Integrating culture, religion, and clinical practice of pain experience

1. Introduction

2. Meaning and context in acute and chronic pain

Acute pain usually has a recent onset and an identifiable cause, and often settles as tissues heal. Chronic pain, defined in the eleventh revision of the International Classification of Diseases (ICD-11) as pain that persists or recurs for longer than three months, may continue after healing and is now recognized as a health condition in its own right [Citation3]. Psychosocial and cultural influences are not confined to the chronic phase. Expectation, attention and learning alter pain perception from the outset, as placebo analgesia and the effects of distraction show [Citation4]. Cultural norms also shape whether pain is voiced, concealed or brought to a clinician at all [Citation5]. What changes as pain persists is the scope of these influences. Over months, appraisals of threat and uncontrollability have more opportunity to affect disability, work and mood [Citation6]. In one systematic review, catastrophising predicted pain and disability at follow-up in most studies of acute, subacute and chronic low back pain that examined these outcomes [Citation7]. Cultural and religious meanings therefore matter across the course of pain, although their consequences may accumulate with time.

3. Religious frameworks of pain

Religious traditions offer resources for interpreting pain, but none offers a single view of it. Some interpretations within Christian traditions, traceable to early Christian writing, link suffering with the suffering of Christ and regard it as potentially redemptive, whereas others emphasize healing and the relief of suffering [Citation8]. Among Muslim patients with terminal hepatitis C in Pakistan, pain was variously understood as a source of strength, as something compensated in the hereafter and, for some, as punishment for wrongdoing [Citation9]. These views reflect one group of patients and should not be taken to represent Islamic teaching or Muslims generally. Some interpretations within Hindu traditions connect suffering with karma, whereas others emphasize acceptance, healing or spiritual development [Citation10]. Adherents differ in whether, and how literally, they apply such ideas to their own pain. Some religious and ascetic traditions include voluntary practices involving discomfort or pain that particular practitioners understand as spiritually meaningful; such practices are not representative of all adherents [Citation11].

These frameworks can make pain more bearable, but they are not uniformly helpful. Some patients in the Pakistani study understood pain as punishment and found that this helped them accept it [Citation9]. For others, a similar belief may bring guilt or self-blame. Certain interpretations that emphasize passive endurance may discourage some individuals from reporting pain or seeking treatment. Negative religious coping, such as feeling abandoned or punished by God, has been associated with poorer mental health [Citation2]. Faith should not be presumed to be either protective or a barrier; its influence depends on the meaning it holds for the individual.

4. Culture and the expression of pain

Culture shapes how pain is described, displayed and managed, but cultural groups are internally diverse and their boundaries are porous. A systematic review in chronic musculoskeletal pain found preliminary to moderate evidence that coping strategies, illness perceptions, self-efficacy and pain attitudes differ between racial, ethnic and national groups; for example, African American participants reported more use of praying and hoping than White participants [Citation12]. The included studies were of low to moderate quality, and group averages conceal wide individual variation. Biomedical care is not uniform either. The biopsychosocial model is widely accepted in pain medicine and underpins much multidisciplinary practice [Citation13]. A contrast between “Western” biomedicine and “non-Western” holistic perspectives is better read as a difference of emphasis that exists within both.

Indigenous perspectives show the same variety. First Nations, Inuit and Métis communities hold diverse understandings of pain, many of which place it within relational, communal and spiritual frameworks. Community-led research using Two-Eyed Seeing, which brings Indigenous and Western ways of knowing together, has been used to make pain research more relevant and respectful to Mi’kmaw communities [Citation14]. Culture does not always assist coping. In a qualitative study in one Mi’kmaw community, children were often stoic and hid their pain, described it through stories rather than numbers, and families reported feeling unheard and stereotyped when seeking care, which led some to avoid further care [Citation5]. Cultural norms and clinical assumptions can combine to delay recognition of pain.

5. Religiosity, spirituality and pain: what the evidence shows

Several mechanisms could link religiosity and spirituality with pain. Meaning-making may make pain seem less threatening and reduce catastrophic thinking; prayer, meditation and ritual may alter attention and arousal; and faith communities offer social support. These remain hypotheses more than established pathways. In a systematic review of 20 studies of adults with chronic pain, religiosity and spirituality were associated with better psychological function, whereas associations with pain intensity and physical function were weak, and no included study examined whether religiosity modifies the relationship between pain beliefs and outcomes [Citation15]. Associations of this kind cannot show that religiosity causes better adjustment. Interventional evidence is sparse. One randomized trial of Islamic spiritual therapy in women with chronic pain reported reductions in pain intensity and catastrophising [Citation16]. A single trial in one population, however, does not establish effectiveness elsewhere. On present evidence, asking about spiritual resources and struggles is well justified; offering spiritual interventions as a treatment for pain is not yet.

6. Clinical implications

The evidence reviewed here supports specific practices more firmly than broad claims about the benefits of cultural or spiritual integration.

7. Conclusion

Culture, religion and spirituality shape pain from its onset, and they can help or hinder recovery. The evidence is strongest for associations with psychological adjustment and weaker for effects on pain intensity, function or treatment outcomes. It supports respectful enquiry, shared decision-making, interdisciplinary referral and care that does not presume a person’s beliefs from the group they belong to. Whether culturally or spiritually adapted interventions improve pain, function or adherence remains an open question. It is best answered by adequately powered trials co-designed with the communities concerned, using outcome measures that capture meaning and participation as well as pain intensity.