Pain Medicine 2015; 16: 51–60

Wiley Periodicals, Inc.

Review Article
Spirituality: What is Its Role in Pain Medicine?

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Philip J. Siddall, MBBS, MM (Pain Mgt), PhD, inclusive, accessible, relevant, and applicable to
FFPMANZCA,*,† people with a wide range of health conditions. In
Melanie Lovell MBBS, PhD, FRACP, FAChPM,†,‡ addition, there is accumulating evidence that inter-
and Rod MacLeod, MB, ChB, MMedEd, PhD, ventions that address the issue of spirituality have
DRCOG, FRCGP, FAChPM†,‡
benefits for physical and emotional health.

Department of *Pain Management; ‡Palliative and Conclusions. Given the firm place that spirituality
Supportive Care, Greenwich Hospital, HammondCare, now holds within other fields and the mounting evi-
Sydney, New South Wales; †Sydney Medical dence for its relevance and benefit for people with
School—Northern, University of Sydney, Sydney, New pain, there is increasing evidence to support the
South Wales, Australia inclusion of spiritual factors as an important com-
ponent in the assessment and treatment of pain.
Reprint requests to: Philip Siddall, MBBS, MM (Pain
Key Words. Pain; Spirituality; Palliative Care; Pain
Mgt), PhD, FFPMANZCA, Department of Pain Man-
Medicine
agement, Greenwich Hospital, Greenwich, NSW 2065,
Australia. Tel: 161 2 8788 3941; Fax: 161 2 9437-
4829; E-mail: [email protected].
The Biological View of Pain

Abstract In the last century, there have been dramatic shifts in

our approach to the understanding, assessment, and
Background. For many years, spirituality has been management of pain. One hundred years ago, our con-
regarded as an integral aspect of patient care in cept of pain was largely based on a fairly unsophisti-
fields closely allied to pain medicine such as pallia- cated view of pain as a sensation that was conveyed by
tive and supportive care. Despite this, it has dedicated neural pathways to the brain. This rather sim-
received relatively little attention within the field of ple view of pain was challenged early in the last century
pain medicine itself. Reasons for this may include a by investigators such as Sherrington, who demonstrated
lack of understanding of what spirituality means, that spinal reflexes and the effects of sensory inputs
doubtfulness of its relevance, an uncertainty about could be modulated by descending pathways from the
brain [1,2]. These and subsequent findings [3–5] dem-
how it may be addressed, or a lack of awareness of
onstrated the powerful influence of the brain on neural
how addressing spirituality may be of benefit.
processing and its ability to modify or regulate afferent
sensory input.
Methods. A review of the literature was conducted
to determine the changing conceptual frameworks
However, these findings occurred within the context of
that have been applied to pain medicine, the emer- the prevailing biomedical model. Despite the strengths
gence of the biopsychospiritual approach and what of this model, it was less equipped to deal with situa-
that means as well as evidence for the benefits of tions and conditions, such as pain, in which the mind
incorporation of this approach for the management played a significant role. Therefore, many scientists and
of pain. clinicians working in this context struggled to develop
an adequate conceptual framework that successfully
Results. Although the concept of spirituality is integrated the roles of the mind and body in pain per-
broad, there is now greater consensus on what is ception. Much of clinical practice was therefore domi-
meant by this term. Many authors and consensus nated by a dualistic view of pain as either being physical
panels have explored the concept and formulated a and therefore “real” or psychological and therefore “in
conceptual framework and an approach that is the mind.”

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Siddall et al.

The Integration of Psychology and Biology resulted in a dramatic shift in our approach to the
assessment and treatment of many conditions. Particu-
Several events and trends in the middle half of the 20th larly for the problem of persistent pain, it has provided a
century helped to radically change this prevailing view of model that encourages and successfully integrates the
pain. The rising prominence and influence of psychology consideration and treatment of the variety of biological,
as a scientific discipline increased attempts to success- psychological, and environmental factors that may be
fully integrate the mind (psychology) with the body (biol- contributing to such a complex condition [15].
ogy) [6]. This collusion of biology and psychology was
never more successfully demonstrated than in the field of The Biopsychospiritual Approach
pain, when a physiologist (Patrick Wall) and a psycholo-
gist (Ronald Melzack) together published an article The biopsychosocial model has been helpful and has
describing a hypothesis that was to hugely accelerate the become the dominant paradigm for assessment and

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integration of mind and body in our approach to pain [7]. treatment in most sections of the pain community. How-
ever, in the broader medical community, there are many
This article by Melzack and Wall hypothesized that the spi- that have advocated a model that includes the spiritual as
nal cord did not work as an inert relay station that merely another important component [16–19]. In particular,
acted as passive conductor of pain signals. Rather, there many in the palliative care community, possibly in
was modulation of incoming pain signals by signals in response to the particular needs of people who are dying
pathways that conducted other sensations such as touch. and receiving end-of-life care, have been active and long-
Importantly for the integration of psychological processes, time proponents of a biopsychosocial–spiritual or biopsy-
it was also proposed that “central” control mechanisms chospiritual model that seeks to integrate a spiritual com-
descended from the brain and exerted an effect on this ponent within the biopsychosocial model [20–25].
spinal gate. This so called “gate theory” provided a fairly
biological and mechanistic model that nevertheless was a Led by the concept of “total pain” as espoused by
large step forward in incorporating the role of the mind in Cicely Saunders, palliative care specialists have for
the perception of pain [8]. It provided a biological frame- many years included the spiritual as part of the treat-
work for the powerful influence of psychological factors ment of people with cancer and other terminal illnesses.
such as attention, expectation and emotion on pain proc- This has led to the exploration, trial, and use of treat-
essing and stimulated the integration of psychological ments that specifically seek to address spiritual issues
approaches into the management of pain [9]. [26–28].

The Biopsychosocial View of Pain It has been demonstrated that those with higher levels
of spiritual well-being are more optimistic and have
Not long after this, another event served to strengthen higher levels of self-esteem and higher levels of function
further the integration of the role of the mind in pain per- [29]. This research in the palliative care field now over-
ception and treatment. Engel’s proposed whelmingly supports the importance of addressing spir-
“biopsychosocial” model [10] came at a time when itual issues in people facing a terminal illness.
many in the pain community were looking for a more
adequate model of health that successfully integrated What Does Spirituality Mean?
the biological, psychological, and environmental
domains. It provided a conceptual framework for the In considering the issue of spirituality, it is important to
increasing recognition of the role of the mind and the discuss what is meant by this term. There are many
influence of behavioral and environmental factors on views. The term has its historical roots within a religious
pain. It was therefore adopted and over time has context [30]. For many people, this link with religion is
become the dominant framework for the understanding, maintained, and many use terms such as spirituality and
assessment, and treatment of persistent pain [11–14]. religion almost interchangeably or argue that spirituality
occurs within a religious and even Christian context that
The rise of the psychological sciences was an integral is linked to a relationship with God [31,32].
component in the successful adoption of the biopsycho-
social model. It increased the comfort of the medical In more recent times, this view of spirituality as the
community in moving forward from a very mechanistic domain of one or even any religion has been increas-
biomedical model to embrace a model that gave more ingly challenged. Many people now take the view that
prominence to an intangible concept such as the mind. religion and spirituality are related but separate concepts
The clear impact of mood and cognitions on physiologi- [17,19,22,24,30,33–35]. This view holds that a person’s
cal functioning demonstrated the importance of this spirituality can be expressed in many contexts outside a
aspect of the person and the necessity of including it in formal or even informal religion, acknowledging that spi-
any satisfactory model of health and disease. rituality means different things to different people.

Therefore, although its acceptance did not come easily, A review of publications dealing with spirituality and
and it still has not been embraced by all sections of the end-of-life care has identified several dominant themes
medical community, the biopsychosocial model has within the literature, including transcendence in relation

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 Pain Medicine and Spirituality

to both self and a higher being, a sense of communion nection with something or someone outside these rela-
or connection, faith or beliefs, and hope [36]. Transcen- tionships that is transcendent or even sacred.
dence is defined variously, but the central issue is of
“going beyond” our physical selves [37]. Although it may Although the concepts of spirituality and psychology
be expressed within the context of a relationship with may be distinguished, they are heavily interdependent.
God or the sacred, it may also be about nature, art, Our psychological state is a major contributor to spiritual
music, family, or community [38]. In this broader view of well-being, and conversely, spiritual well-being is
spirituality, it is most commonly conceptualized in terms strongly related to mood [49]. However, spiritual distress
of those aspects of life that lie at the core of a person’s is more than severe depression or extreme suffering. It
identity and direction, such as the beliefs, values, activ- is usually reserved for those situations in which a per-
ities, and relationships that provide meaning and pur- son’s suffering is of such a nature that it threatens a
pose for life [24,33–35,39]. sense of meaning and purpose to their existence [48].

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These issues of meaning and purpose have long been Van Hooft proposes that there are forms of suffering that
regarded as central to the concept of spirituality. Early relate to the contemplative or integrative aspects of our
proponents of the importance of existential or spiritual being that are constituted by a frustration of the tendency
issues in suffering and resilience such as Viktor Frankl of people to seek integration and meaningfulness in their
suggested that meaning and purpose lie at the heart of lives. He proposed that people who cannot integrate their
spirituality [30,40]. More recently, meaning and purpose pain into their existence will suffer “psychological dis-
has become the most dominant theme that emerges in tress” or a disintegration of the self or of their lives [50].
publications that explore this topic [18,23,30,41–46]. Mako and colleagues propose that the identification of
self (only) with the physical body can often initiate a sense
What emerges from this literature is that while it is very of crisis or spiritual pain in the face of “an embodied expe-
difficult to reach consensus, spirituality can be broadly rience of loss and deterioration” [51].
defined as an experience that incorporates a relation-
ship with the transcendent or sacred that provides a Although the relief of suffering has always been a goal
strong sense of identity or direction that not only has a of physicians, Eric Cassell brought suffering to the fore
strong influence on a person’s beliefs, attitudes, emo- in medicine with his landmark article (1982) and subse-
tions, and behavior but is integral to a sense of meaning quent book (1991). He writes eloquently about the disin-
and purpose in life. tegration of the self and injuries to the integrity of the
person that can be manifest as sadness, anger, grief,
From this framework arises the concept of spiritual well- and withdrawal. However, he points out that these are
being. In this state, a person has a sense of peace, merely outward expressions of injury, pain, and disinte-
comfort, and strength that arises from a sense of mean- gration, and if the injury is sufficient, then the person
ing and purpose that is often linked to a connection to suffers. Cassell suggests that by attending to the mean-
the transcendent but also arises from these other activ- ing of such suffering and perhaps assisting patients to
ities and relationships [47]. Therefore, in the sense that transcend it, the suffering (associated with the destruc-
we all have relationships and activities that provide us tion of those aspects of personhood) may be amelio-
with varying levels of a sense of meaning and purpose rated. To quote Cassell: “Transcendence is probably the
in life, a level of spiritual well-being is common to all. most powerful way in which one is restored to whole-
ness 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 Despite the growing interest in spirituality generally and its
issues such as mood dysfunction and social isolation. wide adoption by some sections of the health profession
Therefore, it may be difficult to separate them because such as palliative care, it has received relatively little atten-
cognitions and emotions are irretrievably connected with tion in the field of pain management. For example, a
the spiritual experience [48]. search of “pain” and “spirituality” shows a steadily increas-
ing annual publication rate, but with a relatively small peak
There are several distinguishing features between psy- of just over 50 publications in 2011 and reaching 1,000
chology and spirituality. Spirituality is firstly about issues citations in 2013. This represents a tiny fraction (approxi-
that lie at the core of a person’s identity and motivation mately 0.1%) of the published pain literature (Figure 1).
for life. For example, a sense of meaning and purpose are
fundamental issues that have a major bearing on the atti- Despite this relative lack of attention, there have been a
tudes, emotions, and behavior that form a person’s iden- number of authors in the pain field who have advocated
tity. The second distinguishing feature is the relationship for consideration of the role of spirituality within pain med-
with the transcendent. Psychological aspects are very icine and the adoption of a biopsychospiritual approach.
much influenced by social relationships. However, inher- In some places, this approach has been actively prac-
ent within the concept of spirituality is a relationship that ticed and studied for some time [53–58]. Therefore, this is
may be shared by our social network but involves a con- not a new call. However, the relatively low number of

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Siddall et al.

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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 com- ing, increased self-efficacy, spiritual and social support,
paratively little attention within the field of pain medicine. distraction, relaxation, and positive reappraisal [57,64].

The evidence that we do have about pain and spirituality Several other studies have found that those who con-
suggests that spirituality is just as important, if not more sider themselves spiritual and religious or engage in reli-
important and relevant, than in other fields. Much of the gious activities score better in terms of mood, well-
existing evidence we have about the relationship being, and pain intensity than those who did not regard
between pain and spiritual well-being is mainly derived themselves as spiritual or religious [63,65,66]. Although
from those with cancer-related pain. There is some pre- some of these studies suggest an association between
liminary evidence from this work that various aspects of spiritual and religious activity and lower levels of pain
the experience of pain within the cancer context are intensity, the overall evidence suggests that spiritual
linked to spiritual well-being [59]. well-being has a stronger link with higher pain tolerance
and higher levels of psychological well-being, including
Some may assume that spirituality is more relevant and satisfaction with life [67,68].
therefore has received greater attention in end-of-life care
because of specific issues related to death and dying. As well as growing evidence for the influence of a per-
However, one study demonstrated that people in a reha- son’s spiritual experience, there is also evidence to indi-
bilitation setting had levels of spiritual distress that signifi- cate that spiritual practices and resources are beneficial
cantly exceeded groups of people with cancer [60]. for people with pain. The use of spiritual practices has
Furthermore, in contrast to the people with cancer, spirit- more often been related to improved tolerance of both
ual distress was a significant contributor to satisfaction acute [69] and chronic [70,71] pain than to reduced
with life in the rehabilitation group and more important intensity of pain. However, a review of studies using
than the physical disability associated with their injury [60]. mindfulness-based interventions that often include a
meditation component found that most studies also
Why Incorporate Spirituality into the Treatment of report a reduction in pain intensity [72]. In one study
Pain? investigating the effectiveness of meditation, the positive
effect of meditation was dependent on it having a spirit-
Spirituality, and particularly religiosity, has often been ual focus. Participants were divided into groups that
regarded as a negative coping style within traditional psy- used relaxation and either a secular or a “spiritual” med-
chology because of its perception as a passive coping itation that included the use of phrases with spiritual
strategy [61]. However, more recent evidence suggests (but not necessarily religious) content. The group that
that the use of spirituality and religiosity can be regarded used the meditation with spiritual content demonstrated
as an active and positive coping process with beneficial a significantly greater improvement in mood and spiritual
effects [54]. For example, those who deal with persistent well-being, and pain tolerance was increased to nearly
pain using positive spiritual coping practices such as double that of the other two groups [69].
looking to God for strength and support adjust better to
pain and have significantly better mental health [62,63]. Despite these studies suggesting the benefits of spiritu-
ality for people experiencing pain, the nature of this rela-
Religious and spiritual coping strategies are associated tionship needs to be qualified. Spirituality alone is not
with feelings of spiritual support and connection as well necessarily a positive factor, and people may use both
as reduced depression and anxiety and a greater sense negative and positive spiritual coping strategies. It has
of peace and calm. This may be due to a number of fac- been demonstrated that those who are experiencing
tors, including the ability to ascribe meaning to the suffer- pain and see God as forgiving and kind have lower pain

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 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 bet-
ter mood and satisfaction with life in the presence of pain.

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Meaning and Pain

Apart from the few studies that have examined the rela-
tionship 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 Figure 2 Diagram of the biological, psychological,
of pain and suggested that developing a meaning that social, spiritual, and environmental contributors to
incorporated the presence of pain was an important pain included in the biopsychospiritual approach.
component of better adjustment [45]. However, there
was no attempt to specifically assess the impact of
dealing with meaning and purpose on pain intensity, better health and pain-related outcomes, there is still a
mood, or other functional outcomes. question of what constitutes a biopsychospiritual
approach. As discussed above, many people assume it
Two other groups working in the field of chronic pain means incorporating a religious aspect to treatment.
have addressed meaning, although from a slightly differ- Others, who take a more inclusive view, often assume
ent perspective [74,75]. McCracken and colleagues that it means incorporating a complementary and alterna-
implicitly address some of the issues discussed by exam- tive approach to treatment. However, as we have dis-
ining the ability of people to reevaluate their life and move cussed, both of these assumptions provide a limited and
toward different goals in the presence of pain. They found narrow perspective of the biopsychospiritual approach.
that the ability to accept the presence of pain and to reor-
ient their lives despite the presence of pain was associ- Coming back to our definition, the biopsychospiritual
ated with improved functioning [74,76]. approach includes exploring and addressing the stand-
ard biological, psychological, social, and environmental
De Vlieger and colleagues expanded somewhat on this factors that form part of the standard biopsychosocial
concept and developed an instrument (the Pain Solutions approach to pain. In addition, it includes exploration of
Questionnaire) incorporating a five-item scale examining spiritual factors such as identity, meaning, and purpose
“meaningfulness of life despite pain.” Higher scores on this (Figure 2). Doing this effectively has implications for both
scale, reflecting a stronger sense of meaningfulness, had a assessment and treatment, as we shall explore below.
strong negative relationship to physical disability and affec-
tive distress as well as attention to pain and catastrophic Incorporating the Spiritual: Assessment
thinking [75]. This suggests that the ability to find meaning in
life despite the presence of pain is associated with better In recent years, spirituality and health has emerged in med-
adjustment, less distress, and less physical disability [77]. ical education as a significant area, taught with the goal of
enabling students and doctors to have a greater under-
Therefore, exploring meaning through reevaluating prior- standing of core competencies, including assessment,
ities and what is important in life as well as finding new that might be needed in the area of spirituality [78,79]. In
avenues that bring meaning and purpose is highly rele- the United States, for example, The Joint Commission on
vant to assisting people living with pain. The positive Accreditation of Healthcare Organizations [80] recognized
impact of being able to do this successfully is demon- the importance of spirituality to patients and now requires
strated by the finding that those who report higher levels that patients’ spiritual issues be addressed.
of meaning demonstrate a significantly increased ability to
enjoy life in the presence of pain [77]. A published report from a Palliative Care Consensus
Conference attended by many highly regarded clinicians
What Does a Biopsychospiritual Approach Look in the field of palliative care also recommended that a
Like? spiritual history be taken as an integral part of assess-
ment [78]. The report identified a number of issues that
Although we may be prepared to consider spirituality as were important to explore, such as identification and
relevant to the person and can find evidence to support exploration of spiritual and religious beliefs, practices,

55
Siddall et al.

and values; spiritual goals; and assessment of spiritual the response that it produces in a person rather than an
distress (meaninglessness, hopelessness) as well as inherent quality of its own.
sources of spiritual strength (hope, meaning, and pur-
pose) [78]. If this is the case, what treatments are spiritual and how
do we incorporate them in our approach to treatment?
A number of assessment tools are available to assess If we assess a treatment by its impact rather than its
this dimension [33,38,47,81]. These tools address a alleged qualities, then there are a variety of treatments,
range of similar themes, including beliefs and practices, some of them very simple, that may be included in a
relationships with others including a higher power, and spiritual approach to treatment. For example, for some
meaning and purpose, as well as qualities such as people, taking a walk in a forest is something that has a
peace, hope, and sense of control. As mentioned previ- powerful influence at a deep level through a sense of
ously, the Pain Solutions Questionnaire provides an connection with the transcendent. For others, music or

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instrument that assesses “meaningfulness of life despite meditation may do the same.
pain” [75]. The Functional Assessment of Chronic Illness
Therapy—Spiritual Well-Being Scale is another question- As mentioned before, if meaning and purpose are central
naire that has been developed and validated as an to spirituality, then targeted treatments that address these
instrument for assessing spiritual well-being [47]. issues may also be part of incorporating a spiritual
approach. For example, contemplation and reflection on
A tool for assessing spiritual history within a clinical con- life provide the opportunity for exploration of issues such
text has been put forward by Puchalski and Romer [38] as meaning, purpose, values, and priorities. For a person
using an acronym (FICA) that identifies four components in pain, this means evaluating how pain has affected
of the spiritual history. These are the following: 1) faith identity and purpose. If these have been damaged or lost,
or beliefs, which includes questions around personal it also means examining a way forward that brings a
meaning, faith, and beliefs; 2) importance and influence, renewed sense of meaning and purpose in the presence
which explores how important faith and beliefs are in of pain. Although it is recognized that this is not easy, it
terms of living with the illness or problem; 3) community, has been shown that the reevaluation of life priorities and
which seeks to understand the importance of relation- goals forced on people by a spinal cord injury or a diag-
ships and particularly whether they are in the context of nosis of cancer can be a positive experience that enables
a spiritual or religious community; and 4) address, which greater acceptance and ability to cope [82].
asks how the person would like to have these issues
addressed as part of their care. Clinicians and researchers who have explored this con-
cept make several recommendations as to how this might
At present, there is no consensus regarding which be put into practice. Most of them focus on or include a
questionnaire should be used or which questions to process of life review or self-examination [22,23,43].
ask. However, what these tools and questionnaires Many palliative care services have developed life review
have in common is that spiritual assessment is about programs following the seminal article by Butler [83].
identifying and exploring a person’s spiritual (including Included within this process is the examination of several
religious) beliefs, relationships, or practices as well as issues, such as the following: 1) the things, activities or
more general issues of meaning and purpose. For those relationships in a person’s life that are important and
with pain, it is also important to assess how these bring meaning; 2) whether life to this point has contained
issues may have been impacted by pain. an explicit purpose; 3) the impact of the illness on a per-
son’s life and in particular those things that bring meaning
Incorporating the Spiritual: Treatment and purpose; and 4) whether the illness resulted in a
reevaluation or reassessment of the things that are impor-
Incorporating the spiritual within treatment is often equa- tant or of purpose or priorities [84].
ted with using “spiritual” treatments as part of the man-
agement approach. However, identifying spiritual Other interventions that have been suggested as
treatments is fraught with difficulty. For example, a sam- approaches that help to alleviate spiritual distress
ple MEDLINE search of “spiritual” and “treatment” will include providing a supportive presence; exploring
return articles about African traditional healers, transcen- issues of guilt, remorse, forgiveness, and reconciliation;
dental meditation, yoga, mindfulness meditation, music facilitating religious expression; reframing goals into
therapy, hypnosis, prayer, and Bolivian susto treatment. short-term endeavors that can be accomplished; and
encouraging the use of practices such as meditation,
We have defined spirituality as an experience that incor- guided imagery, music, reading, poetry, and art [22].
porates a connection with the transcendent that has a
strong influence on attitudes, emotions, and behavior, A Biopsychospiritual Approach to Pain
including a sense of identity, meaning, and purpose.
This suggests that “spiritual treatment” is in fact a highly Therefore, a biopsychospiritual approach to pain incor-
individual concept that is dependent on a person’s porates each of these factors. It means an assessment
beliefs, culture, and values. Therefore, we will take the approach that incorporates assessment of both the
view that the spirituality of a treatment is dependent on impact of persons’ pain on their spirit and their

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 Pain Medicine and Spirituality

experience of spirituality. It means determining those 6 Rogers CR, Skinner BF. Some issues concerning
relationships and activities in persons’ lives that bring the control of human behavior. Science 1956;124:
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Acknowledgement 15 Flor H, Hermann C. Biopsychosocial models of

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The authors acknowledge current grant funding support cial Aspects of Pain: A Handbook for Health Care
from the Australian & New Zealand College of Providers. Seattle: IASP Press; 2004:47–75.
Anaesthetists.
16 Frankl VE. The concept of man in psychotherapy.
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