DOES SPIRITUALITY MATTER? EFFECTS OF MEDITATIVE CONTENT
AND ORIENTATION ON MIGRAINEURS
Amy B. Wachholtz
A Dissertation
Submitted to the Graduate College of Bowling Green State University in partial fulfillment of the requirements for the degree of
DOCTOR OF PHILOSOPHY
May 2006
Committee:
Kenneth I. Pargament, Advisor
Haliu Kassa Graduate Faculty Representative
Robert A. Carels
Dara R. Musher-Eizenman ii
ABSTRACT
Kenneth I. Pargament, Advisor
Migraine headaches are associated with high depressive and anxiety symptoms (Waldie
& Poulton, 2002) as well as low feelings of self-efficacy, which can negatively impact pain tolerance and positive active coping (French, et al., 2000). Previous research suggests that religion can have a positive effect on physical and mental health (Koenig, McCullough, &
Larson, 2001, for a review), and specifically, spiritual meditation may ameliorate some of these negative traits associated with migraine headaches (Wachholtz & Pargament, 2005). Spiritual meditation is one method that may help migraineurs to increase their spiritual experiences, reduce depression and anxiety, and improve their self-efficacy to improve both their quality of life. This study examined two primary questions: 1) Do different meditation types create different outcomes among migraineurs? and, 2) How does meditation orientation affect mental, physical, and spiritual health outcomes among migraineurs?
Eighty-three meditation naïve, frequent migraineurs were gathered from the Bowling
Green State University undergraduate community. Participants were taught Spiritual Meditation,
Internally Focused Secular Meditation, Externally Focused Meditation, or Relaxation techniques.
Participants independently practiced their techniques for twenty minutes a day for one month.
Pre-post tests measured pain tolerance (with a cold pressor task), and headache frequency, as well as a number of mental, and spiritual health variables. Results indicated that over the course of the intervention in comparison to the other three groups, those who practiced spiritual meditation had greater decreases in the frequency of migraine headaches, anxiety, and depression, as well as greater increases in pain tolerance, headache-related self-efficacy, daily iii spiritual experiences, and existential well being. By providing participants with a simple method to access their spiritual resources, spiritual meditation may offer migraineurs a means to improve their spiritual, emotional, and physical health. iv
DEDICATION
To Chris – No words could ever be enough.
v
ACKNOWLEDGEMENTS
I would like to thank my advisor, Dr. Kenneth Pargament, for his invaluable assistance in
developing and refining this project. From our first meeting as a first-year graduate student, he
faithfully guided me through hours of conversation, countless drafts, and innumerable questions.
I have grown to appreciate his wisdom, as both a professor, and as a mentor. I would also like to
thank my committee members, Dr. Robert Carels, and Dr. Dara Musher-Eizenman for their constructive feedback and valuable contributions to this process. I appreciate their efforts and
look forward to the opportunity to consider them colleagues in the field of psychology. Thank
you as well to Dr. Haliu Kassa, for his unique contributions to the psychology dissertation
committee.
My research assistants, Tawana Jackson, Ashley Armstrong, and Nichole Calvert deserve
significant praise for their assistance in teaching the intervention classes, and their extensive
efforts in data entry. The fact that they returned each week despite cold water, paper cuts, and
computer crashes speaks volumes about their levels of pain tolerance.
Finally, I would like to thank my friends and family who have encouraged me and
sustained me throughout this process, particularly, my mother, Natalie, my father, Gene, my
brother, Adam, my friend Melissa, and my fiancé Chris. Thank you for listening, for supporting,
for teaching, and for challenging. Most of all, thank you for reminding me to laugh. vi
TABLE OF CONTENTS
Page
INTRODUCTION ...... 1
Migraine Headaches ...... 3
Spirituality and Health...... 12
Summary of Previous Research...... 29
METHOD ...... 31
Participants...... 31
Screener ...... 31
Adherence ...... 32
Objective Measures...... 32
Psychological Measures...... 33
Headache Specific Surveys...... 35
Spirituality Measures ...... 36
Power Analyses...... 38
Procedure ...... 38
RESULTS ...... 41
Adherence Analyses ...... 41
Manipulation Check Analyses...... 41
Objective Measures...... 42
Psychological Measures...... 43
Headache Specific Surveys...... 44
Spiritual Measures ...... 45 vii
DISCUSSION...... 47
Pain and Spiritual Meditation ...... 47
Mental Health and Spiritual Meditation ...... 48
Spiritual Health and Spiritual Meditation...... 50
Implications ...... 52
Limitations and Future Directions ...... 53
Conclusions...... 54
REFERENCES ...... 56
APPENDIX A. POTENTIAL LINKS BETWEEN SPIRITUAL MEDITATION AND
QUALITY OF LIFE ...... 65
APPENDIX B. ID MIGRAINE SCREENER ...... 66
APPENDIX C. DAILY ADHERENCE DIARY...... 67
APPENDIX D. POSITIVE AND NEGATIVE AFFECT SCALE...... 68
APPENDIX E. STATE-TRAIT ANXIETY INVENTORY, STATE SCALE...... 69
APPENDIX F. STATE-TRAIT ANXIETY INVENTORY, TRAIT SCALE ...... 70
APPENDIX G. CENTER EPIDEMIOLOGICAL STUDIES DEPRESSION SCALE ...... 71
APPENDIX H. MIGRAINE SPECIFIC QUALITY OF LIFE ...... 72
APPENDIX I. HEADACHE MANAGEMENT SELF-EFFICACY SCALE...... 76
APPENDIX J. RELIGIOUS MEASURES QUESTIONNAIRE...... 77
APPENDIX K. SPIRITUAL WELL BEING SCALE ...... 78
APPENDIX L. DAILY SPIRITUAL EXPERIENCES SCALE ...... 79
APPENDIX M. MYSTICISM SCALE ...... 80
APPENDIX N. PROCEDURES...... 82 viii
APPENDIX O. MEDITATION TRAINING SCRIPT...... 84
APPENDIX P. RELAXATION TRAINING SCRIPT...... 86
ix
LIST OF TABLES
Table Page
1 Demographics and Pre-Test Data of the Participant Population ...... 88
2 Demographics by Group ...... 89
3 Manipulation Check Analyses ...... 90
4 Pre- and Post- Intervention Objective Measures by Group ...... 91
5 Pre- and Post- Intervention Psychological and Headache Measures by Group...... 92
6 Pre- and Post- Intervention Spiritual Measures by Group ...... 93
7 Main Effects and Interactions for 2x4 (time x group) Repeated Measures ANOVA 94
x
LIST OF FIGURES
Figure Page
1 Adherence Data Including All Participants ...... 95
2 Headache Occurrence Prior to the Intervention and During the Intervention ...... 96
3 Pain Tolerance by Group and Time ...... 97
4 Negative Affect by Group and Time ...... 98
5 Positive Affect by Group and Time...... 99
6 Trait Anxiety by Group and Time ...... 100
7 Depression by Group and Time ...... 101
8 Migraine Specific Quality of Life by Group and Time ...... 102
9 Headache Management Self-Efficacy by Group and Time ...... 103
10 Spiritual Well-Being by Group and Time...... 104
11 Religious Well-Being by Group and Time ...... 105
12 Existential Well-Being by Group and Time ...... 106
13 Daily Spiritual Experiences by Group and Time...... 107
INTRODUCTION
Headaches are the most common pain related compliant, and the 7th leading reason for visits to medical professionals with approximately 18 million physician visits a year (Ries,
1986). While tension-type headaches are more common than migraines (Rasmussen, Jense,
Schroll, & Olesen, 1991), migraines are a more severe pain related disorder with nearly 20% of migraineurs taking time off for at least a day each year (Pryse-Phillips, et al., 1992). Annually, over 10% of the population of the United States (over 32 million Americans) suffers at least one migraine headache (Stewart, Lipton, Celentanto & Reed, 1992), though the average migraineur experiences 34 to 37.5 attacks a year (Hu, Markson, Lipton, Stewart, & Berger, 1999). Lost labor costs due to migraines are estimated at approximately $13 billion per year (Hu, et al.,
1999).
Research is needed on migraine headaches to reduce these significant personal, professional, and economic impacts. Literature reviews have described a variety of non- pharmacological approaches to preventing and aborting headache pain (Gauthier, Ivers, &
Carrier, 1996; Penzien, Rains, & Andrasik, 2002). Common forms of non-pharmacological approaches include biofeedback (muscular EMG and vascular/thermal warming), relaxation training, education, and coping skills training. Some of these studies show that some non- pharmacological approaches are equal to, or better than, drugs at reducing or preventing headache pain. However there is a surprising dearth of literature on the non-pharmacological approach of meditation on migraine headache pain. Only four studies have explored the potential benefits of meditation on headache pain, two of which are case studies, and no studies to date have focused specifically on the role of spirituality in coping with headache pain. 2
Religious and spiritual experiences may buffer against the negative consequences of this
syndrome. Previous studies have suggested that religion and spirituality have a positive effect on
general health, and decrease depression and mortality among a medically ill population (Koenig,
McCullough, & Larson, 2001, for a review). Further, accessing spiritual resources is related to
improved pain tolerance in arthritis pain (Keefe, et al., 2001), chronic pain (Bush, et al., 1999),
and acute pain (Wachholtz & Pargament, 2005).
Pain is not the only negative consequence of migraine headaches. Migraineurs also tend
to have high levels of depression and anxiety (Kolotylo & Broome, 2000; Stewart & Lipton,
2002), and migraine headaches have a profoundly negative impact on sufferers’ quality of life
(Bigal, Bigal, Betti, Bordini, & Speciali, 2001). Quality of life among migraineurs is even lower
than that reported by chronic tension type headache sufferers (Wang, Fuh, Lu, & Juang, 2001).
Spiritual meditation may help individuals reduce depression and anxiety, and improve
spiritual health and quality of life. Meditation may also result in positive emotional and physical
health outcomes (Alexander, Rainforth, & Gelderloos, 1991; Astin, 1997). Recent research
showed that spiritual meditation increased the number of daily spiritual and mystical experiences
(Wachholtz & Pargament, 2005). Further, higher instances of spiritual and mystical experiences
correlated with decreases in anxiety and depressed mood. In addition, during meditation,
practitioners had significant cardio-vascular relaxation (Wachholtz & Pargament, 2005). These
positive spiritual, psychological, and physical effects suggest that a spiritual meditation
technique may assist individuals who are suffering from migraine headaches.
This study considered the veracity of the claim that spiritual meditation has a unique value beyond that provided by secular meditation for migraineurs. However, prior to addressing issues in spirituality, this term must be defined for the context of this study. Problems arise in 3
attempting to operationalize the construct of “spirituality.” Researchers in this area often choose
different operational definitions and, as a result, attempting to merge those definitions into a
single cohesive whole is difficult at best. Since both conceptual and operational definitions of
spirituality vary greatly in the literature, I chose a broad definition of the construct that includes
the greatest number of viewpoints and incorporates the greatest variety of empyreal expressions.
Larson, Sawyers, & McCullough (1998) initially utilized the idea which was later further developed by Harris, Thoresen, McCullough, & Larson (1999, 414) who defined spirituality as
“a person’s orientation toward or experiences with the transcendent …features of life.” This
would include those concepts, emotions, ideas, and experiences that emotionally elevate the
individual above the mundane.
Spirituality is the experience of transcendence. Spiritual acts, such as meditation, may assist the individual in experiencing the transcendent. This study will examine the experiences of the individuals that occur during the meditation processes. This operational definition will serve as a guideline for this study.
Migraine Headaches
Pain and Migraines
In 1999, Ronald Melzack revolutionized the understanding of pain. He theorized that pain occurs in the context of a neuromatrix. The neuromatrix theory proposes that pain is a complex, multi-dimensional process with multiple overlapping determinants. The brain acts as an active participant in the pain process through a series of neural networks with both ascending
(pain), and descending pathways from the cognitive, emotional, and behavioral “centers” of the brain. When activated, these networks integrate information from multiple sources in the body
including emotional, physical, and cognitive areas to exacerbate or hamper the subjective feeling 4
of pain. These feelings of pain are also influenced by stress-induced cortisol release, which is
connected to many chronic pain syndromes (Melzack, 1999). Therefore psychologists can play an active role in the migraine headache pain process by identifying and addressing the cognitive, behavioral, and emotional issues which may contribute to the exacerbation of pain.
Migraine headaches are a disorder characterized by intense, throbbing pain, uni-laterally, accompanied by nausea or vomiting, and either photo- or phono- phobia (International Headache
Society, 2004). Migraines may also be accompanied by a visual or auditory “aura” that precedes the onset of pain. Migraine headaches often debilitate the individual due to the intense pain experienced during a migraine episode. Compared to tension type headache sufferers, migraineurs tend to perform twice as many maneuvers (isolating themselves, inducing vomiting, changing diet, becoming immobile, etc) to escape or relieve the pain (Martins & Parriera, 2001).
Migraineurs appear to have an increased sensitivity to pain even between headache attacks. Photophobia is one migraine characteristic in which light can create pain in the
migraineurs, however, recent research suggests that this sensitivity is not isolated to the headache
episode. Main, Vlachonikolis, and Dowson (2000) compared migraineurs, tension-type
headache sufferers, and healthy controls. They found that even between attacks migraineurs had
a significantly lower pain threshold than the other two groups. Migraineurs had lower pain
thresholds for light at a multitude of wavelengths, with particular sensitivity to light in the red
band (high wavelength). Other studies have also reported lower thresholds for visual stimulus
pain among migraineurs between attacks. Alternating light and dark stripes created pain in 82%
of migraineurs compared to 18% of chronic (non-migraine) headache controls (Marcus, & Soso,
1989) and flicker/strobe light created discomfort in over 80% of migraineurs in contrast to less
than 15% of controls (Hay, Mortimer, Barker, Debney, & Good, 1994). Between headaches, 5
migraineurs also appear to have increased sensitivity to auditory sensations (Rojahn, & Gerhards,
1986). This increased sensitivity to pain may be biologically based. There is some evidence that
differences in the serotonergic or the dopaminergic pathways of migraineurs mediate increased
sensitivity to painful stimuli (Di Piero, Bruti, Benturi, Talamonti, Biondi, et al., 2001). This
suggests that migraineurs have lower thresholds for pain compared to non-migraineurs even
between migraine attacks.
Causal Hypotheses of Migraines
There are three major competing hypotheses as to the cause of migraine headaches, the
vascular hypothesis, the neural hypothesis, and the brain stem generation hypothesis. The
vascular hypothesis posits that migraine symptoms are caused by vasospasms of the intra-cranial arteries. First, vasoconstriction and resulting transitory ischemic attack creates the migraine
“aura.” Second, the rebounding vasodilatation creates the actual pain sensation. While this hypothesis was the leading theory for a number of years, recent research suggests that it may soon fall out of favor. Recent fMRI scans of active-pain migraine patients do not show a change in diameter in the middle cerebral artery, during migraine attacks or following treatment with non-vasoconstricting analgesics (Limmroth, et al., 1996). Further, researchers have experimentally induced migraine pain in migraineurs without any changes in the diameter of the middle cerebral artery (Kruuse, Thomsen, Birk, & Olesen, 2003). This research suggests that for some individuals there may be a vascular component to migraine pain, however it is not necessarily the only cause for migraine pain.
The second causal hypothesis, the neural hypothesis, does not necessarily discount the vascular hypothesis. Instead, it hypothesizes that the vascular component is the distal cause of migraine pain and proposes neural involvement as a more proximal cause describe the onset of 6 migraine headaches. Brain imaging studies suggest that cortical spreading depression (CSD) creates the migraine aura experience and may be related to decreased blood flow in the brain prior to the onset of a migraine. Researchers supporting this causal hypothesis indicate that the resulting rebound activation in the trigeminovascular system following CSD is responsible for the pain experience of migraines (Pietrobon, & Striessnig, 2003, for review). However given the high number of migraineurs without auras and the shift from cortical depression in the occipital lobe to activation in the trigmeniovascular system create a number of unexplained questions for this theory as well.
The third and final major theory is the brainstem generator hypothesis. This view suggests that migraine aura and headache pain are simultaneous parallel processes rather than sequential causal processes. In contrast to the other two theories, this theory proposes that migraine headaches are caused by dysfunction in the brainstem areas that control pain sensations.
Specifically, researchers point to the dorsal raphe nucleus and locus coeruleus in migraineurs without auras, and the red nucleus and substantia nigra for migraineurs with auras (Bahra,
Matharu, Buchel, Frackowiak, & Goadsby, 2001). Further, researchers have found that migraine attacks frequently correspond to increased blood flow to the brainstem (Weiller, et al., 1995).
However, similar to the neural hypothesis, this hypothesis fails to explain the link between trigeminalvascular activation and brainstem dysfunction.
All three leading causal theories fail to address significant questions. The cause of migraine headaches remains a topic that is still hotly debated among researchers and given that such large holes appear in each theory, it is possible that at some point in the future, all three will be overthrown in favor of an entirely new theory.
7
Treatment of Migraines
Currently, many of the pharmacological treatments of migraines are unsatisfactory. They
do not work for many patients, they do not completely remove the pain, they do not completely prevent reoccurrence of the headaches, or they are accompanied by negative side effects.
Acute pain from migraine headaches is frequently treated with anti-inflammatory analgesics (e.g. Advil, Excederin), Triptans (e.g. Imitrex) or an intranasal form of ergot.
However, these treatments are ineffective for 20-30% of patients experiencing migraine headaches (Goadsby, Lipton, & Ferrari, 2002). Some preventative medications are currently on
the market, however these do not work for all patients and frequently have negative side effects
that are likely to prevent their long-term use among those who do find them effective (Pietrobon,
& Striessnig, 2003). As a last resort some physicians are prescribing anti-depressants “off label”
(meaning the medication has not been approved by the FDA for this purpose) as a means of
preventing migraine headaches, though the efficacy and safety of this treatment is hotly debated.
It has been shown that an anti-convulsant (a form of benzopyran) appears to stop CSD
and its accompanying migraine aura in cats. However, human testing has not yet begun on this
drug, and effectiveness would still likely be limited to those migraineurs who experience an aura
prior to migraine pain (Pietrobon, & Striessnig, 2003).
From causes to treatment, there remains a great deal that we simply do not know about
migraines. Given the lack of pharmacological efficacy with migraines, migraineurs appear to be
an ideal population in which to study alternative practices to headache pain control and
prevention. If meditation and relaxation techniques are found to reduce the frequency and
severity of migraine headaches and consequently improve migraineurs self-efficacy, then it may 8 be possible for them to improve their quality of life rather than simply await a pharmacological solution.
Migraine Headaches and Negative Emotions
Migraineurs appear to have greater psychosomatic sensitivity to stress. Huber and
Henrich (2003) compared 30 migraine patients and 30 healthy subject controls. They found that migraineurs do not have more daily stress in their lives, but they do have elevated feelings of depression and anxiety in response to that stress. Compared to the control group, the migraineurs reported greater difficulties relaxing, increased restlessness, and feelings of being ill during stressful situations (Huber, & Henrich, 2003). Not only do migraineurs rate themselves as having greater anxiety, but a large percentage of migraineurs also report that anxiety (57.9%), worry (58.6%), and irritation (55.3%) can trigger migraine attacks (Lateri-Minet, et al., 2003).
Previous research suggests that emotional factors, such as anxiety and depression, can have a large impact on many aspects of health, including morbidity and mortality in some diseases (Murberg, Bru, & Aarsland, 2001). Specifically, a number of emotional factors that are associated with migraine headaches (fearfulness, irritability, low self-esteem, social anxiety, and helplessness) are conceptualized as biologically based variables (Costa & McCrae, 1987;
Eysnek, 1967), which may impact health and well-being. It is suggested that such emotional factors lead to maladaptive coping styles such as avoidance and escape (Costa & McCrae).
Migraineurs have traditionally been characterized as highly ambitious, success oriented, self-motivated, socially introverted, and neurotic with greater levels of anxiety and depression when under stress (Zwart, et al., 2003). Personality profiles of migraineurs using the MMPI-2 often show the “Conversion V” on Hypochondriasis, Depression, and Hysteria scales suggesting that stress is often converted into psychosomatic symptoms (Huber, & Henrich, 2003; Mongini, 9
Ibertis, Barbalonga, & Raviola, 2000). Further, this pattern of high anxiety and depression has been shown in migraineurs in other cultures, including China (Fan, Gu, & Zhou, 1999), Sweden
(Perrson, 1997), New Zealand (Waldie & Poulton, 2002), Germany (Huber, & Henrich, 2003) and Italy (Mongini, Defilippi, & Negro, 1997).
In addition to higher levels of anxiety and depression, migraineurs display stronger
physiological and psychological reactivity to stress compared to non-headache controls. Persson
(1997) compared 74 migraineurs and their non-migraine full siblings. He found that migraineurs
showed greater physiological reactions to frustrating tasks, but with lower levels of general
expressed anger and frustration. The elevated physiological reaction may be connected to the
cerebro-vascular spasms that create migraine, particularly if the individual has a great deal of
repressed frustration and anger.
In a 26-year etiological study of approximately 1000 migraineurs, Waldie & Poulton
(2002) explored physical and psychological correlates of migraine headaches. They found a
significant history of childhood and young adult depression and anxiety disorders among
migraineurs. Migraine headaches were also linked to high stress reactivity. In the Waldie &
Poulton study, it is unclear whether depression, anxiety or hypersensitivity to stress directly
precipitate migraine headache attacks, but there does appear to be a significant connection
between these emotions and headaches. However, other studies have found the severity of
depression and anxiety symptoms do appear to be related to headache frequency (Zwart, et al.,
2003). Research also indicates that intervention into these symptoms can effectively reduce
headache frequency. In a study of 23 migraineurs’ anxiety and depression levels before and after
a therapeutic intervention, following treatment, migraineurs had significantly less anxiety and depression compared to their pretest scores (Fan, Gu, & Zhou, 1999). 10
Migraine Headaches and Meditation
There are a number of ways in which meditation may improve the quality of life of migraineurs. Though there is a paucity of research dealing with the topic of meditation, some
studies have explored how relaxation therapy may reduce the frequency and severity of migraine
headaches.
Relaxation appears to be an effective way of treating migraine headaches. A meta-
analysis of major techniques for the behavioral management of headaches showed that relaxation
training generally results in a 35-40% reduction over the course of the studies in the frequency
and/or severity of participants’ headaches (Penzien, et al., 2002). Fichtel and Larson (2001) recruited 36 adolescents with migraine or mixed migraine-tension headaches. The researchers led the participants through 8-10 sessions of a relaxation protocol, approximately 45 minutes long. After the completion of the study, both participants’ total number of headaches and their number of migraine headaches decreased significantly. Also, compared to the wait list control group, the relaxation group had significantly fewer migraine headaches, though the number of tension headaches was not significantly different (Fichtel & Larsson, 2001). These findings echo
other studies that show that relaxation can be efficacious in treating severe and incapacitating headaches among young adults (Larsson & Melin, 1988; Richter, et al., 1986).
Blanchard and his colleagues (Blanchard, et al., 1990) compared the effects of
biofeedback, cognitive therapy and “pseudomeditation” (body scanning + mental control)
technique on headache pain. Approximately 150 participants were divided into 4 groups,
thermal biofeedback, thermal biofeedback + cognitive therapy, pseudomeditation, and wait-list
control to participate in this 8 week, 16 session treatment study. In this study the researchers
defined pseudomeditation as a combination of body awareness (mentally scanning areas of the 11
body and becoming aware of sensations associated with those areas) and mental control (creating
images of participating in everyday activities) without any explicit instructions to relax or to
divert attention away from head pain by focusing on other areas of life. The researchers found
that all three of the experimental groups had significant reductions in the number/severity of headaches and concurrent large reductions (p < .10) in the use of medication in response to headaches, and they found no significant differences between the three treatment groups
(Blanchard, et al.). The researchers initially intended the pseudomeditation group to be an inert placebo-control, however, much to their surprise, the pseudomeditation became an active, and efficacious treatment group. While the pseudomeditation group in this study was not a highly developed intervention, it is notable that it still had a demonstrably positive effect on migraine headaches.
Migraineurs often feel a lack of control over the onset and course of their headache attacks. Self-efficacy may be critical in helping migraineurs improve their quality of life. A sense of self-efficacy improves adaptation to pain (Lefebvre, et al.,1990), increased pain tolerance (Keefe, Lefebvre, Maixner, & Salley, 1997), and encourages more active coping techniques (Keefe, et al., 1997). An internal locus of control and sense of self-efficacy can also affect headache related disability. French and his colleagues (French, et al., 2000) studied 329 headache patients. They found that higher feelings of self-efficacy in managing headache pain were related to lower levels of headache disability, anxiety, and more psychological positive coping. In contrast, feeling a lack of control over the onset and course of a headache led to high levels of depression and anxiety (French, et al., 2000). Therefore, providing behavioral management techniques, such as meditation, may improve self-efficacy in controlling headaches and, in turn, may improve pain tolerance and headache related quality of life. 12
Meditation may be one means of improving self-efficacy, and self-management of stress,
anxiety, and mood in both the medically ill and the general population (Bishop, 2002). Debate
continues over the exact functional mechanism of meditation and whether it is simply a state of
deep relaxation or a unique mechanism for achieving physical and psychological benefits.
Spirituality and Health
Many people may cope with the potentially overwhelming pain and difficulties
associated with migraine headaches by turning to religion and/or accessing spiritual resources.
However, there are both potential benefits and costs to utilizing religious/spiritual resources.
Previous research strongly suggests that religion can have a positive impact on physical, psychological health, and social interactions, particularly during stressful situations (Lukoff,
Provenzano, Lu, & Turner, 1999; Pargament, Smith, Koenig, & Perez, 1998, Seeman, Fagan-
Dubin, & Seeman, 2003).
Correlational Studies
Multiple correlational studies indicate the possibility of a positive relationship between
religion/spirituality and health, though the topic remains hotly debated among researchers
(Bergin, Stinchfield, Gaskin, Masters, & Sullivan, 1988; Koenig, et al., 2001; Pargament,
2002a). Correlational research has suggested that individuals with strong religious and/or
spiritual lives also tend to be healthier, psychologically and physically. However, the evidence is
far from conclusive (George, Larson, Koenig, & McCullough, 2000).
Smith, McCullough, & Poll (2003) recently published a meta-analysis comparing 147
independent studies on religiousness and depressive symptoms. After determining that
religiousness does appear to be a protective element against depression, they explored whether
this effect was found generally across all levels of stress or whether the effect was greater at 13
higher stress levels. They found evidence that the greater the life stress, the stronger the negative correlation between religiousness and depressive symptoms. At lower levels of reported stress, this negative correlation between religiousness and depressive symptoms still held, but it was weaker than during periods of high stress (Smith, et al.). The buffering effect of religiousness at higher life stress levels may have implications for psychological and physical health, particularly
for migraineurs who report higher reactivity to life stress (Huber & Henrich, 2003).
In a detailed assessment of spirituality among chronic pain patients, Rippentrop (2004)
found a similar effect. Chronic pain patients who report more spiritual experiences and higher levels of religious support were more likely to have more positive mental health than their counterparts who do not have similar spiritual resources (Rippentrop). This buffering effect was greatest among those in the pain population reporting higher levels of pain, with smaller differences in positive mental health among those in the patient population reporting less general pain. This buffering effect may be particularly critical to migraineurs. Since migraines are extremely painful experiences with significant quality of life impacts, the use of spiritual resources may have an even greater impact on positive mental health than among those who are experiencing general life stress.
Koenig, McCullough, & Larson, (2001) completed a substantial review of the religion and health literature and concluded that religion and spirituality may be a positive influence on the individual. Specifically, religion and spirituality have a positive effect on health, and decrease depression and mortality among a medically ill population (Koenig, et al., for a review).
However, they also identified a few areas in which religious beliefs and practices have been shown to have negative consequences for the practitioners. These include refusing medical services, fostering child abuse or religious abuse, and replacing mental health care with religion 14
(Koenig, et al.). Lukoff, et al. (1999) added that negative outcomes could occur when religious
fervor intermingles with psychosis.
Not all researchers agree on the positive effects of spirituality on health. A study from an
English hospital indicated that, after following 234 patients for nine months from initial
admission to a local hospital, patients with stronger spiritual beliefs were 2.3 times more likely to
show no improvement or show clinical declines (King, Speck, & Thomas, 1999). However, the
researchers only examined spiritual belief. There was no assessment of spiritual practices.
Previous research has indicated that stronger spiritual beliefs do not necessarily correlate with more spiritual practices particularly among medically ill individuals approaching the end of life
(Idler, Kasl, & Hays, 2001). Additionally, a meta-analysis by McCullough, et al., 2000 suggested that spiritual or religious practices, such as attending church services, may moderate the relationship between spirituality and health, and research cannot rely only on minimalistic surveys of self-reported levels of religious/spiritual belief. Associations between religious involvement and survival indicate religiously involved persons were more likely to survive (OR
= 1.43), while the relationship between religious beliefs (ex. finding comfort in one’s religious beliefs) and survival was much weaker (OR = 1.04; McCullough, et al., 2000). Further, King,
Speck and Thomas failed to differentiate between positive and negative forms of spiritual beliefs.
Other researchers have indicated that individuals with strong negative spiritual beliefs (ex. God is punishing me) are more likely to experience negative psychological and physical outcomes than those with positive beliefs (Exline, 2002, Pargament, 1997; Rippentrop, 2004).
In contrast to negative or punishing spiritual beliefs, several studies and books on religious and spiritual participation indicate that strong positive religious or spiritual experiences can mitigate the impact that daily stress has on health (Hixon, Gruchow, & Morgan, 1998; Levin 15
& Vanderpool, 1989; Moore, 1996; Pargament, 1997). Consequently, there is mixed evidence as to the positive and negative effects of religious and spiritual beliefs. Some forms of religion may be more adaptive, while some expressions of belief may be potentially maladaptive (Pargament,
2002a).
Conflicts among the claims of the benefits of religion and spirituality arise most frequently when researchers are too global in their assessment of religion and spirituality or when they make sweeping claims regarding the positives and negatives of religion. Detailed assessments of the field have generally led to the conclusion that certain beliefs and practices tend to be related to more positive outcomes while others appear to be more maladaptive
(Pargament, 2002a). A single broad assessment cannot adequately address the intricacies of spirituality and its relationship to health. In contrast to the global approach, detailed assessment of spirituality in the study of a specific health concern may prove to be more fruitful.
Treatment-Outcome Studies
Although a number of studies have shown positive correlations between religion, health, mental stability, and longevity, there have been relatively few studies utilizing a treatment- outcome design, and fewer specifically examining these factors among a migraine population.
Even fewer studies use treatment-outcome designs to compare religious or spiritual interventions with their secular counterparts. Since treatment-outcome research in this area is sparse at best, we are unable to answer the question, “Does religion add anything special to an intervention?”
While religion and spirituality could prove to be a powerful source of strength and comfort to assist therapy clients in achieving their goals, without further research, it is impossible to state what role, if any, religious therapies play in improving treatment outcomes. 16
Worthington, Kurusu, McCullough, and Sandage (1996) voiced their own frustration with the state of the literature on meditation in the religious context. In a review of 10 years of literature, they found that the role of spirituality in therapy had not yet been adequately addressed. Most relevant to the current study, the authors reported only two studies published since 1984 that utilized a religious meditation technique, and one of these was limited solely to one form of spiritual meditation practice. Thus, only one study attempted to compare a religious devotional or meditative practice with a secular practice.
In 1999, Harris, et al., reviewed the available literature on spiritual and religious interventions. The authors identified two categories of religious or spiritual interventions. The first are those methods, theories, or models, which initially had only secular content, but later added religious or spiritual content in order to improve the client’s reactivity to the method, theory or model. The second major area includes those interventions that implicitly and explicitly originated from a religious tradition. The authors concluded that spiritually based therapies and interventions offer modest improvements in the efficacy of health care. However, they still feel that more research is needed, “Virtually no well-controlled intervention studies have yet focused primarily on changing a spiritual or religious factor,” particularly in the area of controlled intervention studies that use multiple outcome assessment methods (Harris, et al.,
1999, 415). Further, they suggest that future research in this area, “should focus in on comparing explicitly religious or spiritually oriented meditation interventions with more secularized versions…” (Harris, et al., 1999, 420).
Similarly, McCullough (1999) pointed to the need for further research in his meta- analysis on outcomes of religious counseling compared to secular counseling. He found that the two forms of counseling did not show significant differences in treatment outcome. However, he 17
also indicated that research is lacking significantly with respect to treatment satisfaction, spiritual
well-being/improvements, or relapse prevention associated with the two forms of counseling
(McCullough, 1999).
A number of limited studies have experimentally explored connections between solitary
spiritual practices and physical or mental health. Elkins, Anchor, and Sandler (1979) conducted
one of the few research projects that compared a relaxation technique (progressive muscle
relaxation) with a devotional practice (prayer). In this study, 42 participants from similar
religious and cultural backgrounds were divided into three groups. The first group was exposed
to relaxation training, the second group was asked to engage in daily prayer, and the third group
remained as the control group. After 10 days, both experimental groups experienced significant
reductions in subjective stress, though these were more pronounced for the relaxation group.
Prayer, as the Elkins, Anchor, and Sandler (1988) study utilized it, involved either verbalization or thought in communication with God, which required conscious control.
Carlson, Bacaseta, and Simanton (1988) performed a study to compare a more free form
Christian devotional practice to progressive muscle relaxation. They divided 36 Christian participants into three groups: Devotional Meditation group, Progressive Muscle Relaxation group, and Control group. The PMR group listened to a pre-recorded tape for approximately 20 minutes that took the participant through relaxation exercises, recall of a stressful event, and recall of a pleasant event. The DM group also listened to a 20-minute pre-recorded tape that utilized scripture material (e.g. Psalm 23), asked the participant to meditate on its meaning, experience liturgical prayer, and quiet reflection time. At the end of a two-week program, the
DM group reported less anxiety and anger than those who underwent the two-week PMR program. In addition, the DM group had less muscle tension (reduced EMG activity). Their 18 study indicated quiet religious reflection was associated with better results than progressive muscle relaxation. Therefore, despite the rather limited treatment-outcome literature on spiritual practices and health, these findings certainly suggest that it is an area that deserves increased attention.
While the literature addressing links between devotional practices and health is sparse, there is one form of spiritual meditation that has been studied in a number of contexts, transcendental meditation (TM). This form of spiritual meditation has been shown to lower heart rate, blood pressure (Wenneberg, et al., 1997); metabolism (Elias, Guich, & Wilson, 2000); galvanic skin response, respiration rate, plasma lactate rate, and alter EEG readings (Dillbeck &
Orme-Johnson, 1987); enhanced autonomic stability during mentally stressful tasks (Alexander,
Swanson, Rainforth, & Carlisle, 1989); elevated vasopression (O’Halloran, et al., 1985); and altered endocrine responses to stress (Infante, et al., 1998). It has been utilized with a variety of patients as a means of controlling stress, pain and immunological factors. Research has shown that this form of spiritual meditation is more effective than rest, progressive muscle relaxation, or other forms of physically focused meditation.
Many researchers suggest that this type of meditation’s benefits stem from the fact that it is a spiritual experience rather than simply a physical (like progressive muscle relaxation) or educational one (Alexander, Rainforth, & Gelderloos, 1991). In order to test this idea,
Wenneberg, et al., (1997) divided 66 participants into two groups, the first group received stress reduction education (time management skills, diary keeping, dealing with stress, etc), while the second group received spiritual meditation training. At the end of four months of practice, the researchers found no difference between the two groups in cardiac reactivity to mental stressor tasks (tracing a mirror image and subtraction). However, an analysis of high compliance 19
participants showed that the high compliance meditators had significantly lower BP than their pre-training BPs. This group also showed significantly lower BP levels than the low compliance
meditation group and both compliance levels of the stress education group (Wenneberg, et al.,
1997). Consequently, those who consistently practice spiritual meditation for a short period of
time can have reduced reactivity when faced with a stressful situation.
Alexander, Rainforth, and Gelderloos’ (1991) performed a meta-analysis on the
transcendental meditation literature. They examined 18 major studies with over 1200
participants who ranged in meditation experience from five weeks to five years. The researchers
reported that many studies show that within three days of beginning to practice the spiritual
meditation, “virtually all” participants were able to achieve a mystical state and, within this three days time period, individuals began to show psychological and physiological changes. Further, the research indicates that these mystical states occurred more often among spiritual meditation practitioners than among those who practice secular relaxation or meditation techniques.
Correlations have also been reported between the clarity and frequency of mystical experiences
and the levels of psychological and physiological changes (Alexander, et al.). By cultivating
transcendence, spiritual meditation proponents claim that practitioners open themselves up to a
range of new spiritual experiences, such as a deeper connection to others and the universe around
them. This new awareness, in turn, allows them to adapt better to stress, which, in turn, results in
better psychological and physiological health.
A recent study specifically addressed the role of meditation in psychological and physical
health with implications for the use of spiritual meditation for migraineurs. Sixty-eight healthy,
meditation-naïve, undergraduates were taught one of three relaxation or meditation techniques
which they practiced independently for two weeks (Wachholtz & Pargament, 2005). Following 20
the two-week period, participants practiced their technique as their heart rate was monitored.
While practicing their assigned technique, participants placed their hand in 2o C cold water for as
long as they could endure the cold-induced pain. Additionally, both prior and immediately
following the two-week study, participants completed assessments on anxiety, depression, and
other mental and spiritual health variables.
The pain tolerance of the spiritual meditation group was significantly higher, almost
twice the duration of the secular-based technique groups. While all participants experienced the
same painfully cold stimulus, and participants rated the stimulus as equally painful across all
three groups, use of the spiritual technique appeared to create a greater endurance of that pain.
This has implications for those who endure migraine headache pain. Greater endurance may
allow migraineurs to continue to participate in activities despite migraine pain or to better
tolerate the period between migraine pain onset and medication efficacy (Wachholtz &
Pargament, 2005).
Meditation affects cardio-vascular relaxation. In the Wachholtz and Pargament (2005)
study, participants’ heart rate decreased significantly from their baseline heart rates. The cardiac
relaxation observed among the healthy participants suggests that meditation and relaxation decrease circulatory demands of the body. Among migraine patients, meditation may provide the opportunity to relax the cardiovascular system and reduce the frequency of vascular-based headaches.
Finally, spiritual meditation created more positive mood and less anxiety than the secular based techniques (Wachholtz & Pargament, 2005). Previous research indicates both these emotions are related to fewer instances of migraine headache. Therefore, evidence suggests that 21
spiritual meditation may have a greater impact on reducing migraine headache severity and
frequency compared to more secular based approaches (Wachholtz & Pargament).
While this evidence is compelling, some questions were not answered by this study.
Would this protocol be similarly efficacious for a chronic pain population who may have different pain perceptions than the general population? And did the effect occur, not because of a difference in efficacy between the intervention types, but because the relaxation protocol and the internal secular meditation group focus on the self and the body, thereby increasing the participant’s awareness of their hand in the cold water. The current study addresses these issues by using only participants that experience frequent migraine headaches, and by adding a second secular meditation group. The second secular meditation group, the external secular group, focuses outward from the body. If the effects of the previous study were solely due to distraction from the body, then the spiritual meditation group and the external secular group would have very similar outcomes in the present study.
Potential Explanations for the Beneficial Effects of Spiritual Meditation
The links between religion/spirituality and health have yet to be identified. However, many explanations have been offered, including social factors such as increased social support; psychological factors such as increased concentration from prayer/meditation; physiological factors such as reduction of sympathoadrrenal activity, lower levels of angiotensin and aldosterone; and purely spiritual factors such as an inherently positive value in a search for the sacred (Alexander, et al., 1994; Hixson, et al., 1998; Koenig, et al., 2001; Pargament, 1997;
Pargament, 2002b; Payne, Bergin, Bielema, & Jenkins, 1992).
More specifically, there are a number of potential links through which meditation might increase pain tolerance (See Appendix A). These potential explanations include: positive 22
spiritual support, decreased anxiety and depression, greater self-efficacy, distraction from
problems, and a decreased focus on the body. Meditation may work through each of these
potential links to affect the perception and tolerance of pain. Secular meditation utilizes some of
these spiritual resources, however spiritual meditation encompasses all of them, including some
that are uniquely spiritual in nature, such as spiritual support and spiritual connection. Thus,
spiritual meditation may be linked to more robust responses to pain than individuals who use
other forms of meditation.
Spiritual Support
Spiritual support stems from a positive approach to God and a feeling that God is a
benevolent higher power. It involves feeling loved and supported by that higher power. While
feelings of spiritual support may occur during secular meditation, they occur less often and with
less intensity among those using secular meditation (Astin, 1997; Wachholtz & Pargament,
2005). Spiritual support is more likely to be integrated into spiritual meditation than its secular
counterparts. If individuals feel loved and supported by a higher power, they may be less likely
to “give up” on a task and continue active coping with pain, potentially increasing pain tolerance.
Positive religious coping, including when coping with pain, often includes feelings of spiritual
support from God (Keefe, et al., 2001).
Research on religious coping indicates that those individuals who have negative views of
God (i.e., God is punishing them) also tend to have negative psychological and physical reactions. While most individuals appear to use positive forms of religious coping, those
individuals who employ more negative forms of religious coping are less likely to report feelings
of spiritual support (Keefe, et al., 2001). Those individuals who hold more positive, loving
views of God tend to have better religious coping techniques and endorse more positive items on 23
psychological and physical self-report questionnaires (Pargament, 1997). Therefore, when
considering phrases on which to focus a spiritual meditation, it is critical to develop phrases with
positive spiritual focus as a means of cultivating feelings of spiritual support.
McKinney and McKinney (1999) explored the prayer lives of 127 college students of
various faiths and belief systems. They asked students to record their prayers, religious thoughts, feelings, and actions for seven days. On average, participants reported approximately one relaxing or meditative prayer a day. In addition, the authors reported a number of these prayers involved attempts by participants to further their relationship with God. The students often reported that these types of prayers made them feel closer to a loving God.
Carlson, Bacaseta, and Simanton (1988) compared relaxation techniques to spiritual meditation. After the two week intervention, the researchers found that students who were assigned to the devotional meditation condition, reported less anxiety and anger than those who were assigned to the relaxation group (Carlson, et al.). Anecdotally, participants in the devotional meditation group reported feelings of spiritual support not reported by members of the other two groups. The authors indicated that meditating on liturgical writings that reflect a loving, supportive God among a religiously homogenous group of students can serve as a means of spiritual support, thus reducing trait and state anxiety. While not specifically discussed by the
authors, another explanation for the results of the study may involve the meditators’ feelings of
spiritual connection with a higher power (Carlson, et al.). When the participants meditate after
exposure to devotional ideas, the meditators may have more feelings of spiritual connection.
In addition to spiritual support, religious beliefs and activities can also influence the
mood of the individual, which, in turn, reduces the perceived severity of pain. Yates, Chalmer,
St. James, Follansbee, and McKegney (1981) studied how religious beliefs and activities can 24 modulate the presence or severity of pain. They surveyed 71 oncology patients with various forms of advanced cancer. They found that religious beliefs correlated positively with general happiness and life satisfaction. However, the most interesting finding indicated that, while the participants’ religious and spiritual beliefs did not eradicate the presence of pain, those beliefs and practices did correlate with a decreased level of reported and perceived pain. In other words, those who reported strong religious beliefs had a reduced sensitivity to pain (Yates, et al.).
Spiritual coping may also be helpful for those coping specifically with headache pain
(Buenaver, 2003). Using structural equation modeling, Buenaver explored headache pain, religious coping, secular coping, and psychological outcomes. He found that the best-fit model showed that positive religious coping, after controlling for secular coping, had a significant influence on the ability to tolerate and manage headache pain. This connection between religiosity and reduced sensitivity to pain may have important implications in the current study in which individuals will be asked to withstand acute discomfort for as long as possible. A reduced sensitivity should lengthen the amount of time that individuals can keep their hands in the cold water bath.
Internalized Locus of Control
Spiritual forms of meditation also appear to strengthen the participants’ internal locus of control (Ferguson, 1980). In a meta-analysis of those practicing transcendental meditation versus other secular forms of meditation and relaxation, Ferguson (1980) found that the average effect size for the spiritual technique was almost twice that of other techniques on self-report surveys of internal loci of control. Those who practiced the spiritual meditative technique reported feelings of greater control and less stress from external sources. A survey of 329 patients with frequent severe headaches (French, et al., 2000), found that those who report 25 greater feelings of internal control over headache pain had greater pain tolerance with less functional disability after controlling for headache severity (French, et al., 2000).
Simultaneously, a strengthened internal locus of control may contribute to the reduction in trait anxiety that is also observed among individuals practicing spiritual meditation (Ferguson, 1980).
Anxiety
It has been argued that spiritual meditation decreases trait anxiety through “shift awareness to deeper levels of the mind” (Alexander, et al., 1991, 209). Alexander, Rainforth, and Gelderloos (1991) reported in their meta-analysis that even short-term practice of at least one form of spiritual meditation resulted in lessened aggression and a decrease in trait anxiety.
Further, longitudinal research indicated that there is an inverse correlation between duration of meditation practice and levels of trait anxiety. Long-term meditators tend to have the lowest levels of trait anxiety, though significant differences can be noted as early as three days after meditation practice.
Carlson, Bacaseta, and Simanton (1988) also found that anger and anxiety were reduced for individuals who participated in short term spiritual meditation, moreso than individuals in the relaxation and control conditions. In addition, individuals who spiritually meditated reported increased feelings of “peace” and “calmness” after only two weeks of meditation. Thus, after only practicing meditation for a short period of time, studies found significant reductions in reported anxiety levels.
Feelings of peace and calmness often accompany the practice of spiritual meditation
(Alexander, et al., 1991; Carlson, et al., 1988). Since peace and calm by definition cannot coexist with anxiety, it is easy to understand why these studies also found a large decrease in trait anxiety among individuals who practice spiritual meditation techniques. Those who experience 26
secular meditation or relaxation exercises do not generally report such large decreases in trait
anxiety, in contrast, those practicing the spiritually based meditation report decreases in trait
anxiety that are twice as great as those practicing secular meditation or relaxation techniques
(Alexander, et al., 1991).
Psychological reaction to a stressor may alter how an individual perceives pain as a result
of the Cold Pressor task (Low, 1997; Wachholtz & Pargament, 2005). Heiligman, LaMont, and
Kramer (1983) performed a review of the pain literature and identified five predictors for the
severity of pain: increased expectation of pain, increased anxiety about recovery from pain,
increased anxiety as a basic personality trait, increased vigilance toward pain as a coping
behavior, and locus of control. While the authors did not measure it explicitly, they also
described how more positive mood appeared to decrease the severity of the pain experience.
This phenomena was also noted by Koff (1980, 46) in his book when he stated, “depression and
anxiety lower the individual’s threshold to perceive pain.”
Distraction
Some authors argue that meditation distracts the participants from discomfort, thus
allowing them to tolerate pain for longer periods of time (Alexander, et al., 1991). One of the potential purposes of spiritual meditation is the separation of the mind from immediate (or daily)
stressors. During the meditation, brief disconnection from daily stressors allows the individual
to focus on more transcendent ideas or beliefs (Alexander, et al., 1994). This is not simply time
to ruminate on the daily stressors of life, but time to set aside those thoughts in order to integrate
a more spiritual dimension into the individual’s life. By performing spiritual meditation and
focusing on transcendent ideas or beliefs, meditators necessarily reduce their focus on their body.
This may allow spiritual meditators to endure greater levels of pain and prolonged exposure to 27
uncomfortable situations (Alexander, et al., 1994). Thus, meditation of all kinds offers the
benefits of distraction from problems. However, spiritual meditation may provide the meditator
with a more positive source of distraction than does secular meditation (Alexander, et al., 1994).
Mood
Bush, Rye, Brant, Emery, Pargament, and Riessinger (1999) compared the benefits of
religious (positive and negative) and non-religious cognitive-behavioral coping techniques among 61 chronic pain patients. The researchers surveyed individuals who described their religious and non-religious coping techniques. Among chronic pain patients, positive religious
coping was associated with more positive mood, but not with better pain outcomes. While
positive mood was not associated with better pain outcomes among those who suffered from
chronic, uncontrollable pain in this study, other studies have indicated that those who are more
depressed or anxious have less tolerance to pain (Koff, 1980).
Mood and perception of pain are closely intertwined (Lecci & Wirth, 2000). Lecci and
Wirth examined 139 participants and their reactions to one of four conditions: happy-no pain,
happy-with pain, sad-no pain, and sad-with pain. The researchers induced mood through specific
music selections and requested the individual to recall a happy or sad time in his or her life. In
addition, those in the pain condition had a cleat placed on their wrist bone under a semi-inflated
blood pressure cuff. Their results indicated that individuals who experience pain and negative
mood simultaneously had more negative reactions to both (Lecci & Wirth, 2000). Additionally,
in the previously described study by Wachholtz and Pargament (2005), when participants were
collapsed across the three meditation/relaxation groups, those individuals who reported the
greatest spiritual health also reported the highest levels of positive affect.
28
Self-Efficacy
In addition to its effect on pain perception and sensitivity, mood also correlates with
increased feelings of self-efficacy when an individual is faced with a negative stimuli. While
self-efficacy is similar to internal loci of control, research shows that these concepts are related,
but not identical (French, et al., 2000). Whereas internal locus of control refers to the belief that
an individual can control the factors influencing the onset and course of headaches (regardless of
whether they choose to exercise that control or not), self-efficacy refers to beliefs held by an
individual about their ability to take action to influence that onset and course (French, et al.).
Research indicates that positive spiritual and religious coping is correlated with both
improved mood and higher levels of self-reported efficacy to control pain. Keefe, et al., (2001)
explored how individuals who experience chronic pain with rheumatoid arthritis use spiritual and
religious coping techniques in order to manage the pain. Using a 30-day diary method with 35
participants, the researchers performed a daily assessment of the interactions of pain, religious
coping, social support, mood, and spiritual experiences. A significant correlation emerged
between participants’ ability to control pain and the use of positive religious coping techniques,
“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” (Keefe,
et al., 2001, 19). Coping efficacy also correlated with more positive mood and higher levels of
emotional and social support. When individuals rated themselves as highly able to cope with
pain, they also reported more positive mood. Thus, the study indicates that individuals who are
adept at using positive forms of spiritual/religious coping are less likely to feel overwhelmed by
the chronic pain associated with rheumatoid arthritis. In addition, the global concept of positive
mood can affect pain perception by decreasing pain sensitivity. 29
French, et al. (2000) explored headache specific self-efficacy and participant’s beliefs
about preventing and controlling headache pain. In their assessment of 329 headache sufferers,
they found that individuals who felt more empowered in regard to their headaches had less
headache related disability, more active coping, and improved headache pain tolerance. Thus,
increasing migraineurs confidence in their self-efficacy may have numerous positive outcomes.
Conclusion
Spiritual and religious meditation may affect a number of different areas that have an
impact on pain perception and tolerance. Spiritual meditation correlates with feelings of spiritual
support, spiritual connection, peace, calmness, and decreased anxiety and results in an
improvement of mood. More positive mood has been correlated with decreased sensitivity to
pain and increased ability to withstand the impact of negative situations. Additionally, spiritual
meditation may increase feelings of internal loci of control, and decrease the focus on the body,
thus allowing an individual to withstand discomfort longer. These potential benefits suggest that
migraineurs who practice spiritual meditation may have greater tolerance to acute pain than
people who do not practice spiritual meditation. Additionally, spiritual meditation may decrease depressive mood and anxiety, which may be a triggering factor in migraine headaches potentially
reducing the frequency and severity of migraine episodes.
Summary of Previous Research
Spiritual and religious meditation may affect a number of different areas that have an
impact on psychological, physical, or spiritual health in addition to general quality of life.
Spiritual meditation correlates with feelings of spiritual support, spiritual connection, peace, calmness, optimism and decreased anxiety and an improvement of mood. Additionally, spiritual meditation may increase feelings of internal locus of control, and self-efficacy. These potential 30
benefits suggest that individuals who practice spiritual meditation may have a greater resistance
to negative emotions and improved quality of life compared to people who do not practice
spiritual meditation.
This study compares three forms of meditation (two secular and one spiritual) to
determine whether the meditative content yields significantly different responses in a migraine
population. Specifically, it is hypothesized that individuals who perform the spiritually based
meditation will report reduced psychological distress (depression and anxiety), greater spiritual
health, and fewer headache events while displaying greater pain tolerance during the course of the study than those who perform the secular meditation techniques.
31
METHOD
Participants
Eighty-three participants completed the entire study. All participants met the criteria for
vascular headache (migraine, or mixed migraine + tension headache) based on the criteria of the
International Headache Society (2004). Participants were at least 18 years old, and must have
experienced at least two migraine headaches in the previous month. There were 75 women and 8
men with a mean age of 19.1 (SD=1.10) (See Table 1). The 83 Participants were divided into
four groups: Spiritual Meditation (22 participants), Internal Secular Meditation (21 participants),
External Secular Meditation (20 participants), and Relaxation (20 participants). There were no significant differences between the groups on any of the pre-test variables (See Table 2).
Ninety-two participants initially participated in the study but nine participants did not complete the entire month long intervention. Two participants from the Relaxation (RL) group, three from the External Secular Meditation (ES) group, one from the Internal Secular Meditation
(IS) group, and three from the Spiritual Meditation (SP) group did not complete the study. There
were no significant differences between those who completed the study and those who dropped
out, except on the number of reported headaches experienced last month (3.22 headaches in the drop-out group versus 12.28 headaches in the completer group). Those who report fewer headaches were less likely to be motivated to complete the month long intervention than those who experience more headaches.
Screener
All participants passed the ID Migraine screener (Lipton, et al., 2003). This 3-question migraine headache screener provides a brief assessment of headaches to determine if the headache qualifies as a migraine headache (See Appendix B). Screener validity was established 32 on a trial of 563 routine general practitioner patients that completed the in office screener and a later full headache evaluation with a medical expert in the area of headaches. When compared to the expert’s diagnosis, the screener had a sensitivity of 0.81, specificity of 0.75, and a positive predictive value of 0.93 (Lipton, et al., 2003). Two or more positive responses are required to identify migraine headaches. Further, participants needed to report experiencing at least two migraine-type headaches in the past month. Participants were required to complete the screener prior to being signed up for the study.
Adherence
Adherence was measured through a diary in which participants recorded their daily practice of their assigned technique (see Appendix C). The adherence diaries included a short series of questions for participants to complete including daily headache status and completion the meditation/relaxation practice. Participants were required to complete their meditation task for at least 15 of the 30 days. Those who did not complete the task for at least 15 days were classified as dropouts.
Objective Measures
Headache Count
Participants recorded the frequency and severity of their migrainous headaches in their practice diaries. The number of headaches reported by participants for the month prior to the study was compared to the number of headaches reported over the course of the intervention.
Pain Tolerance
Objective measurements of pain tolerance were taken prior to and after a month of daily practice of the assigned technique (spiritual meditation, internally focused secular meditation, externally focused secular meditation, and relaxation). Higher levels of perceived pain in 33
response to the CP task has been linked to the magnitude of increased cardiac reactivity to the
CP task (Peckerman, et al., 1994). An individual’s biological functions react to painfully cold
water by increasing aerial vasoconstriction, heart rate, and venous return which are correlated to
perception of the severity of pain (Schneiderman, et al., 2000). This has also been shown to be a valid predictor of the development of hypertension later in life (Menkes, et al., 1989). The duration that the participant remains in contact with the water during the CP task was timed.
Psychological Measures
A number of well-established psychological measures were used in this study. In addition to the well-established psychological measures, the survey included a short series of questions that asked individuals to rate their subjective experience of relaxation while meditating, and their subjective experience of pain during the CP task. These questions were used both as a manipulation check for the study as well as indicators of the degree to which the meditation affects the factors of interest in the study.
Affect
The Positive and Negative Affect Scale (PANAS) consists of two-10 item subscales (see
Appendix D). One subscale assesses positive affect and the other measures negative affect
(Watson, Clark, & Tellegen, 1988). Though the scale can be used to measure affect at various points in time, this study measures the individual’s immediate affect (i.e., “how do you feel at this moment”). Both the positive and negative scales show high internal consistencies, .89 for positive affect, and .85 for negative affect with a negative correlation (r = -.15) between the two scales. Further, the short-term, state-like version of the questionnaire shows moderately high stability when given after an 8-week retest interval, .54 for the positive affect scale, and .45 for the negative affect scale. The positive affect subscale has convergent validity with other brief 34 positive affect measures (ranging .81-.92), and the negative affect subscale also converges with brief negative affect measures (ranging .76-.91).
Anxiety
The State-Trait Anxiety Inventory (STAI) is a frequently used measure of anxiety. The
STAI is a self-report inventory designed to capture transient (see Appendix E) and stable (see
Appendix F) mood states of the individual. It has been used in over 3000 studies (Bieling,
Antony, & Swinson, 1998). The inventory contains twenty statements, including both positive and negative items on each of the state and trait scales. The individual statements range from 1-
“almost never” to 4- “very much” with the maximum obtainable score for each scale after reverse coding equaling 80. A recent large survey was undertaken to create modern norms for the state scale (Scott & Melin, 1998). One thousand, three hundred and eighty-six participants were surveyed. The scale yielded indicated a mean of 35.57 with a standard deviation of 9.40 and an internal reliability alpha of .91 (Scott & Melin, 1998). In previous surveys, the state anxiety scale has shown concurrent validity with other anxiety questionnaires ranging from .73-
.85. The trait anxiety scale has an average internal reliability alpha of .91 (Spielberger, 1983).
Participants completed the trait scale (TAI) at both pre- and post-intervention. However, the state scale (SAI) was given at post-test only.
Depression
The Center for Epidemiologic Studies Depression Scale (CESD) is a measure of depression (see Appendix G). The CESD is a self-report inventory designed to measure depressive affect over the previous week (Radloff, 1977). It contains a single scale consisting of
20 statements, with responses ranging from 1 (rarely or none of the time), to 4 (most or all of the time). Higher scores indicate greater depressive affect. It has high internal consistencies ranging 35 from .85 - .87 among a general population sample. It has evidence of convergent validity with other depression scales (.51-.85).
Headache Specific Surveys
The two headache specific surveys were given both prior to the intervention and following the month long intervention. These surveys explore the specific effects of migraine headaches on the migraineurs.
Quality of Life
The Migraine Specific Quality of Life (MSQOL) measures the general effect that migraine headaches have on the lives of migraineurs (Wagner, Patrick, Galer, & Berzon, 1996).
It is a 25 item, self-report scale that uses a 4-point Likert scale with higher scores representing higher quality of life (see Appendix H). Internal reliability is extremely high (α=.92) as is test- retest reliability (α =.90). The scale shows concurrent validity with both the Medical Outcomes
Study Short Form (SF-36) and the Psychological General Well-Being Schedule (PGWB)
(Wagner, et al.).
Self-Efficacy
The Headache Management Self-Efficacy Scale (HMSE) is a 25 item, self-report scale that uses a 7-point Likert scale which ranges from 1=strongly disagree to 7 =strongly agree (see
Appendix I; French, et at., 2000). Higher scores indicate greater feelings of self-efficacy and internal locus of control. The scale yields a single unified score that assesses feelings of personal control over the onset, frequency, duration, and severity of serious headaches. It has an internal reliability of .90 (French, et at., 2000). The HMSE has concurrent validity with internal loci of control (.40) and is inversely related to feelings of chance loci of control (-.64), and headache related disability (-.24) (French, et al.). 36
Spirituality Measures
Spiritual measurements were given at two times, immediately after entering the study,
and upon completing the month long study. Portions of the Multi-dimensional Measurement of
Religiousness/Spirituality Scale (Fetzer, 1999) were given to screen participants and compare the
different treatment groups prior to the treatment. The term “spirituality” was used rather than
“religion” because the definition of religion in its vernacular usage often includes communal
properties while meditation does not necessarily have this property.
Religious Measures Questionnaire
Parts of The Brief Multidimensional Measure of Religiousness/Spirituality developed by
the Fetzer /National Institute on Aging Working Group assessed participants’ spiritual life (see
Appendix J; Fetzer, 1999). The survey was normed on a national population as part of the
General Social Survey in 1998 providing an opportunity to compare the study sample to the
larger population. There are two domains of the measure that were particularly pertinent to this
study, the Religious Intensity Questionnaire, and the Private Religious Activities Questionnaire.
The two-item Religious Intensity has a medium reliability rating (.77) and explores the self-
reported levels of religiousness and spirituality of the individual “To what extent do you consider
yourself a spiritual person?” The five-item Private Religious Activities also has mid-level
reliability (.72). This scale inquires about spiritual or religious practices that the individual
performs alone, (ex. “How often do you pray privately in places other than at church or
synagogue?”) However the sub-domain of meditation, “Within your religious or spiritual
tradition, how often do you meditate?” under Private Religious Activities is more limited in its
test-retest reliability (.51) with a mean of 3.39 and a standard deviation of 2.72 (Fetzer).
37
Spiritual Well Being Scale
The SWB scale was developed by Paloutzian and Ellison in 1982 to measure the subjective spiritual quality of life (see Appendix K). It assesses two aspects of an individual’s spiritual life; Religious Well Being (RWB), the individual’s feelings of personal well-being with
God, and Existential Well Being (EWB), a more horizontal measure of well being between self and others. These subscales can be reported separately or combined into a single score. Test- retest reliability across 1, 4, 6, and 10 weeks ranged from .88-.99 for RWB, .73-.98 for EWB, and .82-.99 for SWB scales. Internal reliability coefficients ranged from .82-.94 for RWB, .78-
.86 for EWB, and .89-.94 for the entire SWB scale. Validity information indicates that higher scores on the two subscales and on the combined scale correlate with indicators of positive psychological quality of life (decreased loneliness, higher sense of purpose in life, etc.) (Boivin,
Kirby, Underwood & Silva, 1999).
Daily Spiritual Experiences Questionnaire
This 16-item scale, designed by Underwood and included in the 1999 Fetzer Report, measures how individuals perceive the transcendent in their daily life (Underwood & Teresi,
2002; see Appendix L). Specifically, it assesses how often an individual has a spiritual experience, such as “I feel deep inner peace or harmony.” The author states that the perception of wholeness and transcendence is a major product of spirituality and integration of the experience of spirituality into daily life. Internal reliability estimates a range from .91 to .95 across a variety of sample populations, including the national sample tested by the Fetzer
Institute (Fetzer, 1999). The authors, utilizing factor analysis to support the construct validity of this scale, indicate that the scale consists of a single dimension that taps the transcendent 38
construct in daily life (Underwood & Teresi). Items were reverse coded so that higher scores indicate a greater number of reported daily spiritual experiences.
Mysticism Scale
The Mysticism Scale, designed by Hood (1975), assesses an individual’s “peak” or unusual experiences, such as an extremely peaceful state (see Appendix M). Hood designed his
scale with two subscales (Hood): Intense Experience of Unity (“I had an experience that was both timeless and spaceless,”) and Affectively Charged Religious Revelation (“I had an experience I knew to be sacred.”) Research on this two-factor solution, yielded reliability alpha coefficients were .55 (Religious Revelation), and .69 (Unity). Validity has been established by correlations of the subscales with measures of openness to new experiences, broad religious experiences, high intrinsic religious motivation, and tolerance of others (Hood, Hall, Watson,
Biderman, 1979). The subscales are not related to neuroticism or psychopathology (Caird,
1987). For the purposes of this study, the questions have been modified slightly. Rather than asking whether the individual has ever experienced any of the phenomena, the revised questions ask the individual whether he/she experienced any of these phenomena during the four-week meditation period.
Power Analyses
Preliminary power analyses utilizing an average effect/variance sizes from studies where participants meditated for less than or equal to1 month indicate that 20 participants per cell are required to achieve statistical significance for a power level of .9.
Procedure
Participant contact took place in two phases (See Appendix N). Initially, interested individuals met in a group with other potential participants. At that meeting, research assistants 39 described the project to potential participants and the assistants answered any questions. After the individuals agreed to participate, they read, discussed, and signed the informed consent.
Participants completed a survey packet consisting of demographic, psychological, spiritual, and health assessment tools. As participants completed the survey packet, the group leaders took the participants from the room individually to complete a baseline cold pressor task. After all the participants completed both the survey and the cold pressor task, group leaders trained the participants in how to perform their assigned meditation/relaxation task, and led a practice trial of the tasks. All meditation participants received the same training (See Appendix O); the only difference was the set of meditative phrases available from which they could choose. The relaxation group had basic muscle relaxation training and was not given a meditation phrase (See
Appendix P). As the participants left the training session, they received an adherence diary to track the frequency of their meditation/relaxation practice and they signed up for their individual appointment in one month. During the one-month of meditation/relaxation practice, participants received an email after 2 weeks reminding them of their upcoming appointment, and the contact information for their group leader if they had any questions or needed to change their second appointment. They also received an email 3 days prior to their appointment with this same information.
The participants practiced their meditation for 20 minutes per day for 4 weeks. In the
Spiritual Meditation group (SP), the participants were allowed to choose one of four spiritual meditative phrases in an attempt to allow the participants to use the phrase that best fits their spiritual system: “God is peace,” “God is joy,” God is good,” and “God is love.” Participants from the Internally Focused Secular Meditation (IS) group were offered a choice from four internally focused secular phrases: “I am content,” “I am joyful,” “I am good,” “I am happy.” In 40
the Externally Focused Secular Meditation (ES) group, participants chose from four externally
focused secular meditation phrases: “Grass is green,” “Sand is soft,” “Cotton is fluffy,” “Cloth is
smooth.” The Relaxation (RL) group practiced a progressive muscle relaxation technique.
Following one month of meditation practice, participants met with the investigator again
to engage in the cold pressor stress test, turn in their practice diaries, and complete the psycho-
spiritual self-report tests. Participants received individual sessions after they arrived, and rested for 5 minutes. After the 5-minute rest period, participants initiated the 20-minute meditation/relaxation period. Following 20 minutes of meditation/relaxation, participants continued their technique as they placed their hand in the cold water bath up to their wrist and were instructed to maintain contact “until it becomes too uncomfortable.” After they removed their hand from the CP bath, the participants completed a second survey packet containing the same psychological, spiritual, and health assessment tools as in the first packet. The second packet also contained a series of manipulation check questions regarding the participants’ experiences with the meditation/relaxation and CP task.
41
RESULTS
Repeated measures 2 x 4 (time period x group) ANOVAs were conducted to assess whether the four groups changed in different ways over time. Of particular interest in these analyses was the time x treatment interaction effect. With respect to those variables that were assessed only at pre-test (e.g. demographic variables) or post-test (e.g. manipulation checks), 1 x
4 (variable x group) ANOVAs were conducted to test for differences between the four groups.
The results of the manipulation check and adherence data (See Table 3) are presented below
followed by the results for each class of criterion variables: Objective Measures (See Table 5),
Psychological Measures (See Table 5), Headache Specific Surveys (See Table 5), and Spiritual
Measures (See Table 6).
Adherence Analyses
Adherence data was analyzed with all participants and by group. Two analyses were
conducted. One, included all participants, including dropouts, and the other only included
participants that practiced the meditation protocol at least 15 of the 30 days of the study (See
Table 3). Given the bimodal distribution of participants’ practice data (See Figure 1), only data
from participants that practiced at least 15 of the days were included in the remainder of the
analyses.
Manipulation Check Analyses
A series of manipulation check questions assessed the perceived stressfulness of the CP
task and the perceived relaxation stemming from their assigned technique (See Table 3). There
was no subjective difference between the groups on the stressfulness of the CP task (F (3,79) =
0.69, NS); participants in each group rated the task “somewhat” stressful. Additionally,
participants did not vary greatly on the level of relaxation they experienced from each technique 42
(F (3,79) = 0.19, NS); each group rated their task as “moderately” relaxing. This suggests that participants in each group experienced the CP task and their own technique similarly. The results also suggest that the group members in the relaxation control group did not perceive that that they were assigned to the control group.
Objective Measures
Headaches
There were notable effects of the intervention on the objective measures of headache
count and observed pain tolerance (See Table 4). An analysis of participants’ headaches showed
an extremely strong time period by group interaction effect in the number of reported headaches
prior to the study and those reported during the one month intervention (F(3,79) =15.68, p <
.000) with a strong effect size (Eta2 = .37). The interaction showed the SP group reported a
significantly greater drop in headaches over the course of the study compared to the other groups
(See Table 7 and Figure 2). A 1 x 4 ANOVA of the pre-post change scores with an LSD post-
hoc test, indicated that those in the SP group scores showed a significantly greater drop in
headache frequency than all three groups: IS (p<.01), ES (p<.001), RL (p<.001). The IS group
reportedly experienced a greater drop in headache frequency than the ES (p<.01), or RL (p<.01) groups.
Pain Tolerance
A significant interaction also appeared in the level of pain tolerance displayed by the
different groups prior to the intervention and after the intervention (F(3,79) =4.00, p < .01) with
a moderate effect size (Eta2 = .13). The interaction showed that the SP group reported a
significantly greater increase in their pain tolerance compared to the other groups over the course
of the intervention (See Table 7 and Figure 3). An assessment of pre-post change scores with a 1 43
x 4 ANOVA and LSD post-hoc test, indicated that those in the SP group experienced a
significantly greater increase in pain tolerance than the IS (p<.005), ES (p<.05) or RL (p<.01)
groups.
Psychological Measures
A series of 2x4 between subjects ANOVAs (time x treatment group) was conducted to
examine the differences between the four groups on anxiety, mood, quality of life, and self-
efficacy as assessed by the psychological measures.
NPANAS
A significant time x treatment interaction effect was found for negative mood (F (3,79) =
4.73, p<.005) with a moderate effect size (Eta2 = .15). The interaction showed that the SP group
experienced a greater drop in negative affect scores compared to the other groups (See Table 7
and Figure 4). The pre-post change scores were assessed with a 1 x 4 ANOVA and an LSD post-
hoc test which indicated that those in the SP group reported a significantly greater drop in
negative affect over the course of the study than the IS (p<.001), or ES (p<.005) groups.
Similarly, the RL group scores showed significantly greater reduction in negative affect over the
duration of the intervention than the IS group (p<.05), and marginally less than the ES group
(p<.10).
PPANAS
Though the graph suggests that three of the four groups (SP, IS, RL) experienced some modest improvement in their positive affect, there was no significant time x treatment interaction effect on the positive mood reports of participants (F (3,79) = .26, p=NS) (See Table 7 and
Figure 5).
44
TAI
A significant time x treatment interaction effect occurred for trait anxiety (F (3,79) =
3.31, p<.05) with a small to moderate effect size (Eta2 = .11). The time by group interaction showed that the SP group experienced a significantly larger decrease in trait anxiety compared to the other groups over the intervention (See Table 7 and Figure 6). A 1 x 4 ANOVA of the pre- post change scores with an LSD post-hoc test, indicates that those in the SP group experienced a significantly greater drop in trait anxiety than the ES (p<.005), and marginally greater drop than the IS group (p<.10). The RL group reported a greater drop than the ES group (p<.05).
SAI
The state anxiety survey was given at post-test only. There was no significant difference between the groups (F (3,79) = 1.17, p=NS; see Table 5).
CESD
The time by group interaction effect for self ratings of depression was not significant (F
(3,79) = 0.96, p=NS) (See Table 7 and Figure 7). A visual assessment of the graph suggests that all groups experienced some mild reduction in their CESD scores during the study.
Headache Specific Surveys
MSQL
While the graph of MSQL scores suggested that the SP and IS groups experienced some improvement in their reported quality of life, this was not a significant effect. The time x treatment interaction effect was not significant (F (3,79) = 0.71, p=NS) with respect to migraineurs’ quality of life (See Table 7 and Figure 8).
45
HMSE
A significant time x treatment interaction occurred with respect to headache self-
management efficacy (F (3,79) = 2.99, p<.05). The size of this effect size was moderate (Eta2 =
.10). The interaction effect showed that the SP group reported greater increases in headache self- efficacy over the course of the study than the other groups (See Table 7 and Figure 9). A 1 x 4
ANOVA of the pre-post change scores with an LSD post-hoc test, indicated that those in the SP group reported a significantly greater increase in their confidence to manage their headaches than the IS (p<.005) group and marginally greater confidence than the RL (p<.10) group. The IS group also reported a marginally greater increase in confidence compared to the ES group
(p<.10)
Spiritual Measures
A series of 2x4 ANOVAs (time x treatment group) assessed the differences between the four groups on the spiritual measures.
SWB
There was no significant time by group interaction on general spiritual well being (F
(3,79) = 1.48, p=NS) (See Table 7 and Figure 10), though the graph suggests that three of the groups (SP, IS, RL) experienced some modest improvement in their reported spiritual well being.
Similarly, no significant time x treatment interaction was found on the Religious Well Being subscale (F (3,79) = 0.76, p=NS) (See Table 7 and Figure 11). However, on the Existential
Well-Being subscale a significant interaction (F (3,79) = 2.13, p<.05) was found which accounted for a small amount of variance (Eta2 = .09). The interaction indicates that the SP
group experienced a greater increase in existential well being over the course of the study than
the other groups (See Table 5 and Figure 12). A 1 x 4 ANOVA of the EWB pre-post change 46
scores with an LSD post-hoc test, indicated that those in the SP group reported a significantly
greater increase in their existential well being than the IS (p<.05), and ES (p<.01) groups.
DSE
The ANOVA yielded a significant time x treatment interaction on the number of reported
daily spiritual experiences (F (3,79) = 2.67, p<.05). This resulted in a small effect size (Eta2 =
.09). The interaction indicated that the SP group reported a greater increase in daily spiritual
experiences over the course of the study than the other groups (See Table 7 and Figure 13). A 1 x 4 ANOVA on the pre-post change scores with an LSD post-hoc test, revealed that those in the
SP group had a significantly greater increase in the number of daily spiritual experiences than the
IS (p<.05), and RL (p<.01) groups and a marginally greater increase than the RL (p<.10) group.
Mysticism
The MYST scale was given only at post-test. 1x4 ANOVA’s were conducted and
revealed no significant differences between the four groups on the entire scale (F (3,82) = 0.82,
p=NS), nor on the Revelation subscale (F (3,82) = 1.00, p=NS). However, the four groups did
differ significantly on the Unity subscale (F (3,82) = 2.77, p<.05). A post hoc analysis of the
Unity subscale showed that the spiritual meditation group reported significantly more unity-
focused mystical experiences than the ES group (p < .05) and the RL group (p < .05).
47
DISCUSSION
Individuals with migraine headaches have treatment options that were unavailable just 10 years ago. However, despite advances in prophylactic, post-onset, and analgesic migraine treatment, many are still left without adequate pain management. Migraineurs experience severe headache pain that negatively impacts their mood, their quality of life, their self-identity, their relationships and their ability to work. In the present study, I explored how adding an explicitly spiritual component to meditation creates a distinctive element to improve the efficacy of meditation practice by impacting headache frequency, pain tolerance, mood, anxiety, and quality of life variables among migraineurs. While previous studies have observed consistently positive mental and physical health outcomes among practitioners of meditation (Grossman, Niemann,
Schmidt, & Walach, 2004), few have sought to explore the differences between spiritual and secular forms of meditation. And, to my knowledge, no published studies to date have explored how adding a spiritual component to a meditation practice may increase pain tolerance and reduce headache frequency among migraineurs.
Pain and Spiritual Meditation
The study’s findings supported most of the hypotheses proposed in this project. Not only did migraineurs who practiced spiritual meditation report a greater reduction in the number of headaches they experienced, they displayed more pain tolerance. Similar to other studies that have explored the effects of spiritual practices on pain, the practice of spiritual meditation in this study did not alter people’s sensitivity to pain (based on their ratings of pain severity) but it did alter how well they tolerated those pain levels (Keefe, et al., 2001; Wachholtz & Pargament,
2005). 48
This means that spiritual meditation may create a two-fold benefit to migraineurs. First,
with fewer headaches, migraineurs will experience less pain during their daily lives, without the
hassle, expense, and potential negative side effects of taking daily prophylactic migraine
medication. Second, improved pain tolerance means that when headaches do occur, migraineurs are better able to continue with their daily activities and experience fewer disruptions in their
schedule due to pain. This would allow them to continue working (reducing the economic
impact of migraines mentioned previously), or enjoying their leisure time (improving their
psychological and spiritual health). The spiritual meditation technique is an eminently portable
skill that requires no special equipment or financial commitment, yet appears to yield notable pain reduction benefits to the practitioners. Encouraging spiritual health development among those pain management patients who are interested in spirituality may enhance their ability to withstand pain over time.
Mental Health and Spiritual Meditation
In addition to physical health, mental health is also critical to migraineurs general perception of health. Regular practice of spiritual meditation in this study created significant decreases in negative mood among its practitioners. Spiritual meditators reported a larger decrease in negative affect than those in any of the non-spiritual techniques groups. While
previous research has shown that general forms of meditation can be effective in improving mental health (Grossman, Niemann, Schmidt, & Walach, 2004); the spiritual component appears to have a unique additive effect that expands the inherent usefulness of meditation and takes its
efficacy to new levels.
Not only did spiritual meditation improve mental health by decreasing negative mood, it
also significantly reduced the levels of trait anxiety reported by the practitioners. Similar to the 49
findings with mood, it is not unusual for practitioners of meditation to report a general reduction
in trait anxiety (Wachholtz & Pargament, 2005). However, the unique finding in the present
study is that the addition of an explicitly spiritual component enhanced this effect compared to those using non-spiritual techniques.
Self-efficacy to control the onset and duration of headache pain should also be a consideration in pain management. The ability to feel in control of one’s pain is related to less pain-driven negative emotion and better pain tolerance (French, et al., 2000; Keefe, et al., 2001).
One of the very important findings of the present study is that after only one month, spiritual
meditation participants noticed enough of a difference to report an improved ability to control
and affect their headache status. An interesting point from the efficacy findings is that while
spiritual meditators reported increased feelings of spiritual connection to a higher power, they did not report reduced feelings of self-efficacy in lieu of attributing increased efficacy to a higher power. This suggests that individuals who use their spiritual meditation techniques will attribute their improved pain tolerance to their own actions rather than externalize the control of their pain to a higher power.
Anecdotally, participants in the current study indicated that their migraine headache pain interfered with their lives by consuming valuable time intended for family, friends, work, or leisure. With an initial average of 12 migraine headaches a month among the study population, headache pain created severe intrusions on their daily lives. A reduction of these intrusions, over time, should enhance practitioners’ quality of life. Though not significant in the current study, those participants practicing spiritual meditation showed a strong trend toward improved quality of life, after only practicing the meditation technique for one month. Additionally, since the spiritual meditation group reported improvements in other areas that contribute to quality of life 50
(e.g. fewer headaches, better tolerance of pain, decreased anxiety, less negative mood, improved
headache efficacy), it is possible that continued practice might lead to significant improvements
in their quality of life.
If other pain management patients are able to achieve similar positive mental health
results through spiritual meditation, it could impact their ability to have more fulfilling
interactions with their family and friends, improve their ability to work, and add to their general
quality of life. All of these mental health findings speak to a fundamental improvement in
emotional health and improved feelings of control following the use of spiritual meditation that was not replicated with non-spiritual techniques.
Spiritual Health and Spiritual Meditation
The positive benefits of spiritual meditation appear to reach beyond the physical and
mental health domain, into the spiritual health domain. Spiritual meditators reported significant
increases in their number of daily spiritual experiences. As a result of the spiritual meditation,
meditators appeared to view the world through more of a spiritual lens and experience a greater
sense of connectedness with the sacred on a daily basis.
The spiritual meditation group also reported the greatest improvements in their existential
spiritual well being. The concept of existential well-being deals with the relationship between
individuals and their higher power and time spent in spiritual meditation appears to enhance this
relationship. Greater time spent in spiritual meditation may provide people with the time and
mental space to explore this relationship. Moreover, the positive spiritual meditation phrase may
enhance this connection by focusing people on positive aspects of their relationship with God.
Not only did spiritual meditation appear to enhance the meditators relationship with God,
it also appeared to foster feelings of unity and spiritual inter-connectedness to those around them. 51
Thus, spiritual meditation appeared to enhance both the horizontal spiritual tie between the
individual and other people and the vertical spiritual link between the individual and God.
However, these were not the only spiritual health findings of interest.
Spiritual improvements were also found among the secular meditation and relaxation groups in the area of spiritual well-being. While the improvements were more modest than those observed in the spiritual meditation group, it raises the question as to why spiritual improvements were found at all among practitioners of ostensibly secular tasks.
As found in previous studies (Wachholtz & Pargament, 2005), even secular meditation
techniques may enhance the individual’s spirituality by setting aside daily time to reduce the
external noise of life and focus on quieting the self. It also raises the possibility that participants
in secular meditation are injecting spiritual aspects into the technique. Yet another possibility is that people are extracting a spiritual essence from the seemingly secular technique.
Historically, meditation has been embedded in a larger spiritual matrix. These findings suggest that it may be impossible to disconnect meditative practices fully from this larger context. Thus, the distinction between “secular” and “spiritual” meditation may be overdrawn and artificial. Harris, et al. (1999) ask a number of intriguing questions that may need to be addressed to adequately respond to these observations, “Are the spiritual or religious components of various meditative practices, in essence, ‘delivery systems’ for the actual mechanism of change, that is the relaxation response? Or do the spiritual or religious components, when present, contribute to observed effects of meditative practice in a more integral or facilitative way, allowing the relaxation response to work in a way that otherwise could not or would not happen? Or do the spiritual and religious components act as an addition and separate ‘active ingredient’?” (Harris, et al., 1999, 419). This possibility should be pursued in future studies 52
through daily diaries that allow narrative space for participants to explore their thoughts and
feelings as they experience the meditative process; qualitative analyses of these experiences
could then be conducted among participants in both spiritual and secular meditation groups.
Implications
The findings of this study have important practical implications to those working with
chronic or acute pain patients. It is possible that these results might generalize to other groups of
pain patients. Spiritual meditation could be particularly pertinent to the treatment of those
diagnosed with pain inducing diseases that have a strong stress-related pain component, such as
fibromyalgia, and rheumatoid arthritis. Of course, this awaits further study.
Health practitioners who work with clinical pain patients have varying levels of comfort
in discussing religious or spiritual issues with their patients. But the current study suggests that
allowing patients who have a spiritual faith to integrate their spiritual resources into treatment
may lead to better pain tolerance and, perhaps in turn, reduce their reliance on pain medications.
If spiritual meditation reduces the reliance on pain medication, then this practice could also
reduce the risk of addiction to narcotic or opioid pain medications within this patient population.
The positive mental health findings stemming from spiritual meditation also have implications for pain patients. Since pain-related mood and anxiety can disrupt a number of areas of a patient’s life, spiritual meditation could have positive implications for patients who have difficulties adhering to their medical regiment (e.g., completing physical therapy, attending pain management appointments), and/or socializing with others due to poor mental health.
Finally, the study’s findings that seemingly secular meditation techniques resulted in some spiritual improvements may have implications for exploring how clinicians integrate meditation into clinical practice. For patients who do not have a spiritual faith, it may be 53
misleading to present any meditation technique as a “secular” technique since even ostensibly
non-spiritual meditation techniques appear to have, on some level, a spiritual component. This
may be due to the inherent spirituality of the technique or historical context of meditation. After
all, meditation is deeply embedded in many religious traditions. Regardless of its cause, it
appears to be difficult to strip spirituality from meditation techniques.
Limitations and Future Directions
While this study contributed to our understanding of how different forms of meditation can affect migraineurs, there were limitations to the study. The participant population consisted primarily of undergraduate students, which limited the study’s generalizability to other individuals. The participants in the study were legitimate pain patients, reporting a notable number of monthly migraine headaches (average of 12 headaches/month), but future studies could expand the demographic variability in the participant populations by recruiting migraineurs from pain clinics or the general population. Gathering participants from pain clinics
would also address the second limitation of the study; a pain specialist did not verify
participants’ report of a migraine headache diagnosis. Instead, the Migraine ID screener and a
high number of reported monthly headaches with migraine characteristics were used to identify
potential participants.
Contact between the participants and the experimenter was intentionally held to a
minimum, in order to reduce any potential conflicting therapeutic interventions. However, this
minimal participant contact might also be a limitation. Future studies could integrate the
meditation protocol from this study with a full combination of therapeutic techniques and weekly
therapist contact (individual or group format) to potentially enhance the efficacy of the spiritual
meditation technique. 54
The study contains a large proportion of women (90%). However, within the general
population, women make up approximately 75% of migraine headache patients. Therefore,
while this is a factor that should be noted, the gender differences are not dramatically different
from the larger patient population.
Finally, the present study was limited by lack of follow-up data after the completion of
the study. While the current study showed promising results after only a month of spiritual
meditation practice, it leaves open the question of whether these benefits were sustained over the
long-term. Future studies should include follow-up data, with questionnaires covering continued
practice of the meditation techniques and the emotional, spiritual, and cognitive outcomes at one
to six months following the study.
Yet another potential future direction for this line of research involves a project with a
larger participant population and qualitative analyses of participant writings in their daily diaries.
This would provide the opportunity to better understand participants’ thoughts and feelings during their daily meditation practices. It would also allow the researchers to develop a richer understanding of the developmental process that participants go through as they learn a new meditation/relaxation technique. Furthermore, researchers could identify how participants in the secular meditation groups were integrating spiritual themes into their meditation practice.
Additionally, a larger subject pool would allow for more complex path analyses that would help
solidify our understanding of the relationship between spiritual meditation, anxiety, mood, self- efficacy, and quality of life and their connection to migraine headaches.
Conclusions
The explicit inclusion of spirituality into a meditation task appears to add to the efficacy of this technique among migraine pain patients. Individuals with migraine headaches experience 55 a great deal of pain and pain-related stress as a result of their headaches. This pain and stress often results in functional disability leading to lost time for work, family, social, or other activities. The present study suggested that spiritual meditation has unique properties that mitigate some of the negative impact of migraines on people’s lives. Despite the seemingly minor alteration of the meditation technique used in the study, the addition of an explicitly spiritual component produced profound effects. Spiritual meditation was shown to decrease negative mood, decrease anxiety, increase feeling of spirituality, and increase feelings of self- efficacy in coping with headache pain. Spiritual meditators also displayed an increased pain tolerance and fewer headaches than other participants in the study. Without the addition of spirituality to the relaxation practice, the benefits of meditation were more modest. Thus, the information gained from the present study suggests that the combination of spirituality and meditation in the daily practice of a spiritual meditation technique may enhance psychological, physical, and spiritual health in migraineurs. Additional studies are needed to determine whether spiritual meditation holds similar implications for other chronic and acute pain patients.
56
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APPENDIX A. POTENTIAL LINKS BETWEEN SPIRITUAL MEDITATION AND QUALITY OF LIFE
Self-Efficacy Better Mood Internalized Locus of Control Impulse Control Spiritual Meditation Distraction from Problems Improved Pain Tolerance Improved Quality of Life Spiritual Support/Connection Decreased Trait Anxiety Decreased Focus on the Body
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APPENDIX B. ID MIGRAINE SCREENER
Circle One:
Do your headaches make you feel nauseated or sick to your stomach? YES NO
Did your headache limit you from working studying or doing what you YES NO needed to do for any day in the previous 3 months?
Does light bother you a lot more than when you don’t have headaches? YES NO
How many headaches like these did you have last month? ______
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APPENDIX C. DAILY ADHERENCE DIARY
Daily Adherence Diary -- Day # ______
Date ______ID# ______
Did you perform the meditation for 20 minutes today? ____ Yes _____No
Did you have a headache today? ______Yes ______No If yes, how painful was it at its worst? Rate between 1 (no pain) - 10 (unbearable pain) ______Did you take medicine for this headache? ______Yes If yes, what type(s) and how much? ______Did you have that headache while practicing meditation? ______Yes Did you notice a change in pain levels? ______Yes Pain level before? ______Pain level after?______
Please circle the number describing how you CURRENTLY feel.
Not at All Very Much Happy 1 2 3 4 5 6 7
Angry 1 2 3 4 5 6 7
Sad 1 2 3 4 5 6 7
Calm 1 2 3 4 5 6 7
Negative Positive General Mood 1 2 3 4 5 6 7
Additional Comments:
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APPENDIX D. POSITIVE AND NEGATIVE AFFECT SCALE
This scale consists of a number of words that describe different feelings and emotions. Read each item and then mark the appropriate answer in the space next to that word. Indicate to what extent you felt this way in the past month. Use the following scale to record your answers.
1 2 3 4 5 Very slightly or not at all A little Moderately Quite a bit Extremely
Interested Irritable
Distressed Alert
Excited Ashamed
Upset Inspired
Strong Nervous
Guilty Determined
Scared Attentive
Hostile Jittery
Enthusiastic Active
Proud Afraid
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APPENDIX E. STATE-TRAIT ANXIETY INVENTORY, STATE SCALE
A number of statements which people have used to describe themselves are given below. Reach each statement and then circle the appropriate number to the right of the statement to indicate how you feel right now, that is, at this moment. There are no right or wrong answers. Do not spend too much time on any one statement but give the answer which seems to describe your present feelings best. Not At Somewhat Moderately Very Much All So So
1. I feel calm. 1 2 3 4 2. I feel secure. 1 2 3 4 3. I am tense. 1 2 3 4 4. I feel strained. 1 2 3 4 5. I feel at ease. 1 2 3 4 6. I feel upset. 1 2 3 4 7. I am presently worrying over 1 2 3 4 possible misfortunes. 8. I feel satisfied. 1 2 3 4 9. I feel frightened. 1 2 3 4 10. I feel comfortable. 1 2 3 4 11. I feel self-confident. 1 2 3 4 12. I feel nervous. 1 2 3 4 13. I am jittery. 1 2 3 4 14. I feel indecisive. 1 2 3 4 15. I am relaxed. 1 2 3 4 16. I feel content. 1 2 3 4 17. I am worried. 1 2 3 4 18. I feel confused. 1 2 3 4 19. I feel steady. 1 2 3 4 20. I feel pleasant. 1 2 3 4
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APPENDIX F. STATE-TRAIT ANXIETY INVENTORY, TRAIT SCALE
A number of statements which people have used to describe themselves are given below. Reach each statement and then circle the appropriate number to the right of the statement to indicate how you generally feel. There are no right or wrong answers. Do not spend too much time on any one statement but give the answer which seems to describe your general feelings best.
Not At Somewhat Moderately Very Much All So So 1. I feel pleasant. 1 2 3 4 2. I feel nervous and restless. 1 2 3 4 3. I feel satisfied with myself. 1 2 3 4 4. I wish I could be as happy as others seem to be. 1 2 3 4 5. I feel like a failure. 1 2 3 4 6. I feel rested. 1 2 3 4 7. I am “calm, cool, and collected.” 1 2 3 4 8. I feel that difficulties are piling up so that I cannot overcome them. 1 2 3 4 9. I worry too much over something that doesn’t really matter. 1 2 3 4 10. I am happy. 1 2 3 4 11. I have disturbing thoughts. 1 2 3 4 12. I lack self-confidence. 1 2 3 4 13. I feel secure. 1 2 3 4 14. I make decisions easily. 1 2 3 4 15. I feel inadequate. 1 2 3 4 16. I am content. 1 2 3 4 17. Some unimportant thought runs through my mind and bothers me. 1 2 3 4 18. I take disappointments so keenly that I can’t put them out of my mind. 1 2 3 4 19. I am a steady person. 1 2 3 4 20. I get in a state of tension or turmoil as I think over my recent concerns and interests. 1 2 3 4 71
APPENDIX G. CENTER EPIDEMIOLOGICAL STUDIES DEPRESSION SCALE
Below is a list of some of the ways you may have felt or behaved. Please indicate how often you have felt this way during the past week by checking the appropriate space. 1- Rarely or None of the Time (Less than 1 day) 2- Some or a Little of the Time (1-2 days) 3- Occasionally or a Moderate Amount of the Time (3-4 days) 4- Most or All of the Time (5-7 days)
Rarely Some or Occas or Most or or None a Little a Mod. all of the of the of the Amount Time Time Time of the Time 1. I was bothered by things that usually don’t bother me 1 2 3 4
2. I did not feel like eating; my appetite was poor 1 2 3 4
3. I felt that I could not shake off the blues even with help from my 1 2 3 4 family or friends 4. I felt that I was just as good as other people 1 2 3 4
5. I had trouble keeping my mind on what I was doing 1 2 3 4
6. I felt depressed 1 2 3 4
7. I felt that everything I did was an effort 1 2 3 4
8. I felt hopeful about the future 1 2 3 4
9. I though my life had been a failure 1 2 3 4
10. I felt fearful 1 2 3 4
11. My sleep was restless 1 2 3 4
12. I was happy 1 2 3 4
13. I talked less than usual 1 2 3 4
14. I felt lonely 1 2 3 4
15. People were unfriendly 1 2 3 4
16. I enjoyed life 1 2 3 4
17. I had crying spells 1 2 3 4
18. I felt sad 1 2 3 4
19. I felt that people disliked me 1 2 3 4
20. I could not “get going” 1 2 3 4
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APPENDIX H. MIGRAINE SPECIFIC QUALITY OF LIFE
Migraines affect people’s lives in different ways. Please circle the number of the statement that best describes how you feel in-between your migraines.
1. It is important to avoid changes in the pace of my life because of migraines. a. Yes, it is very important b. Yes, it is quite important c. No, it is not very important d. No, it is not important at all
2. I try to avoid getting too tired because of my migraines a. Yes, I try very hard b. Yes, I try quite hard c. No, I do not try very hard d. No, I do not try at all
3. It is important for me to stay in familiar surroundings because of my migraines a. Yes, it is very important b. Yes, it is quite important c. No, it is not very important d. No, it is not important at all
4. I feel helpless when a migraine starts a. Yes, very much b. Yes, quite a lot c. Yes, a little d. No, not at all
5. I worry about my migraines disrupting other people’s lives a. Yes, I worry about it very much b. Yes, I worry about it quite a lot c. Yes, I worry about it a little d. No, I don’t worry about it all
6. My life revolves around my migraines a. Yes, very much b. Yes, quite a lot c. No, not very much d. No, not at all
7. It’s important for me to eat regularly because of my migraines a. Yes, it is very important b. Yes, it is quite important c. No, it is not very important d. No, it is not important at all 73
8. I worry that I neglect people close to me because of my migraines a. Yes, I worry about it very much b. Yes, I worry about it quite a lot c. Yes, I worry about it a little d. No, I don’t worry about it at all
9. I resent losing time because of my migraines a. Yes, I resent it very much b. Yes, I resent it quite a lot c. Yes, I resent it a little d. No, I do not resent it at all
10. I dislike having to rely on other people because of my migraines a. Yes, very much b. Yes, quite a lot c. No, not very much d. No, not at all
11. I’m reluctant to make plans because of my migraines a. Yes, I am very reluctant b. Yes, I am quite reluctant c. No, I am not very reluctant d. No, I am not reluctant at all
12. I try to avoid too much activity for fear of bringing on a migraine a. Yes, I try very hard b. Yes, I try quite hard c. No, I do not try very hard d. No, I do not try at all
13. I worry about getting a migraine if I have to travel long distances a. Yes, I worry about it very much b. Yes, I worry about it quite a lot c. Yes, I worry about it a little d. No, I don’t worry about it at all
14. My migraines put a strain on my close relationships a. Yes, very much b. Yes, quite a lot c. No, not very much d. No, not at all
15. I try to avoid places that might bring on a migraine (for example bright, noisy, or smoky places) a. Yes, I try very hard b. Yes, I try quite hard c. No, I do not try very hard d. No, I do not try at all 74
16. I worry about the future because of my migraines a. Yes, I worry about it very much b. Yes, I worry about it quite a lot c. Yes, I worry about it a little d. No, I don’t worry about it at all
17. I try to avoid pushing myself too hard because of my migraines a. Yes, very much b. Yes, quite a lot c. No, not very much d. No, not at all
18. I get nervous if I think I am going to get a migraine a. Yes, I get very nervous b. Yes, I get quiet nervous c. Yes, I get a little nervous d. No, I don’t get nervous at all
19. I feel depressed about having migraines a. Yes, I feel very depressed b. Yes, I feel quite depressed c. Yes, I feel a little depressed d. No, I don’t feel depressed at all
20. I worry about letting people down because of my migraines a. Yes, I worry about it very much b. Yes, I worry about it quite a lot c. Yes, I worry about it a little d. No, I don’t worry about it at all
21. I doubt my ability to do a good job because of my migraines a. Yes, very much b. Yes, quite a lot c. No, not very much d. No, not at all
22. It’s important for me to keep to a routine because of my migraines a. Yes, it is very important b. Yes, it is quite important c. No, it is not very important d. No, it is not important at all
23. I find my migraines frightening a. Yes, very much b. Yes, quite a lot c. No, not very much d. No, not at all 75
24. I feel angry that nothing can stop a migraine a. Yes, I feel very angry b. Yes, I feel quite angry c. Yes, I feel a little angry d. No, I don’t feel angry at all
25. I worry that people think I use my migraines as an excuse a. Yes, I worry about it very much b. Yes, I worry about it quite a lot c. Yes, I worry about it a little d. No, I don’t worry about it at all
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APPENDIX I. HEADACHE MANAGEMENT SELF-EFFICACY SCALE
Instructions: You will find below a number of statements related to headaches. Please reach each statement carefully and indicate how much you agree or disagree with the statement by circling a number next to it. Use the following scale as a guide.
Strongly Somewhat Slightly Neither Agree Slightly Moderately Strongly Disagree Disagree Disagree or Disagree Agree Agree Agree 1 2 3 4 5 6 7
1 I can keep even a bad headache from disrupting my day by 1 2 3 4 5 6 7 changing the way I respond to the pain.
2 When I’m in some situations, nothing I do will prevent headaches. 1 2 3 4 5 6 7
3 I can reduce the intensity of a headache by relaxing. 1 2 3 4 5 6 7
4 There are things I can do to reduce headache pain. 1 2 3 4 5 6 7
5 I can prevent headaches by recognizing headache triggers. 1 2 3 4 5 6 7
6 Once I have a headache there is nothing I can do to control it. 1 2 3 4 5 6 7
7 When I’m tense, I can prevent headaches by controlling the tension. 1 2 3 4 5 6 7
8 Nothing I do reduces the pain of a headache. 1 2 3 4 5 6 7
9 If I do certain things every day, I can reduce the number of 1 2 3 4 5 6 7 headaches I will have.
10 If I can catch a headache before it begins, I often can stop it. 1 2 3 4 5 6 7
11 Nothing I do will keep a mild headache from turning into a bad headache. 1 2 3 4 5 6 7
12 I can prevent headaches b y changing how I respond to stress. 1 2 3 4 5 6 7
13 I can do things to control how much my headaches interfere with my life. 1 2 3 4 5 6 7
14 I cannot control the tension that causes my headaches. 1 2 3 4 5 6 7
15 I can do things that will control how long a headache lasts. 1 2 3 4 5 6 7
16 Nothing I do will keep a bad headache from disrupting my day. 1 2 3 4 5 6 7
17 When I’m not under a lot of stress, I can prevent many headaches. 1 2 3 4 5 6 7
18 When I sense a headache is coming, there is nothing I can do to stop it. 1 2 3 4 5 6 7
19 I can keep a mild headache from disrupting my day by changing the 1 2 3 4 5 6 7 way I respond to the pain.
20 If I’m under a lot of stress, there is nothing I can do to prevent headaches. 1 2 3 4 5 6 7
21 I can do things that make a headache seem not so bad. 1 2 3 4 5 6 7
22 There are things I can do to prevent headaches. 1 2 3 4 5 6 7
23 If I am upset , there is nothing I can do to control the pain of a headache. 1 2 3 4 5 6 7
24 I can control the intensity of headache pain. 1 2 3 4 5 6 7
25 I can do things to cope with my headaches. 1 2 3 4 5 6 7
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APPENDIX J. RELIGIOUS MEASURES QUESTIONNAIRE
The following questionnaire consists of multiple choice and fill-in-the-blank items. Please make an X next to your choice or provide the most accurate number for the fill-in-the-blank item.
1. How many times have you attended religious services during the past year? ______times
2. Which of the following best describes your practice of prayer or religious meditation? a. Prayer is a regular part of my daily life. b. I usually pray in times of stress or need but rarely at any other time. c. I pray only for formal ceremonies. d. I never pray.
3. When you have a serious personal problem, how often do you take religious advice or teachings into consideration? a. Almost always b. Usually c. Sometimes d. Never
4. How much influence would you say that religion has on the way that you choose to act and the way That you choose to spend your time each day? a. No influence. b. A small influence. c. Some influence. d. A fair amount of influence. e. A large influence.
5. During the past year, how often have you experienced a feeling of religious reverence or devotion? a. Almost daily b. Frequently c. Sometimes d. Rarely e. Never
6. To what extent do you consider yourself a religious person? a. Very religious b. Moderately religious c. Slightly religious d. Not religious at all
7. To what extent do you consider yourself a spiritual person? a. Very spiritual b. Moderately spiritual c. Slightly spiritual d. Not spiritual at all
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APPENDIX K. SPIRITUAL WELL BEING SCALE
For each of the following statements, place a check in the box that best indicates the extent of your agreement or disagreement as it describes your personal experience
SA= Strongly Agree D= Disagree MA= Moderately Agree MD= Moderately Disagree A = Agree SD=Strongly Disagree
SA MA A D MD SD 1. I don't find much satisfaction in private prayer with God. 2. I don't know who I am, where I came from, or where I am going. 3. I believe that God loves me and cares about me. 4. I feel that life is a positive experience. 5. I believe that God is impersonal and not interested in my daily situations. 6. I feel unsettled about my future. 7. I have a personally meaningful relationship with God. 8. I feel very fulfilled and satisfied with life 9. I don't get much personal strength and support from my God. 10. I feel a sense of well-being about the direction my life is heading in. 11. I believe that God is concerned about my problems 12. I don't enjoy much about life. 13. I don't have a personally satisfying relationship with God. 14. I feel good about my future. 15. My relationship with God helps me not to feel lonely. 16. I feel that life is full of conflict and unhappiness. 17. I feel most fulfilled when I'm in close communion with God. 18. Life doesn't have much meaning. 19. My relationship with God contributes to my sense of well-being. 20. I believe there is some real purpose for my life. 79
APPENDIX L. DAILY SPIRITUAL EXPERIENCES SCALE
The list that follows includes items you may or may not experience. Please consider if and how often you have these experiences, and try to disregard whether or not you feel you should or should not have them. A number of items use the word "God." If this word is not a comfortable one, please substitute Another idea that calls to mind the divine or holy for you.
How often did you experience the following while you practiced your technique?
KEY 1= Many times a day 4= Some days 2= Every day 5= Once in a while 3= Most days 6= Never or almost never Many Every Most Some Once Never/ in a Almost Times Day Days Days while Never 1. I feel God's presence. 1 2 3 4 5 6 2. I experience a connection to all life. 1 2 3 4 5 6 3. During meditation, I feel joy which lifts me out of my daily concerns. 1 2 3 4 5 6 4. I find strength. 1 2 3 4 5 6 5. I find comfort. 1 2 3 4 5 6 6. I feel deep inner peace or harmony. 1 2 3 4 5 6 7. I find help in my daily activities. 1 2 3 4 5 6 8. I feel guided in my daily activities. 1 2 3 4 5 6 9. I feel God's love for me, directly. 1 2 3 4 5 6 10. I feel God's love for me, through others. 1 2 3 4 5 6 11. I am spiritually touched by the beauty of creation. 1 2 3 4 5 6 12. I feel thankful for my blessings. 1 2 3 4 5 6 13. I feel a selfless caring for others. 1 2 3 4 5 6 14. I feel an acceptance toward others. 1 2 3 4 5 6 15. I desire to be closer to God, or in union with God. 1 2 3 4 5 6
In general, how close did you feel to God prior to beginning this experiment? ______Not at all close ______Somewhat close ______Very close ______As close as possible
In general, how close do you feel to God now? ______Not at all close ______Somewhat close ______Very close ______As close as possible 80
APPENDIX M. MYSTICISM SCALE
Below are brief descriptions of a number of experiences. Some descriptions refer to phenomena that you may or may not have experienced while you practiced your technique.
Please rate how each statement describes your experience during the course of the study.
Make a mark in the left margin according to how much the description applies to your experience. In responding, please understand that the items may be considered as applying to one experience or as applying to several different experiences. After completing the questions, please be sure that all items have been marked, leave no items unanswered.
This description is definitely true of my own experience: +2 This description is probably true of my own experience: +1 This description is probably not true of my own experience: -1 This description is definitely not true of my own experience: -2
1. I had an experience that was both timeless and spaceless.
2. I never had an experience which was incapable of being expressed in words.
3. I had an experience in which something greater than myself seemed to absorb me.
4. I had an experience in which everything seemed to disappear from my mind until I was conscious only of a void.
5. I experienced profound joy.
6. I never had an experience in which I felt myself to be absorbed as one with all things.
7. I never experienced a perfectly peaceful state.
8. I never had an experience in which I felt as if all things were alive.
9. I never had an experience which seemed holy to me
10. I never had an experience in which all things seemed to be aware.
11. I had an experience in which I had no sense of time or space.
12. I had an experience in which I realized the oneness of myself with all things.
13. I had an experience in which a new view of reality was revealed to me.
14. I never experienced anything to be divine.
15. I never had an experience in which time and space were non-existent.
16. I never experienced anything that I could call ultimate reality. 81
17. I had an experience in which ultimate reality was revealed to me.
18. I had an experience in which I felt that all was perfection at that time.
19. I had an experience in which I felt everything in the world to be part of the same whole.
20. I had an experience which I knew to be sacred.
21. I never had an experience which I was unable to express adequately through language.
22. I had an experience which left me with a feeling of awe.
23. I had an experience that is impossible to communicate.
24. I never had an experience in which my own self seemed to merge into something greater.
25. I never had an experience which left me with a feeling of wonder.
26. I never had an experience in which deeper aspects of reality were revealed to me.
27. I never had an experience in which time, place, and distance were meaningless.
28. I never had an experience in which I became aware of the unity of all things.
29. I had an experience in which all things seemed to be conscious.
30. I never had an experience in which all things seemed to be unified into a single whole.
31. I had an experience in which I felt nothing is ever really dead.
32. I had an experience that cannot be expressed in words.
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APPENDIX N. PROCEDURES
Session 1 • Hand out informed consent • Give summary of informed consent forms o Discuss any questions about the consent forms o Participants sign informed consent forms • Assign code numbers • Hand out pre-test surveys • Complete pre-test • Pass around sign up sheet for second appointment times • Complete the CP task with individual participants in separate room • Teach class from appropriate lesson plan • Hand out Meditation phrase forms (if applicable) and participants choose their focus phrase • Practice the technique (with phrases if applicable) • Answer any questions • Hand out Daily Diaries • Explain purpose of the diaries how to fill them out, importance of diaries • Collect meditation phrase forms • Collect 2nd appointment sign up sheet • Release participants
*At the end of 7 days of completing the technique, contact participants individually by e-mail Title: Stress and Headache Study “Hi this is (Research Assistant’s Name) with the Stress and Headache study. Now that you have been practicing every day for a week, I wanted to know if you had any questions. Please feel free to contact me at (RA’s email address), or contact the principal investigator at [email protected]. Don’t forget, your second session is on (date/time of participant’s 2nd session) and you’ll need to bring your daily diary. See you then! (RA’s name)
*After 21 days of participating in the study, contact participants individually by email Title: Stress and Headache Study “Hi this is (RA’s name)with the Stress and Headache study. Now that you have been practicing every day for 3 weeks, I wanted to know if you had any questions or difficulties. Please feel free to contact me at (RA’s email address), or contact the principal investigator at [email protected]. Don’t forget, your second session is on (date/time of their 2nd session) and you’ll need to bring your daily diary. See you then! (RA’s name)
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*Three Days prior to participant’s 2nd session, contact the participant individually by email Title: Stress and Headache Study Hi this is (RA’s Name) with the Stress and Headache study. Now that you have been practicing every day for almost a month, I wanted to remind you of your 2nd session appointment. Don’t forget, your second session is in 3 days on (date/time of their 2nd session) in room # ______of the Psychology Building. If you can’t make this time, please let me know ASAP so that we can reschedule you within 24 hours of your original time. Also it is very important that you bring your diary with you to the session If you have any questions, please feel free to contact me at (RA’s email address), or contact the principal investigator at [email protected]. See you on (date/time) in room # _____! (RA’s Name)
Session 2 • Show participants to individual room and seat them in the recliner • Explain procedure of the second session and remind them of informed consent • Participants perform their technique for 20 minutes • Give cue for participants to initiate CP task • After completion of the CP task, complete post-test • Turn in adherence diaries • Debrief participant and provide headache referrals if requested
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APPENDIX O. MEDITATION TRAINING SCRIPT
Hi, thank you for coming in today to participate in this research project. (Review consent form, complete and review the screener) I am handing out a packet of surveys. Please begin filling out those surveys. As you are doing that, you will be called one-by-one to complete the cold-water task discussed in the consent forms. (Complete survey packets and cold pressor task.) Script for Cold Pressor Task For the cold water task, I would like you to sit in this recliner chair (points). This bucket on your right (points) contains cold water. When I signal you, I would like you to place your hand in this bucket of cold water up to your wrist. Please leave your hand in the water until it becomes too uncomfortable, and then you can remove it. If you have not removed your hand in five minutes, I will end the task, but you should feel free to take your hand out of the water before that if it becomes uncomfortable. Do you have any questions? Ok, begin. (following the task, provide a towel to dry hand) Thank you, please go back to the group room now and finish the survey packet.
(When everyone has completed the surveys and cold pressor task) As you may or may not know, there is a great deal of research today that shows that individuals do not spend enough time in quiet, solitary activities. This lack of quiet time can result in increased hypertension, increased distraction, and feelings of spiritual isolation. Some research shows that certain types of relaxation and meditation can reduce the impact of stress and negative emotions on people who practice these techniques. Researchers in this project are comparing various forms of relaxation and meditation activities to see how these techniques affect people with migraines. We are also hoping to teach individuals who experience migraine headaches, some methods of dealing with the stress involved in migraine headaches.
Today you will be asked to begin to quietly meditate for twenty minutes a day. Twenty minutes a day for four weeks may not seem like very long, but you might be surprised. In order to get the 85 most out of your meditation time, you should be alone. The TV, radio, cell phone, and your computer should be off. Your eyes are closed, but you aren’t asleep. You will be given a set of meditative phrases and asked to pick one to use while you are meditating. You begin by repeating the phrase out loud to focus your thinking, once you feel focused, you can shift into silent contemplation about the phrase. Continue to think about the phrase and how you experience it in your life. Do this during the entire twenty minutes. If you find your mind slipping into other areas of thought, that’s ok. You don’t need to be upset or frustrated, simply repeat your phrase out loud briefly to refocus your thoughts and then slip into silent meditation on the phrase again.
Let’s practice for a few minutes. Pick a meditative phrase from your list and close your eyes. Focus your attention on that phrase and try to maintain your concentration on the phrase. Remember, begin by repeating your phrase out loud, to focus your attention on that phrase. Remember it might be a little difficult at first, but if you lose your concentration, just return your thoughts to the phrase and keep going. Let’s practice (five-minute meditation practice). Great, how did that feel? (Discuss the experience) Do you have any questions? You can meditate anytime during the day, as long as you are able to find the quiet time to do it. People often find it helpful to pick one time during the day, but that isn’t required.
I will pass around a set of practice diaries. Everyone should take one. You will see that the pages are numbered, one for each day of the project. After you finish meditating every day, please take a moment and fill out the short survey for the day. I will also pass around a sign up sheet and everyone can sign up for a time to come into the lab to complete the test in four weeks. Please only sign up with one person per time slot, and write down your time so that you will remember. Are there any questions? So, you will practice your meditation every day for four weeks, make sure you fill out your practice diary everyday after you finish meditating. After four weeks, you will come back here to answer some questions and take a stress test.
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APPENDIX P. RELAXATION TRAINING SCRIPT
Hi, thank you for coming in today to participate in this research project. (Review consent form, complete and review the screener) I am handing out a packet of surveys. Please begin filling out those surveys. As you are doing that, you will be called one-by-one to complete the cold-water task discussed in the consent forms. (Complete survey packets and cold pressor task.) Script for Cold Pressor Task For the cold water task, I would like you to sit in this recliner chair (points). This bucket on your right (points) contains cold water. When I signal you, I would like you to place your hand in this bucket of cold water up to your wrist. Please leave your hand in the water until it becomes uncomfortable, and then you can remove it. If you have not removed your hand in five minutes, I will end the task, but you should feel free to take your hand out of the water before that if it becomes uncomfortable. Do you have any questions? Ok, begin. (following the task, provide a towel to dry hand) Thank you, please go back to the group room now and finish the survey packet.
(When everyone has completed the surveys and cold pressor task)
As you may or may not know, there is a great deal of research today that shows that individuals do not spend enough time in quiet solitary activities. This lack of quiet time can result in increased hypertension, increased distraction, and feelings of spiritual isolation. Some research shows that certain types of relaxation and meditation can reduce the impact of stress and negative emotions on people who practice these techniques. Researchers in this project are comparing various forms of relaxation and meditation activities to see how these techniques affect people with migraines. We are also hoping to teach individuals who experience migraine headaches, some methods of dealing with the stress involved in migraine headaches.
Today you will be asked to begin to quietly relax for twenty minutes a day. Twenty minutes a day for four weeks may not seem like very long, but you might be surprised. To do this 87
relaxation exercise, you should be alone. Your TV, radio, telephone, cell phone and computer should be off. Put yourself in a comfortable position. Your eyes can be closed, but you shouldn’t fall asleep. Continue to relax quietly for twenty minutes. You can do your relaxation time at anytime during the day, as long as you are able to find the quiet time to do it. People often find it helpful to pick one time during the day, but that isn’t required.
Let’s practice for a few minutes. Find a comfortable position and close your eyes. Think about relaxing your body in a systematic way. First think about relaxing your feet. Relax all the muscles in your feet. Then move on to you calves and think about making your calves comfortable. Then think about the muscles in your thighs and concentrate on getting rid of any tension in your thighs. Next, move on to your hips and stomach. Think about relaxing those muscles until you are comfortable. After that move on to your chest, find all the tension in your chest and let it go. Then think about the muscles in your back, relax those muscles until the tension is gone. Next, concentrate on the tension in your shoulders and neck, work to release that tension until you feel your muscles loosen. Finally think about the muscles in your face and head. Find all the tension that might be residing there and release it. Let’s practice (five-minute meditation practice). Great, how did that feel? Do you have any questions?
After four weeks of doing the relaxation exercise procedure, and filling out the practice diary everyday after you finish, you will return here to answer some questions and take a stress test. I will pass around a set of practice diaries. Everyone should take one. You will see that the pages are numbered, one for each day of the project. After you finish relaxing every day, please take a moment and fill out the short survey for the day. I will also pass around a sign up sheet and everyone can sign up for a time to come into the lab to complete the test in four weeks. Please only sign up with one person per time slot, and write down your time so that you will remember. Are there any questions?
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Table 1. Demographics and Pre-Test Data of the Participant Population
Number/ Percentage Number /Percentage Gender 75 Women 90.4% 8 Men 9.6%
Race 61 White 73% 9 Black 10.8% 6 Hispanic 7.2% 1 Native American 1.2% 1 Middle Eastern 1.2% 5 Multi-Racial 1.2%
Religious Preference 42 Protestant 50.6% 33 Catholic 39.8% 6 Agnostic 7.2% 1 Buddhist 1.2% 1 Muslim 1.2%
Prayer Frequency 37 Regularly 44.6% 30 During Stress 36.1% 7 Formal 8.4%9 Never 10.8%
Religious Person 9 Very Religious 15.7% 38 Mod. Religious 45.8% 21 Slightly Religious 25.3% 11 Not Religious 13.3%
Spiritual Person 16 Very Spiritual 19.3% 34 Moderately Spiritual 41.0% 24 Slightly Spiritual 28.9% 9 Not Spiritual 10.8%
Mean (SD)Range Low High Age (in years) 19.1 (1.10) 18 25 College Year (freshman=1) 1.6 (0.77) 1 4 Church Attendance (per year) 22.2 (21.81) 0 75 Retrospective 1 month headache count 12.3 (5.77) 3 28 N-PANAS 23.7 (6.64) 12 43 P-PANAS 33.6 (5.79) 19 48 TAI 42.8 (9.02) 24 69 CESD 36.3 (9.01) 21 65 MSQL 76.6 (10.49) 52 97 HMSE 102.9 (20.76) 54 146 RWB 45.3 (11.66) 10 62 EWB 48.3 (7.72) 25 60 SWB 93.7 (17.22) 43 120 DSE 41.3 (16.25) 9 74
NPANAS- Negative Affect; PPANAS- Positive Affect; TAI- Trait Anxiety; CESD-Depression; MSQL-Migraine Specific Quality of Life; HMSE- Headache Management Self-Efficacy; RWB- Religious Well Being; EWB- Existential Well Being; SWB Spiritual Well Being; DSE- Daily Spiritual Experiences 89
Table 2. Demographics by Group. SP IS ES RL
N (%) N (%) N (%) N (%) Gender Women 19 (85.5%) 19 (90.5%) 19 (95%) 18 (90%) Men 3 (13.6%) 2 (9.5%) 1 (5%) 2 (10%) Race White 15 (68.2%) 15 (71.4%) 15 (75%) 16 (80%) Black 1 (4.5%) 3 (14.3%) 4 (20%) 1 (5%) Hispanic 2 (9.1%) 1 (4.8%) 1 (5%) 2 (10%) Native American 1 (4.5%) 0 0 0 Middle Eastern 0 1 (4.8%) 0 0 Multi-Racial 3 (13.6%) 1 (4.8%) 0 1 (5%) Religion Protestant 11 (50.0%) 8 (38%) 12 (60%) 11 (55%) Catholic 10 (45.5%) 11 (52.4%) 5 (25%) 7 (35%) Agnostic 1 (4.5%) 1 (4.8%) 2 (10%) 2 (10%) Buddhist 0 1 (4.8%) 0 0 Muslim 0 0 1 (5%) 0 Prayer Frequency Never 2 (9.1%) 3 (14.3%) 2 (10%) 2 (10%) Formal 2 (9.1%) 3 (14.3%) 1 (5%) 1 (5%) During Stress 10 (45.5%) 8 (38.1%) 6 (30%) 6 (30%) Regularly 8 (36.4%) 7 (33.3%) 11 (55%) 11 (55%) Religious Person Not Religious 5 (22.7%) 2 (9.5%) 3 (15%) 1 (5%) Slightly Religious 5 (22.7%) 8 (38.1%) 4 (20%) 4 (20%) Mod Religious 11 (50.0%) 9 (42.9%) 8 (40%) 10 (50%) Very Religious 1 (4.5%) 2 (9.5%) 5 (25%) 5 (25%) Spiritual Person Not Spiritual 2 (9.1%) 1 (4.8%) 3 (15%) 3 (15%) Slightly Spiritual 3 (13.6%) 7 (33.3%) 6 (30%) 5 (25%) Mod Spiritual 11 (50.0%) 10 (47.6%) 6 (30%) 7 (35%) Very Spiritual 3 (13.6%) 3 (14.3%) 5 (25%) 5 (25%)
M(SD) Age 19.5 (.912) 18.7 (.78) 19.2 (1.67) 18.9 (.72) Church Attendance per year 18.0 (23.86) 20.3 (20.33) 20.5 (19.29) 30.4 (22.74)
*There were no significant differences between any of the groups on any of the variables.
SP- Spiritual Meditation; IS- Internal Secular; ES-External Secular; RL-Relaxation 90
Table 3. Adherence and Manipulation Check Analyses.
All M(SD) SP IS ES RL F Tests
Adherence 23.6 (8.40) 22.5 (9.09) 25.8 (6.38) 22.7 (9.57) 23.5 (8.24) F(3,91) = 0.73 (all NS participants)
Adherence 26.1 (3.28) 25.6 (3.47) 27 (2.81) 26.2 (3.48) 25.8 (3.37) F(3,79) = 0.75 (participants NS w/ 15+ days)
Relaxing 3.5 (.95) 3.4 (1.05) 3.5 (.81) 3.6 (1.15) 3.4 (.81) F (3,79) = 0.19, NS
Stressful 2.0 (1.07) 2.0 (1.11) 1.7 (0.86) 2.1 (1.25) 2.1 (1.05) F (3,79) = 0.69, NS
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Table 4. Pre- and Post- Intervention Objective Measures by Group
SP IS ES RL M (SD) Headache Count/month Pre 13.7(6.36) 12.8 (5.10) 11.1 (5.24) 11.4 (6.25) Post 8.7 (5.88) 9.7 (5.48) 10.1 (5.02) 10.4 (5.08) Pain Tolerance (Sec) Pre 39.1 (31.70) 43.7 (62.92) 43.0 (62.0) 44.6 (63.45) Post 112.1 (81.90) 47.1 (41.21) 70.2 (82.56) 63.2 (72.66)
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Table 5. Pre- and Post- Intervention Psychological and Headache Measures by Group.
SP IS ES RL M(SD) N-PANAS Pre 25.9 (6.57) 23.1 (6.92) 21.1 (6.22) 24.6 (6.25) Post 16.9 (4.20) 22.2 (7.13) 19.1 (4.79) 18.5 (7.50) P-PANAS Pre 34.2 (6.20) 33.1 (5.62) 34.2 (5.61) 32.8 (5.99) Post 36.5 (6.46) 35.6 (4.65) 34.8 (8.38) 34.9 (5.47) TAI Pre 43.2 (10.65) 43.6 (10.19) 40.7 (6.90) 43.7 (7.88) Post 32.0 (6.93) 37.4 (9.89) 37.6 (6.21) 34.5 (6.61) SAI Pre N/A N/A N/A N/A Post 34.1 (6.90) 33.0 (9.80) 29.9 (8.62) 30.7 (7.88) CESD Pre 35.9 (10.65) 37.6 (9.75) 34.6 (8.34) 37.2 (7.33) Post 31.0 (7.45) 34.2 (9.89) 29.3 (4.80) 29.4 (7.11) MSQL Pre 77.3 10.17) 75.8 (12.81) 76.7 (8.50) 76.7 (10.69) Post 82.0 (11.76) 79.0 (8.67) 77.1 (10.80) 76.4 (12.68) HMSE Pre 100.6 (22.89) 105.4 (15.78) 102.4 (24.08) 103.3 (20.62) Post 123.1 (20.54) 107.2 (17.17) 117.5 (21.58) 113.1 (15.89)
93
Table 6. Pre- and Post- Intervention Spiritual Measures by Group SP IS ES RL M(SD) RWB Pre 54.4 (12.13) 44.4 (11.20) 46.8 (14.23) 44.9 (9.30) Post 47.1 (12.72) 47.6 (11.58) 47.4 (15.10) 47.2 (9.14) EWB Pre 48.1 (8.27) 48.7 (8.87) 48.8 (5.59) 47.9 (8.17) Post 53.5 (5.63) 49.7 (7.49) 48.7 (6.14) 50.7 (6.35) SWB Pre 93.4 (18.64) 93.1 (17.80) 95.5 (18.11) 92.8 (15.18) Post 100.6 (15.52) 97.3 (16.68) 96.1 (17.08) 97.9 (14.13) DSE Pre 40.6 (17.08) 42.6 (19.22) 40.4 (14.38) 41.7 (14.74) Post 55.8 (15.14) 43.0 (18.17) 43.8 (13.74) 41.8 (15.84) Mystical Pre N/A N/A N/A N/A Post 92.1 (14.87) 88.6 (14.03) 86.05 (17.33) 87.6 (13.47) Unity Pre N/A N/A N/A N/A Post 59.7 (12.78) 54.2 (8.52) 52.6 (11.13) 50.9 (9.59) Revelation Pre N/A N/A N/A N/A Post 33.2 (6.57) 34.4 (6.96) 33.5 (6.77) 36.7 (8.34)
94
Table 7. Main Effects and Interactions for 2x4 (time x group) Repeated Measures ANOVA
Group Main Effects Time Main Effects Interaction
Objective Measures
Pre-post Headaches (F(3,79)=43373.04, p <.001) (F(1,79) = 0.98, p =NS) (F(3,79)=6450.43, p <.001)
Pain tolerance (F(3,79) = 15.96, p < .000) (F(1,79) = 1.20, p =NS) (F(3,79) =4.00, p < .01)
Psychological Measures
NPANAS (F (3,79) = 0.99, p=NS) (F (1,79) = 27.10, p<.001) (F (3,79) = 4.73, p<.005)
PPANAS (F (3,79) = 0.36, p=NS) (F (1,79) = 4.88, p<.05) (F (3,79) = 0.26, p=NS)
TAI (F (3,79) = 0.61, p=NS) (F (1,79) = 57.41, p<.001) (F (3,79) = 3.31, p<.05)
CESD (F (3,79) = 1.10, p=NS) (F (1,79) = 32.26, p<.01) (F (3,79) = 0.96, p=NS)
Headache Measures
MSQL (F (3,79) = .54, p=NS) (F (1,79) = 2.00, p=NS) (F (3,79) = 0.71, p=NS)
HMSE (F (3,79) = .46, p=NS) (F (1,79) = 23.07, p<.001) (F (3,79) = 2.99, p<.05)
Spiritual Measures
SWB (F (3,79) = 4.73, p<.005) (F (1,79) = 14.14, p<.001) (F (3,79) = 1.48, p=NS)
RWB (F (3,79) = 0.36, p=NS) (F (1,79) = 10.23, p<.01) (F (3,79) = 0.76, p=NS)
EWB (F (3,79) = .42, p=NS) (F (1,79) = 9.06, p<.005) (F (3,79) = 2.13, p<.05)
DSE (F (3,79) = 1.21, p=NS) (F (1,79) = 4.75, p<.05) (F (3,79) = 2.67, p<.05)
95
Figure 1. Adherence Data Including All Participants.
40
30
20
10
0 0.0 5.0 10.0 15.0 20.0 25.0 30.0
Days
96
Figure 2. Headache Occurrence Prior to the Intervention and During the Intervention.
15
14
13
12
11 GROUP Headaches Spiritual Meditation 10 Internal Secular
9 External Meditation
8 Relaxation 1 2
Time
97
Figure 3. Pain Tolerance by Group and Time.
120
110
100
90
80
70 GROUP
60 Spiritual Meditation
Pain Tolerance (seconds) 50 Internal Secular
40 External Meditation
30 Relaxation 1 2
TIME
98
Figure 4. Negative Affect by Group and Time.
28
26
24
22 GROUP NPANAS
20 Spiritual Meditation
Internal Secular 18 External Meditation
16 Relaxation 1 2
Time
99
Figure 5. Positive Affect by Group and Time.
37
36
35
GROUP PPANAS 34 Spiritual Meditation
Internal Secular 33
External Meditation
32 Relaxation 1 2
Time
100
Figure 6. Trait Anxiety by Group and Time.
46
44
42
40
38 TAI GROUP 36 Spiritual Meditation
34 Internal Secular
32 External Meditation
30 Relaxation 1 2
Time
101
Figure 7. Depression by Group and Time.
40
38
36
34
CESD GROUP
32 Spiritual Meditation
Internal Secular 30 External Meditation
28 Relaxation 1 2
Time
102
Figure 8. Migraine Specific Quality of Life by Group and Time.
83
82
81
80
79
MSQL GROUP
78 Spiritual Meditation
77 Internal Secular
76 External Meditation
75 Relaxation 1 2
Time
103
Figure 9. Headache Management Self –Efficacy by Group and Time.
130
120
110
HMSE GROUP
Spiritual Meditation
100 Internal Secular
External Meditation
90 Relaxation 1 2
Time
104
Figure 10. Spiritual Well-Being by Group and Time.
102
100
98
SWB GROUP 96 Spiritual Meditation
Internal Secular 94
External Meditation
92 Relaxation 1 2
Time
105
Figure 11. Religious Well-Being by Group and Time.
50
49
48
47
46
45
RWB GROUP 44 Spiritual Meditation 43
Internal Secular 42
External Meditation 41
40 Relaxation 1 2
Time
106
Figure 12. Existential Well-Being by Group and Time.
57
56
55
54
53
52
EWB GROUP 51 Spiritual Meditation 50
Internal Secular 49
External Meditation 48
47 Relaxation 1 2
Time
107
Figure 13. Daily Spiritual Experiences by Group and Time.
60
50
DSE GROUP
40 Spiritual Meditation
Internal Secular
External Meditation
30 Relaxation 1 2
Time