27

Religion, Spirituality, and Mental Health

Crystal L. Park and Jeanne M. Slattery

Religious suffering is, at the same time, the expression of real suffering and
a protest against real suffering. Religion is the sigh of the oppressed creature,
the heart of a heartless world, and the soul of soulless conditions. It is the
opium of the people.
                                   —Karl M arx

Religion becomes a state of mind achievable in almost any activity of life, if

this activity is raised to a suitable level of perfection.
                                —Abraham M aslow

A s these quotes illustrate, the relationship between religiousness and spiritual-

ity, on the one hand, and mental health, on the other, evokes strong interest, passion, and
contradictory perspectives. Is religion a positive, growth-oriented striving or an indica-
tion of pathology? This issue is an important one, on which writers have opined with
limited information. For example, Ellis (1980) observed that “devout, orthodox, or dog-
Copyright © 2013. Guilford Publications. All rights reserved.

matic religion (or what might be called religiosity) is significantly correlated with emo-
tional disturbance,” and concluded that the “elegant therapeutic solution to emotional
problems is to be quite unreligious” (p. 637). Similar comments are still made (e.g., Wat-
ters, 2007); nonetheless, the research generally shows positive relations between religion
and mental health (cf. Baetz, Bowen, Jones, & Koru-Sengul, 2006; Koenig, McCullough,
& Larson, 2001; Koenig, 2009).
Historically, many such conclusions were drawn in the absence of empirical data
on the relationship between religiousness/spirituality and mental health. Further, much
research has focused on religion’s association with negative aspects of mental health (e.g.,
religion and depression) rather than also considering its possible relationships with posi-
tive functioning, flourishing, and thriving. In this chapter, we first examine the research
on the relationships between religion and mental health, in terms of both psychopathol-
ogy and well-being, flourishing, and thriving. We also discuss moderating variables and
540

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  Religion, Spirituality, and Mental Health   541

potential mechanisms of these relationships as well as the limitations of the data cur-
rently available.

Relationships between Religiousness/Spirituality and Mental Health

Research on the relationships between religion and mental health suffers from severe lim-
itations that make the data difficult to interpret (see Shreve-Neiger & Edelstein, 2004, for
a review). Very few studies are experimental in nature; almost all of the research is cor-
relational, cross-sectional, and contaminated by confounding factors. Without, at mini-
mum, longitudinal research on the relationships between religious variables and mental
health outcomes, accurate interpretation of these correlations is difficult. Furthermore,
religion and spirituality can be measured in many different ways (see Hill, Chapter 3,
this volume), with important and contradictory implications for conclusions about their
relations with mental health (cf. Baetz et al., 2006; Zinnbauer & Pargament, 2005), yet
most studies examine a narrow range of religious dimensions. Much of the research has
been conducted with healthy populations, assessing differences on continua (e.g., number
of depressive symptoms) rather than examining diagnostic criteria for mental disorders.
In addition, self-reported religious behavior can differ in important ways from actual
behavior (Marler & Hadaway, 1999). Finally, researchers do not agree on what men-
tal health is, although there appears to be significant consensus that it is more than an
absence of symptoms (Miller & Kelley, 2005). These limitations should be kept in mind
when interpreting the literature.

Affective Symptoms and Disorders

Probably the religiousness/spirituality–mental health link that has received the most
empirical attention is that of affective symptoms and disorders, particularly depression.
Several large-scale meta-analyses and reviews concluded that religiousness and spiritual-
ity are generally reliably, but modestly, inversely related to depressive symptoms. One
meta-analysis of 147 studies found a statistically reliable relationship of modest effect
size (similar to the association between gender and depressive symptoms), with religious
involvement associated with fewer depressive symptoms (Smith, McCullough, & Poll,
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2003). In a review of 115 cross-sectional and longitudinal studies, 64% reported that
religiousness was related to fewer depressive symptoms, with the majority of the rest
reporting no effect (Koenig et al., 2001).
Not all studies have reported positive relationships between religion/spirituality and
affective disorders or symptoms, however. Only 24% of the studies reviewed by Dew et
al. (2008) found uniformly positive relationships between religiousness and lower lev-
els of depression, while 42% reported mixed positive and nonsignificant findings, 15%
reported nonsignificant findings and the remaining 19% reported only negative ones. For
example, a large-scale interview-based study of 37,000 Canadians using World Health
Organization diagnostic criteria and controlling for demographic variables found that
although religious service attendance was related to lower lifetime and current incidence
of depression and mania, the extent to which people placed value on their spirituality
was positively related to lifetime and current depression and mania (Baetz et al., 2006).

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 542  THE PSYCHOLOGY OF RELIGION AND APPLIED AREAS

Although affective disorders are a significant risk factor for suicide (Hillbrand,
2001), there are other risk factors as well. Nonetheless, in a review of 68 studies, reli-
giousness and spirituality generally predicted more negative attitudes toward suicidality
and lower suicide rates among both adolescents and adults across many world religions
(Koenig et al., 2001).
Religion and spirituality have been inversely associated with depressive symptoms in
a wide variety of groups: African Americans (Randolph-Seng, Nielsen, Bottoms, & Fili-
pas, 2008; Utsey, Hook, & Stanard, 2007), Turkish adolescents (Eskin, 2004), veterans
with a history of traumatic brain injury (Brenner, Homaifar, Adler, Wolfman, & Kemp,
2009), Aboriginals and non-Aboriginals in a Canadian forensic psychiatric hospital pop-
ulation (Mela et al., 2008), and adolescent single parents and their children (Carothers,
Borkowski, Lefever, & Whitman, 2005).

Anxiety Symptoms and Disorders

Research on relations between religiousness/spirituality and anxiety has been mixed (see
Koenig, 2009; Shreve-Neiger & Edelstein, 2004, for reviews). One review of 69 cross-
sectional correlational studies addressing this issue found that 51% reported significantly
less anxiety/stress/fear among the more religious; however, 35% reported no association
with anxiety and 14% reported greater anxiety, stress, or fear (Koenig et al., 2001).
Different dimensions of religion and spirituality may correlate differently with dif-
ferent dimensions of anxiety. For example, in the just-mentioned large-scale Canadian
study, greater frequency of worship was related to lower rates of panic disorder and
social phobia, but higher valuing of spirituality was related to higher rates of both panic
disorder and social phobia (Baetz et al., 2006). A further example is a study of female
college students with histories of panic disorder who reported more religious conflict
than did students in general psychotherapy or healthy control groups (Trenholm, Trent,
& Compton, 1998).
Clearer results emerge with obsessiveness/compulsivity. Religiousness has been
shown to relate positively to levels of obsessive symptoms, compulsive washing, and
thought–action fusion (i.e., the belief that thoughts are morally equivalent to the related
acts) (Abramowitz, Deacon, Woods, & Tolin, 2004) and greater fear of God and of sin-
ful thoughts (Abramowitz, Huppert, Cohen, Tolin, & Cahill, 2002). All of these studies
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were conducted in the United States, although similar findings were reported in an Italian
sample (Sica, Novara, & Sanavio, 2002). Differences in obsessive and compulsive symp-
toms across religious groups (with Christians reporting more symptoms than Jews) are
related to thought–action fusion, with especially religious Christians being much more
likely to equate immoral thoughts and immoral actions (Siev & Cohen, 2007).
The reported relationship between religiousness/spirituality and anxiety is smaller
and less consistent than that for depression or mania, but interpreting it is made diffi-
cult by heavy reliance on correlational and cross-sectional designs. People who are more
anxious may be more religious (perhaps to cope with anxiety), although those who are
religious are not necessarily more susceptible to anxiety (Koenig, 2009). Furthermore,
strong religious beliefs may protect people from existential issues and anxiety, while a
search for meaning or spiritual struggle may lead to increased anxiety, at least in the
short term (Baetz et al., 2006; see Exline & Rose, Chapter 19, this volume).

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  Religion, Spirituality, and Mental Health   543

Posttraumatic Stress Symptoms and Posttraumatic Stress Disorder

A review of 11 studies investigating the relationship between religiousness/spirituality
and posttraumatic stress disorder (PTSD) and associated symptoms reported inconsistent
findings (i.e., three inverse, four positive, three mixed, and one nonassociated) (Chen &
Koenig, 2006). Chen and Koenig attributed these mixed results to the overly simplistic
approaches many studies took to assess the complex constructs of religiousness/spiritual-
ity, the different populations and traumas studied, and the use of cross-sectional designs
and self-report measures. At present, it would be premature to draw conclusions; more
and better research is needed.
More recent studies suggest that religion may protect some people from posttrau-
matic stress symptoms (PTSS) (e.g., Walker, Reid, O’Neill, & Brown, 2009). Religion’s
ability to protect people from PTSS seems to depend on the types of trauma and reli-
gious coping strategies used. A study of Wesleyan missionaries found that they reported
very high levels of exposures to trauma in the field (94%, with 83% being exposed to
multiple incidents) but unexpectedly low rates of PTSS, even when describing their most
distressed period (probably immediately after the trauma) (Bagley, 2003). No missionary
met diagnostic criteria for PTSD when interviewed. Of course, missionaries likely differ
from other groups in other ways, too, making conclusions tentative. Nonetheless, a study
of Iranian veterans (all Muslims) found that those who were more religious reported bet-
ter general health and fewer symptoms of PTSD than did less religious veterans, effects
primarily mediated by religious coping (Aflakseir & Coleman, 2009).

Schizophrenia and Psychotic Disorders

Koenig et al. (2001) identified 10 cross-sectional studies of the relationship between reli-
gion and psychosis. The results across studies were mixed (four with less psychosis for
people who were more religious, three with no association, and two with findings that
varied across dependent measures). Koenig’s (2009) review concluded that other kinds of
religious involvement (other than religious delusions) may improve long-term prognosis
for patients diagnosed with psychotic disorders. People diagnosed with schizophrenia
were more likely than the general population to identify religion as central to their lives,
although fewer were actively involved with a religious group compared with the general
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population (Mohr, Gillieron, Borras, Brandt, & Huguelet, 2007). Another study found
that people diagnosed with schizophrenia reported that religion (in most cases Christian-
ity) helped them develop a sense of meaning that fostered their acceptance of symptoms
and use of positive religious coping strategies while decreasing substance use and abuse,
willingness to act on suicidal ideation, and impact of their symptoms (Huguelet, Mohr,
& Borras, 2009). A small percentage, however, reported negative consequences from
religious coping and increased despair and suicidality. People with a religious affilia-
tion, especially Protestants, were first treated and first hospitalized later and had longer
periods of untreated symptoms relative to those without an affiliation (Moss, Fleck, &
Strakowski, 2006). Although treatment outcomes were not specifically reported, delay-
ing treatment is generally related to poorer outcomes.
A study of people with delusions found that those reporting religious delusions
had lower levels of functioning and were more likely to describe themselves as religious

Paloutzian, R. F., & Park, C. L. (Eds.). (2013). Handbook of the psychology of religion and spirituality, second edition. ProQuest Ebook Central <a
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 544  THE PSYCHOLOGY OF RELIGION AND APPLIED AREAS

(especially taking an orthodox orientation), report hallucinations, and be prescribed higher

levels of antipsychotics than those who had nonreligious delusions (Siddle, Haddock, Tar-
rier, & Faragher, 2002). People with religious delusions were less likely to seek treatment
and more likely to perceive a conflict between their religion and psychiatric treatment;
further, their religion tended to contribute to a negative sense of self and increased symp-
toms (Mohr et al., 2010). In their qualitative study of religious delusions, Drinnan and
Lavender (2006) suggested that delusions and other religious beliefs were often strategies
for understanding difficult family experiences and finding meaning (e.g., their relation-
ship with God provided guidance and protection). The content of delusions and hallucina-
tions seems to be sensitive to and influenced by the person’s familial, cultural, political,
and religious context, although religious upbringing and beliefs did not appear to play a
significant role in schizophrenia’s etiology (Miller & Kelley, 2005; Wilson, 1998).

Substance Abuse
In a review of 138 studies examining relations between substance abuse and religion,
90% of these studies indicated that more religious people had lower use of substances
and were less likely to abuse them (Koenig et al., 2001). Another review of the literature
on religiousness and various aspects of adolescent mental health reported that the most
favorable relationships were with substance use (Dew et al., 2008). In the Canadian study
of 37,000 people, higher reported frequencies of worship and stronger spiritual values
were related to lower rates of current alcohol or drug dependency (Baetz et al., 2006).
Similar findings have been reported in a wide range of populations. Religion and spiritu-
ality may provide one area of vulnerability regarding substance abuse, however, Koenig
(2009) observed that when people from religions that promote complete abstinence from
substances begin using alcohol or drugs, “substance use can become severe and recalci-
trant” (p. 289), presumably because in going against religious proscriptions, they with-
draw from religious involvement, become more isolated, and feel more guilt and shame.

Stress-Related/Posttraumatic Growth
Most people report perceiving positive life changes following adversity, commonly
referred to as stress-related or posttraumatic growth (PTG) (Linley & Joseph, 2004). In
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their review of the literature, Linley and Joseph found that growth was related to numer-
ous aspects of religiousness and spirituality, including positive religious coping, existen-
tial openness, intrinsic religiousness, and religious participation. These findings have
been reported in many different samples, including older adults whose personal and pub-
lic religiousness and religious coping were especially related to perceiving themselves as
having made meaning following a stressful event (Park, 2006), adults who reported more
PTG after multiple traumas when they sought spiritual support (Harris et al., 2008), and
women with breast cancer who were more likely to perceive cancer-related growth when
they had higher levels of religious faith (Yanez et al., 2009).

Psychological Well-Being
Most studies suggest that religiousness and spirituality are associated with increased lev-
els of happiness, life satisfaction, and well-being (see Koenig et al., 2001, for a review).

Paloutzian, R. F., & Park, C. L. (Eds.). (2013). Handbook of the psychology of religion and spirituality, second edition. ProQuest Ebook Central <a
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  Religion, Spirituality, and Mental Health   545

A meta-analysis of 35 studies examining the relationship between type of religiousness

(i.e., institutional religion, ideological religion, and personal devotion) and mental health
(i.e., psychological distress, life satisfaction, self-actualization) found that mental health
was modestly related to institutional religiousness and, fairly strongly related to ideologi-
cal religion and personal devotion. Both ideological religion and personal devotion were
more strongly correlated with life satisfaction and self-actualization than with measures
of distress (Hackney & Sanders, 2003). Similarly, a meta-analysis of 59 studies yielded a
reliable and positive moderate-sized relationship between spirituality and quality of life
(Sawatzky, Ratner, & Chiu, 2005).
Although most of the studies included in these meta-analyses were conducted with
Caucasian, female, U.S.-born Christian young adults, similar positive relationships
between religiousness/spirituality and well-being have been reported with Algerian Mus-
lims (Tiliouine, Cummins, & Davern, 2009), older African Americans (Frazier, Mintz,
& Mobley, 2005), Aboriginals and nonAboriginals in a Canadian forensic psychiatric
center (Mela et al., 2008), and older men (Koenig & Vaillant, 2009).

Summary
Religiousness/spirituality appear to have a consistent relationship with low levels of
substance abuse and dependence; a weaker, although reliable, salutary association with
affective disorders, suicide, and well-being; and a less consistent pattern of associations
for schizophrenia, anxiety, and reactions to trauma (PTSD, PTSS, and perceived growth)
(e.g., Baetz et al., 2006; Koenig, 2009). These relationships can be difficult to interpret
because of the limitations of research designs used (mostly cross-sectional, with many
confounding variables). To some degree, these differences may be attributable to the ways
that people use religion/spirituality to handle difficult experiences (e.g., thought–action
fusion, negative relationships with God). Further, as discussed in the next section, in
some cases, the associations may depend on characteristics such as gender, race, and
denomination.

Moderators of the Relationship between Religiousness/Spirituality

and Mental Health
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The effect of a given dimension of religion/spirituality on mental health can vary based
on some other characteristic that functions as a moderator. Relatively few studies, how-
ever, have examined the role that moderator variables play in the relationships between
religiousness/spirituality and mental health, yet studies attending to moderating variables
have yielded important findings.
Demographic characteristics are commonly suggested as moderating factors. For
example, some studies have found that links between religion and mental health are
stronger for women (e.g., Ellison, Finch, Ryan, & Salinas, 2009; Maselko & Buka,
2008), African Americans (Hackney & Sanders, 2003; Randolph-Seng et al., 2008),
Asian Americans (Randolph-Seng et al., 2008), and Latinos (Ellison, Finch, et al., 2009).
Gender may also be a moderator. One study found that women who made changes
in their religious activity (mostly becoming less active) were more than twice as likely to
have met criteria for a lifetime diagnosis of generalized anxiety disorder, substance abuse,

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 546  THE PSYCHOLOGY OF RELIGION AND APPLIED AREAS

or substance dependence as those who maintained childhood levels of religious activity

(Maselko & Buka, 2008). However, men who changed their religious activity were only
half as likely to have met criteria for lifetime diagnosis with an affective disorder as men
who hadn’t changed. In a national sample of older adults, feeling grateful to God had
stronger stress-buffering effects against the chronic stresses of aging for women than for
men (Krause, 2006).
Such findings regarding race and gender are inconsistent across studies, however. For
example, Musick (2000) observed that beliefs that the world was full of sin were strongly
inversely related to life satisfaction for European Americans but unrelated for African
Americans. But in a meta-analysis of 147 studies, Smith et al. (2003) found no evidence
that gender or race moderated the relationship between religion and depression.
Denomination appears to moderate relationships between religion and mental
health. In one study, both religious beliefs and religious practices were related to lower
levels of depressive symptoms and anxiety for Orthodox Jews but not for non-Orthodox
Jews (Rosmarin, Pirutinsky, Pargament, & Krumrei, 2009). Christians also report more
obsessive and compulsive symptoms than Jews (Siev & Cohen, 2007). In a sample of col-
lege students, intrinsic religiousness buffered the effects of uncontrollable life stress on
depressive and anxiety symptoms for Protestants and controllable life events for Catho-
lics (Park, Cohen, & Herb, 1990). In a sample of older adults, Protestants reported better
morale, less death anxiety, and greater levels of social satisfaction than Jews (Cohen &
Hall, 2009). These relationships have been inconsistent, however, as no denominational
differences in distress were reported by Rosmarin, Krumrei, and Andersson (2009).
Denominational differences probably reflect doctrine-specific beliefs and cultural values
(e.g., Abramowitz et al., 2002, 2004; Siev & Cohen, 2007; see Saroglou & Cohen, Chap-
ter 17, this volume).
Age and income are sociodemographic characteristics worth additional investigation
as moderators. For example, in one study, religious doubt was associated with a wide
variety of psychological symptoms (e.g., depression, anxiety, hostility), but the strength
of this effect was smaller for older than younger adults (Galek, Krause, Ellison, Kudler,
& Flannelly, 2007). In a study of maternal caregivers of ill children, prayer was associ-
ated with better quality of life only for less educated and less affluent caregivers (Banthia,
Moskowitz, Acree, & Folkman, 2007).
Finally, level of stress may serve as a moderator. In some cases, the relationships
Copyright © 2013. Guilford Publications. All rights reserved.

between religiousness/spirituality and mental health are stronger at higher levels of stress
(Smith et al., 2003), although this may depend on the type of stressors encountered (Elli-
son, Finch, et al., 2009).

Potential Pathways through Which Religiousness/Spirituality

Influence Mental Health

Although the results are not entirely consistent, the preponderance of evidence suggests
that some aspects of religiousness and spirituality are related to some aspects of men-
tal health. To account for these relationships, we developed a bidirectional model of
the mediational pathways through which various dimensions of religiousness/spiritual-
ity may help or hinder mental health and vice versa (see Figure 27.1). In this section, we

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  Religion, Spirituality, and Mental Health   547

describe these pathways and the evidence regarding them. Many are presumed to be posi-
tive pathways—for example, religious life often provides social support, which is related
to better psychological well-being (Carothers et al., 2005; Cohen, Yoon, & Johnstone,
2009; Contrada et al., 2008; Ellison, Finch, et al., 2009). However, other aspects of reli-
giousness or spirituality may lead to poorer mental health. It is important to note that
many studies have linked these proposed mediators with religion and mental health, but
few have explicitly tested them these linkages.

How Religiousness/Spirituality May Facilitate Mental Health

Social Support
One of the most obvious benefits to those involved in organized religion is the social sup-
port that comes with that involvement. Individuals regularly involved with a congrega-
tion have larger social networks, interact with network members more frequently, receive
more diverse types of support, and find their support networks more satisfying and more

Religious/Spiritual
Dimensions

•• Social support
•• Social identity
•• Guidelines for living
•• Forgiveness
•• Seeking comfort or relief •• Positive relationship with God
from distress •• Sense of divine or transcendent
•• Available psychological •• Religious coping resources/strategies
and social resources for •• Religious practices
spiritual/transcendent •• Positive and negative affect
activities •• Sense of meaning
•• Positive religious coping •• Emotional regulation
•• Religious struggle or •• Afterlife beliefs
negative religious coping •• Negative religious
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attributions/interpretations
•• Negative religious social interactions
•• Perceptions of treatments as
contraindicated by religion

Mental Illness
Mental Health
Well-Being
Thriving

FIGURE 27.1  Model of proposed relationship between religious and spiritual dimensions and
mental health, with proposed mediators (left, right).

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 548  THE PSYCHOLOGY OF RELIGION AND APPLIED AREAS

reliable than those who do not attend services regularly (Carothers et al., 2005; Cohen
et al., 2009; Contrada et al., 2008; Ellison, Zhang, Krause, & Marcum, 2009). Further,
the social support people gain through their religious involvement may be qualitatively
different than secular social support (Hayward & Elliott, 2009; Krause, 2006). Religious
social support reinforces and is reinforced by a collective framework of ultimate mean-
ing, belongingness, and cohesion in ways that may not be matched by secular groups
(Ladd & McIntosh, 2008; Smith, 2003; Ysseldyk, Matheson, & Hymie, 2010). Given
that social support has long been demonstrated to promote mental health and buffer
stress (Taylor, 2007), the link between religiousness/spirituality and mental health may
in large part be mediated through social support.

Social Identity
One potent pathway through which religiousness may influence mental health is through
the strong social identity that religion can offer, which goes beyond social support.
Although many groups offer a sense of social identity, it has been claimed that religion
“offers a distinctive ‘sacred’ worldview and ‘eternal’ group membership, unmatched by
identification with other social groups” (Ysseldyk et al., 2010, p. 60).

Guidelines for Living

Another route through which religion and spirituality may lead to better mental health
outcomes is the provision of prescriptions, proscriptions, guidelines, and limits for many
areas of life, most of which lead to healthier lifestyles and avoidance of deviant and prob-
lematic behavior. For example, many religions forbid the use of alcohol or other intoxi-
cants. For adherents of those religions, substance abuse is far less likely, and comorbid
conditions, such as depression, may be less likely as well (Smith et al., 2003). Proscrip-
tions against suicide may protect more religious people from taking their own lives (e.g.,
Eskin, 2004; Huguelet et al., 2009), and other proscriptions may prevent adolescents
from making risky decisions (Smith, 2003).

Forgiveness
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Religiousness and spirituality appear to encourage forgiveness and more benevolent atti-
tudes about others after significant interpersonal transgressions (Schultz, Tallman, &
Altmaier, 2010), and people who are more religious tend to score higher on measures
of forgiveness (Worthington & Scherer, 2004). Forgiveness has been related to better
psychological well-being in many studies. For example, in a study of older adults, for-
giveness (by God, of themselves, or of others) partially or completely mediated healthy
relationships between religion and both depressive symptoms and subjective well-being
(Lawler-Row, 2010).

Positive Relationship with God/Sense of Divine or Transcendent

Religious or spiritual individuals may be more likely to experience subjective feelings of
closeness to God, positive views of God and God’s role in one’s life, and a sense of the

Paloutzian, R. F., & Park, C. L. (Eds.). (2013). Handbook of the psychology of religion and spirituality, second edition. ProQuest Ebook Central <a
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  Religion, Spirituality, and Mental Health   549

divine in daily life (Ellison & Fan, 2008). These subjective religious/spiritual experiences
have been favorably related to mental health in a variety of samples, including a group
with heterogeneous medical problems (Cohen et al., 2009), people with chronic pain
(Rippentrop, Altmaier, Chen, Found, & Keffala, 2005), and a large sample representative
of the U.S. population (Bradshaw, Ellison, & Flannelly, 2008). However, these effects
may be substantially due to confounds such as demographic factors. For example, in the
Cohen et al. (2009) study of rehabilitation patients, when statistically controlling for
income, correlations between subjective religious experiences and mental health disap-
peared.

Religious Coping Resources and Strategies

Religiousness and spirituality may promote mental health by providing beliefs that lead
to more benign interpretations of situations, which in turn minimize exposure to negative
affect. Thus, benign religious beliefs can protect people against the daily wear and tear of
stressors as well as help them face highly stressful or traumatic situations. A meta-anal-
ysis of 31 studies examining variables predicting reports of posttraumatic growth found
a strong effect of religious coping (Prati & Pietrantoni, 2009). Positive types of religious
coping (e.g., making benevolent religious reappraisals, seeking spiritual support) tend to
be correlated with indices of positive mental health, although negative religious coping
tends to be associated with poorer adjustment (Ano & Vasconcelles, 2005; Harris et al.,
2008; see Pargament, Ano, & Wachholtz, Chapter 28, this volume).

Religious Practices
Religious and spiritual life presents a panoply of religious practices and rituals in which
adherents can engage, many of which may facilitate mental health. One of the most com-
mon of these is prayer. It is important to note, however, that the nature of prayer varies
dramatically (see Ladd & Spilka, Chapter 22, this volume). Some types of prayer may
lead to increased feelings of peace and support or to more productive ways of viewing a
problem, while other types may cause increased distress (Masters & Spielmans, 2007).
Consistent with this perspective, Ellison and his colleagues (Bradshaw et al., 2008; Elli-
son, Finch, et al., 2009) observed that prayer was related to poorer mental health for
Copyright © 2013. Guilford Publications. All rights reserved.

people with a negative God image and unrelated to mental health for people with a
positive God image. In their summary of the literature, Masters and Spielmans (2007)
also observed that many people use prayer when problems are severe and unresponsive
to other treatments, which may mean that they are more likely to pray when they are
distressed rather than distressed because they pray.

Positive Affect
Positive affect is often associated with higher levels of religion and spirituality (Ellison &
Fan, 2008; Saroglou, Buxant, & Tilquin, 2008; see Lewis & Cruise, 2006), and religions
often explicitly promote spiritually relevant positive emotions (Steffen & Masters, 2005;
Krause, 2002; see Tsai, Koopmann-Holm, Miyazaki, & Ochs, Chapter 14, this volume).
Positive affect is increasingly documented to favorably affect physical health as well as

Paloutzian, R. F., & Park, C. L. (Eds.). (2013). Handbook of the psychology of religion and spirituality, second edition. ProQuest Ebook Central <a
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 550  THE PSYCHOLOGY OF RELIGION AND APPLIED AREAS

emotional well-being (see Pressman & Cohen, 2005; Park & Slattery, 2012, for reviews).
Thus, positive affect is a potentially important pathway through which religion and spiri-
tuality may influence health and well-being (Fredrickson, 2002).

Sense of Meaning
Religion often serves as a core aspect of individuals’ ultimate sense of meaning or pur-
pose (e.g., Emmons, 2005; Park, 2010; Steger & Frazier, 2005) and, as such, seems likely
to be an important pathway protecting individuals against distress and psychopathology
as well as promoting positive mental health and well-being (see Park, Chapter 18, this
volume).

Emotional Regulation
Another pathway through which religion may exert salutary effects on mental health
is the provision of avenues for regulating emotions. Emotional regulation is receiving
increasing attention as an important factor in emotional health and well-being (e.g.,
Gross & Barrett, 2011). Religion and spirituality provide many ways to regulate emo-
tions, some of which may be considered coping, as discussed previously (Watts, 2007),
but others of which are better considered aspects of a more general religious or spiritual
life. For example, contemplative and meditative practices have been shown to decrease
emotional reactivity (Chopko & Schwartz, 2009; Watts, 2007). Even the presence of reli-
gious imagery dampens not only the expression but the experience of negative emotions
(Koole, McCullough, Kuhl, & Roelofsma, 2010). A related but somewhat separate litera-
ture has linked religion to behavioral self-control (e.g., avoiding temptations, regulating
impulses), which may also lead to better emotional well-being (see Zell & Baumeister,
Chapter 25, this volume).

Afterlife Beliefs
Most major religions offer some perspective on an afterlife (Slattery & Park, 2012),
which may provide a comforting perspective on trials experienced during earthly life and
Copyright © 2013. Guilford Publications. All rights reserved.

thus protect against psychological distress. For example, in a national U.S. sample, belief
in life after death was inversely related to a variety of psychiatric symptoms (i.e., anxiety,
depression, obsession–compulsion, paranoia, phobia, and somatization), relationships
that remained even after controlling for demographic and other variables such as stress
and social support (Flannelly, Koenig, Ellison, Galek, & Krause, 2006). Positive views
of the afterlife (e.g., peace and reunion with loved ones) were strongly related to fewer
reported symptoms (Flannelly, Ellison, Galek, & Koenig, 2008).

How Religiousness/Spirituality May Harm Mental Health

Negative Religious Attributions/Interpretations
Copious research has demonstrated the negative effects of negative religious coping
and spiritual struggle on many aspects of psychological well-being. For example, a

Paloutzian, R. F., & Park, C. L. (Eds.). (2013). Handbook of the psychology of religion and spirituality, second edition. ProQuest Ebook Central <a
onclick=window.open('http://ebookcentral.proquest.com','_blank') href='http://ebookcentral.proquest.com' target='_blank' style='cursor: pointer;'>http://ebookcentral.proquest.com</a>
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  Religion, Spirituality, and Mental Health   551

meta-analysis of 49 studies examining relations between religious coping and adjustment

identified a modest but reliable positive association between negative religious coping
(e.g., spiritual discontent, demonic and punishing-God appraisals) and negative adjust-
ment (e.g., depression, anxiety, distress) (Ano & Vasconcelles, 2005). In a nationwide
survey, religious doubt was inversely related to various measures of mental distress,
including depression, anxiety, interpersonal sensitivity, phobic anxiety, obsessive–com-
pulsive symptoms, somatization, paranoid ideation, and hostility (Galek et al., 2007; see
Exline & Rose, Chapter 19, and Pargament et al., Chapter 28, this volume).

Negative Social Interactions

Although social support is a common benefit of religious involvement, negative religious
social interactions with fellow congregants and religious leaders can include disapproval
and criticism or excessive demands, which can be quite distressing (Exline, 2002). In
a nationwide sample of Presbyterians, for example, negative interactions with fellow
church members were correlated with higher levels of depressive symptoms and a lower
sense of well-being (Krause, Ellison, & Wulff, 1998), effects that held across time (Elli-
son, Zhang, et al., 2009). In addition, in a national sample of older adults, negative inter-
actions with clergy members were related to lower levels of self-esteem (Krause, 2003).

Negative Affect
Some types of religion can lead to negative emotions such as hatred, fear, and guilt,
increasing the risk of coping difficulties and depression (Albertsen, O’Connor, & Berry,
2006; Williams & Sternthal, 2007; see Nielsen, Hatton, & Donahue, Chapter 16, this
volume). Further, some religious and spiritual traditions may be linked with negative
affect through their emphasis on the sinful nature of humans and the resulting inner con-
flicts over issues such as sexuality, sexual identity, or selfishness (Slattery & Park, 2012).

Perceptions of Treatment as Contraindicated by Religion

People may perceive medical advice as conflicting with their religious beliefs (Miller &
Kelley, 2005; Mitchell & Romans, 2003; Moss et al., 2006). For example, as cited previ-
Copyright © 2013. Guilford Publications. All rights reserved.

ously, Moss and colleagues (2006) found that when people with schizophrenia perceived
religious and medical advice as conflicting, they had longer periods to first diagnosis and
treatment. Similarly, people with bipolar disorder who were more religious tended to be
less compliant with their medications (Mitchell & Romans, 2003). When they perceived
treatment as inconsistent with their religious beliefs, they were less likely to report that
their religious beliefs helped them manage symptoms.

How Mental Health May Influence Religiousness/Spirituality

Fewer pathways have been proposed for how mental health may influence religion or
spirituality, but one very strong and long-standing theory is that distress or stress pushes
people toward a stronger reliance on or embrace of religion. One version of this is the

Paloutzian, R. F., & Park, C. L. (Eds.). (2013). Handbook of the psychology of religion and spirituality, second edition. ProQuest Ebook Central <a
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 552  THE PSYCHOLOGY OF RELIGION AND APPLIED AREAS

Stark-Bainbridge model of religion as compensation, a sociological model explaining pos-

itive associations of religion and socioeconomic disenfranchisement (Flynn & Kunkel,
1987). A variant of this model, the emotional compensation theory, holds that people
turn to religion for comfort when experiencing psychological distress (Brown, Nesse,
House, & Utz, 2004). People in stress or distress may turn to religion to access a variety
of important coping resources, such as social support, structure, comfort, sense of mean-
ing, or control of undesirable aspects.
Although these models (Brown et al., 2004; Flynn & Kunkel, 1987) are compelling,
empirical tests are sparse and findings inconsistent. Some people in poor mental or physi-
cal health or who are experiencing greater distress turn to religion, while others turn
away (Maselko & Buka, 2008; Pargament, Desai, & McConnell, 2006). Further, such
changes may be short lived. In the aftermath of the 9/11 terrorist attacks, a national sur-
vey found reports of increased church attendance (Schuster et al., 2001), but attendance
quickly returned to pre-9/11 levels (Barna Group, 2001). Finally, high stress levels are
often reported (retrospectively) in cases of religious conversion (see Paloutzian, Murken,
Streib, & Roßler-Namini, Chapter 20, this volume). The ways that poor mental health
or trauma exposure affect religiousness and spirituality may depend on many individual
characteristics, including preexisting religiousness or spirituality and the extent to which
individuals’ religious and spiritual needs are being met (e.g., Walker et al., 2009).
The positive associations between religiousness/spirituality and mental health can
also be explained in terms of psychological resources available to engage in activities fos-
tering a sense of transcendence. People in good mental health may be more expansive and
have more mental energy for religious and spiritual engagement (e.g., Hackney & Sand-
ers, 2003). On the other hand, poorer mental health may decrease resources available to
engage in meaningful activities, lead to greater spiritual struggle, and increase reliance on
negative religious coping (see Exline & Rose, Chapter 19, this volume), all of which may
increase spiritual alienation.

Limitations

Although religiousness/spirituality and mental health are clearly related, this relation-
ship is not simple and is likely bidirectional. Research in this field must acknowledge this
Copyright © 2013. Guilford Publications. All rights reserved.

complexity. Religiousness and spirituality can have both positive and negative effects on
mental health, at both the individual and group level. These differences may be related to
other factors, including hardiness, the rigidity with which religious beliefs are held, and
the ability to assimilate trauma without being shaken to the core (Kelley, 2007; Maddi,
Brow, Khoshaba, & Vaitkus, 2006). People may experience distress during periods of
spiritual struggle, PTG, or otherwise adaptive coping processes, which may reflect short-
term problems incurred in the process of long-term growth (Warner, Mahoney, & Krum-
rei, 2009). Therefore, a one-time measure of church attendance or beliefs is unlikely to
have much predictive validity over the long term. Nor are single or limited measures of
religiousness and spirituality—or mental health—likely to be able to assess the rich and
complicated interactions between these two realms.
Much of the research on the relationships between beliefs and mental health out-
comes is plausible, yet speculative, as it has been based on self-reports and is correlational

Paloutzian, R. F., & Park, C. L. (Eds.). (2013). Handbook of the psychology of religion and spirituality, second edition. ProQuest Ebook Central <a
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  Religion, Spirituality, and Mental Health   553

and cross-sectional in design (e.g., Hackney & Sanders, 2003; Rosmarin, Pirutinsky,
et al., 2009). Findings from studies using such designs cannot determine whether rela-
tionships are causal and, if so, their direction. Group and denominational differences
are difficult to interpret, as they may be better related to differences in willingness to
report mental health problems than mental health per se (Cohen & Hall, 2009). In some
cases, correlations might be a proxy for another variable (e.g., church attendance being a
proxy for functional health) (Koenig & Vaillant, 2009). Performing analyses solely at the
group level also obscures individual differences in connections between religiousness and
spirituality and mental health, such that religiousness and spirituality can be helpful or
protective for some people, hurtful for others, and make little difference for still others
(Rosmarin, Pirutinsky, et al., 2009).
Finally, much of the research on the relationship between religiousness and spiri-
tuality and mental health has used self-report measures of behavior, which are often
inaccurate: People respond according to social desirability biases and sometimes signifi-
cantly overestimate their tithing and church attendance (e.g., Marler & Hadaway, 1999).
Further, religiousness and spirituality are multidimensional variables; outcomes depend
on the specific behaviors and beliefs assessed. Other more ecologically valid strategies
for assessing beliefs, attitudes, and behavior (e.g., children’s drawings of God, narra-
tive responses about coping with stressors and trauma, observations of religious behav-
ior) may further clarify the relationships between religiousness, spirituality, and mental
health (Hill & Pargament, 2003).

Future Research

Research on relationships between religiousness/spirituality and mental health has

focused on a narrow segment of the world population, largely neglecting Buddhists, Mus-
lims, Hindus, and other groups. More empirical research is needed on the roles of global
religions, culture, level of acculturation, gender and age, and the interactions among
these factors on mental health. Religion appears to be more helpful for some groups
under some conditions and less helpful for others (cf. Ellison, Finch, et al., 2009; Ellison,
Zhang, et al., 2009; Rosmarin, Pirutinsky, et al., 2009). Like other cultural factors, reli-
gion may influence not only a person’s risk of mental illness but also the manifestations
Copyright © 2013. Guilford Publications. All rights reserved.

of that illness (e.g., the form of obsessions or delusions) (Miller & Kelley, 2005). Some of
these differences may be related to the nature of the religious and spiritual attributions
drawn (Lawler-Row, 2010; Warner et al., 2009). For example, identifying the degree to
which people who are depressed feel that God has abandoned them, have lost their faith
that God is omnipotent and good, or believe that they are unforgivable may help identify
mediating pathways between mental health and religiousness/spirituality.
Although religiousness and spirituality appear to provide some level of protection
against mental health problems, especially substance abuse and depression, researchers
should also pay attention to happy and healthy nonbelievers, those who are able to thrive
without reference to the divine or the spiritual (Maddi et al., 2006; Miller & Kelley,
2005). Do they take a different path to mental health and well-being, or do they hold
secular beliefs and practices that are similar to those that are helpful for more religious
and spiritual people? For example, many atheists and agnostics also believe that one

Paloutzian, R. F., & Park, C. L. (Eds.). (2013). Handbook of the psychology of religion and spirituality, second edition. ProQuest Ebook Central <a
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 554  THE PSYCHOLOGY OF RELIGION AND APPLIED AREAS

should show compassion to those in need, forgive oneself and others, and care for the
well-being of the planet and its inhabitants. Many hold a sense of meaning and purpose
that informs their daily life. To what degree are religious and spiritual beliefs and rituals
a systematized description of how to live well, find happiness and love, and create fair-
ness and justice? To what degree does having a sense of meaning and peace, of finding a
way of forgiving wrongs—with or without spiritual or religious beliefs—lead to positive
outcomes (Maddi et al., 2006; Schultz et al., 2010; Yanez et al., 2009)?
Although many issues remain, it is clear that we have a stronger understanding of
the linkages between mental health and religion/spirituality than we did even 8 years ago.
The questions being asked are more sophisticated, the comparisons across groups are
becoming more nuanced, and the directions for future progress are better illuminated.

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 558  THE PSYCHOLOGY OF RELIGION AND APPLIED AREAS

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