What physicians should know about spirituality and chronic pain.

There is growing recognition that persistent pain is a complex and multidimensional experience that can influence and be influenced by biologic, psychological, social and spiritual or religious factors. (1-4) Individuals experiencing persistent pain often report they turn to their religion or spirituality to cope with pain. Religious pain coping techniques vary. Some types of religious coping are adaptive and some types are maladaptive. (1) Religious or spiritual practices can help in managing pain in several ways. (1,3-4) First, practices such as daily prayer may serve as a distraction from pain. Second, actively participating in a religious community or church may provide many opportunities for instrumental, social, or spiritual support. Third, religious/spiritual practices such as meditation and prayer may create feelings of relaxation that directly alter the pain experience.

How do different types of religious coping relate to the adjustment to persistent pain? In a study of 61 patients suffering from chronic pain, Bush et al (1) examined the use of positive religious coping and negative religious coping. In these patients, positive religious coping tended to be adaptive, where one looks to a higher power for strength, comfort, and support. Negative religious coping, in contrast, appeared to be more maladaptive and consisted of two subtypes: patients with the "Punishing God" view saw the pain as retribution from God, and patients with the "Absent God" view felt abandoned by God during the time when they most needed support. This study was not only important in delineating positive versus negative forms of religious coping, but also in showing that patients with persistent pain often simultaneously use both secular and religious coping techniques. Furthermore, one of the most crucial findings of this study was that after controlling for gender and pain intensity, positive forms of religious coping were related to significantly higher levels of positive effect and more positive spiritual and religious outcomes. This study was one of the first to provide evidence that positive religious coping has unique effects on adjustment to pain beyond what can be explained on the basis of demographics and pain level.

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Rippentrop and colleagues (2) recently conducted one of the most systematic studies of how positive and negative forms of religious coping affect adjustment to persistent pain. They found that a set of positive religious coping techniques was related to significantly better mental health. Negative religious coping (ie, feeling punished/abandoned by God) was related to significantly poorer physical and mental health outcomes. Interestingly, the use of private religious practices (ie, prayer, meditation) was predictive of poorer physical health status suggesting that persons may turn to these practices as a way of coping with poor health.

We conducted one of the first studies to examine how religious coping relates to adjustment to pain using longitudinal, daily diary methodology. (3) A 30-day diary study found that rheumatoid arthritis patients who reported their religious and spiritual coping strategies were better enabled to control their daily pain, and they experienced much lower levels of pain and negative mood and much higher levels of social support. These findings suggest that day-to-day variations in religious and spiritual coping variables are meaningfully related to the experience of chronic arthritis pain.

There is growing interest in the possibility that interventions that encourage positive religious coping might be beneficial in managing pain. (4) One recent study found that by using positive spiritual meditation twenty minutes a day, patients with frequent migraine headaches were able to improve their pain tolerance and reduce their frequency and severity. Those regularly practicing spiritual meditation also showed improvements in mental, physical, and spiritual health. This research indicates that patients with chronic pain conditions can be taught to use their existing spiritual resources in novel ways to reduce the negative impact that pain has on their lives.

In summary, when assessing and treating patients with pain, physicians may benefit from attending to patients' descriptions of how they use spiritual and religious resources to cope with pain.

Acknowledgments

Preparation of this article was supported, in part, by funding from the Fetzer Institute.

References

1. Bush EG, Rye MS, Brant CR, et al. Religious coping with chronic pain. Appl Psychophysiol Biofeedback 1999;24:249-260.

2. Rippentrop EA, Altmaier EM, Chen JJ, et al. The relationship between religion/spirituality and physical health, mental health, and pain in a chronic pain population. Pain 2005;116:311-321.

3. Keefe FJ, Affleck G, Lefebvre J, et al. Living with rheumatoid arthritis: the role of daily spirituality and daily religious and spiritual coping. J Pain 2001;2:101-110.

4. Wachholtz AB. Does spirituality matter? Effects of meditative content and orientation on migraineurs. Doctoral Dissertation, Bowling Green State University, 2006. Available at: http://www.ohiolink.edu/etd/view.cgi?bgsu1143662175. Accessed Retrieved April, 2006.

The ultimate expression of generosity is not in giving of what you have,
but in giving of who you are.
--Johnnetta B. Cole

Amy B. Wachholtz, PhD and Francis J. Keefe, PhD

From the Department of Psychiatry & Behavioral Sciences, Duke University Medical Center, Durham, NC.

Reprint requests to Francis J. Keefe, PhD, Department of Psychiatry & Behavioral Sciences, Duke University Medical Center, Durham, NC 27710. Email: [e-mail]