Rehabilitation Psychology 2005, Vol. 50, No.

3, 278 284

Copyright 2005 by the Educational Publishing Foundation 0090-5550/05/$12.00 DOI: 10.1037/0090-5550.50.3.278

A Review of the Role of Religion and Spirituality in Chronic Pain Populations

A. Elizabeth Rippentrop
University of Iowa Hospitals and Clinics
Objective: To review the current literature on the relation between religiosityspirituality and health outcomes in chronic pain populations, to discuss the clinical implications of this research, and to provide suggestions for future studies. Conclusions: Additional religionspirituality research and clinical intervention with chronic pain populations is warranted for several reasons. First, many persons with chronic pain use religious and spiritual beliefs and activities to cope with pain. Second, a relation between religionspirituality and various health outcomes has been documented. Third, there is a lack of research on potential mediators of the relation between religionspirituality and health in chronic pain populations. Fourth, well-designed spiritual or religious behavioral interventions for patients with chronic pain are sparse.

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Keywords: chronic pain, religion, religiosity, spirituality, religious coping, spiritual coping

Research has established a relation between religionspirituality and health (George, Larson, Koenig, & McCullough, 2000; Koenig, McCullough, & Larson, 2001; Levin, 1994). Although this association is complex and reasons for the relation remain unclear, religiousness is generally found to have a salutary effect on health. Multiple review articles and special issues have been published on this topic (Kaplan, 2002; W. R. Miller, Thoresen, & Jones, 2003; Thoresen, 1999). Most of the research on the relation between religionspirituality and health has focused on specic medical populations with potential life-threatening diagnoses, such as cancer, coronary disease, cardiovascular disease, and AIDS. An important health population, however, has been somewhat overlooked in the research thus far and deserves greater attention. The National Institute for Healthcare Research Panel, in their consensus report on scientic research on spirituality and health, recommended that future investigations continue to focus on patient populations with conditions of most immediate concern to public health, both in terms of suffering and the economic burden to society (Larson, Swyers, & McCullough, 1997). In their list of populations to be studied were patients with chronic illnesses not well treated by current methods, including chronic pain syndromes. Chronic pain is now recognized as a major public health problem (Arnoff, 1998) that creates a burden in lost productivity, tax revenue, health care expenses, and disability benets for society (Turk, 1996). It is estimated that the annual cost of chronic low back pain in the United States may exceed $70 billion (Arnoff, 1998). One of the most comprehensive conceptualizations of chronic

pain is the gate control theory of pain (Melzack & Casey, 1968; Melzack & Wall, 1965), which suggests that the processing of nociceptive stimulation results from continuous interaction of sensory, affective, and cognitive factors. This was the rst theory to explain how psychological variables, such as emotional stress, past experience, and other cognitive activities, have potentiating or moderating effects on pain processing. It is plausible that religious and spiritual beliefs may inuence cognitive and emotional processes, which, in turn, may directly inuence physiological mechanisms, altering the experience of pain. Only continued research will be able to shed light on this possible relation.

Objectives and Design

The purpose of the current article is to review the literature on religion and spirituality in chronic pain populations and to delineate future research directions and clinical implications. Literature sources were identied using two strategies. First, computer literature searches using Medline and PsychLIT systematically identied studies with a combination of the following keywords: (a) chronic pain, myofascial pain, pain, arthritis, or bromyalgia and (b) religion, religiosity, spirituality, religious coping, or spiritual coping. Second, after retrieving articles based on the rst strategy, the references were consulted to identify other studies not detected in the rst strategy. This review is based only on empirical studies of populations with chronic pain resulting from musculoskeletal conditions or arthritis. All theoretical papers, book chapters, and review papers were excluded. Studies reporting on pain conditions related to terminal illness were also excluded.

Correspondence concerning this article should be addressed to A. Elizabeth Rippentrop, PhD, Iowa Spine Research and Rehabilitation Center, Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242-1088. E-mail: anne-rippentrop@uiowa.edu 278

Literature Review Results

The research studies on religionspirituality in chronic pain populations fall into four research methodology categories: (a) survey studies that document the frequency of different spiritual

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religious variables of those with chronic pain; (b) cross-sectional research designs, in which certain characteristics of individuals with chronic pain are assessed at one point in time and correlated with other characteristics of those individuals; (c) longitudinal research designs in which persons with chronic pain are assessed at one point in time and then monitored for additional reassessments over time; and (d) experimental designs in which a specic spiritual or religious intervention is provided to people with chronic pain.

Survey Studies
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Three survey studies were located that document the use of prayer as a way of coping with pain. Cronan, Kaplan, Posner, Blumberg, and Kozin (1989) contacted 1,811 people in San Diego valley by telephone using a random digit-dialing methodology to ensure a random sample. Of this sample, 382 individuals reported having a musculoskeletal complaint such as arthritis or neck back pain. These persons were read a list of 19 nonmedical remedies for pain management (i.e., dietary and vitamin regimens, massage therapy) and asked whether they had used any such strategies. Prayer was the nonconventional pain management remedy used most often in the previous 6 months. In a study of self-care activities for arthritis used by minorities in an urban setting, 92% of African Americans and 50% of Hispanics reported using prayer as a way of coping with their pain (Bill-Harvey et al., 1989). A qualitative study of 109 Latina women with arthritis demonstrated that the second most common coping strategy was prayer and religious beliefs or activities (Abraido-Lanza, Vasquez, & Echeverria, 2004). Based on these studies, it appears that prayer may be a common coping strategy for dealing with physical pain and suffering.

Cross-Sectional Studies
The majority of studies reviewed were cross-sectional. This is not uncommon when examining the broader religionspirituality literature, when much of the early research was simply the establishment of a relation between religionspirituality and health, typically with a cross-sectional design. In the cross-sectional research with chronic pain populations, such designs compare spiritual and religious levels among different groups of people, examine how religion and spirituality can be a means of coping with pain, and study the relation between religion and spirituality and various health outcomes. Comparing groups on religionspirituality measures. Several studies have compared different clinical groups levels of religion spirituality. J. F. Miller (1985) compared a convenience sample of 64 patients with rheumatoid arthritis and a random healthy control sample of 77 university faculty members. The arthritis group had higher levels of spiritual well-being than the control group, which the author hypothesized may be due to chronic illness stimulating the persons relationship with God. No effort was made, however, to match these groups on age, gender, education, or marital status, nor were these demographic factors controlled in the analysis. In yet another comparison study, persons without pain (n 63) were compared with those with acute (n 97) and chronic (n 112) pain (Skevington, 1998). It should be noted that the patients with pain had a variety of medical diagnoses, the most frequently represented of which were circulation problems (11%), respiration

problems (11%), and musculoskeletal conditions (10%). However, the author did not document the specic medical conditions of the participants in the acute versus chronic pain conditions. Spirituality, as a domain of quality of life, did not differ among these three groups. The author suggested that spiritualityreligion may be an aspect of quality of life not affected by pain, which may help explain some of the comfort those who are suffering derive from spiritualityreligion. Religionspirituality as a means of coping with pain. The majority of studies reviewed focus on religionspirituality as a means of coping with chronic pain. Six studies were located that consider some type of religious coping in people with chronic pain. Of these, all but one used the Coping Strategies Questionnaire (CSQ; Rosenstiel & Keefe, 1983). This is not surprising because the CSQ is well validated and has been used extensively in research on coping and adjustment to pain. The CSQ is a 42-item checklist that assesses seven different coping strategies, one of which is Praying or Hoping. The Praying or Hoping subscale consists of six items, three of which specically query about religious coping and three which measure hoping. The studies in which the CSQ was used either utilized factor analysis to identify superordinate constructs relevant to coping or studied the Praying or Hoping subscale and its association with health outcomes. Rosenstiel and Keefe (1983) administered the CSQ to 61 patients with low back pain, along with measures of average pain, current function, depression, anxiety, and somatization. A factor analysis of the CSQ revealed three principal components, which included cognitive coping and suppression, helplessness, and diverting attention and praying. Participants who scored highly on the diverting attention and praying factor were more functionally impaired and had higher pain levels than those who scored low on this factor. In another factor analysis of the CSQ with a group of 74 patients with chronic low back pain, a similar three-factor solution was found (Turner & Clancy, 1986). However, unlike the Rosenstiel and Keefe (1983) study, in which the component diverting attention and praying was related to more pain, in the current study it was related to less pain intensity. In comparing these divergent ndings, it is important to note that the demographic makeup of the samples were quite different. In addition, pain levels were not measured in the same way. Although in both studies pain was assessed by taking the average of three different measures (current pain, most severe pain in past week, and least severe pain in the past), Rosenstiel and Keefe (1983) measured this at one point in time. By contrast, Turner and Clancy (1986) had patients keep a pain diary over the course of 1 week and rate their pain hourly; these ratings were then averaged. The latter method may have provided a more valid measurement of pain because of a greater number of measurements across time. Rapp, Rejeski, and Millers (2000) factor analysis of the CSQ with 394 older adults with chronic knee pain revealed yet another pattern of responses. To reduce burden on study participants, 21 of the original 42 items on the CSQ were removed, and a factor analysis was done on the abbreviated scale, revealing three factors: catastrophizingprayer, ignoring distracting, and reinterpreting sensation. It should be noted that, unlike the previous studies reviewed, the praying and hoping items in this study did not load together on one factor; rather, the catastrophizing items loaded with praying. The authors believe this may be because they dropped disproportionately more hoping items. Multivariate anal-

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yses that controlled for demographics, health variables, pain frequency, and pain intensity revealed that catastrophizingpraying was signicantly related to more self-reported disability and less distance walked on a 6-min walking test. In a study of 200 Latinos with arthritis, the CSQ was used to measure coping and its relation to psychological adjustment and pain (Abraido-Lanza et al., 2004). Three of the seven subscales of the CSQ were used, including the Praying or Hoping scale, which consists of three questions measuring religious coping and three measuring hoping. In the current study, only the three religious coping items were used; the hoping items were deleted. To supplement the three religious coping items on the CSQ, the authors used three items from the Use of Religion subscale of the Vanderbilt Multidimensional Pain Coping Inventory (Smith, Wallston, Dwyer, & Dowdy, 1997). The authors hypothesized that the effects of religious coping on pain would be indirect. They believed that religious coping would increase acceptance of illness and selfefcacy over arthritis, which would then lead to decreased pain, decreased depression, and greater psychological well-being. Their hypothesis was not supported, because a path analysis revealed that religious coping did not have a direct effect on acceptance of illness or self-efcacy and was not related to pain or depression. Religious coping was directly related to psychological well-being but not with psychological ill-being (i.e., depression). This study is an important addition because it considers possible mediating factors that might explain the complex relation between religion and health in those with chronic pain. In all the coping studies reviewed thus far, religionspirituality has been measured with the three items in the Praying or Hoping subscale of the CSQ. Although Bush et al. (1999) also used the CSQ with a group of 61 people with chronic pain, they dropped all the hopingpraying items from the CSQ and added a measure that specically measured religious coping (Religious Appraisal and Coping Survey). The religious coping measure was created from items compiled from existing measures of religious coping from Pargament et al. (1990). The Religious Appraisal and Coping Survey was factor analyzed and revealed a three-factor solution: positive religious coping, punishing Godnegative religious coping, and absent Godnegative religious coping. Hierarchical multiple regression analyses revealed that, after controlling for demographic variables, pain specic appraisals, and nonreligious coping strategies, positive religious coping was correlated with positive affect but not negative affect. Neither of the negative religious coping scales was correlated with positive or negative affect. This study is an improvement over studies discussed previously because it used a comprehensive and more multidimensional measure of religion rather than just three items. In addition, this study took into consideration the possible negative effects of religious coping. A weakness of the study is that the authors did not use a validated religionspirituality measure. In all but one of the studies reported, the Hoping or Praying subscale of the CSQ was used as the measure of religionspirituality. This is problematic because this scale consists of six items, only three of which measure a religiousspiritual activity, that being prayer. Because the praying items are placed with the hoping items, it is impossible to know whether prayer in and of itself is related to health. Moreover, the type of prayer measured is prayer asking for the pain to stop or lessen, which is a very narrow type of praying. These items do not query, for instance, about praying for strength, acceptance, or peace. Furthermore, prayer is just one

aspect of religionspirituality. In essence, it is impossible to measure religionspirituality with just three items and conceptualize it as a unidimensional variable, as was done in most of these studies. The importance of measuring religionspirituality with multidimensional instruments is paramount rather than using questionnaires designed for other purposes with a few religiousspiritual items embedded within them. That being said, Vandecreek et al. (2004) used the CSQ not as a measure of religious coping but rather as a measure of general coping. Rather than relying on the CSQ subscale of praying or hoping to measure religious coping, they utilized the RCOPE to assess religionspirituality and its relation to coping with pain in 181 persons with rheumatoid arthritis. The RCOPE measures ve dimensions of religious coping: the search for meaning, control, comfort, intimacy, and life transformation. Only moderate correlations were found between religious and nonreligious coping methods, which suggests that, although there is some overlap, they are not one and the same. This supports the argument that religious coping is a complex phenomenon that is not well assessed with generic coping measures that contain several questions about religion. Religionspiritualitys relation to health outcomes. Several studies were designed to determine whether religionspirituality predicts certain mental or physical health outcomes. In a validation study of the World Health Organization Quality of Life Survey (WHOQOL-100), six domains of quality of life were measured in 106 patients with chronic pain. Religionspirituality was included as a domain of quality of life and was assessed by four items (Skevington, Carse, & Williams, 2001). All patients completed a 16-day inpatient pain management program and were given the WHOQOL-100 in addition to measures of negative mood, health status characteristics, and sociodemographic information before the program and 1 month after program completion. Spirituality religion did not show any signicant changes from pretreatment to posttreatment measurement and did not discriminate between overall levels of quality of life (poor vs. good). The domain of religionspirituality was correlated with mental health measures but was unrelated to measures of pain severity, pain distress, and the disruption of activities by pain. The authors explain this lack of association as evidence that spiritual beliefs may provide a useful detachment mechanism for coping with pain. In another study evaluating the relation between spirituality and quality of life, 77 patients with rheumatoid arthritis completed the Short Form Health Survey (SF-36), measuring quality of life; the Spiritual Transcendence Scale, measuring spirituality; the Center for Epidemiologic Studies Depression Scale, measuring depression, and the Affect Balance Scale (Bartlett, Piedmont, Bilderback, Matsumoto, & Barthon, 2003), measuring subjective well-being. Disease activity was assessed by rheumatologists and included number of swollen joints and duration of morning stiffness. Spirituality was an independent predictor of positive affect and selfratings of health on the SF-36, even after controlling for age, disease activity, physical function, and depressive symptoms.

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Longitudinal Studies
Of the studies reviewed, only one monitored patients over time to consider how daily spiritual experiences were related to pain. This methodology provided additional information that has not been able to be assessed with cross-sectional designs. Keefe et al.

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(2001) had 35 individuals with rheumatoid arthritis keep a structured 30-day diary of pain, mood, perceived social support, daily spiritual experiences, religious and spiritual pain coping, and daily religious and spiritual coping efcacy. Patients completed the diary at the end of each day and mailed it the next morning during the 30-day period. Compliance with this protocol was extremely high; 99% of the diaries were returned completed. Analyses revealed that persons who reported frequent daily spiritual experiences had higher levels of daily positive mood, lower levels of negative mood, and higher levels of social support; however, they did not show signicantly different levels of daily pain. Participants belief that their religious or spiritual coping controlled their pain on a given day, dened as spiritual and religious coping efcacy, was related to lower joint pain, better mood, and higher levels of social support. Because pain and spiritualreligious thoughts and behaviors were measured over time rather than once, it was discovered that measures of religion and spirituality were as variable over time as were measures of pain. This suggests that religionspirituality may vary over time and situations and that these variations are related in meaningful ways to pain and mood. The creative research design used by Keefe et al. (2001) was able to show both between-persons differences and within-person variability, providing a much more complete picture than a crosssectional design.

were measured at 3 and 6 months. After this 6-month preintervention stage, they completed the 3-day intercessory prayer intervention. When comparing the rst treatment group 6 months posttreatment with the wait-list controls who had not yet received treatment, the treated group had signicantly fewer mean number of swollen joints and lower perceived arthritis-related disability. Serious methodological problems exist with this study, mainly because of the lack of randomization, unequal sizes of the comparison groups, and a small convenience sample consisting mainly of elderly, retired White women. It also appears there may have been a self-selection bias, because the study sample was more religious than the general population.

Conclusions and Future Research Directions

The literature reviewed here supports the need for more research on the relation between religion and spirituality and health in persons with chronic pain. The following conclusions and future research needs are offered. First, many people with chronically painful illnesses appear to use religion or spiritual beliefs as one way to cope with their suffering (Abraido-Lanza et al., 2004; Bill-Harvey et al., 1989; Cronan et al., 1989). Attempts have been made to determine whether those with pain have stronger spiritual beliefs or feel closer to God than those who are not suffering from daily pain; however, methodological problems in the research have precluded clear answers. What has been established is that religious and spiritual levels in persons with chronic pain are not stable but rather uctuate over time (Keefe et al., 2001). Pargament (2002) has also provided evidence that ones religiousspiritual life may change over time and circumstance. A move from cross-sectional research to prospective or longitudinal designs will be necessary to better understand the potential variability of both religionspirituality and pain levels in chronic pain populations. Such designs may help to pinpoint the interaction of varying religiousspiritual levels and varying pain levels and whether this interaction has an effect on well-being and quality of life. Increased understanding of the variability of religious and spiritual beliefs over time may also shed light on the potential value or harm of religionspirituality over the course of a chronic pain condition. Second, research has suggested that religion and spirituality are related to various health outcomes, yet these ndings are mixed. For instance, certain cross-sectional studies have revealed that praying is related to increased pain (Rapp et al., 2000; Rosenstiel & Keefe, 1983), whereas other research suggests that prayer is associated with reduced pain (Turner & Clancy, 1986). To further complicate the picture, other research has been unable to document any relation between religionspirituality and pain (Abraido-Lanza et al., 2004; Keefe et al., 2001; Skevington et al., 2001). Positive religious coping and spirituality have been correlated with positive affect and psychological well-being but not with negative affect or depression (Abraido-Lanza et al., 2004; Bartlett et al., 2003; Bush et al., 1999). No relation has been reported between religion spirituality and quality of life in those with chronic pain (Skevington et al., 2001). Thus, although relations between health and religionspirituality have been established, there are many divergent ndings, and it is difcult to draw rm conclusions about the meaning of these results. Summarizing these ndings may be difcult in part because of

Experimental Designs
Experimental research designed to test a religious- or spiritualbased psychosocial intervention is sparse. Two studies were identied in which a spiritualreligious treatment was delivered to people with pain. Sundblom, Haikonen, Niemi-Pynttari, and Tigerstedt (1994) randomly assigned 24 patients with idiopathic chronic pain to either a spiritual healing condition or a no-active treatment condition. The participants in the former were treated three to eight times by the same female healing practitioner. The treatment condition lasted 40 min, during which the practitioner held her hands 20 cm above the patient using healing power, presented as originating from the Holy Ghost. The duration of treatment varied between patients because if the healer felt the patient was unresponsive to her treatment, she limited the treatment to three to four sessions. Those patients deemed responsive received up to eight sessions. There were no differences between the control and treatment groups in pain intensity or psychological distress 2 weeks posttreatment. This study is limited by the small sample size, lack of treatment manual, variability in amount of treatment provided, and absence of placebo therapy for the control group. Intercessory prayer was studied as an intervention for patients with rheumatoid arthritis (Matthews, Marlowe, & MacNutt, 2000). A nonrandomized convenience sample of 40 participants (82% female; 100% White) completed a 3-day spiritual intervention composed of group educational sessions on spiritual issues and healing and 6 hr of individualized soaking prayer, during which several prayer ministers prayed aloud and laid their hands over the painful parts of a participants body. The rst 29 volunteers attended the 3-day spiritual intervention; however, only 26 volunteers completed the follow-up measurements at 3, 6, 9, and 12 months. Thus, only 26 people were included in the analysis. The next 15 volunteers received baseline evaluation similar to the rst group and were then designated as a wait-list control in which they

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variations in conceptualizations of religion and spirituality in the studies reviewed. None of the studies dened religion or spirituality or distinguished between these two constructs. Too often the terms religion and spirituality are used interchangeably. However, it has been pointed out that religion can, and often does, exist without spirituality; the opposite is true as well (Hill et al., 2000; Lerner, 2000). Research has shown that different dimensions of religiousness or spirituality may be differentially related to both physical and mental outcomes (Musick, Koenig, Larson, & Matthews, 1998). Because religion and spirituality are multidimensional and complex phenomena, research needs to specify what features of these constructs are being measured (i.e., spiritual coping, transcendence) as well as a theoretical rationale for doing so. To better compare studies and make generalizations about the research, consensual conceptual denitions of spirituality and religiousness need to be adopted such as those articulated by the National Institute for Healthcare Research Panel (Larson et al., 1997). Not only is agreement needed over the denition of religion and spirituality but consistency in the measurement of these constructs as well. Many of the studies reviewed measured religionspirituality with just three items, which is highly restrictive and likely results in smaller effect sizes than would be observed if a greater number of items were used. Because of the complexity of these constructs, capturing the nuances and subtleties of religious and spiritual experiences is only possible through multidimensional measurement tools. One scale has been created through a core working group of the National Institute on Aging. The Multidimensional Measure of Religiousness/Spirituality for Use in Health Research measures 12 domains of religion and spirituality believed to be signicant for health outcomes (John E. Fetzer Institute/ National Institute on Aging Working Group, 1999). Third, there is a dearth of research on potential mediators of the relation between religionspirituality and health in chronic pain populations. Only one study reviewed sought to understand potential indirect relationships between religious coping and pain (Abraido-Lanza et al., 2004). Because of the complex nature of both religionspirituality and pain, expectation of univariate associations may be too simplistic. It is quite possible that other covariates are operating that can better explain the association between religionspirituality and health or pain levels. For instance, such constructs as forgiveness, hopelessness, spiritual maturity, religious history, and anger at God may mediate the relation between religionspirituality and health. Both potential positive mediators such as feelings of inner peace and negative mediators such as feeling unforgiven by God need to be considered. Future research should include adequate measures of potential mediators and use path analysis or structural equation modeling to help disaggregate direct from indirect effects. Fourth, more experimental studies are needed to examine whether a religiousspiritual intervention, or secular intervention with religiousspiritual components, is related to physical and mental health outcomes in those with chronic pain. It is estimated that the annual cost for health care and lost productivity of those with chronic pain is $100 billion (Zagari, Mazonson, & Longton, 1996), signifying that, indeed, chronic pain is a nancial burden to society. Managed-care and insurance companies would look favorably on more cost-effective as well as efcacious interventions for the treatment of chronic pain. Well-designed intervention stud-

ies are needed that use a standardized treatment, randomly assign participants, and have objective outcome measures.

Practice Implications
It is apparent that spiritualityreligiosity is of great importance to many people with chronic pain, is used as a form of coping, and is related to a variety of health outcomes. This suggests that it would be useful for health professionals to integrate and be aware of religiousspiritual factors when interviewing, assessing, and treating patients. When health professionals do this, it can promote clearer communication, improved rapport, and a more thorough conceptualization of patients, leading to more effective treatment. Perhaps more health professionals do not attend to spiritual and religious factors in patients because they view this as outside their area of expertise, and they are not clergy. Likewise, health professionals may think that if their belief system is different than that of their patients, the topic is off limits. This logic is faulty and could be compared with health professionals saying they can only help a patient who uses the exact coping mechanisms they do (Fitchett & Handzo, 1998). All health professionals should be able to talk with their patients about religionspirituality. This does not mean one needs to accept or reject the patients belief systems but rather that one should attempt to understand how the patients religiousspiritual beliefs may help or hinder them when coping with their health problems.

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Assessment
Taking a spiritual history can be a component of the initial patient interview. There are numerous models of assessing spiritualityreligion, and many reliable paper-and-pencil questionnaires. For more detailed reviews of spiritual and religious assessment tools, see Fitchett and Handzo (1998) and Gorsuch and Miller (1999). A brief assessment tool that can be administered in 2 min in any clinical interview uses the acronym FICA to remind practitioners to query about faith beliefs, importance of ones beliefs, community support available, and how the patient wants these beliefs addressed by the practitioner (Puchalski, 1999). This spiritual assessment is now taught at medical schools around the United States and is a brief way to gather important information that may be affecting a patients health and well-being.

Treatment
Typically, the interventions that have spiritual or religious components fall into one of two categories: those that are inherently spiritualreligious often from formal religious traditions (i.e., prayer, reading religious texts) and those that may exist in secular or spiritualreligious form (i.e., meditation, forgiveness therapy, cognitive behavioral therapy [CBT]). Despite a lack of empirical evidence for the value of religiousspiritual treatments, numerous articles and books describe approaches to religiousspiritual therapy (W. R. Miller, 1999; Richards & Bergin, 1997; Shafranske, 1996). Several interventions are described that practitioners could integrate into treatment depending on the clients needs and unique situation. Contact empathic listening. Giving patients a chance to describe their spiritual or religious beliefs in a supportive and empathic environment can be therapeutic in and of itself. Being able

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to tell their story may give patients insight and better understanding of the importance of religionspirituality to their health. Themes of hope, forgiveness, guiltshame, letting go, and spiritual growth can be addressed. Practitioners, by providing emotional support for patients belief system, afrm their worldview and encourage their use of it to cope. CBT. Many practitioners are well aware of the utility and effectiveness of CBT. Although it is a secular treatment, it can incorporate spiritualreligious components based on a patients needs. After assessing a patients religiousspiritual beliefs, a practitioner may become aware of the importance of these beliefs to the patient and can, therefore, integrate such aspects into treatment. For example, a patient may feel that his chronic pain is punishment by God for some sin he has committed. The patient may be holding on to the belief that God will relieve him of the pain once suffering has been proportionate to the transgression. Such beliefs will only impede any reduction in pain symptomatology and reduce overall self-efcacy for improvement. Helping the patient replace these negative thoughts and schemas with more productive thoughts could prove effective. Additionally, helping the patient think about what his or her faith says about suffering, personal trials, and worry can give the patient a new perspective on the pain, which can aid in the process of coping and acceptance. Connection to others. A spiritual assessment gathers information on a persons support system and whether or not he or she belongs to a spiritualreligious community. If a person does have such a community, encouraging connection to this for additional support is useful. Although all health professionals should be able to assess a persons religiousspiritual history, there may be situations in which a person is in spiritual crisis or is asking religious spiritual questions that the health professional feels unable to address. Referral to a hospital chaplain or other clergy member may be indicated. Personal practice. Research is beginning to study the effectiveness of certain religious practices such as prayer and meditation. The usefulness of prayer as an adjunct to medical care is largely uninvestigated, but some work suggests prayer can be used as a method for coping with stressful situations (e.g., Pargament, 1997). Meditation, which can be practiced from a spiritual or secular perspective, has been shown to reduce both physiological and psychological stress (e.g., Benson, 1996). Afrming any personal practices that help the patient cope is an important role of the practitioner. Throughout the process of assessing and treating patients from a religious or spiritual perspective, practitioners may encounter several challenges. First, it is important for practitioners to do a spiritual assessment of themselves so they are aware of their own belief system. This introspection will help practitioners avoid problems with transference and countertransference during treatment. Although it is not necessary for practitioners to denitively determine their religiousspiritual beliefs or their doubts and questions, the process will illuminate their feelings toward these topics and their willingness to address them with patients. Again, it is imperative that practitioners not impose any of their beliefs on their patients but rather support and attempt to understand their patients belief systems. Second, practitioners must be cognizant that, despite their best efforts to be open to discussing spiritual and religious beliefs with their patients, some people will feel their spiritualreligious lives are private and do not want to explore such topics in a clinical

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setting (Hodge, 2001). Respect for this is as important as respect for patients need to discuss their belief system. Finally, there are certain settings in which integrating religious spiritual components into assessment and treatment may be inappropriate (i.e., public education, state or federal government facilities). It seems that respect for the beliefs and needs of the patient is the best gauge for navigating in this area. Integrating spiritual and religious factors into assessment and treatment is risky for professionals because it requires them to delve into unfamiliar areas. However, the benets of such inquiry far outweigh the risk. Practitioners working with patients experiencing chronic pain or disability are urged to begin to address this often-overlooked aspect of patients lives. As Gorsuch and Miller (1999) have stated, It is odd indeed that this aspect of humanity [spiritualityreligion], so often experienced by clients as being central to their well-being, is so rarely measured or even asked about in clinical work (p. 60). Now is the time for change with greater research attention and improved clinical focus on this important aspect of patient care.

References
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Received January 28, 2004 Revision received March 18, 2005 Accepted March 25, 2005