RESPONDING TO SPIRITUAL STRUGGLES: EXPERIENTIAL AVOIDANCE AND MINDFULNESS IN ADJUSTMENT
Carmen K. Oemig Dworsky
A Dissertation
Submitted to the Graduate College of Bowling Green State University in partial fulfillment of the requirements for the degree of
DOCTOR OF PHILOSOPHY
December 2014
Committee:
Kenneth I. Pargament, Advisor
Pricilla K. Coleman Graduate Faculty Representative
William H. O'Brien
Michael J. Zickar
© 2014
Carmen K. Oemig Dworsky
All Rights Reserved iii Abstract
Kenneth I. Pargament, Advisor
Research and theory have demonstrated that spiritual struggles are robustly tied to distress and ill health. Growth and positive outcomes are also possible. However, there is little research illuminating the factors that contribute to growth or decline in the wake of spiritual struggles. Mindfulness and Acceptance, as conceptualized in Acceptance and Commitment
Therapy, have been tied to positive and negative adjustment, respectively. The present study was designed to examine the relationships between experiential avoidance, mindfulness, and adjustment in a sample of 307 adults experiencing spiritual struggles. The predictions were that experiential avoidance would be associated with poorer adjustment and that mindfulness would be associated with better adjustment. It was also predicted that the relationships between spiritual struggles and poorer adjustment would be stronger among people with higher than lower levels of experiential avoidance. Finally, it was predicted that the relationships between spiritual struggles and less problematic adjustment would be stronger among people with higher than lower levels of mindfulness.
The findings generally supported the hypotheses that experiential avoidance is problematic for people experiencing spiritual struggles. With a few notable exceptions, mindfulness, as measured in the present study, was not significantly related to indices of adjustment. Some support was found for the hypothesis that the detrimental effects of spiritual struggles on adjustment would be greater among people with higher than lower levels of experiential avoidance. These findings were particularly robust for the measure of situation- specific experiential avoidance. These findings are discussed along with implications and future directions. iv
I dedicate this project to the family I am from -- my Mom (Dee Oemig), my Dad (Frank Oemig), my sister (Tanya Oemig), and my brother (Eric Oemig), and the family I have chosen –my husband (Dryw Dworsky) and my son (Jax Dworsky). It is impossible to express my gratitude to them with words. They were with me through every part of this project and their love is written into these pages as much as my own –sharing it with them is my humble thank you.
v Acknowledgments
I am thankful for many people who have been important in this helping me see this project to completion. I would first like to express my deep gratitude and respect for my advisor,
Kenneth I. Pargament, for his support, guidance, and encouragement throughout this process. He has been an amazing mentor in so many areas of my professional and personal development – I am truly lucky to work with him. Amy Wagner served as a great research and clinical mentor while I was on internship at the Portland VAMC and her encouragement and belief in me during an early iteration of this project echo through to this more recent version. William O’Brien was one of my first research advisors at BGSU and has also been integral to my clinical development.
He supported me in finding my voice in the “tree house,” in the ACT community, and he continues to remind me to matter. I would also like to thank my committee members, William
O’Brien, Michael Zickar, and Pricilla Coleman for their enthusiastic support and feedback. My mom deserves a special thank you for serving in any and every capacity she could through every stage of this document – she read drafts, cheered me on, and flew out to make meals and pick up my slack for our family during crunch times (among many other things). My husband has also worn many hats as my partner on this journey. He has made “Mommy’s dissertation time” special “Daddy-Jax” time for our son, believed in me, and supported our family. He has shown me what love and dedication are through this process – I love that man. Last but certainly not least, this project would not have happened without the support of my other family and friends, particularly Tanya Oemig, Eric Oemig, Lisa Backus, Carol Ann Faigin, Alexis Hamill, the former Treehouse gang, the Tuesday Morning Playdate moms, Kwan Um Zen Sangha, and FB peeps far and near. Thank you for all of your love, encouragement, and support!
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Table Of Contents
Page
Introduction ...... 1
Spiritual Struggles ...... 1
Experiential Avoidance ...... 4
Mindfulness...... 8
Present Study ...... 14
Method ...... 16
Participants and Procedure ...... 16
Measures ...... 17
Grouping measure ...... 17
Demographic and background information ...... 18
Spiritual Struggles ...... 18
Moderators ...... 19
Experiential avoidance – general ...... 19
Experiential avoidance – spiritual struggle specific ...... 19
Mindfulness...... 20
Adjustment Indices ...... 21
Somatic, anxiety, and depression symptoms ...... 21
Values-consistent living ...... 22
Struggle-related positive and negative affect ...... 22
Struggle-related difficulties with emotion regulation ...... 23
Spiritual Well-Being ...... 24 vii
Spiritual Transformation ...... 24
Attention Check Items ...... 25
Results ...... 26
Preliminary Analyses ...... 26
Main Effects Analyses ...... 27
Moderation Analyses ...... 30
Discussion ...... 33
Experiential Avoidance and Adjustment ...... 33
Mindfulness and Adjustment ...... 38
Limitations, Implications, Future Directions ...... 41
References ...... 44
Appendix A: Recent Life Experiences Survey ...... 57
Appendix B: Demographic and Background Information ...... 58
Appendix C: Religious and Spiritual Struggles Scale ...... 61
Appendix D: Acceptance and Action Questionnaire II ...... 64
Appendix E: Spiritual Struggle Acceptance Questionnaire ...... 65
Appendix F: Toronto Mindfulness Scale – Trait ...... 68
Appendix G: Physicians Health Questionnaire – Somatic, Anxiety, and Depression
Symptoms ...... 69
Appendix H: Values-Based Activity Inventory ...... 72
Appendix I: Positive and Negative Affect Scale – Struggle Specific ...... 77
Appendix J: Difficulties with Emotion Regulation Scale – Struggle Specific ...... 79 viii
Appendix K: Functional Assessment of Chronic Illness Therapy – Spiritual Well-being
Scale (FACIT-Sp) ...... 81
Appendix L: Spiritual Transformation Scale ...... 82
Appendix M: Attention Check Questions ...... 83
Appendix N: Mechanical Turk Job Posting ...... 84
Appendix O: Informed Consent ...... 85
Appendix P: Debriefing Form ...... 87
Appendix Q: HSRB Approval Letter ...... 88 ix
List of Tables
Table Page
1 Participant Demographics & Background ...... 90
2 Descriptive Statistics ...... 94
3 Correlations ...... 95
4 Demographic x Outcome Variables Correlations ...... 96
5 Experiential Avoidance (General) and Anxiety ...... 97
6 Experiential Avoidance (General) and Depression ...... 98
7 Experiential Avoidance (General) and Somatic Symptoms ...... 99
8 Experiential Avoidance (General) and Functioning with Symptoms ...... 100
9 Experiential Avoidance (General) and Values-consistent Living ...... 101
10 Experiential Avoidance (General) and Positive Mood ...... 102
11 Experiential Avoidance (General) and Negative Mood ...... 103
12 Experiential Avoidance (General) and Goal Difficulties ...... 104
13 Experiential Avoidance (General) and Impulse Difficulties ...... 105
14 Experiential Avoidance (General) and Emotion Regulation Strategy
Difficulties ...... 106
15 Experiential Avoidance (General) and Spiritual Well-being ...... 107
16 Experiential Avoidance (General) and Spiritual Growth ...... 108
17 Experiential Avoidance (General) and Spiritual Decline ...... 109
18 Experiential Avoidance (Struggle Specific) and Anxiety ...... 110
19 Experiential Avoidance (Struggle Specific) and Depression ...... 111
20 Experiential Avoidance (Struggle Specific) and Somatic Symptoms ...... 112 x
21 Experiential Avoidance (Struggle Specific) and Functioning with Symptoms ...... 113
22 Experiential Avoidance (Struggle Specific) and Values-consistent Living ...... 114
23 Experiential Avoidance (Struggle Specific) and Positive Mood ...... 115
24 Experiential Avoidance (Struggle Specific) and Negative Mood ...... 116
25 Experiential Avoidance (Struggle Specific) and Goal Difficulties ...... 117
26 Experiential Avoidance (Struggle Specific) and Impulse Difficulties ...... 118
27 Experiential Avoidance (Struggle Specific) and Emotion Regulation
Strategy Difficulties ...... 119
28 Experiential Avoidance (Struggle Specific) and Spiritual Well-being ...... 120
29 Experiential Avoidance (Struggle Specific) and Spiritual Growth ...... 121
30 Experiential Avoidance (Struggle Specific) and Spiritual Decline ...... 122
31 Mindfulness and Anxiety ...... 123
32 Mindfulness and Depression ...... 124
33 Mindfulness and Somatic Symptoms ...... 125
34 Mindfulness and Functional Difficulty with Symptoms ...... 126
35 Mindfulness and Values-consistent Living ...... 127
36 Mindfulness and Positive Mood ...... 128
37 Mindfulness and Negative Mood ...... 129
38 Mindfulness and Goal Difficulties ...... 130
39 Mindfulness and Impulse Difficulties ...... 131
40 Mindfulness and Emotion Regulation Strategy Difficulties ...... 132
41 Mindfulness and Spiritual Well-being ...... 133
42 Mindfulness and Spiritual Growth ...... 134 xi
43 Mindfulness and Spiritual Decline ...... 135
44 Experiential Avoidance (General) Moderating Spiritual Struggle and Anxiety ...... 136
45 Experiential Avoidance (General) Moderating Spiritual Struggle and
Depression...... 137
46 Experiential Avoidance (General) Moderating Spiritual Struggle and Somatic
Symptoms ...... 138
47 Experiential Avoidance (General) Moderating Spiritual Struggle and Functioning
with Symptoms ...... 139
48 Experiential Avoidance (General) Moderating Spiritual Struggle and
Values-consistent Living ...... 140
49 Experiential Avoidance (General) Moderating Spiritual Struggle and Positive
Mood ...... 141
50 Experiential Avoidance (General) Moderating Spiritual Struggle and Negative
Mood ...... 142
51 Experiential Avoidance (General) Moderating Spiritual Struggle and Goal
Difficulties ...... 143
52 Experiential Avoidance (General) Moderating Spiritual Struggle and Impulse
Difficulties ...... 144
53 Experiential Avoidance (General) Moderating Spiritual Struggle and Emotion
Regulation Strategy Difficulties ...... 145
54 Experiential Avoidance (General) Moderating Spiritual Struggle and Spiritual
Well-being...... 146 xii
55 Experiential Avoidance (General) Moderating Spiritual Struggle and Spiritual
Growth ...... 147
56 Experiential Avoidance (General) Moderating Spiritual Struggle and Spiritual
Decline ...... 148
57 Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggle and
Anxiety ...... 149
58 Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggle and
Depression...... 150
59 Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggle and
Somatic Symptoms ...... 151
60 Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggle and
Functioning with Symptoms ...... 152
61 Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggle and
Values-consistent Living ...... 153
62 Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggle and
Positive Mood ...... 154
63 Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggle and
Negative Mood...... 155
64 Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggle and
Goal Difficulties ...... 156
65 Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggle and
Impulse Difficulties ...... 157
xiii
66 Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggle
and Emotion Regulation Strategy Difficulties ...... 158
67 Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggle
and Spiritual Well-being ...... 159
68 Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggle
and Spiritual Growth ...... 160
69 Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggle
and Spiritual Decline ...... 161
70 Mindfulness Moderating Spiritual Struggle and Anxiety ...... 162
71 Mindfulness Moderating Spiritual Struggle and Depression ...... 163
72 Mindfulness Moderating Spiritual Struggle and Somatic Symptoms ...... 164
73 Mindfulness Moderating Spiritual Struggle and Functioning with Symptoms ...... 165
74 Mindfulness Moderating Spiritual Struggle and Values-consistent Living ...... 166
75 Mindfulness Moderating Spiritual Struggle and Positive Mood ...... 167
76 Mindfulness Moderating Spiritual Struggle and Negative Mood ...... 168
77 Mindfulness Moderating Spiritual Struggle and Goal Difficulties ...... 169
78 Mindfulness Moderating Spiritual Struggle and Impulse Difficulties ...... 170
79 Mindfulness Moderating Spiritual Struggle and Emotion Regulation Strategy
Difficulties ...... 171
80 Mindfulness Moderating Spiritual Struggle and Spiritual Well-being ...... 172
81 Mindfulness Moderating Spiritual Struggle and Spiritual Growth ...... 173
82 Mindfulness Moderating Spiritual Struggle and Spiritual Decline ...... 174 xiv
List of Figures
Figures Page
1 Experiential Avoidance (General) Moderating Spiritual Struggles
and Goal Difficulties ...... 175
2 Experiential Avoidance (General) Moderating Spiritual Struggles and Impulse
Difficulties ...... 176
3 Experiential Avoidance (General) Moderating Spiritual Struggles and Emotion
Regulation Strategy Difficulties ...... 177
4 Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggles
and Anxiety ...... 178
5 Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggles and
Depression...... 179
6 Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggles and
Functional Difficulty with Symptoms ...... 180
7 Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggles
and Positive Mood ...... 181
8 Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggles
and Negative Mood ...... 182
9 Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggles and Goal
Difficulties ...... 183
10 Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggles Impulse
Difficulties ...... 184
xv
11 Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggles
and Emotion Regulation Strategy Difficulties ...... 185
Spiritual struggle and adjustment 1
Introduction
Life naturally includes encounters with pain and difficulty. Spiritual struggles may be
among the most challenging of life’s pains because they cut to the core of individuals’
fundamental beliefs and values. In the past decade, research has demonstrated that spiritual
struggles are robustly tied to distress and ill health (e.g., Ano & Vasconcelles, 2005; Exline,
2013). Interestingly, research and theory have also suggested that spiritual struggles may lead to growth and positive outcomes (e.g., Koenig, Pargament, & Nielsen, 1998; Pargament, Magyar,
Benore & Mahoney, 2005; Pargament, Smith, Koenig, & Perez, 1998; Pargament, Koenig &
Perez, 2000). What factors contribute to whether spiritual struggles lead to positive and/or negative psychological and physical health outcomes? Relatively little research has been conducted on this vital question. One source for identifying potentially fruitful predictors of adjustment to spiritual struggle is Acceptance and Commitment Therapy (ACT). This study examines two key factors derived from ACT, experiential avoidance and mindfulness, and their relationship to psychological, spiritual, and health-related functioning in a cross-sectional study
of individuals reporting spiritual struggle. In the following sections, I review literature on the
adjustment-related consequences of spiritual struggles and provide a rationale for examining the
role of experiential avoidance and mindfulness in understanding the sequelae of spiritual
struggles.
Spiritual Struggles
Spirituality has been defined as a search for the sacred (Pargament, 1997). While people
strive toward any number of values or sources of significance, Pargament (2007) emphasized
that, “for many people the sacred is the focal point of their striving, the object of significance
that lends order and coherence to all other goals” (p.55). Research has demonstrated that aspects Spiritual struggle and adjustment 2 of spirituality are often tied to health and well-being (e.g. Koenig, King, & Carson, 2012). In the last decade, investigators have begun to examine the darker side of spirituality (Magyar-Russell
& Pargament, 2006). Spirituality can be a source of potential problems, as illustrated by the phenomenon of spiritual struggles: conflicts, questions, and tensions about spiritual and religious issues. Three types of spiritual struggle have been distinguished: intrapersonal, interpersonal, and supernatural (Exline, 2013; Pargament, Murray-Swank, Magyar, & Ano, 2005).
Intrapersonal struggles refer to conflicts and questions surrounding one’s own beliefs, values, or actions. By contrast, interpersonal spiritual struggles include spiritual or religious conflicts arising in the context of important relationships (e.g., family, friends, or spiritual community).
Finally, struggles can reflect perceived conflict with supernatural agents such as God, the devil, or evil spirits. Regardless of form, all spiritual struggles represent an attempt “to conserve or transform a spiritual or religious framework that has been threatened or harmed” (Pargament, et al., 2005).
Spiritual struggles are not uncommon. For example, 65% of an adult sample reported experiencing some form of religious conflict in their lives (Nielson, 1998), and 62% of a national sample reported that they were sometimes angry at God (Exline, Park, Smyth & Carey, 2011).
In another national sample, 23.2% reported that they felt God may be punishing them and 12% wondered whether God had abandoned them (Fetzer Institute, 1999). Moreover, spiritual struggles are not limited to those who regard themselves as religious or spiritual. In fact, in a national sample, those who indicated no religious affiliation reported more anger toward God than affiliates (Exline, Park, Smyth & Carey, 2011). Some atheists have also shown signs of spiritual struggle as manifested by emotional arousal when asked to dare God to harm themselves or those they are close to (Lindeman, Heywood, Riekki, & Makkonen, 2014). Spiritual struggle and adjustment 3
The negative mental and physical health consequences of spiritual struggles have been
documented in numerous studies across diverse populations, and in both cross-sectional and
longitudinal designs. For example, those struggling with spiritual matters are more likely to
report higher levels of depression, anxiety (Ano & Vasconcelles, 2005), phobic anxiety, paranoid
ideation, obsessive compulsive behaviors, somatization (McConnell, Pargament, Ellison, &
Flannelly, 2006), and symptoms of traumatic exposure (McCann &Webb, 2012). With respect to
health, spiritual struggles are associated with poorer physical health (e.g., Ai, Park, Huang,
Rodgers, & Tice, 2007; Sherman, Simonton, Latif, Spohn, & Tricot, 2005; Zwigman, Wirtz,
Mullerkurber, & Murken, 2006), declines in physical functioning (Fitchett, Rybarczyk,
DeMarco, & Nicholas), and increased mortality (Pargament, Koenig, Tarakeshwar, & Hahn,
2001). Moreover, these links appear to remain robust across diverse religious groups (e.g.,
Pirutinsky, Rosmarin, Pargament, & Midlarsky, 2011; Raiya, Pargament, Mahoney, & Stein,
2008; Tarakeshwar, Pargament, & Mahoney, 2003). Much of the research has focused on the
negative associations and outcomes that accompany spiritual struggles. However, a few studies
have suggested that spiritual struggles may be related to positive outcomes, such as perceptions of stress-related growth and religious growth (e.g., Koenig, Pargament, & Nielson, 1998;
Pargament, Magyar, Benore, & Mahoney, 2005; Pargament, Smith, Koenig, & Perez, 1998;
Pargament, Koenig, & Perez, 2000).
Despite growing awareness of the potential impact of spiritual struggles, few studies have examined factors that may help or hinder people facing spiritual struggles. One exception is a study by Desai and Pargament (2013) who studied college students experiencing spiritual struggles over two points in time. They attempted to identify those factors that were predictive of growth and decline following spiritual struggles. Five variables emerged as predictors of Spiritual struggle and adjustment 4 growth and less decline: greater capacity for making meaning from spiritual struggle, positive religious coping with the struggle (e.g., benevolent religious reappraisal, collaborative religious coping, religious purification, and spiritual connection), religious support, a less avoidant attachment with God, and the severity of the struggle.
One pair of potentially important predictors of adjustment to spiritual struggles grows out of the model for human experience and behavior described by ACT. According to ACT, life naturally involves experiences of pain – one’s posture and response to pain is the key to positive or negative outcomes (i.e., how one functions in the presence of pain). This study will focus on two variables that are central to ACT and mindfulness-based behavior therapies: experiential avoidance and mindfulness. These processes have not yet been applied to the study of spiritual struggle.
Experiential Avoidance
Painful experience is part and parcel of life. Yet, few see pain as desirable. People often attempt to avoid unwanted painful experiences, such as the physical, cognitive, and emotional aspects of life’s disappointments, losses, and traumas. According to Relational Frame Theory
(RFT), the theory of language and cognition that underlies ACT, this general tendency is a predictable consequence of the verbal/cognitive context of literality under which we normally function. People get “caught up” in unwanted thoughts and experience them as literally true, because in this context of literality, thoughts “are” more than products of thinking; they appear to be objective facts, rules that must be followed, or threatening events that must be avoided. When this is the case, unwanted thoughts have a great deal of influence over behavior. Fusion (i.e., literal identification) with unwanted internal experiences (e.g., fears, traumatic memory) in particular, frequently leads to making them a target of avoidance strategies directly. Avoidance is Spiritual struggle and adjustment 5
not a problem, per se. Rather; it becomes problematic when avoiding one’s own unwanted
internal experience becomes a rigid pattern of experiencing and responding to the world.
Hayes and colleagues introduced the concept of experiential avoidance (EA) to describe
efforts to escape or avoid unwanted internal experience, even when efforts to do so are harmful
or contrary to personal values and goals (Hayes, Wilson, Gifford, Follette & Strosahl, 1996).
Consider the example of a divorced father who decides not to attend his son’s first school
performance because of social anxiety and fears of panic. Fusion with, and avoidance of,
unwanted thoughts and feelings has become negatively reinforcing for the father and is leading
him to a rigid pattern of responding. Relieved after missing his child’s first school performance,
the father finds reasons to be unavailable for future performances as well which sets up a pattern
that rewards his avoidance (i.e., he feels relieved) -- at least in the short-term.
Experiential avoidance is ultimately problematic because, in the process of giving greater
priority to the avoidance of unwanted experience, the individual becomes more insensitive to on-
going experiences in the present moment--- leaving little opportunity to learn alternative
responses or to detect new opportunities. In the example above, the father may be so anxious and
preoccupied with determining his avoidance strategy for his son’s bigger events that he is inattentive to the day-to-day joys of fathering when his son is visiting. In cases of severe and persistent avoidance, it is likely difficult to identify, work toward, or experience the qualities that lend a sense of meaning and purpose to life. Further, to the extent that people organize their behavior around efforts to avoid unwanted internal experience, they are likely to encounter fewer opportunities to choose, construct, or engage in values-consistent activity. The consequence may be that personal values are ambiguous, denied, or defined solely according to social convention.
Moreover, as individuals increasingly narrow their behavior around avoidance goals, they are Spiritual struggle and adjustment 6 less effectively influenced by more adaptive constructions such as values-guided goals. As such, behavioral flexibility is limited and participation in valued activities may become increasingly restricted (Hayes, Strohsal, & Wilson, 1999). Returning to our example, because he is predominantly experiencing shame in his parenting role, the father overlooks opportunities for engaging his child in meaningful ways. Over time, he may continue to identify fatherhood as important, but be unable to articulate the ways in which he connects with his child. The more entrenched this avoidance and shame pattern becomes, the less able he is to connect. As his child matures, he doesn’t recognize opportunities to share this vulnerability and become closer, and instead, determining that he is of little value as a parent, relegates himself to the role of
“provider,” ultimately losing contact with his son.
It should be noted, for RFT/ACT, the alternative to avoidance is acceptance. While it is frequently natural to avoid unwanted internal experiences, it is also possible to actively choose to accept them. As described in a later section, ACT introduces exercises that disrupt the context of literality that supports over-identification with thoughts and feelings that lead to avoidance, and instead opens some distance for observing them more objectively—inviting the possibility of acceptance, and making values-guided choices more likely (Hayes, Strohsal, & Wilson, 1999).
For the father, accepting his discomfort at any stage of the avoidance-shame spiral above would tend to broaden his view of the options available to him.
Experiential avoidance has been related to a variety of negative outcomes. In a review by
Ruiz (2010), EA was associated with increases in self-rated depression in 20 studies, and a similar link emerged between EA and increased symptoms of anxiety in 14 studies. In the area of stress-adjustment, EA has also been shown to mediate the impact of the stress of preterm birth and post-discharge adjustment (Greco, Heffner, Ritchie, Polak, Poe, & Lynch, 2005), the stress Spiritual struggle and adjustment 7
of care-taking for a family member with dementia on depression (Spira, Beaudreau, Jimenez,
Kierod, Cusing, et al., 2007), and the stress of the September 11 terrorist attacks on anxiety
(Farach, Mennin, Smith, & Mandelbaum, 2008). In the area of chronic pain, longitudinal and mediational studies have demonstrated the influence of EA, or its inverse (acceptance), on symptoms of depression and anxiety (McCracken & Vowles, 2008; Vowles, McCracken, &
Eccleston, 2008), functional status and functional disability (Esteve, Ramirez, Maestre & Lopez
Martinez, 2007; McCracken & Vowles, 2008), and psychological and physical well-being
(Wicksell, Renofalt, Olsson, Bond, & Melin, 2008).
Similarly, experimental studies of EA demonstrate that avoidance is related to poorer outcomes. For example, participants higher in EA had poorer performance on tests of cold pressor pain tolerance (Zettle, Hocker, Mick, Scofield, Petersen, & Hyunsung et al, 2005) and carbon-dioxide enriched air challenge (Feldner, Zvolensky, Eifert, & Spira, 2003), poorer perceptual-motor adjustment to simulated intoxication (Zettle, Petersen, Hocker, & Provines,
2007), and greater distress, discomfort, and sympathetic arousal when viewing unpleasant films
(Salters-Pedneault, Gentes, & Roemer, 2007; Sloan, 2004). Finally, in experimental comparisons
of the effects of avoidance (e.g., suppression) versus acceptance instructions, avoidance
instructions have been tied to poorer levels of functioning. For example, participants receiving
acceptance instructions reported less distress from intrusive thoughts (Marcks & Woods, 2007),
and less distress and physiological reactivity in response to emotional film content (Campbell-
Sills, Barlow, Brown, & Hofmann, 2006) than those instructed to avoid negative thoughts or
content. Interestingly, Liverant, Brown, Barlow and Roemer (2008) demonstrated that, among
participants with depression, suppression did attenuate sadness in the short-term when anxiety
was low, but ceased to be effective at higher levels of anxiety. In summary, experiential Spiritual struggle and adjustment 8 avoidance has been related to distress and poorer functioning in a variety of naturally occurring and experimentally manipulated contexts, while acceptance appears to be related to a reduction in these variables.
Experiential avoidance, as such, has not been examined in the context of spiritual struggles. However, EA should be relevant to spiritual struggles, because spiritual struggles can be a source of profound pain and confusion, and as such, the struggler may be tempted to avoid thoughts, feelings, and contexts associated with spiritual struggle. However, avoidance may make matters worse. Consider an example of a woman struggling spiritually with feeling abandoned by God. In an effort to avoid thoughts and feelings associated with this perceived denial by God, the struggler may leave behind spiritual and religious practice such as attendance at religious services and prayer —thereby losing important coping resources, dissociate from spiritual fellowship—thereby isolating herself from sources of support, and disengage from valued contexts such as community service —thereby reducing opportunities for meaning- making and positive experiences of the sacred.
A study by Krause and Ellison (2009) suggests that EA may be problematic for those experiencing spiritual struggle. They studied religious doubting, religious coping, and religious involvement in a national sample of older adults over a six-year period. Participants who attempted to suppress their experiences of religious doubt also tended to report less favorable health over time. By contrast, responding to spiritual doubting by seeking opportunities for spiritual growth did not have a significant effect.
Mindfulness
Infusion of Eastern ideas into Western psychology has fueled interest in the use of mindfulness-based approaches in the alleviation of a variety of psychological and physical health Spiritual struggle and adjustment 9
difficulties. Interest in the critical elements associated with the effectiveness of mindfulness-
based therapeutic interventions such as Mindfulness Based Stress Reduction (MBSR; Kabat-
Zinn, 1994), Acceptance and Commitment Therapy (ACT, Hayes et al., 1999) and Dialectical
Behavior Therapy (DBT; Linehan, 1993) has ignited interest in mindfulness research more generally (Bishop, 2002). While definitions of mindfulness vary and are not without some controversy (e.g., Grossman, 2008), many return to the definition offered in the pioneering work in the area by John Kabat-Zinn. Kabat-Zinn (1994, p.4) described mindfulness as, “paying attention in a particular way: on purpose, in the present moment, and non-judgmentally.”
Mindfulness is contrasted from mindlessness which is characterized by the inattentiveness or absent-mindedness which make cognitive failures more likely--such as arriving at a destination, but not remembering the details of the drive (Lau, Bishop, Segal, Buis,
Anderson, Carlson et al., 2006). Additionally, according to the research detailed in the previous section, such mindlessness makes one more vulnerable to being governed by automatic, habitual patterns of over-identification and cognitive reactivity to sensations, thoughts, and emotion that tend to increase stress.
Buddhist teachers would go further to note that, beyond attentiveness, mindfulness involves a particular posture with which one holds this attention in an open, curious, and accepting manner (Bishop, Lau, Shapiro, Carlson, Anderson, Carmody et al., 2004, Gunaratana,
2002). For example, consider a conflict in which a wife feels the sting of her spouse’s accusation that she is “never around.” A habitual and common response is to mindlessly react to the unwanted sting and possible feelings of regret by recoiling in anger and possibly lashing out
against thoughts that one is a “bad partner.” Mindfully hearing this same accusation would
include noting the sting of the words, the desire to defend against them, and a willingness to Spiritual struggle and adjustment 10
observe and stay present with all of these feelings in the service of better understanding the needs
of one’s spouse.
Mindfulness, from an ACT/RFT perspective, disrupts the “context of literality” that dominates typical verbal/cognitive processes and provides for direct experiencing of the present moment because it allows for a temporary setting aside of these literal functions of language
(Hayes & Shenk, 2004). As such, thoughts and feelings are observed to be just that, thoughts and feelings, and one need not be caught up in them or carried away by them. Relatedly, there is no need to fear or avoid them. In this way, mindfulness may be thought of as a beneficial counterpart to experiential avoidance. Whereas EA leads to increasingly rigid and avoidant patterns of behavior that are not responsive to contextual cues, mindfulness denotes a willingness to encounter experiences that should increase sensitivity to context and make flexible, adaptive responding more likely.
The capacity for mindfulness has been viewed as both a dispositional trait (Brown &
Ryan, 2003; Kabat-Zinn, 1990) and as a skill that can be cultivated through a variety of practices
(e.g., meditation), and interventions (e.g., MBSR, DBT, and ACT). Research has demonstrated the effectiveness of mindfulness-based interventions such as MBSR, DBT, and ACT in the treatment of both psychological and physical symptoms. These interventions include techniques that provide opportunities to cultivate the capacity to achieve mindful states in different ways, but all introduce some form of meditative practice. While MBSR relies primarily on meditation focused on the breath as a cognitive anchor, DBT and ACT introduce a variety of experiential activities with the aim of disrupting the context of literality and inviting a cognitive context in which acceptance and flexibility are more likely.
Meta-analyses and comprehensive empirical reviews demonstrate the clinical utility of Spiritual struggle and adjustment 11
mindfulness-based psychotherapies such as MBSR, DBT, and ACT in the treatment of
depression, anxiety, trauma, substance use disorders, chronic pain, and major medical conditions
such as cancer and heart disease. In these studies, researchers reported that the mindfulness-
based treatments were associated with changes in symptoms of distress, quality of life, medical
symptoms, physical pain, physical impairment, and valued-living (Baer, 2003; Bohlmeijer,
Prenger, Taal, & Cuijpers, 2010; Grossman, Niemann, Schmidt, & Walach, 2004; Hayes,
Luoma, Bond, Masuda, & Lillis, 2006; Ruiz, 2010). Interestingly, one study noted improvements in spiritual well-being following an MBSR intervention (Carmody, Reed, Kristeller, & Merriam,
2008).
Experimental manipulation of mindfulness in the laboratory offers support for the notion that the present-moment, defused verbal/cognitive context facilitated by mindfulness plays a role in the clinical utility of mindfulness-based treatments. For example, Hayes and colleagues demonstrated that participants in a condition that included mindful acceptance and defusion exercises from ACT showed improved performance on a cold-pressor task when compared to those in a CBT-based condition. Moreover, in addition to greater pain tolerance, participants evidenced a different perspective on their pain; they were less likely to endorse the belief that experiencing pain should necessarily direct behaviors, such as avoidance (Hayes, Bissett, Korn,
Zettle, Rosenfarb & Cooper et al., 1999). Arch and Craske (2006) compared affective responses to picture slides and willingness to remain in contact with aversive picture slides in various conditions: focused breathing (mindful), unfocused attention (mindless), and worry. Participants that received a brief focused-breathing exercise had more positive responses to neutral material than before the manipulation, while the unfocused and worry conditions had more negative responses to the neutral material. In addition, those in the focused-breathing condition had lower Spiritual struggle and adjustment 12 negativity and reduced emotional intensity to highly aversive slides, and they were more willing to view optional, highly negative slides. These findings support the notion that mindfulness supports a more objective and flexible relationship with cognitive content (i.e., thoughts), and that this has measureable impact on behavior.
While the data on the induction of mindful states are promising, there is also support for the beneficial role of dispositional mindfulness - - that is, having a generally greater capacity for, and tendency to, experience mindful attention and awareness. In non-clinical samples, being generally more mindful (“trait mindfulness”) is associated with reports of fewer symptoms of distress, and maladjustment and higher levels of psychological well-being or adjustment (Brown
& Ryan, 2003; Baer, Smith, Hopkins, Krietemeyer, and Toney, 2006). In medical patients, trait mindfulness was associated with lower reports of both medical symptoms (Carmody, Reed,
Kristeller, & Merriam, 2008) and psychological distress (Carlson & Brown, 2005; Carmody, et al., 2008). In a laboratory study, Arch and Craske (2010) found that higher levels of trait mindfulness were associated with attenuated responses to laboratory stressors in clinically anxious and non-anxious individuals—a finding that was even more pronounced in the clinically anxious subset. In an interesting intervention study, Carmody and colleagues (2008) demonstrated that both state and trait mindfulness improved following an MBSR intervention.
Moreover, these improvements were accompanied by improvements in reports of psychological distress, medical symptoms, and spiritual well-being (Carmody, Reed, Kristeller, & Merriam,
2008)
The capacity for mindfulness has not, as yet, been directly studied in the context of spiritual struggles. However, mindfulness should be relevant to spiritual struggles. In fact, in
Buddhism, mindfulness is explicitly valued and cultivated as a means of freeing oneself from Spiritual struggle and adjustment 13
dualistic thinking (i.e., a mode of thinking about the world that requires judgments and invites
attachment and desire) that, in Buddhism, is the origin of all suffering – including spiritual
suffering (Sahn, 1997). As such, mindful attention to spiritual pain would be a natural focus for
one pursuing spiritual growth in the Buddhist tradition (e.g., Chodron 2000; Kornfield, 1993;
Phillips, Cheng, Oemig, Hietbrink, & Vonnegut, 2012). And, studies demonstrating
improvements in spiritual well-being (Carmody, Reed, Kristeller, & Merriam, 2008) and
increased daily spiritual experiences (Greeson, Webber, Smoski, Brantley, Ekblad, Suarez, &
Wolever, 2011) following MBSR interventions for stress suggest that mindfulness may have
spiritual benefits—even when spiritual struggles are not the focus.
In the context of spiritual struggles, it makes sense that the capacity to willingly
encounter and observe personal spiritual pain would be related to positive outcomes. Return to
the example introduced earlier of the woman who feels abandoned by God. In her mindful
pursuit of connection with the sacred, she will recognize that she is having thoughts about being
abandoned by God, but not feel the need to hide or cover over this thought content – instead, she
is able to recognize her thoughts as simply thoughts. In this defused cognitive/verbal context, she
has a heightened attention to moment-to-moment experiences of the present as she engages in her usual spiritual and religious practices—thereby creating opportunities to experience communion with sacred teaching and authentic fellowship with others, each of which may foster new ideas and opportunities for spiritual involvement and enrichment even while questioning her connection with God. With her wider view of her internal experience, she may recall teachings of spiritual leaders who also experienced spiritual struggles (e.g., Mother Theresa) and view her own struggle as an opportunity to walk a spiritual path, even while feeling spiritually disconnected –perhaps recognizing this as an opportunity for spiritual growth. Her willingness to Spiritual struggle and adjustment 14
remain in contact with her spiritual pain, allows her to continue in her community outreach
efforts, perhaps meeting and ministering to others facing similar struggles –thereby opening the
way to more helpful cognitive/verbal constructions that support a sense of meaning and purpose
in enduring “with” her pain.
In one of the first studies of the links between mindfulness and spiritual struggle, Oman,
Shapiro, Thoresen, Flinders, Driskill, and Plante (2007) conducted an RCT of an MBSR training
program in a sample of Roman Catholic students. Facilitation of mindful states through MBSR
training led to significant decreases on the Brief RCOPE negative religious coping subscale, the
most frequently used measure of spiritual struggles. According to the authors, the attentional
training may be an important mechanism for reducing spiritual struggles in this sample. The
Oman et al. study suggests that mindfulness may be helpful in the context of spiritual struggle;
however additional studies are needed to test this idea.
Present Study
This study uses a cross-sectional design to examine a sample of individuals experiencing spiritual struggles. The purposes of this study are two-fold. First, this study examines the direct
effects of two ACT-related variables (experiential avoidance, mindfulness) on adjustment in
people who are experiencing spiritual struggles. Adjustment is assessed holistically, taking into
account the impact that struggles and efforts to avoid or be mindfully aware may have across
several domains (psychological, physical, spiritual). The primary hypotheses are as follows:
Hypothesis 1: Experiential avoidance will be negatively associated with indices of
psychological, physical, and spiritual adjustment.
Hypothesis 2: Mindfulness will be associated with better psychological, physical, and
spiritual functioning. Spiritual struggle and adjustment 15
A secondary interest of this study is exploratory and addresses the question of whether experiential avoidance and mindfulness moderate the impact of spiritual struggles on functioning. Based on the theoretical notion that the manner in which one responds to difficulty
(i.e., with avoidance or mindful attentiveness) will be most impactful in situations that are most disorienting and where corrective thought and action are perhaps most necessary, it is predicted that experiential avoidance and mindfulness will have greater impact among those reporting high versus low levels of spiritual struggle. Indirect support for this prediction comes from the laboratory study by Arch and Craske (2010) described earlier. They found that higher levels of trait mindfulness were associated with attenuated responses to laboratory stressors in clinically anxious and non-anxious individuals—a finding that was even more pronounced in the clinically anxious subset. Specific moderating effects hypotheses are as follows:
Hypothesis 3: The relationship between spiritual struggle and poorer psychological, physical, and spiritual adjustment will be stronger among those with higher levels of experiential avoidance than among those lower in experiential avoidance.
Hypothesis 4: The relationship between spiritual struggle and fewer difficulties in psychological, physical, and spiritual adjustment will be stronger among those with higher levels of mindfulness than among those lower in mindfulness.
Spiritual struggle and adjustment 16
Method Participants and Procedure
Participants for the present study were 307 adults from Amazon’s Mechanical Turk
(MTurk) worker database. Previous social science research has shown that MTurk samples are similar to other adult samples and that results from this source are psychometrically sound (e.g.,
Buhrmeister, Kwang, & Gosling, 2011). However, it is important to note that Berinsky, Huber,
and Lenz (2011) found that 42% of MTurk workers reported no religious affiliation.
MTurk workers were invited to participate in a study examining how they are dealing
with recent life experiences (Appendix N and O). Participants for the current study were the set
of individuals (307) endorsing at least low levels of current spiritual struggles drawn from a
larger pool of participants (593) that included both those struggling with spiritual matters and
those not experiencing spiritual struggles. Identification of participants for the current spiritual
struggles study began with a brief Recent Experiences Survey detailed below. Participants
endorsing at least one of the spiritual struggle items on the recent events survey were invited to
complete the full battery of assessments detailed below. Those not endorsing any spiritual
struggles items completed measures assessing experiential avoidance, mindfulness, and the
indices of general adjustment (PHQ-SADS, Psychological Well-Being Scale, Values-based
Action, Spiritual Well-being Scale). Each participant received $2.00 for completing her/his portion of the study measures, was debriefed (Appendix P) and thanked for participation.
As noted, 307 participants met both criteria for inclusion in the study. That is, they endorsed a spiritual struggle item on the Recent Life Experience Survey, and they endorsed at least two items at two or higher on the Religious and Spiritual Struggles Scale. As presented in
Table 1, 58.6 % of participants were male, largely married or partnered (41.0%), heterosexual Spiritual struggle and adjustment 17
(87.0%) and ranged in age from 18 to 70 years, with the majority (73.3 %) falling between 21
and 39 years. Participants were 67.4% White/Euro-American, 10.7% Asian American/Pacific
Islander, 8.1% Black/African American, 3.3% Hispanic or Latino American, 4.2% Native
American, 3.6% Bi-/Multi-racial/ethnic, 0.7% Middle Eastern American, and 2.0% “Other.” The majority of participants had at least some college (87.9%), with 39.7% having graduated college, and 15.3% reporting a graduate or professional degree. Most participants identified as either
Protestant (non-Catholic Christian; 26.1%), Agnostic/Atheistic (23.8%), unaffiliated (17.6%) or
Catholic Christian (13.7%). Other religious affiliations reported were: Muslim (4.9%), Hindu
(3.9%), Jewish (1.6%), Buddhist (1.0%), and “other” (7.2%). The religiousness of the present sample is lower than that of reported national averages. In a recent Gallup poll (2012), 42% of those surveyed reported attending religious services about once per week or more, as opposed to
8.8% of the current sample. Instead, 39.7% indicated that they never attend religious services and
35.2% reported no time in private prayer. As indicated in Table 2, the current sample identified as slightly more spiritual than religious, but overall levels of religious and spiritual intensity were modest.
Measures
Grouping and Demographic Measures
Grouping measure. A brief Recent Events Survey was constructed to determine who would complete the entire survey. The Recent Experiences Survey consists of 16 positive, negative, and neutral experience items, as well as one “write-in” option. Participants were instructed that the brief survey would be used to ensure that they are given the set of surveys appropriate to their experiences and asked to select all items describing experiences they have had in the past two to three months. Those individuals endorsing any of the 7 spiritual struggle Spiritual struggle and adjustment 18 items (See Appendix A; spiritual struggle items are starred), were presented with all of the measures detailed below. Those not endorsing any spiritual struggles items were asked to complete only measures assessing spiritual struggle, experiential avoidance, mindfulness, and the indices of general adjustment.
An added verification of spiritual struggles was conducted following data collection to ensure that only data from individuals experiencing at least low levels of current spiritual struggles were included for analysis in this study. Responses from the Religious and Spiritual
Struggles (RSS) scale (Exline, Pargament, Grubbs, & Yali, In press; Appendix C), detailed more extensively below in the Spiritual Measures section, were used to verify spiritual struggle. This measure consists of 26 items assessing six types of spiritual struggles across 3 domains.
Individuals endorsing at least two items of the RSS with a 2 (a little bit) or greater were included in the analyses.
Demographic and background information. Participants were asked to provide information regarding their demographics, religious affiliation, religious and spiritual intensity, belief in God, religious and spiritual practices, and prior exposure to meditative practice. They were also asked an open-ended question about their spiritual struggle: “In a paragraph or two, please describe the struggle you’re having related to your religion or spirituality” (drawn from unpublished spiritual struggle intervention materials; Pargament, Desai, Dworsky, Faigin, Gear, et al., 2008). This question provided participants an opportunity to reflect on their spiritual struggle prior to completing the other assessment measures. See Appendix B.
Spiritual Struggles
Spiritual Struggles were assessed using the Religious and Spiritual Struggles (RSS) scale
(Exline, Pargament, Grubbs, & Yali, in press). This measure consists of 26 items that assess Spiritual struggle and adjustment 19
experiences of six different types of spiritual struggle across the three domains noted earlier:
Intrapersonal (morality/guilt, doubt, and existential concerns about ultimate meaning),
Interpersonal, and Supernatural (divine, demonic). Participants rated the extent to which they have had the experiences described by each of the items on a five-point scale 1 (not at all) to 5 (a great deal). There is also a “does not apply” response option (coded as 1). Data from a large university sample supported the predictive, convergent, and discriminant validity of this measure and good internal consistency in this sample (Exline et al., in press). Cronbach’s α was .91. See
Appendix C.
Moderators
Experiential avoidance -general. Experiential avoidance was assessed using the second version of the Acceptance and Action Questionnaire (AAQ-II; Bond, Hayes, Baer, Carpenter,
Guenole et al., 2011). The seven items of the AAQ-II ask participants to rate “how true” each of the items is for them on a seven-point rating scale from 1 (never true), to 7 (always true).
Examples include, “My painful experiences and memories make it difficult for me to live a life that I would value” and “I am afraid of my feelings.” Validation studies demonstrate the adequate psychometric properties of the measure and support its predictive, incremental, and discriminant validity. Cronbach’s α was .93. See Appendix D.
Experiential avoidance – spiritual struggle specific. A modified version of the Chronic
Pain Acceptance Questionnaire – Revised (McCracken, Vowles, & Eccleston, 2004; 2005) was
used to measure experiential avoidance specific to spiritual struggle. The original 20-item
measure was designed to measure pain acceptance and items are thought to reflect greater pain
willingness and less interruption in pursuit of valued living. The original wording of items is in
both the positive and negative (i.e., some items suggesting avoidance, some acceptance). The Spiritual struggle and adjustment 20
scale was modified for the present study so that references to chronic pain were replaced with
references to “spiritual struggle” or “spiritual suffering.” Examples include, “My life is going
well, even though I have spiritual struggles,” and “I would gladly sacrifice important things in
my life to control my suffering with this spiritual struggle better.” The items are rated on a 7-
point scale from 0 (never true) to 6 (always true). The original measure is scored so that higher
scores signify greater acceptance. To more easily compare to the other measures of the present
study, the appropriate items were reversed so scores in the present study indicate greater struggle
specific experiential avoidance. Cronbach’s α was .85. See Appendix E.
Mindfulness. Mindfulness was assessed using the 13-item Toronto Mindfulness Scale—
Trait (TMS-T; Davis, Lau, & Cairns, 2009). Participants were asked to endorse the degree to
which each statement reflects their own experience using a five-point rating scale from 0 (not at all) to 4 (very much). There are two subscales that reflect a two-facet model of mindfulness.
Items on the Curiosity subscale reflect an openness and interest in learning about one’s ongoing
experience; for example, “I am curious about my reactions to things.” Items of the Decentering
subscale reflect a cognitive context in which one is observing (vs. personally identifying with) thoughts and feelings; for example, “I experience my thoughts more as events in my mind than as a necessarily accurate reflection of the way things ‘really’ are.” Both subscales were demonstrated to be psychometrically sound. However, the curiosity subscale of the TMS-Trait appears to function differently for meditators and non-meditators and is not generally as related to other tests of mindfulness; as such, only the decentering subscale was used in the analyses for the current study. Cronbach’s α was .72. See Appendix F.
Spiritual struggle and adjustment 21
Adjustment Indices
Special attention was given to evaluating indices of adjustment both proximal and distal to the experience of spiritual struggles across several domains of functioning: psychological, physical (somatic), and spiritual. The following measures were used.
Somatic, anxiety, and depression symptoms. Somatic, anxiety, and depression symptoms were assessed using the Patient Health Questionnaire—Somatic, Anxiety, and Depressive
Symptoms scales (PHQ-SADS; Kroenke, Spitzer, Williams, & Lowe, 2010; See Appendix G).
The three brief scales that comprise the PHQ-SADS were originally developed and validated separately. The somatic subscale (PHQ-15; Kroenke, Spitzer, & Williams, 2002) consists of 15 items asking individuals to indicate “how much” each somatic symptom (e.g., headaches) has been bothering them during the previous four weeks using a three-point rating scale from 0 (not bothered at all) to 2 (bothered a lot). The anxiety subscale (GAD-7; Spitzer, Kroenke, Williams,
& Lowe, 2006) asks participants to indicate “how frequently” they have been bothered by each of seven symptoms of anxiety using a four-point rating scale from 0 (not at all) to 3 (nearly every day). Finally, the depression subscale (PHQ-9; Kroenke, Spitzer, & Williams, 2001) is comprised of nine items asking participants “how often” they have been bothered by each symptom, using the same 0 (not at all) to 3 (nearly every day) scale as the GAD-7. Cut points of
5, 10, and 15 indicate Mild, Moderate, and Severe symptom levels on each of the three scales.
Cronbach’s α were .85 (Somatic), .91 (Anxiety), and .88 (Depression).
In a recent systematic review, Kroenke and collegues (2010) demonstrated that each of these subscales offers a valid and reliable measure of the intended construct. The PHQ-SADS includes a final question, not included in the overall score, asking participants to indicate the degree to which endorsed symptoms make it difficult to fulfill relationship and work roles. This Spiritual struggle and adjustment 22
item is examined separately as a global indicator of impairment in functioning. The PHQ-SADS
also includes five items specific to panic attacks that were not included in the present study.
Values-consistent living. The extent to which participants perceive a match between their chosen values and their day-to-day behaviors in eight domains of living was assessed using a modified Chronic Pain Values Inventory (CPVI; McCracken & Keogh, 2009). The CPVI was originally developed from a values clarification exercise from ACT (Hayes, Strosahl, Wilson,
1999), and asks participants to rate the importance and their success in living according to their personal values in the following domains: family, intimate relations, friends, work, health, growth or learning, spirituality, and religion. The CPVI was modified to drop language related to chronic pain and make it more general. For the purposes of this study, two domains, religion and spirituality, were also added to the model measure. For each domain, participants are asked to make two ratings: the first rating reflects the importance of their values in each domain; the second rating reflects their success in living in accordance with their values in that domain. Each of the 16 items is rated on a 0 to 5 scale indicating their degree of importance or success.
McCracken and Keogh (2009) noted that the “importance-items” do not demonstrate adequate variability for use in psychometric analysis. However, they were included in the present study to help participants consider the importance of each area when responding to the “success-items.”
The mean success rating was used in the present study. Cronbach’s α was .78. See Appendix H.
Struggle-related positive and negative affect. Positive and negative affect related to spiritual struggle was measured using a modified version of the Positive Affect/Negative Affect
Schedule (PANAS; Watson, Clark, & Tellegen, 1988). The PANAS is comprised of two 10-item subscales, one subscale uses positive affect words (PANAS-Pos) the other uses negative affect words (PANAS-neg). Participants were asked to indicate the extent to which they felt each Spiritual struggle and adjustment 23 emotion during the prior week using a scale from 1 (very slightly or not at all) to 5 (extremely).
Scores on the PANAS reflect average item responses with higher scores indicating more intense affect. The present study modified the PANAS instructions to introduce the list of words as
“feelings and emotions that may be related to your experience of spiritual struggle.” The word list was not altered. This approach was borrowed from Dworsky, Pargament, Gibbel, Krumrei,
Faigin et al., (2013). Cronbach’s alphas were .93 (positive) and .88 (negative). See Appendix I.
Struggle-related difficulties with emotion regulation. Three subscales of the Difficulties with Emotion Regulation Scale (DERS; Gratz & Roemer, 2004) were chosen for inclusion in this study, consistent with an earlier study of spiritual strugglers by Dworsky, et al., (2013). The preface to the original DERS, “When I’m upset…,” was modified to read, “When I’m upset about my spiritual struggle…,” in order to evaluate emotion regulation difficulties in the context of spiritual struggle-related distress specifically. Participants were asked to endorse items on a scale from 1 (almost never) to 5 (almost always). The five-item Difficulties Engaging in Goal-
Directed Behavior subscale (DERS-Goals) assesses difficulties maintaining desirable behavior, such as staying focused on a task to completion when experiencing negative emotions related to spiritual struggles (e.g., “When I’m upset about my spiritual struggle, I have difficulty getting work done.”). The six-item Impulse Control Difficulties subscale (DERS – Impulse) assesses difficulties with maintaining control of undesirable behavior when experiencing negative emotion related to spiritual struggle (e.g., “When I’m upset about my spiritual struggle, I lose control over my behaviors.”). Finally, the seven-item Limited Access to Emotion Regulation
Strategies subscale (DERS-Strategies) assesses the belief that, once upset about spiritual struggles, there is little one can do to effectively cope with the accompanying negative emotions
(e.g., “When I’m upset about my spiritual struggle, I believe that I’ll end up feeling very Spiritual struggle and adjustment 24
depressed.”). Higher subscale scores reflect more difficulty with emotion regulation. To reduce
participant burden, the present study used the three items with the highest factor-loadings from
each of the three subscales as follows: DERS – Goals #30 (.88), #22 (.88), and #16 (.85); DERS
– Impulse #37 (1.00), #31 (.79), #17 (.75); and DERS – Strategies #20 (.86), #19 (.79), and #35
(.64). Cronbach’s alpha in the present study were .95 (Goals), .94 (Impulse), and .88 (Strategies).
See Appendix J.
Spiritual Well-Being. Spiritual Well-being was assessed using the 12- item Functional
Assessment of Chronic Illness Therapy—Spiritual Well-Being Scale (FACIT-Sp; Peterman,
Fitchett, Brady, Hernandez, & Cella; 2002). The FACIT-Sp was designed to assess spiritual well-being independent of religious beliefs, and has been adapted for use with nonmedical populations (Carmody, Reed, Kristeller, & Merriam, 2008). It includes two subscales: Meaning and Peace and Faith. Participants are asked to indicate “how true” each statement is for them during the past seven days using five-point rating scale from 0 (Not at all) to 4 (Very much).
Example items from these subscales include, “I feel a sense of purpose in my life” (meaning and
peace) and “Difficult times have strengthened my faith or spiritual beliefs,” (faith). The FACIT-
Sp can be calculated as subscale scores or as a single composite score and has been found to
offer reliable and valid index of quality of life. The composite score is used for the present study.
Cronbach’s α was .90. See Appendix K.
Spiritual Transformation. Perceptions of spiritual change were assessed using the
Spiritual Transformations Scale (STS; Cole, Hopkins, Tisak, Steel, & Carr, 2008). This measure
consists of 40 items comprising two factors—spiritual growth and spiritual decline. Participants
are asked to rate “how true” each statement is for them, comparing their current experience to
their experience before encountering spiritual struggle, using a rating scale from 1 (It is not at all Spiritual struggle and adjustment 25
true for you) to 7 (It is true for you a great deal). Example items from the two subscales include,
“Because of spiritual changes I’ve been through I’ve changed my priorities,” and “In some ways
I have shut down spiritually.”
This measure was shortened for the purposes of this study to include the three items with
the highest factor loadings for each subscale. For the spiritual growth subscale, only items with
factor loadings of 0.87 and higher were included (items 2, 9, 21); for the spiritual decline
subscale, only items with factor loadings of 0.73 and higher were included (items 31, 33, 34).
Cronbach’s alphas were .93 (Growth) and .83 (Decline). See Appendix L.
Attention Check Items
Five attention check items were added into the online questionnaire to serve as quality
control checks. Items were distributed among items from other measures and were constructed to
appear similar to the other items of the measures in which they were embedded. For example,
“When I am paying attention to my survey responses, I know to mark this item ‘always true’” appeared in the DERS. See Appendix M.
Spiritual struggle and adjustment 26
Results
Preliminary Analyses
Data were analyzed using SPSS (IBM SPSS Statistics, Version 22). Preliminary analyses
were run in order to determine internal consistency reliability for all measures (Table 2).
Reliability was found to be adequate for all measures (α = .72 - .93). Additionally, ranges, means, and standard deviations were calculated and histograms were created in order to aid in visually assessing normality. No significant problems with range restriction or normality were found.
Mean scores of 7.76 (6.19), 7.52 (5.78), and 7.75 (6.49) on the PHQ depression, anxiety, and somatic subscales indicate that the participants in the present study were experiencing mild to moderate symptoms of psychological and physical distress. They reported a mean spiritual struggle rating of 51.71 (17.11). The average struggles item score (1.99, [0.66]) fell at “a little bit.” On average, participants’ general level of experiential avoidance (24.48, [10.21]) was within the range that has been associated with significant levels of psychological distress in other studies (Bond et al.,2011). The mean value of spiritual struggle specific avoidance was (73.18,
[17.97]. The average struggle avoidance score (3.67, [.90]) fell between “seldom true” and
“sometimes true.” On the measure of mindfulness, participants had a mean score of 14.11 (4.90)
–corresponding with an average mindfulness item score of “moderately.”
Correlations between outcome variables and demographic variables were conducted to assess the need to control for variables in subsequent analyses. As indicated in Table 4, Gender,
Race, Marital Status, and Education were each significantly correlated with three or more outcomes of interest and were used as control variables in all subsequent analyses.
Spiritual struggle and adjustment 27
Main Effects Analyses
Bivariate correlations were run to test the hypothesis that experiential avoidance would
be related to more negative outcomes (Table 3). In support of the hypothesis, both the general
(AAQ) and spiritual struggle-specific (SSAQ) experiential avoidance scales were significantly
related to nearly all of the outcome variables. The correlations were generally moderate to strong in magnitude. For example, the AAQ was positively related to anxiety (r = .64, p < .01), depression (r = .61, p < .01), somatic symptoms (r = .42, p < .01), negative affect (r = . 55, p <
.01), and difficulties with emotion regulation affecting goals (r = .35, p < .01), impulse control (r
= .40, p < .01), and access to coping strategies (r = . 48, p < .01), as well as spiritual decline (r =
.27, p < .01). The AAQ was negatively related to success with values-consistent living (r = -.31,
p < .01,) positive affect (r = -.15, p <. 01), and spiritual well-being (r = -.48, p < .01). With respect to spiritual struggle specific avoidance, the strength of correlations was more modest.
The SSAQ was positively related to anxiety (r = .25, p < .01), depression (r = .23, p < .01), somatic symptoms (r = .15, p < .01), negative affect (r = .34, p < .01), and difficulties with emotion regulation affecting goals (r = .43, p < .01), impulse control (r = .44, p < .01), and strategies (r = .36, p < .01). Contrary to prediction, the SSAQ also had a weak positive relationship with positive affect (r = .12, p < .01), and spiritual growth (r = .33, p < .01). There were a few instances in which the avoidance measures were not related to outcome variables. For example, the general experiential avoidance (AAQ) scale was not related to spiritual growth, and the spiritual struggle-specific experiential avoidance scale (SSAQ) was not related to the measures of values-consistent living, spiritual well-being, or spiritual decline.
Main effects of general experiential avoidance on outcomes were tested using linear regression analyses and are presented in Tables 5a – 5m. Separate analyses were conducted for Spiritual struggle and adjustment 28
each outcome variable. Controls (gender, education, race/ethnicity, and marital status) were
added in Step 1, followed by general experiential avoidance in Step 2. After accounting for the
control variables, higher general experiential avoidance was related to greater anxiety (β = .645,
p < .001), depression (β = .606, p < .001), somatic symptoms, (β = .463, p < .001), difficulty
with psychological symptoms (β = .456, p < .001), negative mood (β = .556, p < .001) as well as
less values-consistent living (β = -.300, p < .001), and less positive mood (β = -.148, p < .01).
Higher general experiential avoidance was also related to more problems with emotion
regulation in the context of spiritual struggle. Specifically, higher general EA was linked to more
problems with impulse control (β = .400, p < .001), perceived access to emotion regulation
strategies (β = .481, p < .001), and more difficulty maintaining concentration to accomplish tasks
(β = .361, p < .001) when distressed by spiritual struggles. Finally, higher general EA was related to lower levels of spiritual well-being (β = -.473, p < .001) and higher levels of spiritual
decline, (β = .259, p < .001). General experiential avoidance was unrelated to spiritual growth.
Main effects of spiritual struggle-specific experiential avoidance on each outcome were tested using linear regression analyses and are presented in Tables 6a – 6m. Controls (gender, education, race/ethnicity, and marital status) were added in Step 1, followed by spiritual struggle specific avoidance in Step 2. After accounting for the control variables, higher spiritual struggle specific experiential avoidance was related to greater anxiety (β = .295, p < .001), depression (β
= .267, p < .001), somatic symptoms, (β = .190, p < .001), difficulty with psychological
symptoms (β = .214, p < .001), negative mood (β = .338, p < .001) as well as less values-
consistent living (β = -.139, p < .05). Higher spiritual struggle specific experiential avoidance
was also related to more problems with emotion regulation in the context of spiritual struggle.
Specifically, higher spiritual struggle specific EA was linked to more problems with impulse Spiritual struggle and adjustment 29 control (β = .406, p < .001), perceived access to coping strategies (β = .370, p < .001), and more difficulty maintaining concentration to accomplish tasks (β = .424, p < .001) when distressed by spiritual struggles. Finally, higher spiritual struggle specific EA was related to lower levels of spiritual well-being (β = -.121, p < .05). Contrary to expectation, higher spiritual struggle specific EA was related to higher levels of spiritual growth (β = .302, p < .001). Spiritual struggle specific avoidance was unrelated to positive mood and spiritual decline.
Bivariate correlations were run to test the hypothesis that mindfulness would be related to more positive outcomes (Table 3). Consistent with the hypothesis, there were weak positive relationships between the “decenter” facet of mindfulness and success with values-consistent living (r = .166, p < .01), positive affect (r = .192, p < .01), and spiritual well-being (r = .228, p <
.01). However, contrary to prediction, mindfulness also had weak positive relationships with impulse control difficulties (r = .129, p < .05) and spiritual decline (r = .139, p < .05).
Mindfulness was not significantly related to anxiety, depression, somatic symptoms, goal persistence, perceived access to coping strategies, or spiritual growth.
Main effects of mindfulness on outcomes were tested using linear regression analyses and are presented in Tables 7a – 7m. Controls (gender, education, race/ethnicity, and marital status) were added in Step 1, followed by the “decenter” facet of mindfulness in Step 2. After accounting for the control variables, mindfulness was significantly related to success with values-consistent living (β = .161, p < .01) and spiritual well-being (β = .227, p < .001). This is consistent with prediction. However, this facet of mindfulness was unrelated to anxiety, depression, somatic symptoms, values-consistent living, negative mood, impulse control, perceived access to coping strategies, or spiritual growth. Contrary to prediction, the decenter facet of mindfulness was also related to reports of higher spiritual decline (β = .120, p < .05). Spiritual struggle and adjustment 30
Moderation Analyses
Hierarchical regression was used to examine the potential moderating effects of avoidance and mindfulness on the relationship between spiritual struggles and indices of adjustment (Tables 8a – 10m). Control variables (gender, education, race/ethnicity, and marital status) were entered into Step 1 of all moderation analyses. The independent variable, spiritual struggle, was entered as Step 2. The moderator (i.e., general avoidance, spiritual struggle specific avoidance, or mindfulness) was entered into Step 3. In Step 4 the multiplicative term was entered into the equation. Both the moderation and independent variables are continuous. Baron and
Kenny (1986) note the low statistical power of this approach. As such, interaction tests resulting in a significance level of p < .10 are reported. As presented in figures 1 - 11, interaction graphs were created using an excel program retrieved online (Dawson, 2013) based on Aiken and West
(1991). Interactions were plotted of the slopes between spiritual struggles and adjustment at two values of the moderator variable (i.e., experiential avoidance, mindfulness) namely, one standard deviation above and below the mean of the scale. All statistics were run with the continuous variables, but for graphing purposes, spiritual struggle was also split into two levels (one standard deviation above and below the mean).
After controlling for demographic variables, general experiential avoidance was a significant moderator of the relationship between spiritual struggles and three indices of adjustment. Specifically, general experiential avoidance moderated the relationship between spiritual struggles and difficulties maintaining necessary focus for accomplishing goals (β =
.204, p < .01; Table 8h, Figure 1), problems with impulse control (β = .207, p < .01; Table 8i,
Figure 2), and perceived access to coping strategies (β = .126, p =.053; Table 8j, Figure 3) when distressed by spiritual struggles. Consistent with the prediction, the direct relationship between Spiritual struggle and adjustment 31 spiritual struggles and these three emotion regulation variables was stronger for individuals who reported higher levels of general experiential avoidance than for those who reported lower levels of general experiential avoidance. By contrast, general experiential avoidance did not moderate the relationship between spiritual struggles and other indices of adjustment.
After controlling for demographic variables, spiritual struggle specific avoidance was a significant moderator of the relationship between spiritual struggles and eight of the adjustment indices. Spiritual struggle-specific experiential avoidance moderated the relationship between spiritual struggles and anxiety (β = .210, p < .001; Table 9a, Figure 4) and depression (β = .117, p < .05; Table 9b, Figure 5). As predicted, the relationship between spiritual struggles and symptoms of psychological distress was stronger as reports of experiential avoidance increased.
As shown in Table 9d and Figure 6, struggle-specific EA also moderated the relationship between spiritual struggles and the functional difficulty (β = .178, p < .001) that participants reported as a consequence of their psychological and physical symptoms noted above. As predicted, at higher levels of struggle avoidance, difficulty with symptoms increased as spiritual struggle increased. Interestingly at lower levels of struggle avoidance, difficulty with symptoms decreased as the level of spiritual struggle increased. With respect to mood, at higher levels of spiritual struggle specific avoidance, reports of less positive (β = -.119, p =.057; Table 9f, Figure
7) and more negative mood (β = .140, p < .05; Table 9g, Figure 8) increased as spiritual struggle increased. The relationship between spiritual struggles and mood was stronger as reports of spiritual struggle specific experiential avoidance increased. Spiritual struggle specific EA also moderated the relationship between spiritual struggles and the three indices signifying difficulties with emotion regulation in the context of spiritual struggles: difficulties maintaining necessary focus for accomplishing goals (β = .110, p < .05; Table 9h, Figure 9), problems with Spiritual struggle and adjustment 32 impulse control (β = .167, p < .001; Table 9i, Figure 10), and perceived access to coping strategies (β = .124, p < .05; Table 9j, Figure 11). Consistent with the prediction, the relationship between spiritual struggles and these three indices of emotion regulation was stronger at higher levels of spiritual struggle specific avoidance than it was at lower levels of struggle specific avoidance. Spiritual struggle-specific avoidance did not moderate the relationship between spiritual struggles and somatic symptoms, success with values-consistent living, spiritual well- being, spiritual growth, or spiritual decline.
Contrary to the prediction, mindfulness did not moderate the relationship between spiritual struggles and indices of adjustment.
Spiritual struggle and adjustment 33
Discussion
The present study was designed to examine the relationships between experiential
avoidance, mindfulness, and adjustment in a sample of people experiencing spiritual struggles.
The predictions were that experiential avoidance would be associated with poorer adjustment and
that mindfulness would be associated with better adjustment. It was also predicted that the
relationships between spiritual struggles and poorer adjustment would be stronger among people
with higher than lower levels of experiential avoidance. Finally, it was predicted that the
relationships between spiritual struggles and less problematic adjustment would be stronger
among people with higher than lower levels of mindfulness.
The findings supported the hypotheses that experiential avoidance as a general approach
to difficult internal experiences is problematic for people experiencing spiritual struggles. With
respect to avoidance tied more specifically to the struggle, similar though somewhat less robust
findings emerged, perhaps due to the properties of the measure. With few exceptions,
mindfulness, as measured in the present study, was not significantly related to indices of
adjustment. Some support was found for the hypothesis that the detrimental effects of spiritual
struggles on adjustment would be greater among people with higher than lower levels of
experiential avoidance. These findings were particularly robust for the measure of situation-
specific experiential avoidance. Possible reasons for these findings are explored. Implications
and future directions are also discussed.
Experiential Avoidance and Adjustment
The first hypothesis predicted that experiential avoidance would be negatively associated with indices of psychological, physical, and spiritual adjustment. Consistent with the prediction,
general EA was associated with poorer adjustment in all areas. After accounting for the control Spiritual struggle and adjustment 34 variables, higher general EA was associated with reports of higher levels of anxiety, depression, somatic symptoms and functional difficulty as a consequence of these symptoms. Higher EA was also related to more negative mood, less positive mood, and reports of less success living in a manner consistent with personal values. In the spiritual domain, higher general EA was also related to more problems with emotion regulation in the context of spiritual struggles. Higher general EA was linked to more problems with impulse control, perceived access to effective emotion regulation strategies, and more difficulty maintaining concentration to accomplish tasks when experiencing distress surrounding spiritual struggles. Finally, higher general levels of EA were related to lower levels of spiritual well-being and reports of greater spiritual decline.
General EA was not related to spiritual growth. In summary, these findings provide strong and consistent support for the notion that avoidance is problematic for spiritual struggles, and extends this area of study in important ways to the spiritual domain.
Similar to the findings for general experiential avoidance, spiritual struggle specific avoidance was associated with poorer psychological and physical adjustment, and one index of spiritual adjustment. After accounting for control variables, higher spiritual struggle specific EA was associated with reports of greater anxiety, depression, somatic symptoms and functional difficulty as a consequence of these symptoms. Higher struggle specific EA was also related to more negative mood and reports of less success with values-consistent living. In the spiritual domain, higher spiritual struggle specific EA was related to more problems with emotion regulation in the context of spiritual struggles. Higher spiritual struggle specific EA was linked to more problems with impulse control, perceived access to effective emotion regulation strategies, and more difficulty maintaining concentration to accomplish tasks when experiencing distress surrounding spiritual struggles. Additionally, higher levels of struggle specific EA were Spiritual struggle and adjustment 35 related to lower levels of spiritual well-being. Contrary to expectation, higher spiritual struggle specific EA was related to reports of greater spiritual growth. Spiritual struggle specific avoidance was unrelated to reports of positive mood and spiritual decline. Thus, the first hypothesis was largely supported for spiritual struggle specific avoidance. Avoidance of struggles with spiritual or religious concerns appears to have deleterious implications for both psychological and spiritual domains.
The third hypothesis predicted that the relationship between spiritual struggle and poorer psychological, physical, and spiritual adjustment would be stronger among those with higher levels of experiential avoidance than among those lower in experiential avoidance. General experiential avoidance did moderate the relationship between spiritual struggles and three indices of adjustment – all emotion regulation variables. Specifically, general EA moderated the relationship between spiritual struggles and difficulties maintaining necessary focus to accomplish goals, problems with impulse control, and perceived access to effective coping strategies when distressed by spiritual struggles. Consistent with the prediction, the relationship between spiritual struggles and these three spiritual struggle specific emotion regulation variables was stronger as levels of general EA increased. General EA did not moderate the relationship between spiritual struggles and other indices of psychological, physical, and spiritual adjustment. The moderating findings suggest that the general tendency to approach unwanted internal experiences with avoidance becomes even more problematic, especially for emotional regulatory functioning, at higher levels of spiritual struggles. This underscores the risks of not facing some of life’s most profound existential concerns.
As noted above in the context of general EA, the third hypothesis predicted that the relationship between spiritual struggle and poorer psychological, physical, and spiritual Spiritual struggle and adjustment 36 adjustment would be stronger among those with higher levels of EA than among those lower in experiential avoidance. This prediction also held even more strongly in the context of spiritual struggle specific avoidance. Spiritual struggle specific EA was a significant moderator of the relationship between spiritual struggles and eight indices of psychological and spiritual adjustment. As predicted, the relationship between spiritual struggles and symptoms of psychological distress (anxiety and depression) was stronger as reports of spiritual struggle specific EA increased. Similarly, at higher levels of struggle avoidance, reports of functional difficulty associated with symptoms of distress increased as spiritual struggle increased. Notably, at lower levels of struggle avoidance, difficulty with symptoms decreased as the level of spiritual struggle increased. Spiritual struggle specific EA also moderated the relationship between spiritual struggles and mood. Spiritual struggle specific EA was associated with reports of less positive mood and more negative mood as spiritual struggle increased. Spiritual struggle specific
EA also moderated the relationship between spiritual struggles and the three indices signifying difficulties with emotion regulation in the context of spiritual struggles: difficulties maintaining necessary focus for accomplishing goals, problems with impulse control, and perceived access to effective coping strategies. The relationship between spiritual struggles and these three spiritual struggle specific emotion regulation variables was stronger as levels of spiritual struggle specific
EA increased. Spiritual struggle did not moderate the relationship between spiritual struggles and somatic symptoms, success with values-consistent living, spiritual well-being, spiritual growth, or spiritual decline.
It is of interest to note the differences between general experiential avoidance and spiritual struggle specific avoidance. There was more support for the prediction that avoidance would moderate the relationship between spiritual struggles and indices of adjustment in the case Spiritual struggle and adjustment 37 of spiritual struggle specific EA than there was for general EA --there were three significant relationships in the case of general EA, and eight in the case of spiritual struggle specific EA.
One possible explanation for this may be the differences in how general and specific avoidance were measured. The general EA measure was constructed to tap experiential avoidance and all items were negatively worded. The measure of spiritual struggle specific avoidance was modified from a scale originally intended as a measure of acceptance, and contained items worded in both the positive (acceptance) and negative (avoidance). Illustrative positive and negative items from the Spiritual Struggle Acceptance Questionnaire (SSAQ) “I am getting on with the business of living no matter what my level of pain about my spiritual struggle(s) is,” and
“I would gladly sacrifice important things in my life to control my suffering with spiritual things better” demonstrate the general trend in this measure to tap acceptance or non-acceptance very directly. Acceptance of pain and struggle allows for vital living even in the presence of that pain and struggle. Restated, the items juxtapose vital living and struggle, and the only way to have both is to indicate acceptance of the struggle. The shorter Acceptance and Action Questionnaire
(AAQ) does not tap into this same psychological process as consistently. Items such as, “I’m afraid of my feelings” and “Emotions cause problems in my life” may be tapping motivations and consequences of avoidance more directly. For the present study, the SSAQ measure was scored to indicate spiritual struggle specific avoidance, but in its original form, it was used as a measure of acceptance. As such, the moderating effects findings may underscore the notion that failure to accept spiritual struggles may be risky, exacerbating the connection between spiritual struggles and poorer adjustment
If the SSAQ measure does indeed assess acceptance more than avoidance, it is interesting to revisit one of the findings in particular. As was the case for general EA, at higher levels of Spiritual struggle and adjustment 38 struggle avoidance, reports of functional difficulty associated with symptoms of distress increased as spiritual struggle increased. However, it is noteworthy that at lower levels of spiritual struggle specific EA (and not general EA), functional difficulty decreased as the level of spiritual struggle increased. On the one hand, this points to the negative implications of avoidance for functioning. But, if we understand the SSAQ as the measure of acceptance it was originally intended to be, the improved functioning at higher levels of spiritual struggle suggests that struggle-specific acceptance may actually preserve functioning even in the context of significant spiritual struggles.
Mindfulness and Adjustment
The second hypothesis predicted that mindfulness would be associated with better psychological, physical, and spiritual functioning. Consistent with the prediction, mindfulness was significantly related to reports of greater success at values-consistent living and with spiritual well-being. However, contrary to expectation, the decenter facet of mindfulness was also related to reports of greater spiritual decline. Mindfulness was unrelated to other indices of psychological, physical or spiritual adjustment (i.e., anxiety, depression, somatic symptoms, values-consistent living, negative mood, impulse control, perceived access to coping strategies, or spiritual growth).
The fourth hypothesis predicted that the relationship between spiritual struggle and fewer difficulties in psychological, physical, and spiritual adjustment would be stronger among those with higher levels of mindfulness than among those lower in mindfulness. This hypothesis was not supported in the present study.
It is unclear why mindfulness was, with some notable exceptions, unrelated to adjustment in the present study. However, there are at least four possibilities. The first is the most Spiritual struggle and adjustment 39
parsimonious; it is possible that trait mindfulness does not play an important role in adjustment
to spiritual struggle. Perhaps mindfulness has less significant implications for stressors in the
spiritual realm. However, given early evidence in other non-clinical and medical samples that
trait mindfulness was associated with better adjustment (Brown & Ryan, 2003; Baer, Smith,
Hopkins, Krietemeyer, and Toney, 2006; Carlson & Brown, 2005; Carmody, Reed, Kristeller, &
Merriam, 2008), it seems worth exploring other possible explanations for the failure of
mindfulness to emerge as a predictor of adjustment in this study.
A second explanation reflects the fact that in the present study only one facet of
mindfulness was chosen and measured as a dispositional characteristic. To be “mindful” in this
study, the individual had to endorse items suggesting she/he held an objective, observing view of
internal experiencing. This “decenter” measure of mindfulness was chosen for its similarity to the type of “defused” verbal/cognitive context described by ACT. However, as a multifaceted construct, it may be the case that the “decenter” facet as measured by the Toronto Mindfulness
Scale – Trait version (TMS-T) is not the critical element of mindfulness, or at least the aspect of
mindfulness most salient to spiritual struggles. In this study, having a general capacity for, and
tendency to, view ones internal experiences from this more defused/objective (vs. over-
identified) posture, was associated with greater success at living in accord with personal values,
and with reporting a greater sense of spiritual well-being. It was also associated with a sense of
spiritual decline. These seemingly disparate findings may be related to the fact that the scale is
tapping into this more “objective” view. Being more able to view internal experience objectively
may support the ability to make behavioral choices that are consistent with valued-living even
when that is difficult. Further, generally, not being “caught-up” in the literal content of one’s
thoughts may lend itself to a sense of spiritual well-being. In fact, this was also the case in a Spiritual struggle and adjustment 40
study by Carmody, Reed, Kristeller, & Merriam (2008). What remains unclear is why this
tendency was also related to the apparently contrary reports of greater spiritual decline.
If the “decenter” facet isn’t the critical factor here we are left wondering what element or
elements may be more important. As noted in the introduction, this point is still a source of
debate in the field and has sparked the design of numerous mindfulness measures, including
several multi-faceted measures. The decenter facet of mindfulness in the present study resembles
the defused, observing state discussed in Acceptance and Commitment Therapy. ACT introduces
a variety of activities with the aim of disrupting the context of literality and inviting a cognitive
context in which acceptance and flexibility are more likely. This context may, in fact be a critical
first step in laying the foundation for progress, but the additional step of acceptance may be
necessary for there to be measurable changes in adjustment. In the context of therapy, the
clinician is able to help leverage that defused cognitive context in ways that facilitate the client’s
movement toward acceptance.
Third, in using a dispositional measure of mindfulness, instead of a state-based measure,
we were unable to capture the moment-to-moment nature of mindfulness. And yet, mindfulness
measured as a state may be the more sensitive predictor of adjustment to spiritual struggles. In
support of this notion many of the strongest findings on mindfulness come from the clinical
literature in which mindfulness has been assessed as a state. For example, involvement in mindfulness training in MBSR, DBT, or ACT has been tied to reductions in symptoms of distress, improved quality of life (Baer, 2003; Bohlmeijer et al., 2010; Grossman et al, 2004;
Hayes et al, 2006; Ruiz, 2010) and even improvements in spiritual well-being (Carmody et al,
2008). These findings underscore the value of operationalizing mindfulness as a state-like
construct, one that is sensitive to context and change. Spiritual struggle and adjustment 41
Finally, it is important to note that this study used a general measure of mindfulness, not a measure of mindfulness that focuses specifically on the context of spiritual struggles. It is possible that mindfulness tailored to the challenge of spiritual struggles in particular, may have produced different results. This would be an interesting avenue for future research.
Limitations, Implications and Future Directions
The present study has several limitations. First, the methods were retrospective. It would
be interesting to do studies of struggle, avoidance, and mindfulness among people in the midst of
their struggles rather than retrospectively. Secondly, assessment was limited to self-report.
Future studies may benefit by supplementing self-report measures with reports of others, behavioral measures, and perhaps biomarkers. Third, this study was correlational. Experimental and treatment-based studies are needed to determine the direction and strength of causal relationships among these variables. Fourth, assessment of mindfulness is technically challenging as a degree of self-awareness is required in order to report on one’s level of awareness. It is unclear which facets of mindfulness are most critical, and which measure best taps into them. Finally, it is possible that the results of this study were affected by the choice to sample exclusively from the Mechanical Turk worker database. Studies which examine the generality of these results to other groups that are spiritually suffering are needed to further substantiate the role of avoidance and/or mindfulness in adjustment more broadly.
The most salient finding of the present research is that avoidance of spiritual struggle has implications for psychological and spiritual adjustment. This has several implications. First, mental health providers may find it useful to help clients with spiritual struggles face their difficulties. More tools are necessary in this arena. There is one protocol already developed that targets avoidance and reduction of stigma associated with spiritual struggles. A pilot Spiritual struggle and adjustment 42 effectiveness study of the Winding Road demonstrated promising results in a sample of college students with spiritual struggles (Dworsky et al., 2013). Additionally, tailoring Acceptance and
Commitment Therapy to these purposes may be useful. Further treatment effectiveness studies are needed to help clinicians skillfully bring psychological science to the treatment of spiritual struggles. Secondly, it may be helpful to intervene upon factors that contribute to struggle avoidance. For example, normalizing the very natural occurrence of spiritual struggle across the lifespan may be an important way to support those with spiritual struggle for whom the associated stigma creates a barrier to seeking care. In this regard, both patients and mental health care professionals need to be educated on the ubiquity of spiritual struggles.
Being generally more mindful was associated with greater success with living in accord with personal values and with spiritual well-being. Introducing mindfulness into therapeutic practices could have implications for quality of life, even if it did not appear to be associated with symptom reduction in the present study. Helping clients cultivate mindfulness, may support their continued involvement and connection with the most important and meaningful aspects of a life well-lived –even while they face challenges in the spiritual domain.
There were some interesting differences detected between the correlates of general avoidance and situation specific avoidance in this study. Further, these findings may be complicated by the nature of the measurement tools used to assess the general and specific domains that may have tapped into acceptance in the specific, but not the general domain. An interesting avenue for future research would be to take a careful look at these constructs and their unique contributions to adjustment in spiritual struggles. Including analogous measures of general and specific avoidance and a separate measure of acceptance would be an excellent first step in this regard. The issue of general and specific measures of avoidance also raises the issue Spiritual struggle and adjustment 43
of whether the general measure of mindfulness used in the present study missed a critical
element of mindfulness in the context of spiritual struggles. In addition to identifying other
salient aspects of mindfulness, future research on mindfulness in spiritual struggle may benefit
from 1) inclusion of a measure that assesses mindfulness of one’s experience of spiritual struggle in particular and/or 2) measurement of mindfulness in the context of a mindfulness intervention
for spiritual struggles.
To summarize, the present study extends research regarding avoidance and adjustment to
the spiritual domain and introduces mindfulness as a potential area for future research in spiritual
struggles. Avoidance was robustly and consistently associated with poorer adjustment to spiritual
struggles. Moreover, the strength of the relationship between spiritual struggles and adjustment
was higher at higher levels of avoidance – particularly when spiritual struggle specific avoidance was considered. Mindfulness was associated with indices of valued living and spiritual well- being, but not symptoms reduction—raising interesting questions about its role in the context of spiritual struggles.
Spiritual struggle and adjustment 44
References
Ai, A., Tice, T., Peterson, C., & Huang, B. (2005). Prayers, spiritual support, and positive
attitudes in coping with the September 11 national crisis. Journal Of Personality, 73(3),
763-791. doi:10.1111/j.1467-6494.2005.00328.x
Ai, A. L., Park, C., Huang, B., Rodgers, W., & Tice, T. N. (2007). Psychosocial mediation of
religious coping: A prospective study of short-term psychological distress after cardiac
surgery. Personality and Social Psychology Bulletin, 33, 867–882. doi:
Aiken, L. S., & West, S. G. (1991). Multiple regression: Testing and interpreting interactions.
Newbury Park, London, Sage.
Ano, G., & Vasconcelles, E. (2005). Religious coping and psychological adjustment to stress: a
meta-analysis. Journal Of Clinical Psychology, 61(4), 461-480. doi:10.1002/jclp.20049
Arch, J. J., & Craske, M. G. (2006). Mechanisms of mindfulness: Emotion regulation following a
focused breathing induction. Behaviour research and therapy, 44(12), 1849-1858.
Arch, J. J., & Craske, M. G. (2010). Laboratory stressors in clinically anxious and non-anxious
individuals: The moderating role of mindfulness. Behaviour research and therapy, 48(6),
495-505.
Baron, R. M., & Kenny, D. A. (1986). The moderator–mediator variable distinction in social
psychological research: Conceptual, strategic, and statistical considerations. Journal of
personality and social psychology, 51(6), 1173-1182.
Baer, R. A. (2003). Mindfulness training as a clinical intervention: A conceptual and empirical
review. Clinical psychology: Science and practice, 10(2), 125-143.
doi:10.1093/clipsy.bpg015 Spiritual struggle and adjustment 45
Baer, R. A., Smith, G. T., Hopkins, J., Krietemeyer, J., & Toney, L. (2006). Using self-report
assessment methods to explore facets of mindfulness.Assessment, 13(1), 27-45.
doi: 10.1177/1073191105283504
Berger, B. E., Ferrans, C. E., & Lashley, F. R. (2001). Measuring stigma in people with HIV:
Psychometric assessment of the HIV stigma scale. Research in nursing & health, 24(6),
518-529.
Berinsky, A., Huber, G., and Lenz, G. (2012). Using mechanical turk as a subject recruitment
tool for experimental research. Political analysis, 20, 351 – 368.
Bishop, S. R. (2002). What do we really know about mindfulness-based stress reduction?
Psychosomatic medicine, 64(1), 71-83.
Bishop, S. R., Lau, M.,Shapiro, S., Carlson, L., Anderson, N. D., Carmody, J, Segal, Z.V.,
Abbey, S., Speca, M., Velting, D., & Devins, G. (2004). Mindfulness: A proposed
operational definition. Clinical psychology: Science and practice, 11(3), 230-241.
doi: 10.1093/clipsy.bph077
Bohlmeijer, E., Prenger, R., Taal, E., & Cuijpers, P. (2010). The effects of mindfulness-based
stress reduction therapy on mental health of adults with a chronic medical disease: a
meta-analysis. Journal of psychosomatic research,68(6), 539-544.
Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K.,Waltz, T.,
& Zettle, R. D. (2011). Preliminary psychometric properties of the Acceptance and
Action Questionnaire–II: A revised measure of psychological inflexibility and
experiential avoidance. Behavior Therapy, 42(4), 676-688. Spiritual struggle and adjustment 46
Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: mindfulness and its role in
psychological well-being. Journal of personality and social psychology, 84(4), 822-848.
doi:10.1037/0022-3514.84.4.822
Buhrmeister, M., Kwang, T., & Gosling, S.D. (2011). Amazon’s Mechanical Turk: A new source
of inexpensive, yet high-quality, data? Perspectives on Psychological Science, 6, 3-5.
Campbell-Sills, L., Barlow, D. H., Brown, T. A., & Hofmann, S. G. (2006). Effects of
suppression and acceptance on emotional responses of individuals with anxiety and
mood disorders. Behaviour research and therapy, 44(9), 1251-1263.
Carlson, L. E., & Brown, K. W. (2005). Validation of the Mindful Attention Awareness Scale in
a cancer population. Journal of psychosomatic research,58(1), 29-33.
Carmody, J., Reed, G., Kristeller, J., & Merriam, P. (2008). Mindfulness, spirituality, and health-
related symptoms. Journal of psychosomatic research,64(4), 393-403.
Chodron, P. (2000). When things fall apart: Heart advice for difficult times. Boston: Shambala
Publications.
Cole, B. S., Hopkins, C. M., Tisak, J., Steel, J. L., & Carr, B. I. (2008). Assessing spiritual
growth and spiritual decline following a diagnosis of cancer: reliability and validity of
the spiritual transformation scale. Psycho‐Oncology,17(2), 112-121.
Davis, K. M., Lau, M. A., & Cairns, D. R. (2009). Development and preliminary validation of a
trait version of the Toronto Mindfulness Scale. Journal of Cognitive
Psychotherapy, 23(3), 185-197. Spiritual struggle and adjustment 47
Desai, K. M., & Pargament, K. I. (2013). Predictors of growth and decline following spiritual
struggles. International Journal for the Psychology of Religion.
doi:10.1080/10508619.2013.847697
Dworsky, C. K. O., Pargament, K. I., Gibbel, M. R., Krumrei, E. J., Faigin, C. A., & Warner, H.
L. (2013). Winding Road: Preliminary Support for a Spiritually Integrated Intervention
Addressing College Students’ Spiritual Struggles. In Research in the Social Scientific
Study of Religion, 24. 309-339
Esteve, R., Ramírez-Maestre, C., & López-Martínez, A. E. (2007). Adjustment to chronic pain:
the role of pain acceptance, coping strategies, and pain-related cognitions. Annals of
Behavioral Medicine, 33(2), 179-188. doi: 10.1007/BF02879899
Exline, J. J. (2013). Religious and spiritual struggles. In K. I. Pargament (Ed.in-Chief), J.J.
Exline & J. Jones (Assoc. Eds.), APA handbooks in psychology: APA handbook of
psychology, religion and spirituality: Vol1. Context, theory, and research (pp.459-476).
Washington, DC: American Psychological Association.
Exline, J. J., Pargament, K. I., Grubbs, J. B., & Yali, A.M. (In Press). The religious and spiritual
struggles scale: development and initial validation. Psychology of Religion and
Spirituality.
Exline, J. J., Park, C. L., Smyth, J. M., & Carey, M. P. (2011). Anger toward God:
Social-cognitive predictors, prevalence, and links with adjustment to bereavement and
cancer. Journal of Personality and Social Psychology, 100, 129-148. Spiritual struggle and adjustment 48
Farach, F. J., Mennin, D. S., Smith, R. L., & Mandelbaum, M. (2008). The impact of pretrauma
analogue GAD and posttraumatic emotional reactivity following exposure to the
September 11 terrorist attacks: A longitudinal study.Behavior therapy, 39(3), 262-276.
Feldner, M. T., Zvolensky, M. J., Eifert, G. H., & Spira, A. P. (2003). Emotional avoidance: An
experimental test of individual differences and response suppression using biological
challenge. Behaviour research and therapy, 41(4), 403-411.
Fetzer, I. (1999). Multidimensional measurement of religiousness/spirituality for use in health
research: A report of the Fetzer Institute/National Institute on Aging Working Group.
Kalamazoo, Mich: John E. Fetzer Institute.
Fitchett, G., Rybarczyk, B. D., DeMarco, G. A., & Nicholas, J.J. (1999). The role of religion in
medical rehabilitation outcomes: A longitudinal study. Rehabilitation Psychology, 44(4),
333 – 353. doi:10.1037/0090-5550.44.4.333
Gratz, K. L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and
dysregulation: Development, factor structure, and initial validation of the difficulties in
emotion regulation scale. Journal of Psychopathology and Behavioral Assessment, 26(1),
41-54.
Greco, L. A., Heffner, M., Poe, S., Ritchie, S., Polak, M., & Lynch, S. K. (2005). Maternal
adjustment following preterm birth: Contributions of experiential avoidance. Behavior
Therapy, 36(2), 177-184.
Greeson, J. M., Webber, D. M., Smoski, M. J., Brantley, J. G., Ekblad, A. G., Suarez, E. C., &
Wolever, R. Q. (2011). Changes in spirituality partly explain health-related quality of life
outcomes after Mindfulness-Based Stress Reduction. Journal of behavioral
medicine, 34(6), 508-518. doi:10.1007/s10865-011-9332-x Spiritual struggle and adjustment 49
Grossman, P. (2008). On measuring mindfulness in psychosomatic and psychological
research. Journal of psychosomatic research, 64(4), 405-408.
DOI:10.1016/j.jpsychores.2008.02.001
Grossman, P., Niemann, L., Schmidt, S., & Walach, H. (2004). Mindfulness-based stress
reduction and health benefits: A meta-analysis. Journal of psychosomatic
research, 57(1), 35-43.
Gunaratana, B. H. (2002). Mindfulness in plain English. Somerville, MA: Wisdom Publications.
Hayes, S. C., Bissett, R. T., Korn, Z., Zettle, R. D., Rosenfarb, I. S., Cooper, L. D., & Grundt, A.
M. (2012). The impact of acceptance versus control rationales on pain tolerance. The
Psychological Record, 49(1), 33-47.
Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and
commitment therapy: Model, processes and outcomes.Behaviour research and
therapy, 44(1), 1-25.
Hayes, S. C., & Shenk, C. (2004). Operationalizing mindfulness without unnecessary
attachments. Clinical Psychology: Science and Practice, 11(3), 249-254. doi:
10.1093/clipsy.bph079
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An
experiential approach to behavior change. New York: Guilford Press.
Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Experiential
avoidance and behavioral disorders: a functional dimensional approach to diagnosis and
treatment. Journal of consulting and Clinical Psychology, 64(6), 1152-1168.
doi: 10.1037/0022-006X.64.6.1152 Spiritual struggle and adjustment 50
Kabat-Zinn., J. (1990). Full catastrophe living: Using the wisdom of your mind to face stress,
pain and illness. New York: Dell.
Kabat-Zinn, J. (1994). Wherever you go, there you are: mindfulness meditation in everyday life.
New York: Hyperion.
Koenig, H. G., King, D. E, Carson, V. B. (2012) Handbook of Religion and Health. New York:
Oxford University Press.
Koenig, H. G., Pargament, K. I., Nielsen, J. (1998). Religious coping and health status in
medically ill hospitalized older adults. The journal of nervous and mental disease (0022-
3018), 186 (9), p. 513-521 doi:10.1097/00005053-199809000-00001.
Kornfield, J. (1993) A path with heart: A guide through the perils and promises of spiritual life.
New York: Bantam.
Krause, N., & Ellison, C. G. (2009). The doubting process: A longitudinal study of the
precipitants and consequences of religious doubt in older adults. Journal for the Scientific
Study of Religion, 48(2), 293-312. doi: 10.1111/j.1468-5906.2009.01448.x
Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The Phq‐9. Journal of general internal
medicine, 16(9), 606-613.
Kroenke, K., Spitzer, R. L., & Williams, J. B. (2002). The PHQ-15: validity of a new measure
for evaluating the severity of somatic symptoms. Psychosomatic Medicine, 64(2), 258-
266.
Kroenke, K., Spitzer, R. L., Williams, J. B., & Löwe, B. (2010). The patient health questionnaire
somatic, anxiety, and depressive symptom scales: a systematic review. General hospital
psychiatry, 32(4), 345-359. Spiritual struggle and adjustment 51
Lau, M. A., Bishop, S. R., Segal, Z. V., Buis, T., Anderson, N. D., Carlson, L., ... & Devins, G.
(2006). The Toronto mindfulness scale: Development and validation. Journal of clinical
psychology, 62(12), 1445-1467. doi: 10.1002/jclp.20326
Lindemann, M., Heywood, B., Riekki, T., & Makkonen, T. (2014). Atheists become emotional
arounsed when daring God to do terrible things. International Journal for the
Psychology of Religion, 24(2), 124-131. doi: 10.1080/1008619.2013.271991
Linehan, M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford
Press.
Liverant, G. I., Brown, T. A., Barlow, D. H., & Roemer, L. (2008). Emotion regulation in
unipolar depression: The effects of acceptance and suppression of subjective emotional
experience on the intensity and duration of sadness and negative affect. Behaviour
Research and Therapy, 46(11), 1201-1209.
Magyar-Russell, G. & Pargament, K. I. (2006). The darker side of religion: Risk factors for
poorer health and well-being. In P. McNamera (Ed.), Where God and man meet. How the
brain and evolutionary studies alter our understanding of religion, Vol.III, Psychology of
Religious Experience (pp.91-117). Westport, CT: Praeger Publishers.
Marcks, B. A., & Woods, D. W. (2007). Role of thought-related beliefs and coping strategies in
the escalation of intrusive thoughts: An analog to obsessive–compulsive
disorder. Behaviour Research and Therapy, 45(11), 2640-2651.
McCann, R. A., & Webb, M. (2012). Enduring and struggling with God in relation to traumatic
symptoms: The mediating and moderating roles of cognitive flexibility. Psychology of
Religion and Spirituality, 4(2), 143-153. doi:10.1037/a0026404 Spiritual struggle and adjustment 52
McConnell., K. M., Pargament, K. I., Ellison, C. G., & Flannelly, K. J. (2006). Examining the
links between spiritual struggles and symptoms of psychopathology in a national sample.
Journal of Clinical Psychology, 62(12), 1469–1484.
McCracken, L. M., & Keogh, E. (2009). Acceptance, mindfulness, and values-based action may
counteract fear and avoidance of emotions in chronic pain: an analysis of anxiety
sensitivity. The Journal of Pain, 10(4), 408-415.
McCracken, L. M., & Vowles, K. E. (2008). A prospective analysis of acceptance of pain and
values based action in patients with chronic pain.Health Psychology, 27(2), 215-220. doi:
10.1037/0278-6133.27.2.215
Nielson, M. E. (1998). An assessment of religious conflicts and their resolutions. Journal for the
Scientific Study of Religion, 37, 181-190. doi:10.2307/1388036
Oman, D., Shapiro, S. L., Thoresen, C. E., Flinders, T., Driskill, J. D., & Plante, T. G. (2007).
Learning from spiritual models and meditation: A randomized evaluation of a college
course. Pastoral Psychology, 55(4), 473-493. doi:10.1007/s11089-006-0062-x
Pargament, K. I. (1997). The psychology of religion and coping: Theory, research, and practice.
New York: Gilford Press.
Pargament, K. I. (2007). Spiritually integrated psychotherapy: Understanding and addressing
the sacred. New York: Gilford Press.
Pargament, Desai, Dworsky, Faigin, Gear, et al., (unpublished materials). Spiritual struggle and adjustment 53
Pargament, K. I., Koenig, H. G., & Perez. L. (2000). The many methods of religious coping:
Development and initial validation of the RCOPE. Journal of Clinical Psychology, 56,
519-543. doi:10.1002/(sici)1097-4679(200004)56:4<519::aid-jclp6>3.0.co;2-1
Pargament, K. I., Koenig, H. G., Tarakeshwar, N., & Hahn, J. (2001). Religious struggle as a
predictor of mortality among medically ill elderly patients. Archives of Internal
Medicine, 161, 1881-1885. doi:10.001/aechinte.161.15.1881
Pargament, K. I., Magyar, G. M., Benore, E. & Mahoney, A. (2005). Sacrilege: A study of
sacred loss and desecration and their implications for health and well-being in a
community sample. Journal for the Scientific Study of Religion, 44, 59-78.
doi:10.1111/j.1468-5906.2005.00265.x
Pargament, K. I., Murray-Swank, N. A., Magyar, G. M., Ano, G. G. (2005). Spiritual struggle: A
phenomenon of interest to psychology and religion. In Miller, W. R. & Delaney H. D.
(Eds.), Judeo-Christian perspectives on psychology: Human nature, motivation, and
change (pp. 245-268). Washington, DC: American Psychological Association, xvi.
doi:10.1037/10859-013
Pargament, K.I., Smith, B.W., Koenig, H.G., & Perez, L. (1998). Patterns of positive and
negative religious coping with major life stressors. Journal for the Scientific Study of
Religion, 37, 710-724. doi:10.2307/1388152
Peterman, A. H., Fitchett, G., Brady, M. J., Hernandez, L., & Cella, D. (2002). Measuring
spiritual well-being in people with cancer: the functional assessment of chronic illness
therapy—Spiritual Well-being Scale (FACIT-Sp). Annals of behavioral medicine, 24(1),
49-58. Spiritual struggle and adjustment 54
Phillips, R. E., Michelle Cheng, C., Oemig, C., Hietbrink, L., & Vonnegut, E. (2012). Validation
of a Buddhist Coping Measure Among Primarily Non‐Asian Buddhists in the United
States. Journal for the Scientific Study of Religion,51(1), 156-172. doi: 10.1111/j.1468-
5906.2012.01620.x
Pirutinsky, S., Rosmarin, D. H., Pargament, K. I., & Midlarsky, E. (2011). Does negative
religious coping accompany, precede, or follow depression among Orthodox
Jews?. Journal of affective disorders, 132(3), 401-405. doi:10.1016/j.jad.2011.03.015
Raiya, H. A., Pargament, K. I., Mahoney, A., & Stein, C. (2008). A psychological measure of
Islamic religiousness: Development and evidence of reliability and validity. The
International Journal for the Psychology of Religion, 18(4), 291-315.
doi:10.1080/10508610802229270
Ruiz, F. J. (2010). A Review of Acceptance and Commitment Therapy (ACT) Empirical
Evidence: Correlational, Experimental Psychopathology, Component and Outcome
Studies. International Journal of Psychology & Psychological Therapy, 10(1), 125-162.
Ryff, C. D., & Keyes, C. L. M. (1995). The structure of psychological well-being
revisited. Journal of personality and social psychology, 69(4), 719-727. doi:
10.1037/0022-3514.69.4.719.
Sahn, S. (1997). The compass of Zen. Boston: Shambala Publications
Salters‐Pedneault, K., Gentes, E., & Roemer, L. (2007). The role of fear of emotion in distress,
arousal, and cognitive interference following an emotional stimulus. Cognitive Behaviour
Therapy, 36(1), 12-22. doi: 10.1080/16506070600874281 Spiritual struggle and adjustment 55
Sherman, A. C., Simonton, S., Latif, U., Spohn, R., & Tricot, G. (2005). Religious struggle and
religious comfort in response to illness: Health outcomes among stem cell transplant
patients. Journal of Behavioral Medicine, 28(4), 359-367. doi:10.1007/s10865-005-
9006-7
Sloan, D. M. (2004). Emotion regulation in action: Emotional reactivity in experiential
avoidance. Behaviour Research and Therapy, 42(11), 1257-1270.
Spira, A. P., Beaudreau, S. A., Jimenez, D., Kierod, K., Cusing, M. M., Gray, H. L., &
Gallagher-Thompson, D. (2007). Experiential avoidance, acceptance, and depression in
dementia family caregivers. Clinical gerontologist, 30(4), 55-64. doi:
10.1300/J018v30n04_04
Spitzer, R. L., Kroenke, K., Williams, J. B., & Löwe, B. (2006). A brief measure for assessing
generalized anxiety disorder: the GAD-7. Archives of internal medicine, 166(10), 1092-
1097.
Tarakeshwar, N., Pargament, K. I., & Mahoney, A. (2003). Initial development of a measure of
religious coping among Hindus. Journal of Community Psychology, 31, 607-628.
doi:10.1002/jcop.10071
Vowles, K. E., McCracken, L. M., & Eccleston, C. (2008). Patient functioning and
catastrophizing in chronic pain: the mediating effects of acceptance. Health
Psychology, 27(2S), 136-143. doi: 10.1037/02786133.27.2(Suppl.).S136
Watson, D., Clark, L. A., & Tellegen, A. (1988). Development and validation of brief measures
Of positive and negative affect: the PANAS scales. Journal of personality and social Spiritual struggle and adjustment 56
psychology, 54(6), 1063-1070. doi:10.1037/0022-3514.54.6.1063
Wicksell, R. K., Renöfält, J., Olsson, G. L., Bond, F. W., & Melin, L. (2008). Avoidance and
cognitive fusion–Central components in pain related disability? Development and
preliminary validation of the Psychological Inflexibility in Pain Scale (PIPS). European
Journal of Pain, 12(4), 491-500. doi: 10.1016/j.ejpain.2007.08.003
Zettle, R. D., Hocker, T. R., Mick, K. A., Scofield, B. E., Petersen, C. L., Song, H., &
Sudarijanto, R. P. (2005). Differential strategies in coping with pain as a function of level
of experiential avoidance. Psychological Record, 55(4), 511-524.
Zettle, R. D., Petersen, C. L., Hocker, T. R., & Provines, J. L. (2007). Responding to a
challenging perceptual-motor task as a function of level of experiential
avoidance. Psychological Record, 57(1), 49-62.
Zwingmann, C., Wirtz, M., Müller, C., Körber, J., & Murken, S. (2006). Positive and negative
religious coping in German breast cancer patients. Journal of Behavioral Medicine, 29,
533-547. doi:10.1007/s10865-006-9074-3
Spiritual struggle and adjustment 57
Appendix A: Recent Experiences Survey (RES)
Welcome to the Recent Life Experiences Study!
Thank you for your interest in this study! This research study will be examining the way people respond to RECENT life events. It is likely that you have experienced several of the items below over the course of your lifetime. Your responses will allow us to determine which surveys are most appropriate for you to complete as part of this study. With this in mind, please only endorse an item if you have had the experience in the PAST 2 -3 MONTHS. Everyone should be able to qualify to participate in this study by selecting, or writing in, at least one life experience occurring in the past month. SELECT ALL THAT APPLY. It is okay if the written-in item seems "ordinary" to you.
□ Became a parent or grandparent
□ Questioned whether life really matters *
□ Felt I was in the presence of evil or that evil forces were acting on me *
□ Got married or started a new relationship
□ Got divorced or ended a difficult relationship
□ Felt that I failed to live up to my own religious or spiritual standards. *
□ Experienced the death of a loved one
□ Questioned my belief in, or felt abandoned by, God or a higher power. *
□ Changed Jobs
□ Experienced personal conflict regarding my religious/spiritual beliefs or had doubts about religion/spirituality *
□ Was harassed or ridiculed based on my race, gender, or sexual orientation
□ Helped my friend or family member through a difficult time
□ Felt hurt, mistreated, or offended by others because of my views about religion/spirituality*
□ Moved
□ Made a major purchase (e.g., computer, household appliance, car, house)
□ Felt angry or let down by God, or felt punished by God*
□ Other life event: Write in ______
*Spiritual Struggle items Spiritual struggle and adjustment 58
Appendix B: Demographic and background information
1. What is your age?
____ years
2. What is your gender?
____ Male ____ Female ____ Transgender
3. How would you describe your racial/ethnic identity?
____White/Euro-American ____Asian/Pacific Islander ____Multi-racial/ethnic
____Black/African American ____Hispanic or Latino ____Native American
____ Middle Eastern ____ Other: ______
4. What is your sexual orientation?
____Heterosexual/Straight ____Lesbian/Gay ____Other (e.g., bisexual, questioning, asexual)
5. What is your current marital/relationship status?
____ Single ____Dating ____Married/Partnered
_____Widow/Widower ____Separated/Divorced
6. What is your highest educational background?
____ Less than 7 years
____ Junior high school
____ Partial high school (10th-11th grade)
____ High school graduation
____ Partial college/post high school training (1 year or more)
____ Standard college graduation
____ Graduate/professional degree
Spiritual struggle and adjustment 59
7. What is your current religious or spiritual faith preference?
____ Protestant (non-Catholic) Christian ____Muslim
____ Catholic Christian ____Jewish
____Buddhist ____Hindu
____Agnostic/Atheistic ____None
____Other (specify): ______
8. Which of the four statements below most closely describes what you believe about God? Provide comments if needed.
____ I don’t believe in God.
____I don’t know whether there is a God and there probably is not a way to find out.
____I feel that I do believe in God even though I am not able to explain fully who or what God is.
____I know God really exists and I have no doubts about it.
____Choose not to answer.
Comments: ______
9. How often do you attend religious services?
___Several times a week ___2-3 times per month ___About once or twice a year
___Every week ___About once per month ___Less than once per year
___Several times a year ___Never
10. How often do you pray privately in places other than church or synagogue or temple?
___More than once per day ___Once a week ___Less than once a month
___Once a day ___A few times a month ___Never
___A few times a week ___Once a month
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11. How religious do you consider yourself to be?
___Not at all religious
___A little religious
___Moderately religious
___Quite Religious
___Very religious
12. To what extend to you consider yourself to be a spiritual person?
___Not at all spiritual
___A little spiritual
___Moderately spiritual
___Quite Spiritual
___Very Spiritual
13. Which of the following best describes your experience with meditation and relaxations strategies, including meditative practices involved in yoga and tai chi?
___ I have never received instruction in meditation or relaxation
___I have received instruction in meditation or relaxation, and I rarely practice.
___I have received instruction in meditation or relaxation, and I sometimes practice.
___I have received instruction in meditation or relaxation, and I regularly practice.
Spiritual Struggles – open-ended.
14. Please spend about 5 minutes (a paragraph or two of text), describing the struggles you are having related to your religion or spirituality.
Spiritual struggle and adjustment 61
Appendix C: Religious and Spiritual Struggles Scale (RSS)
Within the past 2 - 3 MONTHS, to what extent have you struggled with each of the following?
Does Not at all A little bit Somewhat Quite a A not bit great apply deal 1. …felt guilty for not living up to my moral standards 2. ...felt angry at God
3. …had concerns about whether there is any ultimate purpose to life or existence. 4. …felt hurt, mistreated, or offended by religious / spiritual people 5. …struggled to figure out what I really believe about religion/spirituality 6. …felt attacked by the devil or by evil spirits 7. …questioned whether life really matters 8. …felt torn between what I wanted and what I knew was morally right 9. …questioned God’s love for me 10. …had conflicts with other people about religion / spirituality matters
11. …felt as though the devil (or an evil spirit) was trying to turn me away from what was good 12. …felt as though my life had no deeper meaning 13. …felt angry at organized religion 14. …worried that my actions were morally or spiritually wrong 15. …felt confused about my religious/spiritual beliefs 16. …felt as though God was punishing me Spiritual struggle and adjustment 62
Does Not at all A little bit Somewhat Quite a A not bit great apply deal 17. …felt rejected or misunderstood by religious/spiritual people 18. …worried that the problems I was facing were the work of the devil or evil spirits 19. …felt as though God had abandoned me 20. …worried about whether my beliefs about religion/ spirituality were correct 21. …wrestled with attempts to follow my moral principles 22. …questioned whether my life will really make any difference in the world 23. …felt as though God had let me down 24. …felt troubled by doubts or questions about religion or spirituality 25. …felt tormented by the devil or evil spirits 26. …felt as though others were looking down on me because of my religious/spiritual beliefs
If you’ve struggled with any of the above how much distress have these struggles caused you over the past month? *
____Does not apply ____No distress ____A little distress ____Some distress ____Quite a bit of distress ____A great deal of distress
Spiritual struggle and adjustment 63
If you’ve struggled with any of the above, how difficult have these struggles made it for you to do your work, take care of things at home, or get along with other people in the past month? *
____Does not apply ____No difficulty ____A little difficulty ____Some difficulty ____Quite a bit of difficulty ____A great deal of difficulty
Spiritual struggle and adjustment 64
Appendix D: Acceptance and Action Questionnaire-II (AAQ-II)
Please read each of the statements and rate how true each statement is for you. 1 2 3 4 5 6 7 Never Very Seldom Sometimes Frequently Almost Always true seldom true true true always true true true 1. My painful experiences and memories make it difficult for me to live a life that I would value. 2. I’m afraid of my feelings. 3. I worry about not being able to control my worries and feelings. 4. My painful memories prevent me from having a fulfilling life. 5. Emotions cause problems in my life. 6. It seems like most people are handling their lives better than I am. 7. Worries get in the way of my success.
Spiritual struggle and adjustment 65
Appendix E: Spiritual Struggle Acceptance Questionnaire (SSAQ)
Directions: below you will find a list of statements. Please rate the truth of each statement as it applies to you. Use the following rating scale provided to make your choices.
Please read each of the statements and rate how true each statement is for you. 0 1 2 3 4 5 6 Never Very Seldom Sometimes Often Almost Always true rarely true true true always true true true 1. I am getting on with the business of living no matter what my level of pain about my spiritual struggle is… 2. My life is going well, even though I have spiritual struggle(s). 3. It’s okay to experience spiritual struggle.
4. I would gladly sacrifice important things in my life to control my suffering with this spiritual struggle better. 5. It’s not necessary for me to control my spiritual struggle(s) in order to handle my life well. 6. Although things have changed, I am living a normal life despite my spiritual struggle(s). Spiritual struggle and adjustment 66
0 1 2 3 4 5 6 Never Very Seldom Sometimes Often Almost Always true rarely true true true always true true true 7. I need to concentrate on getting rid of my spiritual struggle(s). 8. There are many activities I do even when I feel the pain of my spiritual struggle(s). 9. I lead a full life even though I have spiritual struggle(s). 10. Controlling the pain of my spiritual struggle(s) is less important than any other goals in my life. 11. My thoughts and feelings about my spiritual struggle(s) must change before I can take important steps in my life. 12. Despite my spiritual struggle(s), I am now sticking to a certain course in my life. 13. Keeping my spiritual suffering under control takes first priority whenever I’m doing something. Spiritual struggle and adjustment 67
0 1 2 3 4 5 6 Never Very Seldom Sometimes Often Almost Always true rarely true true true always true true true 14. Before I can make any serious plans, I have to get some control over my spiritual struggle(s) 15. When my spiritual suffering increases, I can still take care of my responsibilities. 16. I will have better control over my life if I can control my negative thoughts about my spiritual struggle(s). 17. I avoid putting myself in situations where my spiritual suffering might increase 18. My worries and fears about what spiritual struggle(s) will do to me are true. 19. It’s a relief to realize that I don’t have to change my spiritual struggle(s) to get on with my life. 20. I have to struggle to do things when I have spiritual suffering.
Spiritual struggle and adjustment 68
Appendix F: Toronto Mindfulness Scale-Trait (TMS-Trait)
Below is a list of things that people sometimes experience. Please read each statement and indicate the extent to which you agree with it. In other words, how well does the statement describe your experience? There are no “right” or “wrong” answers, so please answer in a way that reflects your own experiences.
0 1 2 3 4 Not at all A little Moderately Quite a Very bit Much 1. I experience myself as separate from my changing thoughts and feelings. 2. I am more concerned with being open to my experiences than controlling them or changing them. 3. I am curious about what I might learn about myself by taking notice of how I react to certain thoughts, feelings or sensations. 4. I experience my thoughts more as events in my mind than as a necessarily accurate reflection of the way things ‘really’ are. 5. I am curious to see what my mind is up to from moment to moment. 6. I am curious about each of my thoughts and feelings as they occur. 7. I am receptive to observing unpleasant thoughts and feelings without interfering with them. 8. I am more invested in just watching my experiences as they arise, than in figuring out what they could mean. 9. I approach each experience by trying to accept it, no matter whether it is pleasant or unpleasant. 10. I remain curious about the nature of each experience as it arises. 11. I am aware of my thought and feelings without over-identifying with them.
12. I am curious about my reactions to things. 13. I am curious about what I may learn about myself just by taking notice of what my attentions gets drawn to.
Spiritual struggle and adjustment 69
Appendix G: Physicians Health Questionnaire – Somatic Anxiety and Depression Symptoms
Over the last 2 weeks, how often have you been bothered by the following problems? Choose 0 1 2 3 not to Not at Several More Nearly answer all days than every half the day days 1. Feeling nervous, anxious or on edge *
2. Not being able to stop or control worrying * 3. Worrying too much about different things * 4. Trouble relaxing *
5. Being so restless that it is hard to sit still * 6. Becoming easily annoyed or irritable*
7. Feeling afraid as if something awful might happen *
Over the last 2 weeks, how often have you been bothered by the following problems? 0 1 2 3 Choose Not at Several More Nearly not to all days than every answer half the day days 1. Little interest or pleasure in doing things * 2. Feeling down, depressed or hopeless *
3. Trouble falling or staying asleep, or sleeping too much * 4. Feeling tired or having little energy *
5. Poor appetite or over-eating *
6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down * 7. Trouble concentrating on things, such as reading the newspaper or watching television * Spiritual struggle and adjustment 70
0 1 2 3 Choose Not at Several More Nearly not to all days than every answer half the day days 8. Moving or speaking so slowly that other people could have noticed. Or the opposite – being so fidgety or restless that you have moving around a lot more than usual *
9. Thoughts that you would be better off dead or hurting yourself in some way. *If you have thoughts of harming yourself or others, call “911” or go to the nearest hospital emergency room immediately for an evaluation.*
Over the last 2 weeks, how often have you been bothered by the following problems?
0 1 2 3 Choose Not at Several More Nearly not to all days than every answer half the day days 1. Stomach pain *
2. Back pain *
3. Pain in your arms, legs, or joints (knees, hip etc.) * 4. Menstrual cramps or other problems *
5. Headaches *
6. Chest pain *
7. Dizziness *
8. Fainting spells *
9. Feeling your heart pound or race *
10. Shortness of breath *
11. Pain or problems during intercourse * Spiritual struggle and adjustment 71
0 1 2 3 Choose Not at Several More Nearly not to all days than every answer half the day days 12. Constipation, loose bowels, or diarrhea * 13. Nausea, gas, or indigestion *
14. Feeling tired or having low energy *
15. Trouble sleeping *
If you checked any problems listed above, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? *
____Not at all difficult
____Somewhat difficult
____Very difficult
____Extremely difficult
____Choose not to answer
Spiritual struggle and adjustment 72
Appendix H: Values-Based Action Inventory (VBAI)
For each of the areas listed below consider how you most want to live your life. Then rate how IMPORTANT each domain is for you. This is NOT about how well you are doing in each area – it is about how important it is to you. Rate the importance you place in each domain using any number on the scale from 0 (not at all important) to 5 (very important). Each area need not be important to you – rate an area low if it is not important to you personally.
Consider each area according to your values, the important ways that you most want to live your life in each domain.
Rate the IMPORTANCE of each domain to you 0 1 2 3 4 5 Not at all Slightly Somewhat Moderately Very Extremely Important Important Important Important Important Important 1. Family: Participation in relationships with parents, children or other close people you live with, or whoever is your “family.” 2. Intimate relationships: Being the kind of partner you want to be for your spouse or closest partner in life.
3. Friends: Spending time with friends, doing what you need to maintain friendships, or providing help and support for others as a friend
Spiritual struggle and adjustment 73
0 1 2 3 4 5 Not at all Slightly Somewhat Moderately Very Extremely Important Important Important Important Important Important 4. Work: engaging in whatever is your occupation, your job, volunteer work, community service, education, or your work around your own home 5. Health: Keeping yourself fit, physically able, and healthy, just as you would most want to do 6. Growth & Learning: Learning new skills or gaining knowledge, or improving yourself as a person as you would most want
7. Religion: Following the teachings of your religion, attending services, helping fellow congregants, engaging in religious practice
Spiritual struggle and adjustment 74
0 1 2 3 4 5 Not at all Slightly Somewhat Moderately Very Extremely Important Important Important Important Important Important 8. Spirituality: Connecting with what you hold sacred, being spiritually grounded, growing spiritually, seeking or providing spiritual resources.
In this section, we want you to look at how much SUCCESS you have had in living according to your personal values. Many times when people face difficulties, they find it difficult to live their life as they want to live it.
For each of the areas of life listed below consider again how you most want to live your life. Then rate how SUCCESSFUL you have been living according to your values during the past two weeks. These questions are NOT asking how successful you want to be, but how successful you have been. Rate your success using any number on the scale from 0 (not at all successful) to 5 (very successful).
Rate your level of SUCCESS in living according to your values. 0 1 2 3 4 5 Not at all Slightly Somewhat Moderately Very Extremely Successful Successful Successful Successful Successful Successful 1. Family: Participation in relationships with parents, children or other close people you live with, or whoever is your “family.” Spiritual struggle and adjustment 75
0 1 2 3 4 5 Not at all Slightly Somewhat Moderately Very Extremely Successful Successful Successful Successful Successful Successful 2. Intimate relationships: Being the kind of partner you want to be for your spouse or closest partner in life.
3. Friends: Spending time with friends, doing what you need to maintain friendships, or providing help and support for others as a friend
4. Work: engaging in whatever is your occupation, your job, volunteer work, community service, education, or your work around your own home 5. Health: Keeping yourself fit, physically able, and healthy, just as you would most want to do 6. Growth & Learning: Learning new skills or gaining knowledge, or improving yourself as a person as you would most want
Spiritual struggle and adjustment 76
0 1 2 3 4 5 Not at all Slightly Somewhat Moderately Very Extremely Successful Successful Successful Successful Successful Successful 7. Religion: Following the teachings of your religion, attending services, helping fellow congregants, engaging in religious practice
8. Spirituality: Connecting with what you hold sacred, being spiritually grounded, growing spiritually, seeking or providing spiritual resources.
Spiritual struggle and adjustment 77
Appendix I: Positive and Negative Affect Scale – Struggle-Specific (PANAS-SS)
This table consists of a number of words that describe different feelings and emotions related to your experience with spiritual struggle. Mark the appropriate box that indicates the degree to which you generally feel this way, that is, how you feel on the average during the past 7 days.
1 2 3 4 5 Very A little Moderately Quite a bit Extremely slightly or not at all
1. Interested
2. Disinterested
3. Excited
4. Upset
5. Strong
6. Guilty
7. Scared
8. Hostile
9. Enthusiastic
10. Proud
11. Irritable
12. Alert
13. Ashamed
14. Inspired
15. Nervous
16. Determined
17. Attentive
18. Jittery
19. Active Spiritual struggle and adjustment 78
1 2 3 4 5 Very A little Moderately Quite a bit Extremely slightly or not at all
20. Afraid
Spiritual struggle and adjustment 79
Appendix J: Difficulties with Emotion Regulation Scale- Struggles Specific (DERS-Struggle)
Below is a list of things that people sometimes experience related to spiritual struggles. Please read each statement and indicate the extent to which you agree with it. In other words, how well does the statement describe your experience? There are no “right” or “wrong” answers, so please answer in a way that reflects your own experiences.
1 2 3 4 5 Almost Sometimes About half Most of Almost never the time the time always 1. When I’m upset about my spiritual struggle, I have difficulty concentrating. 2. When I’m upset about my spiritual struggle, I have difficulty focusing on other things. 3. When I’m upset about my spiritual struggle, I have difficulty getting work done. 4. When I’m upset about my spiritual struggle, I have difficulty thinking about anything else. 5. When I’m upset about my spiritual struggle, I can still get things done. 6. When I’m upset about my spiritual struggle, I lose control over my behaviors. 7. When I’m upset about my spiritual struggle, I have difficulty controlling my behaviors. 8. When I’m upset about my spiritual struggle, I become out of control. 9. When I’m upset about my spiritual struggle, I feel out of control. 10. I experience my emotions as overwhelming and out of control. 11. When I’m upset about my spiritual struggle, I feel like I can remain in control of my behaviors. 12. When I’m upset about my spiritual struggle, I believe I will end up feeling very depressed. 13. When I’m upset about my spiritual struggle, I believe I will remain that way for a long time. 14. When I’m upset about my spiritual struggle, I believe that wallowing in it is all I can do. Spiritual struggle and adjustment 80
1 2 3 4 5 Almost Sometimes About half Most of Almost never the time the time always 15. When I’m upset about my spiritual struggle, I believe that there is nothing I can do to make myself feel better. 16. When I’m upset about my spiritual struggle, I know that I can find a way to eventually feel better. 17. When I’m upset about my spiritual struggle, my emotions feel overwhelming. 18. When I’m upset about my spiritual struggle, I start to feel very bad about myself.
Spiritual struggle and adjustment 81
Appendix K: Functional Assessment of Chronic Illness Therapy-Spiritual Well-being Scale (FACIT-Sp)
Indicate how true each statement has been for you during the past 7 days. 0 1 2 3 4 Not at all A little bit Somewhat Quite a bit Very much
1. I feel peaceful.
2. I have a reason for living.
3. My life has been productive. 4. I have trouble feeling peace of mind. 5. I feel a sense of purpose in my life. 6. I am able to reach down deep into myself for comfort. 7. I feel a sense of harmony within myself. 8. My life lacks meaning and purpose. 9. I feel comfort in my faith and spiritual beliefs. 10. I feel strength in my faith and spiritual beliefs 11. My struggle has strengthened my faith or spiritual beliefs. 12. I know that whatever happens, things will be okay.
Spiritual struggle and adjustment 82
Appendix L: Spiritual Transformation Scale (STS)
Whether you are or are not spiritual or religious, please indicate the extent to which these statements are true for you since you began experiencing spiritual struggle. Think about how you were before your spiritual struggle and how you are now. Check the box that best describes any changes that have occurred using the scale from 1 to 7 in the following table.
1 2 3 4 5 6 7 Not at Seldom Someti About half Frequently Almost Always all true true mes and half true always true true true 1. My way of looking at the life has changed to be more spiritual. 2. I have a stronger spiritual connection to other people. 3. I have grown spiritually. 4. My faith has been shaken and I am not sure what I believe. 5. I n some ways I have shut down spiritually. 6. In some ways I think I am spiritually lost.
Spiritual struggle and adjustment 83
Appendix M: Attention Check Questions
These items were added into the online question format as a quality control check as discussed.
1. At end of AAQ-II: If you are paying attention to what you are doing in this survey, then do not provide a response to this item. 2. Item 20 in RSS: Paying attention? Select “quite a bit” for this item. 3. Statement 7, Q1 of SSAQ: Paying attention? Leave blank 4. Statement 12, Q1 TMS-Trait: I am paying attention to my responses on this survey. If you read this, leave this set blank. 5. Question 3, DERS: When I am paying attention to my survey responses, I know to mark this item "always true"
Spiritual struggle and adjustment 84
Appendix N: Mechanical Turk Job Posting
Welcome to the Recent Life Experiences Study
****DO NOT REPEAT THIS HIT IF YOU HAVE ALREADY DONE IT****
Requester: Carmen O Dworsky Hit Expiration Date: _____ Reward: $2.00
Time Allotted: 40 – 60 minutes HITs Available: 1
Description: This task involves filling out a survey about your experiences, how you tend to respond to stress, and how you feel and think about things. You must be a US resident, fluent in English, and at least 18 years old to participate. For your participation, you will receive $2.00 for 40 – 75 minutes of your time (please note: you are allotted up to 180 minutes to complete the survey in case you need to take breaks or step away for a while).
Please note: while this survey should be fairly easy for you to complete, it is important that you read each question carefully and think about your response before answering. Unfortuantely, there are a number of people on MTurk who respond randomly to surveys. To prevent this, we have included a number of “ATTENTION-CHECK QUESTIONS” that ask you to respond in a particular way. Please keep a look out for these questions and respond in the way that is directed. If you answer an attention-check question incorrectly, the survey will stop and you will be asked to return this HIT in order to avoid receiving a rejection.
Keywords: survey, study, research, psychology, religion, spirituality,
Qualifications Required: Location is US
Survey About Recent Life Experiences:
Researchers at Bowling Green State University are conducting a survey about recent life experiences. You must be a United States resident and at least 18 years old to take part in this survey. If you do not meet these qualifications, we will be unable to accept your HIT. This study will take 45 – 75 minutes, though you are allotted up to 180 minutes to complete the survey. You will be compensated $2.00 for your time. Please select the link below to complete the survey.
This research is ongoing and you are only allowed to participate in it once. To find out if you are eligible, follow the survey link below. If you are eligible to participate, you will be automatically sent to the study. If you have already taken this survey, you will be informed of this and prevented from accessing the survey again. Although you are given several days to complete the HIT, once you have opened the survey it must be completed in one sitting.
At the end of the survey, you will be asked to enter a confirmation code into the box below to receive credit for taking our survey. Spiritual struggle and adjustment 85
Appendix O: Informed Consent
Introduction: I am Carmen Oemig Dworsky, M. A., a doctoral student in Clinical Psychology at Bowling Green State University (BGSU). My advisor is Kenneth Pargament, Ph.D. I am conducting a study of adjustment to life experiences ranging from positive and neutral events, such as a major purchase, to difficult or negative events, such as struggling with spiritual or religious matters. I have a special interest in spiritual and religious struggles. You are invited to participate in this study because you indicated interest in participating. To qualify to participate, you must be a US Citizen, fluent in English, and age 18 or older.
Purpose: Research shows that spiritual and religious concerns (termed spiritual struggles) are not uncommon, and researchers and clinicians are becoming interested in understanding the things that make living with spiritual struggles easier or more difficult. Additionally, there is interest in understanding whether adjustment to spiritual struggles is different than adjusting to other stresses and strains of daily living. This study examines common ways of responding to stress generally, and spiritual struggles specifically, and how this relates to positive and negative outcomes. We hope this understanding will ultimately guide how clinicians work with clients with spiritual struggles in therapy. You will be compensated $2.00 for your participation.
Procedure: You must be 18 years or older, a United States citizen, and fluent in English to participate. Should you decide to participate, you will be asked to complete an online questionnaire that will take between 40 – 60 minutes. The questionnaire contains questions about life experiences, demographics, psychological symptoms and experiences, and spiritual/religious background and experiences. Unfortunately, there are people on Mechanical Turk who respond randomly to questionnaires, so there are also “attention check” questions that ask you to respond in a particular way. Upon completion of the questionnaire, you will be given instructions for how to “complete the HIT” to get credit for your work on Mechanical Turk. Once your responses pass the “attention check” review, you will be paid $2.00 through Mechanical Turk. Review may take up to one week.
Note that this study has been designed to be appropriate for individuals with a range of spiritual backgrounds and beliefs, including no beliefs.
Voluntary nature: Your participation is completely voluntary. You are free to withdraw at any time. You may decide to skip questions (or not do a particular task) or discontinue participation at any time without penalty. Deciding to participate or not will not affect your rating or your relationship with Mechanical Turk, nor will it affect your relationship with the investigators of Bowling Green State University.
Confidentiality/Anonymity Protection: The results of this study may be published, but your name and identity will not be revealed and all of the information collected from you will remain anonymous. All data will be identified with numbers that have no links to you as a research participant. Data will be stored in a password protected digital file and only members of the research team will have access to the data. Since this is an electronic survey, please note the following: (1) some employers may use tracking software so you may want to complete your Spiritual struggle and adjustment 86 survey on a personal computer, (2) do not leave survey open if using a public computer or a computer others may have access to, (3) clear your browser cache and page history after completing the survey.
Risks: There is some risk that you may experience mild distress while completing questionnaires asking about distressing experiences. It is not anticipated that this will rise above the level of distress you might feel were you to think about it on your own. In the unlikely event that a question makes you feel very uncomfortable, you may choose not to respond. You will receive compensation even if you choose to leave certain questions unanswered. There is a small risk that you will receive a work rejection in Mechanical Turk. However, this will ONLY happen if you attempt to complete this questionnaire multiple times, or if you answer the very simple “attention check” questions in a manner that demonstrates that you were not paying attention for much of your work. To minimize this risk, you will be offered the opportunity to “return the HIT,” to avoid receiving a rejection, in the event that you complete “attention check” items incorrectly.
Contact information: If you have any questions about this study or your participation, you may contact the principle investigator: Carmen Oemig Dworsky, M.A., Graduate Student, Psychology Department, BGSU, by phone (608)213-0118, or by email [email protected] or the investigator’s advisor, Kenneth Pargament, Ph.D., by phone at (419)372-7255, or by email at [email protected]. You may also contact the Chair of the Human Subjects Review Board at BGSU at 419-372-7716 or [email protected], if you have any questions about your rights as a participant in this research.
Thank you for your time and interest in participating in this study!
Consent: Continuing on to the study by “Accepting” the Mechanical Turk “HIT” indicates consent to complete this survey and agreement that you meet the qualifications of being a U.S. Citizen, fluent in English, and at least 18 years of age.
Spiritual struggle and adjustment 87
Appendix P: Debriefing Form
Thank you for participating in this study. The study in which you just participated relates to the general area of spirituality and psychology. More specifically, the purpose of this study was to examine adjustment to life experiences, with a special emphasis on adjusting to religious and spiritual difficulties.
Thinking deeply about an intense personal experience can sometimes make people feel a little insecure or distressed. This is a natural reaction which serves as a reminder of how important our past experiences are to our well-being. If you’re feeling some distress from the experience you thought about, you should know that research shows this effect should fade with time. Having said that, if there are things that are distressing you and you are not sure how to deal with them, please consider contacting the National Alliance on Mental Illness (NAMI)1-800-950- NAMI(6264), the United States National Suicide and Crisis Hotline at 1-800-784-2433or1-800- 273-8255, or a local mental health agency.
If you have any concerns at all about the study itself, please feel free to discuss them with the researcher, Carmen Oemig Dworsky, at [email protected]. If you have questions about your rights as a research participant, please feel free to contact the Chair of the Bowling Green State University Human Subjects Review Board at 419-372-7716 or [email protected].
Thank you again for participating in this project!
Spiritual struggle and adjustment 88
Appendix Q: HSRB Approval Letter
Spiritual struggle and adjustment 89
Spiritual struggle and adjustment 90
Table 1: Participant Demographics & Background
(n = 307)
N Percent
Gender
Male 180 58.6
Female 127 41.4
Sexual Orientation
Heterosexual/Straight 267 87.0
Lesbian/Gay 9 2.9
Other (e.g., bisexual, questioning, asexual) 29 9.4
Missing 1 0.3
Age
18-20 8 2.6
21-29 131 42.7
30-39 94 30.6
40-49 43 14.0
50-59 24 7.8
60-69 6 2.0
70-79 1 0.3
Marital Status
Single 113 36.8
Dating 52 16.9
Married/Partnered 126 41.0
Widow/Widower 3 1.0 Spiritual struggle and adjustment 91
Separated/Divorced 12 3.9
Missing 1 0.3
Ethnicity
Asian American /Pacific Islander 33 10.7
Black/African American 25 8.1
Hispanic or Latino American 10 3.3
Middle Eastern American 2 0.7
Native American 13 4.2
White/Euro-American 207 67.4
Bi-/Multi-racial/ethnic 11 3.6
Other: 6 2.0
Education
Junior high school 2 0.7
Partial high school (10th-11th grade) 1 0.3
High school graduation 33 10.7
Partial college/post high school training 101 32.9
(1 year or more)
Standard college graduation 122 39.7
Graduate/professional degree 47 15.3
Religious Preference
Protestant (non-Catholic Christian) 80 26.1
Catholic Christian 42 13.7
Jewish 5 1.6
Muslim 15 4.9
Hindu 12 3.9 Spiritual struggle and adjustment 92
Buddhist 3 1.0
Agnostic/Atheistic 73 23.8
None 54 17.6
Other (Total) 22 7.2
Belief about God
I don’t believe in God 57 18.6
I don’t know whether there is a God and 57 18.6 there probably is not a way to find out.
I feel that I do believe in God even though I 78 25.4 am not able to explain fully who or what God is
I know God exists and I have no doubts 101 32.9 about it
Choose not to answer 4 1.3
Other (Total) 9 2.9
Missing 1 0.3
Frequency of attendance at religious services
Never 122 39.7
Less than once per year 42 13.7
About once or twice per year 47 15.3
Once a month 15 4.9
2-3 times a month 26 8.5
Once a week 27 8.8
2-3 times a week 21 6.8
Daily 6 2.0
Frequency of private prayer
Never 108 35.2
Less than once a month 35 11.4 Spiritual struggle and adjustment 93
Once a month 13 4.2
A few times a month 24 7.8
Once a week 11 3.6
A few times a week 31 10.1
Once a day 41 13.4
More than once per day 43 14.0
Exposure to Meditation
I have never received instruction in 128 41.7 meditation or relaxation
I have received instruction in meditation or 96 31.3 relaxation and I rarely practice
I have received instruction in meditation or 64 20.8 relaxation and I sometimes practice
I have received instruction in meditation or 19 6.2 relaxation and I regularly practice
Spiritual struggle and adjustment 94
Table 2: Descriptive statistics
(n = 307)
Minimum Maximum Measure (# of items) M SD α (observed) (observed)
Religious Intensity (1) 0 5 2.27 1.34
Spiritual Intensity (1) 0 5 2.83 1.39
Attendance of Religious Services (1) 0 8 2.91 2.13
Frequency of Private Prayer (1) 0 8 3.86 2.76
Spiritual Struggle - RSSS (26) 27 122 51.71 17.11 0.91
Spiritual Struggle - Distress (1) 1 5 2.58 1.03
Spiritual Struggle – Difficulty (1) 1 5 1.98 1.15
Experiential Avoidance - AAQ (7) 7 49 24.48 10.21 0.93
Experiential Avoidance - SSAQ (20) 25 114 73.18 17.97 0.85
Trait Mindfulness – TMS Decenter (7) 1 29 14.11 4.90 0.72
PHQ - Anxiety (7) 0 21 7.52 5.78 0.91
PHQ - Depression (9) 0 25 7.76 6.19 0.88
PHQ - Somatic (15) 0 28 7.75 6.49 0.85
PHQ - Difficulty (1) 0 3 1.11 0.91
Values – Success (8) 0 4.75 2.39 0.95 0.78
PANAS – Positive (10) 1 5 2.61 0.98 0.93
PANAS – Negative (10) 1 5 1.96 0.79 0.88
DERS – Goals (3) 3 21 8.19 4.45 0.95
DERS – Impulse (3) 3 21 6.27 4.08 0.94
DERS – Strategies (3) 3 21 7.32 4.20 0.88
FACIT – Composite (12) 0 48 23.96 10.52 0.90
Spiritual Transformation - Growth (3) 3 21 10.17 5.62 0.93
Spiritual Transformation – Decline (3) 3 21 8.71 4.81 0.83
Spiritual struggle and adjustment 95
Spiritual struggle and adjustment 96
Table 3: Correlations
(n = 307)
RSSS AAQ SSAQ TMSd PHQa PHQd PHQs ValSuc PA NA DERg DERi DERs FACIT STg STd 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 1 - 2 .510** - 3 -.212 -.380** - 4 .088 -.053 -.171** - 5 .353** .641** .252** -.091 - 6 .444** .610** .228** -.072 .790** - 7 .450** .421** .153** .018 .537** .652** - 8 -.056 -.306** -.102 .166** -.273** -.310** -.152** - 9 .108 -.153** .119* .192** -.198** -.255** -.034 .453** - 10 .471** .552** .338** -.012 .648** .607** .500** -.162** -.028 - 11 .409** .354** .434** .080 .301** .293** .283** .075 .216** .405** - 12 .428** .398** .441** .129* .256** .257** .256** .152** .287** .488** .631** - 13 .474** .484** .358** .080 .338** .371** .324** .000 .117* .511** .676** .744** - 14 -.183** -.484** -.080 .228** -.455** -.518** -.209** .587** .529** -.256** .031 .021 -.177** - 15 .174** -.016 .328** .081 .016 -.064 .121* .413** .518** .141* .452** .396** .255** .536** - 16 .469** .274** -.014 .139* .125* .212* .209** -.105 -.055 .270** .182** .287** .379** -.273** -.158** -
* p < .05, ** p < .01, two-tailed.
1. RSSS = Spiritual Struggle 2. AAQ = Experiential Avoidance (general) 3. SSAQ = Experiential Avoidance (struggle specific) 4. TMSd = Mindfulness 5. PHQa = Anxiety 6. PHQd = Depression 7. PHQs = Somatic 8. ValSuc = Values consistent living 9. PA = Positive Affect 10. NA = Negative Affect 11. DERg = Difficulties with Emotion Regulation for Goals 12. DERs = Difficulties with Emotion Regulation - Impulses 13. Difficulties with Emotion Regulation Strategies 14. FACIT = Spiritual Well-being 15. STg = Spiritual Growth 16. STd = Spiritual Declin Spiritual struggle and adjustment 97
Table 4: Demographic x outcome variables correlations
(n = 307) Age Gender Marital Race Education Status
PHQ – Anxiety -0.038 -0.009 0.065 -0.036 -0.89*
PHQ- Depression -0.014 0.009 0.021 -0.084 -0.113**
PHQ- Somatic 0.082 -0.129** 0.068 0.097* -0.72
Values – Success 0.065 -0.089* -0.127** 0.179** 0.11*
Positive Affect 0.003 0.071 -0.193** 0.17** 0.056
Negative Affect -0.068 0.034 -0.101 0.038 -0.021
DERS – Goals -0.047 0.001 -0.108 0.087 0.056
DERS – Impulse -0.171** 0.057 -0.245** 0.084 0.093
DERS – Strategies -0.107 -0.002 -0.178** 0.017 0.052
FACIT (Spiritual Well-being) 0.018 -0.039 -0.122* 0.272** 0.158**
Spiritual Transformation - Growth 0.064 -0.121* -0.14* 0.266** 0.11
Spiritual Transformation – Decline -0.062 -0.014 -0.107 -0.079 0.046
Spiritual struggle and adjustment 98
Table 5: Experiential Avoidance (General) and Anxiety
Anxiety n = 307
Step 1 Step 2
β β
Gender -.007 .011
Education -.140* -.107*
Race/Ethnicity .062 .110**
Marital Status -.043 .010
Experiential Avoidance (AAQ) .645***
R2 .027 .027
ΔR2 .437 .410***
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 99
Table 6: Experiential Avoidance (General) and Depression
Depression n = 307
Step 1 Step 2
β β
Gender -.019 -.002
Education -.152** -.122**
Race/Ethnicity .022 .067
Marital Status -.085 -.035
Experiential Avoidance (AAQ) .606***
R2 .033* .033
ΔR2 .394 .361***
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 100
Table 7: Experiential Avoidance (General) and Somatic Symptoms
Somatic Symptoms n = 307
Step 1 Step 2
β β
Gender -.107 -.094
Education -.151** -.128**
Race/Ethnicity .038 .073
Marital Status .131* .169***
Experiential Avoidance (AAQ) .463***
R2 .059*** .059
ΔR2 .270 .211***
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 101
Table 8: Experiential Avoidance (General) and Functioning with symptoms
PHQ-Functional Difficulty n = 307
Step 1 Step 2
β β
Gender -132* -.119*
Education -.022 .001
Race/Ethnicity .086 .120*
Marital Status -.012 .026
Experiential Avoidance (AAQ) .456***
R2 .026 .026
ΔR2 .230 .204***
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 102
Table 9: Experiential Avoidance (General) and Values-consistent Living
Values-consistent Living n = 307
Step 1 Step 2
β β
Gender -.006 -.015
Education .076 .061
Race/Ethnicity -.133* -.155**
Marital Status .194*** .169**
Experiential Avoidance (AAQ) -.300***
R2 .061*** .061
ΔR2 .149 .089***
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 103
Table 10: Experiential Avoidance (General) and Positive Mood
Positive Mood (PANAS - Pos) n = 307
Step 1 Step 2
β β
Gender .092 .088
Education .035 .028
Race/Ethnicity -.197*** -.208***
Marital Status .217*** .205***
Experiential Avoidance (AAQ) -.148**
R2 .085 .085***
ΔR2 .107 .022**
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 104
Table 11: Experiential Avoidance (General) and Negative Mood
Negative Mood n = 307
Step 1 Step 2
β β
Gender .045 .061
Education -.025 .003
Race/Ethnicity -.122* -.080
Marital Status .055 .101*
Experiential Avoidance (AAQ) .556***
R2 .018 .018
ΔR2 .322 .304***
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 105
Table12: Experiential Avoidance (General) and Goal difficulties
Goal difficulties (DERS-Goals) n = 307
Step 1 Step 2
β β
Gender .020 .031
Education .059 .077
Race/Ethnicity -.124* -.097
Marital Status .091 .121*
Experiential Avoidance (AAQ) .361***
R2 .027 .027
ΔR2 .156 .128***
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 106
Table 13: Experiential Avoidance (General) and Impulse difficulties
Impulse difficulties (DERS- Impulse) n = 307
Step 1 Step 2
β β
Gender .075 .086
Education .094 .114*
Race/Ethnicity -.256*** -.266***
Marital Status .108 .141**
Experiential Avoidance (AAQ) .400***
R2 .091*** .091
ΔR2 .249 .158***
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 107
Table 14: Experiential Avoidance (General) and Emotion Regulation Strategy Difficulties
DERS-Strategies n = 307
Step 1 Step 2
β β
Gender .008 .021
Education .023 .047
Race/Ethnicity -.192*** -.156**
Marital Status .026 .066
Experiential Avoidance (AAQ) .481***
R2 .038* .038
ΔR2 .266 .288***
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 108
Table 15: Experiential Avoidance (General) and Spiritual Well-being
Spiritual Well-being (FACIT) n = 307
Step 1 Step 2
β β
Gender -.017 -.031
Education .104 .080
Race/Ethnicity -.139* -.174***
Marital Status .282*** .242***
Experiential Avoidance (AAQ) -.473
R2 .110*** .110
ΔR2 .330 .220***
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 109
Table 16: Experiential Avoidance (General) and Spiritual Growth
Spiritual Growth (STS-Growth) n = 307
Step 1 Step 2
β β
Gender -.088 -.088
Education .108* .108*
Race/Ethnicity -.154** -.154**
Marital Status .267*** .267***
Experiential Avoidance (AAQ) -.001
R2 .120*** .120
ΔR2 .120 .000
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 110
Table 17: Experiential Avoidance (General) and Spiritual Decline
Spiritual Decline (STS-Decline) n = 307
Step 1 Step 2
β β
Gender -.016 -.008
Education -.056 -.043
Race/Ethnicity -.129* -.110*
Marital Status -.078 -.056
Experiential Avoidance (AAQ) .259***
R2 .026 .026
ΔR2 .092 .066***
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 111
Table 18: Experiential Avoidance (Struggle Specific) and Anxiety
Anxiety n = 307
Step 1 Step 2
β β
Gender .007 .009
Education .140* .183***
Race/Ethnicity -.062 -.098
Marital Status .043 .046
Spiritual Struggle Experiential .295*** Avoidance (SSAQ)
R2 .027 .027
ΔR2 ..111 .084***
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 112
Table 19: Experiential Avoidance (Struggle Specific) and Depression
Depression n = 307
Step 1 Step 2
β β
Gender .019 .021
Education .152** .191***
Race/Ethnicity -.022 -.055
Marital Status .085 .088
Spiritual Struggle Experiential .267*** Avoidance (SSAQ)
R2 .033* .033
ΔR2 .101 .068***
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 113
Table 20: Experiential Avoidance (Struggle Specific) and Somatic Symptoms
Somatic Symptoms n = 307
Step 1 Step 2
β β
Gender .107 .109
Education .151** .179**
Race/Ethnicity -.038 -.062
Marital Status -.131* -.129*
Spiritual Struggle Experiential .190*** Avoidance (SSAQ)
R2 .059*** .059
ΔR2 .094 .035***
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 114
Table 21: Experiential Avoidance (Struggle Specific) and Functional Difficulty with
symptoms
PHQ- Functional Difficulty n = 307
Step 1 Step 2
β β
Gender .132* .134*
Education .022 .054
Race/Ethnicity -.086 -.112
Marital Status .012 .014
Experiential Avoidance (AAQ) .214***
R2 .026 .026
ΔR2 .070 .044***
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 115
Table 22: Experiential Avoidance (Struggle Specific) and Values-consistent Living
Values-consistent Living n = 307
Step 1 Step 2
β β
Gender .006 .005
Education -.076 -.094
Race/Ethnicity .133 .150**
Marital Status -.194*** -.196***
Spiritual Struggle Experiential -.139* Avoidance (SSAQ)
R2 .061*** .061
ΔR2 .079 .019*
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 116
Table 23: Experiential Avoidance (Struggle Specific) and Positive Mood
Positive Mood (PANAS - Pos) n = 307
Step 1 Step 2
β β
Gender -.092 -.091
Education -.035 -.022
Race/Ethnicity .197*** .186***
Marital Status -.217*** -.216
Spiritual Struggle Experiential .088 Avoidance (SSAQ)
R2 .085*** .085
ΔR2 .092 .007
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 117
Table 24: Experiential Avoidance (Struggle Specific) and Negative Mood
Negative Mood n = 307
Step 1 Step 2
β β
Gender -.045 -.042
Education .025 .075
Race/Ethnicity .122 .080
Marital Status -.055 -.052
Spiritual Struggle Experiential .338*** Avoidance (SSAQ)
R2 .018 .018
ΔR2 .128 .110***
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 118
Table 25: Experiential Avoidance (Struggle Specific) and Goal difficulties
Goal difficulties (DERS-Goals) n = 307
Step 1 Step 2
β β
Gender -.020 -.017
Education -.059 .003
Race/Ethnicity .124* .072
Marital Status -.091 -.086
Spiritual Struggle Experiential .424*** Avoidance (SSAQ)
R2 .027 .027
ΔR2 .200 .173***
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 119
Table 26: Experiential Avoidance (Struggle Specific) and Impulse difficulties
Impulse difficulties (DERS- Impulse) n = 307
Step 1 Step 2
β β
Gender -.075 -.072
Education -.094 -.034
Race/Ethnicity .256*** .206***
Marital Status -.108 -.104*
Spiritual Struggle Experiential .406*** Avoidance (SSAQ)
R2 .091*** .091
ΔR2 .249 .158***
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 120
Table 27: Experiential Avoidance (Struggle Specific) and Emotion Regulation Strategy
Difficulties
DERS-Strategies n = 307
Step 1 Step 2
β β
Gender -.008 -.005
Education -.023 .031
Race/Ethnicity .192*** .147**
Marital Status -.026 -.022
Spiritual Struggle Experiential .370*** Avoidance (SSAQ)
R2 .038* .038
ΔR2 .169 .131***
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 121
Table 28: Experiential Avoidance (Struggle Specific) and Spiritual Well-being
Spiritual Well-being (FACIT) n = 307
Step 1 Step 2
β β
Gender .017 .016
Education -.104 -.122*
Race/Ethnicity .139* .154**
Marital Status -.282*** -.283***
Spiritual Struggle Experiential -.121* Avoidance (SSAQ)
R2 .110*** .110
ΔR2 .124 .014*
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 122
Table 29: Experiential Avoidance (Struggle Specific) and Spiritual Growth
Spiritual Growth (STS-Growth) n = 307
Step 1 Step 2
β β
Gender .088 .090
Education -.108* -.064
Race/Ethnicity .154** .117*
Marital Status -.267*** -.264***
Spiritual Struggle Experiential .302*** Avoidance (SSAQ)
R2 .120*** .120
ΔR2 .207 .088***
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 123
Table 30: Experiential Avoidance (Struggle Specific) and Spiritual Decline
Spiritual Decline (STS-Decline) n = 307
Step 1 Step 2
β β
Gender .016 .016
Education .056 .053
Race/Ethnicity .129* .132*
Marital Status .078 .077
Spiritual Struggle Experiential -.023 Avoidance (SSAQ)
R2 .026 .026
ΔR2 .027 .001
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 124
Table 31: Mindfulness and Anxiety
Anxiety n = 307
Step 1 Step 2
β β
Gender -.007 -.005
Education -.140* -.146*
Race/Ethnicity .062 .049
Marital Status -.043 -.043
Mindfulness (TMS-Decenter) -.093
R2 .027 .027
ΔR2 .036 .008
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 125
Table 32: Mindfulness and Depression
Depression n = 307
Step 1 Step 2
β β
Gender -.019 -.017
Education -.152** -.158**
Race/Ethnicity .022 .011
Marital Status -.085 -.085
Mindfulness (TMS-Decenter) -.080
R2 .033* .033
ΔR2 .039 .006
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 126
Table 33: Mindfulness and Somatic Symptoms
Somatic Symptoms n = 307
Step 1 Step 2
β β
Gender -.107 -.108
Education -.151** -150**
Race/Ethnicity .038 .041
Marital Status .131* .131*
Mindfulness (TMS-Decenter) .022
R2 .059*** .059
ΔR2 .059 .000
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 127
Table 34: Mindfulness and Functional Difficulty with symptoms
PHQ-Functional Difficulty n = 307
Step 1 Step 2
β β
Gender -.132* -134*
Education -.022 -.018
Race/Ethnicity .086 .094
Marital Status -.012 -.012
Experiential Avoidance (AAQ) .059
R2 .026 .026
ΔR2 .029 .003
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 128
Table 35: Mindfulness and Values-consistent Living
Values-consistent Living n = 307
Step 1 Step 2
β β
Gender -.006 -.011
Education .076 .087
Race/Ethnicity -.133* -.110*
Marital Status .194*** .195***
Mindfulness (TMS-Decenter) .161**
R2 .061*** .061
ΔR2 .086 .025**
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 129
Table 36: Mindfulness and Positive Mood
Positive Mood (PANAS - Pos) n = 307
Step 1 Step 2
β β
Gender .092 .087
Education .035 .047
Race/Ethnicity -.197*** -.172**
Marital Status .217*** .218***
Mindfulness (TMS-Decenter) .174**
R2 .085*** .085
ΔR2 .115 .029**
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 130
Table 37: Mindfulness and Negative Mood
Negative Mood n = 307
Step 1 Step 2
β β
Gender .045 .046
Education -.025 -.027
Race/Ethnicity -.122* -.126*
Marital Status .055 .055
Mindfulness (TMS-Decenter) -.030
R2 .018 .018
ΔR2 .019 .001
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 131
Table 38: Mindfulness and Goal difficulties
Goal difficulties (DERS-Goals) n = 307
Step 1 Step 2
β β
Gender .020 .018
Education .059 .064
Race/Ethnicity -.124* -.114*
Marital Status .091 .091
Mindfulness (TMS-Decenter) .069
R2 .027 .027
ΔR2 .032 .005
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 132
Table 39: Mindfulness and Impulse difficulties
Impulse difficulties (DERS- Impulse) n = 307
Step 1 Step 2
β β
Gender .075 .072
Education .094 .100
Race/Ethnicity -.256*** -.242***
Marital Status .108 .108
Mindfulness (TMS-Decenter) .102
R2 .091*** .091
ΔR2 .101 .010
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 133
Table 40: Mindfulness and Emotion Regulation Strategy Difficulties
DERS-Strategies n = 307
Step 1 Step 2
β β
Gender .008 .006
Education .023 .027
Race/Ethnicity .192*** -.184***
Marital Status .026 .026
Mindfulness (TMS-Decenter) .057
R2 .038* .038
ΔR2 .041 .003
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 134
Table 41: Mindfulness and Spiritual Well-being
Spiritual Well-being (FACIT) n = 307
Step 1 Step 2
β β
Gender -.017 -.024
Education .104 .119*
Race/Ethnicity -.139* -.107*
Marital Status .282*** .282***
Mindfulness (TMS-Decenter) .227***
R2 110*** .110
ΔR2 .160 .050***
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 135
Table 42: Mindfulness and Spiritual Growth
Spiritual Growth (STS-Growth) n = 307
Step 1 Step 2
β β
Gender -.088 -.090
Education .108* .113*
Race/Ethnicity -.154** -.143**
Marital Status .267** .267***
Mindfulness (TMS-Decenter) .076
R2 .120*** .120
ΔR2 .125 .006
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 136
Table 43: Mindfulness and Spiritual Decline
Spiritual Decline (STS-Decline) n = 307
Step 1 Step 2
β β
Gender -.016 -.019
Education -.056 -.048
Race/Ethnicity -.129* -.112
Marital Status .078 -.077
Mindfulness (TMS-Decenter) .120*
R2 .026 .026
ΔR2 .040 .014*
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 137
Table 44: Experiential Avoidance (General) Moderating Spiritual Struggle and Anxiety
Anxiety n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender -.008 -.021 .007 .007
Race/Ethnicity .060 .120* .113* .113*
Education -.138* -.120* -.108 -.108*
Marital Status -.043 -.063 .006 .006
Spiritual Struggle .370*** .051 .048
Experiential Avoidance (General) .619*** .618***
Spiritual Struggle x Experiential .006 Avoidance
R2 .027+ .160*** .439*** .439***
ΔR2 .027 .133*** .279*** .011
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 138
Table 45: Experiential Avoidance (General) Moderating Spiritual Struggle and Depression
Depression n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender -.019 -.035 -.011 -.012
Race/Ethnicity .023 .097+ .091* .092*
Education -.141* -.119* -.109* -.109*
Marital Status -.086 -.110* -.054 -.054
Spiritual Struggle .458*** .196*** .181**
Experiential Avoidance (General) .507*** .499***
Spiritual Struggle x Experiential .030 Avoidance
R2 .029+ .233*** .420*** .420***
ΔR2 .029 .204*** .187*** .000
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 139
Table 46: Experiential Avoidance (General) Moderating Spiritual Struggle and Somatic
Symptoms
Somatic Symptoms n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender -.105+ -.121* -.107* -.107*
Race/Ethnicity .044 .118* .115* .115*
Education -.130* -.107* -.101* -.102*
Marital Status .130* .105* .139** .139**
Spiritual Struggle .461*** .301*** .289***
Experiential Avoidance (General) .311*** .305***
Spiritual Struggle x Experiential .024 Avoidance
R2 .053** .260*** .330*** .330***
ΔR2 .053 .207*** .070*** .000
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 140
Table 47: Experiential Avoidance (General) Moderating Spiritual Struggle and Functional
Difficulty with Symptoms
PHQ – Functional Difficulty n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender -.133* -.142* -.115* -.115*
Race/Ethnicity .084 .127* .117* .118*
Education -.023 -.006 -.009 -.009
Marital Status -.013 -.029 .026 .026
Spiritual Struggle .244*** .010 .004
Experiential Avoidance (General) .449*** .446***
Spiritual Struggle x Experiential .011 Avoidance
R2 .026+ .083*** .229*** .229***
ΔR2 .026 .057*** .146*** .000
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 141
Table 48: Experiential Avoidance (General) Moderating Spiritual Struggle and Values-
consistent Living
Values-consistent living n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender -.001 .002 -.014 -.015
Race/Ethnicity -.122* -.136* -.132* -.131*
Education .102+ .098+ .091+ .091+
Marital Status .193*** .197*** .159** .159**
Spiritual Struggle -.086 .094 .084
Experiential Avoidance (General) -.349*** -.354***
Spiritual Struggle x Experiential .020 Avoidance
R2 .064*** .071*** .160*** .160***
ΔR2 .064 .007 .089*** .074
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 142
Table 49: Experiential Avoidance (General) Moderating Spiritual Struggle and Positive
Mood
Positive Mood (PANAS – Positive) n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender .096+ .094+ .083 .083
Race/Ethnicity -.186*** -.175** -.172** -.173**
Education .062 .065 .060 .060
Marital Status .216*** .212*** .185*** .185***
Spiritual Struggle .068 .197** .217**
Experiential Avoidance (General) -.250*** -.240***
Spiritual Struggle x Experiential -.039 Avoidance
R2 .086*** .091*** .136*** .137***
ΔR2 .086 .004 .045*** .001
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 143
Table 50: Experiential Avoidance (General) Moderating Spiritual Struggle and Negative
Mood
Negative Mood (PANAS – Negative) n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender .049 .033 .053 .053
Race/Ethnicity -.113+ -.038 -.043 -.042
Education .000 .023 .031 .031
Marital Status .054 .029 .078 .078
Spiritual Struggle .460*** .235*** .212***
Experiential Avoidance (General) .437*** .426***
Spiritual Struggle x Experiential .043 Avoidance
R2 .016 .222*** .361*** .362***
ΔR2 .061 .206*** .139*** .001
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 144
Table 51: Experiential Avoidance (General) Moderating Spiritual Struggle and Goal
Difficulties
Goal Difficulties (DERS – Goals) n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender .026 .012 .022 .021
Race/Ethnicity -.111+ -.046 -.049 -.042
Education .092 .111+ .115* .114*
Marital Status .089 .068 .092+ .090+
Spiritual Struggle .398*** .287*** .182**
Experiential Avoidance (General) .215*** .163**
Spiritual Struggle x Experiential .204** Avoidance
R2 .031+ .185*** .218*** .240***
ΔR2 .031 .154*** .034*** .022**
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 145
Table 52: Experiential Avoidance (General) Moderating Spiritual Struggle and Impulse
Difficulties
Impulse Difficulties (DERS – Impulse) n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender .083 .069 .082+ .081+
Race/Ethnicity -.239*** -.175*** -.178*** -.171***
Education .139* .158** .163*** .163***
Marital Status .106+ .085+ .114* .113*
Spiritual Struggle .395*** .255*** .148*
Experiential Avoidance (General) .271*** .219***
Spiritual Struggle x Experiential .207** Avoidance
R2 .099*** .251*** .304*** .327***
ΔR2 .099 .152*** .053*** .023**
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 146
Table 53: Experiential Avoidance (General) Moderating Spiritual Struggle and Emotion
Regulation Strategy Difficulties
Emotion Regulation Strategy Difficulties (DERS – Strategies) n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender .014 -.002 .014 .013
Race/Ethnicity -.178** -.104* -.108* -.104*
Education .062 .084+ .090+ .090+
Marital Status .024 .000 .037 .037
Spiritual Struggle .456*** .281*** .216***
Experiential Avoidance (General) .340*** .308***
Spiritual Struggle x Experiential .126+ Avoidance
R2 .039* .241*** .325*** .333***
ΔR2 .039 .202*** .084*** .008+
Note. Regression weights are standardized. * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 147
Table 54: Experiential Avoidance (General) Moderating Spiritual Struggle and Spiritual
Well-being
Spiritual Well-being (FACIT) n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender -.014 -.006 -.028 -.029
Race/Ethnicity -.130* -.165** -.160*** -.158***
Education .123* .112* .103* .102*
Marital Status .281*** .292*** .238*** .238***
Spiritual Struggle -.219*** .035 .005
Experiential Avoidance (General) -.491*** -.206***
Spiritual Struggle x Experiential .058 Avoidance
R2 .113*** .160*** .335*** .337***
ΔR2 .113 .046*** .176*** .002
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 148
Table 55: Experiential Avoidance (General) Moderating Spiritual Struggle and Spiritual
Growth
Spiritual Growth (STS – Growth) n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender -.083 -.088 -.093+ -.093+
Race/Ethnicity -.142** -.118* -.117* -.118*
Education .134* .141** .139** .139**
Marital Status .266*** .258*** .246*** .246***
Spiritual Struggle .149** .204*** .222**
Experiential Avoidance (General) -.106+ -.097
Spiritual Struggle x Experiential -.035 Avoidance
R2 .124*** .145*** .153*** .154***
ΔR2 .124*** .022** .008+ .001
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 149
Table 56: Experiential Avoidance (General) Moderating Spiritual Struggle and Spiritual
Decline
Spiritual Decline (STS – decline) n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender -.012 -.028 -.026 -.026
Race/Ethnicity -.120* -.045 -.046 -.046
Education -.029 -.006 -.006 -.006
Marital Status -.079 -.104* -.100+ -.100+
Spiritual Struggle .462*** .445*** .459***
Experiential Avoidance (General) .033 .039
Spiritual Struggle x Experiential -.026 Avoidance
R2 .022 .230*** .231*** .231***
ΔR2 .022 .208*** .001 .138
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 150
Table 57: Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggle and
Anxiety
Anxiety n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender -.034 -.034 -.035 -.046
Race/Ethnicity -.143* -.131* -.169*** -.159**
Education .083 .131* .157** .164**
Marital Status -.049 -.069 -.065 -.074
Spiritual Struggle .373*** .326*** .260***
Experiential Avoidance (Struggle .242*** .187*** Specific)
Spiritual Struggle x Experiential .210*** Avoidance
R2 .034* .171*** .224*** .259***
ΔR2 .034 .137*** .054*** .035***
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 151
Table 58: Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggle and
Depression
Depression n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender -.029 -.029 -.030 -.036
Race/Ethnicity -.147* -.132* -.163** -.157**
Education .037 .096+ .118* .122*
Marital Status -.073 -.099+ -.095+ -.101*
Spiritual Struggle .465*** .427*** .390***
Experiential Avoidance (Struggle .196*** .165** Specific )
Spiritual Struggle x Experiential .117* Avoidance
R2 .031+ .244*** .279*** .290***
ΔR2 .031 .213*** .035*** .011*
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 152
Table 59: Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggle and
Somatic Symptoms
Somatic Symptoms n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender -.130* -.130* -.131** -.135**
Race/Ethnicity -.127* -.111* .129* -.125*
Education .074 .132** .144** .147**
Marital Status .123* .098+ .100+ .096+
Spiritual Struggle .456*** .434*** .406***
Experiential Avoidance (Struggle .111* .088 Specific)
Spiritual Struggle x Experiential .089 Avoidance
R2 .062*** .266*** .277*** .284***
ΔR2 .062 .204*** .011* .006
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 153
Table 60: Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggle and
Functional Difficulty with Symptoms
PHQ – Functional Difficulty n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender -152** -.154** -.156** -.164**
Race/Ethnicity -.001 .012 -.012 -.009
Education .108+ .140* .163** .165**
Marital Status -.050 -.064 -.064 -.069
Spiritual Struggle .239*** .204*** .147*
Experiential Avoidance (Struggle .184** .136* Specific)
Spiritual Struggle x Experiential .178** Avoidance
R2 .034* .090*** .121*** .146***
ΔR2 .034 .056*** .031** .025**
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 154
Table 61: Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggle and
Values-consistent Living
Values-consistent living n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender .033 .033 .034 .030
Race/Ethnicity .099+ .097+ .121* .124*
Education -.122* -.131* -.148** -.146*
Marital Status .207*** .211*** .209*** .206***
Spiritual Struggle -.072 -.043 -.064
Experiential Avoidance (Struggle -.149** -.166** Specific)
Spiritual Struggle x Experiential .066 Avoidance
R2 .067*** .072*** .093*** .096***
ΔR2 .067 .005 .020* .003
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 155
Table 62: Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggle and
Positive Mood
Positive Mood (PANAS – Positive) n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender .108+ .108+ .107+ .113*
Race/Ethnicity .067 .070 .058 .052
Education -.200*** -.191*** -.183** -.187***
Marital Status .197*** .193*** .194*** .199***
Spiritual Struggle .073 .059 .096
Experiential Avoidance (Struggle .072 .103+ Specific)
Spiritual Struggle x Experiential -.119+ Avoidance
R2 .086*** .091*** .096*** .107***
ΔR2 .086 .005 .219 .057+
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 156
Table 63: Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggle and
Negative Mood
Negative Mood (PANAS – Negative) n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender .028 .028 .027 .020
Race/Ethnicity .004 .019 -.023 -.016
Education -.093 -.037 -.008 -.003
Marital Status .044 .019 .024 .018
Spiritual Struggle .446*** .395*** .351***
Experiential Avoidance (Struggle .262*** .225*** Specific)
Spiritual Struggle x Experiential .140* Avoidance
R2 .010 .206*** .268*** .284***
ΔR2 .010 .195*** .063*** .016*
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 157
Table 64: Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggle and
Goal Difficulties
Goal Difficulties (DERS – Goals) n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender .010 .009 .008 .002
Race/Ethnicity .086 .100+ .042 .048
Education -.101+ -.050 -.010 -.006
Marital Status .095 .072 .079 .074
Spiritual Struggle .405*** .335*** .300***
Experiential Avoidance (Struggle .360*** .331*** Specific)
Spiritual Struggle x Experiential .110* Avoidance
R2 .028+ .189*** .307*** .317***
ΔR2 .028 .161*** .118*** .010*
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 158
Table 65: Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggle and
Impulse Difficulties
Impulse Difficulties (DERS – Impulse) n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender .074 .073 .072 .064
Race/Ethnicity .158** .172*** .117* .125**
Education -.226*** -.176*** -.138** -.132**
Marital Status .098 .076 .082+ .075
Spiritual Struggle .397*** .331*** .278***
Experiential Avoidance (Struggle .340*** .296*** Specific)
Spiritual Struggle x Experiential .167*** Avoidance
R2 .096*** .251*** .357*** .379***
ΔR2 .096*** .155*** .106*** .022***
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 159
Table 66: Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggle and
Emotion Regulation Strategy Difficulties
Emotion Regulation Strategy Difficulties (DERS – Strategies) n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender .012 .012 .011 .004
Race/Ethnicity .064 .079 .033 .040
Education -.162** -.103* -.071 -.066
Marital Status .021 -.005 .000 -.005
Spiritual Struggle .467*** .411*** .372***
Experiential Avoidance (Struggle .288*** .255*** Specific)
Spiritual Struggle x Experiential .124* Avoidance
R2 .033* .247*** .323*** .335***
ΔR2 .033 .214*** .076*** .012*
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 160
Table 67: Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggle and
Spiritual Well-being
Spiritual Well-being (FACIT) n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender .013 .013 .013 .016
Race/Ethnicity .125* .118* .135* .132*
Education -.131* -.157** -.169** -.171**
Marital Status .294*** .305*** .303*** .306***
Spiritual Struggle -.206*** -.185*** -.167**
Experiential Avoidance (Struggle -.107+ -.092 Specific)
Spiritual Struggle x Experiential -.057 Avoidance
R2 .119*** .160*** .171*** .173***
ΔR2 .119 .042*** .010+ .342
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 161
Table 68: Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggle and
Spiritual Growth
Spiritual Growth (STS – Growth) n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender -.100+ -.100+ -.101+ -.098+
Race/Ethnicity .135* .140* .094+ .092+
Education -.128* -.109* -.078 -.079
Marital Status .271*** .263*** .268*** .270***
Spiritual Struggle .145** .089+ .103+
Experiential Avoidance (Struggle .286*** .297*** Specific)
Spiritual Struggle x Experiential -.044 Avoidance
R2 .126*** .147*** .221*** .223***
ΔR2 .126 .021** .075*** .002
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 162
Table 69: Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggle and
Spiritual Decline
Spiritual Decline (STS – decline) n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender -.023 -.023 -.022 -.019
Race/Ethnicity -.012 .004 .024 .021
Education -.083 -.023 -.037 -.039
Marital Status -.090 -.116* -.118* -.115*
Spiritual Struggle .474*** .499*** .520***
Experiential Avoidance (Struggle -.127* -.109 Specific)
Spiritual Struggle x Experiential -.067 Avoidance
R2 .016 .238*** .252*** .256***
ΔR2 .016 .221*** .015* .004
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 163
Table 70: Mindfulness Moderating Spiritual Struggle and Anxiety
Anxiety n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender -.008 -.021 -.018 -.014
Race/Ethnicity .060 .120* .104+ .105+
Education -.138 -.120* -.127* -.125*
Marital Status -.043 -.063 -.064 -.066
Spiritual Struggle .370*** .378*** .384***
Mindfulness -.117* -.102+
Spiritual Struggle x Mindfulness -.039
R2 .027+ .160*** .173*** .175***
ΔR2 .027 .133*** .013* .001
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 164
Table 71: Mindfulness Moderating Spiritual Struggle and Depression
Depression n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender -.019 -.035 -.032 -.031
Race/Ethnicity .023 .097+ .083 .083
Education -.141* -.119* -.125* -.125*
Marital Status -.086 -.110* .111* -.111*
Spiritual Struggle .458*** .465*** .465***
Mindfulness -.110* -.108+
Spiritual Struggle x Mindfulness -.005
R2 .029+ .233*** .245*** .245***
ΔR2 .029 .204*** .021* .000
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 165
Table 72: Mindfulness Moderating Spiritual Struggle and Somatic Symptoms
Somatic Symptoms n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender -.105+ -.121* -.121* -.124*
Race/Ethnicity .044 .118* .117* .117*
Education -.130* -.107* -.108* -.109*
Marital Status .130* .105* .105* .106*
Spiritual Struggle .461*** .462*** .459***
Mindfulness -.008 -.016
Spiritual Struggle x Mindfulness .021
R2 .053** .260*** .260*** .260***
ΔR2 .053 .207*** .024 .143
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 166
Table 73: Mindfulness Moderating Spiritual Struggle and Functional Difficulty with
Symptoms
PHQ – Functional Difficulty n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender -.133* -.142* -.142* -.146*
Race/Ethnicity .084 .127* .131* .131*
Education -.023 -.006 -.005 -.005
Marital Status -.013 -.029 -.028 -.027
Spiritual Struggle .244*** .241*** .237***
Mindfulness .037 .025
Spiritual Struggle x Mindfulness .028
R2 .026+ .083*** .085*** .085***
ΔR2 .026 .057*** .001 .001
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 167
Table 74: Mindfulness Moderating Spiritual Struggle and Values-consistent Living
Values-consistent living n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender -001 .002 -.003 -.011
Race/Ethnicity -.122* -.136* -.114* -.115*
Education .102+ .098+ .107+ .104+
Marital Status .193*** .197*** .199*** .203***
Spiritual Struggle -.086 -.097+ -.107+
Mindfulness .167** .141*
Spiritual Struggle x Mindfulness .067
R2 .064*** .071*** .098*** .102***
ΔR2 .064 .007 .027** .004
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 168
Table 75: Mindfulness Moderating Spiritual Struggle and Positive Mood
Positive Mood (PANAS – Positive) n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender .096+ .094+ .089 .083
Race/Ethnicity -.186*** -.175** -.153** -.154**
Education .062 .065 .075 .072
Marital Status .216*** .212*** .214*** .217***
Spiritual Struggle .068 .057 .049
Mindfulness .170** .149*
Spiritual Struggle x Mindfulness .054
R2 .086*** .091*** .119*** .121***
ΔR2 .086 .004 .028** .002
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 169
Table 76: Mindfulness Moderating Spiritual Struggle and Negative Mood
Negative Mood (PANAS – Negative) n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender .049 .033 .034 .044
Race/Ethnicity -.113+ -.038 -.046 -.045
Education .000 .023 .019 .024
Marital Status .054 .029 .029 .024
Spiritual Struggle .460*** .464*** .467***
Mindfulness -.060 -.028
Spiritual Struggle x Mindfulness -.082
R2 .016 .222*** .226*** .231***
ΔR2 .061 .206*** .004 .005
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 170
Table 77: Mindfulness Moderating Spiritual Struggle and Goal Difficulties
Goal Difficulties (DERS – Goals) n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender .026 .021 .011 .005
Race/Ethnicity -.111+ -.046 -.041 -.041
Education .092 .111* .114* .111*
Marital Status .089 .068 .068 .071
Spiritual Struggle .398*** .395*** .388***
Mindfulness .044 .025
Spiritual Struggle x Mindfulness .049
R2 .031+ .185*** .187*** .188***
ΔR2 .031 .154*** .002 .002
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 171
Table 78: Mindfulness Moderating Spiritual Struggle and Impulse Difficulties
Impulse Difficulties (DERS – Impulse) n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender .083 .069 .067 .062
Race/Ethnicity -.239*** -.175*** -.165** -.165**
Education .139* .158** .163*** .161**
Marital Status .106+ .085+ .085+ .088+
Spiritual Struggle .395*** .390*** .384***
Mindfulness .077 .061
Spiritual Struggle x Mindfulness .042
R2 .099*** .251*** .257*** .258***
ΔR2 .099 .152*** .006 .001
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 172
Table 79: Mindfulness Moderating Spiritual Struggle and Emotion Regulation Strategy
Difficulties
Emotion Regulation Strategy Difficulties (DERS – Strategies) n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender .014 -.002 -.003 -.003
Race/Ethnicity -.178** -.104* -.101+ -.101+
Education .062 .084+ .086+ .086+
Marital Status .024 .000 .000 .000
Spiritual Struggle .456*** .454*** .454***
Mindfulness .028 .028
Spiritual Struggle x Mindfulness .001
R2 .039* .241*** .242*** .242***
ΔR2 .039 .202*** .001 .000
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 173
Table 80: Mindfulness Moderating Spiritual Struggle and Spiritual Well-being
Spiritual Well-being (FACIT) n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender -.014 -.006 -.013 -.017
Race/Ethnicity -.130* -.165** -.134* -.134*
Education .123* .112* .126* .124*
Marital Status .281 .292*** .294*** .297***
Spiritual Struggle -.219*** -.234*** -.240***
Mindfulness .242*** .226***
Spiritual Struggle x Mindfulness .041
R2 .113*** .160*** .217*** .218***
ΔR2 .113*** .046*** .057*** .001
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 174
Table 81: Mindfulness Moderating Spiritual Struggle and Spiritual Growth
Spiritual Growth (STS – Growth) n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender -.083 -.088 -.090+ -.096+
Race/Ethnicity -.142** -.118* -.110* -.110*
Education .134* .141** .145** .142**
Marital Status .266*** .258*** .258*** .262***
Spiritual Struggle .149** .145** .138*
Mindfulness .066 .046
Spiritual Struggle x Mindfulness .051
R2 .124*** .145*** .150*** .152***
ΔR2 .124*** .022** .004 .002
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 175
Table 82: Mindfulness Moderating Spiritual Struggle and Spiritual Decline
Spiritual Decline (STS – decline) n = 307
Step 1 Step 2 Step 3 Step 4
β β β β
Gender -.012 -.028 -.030 -.025
Race/Ethnicity -.120* -.045 -.033 -.033
Education -.029 -.006 -.001 .001
Marital Status -.079 -.104* -.103* -.106*
Spiritual Struggle .462*** .456*** .463***
Mindfulness .091+ .108+
Spiritual Struggle x Mindfulness -.042
R2 .022 .230*** .238*** .239***
ΔR2 .022 .208*** .008+ .001
Note. Regression weights are standardized. + p < .10, * p < .05, ** p < .01, *** p < .001 two-tailed.
Spiritual struggle and adjustment 176
Figure 1: Experiential Avoidance (General) Moderating Spiritual Struggles and Goal
Difficulties
9
8
7
6 Low EA (General) 5 High EA (General) Goal Difficulties
4
3
2 Low Spiritual Struggle High Spiritual Struggle
Spiritual struggle and adjustment 177
Figure 2: Experiential Avoidance (General) Moderating Spiritual Struggles and Impulse
Difficulties
6
5
4
3 Low EA (General) High EA (General) 2 Impulse Difficulties
1
0 Low Spiritual Struggle High Spiritual Struggle
Spiritual struggle and adjustment 178
Figure 3: Experiential Avoidance (General) Moderating Spiritual Struggles and Emotion
Regulation Strategy Difficulties
9
8
7
6 Low EA (General) 5 High EA (General)
4
3
Emotion Regulation Strategy Difficulties Strategy Regulation Emotion 2 Low Spiritual Struggle High Spiritual Struggle
Spiritual struggle and adjustment 179
Figure 4: Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggles and
Anxiety
18 17 16 15
14 Low EA (Struggle)
Anxiety 13 High EA (Struggle) 12 11 10 9 Low Spiritual Struggle High Spiritual Struggle
Spiritual struggle and adjustment 180
Figure 5: Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggles and
Depression
20
18
16
Low EA (Struggle) 14 High EA (Struggle) Depression 12
10
8 Low Spiritual Struggle High Spiritual Struggle
Spiritual struggle and adjustment 181
Figure 6: Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggles and
Functional Difficulty with Symptoms
2.5
2
1.5 Low EA (Struggle) High EA (Struggle) 1
Difficulty with Symptoms with Difficulty 0.5
0 Low Spiritual Struggle High Spiritual Struggle
Spiritual struggle and adjustment 182
Figure 7: Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggles and
Positive Mood
2.9
2.7
2.5
2.3 Low EA (Struggle) High EA (Struggle) 2.1 Positive Mood Positive
1.9
1.7
1.5 Low Spiritual Struggle High Spiritual Struggle
Spiritual struggle and adjustment 183
Figure 8: Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggles and
Negative Mood
3
2.5
2 Low EA (Struggle)
High EA (Struggle)
Negative Mood Negative 1.5
1
0.5 Low Spiritual Struggle High Spiritual Struggle
Spiritual struggle and adjustment 184
Figure 9: Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggles and
Goal Difficulties
12
11
10
9
8 Low EA (Struggle) 7 High EA (Struggle) 6 Goal Difficulties 5
4
3
2 Low Spiritual Struggle High Spiritual Struggle
Spiritual struggle and adjustment 185
Figure 10: Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggles and
Impulse Difficulties
8
7
6
5 Low EA (Struggle) 4 High EA (Struggle) 3 Impulse Difficulties 2
1
0 Low Spiritual Struggle High Spiritual Struggle
Spiritual struggle and adjustment 186
Figure 11: Experiential Avoidance (Struggle Specific) Moderating Spiritual Struggles and
Emotion Regulation Strategy Difficulties
11
10
9
8 Low EA (Struggle) 7 High EA (Struggle) 6
5
4 Emotion Regulation Strategy Difficulties Strategy Regulation Emotion
3 Low Spiritual Struggle High Spiritual Struggle