Pain Medicine 2015; 16: 51–60 Wiley Periodicals, Inc.
Review Article Spirituality: What is Its Role in Pain Medicine?
Philip J. Siddall, MBBS, MM (Pain Mgt), PhD, FFPMANZCA,*,† Melanie Lovell MBBS, PhD, FRACP, FAChPM,†,‡ and Rod MacLeod, MB, ChB, MMedEd, PhD, DRCOG, FRCGP, FAChPM†,‡
inclusive, accessible, relevant, and applicable to people with a wide range of health conditions. In addition, there is accumulating evidence that interventions that address the issue of spirituality have benefits for physical and emotional health.
Department of *Pain Management; ‡Palliative and Supportive Care, Greenwich Hospital, HammondCare, Sydney, New South Wales; †Sydney Medical School—Northern, University of Sydney, Sydney, New South Wales, Australia
Conclusions. Given the firm place that spirituality now holds within other fields and the mounting evidence for its relevance and benefit for people with pain, there is increasing evidence to support the inclusion of spiritual factors as an important component in the assessment and treatment of pain.
Reprint requests to: Philip Siddall, MBBS, MM (Pain Mgt), PhD, FFPMANZCA, Department of Pain Management, Greenwich Hospital, Greenwich, NSW 2065, Australia. Tel: 161 2 8788 3941; Fax: 161 2 94374829; E-mail: [email protected].
Key Words. Pain; Spirituality; Palliative Care; Pain Medicine
The Biological View of Pain Abstract Background. For many years, spirituality has been regarded as an integral aspect of patient care in fields closely allied to pain medicine such as palliative and supportive care. Despite this, it has received relatively little attention within the field of pain medicine itself. Reasons for this may include a lack of understanding of what spirituality means, doubtfulness of its relevance, an uncertainty about how it may be addressed, or a lack of awareness of how addressing spirituality may be of benefit. Methods. A review of the literature was conducted to determine the changing conceptual frameworks that have been applied to pain medicine, the emergence of the biopsychospiritual approach and what that means as well as evidence for the benefits of incorporation of this approach for the management of pain. Results. Although the concept of spirituality is broad, there is now greater consensus on what is meant by this term. Many authors and consensus panels have explored the concept and formulated a conceptual framework and an approach that is
In the last century, there have been dramatic shifts in our approach to the understanding, assessment, and management of pain. One hundred years ago, our concept of pain was largely based on a fairly unsophisticated view of pain as a sensation that was conveyed by dedicated neural pathways to the brain. This rather simple view of pain was challenged early in the last century by investigators such as Sherrington, who demonstrated that spinal reflexes and the effects of sensory inputs could be modulated by descending pathways from the brain [1,2]. These and subsequent findings [3–5] demonstrated the powerful influence of the brain on neural processing and its ability to modify or regulate afferent sensory input. However, these findings occurred within the context of the prevailing biomedical model. Despite the strengths of this model, it was less equipped to deal with situations and conditions, such as pain, in which the mind played a significant role. Therefore, many scientists and clinicians working in this context struggled to develop an adequate conceptual framework that successfully integrated the roles of the mind and body in pain perception. Much of clinical practice was therefore dominated by a dualistic view of pain as either being physical and therefore “real” or psychological and therefore “in the mind.” 51
Siddall et al. The Integration of Psychology and Biology Several events and trends in the middle half of the 20th century helped to radically change this prevailing view of pain. The rising prominence and influence of psychology as a scientific discipline increased attempts to successfully integrate the mind (psychology) with the body (biology) [6]. This collusion of biology and psychology was never more successfully demonstrated than in the field of pain, when a physiologist (Patrick Wall) and a psychologist (Ronald Melzack) together published an article describing a hypothesis that was to hugely accelerate the integration of mind and body in our approach to pain [7]. This article by Melzack and Wall hypothesized that the spinal cord did not work as an inert relay station that merely acted as passive conductor of pain signals. Rather, there was modulation of incoming pain signals by signals in pathways that conducted other sensations such as touch. Importantly for the integration of psychological processes, it was also proposed that “central” control mechanisms descended from the brain and exerted an effect on this spinal gate. This so called “gate theory” provided a fairly biological and mechanistic model that nevertheless was a large step forward in incorporating the role of the mind in the perception of pain [8]. It provided a biological framework for the powerful influence of psychological factors such as attention, expectation and emotion on pain processing and stimulated the integration of psychological approaches into the management of pain [9]. The Biopsychosocial View of Pain Not long after this, another event served to strengthen further the integration of the role of the mind in pain perception and treatment. Engel’s proposed “biopsychosocial” model [10] came at a time when many in the pain community were looking for a more adequate model of health that successfully integrated the biological, psychological, and environmental domains. It provided a conceptual framework for the increasing recognition of the role of the mind and the influence of behavioral and environmental factors on pain. It was therefore adopted and over time has become the dominant framework for the understanding, assessment, and treatment of persistent pain [11–14]. The rise of the psychological sciences was an integral component in the successful adoption of the biopsychosocial model. It increased the comfort of the medical community in moving forward from a very mechanistic biomedical model to embrace a model that gave more prominence to an intangible concept such as the mind. The clear impact of mood and cognitions on physiological functioning demonstrated the importance of this aspect of the person and the necessity of including it in any satisfactory model of health and disease. Therefore, although its acceptance did not come easily, and it still has not been embraced by all sections of the medical community, the biopsychosocial model has 52
resulted in a dramatic shift in our approach to the assessment and treatment of many conditions. Particularly for the problem of persistent pain, it has provided a model that encourages and successfully integrates the consideration and treatment of the variety of biological, psychological, and environmental factors that may be contributing to such a complex condition [15]. The Biopsychospiritual Approach The biopsychosocial model has been helpful and has become the dominant paradigm for assessment and treatment in most sections of the pain community. However, in the broader medical community, there are many that have advocated a model that includes the spiritual as another important component [16–19]. In particular, many in the palliative care community, possibly in response to the particular needs of people who are dying and receiving end-of-life care, have been active and longtime proponents of a biopsychosocial–spiritual or biopsychospiritual model that seeks to integrate a spiritual component within the biopsychosocial model [20–25]. Led by the concept of “total pain” as espoused by Cicely Saunders, palliative care specialists have for many years included the spiritual as part of the treatment of people with cancer and other terminal illnesses. This has led to the exploration, trial, and use of treatments that specifically seek to address spiritual issues [26–28]. It has been demonstrated that those with higher levels of spiritual well-being are more optimistic and have higher levels of self-esteem and higher levels of function [29]. This research in the palliative care field now overwhelmingly supports the importance of addressing spiritual issues in people facing a terminal illness. What Does Spirituality Mean? In considering the issue of spirituality, it is important to discuss what is meant by this term. There are many views. The term has its historical roots within a religious context [30]. For many people, this link with religion is maintained, and many use terms such as spirituality and religion almost interchangeably or argue that spirituality occurs within a religious and even Christian context that is linked to a relationship with God [31,32]. In more recent times, this view of spirituality as the domain of one or even any religion has been increasingly challenged. Many people now take the view that religion and spirituality are related but separate concepts [17,19,22,24,30,33–35]. This view holds that a person’s spirituality can be expressed in many contexts outside a formal or even informal religion, acknowledging that spirituality means different things to different people. A review of publications dealing with spirituality and end-of-life care has identified several dominant themes within the literature, including transcendence in relation
Pain Medicine and Spirituality to both self and a higher being, a sense of communion or connection, faith or beliefs, and hope [36]. Transcendence is defined variously, but the central issue is of “going beyond” our physical selves [37]. Although it may be expressed within the context of a relationship with God or the sacred, it may also be about nature, art, music, family, or community [38]. In this broader view of spirituality, it is most commonly conceptualized in terms of those aspects of life that lie at the core of a person’s identity and direction, such as the beliefs, values, activities, and relationships that provide meaning and purpose for life [24,33–35,39].
nection with something or someone outside these relationships that is transcendent or even sacred.
These issues of meaning and purpose have long been regarded as central to the concept of spirituality. Early proponents of the importance of existential or spiritual issues in suffering and resilience such as Viktor Frankl suggested that meaning and purpose lie at the heart of spirituality [30,40]. More recently, meaning and purpose has become the most dominant theme that emerges in publications that explore this topic [18,23,30,41–46].
Van Hooft proposes that there are forms of suffering that relate to the contemplative or integrative aspects of our being that are constituted by a frustration of the tendency of people to seek integration and meaningfulness in their lives. He proposed that people who cannot integrate their pain into their existence will suffer “psychological distress” or a disintegration of the self or of their lives [50]. Mako and colleagues propose that the identification of self (only) with the physical body can often initiate a sense of crisis or spiritual pain in the face of “an embodied experience of loss and deterioration” [51].
What emerges from this literature is that while it is very difficult to reach consensus, spirituality can be broadly defined as an experience that incorporates a relationship with the transcendent or sacred that provides a strong sense of identity or direction that not only has a strong influence on a person’s beliefs, attitudes, emotions, and behavior but is integral to a sense of meaning and purpose in life. From this framework arises the concept of spiritual wellbeing. In this state, a person has a sense of peace, comfort, and strength that arises from a sense of meaning and purpose that is often linked to a connection to the transcendent but also arises from these other activities and relationships [47]. Therefore, in the sense that we all have relationships and activities that provide us with varying levels of a sense of meaning and purpose in life, a level of spiritual well-being is common to all.
Although the concepts of spirituality and psychology may be distinguished, they are heavily interdependent. Our psychological state is a major contributor to spiritual well-being, and conversely, spiritual well-being is strongly related to mood [49]. However, spiritual distress is more than severe depression or extreme suffering. It is usually reserved for those situations in which a person’s suffering is of such a nature that it threatens a sense of meaning and purpose to their existence [48].
Although the relief of suffering has always been a goal of physicians, Eric Cassell brought suffering to the fore in medicine with his landmark article (1982) and subsequent book (1991). He writes eloquently about the disintegration of the self and injuries to the integrity of the person that can be manifest as sadness, anger, grief, and withdrawal. However, he points out that these are merely outward expressions of injury, pain, and disintegration, and if the injury is sufficient, then the person suffers. Cassell suggests that by attending to the meaning of such suffering and perhaps assisting patients to transcend it, the suffering (associated with the destruction of those aspects of personhood) may be ameliorated. To quote Cassell: “Transcendence is probably the most powerful way in which one is restored to wholeness after an injury to personhood” (p. 644) [52].
How is Spirituality Distinct from Psychology? Spirituality and Pain The conceptualization of spirituality is not clear-cut, and it can be seen that there is an overlap with psychosocial issues such as mood dysfunction and social isolation. Therefore, it may be difficult to separate them because cognitions and emotions are irretrievably connected with the spiritual experience [48]. There are several distinguishing features between psychology and spirituality. Spirituality is firstly about issues that lie at the core of a person’s identity and motivation for life. For example, a sense of meaning and purpose are fundamental issues that have a major bearing on the attitudes, emotions, and behavior that form a person’s identity. The second distinguishing feature is the relationship with the transcendent. Psychological aspects are very much influenced by social relationships. However, inherent within the concept of spirituality is a relationship that may be shared by our social network but involves a con-
Despite the growing interest in spirituality generally and its wide adoption by some sections of the health profession such as palliative care, it has received relatively little attention in the field of pain management. For example, a search of “pain” and “spirituality” shows a steadily increasing annual publication rate, but with a relatively small peak of just over 50 publications in 2011 and reaching 1,000 citations in 2013. This represents a tiny fraction (approximately 0.1%) of the published pain literature (Figure 1). Despite this relative lack of attention, there have been a number of authors in the pain field who have advocated for consideration of the role of spirituality within pain medicine and the adoption of a biopsychospiritual approach. In some places, this approach has been actively practiced and studied for some time [53–58]. Therefore, this is not a new call. However, the relatively low number of 53
Siddall et al.
Figure 1 (A) Annual indexed publications following a search of “pain” and “spirituality” from 1994 to 2013. (B) Annual indexed citations following a search of “pain” and “spirituality” from 1994 to 2013. Source: Thomson Reuters Web of Science.
publications makes it clear that spirituality receives comparatively little attention within the field of pain medicine.
ing, increased self-efficacy, spiritual and social support, distraction, relaxation, and positive reappraisal [57,64].
The evidence that we do have about pain and spirituality suggests that spirituality is just as important, if not more important and relevant, than in other fields. Much of the existing evidence we have about the relationship between pain and spiritual well-being is mainly derived from those with cancer-related pain. There is some preliminary evidence from this work that various aspects of the experience of pain within the cancer context are linked to spiritual well-being [59].
Several other studies have found that those who consider themselves spiritual and religious or engage in religious activities score better in terms of mood, wellbeing, and pain intensity than those who did not regard themselves as spiritual or religious [63,65,66]. Although some of these studies suggest an association between spiritual and religious activity and lower levels of pain intensity, the overall evidence suggests that spiritual well-being has a stronger link with higher pain tolerance and higher levels of psychological well-being, including satisfaction with life [67,68].
Some may assume that spirituality is more relevant and therefore has received greater attention in end-of-life care because of specific issues related to death and dying. However, one study demonstrated that people in a rehabilitation setting had levels of spiritual distress that significantly exceeded groups of people with cancer [60]. Furthermore, in contrast to the people with cancer, spiritual distress was a significant contributor to satisfaction with life in the rehabilitation group and more important than the physical disability associated with their injury [60]. Why Incorporate Spirituality into the Treatment of Pain? Spirituality, and particularly religiosity, has often been regarded as a negative coping style within traditional psychology because of its perception as a passive coping strategy [61]. However, more recent evidence suggests that the use of spirituality and religiosity can be regarded as an active and positive coping process with beneficial effects [54]. For example, those who deal with persistent pain using positive spiritual coping practices such as looking to God for strength and support adjust better to pain and have significantly better mental health [62,63]. Religious and spiritual coping strategies are associated with feelings of spiritual support and connection as well as reduced depression and anxiety and a greater sense of peace and calm. This may be due to a number of factors, including the ability to ascribe meaning to the suffer54
As well as growing evidence for the influence of a person’s spiritual experience, there is also evidence to indicate that spiritual practices and resources are beneficial for people with pain. The use of spiritual practices has more often been related to improved tolerance of both acute [69] and chronic [70,71] pain than to reduced intensity of pain. However, a review of studies using mindfulness-based interventions that often include a meditation component found that most studies also report a reduction in pain intensity [72]. In one study investigating the effectiveness of meditation, the positive effect of meditation was dependent on it having a spiritual focus. Participants were divided into groups that used relaxation and either a secular or a “spiritual” meditation that included the use of phrases with spiritual (but not necessarily religious) content. The group that used the meditation with spiritual content demonstrated a significantly greater improvement in mood and spiritual well-being, and pain tolerance was increased to nearly double that of the other two groups [69]. Despite these studies suggesting the benefits of spirituality for people experiencing pain, the nature of this relationship needs to be qualified. Spirituality alone is not necessarily a positive factor, and people may use both negative and positive spiritual coping strategies. It has been demonstrated that those who are experiencing pain and see God as forgiving and kind have lower pain
Pain Medicine and Spirituality intensity and are higher-functioning as compared with those who see God as harsh or abandoning [62,63,73]. In summary, there is now a growing body of evidence to support the benefit of a person’s spiritual experience and practice for the experience of pain. Although there is less evidence to support a link between spirituality and lower levels of pain, there is evidence from a number of studies to indicate that positive spiritual coping strategies are associated with a higher tolerance of pain as well as better mood and satisfaction with life in the presence of pain. Meaning and Pain Apart from the few studies that have examined the relationship between religion and pain, there are few studies that have considered or examined broader aspects of spirituality such as meaning and purpose. One study identified the importance of meaning in the experience of pain and suggested that developing a meaning that incorporated the presence of pain was an important component of better adjustment [45]. However, there was no attempt to specifically assess the impact of dealing with meaning and purpose on pain intensity, mood, or other functional outcomes. Two other groups working in the field of chronic pain have addressed meaning, although from a slightly different perspective [74,75]. McCracken and colleagues implicitly address some of the issues discussed by examining the ability of people to reevaluate their life and move toward different goals in the presence of pain. They found that the ability to accept the presence of pain and to reorient their lives despite the presence of pain was associated with improved functioning [74,76]. De Vlieger and colleagues expanded somewhat on this concept and developed an instrument (the Pain Solutions Questionnaire) incorporating a five-item scale examining “meaningfulness of life despite pain.” Higher scores on this scale, reflecting a stronger sense of meaningfulness, had a strong negative relationship to physical disability and affective distress as well as attention to pain and catastrophic thinking [75]. This suggests that the ability to find meaning in life despite the presence of pain is associated with better adjustment, less distress, and less physical disability [77]. Therefore, exploring meaning through reevaluating priorities and what is important in life as well as finding new avenues that bring meaning and purpose is highly relevant to assisting people living with pain. The positive impact of being able to do this successfully is demonstrated by the finding that those who report higher levels of meaning demonstrate a significantly increased ability to enjoy life in the presence of pain [77]. What Does a Biopsychospiritual Approach Look Like? Although we may be prepared to consider spirituality as relevant to the person and can find evidence to support
Figure 2 Diagram of the biological, psychological, social, spiritual, and environmental contributors to pain included in the biopsychospiritual approach. better health and pain-related outcomes, there is still a question of what constitutes a biopsychospiritual approach. As discussed above, many people assume it means incorporating a religious aspect to treatment. Others, who take a more inclusive view, often assume that it means incorporating a complementary and alternative approach to treatment. However, as we have discussed, both of these assumptions provide a limited and narrow perspective of the biopsychospiritual approach. Coming back to our definition, the biopsychospiritual approach includes exploring and addressing the standard biological, psychological, social, and environmental factors that form part of the standard biopsychosocial approach to pain. In addition, it includes exploration of spiritual factors such as identity, meaning, and purpose (Figure 2). Doing this effectively has implications for both assessment and treatment, as we shall explore below. Incorporating the Spiritual: Assessment In recent years, spirituality and health has emerged in medical education as a significant area, taught with the goal of enabling students and doctors to have a greater understanding of core competencies, including assessment, that might be needed in the area of spirituality [78,79]. In the United States, for example, The Joint Commission on Accreditation of Healthcare Organizations [80] recognized the importance of spirituality to patients and now requires that patients’ spiritual issues be addressed. A published report from a Palliative Care Consensus Conference attended by many highly regarded clinicians in the field of palliative care also recommended that a spiritual history be taken as an integral part of assessment [78]. The report identified a number of issues that were important to explore, such as identification and exploration of spiritual and religious beliefs, practices, 55
Siddall et al. and values; spiritual goals; and assessment of spiritual distress (meaninglessness, hopelessness) as well as sources of spiritual strength (hope, meaning, and purpose) [78]. A number of assessment tools are available to assess this dimension [33,38,47,81]. These tools address a range of similar themes, including beliefs and practices, relationships with others including a higher power, and meaning and purpose, as well as qualities such as peace, hope, and sense of control. As mentioned previously, the Pain Solutions Questionnaire provides an instrument that assesses “meaningfulness of life despite pain” [75]. The Functional Assessment of Chronic Illness Therapy—Spiritual Well-Being Scale is another questionnaire that has been developed and validated as an instrument for assessing spiritual well-being [47]. A tool for assessing spiritual history within a clinical context has been put forward by Puchalski and Romer [38] using an acronym (FICA) that identifies four components of the spiritual history. These are the following: 1) faith or beliefs, which includes questions around personal meaning, faith, and beliefs; 2) importance and influence, which explores how important faith and beliefs are in terms of living with the illness or problem; 3) community, which seeks to understand the importance of relationships and particularly whether they are in the context of a spiritual or religious community; and 4) address, which asks how the person would like to have these issues addressed as part of their care. At present, there is no consensus regarding which questionnaire should be used or which questions to ask. However, what these tools and questionnaires have in common is that spiritual assessment is about identifying and exploring a person’s spiritual (including religious) beliefs, relationships, or practices as well as more general issues of meaning and purpose. For those with pain, it is also important to assess how these issues may have been impacted by pain. Incorporating the Spiritual: Treatment Incorporating the spiritual within treatment is often equated with using “spiritual” treatments as part of the management approach. However, identifying spiritual treatments is fraught with difficulty. For example, a sample MEDLINE search of “spiritual” and “treatment” will return articles about African traditional healers, transcendental meditation, yoga, mindfulness meditation, music therapy, hypnosis, prayer, and Bolivian susto treatment. We have defined spirituality as an experience that incorporates a connection with the transcendent that has a strong influence on attitudes, emotions, and behavior, including a sense of identity, meaning, and purpose. This suggests that “spiritual treatment” is in fact a highly individual concept that is dependent on a person’s beliefs, culture, and values. Therefore, we will take the view that the spirituality of a treatment is dependent on 56
the response that it produces in a person rather than an inherent quality of its own. If this is the case, what treatments are spiritual and how do we incorporate them in our approach to treatment? If we assess a treatment by its impact rather than its alleged qualities, then there are a variety of treatments, some of them very simple, that may be included in a spiritual approach to treatment. For example, for some people, taking a walk in a forest is something that has a powerful influence at a deep level through a sense of connection with the transcendent. For others, music or meditation may do the same. As mentioned before, if meaning and purpose are central to spirituality, then targeted treatments that address these issues may also be part of incorporating a spiritual approach. For example, contemplation and reflection on life provide the opportunity for exploration of issues such as meaning, purpose, values, and priorities. For a person in pain, this means evaluating how pain has affected identity and purpose. If these have been damaged or lost, it also means examining a way forward that brings a renewed sense of meaning and purpose in the presence of pain. Although it is recognized that this is not easy, it has been shown that the reevaluation of life priorities and goals forced on people by a spinal cord injury or a diagnosis of cancer can be a positive experience that enables greater acceptance and ability to cope [82]. Clinicians and researchers who have explored this concept make several recommendations as to how this might be put into practice. Most of them focus on or include a process of life review or self-examination [22,23,43]. Many palliative care services have developed life review programs following the seminal article by Butler [83]. Included within this process is the examination of several issues, such as the following: 1) the things, activities or relationships in a person’s life that are important and bring meaning; 2) whether life to this point has contained an explicit purpose; 3) the impact of the illness on a person’s life and in particular those things that bring meaning and purpose; and 4) whether the illness resulted in a reevaluation or reassessment of the things that are important or of purpose or priorities [84]. Other interventions that have been suggested as approaches that help to alleviate spiritual distress include providing a supportive presence; exploring issues of guilt, remorse, forgiveness, and reconciliation; facilitating religious expression; reframing goals into short-term endeavors that can be accomplished; and encouraging the use of practices such as meditation, guided imagery, music, reading, poetry, and art [22]. A Biopsychospiritual Approach to Pain Therefore, a biopsychospiritual approach to pain incorporates each of these factors. It means an assessment approach that incorporates assessment of both the impact of persons’ pain on their spirit and their
Pain Medicine and Spirituality experience of spirituality. It means determining those relationships and activities in persons’ lives that bring them a sense of meaning and purpose and how they contribute in a positive or negative sense to their experience of pain. It also includes assessment of the impact of the pain on those aspects of a person’s life.
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On the therapeutic side, the ability to place and make sense of adversity and to give it a meaningful place within the overall context, direction, or purpose of life can make it easier to endure, particularly if it is seen to be beneficial. Reframing life goals and purpose also allows the formulation of a different direction that still provides a sense of meaningful purpose.
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Thus, there appears to be growing evidence that addressing issues of spirituality in the person with persistent pain is an important, if not crucial, aspect of managing the pain. Although it is a recognized and recommended component of palliative care, addressing spiritual factors is just as important, if not more important, in people with persistent pain who suffer from both pain and long-term reductions in physical capacity that can have a severe impact on activities and relationships that provide meaning, purpose, and identity. Assessment and management of spiritual factors impacting on persistent pain should be included as routine core elements in the integrated care of the whole person. Future research should more clearly delineate which aspects of spirituality are important to people and test interventions that may be beneficial by addressing these important issues.
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Acknowledgement
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Review Article Spirituality: What is Its Role in Pain Medicine?
Philip J. Siddall, MBBS, MM (Pain Mgt), PhD, FFPMANZCA,*,† Melanie Lovell MBBS, PhD, FRACP, FAChPM,†,‡ and Rod MacLeod, MB, ChB, MMedEd, PhD, DRCOG, FRCGP, FAChPM†,‡
inclusive, accessible, relevant, and applicable to people with a wide range of health conditions. In addition, there is accumulating evidence that interventions that address the issue of spirituality have benefits for physical and emotional health.
Department of *Pain Management; ‡Palliative and Supportive Care, Greenwich Hospital, HammondCare, Sydney, New South Wales; †Sydney Medical School—Northern, University of Sydney, Sydney, New South Wales, Australia
Conclusions. Given the firm place that spirituality now holds within other fields and the mounting evidence for its relevance and benefit for people with pain, there is increasing evidence to support the inclusion of spiritual factors as an important component in the assessment and treatment of pain.
Reprint requests to: Philip Siddall, MBBS, MM (Pain Mgt), PhD, FFPMANZCA, Department of Pain Management, Greenwich Hospital, Greenwich, NSW 2065, Australia. Tel: 161 2 8788 3941; Fax: 161 2 94374829; E-mail: [email protected].
Key Words. Pain; Spirituality; Palliative Care; Pain Medicine
The Biological View of Pain Abstract Background. For many years, spirituality has been regarded as an integral aspect of patient care in fields closely allied to pain medicine such as palliative and supportive care. Despite this, it has received relatively little attention within the field of pain medicine itself. Reasons for this may include a lack of understanding of what spirituality means, doubtfulness of its relevance, an uncertainty about how it may be addressed, or a lack of awareness of how addressing spirituality may be of benefit. Methods. A review of the literature was conducted to determine the changing conceptual frameworks that have been applied to pain medicine, the emergence of the biopsychospiritual approach and what that means as well as evidence for the benefits of incorporation of this approach for the management of pain. Results. Although the concept of spirituality is broad, there is now greater consensus on what is meant by this term. Many authors and consensus panels have explored the concept and formulated a conceptual framework and an approach that is
In the last century, there have been dramatic shifts in our approach to the understanding, assessment, and management of pain. One hundred years ago, our concept of pain was largely based on a fairly unsophisticated view of pain as a sensation that was conveyed by dedicated neural pathways to the brain. This rather simple view of pain was challenged early in the last century by investigators such as Sherrington, who demonstrated that spinal reflexes and the effects of sensory inputs could be modulated by descending pathways from the brain [1,2]. These and subsequent findings [3–5] demonstrated the powerful influence of the brain on neural processing and its ability to modify or regulate afferent sensory input. However, these findings occurred within the context of the prevailing biomedical model. Despite the strengths of this model, it was less equipped to deal with situations and conditions, such as pain, in which the mind played a significant role. Therefore, many scientists and clinicians working in this context struggled to develop an adequate conceptual framework that successfully integrated the roles of the mind and body in pain perception. Much of clinical practice was therefore dominated by a dualistic view of pain as either being physical and therefore “real” or psychological and therefore “in the mind.” 51
Siddall et al. The Integration of Psychology and Biology Several events and trends in the middle half of the 20th century helped to radically change this prevailing view of pain. The rising prominence and influence of psychology as a scientific discipline increased attempts to successfully integrate the mind (psychology) with the body (biology) [6]. This collusion of biology and psychology was never more successfully demonstrated than in the field of pain, when a physiologist (Patrick Wall) and a psychologist (Ronald Melzack) together published an article describing a hypothesis that was to hugely accelerate the integration of mind and body in our approach to pain [7]. This article by Melzack and Wall hypothesized that the spinal cord did not work as an inert relay station that merely acted as passive conductor of pain signals. Rather, there was modulation of incoming pain signals by signals in pathways that conducted other sensations such as touch. Importantly for the integration of psychological processes, it was also proposed that “central” control mechanisms descended from the brain and exerted an effect on this spinal gate. This so called “gate theory” provided a fairly biological and mechanistic model that nevertheless was a large step forward in incorporating the role of the mind in the perception of pain [8]. It provided a biological framework for the powerful influence of psychological factors such as attention, expectation and emotion on pain processing and stimulated the integration of psychological approaches into the management of pain [9]. The Biopsychosocial View of Pain Not long after this, another event served to strengthen further the integration of the role of the mind in pain perception and treatment. Engel’s proposed “biopsychosocial” model [10] came at a time when many in the pain community were looking for a more adequate model of health that successfully integrated the biological, psychological, and environmental domains. It provided a conceptual framework for the increasing recognition of the role of the mind and the influence of behavioral and environmental factors on pain. It was therefore adopted and over time has become the dominant framework for the understanding, assessment, and treatment of persistent pain [11–14]. The rise of the psychological sciences was an integral component in the successful adoption of the biopsychosocial model. It increased the comfort of the medical community in moving forward from a very mechanistic biomedical model to embrace a model that gave more prominence to an intangible concept such as the mind. The clear impact of mood and cognitions on physiological functioning demonstrated the importance of this aspect of the person and the necessity of including it in any satisfactory model of health and disease. Therefore, although its acceptance did not come easily, and it still has not been embraced by all sections of the medical community, the biopsychosocial model has 52
resulted in a dramatic shift in our approach to the assessment and treatment of many conditions. Particularly for the problem of persistent pain, it has provided a model that encourages and successfully integrates the consideration and treatment of the variety of biological, psychological, and environmental factors that may be contributing to such a complex condition [15]. The Biopsychospiritual Approach The biopsychosocial model has been helpful and has become the dominant paradigm for assessment and treatment in most sections of the pain community. However, in the broader medical community, there are many that have advocated a model that includes the spiritual as another important component [16–19]. In particular, many in the palliative care community, possibly in response to the particular needs of people who are dying and receiving end-of-life care, have been active and longtime proponents of a biopsychosocial–spiritual or biopsychospiritual model that seeks to integrate a spiritual component within the biopsychosocial model [20–25]. Led by the concept of “total pain” as espoused by Cicely Saunders, palliative care specialists have for many years included the spiritual as part of the treatment of people with cancer and other terminal illnesses. This has led to the exploration, trial, and use of treatments that specifically seek to address spiritual issues [26–28]. It has been demonstrated that those with higher levels of spiritual well-being are more optimistic and have higher levels of self-esteem and higher levels of function [29]. This research in the palliative care field now overwhelmingly supports the importance of addressing spiritual issues in people facing a terminal illness. What Does Spirituality Mean? In considering the issue of spirituality, it is important to discuss what is meant by this term. There are many views. The term has its historical roots within a religious context [30]. For many people, this link with religion is maintained, and many use terms such as spirituality and religion almost interchangeably or argue that spirituality occurs within a religious and even Christian context that is linked to a relationship with God [31,32]. In more recent times, this view of spirituality as the domain of one or even any religion has been increasingly challenged. Many people now take the view that religion and spirituality are related but separate concepts [17,19,22,24,30,33–35]. This view holds that a person’s spirituality can be expressed in many contexts outside a formal or even informal religion, acknowledging that spirituality means different things to different people. A review of publications dealing with spirituality and end-of-life care has identified several dominant themes within the literature, including transcendence in relation
Pain Medicine and Spirituality to both self and a higher being, a sense of communion or connection, faith or beliefs, and hope [36]. Transcendence is defined variously, but the central issue is of “going beyond” our physical selves [37]. Although it may be expressed within the context of a relationship with God or the sacred, it may also be about nature, art, music, family, or community [38]. In this broader view of spirituality, it is most commonly conceptualized in terms of those aspects of life that lie at the core of a person’s identity and direction, such as the beliefs, values, activities, and relationships that provide meaning and purpose for life [24,33–35,39].
nection with something or someone outside these relationships that is transcendent or even sacred.
These issues of meaning and purpose have long been regarded as central to the concept of spirituality. Early proponents of the importance of existential or spiritual issues in suffering and resilience such as Viktor Frankl suggested that meaning and purpose lie at the heart of spirituality [30,40]. More recently, meaning and purpose has become the most dominant theme that emerges in publications that explore this topic [18,23,30,41–46].
Van Hooft proposes that there are forms of suffering that relate to the contemplative or integrative aspects of our being that are constituted by a frustration of the tendency of people to seek integration and meaningfulness in their lives. He proposed that people who cannot integrate their pain into their existence will suffer “psychological distress” or a disintegration of the self or of their lives [50]. Mako and colleagues propose that the identification of self (only) with the physical body can often initiate a sense of crisis or spiritual pain in the face of “an embodied experience of loss and deterioration” [51].
What emerges from this literature is that while it is very difficult to reach consensus, spirituality can be broadly defined as an experience that incorporates a relationship with the transcendent or sacred that provides a strong sense of identity or direction that not only has a strong influence on a person’s beliefs, attitudes, emotions, and behavior but is integral to a sense of meaning and purpose in life. From this framework arises the concept of spiritual wellbeing. In this state, a person has a sense of peace, comfort, and strength that arises from a sense of meaning and purpose that is often linked to a connection to the transcendent but also arises from these other activities and relationships [47]. Therefore, in the sense that we all have relationships and activities that provide us with varying levels of a sense of meaning and purpose in life, a level of spiritual well-being is common to all.
Although the concepts of spirituality and psychology may be distinguished, they are heavily interdependent. Our psychological state is a major contributor to spiritual well-being, and conversely, spiritual well-being is strongly related to mood [49]. However, spiritual distress is more than severe depression or extreme suffering. It is usually reserved for those situations in which a person’s suffering is of such a nature that it threatens a sense of meaning and purpose to their existence [48].
Although the relief of suffering has always been a goal of physicians, Eric Cassell brought suffering to the fore in medicine with his landmark article (1982) and subsequent book (1991). He writes eloquently about the disintegration of the self and injuries to the integrity of the person that can be manifest as sadness, anger, grief, and withdrawal. However, he points out that these are merely outward expressions of injury, pain, and disintegration, and if the injury is sufficient, then the person suffers. Cassell suggests that by attending to the meaning of such suffering and perhaps assisting patients to transcend it, the suffering (associated with the destruction of those aspects of personhood) may be ameliorated. To quote Cassell: “Transcendence is probably the most powerful way in which one is restored to wholeness after an injury to personhood” (p. 644) [52].
How is Spirituality Distinct from Psychology? Spirituality and Pain The conceptualization of spirituality is not clear-cut, and it can be seen that there is an overlap with psychosocial issues such as mood dysfunction and social isolation. Therefore, it may be difficult to separate them because cognitions and emotions are irretrievably connected with the spiritual experience [48]. There are several distinguishing features between psychology and spirituality. Spirituality is firstly about issues that lie at the core of a person’s identity and motivation for life. For example, a sense of meaning and purpose are fundamental issues that have a major bearing on the attitudes, emotions, and behavior that form a person’s identity. The second distinguishing feature is the relationship with the transcendent. Psychological aspects are very much influenced by social relationships. However, inherent within the concept of spirituality is a relationship that may be shared by our social network but involves a con-
Despite the growing interest in spirituality generally and its wide adoption by some sections of the health profession such as palliative care, it has received relatively little attention in the field of pain management. For example, a search of “pain” and “spirituality” shows a steadily increasing annual publication rate, but with a relatively small peak of just over 50 publications in 2011 and reaching 1,000 citations in 2013. This represents a tiny fraction (approximately 0.1%) of the published pain literature (Figure 1). Despite this relative lack of attention, there have been a number of authors in the pain field who have advocated for consideration of the role of spirituality within pain medicine and the adoption of a biopsychospiritual approach. In some places, this approach has been actively practiced and studied for some time [53–58]. Therefore, this is not a new call. However, the relatively low number of 53
Siddall et al.
Figure 1 (A) Annual indexed publications following a search of “pain” and “spirituality” from 1994 to 2013. (B) Annual indexed citations following a search of “pain” and “spirituality” from 1994 to 2013. Source: Thomson Reuters Web of Science.
publications makes it clear that spirituality receives comparatively little attention within the field of pain medicine.
ing, increased self-efficacy, spiritual and social support, distraction, relaxation, and positive reappraisal [57,64].
The evidence that we do have about pain and spirituality suggests that spirituality is just as important, if not more important and relevant, than in other fields. Much of the existing evidence we have about the relationship between pain and spiritual well-being is mainly derived from those with cancer-related pain. There is some preliminary evidence from this work that various aspects of the experience of pain within the cancer context are linked to spiritual well-being [59].
Several other studies have found that those who consider themselves spiritual and religious or engage in religious activities score better in terms of mood, wellbeing, and pain intensity than those who did not regard themselves as spiritual or religious [63,65,66]. Although some of these studies suggest an association between spiritual and religious activity and lower levels of pain intensity, the overall evidence suggests that spiritual well-being has a stronger link with higher pain tolerance and higher levels of psychological well-being, including satisfaction with life [67,68].
Some may assume that spirituality is more relevant and therefore has received greater attention in end-of-life care because of specific issues related to death and dying. However, one study demonstrated that people in a rehabilitation setting had levels of spiritual distress that significantly exceeded groups of people with cancer [60]. Furthermore, in contrast to the people with cancer, spiritual distress was a significant contributor to satisfaction with life in the rehabilitation group and more important than the physical disability associated with their injury [60]. Why Incorporate Spirituality into the Treatment of Pain? Spirituality, and particularly religiosity, has often been regarded as a negative coping style within traditional psychology because of its perception as a passive coping strategy [61]. However, more recent evidence suggests that the use of spirituality and religiosity can be regarded as an active and positive coping process with beneficial effects [54]. For example, those who deal with persistent pain using positive spiritual coping practices such as looking to God for strength and support adjust better to pain and have significantly better mental health [62,63]. Religious and spiritual coping strategies are associated with feelings of spiritual support and connection as well as reduced depression and anxiety and a greater sense of peace and calm. This may be due to a number of factors, including the ability to ascribe meaning to the suffer54
As well as growing evidence for the influence of a person’s spiritual experience, there is also evidence to indicate that spiritual practices and resources are beneficial for people with pain. The use of spiritual practices has more often been related to improved tolerance of both acute [69] and chronic [70,71] pain than to reduced intensity of pain. However, a review of studies using mindfulness-based interventions that often include a meditation component found that most studies also report a reduction in pain intensity [72]. In one study investigating the effectiveness of meditation, the positive effect of meditation was dependent on it having a spiritual focus. Participants were divided into groups that used relaxation and either a secular or a “spiritual” meditation that included the use of phrases with spiritual (but not necessarily religious) content. The group that used the meditation with spiritual content demonstrated a significantly greater improvement in mood and spiritual well-being, and pain tolerance was increased to nearly double that of the other two groups [69]. Despite these studies suggesting the benefits of spirituality for people experiencing pain, the nature of this relationship needs to be qualified. Spirituality alone is not necessarily a positive factor, and people may use both negative and positive spiritual coping strategies. It has been demonstrated that those who are experiencing pain and see God as forgiving and kind have lower pain
Pain Medicine and Spirituality intensity and are higher-functioning as compared with those who see God as harsh or abandoning [62,63,73]. In summary, there is now a growing body of evidence to support the benefit of a person’s spiritual experience and practice for the experience of pain. Although there is less evidence to support a link between spirituality and lower levels of pain, there is evidence from a number of studies to indicate that positive spiritual coping strategies are associated with a higher tolerance of pain as well as better mood and satisfaction with life in the presence of pain. Meaning and Pain Apart from the few studies that have examined the relationship between religion and pain, there are few studies that have considered or examined broader aspects of spirituality such as meaning and purpose. One study identified the importance of meaning in the experience of pain and suggested that developing a meaning that incorporated the presence of pain was an important component of better adjustment [45]. However, there was no attempt to specifically assess the impact of dealing with meaning and purpose on pain intensity, mood, or other functional outcomes. Two other groups working in the field of chronic pain have addressed meaning, although from a slightly different perspective [74,75]. McCracken and colleagues implicitly address some of the issues discussed by examining the ability of people to reevaluate their life and move toward different goals in the presence of pain. They found that the ability to accept the presence of pain and to reorient their lives despite the presence of pain was associated with improved functioning [74,76]. De Vlieger and colleagues expanded somewhat on this concept and developed an instrument (the Pain Solutions Questionnaire) incorporating a five-item scale examining “meaningfulness of life despite pain.” Higher scores on this scale, reflecting a stronger sense of meaningfulness, had a strong negative relationship to physical disability and affective distress as well as attention to pain and catastrophic thinking [75]. This suggests that the ability to find meaning in life despite the presence of pain is associated with better adjustment, less distress, and less physical disability [77]. Therefore, exploring meaning through reevaluating priorities and what is important in life as well as finding new avenues that bring meaning and purpose is highly relevant to assisting people living with pain. The positive impact of being able to do this successfully is demonstrated by the finding that those who report higher levels of meaning demonstrate a significantly increased ability to enjoy life in the presence of pain [77]. What Does a Biopsychospiritual Approach Look Like? Although we may be prepared to consider spirituality as relevant to the person and can find evidence to support
Figure 2 Diagram of the biological, psychological, social, spiritual, and environmental contributors to pain included in the biopsychospiritual approach. better health and pain-related outcomes, there is still a question of what constitutes a biopsychospiritual approach. As discussed above, many people assume it means incorporating a religious aspect to treatment. Others, who take a more inclusive view, often assume that it means incorporating a complementary and alternative approach to treatment. However, as we have discussed, both of these assumptions provide a limited and narrow perspective of the biopsychospiritual approach. Coming back to our definition, the biopsychospiritual approach includes exploring and addressing the standard biological, psychological, social, and environmental factors that form part of the standard biopsychosocial approach to pain. In addition, it includes exploration of spiritual factors such as identity, meaning, and purpose (Figure 2). Doing this effectively has implications for both assessment and treatment, as we shall explore below. Incorporating the Spiritual: Assessment In recent years, spirituality and health has emerged in medical education as a significant area, taught with the goal of enabling students and doctors to have a greater understanding of core competencies, including assessment, that might be needed in the area of spirituality [78,79]. In the United States, for example, The Joint Commission on Accreditation of Healthcare Organizations [80] recognized the importance of spirituality to patients and now requires that patients’ spiritual issues be addressed. A published report from a Palliative Care Consensus Conference attended by many highly regarded clinicians in the field of palliative care also recommended that a spiritual history be taken as an integral part of assessment [78]. The report identified a number of issues that were important to explore, such as identification and exploration of spiritual and religious beliefs, practices, 55
Siddall et al. and values; spiritual goals; and assessment of spiritual distress (meaninglessness, hopelessness) as well as sources of spiritual strength (hope, meaning, and purpose) [78]. A number of assessment tools are available to assess this dimension [33,38,47,81]. These tools address a range of similar themes, including beliefs and practices, relationships with others including a higher power, and meaning and purpose, as well as qualities such as peace, hope, and sense of control. As mentioned previously, the Pain Solutions Questionnaire provides an instrument that assesses “meaningfulness of life despite pain” [75]. The Functional Assessment of Chronic Illness Therapy—Spiritual Well-Being Scale is another questionnaire that has been developed and validated as an instrument for assessing spiritual well-being [47]. A tool for assessing spiritual history within a clinical context has been put forward by Puchalski and Romer [38] using an acronym (FICA) that identifies four components of the spiritual history. These are the following: 1) faith or beliefs, which includes questions around personal meaning, faith, and beliefs; 2) importance and influence, which explores how important faith and beliefs are in terms of living with the illness or problem; 3) community, which seeks to understand the importance of relationships and particularly whether they are in the context of a spiritual or religious community; and 4) address, which asks how the person would like to have these issues addressed as part of their care. At present, there is no consensus regarding which questionnaire should be used or which questions to ask. However, what these tools and questionnaires have in common is that spiritual assessment is about identifying and exploring a person’s spiritual (including religious) beliefs, relationships, or practices as well as more general issues of meaning and purpose. For those with pain, it is also important to assess how these issues may have been impacted by pain. Incorporating the Spiritual: Treatment Incorporating the spiritual within treatment is often equated with using “spiritual” treatments as part of the management approach. However, identifying spiritual treatments is fraught with difficulty. For example, a sample MEDLINE search of “spiritual” and “treatment” will return articles about African traditional healers, transcendental meditation, yoga, mindfulness meditation, music therapy, hypnosis, prayer, and Bolivian susto treatment. We have defined spirituality as an experience that incorporates a connection with the transcendent that has a strong influence on attitudes, emotions, and behavior, including a sense of identity, meaning, and purpose. This suggests that “spiritual treatment” is in fact a highly individual concept that is dependent on a person’s beliefs, culture, and values. Therefore, we will take the view that the spirituality of a treatment is dependent on 56
the response that it produces in a person rather than an inherent quality of its own. If this is the case, what treatments are spiritual and how do we incorporate them in our approach to treatment? If we assess a treatment by its impact rather than its alleged qualities, then there are a variety of treatments, some of them very simple, that may be included in a spiritual approach to treatment. For example, for some people, taking a walk in a forest is something that has a powerful influence at a deep level through a sense of connection with the transcendent. For others, music or meditation may do the same. As mentioned before, if meaning and purpose are central to spirituality, then targeted treatments that address these issues may also be part of incorporating a spiritual approach. For example, contemplation and reflection on life provide the opportunity for exploration of issues such as meaning, purpose, values, and priorities. For a person in pain, this means evaluating how pain has affected identity and purpose. If these have been damaged or lost, it also means examining a way forward that brings a renewed sense of meaning and purpose in the presence of pain. Although it is recognized that this is not easy, it has been shown that the reevaluation of life priorities and goals forced on people by a spinal cord injury or a diagnosis of cancer can be a positive experience that enables greater acceptance and ability to cope [82]. Clinicians and researchers who have explored this concept make several recommendations as to how this might be put into practice. Most of them focus on or include a process of life review or self-examination [22,23,43]. Many palliative care services have developed life review programs following the seminal article by Butler [83]. Included within this process is the examination of several issues, such as the following: 1) the things, activities or relationships in a person’s life that are important and bring meaning; 2) whether life to this point has contained an explicit purpose; 3) the impact of the illness on a person’s life and in particular those things that bring meaning and purpose; and 4) whether the illness resulted in a reevaluation or reassessment of the things that are important or of purpose or priorities [84]. Other interventions that have been suggested as approaches that help to alleviate spiritual distress include providing a supportive presence; exploring issues of guilt, remorse, forgiveness, and reconciliation; facilitating religious expression; reframing goals into short-term endeavors that can be accomplished; and encouraging the use of practices such as meditation, guided imagery, music, reading, poetry, and art [22]. A Biopsychospiritual Approach to Pain Therefore, a biopsychospiritual approach to pain incorporates each of these factors. It means an assessment approach that incorporates assessment of both the impact of persons’ pain on their spirit and their
Pain Medicine and Spirituality experience of spirituality. It means determining those relationships and activities in persons’ lives that bring them a sense of meaning and purpose and how they contribute in a positive or negative sense to their experience of pain. It also includes assessment of the impact of the pain on those aspects of a person’s life.
6 Rogers CR, Skinner BF. Some issues concerning the control of human behavior. Science 1956;124: 1057–66.
On the therapeutic side, the ability to place and make sense of adversity and to give it a meaningful place within the overall context, direction, or purpose of life can make it easier to endure, particularly if it is seen to be beneficial. Reframing life goals and purpose also allows the formulation of a different direction that still provides a sense of meaningful purpose.
8 Melzack R, Casey KL. Sensory, motivational and central determinants of pain: A new conceptual model. In: Kenshalo DR, ed. The Skin Senses. Springfield, IL: Thomas; 1968:423–43.
Thus, there appears to be growing evidence that addressing issues of spirituality in the person with persistent pain is an important, if not crucial, aspect of managing the pain. Although it is a recognized and recommended component of palliative care, addressing spiritual factors is just as important, if not more important, in people with persistent pain who suffer from both pain and long-term reductions in physical capacity that can have a severe impact on activities and relationships that provide meaning, purpose, and identity. Assessment and management of spiritual factors impacting on persistent pain should be included as routine core elements in the integrated care of the whole person. Future research should more clearly delineate which aspects of spirituality are important to people and test interventions that may be beneficial by addressing these important issues.
10 Engel GL. The need for a new medical model: A challenge for biomedicine. Science 1977;196:129–36.
Acknowledgement
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