A Review of the Role of Religion and Spirituality in ChronicPain Populations

A. Elizabeth RippentropUniversity of Iowa Hospitals and Clinics

Objective: To review the current literature on the relation between religiosity–spirituality and healthoutcomes in chronic pain populations, to discuss the clinical implications of this research, and to providesuggestions for future studies. Conclusions: Additional religion–spirituality research and clinical inter-vention with chronic pain populations is warranted for several reasons. First, many persons with chronicpain use religious and spiritual beliefs and activities to cope with pain. Second, a relation betweenreligion–spirituality and various health outcomes has been documented. Third, there is a lack of researchon potential mediators of the relation between religion–spirituality and health in chronic pain populations.Fourth, well-designed spiritual or religious behavioral interventions for patients with chronic pain aresparse.

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

Research has established a relation between religion–spiritualityand health (George, Larson, Koenig, & McCullough, 2000; Koe-nig, McCullough, & Larson, 2001; Levin, 1994). Although thisassociation 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 onthis topic (Kaplan, 2002; W. R. Miller, Thoresen, & Jones, 2003;Thoresen, 1999).

Most of the research on the relation between religion–spiritual-ity and health has focused on specific medical populations withpotential life-threatening diagnoses, such as cancer, coronary dis-ease, cardiovascular disease, and AIDS. An important health pop-ulation, however, has been somewhat overlooked in the researchthus far and deserves greater attention. The National Institute forHealthcare Research Panel, in their consensus report on scientificresearch on spirituality and health, recommended that future in-vestigations continue to focus on patient populations with condi-tions of most immediate concern to public health, both in terms ofsuffering and the economic burden to society (Larson, Swyers, &McCullough, 1997). In their list of populations to be studied werepatients with chronic illnesses not well treated by current methods,including chronic pain syndromes.

Chronic pain is now recognized as a major public health prob-lem (Arnoff, 1998) that creates a burden in lost productivity, taxrevenue, health care expenses, and disability benefits for society(Turk, 1996). It is estimated that the annual cost of chronic lowback 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 ofnociceptive stimulation results from continuous interaction of sen-sory, affective, and cognitive factors. This was the first theory toexplain how psychological variables, such as emotional stress, pastexperience, and other cognitive activities, have potentiating ormoderating effects on pain processing. It is plausible that religiousand spiritual beliefs may influence cognitive and emotional pro-cesses, which, in turn, may directly influence physiological mech-anisms, altering the experience of pain. Only continued researchwill be able to shed light on this possible relation.

Objectives and Design

The purpose of the current article is to review the literature onreligion and spirituality in chronic pain populations and to delin-eate future research directions and clinical implications. Literaturesources were identified using two strategies. First, computer liter-ature searches using Medline and PsychLIT systematically identi-fied studies with a combination of the following keywords: (a)chronic pain, myofascial pain, pain, arthritis, or fibromyalgia and(b) religion, religiosity, spirituality, religious coping, or spiritualcoping. Second, after retrieving articles based on the first strategy,the references were consulted to identify other studies not detectedin the first strategy. This review is based only on empirical studiesof populations with chronic pain resulting from musculoskeletalconditions or arthritis. All theoretical papers, book chapters, andreview papers were excluded. Studies reporting on pain conditionsrelated to terminal illness were also excluded.

Literature Review Results

The research studies on religion–spirituality in chronic painpopulations fall into four research methodology categories: (a)survey studies that document the frequency of different spiritual–

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

Rehabilitation Psychology2005, Vol. 50, No. 3, 278–284

Copyright 2005 by the Educational Publishing Foundation0090-5550/05/$12.00 DOI: 10.1037/0090-5550.50.3.278

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religious variables of those with chronic pain; (b) cross-sectionalresearch designs, in which certain characteristics of individualswith chronic pain are assessed at one point in time and correlatedwith other characteristics of those individuals; (c) longitudinalresearch designs in which persons with chronic pain are assessedat one point in time and then monitored for additional reassess-ments over time; and (d) experimental designs in which a specificspiritual or religious intervention is provided to people withchronic pain.

Survey Studies

Three survey studies were located that document the use ofprayer as a way of coping with pain. Cronan, Kaplan, Posner,Blumberg, and Kozin (1989) contacted 1,811 people in San Diegovalley by telephone using a random digit-dialing methodology toensure a random sample. Of this sample, 382 individuals reportedhaving a musculoskeletal complaint such as arthritis or neck–backpain. These persons were read a list of 19 nonmedical remedies forpain management (i.e., dietary and vitamin regimens, massagetherapy) and asked whether they had used any such strategies.Prayer was the nonconventional pain management remedy usedmost often in the previous 6 months. In a study of self-careactivities for arthritis used by minorities in an urban setting, 92%of African Americans and 50% of Hispanics reported using prayeras a way of coping with their pain (Bill-Harvey et al., 1989). Aqualitative study of 109 Latina women with arthritis demonstratedthat the second most common coping strategy was prayer andreligious beliefs or activities (Abraido-Lanza, Vasquez, & Echev-erria, 2004). Based on these studies, it appears that prayer may bea common coping strategy for dealing with physical pain andsuffering.

Cross-Sectional Studies

The majority of studies reviewed were cross-sectional. This isnot uncommon when examining the broader religion–spiritualityliterature, when much of the early research was simply the estab-lishment of a relation between religion–spirituality and health,typically with a cross-sectional design. In the cross-sectional re-search with chronic pain populations, such designs compare spir-itual and religious levels among different groups of people, exam-ine how religion and spirituality can be a means of coping withpain, and study the relation between religion and spirituality andvarious health outcomes.

Comparing groups on religion–spirituality measures. Severalstudies have compared different clinical groups’ levels of religion–spirituality. J. F. Miller (1985) compared a convenience sample of64 patients with rheumatoid arthritis and a random healthy controlsample of 77 university faculty members. The arthritis group hadhigher levels of spiritual well-being than the control group, whichthe author hypothesized may be due to chronic illness stimulatingthe person’s 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 patientswith pain had a variety of medical diagnoses, the most frequentlyrepresented of which were circulation problems (11%), respiration

problems (11%), and musculoskeletal conditions (10%). However,the author did not document the specific medical conditions of theparticipants in the acute versus chronic pain conditions. Spiritual-ity, as a domain of quality of life, did not differ among these threegroups. The author suggested that spirituality–religion may be anaspect of quality of life not affected by pain, which may helpexplain some of the comfort those who are suffering derive fromspirituality–religion.

Religion–spirituality as a means of coping with pain. Themajority of studies reviewed focus on religion–spirituality as ameans of coping with chronic pain. Six studies were located thatconsider 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 becausethe CSQ is well validated and has been used extensively inresearch on coping and adjustment to pain. The CSQ is a 42-itemchecklist that assesses seven different coping strategies, one ofwhich is Praying or Hoping. The Praying or Hoping subscaleconsists of six items, three of which specifically query aboutreligious coping and three which measure hoping. The studies inwhich the CSQ was used either utilized factor analysis to identifysuperordinate constructs relevant to coping or studied the Prayingor Hoping subscale and its association with health outcomes.

Rosenstiel and Keefe (1983) administered the CSQ to 61 pa-tients with low back pain, along with measures of average pain,current function, depression, anxiety, and somatization. A factoranalysis of the CSQ revealed three principal components, whichincluded cognitive coping and suppression, helplessness, and di-verting attention and praying. Participants who scored highly onthe diverting attention and praying factor were more functionallyimpaired and had higher pain levels than those who scored low onthis factor.

In another factor analysis of the CSQ with a group of 74 patientswith chronic low back pain, a similar three-factor solution wasfound (Turner & Clancy, 1986). However, unlike the Rosenstieland Keefe (1983) study, in which the component diverting atten-tion and praying was related to more pain, in the current study itwas related to less pain intensity. In comparing these divergentfindings, it is important to note that the demographic makeup of thesamples were quite different. In addition, pain levels were notmeasured in the same way. Although in both studies pain wasassessed by taking the average of three different measures (currentpain, most severe pain in past week, and least severe pain in thepast), Rosenstiel and Keefe (1983) measured this at one point intime. By contrast, Turner and Clancy (1986) had patients keep apain diary over the course of 1 week and rate their pain hourly;these ratings were then averaged. The latter method may haveprovided a more valid measurement of pain because of a greaternumber of measurements across time.

Rapp, Rejeski, and Miller’s (2000) factor analysis of the CSQwith 394 older adults with chronic knee pain revealed yet anotherpattern of responses. To reduce burden on study participants, 21 ofthe original 42 items on the CSQ were removed, and a factoranalysis was done on the abbreviated scale, revealing three factors:catastrophizing–prayer, ignoring–distracting, and reinterpretingsensation. It should be noted that, unlike the previous studiesreviewed, the praying and hoping items in this study did not loadtogether on one factor; rather, the catastrophizing items loadedwith praying. The authors believe this may be because theydropped disproportionately more hoping items. Multivariate anal-

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yses that controlled for demographics, health variables, pain fre-quency, and pain intensity revealed that catastrophizing–prayingwas significantly related to more self-reported disability and lessdistance walked on a 6-min walking test.

In a study of 200 Latinos with arthritis, the CSQ was used tomeasure coping and its relation to psychological adjustment andpain (Abraido-Lanza et al., 2004). Three of the seven subscales ofthe CSQ were used, including the Praying or Hoping scale, whichconsists of three questions measuring religious coping and threemeasuring hoping. In the current study, only the three religiouscoping items were used; the hoping items were deleted. To sup-plement the three religious coping items on the CSQ, the authorsused three items from the Use of Religion subscale of the Vander-bilt Multidimensional Pain Coping Inventory (Smith, Wallston,Dwyer, & Dowdy, 1997). The authors hypothesized that the effectsof religious coping on pain would be indirect. They believed thatreligious coping would increase acceptance of illness and self-efficacy over arthritis, which would then lead to decreased pain,decreased depression, and greater psychological well-being. Theirhypothesis was not supported, because a path analysis revealedthat religious coping did not have a direct effect on acceptance ofillness or self-efficacy and was not related to pain or depression.Religious coping was directly related to psychological well-beingbut not with psychological ill-being (i.e., depression). This study isan important addition because it considers possible mediatingfactors that might explain the complex relation between religionand health in those with chronic pain.

In all the coping studies reviewed thus far, religion–spiritualityhas been measured with the three items in the Praying or Hopingsubscale of the CSQ. Although Bush et al. (1999) also used theCSQ with a group of 61 people with chronic pain, they dropped allthe hoping–praying items from the CSQ and added a measure thatspecifically measured religious coping (Religious Appraisal andCoping Survey). The religious coping measure was created fromitems compiled from existing measures of religious coping fromPargament et al. (1990). The Religious Appraisal and CopingSurvey was factor analyzed and revealed a three-factor solution:positive religious coping, punishing God–negative religious cop-ing, and absent God–negative religious coping. Hierarchical mul-tiple regression analyses revealed that, after controlling for demo-graphic variables, pain specific appraisals, and nonreligious copingstrategies, positive religious coping was correlated with positiveaffect but not negative affect. Neither of the negative religiouscoping scales was correlated with positive or negative affect. Thisstudy is an improvement over studies discussed previously becauseit used a comprehensive and more multidimensional measure ofreligion rather than just three items. In addition, this study tookinto consideration the possible negative effects of religious coping.A weakness of the study is that the authors did not use a validatedreligion–spirituality measure.

In all but one of the studies reported, the Hoping or Prayingsubscale of the CSQ was used as the measure of religion–spiritu-ality. This is problematic because this scale consists of six items,only three of which measure a religious–spiritual activity, thatbeing prayer. Because the praying items are placed with the hopingitems, it is impossible to know whether prayer in and of itself isrelated to health. Moreover, the type of prayer measured is prayerasking for the pain to stop or lessen, which is a very narrow typeof praying. These items do not query, for instance, about prayingfor strength, acceptance, or peace. Furthermore, prayer is just one

aspect of religion–spirituality. In essence, it is impossible to mea-sure religion–spirituality with just three items and conceptualize itas a unidimensional variable, as was done in most of these studies.The importance of measuring religion–spirituality with multidi-mensional instruments is paramount rather than using question-naires designed for other purposes with a few religious–spiritualitems embedded within them.

That being said, Vandecreek et al. (2004) used the CSQ not asa measure of religious coping but rather as a measure of generalcoping. Rather than relying on the CSQ subscale of praying orhoping to measure religious coping, they utilized the RCOPE toassess religion–spirituality and its relation to coping with pain in181 persons with rheumatoid arthritis. The RCOPE measures fivedimensions of religious coping: the search for meaning, control,comfort, intimacy, and life transformation. Only moderate corre-lations were found between religious and nonreligious copingmethods, which suggests that, although there is some overlap,they are not one and the same. This supports the argument thatreligious coping is a complex phenomenon that is not well as-sessed with generic coping measures that contain several questionsabout religion.

Religion–spirituality’s relation to health outcomes. Severalstudies were designed to determine whether religion–spiritualitypredicts certain mental or physical health outcomes. In a validationstudy of the World Health Organization Quality of Life Survey(WHOQOL-100), six domains of quality of life were measured in106 patients with chronic pain. Religion–spirituality was includedas a domain of quality of life and was assessed by four items(Skevington, Carse, & Williams, 2001). All patients completed a16-day inpatient pain management program and were given theWHOQOL-100 in addition to measures of negative mood, healthstatus characteristics, and sociodemographic information beforethe program and 1 month after program completion. Spirituality–religion did not show any significant changes from pretreatment toposttreatment measurement and did not discriminate betweenoverall levels of quality of life (poor vs. good). The domain ofreligion–spirituality was correlated with mental health measuresbut was unrelated to measures of pain severity, pain distress, andthe disruption of activities by pain. The authors explain this lack ofassociation as evidence that spiritual beliefs may provide a usefuldetachment mechanism for coping with pain.

In another study evaluating the relation between spirituality andquality of life, 77 patients with rheumatoid arthritis completed theShort Form Health Survey (SF-36), measuring quality of life; theSpiritual Transcendence Scale, measuring spirituality; the Centerfor Epidemiologic Studies Depression Scale, measuring depres-sion, and the Affect Balance Scale (Bartlett, Piedmont, Bilderback,Matsumoto, & Barthon, 2003), measuring subjective well-being.Disease activity was assessed by rheumatologists and includednumber of swollen joints and duration of morning stiffness. Spir-ituality was an independent predictor of positive affect and self-ratings of health on the SF-36, even after controlling for age,disease activity, physical function, and depressive symptoms.

Longitudinal Studies

Of the studies reviewed, only one monitored patients over timeto consider how daily spiritual experiences were related to pain.This methodology provided additional information that has notbeen able to be assessed with cross-sectional designs. Keefe et al.

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(2001) had 35 individuals with rheumatoid arthritis keep a struc-tured 30-day diary of pain, mood, perceived social support, dailyspiritual experiences, religious and spiritual pain coping, and dailyreligious and spiritual coping efficacy. Patients completed thediary at the end of each day and mailed it the next morning duringthe 30-day period. Compliance with this protocol was extremelyhigh; 99% of the diaries were returned completed. Analyses re-vealed that persons who reported frequent daily spiritual experi-ences had higher levels of daily positive mood, lower levels ofnegative mood, and higher levels of social support; however, theydid not show significantly different levels of daily pain. Partici-pants’ belief that their religious or spiritual coping controlled theirpain on a given day, defined as spiritual and religious copingefficacy, was related to lower joint pain, better mood, and higherlevels of social support. Because pain and spiritual–religiousthoughts and behaviors were measured over time rather than once,it was discovered that measures of religion and spirituality were asvariable over time as were measures of pain. This suggests thatreligion–spirituality may vary over time and situations and thatthese variations are related in meaningful ways to pain and mood.The creative research design used by Keefe et al. (2001) was ableto show both between-persons differences and within-person vari-ability, providing a much more complete picture than a cross-sectional design.

Experimental Designs

Experimental research designed to test a religious- or spiritual-based psychosocial intervention is sparse. Two studies were iden-tified in which a spiritual–religious treatment was delivered topeople with pain. Sundblom, Haikonen, Niemi-Pynttari, and Ti-gerstedt (1994) randomly assigned 24 patients with idiopathicchronic pain to either a spiritual healing condition or a no-activetreatment condition. The participants in the former were treatedthree to eight times by the same female healing practitioner. Thetreatment condition lasted 40 min, during which the practitionerheld her hands 20 cm above the patient using “healing power,”presented as originating from the “Holy Ghost.” The duration oftreatment varied between patients because if the healer felt thepatient was unresponsive to her treatment, she limited the treat-ment to three to four sessions. Those patients deemed responsivereceived up to eight sessions. There were no differences betweenthe control and treatment groups in pain intensity or psychologicaldistress 2 weeks posttreatment. This study is limited by the smallsample size, lack of treatment manual, variability in amount oftreatment provided, and absence of placebo therapy for the controlgroup.

Intercessory prayer was studied as an intervention for patientswith rheumatoid arthritis (Matthews, Marlowe, & MacNutt, 2000).A nonrandomized convenience sample of 40 participants (82%female; 100% White) completed a 3-day spiritual interventioncomposed of group educational sessions on spiritual issues andhealing and 6 hr of individualized “soaking prayer,” during whichseveral prayer ministers prayed aloud and laid their hands over thepainful parts of a participant’s body. The first 29 volunteers at-tended the 3-day spiritual intervention; however, only 26 volun-teers completed the follow-up measurements at 3, 6, 9, and 12months. Thus, only 26 people were included in the analysis. Thenext 15 volunteers received baseline evaluation similar to the firstgroup and were then designated as a wait-list control in which they

were measured at 3 and 6 months. After this 6-month preinterven-tion stage, they completed the 3-day intercessory prayer interven-tion. When comparing the first treatment group 6 months post-treatment with the wait-list controls who had not yet receivedtreatment, the treated group had significantly fewer mean numberof swollen joints and lower perceived arthritis-related disability.Serious methodological problems exist with this study, mainlybecause of the lack of randomization, unequal sizes of the com-parison groups, and a small convenience sample consisting mainlyof elderly, retired White women. It also appears there may havebeen a self-selection bias, because the study sample was morereligious than the general population.

Conclusions and Future Research Directions

The literature reviewed here supports the need for more researchon the relation between religion and spirituality and health inpersons with chronic pain. The following conclusions and futureresearch needs are offered.

First, many people with chronically painful illnesses appear touse religion or spiritual beliefs as one way to cope with theirsuffering (Abraido-Lanza et al., 2004; Bill-Harvey et al., 1989;Cronan et al., 1989). Attempts have been made to determinewhether those with pain have stronger spiritual beliefs or feelcloser to God than those who are not suffering from daily pain;however, methodological problems in the research have precludedclear answers. What has been established is that religious andspiritual levels in persons with chronic pain are not stable butrather fluctuate over time (Keefe et al., 2001). Pargament (2002)has also provided evidence that one’s religious–spiritual life maychange over time and circumstance.

A move from cross-sectional research to prospective or longi-tudinal designs will be necessary to better understand the potentialvariability of both religion–spirituality and pain levels in chronicpain populations. Such designs may help to pinpoint the interactionof varying religious–spiritual levels and varying pain levels andwhether this interaction has an effect on well-being and quality oflife. Increased understanding of the variability of religious andspiritual beliefs over time may also shed light on the potentialvalue or harm of religion–spirituality over the course of a chronicpain condition.

Second, research has suggested that religion and spirituality arerelated to various health outcomes, yet these findings are mixed.For instance, certain cross-sectional studies have revealed thatpraying is related to increased pain (Rapp et al., 2000; Rosenstiel& Keefe, 1983), whereas other research suggests that prayer isassociated with reduced pain (Turner & Clancy, 1986). To furthercomplicate the picture, other research has been unable to documentany relation between religion–spirituality and pain (Abraido-Lanzaet al., 2004; Keefe et al., 2001; Skevington et al., 2001). Positivereligious coping and spirituality have been correlated with positiveaffect and psychological well-being but not with negative affect ordepression (Abraido-Lanza et al., 2004; Bartlett et al., 2003; Bushet al., 1999). No relation has been reported between religion–spirituality and quality of life in those with chronic pain (Skev-ington et al., 2001). Thus, although relations between health andreligion–spirituality have been established, there are many diver-gent findings, and it is difficult to draw firm conclusions about themeaning of these results.

Summarizing these findings may be difficult in part because of

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variations in conceptualizations of religion and spirituality in thestudies reviewed. None of the studies defined religion or spiritu-ality or distinguished between these two constructs. Too often theterms religion and spirituality are used interchangeably. However,it has been pointed out that religion can, and often does, existwithout spirituality; the opposite is true as well (Hill et al., 2000;Lerner, 2000). Research has shown that different dimensions ofreligiousness or spirituality may be differentially related to bothphysical and mental outcomes (Musick, Koenig, Larson, & Mat-thews, 1998). Because religion and spirituality are multidimen-sional and complex phenomena, research needs to specify whatfeatures of these constructs are being measured (i.e., spiritualcoping, transcendence) as well as a theoretical rationale for doingso. To better compare studies and make generalizations about theresearch, consensual conceptual definitions of spirituality and re-ligiousness need to be adopted such as those articulated by theNational Institute for Healthcare Research Panel (Larson et al.,1997).

Not only is agreement needed over the definition of religion andspirituality but consistency in the measurement of these constructsas well. Many of the studies reviewed measured religion–spiritu-ality with just three items, which is highly restrictive and likelyresults in smaller effect sizes than would be observed if a greaternumber of items were used. Because of the complexity of theseconstructs, capturing the nuances and subtleties of religious andspiritual experiences is only possible through multidimensionalmeasurement tools. One scale has been created through a coreworking group of the National Institute on Aging. The Multidi-mensional Measure of Religiousness/Spirituality for Use in HealthResearch measures 12 domains of religion and spirituality believedto be significant 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 therelation between religion–spirituality and health in chronic painpopulations. Only one study reviewed sought to understand poten-tial indirect relationships between religious coping and pain(Abraido-Lanza et al., 2004). Because of the complex nature ofboth religion–spirituality and pain, expectation of univariate asso-ciations may be too simplistic. It is quite possible that othercovariates are operating that can better explain the associationbetween religion–spirituality and health or pain levels. For in-stance, such constructs as forgiveness, hopelessness, spiritual ma-turity, religious history, and anger at God may mediate the relationbetween religion–spirituality and health. Both potential positivemediators such as feelings of inner peace and negative mediatorssuch as feeling unforgiven by God need to be considered. Futureresearch should include adequate measures of potential mediatorsand use path analysis or structural equation modeling to helpdisaggregate direct from indirect effects.

Fourth, more experimental studies are needed to examinewhether a religious–spiritual intervention, or secular interventionwith religious–spiritual components, is related to physical andmental health outcomes in those with chronic pain. It is estimatedthat the annual cost for health care and lost productivity of thosewith chronic pain is $100 billion (Zagari, Mazonson, & Longton,1996), signifying that, indeed, chronic pain is a financial burden tosociety. Managed-care and insurance companies would look fa-vorably on more cost-effective as well as efficacious interventionsfor the treatment of chronic pain. Well-designed intervention stud-

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

Practice Implications

It is apparent that spirituality–religiosity is of great importanceto many people with chronic pain, is used as a form of coping, andis related to a variety of health outcomes. This suggests that itwould be useful for health professionals to integrate and be awareof religious–spiritual factors when interviewing, assessing, andtreating patients. When health professionals do this, it can promoteclearer communication, improved rapport, and a more thoroughconceptualization of patients, leading to more effective treatment.

Perhaps more health professionals do not attend to spiritual andreligious factors in patients because they view this as outside theirarea of expertise, and they are not clergy. Likewise, health pro-fessionals may think that if their belief system is different than thatof their patients, the topic is “off limits.” This logic is faulty andcould be compared with health professionals saying they can onlyhelp a patient who uses the exact coping mechanisms they do(Fitchett & Handzo, 1998). All health professionals should be ableto talk with their patients about religion–spirituality. This does notmean one needs to accept or reject the patients’ belief systems butrather that one should attempt to understand how the patients’religious–spiritual beliefs may help or hinder them when copingwith their health problems.

Assessment

Taking a spiritual history can be a component of the initialpatient interview. There are numerous models of assessing spiri-tuality–religion, and many reliable paper-and-pencil question-naires. For more detailed reviews of spiritual and religious assess-ment tools, see Fitchett and Handzo (1998) and Gorsuch andMiller (1999). A brief assessment tool that can be administered in2 min in any clinical interview uses the acronym FICA to remindpractitioners to query about faith–beliefs, importance of one’sbeliefs, community support available, and how the patient wantsthese beliefs addressed by the practitioner (Puchalski, 1999). Thisspiritual assessment is now taught at medical schools around theUnited States and is a brief way to gather important informationthat may be affecting a patient’s health and well-being.

Treatment

Typically, the interventions that have spiritual or religious com-ponents fall into one of two categories: those that are inherentlyspiritual–religious often from formal religious traditions (i.e.,prayer, reading religious texts) and those that may exist in secularor spiritual–religious form (i.e., meditation, forgiveness therapy,cognitive–behavioral therapy [CBT]). Despite a lack of empiricalevidence for the value of religious–spiritual treatments, numerousarticles and books describe approaches to religious–spiritual ther-apy (W. R. Miller, 1999; Richards & Bergin, 1997; Shafranske,1996). Several interventions are described that practitioners couldintegrate into treatment depending on the client’s needs and uniquesituation.

Contact–empathic listening. Giving patients a chance to de-scribe their spiritual or religious beliefs in a supportive and em-pathic environment can be therapeutic in and of itself. Being able

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to tell their story may give patients insight and better understand-ing of the importance of religion–spirituality to their health.Themes of hope, forgiveness, guilt–shame, letting go, and spiritualgrowth can be addressed. Practitioners, by providing emotionalsupport for patients’ belief system, affirm their worldview andencourage their use of it to cope.

CBT. Many practitioners are well aware of the utility and effec-tiveness of CBT. Although it is a secular treatment, it can incorporatespiritual–religious components based on a patient’s needs. After as-sessing a patient’s religious–spiritual beliefs, a practitioner may be-come 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 punish-ment by God for some sin he has committed. The patient may beholding on to the belief that God will relieve him of the pain oncesuffering has been proportionate to the transgression. Such beliefswill only impede any reduction in pain symptomatology andreduce overall self-efficacy for improvement. Helping the patientreplace these negative thoughts and schemas with more productivethoughts could prove effective. Additionally, helping the patientthink about what his or her faith says about suffering, personaltrials, 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 informa-tion on a person’s support system and whether or not he or shebelongs to a spiritual–religious community. If a person does havesuch a community, encouraging connection to this for additionalsupport is useful. Although all health professionals should be ableto assess a person’s religious–spiritual history, there may be situ-ations in which a person is in spiritual crisis or is asking religious–spiritual questions that the health professional feels unable toaddress. Referral to a hospital chaplain or other clergy membermay be indicated.

Personal practice. Research is beginning to study the effec-tiveness of certain religious practices such as prayer and medita-tion. The usefulness of prayer as an adjunct to medical care islargely uninvestigated, but some work suggests prayer can be usedas a method for coping with stressful situations (e.g., Pargament,1997). Meditation, which can be practiced from a spiritual orsecular perspective, has been shown to reduce both physiologicaland psychological stress (e.g., Benson, 1996). Affirming any per-sonal practices that help the patient cope is an important role of thepractitioner.

Throughout the process of assessing and treating patients froma religious or spiritual perspective, practitioners may encounterseveral challenges. First, it is important for practitioners to do aspiritual assessment of themselves so they are aware of their ownbelief system. This introspection will help practitioners avoidproblems with transference and countertransference during treat-ment. Although it is not necessary for practitioners to definitivelydetermine their religious–spiritual beliefs or their doubts and ques-tions, the process will illuminate their feelings toward these topicsand their willingness to address them with patients. Again, it isimperative that practitioners not impose any of their beliefs ontheir patients but rather support and attempt to understand theirpatients’ belief systems.

Second, practitioners must be cognizant that, despite their bestefforts to be open to discussing spiritual and religious beliefs withtheir patients, some people will feel their spiritual–religious livesare private and do not want to explore such topics in a clinical

setting (Hodge, 2001). Respect for this is as important as respectfor patients’ need to discuss their belief system.

Finally, there are certain settings in which integrating religious–spiritual components into assessment and treatment may be inap-propriate (i.e., public education, state or federal government facil-ities). It seems that respect for the beliefs and needs of the patientis the best gauge for navigating in this area.

Integrating spiritual and religious factors into assessment andtreatment is risky for professionals because it requires them todelve into unfamiliar areas. However, the benefits of such inquiryfar outweigh the risk. Practitioners working with patients experi-encing chronic pain or disability are urged to begin to address thisoften-overlooked aspect of patients’ lives. As Gorsuch and Miller(1999) have stated, “It is odd indeed that this aspect of humanity[spirituality–religion], so often experienced by clients as beingcentral to their well-being, is so rarely measured or even askedabout in clinical work” (p. 60). Now is the time for change withgreater research attention and improved clinical focus on thisimportant aspect of patient care.

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Received January 28, 2004Revision received March 18, 2005

Accepted March 25, 2005 �

284 RIPPENTROP

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