374 11 Religion, Spirituality, and Mental Health

(e.g., Marlatt et al., 2004). As a result, efforts have been made to develop other strat-
egies, especially ones that avoid any kind of theistic content (e.g., Vick, Smith, &
Herrera, 1998). One possibility is to use Hindu-inspired techniques like Transcen-
dental Meditation (TM; e.g., O’Murchu, 1994; see Section 13.5.3). TM work for
addictions involves individual and group instruction as well as daily practice. The
theory is that substance abuse is caused by attempts to optimize psychophysiologi-
cal function, and so if we maintain a positive psychological state through medita-
tion, it removes the incentive to use drugs. It also reduces risk factors for substance
abuse like stress, anxiety, or depression, thus addressing deeper causes of addiction
(Goodman, Walton, Orme-Johnson, & Boyer, 2003; Hawkins, 2003). Studies sug-
gest that TM significantly reduces drug and alcohol use. Effect sizes appear to be
larger in at-risk populations than in general ones. It also appears to be more effec-
tive for cigarette and illicit drug use than alcohol (Alexander et al., 1994; Walton &
Levitsky, 1994).
Approaches based on Buddhist philosophy or techniques are also possible. In
Buddhism, addiction is conceptualized as a disease of the mind. It involves attach-
ment to behaviors that promise relief from suffering but actually increase craving,
because they do not address our basic problem of ignorance. In this view, meditation
is key to the recovery process by enhancing mindfulness and breaking the power
of attachments (Marlatt, 2002; Dudley-Grant, 2003; cf. Section 13.5.1). However,
initial studies with mindfulness meditation have shown less promise (Alterman,
Koppenhaver, Mulholland, Ladden, & Baime, 2004).

11.3.2 Depression

Depression is a condition that can involve sadness, loss of interest in activities,

changes in cognition such as negative thoughts, and a number of physical prob-
lems such as disturbed sleep. It is also associated with problems in mood regu-
lation such as a tendency toward automatic, stronger, and persistent responses to
negative stimuli (Davidson, 2003; Davidson, Pizzagalli, Nitschke, & Putnam, 2002;
Larson, Nitschke, & Davidson, 2007; Jackson et al., 2003). It is common all over
the world, and in Western countries it has increased dramatically in the last 50
years; in the US, depression rates have doubled in the last generation so that about
1 in 6 adults can be expected to have at least one serious episode of depression in
their lifetime. Women appear to be particularly affected by the growing problem
(Compton, Conway, Stinson, & Grant, 2006; Norman, 2004; Murphy, Horton et al.,
2004). These increasing rates seem to be connected with modernization, which
appears to increase narcissism and promote a loss of meaning and hope (Seligman,
1990; Stone, 1998). For many, depression is a chronic and highly disabling con-
dition requiring continuing treatment. It is associated with increased mortality, as
well as decreased quality of life and productivity (Murphy, Nierenberg et al., 2002;
Ebmeier, Donaghey, & Steele, 2006; Hollon, Thase, & Markowitz, 2002; Westen,
Novotny, & Thompson-Brenner, 2004).
11.3 Psychological and Spiritual Views on Specific Problems 375

11.3.2.1 Religion and Rates of Depression

Overall, religious involvement and affiliation appears to be related to fewer problems

with depression, higher levels of well-being, and quicker recovery from depressive
episodes when problems occur, especially in those with an intrinsic religious motiva-
tion (McCullough & Smith, 2003; Koenig, 2001a; Loewenthal, Cinnirella, Evdoka,
& Murphy, 2001; Koenig, George, & Peterson, 1998). This has been found in both
the US and Europe using well-controlled cross-sectional and prospective longitudinal
studies (Miller, Warner, Wickramaratne, Weissman, 1999; Larson & Larson, 2003;
Coleman, Ivani-Chalian, & Robinson, 2004). Although the relationship between reli-
gious involvement and depression is complex, and the correlation between them is
somewhat inconsistent, individuals with no religious involvement have a 20–60%
greater chance of a major depressive episode than those who are involved (Smith,
McCullough, & Poll, 2003; Koenig & Larson, 2001; McCullough & Larson, 1999;
Eliassen, Taylor, & Lloyd, 2005; cf. Kennedy, Kelman, Thomas, & Chen, 1996). There
is even stronger evidence for a relationship between religiousness and suicide. Higher
rates of suicide are observed in countries with lower rates of religious participation,
and lower rates of suicide may be associated with specific religious beliefs and prohi-
bitions (Koenig, 2001a; Clarke, Bannon, & Denihan, 2003; Dervic et al., 2004; Stack,
1991; cf. Zhang & Jin, 1996). A stronger connection between religion and lower rates
of depression can also be found among groups that tend to be more religious, such
as older adults, those that live in rural areas, and US minority groups such as African
Americans and Mexican Americans (Mitchell & Weatherly, 2000; Cummings, Neff,
& Husaini, 2003; Koenig, Cohen, Blazer, Kudler et al., 1995; Levin, Markides, & Ray,
1996; Braam, Beekman et al., 1997; Braam, Sonnenberg et al., 2000; Braam, van den
Eeden et al., 2001; Braam, Hein et al., 2004; cf. Hill, Burdette, Angel, & Angel, 2006).
The connection may be weaker for those who live in cultural settings not supportive
of religion. As in the case of other health problems, religion seems to act by providing
a buffering effect, so it is more likely to be effective in groups of people under greater
stress or at risk for depression (Flannelly, Koenig, Ellison, Galek, & Krause, 2006).
While religion appears to have a generally positive effect on depression, religious
problems can be associated with higher rates of depression, and some religious
groups such as Pentecostal Christians appear to have more problems (Meador,
Koenig, Hughes, & Blazer, 1992). College students reporting religious strain, such
as religious doubts or disagreements with family over religious issues, reported
higher levels of depression and suicidality independent of religiousness and the
degree of comfort provided by religion. In these students, depression is associated
with alienation from God. Those with higher levels of strain were also more inter-
ested in discussing religious issues in counseling (Exline, Yali, & Sanderson, 2000).
Thus, the presence of positive religiousness does not mean that a person may not
have religious problems that are negatively impacting their mental health.
Inconsistencies in the research appear to reflect a number of factors. Results
can be affected by the aspect and type of depression that is measured, for instance
religion effects seem to be bigger with cognitive than with physical symptoms of
depression (Koenig, 1995). It can also be affected by the specific aspects of religion
376 11 Religion, Spirituality, and Mental Health

or spirituality that are assessed, with sophisticated multiple measures more likely to
find results (e.g., Mitchell & Weatherly, 2000). The most consistent results appear
to be an association between participation or group involvement and lower rates
of depression, while studies about the effects of individual spirituality or personal
devotion are more inconsistent (McCullough & Smith, 2003; Davidson, Pizzagalli,
Nitschke, & Putnam, 2002; Baetz, Griffin, Bowen, Koenig, & Marcoux, 2004;
McCullough & Larson, 1999; Kendler, Gardner et al., 1997; Bosworth, Park,
McQuoid, Hays, & Steffens, 2003). Results also seem to be related to high levels
of religiousness, as some studies have found that moderately religious individuals
have higher rates of depression than those with low or high religiosity, perhaps
because of problems related to religious ambivalence or conflict (Miller, Weissman,
Gur, & Greenwald, 2002; McCullough & Smith, 2003; Schnittker, 2001; Nordin,
Wasteson, Hoffman, Glimelius, & Sjoden, 2001).

11.3.2.2 Mechanisms

A number of models and mechanisms for the relation between religiosity and
depression have been proposed (Kennedy, 1998; Smith, McCullough et al., 2003;
Plante & Sharma, 2001). Three commonly discussed possibilities are:
1. Religiousness influences depression by buffering stress, acting as a suppressor or
moderator, and providing positive coping or appraisal mechanisms. In the sup-
pressor model, religious practices increase in response to stress and act to buffer
its potential to trigger depression. In the moderator model, religious practices
do not increase, but they become more effective at higher levels of stress, buffer-
ing against the possibility of depression. The presence of a perceived loving rela-
tionship with God appears to have an especially strong buffering effect (Levin,
2002; cf. Section 10.1.2).
2. Religiousness helps the person cope with the emotional effects of depression,
perhaps providing a way of seeking comfort or deterring distress.
3. Religiousness helps prevent depression by discouraging behaviors that increase
the risk of stress or depression, such as substance use.
There is evidence supporting all of these models, as well as evidence that there
might be common developmental or biological influences that affect both religious-
ness and depression. Most research has suggested that the main helpful effect comes
from long-term involvement in beliefs, practices, and community life that then exer-
cise a protective factor, buffering the negative effects of stress on mental health and
psychological well-being (Williams, Larson, Buckler, Heckmann, & Pyle, 1991;
Wink, Dillon, & Larsen, 2005). Spirituality when separated from religion does not
have the same effect. There is support for both suppressor and moderator models,
as the negative correlation between religion and depression is stronger in high stress
situations (Smith, McCullough et al., 2003; cf. Table 10.1). The public involve-
ment aspects of religiousness appear to have a stronger buffering effect, but some
studies (e.g., Schnittker, 2001) have found that devotional activities and spiritual
11.3 Psychological and Spiritual Views on Specific Problems 377

help-seeking can have a buffering effect in the presence of multiple negative life
events. Some specific factors that buffer, provide comfort or prevent depression
include the following:
1. Specific beliefs, including (a) afterlife beliefs, which may reduce depression
and anxiety particularly among the bereaved (Flannelly et al., 2006; Patrick &
Kinney, 2003); (b) God image beliefs, with a stern God image related to higher
levels of depression in men (Greenway, Milne, & Clarke, 2003); or (c) beliefs
that reduce hopelessness (Murphy et al., 2000a, 2000b; P. Murphy, Ciarrocchi
et al., 2000).
2. The use of positive religious coping such as seeing God as a partner. Nega-
tive strategies such as pleading are associated with higher levels of sadness
(Koenig, Cohen, Blazer, Pieper et al., 1992; Smith, McCullough et al., 2003; see
Section 10.2.2).
3. Social support from others in a religious community, or spiritual support,
a sense that a person is loved by God and can love in return. Both kinds of
support are related to protective effects against stress, lower levels of depres-
sion, and higher levels of life satisfaction. Familial agreement on religion has
a similar effect (Fiala et al., 2002; Levin, 2001; Wright, Frost, & Wisecarver,
1993; Nelson, Rosenfeld, Breitbart, & Galieta, 2002; Harris et al., 2008; Miller,
Warner, Wickramaratne, & Weissman, 1997).
4. Religious motivation. US and UK studies have found that adults with high levels
of intrinsic motivation are associated with lower levels of anxiety and depres-
sion, fewer signs of character disorder, and higher ego strength, while those with
extrinsic motivation have higher levels of depression. However, there is consider-
able individual variation in the relationship, and there are likely complex relation-
ships between religious coping, motivation, type of stress, and depression that are
not adequately understood (Laurencelle, Abell, & Schwartz, 2002; McCullough
& Smith, 2003; Maltby & Day, 2000; Nelson et al., 2002; Miller, Weissman et
al., 2002; Parker et al., 2003; Strawbridge, Shema, Cohen, Roberts, & Kaplan,
1998). There is probably an additional holistic effect among beliefs, coping,
support, and motivation that goes beyond the individual components (Westgate,
1996).

11.3.2.3 Theological Perspectives on Depression and Spirituality:

The Dark Night

Much of the psychological literature on depression assumes that it is an abnor-

mal state to be avoided. An alternate view is that there might be cases in which
depression-like conditions are normal, natural, or even an essential part of spiritual
development. This is the position taken by the Carmelite Christian mystic John of
the Cross (1542–1591), who described what he called a dark night experience, a
kind of purification and stripping away in preparation for advancement to a higher
level of spiritual development. The experience increases our sensitivity so that we
378 11 Religion, Spirituality, and Mental Health

become aware of God’s presence and work within us in ways that were previously
beyond our awareness. Ultimately it frees us to love (May, 2004).
John described two kinds of dark night experiences (John of the Cross, 1973,
pp. 311–352). In the dark night of the senses, it is our sensory abilities that are
purified and accommodated to the Spirit. He believed that this is a fairly common
experience. It involves moving away from a dependence on sensory pleasure that
characterizes prayer in the beginner, to a focus on spiritual delight. This initially
manifests itself as a dryness in prayer and meditation, where spiritual practices that
previously were pleasurable are no longer satisfying. Paradoxically, this is com-
bined with an increased longing for God and a desire to be alone with the Divine
in a quiet state without thought. In this new state of open awareness, we become
aware of changes taking place within us that seem beyond our natural powers. These
changes manifest themselves in our psychological life through increasing inner har-
mony, peacefulness, self knowledge, and humility. External manifestations include
a strengthened practice of virtue and increased love for those around us. All of this
involves a new state of spiritual satisfaction.
A second and much rarer kind of experience is the dark night of the spirit. In this
experience, we become deprived of spiritual satisfaction. This is sometimes experi-
enced as a loss of meaning and direction, or as alienation from God, and a crisis of
faith (Turner, 1995, p. 232; O’Connor, 2002). It is a painful experience involving
feelings of desolation that may last for an extended period of time. In John’s view,
this darkness is actually God at work in a very intimate way, with a kind of pain
resulting from the nearness and purity of God working to perfect us beyond our nor-
mal capacities. It is an experience of infused contemplation (see Section 13.3.1).
As the experience progresses, we have increasing periods with a sense of freedom,
abundance, peace, and an intimate relationship with God. We come to know and
love God not because of what God does for us, but because of who God is. We
desire God without a need to possess. This work prepares us for experiences of
union with God, which become increasingly more common and persistent (Turner,
1995, pp. 236–244).
John of the Cross describes a process that bears some similarities to depres-
sion. It involves experiences of loss and removal of pleasure, as well as inner pain.
Like depression, it affects our psychological self: our appetites, experiences, and
how we think or talk about ourselves, possibly leading to feelings of emptiness,
hopelessness, and lack of motivation. However, John and his contemporaries like
Teresa of Avila (1515–1582) also distinguished between dark night experiences
and depression (Turner, 1995, pp. 227–251; Welch, 1982, pp. 144–145; May,
2004, pp. 155–157):
• The dark night is really a normal process, whereas most people consider depres-
sion to be an abnormal condition.
• The causes of the condition are different. Depression is related to losses of
objects such as a job or relationship, while the dark night is related to losses in
our experience of God. John also thought that severe depression had physiologi-
cal causes that were not a factor in dark night experiences.
11.4 Religion and Spirituality in Mental Health Treatment 379

• In dark night experiences, work and relationships may continue normally or even
be enhanced, while in depression they typically suffer.
• In depression, there is destruction that feels forced with nothing to take the
place of what is lost. In dark night experiences, a person can acquiesce to the
experience and gains inner transformation.
While there are clear differences between a dark night experience and depres-
sion, this does not mean that in practice the conditions are always separate. They
could coexist or be triggers for each other (O’Connor, 2002). The relationship
between depression and dark night experiences is a reminder of the complexity of
trying to understand the convergences and divergences between mental health and
spiritual growth. A key insight is that “feeling good” is neither necessarily a sign of
spiritual progress nor is “feeling bad” a sign that things are not going in productive
directions (Dieker, 2005). In fact, feeling bad can be an opportunity for further spiri-
tual exploration and growth (Anthony, 1966, p. 49). Using psychological language,
negative moods can have a regulatory function that motivates the person to make
positive corrections in their life (Damasio, 2002). All of this raises a fundamental
issue: mood states which are labeled “abnormal” in the medical or hedonic models
may in some situations be a natural, expected reaction to life and developmental
events (Tillich, 1962), and that attempts to remove the symptoms may at the least
miss their true significance and at most actually hinder our development.

11.4 Religion and Spirituality in Mental Health Treatment

Recently the psychology and religion dialogue has shifted in important

ways. Through much of the 20th century, the conversation was primarily psy-
chology talking about and studying religion. With some notable exceptions
(see e.g., Sections 1.5.1 and 1.5.2), religious voices were silent, and their con-
tribution to psychology was behind the scenes. This one-sided conversation has
changed in the last couple of decades, as the field has seen more and more instances
of psychology trying to learn from religion and borrow techniques that might be of
help in mental health treatment. In this section, we examine two of these practices:
forgiveness, which is borrowed from Christianity, and mindfulness, which is an
importation from Buddhism.

11.4.1 Forgiveness

Forgiveness is a central virtue and practice within Christianity and other religious tra-
ditions. It allows us to move forward without being controlled by the past (Schreiter,
1998, pp. 56–63). It has obvious relevance to many situations involving relational
difficulties, abuse, or trauma that can lead to mental health problems (Lin, Mack,
Enright, Krahn, & Baskin,, 2004; Reed & Enright, 2006). Because of its intensively