CHAMP The Center for Health and Medical Psychology

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1 CHAMP The Center for Health and Medical Psychology Report of External Review Date of review: 28 and 29 April 2009 Reviewers Professor Stephen Morley, University of Leeds Professor Örjan Sundin, Mid Sweden University Summary quotes from the review We conclude that this is a very promising beginning for CHAMP. It is already attained a prominent position for providing a platform stimulating cooperative scientific efforts, especially with regard to pain. There is evidence that work on sleep and anxiety is beginning to attain a similar level of distinction Pursuing applied research embedded in clinical practice with well funded projects (several projects funded by FAS) and in cooperation with the county, also gives the CHAMP a strong opportunity to support, stimulate and guide students of psychology to establish an interest in research. Overall, CHAMP is well on the way to achieving its stated goals. The reviewers, after interviewing members of CHAMP and its doctoral students, also note that, besides the high productivity, the scientific setting has an open climate, including an equal exchange of information and shared decision making. 1

2 Preamble This report presents the results from the evaluation of The Center for Health and Medical Psychology (CHAMP). The request for the evaluation was made by Professor Steven Linton, the director of CHAMP and the review was conducted by Örjan Sundin (Professor of Clinical Psychology, Mid Sweden University, SE) and Stephen Morley (Professor of Clinical Psychology, University of Leeds, UK). The reviewers received a portfolio of documentation stating CHAMP s mission, providing details of CHAMP s activity since its foundation in 2005, an extensive list of outputs (bibliography) and grant awards, and a selection of reprints of papers authored by members of CHAMP. The reviewers were given adequate time to read this material prior to making a site visit on 28th and 29th April During the visit members of CHAMP presented their research work that covers three main areas: pain (Dr Katja Boersma), sleep (Dr Markus Jansson) and anxiety (Dr Maria Tillfors). The reviewers also met PhD students to discuss their role and involvement in CHAMP. We also had ample opportunity for informal discussion with all members of CHAMP. The reviewers would like to thank Professor Steven Linton and the staff at CHAMP for their hospitality and their willingness to engage in the review process, and Mrs. Monika Geisser for her administrative support CHAMP s mission statement CHAMP was established in 2005 with the aim of stimulating collaborative research in how psychological mechanisms interact with health and disease. It brought together a small group of experienced researchers with the aim of maximizing the benefits of collaboration. Research is focused on three areas; pain, sleep and anxiety, and is particularly concerned with psychological processes that are important for understanding risk factors and preventing the development of chronicity. The external reviewers evaluated CHAMP s activity against the criteria set out by CHAMP in its mission statement. In addition to this we initiated a simple SWOT (strengths, weaknesses, opportunities and threats) review of CHAMP that was also conducted by many of CHAMP s staff. We identified four main criteria: 1. To provide a platform for stimulating cooperation between researchers at Örebro University and internationally; 2

3 2. To promote excellence in education by developing an evidenced based approach to clinical practice and knowledge, especially tailored for students studying clinical psychology; 3. To provide support to psychological and health care services by disseminating knowledge derived from CHAMP to practitioners, the general public and students and; 4. To promote excellence in research (as measured by the impact of the publications) 1. Providing a platform stimulating cooperative scientific efforts At a national level CHAMP hosts among its active members one professor, one associate professor, two lecturers, and with less involvement an additional associate professor and one lecturer. There are also ten doctoral students associated to the center. Despite the few years the center has been operative several of the top international sites in pain research are represented, including well established international researchers in the field of pain (Johan Vlayaen, Leuven University; William Shaw, University of Boston; Madelon Peters, Maastricht University; Michael Nicholas, University of Sydney; Chris Main, Keele University) and in sleep (Alison Harvey, Berkeley University). In the last two years this has led to 10 publications coauthored by international guest researchers and 14 with other researchers in Sweden. We conclude that this is a very promising beginning for CHAMP. It is already attained a prominent position for providing a platform stimulating cooperative scientific efforts, especially with regard to pain. There is evidence that work on sleep and anxiety is beginning to attain a similar level of distinction, but both these topics were less well established in the research portfolio that was present before the formation of CHAMP. 2. Promoting excellence in education by developing evidenced-based approaches The effort to understand psychological processes underlying development and maintenance of health problems in pain in order to improve prevention and treatment has long been a distinguishing feature of work in Örebro. More recently distinctive work on sleep has begun and similar developments in anxiety are taking place. Most of the studies emanating from the Center during concern predicting the course and identifying variables important for the development and processes from acute to more chronic ailment of various health problems. The center has various projects with doctoral students involved trying to find mechanism explaining the development of pain, insomnia and anxiety. One 3

4 interesting approach is the attempt to find shared cognitive and behavioral processes across different conditions and the development of measurement of transdiagnostic processes. Another fruitful approach is the ongoing research of interrelationships between risk factors within people over time and the attempt to match intervention to risk profile there are several randomized controlled intervention studies from CHAMP in action. One significant issue being researched by CHAMP is the attempt to identify significant processes that distinguish between individuals and which may then facilitate the matching of individuals to treatments. Researchers have noted that There are no data available to determine what set of patients with what characteristics are most likely to benefit from what set of treatment modalities, provided in what type of format (quotation from Turk and Gatchel, 1999). Thus, this is an important endeavor since it brings the scientist practitioner model in to focus, making results from scientific research more tied to clinical practice. Pursuing applied research embedded in clinical practice with well funded projects (several projects funded by FAS) and in cooperation with the county, also gives the CHAMP a strong opportunity to support, stimulate and guide students of psychology to establish an interest in research. As evidence of this over 50% of Master theses at the Clinical Psychology program have been conducted in conjunction with the CHAMP and four theses have been published in peer reviewed journals. 3. Providing support to psychological and health care services CHAMP has a number of projects regarding implementation and dissemination of knowledge on early identification and modification of risk factors, primarily in pain research. The multidisciplinary approach using the Örebro Muscoskeletal Pain Questionnaire in a primary care setting to find and treat chronic pain patients with doctoral students firmly established at the primary care site, and the implementation of evidenced based therapy into a physiotherapy setting, are good examples. 4. To promote excellence in research The productivity at the center is high. Since 2005 members of the CHAMP core group have published over 50 articles in peer reviewed journals with good to excellent impact factors. In addition they have published 2 books and 9 book chapters, participated at 58 meeting /conferences with oral presentations, and several invited plenary addresses. All researchers at CHAMP are listed in Scopus and the ISI Web of Science, with Professor Linton, the leader of the centre, noted for 40 publications, 433 citations and an H index of 12 during this time period. Dr Jansson Fröjmark was named and Young Psychologist researcher of the year by the Royal Academy of Science in

5 The reviewers, after interviewing members of CHAMP and its doctoral students, also note that, besides the high productivity, the scientific setting has an open climate, including an equal exchange of information and shared decision making. Summary evaluation and some recommendations Overall CHAMP is well on the route to achieving it stated aims the following comments are based on a brief SWOT analysis made by the reviewers. We also asked members of CHAMP to conduct their own SWOT analysis and material from this can be used by the group to further their review of CHAMP and provide a basis for its strategic development. Strengths The reviewers were impressed by the openness and mutually supportive atmosphere that was evident among the members of CHAMP. Members appeared to hold each other in mutual respect irrespective of their academic status or professional identity. (The group is made up of members of several different disciplines psychology, physiotherapy and medicine.) The group is actively attending to ways in which research in three main areas (sleep, pain and anxiety) may benefit from each other. One current idea is to focus on transdiagnostic processes that may be present in each problem domain. CHAMP has been successful in obtaining funding and many projects appear to be well funded and supported. CHAMP is actively linked to a Masters clinical psychology programme, this is of mutual benefit to both the clinical psychology students, who have access to a first class research environment, and to CHAMP which has the opportunity to recruit good students to support its research objectives. Weakness Although CHAMP has many active links with highly regarded international researchers we were less convinced that it was currently meeting its stated aim of developing centre of national importance. Paradoxically its work may be more highly regarded outside of Sweden. There are some links with other Swedish behavioural scientists; many of these are with collaborators within the field rather than other academic institutions. Second, we formed the opinion that research in anxiety, although being of high standard, has yet to be fully integrated into CHAMP. This presents a challenge to the group but may have considerable benefits if they can identify novel applications of anxiety theory and research within the context of physical health problems. Opportunities We concluded that the research on sleep offered an opportunity to develop a unique position in the field. This work has developed over the last few years and recognition 5

6 of Dr Jansson s competence as a potential high class researcher represents an opportunity for this work to take a further step forward. As noted above the integration of anxiety research more fully into the work of CHAMP should present additional opportunities for researchers to identify new issues relating to pain and sleep. CHAMP has no local competitors and it has good relationships with other local organizations (health care and education). This provides a potential test bed for implementing research led improvements in health and an opportunity to provide demonstration projects. CHAMP might consider how best to use these opportunities to further its aim of making an impact nationally. CHAMP might also look at opportunities to recruit further members, particularly those of other disciplines e.g. epidemiology, primary care. Further opportunities will arise if the University is given permission to develop a medical school. Threats Our initial thoughts on this issue identified two potential threats. First, there is the potential lure of Stockholm with its high profile, international status research facilities. This might prove attractive to members of CHAMP. There is a threat that CHAMP might develop staff for them only recruited to Stockholm. While this is always a possibility CHAMP may be to offset the perceived attractions of Stockholm with its easier to field collaborators and a research populations. The issue of staff development and retention probably requires some further consideration. Second, although Professor Linton still has a number of years before retirement it might be appropriate to consider how CHAMP will develop when he is no longer its director. This may stimulate developmental plans for younger members of the group. Some additional reflections We were impressed by the rapid development of CHAMP and especially by the atmosphere of mutual respect and support between its individual members. The staff group is of course CHAMP s greatest resource. The comments that follow are suggestions for consideration by CHAMP; they are intended to provoke discussion and debate and to further the development of the group. 1. During the course of our visit it became clear that the main focus of activities in CHAMP was secondary prevention. We wondered whether CHAMP ought to make this more explicit and establish this as the distinguishing feature of CHAMPs activity. Our further reflection was that in order to further this theme any research group needed: (a) good epidemiology to help frame the right question and obtain robust data; (b) good model development models that can be tested independently of an intervention [the fear avoidance model in pain is a good example]; and (c) focused and theoretically coherent interventions. Putting all three of these strands in place may take some time but we think it may provide 6

7 a framework for developing CHAMP. For example, it may lead CHAMP to consider developing epidemiological expertise (an appointment in this field would almost certainly bring new statistical modeling skills); good model development would also encourage the development of laboratory type experimental studies (these would be an ideal training ground for junior researchers and masters students). 2. CHAMPS aims are to promote excellence in research such as measured by impact of its publications. We would like to invite CHAMP to consider both a broader construct of impact and also to develop explicit strategies whereby each may be achieved. For example, we suspect that one aim of CHAMP is to make a difference to the quality of health care. This can be achieved by, for example (a) increasing knowledge and research publications; (b) by having an impact on government policy; and (c) by developing methods for the implementation new procedures and treatments. CHAMP might further consider ways in which it wishes to have an impact. We also believe it would be advantageous to develop strategies for pursuing each aim. For example, CHAMP should consider the rationale for publishing in journals. Current publication is slanted towards empirically based articles in specialist journals for pain, sleep and anxiety. While these journals are highly regarded their impact is limited. High impact articles are often reviews that provide a state of the art comment on the field and advance new hypotheses and set out a research agenda and meta analyses. These articles are often published in high status general journals such as Psychological Bulletin, Health Psychology, Journal of Consulting and Clinical Psychology or more general medical journals, Lancet, JAMA, BMJ, New England Journal of Medicine. Writing high quality reviews is time consuming and challenging but may be worth considering. The obvious focus for such a review is the topic of secondary prevention that defines much of CHAMPs work. 3. We have already noted the position of anxiety research within CHAMP and would like to encourage CHAMP to consider how the expertise present could help the development of new research field. At present anxiety research is strongly focused on developmental issues in social anxiety. Relatively little is known about the impact of chronic ill health on anxiety (other than anxiety related to symptoms) and this presents an opportunity for some creative work within CHAMP. 4. We encourage CHAMP to consider staff development and retention. It is in the position to attract and develop talented researchers and it needs to retain a proportion of these. 7

8 5. The links to the clinical psychology programme are excellent and offer a several advantages. We would encourage CHAMP to consider how clinical psychology master s research projects can be built into its major funded projects at an early stage. For example, the matching project requires that therapy implementation be tested for adherence and fidelity. Therapy requires careful definition and tapes and by products of therapy (daily diary) can be analyzed to establish the manipulation validity. These issues offer excellent opportunities for research projects for students. 6. We have already noted the sense of coherence and collaborative engagement between members of the group. There are many opportunities for informal meetings and PhD students are well supported. We would however like to suggest that CHAMP considers instituting some more regular (fortnightly or monthly) formal meetings such as a journal club (presentation of a current publication for critical evaluation). This, we believe, would foster the further development of academic excellence and provide additional training for PhD students. Örjan Sundin Stephen Morley 19 May

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