This article has been developed from the original work of Revd Robert Lloyd Richards who wrote the material for the MSc in Pain Management when he was a Senior Anglican Chaplain at the University Hospital of Wales NHS Trust and from a dissertation completed by Jamie Given, a previous MSc Student.
Patient accounts have praised the skills of doctors and nurses, but also highlight the lack of emotional and spiritual care (, ). Health care professionals are frequently asked by patients and family members, ‘What will happen to me?’ ‘Will I live?’ ‘What will life be like after this illness?’ . Despite the recognition that emotional and spiritual care are aspects of care integral to treating patients as people , there is evidence in the literature to suggest a lack of knowledge on the part of health professionals regarding these aspects of pain and suffering .
Spiritual pain is an elusive concept and difficult to define. Spirituality has been expressed in a number of ways such as searching for meaning, and adherence to a religion  and although there is evidence to show that spirituality enhances health, the literature fails to offer a clear definition of spirituality , and often this difficulty is articulated in other articles addressing spirituality (, ). Dyson et al  argue that although spiritual needs of patients is fundamental to providing holistic care, the assessment and meeting of those needs is impeded by inadequate definitions and conceptual frameworks.
Following a literature review, they suggest that emerging themes associated with spirituality can be utilised as a framework to give direction for future exploration on the concept of spirituality. The literature on spirituality raises important questions related to finding a clear definition of spirituality and distinguishing it from religion .
As we shall see, almost all the literature on spiritual pain makes some distinction between religion and spirituality, and however elusive a definition of spiritual pain may be, it is difficult to claim that spiritual pain is an illusion. Later, we will be looking at the idea of spiritual distress as a diagnosis and we will examine some of the research on the relationship between patient spirituality/religion and prognosis.
It is interesting to note how many different labels have been used to describe pain. No pain exists in isolation from the meaning and interpretation that is put upon it. More than that, there are also the potentially competing explanations of pain experience and thus its management. On the one hand, we can think of this from the patient’s perspective and on the other hand the health care professional’s. At some point between these two different perspectives or frames of reference, both cared for and carer have to co-operate in their management.
Ramsey  describes this in terms of a patient/doctor covenant. The idea of a covenant is one that has some power when we think of pain management. Within a covenant, there has to be a promise and commitment; there is a sense of shared goals seeking a good outcome, a commonality of interests and a sharing of meanings.
The more traditional model of viewing pain management is captured in the following figure (Fig.1.), but as we know, some painful conditions are rarely managed this simply and easily.
Fig. 1. A linear model of pain management.
This figure provides an example of a problem-solving process. Pain must be identified, its cause exposed and appropriate management sought, including types and levels of analgesia.
This kind of approach is, of course, wholly appropriate for uncomplicated acute pain scenarios. Nevertheless, the weakness of the linear approach is the assumption that the ‘problem’ i.e. the pain, can be fully identified and then causally linked and that a neat solution exists. Unfortunately, if the pain is not related to the patient as a person, the management of pain will not be effective.
Whatever the positive aspects of the linear model of pain management is, we need another model if we are going to look at pain management from the perspective of the patient. What follows is not so much a matter of treating pain as a problem that needs solving, but more a set of painful experiences which need managing.
Putting the person at the centre of the model means we can consider all the factors influencing the pain experience through a dynamic model based on an understanding of the two key frames of reference, that of the patient and that of the carer.
Taylor et al  illustrate the importance of understanding the beliefs and values that influence individuals’ decisions and conflicts, because ‘discrepant perceptions of the pain experienced among patients, caregivers and nurses can interfere with the satisfactory management of pain’.
Fig 2. A dynamic model for the management of pain
Far from being linear, both frames of reference overlap and provide the context in which joint management of pain takes place. There are four areas where this happens:
Shared knowledge: the health carer and the cared for have different knowledge of the pain. It is the patient who experiences the direct knowledge of the pain; it is the health carer who has the theoretical knowledge of the pain. Carers also experience pain and this may well enlarge their theoretical knowledge of pain, but the carer’s knowledge of the patient’s specific pain must, by definition, be theoretical. Within the covenant of pain management, is the patient’s direct knowledge of their specific pain of
more or less importance than the carer’s theoretical knowledge?
Shared meanings: what is meant by shared meanings is the agreement between patient and carer that they are both talking about the same thing. Some labels are easy to agree on, for example ‘postoperative’ pain. Others are not as easy. Chronic low back pain might be the label put on by a sufferer, while the carer who probably cannot find a ‘cause’ let alone a ‘solution’ might also add a label such a ‘psychological’ or ‘imaginary’ or even ‘malingerer’. If carer and patient do not share the same meanings about the experience of pain there can be no shared management.
Shared best interests: the idea of arguing for ‘best interests’ is notoriously prone to misinterpretation. Here, clearly the best interests of the patient must take priority, and the best interest of the patient in pain is to be pain free. In seeking this goal the carer may be aware of other interests of other people, or even the institution, and these may form part of his or her agenda. These range from pressure on beds, to the cost of drugs, to the research needs of the scientific community.
A shared best interest in terms of shared pain management has to be made explicit in the same way as any other factor. Hidden in best interest arguments are also issues of power and control. Patient-controlled analgesia may give significant control to the patient and is a good example of shared pain management, but in the end, it is not the patient who decides the lockout period. Equally important however, might be respecting a patient’s wish to tolerate a certain degree of, say, terminal pain in order to remain conscious and sufficiently functioning, in order to say goodbye to loved ones.
Shared understandings: many factors influence an understanding of the experience of pain. Psychological, sociological and spiritual aspects are found in most, if not all, painful situations and to neglect the understanding of these three aspects is to be lacking in the total management of pain. However, spiritual distress as a component of pain experience is one thing, spiritual pain as a genuine diagnosis is another. Opinions are divided as to whether spiritual pain is a distinct diagnosis, but there is little argument that spiritual pain can be a distinct component of other pain.
This shared management model is dependent upon, as well as creates, trust between carer and cared for. Within the shared management of pain, there is a giving and a receiving by both sides. Within the overlap of the frames of reference the patient can teach the carer as much as the other way round.
The area of shared management can itself be an area of pain experience. Objectively identifying and dealing with pain as if it was unrelated to the person whose pain it is, is not especially costly to the technician who ‘manages’ it. Interrelating with another person and seeking shared management of the person in pain, can itself be painful.
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