Pain From a Distance: Can Third-Person Self-Talk Mitigate Pain Sensitivity and Pain Related Distress During Experimentally Induced Pain?

Methods

Results

Descriptive Statistics

Mean and SD for the different conditions (Third-person self-talk; First-person self-talk; Cue-card control; Non-interventional Control are presented in Table 1.

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Table 1.

Mean and SD for the Different Conditions (Third-Person Self-Talk; First-Person Self-Talk; Cue-Card Control; Non-interventional Control). For all Blood Pressure Measurements, the Difference Between the Intervention Measure and Baseline Measure is Reported.

Condition	Pain tolerance mean (SD)	Pain intensity (mean, SD)	Negative affect (mean, SD)	Systolic blood pressure (mean, SD)	Diastolic blood pressure (mean, SD)	Pulse (mean, SD)
Third-person self-talk	132.34 (115.1)	7.01 (1.22)	4.52 (2.20)	−11.20 (9.28)	−10.75 (8.79)	−10.86 (11.31)
First-person self-talk	149.47 (118.74)	7.24 (1.26)	4.75 (2.37)	−13.84 (8.83)	−12.21 (8.70)	−11.77 (10.26)
Cue-card control	161.52 (119.71)	7.00 (1.47)	4.97 (2.44)	−10.28 (10.66)	−10.28 (10.66)	−13.16 (12.02)
Control	168.56 (121.27)	6.91 (1.47)	4.33 (2.66)	−12.62 (9.91)	−13.83 (7.91)	−12.64 (13.26)

Discussion

The aim of this study was to examine the effect of third-person self-talk (self-distancing perspective) on pain tolerance, pain intensity, pain-related negative affect, and blood pressure in experimentally induced pain in healthy participants. It was hypothesized that engaging in third-person self-talk would lower pain intensity and negative affect, increase pain tolerance, and lower blood pressure. In this study, we did not find any effect of third-person self-talk on pain tolerance, estimated pain intensity, or estimated negative affect. Nor did we find any effect on blood pressure (systolic or diastolic) or the pulse when the third-person self-talk condition was compared to first-person self-talk or the cue-card control condition. When comparing the third-person self-talk to the non-interventional control condition, significantly decreased diastolic blood pressure was found. Considering that no other dependent variables differed significantly between the third-person self-talk condition and any of the other conditions, this difference seems to be of little importance when considering third-person self-talk as a potential pain-relieving strategy. Since this was a well-powered study, and the descriptive data showed that the participants experienced substantial pain induction levels with the cold pressor test (Table 1), and complied with the experimental manipulation, it appears that engaging in self-distancing through third-person self-talk does not have a meaningful effect on the measured experimental pain variables.

Our hypothesis regarding third-person self-talk was partly informed by previous research on the facilitating effects of third-person self-talk on emotion-regulation (Kross et al., 2014, 2017; Nook et al., 2017; Orvell et al., 2021; Streamer et al., 2017) and the coexistence of negative affective states and physical pain (Brown et al., 2002; Suhr & Spickard, 2012; Vlaeyen & Linton, 2000). However, it should be noted that the link between the nociceptive transmission and the negative emotional affective state is much stronger in clinical pain compared to induced experimental pain.

Pain is part of our survival system, like hunger, thirst, sleep, and sex. To avoid pain is highly rewarding (Porreca & Navratilova, 2017), but possibly, the knowledge that we could easily stop the pain, would lower the threatening value coexisting with pain substantially. There is support for the notion that the prefrontal cortex governs the activation in brain areas responsible for the emotional component in pain experiences (Thompson & Neugebauer, 2017; Wiech & Tracey, 2009), and this could possibly affect the threatening value in experimentally induced pain. The induced experimental pain in this study was short in duration and could be terminated whenever the participant wanted. When enrolling into the research experiment the participants were also informed that the pain induction would be completely harmless, and that they could terminate the pain induction whenever they wanted. Therefore, it is likely that the experienced pain was accompanied by lower levels of emotional distress compared to the pain experience in clinical pain. Some support for this could be seen in the descriptive data, where the mean of the negative affective estimations was below the pain intensity measures for all groups (Table 1). The mean estimation of negative affect was close to the midpoint of the scale for all different conditions, and it has been suggested that an estimation of 4–6 on the NRS-A could be categorized as medium-fairly anxious (Propokowicz et al., 2022). It is possible that this level of negative affect was too low to allow for an observable effect of third-person self-talk.

The results from our study were not in line with the results from the laboratory study conducted by Wang et al. (2019), where a self-distanced perspective significantly decreased both pain intensity ratings and ratings of pain stress. However, there are two important differences between Wang’s et al. (2019) study and our study. One is that they did not induce the self-distanced perspective through third-person self-talk. Instead, the participants adopted a self-distanced perspective from a “fly on the wall” vantage point. Perhaps these different induction methods could affect the amount of self-distancing achieved. Third-person self-talk has been used successfully in earlier research to induce a self-distanced perspective, and to lower negative emotional reactivity and reduce the impact of emotional experiences (Kross et al., 2014, 2017; Nook et al., 2017; Orvell et al., 2021; Streamer et al., 2017). Another important difference was that the Wang et al. study (2019) was considerably smaller with 21–23 participants in each experimental (between-subjects) condition (N = 65). In their study, the observed self-distancing effect on pain intensity and stress was large. It might, of course, be that Wang et al. estimated the true effect. However, it should be interpreted with caution given that small sample sizes tend to yield more variable effect sizes, reducing the likelihood that a statistically significant result reflects a true effect (Button et al., 2013).

The results from this study are consistent with the results from an earlier, well-powered experimental study investigating the effect of abstract thinking on experimental pain (Gunnarsson & Agerström, 2023). In that study, the participants adopted an abstract mindset (why they experienced the experimental pain) or a concrete mindset (how they experienced the experimental pain). Because a third-person perspective is more psychologically distant and abstract than a first-person perspective (Kross et al., 2014; Trope & Liberman, 2010) the results converge at a conceptual level.

The results of the current study suggest that engaging in third-person self-talk has no effect on acute, experimental pain. The practical implication of this finding is that is seems futile for people to use third-person self-talk to alleviate acute pain, although there is nothing in our data suggesting that it has a debilitating effect. It is, of course, possible that we failed to detect a small effect since our study only had high a priori power to detect a medium-sized effect. However, whether a small effect would be meaningful in the current context could be debated. Furthermore, as a general observation, it seems rare for experimental studies on pain management to be adequately powered to detect small effects.

Future research should examine the effectiveness of educational self-talk interventions performed outside the laboratory, such as in the home or at work, by people with chronic pain. Importantly, such interventions should be designed to elicit organic self-talk, and hence to increase chronic pain patients’ inclination to spontaneously use third-person self-talk in their everyday lives. Besides making the occurrence of self-talk more natural, this type of self-talk may facilitate the participants’ rational thought processes, possibly having a pain-relieving effect. Generally speaking, third-person self-talk should tax relatively few cognitive control resources (Moser et al., 2017), which is arguably important since chronic pain is very resource depleting (Berryman et al., 2013; Legrain et al., 2009; Nouwen et al., 2006). Compared to other available psychological treatment programs of chronic pain, such as cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT), which tend to be lengthy and require extensive training with a clinician (McCracken et al., 2022; Williams et al., 2020), third-person self-talk may be easier to learn and conduct at home whenever needed.

It is also possible that other types of self-distancing techniques, such as the “fly on the wall” perspective adopted by participants in the Wang et al. (2019) study, are more effective although larger studies are needed to establish this. Future research also needs to examine whether such self-distancing techniques have the potential to alleviate chronic pain and pain related distress. We believe that self-distancing could be a viable strategy when dealing with chronic pain given the more prominent role that negative emotions (e.g., fear and anxiety) play in chronic pain (Brown et al., 2002; Suhr & Spickard, 2012; Vlaeyen & Linton, 2000) and the robust finding that self-distancing reduces emotional reactivity and the impact of emotional experiences across numerous contexts (Kross et al., 2014, 2017; Nook et al., 2017; Orvell et al., 2021; Streamer et al., 2017).

Our experiment comes with some limitations. The fact that participants knew their pain would be brief and that they could terminate it at their own discretion meant that negative affect was kept relatively low. Hence, there was relatively little emotional reactivity to regulate in the first place, which may have restricted the impact of third-person self-talk. In addition, although the experiment included two control conditions (one controlling for a possible cue card effect and another eliciting no specific strategy), there was no comparison strategy for third-person self-talk other than first-person self-talk. It would have been interesting to include another comparison condition consisting of a successful pain management strategy (e.g., distraction) as a benchmark. However, this would have been more useful had we found an effect of third person self-talk whose effectiveness we could compare to more established strategies. In the non-interventional control condition, where the participants were allowed to think of whatever they preferred, we had no manipulation check to shed light on any potentially pain-relieving strategy they might have used. It is possible that some participants in this condition might have spontaneously engaged in self-distancing practices, such as imagining themselves being outside of their bodies, or imagining themselves being somewhere else, or even using organic self-talk. This could be seen as a limitation in our study. Hence, future experimental studies examining the effectiveness of self-distancing and third person self-talk should control for spontaneous use of such strategies among non-intervention participants. In addition, it would also be interesting to examine how often pain-afflicted individuals spontaneously use such pain management strategies in everyday life using diary methods.

Another limitation of the current study is that the experimenter was not blinded to the different interventions. However, to counteract experimenter bias and demand characteristics, the experimenter provided standardized written and oral instructions to all participants. Therefore, we believe it is unlikely that any systematic bias would have impacted the results.

Finally, it should be noted that although the theoretical rationale underlying our hypothesis was partly based on the assumption that attention to pain (facilitated by a concrete self-immersed first-person perspective) would increase its perceived intensity (e.g., McCracken, 1997), the impact of attention needs clarification. There are studies suggesting that pain intensity is dynamically modulated by attention (Adamczyk et al., 2023; Kucyi & Davis, 2015; Quevedo & Coghill, 2007). For example, when attention is focused on a more restricted (as opposed to global) body area of induced pain, perceived pain intensity is reduced (Adamczyk et al., 2023). Although this is an interesting finding that paints a somewhat more complex picture of attention, we do not see this as conflicting with our theoretical rationale which simply assumes that a self-immersed first-person perspective would increase attention to the pain per se. Nevertheless, future research may want to examine whether first-person and third-person self-talk influence perceived pain intensity differently depending on whether the pain is localized as opposed to more global (expanding across body areas).

In conclusion, this relatively large and well-powered experimental study showed no effect of third-person self-talk on pain tolerance, pain intensity, pain-related negative affect, or blood pressure (systolic, diastolic, pulse) in conjunction with experimentally induced pain. Since clinical pain is different from experimental pain, future research should examine whether self-distancing, and third-person self-talk specifically, has the potential to alleviate clinical pain states, especially chronic pain states.