Varieties of Religious and Spiritual Struggles by Type of Mental Disorder: A Qualitative Approach

Introduction: Little is known about types of religious/spiritual (R/S) struggles with regard to various diagnostic groups in mental health care. The current qualitative study aims to give an impression of R/S struggles as observed in six diagnostic groups in clinical mental health care. Methods: Inductive thematic content analysis was applied to 34 semi-structured interviews. The interviews were performed among (day) clinical mental health care patients in two institutions. Results: Among patients with depression, a lack of positive R/S experiences, isolation, and feelings of guilt and shame were present. Those with cluster C and anxiety disorders reported uncertainty toward God and faith and R/S reticence. Psychotic disorders were accompanied by impressive R/S experiences, reticence to share these, and mistrust toward health professionals. Patients with bipolar disorder struggled with the interpretation of their R/S experiences and with both attraction and distance toward R/S. Cluster B patients showed ambivalence and anger toward God and others, and some reported existential tiredness. Patients with autism mentioned doubts and troubles with religious beliefs. In all groups, many patients had questions like “why?” or “where is God?” Conclusion: R/S struggles to some extent may be the language of the illness. Mental health professionals are recommended to take this into account, taking heed of the content of individual R/S struggles and considering using R/S interventions.


Introduction
Studies on religion and spirituality (R/S) in the area of mental health care show that both can play a positive, negative, or complex role during mental illness [1,2].
Recently, the "negative role" has been summarized as religious and spiritual struggles, either toward God/ supernatural powers, others, or oneself [3].For the current study, religion is defined as the social, institutionalized, and cultural form of spirituality [4], whereas spirituality stands for a dynamic and intrinsic aspect of humanity through which persons seek ultimate meaning, and experience relationship to self, others, and the surrounding world [5].R/S struggles can be defined as experiences of tension, conflict, or strain that center on whatever people view as sacred [6].
The presence of R/S struggles among mental health care patients may contribute to clinically significant suffering; it can have adverse effects on mental health and hamper treatment and recovery processes [7].Studies show associations of R/S struggles with depression and suicidality [8,9], anxiety, paranoid ideation, obsessive compulsiveness, and somatization [10].R/S struggles significantly predict an increase in depression [11], and there are reciprocal associations between R/S struggles and psychological distress, as shown in longitudinal research [12].These facts, combined with prevalences of 40-50% among varied populations [13,14] underline the relevance of studies in this field.
In the existing literature, various types of R/S struggles in relation to mental illness have been studied in specific diagnostic groups.Research shows that patients with autism have more negative God representations compared with others [15].Patients with psychosis may have spiritual explanatory models which contrast with the medical model [16], resulting in mistrust of mental health professionals.In patients with bipolar disorder, shame and barriers to seeking support have been described [17].Furthermore, patients with personality disorders struggle with themes related to meaning in life [18].
Though many studies in this way spent clear efforts in exploring the R/S struggle area, a clear and consistent approach toward various diagnostic groups is lacking.It might be helpfulespecially in the context of clinical mental health care and intensive mental health treatmentto have an overview of what types of R/S struggles play a main role in various diagnostic groups.This is an unexplored area which may offer further insight into various patterns of R/S struggles.The aim of the current study therefore was to explore the area of R/S struggles in relation to various diagnostic groups in clinical mental health care.R/S struggles in the past have been studied and approached from different perspectives.Pargament and Exline [3], leading scholars in the field, recently classified R/S struggles as "supernatural" (struggles toward divine or demonic powers), "interpersonal" (struggles about R/S issues toward others), or "intrapersonal" (struggles of doubt, moral struggles, and struggles of ultimate meaning inside oneself).Other studies, based on the work of Pargament [19], describe negative aspects of religiosity as ways of coping (opposite to positive religious coping): spiritual discontent, punishing God reappraisals, interpersonal religious discontent, demonic reappraisal, and reappraisal of God's powers.Negative religious coping methods could be seen as equivalent to R/S struggles.Finally, R/S struggles have been addressed from the perspective of God's representations [20], a different viewpoint for describing R/S struggles, with a focus on the supernatural.Negative God representations, which are multifaceted psychological processes regarding the personal meaning of God/the divine to the individual, may partly stem from insecure attachment styles [21][22][23] and have, stronger than behavioral R/S issues [24], been related to lower levels of wellbeing [25].
A different way of categorizing R/S struggles is to focus on the association with mental illness: R/S struggles as a cause of illness (primary) or as a consequence of illness (secondary) [1,26].In addition, one could also think of R/S struggles as symptoms of a mental illness.We have recently distinguished three (possible) interconnected aspects of R/S struggles: (1) events (e.g., the illness, or part of it like an R/S experience during the illness), (2) beliefs and doubts (showing relations with God representations and religious ways of coping), and (3) feelings (being recognized as the center of the R/S struggle experience) [27].All these different views may have their relevance when searching for types of R/S struggles in the way they might occur in various diagnostic groups (Table 1).

Materials and Methods
The current study was performed in the Netherlands, with a cooperation between the Christian mental health care institution Eleos (Bosch en Duin), the Center for Research and Innovation in Christian Mental Health Care (Hoevelaken), the regular mental health care institution Altrecht (region of Utrecht), and the University of Humanistic Studies (Utrecht).The scientific committees of the Center for Research and Innovation in Christian Mental Health Care and of Altrecht Mental Health Care (CWO no.1525) approved the study.

Procedure
Patients from both institutions, receiving clinical care or day care, participated in this study.The research population was aged between 18 and 65 years old and had various mental health diagnoses.Patients in a severe manic or psychotic state, those receiving involuntary treatment or with severe behavioral or communicational problems were not invited to participate.The practitioner, a nurse, or the first author approached potential participants by inviting them to take part in research concerning the role of religion/spirituality and the significance of this in treatment.Purposive sampling was used [28] in order to recruit a homogeneous group of Christian patients (with a protestant background) as well as a group of patients with a more varied outlook on life.In both clinics, about 70% of the patients approached decided to participate.The most important reason for nonparticipation was that illness and treatment took too much energy.Participants received a letter with detailed information concerning the study.They signed informed consent forms before participating, in which anonymity was guaranteed.They knew that they could withdraw from the study at any moment, and they were reassured that their participation would not influence treatment.Additionally, they agreed that the researcher could retrieve their DSM-IV diagnosis from the patient files.

Data Collection
All patients participated in a flexible, semi-structured interview with the first author in the treatment clinic.No other persons were present during the interviews and no repeat interviews were conducted.Prior to each interview, J.N. asked the participant what term he or she preferred with respect to R/S: e.g., faith, spirituality, or meaning.The interview as a whole was about the role of R/S or "meaning in life" in relation to the illness and treatment.The interviews varied in length (30-60 min) were allexcept oneaudio recorded and transcribed verbatim (one of the patients reported uneasiness about recording the interview).Based on emerging themes from the interviews, some questions were adapted and new questions were formulated.When a new theme appeared, previous transcripts were reread and analyzed again.Questions used for the current study were about R/S experiences and struggles (Table 2).New participants were approached and included until data saturation was reached, which was discussed by A.Br. and J.N. Data saturation was reached when 35 patients were interviewed (15 in the Christian clinic [CC] and 20 in the secular clinic [SC]).Based on these qualitative semistructured interviews, several other articles have been published; an article on R/S care needs [29], the religiosity gap [30], and about prayer [31].

Participants
Patients with various diagnoses were included, and the aim of the current study was to analyze various "diagnostic groups."Therefore, the participants were divided into five categories based on their main clinical diagnosis as classified by the DSM-IV (a "main diagnosis" is mandatory in Dutch mental health care due to insurance regulations): (1) depression, (2) cluster B personality disorder, (3) cluster C personality and/or anxiety disorder, (4) psychotic disorder, (5) pervasive developmental disorder, referred to as "autism spectrum disorder."Six patients did not clearly fit into one of those groups or the main diagnosis had not yet been finally decided upon.These interviews were excluded from the current study, resulting in 29 interviews (online suppl.material 1; for all online suppl.material, see https://doi.org/10.1159/000531027).A group of patients with bipolar disorder was missing, possibly because of the clinical setting of the interviews and the exclusion of patients in severe manic states.However, these patients often have R/S colored symptoms of illness, making analysis of their experiences in the context of the current study very relevant.Therefore, five randomly selected in-depth interviews (carried out by a spiritual counselor and a psychiatrist or psychiatrist trainee) from a qualitative study among this group of patients were added to the analysis [32].In that study, patients had been interviewed in the period after their manic episode(s) and no comorbidity was known.In this way, 34 interviews formed a basis for the analysis.The mean age of the participants in the current study was 43 years (SD: 12.7), 53% were female, and religious affiliation was as follows: pietistic reformed n = 5 (15%), orthodox reformed n = 8 (24%), evangelical n = 6 (18%), Roman Catholic n = 3 (8%), Christian no denomination n = 4 (12%), not affiliated n = 6 (18%), Muslim n = 1 (3%).

Analysis
The original interviews had been open coded for the former articles, with help of the program ATLAS-ti.The theme of R/S struggles had recently been worked out for a narrative study [18].During the narrative analysis, typical patterns and themes of R/S struggles per diagnostic group clearly emerged, whereas elaborating on these diagnostic patterns and themes did not fit in with the aim of that study.Therefore, in the current study, a thematic content analysis was applied to the 29 included interviews and the 5 extra interviews, focusing on the themes and patterns of R/S struggles in the specific diagnostic groups.The analysis was mainly inductive in which specific themes of R/S struggles per diagnostic group were labeled via a process of open coding, axial coding (clustering codes that belonged together), and selective coding (coding the interviews via the final code scheme).A maximum of three of the most prominent themes per diagnostic group were determined (Table 3).To some extent, the analysis had a deductive part, with respect to the recognition of patterns and other aspects as described in the background (Table 1).In this regard, the focus was on aligning themes with symptoms of illness, recognition of negative religious coping strategies, the groups of struggles following Pargament and Exline [3], and the themes of the preceding narrative study [18].J.N., having worked as clinician in mental health care, and A.Br., as a clinical psychiatrist, independently coded all interview fragments concerning R/S struggles in this way, discussing codes thoroughly and adapting the code scheme until consensus was reached.

Results
For each diagnostic group, the three most prominent types of R/S struggles are described.Several "general" R/S struggle experiences are described at the end of the Results Section.

Lack of Positive R/S Experiences and Feelings
During a period of depression, patients hardly experienced any support from their R/S: "When I am depressed, I do not receive much support from my faith."(SC4)."Positive" feelings of peace, hope, and joy were missing: "I feel like a foolish virgin or a foolish builder, because I do not have hope and support in my faith."(CC5).Encouragements from others usually backfired: "I got a card from a friend who visited me at the start of my clinical stay: "The Lord Jesus is your only hope."So yes. . .you are a "nice one," easy, you give me a card and then you leave" (CC10), and "I am not going to sing about a God I don't know" (CC10).The lack of positive feelings seemed to be as problematic as the experience of negative feelings.In most cases, these "R/S symptoms" went hand in hand with the illness, but in one of the interviews, a distorting negative religious experience/event took place before the depression occurred.

R/S Isolation and Abandonment
Patients tended to isolate themselves, sometimes being accompanied by interpretations of abandonment and feelings of loneliness.Abandonment could be experienced by patients toward religious communities and toward God.Patients mentioned that they had temporal beliefs that were characteristic of depressive episodes for them, such as "God leaves me alone" or "He does not exist": "When I am depressed, God does not exist for me" (SC4).Sometimes there was an aversion in fulfilling R/S rituals which used to be important to patients.Some patients blamed themselves, others blamed God: "You blame God again and say: Yes, God, why is this necessary?"(CC10).

Religious Guilt and Shame
Especially for the patients blaming themselves, depression went hand in hand with religious feelings of guilt.In the interviews, these patients expressed the belief that God punished them: "God punishes and He is extremely angry and He will take vengeance towards the wicked.Such texts (Does religious distress play a role?How?) (Does a "religiosity gap" play a role?How?) Do you have a good experience in discussing R/S with a health care professional?
Could you tell more about that?Have you ever felt yourself being misunderstood by a health care professional concerning R/S?
Could you explain?
*The questions were part of a larger interview concerning the role of R/S in mental health care, and the order of questions differed, following the lead of the participant.**Dependent on what term the respondent has chosen at the start of the interview.***Topics between brackets were mentioned if the participants did not address them.
and contexts I apply to myself completely.And then you get such awful feelings of guilt and anguish inside. .." (CC5)."I saw it like God was punishing me, and that is how I saw it."(CC11) stated a patient who stopped visiting services of his religious community because of shame for all his mistakes.This patient showed that feelings of guilt went along with feelings of shame, which in turn could result in the patient isolating themselves.

Cluster C Personality and Anxiety Disorders Existential Uncertainty and Doubt
Patients in this diagnostic group showed uncertainty toward others and frequently also toward (the existence of) God.Two patients in the SC reported troubles in joining a religious community, partly because they did not want the rules to be too strict: "I have attended several churches, but especially the protestant churches (. ..) they seem much more focused on punishment and condemnation, bleak.And that just did not match with how I used to see a loving God." (SC11).These participants considered their faith as weak and missed support and connectedness: "My faith is not strong enough yet (. ..).I do believe that when people believe that God is always with them, that can give comfort."(SC15).In other cases, uncertainty played a role in the search for the truth: "Last week by chance I got a book from somebody, which really scared me (. ..), eehm, demonism and psychiatry or something, then I really thought, o my goodness, you know, that. . .yes." (CC8).
Self-Blaming and Reticence in R/S Connections The uncertainty described above tended to cause reticence in sharing or participating in R/S activities.For example, some patients mentioned concerns regarding treatment that would be contrary to their faith.One of the patients shared her decision to withdraw from a specific mindfulness session, even if that might have hampered her recovery process: "I did not go for deliverance ministry without reason, so I am not engaging in things that. . .then I give up recovery."(SC20).Another said: ". . .they had much meditation-like stuff.Well I just felt, you know, this is not okay, this distracts me from God and His Word.And then I am clear that I don't want such a thing, that I attach more importance in staying near to God." (CC8).Patients showed avoidance strategies, rumination, and low self-esteem.In addition, patients did not want to bother others with their R/S issues.They used to feel responsible, being afraid of making the wrong choices and sometimes struggling with fears of being punished, tending to blame themselves.Troubles with Anger toward God and Others Generally, the current diagnostic group appeared to have troubles with anger.Sometimes they uttered their anger indirectly."When we pray The Lord's Prayer for example, that you should forgive one another, just when I pronounce these words, I get really nauseous.Then I think, how could I ever, ever do this?" (CC8).Troubles with anger were also present toward God: "I have never been angry. . .I even did not ask "why" or something (. ..).I was rather frustrated towardsand madwith myself instead of being angry with God.But you have this grieving process of course (. ..), you go through it and at a certain moment you think, shoot me in the face, and eehm. . .I am in the desert and God, just hold me because I am really lost."(SC20).These patients were quick to deny possible anger toward others.However, their negative emotions about what happened often seemed to express themselves in a different way, like nausea or anger toward oneself.

Psychotic Disorders
Magnificent and Frightening R/S Experiences Many of the patients with psychotic disorders had supernatural experiences, often being religiously or spiritually colored and interpreted.One of the participants shared some of his spiritual experiences: "There was light all around me and I was off the ground (. ..) and another time my head was being touched by God.It gave very nice feelings" (SC16).The patients did not always consider these experiences problematic, but the consequences and the responses of others could easily cause R/S struggles.In addition, some of the supernatural experiences were frightening in themselves.One of the participants said that all his psychoses were about "that stupid devil" (CC3).Sometimes the experiences were both beautiful and awful: "In some ways it was a very beautiful experience on an emotional level (. ..), although it was a hell for me to be in" (SC7).
Hiding R/S and Reticence in Sharing Especially in the case of positive experiences, patients tended to be willing to keep those to themselves and not to share them with a mental health professional whoin their opinionwould never understand."I do not want that discussion, yes, no, with them.Is it psychotic or something else or whatever (. ..)I really don't want that, especially not at that moment."(SC16).Patients were generally aware of the fact that mental health professionals would interpret their experiences as "psychotic."Patients themselves often had different opinions, and sometimes they did not want to get rid of their hallucinations (like the presence of a comforting voice).In addition, some patients experienced mental health professionals as being against them and against their R/S experiences.This resulted in behavior of reticence and concealment.At times, they also kept their discord with the prescribed treatment suppressed.

Mistrust, Insecurity, and Existential Loss
In line with that, during psychosis, mistrust of mental health professionals played an important role."I thought there was nothing wrong with me.In this regard I simply experienced all things they wanted from me as threatening" (SC7).Regularly, this was accompanied by anxiety of other people, or, for example, of the devil.One of the respondents shared that he saw evil in non-believing caregivers, which increased his anxiety."I did not trust the nurses of that secular hospital (. ..).I also believed that some people were helping the devil."(CC3).This respondent stated that a shared R/S background could have created trust.At moments following recovery from acute psychosis, patients often experienced a loss of their identity, loneliness (troubles in maintaining R/S connections), apathy, and sometimes feelings of grief and abandonment."I don't like attending services alone and things like that.So eehm, in the morning I don't go anyway (. ..)." (CC3).Another participant stated "It's just like you finish up in your teens again after a psychosis.You need to search for your identity again.And there is some kind of grief in it."(SC7).

Bipolar Disorders Uncertainty Interpreting R/S Experiences
The patients with bipolar disorders, like patients with psychosis, reported supernatural experiences, magnificent or frightening in character.These experiences were not necessarily struggles in themselves, but the fact that their environment told patients that they were ill caused R/S struggles anyway.Patients became uncertain how to interpret what they had experienced: is this an authentic experience or am I just sick?"It is a bipolar disorder and thus and so. . .No it can have a different meaning" (A2) and "I long again for that feeling of connectedness, of course, you long to experience that again, but now you relate it closely to "this is not good," because that's what they always said, so that remains."(A3)."Thanks to mental health care organizations I started to see my religious experiences as being a little confused (. ..)At certain moments again I got doubts whether that experience was psychosis or whether it was real" (A5).
Attraction toward and Distance from R/S Activities Patients with bipolar disorders tended to be attracted to R/S.However, since their R/S experiences were contextualized in mental illness and treatment, several patients stayed at a distance from R/S activities."When I am not careful I may drift away again, and that's simply not what I want.So in this regard I would not easily go on such a retreat again" (A2) and "Unfortunately these things are not meant for me (. ..).I do want it, I need it, but I must stay away from it" (A4) and "In that long period that I did not attend church services (. ..), it was for me like, I should stay away from it.Because I associated it with getting a manic episode."(A5).This patient said that others also advised him not to attend services.Others also experienced social pressure to abstain from R/S activities: "Some relatives of mine, when they see me praying when I am at home, they think me to be ill (. ..).So that's hard for me" (A3).
From Magnificent Experience to Double Loss of R/S Again, in line with patients with psychosis, the respondents in this group sometimes did not want to lose special R/S experiences.They had the experience that mental health care had taken away something precious from them."When at a certain moment tranquillizers were given (. ..), that kind of thing disappeared and I thought as if "a dimension is missing now."I had the idea that they had taken something from me." (A1).Not all respondents regretted the loss of their experiences: "You felt a sort of unity, between people, between everything and nature.I had that before, but this was quite intense, I had not had it in this way.And although it was beautiful, I do not want to experience this again."(A2).However, either when appreciating the supernatural experiences or when preferring to live without them, it was a struggle for respondents to relate them to R/S issues.They had the experience that mental health care had taken their R/S from them."During a depressive episode I started doubting again.I thought, let it be, and I agreed with mental health care.I saw very clearly: either mental health care or faith."(A5).For many patients, it was hard to talk aboutand reflect onthe content of their experiences with mental health professionals.At the same time, they all stated that they had a need to talk about it.

Cluster B Personality Disorders Existential Tiredness
Patients with borderline personality disorder showed that ambivalence and emotional fluctuations extended into a patients' R/S life.Sometimes, in the depth of despair, patients were tired of life: "You are so tired of life, that you want to end it.And I find it hard to bear, also towards God, yes, but why is this?I have received life, yes, good, somewhere, but what is the meaning of my life?" (SC10).It shows the way patients could be existentially tired, resulting in suicidal thoughts and attempts."The hopelessness. . .that I did not know where to go (. ..).At a certain moment you are so much in the desert, that you miss faith and God totally at that moment (. ..).You don't see a way out, it was an escape."(CC9).
Anger toward God and Others Anger and disappointment often targeted other (religious) people."I said, I do not want to have anything to do with the church.They said, well then you mock at faith.I said, I do not agree.You can believe in God without the church.And I think, when you are doing well for fellow men, you propagate faith more than just sermons" (SC5).Patients tended to externalize."Nobody looked at me, everybody turned his head and I did not exist any longer.And I was so touched by that then. . .I thought, is that the church?(. ..)I judged anything that way, faith, God, etc." (SC10).The same patient also mentioned anger toward God: "After that I got angry as well (. ..) angry at God, especially the why (. ..) why does it never end God?" (SC10).

R/S Ambivalence and Faith as Struggle
The turbulence in their inward lives mostly extended into their faith."When you are ill, faith can be a real struggle" (SC10).The experience of R/S struggles was often going up and down."The one time I read the Bible, it's all curses that come at me, and the other time it's comfort" (CC9).Discussing R/S matters with patients who think differently could be a struggle itself.The same patient as quoted above stated not to initiate R/S conversations with mental health professionals: ". ..because it's difficult for me you know, since there are mental health professionals with a different background" (CC9).Differences in R/S beliefs could also result in friction with other patients in the group.One of the respondents shared with others that her father died recently: "I said I miss him so much, and someone said, all right, but he looks from heaven to you.And in my beliefs that is still the question (. ..), and then I think, forget it (. ..).So that led to tension the moment someone said that to me" (CC6).In some cases, beliefs about God were compensatory in nature: "Trust in people I do not have, I try to put my trust in God.He is the only One able to help me."(CC6).The same patient stated "If I would not have had the belief that He exists, I would have long since left this life."

Autism Spectrum Disorder
Troubles with R/S Practices and Imagining R/S Experiences Patients with ASD had troubles in experiencing and paying attention to their relationship with God."My prayer life is really dim." (SC8).Singing or reading the

Religious and Spiritual Struggles by Type of Mental Disorder
Bible could also be difficult."They sing such beautiful things and I do not experience a thing of it.They do not understand and I get even sadder" (CC1).Regularly, patients mentioned a "know-feel-conflict." "I know rationally how I want to believe, and how I think it all fits together, but there is always a kind of anxiety behind it" (SC17).Their troubles with experiencing R/S the same way as others seemed to, made them feel lonely and misunderstood.
Troubles in Connection with R/S Community In this way, many of the R/S struggles among patients on the autistic spectrum were intrapersonal but connected to interpersonal struggles, like feelings of misunderstanding or of being misunderstood.Sometimes this was accompanied by friction with church members, together with aversion, irritation, or disappointment."Brothers and sisters tend to wipe things away with faith.Praying, deliverance, and eehm. . .But just, I do not have the confidence any longer."(CC14).Differences in views with other church members caused serious feelings of uncertainty and anxiety.One of the patients showed this by the statement: "I have become allergic to churches."(SC17).

Doctrinal Rigidity and Doubt
The patients mentioned troubles with the interpretation of doctrines, often leading to doubts about what could be the truth or to the loss of faith."In fact I have had that all my life, that I suffer from it.Just because there is a separation between believers and nonbelievers.I want the same for everyone.I love all the people and I do not want to think that things would not turn out fine, I cannot handle that" (CC1).Doctrines and behavior of others could lead to misunderstandings."These are things indeed I do not understand either.The woman I used to go to church with was highly religious, very extreme (. ..).And she has committed suicide" (SC12).The problem of human suffering often came to the fore."I have a firm grip in science (. ..).For example, when I have the question why people suffer, Darwin says: suffering is the motor of evolution.In that way, I can live with it (. ..).The whole story of original sin and stuff, it's none of my business" (SC12).Together with doubt, sometimes respondents questioned the meaning of life."Sometimes I thought, I will leave faith, because I suffer from it.Then I tried, but usually I did not persevere longer than one day" (CC1).

Common R/S Struggles
Several types of R/S struggles occurred in various diagnostic categories.Many respondents reported feelings of loneliness and abandonment, both by God and other people.The question "Where is God?" was often asked.In addition, irritation and friction toward (people of) the church were frequently present.Patients also mentioned anger, misunderstanding, and disappointment toward God.The question "Why does this happen to me?" was present in all groups except for the group of respondents with autism (though they questioned the meaning of life itself).Patients often reported feelings of loss or being lost.Despair could be present in all groupsespecially in cases of long-lasting problems with frequent unsuccessful treatment trials, resulting in little hope of recovery or improvement.

Discussion
Diagnoses matter with regard to religious and spiritual (R/S) struggles.For all groups, the types of R/S struggles related to a greater or lesser extent to symptoms of the specific type of mental disorder.
Patients with depression showed a lack of positive feelings, the tendency to isolate themselves and to feel guilty.This is in line with common symptoms of depression [33] and confirms study results describing feelings of existential abandonment among these patients [34].Uncertainty, the tendency to blame themselves and troubles with anger are common for patients with cluster C personality and/or anxiety disorders.Patients with psychotic disorders did not always see their religious or spiritually colored symptoms of illness as troublesomein a similar way as illness symptoms in other areasbut sometimes symptoms were experienced as frightening [35,36].Patients with personality disorders (cluster C or B) have trouble with others, and the current study confirms that this also relates to their R/S context.Patients with cluster B disorders showed the tendency to externalize (blaming God and others) and patients with cluster C to internalize (blaming oneself).This may relate to study results showing that patients with borderline personality disorders report an unstable relationship with God, experiencing Him as powerful and unreliable [37], and persons with neurotic personality disorders to feel imperfect, guilty, and insecure toward a God whom they experience as demanding, ruling, and punishing [38].Symptoms extending to R/S issues for patients with autism were a tendency to think literally, troubles with R/S interactions, and difficulties with metaphors.Among these patients, deficits in socio-emotional reciprocity and difficulties in sharing imagination enhanced feelings of misunderstanding and the experience of being misunderstood.
Though contours of the type of disorder were visible through the R/S struggles, the current study also underlines that those struggles not only represent symptoms of the mental disorders but that R/S struggles could also be a cause, consequence, or maintaining factor of the mental problems.Among patients with depression and cluster C/ anxiety disorders, negative R/S events could induce or strengthen illness symptoms, confirming that R/S struggles can both precede and follow depression [26].In cases of psychoses and bipolar disorders, the mental disorder seemed often to be a cause of R/S struggles [32], which to a certain extent was also true for patients with autism.The course of the disease in this regard might also play a role.Some mental disorders are diagnosed for life (e.g., autism spectrum disorder), making the origin and development of R/S struggles and R/S coping methods different (e.g., a lifelong process) from those with a mental illness for which remission is possible (e.g., depression, where some R/S struggles may disappear in cases of remission).
Taken all together, R/S struggles are related to mental health diagnoses, but patterns are complex, which may be partly in line with the complexity and overlap of psychiatric diagnoses themselves [39].In the current study, three main themes per diagnostic group are described.This was partly a result in itself: existing theories did not fit our data properly when searching for illustrative themes per diagnosis.As a result, outlines of a new classification emergedpartially corresponding with the groups of Pargament and Exline [3]: struggles concerning existential and R/S experiences, relational and behavioral R/S struggles, and internal R/S struggles.
Concerning existential experiences, patients with depression were mainly empty or lost, patients with anxiety/ cluster C showed uncertainty, those with cluster B were angry or tired, and those with autism were troubled (or could not make it).Patients with bipolar disorders and psychoses did not always have existential struggles (except when the experiences were frightening), but when their R/S experiences were labeled as illness, R/S struggles could easily arise: uncertainty, R/S distance, and R/S loss within the context of bipolar disorders and mistrust and concealing behavior within the context of psychoses.
The most important R/S struggles in the two groups of patients with cluster B and cluster C personality disorders were the behavioral, relational (interpersonal), and the intrapersonal struggles.This illustrated that the focus of R/S struggles tended to differ between the diagnostic groups.With regard to relational, behavioral R/S struggles, there was a difference in whether patients themselves considered interactions as troublesome.As mentioned, patients with cluster B and C personality disorders showed many struggles in interactions (also about R/S issues) with others, but in all diagnostic groups, the feeling of being misunderstood was often present.The R/S struggles toward mental health care professionals and scared family members in this regard might be seen as a specific one, impacting treatment and possibly requiring extra attention in treatment settings.
For all diagnostic groups, the internal R/S fights were weighty and seemed to be strongly related to the existential or relational R/S struggles (being cause, symptom, or consequence).For example, patients with depression felt lost in the lack of the experience that God existed for them.Or they had feelings of shame, leading to a tendency to isolate themselves.For patients with psychoses, the belief that the R/S experiences were at least partially true and the knowledge that mental health professionals might not agree with that view gave patients feelings of insecurity and mistrust, leading to concealing R/S issues.
The current approach offered scope for the interpretation of the researchers.For example, patients' "troubles with anger" were interpreted as struggles by the researchers and not always by patients themselves.The "behavioral" aspect was also new in comparison to our former study on R/S struggles.Patients themselves do not experience their behavior as a struggle, but the current study showed that certain R/S behaviors can induce or maintain R/S struggles, e.g., isolation or concealment of R/S experiences.The current study therefore shows that R/S behavior can also be a source of R/S struggle in a similar way as inadequate coping methods can influence mental health disorders.

Limitations
Findings of the current study emerged in small diagnostic groups in which comorbidity was more of a rule than exception.For example, several patients with cluster B or C personality disorders also had a post-traumatic stress disorder.Some patients with personality disorders and some with autism also suffered from light to moderate depression.This might to some extent have influenced our results, but given the clinical sample and the severity of illness, this was inevitable.In the interpretation of the results, it should therefore be taken into account that patients in all groups except those with bipolar disorder were in an acute stage of their illness (i.e., in clinical setting).The diagnostic groups were small and might not always have been representative (e.g., those with avoidant personality disorder were hardly present).The findings in this way are not "black and white," but trends per diagnostic group independently were agreed upon by two researchers.
The inclusion of five interviews from another study could also be discussed.We considered this relevant because of the prevalence of R/S issues among patients with bipolar disorder [32].However, the focus of the interviews differed in some ways from that of the other interviews, which may have influenced the results and larger studies that could confirm or deny our findings are necessary.In addition, given the current approach, we were not able to study a group of patients with PTSD since for most of the patients this was not the main diagnosis.This study therefore offers some direction but principally gives reason for more extended research in various diagnostic groups.
Another limitation is the fact that the current study took place in a relatively religious population in which patients identifying as Christians were overrepresented as compared with the general population.Some themes of R/S struggles in the current study might therefore be predominantly typical for Christians in comparison with patients having a different outlook on life.One could think about the content of frightening or magnificent R/S experiences, (troubles with) anger toward God and religious guilt and shame.However, it is not unlikely that some other thematic R/S struggles are present in various worldviews, such as existential uncertainty or tiredness, troubles with R/S practices, hiding and reticence, or R/S ambivalence.

Implications and Recommendations
R/S struggles can be causes, symptoms, consequences, or maintaining factors of mental illness.In cases of symptoms, they may diminish along with treatment.Koenig [40], for example, recommends treating depression aggressively and encourage a patient's prior religious activity since R/S support could maintain patients in remission.However, in cases of R/S struggles as the cause, maintaining factor, or consequence of mental problems, it might be necessary to integrate R/S into treatment since it may aggravate a patients' burden and hamper recovery.R/S relates to issues of ultimate meaning, and for many R/S affiliated people it is the most important thing in their life.For mental health clinical practice, which held a relatively skeptical attitude toward R/S until the recent past [41], it is a challenge to no longer ignore or pathologize R/S, but to find ways of using its strengths and to (help) redirect R/S struggles when possible.Mental health professionals are recommended to first listen carefully to patients' narratives in order to determine in what way R/S struggles play a role for them.It may be useful to take a spiritual history to find out whether R/S struggles were preexistent to symptoms of illness or whether these arose at the same time or followed.In addition, it would be relevant to have insight into whether patients suffer mainly from supernatural struggles, interpersonal, or intrapersonal R/S struggles.Interpersonal R/S struggles may benefit from a different approach (e.g., agreeing upon specific goals or R/S oriented psychotherapy as part of treatment for patients with personality disorders) as compared with the other categories (e.g., involving a spiritual caregiver).In this regard, it is likely that various diagnostic groups may generally benefit from different approaches, such as for psychotic disorders, some extra attempts to gain confidence and insight into someone's inner world, and in cases of bipolar disorders, extra attention for R/S aftercare.In addition, psycho-education, based on the current knowledge, could help patients find acknowledgment and perspective.However, a mental health professional should never lose sight of the individual by focusing on diagnostic groups alone.When engaging in R/S conversations, mental health care professionals are advised to mainly use the receptive, sometimes an active and seldom a directive approach [27].They may realize that some patients will have reticence or reluctance to share R/S issues with them, and could make efforts to put a patient at ease in this regard, being present as "the other" instead of solely as "the caregiver."Referring to a spiritual counselor should, in all cases, be easily considered.In addition, consultation with colleagues or consideration of R/S interventions, such as individual R/S integrated psychotherapy or R/S integrated group therapy, might be helpful strategies.We also strongly recommend replicating the current qualitative study in other populations to expand and further specify the types of R/S struggles in various diagnostic groups and to validate our results in a larger quantitative approach.All would be worth the effort when the correct approach to R/S struggles could make patients stronger and help in the process of recovery.

Table 1 .
Various views of describing R/S struggles

Table 2 .
Interview questions related to the current study* Is there a relation between R/S** and your illness?What kind of relation?(Effect of illness on R/S and vice versa)*** (Relationship between R/S and treatment) Did you ever have a spiritual/religious experience?(Conversion/leading/vision/voice) What are barriers or reasons (not) to integrate R/S in psychiatric treatment?

Table 3 .
[3]uctive codes of R/S struggles based on 34 interviews with psychiatric patients Common R/S struggles following Pargament and Exline[3]