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Are Spirituality and Religiosity Resources for Patients with Chronic Pain Conditions?

Arndt Büssing Prof Dr, MD, Andreas Michalsen Prof Dr, MD, Hans-Joachim Balzat MD, Ralf-Achim Grünther Dr, MD, Thomas Ostermann Prof Dr, PhD, Edmund A. M. Neugebauer Prof Dr, MD, PhD, Peter F. Matthiessen Prof Dr, MD
DOI: http://dx.doi.org/10.1111/j.1526-4637.2009.00572.x 327-339 First published online: 1 March 2009

Abstract

Objective. We studied whether or not spirituality/religiosity is a relevant resource for patients with chronic pain conditions, and to analyze interrelations between spirituality/religiosity (SpREUK Questionnaire; SpREUK is an acronym of the German translation of “Spiritual and Religious Attitudes in Dealing with Illness”), adaptive coping styles that refer to the concept of locus of disease control (AKU Questionnaire; AKU is an acronym of the German translation of “Adaptive Coping with Disease”), life satisfaction, and appraisal dimensions.

Patients. In a multicenter cross-sectional study, 580 patients with chronic pain conditions were enrolled.

Results. We found that the patients relied on both external powerful sources of disease control and on internal powers and virtues, while Trust in Higher Source (intrinsic religiosity) or Illness as Chance (reappraisal) were valued moderately; Search for Meaningful Support/Access (spiritual quest orientation) was of minor relevance. Stepwise regression analyses revealed that the internal sources of disease control, such as Conscious and Healthy Way of Living and Positive Attitudes, were (apart from the religious denomination) the strongest predictors of patients' reliance on spirituality/religiosity. Both behavioral styles were rated significantly lower in patients who regarded themselves as neither religious nor spiritual. Positive disease interpretations such as Challenge and Value were clearly associated with a spiritual quest orientation and intrinsic religiosity.

Conclusion. The associations between spirituality/religiosity, positive appraisals. and internal adaptive coping strategies indicate that the utilization of spirituality/religiosity goes far beyond fatalistic acceptance, but can be regarded as an active coping process. The findings support the need for further research concerning the contributions of spiritual coping in adjustment to chronic pain.

  • Spirituality
  • Religion
  • Coping
  • Life Satisfaction
  • Chronic Pain Conditions

Introduction

Although interest in spirituality and pain is relatively recent in terms of pain research, spirituality and pain have historically been intertwined, as the causes of pain are often elusive, and persistent pain may lead to suffering [1]. Spirituality and religion have a significant bearing on patients' beliefs about pain, strategies for coping with pain, and approaches to pain management. These beliefs are often unknown to health professionals, because spiritual issues are perceived as personal and private [2]. Suffering can lead one to wonder about the meaning and purpose of one's life, an attitude which is an integral aspect of spirituality [3–5].

In recent years, an increasing number of published studies, commentaries, and reviews have examined the connection between spirituality and religiosity, health, and quality of life, and its potential to prevent, heal, or cope with disease [6–11]. These studies indicate that religious involvement is related to better mental and physical health, improved coping with illness, and improved medical outcomes [12]. In fact, chronic pain patients are reported to use a number of cognitive and behavioral strategies to cope with their pain, including religious/spiritual forms of coping, such as prayer, and seeking spiritual support to manage their pain [13]. In chronic pain patients, positive religious coping strategies were associated with positive affect (mood) and religious outcome (i.e., spiritual growth, closeness to God, satisfaction with religious life), but not with pain-specific outcomes; however, negative religious coping strategies were not associated with any of the outcomes [14]. Yates et al. [15] reported that religious beliefs were positively associated with measures of well-being and less pain, particularly in patients with advanced cancer. A study by Rippentrop et al. [16] found that forgiveness, negative religious coping, daily spiritual experiences, religious support, and self-rankings of religious/spiritual intensity significantly predicted mental health status of patients with pain conditions, while spirituality/religiosity was unrelated to pain intensity and life interference due to pain.

However, the impact of spirituality/religiosity on health and disease-related aspects are highly dependent on the cultural context [17,18], and thus results from studies enrolling U.S. patients cannot be easily transferred to other countries. Moreover, it is a fact that secularization and individualization proceed in Europe [17], and thus we aimed to investigate spirituality/religiosity in patients with chronic pain conditions from Germany. The main focus of the analysis was not to prove the “effectiveness” of spirituality/religiosity in pain management, but to investigate whether spirituality/religiosity is a relevant resource at all for the patients. The second objective was to analyze interrelations between spirituality/religiosity, adaptive coping styles, life satisfaction, and disease interpretation (illness as something negative or even something positive). These aspects are (apart from effective pain reduction) end points of considerable importance in the management of chronic pain.

Methods

Patients

In this multicenter cross-sectional survey, we analyzed data from 580 patients, recruited at the outpatient pain clinic of the Communal Hospital in Herdecke (N = 153), the Department of Internal and Integrative Medicine at the Essen-Mitte Clinics (N = 329), the Orthopedic Clinic in Bad Bocklet (N = 78), and the Baumrain Clinic in Bad Berleburg (N = 20). Their institutional heads provided approval to conduct this anonymous survey. All individuals were informed of the purpose of the study, were assured of confidentiality, and consented to participate. The pseudonymous pooled data cannot be tracked back to the individual patients.

To minimize bias from convenience sampling, different medical centers in West Germany were chosen. Patients were recruited consecutively as they attended the respective clinics. Because we intended to have a more complete picture, we had neither inclusion nor exclusion criteria (with the exception of the diagnosis chronic pain disease and consent to participate). We cannot judge the exact response rates in the distinct institutions because we completely left it up to the recruiting physicians to ask patients who would be willing to complete the questionnaires. Even in the recruiting center, which added only 20 patients, we do not assume a strong selection bias, because they enrolled only patients with phantom pain after limp amputations. Moreover, because 50% of the patients did not regard themselves as religious, selection bias in favor of religious patients is unlikely. Less than 20 questionnaires were not completed and thus did not enter the database.

Measures

From a conceptual point of view, one should distinguish religious from spiritual attitudes. Spirituality is a complex and multidimensional issue, and can be defined as an individual and open approach in the search for meaning and purpose in life. In contrast, religion is an institutional and culturally determined approach that organizes the collective experiences of people (faith) into a closed system of beliefs and practices [4]. Spirituality can be found through religious engagement, through an individual experience of the divine, and/or through a connection to nature [4]. Thus, one should differentiate between spirituality in religion, which connotes a more open, individual, and pluralistic faith, and spirituality as opposed to religion (which rejects organized religiosity), thus defining it as multiple, individual “paths” to the one truth [5]. Tanyi [3] globally defined spirituality as humans' search for meaning in life, while religion involves an organized entity with rituals and practices about a higher power or God.

Spiritual and Religious Attitudes in Dealing with Illness

In order to examine how patients with severe diseases view the impact of spirituality/religiosity on their health and how they cope with illness, we have developed the SpREUK Questionnaire (SpREUK is an acronym of the German translation of “Spiritual and Religious Attitudes in Dealing with Illness”) [11,19–22], which measures spiritual/religious attitudes and convictions. This tool appears to be a good choice for assessing a patient's interest in spiritual/religious concerns, which is not biased for or against a particular religious commitment. The instrument relies on essential motifs found in counseling interviews with chronic disease patients (i.e., having trust/faith, search for a transcendent source to rely on/to keep grounded, hint to change life/message of disease) [23], and avoids exclusive terms such as God, Jesus, church, etc.

For this study, we have used the SpREUK version short-form 24, which differentiates three factors (Cronbach's alpha: 0.931): 1) Search for Meaningful Support/Access; 2) Trust in Higher Source; and 3) Positive Interpretation of Disease[in terms of reflection and change]). The SF-24 contains an additional nine-item factor to address Support of Life Through Spirituality/Religiosity (alpha = 0.963), which was evaluated only in patients who regarded themselves as spiritual and/or religious (as indicated by scores >2 in items “To my mind, I am a religious individual” and/or “To my mind, I am a spiritual individual”). To avoid exclusive definitions, which would restrict the highly individual view what spirituality might be to the patients, we completely left it up to respondents to assess whether they categorize themselves as religious and/or spiritual. The spiritual/religious self-categorization was regarded as an external indicator and not as a valid measure.

The factor Search for Meaningful Support/Access represents a spiritual quest orientation, which is founded on a willingness to question complex ideas; the persons are open to the exploration of existential questions and new information and doubts [24,25]. This factor is correlated with Martsolf and Mickley's Becoming domain [26], and thus related to existentialistic practices and spiritual (body–mind) practice [22,26].

Trust in Higher Source is a measure of intrinsic religiosity, which identifies religion as an end in itself. Characteristics of intrinsic religiosity are strong personal convictions, beliefs, and values that matter, while the social aspects of religion are not that important [24,25]. This factor refers to Martsolf and Mickley's Connecting domain [26] and Pargaments “Search for the Holy”[27], and thus correlated best with gratitude practice and a conventional religious practice [22,26].

In contrast, Positive Interpretation of Disease (it is possible to interpret illness as an opportunity, a hint to change life, or to reflect upon what is essential in life) refers to an appraisal coping. Nevertheless, it has a spiritual connotation [11,18,20], is associated with the Meaning domain of Martsolf and Mickley [26], and was found to correlate with an existentialistic insight practice and with Search for Meaningful Support[22,26]. However, even patients without an explicit interest in spirituality/religiosity can interpret illness as an opportunity to change life or to reflect upon what is essential in life.

The factor Support of Life Through Spirituality/Religiosity addresses the beneficial effects of spirituality/religiosity with respect to external dimensions, i.e., deeper connection with others and the world around, conscious management of life, as well as one that assesses internal dimensions, i.e., promotion of inner strength, feeling of inner peace, and health-related issues, i.e., better coping with illness, restoration of mental and physical health, etc. This factor was measured only in patients who valued themselves as spiritual/religious (according to the self-categorization).

The items of the SpREUK were scored on a five-point scale from disagreement to agreement (0—does not apply at all; 1—does not truly apply; 2—do not know; 3—applies quite a bit; 4—applies very much).

Spiritual and Religious Practices

To avoid an intermix of attitudes, convictions, and practices, the distinct forms and frequencies of spiritual/religious practices were measured with an additional manual, the SpREUK-P (P—practices) Questionnaire, which differentiates spiritual, religious, existentialistic, and philosophical practices [22,28]. The shortened SF-25 version (alpha = 0.916) has four factors: 1) Conventional Religious Practice/Gratitude (which includes praying, church attendance, etc.); 2) Existentialistic Practice (personal insight and development, but also an orientation to nature); 3) Spiritual Mind–Body Practices (such as meditation, rituals, etc.); and 4) Humanistic Practice (turning to and caring for others, etc.). The items of the SpREUK-P were scored on a four-point scale (0—never; 1—seldom; 2—often; 3—regularly). The scores are referred to a 100% level (4 “regularly” = 100%), which reflect the degree of an engagement in the distinct forms of a spiritual/religious practice (“engagement scores”).

Adaptive Coping with Disease

Adaptive coping styles, in terms of locus of disease control, were measured with the AKU Questionnaire (AKU is an acronym of the German translation of “Adaptive Coping with Disease”) [22,23,29], which was designed to differentiate active adaptive styles to cope with illness, i.e., create favorable conditions, search for information, medical support, religious support, social support, initiative spirit, and positive (re)interpretation of disease. The instrument demonstrated high internal consistency (Cronbach's alpha = 0.876). It differentiates the following six factors: Conscious and Healthy Way of Living (intrinsic locus of control), Positive Attitudes (intrinsic locus of control), Reappraisal: Illness as Chance (intrinsic, appraisal), Trust in Medical Help (external locus of control), Search for Information/Alternative Help (external locus of control), and Trust in God's Help (external locus of control).

Trust in God's Help in response to disease addresses nonorganized intrinsic religiosity, and can be regarded as an external transcendent locus of disease control. Conscious and Healthy Way of Living, as well as Positive Attitudes, are highly interconnected and address active, cognitive–behavioral styles as a response to deal with illness. Trust in Medial Help addresses an external locus of disease control, which refers to the pharmaceutical, technical, and the social dimensions of medicine, while Search for Information/Alternative Help refers to the search for additional information and ways of healing in a social context. Both factors are strongly interconnected because they refer to the need of an external intervention. Reappraisal: Illness as Chance refers to cognitive internal styles to cope with disease in terms of redefining the value of illness (appraisal).

The AKU bears an independent three-item scale termed Escape from illness, which is an indicator of an escape–avoidance strategy to deal with illness (i.e., “fear what illness will bring,” “would like to run away from illness,” “when I wake up, I don't know how to face the day”). In a study enrolling patients with depressive disorders, we demonstrated that this Escape scale correlated strongly with depression, with disease perceptions (appraisals) such as “weakness/failure” and “punishment,” and negatively with life satisfaction [30]. The items were scored on a five-point scale from disagreement to agreement.

The interpretation of illness was measured with eight items according to Lipowsky's “Meaning of Illness”[31], a scale which was recently validated [22]. This Interpretation of Illness Scale (IIS) includes positive interpretations (i.e., challenge, value), strategy-associated interpretations (i.e., relieving break of life, illness as a call for help), but also guilt-associated interpretations (i.e., punishment, weakness) and fatalistic negative interpretations (i.e., threat/enemy, irreparable loss/interruption of life). The items were scored on a five-point scale from disagreement to agreement.

Life Satisfaction

Life satisfaction was measured with a modified version of the Brief Multidimensional Students' Life Satisfaction Scale (BMLSS) [32,33]. This BMLSS addresses the following aspects: family life, friendships, work, myself, where I live, overall life, financial situation, and future perspectives. The instrument was currently validated in elderly patients (Büssing et al., submitted for publication), and thus can be used in this context. This tool has a six-point rating scale.

In all cases, the questionnaire scores were referred to a 100% level. Scores >50% indicate agreement, interest, or usage, while scores <50% represent disagreement or disinterest.

Statistical Analysis

anova, covariate interactions, correlation, and regression analyses were performed with SPSS for Windows 15.0 (SPSS Inc., Chicago, IL). In general, the sociodemographic variables were the independent variables, and the respective scales, the dependent variables. We judged P < 0.001 as highly significant, and P < 0.05 as significant.

Results

Demographic Characteristics

We analyzed 580 patients (80% female, 20% male; mean age 53.8 ± 14.4 years) with chronic pain conditions (mean duration of disease: 97 ± 59 months). Most of them were married (48%) or lived with a partner not married with (9%), 15% lived alone, 14% were divorced, and 14% were widowed. Most had a secondary education (Hauptschule; 47%), 24% a junior high school education (Realschule), 15% a high school education (Gymnasium), and 13% other.

The underlying pain conditions were heterogeneous: 16% had spine-associated pain syndromes (low back pain etc.), 13% fibromyalgia, 8% polyarthritis/-arthrosis, 5% migraine/headache, 4% chronic inflammatory bowel diseases, 4% cancer, 3% amputations, and 47% other pain syndromes or diseases.

Among the appraisal dimension, Irreparable Loss/Interruption of Life was rated highest (35% agreement), while positive interpretations were rated lower (Challenge: 16%, Strategy/Call for Help: 13%, Value: 10%, Relieving Break: 6%). Negative interpretations such as Punishment (9%) or Weakness/Failure (7%) were of minor importance to the pain patients. However, several rated Threat/Enemy as somewhat relevant (15%). Nevertheless, the study sample demonstrated a moderate rating score for Escape from Illness (mean value 51.9 ± 26.8), indicating that this escape–avoidance strategy was not of major relevance. To underline this, the Life Satisfaction sum score (mean value 66.0 ± 17.3) was moderately high.

Spiritual/Religious Attitudes

Despite the predominance of a Christian denomination (82%; 5% had other religious affiliations, 14% had none), 50% of the pain patients would not regard themselves as religious. At least 32% reported themselves as religious but not spiritual (R+S−), and 18% as both religious and spiritual (R+S+), while 8% regarded themselves as not religious but spiritual (R−S+), and 42% as neither religious nor spiritual (R−S−).

As shown in Table 1, the patients had moderate interest in spiritual/religious issues—i.e., we found moderate Trust in Higher Source and Positive Interpretation of Disease, while Search for Meaningful Support/Access was of minor relevance. Women had significantly higher Trust in Higher Source than men (F = 8.2, P = 0.004), which is in line with our previous findings [11,20,23].

View this table:
Table 1

Mean values (±SD) of 580 patients with chronic pain conditions

Independent VariablesMeans ± SDInterpretation (with Respect to the Respective Attitude or Engagement)
SpREUK (0–100)
  Search for Meaningful Support/Access40.3 ± 27.5Low
  Trust in Higher Source54.0 ± 29.4Moderate
  Positive Interpretation of Disease54.3 ± 23.0Moderate
Support of life through SpR (Benefit)60.4 ± 28.1High
Spiritual/religious practices (0–100)
  Conventional Religious/Gratitude41.0 ± 27.2Low
  Spiritual Mind–Body20.4 ± 22.9Very low
  Existentialistic57.2 ± 20.0Moderate
  Humanistic62.8 ± 18.9High
Adaptive coping (0–100)
  External locus of control
    Trust in Medical Help80.0 ± 18.9Very high
    Search for Alternative Help76.5 ± 18.4Very high
    Trust in God's Help55.6 ± 32.6Moderate
  Internal locus of control
    Conscious and Healthy Way of Living73.9 ± 15.9High
    Positive Attitudes70.3 ± 16.7High
    Reappraisal: Illness as Chance49.9 ± 26.2Moderate
  • SpREUK = German translation of “Spiritual and Religious Attitudes in Dealing with Illness.”

To address the circumstances that spirituality/religiosity may play a role in patients' lives, we measured the Support of Life Through Spirituality/Religiosity (Benefit) in those reporting being spiritual/religious. As shown in Figure 1, particularly religious and spiritual (R+S+) patients value the positive effects of spirituality/religiosity on their life concerns, but not the nonreligious/nonspiritual patients (R−S−).

Figure 1

Spiritual/religious attitudes and convictions of patients with chronic pain conditions with respect to their spiritual/religious self-categorization. Scores >50% represent a positive attitude (agreement), while scores <50% represent a negative attitude (disagreement). Mean values are significantly different (**P < 0.01; anova). SpREUK = German translation of “Spiritual and Religious Attitudes in Dealing with Illness”; R+S+ = religious and spiritual; R+S− = religious but not spiritual; R−S+ = not religious but spiritual; R−S− = neither religious nor spiritual.

Spiritual/Religious Practices

Next, we investigated forms and engagement frequency in spiritual/religious practices because convictions and attitudes are not necessarily identical with concrete engagement. As shown in Table 1, the patients relied predominantly on Humanistic and Existentialistic forms of practice rather than Conventional Religious Practices or Spiritual Mind–Body Practices, which were of minor relevance (Table 1).

Correlation Analyses

To define the putative field of relevance in pain patients' dealing with life and illness, we investigated the intercorrelations between spirituality/religiosity, appraisal dimensions, adaptive coping styles, and life satisfaction.

As shown in Table 2, Search for Meaningful Support/Access and Trust in Higher Source were strongly associated (r = 0.6) and correlated both with Positive Interpretation of Disease (r > 0.5), thus indicating that Reappraisal may have a spiritual connotation (Table 2). Similarly, we found that the positive disease interpretations Challenge and Value correlated particularly with Positive Interpretation of Disease (r > 0.4) and Search for Meaningful Support/Access (r > 0.3). Thus, intercorrelations between spiritual/religious issues and appraisal dimensions may have relevance for patients' coping with illness and decision making.

View this table:
Table 2

Correlations analyses

Search for Meaningful Support/AccessTrust in Higher SourcePositive Interpretation of DiseaseSupport of Life Through SpR (Benefit)
Spiritual/religious attitudes (SpREUK)
  Search for Meaningful Support/Access 1 0.639* 0.605* 0.506*
  Trust in Higher Source 1 0.505* 0.670*
  Positive Interpretation of Disease 1 0.440*
Spiritual/religious practices (SpREUK-P)
  Conventional Religious/Gratitude 0.470* 0.721* 0.261* 0.548*
  Spiritual Mind–Body 0.615* 0.525* 0.397* 0.579*
  Existentialistic 0.515* 0.451* 0.455* 0.464*
  Humanistic 0.239* 0.330* 0.125* 0.302*
Adaptive coping (AKU)
  External locus of control
    Trust in Medical Help 0.016 0.036 0.010−0.021
    Search for Alternative Help 0.176* 0.179* 0.173* 0.099
    Trust in God's Help 0.481* 0.778* 0.330* 0.488*
  Internal locus of control
    Conscious and Healthy Way of Living 0.180* 0.258* 0.163* 0.237*
    Positive Attitudes 0.199* 0.213* 0.239* 0.261*
    Illness as Chance 0.499* 0.434* 0.616* 0.452*
Escape from Illness 0.045−0.019−0.012−0.089
Life Satisfaction (BMLSS)
  Family life−0.061−0.077−0.067 0.201
  Friendships−0.025−0.030−0.019 0.094
  Work−0.015 0.010−0.050 0.052
  Myself 0.104 0.132 0.037 0.347*
  Where I live−0.046 0.008−0.027 0.140
  Overall life 0.076 0.138 0.077 0.262
  Financial situation 0.014 0.030 0.016−0.051
  Future perspectives 0.092 0.194* 0.051 0.376*
Appraisals (Interpretation of Illness)
  Fatalistic negative
    Enemy/Threat 0.084−0.011 0.015 0.003
    Irreparable Loss/Interruption−0.056−0.080−0.150*−0.076
  Guilt-associated negative
    Punishment 0.046−0.033 0.022−0.003
    Weakness/Failure 0.093−0.008 0.109* 0.085
  Strategy associated
    Relieving Break 0.193* 0.135* 0.194* 0.028
    Strategy/Call for Help 0.303* 0.198* 0.256* 0.055
  Positive
    Challenge 0.363* 0.284* 0.443* 0.326*
    Value 0.408* 0.346* 0.455* 0.291*
  • * Pearson correlation is significant at the 0.01 level (two-tailed).

  • SpREUK = German translation of “Spiritual and Religious Attitudes in Dealing with Illness”; AKU = German translation of “Adaptive Coping with Disease”; BMLSS, Brief Multidimensional Students' Life Satisfaction Scale.

Although the spiritual quest orientation and intrinsic religiosity were overlapping concepts, both were associated with unique engagement features (Table 2): The Search factor correlated strongly with Spiritual Mind–Body Practices and Existentialistic Practices (r > 0.5), while the Trust factor correlated best with Conventional Religious Practice/Gratitude (r = 0.7). This means that the intercorrelations between spiritual/religious attitudes/convictions and engagement in distinct spiritual/religious practices support the underlying concepts of spirituality/religiosity [4,11,18].

However, with the exception of the life satisfaction aspect Future Perspectives (r = 0.194), spirituality/religiosity did not correlate with the other life satisfaction aspects nor with Escape from Illness (Table 2). For religious and spiritual (R+S+) patients, the Life Satisfaction aspect Future Perspectives correlated moderately with Search for Meaningful Support/Access (r = 0.446), and myself (r = 0.434).

Who Has Interest in Spiritual/Religious Issues?

Renewed interest in spiritual/religious issues because of their illness was stated in 22% of patients, and only 21% are convinced that finding access to a spiritual source can have a positive influence on their illness. Consequently, 21% are searching for access to spirituality/religiosity. On the other hand, 58% are in search of grounding and meaning in their life, indicating that this issue was not expected in the context of spirituality/religiosity.

Forty-eight percent of pain patients believed that God will help them (AKU item a36), 49% prayed to become healthy again (item a38), and consequently, faith is a strong support for 49% even in hard times (item 37).

Associations Between Sociodemographic Variables and Spiritual/Religious Dimensions

The mean values of the SpREUK factors did not significantly differ with respect to duration of disease (F < 2.0). Other independent variables were associated with higher Trust in Higher Source/Access, i.e., Christian denomination (F = 15.127; P < 0.0001), higher age (F = 4.768, P < 0.0001), and female gender (F = 8.196; P = 0.004). Family status was relevant to Trust in Higher Source (F = 3.226; P = 0.013) and Positive Interpretation of Disease (F = 2.447, P = 0.046). In contrast, educational level had a strong association with Search for Meaningful Support/Access (F = 5.226; P < 0.0001) and Positive Interpretation of Disease (F = 2.948, P = 0.012). However, as shown in Figure 1, the strongest variances were found for the spiritual/religious self-categorization (F values ranging from 38.6 to 165.0, P < 0.0001).

Variance analyses (general linear model [GLM] univariate, between subject effects) revealed that gender, age, educational level, and religious denomination were not associated with the Search for Meaningful Support/Access and Positive Interpretation of Disease (Table 3). In contrast, age and religious denomination was significantly associated with Trust in Higher Source and Support of Life Through Spirituality/Religiosity (Table 3). Some minor interactions (F < 0.3; 0.01 > P < 0.05) of the independent covariates (educational level, age, and religious affiliation) were found only for Trust in Higher Source and with respect to Positive Interpretation of Disease (Table 3).

View this table:
Table 3

Covariates and interactions with respect to spiritual/religious attitudes and convictions (GLM univariate, between-subject effects)

Dependent VariablesIndependent VariablesF ValueSignificance*
1. Search for Meaningful Support/AccessGender1.437ns
Educational level1.758ns
Age group0.72ns
Religious affiliation1.489ns
Significant interactions:
2. Trust in Higher SourceGender1.6770.196
Educational level1.0410.393
Age group4.0260.001
Religious affiliation5.4040.005
Significant interactions:
  Gender × Age group2.5250.029
  Educational level × Religious affiliation2.3280.032
  Age group × Religious affiliation1.9850.04
  Gender × Age group × Religious affiliation2.8180.039
3. Positive Interpretation of DiseaseGender0.375ns
Educational level0.731ns
Age group0.569ns
Religious affiliation0.369ns
Significant interactions:
  Educational level × Age group × Religious affiliation2.1760.015
4. Support Through Spirituality/ReligiosityGender0.157ns
Educational level2.6460.025
Age group3.1250.01
Religious affiliation5.2350.006
Significant interactions:
  • * Levene's test for equality of variances was significant in all cases, and thus the level of significance should be P < 0.01.

  • Only statistically remarkable results were presented.

  • ns = not significant.

Predictors of Spiritual/Religious Issues in Pain Patients

To determine the predictors of the spiritual/religious issues found in patients with chronic pain conditions, we performed stepwise regression analyses. On the basis of variance and correlation analyses, the following variables emerged as significant: age, religious denomination, spiritual/religious self-categorization, Life Satisfaction, Conscious and Healthy Way of Living, and Perspectives and Positive Attitudes. We did not include the Reappraisal dimension because of a strong overlap with Positive Interpretation of Illness, which, by itself, was related to the Trust and the Search factor of spirituality/religiosity, respectively.

As shown in Table 4, the standardized beta coefficients indicate that the internal adaptive coping strategy, Positive Attitudes, was the strongest predictor for the Search factor, followed by religious denomination.

View this table:
Table 4

Predictors of spiritual/religious attitudes in chronic pain patients (stepwise regression model)

Dependent VariablesPredictors*R2*Unstandard CoefficientsStandard CoefficientsTSign. T
BStd. errorBeta
Search for Meaningful Support/Access(Constant)0.12312.6587.3961.7110.088
Perspectives and positive attitudes0.4640.0990.3004.6700.000
Religious denomination−3.0121.059−0.183−2.8460.005
Trust in Higher Source(Constant)0.16435.3508.2264.2970.000
Religious denomination−6.1281.174−0.326−5.2220.000
Perspectives and positive attitudes0.4190.1100.2383.8140.000
Positive Interpretation of Disease(Constant)0.12028.3978.4543.3590.001
Perspectives and positive attitudes0.2820.1070.2122.6270.009
Religious denomination−3.0180.910−0.213−3.3150.001
Conscious and healthy way of living0.2760.1210.1782.2820.024
Life satisfaction−0.1950.097−0.145−2.0190.045
Support Through Spirituality/Religiosity(Constant)0.11310.33812.7980.8080.421
Conscious and healthy way of living0.6390.1630.3353.9170.000
  • * Only the strongest prediction model was presented.

  • B = factor B; Beta = beta coefficient; Std. Error = standard error of B; T = t-test; sign. T = significance (T).

For the Trust factor, the standardized beta coefficients indicate that religious denomination was the strongest predictor, followed by Positive Attitudes (Table 4).

Positive Interpretation of Disease can be predicted best by Positive Attitudes, followed by religious denomination, Conscious and Healthy Way of Living, and Life Satisfaction.

The Support of Life Through Spirituality/Religiosity can be predicted alone by Conscious and Healthy Way of Living (Table 4).

Associations Between Spiritual/Religious Attitudes, Coping, and Disease Interpretation

The spiritual/religious convictions and attitudes of the patients are reflected in part by the spiritual/religious self-categorization. Therefore, we investigated the relevance of this self-categorization with respect to the utilization of adaptive coping styles, Escape from Illness, and life satisfaction.

As shown in Figure 2, patients with a religious attitude (R+S+ and R+S−) strongly relied on God's help, especially patients with a spiritual attitude (R+S+ or R−S+) who regarded their illness as chance (Reappraisal). The overall highly valued adaptive coping styles associated with an internal locus of disease control, i.e., Conscious and Healthy Way of Living and Positive Attitudes, were rated significantly lower in patients with a nonreligious/nonspiritual (R−S−) attitude. However, scores for Trust in Medical Help, Escape from Illness, and Life Satisfaction (neither the sum score nor any of the eight underlying life satisfaction aspects) did not significantly differ with respect to spiritual/religious self-categorization (Figure 2).

Figure 2

Adaptive coping strategies, Escape from Illness and Life Satisfaction of patients with chronic pain conditions with respect to their spiritual/religious self-categorization. Scores >50% represent a positive attitude (agreement), while scores <50% represent a negative attitude (disagreement). Mean values are significantly different (**P < 0.01; anova). AKU = German translation of “Adaptive Coping with Disease”; R+S+ = religious and spiritual; R+S− = religious but not spiritual; R−S+ = not religious but spiritual; R−S− = neither religious nor spiritual.

We hypothesized associations between spiritual/religious self-categorization and positive appraisals (Interpretation of Illness). In fact, we found significant (P < 0.001) differences, particularly for Value (F = 19.813) and Challenge (F = 15.752), i.e., the highest scores were found in patients with a religious attitude (either R+S+ or R+S−), and the lowest in nonreligious/nonspiritual (R−S−) patients. In contrast, the interpretation Irreparable Loss/Interruption of Life was highest in nonreligious patients (R−S− and R−S+; F = 3.819; P = 0.023), while Strategy/Call for Help was of higher relevance in patients with a spiritual attitude (R+S+ and R−S+; F = 3.846; P = 0.010). Moreover, Escape from Illness correlated significantly with Enemy, Loss, or Punishment (r > 0.3), but not with positive perceptions, such as Challenge or Value (r < −0.1).

Discussion

Spiritual/religious views can have a substantial impact on patients' understanding of pain and decisions about pain management [1]. Although not each patient with pain is suffering, suffering can lead one to reflect upon meaning and purpose of one's life. Although suffering is an important topic addressed by the world religions (i.e., Christianity, Judaism, Islam, Hinduism, Buddhism), we did not focus on management of suffering in the light of a patient's spiritual/religious attitude, but to investigate whether patients with chronic pain conditions rely on spiritual/religious resources.

Although suffering and pain may impact several aspects of a patient's life (and, of course, the utilization of spirituality/religiosity as a resource), the patients with chronic pain conditions analyzed herein were nevertheless satisfied with several aspects of their life. Moreover, they did not exhibit an (passive) escape–avoidance strategy (i.e., Escape from Illness). Apart from the highly valued, (active) adaptive coping styles associated with an internal locus of disease control (which were found to be the main predictors of an involvement in the spiritual/religious issues investigated herein), the medical locus of disease control was of higher relevance than the external fatalistic/divine locus of control. Nevertheless, about half of the patients had a strong belief that God will help them and prayed to become healthy again. This is in agreement with findings of Glover-Graf et al. [34] that the most frequent responses to pain were taking medication (89%) and praying (61%). However, they found that the majority of U.S. respondents perceived God or a spiritual power as helping them cope with pain and as a source of happiness, connection, and meaning in life. Similar attitudes, albeit to a lesser extent, were observed in the German study population, too. Of course, the cross-sectional study design limits causal inferences, and one may not generalize our findings to other settings. Moreover, one may argue that it is a limitation of this study that we did not consecutively enroll each patient attending the respective recruiting centers. Apart from cultural differences that may explain such differences in part, we do not assume a strong selection bias in favor of highly religious patients, because 50% of the patients did not regard themselves as religious at all.

In contrast to cancer patients who highly relied on spiritual/religious issues as a relevant resource [11,19,20,23], the majority of patients with chronic pain conditions had moderate or indifferent interest in spirituality/religiosity. To explain these differences, one may argue that cancer patients were much older, comprised a higher proportion of religious individuals, had a higher educational level—and a shorter course of disease. As shown in this investigation, age was relevant for the religious factor Trust in Higher Source. Because of the shorter course of illness found in cancer patients [11,23], one may speculate that they would rely more hopefully on spiritual/religious sources than the patients with chronic pain conditions, who may have experienced the limitations of the medical system and might have experienced abandonment by higher sources during their suffering. As a result, they may have lower trust in God's help. Rippentrop et al. [16] suggested that pain patients feel less desire to reduce pain in the world and feel more abandoned by God than the general population. They reported that private religious practice (e.g., prayer, meditation, etc.) was inversely related to physical health outcomes, indicating that those experiencing worse physical health were more likely to engage in private religious activities, but spirituality/religiosity was unrelated to pain intensity and life interference due to pain. Also, Aukst-Margetić et al. [35] reported that religiosity was not related to the intensity of pain perception.

In breast cancer patients, Aukst-Margetić et al. [35] found religiosity associated with older age and lower education and significantly lower prevalence of depression. In addition, they found that older women with pain diseases and older people of minority racial background used religious coping strategies more often to manage their pain than older Caucasian men [36]. We found similar correlations between the religious factor Trust in Higher Source and increasing age, but we did not find similar correlations with an escape–avoidance strategy or lower education level.

Nevertheless, although the reliance on spirituality/religiosity as a resource was much lower in patients with chronic pain conditions than in cancer patients [11,23], we identified patients which did rely on spiritual/religious issues, particularly older women and patients that regard themselves as both religious and spiritual (R+S+). It would, however, be an oversimplification to assume that these patients were less depressed, or would have had a higher life satisfaction just because of their religious/spiritual attitude. Rather, it is true that they cope differently; particularly, the nonreligious/nonspiritual (R−S−) patients do not regard their illness as a chance to reflect and change life (Reappraisal). Moreover, nonreligious/nonspiritual (R−S−) patients had significantly lower internal or behavioral coping styles, such as Positive Attitudes or a Conscious and Healthy Way of Living (which were overall highly valued). Although Irreparable Loss was the most highly rated appraisal in pain patients, they nevertheless interpreted their illness as a Challenge or Value, too. Both positive interpretations did correlate with the spiritual quest orientation and intrinsic religiosity. In summary, we found intercorrelations between spirituality/religiosity and positive appraisals, which were confirmed by strong correlations with Positive Disease Interpretation and Reappraisal: Illness as Chance. Also, breast cancer patients would choose the appraisal dimensions Challenge or Value [37,38]. Three years after their diagnosis, women with breast cancer who ascribed a negative meaning of illness (i.e., Enemy, Loss, Punishment) had significantly higher levels of depression and anxiety and poorer quality of life than women who indicated a more positive meaning [37]. Similar in our study, negative interpretations (i.e., Enemy, Loss, Punishment) correlated significantly with Escape from Illness, but not the positive appraisals (i.e., Challenge, Value). However, the disease interpretation Irreparable Loss/Interruption of Life was highest in nonreligious patients (either R−S− or R−S+), and thus one may consider a chance for a psychological intervention in this subgroup.

In our sample, the Reappraisal dimension (Illness as Chance and Positive Disease Interpretation) was valued by religious patients (R+S+ and R+S−). Particularly, this unique topic was of relevance for patients with chronic diseases [4,11,21]—and it is a measure independent of any religion or specific belief. This factor refers to an appraisal coping, but has nevertheless a spiritual connotation, and is conceptually associated with the Meaning domain of Martsolf and Mickley [26]. Moreover, it correlated well with Existentialistic Practice, and Search for Meaningful Support[11]. The factor Positive Interpretation of Disease was associated with positive appraisals, such as Challenge and Values. Nevertheless, even patients without an explicit interest in spirituality/religiosity can interpret illness as an opportunity to change life, or to reflect upon what is essential in life. This fact has to be taken into account for conventional care, and might be an opportunity to widen the perspective of these patients in the psychoemotional struggle with their disease. As mentioned by Bush et al. [14], practitioners of applied psychophysiology should assess their chronic pain patients' religious appraisals and religious coping as another important stress management strategy. In palliative care, the discussion of religious and spiritual/existential concerns should be encouraged, and it has been documented that resolution of religious and spiritual/existential concerns may greatly help pain control [39]. Kotur [39] recommended that pastoral care workers should be included in the multidisciplinary approach to patient care and pain management. A recent survey of chronic pain in Europe has shown that chronic pain of moderate to severe intensity occurs in 19% of adult Europeans, seriously affecting the quality of their social and working lives, and that very few were managed by pain specialists, and nearly half received inadequate pain management [40]. Thus, a comprehensive approach is needed.

One cannot ignore the fact that health policies focus on fast access to healing and throughput; therefore, addressing spiritual needs may not be practical for health professionals. Regardless of their own belief system, physicians should not allow their own bias to blind them to the possibility that spiritual/religious beliefs play an important role for their patients. Research indicates that health professionals can play an important role in enhancing psychospiritual well-being, i.e., self-awareness, coping and adjusting effectively with stress, relationships, sense of faith, sense of empowerment and confidence, and living with meaning and hope [41]. However, 23% of the patients investigated here would like to talk with a priest or chaplain about their spiritual needs, 20% had no partner to talk about these needs, while for 37%, it is important to talk with their medical doctor about these needs. Yet medical practitioners may lack the necessary time and skills to uncover and address spiritual needs of their patients [42]. Nevertheless, the findings support the need for further research concerning the contributions of spiritual coping in adjustment to chronic pain.

Acknowledgments

We are grateful to our patients for their willingness to fill in the questionnaires. This is a research project of the Interdisciplinary Center of Health Care Research, University Witten/Herdecke.

References

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