struggling and enduring with god, religious support, and recovery from severe mental illness

Struggling and Enduring With God, Religious Support, and Recovery FromSevere Mental Il lness

Marcia Webb, Anna M. Charbonneau, Russell A. McCann, and Kristin R. Gayle

Seattle Pacific University

Objectives: People with severe mental illnesses may achieve varying degrees of recovery, including

symptom reduction and community integration. Research also indicates that religiosity facilitates

coping with psychological disorders. In this study, we assessed the relationship between religiosity

and recovery from severe mental illnesses. Design: Self-report data were collected from 81

participants with severe mental illnesses. We measured recovery, religious support, and participants’

struggle or endurance with faith. Results: Religious support and enduring with faith were positively

associated with recovery. Struggling was negatively associated with recovery, and that relationship

was mediated by religious support. Conclusions: Religious variables, including religious support and

spiritual struggle, might affect recovery from severe mental illnesses. & 2011 Wiley Periodicals, Inc. J

Clin Psychol 67:1161–1176, 2011.

Keywords: Religious struggle; Religious support; Recovery; Severe and persistent mental illness

It has long been assumed by both the mainstream Western culture and health professionals

within that culture that recovery for people with severe mental illnesses cannot be achieved.

Instead, the predominant opinion of the public and of clinicians working with this population

has been that these disorders predict enduring disability in multiple arenas, and that they

might in fact be degenerative, with afflicted people experiencing continual decline across the

lifespan (Allot, Loganathan, & Fulford, 2002; Carpenter, 2002; Corrigan, Giggort, Rashid,

Leary, & Okeke, 1999; Corrigan, Salzer, Ralph, Sangster, & Keck, 2004).

In recent decades, longitudinal research has challenged these views. Despite the potentially

lifelong challenge of severe mental illnesses like schizophrenia, schizoaffective disorder,

bipolar disorder, and recurrent major depressive disorder, studies confirm that individuals

with these disorders can achieve various degrees of symptom reduction and management,

successful community integration, and vocational stability. For example, in pioneering

research conducted by Harding, Brooks, Ashiga, Strauss, and Brier (1987a, 1987b), 250

persons with severe mental illnesses were assessed across a 32-year period. At the conclusion of

this study, 34% of those diagnosed with schizophrenia demonstrated no current

symptomology of their disorders, were no longer maintained on medications, and were

successfully integrated into the community, both socially and vocationally. An additional 34%

of the research sample showed significant improvements in psychiatric and social functioning.

This landmark study spurred further efforts to conduct longitudinal research with this

population in subsequent decades. A meta-analysis by de Girolamo (1996) of 27 of these

studies demonstrated reduction in symptomology for a range of 6% to 66% of those with

severe mental illnesses. A range of 17% to 75% of these individuals also showed social skill

improvement, evident by their reintegration into the community.

In consideration of these studies, some researchers concluded that recovery was not just

possible in this population, but it was a regular occurrence (Kelly & Gamble, 2005). Harding

(2002) concurred with this conclusion, commenting that ‘‘a very large group of consumers

have achieved remarkable recovery. They are people who, in spite of ongoing symptoms, have

carved out a life’’ (as cited in Kelly & Gamble, 2005, p. 246).

Correspondence concerning this article should be addressed to: Dr. Marcia Webb, 3307 Third AvenueWest, Seattle, Washington 98119; e-mail: [email protected]

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 67(12), 1161--1176 (2011) & 2011 Wiley Periodicals, Inc.Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI : 10.1002/ jclp .20838

However, methodological challenges impede our understanding of the recovery phenomenon.

One such challenge is the plethora of definitions employed for the term. Even so, some

consensus does exist among researchers about the qualities typically evident in recovery.

Assumed to be a nonlinear process, recovery occurs along a continuum (Corrigan & Ralph,

2005; White, Boyle, & Loveland, 2005) and differs in its individual expression for each person

(Kelley & Gamble, 2005). It does not necessarily mean the absence of psychotherapeutic or

pharmacological interventions. Nor does it necessarily mean that people are free from all

limitations imposed by their disorders. Rather, recent scholarship describing recovery

emphasizes that people with severe mental illnesses can find successful means of coping actively

with their symptoms, develop a positive sense of self and of relationships, exercise initiative and

self-determination, and, finally, experience hope, life satisfaction, and a sense of meaning

(Anthony, 1993; Deegan, 1988; Resnick, Fontana, Lehman, & Rosenheck, 2005; Young &

Ensing, 1999). In recovery, people accept the reality of their illnesses, and yet move beyond

identifying themselves exclusively in terms of their illnesses (Repper & Perkins, 2003).

The Role of Religion and Spirituality in Recovery

Qualitative investigations of recovery have reported the role of religion and spirituality as a

facilitator of this process (Fallot, 1998, 2007; Kinsella, Anderson, & Anderson, 1996;

Huguelet, Mohr, Jung, et al., 2006; Lindgren & Coursey, 1995; Mohr, Brandt, Borras,

Gillieron, & Huguelet, 2006; Young & Ensing, 1999). In particular, Sullivan (1998) reported

that spirituality plays a role in stress reduction for people with mental illnesses, improves their

sense of well-being, and provides social support in a faith community.

The potentially positive role of religion and spirituality in the mental health of these people

is perhaps not surprising. A wealth of literature from the psychology of religion has

demonstrated the efficacy of religious coping for the general population in a multitude of

stressful life situations (e.g., Pargament, 1997; Pargament, Ano, & Wachholtz, 2005).

Yet the means by which religion facilitates the coping process may be varied and complex.

Pargament (1997) has theorized that religion may provide a constructive means of coping in

that it lends guidance, support, and hope to troubled individuals. Spilka, Shaver, and

Kirkpatrick (1985) have described religion’s role in offering a cognitive framework for

understanding, predicting, and managing events that might otherwise seem overwhelming.

The faith community might further provide supportive social networks in which individuals

can describe daily challenges and express needs as they arise (Oman & Thoresen, 2005).

Spiritual activities such as prayer and meditation have been demonstrated to serve a stress-

buffering function (Rapp, Rejeski, & Miller, 2000; Seeman, Dubin, & Seeman, 2003). Finally,

religious doctrine may advocate for lifestyles that contribute to better health, such as reduced

alcohol consumption (Hood, Hill, & Spilka, 2009; Miller, 1998; Stewart, 2001).

Even so, while empirical evidence has suggested that religious coping is associated with

improved mental health in the general population (Koenig, 1998), there has been a dearth of

quantitative studies specifically focused upon the potentially efficacious role of religion and

spirituality in the lives of people with severe mental illnesses. This might be attributed in part

to various theoretical assumptions about the psychopathic nature of religious ideation in these

disorders. Prior research has generally focused upon the analysis of psychotic material with

religious content (Mohr, Gillieron, Borras, Brandt, & Huguelet, 2007). Recently, however,

these assumptions have been called into question. Professionals and adults with mental

illnesses alike have suggested that this population has religious and spiritual needs similar to

that of the general population, and can similarly benefit from these resources (Huguelet,

Mohr, Borras, Gillieron, & Brandt, 2006).

With the exception of a few studies, it is only in the last decade that quantitative evidence

that examines these issues has begun to surface. Research indicates a consistently high

prevalence of spirituality and religiosity among adults with severe mental illnesses (Borras et

al., 2010; Bussema & Bussema, 2007; Mitchell & Romans, 2003; Russinova & Cash, 2007);

some studies have demonstrated, in fact, higher rates of religiosity in people with severe mental

illnesses than in the general population (Fallot, 2001; Neeleman & Lewis, 1994). In addition,

1162 Journal of Clinical Psychology, December 2011

researchers have noted that the understanding of both religion and spirituality by these people

might be highly complex and nuanced (Russinova & Cash). One researcher commented,

‘‘Religious forms of coping may be particularly relevant and compelling for people with

schizophrenia, recurrent major depression, and other forms of severe mental illness

because of the overall loss of hope, control, and purpose that these illnesses may engender’’

(Tepper, Rogers, Coleman, & Maloney, 2001, pp. 660-1). Others have theorized that

spirituality and religiosity in this population might facilitate enhancements in empowerment and

quality of life (Huguelet, Mohr, Borras, et al., 2006; Kroll & Sheehan, 1989; Mohr et al., 2007;

Yangarber-Hicks, 2004).

Negative Religious Responses and Health Outcomes

These data are not uniformly positive, however. Both qualitative and quantitative studies

suggest that this population might also report negative experiences with religiosity, including

the onset of ‘‘spiritual despair’’ (Mohr et al., 2006, p. 1952). For example, while some

individuals described their faith as a protective factor against suicidal behavior, others

indicated that anger toward God, disillusionment with one’s faith, or the destruction of

relationships in the religious community were risk factors for suicide (Huguelet, Mohr, Jung,

et al., 2006). Similarly, while some people described their mental illnesses as ‘‘part of God’s

plan’’ or ‘‘as a gift from God to help me grow,’’ others portrayed their mental illnesses as

‘‘punishment sent by God for my sins’’ or ‘‘the work of the Devil’’ (Borras et al. 2008, p. 1242).

Religious communities might also be viewed, either positively or negatively, as valued sources of

social interaction or as reminders of one’s social isolation. A participant in one study commented,

‘‘I sing in the choir. The pastors and church members pray for me,’’ while another

participant reported, ‘‘I am angry with my brothers in Christ because they did not help me at

all. Religious teaching helps me, but I haven’t found any warmth in relationships with people

y.’’ (Mohr et al., 2006, p. 1955). Finally, coping styles that include God have been shown

to facilitate empowerment or improve quality of life, while those that exclude God entirely (i.e.,

are self-directing) or are characterized by pleading for miraculous intervention from God are

correlated with less favorable psychosocial outcomes; in particular, pleading has been associated

with greater symptom distress in this population (Yangarber-Hicks, 2004). Thus, religiosity for

this population is a diverse and heterogeneous variable, with multiple potential relationships to

overall mental health.

Research has suggested that people from the general population might also have negative

religious responses to a multiple life stressors. Studies have examined the potential for these

negative religious responses in a wide variety of samples, including, for example, college-aged

adults (Bryant & Astin, 2008), Presbyterian ministers (Ellison, Roalson, Guillory, Flannelly, &

Marcum, 2010), Jews (Rosmarin, Pargament, & Flannelly, 2009), individuals recently

experiencing a serious illness or injury (McConnell, Pargament, Ellison, & Flannelly, 2006),

caregivers of people with Alzheimer’s disease (Shah, Snow, & Kunik, 2001), terminally ill

medical patients (Edmondson, Park, Chaudoir, & Wortmann, 2008), victims of the 1993

flooding in the Midwest (Smith, Pargament, Brant, & Oliver, 2000), and church members

living in proximity to the Oklahoma City bombing (Pargament, Smith, Koenig, & Perez,

1998). This research has repeatedly demonstrated associations between struggling with one’s

faith and poorer physical and psychological functioning (Exline & Martin, 2005; Pargament,

2002; Pargament, Murray-Swank, Magyar, & Ano, 2005). Indeed, a meta-analysis involving

49 studies found an association between negative religious responses and impairments in

mental health, such as increased anxiety and depression (Ano & Vasconcelles, 2005).

Given that these multiple studies have revealed a consistent relationship between negative

religious responses and poorer health outcomes, researchers have begun to describe a

phenomenon entitled ‘‘spiritual struggle,’’ conceptualizing it as a type of chronic stressor,

which might function as a catalyst for various impairments in overall health (Exline & Martin,

2005; McEwen, 2002; Wood, Worthington, Exline, Yali, Aten, & McMinn, 2010). Theorists

have suggested that religious worldviews normally serve a stress-buffering role (Bjorck &

Thurman, 2007; Edmondson et al., 2008), acting as an ‘‘orienting system’’ that provides

1163Religiosity and Recovery From Mental Illness

resources for a continued sense of self-worth and of life’s value despite the challenges of

various stressors (Pargament, 1997, p. 100). Yet this orienting system itself is vulnerable to

external influences, including life stressors. Spiritual struggle might emerge when the

magnitude of a particular stressor exceeds the capacity of the religious worldview to maintain

its normative orientation; thus, the expected coping process falters and individuals report

religious strain and disillusionment (Pargament, Murray-Swank, Magyar, & Ano, 2005).

Unfortunately, this strain and disillusionment might ultimately function as an additional

stressor for the individual, resulting in greater overall psychological distress and health

impairment (McEwen, 2002; Wood et al.).

Religious Support and Health Outcomes

Other variables in addition to spiritual struggle might be cited as influential in the process of

coping with life stressors. Social support, for example, has consistently been associated with

improved overall functioning in people engaged in the coping process (Winemiller, Mitchell,

Sutcliff, & Cline, 1993). Researchers have further suggested that social support might include

relationships established in an individual’s faith community (Bjorck & Kim, 2009; Fiala,

Bjorck, & Gorsuch, 2002; Lazar & Bjorck, 2008). Several studies have revealed that

involvement in one’s religious community is related to various positive outcomes, including

reduced mortality rates (Powell, Shahabi, & Thoresen, 2003), improved psychological

functioning (Fiala et al., 2002), better lifestyle health habits, marital stability (Strawbridge,

Shema, Cohen, & Kaplan, 2001), larger social networks, and the increased perception of

psychological support within those networks (Oman & Thoresen, 2005).

The mechanisms by which social support, and specifically religious social support, improve

overall functioning may be multidimensional. Theorists have suggested that social support

provides individuals with an abundance of resources during periods of increased stress,

including instrumental aid (e.g., financial or material support), emotional aid (e.g., empathy,

advice, constructive feedback), and a sense of security associated with the perception of

belonging (Stone, Cross, Purvis, & Young, 2004). Others have noted that faith communities

might offer individuals opportunities for social involvement with people who share similar

personal values and worldview commitments (Ellison & Levin, 1998; Krause, 2009). Krause

further proposed that social relationships are critical in the formation of self-concept, as

significant others offer feedback affecting one’s sense of personal worth. This particular insight

was grounded in reference group theory, which has suggested that individuals’ behaviors and

attitudes are molded by the social networks in which they are engaged (Bock, Beeghley, &

Mixon, 1983). In support of this theoretical rationale, enhanced perceptions of self-worth have

been correlated with greater religious involvement in various studies (e.g., Ellison, 1993;

Reiland & Lauterbach, 2008)

Study Purposes and Hypotheses

Our intent was to expand upon earlier investigations of religious coping in adults

coping with a particular type of stressor, that of severe mental illness. Among our religious

variables, we examined two categories of negative religious responses described in the

literature, involving either (a) distress in one’s relationship with God and (b) tensions or

disruptions in one’s relationships with the religious community (McConnell et al., 2006;

Pargament, Murray-Swank, Magyar, & Ano, 2005). In particular, for our study, we assessed

struggling with God, or respondents’ experiences of religious doubt, anger toward God, and

disillusionment with traditional concepts of God as loving, all-powerful, and all-wise. As a

measure of positive religious coping, we also assessed endurance in faith, or the endorsement

of the beliefs that God is loving, God has reasons for allowing adverse events to occur, God

provides help to cope with stressors, and one’s faith has been strengthened by suffering. These

latter descriptions of struggling and enduring with faith are based on recent research by Webb,

Sink, McCann, and Chickering (2010). Finally, our religious variables included a measure of

religious support, assessing the perceived quality of social interactions within, and the


assistance received from, one’s religious community, religious leaders, and God. Each of these

religious variables were then examined in light of participants’ reports of recovery from severe

mental illness.

Based upon the extant literature regarding religious coping, religious social support, and

health, we hypothesized that struggling with one’s faith would be negatively associated with

recovery and with religious social support. Second, we hypothesized that endurance in one’s

faith would be positively associated with recovery and with religious social support. Third, we

hypothesized that religious community support would be positively associated with recovery.

Finally, dependent upon our findings examining these relationships, we also proposed to test

two mediation models. In the first, our intent was to examine struggling as a predictor of

recovery, with religious social support as a mediating variable. In the second, we hoped to

examine endurance as a predictor of recovery, with religious social support functioning again

as a mediating variable.

Method

Participants

The current study included 81 participants, 43 female and 36 male (two participants declined

to provide information on gender). The majority of participants were Caucasian (84%). The

remaining participants were Hispanic (12.3%), African American (1.4%), and Asian (1.4%).

One person declined to provide ethnicity information. The sample was diverse in terms of

education, with 25% reporting attaining a high school degree or less, 41% reporting

completing a vocational degree or some college, and 33% reporting completing a college

degree or higher. One person declined to provide educational information. Approximately half

of the sample provided information on current age (n 5 35); of those participants, the age

range was 19 through 68 (mean [M] 5 43 years, standard deviation [SD] 5 12 years).

In terms of psychiatric diagnoses, participants presented with a mixed picture, with 22% of

the total sample indicating that they are living with multiple diagnoses. In addition, 41%

indicated a primary diagnosis of depression, 19% indicated a primary diagnosis bipolar

disorder, and 15% indicated a primary diagnosis of schizoaffective disorder or schizophrenia.

Four percent of participants declined to provide this information.

We also asked participants to report on their belief in God. Belief in God was assessed using

the item ‘‘I believe there is a God in the universe.’’ Participants were asked to rank their

personal belief in this statement on a 5-point Likert-type scale, ranging from 1 (definitely not

true of me) to 5 (definitely true of me). The majority of participants (68%) indicated that the

statement ‘‘I believe there is a God in the Universe’’ was definitely true of them. Eleven percent

of participants indicated that the statement tends to be true for them, 15% were unsure, 2.5%

indicated that the statement tends not to be true for them, and 3.7% reported that the

statement was definitely not true for them. For the purpose of this study, all participants were

included in the analyses.

Measures

Demographics inventory. Respondents completed a demographics inventory to

determine participant variables such as gender, age, ethnicity, and diagnosis

Recovery from severe mental illness. To assess recovery from mental illness, we

included among our measures the Recovery Assessment Scale (RAS; Giffort, Schmook,

Woody, Vollendorf, & Gervain, 1995). The scale comprises 41 statements, and participants

were asked to rate the extent to which they agreed with each statement on a 5-point Likert-

type scale, ranging from 1 (strongly disagree) to 5 (strongly agree). Items constructed

for the scale were originally based on themes prevalent in the recovery narratives of

individuals with severe mental illness. Prior exploratory and confirmatory factor analysis of

this widely used instrument yielded five factors, those of personal confidence, willingness to

seek assistance, goal orientation, symptom management, and no domination by symptoms


(Corrigan et al., 2004). The first of these factors, personal confidence, comprises items

describing hope for the future, the perception that one can handle stress, and a positive sense

of self. The second factor, willingness to ask for help, comprises items describing respondents’

insight regarding personal needs and their ability to seek help from others. Goal and success

orientation, the third factor, comprises items focused upon one’s personal motivation and

plans to succeed, as well as an overall sense of empowerment and purpose in one’s life.

Reliance on others, the fourth factor, focused on the importance of community in recovery and

included items addressing the respondents’ beliefs that other people in their lives are

trustworthy and value them as individuals. Finally, items in the fifth factor, no domination by

symptoms, stressed the respondents’ ability to conduct self-management of the symptoms of

their disorders well enough such that their symptoms were no longer the focus of their lives. In

our study, all items for all five factors were summed to yield a single score indicating degree of

recovery, with higher scores representing higher overall rates of recovery.

Prior research has demonstrated the test-retest reliability of the RAS at .88, and Cronbach’s

alpha at .93. RAS scores have also been positively correlated with indices of empowerment,

self-esteem, and quality of life (Corrigan et al., 1999). The internal consistency for this scale in

our sample was.97.

Suffering with God. The Suffering With God Scale (SWG; Webb, Sink, McCann, &

Chickering, 2010) was incorporated in the study design to assess for participants’ tendencies

both toward struggling with faith and enduring in faith. The SWG comprises 16 items

designed to assess individual cognitive and affective reactions to God in relation to personal

suffering. The scale content was at approximately the fifth-grade reading level, permitting its

use with individuals with a broad range of academic ability. Respondents were asked to rate

their endorsement of items on a Likert-type scale, ranging from 1 (strongly disagree) to 6

(strongly agree).

In the original construction of the scale, the measure was distributed to a sample of 221

adults in the general population (Webb et al., 2010). Principle factor analysis produced a two-

factor solution. The first of these solutions was entitled Struggling With God, with 12 items

describing the degree to which individuals struggle in their faith. Higher scores on this measure

indicated higher internal conflict, with more doubt about God’s goodness, power, or wisdom,

as well as more anger and despair toward God. This subscale comprised statements such as

‘‘I think that I am losing my faith in God’’ and ‘‘I wonder at times if God really listens to my

prayers.’’ In the original sample, this factor’s internal consistency was determined at .93.

Struggling With God was also negatively correlated with participation in organized religion,

practice of personal devotions, and intrinsic religiosity. In the current study sample, internal

consistency was also .93.

The second of the two factors was entitled Enduring With God (Webb et al., 2010). This

4-item subscale measured the extent to which a person continued to maintain faith in God

despite personal adversity. Its statements included, for example, ‘‘I believe that God is always

able to help us no matter what we face’’ and ‘‘I think that God allows suffering for reasons we

do not understand.’’ Cronbach’s alpha for this factor in the original sample was .83. Enduring

With God was further positively related to participation in organized religion, practice of

personal devotions, and intrinsic religiosity. In the current study sample, internal reliability for

this measure was .80.

Religious social support. We used the Religious Support Scale (RSS) to measure the

extent to which individuals experience religious support (Fiala, Bjorck, & Gorsuch, 2002). The

RSS comprises 21 items focusing on three domains, including support from the congregation,

from church leaders, and from God. Each domain comprised seven statements, such as

‘‘Others in my congregation care about my life and situation’’ (congregational support), ‘‘I can

turn to church leadership for advice when I have problems’’ (church leader support), and

‘‘God gives me the sense that I belong’’ (God support). Participants were asked to rate the

extent to which each statement applied to them on a 5-point Likert-type scale, ranging from 1

(strongly disagree) to 5 (strongly agree). As such, higher scores on the RSS indicated a higher


degree of feeling religiously supported. While the RSS can be broken down into the three

subscales described above, we elected initially to use the total score only in our meditational

analyses.

In the original construction of the measure, Cronbach’s alpha was determined at .91 for the

total scale (Fiala et al., 2002). Convergent validity was also supported, with scale scores

positively associated with report of religious attendance and with life satisfaction. Negative

associations were also demonstrated between scale scores and depression. The internal

reliability for the RSS in our sample was .95.

Procedure

We recruited the majority of participants (85%) at advocacy walks sponsored by the National

Alliance for Mental Illness in the Pacific Northwest region of the United States. This

community sample of people with severe mental illnesses included only individuals who were

diagnosed with schizophrenia, schizoaffective disorder, bipolar disorder, or major depression.

We recruited an additional 15% of the study sample at group homes associated with a large

state-sponsored psychiatric hospital in Washington State. Recruitment of group home

residents was also restricted to individuals diagnosed with schizophrenia, schizoaffective

disorder, bipolar disorder, or major depression.

At both recruitment venues, informed consent forms were distributed to all participants.

These forms described the topic and methods of the study and the voluntary and confidential

nature of participation. Once the forms had been signed, participants received the

questionnaire packets and pencils to complete the enclosed measures. Throughout the

administration of these procedures, investigators were available to answer questions from

respondents. Five respondents at the group home setting requested assistance from

investigators to read the informed consent form and the questionnaires. Study participants

received a $ 5 gift card to a chain of local coffee shops. Investigators also fielded questions

from the respondents following the study.

Results

Data Analytic Plan

We used correlational analyses to examine our initial hypotheses regarding relationships

between recovery, religious community support, and the struggling and enduring subscales of

the SWG Scale. To test our meditational hypotheses, we used hierarchical linear regression

and examined the results using the traditional causal steps approach (Baron & Kenny, 1986).

The causal steps approach is useful for capturing large effect sizes and is the most widely

used approach in the social sciences literature to test mediation. Baron and Kenny set forth

four criteria for establishing full mediation. First, the independent variable must be a

significant predictor of the dependant variable. Second, the independent variable must be

a significant predictor of the mediator. Third, the mediator must be a significant predictor of

the dependent variable, with a unique relationship over and above the relationship between the

independent and dependent variables. Fourth, when the mediator is entered into the equation,

the strength of the relationship between the independent and dependent variables must be

reduced to statistical nonsignificance. The relationship can be considered partially mediated if

there is a significant reduction in the strength of the relationship between the independent and

dependent variables, though that relationship remains statistically significant.

Correlational Analyses

The Pearson correlations between all variables are presented in Table 1. As seen in Table 1,

our first hypothesis was supported: struggling with faith was significantly negatively correlated

with both recovery and religious social support. Our second hypothesis was also supported, as

endurance in faith was significantly positively correlated with recovery and with religious

social support. Religious support was also significantly positively correlated with recovery,


confirming our third hypothesis. Given that each of our first three hypotheses were supported,

we proceeded to investigate the data for potential meditational relationships.

Mediational Analyses

To examine religious support as a mediator of the relationship between struggling and

recovery, we used hierarchical linear regression to examine the relationships between each of

the measures to determine if there were significant univariate relationships between them.

Struggling was a significant predictor of recovery, F(1, 79) 5 7.31, b 5 �.013, b 5 �.291,

p 5 .008, r2 5 .09, meeting the first criteria for mediation. These results indicate that more

struggling was associated with less recovery. Struggling was also a significant predictor of

religious support, F(1, 79) 5 9.17, b 5 �.019, b 5 �.323, p 5 .003, r2 5 .11, meeting the

second criteria for mediation. Again, higher struggling was predictive of lower religious support.

Religious support had a significant unique relationship to recovery, DF(1, 78) 5 4.28, b 5 .172,

b 5 .230, p 5 .042, r2 5 .13, meeting the third criteria for mediation. Higher religious support

was predictive of higher levels of recovery. When religious support was entered as a mediator in

the relationship between struggling and recovery, the relationship between struggling and

recovery is reduced and becomes nonsignificant, the p value rising from.008 to.055. These data

meet all four criteria established by Baron and Kenny for full mediation.

To examine religious support as a mediator of the relationship between enduring with God

and recovery, we also began by calculating the relationships between the measures to

determine any significant univariate relationships between them. Enduring was a significant

predictor of recovery, F(1, 79) 5 5.78, b 5 .034, b 5 .261, p 5 .019, r2 5 .07, meeting the first

criteria for mediation. These results indicate that higher levels of enduring with God were

predictive of higher recovery. Enduring was also a significant predictor of religious support,

F(1, 79) 5 93.43, b 5 .129, b 5 .736, p o.001, r2 5 .54, meeting the second criteria for

mediation. This indicates that higher enduring is also predictive of higher levels of religious

support. However, religious support did not have a significant unique relationship to recovery

when enduring was also entered in the equation, DF(1, 78) 5 2.195, b 5 .176, b 5 .236,

p 5 .142, r2 5 .09, violating the third criteria for mediation. As such, the results indicate that

religious support is not a significant mediator of the relationship between enduring and

recovery.

Upon further review of our analyses, it was noted that there was a strong correlation

between enduring and religious support. This correlation might be because of a conceptual

overlap between the items in the Enduring subscale and items within one of the three subscales

of the RSS, the God Support subscale. To examine this possibility, we examined correlations

between the Enduring subscale and each of the three subscales of the RSS. Enduring was

significantly correlated with each of the subscales, including congregational support (r 5 .63),

God support (r 5 .82), and church leader support (r 5 .60).

Table 1Means, Standard Deviations, and Correlation Matrix for All Variables

1 2 3 4 5 6 7 M (SD)

1. Struggling with God – 34.38 (15.79)

2. Enduring with God �.23� – 17.48 (5.43)

3. Recovery �.29�� .26� – 162.71 (29.06)

4. Total religious support �.32�� .74�� .30�� – 69.37 (19.98)

5. Congregational support �.26� .63� .29�� .95�� – 22.16 (7.35)

6. God support �.39�� .82�� .33�� .86�� .70�� – 24.92 (6.89)

7. Church leader support �.25� .60�� .21 .95�� .92�� .69�� – 22.28 (7.44)

Note. M5mean; SD5 standard deviation.

N5 81.�p o.05. ��p o.01.


Given the particularly strong correlation between the Enduring subscale and the RSS, we

removed the God support subscale from the RSS and repeated the meditational analysis to

examine whether the remaining subscales of the RSS would mediate the relationship between

enduring and recovery. Here again, enduring was a significant predictor of the remaining

subscales of the RSS, F(1, 79) 5 51.27, b 5 .235, b 5 .626, p o.001, r2 5 .39. However, as

before, when the remaining subscales of the RSS were entered into the equation, religious

support did not have a significant unique relationship to recovery F(1, 78) 5 1.23, b 5 .008,

b 5 .155, p 5 .268, r2 5 .08.

Discussion

Our study supports previous research suggesting relationships between religiosity and mental

health. Because religiosity is a heterogeneous variable, the specific content of one’s religious

schemata, and the emotional valence of one’s religious experience, might be related either to

the promotion or the hindrance of mental health.

Results of this research affirm our hypothesis that religious support mediates the inverse

relationship between struggling with God and recovery for individuals with severe mental

illnesses. That is, it appears that religious support might provide a helpful resource for

recovery for those individuals with mental illnesses who are struggling with religious doubts,

anger, or despair in their relationships with God.

Our hypothesis that religious support would also mediate the relationship between enduring

in faith and recovery was not supported. While religious community support and enduring in

faith are predictive of recovery, religious community support did not have a unique predictive

relationship to recovery over and above enduring in faith. This result was further confirmed

when we removed the God support item scores from the total RSS score, and reran our

mediation analysis, examining only the influence of congregational support and church leader

support.

Various possibilities accounting for these results may be suggested. Earlier research by

Webb and colleagues (2010) has demonstrated that enduring in faith is associated positively

with intrinsic religiosity, or an experience of faith motivated by personal, rather than

exclusively social, goals. People with intrinsic religiosity describe their faith as foundational to

the totality of their lives. Perhaps, then, those with the tendency to endure in faith despite

hardship have an internalized and stable understanding of their faith, and of God, which is not

readily altered by external circumstances, whether those circumstances include personal

suffering or the community assistance of other believers. Webb and colleagues further

demonstrated that struggling with God was inversely associated with intrinsic religiosity. In a

similar vein, then, it might be that people who struggle with God are more likely to be affected

by the external circumstances in which they find themselves, circumstances that might involve

either personal adversity or the lack of religious support. Research is necessary, however, to

test these theoretical possibilities.

Clinical Implication and Application of Findings

To, then, address the spiritual needs of individuals with mental illness, with the intent to

promote recovery, various approaches to intervention might be necessary.

Religion-accommodative treatment. First of all, mental health professionals need to be

cognizant of spiritual issues for people with severe mental illnesses. Unfortunately, recent

research indicates that clinicians underestimate or even ignore the spiritual concerns of their

clients with severe mental illnesses (Huguelet, Mohr, Borras et al., 2006). Greater

understanding of the complexity of religious experience for this population is necessary

within the field; it must no longer be assumed, for example, that religiosity among people with

these disorders is evidence of psychopathology. The Diagnostic and Statistical Manual of

Mental Disorders IV-TR (American Psychiatric Association, 2000) has highlighted the

possibility that religious and spiritual issues might be a concern for treatment with its inclusion


of the V-code, Religious or Spiritual Problem (62.89). Thus, clinical intervention with this

population might incorporate exploration of clients’ use, or lack thereof, of religious coping

strategies, including personal devotions and participation in organized religious activity.

Evidence for any distress around these matters might then be explored, with the goal of

facilitating clients’ skills to resolve their confusion or conflict.

In the previous few decades, psychotherapeutic strategies incorporating religious or

spiritual components have begun to surface. Early reviews of these religion-accommodative

treatments indicated that they might be as successful as conventional treatment strategies in

reducing depression for a variety of client samples (McCullough, 1999). Research continues to

support these findings. In a recent review, Hook et al. (2010) examined multiple studies

evaluating the efficacy of religious and spiritual therapies for a wide range of mental health

concerns, including depression, anxiety, eating disorders, substance use disorders, and marital

problems. These researchers also demonstrated that, in general, these interventions were

effective, producing the various desired outcomes in participants.

Less is known about the efficacy of religion-accommodative treatments with individuals

coping specifically with severe mental illnesses. Lindgren and Coursey (1995) reported perhaps

the first attempt to provide a structured group intervention focused upon spirituality for this

population. While reduction in participant depression or hopelessness was not found at the

conclusion of the intervention, group participants reported a greater sense of spiritual support.

In a qualitative study, O’Rourke (1997) similarly described the provision of a weekly spiritual

intervention group for adults with severe mental illnesses. In these groups, participants from a

variety of religious backgrounds discussed spiritual concerns together in an open-ended,

nonjudgmental format. Coding of audiotaped sessions demonstrated that the group assisted in

the transition of its members from the inpatient to the outpatient setting, as it helped to build a

bridge with the religious community. It also offered participants the opportunity to express

doubts about their faith, including their sense of God’s abandonment. Finally, the group

offered participants an opportunity to resolve both spiritual and psychological concerns. More

recently, Phillips, Lakin, and Pargament (2002) described the development and administration

of a spiritual and psychoeducational group with this same population. The group examined

issues such as hope, forgiveness, and spiritual struggle, and allowed members the opportunity

to share their concerns and learn from each other. At the conclusion of the intervention, the

majority of group members expressed the hope that the group might continue; they described

a sense of connection with others, and the freedom to express concerns about issues that are

normally ignored in mental health settings. Although these efforts toward religion-

accommodative interventions for people with severe mental illnesses are promising, the need

remains for greater empirical investigation, providing in particular quantitative data, to

support their efficacy.

Psychoeducation. A second strategy for intervention is also critical, however, in the

application of this study’s findings. Mental health professionals might not only provide

opportunities in treatment for clients to resolve issues involving their personal spirituality and

their relationships with the religious communities of their choice; mental health professionals

might also provide faith communities with education about severe mental illnesses. The intent

of this latter effort would be to minimize the possibility of misunderstanding and stigma

regarding these disorders in religious populations and increase both the quality and quantity

of religious community support available to those recovering from severe mental illnesses.

This education could occur within the context of the local faith community, at the site of

regular worship; however, it would perhaps best begin in institutions of higher learning, where

those in training to become priests, pastors, rabbis, and imams acquire the requisite

competencies to serve as leaders of religious communities.

Religious professionals with training in mental health might also contribute to these efforts.

Ministries geared specifically toward the needs of individuals with severe mental illnesses

might further promote recovery; examples of these ministries are evident, for example, in the

Pacific Northwest region of the United States (Stetz, Webb, Anderson, & Zucker, 2011); their


effectiveness in advancing the recovery of individuals with severe mental illnesses has yet to be

confirmed by empirical investigation.

Study Limitations

Interpretation of study results are limited by the use of survey data as a research methodology.

Although paper and pencil measures may at times be necessary in the assessment of religious

beliefs, behavioral observations of participation in the religious community will improve

future research investigating this variable. In addition, adults with severe mental illnesses

might have academic and cognitive limitations that impede their ability to complete

questionnaires. Although the SWG requires lower reading ability, other questionnaires in

this research might have proven more challenging for some mentally ill people. However, it is

likely that the majority of our participants had higher daily functioning skills in comparison to

other samples of mentally ill people, given their ability, for example, to reside in group homes,

or to participate in national advocacy walks.

Behavioral observations of participation in the religious community may also be important

because self-report measures can ultimately provide only clarity regarding the participants’

perceptions of their support. People with certain diagnoses, such as recurrent major

depression, might inadvertently misinterpret or discount genuine support from others in

their communities, and this perception might override what might otherwise be a source of

efficacious coping for them.

The cross sectional nature of the study design further limits the interpretation of its results.

It is unknown, for example, if individuals, whether from the general population or from the

population of severely mentally ill adults, might sometimes naturally experience periods of

spiritual struggle, and religious community alienation, as developmental phases in their

progress toward more resilient, stable, existentially complex, and health-affirming expressions

of faith. As evidence of this possibility, some researchers have noted that spiritual struggle

might be related to posttraumatic growth (Pargament, Smith, Koenig, & Perez, 1998;

Profitt, Calhoun, Tedeshi, & Cann, 2002, as cited in McConnell et al., 2006). Other studies

have suggested that it is the duration of the period of spiritual struggle, which is most critical

in the determination of health outcomes for the individual, and not the experience of struggle

itself (Pargament, Koenig, Tarakeshwar, & Hahn, 2001; Pargament, Koenig, Tarakeshwar,

& Hahn, 2004).

Future Directions for Research

Future directions for research might then focus upon the potential variables associated with

the development and maintenance of either endurance in faith or struggling with God. For

example, research might consider how the resolution of previous life challenges might affect

the believer’s current tendency to either endure in faith or struggle with God. Perhaps people

with a greater capacity to endure in faith do so because of previous events that challenged their

beliefs and yet were resolved in such a way as to restore faith. To the best of our knowledge,

one’s perceptions of God’s prior assistance, or the lack thereof, in one’s past experience has

not yet been investigated as a developmental factor in the emergence of either spiritual struggle

or endurance in faith. Furthermore, it might be that these perceptions of God’s prior

assistance are related to experiences of social support in a faith community (for example, in

one’s youth). Perhaps people who endure in faith but who do not currently experience

religious support have memories of previous religious support, which then sustain them during

times when this support is lacking. These memories might be associated with the successful

resolution of various crises and with a more firmly established sense of God’s faithfulness

despite life’s multiple trials. Alternatively, perhaps people who struggle in faith have fewer, if

any, memories of religious social support, and of God’s assistance, upon which to draw during

times of challenge and crisis. The role of an individual’s lifelong history of religious social

support, and the conceptions of God that might be then associated with that history, has yet to

be fully explored in religious coping research.


Spiritual struggle itself has emerged only recently as focus of empirical inquiry, lending

to the need for greater exploration of its potentially multifaceted nature. Pargament,

Murray-Swank, Magyar, and Ano (2005) have theorized that there are three potential forms

of spiritual struggle, including Divine struggle (tensions people experience in their relation-

ships with God), interpersonal struggle (tensions between people and their faith communities),

and intrapsychic struggle (tensions between people and the tenets of their belief systems).

According to this conceptual matrix, our study addressed the first two of these forms of

struggle. Future research might investigate the potential that individuals also alter their beliefs

(due to intrapsychic struggle) in conjunction with episodes of Divine or interpersonal struggle.

Additionally, Exline and Martin (2005) have focused their attention upon one component

within the broader spiritual struggle construct, that of anger toward God. In particular, this

branch of research has demonstrated multiple predictors of anger toward God, including age,

attachment style, attributional processes, trait anger, and entitlement (Exline, Park, Smyth, &

Carey, 2011; Exline & Martin, 2005; Exline, Yali, & Lobel, 1999). Research has also revealed a

particularly surprising and paradoxical finding: in some cases, individuals who reported that

they did not believe in God nonetheless indicated that they were angry with God (Exline &

Martin, 2005; Exline & Rose, 2005; Exline et al., 1999; Webb et al., 2010). Exline and Rose

have described this subgroup within samples using the terms ‘‘conflicted unbelievers’’ or

‘‘emotional atheists’’ (p. 318). At present, there is a dearth of research focused upon these

individuals. Future research in the psychology of religion needs to direct greater attention

toward atheism in general, and in particular to types of atheism that might be related to

various forms of spiritual struggle.

Future research might also involve the potential applications of this study’s findings. For

example, empirical inquiry might include quantitative investigations of the efficacy of religion-

accommodative interventions for people with severe mental illnesses. In addition, both

qualitative and quantitative research focused upon the effect of psychoeducation regarding

severe mental illnesses in faith communities is needed. This research might help to determine if

psychoeducation can reduce stigma and promote greater understanding of these disorders,

thus potentially increasing the possibility for greater acceptance and assimilation of people

with mental illnesses into religious communities.

Concluding Comments

Severe mental illnesses present individuals with enormous and potentially lifelong

psychological, social, medical, educational, vocational, and financial obstacles. It is perhaps

to be expected, then, that these obstacles might at times challenge an afflicted person’s belief in

a loving, powerful, and wise Deity. Our research indicates, however, that people with severe

mental illnesses who are able to maintain such belief might also experience greater progress

toward recovery from their disorders. Alternatively, for mentally ill people in the midst of a

period of spiritual conflict, a supportive faith community might have a profoundly

transformative influence upon their recovery process.

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