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BY: MARY T. O’NEILL, D.Min., B.C.C. and CATERINA MAKO, Th.M., B.C.C.

The experience of pain is a complex phenomenon. Volumes are written on ways to alleviate pain in the body resulting from illness, surgery, disease.¹ Likewise, in recent years there has been increasing focus on the care of the whole person — on mind, body, spirit and emotion, not just bodily disease.²

Spiritual pain is a component of the psychosocial factors that contribute to a person's experience of pain.³ As such, it must be identified and treated.

Physical pain can be exacerbated by nonphysical causes, including the following:

• Fear
• Anxiety
• Grief and impending loss
• Unrecognized guilt
• Unmet spiritual needs
• Loss of control

Spiritual issues can have an impact on how one deals with physical pain. For example, a person may refuse medications or treatments for reasons based on belief systems, i.e., "God sent me this pain; therefore, I have to accept and endure it."

Unrelieved physical pain can cause emotional or spiritual pain and suffering. For example, a person might wonder why the pain was not relieved and may feel unduly punished.

Cultures and religious traditions also may influence how people interpret and deal with the experience of pain. Dame Cicely Saunders, the founder of the modern hospice movement, coined the term "total pain" to describe pain that is all-encompassing of mind, body, spirit and emotion in the person facing the end of life, as well as in that person's family.⁴

Spirituality is not just a part of us as human beings, it is intrinsic, our essence as humans. Rachel Naomi Remen describes it as "our birthright."⁵ Whether we acknowledge its presence or not, it is integral to our being human.

SOME DEFINITIONS OF SPIRITUALITY
Many writers have attempted to capture and define spirituality.⁶ Among the most classic of definitions is "the search for meaning and direction in life." It is beyond the physical and expresses a kind of beckoning (more than mere curiosity) of the self toward something greater than the self. It describes a sense of instinctive relatedness or connection to a power or energy that is real, though not material, that is both within and beyond the person. Some might call this interior dynamism "power" or "energy," God, Allah, Buddha or other deity or religious figure. Some people may be less specific and may regard spirituality as nature, the universe, etc. As human beings, we know it by direct experience and, for millennia, have expressed our encounters with it as "deep calling unto deep." It is a resource for strength, guidance, courage and support in life's journey.

Just as we live with varied cycles and levels of growth and development in our bodies, minds and emotions, so it is in spiritual development. While some may have a well-nurtured and developed spirituality, others may be underdeveloped, impoverished or even bankrupt in their spiritual selves. Most of us live in between these two poles. When a person is surprised or shocked by the advent of an illness, he or she can readily be thrown into the crisis of questioning, wondering and struggling to find meaning: "How do I cope with this?" "What does this mean for my life, my family, my future?" "Why is this happening?" "Where do I turn?" It is one's spiritual self that can be the resource for coping and inner strength in the struggle, mediating integration of the illness into its place in a still meaningful existence.

COMPONENTS OF SPIRITUALITY
There are four components generally associated with spirituality: belief, practice, awareness and experience.

• Belief includes a conviction about a domain or existence that goes beyond the material world
• Practice may involve exercises of expression and desire, such as prayer, contemplation, reading, reflection, meditation, poetry, participation in ritual and worship
• Awareness involves a consciousness of being moved by and responsive to this dimension that is other than and greater than ourselves
• Experience may be a simple knowing and connecting beyond the material world that evokes an inclination or movement toward an unseen "otherness" greater than the self, recognized from deep within the attentive self. This awareness or attunement may come unbidden in quiet moments of prayer or even in stressful situations where one might feel protected or companioned⁷

SPIRITUAL PAIN
The North American Nursing Diagnosis Association describes spiritual pain as "a disruption in the principle which pervades a person's entire being and which integrates and transcends one's biological nature."⁸ It is a state of disorder in a person's inner core. It might be a chronic or an acute heartache, an existential dissonance that expresses itself in behavioral incongruities. An important characteristic is that it is a pain appropriate medication does not relieve. The experiential features of spiritual pain may be demonstrated/established/verified in the following indicators:

• Disconnection from others; unwillingness to engage
• Preoccupation with self
• Feeling outcast and alone
• Expressing a loss of future
• Feeling abandoned
• Distress, despair, withdrawal
• No joy in anything
• Pain is fixed
• Feeling trapped
• Anger, shame, guilt

It is present in persons experiencing conflict between their beliefs and actual life events. They say any variety of the following: "I don't deserve this;" "I never hurt anyone." "Why is this happening to me?"

It is present in persons who suffer irreconcilable loss, whether physical or mental diminishment, material loss, loss of a relationship or impending loss of one's life. Persons are at risk for spiritual pain when they receive bad news about themselves or loved ones, or when they are told that curative treatment is now futile, or when loved ones become ill. A painful spiritual ache is the feeling of helplessness and hopelessness when one realizes there is nothing that anyone can do to prevent an undesirable outcome.

Persons are at risk for spiritual pain when they have deep feelings of loneliness or abandonment, when they hurt from missing loved ones, living or dead. Another risk factor is the absence of visitors. It is important to listen for expressions of fear or dread that might be uttered through dreams, or behaviors that speak of distrust or agitation. Today's focus on team-based delivery of patient-centered care should routinely prompt members of the interdisciplinary team to screen for spiritual pain as part of the ordinary medical encounter. This implies that team members be cognizant of their own spirituality and that they let go of the need to have answers for another person's questions of meaning and direction.

HOW SCREENING HELPS
Screening for spiritual pain helps identify and include spiritual care in the treatment plan. It also helps identify non-physical contributors to pain and promotes more effective pain management. But perhaps most importantly, it provides patients the opportunity to draw upon available resources that might help them cope with unrelieved physical pain.

For example:

• Prayer, relaxation techniques, rituals in the person's tradition, etc.
• Complementary modalities, such as imagery, music, arts, massage

Naming spiritual pain enables a person who is suffering to connect or reconnect to spiritual resources that may be underdeveloped and can grow, even as the physical body diminishes. It fosters an environment of sensitivity and caring for the whole person. This is important for the medical care team because engaging the patients' inner resources can have a deep impact on medical care goals to manage physical pain.

Keep in mind the following issues when screening for spiritual pain:

• Level of stress or distress with the diagnosis or prognosis

• The quality of relationships and support in the person's life
• The person's spiritual point of view and reference points
• The quality of religious involvement: none, occasional, regular
• The person's religious coping, whether positive or negative
• The person's feelings about a faith community of support.

SPECIALISTS MEET NEEDS
The assessment of spiritual pain does not mean that the person doing the assessing must be the one to meet the spiritual needs. Rather, he or she is the one to identify the possible spiritual pain. There are spiritual and religious resources that can assist the person in pain. Naming the spiritual pain affirms the person as an individual who is being human and not just an object of care. Similarly, it helps the person restore his or her dignity, which so easily can be lost in the medical setting when surrounded by technology and equipment.

Just as a physician may call upon a specialist in an area that requires focused expertise, so, when a spiritual pain is identified, the caregiver ought to call upon the expert in matters of spiritual pain — the chaplain. The task of the chaplain is to work with the patient to devise a plan of spiritual care that will address the pain that is specific to this person and, when appropriate, family members.

The starting point is always the patient and what his or her desires are for relief. Acute sensitivity and respect for the culture, traditions and perspectives of patient and family members are the hallmarks of this care. The chaplain evaluates how spirituality functions in that person's life and illness, and how it affects the person's experience of pain. The chaplain looks for issues of shame, guilt, fear, reconciliation needs, life review, coping and grief, among others. An important task is to enable the patient and family members to speak openly about the pain and to empower them to speak with each other in helpful and healing ways.⁹

HEALING BRINGS PEACE
While there is ongoing evaluation of the spiritual care treatment plan, the chaplain also keeps the interdisciplinary team apprised of the outcomes of care. These may include indicators such as:

• Is the patient coping better?
• Is the patient more peaceful?
• Is the patient more cooperative?
• Is the patient speaking about inner conflicts, reconciliation needs, grief, losses, regrets, impending or possible death, saying good-bye?

When medical treatment is no longer working, there is always room for spiritual care and support. Rituals and sacramental availability may be very meaningful to the patient and family members. A simple gesture like setting aside a little space in the room for symbols and sacred texts significant to the patient may prove very comforting. We can never underestimate the calming reach of music into the soul: favorite hymns, chants, relaxing tones or compositions often say what words cannot. This is a time to look for anything that helps the person experience hope, strength, comfort, peace. The selections are determined by what is meaningful for the patient and, in many cases, as recounted in dialogue with family members.

Ultimately, it helps to remember that in all care, healing is measured not by the condition of the body, but by the peace that surrounds and permeates the person.

MARY T. O'NEILL is vice president, spiritual care/pastoral education and CATERINA MAKO is director of chaplaincy at Catholic Health Services of Long Island, Rockville Centre, N.Y.

NOTES

1. Dennis C. Turk, Ronald Melzack, eds., Handbook of Pain Assessment, 2nd ed. (New York: Guilford Press, 2001).
2. Eduardo Bruera, Hak Nam Kim, "Cancer Pain," JAMA 290, no. 18 (2003): 2476-2479.
3. Sam H. Ahmedzai, Jason Boland, "The Total Challenge of Cancer Pain in Supportive and Palliative Care," Current Opinion in Supportive and Palliative Care 1 (April 2007): 3-5.
4. L. H. Heyse-More, "On Spiritual Pain in the Dying," Mortality 1 (1996): 297-315.
5. Rachel Naomi Remen, Kitchen Table Wisdom (New York: Riverhead Books, 2006).
6. Michael King and Harold Koenig, "Conceptualizing Spirituality for Medical Research and Health Service Provision," BMC Health Services Research 9 (2009): 116.
7. King and Koenig.
8. North American Nursing Diagnosis Association: NANDA Nursing Diagnoses: Definitions and Characteristics (Philadelphia: NANDA, 1992).
9. Eric J. Cassell, The Nature of Suffering and the Goals of Medicine, (New York: Oxford University Press USA, 1991).