has largely detrimental effects on relationship quality, emotional well-being, and physical functioning of patients. Thus, incorporating empathy and validation training in interventions may be a promising tool in couples with chronic pain. Based on the literature presented in this study, we believe that the positive effects of empathy and the disadvantages of invalidation in a chronic pain context might not be restricted to intimate relationships. Anyone dealing with a person in pain, whether professionally or privately, should bear in mind that their experience is real and legitimate and that nobody should be invalidated for disclosing their (pain-related) thoughts or feelings. Clinicians who counsel spouses or family members of ICPs should recommend more empathic and validating responses to pain-related emotional disclosures and ensure that they consistently display these behaviors themselves. This could advance our understanding and treatment of chronic pain, and many patients and their loved ones will benefit.

Disclosures

K.T., H.G., L.M.B., G.K., P.K., H.L.R., and A.M.F.R. have no conflicts of interest.

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