Conceptualization and Management of Chronic Pain in an Over 65 Using an ACT Lens—A Single Case Study

1 Theoretical and Research Basis for Treatment

The increase in longevity for our global population brings substantial challenges across many aspects of healthcare. Extended longevity is not necessarily accompanied with a parallel extension of wellbeing (Begg, 2014). Literature (e.g., Lim et al., 2017; Woo, 2017) highlights the role of complex psychological and physical problems experienced in later years which can impact wellbeing significantly. Healthcare Services are compelled to develop resources to better support the requirements of our rapidly changing demographics and to establish empirically valid and reliable treatment models for older persons (Dall et al., 2013). This need extends to the field of psychology (Pachana et al., 2015). Psychological approaches have a significant role in a wide range of healthcare agendas, including the management of diagnosed disease along with health promotion in older adults.

Although various models of psychotherapy seem to be efficacious with older adults, research remains limited to which psychotherapeutic model may best suit an older demographic (Arean, 2012). Models that can promote wellbeing in later years, whilst accommodating the chronicity and complexity of conditions seen in aging, should be identified (Petkus & Wetherell, 2013), to assist practitioners providing clinical services to older clients. Guidelines around selection and implementation of such approaches should form part of the evidence-based practice for psychologists treating this population. However, such guidelines are yet to be fully developed and tested.

When pain persists “either after healing or due to other unknown reasons, for long durations (usually >3–6 months)” it is considered as chronic pain (Apkarian, 2019). It is a significant health issue affecting 1 in 5 Australians (Henderson et al., 2013). In 2018, 3.24 million Australians were living with chronic pain. Chronic pain had an estimated total financial cost of $73.2 billion dollars in Australia in 2018. Persons with chronic pain experience reduction in their quality of life, estimated at an additional cost of $66.1 billion (Deloitte Access Economics, 2019). Chronic pain is challenging for healthcare providers and the conventional treatment approaches have relied on medication regimes. It is an area many general practitioners believe to be outside their area of expertise (National Drug and Alcohol Research Centre, 2012), yet it is general practitioners who are most frequently sought to treat chronic pain. Some medications involve risks for all age brackets and these may be substantially more significant for the elderly. Risks may include dependence, addiction, and increased propensity for the development of drug-related conditions (e.g., Opioid-induced hyperalgesia) (Servick, 2016).

A compelling reason to continue exploration of psychological approach to chronic pain for older persons is that some mainstream treatment approaches may be unsuitable with this cohort. Use of medications for pain management is more problematic in older populations as they are more vulnerable to side effects and drug interactions (Hayes, 2013). Surgical interventions become complicated with increasing age and can entail longer recovery time. Co-morbidities may also compound suitability for some treatments and impact recovery from more intensive surgical procedures. It is also important to note that many older persons display a preference for alternatives to pharmacological treatment (Wetherell et al., 2015).

It is believed that ACT has potential to address many chronic conditions such as chronic pain, HIV, cancer, and epilepsy (Graham et al., 2016). One of the reasons for this, is that the negative beliefs and thoughts which may accompany many long term/chronic conditions may be highly accurate and true for the individual. This accuracy would make some aspects of traditional CBT for, for example, challenging or restructuring of some thoughts, difficult.

ACT does not require that specific changes to thinking patterns be made. This perhaps increases receptivity in clients who find the concept of changing cognitions challenging (Petkus & Wetherell, 2013). Accompanying the physical aging process is cognitive maturation. Crystallized intelligence, or one’s general store of knowledge, is thought to expand and be preserved throughout adulthood, with mild decline only after 70 years of age. However, free recall, processing speed, and fluid intelligence are believed to decline (Knight & Poon, 2008). It is possible that cognitive restructuring both theoretically, and practically, may pose difficulties for some older persons, due to its reliance on changing, reshaping, and reorganization of thinking patterns. Many of the guidelines for use of CBT with older persons advocate additional sessions, materials, and reduced content to accommodate some of the possible changes in cognitive processing (Knight & Satre, 1999). Meta-analytical studies have suggested that CBT is not as effective for older persons, as it is for working-age adults, across some presentations, for example, anxiety disorders (Gould et al., 2012). Reasons behind such findings are yet to be known, but the researchers advocate for a continued effort in seeking out explanations, along with continued exploration of alternative therapies or therapies which could augment CBT for older populations (Gould et al., 2012).

The unique requirements and responsivity of older adults to psychological treatment of chronic pain is an under-researched domain (Moore et al., 2014). Despite the high prevalence of chronic pain in older adults, and the challenges with mainstream medical interventions, few guidelines exist for the selection and delivery of best practice psycho-therapeutic interventions. This is not to assume that existing treatments for chronic pain do not offer any benefits for older patients, but rather to draw attention to the possibility of improved treatment response if the particular needs and characteristics of the elderly are taken into consideration (Pachana et al., 2015; Wetherell et al., 2015). Furthermore, studies in this area present some disappointing results for older persons’ response to more traditional modes of psychological treatment of chronic pain, advocating research aimed at better servicing their needs (McCracken & Jones, 2012).

ACT facilitates chronic pain management via development of acceptance and a focus on the individual’s value system. It aims at achieving psychological flexibility allowing acknowledgement of the physical condition and resulting distressing emotions, but without avoidable additional negative reaction. In developing the ability to pursue meaningful life values quality of life is enhanced (Dahl et al., 2005) despite the unwanted experiences.

Understanding Chronic Pain for Older Persons Using an ACT Lens

In this study, an approach to assessment and treatment was taken incorporating factors specific to aging using an ACT lens. According to ACT theory, the greater the psychological rigidity, the more likely pathology/distress. The six core components of rigidity are: disconnection from values, inaction (lack of committed action toward values), fusion (when we are entangled with our thoughts), experiential avoidance (when we take action/exert effort in order to avert an unwanted feeling or state, even if this entailed harm to self), over-focus on past and/or future and conceptualized self (awareness of self, and how one observes and describes self). These components manifest in chronic pain as: control of pain being the central focus, all/most resources used to control pain, fusion with pain cognitions (e.g., “my pain is unbearable”), repeated attempts to fight or remove pain, pain-focused prediction/rumination (potentially causing mental and physical stress/tension), and a self-concept reflecting the pain (e.g., “pain sufferer”) (Harris, 2009).

An extension of the existing ACT model of pathology and chronic pain was developed and explored in this case study (Figure 1). The proposed model, adapted from Dahl et al. (2005) and Harris (2009), includes aging specific factors in the understanding of the development and maintenance of chronic pain for older persons, via the ACT model.

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Figure 1.

Aging-specific factors contributing to psychological rigidity in chronic pain.

Disconnection from values may be more significant due to the possibility that older persons may have more limited resources (e.g., financial, physical energy), all or much of which are directed at the pain, rather than pursuing other areas of life which may have once been important. Additionally, there may have been a longer period since values were attended to, simply due to older persons having lived longer. It is also possible that personal values may have never or rarely been prioritized depending on the course/nature of the older person’s life and specific generational factors and experiences (e.g., during times of hardship personal values may be unlikely to be prioritized). Similarly, pursuing values (i.e., committed action in the ACT model) is likely to be lacking if values are poorly identified and if most/all limited resources (energy, money, transport, etc.) are channeled toward pain control.

Fusion with pain-related cognitions is relevant for many sufferers of chronic pain and perhaps even more so with older persons. This is due to both the possibility that the pain cognitions have been practiced and reinforced for longer periods of time and because the aging process itself can form part of these cognitions (e.g., “at my age pain is inevitable”).

Experiential avoidance or attempts to fight, stop and remove pain may be also heightened in some older persons. There may exist a greater propensity to continue to seek cures/relief from pharmaceutical or surgical treatment due to faith in the medical system and tendency to not ask questions, a trait associated with the “silent generation” (born before 1945) in particular (Appold, 2017).

Lack of contact-with-the-present moment or being overly focused on pain related predictions and rumination may manifest to a greater degree in older persons due to their possible longer history of pain/discomfort and/or a heightened fear of future due to such factors as end of life contemplation and loss of peers.

Conceptualized self for an older person may also involve age-related factors. Not only may they see themselves as a “pain sufferer” but “weak,” “frail” and/or other negatively charged descriptors which individuals and society often use to view more mature adults.

It is proposed that advanced age may add an additional and significant layer to the factors that can render an individual vulnerable to psychological rigidity that can accompany chronic pain. Psychological rigidity reduces the individual’s ability to cope and deal with chronic pain and any distress which may be experienced. This is over and above the physiological impact of age increasing the likelihood of conditions which may cause or be related to chronic pain. Essentially, in testing and exploring an ACT treatment approach in the research described, the proposed extension of the existing ACT model is also being tested.

2 Case Introduction

John (pseudonym), a 72-year-old Caucasian male residing in a remote city in Australia, was referred to assist with management of his chronic pain. His physical health status was complex. John had undergone a major organ transplant, is a diabetic and suffers from cardiovascular issues. He had suffered a stroke in 2017, reportedly whilst on a Care flight journey interstate following hospitalization for an infection. John was reported as being cognitively intact. He suffers with arthritic knee and shoulder/neck pain, as well as pain from skin lesions/cancers. Pain was reported to be exacerbated by his current medication regime increasing his sensitivity. Left-side mobility was significantly impaired.

3 Presenting Complaints

John presented as a pleasant-natured and agreeable Australian man of Caucasian background. He exhibited visible physical discomfort, awkward movement and frequent shifting in his chair. His physical condition seemed poor and he carried excess weight. He described pain being predominantly in his left hip, lower back and feet at present. His current medication included immunosuppressants which may involve pain as a side effect, and this was reported by John. He reported experiencing pain every day, intensity being 7/10 and was “uncomfortable all the time”. He rated the impairment caused by pain as 8/10. The pain was reported as impacting every aspect of living, sleeping, eating, mobility, interaction with others, domestic jobs and mood. He rated himself as 9/10 in terms of “depression.”

4 History

John was born in Australia. His father, upon returning from war, suicided when John was 4 years old, a death he witnessed. He moved several times as a child and his adulthood also involved numerous moves. He completed secondary school to Form 4 (Leaving Certificate). John smoked from his early life and he became a very heavy smoker, which led to debilitating emphysema.

John lives on his own and he uses his own transport. He was divorced from his wife when his youngest son was 10 years old, this was an acrimonious split which continues to be a source of distress. John’s lifestyle tends to be isolated, with limited social contact. He did not report previous consultation with psychological therapy.

5 Assessment

Initial assessment included a structured interview, The Brief Older Persons Quality of Life (Bowling et al., 2013), Geriatric Depression Scale-short form (Sheikh & Yesavage, 1986), Rapid Assessment of Physical Activity (Topolski et al., 2006), and the Acceptance and Action Questionnaire-II (Bond et al., 2011). Pain was assessed using measures of frequency and ratings of intensity and degree of impairment.

Selection of assessment procedures required consideration of the potential to overburden the participant, whilst still seeking to measure a range of domains regularly throughout therapy. It was therefore decided that the study use four brief questionnaires introduced during initial assessment and repeated at each session and follow-up. These questionnaires were selected due to their relevance to the goals of ACT, over a broad range of domains.

Pain was assessed during the initial assessment interview and in final session. No specific pain questionnaire was administered as direct focus on pain contradicts the central principles of the ACT approach. Improvement in symptoms (e.g., pain) is often a byproduct of the therapy as it seeks to enhance psychological flexibility rather than targeting symptoms or conditions.

The participant offered his consent and seemed comfortable completing all four questionnaires at each of the eight time points.

6 Case Conceptualization

John’s condition appeared to reflect the proposed model for the development and maintenance of chronic pain in older persons through an ACT lens. His pattern of withdrawal, isolation, and inactivity reflected the reduced focus on values driven by his attention being taken from values and toward the pain/physical conditions. Because pain had become central to his identity, it was dictating his lifestyle, hence the neglect of values, and an ensuing distinct lack of action toward any values. John had adjusted his lifestyle, believing this was necessary to cope with his pain condition, and, in the process, had sacrificed significant social interaction and engagement with community. His description of pain-related developments in his life reflected how he had seemed to succumb to the diagnosis. These developments then began contributing to a poorer sense of wellbeing as aspects of his life such as interaction and community/social engagement had once been a core value and source of meaning for John. Therefore, the aspects of life which likely helped maintain psychological health were being eroded due to the chronic pain.

There was evidence of fusion with some pain thoughts, especially in terms of the inevitability of his condition. Given that he has complex medical history, and pain had been prevalent for decades, this fusion was entrenched. Whilst John did exhibit acceptance toward some aspects of his condition, this was perhaps more of a bitter resignation and experiential avoidance was reflected in an emphasis on rest and reduction in activity or involvement (e.g., “I can’t play golf because I won’t make 18 holes, it will be painful and it will be annoying for my son.”). For John rumination on a long life of painful experiences and challenges was problematic and his conceptualization of self was as a patient/sick person. This eroded his ability to remain in the present.

The assessment indicated that John had endured significant distressing events and periods in his life; his description of these experiences also highlighted that he likely had exhibited stoicism and developed strategic coping mechanisms.” The fact that he had survived well beyond what was expected of a major organ recipient (at that time) was probable testament to not only physical resilience, but psychological too. It seemed attitudinal and psychological factors tied to his lengthy and challenging life experience may point to him being a suitable recipient of ACT therapy, primed toward the approaches used. For example, components of psychological flexibility (e.g., cognitive defusion, acceptance, and distress tolerance) were evident and simply required further development and specific application to the experience of pain. The fact that he had successfully survived through these challenging times provided concrete evidence for John that he possessed the necessary traits to overcome distress and difficulties. He possessed true experiential knowledge of these factors which was able to be harnessed during therapy.

In terms of Contact-with-the-Present-Moment, John was avoiding this by shutting out, to a large degree, the world around him, watching tv, and ruminating. This allowed him to focus away from concerns over what his future held health-wise. His rumination involved past hurts, primarily related to his ex-wife and his divorce.

Hence, the factors contributing to the psychological rigidity which is the source of distress in chronic pain (and many other conditions) apply to John, as well as the proposed additional factors driven by advanced years which are proposed in the extended model conceptualizing the development and maintenance of chronic pain in the over 65s.

7 Course of Treatment and Assessment of Progress

The therapy program constituted eight sessions. The first session focused on the initial assessment and the final session on consolidation, de-briefing and reflection on the therapeutic process. The six sessions of therapy incorporated specific components of the ACT model in a predetermined fashion addressing the goal of enhancing psychological flexibility.

Outcome

As therapy progressed John’s engagement remained high. There was a positive trend seen in the quality of life measure (Figure 2), rising from 47 to 57, but then, in line with the GDS score, declining again in the last week to 48. His scores on AAQ-II were consistently low across assessments indicating good acceptance and action (Figure 3).

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Figure 2.

OPQOL scores—8-week treatment.

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Figure 3.

AAQ scores—8-week treatment.

Positive change was seen in John’s depression scores with a reduction from 13 to 5 in week 7 (a score of more than 5 is indicative of depression warranting further assessment). This score then increased in week 8 to 7, but at this time he was again facing likely medical procedures (Figure 4). The Reliable Change Index (Jacobson & Truax, 1991) was used to assess statistical significance, yielding a value of 3.21, suggesting meaningful clinical change had occurred.

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Figure 4.

GDS scores—8-week treatment.

In terms of physical activity again there was a change in scores indicative of positive response to therapy with John moving from a score of 2 for the first 5 weeks, to a score of 4 for weeks 6 and 7. He then returned to 3—a decline which was in keeping with other scores’ slight decrease, assumed to be in response to challenges being faced in this last week and was possibly related to the knowledge that contact would soon be ending. In week 5 John’s reported activity/engagement with others increased which presented in session as an improvement in mood (Figure 5). This was reflected in his GDS score. John reported a slight decrease in frequency of pain (from “every day” to “most days,” in intensity (from 7/10 to 5/10) and degree of impairment (from 8/10 to 4/10).

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Figure 5.

RAPA scores—8-week treatment.

8 Complicating Factors

Factors which add complexity for John’s treatment included that he faced ill-health over some of the treatment weeks, notably dental problems and additional associated pain. His ongoing struggles with his physical health were exacerbated by limited access to healthcare due to his place of residence.

9 Access and Barriers to Care

Like many older persons, John’s knowledge of, and exposure to, psychological services was very limited. Another barrier would likely have been reluctance in acknowledging much of the emotional struggle, likely due to the stoicism which his generation often exhibits, along with perceived stigma attached to mental health issues.

10 Follow-Up

The final scheduled session provided de-briefing and the opportunity for John to reflect on his experience while participating in the program. He emphasized that he had been surprised and pleased with undertaking the therapy. He stated that he would like to continue, but this would be after travel to his pulmonary specialist in another state as his health had been predictably deteriorating (as a result of his organ transplant and ensuing complications) and hospitalization for monitoring and possible intervention was likely. Phone contact 2 months following contact confirmed this had been the case, but he was reported that his improvement in mood had been sustained.

11 Treatment Implications of the Case

As with any psychological treatment approach, it is always possible that the very contact itself and the therapeutic relationship was the potential source of improvement (Wampold, 2001). This may be especially the case when the client lives a somewhat solitary life and loneliness is evident. However, there seemed to be evidence that aspects of the ACT model boded well for this individual despite a very complex and chronic physical health status and a history of trauma. First, he had experienced numerous and significant distressing periods in his life, not the least of which was his father suiciding at a very young age and chronic emphysema and subsequent major and life-saving organ transplant, essentially a life-threatening condition and procedure. Therapy approaches which rely on attempts to challenge or dispute negative cognitions about such a history or situation seem inappropriate as negative cognitions about John’s situation do seem rational, albeit distressing. The ACT focus on finding some vitality and meaning beyond the pain and trauma represented a sounder therapeutic fit. This is important in terms of the therapist’s experience in delivering the treatment. An approach that more fully caters for the extent of problems and that entails potentially less resistance (as there is no need for “challenging,” “disputing,” etc.) is likely to facilitate better therapeutic alliance.

It became apparent early in sessions that this individual had utilized various personal forms of distress tolerance and acceptance over the course of his life. John’s personality naturally lent itself to these factors and such existing strength was able to be harnessed and enhanced during therapy.

12 Recommendations to Clinicians and Students

This case study has formed the preliminary stage of utilizing an extension of the existing ACT model to conceptualize and treat chronic pain in older persons. The extended model proposes that age-related factors contribute to the development and maintenance of chronic pain in older persons and therefore these factors should contribute to the design and application of treatment approach for older persons.