SUFFERING IS A WAY TO PROGRESS SPIRITUALLY

Hinduism is a religious tradition of Indian origin, and, with 900 million practitioners, is the third largest religious community in the world, after Christianity and Islam. Hindus are located primarily in India, Nepal, and Bali; 2% live outside India, and 1.5 million live in the United States. Hinduism clearly addresses pain and suffering, and the concept of acceptance, which is present in Hinduism, has been addressed in the pain medicine literature. 

Although there are distinct schools within Hinduism, the concepts  are common across these schools and underlie Hinduism as a whole.

As with any religion, patients who consider themselves Hindu may hold all the central beliefs. As such, there is not one single description of what every Hindu believes. Pain medicine practitioners must be culturally sensitive to patients of other religious traditions in general; as well, they must be sensitive to the unique beliefs of each individual they treat whether of a differing religion, or even of patients who share their own religious tradition. Likewise, individual Hindus will certainly approach their experiences with pain in different manners. Rather, having a grounding in how Hindu traditions view pain and suffering will give the practitioner a more solid footing on which to discuss these issues with their patients.

Definitions of Terms 

1. Attachment: Overinvolvement in this world, having desires for things that one does not have and clinging to things one has.

2. Detachment: Turning away from overinvolvement in the world and towards God/The Ultimate.

3. Dharma: Guidelines for living one’s life.

4. Karma: The principle that governs the unfolding of events and is based for a person on the integrity with which he has lived previous lives.

5. Moksha: Complete release from the cycle of rebirths.

6. Samsara: The process of successive rebirths until one reaches moksha, complete release from the cycle of rebirths.

Several concepts are central to Hinduism. Table 1 provides a list of terms and definitions. The first of these concepts is karma, which is the principle that governs the unfolding of events and is based for a person on the integrity with which he has lived previous lives. Karma is not imposed by an outside, punitive force, or God, but is rather an “exercise of the moral law in the universe”, these laws being inherently within the universe.

Karma is encompassed by God/The Ultimate, as is each person’s soul. As both karma and souls are part of God/The Ultimate, karma is not external to the individual, but each is a part of the same greater   whole. (Many Hindus believe in a single deity. Aspects of this one deity may be personified or embodied as individual deities but are not worshipped as separate gods.

Other Hindus may use other words, for example, The Ultimate, for a nondeity force or unknown mystery. God/ The Ultimate is also referred to as Brahman in Hinduism.

A related belief is samsara, the process of successive rebirths until one reaches moksha, the complete release from the cycle of rebirths.
 Hindu traditions promote living with integrity, causing no harm, and progressing further on a spiritual path by living according to dharma, stage-of-life–appropriate guidelines or “patterns of life”,or by one’s “sacred duty”.

A central life’s work is to become detached from overinvolvement in the world that is apparent to us, which is seen as illusory and temporary, and turn toward God/The Ultimate. 
Many of these concepts are shared by or are similar to concepts in other eastern religions, for example, Buddhism. Four different paths to achieve life goals are present:

1) The path of devotion, in which “a devotee submits himself or herself to the will of God, and through devotional practices, such as prayer, aims to become one with God and attain spiritual liberation”.

2) The path of ethical action, in which “an individual chooses to perform work without attachment to its effects; this attitude purifies his or her mind so that he or she can attain a sense of God-vision”;

3) The path of knowledge, in which “he or she dedicates himself or herself to acquiring knowledge that reveals the impermanence and ineffectuality of things in the world, and thereby frees the self from the bondage of ignorance, leading to spiritual liberation”.

4) The path of mental concentration, in which “he or she practices disciplinary measures that involve physiological and psychological restraints to free the self from all impurities so that the Divine self of the person can then manifest itself, leading to spiritual liberation”.

Suffering, both mental and physical, is thought to be part of the unfolding of karma and is the consequence of past inappropriate action (mental, verbal, or physical) that occurred in either one’s current life or in a past life.

It is not seen as punishment but as a natural consequence of the moral laws of the universe in response to past negative behavior. Hindu traditions promote coping with suffering by accepting it as a just consequence and understanding that suffering is not random. If a Hindu were to ask “why me?” or feel his/ her circumstances were “not fair,” a response would be that his/her current situation is the exactly correct situation for him/her to be in, given her soul’s previous action. 

Experiencing current suffering also satisfies the debt incurred for past negative behavior. Suffering is seen as a part of living until finally reaching moksha. Until reaching this state, suffering is always present on life’s path. Hindu tradition holds that as we are in human form on earth, we are bound by the laws of our world and will experience physical pain. Pain is truly felt in our current physical bodies; it is not illusory in the sense of not really being felt .But while the body may be in pain, the Self or soul is not affected or harmed. Arjuna, a seeker of wisdom in The Bhagavad-Gita, is told: 

“The self embodied in the body of every being is indestructible”, and “Weapons do not cut it, fire does not burn it, waters do not wet it, wind does not wither it. It cannot be cut or burned; it cannot be wet or withered; it is enduring, all-pervasive, fixed, immovable, and timeless”.

As the Self is not affected, there need be no concern over temporary suffering. Patients may gain comfort by viewing the pain as only a temporary condition and one that does not affect their inner Self. Pain and suffering are not seen as solely bad but as experiences that need to be viewed from multiple perspectives.

Hindu traditions hold that all things are manifestations of God/The Ultimate, so nothing is only good or bad; God/The Ultimate encompasses everything. Everything, including pain and suffering, is given by God/ The Ultimate. To view suffering as bad is to see only one side of it. Suffering can be positive if it leads to progress on a spiritual path. 

Some even embrace suffering as a way to progress on his spiritual path, to be tested and learn from a difficult experience. Attachment and detachment are concepts that in Hindu traditions relate to one’s level of involvement in this world and to the power this world holds over one’s state of mind. Attachment signifies overinvolvement in this world, having desires for things that one does not have and clinging to things one has.

Detachment is a positive state of objectivity toward this world, where relationships, objects, and circumstances hold no power over one’s state of mind. Attachment is a primary stumbling block to achieving moksha, complete release. Attachment perpetuates the “terrible bondage” that keeps a person in the cycles of samsara, rebirth. Only through recognition that the Self is not bound to this world of suffering can release be achieved. Perfect detachment creates an “. . . even disposition in the face of either happiness or sorrow . . .”.

When one achieves perfect detachment, no problem or circumstance, including pain, can cause one to suffer. 

“Contacts with matter make us feel heat and cold, pleasure and pain. Arjuna, you must learn to endure fleeting things—they come and go! When these cannot torment a man, When suffering and joy are equal for him and he has courage, he is fit for immortality”.

What suggestions are made for achieving this detachment? It cannot be simply an intellectual understanding that the Self is part of God/The Ultimate. It is not escapist, pretending that suffering does not exist. One part of achieving detachment is to follow dharma, appropriate action, but to be unconcerned with the outcomes of these actions.
Arjuna is told:

 “Be intent on action, not on the fruits of action; avoid attraction to the fruits and attachment to inaction! Perform actions, firm in discipline, relinquishing attachment; be impartial to failure and successthis equanimity is called discipline”.

Patients in pain are not to be passive and give up and can continue to attempt to lessen suffering. The ultimate goal would be to become neutral in the face of whatever outcome occurs, to not desperately strive for pain relief. Most important, however, would be to refocus away from pain to dharma. The guidance to seek detachment from outcomes would likewise apply to pain medicine practitioners, though this may challenge the outcome orientation of Western medicine. Lack of immediate success in treating patients can be frustrating; however, an approach based in Hindu traditions would suggest continuing to try one’s utmost to heal patients but not becoming upset by failure. The dharma for a pain practitioner would be to be the best practitioner possible, while accepting all outcomes.
 To be clear, this is not to suggest becoming indifferent to our patients’ suffering. Hindu traditions would support still caring deeply for our patients but needing to recognize that we are not in control of outcomes, nor do we know what is the appropriate outcome from the perspective of karma.

  Specific tools for achieving detachment also include meditation and yoga. These tools teach the understanding and control of one’s mind, and seeing beyond one’s mind to God/The Ultimate. As the focus of one’s life should be on God/The Ultimate, priority is given to this inner journey, with less focus on the world. By becoming less attached to one’s circumstances, including being in pain, a person can focus his life on God/The Ultimate, not pain. Hindu traditions hold that all have a capacity to achieve this.

“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.