Does Spirituality as a Coping

Mechanism Help or Hinder Coping

With Chronic Pain?
Amy B. Wachholtz, PhD, MDiv, and Michelle J. Pearce, PhD

Corresponding author which the patient’s reliance on spirituality helps or hin-

Amy B. Wachholtz, PhD, MDiv ders coping with chronic pain; and 3) outline how a busy
Department of Psychiatry, UMass Memorial Medical Center, physician can attend to and provide care for the spiritual
55 Lake Avenue, Worcester, MA 01655, USA.
E-mail: [email protected]
dimension of health.
Current Pain and Headache Reports 2009, 13:127–132
Current Medicine Group LLC ISSN 1531-3433
Copyright © 2009 by Current Medicine Group LLC Spirituality and Pain
It is important to define what we mean by spirituality. Spir-
ituality has been defined as “every person’s inherent search
Chronic pain is a complex experience stemming for ultimate meaning and purpose in life” [3]. Spirituality
from the interrelationship among biological, psycho- may or may not include belief in a higher power. It can be
logical, social, and spiritual factors. Many chronic expressed in a set of philosophical beliefs, in relationships
pain patients use religious/spiritual forms of coping, with art, nature, and music, or in relationships with loved
such as prayer and spiritual support, to cope with ones [2]. Spirituality helps to inform our unique view of
their pain. This article explores empirical research the world. This worldview plays an important role in
that illustrates how religion/spirituality may impact determining how we understand negative events, including
the experience of pain and may help or hinder the illness, and how we choose to cope with them. Notably,
coping process. This article also provides practical many patients believe that spirituality should not just be
suggestions for health care professionals to aid in the a private affair. Research has shown that 41% to 94% of
exploration of spiritual issues that may contribute to patients want their physicians to address spiritual issues
the pain experience. [4,5]. A national Gallup survey revealed that 70% of adults
reported that it was somewhat to very important to have a
physician who is spiritually attuned to them [6].
Introduction Chronic pain is a severe, often intractable, disorder
There is general agreement that health care, including that can severely impede quality of life. Medications
chronic pain management, involves more than treating for pain management can be useful but they often cause
an ill physical body. Relational models of health suggest unpleasant side effects. This may leave patients seeking
that caring for the sick requires attending to all of the out alternative pain control resources, such as those that
patient’s disrupted relationships, including those that are include their spiritual beliefs and practices [7]. The Gate
biological, neurological, psychological, social, and spir- Control/Neuromatrix Theory of Pain provides a con-
itual [1,2]. This can present a daunting task for physicians ceptual basis for how spiritual beliefs and practices may
who are given an average of 7 minutes to create rapport, influence pain management by describing how psycho-
assess, diagnose, and develop/describe a treatment plan. logical and biological pain factors are related [8,9]. These
Given competing time demands, one may wonder if spir- theories propose that the experience of pain is more than
ituality should be discussed in the clinical encounter and a simple biochemical transmission of pain from the body
in chronic pain management. If spirituality influences the up the dorsal horn of the spinal cord to the brain. Instead,
patient’s ability to cope with chronic pain, in either posi- multiple pathways involving cognitions, emotions,
tive or negative ways, then considering spirituality would and behavior can influence the pain signal, reducing or
be an important discussion. In this review, we hope to 1) increasing the actual experience of pain in real time. The
demonstrate that the patient’s spiritual beliefs and prac- Gate Control/Neuromatrix models of pain emphasize the
tices are relevant to health care; 2) describe the ways in role of psychological states as potential mediators of pain
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individual [17,18•,19••]. One way of categorizing these

Spiritual beliefs Possible unique
and practice R/S factor R/S coping strategies, similar to secular coping strategies,
Positive vs negative Spiritual support is as emotion- or problem-focused in nature [20]. Because
Public vs private Spiritual growth different situations create different coping needs, the
Intrinsic vs extrinsic Spiritual meaning-making
Existential vs religious attributions
application of healthy religious coping strategies depends
Additional efficacy beliefs in part on the demands of the situation.
Religious coping strategies have also been grouped into
positive and negative categories. Positive R/S coping rep-
Psychosocial changes resents a sense of spirituality, a secure relationship with a
Meaning-making attributions
Self-efficacy benevolent God, a belief that there is meaning in life, and
Distraction a sense of spiritual connection with others [21]. It is asso-
Social support ciated with higher self-esteem, better quality of life and
Instrumental support psychological adjustment, and spiritual and stress-related
Relaxation
growth. Conversely, negative R/S coping is an expression
of a less secure relationship with God, a tenuous and pes-
Physiological/neurological changes simistic view of the world, a feeling of punishment, and a
Altered neurotransmitter levels
religious struggle in the search for significance (Table 1).
Changed conduction of pain signals
Different threshold for recognizing pain signals It is related to depression, emotional distress, and callous-
Decreased HPA activity levels ness, along with poor physical health, quality of life, and
problem resolution [21–24].
Pargament et al. [25] identified three types of R/S
Altered pain perception
Increased/decreased sensitivity coping styles related to the level of passivity or activity
Increased/decreased tolerance that a person takes in addressing his or her problem. The
fi rst type, Self-Directing, refers to a style in which the
individual is very active and God is completely passive.
Figure 1. Potential pathways between spirituality and pain. The second type, Deferring, describes a style in which
HPA—hypothalamus-pituitary-adrenal axis; R/S—religious/spiritual. the individual takes no active steps and passively waits
(From Wachholtz et al. [19••]; with permission.)
for God to solve the problem. The third type, Collabora-
tive, describes a pattern of coping in which the individual
[10]. It also recognizes the potential for psychosocial fac- and God both take active roles, in partnership with each
tors, such as negative emotions, social support, sense of other, to solve a problem. Generally, the Collabora-
self-efficacy, and coping strategies, to impact reports of tive and Self-Directing styles are associated with better
pain [11,12] (Fig. 1). psychological, physical, and health outcomes [26•]. How-
Biologically, there are multiple potential pathways ever, patients who choose Self-Directed coping because
through which religion or spirituality may affect the they are struggling with their faith or feel abandoned by
experience of pain [13••]. Research exploring specific bio- their higher power tend to have higher morbidity and
logical pathways has shown that the density of serotonin mortality [21,27]. It should be noted that the religious
receptors in the brain is related to spiritual proclivities. coping style that patients are most likely to use when
This raises the possibility that spiritual practices may coping with acute pain (Self-Directed) is the style that
actually influence serotonin pathways in the brain that they are least likely to use when coping with chronic pain
regulate mood and pain [14]. (Collaborative) [28].

Religious/Spiritual Coping Strategies Empirical Research

Religious/spiritual (R/S) coping strategies, such as prayer A recent review of the literature on R/S among chronic
and church attendance, have been linked to a variety of pain populations revealed that prayer was either the
favorable mental and physical health outcomes, ranging primary or second most frequently used coping strategy
from lower levels of affective distress and pain among to deal with physical pain [29,30]. More than 60% of
individuals with sickle cell disease (SCD) [15] to shorter chronic pain patients report that they use prayer to help
postsurgical hospitalizations among cardiac patients them cope with pain [31]. Prayer use increases in response
[16]. Various defi nitions of R/S coping have been offered to pain [32], and 40% of pain patients report becoming
in the literature. The construct is broadly defi ned as a more R/S after the onset of the painful condition [33]. In
multidimensional variable that comprises a range of R/S most research, prayer is identified as a positive resource
strategies that may function to reduce distress and gener- and is associated with reduced pain and greater psycho-
ate solutions to problems or stressors confronted by the logical well-being and positive affect [34,35].
 Does Spirituality Help or Hinder Coping With Chronic Pain?
I Wachholtz and Pearce
I 129

Table 1. Examples of positive and negative religious coping techniques

Positive forms Negative forms
Seek spiritual connection Interpersonal religious discontent
Seek spiritual support Punishing God reappraisal
Religious assistance to forgive others Demonic reappraisal
Asking forgiveness Spiritual discontent
Benevolent religious reappraisal Reappraisal of God’s power
Religion as distraction
Finding spiritual role models for coping
Collaborative problem solving with God

In addition to the more private activity of prayer, reducing muscle tension that would otherwise worsen
public religious activity (eg, church attendance) has been pain by limiting blood flow to affected regions [40].
shown to impact pain. In a recent study among individuals Despite contemporary research that suggests that
with SCD, more frequent church attendance was related prayer is a positive coping mechanism, past research on
to lower sensory and affective experiences of pain, as using prayer as a coping technique has reported conflicting
well as fewer symptoms of somatization, depression, and results. In 2005, Rippentrop [30] published a review of six
anxiety [15]. Frequent church attendance (ie, once or more cross-sectional studies examining religion or spirituality as
per week) was also linked to lower self-reports of pain a means of coping with pain. Five of the six studies used the
intensity among individuals with SCD. The particular R/S same Praying or Hoping subscale on the Coping Strategies
coping technique used to cope with pain does not appear Questionnaire to measure spiritual coping [41]. In some
to be as important as the valence of the technique: posi- studies, high scores on this subscale were related to more
tive R/S coping techniques (eg, seeking spiritual support or functional impairment, self-reported disability, and higher
benevolent religious reappraisal) are associated with posi- pain levels [41,42]. Some of the conflicting research results
tive outcomes among chronic pain patients [35,36]. may stem from the original theoretical underpinnings of
Research shows that when pain severity and toler- the questionnaire’s Prayer/Hoping subscale. Initially, the
ance are both assessed, accessing R/S resources is more authors of the scale assumed that both prayer and hoping
often related to improved pain tolerance and less related were part of a passive coping construct. Over time, how-
to reduced reports of pain severity in arthritis pain ever, research has suggested that prayer is an active way of
[36], chronic pain [35], SCD-related pain [15], migraine dealing with pain and health issues and is not necessarily
headaches [37•], and acute pain [38]. In these studies, related to the more passive coping technique of hoping [35].
patients may identify that they are experiencing the same In addition, Rippentrop [30] noted that differences in the
level of pain as those who do not use R/S strategies but demographic makeup of the samples, measurement of pain
display higher levels of pain tolerance. This suggests that levels, and the augmentation of the R/S coping measure may
R/S coping does not necessarily change pain severity account for these mixed findings.
but changes pain tolerance, allowing pain patients to The relationship between R/S coping and pain may
continue functioning with their daily activities despite also depend on the way in which the outcome of pain is
elevated pain levels [19••]. defi ned. Specifically, a decrease in pain severity should be
R/S beliefs and activities can also influence an indi- differentiated from an increase in pain tolerance. Although
vidual’s mood, which, in turn, can reduce the perceived these concepts are both based on the individual’s pain
severity of pain. Yates et al. [39] studied how religious perception, when they are differentiated, a patient may
beliefs and activities can modulate the presence or report that he or she is still experiencing the same level of
severity of pain indirectly through improving mood. They pain but report or display better coping with that pain.
surveyed oncology patients and found that R/S beliefs Koenig et al. [43] completed a substantial review of
correlated positively with general happiness and life sat- the religion and health literature and identified multiple
isfaction. Similar to other studies, the participants’ R/S areas in which research has indicated that religion and
beliefs did not eradicate the presence of pain, but those spirituality may have a positive influence on the individual.
beliefs and practices did correlate with a decreased level However, they also identified eight major areas in which
of reported and perceived pain. In addition, longitudinal religious beliefs and practices may have negative conse-
diary studies of pain patients support the concept that quences. These include stopping life-saving medications,
R/S coping may improve one’s ability to cope with pain failing to seek medical care, refusing blood transfusions,
[36]. For example, case reports suggest that R/S activities refusing childhood immunizations, refusing prenatal care
reduce anxiety, allowing relaxation and rest and thereby and physician-assisted delivery, ignoring or promoting
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Table 2. Two brief spirituality assessment instruments

SPIRIT FICA
Spiritual belief system Faith and beliefs
Personal spirituality Importance of spirituality in your life
Integration with a spiritual community Spiritual Community of support
Ritualized practices and restrictions How do you wish these issues Addressed
Implications for medical care
Terminal events planning
(Data from Maugans [51] and Post et al. [52].)

child abuse, fostering religious abuse, and replacing mental recent OASIS (Oncologist Assisted Spiritual Intervention
health care with religion [43]. In addition, spiritual strug- Study) study, oncologists were trained to use a semi-
gles and distress, sometimes referred to as negative valence structured interview to ask patients how they use their
R/S coping, is associated with poorer mental and physical spiritual beliefs to cope with their illness [47]. Training
health outcomes [44]. for the oncologists consisted of a short (2–3 hour) train-
ing session that included information on the study itself,
general interviewing and patient communication styles,
Practical Applications for Health Care Providers and practicing delivery of the study’s semistructured
Although a majority of patients would like their physi- interview. After this short training period, physicians
cians to be spiritually attuned to them, and physicians reported feeling comfortable delivering the intervention
generally agree on the need to attend to and respect in 85% of the patient interactions. No patients reported
patients’ religious commitments, physicians often hesitate feeling uncomfortable with the interaction when assessed
to raise spiritual issues in the treatment context [45,46]. 3 weeks after the brief spiritual conversation, and 98% of
As such, physicians are unlikely to notice the potential patients felt that this discussion was a least a little help-
benefits or harm that a patient’s spirituality may afford ful. Patients in the spiritual conversation group also had
him or her in coping with chronic pain, and will be less significantly lower depression scores, higher quality of life
likely to be in a position to encourage or intervene when ratings, and greater increases in their satisfaction with the
appropriate. Spirituality is a sensitive and complex topic; care provided by their oncologist compared with those
it is not surprising that physicians tend to shy away from who did not receive the spiritual discussion [47].
discussing spirituality with their patients. The reasons
physicians typically give for not addressing spiritual issues Know yourself
include lack of time or training, fear of projecting one’s As with other value-laden issues (eg, sexuality), to inquire
own beliefs, difficulty identifying those who would desire about spirituality does not necessitate that a physician
these types of conversation, the assumption that patients have a faith tradition of his or her own, nor does it require
will self-refer, the lack of a physician’s own R/S beliefs, agreement with a patient’s R/S point of view. One can
and feeling overburdened with competing demands [46]. “take account” without “taking on.” Physicians hold
These are all legitimate and important concerns. We con- a powerful position in society, with great potential to
clude this review by providing some practical suggestions influence those under their care. As such, it is important
that address these concerns. that physicians are sensitive to this fact and cultivate an
awareness of their own worldview and understanding of
Keep the inquiry brief spirituality. Self-awareness will help to keep clear bound-
Understanding the importance of spirituality to patients aries between physician and patient, such that patients
and the role it may or may not be playing in their manage- will not feel coerced to believe as their physician believes.
ment of pain does not need to take a great amount of time, Proselytizing is not appropriate under any circumstances.
nor does it take a lot of training. A few brief questions about
R/S can be asked as part of the assessment (eg, Are you Know your limits and your local resources
part of a faith community? Is spirituality something that is Inquiring about the role that spirituality may play in a
relevant to your life or the way you manage your chronic patient’s life and management of chronic pain does not
pain?) (Table 2). Asking just a few questions can uncover necessitate a discussion of specific theological topics or
strengths and resources that may be useful to patients in the engagement of religious rituals or prayer. Nor do we
understanding their illness and in managing their pain. believe it should. Clergy and chaplains are well trained to
Even brief discussions about a patient’s spirituality do this type of work, and we argue that they should be
with a care provider can have significant impacts. In the included in the health care team when these types of issues
 Does Spirituality Help or Hinder Coping With Chronic Pain?
I Wachholtz and Pearce
I 131

arise. Spiritual struggles and distress are common among References and Recommended Reading
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