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  • 1.
    Edlund, Sara
    Örebro University, School of Law, Psychology and Social Work.
    Calm down: strategies for emotion regulation in clinical practice2017Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Problems with emotion regulation are common in people who seek help from health care professionals working with problems featuring psychological factors. Two such patient groups, chronic pain patients and patients with severe anxiety, are of interest in this dissertation. Effectively regulating and increasing functional emotion regulation in these patients is often challenging for clinicians, and effective strategies are needed. One treatment that greatly emphasizes the importance of functional emotion regulation is dialectical behavior therapy (DBT). DBT has a strong empirical basis in other patients with severe problems with emotion regulation, raising the question of whether the treatment and its more specific components (e.g., validation, which means communicating understanding and acceptance) could be effec-tive in the groups of patients of interest here.

    Accordingly, the overall aim of this dissertation was to expand our knowledge of how to use functional emotion-regulation strategies from DBT to regulate emotions in patients with chronic pain or treatment-resistant anxiety disorders. Study I examined whether brief training was enough to increase validation in partners of people with chronic pain, and whether this was associated with better-regulated emotion in the people with chronic pain. Study II explored patient perceptions of validation and invalidation by the physician in a clinical chronic pain context. Lastly, study III investi-gated whether a more extensive treatment intervention inspired by DBT was feasible and effective in patients suffering from treatment-resistant anxiety disorders.

    The findings indicate that emotion-regulation strategies from DBT can be effective in regulating emotions in these patients. The dissertation also illus-trates some of the difficulties in doing this, providing important information for future work, such as suggestions for modifications that might further increase positive outcomes.

    List of papers
    1. I see you're in pain: the effects of partner validation on emotions in people with chronic pain
    Open this publication in new window or tab >>I see you're in pain: the effects of partner validation on emotions in people with chronic pain
    Show others...
    2015 (English)In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 6, p. 16-21Article in journal (Other academic) Published
    Abstract [en]

    Background and aims

    Chronic pain not only affects the person in pain, but can also have a negative impact on relationships with loved ones. Research shows that chronic pain is associated with difficulties in marital relationships, which in turn is related to a variety of negative outcomes such as psychological distress and conflict within the family. This suggests that couples where chronic physical pain is present also struggle with emotional pain and relationship problems, and thus targeting relationship skills and interpersonal functioning might be helpful for these couples. Although studies in this area are promising, their numbers are few. In the present study, validation as a way of communicating is suggested for handling emotional expression in interpersonal interactions. Validation communicates understanding and acceptance of the other person's experience, and it has been shown to have a down-regulating effect on negative emotions. It has previously been demonstrated to be important for these couples. However, the feasibility and effects of increasing partner validation in these couples are unknown. Therefore, the aim of the present study was to investigate if a brief training session in validation for spouses would result in more validating and fewer invalidating responses towards their partners with pain, and to investigate if changes in these behavioural responses were associated with changes in emotion and pain level in the partner with pain.

    Methods

    Participants were 20 couples where at least one partner reported chronic pain. The study employed a within-groups design in which spouses of people with pain received validation training (without their partner's knowledge), and their validating and invalidating responses were rated pre- and post-intervention using a reliable observational scale. Also, positive and negative affect and subjective pain level in the persons with pain were rated pre- and post-intervention.

    Results

    Results showed that the validation training was associated with increased validating and decreased invalidating responses in the partners. Their spouses with chronic pain reported a decrease in negative affect from pre- to post-training.

    Conclusions

    Our results indicate that the partner or closest family member, after brief validation training, increased validating responses and decreased invalidating responses towards the person with pain, which had an immediate positive impact on emotions in the other person.

    Implications

    This study suggests that using validation in interpersonal interactions is a promising tool for couples where chronic pain is present.

    Place, publisher, year, edition, pages
    Elsevier, 2015
    Keywords
    Affect; Chronic pain; Emotion regulation; Invalidation; Partner communication; Validation
    National Category
    Applied Psychology
    Research subject
    Psychology
    Identifiers
    urn:nbn:se:oru:diva-37521 (URN)10.1016/j.sjpain.2014.07.003 (DOI)000217936400006 ()2-s2.0-84927607276 (Scopus ID)
    Available from: 2014-10-06 Created: 2014-10-06 Last updated: 2018-06-26Bibliographically approved
    2. Pain patients´ experiences of validation and invalidation from physicians before and after multimodal pain rehabilitation: Associations with pain, negative affectivity and treatment outcome
    Open this publication in new window or tab >>Pain patients´ experiences of validation and invalidation from physicians before and after multimodal pain rehabilitation: Associations with pain, negative affectivity and treatment outcome
    Show others...
    2017 (English)In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 17, p. 77-86Article in journal (Refereed) Published
    Abstract [en]

    Background and aims: Validating and invalidating responses play an important role in communication with pain patients, for example regarding emotion regulation and adherence to treatment. However, it is unclear how patients’ perceptions of validation and invalidation relate to patient characteristics and treatment outcome. The aim of this study was to investigate the occurrence of subgroups based on pain patients’ perceptions of validation and invalidation from their physicians. The stability of these perceptions and differences between subgroups regarding pain, pain interference, negative affectivity and treatment outcome were also explored.

    Methods: A total of 108 pain patients answered questionnaires regarding perceived validation and invalidation, pain severity, pain interference, and negative affectivity before and after pain rehabilitation treatment. Two cluster analyses using perceived validation and invalidation were performed, one on pre-scores and one on post-scores. The stability of patient perceptions from pre- to post-treatment was investigated, and clusters were compared on pain severity, pain interference, and negative affectivity. Finally, the connection between perceived validation and invalidation and treatment outcome was explored.

    Results: Three clusters emerged both before and after treatment: (1) low validation and heightened invalidation, (2) moderate validation and invalidation, and (3) high validation and low invalidation. Perceptions of validation and invalidation were generally stable over time, although there were individuals whose perceptions changed. When compared to the other two clusters, the low validation/heightened invalidation cluster displayed significantly higher levels of pain interference and negative affectivity post-treatment but not pre-treatment. The whole sample significantly improved on pain interference and depression, but treatment outcome was independent of cluster. Unexpectedly, differences between clusters on pain interference and negative affectivity were only found post-treatment. This appeared to be due to the pre- and post-heightened invalidation clusters not containing the same individuals. Therefore, additional analyses were conducted to investigate the individuals who changed clusters. Results showed that patients scoring high on negative affectivity ended up in the heightened invalidation cluster post-treatment.

    Conclusions: Taken together, most patients felt understood when communicating with their rehabilitation physician. However, a smaller group of patients experienced the opposite: low levels of validation and heightened levels of invalidation. This group stood out as more problematic, reporting greater pain interference and negative affectivity when compared to the other groups after treatment. Patient perceptions were typically stable over time, but some individuals changed cluster, and these movements seemed to be related to negative affectivity and pain interference. These results do not support a connection between perceived validation and invalidation from physicians (meeting the patients pre- and post-treatment) and treatment outcome. Overall, our results suggest that there is a connection between negative affectivity and pain interference in the patients, and perceived validation and invalidation from the physicians. Implications In clinical practice, it is important to pay attention to comorbid psychological problems and level of pain interference, since these factors may negatively influence effective communication. A focus on decreasing invalidating responses and/or increasing validating responses might be particularly important for patients with high levels of psychological problems and pain interference.

    Place, publisher, year, edition, pages
    Walter de Gruyter, 2017
    Keywords
    Chronic pain; Communication; Validation; Invalidation; Treatment outcome
    National Category
    Psychology Neurology
    Research subject
    Psychology
    Identifiers
    urn:nbn:se:oru:diva-59104 (URN)10.1016/j.sjpain.2017.07.007 (DOI)000419851500012 ()28850377 (PubMedID)2-s2.0-85026788123 (Scopus ID)
    Note

    Funding Agency:

    Regional Research Council (Regionala Forskningsradet, RFR) 

    Available from: 2017-08-15 Created: 2017-08-15 Last updated: 2018-08-01Bibliographically approved
    3. Dialectical behavior therapy to augment stand-ard cognitive behavioral therapy for treatment-resistant anxi-ety disorders: A replicated single-subject pilot study
    Open this publication in new window or tab >>Dialectical behavior therapy to augment stand-ard cognitive behavioral therapy for treatment-resistant anxi-ety disorders: A replicated single-subject pilot study
    Show others...
    (English)Manuscript (preprint) (Other academic)
    National Category
    Psychology (excluding Applied Psychology)
    Identifiers
    urn:nbn:se:oru:diva-62078 (URN)
    Available from: 2017-10-31 Created: 2017-10-30 Last updated: 2017-10-30Bibliographically approved
  • 2.
    Edlund, Sara M.
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Carlsson, Maria L.
    Örebro University, School of Law, Psychology and Social Work.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    Fruzzetti, Alan E.
    Tillfors, Maria
    Örebro University, School of Law, Psychology and Social Work.
    I see you're in pain: the effects of partner validation on emotions in people with chronic pain2013Conference paper (Other academic)
  • 3.
    Edlund, Sara M.
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Carlsson, Maria L.
    School of Law, Psychology and Social Work, Örebro University, Örebro, Sweden.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    Fruzzetti, Alan E.
    Department of Psychology 298, University of Nevada, Reno, USA.
    Tillfors, Maria
    Örebro University, School of Law, Psychology and Social Work.
    I see you're in pain: the effects of partner validation on emotions in people with chronic pain2015In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 6, p. 16-21Article in journal (Other academic)
    Abstract [en]

    Background and aims

    Chronic pain not only affects the person in pain, but can also have a negative impact on relationships with loved ones. Research shows that chronic pain is associated with difficulties in marital relationships, which in turn is related to a variety of negative outcomes such as psychological distress and conflict within the family. This suggests that couples where chronic physical pain is present also struggle with emotional pain and relationship problems, and thus targeting relationship skills and interpersonal functioning might be helpful for these couples. Although studies in this area are promising, their numbers are few. In the present study, validation as a way of communicating is suggested for handling emotional expression in interpersonal interactions. Validation communicates understanding and acceptance of the other person's experience, and it has been shown to have a down-regulating effect on negative emotions. It has previously been demonstrated to be important for these couples. However, the feasibility and effects of increasing partner validation in these couples are unknown. Therefore, the aim of the present study was to investigate if a brief training session in validation for spouses would result in more validating and fewer invalidating responses towards their partners with pain, and to investigate if changes in these behavioural responses were associated with changes in emotion and pain level in the partner with pain.

    Methods

    Participants were 20 couples where at least one partner reported chronic pain. The study employed a within-groups design in which spouses of people with pain received validation training (without their partner's knowledge), and their validating and invalidating responses were rated pre- and post-intervention using a reliable observational scale. Also, positive and negative affect and subjective pain level in the persons with pain were rated pre- and post-intervention.

    Results

    Results showed that the validation training was associated with increased validating and decreased invalidating responses in the partners. Their spouses with chronic pain reported a decrease in negative affect from pre- to post-training.

    Conclusions

    Our results indicate that the partner or closest family member, after brief validation training, increased validating responses and decreased invalidating responses towards the person with pain, which had an immediate positive impact on emotions in the other person.

    Implications

    This study suggests that using validation in interpersonal interactions is a promising tool for couples where chronic pain is present.

  • 4.
    Edlund, Sara M.
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Fruzzetti, Alan E
    McLean Hospital & Department of Psychiatry, Harvard Medical School, Boston, USA.
    Holländare, Fredrik
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Psychiatry.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    Tillfors, Maria
    Örebro University, School of Law, Psychology and Social Work.
    Dialectical behavior therapy to augment stand-ard cognitive behavioral therapy for treatment-resistant anxi-ety disorders: A replicated single-subject pilot studyManuscript (preprint) (Other academic)
  • 5.
    Edlund, Sara
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Wurm, Matilda
    Örebro University, School of Law, Psychology and Social Work.
    Holländare, Fredrik
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Psychiatry, Örebro University Hospital, Örebro, Sweden.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    Fruzzetti, Alan E.
    McLean Hospital & Department of Psychiatry, Harvard Medical School, Boston, USA.
    Tillfors, Maria
    Örebro University, School of Law, Psychology and Social Work.
    Pain patients´ experiences of validation and invalidation from physicians before and after multimodal pain rehabilitation: Associations with pain, negative affectivity and treatment outcome2017In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 17, p. 77-86Article in journal (Refereed)
    Abstract [en]

    Background and aims: Validating and invalidating responses play an important role in communication with pain patients, for example regarding emotion regulation and adherence to treatment. However, it is unclear how patients’ perceptions of validation and invalidation relate to patient characteristics and treatment outcome. The aim of this study was to investigate the occurrence of subgroups based on pain patients’ perceptions of validation and invalidation from their physicians. The stability of these perceptions and differences between subgroups regarding pain, pain interference, negative affectivity and treatment outcome were also explored.

    Methods: A total of 108 pain patients answered questionnaires regarding perceived validation and invalidation, pain severity, pain interference, and negative affectivity before and after pain rehabilitation treatment. Two cluster analyses using perceived validation and invalidation were performed, one on pre-scores and one on post-scores. The stability of patient perceptions from pre- to post-treatment was investigated, and clusters were compared on pain severity, pain interference, and negative affectivity. Finally, the connection between perceived validation and invalidation and treatment outcome was explored.

    Results: Three clusters emerged both before and after treatment: (1) low validation and heightened invalidation, (2) moderate validation and invalidation, and (3) high validation and low invalidation. Perceptions of validation and invalidation were generally stable over time, although there were individuals whose perceptions changed. When compared to the other two clusters, the low validation/heightened invalidation cluster displayed significantly higher levels of pain interference and negative affectivity post-treatment but not pre-treatment. The whole sample significantly improved on pain interference and depression, but treatment outcome was independent of cluster. Unexpectedly, differences between clusters on pain interference and negative affectivity were only found post-treatment. This appeared to be due to the pre- and post-heightened invalidation clusters not containing the same individuals. Therefore, additional analyses were conducted to investigate the individuals who changed clusters. Results showed that patients scoring high on negative affectivity ended up in the heightened invalidation cluster post-treatment.

    Conclusions: Taken together, most patients felt understood when communicating with their rehabilitation physician. However, a smaller group of patients experienced the opposite: low levels of validation and heightened levels of invalidation. This group stood out as more problematic, reporting greater pain interference and negative affectivity when compared to the other groups after treatment. Patient perceptions were typically stable over time, but some individuals changed cluster, and these movements seemed to be related to negative affectivity and pain interference. These results do not support a connection between perceived validation and invalidation from physicians (meeting the patients pre- and post-treatment) and treatment outcome. Overall, our results suggest that there is a connection between negative affectivity and pain interference in the patients, and perceived validation and invalidation from the physicians. Implications In clinical practice, it is important to pay attention to comorbid psychological problems and level of pain interference, since these factors may negatively influence effective communication. A focus on decreasing invalidating responses and/or increasing validating responses might be particularly important for patients with high levels of psychological problems and pain interference.

  • 6.
    Linton, Steven J.
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Flink, Ida
    Örebro University, School of Law, Psychology and Social Work.
    Nilsson, Emma
    Edlund, Sara
    Örebro University, School of Law, Psychology and Social Work.
    Can training in empathetic validation improve medical students´communication with patients suffering pain?: A test of concept2017In: Pain Reports, ISSN 2471-2531, Vol. 2, no 3, article id e600Article in journal (Refereed)
    Abstract [en]

    Introduction: Patient-centered, empathetic communication has been recommended as a means for improving the health care ofpatients suffering pain. However, a problem has been training health care providers since programs may be time-consuming anddifficult to learn. Validation, a form of empathetic response that communicates that what a patient experiences is accepted as true,has been suggested as an appropriate method for improving communication with patients suffering pain.

    Objectives: We study the immediate effects of providing medical students with a 2-session (45-minute duration each) program invalidation skills on communication.

    Methods: A one group, pretest vs posttest design was employed with 22 volunteer medical students. To control patient variables,actors simulated 1 of 2 patient scenarios (randomly provided at pretest and posttest). Video recordings were blindly evaluated. Selfratingsof validation and satisfaction were also employed.

    Results: Observed validation responses increased significantly after training and corresponded to significant reductions ininvalidating responses. Both the patient simulators and the medical students were significantly more satisfied after the training.

    Conclusions: We demonstrated that training empathetic validation results in improved communication thus extending previousfindings to a medical setting with patients suffering pain. Our results suggest that it would be feasible to provide validation training forhealth care providers and this warrants further investigation in controlled studies.

  • 7.
    Wurm, Matilda
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Edlund, Sara
    Örebro University, School of Law, Psychology and Social Work.
    Boersma, Katja
    Örebro University, School of Law, Psychology and Social Work.
    Tillfors, Maria
    Örebro University, School of Law, Psychology and Social Work.
    Comorbi social anxiety and pain: Relationship with transdiagnostic psychological processes2013Conference paper (Other academic)
  • 8.
    Wurm, Matilda
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Edlund, Sara
    Örebro University, School of Law, Psychology and Social Work.
    Tillfors, Maria
    Örebro University, School of Law, Psychology and Social Work.
    Boersma, Katja
    Örebro University, School of Law, Psychology and Social Work.
    Characteristics and consequences of the co-occurence between social anxiety and pain-related fear in chronic pain patients receiving multimodal pain rehabilitation treatment2016In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 12, p. 45-52Article in journal (Refereed)
    Abstract [en]

    Background and aims: Chronic pain problems are related to specific pain related fears and maladaptive pain-coping but also commonly co-occur with other anxiety problems. Shared emotional vulnerabil-ity factors may explain this comorbidity and may influence treatment outcome. Indeed, pain patients going through multimodal pain treatment are a heterogeneous group and treatment results vary. One understudied anxiety disorder co-occurring with pain is social anxiety. This may be relevant as many pain-related challenges are situated in social contexts. The aim of this study is to investigate the occur-rence of subgroups with differential patterns of social anxiety and pain related fear in a sample of chronic pain patients who receive multimodal pain treatment. The aim is also to study the characteristics of these potential subgroups and the consequences of different patterns of social anxiety and pain related fear.

    Methods: 180 patients with chronic musculoskeletal pain answered questionnaires before and after a multimodal pain treatment in a hospital rehabilitation setting in middle Sweden. A cluster analysis using pre-treatment scores on the Social Phobia Screening Questionnaire and the Tampa Scale of Kinesiophobia was performed. Subgroups were thereafter validated and compared on impairment due to social anxi-ety, pain catastrophizing, anxiety, and depression. Moreover, subgroups were described and compared on vulnerability factors (anxiety sensitivity, negative affect) and outcome factors (pain intensity, pain interference, and return to work self-efficacy).

    Results: Four distinct clusters emerged: (1) low scores, (2) pain-related fear only, (3) social concern only, and (4) high social anxiety and pain-related fear. Patients high on social anxiety and pain-related fear had significantly higher levels of anxiety sensitivity, negative affect, and higher general emotional symptomatology. They also had remaining problems posttreatment.

    Conclusions: A subgroup of patients with clinical levels of social anxiety has suboptimal rehabilitation results, with residual emotional problems and high levels of emotional vulnerability.

    Implications: These patients may be in need of additional treatment efforts that are not being met today. To prevent insufficient treatment results and prolonged work disability, these patients need to be detected during screening and may benefit from pain treatment that takes their emotional problems into account.

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