The Role of Spirituality in Healing

Part 1 of a Two-part Series

Mind and Body in Chronic Pain:  The Role of Spirituality in Healing

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Chronic pain is experienced by mind and body, a metaphysical connection that is impossible to separate.  The mind can be touched by ethereal connections much the same way as the body can be touched by physical treatments.  It is impossible to treat chronic pain while ignoring either one of these dimensions.  Medications, physical therapy, and surgeries all accommodate the body; spirituality touches the soul and mind of an individual.  Together they can create a great change in quality of life for people suffering with chronic pain.
Spirituality and its role in chronic pain management will be reviewed in the next several issues of Fibromyalgia & Chronic Pain Advocate Voice Newsletter.  How can spirituality help connect mind and body in potentially helping you find physical and spiritual relief from chronic pain?
Religious definition of spirituality:  Devotion to metaphysical matters, as opposed to worldly things. Activities which renew, lift up, comfort, heal and inspire both ourselves and those with whom we interact."
Medical definition of spirituality:  (National Cancer Institute) Spirituality is having to do with deep, often religious, feelings and beliefs, including a person’s sense of peace, purpose, connection to others, and beliefs about the meaning of life.
Nursing definition of spirituality:  A broad, inclusive definition: spirituality is that which gives meaning to one's life and draws one to transcend oneself. Spirituality is a broader concept than religion, although that is one expression of spirituality. Other expressions include prayer, meditation, interactions with others or nature, and relationship with God or a higher power.  (Burkhardt, M. "Spirituality: An Analysis of The Concept," Holistic Nursing Practice, May 1989:60-77)
Neurobehavioral definition of spirituality:  Spirituality means any experience that is thought to bring the experience into contact with the divine (in other words, not just any experience that feels meaningful).  While “’religious’ experiences are experiences that arise from following religious tradition, mysticism generally means the pursuit of an altered state of consciousness that enables the mystic to become aware of cosmic realities that cannot be grasped during normal states of consciousness.”  (Beauregard & O’Leary, 2007:59)

Part I:  Spirituality Assessments and Interventions in Pain Medicine

What are the current philosophies and practices of medical professionals when it comes to including spirituality in a chronic pain assessment and treatment regimen?  

It might be surprising to know that a recent Medline search using spirituality as the key word produced 1374 references between 1993 and 2003; and 4634 results from 2004 to 2013.  For many people with chronically painful illnesses, spiritual beliefs shape the way they view their pain.  Scientific research has shown that the use of spiritual practices helps patients cope with pain, reduces pain intensity, and lessens the degree to which pain interferes with daily living activities.  Chronic pain patients find prayer helpful and use prayer to cope more than the general population.  This is encouraging information regarding the usefulness of these practices in the clinical settings of pain management.
Research has shown that patients want their physicians to be aware of their spiritual beliefs, to ask about those beliefs, and to include spiritual issues in their medical care.   These patients felt that this knowledge would positively affect their relationship with their provider and would change their medical treatment in a positive way.
Researchers focused on chronic pain and spirituality support, including a related dialogue during a patient physical health-related visit.  They found that spirituality can become a non-pharmacological tool for the physician to help manage chronic pain, as spiritual coping has an impact on pain intensity.  Additionally, sensitivity to spiritual factors could prevent use of  ineffective or prolonged treatment.  
This body of knowledge indicates that there is a strong need for clinicians to consider how spirituality can be included in a treatment plan.  Determining how to accomplish this in a time-efficient manner can become a daunting task for the clinician.  Several possibilities about incorporating spiritual issues in assessments and treatment planning are included below.

Patient Spiritual Practices and Beliefs
Opening the door to discussing spiritual practices and beliefs with patients offers a wide variety of possible responses.  Technically, spiritual practices are defined as therapeutic strategies that incorporate a spiritual or religious dimension as a central component of an intervention to manage distress or pain or improve quality of life.  They can be generally defined as cognitive-behavioral or social practices.  
Interventions geared toward spiritual thoughts, meanings, feelings, values, or beliefs are cognitive-behavioral practices.  Sometimes these include a sensory motor component that helps connect the mental with the physical components of spirituality, i.e., when people have a daily practice of thinking and writing about three things for which they are grateful.  Some people use rosary beads or move their bodies in a specific way when praying.  Most mental-spiritual practices create an awareness of the body, reduce physiological arousal, or use a ritual that involves a rhythmic pattern.  Saying or invoking a religious image while slowing one’s breath or repeating stanzas in prayer are other examples.
Cognitive-behavioral practices are personal, internal, mental processes that include a variety of modalities including: meditation, mindfulness meditation, prayer, hoping, affirmation of self as spiritual or religious, interpretation of the meaning of distress, passive religious deferral to a higher power, appraisal of divine intervention, cognitive reframing, appraisal of post-traumatic growth or resilience, yoga, diaphragmatic breathing and studying religious literature.
A study done by Reiner, et al, looking at the literature on mindfulness meditation and chronic pain found that eight uncontrolled and eight controlled trials demonstrated a statistically significant decrease in pain intensity among persons practicing mindfulness meditation.  
Spiritual practices that involve seeking out other people or groups of people are considered  social practices.  Links between health and social support include practical and emotional assistance, a chance to participate in normalizing human interactions, motivation to improve physical function, (walking, bathing, etc), exposure to positive health practices (avoiding smoking or drugs), or an activity where health is affected by being part of an active and integrated social network.  Several positive social practices were identified in one study, including seeking spiritual connection or finding religious assistance to forgive others.    Social spiritual practices include seeking support from clergy or others with similar spiritual practices, attending a religious service, participating in a congregational meeting, activity or gathering, talking to others about spiritual emotions or concerns or confession.
Do Physicians Include Spirituality in Medical Visits?
In a survey of 2,000 practicing US physicians from all specialties about spirituality and the clinical encounter, 91% said it is appropriate to discuss religion and spirituality if the patient brings them up; 17% said they would never pray with patients; while 53% do so when patients ask. 76% of the most religious doctors said they ask about their patients’ beliefs compared to 23% of the minimally religious physicians polled.
For most physicians, real issues are time constraints, or knowing what to say when questions crop up about spirituality during a medical office visit for chronic pain.  This causes many physicians to exclude spirituality from the history discussion.  One physician said that special training might be needed before doctors would feel comfortable broaching this topic.  A palliative care physician experienced in these discussions described the ease of asking one question to start the conversation: “What role does spirituality or religion play in your life?” This question requires no more than a minute of conversation.  But once it is brought up, it becomes easier for the physician to talk about it later during a critical juncture.
How Spirituality Affects Chronic Pain Medical Visits
A conversation about a patient’s spiritual practices can strengthen the therapeutic relationship as the clinician demonstrates collaboration, understanding, and involvement in the patients’ motivations, goals, or perceptions regarding their pain.  The ability to identify and address spiritual issues is also a core competency for cultural sensitivity.1,7  For some patients with a prior history of feeling ignored, marginalized, or disrespected by their physician, this interaction can become especially important.
Asking a patient about their spirituality might also open a discussion regarding the benefit of non-pharmacological strategies to manage pain or autonomic arousal that magnifies pain. For example, a patient might reveal that he or she took a class on meditation and found that it helped them feel calm.  However, the class was several years prior, and the patient is rusty on how to meditate.  This is an opportunity for the physician to encourage the patient to reconnect with this practice and then follow up with their experiences during future appointments.
Most pain patients already have used successful self-management, non-pharmacological treatment strategies, but for various reasons no longer practice them.  In research studies it was noted that people with chronic pain have fluctuating and changing levels of spirituality and spiritual practices.  If the practice provided benefit, it would be helpful for the physician to reinforce its use . There are several possible outcomes that might be generated from such a discussion, including possible referrals to clergy, psychology, occupational therapy, and psychotherapy providers who may enhance the patient’s practice or identify barriers to practice.
A concern for the medical practitioner may be the discovery that a patient’s spiritual beliefs  present a barrier to receiving care.  Research has shown that some patients have “negative” spiritual practices or suffer spiritual discontent. For instance a few patients might decline help because they believe pain is a metaphysical punishment that they deserve or that medical interventions interfere with a divine plan.  Others might have specific religious beliefs that view the need to suffer a certain amount to receive forgiveness or to learn a particular lesson.  In light of these observations, a patient’s spiritual beliefs about coping may affect how they manage their pain, decision making about treatments, or adherence.  These revelations might offer insights to the physician about actions of a “non-compliant” patient as one who wants their treatment plan to be a collaboration between God, the physician, and the patient.
It is also concerning that many people with chronic pain conditions experience social isolation that contributes to increased pain, depression, and low activity levels.  People need social interaction to regulate themselves.  Social isolation affects multiple cognitive and physical systems necessary to modulate pain perception and management.  Becoming isolated leaves the person without the benefit of physical proximity, eye contact, touch, human voice and movement/stillness with others that are necessary for neurobiological function and repair from disease or injury.
In a study by Harrison et al, attending church once or more per week was associated with decreased pain levels.  Reinforcement by a physician of the patient’s attendance at a place of worship can both help the person identify and achieve a functional goal and a pain management strategy.
But how does the physician incorporate questions about spirituality into conversations with patients?  The first step can be associated with either: (1) asking one or a series of questions (interview); or (2) presenting the patient with a survey related to spiritual concerns as part of the standard office paperwork.  
Part 2:   Spirituality Interviews and Surveys:

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