Spirituality: What is Its Role in Pain Medicine?

Pain Medicine 2015; 16: 51–60 Wiley Periodicals, Inc. Review Article Spirituality: What is Its Role in Pain Medicine? inclusive, accessible, relevant, and applicable to people with a wide range of health conditions. In addition, there is accumulating evidence that interventions that address the issue of spirituality have benefits for physical and emotional health. Department of *Pain Management; ‡Palliative and Supportive Care, Greenwich Hospital, HammondCare, Sydney, New South Wales; †Sydney Medical School—Northern, University of Sydney, Sydney, New South Wales, Australia Conclusions. Given the firm place that spirituality now holds within other fields and the mounting evidence for its relevance and benefit for people with pain, there is increasing evidence to support the inclusion of spiritual factors as an important component in the assessment and treatment of pain. Reprint requests to: Philip Siddall, MBBS, MM (Pain Mgt), PhD, FFPMANZCA, Department of Pain Management, Greenwich Hospital, Greenwich, NSW 2065, Australia. Tel: 161 2 8788 3941; Fax: 161 2 94374829; E-mail: . Key Words. Pain; Spirituality; Palliative Care; Pain Medicine The Biological View of Pain Abstract Background. For many years, spirituality has been regarded as an integral aspect of patient care in fields closely allied to pain medicine such as palliative and supportive care. Despite this, it has received relatively little attention within the field of pain medicine itself. Reasons for this may include a lack of understanding of what spirituality means, doubtfulness of its relevance, an uncertainty about how it may be addressed, or a lack of awareness of how addressing spirituality may be of benefit. Methods. A review of the literature was conducted to determine the changing conceptual frameworks that have been applied to pain medicine, the emergence of the biopsychospiritual approach and what that means as well as evidence for the benefits of incorporation of this approach for the management of pain. Results. Although the concept of spirituality is broad, there is now greater consensus on what is meant by this term. Many authors and consensus panels have explored the concept and formulated a conceptual framework and an approach that is In the last century, there have been dramatic shifts in our approach to the understanding, assessment, and management of pain. One hundred years ago, our concept of pain was largely based on a fairly unsophisticated view of pain as a sensation that was conveyed by dedicated neural pathways to the brain. This rather simple view of pain was challenged early in the last century by investigators such as Sherrington, who demonstrated that spinal reflexes and the effects of sensory inputs could be modulated by descending pathways from the brain [1,2]. These and subsequent findings [3–5] demonstrated the powerful influence of the brain on neural processing and its ability to modify or regulate afferent sensory input. However, these findings occurred within the context of the prevailing biomedical model. Despite the strengths of this model, it was less equipped to deal with situations and conditions, such as pain, in which the mind played a significant role. Therefore, many scientists and clinicians working in this context struggled to develop an adequate conceptual framework that successfully integrated the roles of the mind and body in pain perception. Much of clinical practice was therefore dominated by a dualistic view of pain as either being physical and therefore “real” or psychological and therefore “in the mind.” 51 Philip J. Siddall, MBBS, MM (Pain Mgt), PhD, FFPMANZCA,*,† Melanie Lovell MBBS, PhD, FRACP, FAChPM,†,‡ and Rod MacLeod, MB, ChB, MMedEd, PhD, DRCOG, FRCGP, FAChPM†,‡ Siddall et al. The Integration of Psychology and Biology This article by Melzack and Wall hypothesized that the spinal cord did not work as an inert relay station that merely acted as passive conductor of pain signals. Rather, there was modulation of incoming pain signals by signals in pathways that conducted other sensations such as touch. Importantly for the integration of psychological processes, it was also proposed that “central” control mechanisms descended from the brain and exerted an effect on this spinal gate. This so called “gate theory” provided a fairly biological and mechanistic model that nevertheless was a large step forward in incorporating the role of the mind in the perception of pain [8]. It provided a biological framework for the powerful influence of psychological factors such as attention, expectation and emotion on pain processing and stimulated the integration of psychological approaches into the management of pain [9]. The Biopsychosocial View of Pain Not long after this, another event served to strengthen further the integration of the role of the mind in pain perception and treatment. Engel’s proposed “biopsychosocial” model [10] came at a time when many in the pain community were looking for a more adequate model of health that successfully integrated the biological, psychological, and environmental domains. It provided a conceptual framework for the increasing recognition of the role of the mind and the influence of behavioral and environmental factors on pain. It was therefore adopted and over time has become the dominant framework for the understanding, assessment, and treatment of persistent pain [11–14]. The rise of the psychological sciences was an integral component in the successful adoption of the biopsychosocial model. It increased the comfort of the medical community in moving forward from a very mechanistic biomedical model to embrace a model that gave more prominence to an intangible concept such as the mind. The clear impact of mood and cognitions on physiological functioning demonstrated the importance of this aspect of the person and the necessity of including it in any satisfactory model of health and disease. Therefore, although its acceptance did not come easily, and it still has not been embraced by all sections of the medical community, the biopsychosocial model has 52 The Biopsychospiritual Approach The biopsychosocial model has been helpful and has become the dominant paradigm for assessment and treatment in most sections of the pain community. However, in the broader medical community, there are many that have advocated a model that includes the spiritual as another important component [16–19]. In particular, many in the palliative care community, possibly in response to the particular needs of people who are dying and receiving end-of-life care, have been active and longtime proponents of a biopsychosocial–spiritual or biopsychospiritual model that seeks to integrate a spiritual component within the biopsychosocial model [20–25]. Led by the concept of “total pain” as espoused by Cicely Saunders, palliative care specialists have for many years included the spiritual as part of the treatment of people with cancer and other (...truncated)