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Counseling clients with chronic pain: a religiously oriented cognitive behavior framework.

Each year, 50 million Americans are affected by chronic pain, resulting in annual health care and economic costs of more than $100 billion (American Chronic Pain Association, n.d.). Physically, these individuals face functional limitations, reduction in activity levels, loss of libido, sleep disorders, and appetite changes; these and other issues often lead to a pervasive dependence on the health care system (Eimer & Freeman, 1998). Social implications include occupational, familial, or other interpersonal difficulties that further complicate successful adaptation (Lewandowski, Morris, Draucker, & Risko, 2007). However, psychological factors may pose the greatest impediment to effective coping with chronic pain.

The literature supports the notion of the mind-body-spirit as an interactive system, with each element influencing the other, particularly in the case of chronic pain (Culver & Kell, 1995; Lewandowski et al., 2007). Cognitions, including religious beliefs, play a crucial role in the appraisal, management, and outcome of this condition (Bush et al., 1999). Although religious beliefs derived from institutional doctrine and practice may differ from personalized spiritual beliefs, both often include faith in a transcendent force.

Religious beliefs are common in our society; for example, 90% of Americans state a belief in God (Winseman, 2005). When positive (e.g., a benevolent, supportive God), these beliefs can contribute to healthy adaptation; conversely, negative religious beliefs (e.g., a conditional, vengeful God) may exacerbate problems associated with chronic pain (Rippentrop, Altmaier, Chen, Found, & Keffala, 2005). Although the inclusion of religious material has been historically overlooked in therapy (Faiver, O'Brien, & Ingersoll, 2000), many clients state a preference for counselors who hold similar beliefs or who are at least sensitive to religious issues (Burke et al., 1999).

The Association for Spiritual, Ethical and Religious Values in Counseling created the Spiritual Competencies to guide ethical practice in this regard (Genia, 1994). Yet, some counselors continue to believe that religious topics should be left to clergy, whereas others admit that they lack the expertise to address these concerns (Faiver et al., 2000; Genia, 1994). Failure to consider religious matters may constitute neglect of a viable resource. For example, positive religious beliefs have been shown to moderate pain beliefs, alleviate helplessness, and reinstate hope (Cole, 2005; D' Souza & Rodrigo, 2004; Keefe et al., 2001). Thus, it is essential for counselors to gain an awareness of their clients' religious belief system, explore its interaction with pain-related beliefs, and guide clients toward more positive coping strategies (Bond, 2001).

The purpose of this article is to examine the effects of religious beliefs on the mental health outcomes of clients experiencing chronic pain. A framework involving religious schemas and pain-related beliefs is proposed, along with a cognitive behavior strategy for moderating negative patterns.

Pain, Depression, and Counseling

Pain, as defined by the International Association for the Study of Pain, is a subjective, "unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" (Merskey & Bogduk, 1994, p. 210). Pain is considered chronic when, despite treatment, it persists for months or years beyond the expected recovery period (American Chronic Pain Association, n.d.). Individuals experiencing chronic pain commonly hold beliefs that compromise their self-image, they believe that pain is beyond their control, and they harbor excessive concern about present and future functioning, all of which lead to perceived hopelessness, meaninglessness, social isolation, and exaggerated fear-based beliefs (Bond, 2001; Eimer & Freeman, 1998; Westgate, 1996).

Because these perceptions are also commonly linked to depression, it is not surprising that pain and depression are comorbid (54%; Cianfrini & Doleys, 2006). Depressive symptomatology compounds the experience of pain by introducing an increased risk of suicide, an exacerbation of existing pain symptoms, and an intensification of psychosocial stressors (Eimer & Freeman, 1998). Clients presenting with both pain and depression pose a unique challenge to counselors, because the manifestation of each condition contributes to symptoms of the other. Traditional psychotherapeutic intervention aimed at breaking this destructive loop includes the moderation of cognitions that influence the experience of pain, depression, and related variables.

Cognitive behavior therapy (CBT) is widely supported for mediating the effects of maladaptive cognitions on pain and depression (Grant & Haverkamp, 1995; Sullivan, Sullivan, & Adams, 2002). Strategies such as distraction, reframing, and imagery are engaged to restructure problematic cognitions that contribute to distress. Cognitive distortions, including dichotomous thinking (black-or-white thinking), catastrophizing (imagining the worst possible outcome), and overgeneralization (applying the consequences of one incident to all similar events), guide behavior and influence cognitive processes, emotions, perceptions of pain, and the maintenance of depressive symptoms (Beck, Rush, Shaw, & Emery, 1979; Eimer & Freeman, 1998). The counselor's task is to facilitate the client's understanding of the impact of cognitions on behavior and emotions; identify, monitor, and challenge dysfunctional thoughts; and promote cognitive and behavioral modification (Propst, 1988).

Religion, CBT, and Coping

Often included in one's personal paradigm are highly influential beliefs that are religious in nature; for example, belief in a universal spirit has remained in the mid-90% range across the last 60 years (Gallup, 2001). In other polls, 74% of respondents believe that God is actively involved in their lives (Gallup, 2003), and 80% say that religion is at least "fairly important" to them (Gallup, 2005). Because religious beliefs are often infused into coping strategies and, for many, become more salient in times of stress (Burke et al., 1999), the implications for counselors cannot be understated. These beliefs must be assessed for their contribution to presenting concerns, and when they are detrimental to coping, an intervention should be considered.

Although many CBT strategies are easily adapted to include religious beliefs, there is a lack of experimental research examining their effects on pain management. One exception is spiritually focused therapy implemented by Cole (2005) in a pilot study of individuals with cancer. Results suggest that spiritually focused therapy was instrumental in stabilizing pain severity and depression relative to the control group. Although Cole used several CBT techniques, the extent to which cognitive modification/restructuring was used (specific to the impact of religious schemas on other beliefs) is unclear.

Several studies using religiously oriented CBT in the treatment of depression have proven successful. In two controlled studies, religiously based imagery and disputation of irrational thoughts were beneficial for individuals with depression (Propst, 1980; Propst, Ostrom, Watkins, Dean, & Mashburn, 1992). The experimental groups showed fewer depressive symptoms and better social adjustment, even when the therapist was not religiously oriented. In three randomized controlled trials using a spiritually based CBT, D' Souza and Rodrigo (2004) found lower rates of depression, improved self-efficacy, and better treatment adherence with a meditation, prayer, and spiritually based cognitive restructuring protocol. In other studies, Johnson and colleagues (Johnson, DeVries, Ridley, Pettorini, & Peterson, 1994; Johnson & Ridley, 1992) reported reduced irrational thought and lower depression levels with a Christian-based CBT.

A Religious Framework for Pain-Related Beliefs

Religious beliefs are major contributors to the coping process. Positive coping strategies include seeking comfort and support through a collaborative relationship with a benevolent God, religious reframing and distraction, meditation, and prayer (Pargament, 1997; Richards & Bergin, 1997). Research supports these strategies for the promotion of well-being, self-esteem, and life satisfaction and the moderation of pain, anxiety, and depression (Jenkins & Pargament, 1995; Keefe et al., 2001; Pargament, 1997). Alternatively, Pargament, Zinnbauer, et al. (1998) discussed the "red flags" of religious beliefs that can undermine adjustment to stressful events. Examples include overemphasizing religion to the point of self-negligence, religious apathy, and feeling punished by God. These types of beliefs are linked to anxiety, lower self-esteem, greater pain, and compromised mental health (Jenkins & Pargament, 1995; Pargament, Zinnbauer, et al., 1998).

Outside of the religious realm, Eimer and Freeman (1998) discussed core beliefs common to clients experiencing chronic pain, such as perceiving the self as defective or vulnerable. A sense of guilt for real or imagined transgressions that necessitate the "punishment" of pain is common and often leads to perceptions of being out of control and feeling helpless or hopeless. These core beliefs facilitate the notion that pain is a severe, mysterious, and permanent experience that produces frightening and catastrophic consequences.

The interaction between religious beliefs and those related to pain can be illustrated through a framework that borrows from Pargament, Zinnbauer, et al.'s (1998) red flags of negative religious coping and Eimer and Freeman's (1998) core pain beliefs. In this framework, religious schemas are foundational and influence the origination and maintenance of the pain beliefs. The schemas involve guilt and punishment; defectiveness, incompetence, and alienation; and vulnerability and dependence. For the ease of illustration, the following examples are presented as independent constructs; in reality, however, they are highly interrelated.

Pain-Related Schema: Guilt and Punishment

Religious schema: God is always fair and does not let bad things happen to good people; guilt is my awareness of having sinned.

Core belief: I'm to blame when things go wrong.

Red flag: I created and deserve this; pain is a punishment from God for my sins.

Guilt is viewed by some as a healthy regulatory function intended to prevent "bad" behavior. Mental health is compromised, however, when guilt manifests in unrealistic self-expectations or over responsibility for real or imagined infractions of a moral or ethical code (Beck et al., 1979). The ensuing sense of wrongdoing is compounded by the aversive sensations of pain, which may very well be perceived as punishment (Eimer & Freeman, 1998).

As McIntosh (1995) explained, schemas are automatic and immediately influence perceptions of an event. In the present example, a religious schema initially formulated from misinterpretation or overpersonalization of religious doctrine (e.g., pain is the result of having sinned) interacts with the core pain belief of self-blame and leads to the appraisal that pain is a deserved punishment (i.e., from God). Such perceptions exacerbate decision-making skills, self-esteem, feelings of helplessness, and depressive symptomatology (Faiver et al., 2000).

Cognitive distortions that contribute to feelings of guilt and punishment are dichotomous thinking, overgeneralization, and "should" statements (Eimer & Freeman, 1998). The counselor's task is to determine the relationship between the perceived transgression and the appropriateness of guilt. If this relationship is inappropriate, counselors can challenge maladaptive beliefs and facilitate congruence between the client's healthy values and schemas; if there is a veridical basis for the client's guilt, the counselor can facilitate a so-called confession and promote forgiveness (Faiver et al., 2000). Sacred texts specific to working through guilt and gaining forgiveness can be assigned as homework. Encouraging religious practice (e.g., prayer, rituals, congregational activity) may also be beneficial for moderating maladaptive schemas related to these issues.

Pain-Related Schema: Defectiveness, Incompetence, and Alienation

Religious schema: God expects perfection; I am unworthy in the eyes of God; The church helps people with their problems.

Core belief: I am defective and/or unlovable; ! am a failure.

Red flag: I will stop caring about important things in my life; Pain is God's way of telling me I failed Him; I am angry at the church for not supporting me.

Perfectionism is a trait often found in people with chronic pain, and, for many, there is a history of compulsive striving to achieve (Eimer & Freeman, 1998). Treatment-resistant pain and changes in physical functioning intensify fear, self-blame, and feelings of defectiveness and incompetence. Many use perfectionism to overcome their "defect," or they may separate from parts of themselves that they perceive as bad or evil (Sorotzkin, 1998). When clients cannot live up to the standards set forth by religious teachings, they feel they have failed and are no longer worthy. Richards, Owen, and Stein (1993) suggested that the rigid and literal interpretation of sacred texts contributes to religious perfectionism. The authors found that as cognitive interventions, religious bibliotherapy, psychoeducation, and group discussions moderate perfectionistic tendencies, depressive symptomatology abates and self-esteem improves. Self-esteem and self-efficacy are further reinforced when clients believe they are effective with problem solving, if and when they can maintain a sense of control in life, and when a collaborative religious coping style is used (Pargament, Smith, Koenig, & Perez, 1998; Witty, Heppner, Bernard, & Thoreson, 2001).

Many individuals seek comfort from their congregations. However, if extreme dependency or perseveration about the pain persists, others may withdraw. Being unable to realize expectations of support, the individual feels alienated and abandoned by both the church and God (Westgate, 1996). Conversely, he or she may socially withdraw because of feelings of defectiveness and incompetence. In either case, the absence of social support exacerbates the experience of pain and depression (Eimer & Freeman, 1998). Realistic expectations of religious fellowship can reconcile feelings of abandonment and alienation and provide a sense of being valued and cared for by others and by God (Pargament, 1997; Westgate, 1996). The practice of daily religious beliefs and perceived support from a religious community is positively related to mental health outcomes (Keefe et al., 2001; Rippentrop et al., 2005). Conversely, McCullough and Larson (1999) determined that the risk for depression in individuals without links to religious organizations could be as high as 60%.

Cognitive distortions related to beliefs of defectiveness, incompetence, and alienation are overgeneralization, dichotomous thinking, and pain-based emotional reasoning (Eimer & Freeman, 1998). Reframing, religious distraction, and cognitive restructuring can be used to challenge perfectionistic tendencies and unrealistic social expectations. Sacred texts involving examples of humankind's inherent shortcomings and realistic assessment of God's expectations can be examined to ease self-expectations. Interventions, such as religious affirmations or imagery, are beneficial for encouraging positive thoughts and changing harmful beliefs (Cole, 2005; Rippentrop et al., 2005). Realistic expectations of others can be processed, and healthy congregational fellowship can be encouraged. Finally, counselors can help clients examine the impact of their behavior on others.

Pain-Related Schema: Vulnerability and Dependence

Religious schema: God controls/causes everything; God answers all prayers; I am totally helpless without God.

Core belief: I cannot function on my own; I don't have the re sources to cope.

Red flag: I am angry at God for not answering my prayers; I will surrender completely to God since I can't do anything about it.

Perceptions of defectiveness, incompetence, and alienation, common for clients with chronic pain, contribute to feelings of helplessness and the notion that pain is unduly threatening and outside of one's control (Eimer & Freeman, 1998). Pain is often conceptualized as a prevailing experience that must be single-handedly endured. Believing that pain is uncontrollable, individuals experience increasing vulnerability, give up trying to help themselves, and become overly dependent on others (or on God) to meet their needs. A sense of helplessness may be particularly poignant if one believes that pain represents the wrath of an omnipresent God. Clients may become angry at God for allowing the suffering to continue, particularly if they do not feel responsible for any infraction that warranted the "punishment." Excessive anger is maladaptive in any context, but perhaps more so when the anger is directed at God. Alternatively, the individual may adopt complete dependence on God and, therefore, refrain from self-help. Either conclusion facilitates helplessness and hopelessness and is detrimental to effective coping (Pargament, Smith, et al., 1998).

Better mental health outcomes are realized by individuals who engage a collaborative style in which God is conceptualized as a partner and problems are negotiated together (Pargament, Smith, et al., 1998). Helplessness, vulnerability, and dependence are minimized by assuming responsibility for what can be controlled (e.g., maintaining pain management regimens, working through self-defeating thoughts) and releasing to God those things that cannot (e.g., the existence of pain). Findings support the notion that relinquishing the uncontrollable to God mediates the severity of pain, stabilizes depression, and contributes to better emotional and physical functioning (Cole, 2005). Religious bibliotherapy can be explored for examples of working with God to navigate difficulties. Furthermore, the collaborative counseling process serves as a model for shared responsibility and as an example of the benefits of becoming self-sufficient.

Cognitive distortions that contribute to vulnerability, dependence, feelings of helplessness, and loss of control are pain-based emotional reasoning, dichotomous thinking, and catastrophizing (Eimer & Freeman, 1998). The latter is of specific concern, because it is one of the strongest predictors of feelings of helplessness and perception of disability in those with chronic pain (Sullivan et al., 2002). Particularly effective interventions for increasing a sense of control and minimizing helplessness involve active coping strategies, such as problem solving, positive appraisal, and religious reframing; the benefits are fewer requests for pain relief, increased self-efficacy, and lower levels of psychological distress (Bond, 2001; Witty et al., 2001). Counselors can help clients identify strategies to negotiate problems, explore alternative reasons for pain within a religious framework, challenge cognitive distortions, and examine the utility of automatic thoughts related to feelings of helplessness.

Finding meaning and purpose are particularly salient concerns for clients who feel helpless and out of control (Eimer & Freeman, 1998). Doubts of faith and existential concerns can be reconciled through the counseling process to restore hope and find meaning (Cole, 2005; Westgate, 1996). As an example, pain can be refrained as a lesson, a challenge, part of God's mysterious plan, or a time for growth. Seeking divine purpose through meditation, prayer, cognitive restructuring, and monitoring the effects of belief systems reduces distress through gains in faith and acceptance (D'Souza & Rodrigo, 2004).

Implications for Counseling

When negative religious schemas interact with secular beliefs common to clients experiencing chronic pain, the resolution of dysfunctional thought processes is further complicated. Conversely, positive religious coping strategies can facilitate adaptation. The counselor's challenge is to determine how a client's religious belief system is affecting the experience of pain and either restructure problematic schemas or engage existing, healthy beliefs.

Structured interviews or questionnaires help counselors understand clients' experience of pain and the coping strategies that are in operation. Although many intake formats include inquiry into religious affiliation, they reveal little about the depth and nature of religious issues. Consider, for example, a client who indicates no religious affiliation on a simple checklist. This format fails to identify beliefs that exist in the absence of church affiliation but that continue to influence the experience of pain. Culver and Kell (1995) recommended using a structured "religiospiritual" questionnaire with questions such as, What are your current beliefs and practices? Does God punish? Is God responsible for pain and suffering? What gives your life meaning and purpose? and Is your religious community supportive? (p. 56). Such in-depth questioning can reveal unconscious relationships between perceptions of pain and religious beliefs that may have otherwise remained unknown. An in-depth religious inquiry also informs clients that their beliefs are valid topics in counseling (Westgate, 1996).

In addition to the CBT strategies previously mentioned, religiously oriented imagery, visualization, and journaling have also proven beneficial (Cole, 2005; D'Souza & Rodrigo, 2004; Propst et al., 1992). Three other religious practices are worthy of further mention. First, meditation enhances both mental and physical functioning. Outcomes are greater when religious material is infused into this practice. Wachholtz and Pargament (2005) found that participants in a spiritual meditation group had lower levels of anxiety and higher pain tolerance than did those in either a secular meditation or a relaxation group. In another study, medication adherence improved and levels of despair declined when depressed clients used religious meditation and prayer (D'Souza & Rodrigo, 2004).

A second practice, prayer, is also effective in counseling; however, the type of prayer is an important consideration (Richards & Bergin, 1997). Colloquial or meditative prayer is associated with well-being, but petitionary prayer increases rumination and negative affect (Poloma & Pendleton, 1991). Meditative prayer also serves as a buffer for excessive worry, anxiety, and self-focused attention (James & Wells, 2003). However, counselors must remain aware of the potential for role confusion and transference when praying with clients (Richards & Bergin, 1997); therefore, it may be more appropriate to encourage the client to lead.

Finally, Richards and Bergin (1997) promoted sacred writings as a source of inspiration, guidance, and insight for religious clients because many believe that they are a direct communication with the divine. Individuals who identify with religious writings may find comfort and support as their problems are universalized. The authors endorsed the use of sacred texts to modify dysfunctional beliefs, reframe problems, and clarify religious understandings. They also reported that reference to sacred texts is more frequent in counseling than in any other religious intervention.

Counselors must be aware of several practical and ethical concerns. For example, it is essential to become familiar with a client's religious tradition, while remaining aware that the client's experiences within that tradition are unique. Counselors must ensure that interventions resonate with the client's values and belief systems. Although it is not necessary for counselors to be religious to successfully use religiously based interventions in counseling (Propst et al., 1992), they must have a thorough awareness of their own beliefs. The reader is referred to the Association for Spiritual, Ethical and Religious Values in Counseling's (n.d.) Spiritual Competencies for further guidelines. A holistically minded, competent counselor is well prepared to address the spiritual aspect of the mind body-spirit triad.

Ethical considerations prescribed by Richards and Bergin (1997) included informed consent, respecting religious diversity, refraining from imposing or condemning values, and referral to religious leaders when client needs exceed counselor competence. For counselors to maintain boundaries, the authors recommended that the counselor assume an ecumenical versus a denominational approach, allowing the client's religious preferences to guide intervention. Counselors should also be cautious when working with clients who are severely psychologically disturbed or cognitively impaired, when in settings where the division of church and state is maintained, when clients do not wish to address such concerns, and when religious material is irrelevant to presenting issues (Richards & Bergin, 1997). Finally, as with any intervention, clients should be continuously monitored to gauge the effectiveness of this approach for reaching clinical goals.

Conclusion

"The efficacy of coping is related to the degree to which a person's beliefs, emotions, relationships and values are integrated in their response to specific stressors" (Pargament, Zinnbauer, et al., 1998, p. 1345). Schemas, including those that are religious in nature, influence perceptions, appraisals, and affect and provide a structure from which to understand self and the world. When religious beliefs are maladaptive, the coping process and, ultimately, health are compromised.

It is essential for counselors to become aware of these beliefs, explore their interaction with common pain-related beliefs, and guide clients toward more positive coping strategies. The impact of religious beliefs on chronic pain is revealed through comprehensive intake interviews that assess current and historical religious experiences and attitudes. Moreover, counselor sensitivity to client expression of the red flags of religious coping and related cognitions offers insight into beliefs that exacerbate the experience of chronic pain.

Religiously oriented CBT is a useful framework for addressing dysfunctional religious schemas and encouraging healthy religious attitudes that promote successful adaptation. Such strategies assist with altering core pain beliefs; moderate the physiological experience of chronic pain, depression, anxiety, and fear; and improve self-esteem, self-efficacy, and the perceived quality of social networks. Sacred texts provide metaphors of client issues. Pain is reframed through religious material. Prayer, meditation, and ritual lead to discovering hope and meaning. Personal control is reinstated and helplessness is alleviated by encouraging a collaborative relationship with God. Finally, a counselor's encouragement for reinstating religious fellowship allows for much-needed social support. With issues as difficult as those related to chronic pain, all resources, including those that are religious, should be called on to moderate the effects of this disabling condition.

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Linda A. Robertson and K. Dayle Jones, both at the Department of Child, Family, and Community Sciences, University of Central Florida; Heather L. Smith, Department of Human Organizational Development, Vanderbilt University; Shannon L. Ray, Center for Psychological Studies, Nova Southeastern University. Correspondence concerning this article should be addressed to Linda A. Robertson, Department of Child, Family, and Community Sciences, University of Central Florida, PO Box 161250, Orlando, FL 32816-1250 (e-mail: wedhed@cfl.rr.com).
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Title Annotation:Practice & Theory
Author:Robertson, Linda A.; Smith, Heather L.; Ray, Shannon L.; Jones, K. Dayle
Publication:Journal of Counseling and Development
Article Type:Report
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Date:Jun 22, 2009
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