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11 Articles in Volume 14, Issue #5
DEA and Doctors Working Together
Working With Law Enforcement and DEA
Demystifying CRPS: What Clinicians Need to Know
Glial Cell Activation and Neuroinflammation: How They Cause Centralized Pain
History of Pain: The Treatment of Pain
Spirituality Assessments and Interventions In Pain Medicine
The Stanford Opioid Management Model
We Need More “Tolerance” in Medical Pain Management
Treating Rebound or Chronic Daily Headaches
Buprenorphine With Naloxone for Chronic Pain
More on Nitrous Oxide and Meperidine in Pain Care

Spirituality Assessments and Interventions In Pain Medicine

Spiritual beliefs can shape the way a patient views his/her pain. Clinicians should ask patient's about their spiritual beliefs in order to provide integrative strategies to manage their pain.

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

A query about spirituality might trigger a discussion of the benefit of non-pharmaceutical strategies to manage pain or to manage the autonomic arousal that magnifies pain. For instance, a patient might reveal that in the past, he or she took a class on meditation and found that it helped them feel calm. However, this was several years ago and the patient currently doesn’t recall what the practice involved. It is not unusual for chronic pain patients to already have some non-pharmacological strategies for self-regulation that work but that they no longer apply. Rippentrop noted that people who have chronic pain had fluctuating and changing levels of spirituality and spiritual practice; if the practice provided benefit, it would be helpful to reinforce it.19 Perlman et al identified the benefits of a consistent meditation practice in the ability to manage pain.20 The discussion might trigger a recommendation for referral. A clinician could identify clergy, psychology, occupational therapy, or psychotherapy providers who have the expertise to offer ways to enhance the patient’s practices or identify barriers to practice.

A patient’s spiritual beliefs about their pain may present a barrier to receiving care. The physician’s initial discussion about these beliefs could segue into a consultation with a provider to discuss these beliefs more in-depth. Wachholtz et al identified that some patients have “negative” spiritual practices or suffer spiritual discontent.13 Some patients might decline help for their chronic pain because they believe that pain is a metaphysical punishment that they deserve or that medical interventions interfere with a divine plan. Some people’s specific religious beliefs hold to the need to suffer a certain amount to receive forgiveness or to learn a specific lesson. The patient’s spiritual beliefs about coping may affect how they manage their pain, decision making about treatments, or adherence. A physician could reassess a judgment of a “noncompliant” patient as one who wants to be sure that there is a collaborative process of care, with treatment involving collaboration with God, the physician, and the patient.

Social isolation is especially problematic for patients with chronic pain and contributes to factors that can exacerbate pain, including depression, low activity levels, and lack of social reinforcement for positive health behaviors. On a basic level, humans need social interaction to regulate themselves. A disturbance in the ability to engage with others affects multiple cognitive and physical systems that modulate pain perception and management. The shift from interaction to solitude leaves the patient 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.21

In a study by Harrison et al, attending church once or more per week was associated with decreased pain levels.11 The physician’s reinforcement of the patient’s attendance at a place or worship can both help the patient identify and achieve a functional goal and a pain management strategy.

In order to find out if spirituality is important to a patient, the physician can take the first step by either asking questions (interview) or presenting the patient with a survey. An interview consists of a question or series of questions the physician would ask during an office visit. Or, the physician can include, as part of standard office paperwork, a survey of questions related to spiritual concerns. This survey is filled out by the patient and reviewed by the physician, who can then decide what to do with the information.

Interview

Goals of interview questions during a medical visit include clarifying patient’s concerns, making a connection, identifying goals of care, and mobilizing specific resources. The 2002 article in JAMA on spirituality provides several examples of how physicians add on these types of queries.16 Despite the end-of-life context, the article provides excellent suggestions for physicians seeing all types of patients. The article includes phrases to elicit patient concerns and what to say in response.

In a 2008 presentation, Koenig recommended that a brief (2-4 minute) spiritual history be presented to the patient as a routine part of the clinical visit.22 The physician would determine the patient’s religious or spiritual background, beliefs used to cope with illness or that are a source of distress, spiritual beliefs that might conflict with medical care or influence medical decisions, involvement in a spiritual community, and spiritual needs that may be present. He recommended that the history and recommendations or referrals made be documented in the patient’s file.

Lee and Newberg provided several questions for providers who feel uncertain, inexperienced, or untrained in taking a spiritual history.5 Some of their recommended questions are from a 1999 American College of Physicians Consensus Panel. For a patient with chronic pain, these questions could thus be adapted:

  • Do you rely on your spiritual beliefs to help you cope with pain?
  • How do your spiritual beliefs influence your treatment?
  • Is faith (religion and spirituality) important to you in this illness (injury, disease)?
  • Are there any religious or spiritual issues that need addressing?
  • Would you like to explore religious matters with someone?

The FICA Spiritual History Tool23-25 was developed by physicians as a guide for non-chaplain clinicians to incorporate open-ended questions regarding spirituality into a standard comprehensive history in the medical setting. Several studies suggest that this tool is feasible to use in the medical setting. FICA, an acronym for the 11 questions that cover the individuals’ Faith or beliefs, the Importance of spirituality on the person’s life and health care decision making, the person’s spiritual Community, and interventions to Address the person’s needs. Sample questions from this survey are shown in Table 1. FICA pocket cards and a demonstration on how to perform a spiritual history may be found at The George Washington Institute for Spirituality and Health website, www.gwish.org.

Most providers will say that they do not have time for either a structured or unstructured interview regarding spirituality. A written format can be helpful for improving that part of the communication effort by the physician. Cuing the physician to address spirituality and providing the physician feedback about a patient’s beliefs and concerns also can be accomplished through a patient self-report survey. A self-report survey focuses attention on the patient; therefore, the communication does not depend on whether the doctor “asks” about spirituality. For patients who are disenfranchised due to past experiences of rejection or non-response about spiritual issues, the survey tool itself is a prompt about the importance of spiritual practices and that the clinician is interested in this topic.

Surveys

A screening tool used in the clinical setting needs to be easy for the patient to fill out and for the clinician to scan quickly. The tool should be chosen based on the clinician’s comfort level with how the tool will be used. The tool could be used for basic assessment, for providing positive feedback, for referral, or to prompt discussion about non-pharmacological approaches to pain management. Table 2 outlines things to consider when deciding on what kind of survey to use clinically.

There are many self-report surveys used by researchers that will work as a screening tool. For instance, 33 self-report surveys to assess spirituality are described on a website developed to create “a database of outcome measures of particular importance to Complementary and Alternative Medicine (CAM) and Integrative Health Care (IHC) effectiveness and efficacy research.”26

The Fetzer Institute27 has made available a booklet, which contains many questionnaires that can be used or reprinted without permission. The booklet also documents the findings of a working group on key dimensions of spirituality as they relate to physical and mental health outcomes. There are examples and references for a number of surveys that are broken down into domains (Table 3) so that a researcher or clinician can match the appropriate questionnaire with his or her area of interest.

A frequently used survey in the research on spirituality and chronic pain is the Coping Strategy Questionnaire (CSQ).28 This validated scale is short and easy to administer and was originally developed to identify how people cope with back pain.29 The CSQ consists of 7 pain coping scales and includes praying/hoping items. Items are rated on a scale ranging from 0 (never do) to 6 (always do that when in pain). This scale takes approximately 5 minutes to complete and is easy to score.

Another potential tool is the Internet. There are thousands of apps related to spirituality and religion and there are numerous Internet tools that researchers gathering information about spirituality and religion provide free and anonymously.

Treatment Tips

The physician who can flex a spiritual muscle has additional tools to help a patient who is not progressing in treatment or appears to be suffering in excess of their diagnosis. Many pain physicians want alternative options to prescribing more medication. In practice, pain physicians traditionally provide nonpharmacological “tips” on coping with pain, such as the promotion of good sleep hygiene. Tips can also be made to patients about trying spiritual strategies, like gratitude exercises or meditation. Steven H. Richeimer, MD, a coauthor of this article, has written a patient-friendly guide to chronic pain management that can be used by the physician for “tips.”30 A physician could quickly discuss “Eight easy ways to practice gratitude” or suggest possible “spiritually satisfying rituals” for a patient to consider. His book also discusses suffering. This section might help physicians identify patients who are having a spiritual crisis and provides examples of how this struggle is expressed in patient’s thoughts that makes pain worse. He identifies spiritual tools that a physician could consider using or that the patient could use, including reframing spiritual thoughts, spiritual meditation, and motivation to engage in life.

Clinical Examples

Example 1

Dr. Silver is a pain physician in a large, metropolitan clinic. After attending a lecture on chronic pain and spirituality, Dr. Silver wants to incorporate spiritual issues into his practice. He is very interested in reinforcing interventions that do not involve medications. He thinks that a short questionnaire that the patient would fill out prior to the visit would be most helpful. He would scan the questionnaire to see if the patient identified any spiritual issues or practices. Dr. Silver is most interested in whether his patients endorse spiritual or religious feelings because he thinks that his patients want him to know that spiritual issues guide their healthcare decisions. He chooses a free, 16-item scale, the Daily Spiritual Experiences Scale31 that has questions like “I ask for God’s help in the midst of daily activities” and “I feel thankful for all of my blessings.” If they respond affirmatively, this is an opportunity to bring up the topic of spirituality, engage the patient in a brief discussion using some of the FICA questions.

Example 2

Dr. Waters is a pain physician in a multidisciplinary pain rehabilitation setting who is less comfortable with a discussion about spirituality. However, she wonders if looking at the “spiritual angle” might be a way to reinforce referral to other non-physician providers. She picks out specific sections of the Fetzer Institute booklet27 related to private and organizational religious practices, for a total of 6 questions. She hopes to tap into patients who need more exposure to organizational support and refer them to occupational therapy in order to establish a better routine, maintain independence, and prevent a more disabled lifestyle. She guesses that endorsement of private religious practice (personal prayer, reading bible, watching religious television) might indicate that patients are less physically functional or do not have access to transportation.

Summary

Patients with chronic pain want their physicians to ask about spiritual issues. Surveys filled out by your patients present an efficient and easy initial step. Think about what you would do with the information that you would learn. Be ready with resources on spirituality you would provide to interested patients. Make connections in your organization or community with chaplains, or with psychologists and occupational therapists who prioritize spiritual issues. Learn more—the best resource might be your patient!

Assisting Drs. Weinstein and Richeimer in the writing of the article were Aryeh Bernstein, Talya Kapenstein, and Elana Penn. All were research assistants in the Department of Anesthesiology at the Keck School of Medicine at the University of Southern California at the time the article was published. 

Last updated on: May 12, 2017

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