To Örebro University

Objective: The aim of this study was to investigate physiotherapists' validating and invalidating communication, before and after brief Cognitive Functional Therapy (CFT) training that included a session on validation skills. Associations between validation/invalidation and the characteristics of the interviews and physiotherapists were also explored.

Methods: Eighteen physiotherapists treating patients with low back pain participated in the study. The study had a within-group design in which validation and invalidation for physiotherapists were rated before and after training using a reliable observational scale. We also collected data on interview length and physiotherapists' and patients' speech percentages.

Results: The physiotherapists' validating responses increased and invalidating responses decreased from pre- to post-training. The within-group effect size was large for validating responses and medium for invalidating responses. The interview length increased from pre- to post-training (large effect size). However, the reason for this was related to factors other than validation and invalidation. The results indicate that increased validation is associated with an increase in physiotherapists' speech percentage.

Conclusions: The results of this study show changes invalidating and invalidating communication among physiotherapists from pre- to post-CFT training. The study also found associations between specific interview characteristics and validating communication. Future studies with larger samples and control groups are needed.

Historically, the dominating theoretical framework for communication in the context of acute pain is reassurance. An inherent assumption of this framework is that the person in pain needs to have their fears and doubts removed and be educated, or persuaded, that the pain problem is not dan-gerous. This is then thought to lead to a shift in beliefs that later explain future beneficial outcomes

In later years, another communication technique known as validation has started to gain traction in the pain field. This technique focuses on le-gitimizing the thoughts and emotions of pain patients and is instead thought to influence outcomes through better emotion regulation.

The overall aim of this dissertation is to extend current knowledge on effective communication in the context of acute pain. In one observational study a variable supposedly sensitive to shifts in beliefs was observed in a cohort of acute pain patients over the course of the first three months after pain onset. Also, in two controlled experiments we explored the impact of validating communication on pain relevant variables while investigating if this effect was due to improved emotion regulation.

Taken together, this dissertation indicates that validating communica-tion shows promise as a form of effective communication in the context of acute pain, in that it influences both pain catastrophizing and recall. The dissertation does not give support to either changes in beliefs nor emotion regulation being the mechanism of change for effective communication. Thus, this dissertation propose a new model of effective communication based both on previous research highlighting the effectiveness of infor-mation and the research presented in this dissertation, more focused on the role of psychological processes such as pain catastrophizing.

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.

BACKGROUND: Increasing recall of instructions and advice in a pain consultation is important, since it is a prerequisite for adherence to treatment recommendations. However, interference due to pain-related distress may result in poor recall. Whereas there are some indications that recall can be increased by empathic communication that reduces interference, this interesting possibility remains largely untested experimentally. The current experiment aimed at studying effects of empathic communication, and more specifically validation, on recall during a pain test and possible mediators and moderators of this effect.

METHOD: Participants received either validating (N=25) or invalidating responses (N=25) from the experimenter during a pain provoking task, followed by self-report measures of interference (affect, situational pain catastrophizing) and recall (accurate and false memories of words).

RESULTS: As expected, the validated group exhibited higher accurate recall and less false memories following the pain test as compared to the invalidated group. This was partly due to the effect of interference being counteracted by moderating the relationship between pain catastrophizing and recall.

CONCLUSION: These novel results suggest that validating communication can counteract interference due to pain catastrophizing on recall, at least in a controlled experimental setting.

IMPLICATIONS: Good communication by health professionals is of utmost importance for adherence to pain management. The current results expand our knowledge on the effects of pain communication by establishing and explaining a clear link between empathic communication and recall, highlighting the role of pain catastrophizing.

In the last decades, there has been a clear recognition of the importance of psychosocial factors in the explanation of chronic musculoskeletal pain. It is generally accepted that chronic musculoskeletal pain and disability has multiple causes, a view that is summarized in the so-called biopsychosocial models (Gatchel, Peng, Peters, Fuchs, & Turk, 2007). However, psychosocial factors have proven to be important predictors of chronic pain and disability already early on in acute and subacute stages of pain. A range of reviews conclude that factors, such as depression, anxiety, pain beliefs, catastrophizing, and coping behaviors, play a primary role in the transition from acute to chronic pain and disability (Linton, 2002; Main, Sullivan, & Watson, 2007; Nicholas, Linton, Watson, & Main, 2011). This supports the notion that psychosocial factors are preferably viewed as an integrated part of musculoskeletal pain, not only in the rehabilitation of chronic problems but also in prevention in the subacute stages.

Background Expectations for recovery are a known predictor for returning to work. Most studies seem to conclude that the higher the expectancy the better the outcome. However, the development of expectations over time is rarely researched and experimental studies show that realistic expectations rather than high expectancies are the most adaptive. This study aims to explore patterns of stability and change in expectations for recovery during the first weeks of a back-pain episode and how these patterns relate to other psychological variables and outcome.

Methods The study included 496 volunteer patients seeking treatment for work-related, acute back pain. The participants were measured with self-report scales of depression, fear of pain, life impact of pain, catastrophizing and expectations for recovery at two time points. A follow-up focusing on recovery and return to work was conducted 3 months later. A cluster analysis was conducted, categorizing the data on the trajectories of recovery expectations.

Results Cluster analysis revealed four clusters regarding the development of expectations for recovery during a 2-week period after pain onset. Three out of four clusters showed stability in their expectations as well as corresponding levels of proximal psychological factors. The fourth cluster showed increases in distress and a decrease in expectations for recovery. This cluster also has poor odds ratios for returning to work and recovery. Conclusion Decreases in expectancies for recovery seem as important as baseline values in terms of outcome, which has clinical and theoretical implications.