Addressing physical pain with religion and spirituality during and after the COVID-19 pandemic

meaning to pain, prayer, meditation, scripture, music, support from the religious community and helping others. Contribution: This article highlights the importance of an interdisciplinary approach that incorporates religion and/or spirituality to address physical pain during and after the COVID-19 pandemic.


Introduction
At the last PainSA 1 conference, held in September 2021, it became clear that COVID-19 is associated with various painful symptoms, resulting in chronic pain experienced by many. Different variables such as depression and extreme fatigue caused by long-COVID can have an impact on the pain experience, prompting a physician from the United Kingdom to warn against the Paindemic that is sure to follow the COVID-19 pandemic and is expected to last for the next 10-20 years (Ravindran 2021). Clauw et al. (2020Clauw et al. ( :1694 agree that the pandemic has the potential to increase chronic pain. Hence, it is important to initiate and encourage discussions among disciplines and to join forces to address this pain. As C.S. Lewis (1940) puts it: … pain insists upon being attended to. God whispers to us in our pleasures, speaks in our conscience, but shouts in our pains: it is His megaphone to rouse a deaf world. (p. 81) This article will therefore explore the emerging scientific evidence with regard to physical, social and spiritual pain, the link between the different dimensions of pain, as well as how spirituality and religion can address physical pain. Even before the pandemic, it was difficult to convince healthcare professionals in our western healthcare system wherein it is important to include the spiritual support of patients in the treatment plan. During a crisis such as the COVID-19 pandemic, the focus tends to intensify around saving lives and treating bodies, and the spiritual support of patients becomes even more redundant. De la Porte (2016:1) warns that healthcare in South Africa is experiencing a crisis and explained the valuable contribution that spirituality and pastoral work can make.
The purpose of this article is to argue the importance of spirituality and religion when supporting COVID-19 patients, not only in hospital but also afterwards as they battle the long-lasting effects of the illness. Please note that the intention of this article is not to suggest that spiritual support could replace medical care. Physical pain might be an indication of a serious underlying medical condition and should always be investigated by a medical professional.
1.PainSA is the South African chapter of the International Association for the Study of Pain (IASP) (https://painsa.org.za/). The coronavirus disease 2019 (COVID-19) pandemic is associated with various painful symptoms and could potentially lead to a significant increase in patients experiencing chronic pain. While churches had to close their doors during the pandemic, emerging scientific data suggest that, when our spiritual needs are not met, our well-being can be in jeopardy, and it could also increase the experience of physical pain. The aim of this article is, therefore, to explore the role that spirituality and religion could play in addressing physical pain. An interdisciplinary approach is used with the goal of integrating different insights so as to construct a more comprehensive understanding of the problem. Literature in the disciplines of humanities, health sciences, as well as social sciences is explored to identify the concepts of physical, social and spiritual pain and to explore the link between the different dimensions of pain. It became clear that physical, social, and spiritual pain can influence one another, and addressing one kind of pain can also improve pain in another dimension. Several spiritual and religious interventions were found in the literature and confirmed to be valuable in helping patients cope with physical pain, such as accepting and giving meaning to pain, prayer, meditation, scripture, music, support from the religious community and helping others.

Exploring the concepts…
Literature in the disciplines of humanities, health sciences as well as social sciences was explored to identify the concepts of physical, social and spiritual pain. The goal of this interdisciplinary approach was to integrate different insights so as to construct a more comprehensive understanding of the problem.

Physical pain
The definition of pain was recently revised and unanimously accepted by the International Association for the Study of Pain (IASP) Council in 2020 as 'an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage' (Raja et al. 2020(Raja et al. :1976. Humans are wired for survival, and pain is the alarm system of the body that will trigger if a threat to the body is detected. Groves and Klauser (2009:37) explain that all pain, spiritual as well as physical pain will either make us feel helpless or motivate us to do something to stop the suffering.
Interesting enough, the first model of pain was not coined by a medical doctor, but by the philosopher, Rene Descartes. He compared pain to a bell tower -the harder you pull on the cord, the louder the bell will sound. In the same way, the more physical damage a body experiences, the more pain will register in the brain (Marchant 2012:107). Although Descartes made a significant contribution to the development of the scientific foundation of pain in the 17th century, this theory is currently used worldwide by pain experts as an example of what pain is not. The brain does not just passively accept a pain message from the body as it is sent. Instead, there are many variables influencing or regulating the pain message along the pain pathways and eventually determining a person's pain experience, also called pain modulation (Marchant 2012:82). The pain alarm can also go off if there is the perception that something is an actual or potential threat to the body. At other times, neurons might start to send off false pain messages to the brain, much like an alarm system that is malfunctioning. As Phipps (2021) puts it: 'We experience pain, not because it is, but because we can'.
Pain may become chronic when it continues after the initial injury has been treated or when a medical condition cannot be treated successfully. The World Health Organization (2021) recently included the diagnosis of Chronic Primary Pain in the International Classification of Diseases, stating that chronic pain is often independent of any other contributors, and should therefore be a primary diagnosis. This decision validates the experience of chronic pain for patients when a cause for their pain cannot be found, as is the case for many sufferers.

Social pain
It is not only physical pain that sounds an alarm in the body, but social pain can be experienced just as devastating as searing physical pain. Deeply embedded in our genetic makeup, we as human beings instinctively know that we need other people to survive, and when we encounter social rejection and the termination of relationships, it is regarded as a threat to our survival, resulting in social pain that is processed in the brain in the same way as physical pain (Eisenberger 2011:54;Kross et al. 2011:6270).
Jensen-Campbell and MacDonald (2011:3) define social pain (also called emotional or psychological pain) as 'a negative emotional state that arises from social injuries, or from perceptions of interpersonal rejection or loss, such as unrequited love, a relationship breakup, or the death of a loved one'. Anxiety and depression experienced by many because of the pandemic, as well as social isolation, can all have an impact on the way people experience pain.

Spiritual pain
Before we discuss spiritual pain, let's pause for a moment to consider the definition of spirituality. In order to reach a consensus on the definition of spirituality so that it could be integrated into healthcare, Puchalski et al. (2014) hosted two conferences and many discussions to define spirituality as: a dynamic and intrinsic aspect of humanity through which persons seek ultimate meaning, purpose and transcendence, and experience relationship to self, family, others, community, society, nature and the significant or sacred. Spirituality is expressed through beliefs, values, traditions and practices. (p. 646) Monareng (2012:4) adds the concept harmonious connectedness, which includes healthy relationships as well as the concept of forgiveness. Hiza (1996:12) distinguishes between religion and spirituality by pointing out that not all people feel the necessity to join a religion, but spiritual needs are universal to all. Coppola et al. (2021:12) found that even though people do not belong to a certain religion, they still use certain belief systems to make sense of the pandemic.
It can, therefore, be concluded that we as human beings have a need to connect and to stand in a relationship with God or with someone or something bigger than ourselves; we have the innate need to experience meaning and purpose in our lives and we need to experience harmonious connectedness.
Not having our spiritual needs met can, therefore, threaten our well-being, and, just as with social pain, we experience spiritual pain when our spiritual needs are not met. As Lombard (2017:e13), a neurologist, explains 'the need for faith is so deeply embedded in our biology that, even if we don't identify it, its absence will let itself be known regardless'. When we are disappointed in God, when we've lost meaning and purpose in our lives or when we struggle with giving or receiving forgiveness, we can experience spiritual pain.

The link between physical, social and spiritual pain
Physical, social and spiritual pain can influence one another, and addressing one kind of pain can also improve pain in another dimension. It is a well-known fact in the medical community that negative emotional state such as anxiety increases pain, whether during labour or after an operation. Pieterse and Landman (2021:9) point out that COVID-19 can be regarded as a 'spiritual virus' because it also causes intense emotional and spiritual turmoil. Hiza (1996:15) concludes that spiritual pain can be just as harmful as physical pain, but it is often misunderstood and not acknowledged in the same way. Harris et al. (2018:761) explain that spiritual distress could increase the experience of pain by increasing pain catastrophising 2 and pain interference. 3 Scientific evidence has lately shown that there is a close link between the different dimensions of pain, and modern technology is now able to visually demonstrate these links. Using functional magnetic resonance imaging (MRI) brain scans, Kross et al. (2011:6270) were able to establish that physical pain and social pain activate the same sensory areas in the brain, giving 'new meaning to the idea that rejection pain "hurts"'. It was also found that people who are more distressed by social rejection are also more sensitive to physical pain (Eisenberger 2011:62;Yao et al. 2020). It could, therefore, be concluded that social isolation can lead to an increase in physical pain and suffering. Wiech et al. (2009) compared practising Catholics with a control group of self-declared atheists and agnostics during a painful stimulus and found that when the believers contemplated an image of the Virgin Mary, their physical pain experience was much lower than when they viewed a non-religious image. In the control group, there were no differences in pain experiences between the two images, and these experiences were all confirmed by a functional MRI brain scan. Catholics consider the Virgin Mary as an intercessor, praying on behalf of the believer (Koenig 2017:12). Siddall, Lovell and MacLeod (2015:54) refer to several studies showing that the use of spirituality and religion increases mental health, reduces depression and anxiety, increases peace and calm, increases pain tolerance and can be beneficial in coping with pain. They further explain that it can give meaning to suffering and conclude that spiritual support should form a vital part of the pain management of chronic pain patients (Siddall et al. 2015:57).
As spiritual pain could have an impact on physical pain, it is, therefore, important to start with a spiritual assessment as discussed next.

Spiritual assessment
Spiritual assessment helps to recognise how spiritual concerns can contribute to pain so that pain management can be more • Spiritual pain -concerns with regard to the relationship with God as well as a lack of spiritual fulfilment. • Spiritual alienation -feelings of loneliness and a sense of not being close to God. • Spiritual anxiety -the fear of being punished by God and God's anger. • Spiritual guilt -a sense of having failed to live a life pleasing to God and of not following God's will. • Spiritual anger -feelings of anger towards God for allowing pain and suffering. • Spiritual loss -the fear of losing God's love, feeling of emptiness and uselessness, alienated from anything or any person perceived as good. • Spiritual despair -having no hope of ever having a relationship with God, feeling that God does not care.
The concerns above reflect aspects of the relationship a person may have with God. The relationship with God is also connected to coping styles or responses as influenced by religion, and Pargament et al. (1988) describe the Collaborative coping style (working with God and sharing the responsibility), the Deferred coping style (God is in control, I am not) and the Self-directed coping style (I am in control and no higher power is involved in my life). Another coping style, Abandonment, has been identified by Phillips et al. (2004), where people who previously believed in God now feel abandoned by him. Rush, Vagnini and Wachholtz (2020:184) refer to several research studies, all confirming that the Collaborative coping style has been linked to the best mental and physical health outcomes.
Sometimes, certain religious teachings can have a devastating effect on people. One such perception is that sin causes physical pain (Bourke 2014:e87

Addressing physical pain with spirituality and religion
While the medical aspects of pain management are beyond the scope of this article, it is important to note that every effort should be made to relieve physical pain. However, the reality is that treatment is not always successful, and many people are, therefore, living with chronic pain.
Although there are variables, such as culture, influencing the relationship between spirituality/religion and pain outcomes, research confirms that religious and spiritual interventions could be beneficial in addressing physical pain (Rush et al. 2020:204). However, Dueck (2006:2) distinguishes between thick spirituality (culturally rich and embedded in a faith tradition) and thin spirituality (tending to be commercialised and described as a private experience). This author warns against the universal application of spiritual interventions, explaining that faith traditions are rich in meaning and rituals, and that it is important to adapt to the specific worldview of a person (Dueck 2006:4).
The following spiritual and religious interventions have been mentioned in the literature as beneficial when coping with pain.

Accept the pain
Accepting pain might sound like advice coming from an earlier time and not from the scientific advanced era we currently live in. But, as mentioned, many people must live with constant pain, and accepting the pain is one way of dealing with it and even reducing the pain (Perrin et al. 2021:9). This does not imply a passive surrender but rather a 'conscious choice to bear the cross' (Koenig 2003:161). Acceptance and commitment therapy (ACT) is an empirically validated cognitive behaviour therapy used by clinicians for the treatment of chronic pain, where participants are encouraged not to avoid activities, but to commit to goals that are meaningful to them while embracing any pain and discomfort as part of them (Feliu-Soler et al. 2018:2145-2146. Karekla and Constantinou (2010:371) point out that ACT takes spirituality and religion into account as it centres around the values of the patient. Using functional MRI brain scans, Aytur et al. (2021) were able to demonstrate changes in brain activation following ACT that correlates with positive changes in the behaviour of the participants, such as a reduction in depression and an increase in social participation. Koenig (2003:161) concludes that when everything has been done to treat the pain, the patient must work at gaining special insight to accept it when pain remains and to trust God to take care of it. In fact, through the ages, when the treatment of pain was not an option, the only thing Christians could do was to surrender and to accept the pain (Bourke 2014:e97).

Give meaning to the pain
Spirituality and religion can help people to find meaning in pain and suffering and help them make sense of what is happening during the COVID-19 pandemic (Coppola et al. 2021:12). Even children living with a chronic disease often believed that everything was predestined and that there was a plan for their lives that included their medical condition (Damsma Bakker, Van Leeuwen, & Roodbol 2018:111). Someone living with debilitating pain once mentioned that she was grateful for the pain, as it was God's way of keeping her confined to the bed so that she would have the time to pray for others. 4 Norris (2009:22) explains that suffering will increase if we don't see any value in pain, and if pain is considered to be valuable, it could lead to spiritual transformation. This is the opposite of modern thinking, where pain should be resisted as it is regarded as futile and meaningless (Norris 2009:23).
Koenig (2003), a physician who also struggles with chronic pain, indicates that chronic pain can equip the sufferer with a unique ability to understand the pain of others. He explains: [I]f we accept this calling, then every ache and every twinge of pain will serve to remind us of why we are here. Rather than drain life of its purpose, pain will instead help to infuse it with meaning. Rather than see pain as a punishment for past sins, mistakes or errors, or as a random act by a cruel devil or god, it is possible to come to a place where we can see pain almost as a blessing. (p. 162)

Prayer
People turn to prayer during difficult times, and Bentzen (2021:542) mentions that in March 2020, when COVID-19 was declared a pandemic, Google searches for prayer increased by 30%, reaching an all-time high. Prayer is also often used to combat pain, and Rush et al. (2020:206) cite several studies confirming the important role of prayer in managing pain. It was also most often used by children and adolescents as strategies to cope with a painful chronic disorder (Clayton- Jones & Haglund 2016:355). Koenig (2003:165) refers to prayer as a weapon to combat pain and suggest that people with chronic pain should pray for the following: • The strength to put God first.
• The ability to walk closer to God.
• Faith in God's power and ability to heal.
• The ability to love.
Prayers are not always answered the way we expect it to be, and it might feel as if God is absent or not responding to pleas for help from people in pain. However, Koenig (2003:172) reminds readers that God will never abandon us, but 'sometimes we are forced to fly awhile on our own to strengthen our wings of faith'. In the wise words of a 7-year-old living with a chronic condition: [I]f a pastor prayed over me and it [getting better or a cure] didn't happen, then I would think that it wasn't supposed to happen, because prayers don't always happen. (Pendleton et al. 2002:5)

Meditation
Meditation is frequently used for pain management, and Rush et al. (2020:208) refer to several research studies confirming that spiritual meditation was proven more effective in relieving migraine pain than secular meditation. However, it is important to note that Farias et al. (2020:374) conducted a systematic review of studies reporting on meditation practices and found various adverse events (such as anxiety, depression and cognitive anomalies) occurring in people with no previous history of such events. These authors did not speculate on the reason for these results but point out that more research on this topic is warranted. Koenig (2011:54) agrees and refers to a gap in the research to determine whether Eastern forms of spiritual practices such as meditation, when it is separated from the original religious traditions, will still have the same mental health benefits. Koenig (2003:165) mentions that cognitive therapy is the most common form of secular psychotherapy, focussing on replacing negative thoughts with positive ones. He further explains that these principles are taught right through the Bible, and that it can be healing to meditate on Scripture. This author advises people with pain to find consolation in the suffering of Biblical figures and how they overcame adversity (Koenig 2003:164). Rush et al. (2020:206) comment that people tend to turn to religious figures during times of suffering, and this emotional connection can reduce the experience of pain, assist in coping and give hope. Koenig (2003:184) compiled a list of many scripture references concerning suffering, pain and healing. He found 27 references on suffering, and 60 references on healing, pointing out that reading these verses can be just as powerful as any medicine. O'Neill and Mako (2011:45) mention the calming effect that hymns and chants could have on the person with pain. Pretorius (2017:4) discusses the positive impact that music has on our spiritual and emotional well-being and explains that there are numerous references throughout the Old and New Testaments to the healing power of music. This author references several empirical studies confirming that music can reduce pain, speed up recovery and reduce stress and stress-related symptoms (Pretorius 2017:5-6). Baetz and Bowen (2008:386) conclude that frequent religious worship was linked to a reduction in chronic pain as well as better psychological well-being. In a literature review, Clayton-Jones and Haglund (2016:355) also found evidence that church attendance was associated with lower pain scores in adults living with a painful chronic condition. Koenig (2003:164) refers to several studies confirming that social isolation can lead to changes in the human body, affecting the natural ability of the body to fight off disease and assist in recovery. This author echoes the words of the apostle Paul in Hebrews 10:25 when he encourages people with pain to participate in their faith community as we as human beings need their support and encouragement (Koenig 2003:164).

Support from the religious community
However, during the COVID-19 pandemic, churches had to close their doors, and social contact and spiritual support were limited. One can just speculate on the disastrous effect this could have on the pain experience of people, as research on this topic is limited. However, people can be very creative and Lucchetti et al. (2021:677) mention several alternatives for church attendance during the pandemic, such as worshipping on balconies, from their cars or online. Koenig (2003:180) refers to praying for, encouraging or helping other people as Acts of Mercy that can also assist in combating chronic pain. He further explains that when people learn to cope with their own pain, they can grow spiritually so that they are able to support other people going through challenging times (Koenig 2003:164).

Conclusion
Scientific evidence clearly shows a link between physical, social and spiritual pain, and how spirituality and religion can address physical pain. Several spiritual and religious interventions have been mentioned in the literature as beneficial when coping with pain. However, these interventions should be regarded as an additional option and not intended to replace medical treatment.
When we anticipate a complete elimination of physical pain, the outcome might also not be what we expect, and O' Neill and Mako (2011:45) suggest that healing should not be measured in biological terms, 'but by the peace that surrounds and permeates the person'. Focussing on spiritual and religious interventions when supporting COVID-19 patients should be a priority, not only in hospital but also afterwards as they battle the long-lasting effects of the illness.