Social Service Innovations: Is Seeing Believing?
By Heather Burton, LCSWR
Social Work Today
Vol. 23 No. 3 P. 8

Does the use of empathy-building virtual reality by staff improve treatment outcomes for veterans with chronic pain?

Let’s face it, even social workers find empathy challenging when faced with complex problems such as chronic pain. So it stands to reason that medical staff, who treat this issue day after day, will struggle with it too.

Knowing that we matter and that our experiences are important to others validates our very existence. Veterans often confide to clinical social workers that their complaints of chronic pain are dismissed, downplayed, or altogether disbelieved. They feel as though no one is listening and no one cares about their pain. And providers express frustration about veterans who are noncompliant with treatment recommendations and, as a result, show little improvement. Validation and empathy building may be helpful in bridging this gap to create a win-win environment where veterans with chronic pain and their medical providers both feel as though they are being heard and are working together for the ultimate goal of improved treatment outcomes.

Invalidation is known to make people shut down and disconnect. In order to validate our clients, we must be able to empathize, to put ourselves into someone else’s shoes, so to speak. If we can imagine what another must be going through, we can offer them genuine understanding, care, and support.

Can virtual reality (VR) help practitioners put themselves in the shoes of their patients? Chronic pain is a difficult problem to treat; provider empathy may be facilitated by VR, therefore leading to improved treatment outcomes. As providers gain a better understanding of what it’s like to live with chronic pain, they may interact with more empathy toward their patients, providing them with validation and support, which will lead to better collaboration with the patient, better compliance, and improved treatment outcomes.

Chronic Pain and Empathy
The International Association for the Study of Pain defines chronic pain as a condition that lasts longer than three months and continues even after the initial cause of the pain has healed. It’s one of the most common reasons patients seek care, and yet is one of those ‘invisible’ conditions that are too often discredited. Since chronic pain lingers after healing and the experience of it is subjective, people with chronic pain are vulnerable to stigmatization, and they frequently hear remarks that sound like “it’s all in your head.” Chronic pain sufferers are often stereotyped as untrustworthy and either drug or disability seeking—a stereotype that can also negatively influence their providers’ clinical judgment and caregiving.1-3

According to 2022 research by Wilson and colleagues, veterans report chronic pain at double the rate the civilian population does.4 Chronic pain is often complicated in the veteran population because, many times, it’s the result of traumatic events that lead to complex medical and psychiatric problems.5 The physical pain is a reminder of the trauma, creating emotional pain, which in turn, leads to more physical pain.

Tong and colleagues define empathy as “our ability to perceive, understand, and respond to the experiences and behavior of others.’’3 The patient-provider relationship is a critical component of effective treatment for chronic pain. Research about the impact of empathy on patients who suffer chronic pain is plentiful. Provider empathy increases patient satisfaction, patient activation, and medication compliance. and treatment outcomes. Research conducted by Käthner and colleagues found that simply watching a provider interact empathetically with someone else can lead to improved pain tolerance for patients due to the importance of social support in pain modulation.6 Cánovas and colleagues found that provider empathy also improves the providers’ career satisfaction, increases clinical competence, and decreases burnout. Therefore, interventions that improve provider empathy can have positive outcomes for both the provider and patient.7

Virtual Reality
VR often borrows concepts from social learning theory, which suggests that people learn by observing and imitating behaviors. Riches and colleagues found that VR simulations can mirror patient experiences and expose medical professionals to an array of situations that they are likely to encounter.8 One such program, AS IF, is a VR video game developed by Tong and colleagues that allows users to inhabit an avatar of a person with chronic pain. Users virtually embody patients, putting them in the shoes of a person in pain so that they can experience daily activities, symptoms, limitations, and self-talk that a typical patient with chronic pain may experience. After using this program, practitioners reported higher scores on a Willingness to Help questionnaire and the kindness subscale, which is an adaptation of an empathy questionnaire. Participants also reported a sense of ownership and control over the avatar’s body, with some divergence for those who felt disembodied from their avatar due to differing characteristics in terms of gender, ethnicity, height, and shape. Ultimately, results indicated that this tool helped providers put themselves in the position of patients to better understand their chronic pain experiences.3

Another study, by Elzie and Shaia, had medical students use an immersive caregiver learning and training platform software to embody a patient diagnosed with terminal cancer. In this research, students virtually experienced going with their families to the doctor’s office, hoping for good news but instead learning of their loved ones’ terminal diagnoses and prognoses. Next, the users experienced learning about hospice care and transitioning home with it, once again alongside their families. The medical students were given surveys before and after participating in these labs, and the results showed that 84% of them reported a better understanding of terminal cancer patients’ experiences, and 90% reported an improved understanding of the families’ experiences. Through modeling effective ways of delivering sensitive news to patients, the students demonstrated enhanced empathy, increased confidence and comfort for having difficult end of life discussions, and improved understanding of the terminal cancer patients’ experiences. An increased awareness of patients’ experiences helps medical providers understand and respond to their patients’ needs in a more supportive and effective manner.9

Health care providers for veterans are no strangers to VR, and many implement it to help veterans with the treatment of chronic pain, phantom limb pain, PTSD, and specific phobias. Darken and colleagues explain that veterans can use VR as a form of exposure therapy and can learn and practice mindfulness exercises.10 As technology grows, it’s also become more affordable and accessible to the general population as well as more accepted as an intervention. Veteran health providers now equip veterans with VR devices to use as a part of their treatment.

Implications for Social Work
Some professionals express concern about the use of technology in the field of social work. The hesitation comes, in part, from fear that technology will replace the human touch that’s so necessary in social work. The need to be heard, understood, and validated is crucial to feeling connected with others. Perhaps we could view technology as a partner rather than a replacement in the instance of using empathy-building VR. Providers can use this tool to build and strengthen a skill they need to work more effectively with their patients. Similarly, social work students and professionals can use role playing strategies to practice interacting with clients or to help clients practice interacting with others. VR exposes users to firsthand, lifelike scenarios, some of which allow them to embody another person’s experience to gain deeper understanding.

Limitations to integrating VR in social work settings exist. For instance, issues related to access and affordability of VR technology, as well as potential barriers to implementation and maintenance of VR programs for staff, may pose difficulties for some programs. But social workers are an important piece of the technology puzzle. It’s our role to advocate for others by ensuring that technology is representative and inclusive so it may be effective for all. Social workers bring a unique perspective to the table by looking at clients’ experiences and ways to enhance them. Future research might explore whether VR users would have an even more impactful experience with the technology if their avatars were similar to themselves in terms of ethnicity, gender, age, etc. Technology holds many opportunities for social workers. We can assist clients and agencies by identifying programs that are necessary and helpful and by collaborating with creators to develop realistic scenarios that are relevant and relatable.

Veterans are at a higher risk for chronic pain than are those in the general public, and their conditions often have additional complexities. Add to this complicated treatment strategies and a healthy dose of stigma, and you’ve got the makings for high levels of frustration for both the veterans and the providers. Increased provider empathy can help veterans feel validated and understood, creating a higher likelihood that they will adhere to the treatment plan and report a greater sense of control over their pain. Providers also benefit from increased empathy for their patients with chronic pain and, therefore, can be more supportive and compassionate collaborators in their patients’ care. VR can be a useful tool in building this empathy by allowing providers to gain virtual, first-person experience of what it’s like to have chronic pain. This technology is now affordable and accessible via veterans’ organizations and enables users a unique perspective on what it is like to be in another’s shoes. It’s possible that the use of VR can help untangle stigma from the complicated knot of chronic pain and allow both veterans and providers to have the win-win outcome they desire.

— Heather Burton, LCSWR, is a clinical social worker in the pain clinic at the Hudson Valley VA in Wappingers Falls, New York. In addition to her work with veterans, she also works privately with people struggling with trauma. She’s a DSW student at the University of Buffalo.

References
1. Chibnall JT, Tait RC, Gammack JK. Physician judgments and the burden of chronic pain. Pain Med. 2018;19(10):1961-1971.

2. Perugino F, De Angelis V, Pompili M, Martelletti P. Stigma and chronic pain. Pain Ther. 2022;11(4):1085-1094.

3. Tong X, Gromala D, Kiaei Ziabari SP, Shaw CD. Designing a virtual reality game for promoting empathy toward patients with chronic pain: feasibility and usability study. JMIR Serious Games. 2020;8(3):e17354.

4. Wilson M, Skeiky L, Muck RA, et al. Pain catastrophizing mediates the relationship between pain intensity and sleep disturbances in U.S. veterans with chronic pain. Mil Med. 2022:usac065.

5. Hoffman HG, Rodriguez RA, Gonzalez M, et al. Immersive virtual reality as an adjunctive non-opioid analgesic for pre-dominantly Latin American children with large severe burn wounds during burn wound cleaning in the intensive care unit: a pilot study. Front Hum Neurosci. 2019;13:262.

6. Käthner I, Eidel M, Häge AS, Gram A, Pauli P. Observing physicians acting with different levels of empathy modulates later assessed pain tolerance. Br J Health Psychol. 2022;27(2):434-448.

7. Cánovas L, Carrascosa AJ, García M, et al. Impact of empathy in the patient-doctor relationship on chronic pain relief and quality of life: a prospective study in Spanish pain clinics. Pain Med. 2018;19(7):1304-1314.

8. Riches S, Iannelli H, Reynolds L, Fisher HL, Cross S, Attoe C. Virtual reality-based training for mental health staff: a novel approach to increase empathy, compassion, and subjective understanding of service user experience. Adv Simul (Lond). 2022;7(1):19.

9. Elzie CA, Shaia J. A pilot study of the impact of virtually embodying a patient with a terminal illness. Med Sci Educ. 2021;31(2):665-675.

10. Darken RP, Peterson B, Gore J. Editorial: virtual reality applications in military and veteran medicine and healthcare. Front Virtual Real. 2022;3:856666.