Spirituality Assessments and Interventions In Pain Medicine
For many people with chronically painful conditions, spiritual beliefs shape the way they view their pain or provide strategies to manage their pain. Research results have supported the use of spiritual practices in helping patients cope with pain, reduce pain intensity, and lessen the degree to which pain interferes with the activities of daily living. Patients with chronic pain find prayer helpful and use prayer to cope more than the general population.1,2 Patient preferences for spiritual interventions and the increased research data regarding the usefulness of these practices in the healthcare setting encourage their transition to the clinical setting of pain management. Using spirituality as a keyword in a Medline search produced 1374 results between 1993 and 2003 and 4634 results from 2004 to 2013.
Medical patients want their physicians to be aware of their spiritual beliefs, to ask about their spiritual beliefs, and to include spiritual issues in their medical care.3-5 These patients felt that this knowledge would positively affect their relationship with their provider and would change their medical treatment.
Researchers who have focused on chronic pain and spirituality support including a discussion of spirituality during a physical health-related visit. Spirituality can become a non-pharmacological tool for the physician to help manage chronic pain, as spiritual coping has an impact on pain intensity.6-8 In addition, sensitivity to spiritual factors could prevent ineffective or prolonged treatment.9
Taken together, this body of knowledge indicates that there is a strong need for clinicians to consider how spirituality can be included in a treatment plan. However, determining how this can be accomplished in a time-efficient manner may be a challenge for the clinician. We have presented here several strategies that may be helpful to clinicians who are contemplating including spiritual issues in their assessment and treatment planning.
Patient Practices and Beliefs
There are a wide variety of spiritual practices and beliefs that patients might bring to a discussion. 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. Patient spiritual practices can be generally described as cognitive-behavioral or social.
Cognitive-behavioral practices are those interventions aimed at spiritual thoughts, meanings, feelings, values, or beliefs. Often, these strategies include a sensory motor component that helps to connect the mental with the physical components of spirituality. For instance, people with a daily practice of thinking about three things they are grateful for will write down those items. With prayer, some people use rosary beads or move their bodies in a specific way. Most mental-spiritual practices are done with an awareness of the body, reduce physiological arousal, or use a ritual that involves a rhythmic-repetitive pattern. Repeated stanzas in prayer or saying or invoking a religious image while slowing one’s breath are examples.
Cognitive-behavioral practices are personal, internal, mental processes that include a wide variety of modalities: 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.10,11
Researchers have attempted to demonstrate that these cognitive-
behavioral practices can reduce pain levels. Reiner et al reviewed the literature on mindfulness meditation and chronic pain. Findings from 8 uncontrolled and 8 controlled trials demonstrated a statistically significant decrease in pain intensity among persons practicing mindfulness meditation. The findings were more consistently positive for samples limited to persons with pain.12
When the practice involves seeking out other people or groups of people, these spiritual practices are considered social. Links between health and social support include practical and emotional assistance, a chance to participate in normalizing human interactions, motivation to improve physical function (eg, walking, bathing), exposure to positive health practices (avoiding smoking or drugs), or an understanding that health is affected by being part of an active and integrated social network. Wachholtz et al identified several positive social practices, such as seeking spiritual connection or finding religious assistance to forgive others.13 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.14,11
Do Physicians Include Spirituality in Medical Visits?
Curlin et al surveyed 2,000 practicing US physicians from all specialties about spirituality and the clinical encounter. Ninety one percent of these physicians said it is appropriate to discuss religion and spirituality if the patient brings them up. Although 17% said they would never pray with patients, 53% do so when patients ask. Seventy-six percent of the most religious doctors in the survey said they ask about their patients’ beliefs compared to 23% of the minimally religious physicians polled.15
There is a concern among physicians about time constraints or knowing what to say when questions of spirituality arise during a medical visit for chronic pain. Thus, many physicians exclude spirituality from the history discussion. In a response to a 2002 article in JAMA about spiritual discussions in end-of-life care,16 one physician said that special training might be needed before physicians broach this topic. A palliative care physician, well versed in these discussions, described the ease of asking one question to start the conversation: “What role does spirituality or religion play in your life?” Posing this question requires no more than a minute of conversation. Once brought up, it becomes easier for the physician to bring up later during a critical juncture.17
How Spirituality Affects Chronic Pain Medical Visits
Information about patient’s spirituality can be useful in a variety of ways. For instance, an exchange about spiritual practices can strengthen the therapeutic alliance—the clinician is demonstrating 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.17 For some patients with prior experiences of feeling ignored, marginalized, or disrespected by their physician, this interaction could be especially important.18