Background Chronic pain remains a leading cause of patient distress in primary care and effective pain management presents an ongoing challenge in patient-clinician interactions. The prescribing of opioids further contributes to communication and shared decision-making disparities between patients and general practitioners. Gaining greater insight into patients' experiences of opioid treatment is valuable as there still is limited knowledge. Patients' perspectives and expectations can provide important contributions to enhance mutual understanding in clinical encounters.Aim To explore how patients experience, and what they expect from, pain management consultations regarding opioid use.Design and setting A qualitative study with patients in rural Örebro County, Sweden.Method Semi-structured interviews were carried out with fifteen chronic pain patients prescribed opioids managed in primary care. The interviews were analyzed using reflexive thematic analysis.Result Two main themes were generated to capture patients experience and their expectations concerning pain management and opioids. Prescribing Validation gives insights to what expectations patients have and how they perceive prescriptions. Renewals are interpreted as validation of the pain condition, and dismissals as mistrust. The Battle for the Steering Wheel capture how patients, based on the lived experience of chronic pain, expect and seek to assert their own expertise in consultations but often feel frustrated over being unheard.Conclusion While education about the biopsychosocial nature of pain may provide a necessary foundation for communication around reducing opioid use, validation of patient experience is pivotal for building a trusting alliance.

BACKGROUND:Chronic pain frequently co-occurs with emotional problems, highlighting the need for integrated treatment approaches. Previously, we evaluated a hybrid emotion-focused treatment with positive results. However, there is a dire need for studies evaluating treatments in 'real world' clinical contexts. Therefore, this study evaluated the effectiveness of this treatment in regular clinical care. METHODS:Using a sequential single-case experimental AB design with randomized baseline lengths (4, 5 or 6 weeks), pain, emotional problems and cognitive behavioural factors were assessed weekly across a 20-week study period. Additional outcome measurements were collected at pre-, post- and 12-month follow-up. Patients from primary and secondary care (final n = 31) with chronic pain and anxiety/depression were recruited, and their psychologists delivered the treatment. Individual effects were evaluated using non-overlap of all pairs and aggregated effects via multilevel shift models. Acceptability, adherence and fidelity were summarized, and responders and non-responders compared using group-level analyses. RESULTS:Most (87%) demonstrated a treatment response on ≥ 1 outcome, and over half (55%) on ≥ 3 outcomes. One-third were classified as broad responders. Aggregated analysis showed a significant effect on pain interference. The treatment was viewed as credible and acceptable, with greater satisfaction among responders. Non-responders showed more variability in attendance and lower progression through later treatment phases involving exposure. CONCLUSION:The findings support the feasibility and potential effectiveness of the hybrid emotion-focused treatment for patients in routine clinical care. The treatment benefits most patients to some extent and a smaller subset of patients to a clinically significant extent. SIGNIFICANCE STATEMENT:This pragmatic trial evaluates effectiveness in a clinically representative patient sample reflecting the complexity of routine care, including pain and psychiatric comorbidity, sociodemographic diversity and health care utilization. The hybrid emotion-focused treatment represents one of several emerging approaches targeting pain-emotion connections. These findings extend results from a prior RCT and highlight the importance of evaluating interventions under real-world clinical conditions.

BACKGROUND:Persistent pain, one of the most common reasons for suffering and health care seeking, often co-occurs with emotional problems such as depression and anxiety. Within the Center for Health and Medical Psychology at Örebro University, Sweden, we have developed a new treatment aimed at addressing co-occurring persistent pain and emotional problems: hybrid emotion-focused exposure treatment. The overarching idea behind the treatment is that patients who struggle with comorbid pain and emotional problems need to develop skills in dealing with emotions as well as pain. With better skills in tolerating and soothing difficult emotions, patients will be more able to approach previously avoided stimuli and situations, such as movements, activities and social interaction. OBJECTIVES:This review aims to delineate the development of the hybrid emotion-focused exposure treatment. It begins by outlining the theoretical background, then proceeds to describe the techniques, discuss the evidence and conclude with an illustrative case example. RESULTS:Thus far, the treatment has been tested in a single-case study and a randomized controlled trial with promising outcomes. Overall, the hybrid treatment seems to have a good effect on patients' depressive symptoms and pain interference. The treatment is currently being implemented, and the implementation process evaluated, in primary and specialist care across Sweden. CONCLUSIONS:The hybrid emotion-focused exposure treatment seems to be a well-suited treatment for people with a high burden of persistent pain and emotional difficulties. There is good reason to implement the treatment in clinical practice and continue evaluating treatment effects across different contexts.

By simultaneously examining minority-related stressors and general stressors experienced by the whole population, the study's aim was to provide a more comprehensive understanding of the health and well-being of LGBTQ+ young adults in Sweden during the Covid-19 pandemic. This study explored differences in mental health and quality of life between subgroups of young LGBTQ+ adults. Further, it explored how distal and proximal minority stressors, as well as stress related to the Covid-19 pandemic, and family support were associated with mental health outcomes (depression, anxiety, and quality of life) using linear regression analyses in a sample of 245 young LGBTQ+ Swedish individuals. The results showed increased mental distress in transgender and nonbinary (TNB) young adults and that minority stress influences health in LGBTQ+ young adults above and beyond the general stress of living through a pandemic. Nevertheless, different predictors were significant for different outcomes. For all outcomes, family support was highlighted as an important protective factor for LGBTQ+ young adults. Findings support the minority stress model and highlight the need for interventions aimed at reducing minority stress as well as tailored support and resources for TNB individuals during times of general high stressor load. This may include support aimed at their close families.

Persistent pain, one of the most common reasons for suffering and health care seeking, often co-occurs with emotional problems such as depression and anxiety. Within the Center for Health and Medical Psychology at Örebro University, Sweden, we have developed a new treatment aimed at addressing co-occurring persistent pain and emotional problems: hybrid emotion-focused exposure treatment. The overarching idea behind the treatment is that patients who struggle with comorbid pain and emotional problems need to develop skills in dealing with emotions as well as pain. With better skills in tolerating and soothing difficult emotions, patients will be more able to approach previously avoided stimuli and situations, such as movements, activities and social interaction. This review aims to delineate the development of the hybrid emotion-focused exposure treatment. It begins by outlining the theoretical background, then proceeds to describe the techniques, discuss the evidence and conclude with an illustrative case example. Thus far, the treatment has been tested in a single-case study and a randomized controlled trial with promising outcomes. Overall, the hybrid treatment seems to have a good effect on patients’ depressive symptoms and pain interference. The treatment is currently being implemented, and the implementation process evaluated, in primary and specialist care across Sweden. The hybrid emotion-focused exposure treatment seems to be a well-suited treatment for people with a high burden of persistent pain and emotional difficulties. There is good reason to implement the treatment in clinical practice and continue evaluating treatment effects across different contexts.

Providing new psychological treatments in clinical settings requires implementation strategies adapted to the organizational context. This study explored how licensed psychologists experienced their context when providing a new transdiagnostic psychological treatment, "the hybrid treatment", to treat comorbid pain and emotional problems in a clinical setting. We aimed to identify which contextual factors the therapists experienced as facilitating or hindering, to gain a better understanding of important considerations when planning a future implementation strategy. Contextual factors were identified using the Consolidated Framework of Implementation Research (CFIR) in data collection and analysis. Data were collected through semi-structured interviews (N = 9). Thematic analysis resulted in the identification of five main influencing factors: Perception of the intervention's adaptability, prioritization of the patient's needs, leadership engagement, structure for collaboration, and therapists' professional engagement. The results highlight the importance of ensuring a clearly stated mandate for the key individuals involved. The findings may guide future implementation of new psychological treatments into regular care, to enhance facilitators and overcome barriers.

A challenge for professional psychology programs is the assessment of students' professional competence. Despite its potential, objective structured clinical examination (OSCE) has not gained widespread use in the psychological field. However, at Ume & aring; University and & Ouml;rebro University in Sweden, the OSCE has been introduced at the Clinical psychology programs to assess professional competence. The aim of this study was to explore students' perceptions of whether and how, preparing for and performing the OSCE benefits their professional learning and prepares them for clinical practice. A web-based questionnaire was administered to 88 psychology students who completed the OSCE and field training. Most of the students perceived the OSCE as a valuable experience that benefits their learning. The OSCE prepared them for clinical practice through practical hands-on training, and by providing essential experience in client interaction, increasing students' confidence in the role as a psychologist. Students also reported that feedback from the OSCE was crucial for their ongoing learning, but that the authenticity of the examination can be improved. Based on these findings, recommendations for future OSCEs in professional psychology include appropriate preparations, providing constructive feedback as well as striving for high authenticity in the tasks of the OSCE stations.

Deliberate practice (DP) is well established and widely accepted in expert performance research within a variety of fields. Recently, researchers have started to examine if the same training principles can be applied to psychotherapists. The aim of this study was to examine the impact on intrapersonal skills and the experiences of a six-week DP intervention on seven therapist trainees (n = 7). To do this, a single-case research design was used, combining weekly repeated measurements and pre- and post-intervention measurements as well as a qualitative study analyzed by inductive thematic analysis. The results from our measurements indicate mixed results, where three out of seven participants achieved a significant positive intervention effect and we can see that most participants change in the hypothesized direction on mindful attention (MAAS), experiential avoidance (MEAQ), emotional processing (EPI), and self-compassion (SCS). The participants described gains on increased self-awareness, more compassionate treatment of oneself, increased tolerance of unpleasant feelings as well as a sense of being able to use their own experiences to understand their relationship to other people. The intervention also gave the participants an ability to hold contrasting thoughts and emotions and provided an increased sense of hope for their own future development. The findings of our study should be interpreted in light of its pilot nature and the limited extent of our design. However, it indicates that it seems possible to achieve positive results on intrapersonal skills from a relatively short period of training.

Purpose There is a wide range of individual and work environment factors that influence work ability among workers with pain and stress-related ill-health. The multiple interactions and overlap between these factors are insufficiently understood, and a network approach could mitigate limitations of previous research. This pilot study aimed to explore interactions between individual characteristics and psychosocial work environment and potential links to long-term work ability. Methods Prospective data from a prevention project was used. Individuals (N = 147) with pain and/or stress-related ill-health (95% women) at public sector workplaces filled out baseline questionnaires about a collection of individual and work environment factors, which were used for constructing undirected networks. The model was run in three subsamples of workplaces. Finally, a separate model was established with work ability at 6-month follow-up as outcome variable. A shortest pathway analysis was calculated to identify mediators of work ability. Results Symptom catastrophizing and perceived stress were the most influential factors in all network models. Symptom catastrophizing and pain-disability risk were found to mediate the relation between perceived stress and long-term work ability. Further, demand-control-support factors were interrelated, and patterns of interaction differed between different types of workplaces. Conclusion The findings support the importance of individual factors, specifically symptom catastrophizing in an individual's coping with pain or stress-problems and its influence on long-term work ability. Catastrophizing might play a role in stressrelated disorders which should be further investigated. Individual and work environment factors interact and vary across context, which needs to be taken into consideration to prevent pain and stress-related ill-health at work.

In a clinical psychology training context, there is a need to examine students’ theoretical knowledge as well as their professional competence. One promising method to assess students’ professional competence is the Objective and Structured Clinical Examination (OSCE). In this report, we describe and discuss the implementation of OSCE on a clinical psychology programme at a university in Sweden, including lesson learned regarding the structure and content for this examination. We also report on preliminary results, in which we explored students’ perceived competence and worries, and their supervisors’ reports regarding their clinical practicum, in relation to a new curriculum that includes more simulation-based elements (including the OSCE) than the old curriculum. Results showed that students on the new curriculum reported lower levels of perceived competence before the clinical practicum, but increased significantly more over time in comparison to students on the old curriculum. These results are discussed in relation to the potential role of OSCE in clinical psychology students’ development of professional competence. Due to methodological limitations, these results should be interpreted with caution and should be viewed as exploratory. All in all, this report can be viewed as a guideline for implementation of OSCE on similar programmes in psychology.

Repetitive negative thinking (RNT) has been identified as a key maintaining process of emotional difficulties. However, the consequences of repetitive thinking may depend on whether negative thoughts or feelings are processed in an abstract, evaluative mode, or in a concrete, process-focused mode. In recent years an increasing number of studies has also explored the effect of processing mode in relation to positive events, yielding inconsistent results. So far, the studies using positive material have not examined the interaction between trait rumination and processing mode. Consequently, the purpose of this study was to further explore the effects of abstract vs. concrete mode of processing on positive affect and negative affect in the context of a success task in a sample scoring high on trait rumination. 62 participants were randomly assigned to abstract vs. concrete processing training prior to a success task. The results showed that positive affect increased whereas negative affect and state RNT decreased after the success task in both groups. However, abstract vs. concrete processing did not have an effect on outcome. The findings indicate that processing mode does not influence outcome in the context of a success task.

Purpose A previous study (Bergbom et al. in J Occup Rehabil, 2013) showed that matching people at risk for pain-related disability to an intervention aimed at targeting their psychological problem profile did not, as hypothesized, improve the effect of the intervention. Methodological issues were suggested to explain the lack of differential effect. It was questioned whether the profiles used to allocate people to treatment were adequate. The aim of this study was to investigate if the risk profiles used to determine matching were sufficiently stable and valid by comparing the original profiles with profiles constructed using other methods. Methods Ninety-five people suffering musculoskeletal problems were screened, profiled, and matched to workplace based early interventions according to profiles. We studied stability and validity of their psychological risk profiles by investigating their concordance at different time points. People were originally assigned to profiles at inclusion, using a brief screening questionnaire. Then, they were profiled just before treatment start, using the same items. Finally, they were profiled again at treatment start, using extensive questionnaires. Concordance among the three sets of profiles was investigated. Results Profiles at inclusion were unstable until treatment start. People moved from profiles with more severe elevations in psychological variables, to a profile with moderate elevations. Concordance between the two means of profiling at treatment start was better; the brief screening and the extensive questionnaires assigned people to similar profiles. Conclusions Risk level may be determined with brief instruments at an early stage of problem development. However, profiles and targets for interventions should be determined immediately prior to treatment start, preferably using full questionnaires.

Background and purpose Dealing with chronic pain is difficult and affects physiological as well as psychological well-being. Patients with chronic pain are often reporting concurrent emotional problems such as low mood and depressive symptoms. Considering this, treatments need to involve strategies for improving mood and promoting well-being in this group of patients. With the rise of the positive psychology movement, relatively simple intervention strategies to increase positive feelings, cognitions, and behaviours have become available. So far, the evidence for positive psychology techniques mainly comes from studies with healthy participants, and from studies with patients expressing emotional problems such as depression or anxiety as their main complaint. This study describes an initial attempt to explore the potential effects of a positive psychology intervention in a small sample of patients suffering from chronic pain. Methods A replicated single case design was employed with five participants. The participants started to fill out daily self-reports and weekly questionnaires two weeks before the intervention started, and continued throughout the intervention. In addition, they filled out a battery of questionnaires at pretest, posttest, and at a three months follow-up. The instruments for assessment were selected to cover areas and constructs which are important for pain problems in general (e.g. disability, life satisfaction, central psychological factors) as well as more specific constructs from positive psychology (e.g. compassion, savoring beliefs). Results The results on pre and post assessments showed an effect on some of the measures. However, according to a more objective measure of reliable change (Reliable Change Index, RCI), the effects were quite modest. On the weekly measures, there was a trend towards improvements for three of the participants, whereas the other two basically did not show any improvement. The daily ratings were rather difficult to interpret because of their large variability, both between and within individuals. For the group of participants as a whole, the largest improvements were on measures of disability and catastrophizing. Conclusions The results of this preliminary study indicate that a positive psychology intervention may have beneficial effects for some chronic pain patients. Although it is not to be expected that a limited positive psychology intervention on its own is sufficient to treat pain-related disability in chronic patients, our findings suggest that for some it may be an advantageous complement to enhance the effects of other interventions. Implications The results of this pilot study about the potential effects of a positive psychology intervention for chronic pain patients may be encouraging, warranting a larger randomized controlled study. Future studies may also concentrate on integrating positive psychology techniques into existing treatments, such as composite CBT-programs for chronic pain patients. Our advice is that positive psychology interventions are not to be regarded as stand-alone treatments for this group of patients, but may potentially enhance the effect of other interventions. However, when and for which patients these techniques may be recommended is to be explored in future research.

We know little about why some people get better after psychological treatments for pain disability, whereas other people do not. In order to understand differences in treatment response, we need to explore processes of change during treatment. It has been suggested that people with pain complaints who change early in treatment have better outcomes. Therefore, we aimed to investigate whether changes in psychological variables at different time points are related to outcome, and whether early or late changes are better predictors of outcome. We used the fear avoidance model as a theoretical framework. We followed 64 patients weekly over 6–7 weeks and then determined outcome. Our findings indicate that people who decrease in catastrophizing and function early in treatment as well as in depressive symptoms, worry, fear avoidance beliefs and function late in treatment have better outcomes. Early decreases in function, and late decreases in depressive symptoms and worry uniquely predict improvements in disability. While early and late changes covaried concurrently, there were no significant sequential relationships between early and late changes. Changes in the proposed process variables in the fear avoidance model, early as well as late in treatment, thus add valuable information to the explanation of outcome.

Purpose This randomized controlled trial had two main aims. The first aim was to investigate the effect of early preventive, psychologically informed, interventions for pain-related disability. The second aim was explore whether people who are matched to an intervention specifically targeting their psychological risk profile had better outcomes than people who were not matched to interventions. Methods A total of 105 participants were recruited from their workplace, screened for psychological risk factors and classified as being at risk for long-term pain-related disability. They were subgrouped into one of three groups based on their psychological profile. Three behaviorally oriented psychological interventions were developed to target each of the three risk profiles. Half of the participants were assigned a matched intervention developed to target their specific profile, and half were assigned an unmatched intervention. After treatment, repeated measure ANOVAs and χ 2 tests were used to determine if treatments had an effect on primary and secondary outcomes including perceived disability, sick leave, fear and avoidance, pain catastrophizing and distress, and if matched participants had better outcomes than did unmatched. Results Treatments had effects on all outcome variables (effect sizes d ranging between 0.23 and 0.66), but matched participants did not have better outcomes than unmatched. Conclusions Early, preventive interventions have an impact on a number of outcome variables but it is difficult to realize a matching procedure. More in-depth research of the process of matching is needed.

We know little about why some people get better after psychological treatments for pain disability, whereas other people do not. In order to understand differences in treatment response, we need to explore processes of change during treatment. It has been suggested that people with pain complaints who change early in treatment have better outcomes. Therefore, we aimed to investigate whether changes in psychological variables at different time points are related to outcome, and whether early or late changes are better predictors of outcome. We used the fear avoidance model as a theoretical framework. We followed 64 patients weekly over 6–7 weeks and then determined outcome. Our findings indicate that people who decrease in catastrophizing and function early in treatment as well as in depressive symptoms, worry, fear avoidance beliefs and function late in treatment have better outcomes. Early decreases in function, and late decreases in depressive symptoms and worry uniquely predict improvements in disability. While early and late changes covaried concurrently, there were no significant sequential relationships between early and late changes. Changes in the proposed process variables in the fear avoidance model, early as well as late in treatment, thus add valuable information to the explanation of outcome.

Many patients with musculoskeletal pain also suffer from a depressed mood. Catastrophizing is one process that may link depression and pain since it is a key concept in models of both problems. Earlier research has suggested that catastrophizing measures something above and beyond depression. This study tests the idea that if depressed mood and catastrophizing are separate entities then when one is absent the other should still contribute to poor outcome, and, when both are present there should be an additional adverse effect.

BACKGROUND:Pain catastrophizing and emotional distress can act as prognostic factors for pain and disability. Research on how these variables interact within individuals and over time is in an early stage. Understanding various patterns of prognostic factors and how these factors change during treatment is important for developing treatments targeting important factors.OBJECTIVE:The primary aim of this study was to investigate relationships between pain catastrophizing and depressed mood in people seeking primary care for musculoskeletal pain. An additional aim was to relate these patterns of prognostic factors to outcomes during a 6-month period.DESIGN:The design was prospective; data were obtained at baseline and at follow-up.METHODS:Forty-two physical therapists taking part in an educational program recruited, from their clinical practices in primary care, consecutive patients who were currently experiencing a pain problem. Patients received various physical therapy interventions between baseline and follow-up.RESULTS:On the basis of patterns of scoring for pain catastrophizing and depressed mood, 4 subgroups of participants were found. Belonging to a subgroup with elevated levels of either pain catastrophizing or depressed mood at baseline was related to the absence of improvement and elevated levels of disability after physical therapy interventions. Furthermore, elevated levels of both variables were related to the highest levels of disability.LIMITATIONS:The analyses relied on self-report. Neither treatment content nor pain-related fear was measured. The sample was a mixture of participants reporting acute pain and subacute pain.CONCLUSIONS:The results stress the importance of assessing and targeting prognostic factors. Moreover, the results suggest the need to tailor treatments to match patterns of prognostic factors and the need to target depressed mood and pain catastrophizing in physical therapy interventions.

Background and aims Patients seeking care for a pain problem very often also report symptoms of depression.In fact, depression is associated with the development of chronic pain as well as poor treatment results. Yet, the mechanisms by which depression and pain impact upon one another are not clear. This paper provides a critical review of the literature with the aim of shedding light on the relationship between pain and depression. Further, we introduce the Örebro Behavioral Emotion Regulation Model which may stimulate understanding in addition to research. Method Data bases (MedLine and PsychINFO) were searched as well as reference lists to locate relevant articles, especially previous reviews, published since 2000. We located 244 articles including 6 reviews. Results We found that while depression is strongly linked to pain, there is little understanding of how this link works or how it might be utilized in clinical settings. It is not clear whether one of the symptoms precedes the other, but when both are present prognosis is significantly affected. Clinicians often fail to assess both depression and pain resulting in probable "under" treatment of one or both problems. There is little evidence that treating the pain will result in the disappearance of the depression. Indeed, early improvements in depression are associated with overall treatment gains for patients with musculoskeletal pain. Therefore, treatment outcomes might be substantially enhanced by addressing both the pain and the depression. Moreover, directly addressing the depression early in treatment may be especially valuable. While pharmacological treatments of depression are often pursued for pain patients, the results for depression, pain and function are not impressive. Although there are effective cognitive-behavioral techniques for depression, these have not been properly evaluated in patients with co-morbid pain and depression. We found two likely mechanisms that can help to explain the link between depression and pain. First, catastrophizing plays a central role in models of both pain and depression and hence might form an important link between them. Second, emotion regulation is important in both depression and pain since they both can be viewed as significant emotional stressors. We offer a model which focuses on the recurrent nature of pain and depression. It hypothesizes that flare-ups trigger catastrophic worry which in turn strains the individual's emotion regulation system. Successful behavioral emotion regulation is said to result in coping while negative behavioral emotion regulation results in spiraling negative affect, pain and mood related disability and, in the long term, a consequent relapse. Implications Since both pain and depression are closely linked and are both involved in the development of long-term problems, it is important for clinicians to assess them as early as possible. Moreover, both symptoms should be monitored and addressed in treatment to maximize outcome results. Because pharmacological treatment has limited effects, cognitive-behavioral therapy is an alternative. Behavioral emotion regulation may be an important mechanism linking depression and pain. Conclusions It is concluded that pain and depression impact on each other and play an important role in the development and maintenance of chronic problems. Future studies of treatments for co-morbid depression and pain are urgently required. The purposed Örebro Behavioral Emotion Regulation Model provides much needed guidance for investigating the psychological mechanisms involved.