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October 2008 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Wachholtz, A. B. and Pargament, K. I. "Migraines and meditation: Does spirituality matter?" Journal of Behavioral Medicine 31, no. 4 (August 2008): 351-366.


SUMMARY and COMMENT: This month's featured study builds upon previous research by the authors that was highlighted in our December 2005 Article-of-the-Month, which indicated that a spiritual meditation practice showed greater efficacy in influencing some health outcomes than did a secular meditation or a relaxation exercise. The affected outcome of greatest interest in the earlier study was pain tolerance, and in the new study pain is a principal focus, particularly headache pain. This work by Amy Wachholtz, PhD, MDiv, and Kenneth Pargament, PhD, adds to a small but growing body of research which shows that explicitly spiritual practices--even simple, teachable, non-denominational ones--may hold greater benefit for patients than meditative practices that are not explicitly spiritual. This line of research may come to support chaplains as professionals best suited to facilitate patients' spiritual coping with certain problems like pain, inasmuch as chaplains should have special capacity to engage spirituality issues explicitly.

The study was conducted with 83 migraine sufferers (out of an original sample of 92), 75 of whom were women, and 9 were men. The group "consisted largely of undergraduate students" [p. 364]. Participants were divided into four groups for Spiritual Meditation, Internal Secular Meditation, External Secular Meditation, and Relaxation, with each group practicing meditation/relaxation for one month.

Meditation participants were instructed to begin their meditation by softly repeating their meditation aloud a few times to help them focus, and then to continue to silently focus on the phrase, and how the phrase is reflected in their lives. If the participants felt they were losing focus, they should repeat the phrase aloud to refocus and then continue with the silent meditation. All meditation participants received the same training; the only difference was the set of meditative phrases available from which they could choose. Spiritual Meditation participants were allowed to choose one of four spiritual meditative phrases: "God is peace," "God is joy," "God is good," and "God is love." Those who were uncomfortable with the term "God" were allowed to choose another term that they felt better reflected the focus of their spirituality, only one participant chose to use an alternate term. He chose to use "Mother Earth" instead of "God." Internal Secular Meditation participants chose from four internally focused secular phrases: "I am content," "I am joyful," "I am good," "I am happy." In the External Secular Meditation group, participants chose from four externally focused secular meditation phrases: "Grass is green," "Sand is soft," "Cotton is fluffy," "Cloth is smooth." The participants were asked to practice their meditation for 20 min per day for 30 days. Relaxation participants were taught a progressive muscle relaxation…in which they tensed and released muscle groups in their bodies. The relaxation group was not provided a meditation phrase. [p. 358]

The results:

  • "[T]he Spiritual Meditation group showed a significantly greater reduction in headache frequency than all three other groups," with the effect size being "strong" [p. 359].
  • "[T]he Spiritual Meditation group reported a significantly greater increase in pain tolerance compared to the other groups," with the effect size being "moderate" [p. 359]. "[T]he practice of spiritual meditation in this study did not alter people’s sensitivity to pain (based on ratings of pain severity), but it did alter how well they tolerated those pain levels" [p. 366].
  • "[T]he Spiritual Meditation group experienced a greater drop in negative affect scores compared to the other groups," with the effect size being "moderate" [p. 359].
  • "The Spiritual Meditation group experienced a significantly larger decrease in trait anxiety compared to the other groups," with the effect size being "small to moderate" [p. 361].
  • "[T]he Spiritual Meditation group reported greater increases in headache self-efficacy over the course of the study than the other groups," with the effect size being "moderate" [p. 361].
  • "The Spiritual Meditation group reported a greater increase in daily spiritual experiences over the course of the study than the other groups," with the effect size being "modest" [p. 362].
  • "[T]he Spiritual Meditation group experienced a greater increase in existential well being than the Internal Secular Meditation…and External Secular Meditation…groups," with the effect size being "small" [p. 362].
  • While some improvement in spiritual well-being was found among the Spiritual Meditation group, it was also--if to a lesser extent--found "among the secular meditation and relaxation groups," which may suggest that "even secular meditation techniques may enhance the individual’s spiritual well-being by setting aside daily time to reduce the external noise of life and focus on quieting the self. ...Thus, the distinction between 'secular' and 'spiritual' meditation may be overdrawn" [p. 363].
  • There was no significant differences observed between the groups regarding positive affect, depression, migraine-specific quality-of-life, or Spiritual Well-Being/Religious Well-Being.

The authors discuss their study's limits [--see p. 364], but the results noted above are worth careful consideration. For this reader, two findings stand out: First, the improvement in pain tolerance, as measured by the amount of time participants could hold their hand in a cold water bath, is remarkable. The Spiritual Meditation group was able to go from 39.1 seconds to 112.1 seconds, on average [--see Table 2, p. 360]. The External Secular Meditation group went from 43.1 to 70.2, the Relaxation group went from 44.6 to 63.2, and Internal Secular Meditation group only went from 43.7 to 47.1. In the practical world of patient care, an increase in pain tolerance may be almost as important as a reduction of pain itself, and this is the sort of finding that can forge new alliances between clinicians and chaplains. Second, the number of migraines per month was reduced from an average of 13.7 to 8.7 for the Spiritual Meditation group [--see Table 2, p. 360]. In practical terms, for migraine sufferers, who often find pharmacological remedies inadequate and therefore relief elusive, having perhaps an average of one less migraine a week would seem to constitute a noticeable improvement from a patient perspective (and maybe even more so in light of the potential for increased pain tolerance whenever a migraine did occur). Chaplains may wish to explore opportunities to work with migraine sufferers as a group in which spiritual interventions could lead to measurable outcomes.

One final comment: This article is much easier to read than the earlier work that appeared as our December 2005 Article-of-the-Month. It is well organized, clearly written, and illustrated with graphs of the findings, tables giving data and demographic information, and a figure showing the division of groups.


Suggestions for the Use of the Article for Discussion in CPE: 

CPE students at all levels should be able to engage this material. While quite a bit of statistical information is presented, it is largely relegated to tables and parenthetical notes, such that it tends not to interrupt the narrative flow of the report. Several graphs [p. 361] well display key changes between pre-treatment and post-treatment data. The authors offer a good introduction that includes an overview of research, they then clearly lead the reader through their methodology and findings, and wrap up with a discussion that takes into account clinical implications. The most salient topics for discussion with students are probably the nature of the intervention(s) and the role of spirituality in pain control. Why might an explicitly spiritual intervention produce a greater effect than the other interventions tested, and how might the particular spiritual intervention here be similar or dissimilar to the sorts of meditation/prayer interventions that chaplains typically use? Students should be asked to consider the interplay of the various factors identified in the study: for instance, how patients might both experience fewer headaches and have increased pain tolerance for those that that do occur. Self-efficacy may be a particularly valuable concept to discuss, and students might relate the concept to their goals in pastoral care: How, for instance, is the concept related to chaplains' efforts to follow the patient's lead or to empower patients? [For more on self-efficacy, see sections II and III of Related Items of Interest, below.] Finally, students may wish to practice the various meditation/relaxation practices outlined in the study and then discuss them in a follow-up session.


Related Items of Interest:

I. Other articles by Amy B. Wachholtz or Kenneth I. Pargament, especially with regard to issues of pain and spiritual coping.

Bush, E. G., Rye, M. S., Brant, C. R., Emery, E., Pargament, K. I. and Riessinger, C. A. "Religious coping with chronic pain." Applied Psychophysiology & Biofeedback 24, no. 4 (December 1999): 249-260. [(Abstract:) This study examined the role of religious and nonreligious cognitive-behavioral coping in a sample of 61 chronic pain patients from a midwestern pain clinic. Participants described their chronic pain and indicated their use of religious and nonreligious cognitive-behavioral coping strategies. Results supported a multidimensional conceptualization of religious coping that includes both positive and negative strategies. Positive religious coping strategies were associated significantly with positive affect and religious outcome after statistically controlling for demographic variables. In contrast, measures of negative religious coping strategies were not associated significantly with outcome variables. Several significant associations also were found between nonreligious cognitive-behavioral coping strategies and outcome variables. The results underscore the need for further research concerning the contributions of religious coping in adjustment to chronic pain. Practitioners of applied psychophysiology should assess their chronic pain patients' religious appraisals and religious coping as another important stress management strategy.]

[Added 8/13/14] Dezutter, J., Wachholtz, A. and Corveleyn, J. [Department of Psychology, Catholic University of Leuven, Belgium]. "Prayer and pain: the mediating role of positive re-appraisal." Journal of Behavioral Medicine 34, no. 6 (Dec 2011): 542-549. [(Abstract:) The present study explored in a sample of Flemish pain patients the role of prayer as a possible individual factor in pain management. The focus on prayer as a personal religious factor fits with the current religious landscape in Western-Europe where personal religious factors are more important than organizational dimensions of religion. Our study is framed in the transactional theory of stress and coping by testing first, whether prayer was related with pain severity and pain tolerance and second, whether cognitive positive re-appraisal was a mediating mechanism in the association between prayer and pain. We expected that prayer would be related to pain tolerance in reducing the impact of the pain on patient's daily life, but not necessarily to pain severity. A cross-sectional questionnaire design was adopted in order to measure demographics, prayer, pain outcomes (i.e., pain severity and pain tolerance), and cognitive positive re-appraisal. Two hundred and two chronic pain (CP) patients, all members of a Flemish national patients association, completed the questionnaires. Correlational analyses showed that prayer was significantly related with pain tolerance, but not with pain severity. However, ancillary analyses revealed a moderational effect of religious affiliation in the relationship between prayer and pain severity as well as pain tolerance. Furthermore, mediation analysis revealed that cognitive positive re-appraisal was indeed an underlying mechanism in the relationship between prayer and pain tolerance. This study affirms the importance to distinguish between pain severity and pain tolerance, and indicates that prayer can play a role in pain management, especially for religious pain patients. Further, the findings can be framed within the transactional theory of stress and coping as the results indicate that positive re-appraisal might be an important underlying mechanism in the association between prayer and pain. (NOTE: This article is part of a theme issue of the journal on spirituality & health.)]

Kaplar, M. E., Wachholtz, A. B. and O'Brien, W. H. "The effect of religious and spiritual interventions on the biological, psychological, and spiritual outcomes of oncology patients: a meta-analytic review." Journal of Psychosocial Oncology 22, no. 1 (2004): 39-49. [In addition to biomedical forms of treatment, many cancer patients have elected to use complementary and alternative medicine (CAM) of a spiritual or religious nature. However, the effectiveness of such spiritual and religious interventions is uncertain. Using a meta-analytic approach, the present study synthesized available treatment-outcome studies on spiritual and religious interventions for cancer patients to determine the efficacy of such interventions. Effect sizes were calculated for three types of outcome measures: biological, psychological, and spiritual. The authors found that nondrug spiritual and religious interventions produced small to moderate effect sizes for treatment versus control comparisons and small effect sizes for preversus posttreatment comparisons. Studies that used psychedelic drugs to promote spiritual experiences produced large effect sizes for both treatment versus control and preversus posttreatment comparisons. Finally, they found that, overall, treatment versus control comparisons produced larger effect sizes than did preversus posttreatment comparisons. Limitations of the studies discussed in the present meta-analysis included the lack of control groups, randomization, and a large number of participants. The results suggest that there is a shortage of sufficiently detailed, high-quality treatment outcome studies examining the efficacy of spiritual and religious interventions for oncology patients.]

Keefe, F. J., Affleck, G., Lefebvre, J., Underwood, L., Caldwell, D. S., Drew, J., Egert, J., Gibson, J. and Pargament, K. "Living with rheumatoid arthritis: the role of daily spirituality and daily religious and spiritual coping." Journal of Pain 2, no. 2 (April 2001): 101-110. [(Abstract:) The objective of this preliminary study was to evaluate more fully the role of daily spiritual experiences and daily religious/spiritual coping in the experience of individuals with pain due to rheumatoid arthritis (RA). Thirty-five individuals with RA were asked to keep a structured daily diary for 30 consecutive days. The diary included standardized measures designed to assess spiritual experiences, religious and spiritual pain coping, salience of religion in coping, religious/spiritual coping efficacy, pain, mood, and perceived social support. The participants in this study reported having spiritual experiences, such as feeling touched by the beauty of creation or feeling a desire to be closer or in union with God, on a relatively frequent basis. These participants also reported using positive religious and spiritual coping strategies much more frequently than negative religious and spiritual coping strategies. Although most of the variance in these measures was due to differences between persons, each measure also displayed a significant variability in scores from day to day. Indeed, there was just as much (or more) variability in these measures over time as there was variability in pain. Individuals who reported frequent daily spiritual experiences had higher levels of positive mood, lower levels of daily negative mood, and higher levels of each of the social support domains. Individuals who reported that religion was very salient in their coping with pain reported much higher levels of instrumental, emotional, arthritis-related, and general social support. Coping efficacy was significantly related to pain, mood, and social support in that on days that participants rated their ability to control pain and decrease pain using spiritual/religious coping methods as high, they were much less likely to have joint pain and negative mood and much more likely to have positive mood and higher levels of general social support. Taken together, these results suggest that daily spiritual experiences and daily religious/spiritual coping variables are important in understanding the experience of persons who have RA. They also suggest that newly developed daily diary methods may provide a useful methodology for studying religious and spiritual dimensions of living with arthritis.]

Wachholtz, A. B. and Keefe, F. J. "What physicians should know about spirituality and chronic pain." Southern Medical Journal 99, no. 10 (October 2006): 1174-1175. [This is a brief, clinically-minded overview, as part of the Southern Medical Association's Spirituality & Medicine Interface Project.]

Wachholtz, A. B. and Pargament, K. I. "Is spirituality a critical ingredient of meditation? Comparing the effects of spiritual meditation, secular meditation, and relaxation on spiritual, psychological, cardiac, and pain outcomes." Journal of Behavioral Medicine 28, no. 4 (August 2005): 369-384. [For a summary and comment, see the December 2005 Article-of-the-Month.]

[Added 8/13/14] Wachholtz, A. B. and Pearce, M. J. [Dept. of Psychiatry, UMass Memorial Medical Center, Worcester, MA]. "Does spirituality as a coping mechanism help or hinder coping with chronic pain?." Current Pain and Headache Reports 13, no. 2 (Apr 2009): 127-132. [(Abstract:) Chronic pain is a complex experience stemming from the interrelationship among biological, psychological, social, and spiritual factors. Many chronic pain patients use religious/spiritual forms of coping, such as prayer and spiritual support, to cope with their pain. This article explores empirical research that illustrates how religion/spirituality may impact the experience of pain and may help or hinder the coping process. This article also provides practical suggestions for health care professionals to aid in the exploration of spiritual issues that may contribute to the pain experience.]

Wachholtz, A. B., Pearce, M. J. and Koenig, H. "Exploring the relationship between spirituality, coping, and pain." Journal of Behavioral Medicine 30, no. 4 (August 2007): 311-318. [(Abstract:) There is growing recognition that persistent pain is a complex and multidimensional experience stemming from the interrelationship among biological, psychological, social, and spiritual factors. Chronic pain patients 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. This article will explore the relationship between the experience of pain and religion/spirituality with the aim of understanding not only why some people rely on their faith to cope with pain, but also how religion/spirituality may impact the experience of pain and help or hinder the coping process. We will also identify future research priorities that may provide fruitful research in illuminating the relationship between religion/spirituality and pain. (References: 52)]

NOTE: Amy Wachholtz's 2006 doctoral dissertation, Does Spirituality Matter? Effects of Meditative Content and Orientation on Migraineurs, completed with Kenneth Pargament as her advisor at Bowling Green State University, is available online at

II. Self-efficacy is the belief that one can accomplish specific actions/goals. It developed out of the cognitive theory of the psychologist, Albert Bandura, and is occasionally mentioned in pastoral literature. [See, for instance, Miller, J. F., McConnell, T. R. and Klinger, T. A., "Religiosity and spirituality: influence on the quality of life and perceived patient self-efficacy among cardiac patients and their spouses," Journal of Religion and Health 46, no. 2 (June 2007): 299-313; and also Kyle Johnson's notes for our July 2006 Article-of-the-Month on "Spiritual Modeling."] Yet the concept may have great untapped potential for pastoral care theory (and even CPE educational theory). Bandura's seminal article on the subject, which has to date been cited over 6,500 times in the journal literature, is:

Bandura, A. "Self-efficacy: toward a unifying theory of behavioral change." Psychological Review 84 (1977): 191-215. [(Abstract:) The present article presents an integrative theoretical framework to explain and to predict psychological changes achieved by different modes of treatment. This theory states that psychological procedures, whatever their form, alter the level and strength of self-efficacy. It is hypothesized that expectations of personal efficacy determine whether coping behavior will be initiated, how much effort will be expended, and how long it will be sustained in the face of obstacles and aversive experiences. Persistence in activities that are subjectively threatening but in fact relatively safe produces, through experiences of mastery, further enhancement of self-efficacy and corresponding reductions in defensive behavior. In the proposed model, expectations of personal efficacy are derived from four principal sources of information: performance accomplishments, vicarious experience, verbal persuasion, and physiological states. The more dependable the experiential sources, the greater are the changes in perceived selfefficacy. A number of factors are identified as influencing the cognitive processing of efficacy information arising from enactive, vicarious, exhortative, and emotive sources. The differential power of diverse therapeutic procedures is analyzed in terms of the postulated cognitive mechanism of operation. Findings are reported from microanalyses of enactive, vicarious, and emotive modes of treatment that support the hypothesized relationship between perceived self-efficacy and behavioral changes. Possible directions for further research are discussed.]

III. Below is sample of articles on self-efficacy in relation to pain issues.

Arnstein, P. "The mediation of disability by self efficacy in different samples of chronic pain patients." Disability & Rehabilitation 22, no. 17 (November 20, 2000): 794-801. [(Abstract:) PURPOSE: A path analytic model conceptualizing self efficacy as a mediator of disability was tested. This model could help explain the circumstances under which disability develops more in some chronic pain patients than in others. METHOD: Questionnaires from 479 chronic pain patients were collected prior to an initial consultative visit with a pain specialist at three pain clinics. These patients represented three separate samples. One sample from a tertiary care hospital (n = 226), one from a community-based clinic (n = 137) and a third sample from combined settings, but excluding patients with a history of depression prior to the onset of their pain (n = 116). Hypothesized and alternative models were tested to identify the model best fitting these data. RESULTS: Regression analysis supported self efficacy as a mediator of the relationship between pain intensity and disability (p < 0.001) in all three groups. This model was best supported in the group with no prior depression (accounting for 47% of the explained variance in disability). The "no-prior depression" group was different than the other samples in that depression did not contribute to disability in this sample where prior depression was not controlled for. CONCLUSION: Self efficacy in an important variable contributing to the disability of chronic pain patients. Therefore, evaluating and bolstering the patient's belief in their own abilities may be an important component of therapy.]

French, D. J., Holroyd, K. A., Pinell, C., Malinoski, P. T., O'Donnell, F. and Hill, K. R. "Perceived self-efficacy and headache-related disability." Headache 40, no. 8 (September 2000): 647-656. [(Abstract:) BACKGROUND: Headache-specific self-efficacy refers to patients' confidence that they can take actions that prevent headache episodes or manage headache-related pain and disability. According to social cognitive theory, perceptions of self-efficacy influence an individual's adaptation to persistent headaches by influencing cognitive, affective, and physiological responses to headache episodes as well as the initiation and persistence of efforts to prevent headache episodes. OBJECTIVE: The objective of the present study was to construct and validate a brief measure of headache specific self-efficacy and to examine the relationship between self-efficacy and headache-related disability. METHODS: A sample of 329 patients seeking treatment for benign headache disorders completed the Headache Management Self-Efficacy Scale and measures of headache-specific locus of control, coping, psychological distress, and headache-related disability. A subset of 262 patients also completed 4 weeks of daily headache recordings. RESULTS: As predicted, patients who were confident they could prevent and manage their headaches also believed that the factors influencing their headaches were potentially within their control. In addition, self-efficacy scores were positively associated with the use of positive psychological coping strategies to both prevent and manage headache episodes and negatively associated with anxiety. Multiple regression analyses revealed that headache severity, locus-of-control beliefs, and self-efficacy beliefs each explained independent variance in headache-related disability.]

Porter, L. S., Keefe, F. J., Garst, J., McBride, C. M. and Baucom, D. "Self-efficacy for managing pain, symptoms, and function in patients with lung cancer and their informal caregivers: associations with symptoms and distress." Pain 137, no. 2 (July 15, 2008): 306-315. [(Abstract:) This study examined self-efficacy for managing pain, symptoms, and function in patients with lung cancer and their caregivers, and associations between self-efficacy and patient and caregiver adjustment. One hundred and fifty-two patients with early stage lung cancer completed measures of self-efficacy, pain, fatigue, quality of life, depression, and anxiety. Their caregivers completed a measure assessing their self-efficacy for helping the patient manage symptoms and measures of psychological distress and caregiver strain. Analyses indicated that, overall, patients and caregivers were relatively low in self-efficacy for managing pain, symptoms, and function, and that there were significant associations between self-efficacy and adjustment. Patients low in self-efficacy reported significantly higher levels of pain, fatigue, lung cancer symptoms, depression, and anxiety, and significantly worse physical and functional well being, as did patients whose caregivers were low in self-efficacy. When patients and caregivers both had low self-efficacy, patients reported higher levels of anxiety and poorer quality of life than when both were high in self-efficacy. There were also significant associations between patient and caregiver self-efficacy and caregiver adjustment, with lower levels of self-efficacy associated with higher levels of caregiver strain and psychological distress. These preliminary findings raise the possibility that patient and caregiver self-efficacy for managing pain, symptoms, and function may be important factors affecting adjustment, and that interventions targeted at increasing self-efficacy may be useful in this population.]

Woby, S. R., Urmston, M. and Watson, P. J. "Self-efficacy mediates the relation between pain-related fear and outcome in chronic low back pain patients." European Journal of Pain 11, no. 7 (October 2007): 711-718. [(Abstract:) This study aimed to determine whether self-efficacy beliefs mediated the relation between pain-related fear and pain, and between pain-related fear and disability in CLBP patients who exhibited high pain-related fear. In a cross-sectional design, 102 chronic low back pain (CLBP) patients completed measures for pain, disability, self-efficacy and pain-related fear (fear of movement and catastrophizing). Multistep regression analyses were performed to determine whether self-efficacy mediated the relation between pain-related fear and outcome (pain and/or disability). Self-efficacy was found to mediate the relation between pain-related fear and pain intensity, and between pain-related fear and disability. Therefore, this study suggests that when self-efficacy is high, elevated pain-related fear might not lead to greater pain and disability. However, in instances where self-efficacy is low, elevated pain-related fear is likely to lead to greater pain and disability. In view of these findings, we conclude that it is imperative to assess both pain-related fear and self-efficacy when treating CLBP patients with high pain-related fear.]

IV. For more on SPIRITUALITY & PHYSICAL PAIN, see also the January 2007 Article-of-the-Month page; and for the related topic of SPIRITUAL/EXISTENTIAL PAIN, see the June 2004 Article-of-the-Month page.


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