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Morgan Howen

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Acceptance of Suffering is not Passivity


 “Let me not beg for the stilling of my pain but for the heart to conquer it.”
 -Rabindranath Tagore (1861-1941) Indian Hindu mystic philosopher.

Religion and spiritual practices are among the resources used by patients to cope with chronic pain.. By becoming more familiar with Hindu views of pain and suffering, pain medicine practitioners can offer potentially helpful concepts to all patients and support Hindus’ spirituality as it relates to pain and suffering. Religion or spirituality is often important to patients. 
Clinicians who treat patients with significant pain know all too well that the field of medicine provides incomplete pain relief to many of our patients. A significant percentage of patients remain in moderate to severe pain, and their lives are drastically changed in areas including relationships, work, and leisure. Both the pain itself and the psychosocial sequelae challenge our patients’ spirits. Because living with pain is often an enormous challenge, optimizing any and all resources that a patient has to cope with the experience is worthwhile. These resources may be biological, psychological, social, and religious or spiritual. Indeed, multiple studies have confirmed that a biopsychosocial approach to pain management is optimal.
Patients with chronic pain may turn or return to religion and spiritual practices to help them cope, as do patients with other significant medical illnesses. Although a full review of the research on the relation between religion/spirituality and coping with pain is beyond the scope of a brief note, it can be stated that results have been mixed. Studies have found religion/spirituality to be related to higher pain levels, lower pain levels, or unrelated to pain severity, pain distress, and the disruption of activities by pain. Multiple reasons can account for the variable results, including differences in:

1) Patient populations with respect to ethnicity, and type and severity of pain; 2) Study measurements for religiosity/spirituality; and 3) classification of religious coping as either active or passive. As well, many of the studies used a cross-sectional design, which is unable to measure changes in pain levels and religious involvement over time.
Rather than viewing “religious coping” as a single variable, it is helpful to recognize that there are a variety of religious coping mechanisms and to identify which are potentially helpful or harmful. Pain and suffering are understood in Hinduism. 

There are few studies that scientifically examine the beliefs and traditions of most religions as they relate to pain management. For the majority of religions, we are at the initial stages of our scientific understanding of how their tenets and practices affect health. As such, suggestions for possible future investigations will be offered. 

Although religion can be a positive resource for some, there are times when religious coping can be ineffective. For Hindus, a first potential challenge may be the feeling of passivity or fatalism that may arise because of karma. A patient can feel hopeless or unable to change things because he feels that things are fixed by karma. Hindu traditions counter this by saying that a person can start in the present moment and go forward, living his life in a positive way by following dharma. If a patient currently experiences pain, change can occur by attending to present appropriate action. “If one’s present state is a consequence of what has gone before, the urgency of responsible and appropriate action becomes greater, not less”.
Acceptance can be misunderstood as passivity. Hindu traditions do advise a focus on appropriate action, rather than outcome, but this does not mean inaction, “avoid . . . attachment to inaction!”. Patients can be encouraged to actively manage their pain and continue to seek improvement but become detached from the outcome of these efforts. Last, there can be a risk of feeling that one is failing the test of pain and suffering, that one is not succeeding in achieving an even disposition.

However, the religious practices of Hindus teach trying one’s best. Detachment can even be sought from the degree one achieves detachment; that is, a person can attempt to be less concerned about his success or failure to be detached. 
The process o believing that their suffering will be relieved and support will be provided. It would be important to note that a particular patient may be at any stage of spiritual growth with respect to viewing their physical pain and suffering as Hindu traditions teach. A patient may or may not even be using his religious resources for support to cope with pain. The level of religious coping may change across time, for example, as aspects of a patient’s illness change, including severity of pain, and as the availability of other resources changes. As in any religion, there would probably be only a small minority of Hindus who would not struggle with some aspect of their experience of pain or for whom acceptance is easy and unchanging; however, many strive to be faithful to their own religious tradition.

 Patience with oneself is encouraged. Patients can also try to learn as much as possible from their current situation, including their apparent failures.
Although acceptance is not unique to Hinduism, it is certainly central to the religion, and includes at least 2 aspects. First, Hindu traditions view acceptance as a logical attitude towards what one’s life presents, including pain and suffering, because all is to be seen as the just working of karma. Second, the practice of acceptance is also a means to a greater end, detachment. The process of accepting one’s life lessens one’s desire for things to be different than they are. As desires fall away, detachment is achieved. Related to pain, both painful and pain-free states would be accepted equally. Detachment from this world, to be focused on God/The Ultimate, is a primary goal in Hinduism. 
The theory supporting acceptance-based strategies can be contrasted to that of control-based strategies. In control-based strategies, the goal is to decrease problematic thoughts, feelings, or experiences, and it is believed that these need to be reduced for improvement to occur. For example, relaxation treatment is a controlbased strategy for anxiety, in which relaxation exercises are used to decrease the thoughts and feelings described as “anxiety.” The treatment goal would be a reduction or elimination of anxiety.

In contrast, acceptance approaches attempt to “teach clients to feel emotions and bodily sensations more fully and without avoidance, and to notice fully the presence of thoughts without following, resisting, believing, or disbelieving them”. However, uncomfortable thoughts and feelings are delinked from behavior. Thus, problematic thoughts, feelings, or experiences do not have to be reduced for improvements in behavioral end points to occur. Patients can focus on making desired behavior choices regardless of their feelings or thoughts. In treating chronic pain, the goal of treatment would not be to decrease pain. As well, patients would be taught to not have their pain level determine their activity level, decoupling uncomfortable feelings from behavior.9,10 Acceptance and Commitment Therapy (ACT) has further refined this theory and can be useful for a wide range of disorders.Specifically in the pain medicine literature. 

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