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Teaching in the field of pain medicine seems to be dominated by emphasis on pain as a symptom. This is a natural response to the scientism that dominates our medical training, thinking and practice. The topic of pain and spirituality affords us the opportunity to re-focus our attention on the multidimensional aspects of the pain experience, as many have so eloquently done before. (1,2,3) We introduce our topic by posing several questions:

How important is spirituality in the lives of patients?

How important is the spirituality in the lives of physicians?

What role does spirituality play in health/wellness, recovery from illness, and relief from suffering?

How can physicians attend to patients spiritual needs?

Can we understand some concepts of spiritual experience in neurophysiological terms?

Can such understanding help bridge the gap between the scientific and the spiritual?

"Pain" and "Spirituality" are terms that everyone understands, but everyone understands them uniquely. The same words may convey different means to different people. "Pain" and "spirituality" are laden with meaning and with ambiguity. In many ways they are beyond the ability of words to describe. Yet it is language we must use to communicate life's innermost and most personal experiences, and their close, ineffable relationship. In order to create a shared understanding that will be important to physicians, no less than patients, we will explore the layers of nuance in pain and spirituality. Especially the conversations physicians must be prepared to have with their patients depend on some level of mutual understanding and empathy. What is pain? What is spirituality? How do we communicate our experiences of these to others? How do we understand what others intend when they try to communicate their experience to us?

Pain is a universal human experience, which in the modern (or postmodern) era may be understood to be either physical or mental/emotional. In fact it may be both. The dictionary definition reflects this cultural dualism. It tells us that pain is either physical suffering or discomfort (in a particular part of the body) caused by illness or injury or that pain is mental suffering or distress (New Oxford American Dictionary). Body or mind. Either/or. It wasn't always this way. Aristotle thought of pain as an emotion, like joy. Descartes, who ushered in the idea of a mind-body split, considered pain a sensation. Are physical pain and emotional pain different experiences or different aspects of the same experience? There is an obvious difference between a toothache and heartache, but does it make sense to think of unpleasant experience as issuing from separate realms? We might be tempted to say from a medical point of view that pain is a symptom, a problem, something to be treated or eliminated. And often it is. But we would not wish for a world without sensation. We would not wish to eliminate the warning pains that teach a child to pull its hand away from a fire. We would not wish for a world without emotions, the joys that put our sorrows in perspective or vice versa. These are the experiences that make us human, that give life meaning. It is not always fun. It cannot be.

The question of meaning leads us to the relationship of pain and spirituality. Spirituality, like pain, is richly laden with meaning and ambiguity. For many people, spirituality can be equated with religion. For many people, their faith, their religion, provides a source of meaning and comfort and understanding. It makes life bearable. It may alleviate pain and suffering. In this sense religion (or spirituality) becomes medically interesting. But for others, religion may be problematic, a source of dogma, discomfort, or divisiveness. So we are led to make distinctions. We look for the clear and distinct idea that so inspired Descartes, but we communicate with languages rich in nuance and ambiguity, that evoke meanings, rather than truncate them. Spirituality may be of benefit and satisfaction even for those who do not identify with a particular religion or sect.

Religious or Spiritual?

In the latter part of the twentieth century, there has been a trend to distinguish between religion and spirituality. Older (pre-1960's) definitions of "religion" and "spirituality" typically saw the two as interpenetrating, often interchangeable concepts. Most frequently spirituality was viewed as the intensely internalized aspects of one's espoused religion. Religion has its times of general spiritual intensification. Spirituality was often considered a path or discipline for incorporating religious precepts into one's personal living and consciousness. Spirituality's connection to religion with its theological and ritual dimensions overseen by a priesthood of some kind was considered essential to keep spirituality "within rational bounds" and not spinning out of control. Beginning with the 1970's, articles related to religion and spirituality began to appear with increasing frequency in the psychotherapy literature. Those articles that defined religion and spirituality in mutually exclusive terms tended to value spirituality and be dismissive of religion. Definitions that saw them as overlapping tended to value both. (4,5,6)

In the current phase of intensified interest in spirituality and religion, the option of regarding oneself as "spiritual" but not necessarily "religious" has increased dramatically. "Religion" in many instances is more closely aligned with the political than with the spiritual, while spirituality retains the sense of a personal concern with meaning and transcendence. These concerns may or may not be grounded in institutional beliefs and practices. Whether this concern for the transcendent necessarily involves the sacred is a matter of personal consideration. Being captivated by a sunset, a sports team, or a political campaign is not intrinsically a spiritual experience simply because one feels connected to something larger than oneself. However, if these experiences are imbued with a sense of connection with the sacred, or ultimate reality, or things as they really are, then that would represent a spiritually significant experience. The ordinary activities of everyday life can thus become invested with spiritual meaning as is the case for a Buddhist focusing mindfully on sweeping the steps or eating a raisin, a Jew reciting a prayer while washing his hands, or a Catholic who views preparing a meal as a sacrament. In this sense both religiousness and spirituality are seen as reflecting "the feelings, thoughts, experiences, and behaviors that arise from a search for the sacred." (4)

What might spirituality be, then, if not an approximate synonym for religious? Spirituality derives from spirits, ghosts and the rituals that primitive cultures have developed to help cope with the feelings of lost loved ones. We now say more respectfully "traditional cultures", but our euphemism belies the connection with an unrefined, unenlightened, unscientific, struggle to make sense and find meaning of a world beyond our control.

Pain and Evil

Evil stands as the antithesis of good, that which is valued. Evil is bad, and pain is disvalued, hence bad, hence evil. Evil is sometimes divided into natural evil, events beyond human control such as tsunamis and earthquakes, and man-made (human-made) evil, the bad things that people do, assaults, murders, and perhaps wars, the activities of sociopaths who act outside the bounds of conscience and civil responsibility. Illness (and pain) defy such classification. While disvalued, they are not necessarily caused unless one believes in an omnipotent being who causes everything. Such a belief challenges faith. Why would an omnipotent being cause suffering? If not as a deserved punishment, it would clearly be an injustice. This apparent contradiction is called theodicy, the vindication of divine goodness and providence in view of the existence of evil. Why would bad things happen to good people? The question is important not only for those who consider themselves religious, but for anyone who experiences suffering and tries to make sense of their experience. It is a conversation doctors should be having with patients, whose insights about their pain experiences offer clues for ways to help relieve their suffering.

The case of Job

The Hebrew Bible (Old Testament) poses this question in the Book of Job in the context of man's relationship to God.

Job a very pious and prosperous man. He had seven sons and three daughters and many possessions. He constantly feared that his sons may have sinned and cursed God in their hearts, so he offered burnt offerings as a pardon for their sins. God asks Satan his opinion of Job, and Satan suggests that he is only pious because he is prosperous. God gives Satan permission to destroy Job's family and his possessions. In spite of these losses, Job remains faithful. "YHVH has given and YHVH has taken away" (Genesis 31:9). Job does not curse God, but he does question him. Satan asks for permission to afflict Job's body as well and causes Job to break out in boils. Still he does not curse God, even when his wife urges him to do so. Job's three friends, Eliphaz, Bildad, and Zophar, believe that Job must have sinned to incite God's punishment. They believe Job must deserve his suffering because God always rewards good and punishes evil. Job's fourth friend Elihu takes a different view. He argues that Job may not have committed a specific sin for which he is being punished, but that the he is not perfect, and God as creator is such that his motives cannot be questioned by man. Elihu stresses that real repentance entails renouncing moral authority (the knowledge of good and evil), which is God's alone. Elihu therefore underscores the inherent arrogance in Job's desire to 'make his case' before God, which presupposes that Job possesses a superior moral standard that can be prevailed upon God. Job prays for forgiveness (for himself and his friends) realizing that he cannot understand the ways of God. His wealth is restored twofold; he is given seven more sons and three more daughters and lives to see the fourth generation.

This kind of introspection lies at the heart of one of the most successful disciplines in the treatment of addiction disorders, the Twelve Step Programs of Alcoholics Anonymous and related community organizations such as Narcotics Anonymous. Although not widely used it may have direct applicability to those suffering with chronic pain and other chronic illnesses (7)

Pain and Suffering

David Morris, in his far reaching analysis of pain in our culture, The Culture of Pain, has probably gone farther than anyone else in highlighting the tension and contradictions in our modern understanding of pain. (8) He observes "The secular, scientific spirit of modern medicine has so eclipsed other systems of thought as almost to erase the memory that pain-far from registering its presence mostly in meaningless mental circuits or in some sterile, living-death of hysterical numbness---once possessed redemptive and visionary powers. We need to recover this understanding partly because it shows so clearly how pain inhabits a social realm that sprawls well outside the domain of medicine." Suffering is a passive experience. Something bad or unpleasant, like pain or illness, befalls the person. What Morris is suggesting is that the interpretation of that experience may be redemptive in some way, as with the twelve step programs. Understanding this may put suffering into a different context that allows an individual to overcome it, at least conceptually, by active mastery. That taking control may be religious or spiritual or even political in some self-chosen way, a way that modern medicine may have forgotten or dismissed.

The Case of Ivan Ilych

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Dr. Richard Stieg is board certified in Neurology, Pain Medicine, and Addiction Medicine. He is a founding member and tenth President of the American Academy of Pain Medicine. He has also served the American Pain Society in various board capacities and as co-founder of their journal, Pain Forum.

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