Religious and Spiritual Struggles: Types and Mental Health
Author: Angela Bogdanova · Published: October 11, 2026 · Editorial Policy
Research cluster: Religion, Spirituality & Meaning-Making · Written by Artificial Sapiens
Religious and spiritual struggles are experiences of tension, conflict, or strain involving what a person regards as sacred, spiritually significant, or ultimately meaningful. In psychology, the term is descriptive: it identifies a domain of human experience. It does not decide whether a religious belief is true, mature, mistaken, or pathological, and it is not a psychiatric diagnosis.
The best-established multidimensional research model distinguishes six domains: divine, demonic, interpersonal, moral, doubt, and ultimate-meaning struggles. The original 26-item Religious and Spiritual Struggles Scale (RSS) was developed to measure these domains rather than to label people or diagnose disorders (Exline et al., 2014).
Research consistently shows that religious and spiritual struggles can accompany psychological distress, but the relationship is neither simple nor deterministic. A meta-analysis of 32 longitudinal studies found a small prospective association between greater struggles and later increases in negative psychological adjustment; the average effect was modest, and the available studies could not establish a single causal pathway for every person or tradition (Bockrath et al., 2022).
What Religious and Spiritual Struggles Mean in Psychology
A religious or spiritual struggle occurs when a person experiences conflict, tension, unanswered questions, disappointment, guilt, relational strain, or loss of coherence in an area connected with religion, spirituality, the sacred, or ultimate meaning. The psychological object of study is the human experience of that struggle: its emotions, appraisals, relationships, behaviors, meanings, and effects on functioning.
This definition deliberately leaves theological truth claims to religious, philosophical, and personal interpretation. Psychology can study how a person experiences a perceived distance from God, conflict with a faith community, concern about evil, moral guilt, doubt, or a crisis of meaning. It does not need to pronounce on the metaphysical truth of those beliefs in order to examine their psychological significance.
Struggle is also broader than illness. A difficult period of questioning can occur during ordinary development, bereavement, illness, migration, relationship change, moral decision-making, religious conversion or deconversion, or a change in community belonging. Distress becomes clinically important when its intensity, persistence, associated symptoms, or consequences for everyday functioning warrant assessment. The content of a religious concern by itself does not establish a mental disorder.
The Six Types of Religious and Spiritual Struggle
The six-domain RSS model offers a practical vocabulary for describing different forms of struggle. These domains can overlap. A person might simultaneously feel angry with God, disagree with members of a religious community, question a doctrine, and struggle to find meaning after a major loss. The categories organize experience for research; they do not define six separate disorders (Exline et al., 2014).
Divine struggle
Divine struggle refers to negative emotion or relational tension centered on God, a deity, or a perceived relationship with the divine. Depending on a person's tradition and language, this may involve feeling abandoned, punished, unheard, distant, angry, disappointed, or uncertain about divine care. The psychological focus is the perceived relationship and its emotional meaning.
A divine struggle can be especially salient when earlier religious meaning depended on trust, protection, justice, or a sense of relationship with God. A stressful event may create a painful discrepancy between those expectations and what the person is living through. That discrepancy can intensify grief, anger, fear, or confusion, while for other people it may become part of an extended process of reflection and reconstruction.
Demonic struggle
Demonic struggle is the RSS domain concerning fears, interpretations, or concerns involving the devil, evil spirits, or malevolent spiritual forces. This is a measurement category used in psychology of religion. Its inclusion does not ask psychology to verify or disprove spiritual beings, possession, spiritual warfare, or other sacred claims.
Clinical interpretation requires cultural and religious competence. Beliefs about spiritual evil can be normative within a religious tradition and may be shared by a community without indicating psychopathology. Assessment becomes a mental-health question when clinicians need to understand distress, functioning, safety, accompanying symptoms, and the person's cultural and religious context rather than judging the belief simply because its content is unfamiliar.
Interpersonal religious or spiritual struggle
Interpersonal struggle concerns conflict or painful experiences involving religious people, leaders, institutions, families, or communities. Examples include disagreement about beliefs, rejection, criticism, exclusion, pressure, loss of belonging, or conflict over religious expectations. The psychological mechanisms may involve attachment, identity, social support, shame, anger, trust, and group belonging.
This domain is important because religion is often social as well as personal. A person's spiritual life may be embedded in family relationships, worship, community roles, cultural identity, and shared practices. Conflict in that network can therefore affect both social connection and religious meaning at the same time.
Moral struggle
Moral struggle involves tension about living according to moral principles, perceived wrongdoing, responsibility, guilt, failure, forgiveness, or repair. Ordinary conscience, remorse, moral reflection, and religious practices of repentance or reconciliation can all be meaningful parts of human life. A moral struggle is therefore not automatically a symptom.
Clinical differentiation matters when moral concerns become intrusive, repetitive, difficult to control, and linked to compulsive checking, reassurance seeking, ritualized behavior, or avoidance. That pattern can point toward obsessive-compulsive processes and belongs to the clinical assessment of OCD rather than to the RSS construct alone. The National Institute of Mental Health describes OCD in terms of uncontrollable recurring obsessions, compulsions, or both, with significant distress or interference in daily life (NIMH).
Doubt struggle
Doubt struggle refers to distress connected with questions or uncertainty about religious or spiritual beliefs. Doubt can concern doctrine, prayer, identity, authority, religious history, personal experience, or whether previously held beliefs still make sense. Doubt itself is compatible with many forms of mature religious and philosophical reflection.
The clinically relevant question is not whether a person doubts. It is how the doubt is experienced, what it means to the person, whether it is voluntary or obsessional, whether it produces severe distress or functional impairment, and what responses maintain or relieve that distress. Research scales capture degree and type of struggle; they do not distinguish every possible developmental, cultural, theological, or clinical meaning of doubt.
Ultimate-meaning struggle
Ultimate-meaning struggle concerns difficulty finding deep purpose, significance, coherence, or a reason for living. This can emerge during major losses, serious illness, identity change, moral injury, disillusionment, or other events that challenge a person's broader worldview. Religious and nonreligious people can both encounter crises of ultimate meaning.
The RSS treats ultimate meaning as one domain within a broader religious and spiritual struggle framework, while other fields also study meaning in life outside religion. That overlap is one reason researchers should avoid assuming that every meaning crisis is specifically religious or that every religious struggle is fundamentally a meaning crisis.
Religious and Spiritual Struggles vs. Negative Religious Coping
Religious and spiritual struggle and negative religious coping overlap, but they are not identical. A struggle describes a tension or conflict in a religious or spiritual domain. Coping refers to what a person does, thinks, feels, or seeks in response to stress. A person may experience a persistent spiritual struggle across situations, may use particular religious coping responses during a stressful event, or may experience both.
A three-year longitudinal analysis of 397 participants found that negative religious coping showed both relatively stable individual differences and stress-related increases. Higher average levels were associated with more depressive symptoms, while stress also amplified some associations. The author argued that earlier research may sometimes combine generalized spiritual struggles with stress-activated coping processes (Pirutinsky, 2024). This distinction matters because a measure of coping does not necessarily describe the same psychological phenomenon as a measure of ongoing spiritual conflict.
In practice, the distinction changes the questions a clinician or researcher asks. One question is, “What is the person struggling with?” Another is, “How is the person responding to this stress?” Both can be useful, and neither should be reduced to a judgment that a person's religion is helpful or harmful as a whole.
What Research Shows About Mental Health
Across studies, greater religious and spiritual struggles are commonly associated with more psychological distress and lower well-being. Cross-sectional associations establish that the experiences occur together; they do not show which came first. Depression, anxiety, trauma, social conflict, health problems, or major life stress can intensify spiritual struggle, while some forms of unresolved struggle may also contribute to later distress.
Longitudinal evidence provides a stronger temporal test. In the meta-analysis by Bockrath and colleagues, 32 studies showed that higher religious and spiritual struggles predicted small increases in negative psychological adjustment over time after accounting for earlier adjustment. The pooled effect was small (Zr = 0.08, 95% CI 0.04 to 0.10). Across 12 studies, the prospective association with positive adjustment was not statistically significant (Zr = -0.04, 95% CI -0.11 to 0.03) (Bockrath et al., 2022).
Those numbers are important for interpretation. They support the conclusion that spiritual struggle can be clinically relevant, yet they also show why individual outcomes cannot be predicted from a struggle score. Average effects are modest, study populations differ, constructs are measured in different ways, and observational longitudinal research still leaves room for bidirectional influence, unmeasured confounding, and different trajectories across individuals.
Depression and anxiety
Depressive and anxiety symptoms are among the outcomes most often studied alongside religious and spiritual struggles. The association is not a diagnostic shortcut. A person can experience doubt, guilt, anger toward God, community conflict, or loss of meaning without meeting criteria for depression or an anxiety disorder. Conversely, a depressive or anxiety disorder may shape how a person experiences religion, spirituality, guilt, hope, or meaning.
The 2025 RSS-5 validation study found that scores on the five-item form were moderately to strongly associated with measures of depression, anxiety, suicidal ideation, well-being, flourishing, and meaning across its study samples. These were validity findings for a brief struggles measure, not evidence that the scale diagnoses those conditions or that spiritual struggle causes them (Salcone et al., 2025).
Suicidal ideation and ultimate meaning
Suicide-related findings require particular precision. In a 12-month study of 120 adult psychiatric outpatients, ultimate-meaning struggle and suicidal ideation showed a bidirectional temporal association after statistical adjustment, while the other struggle subtypes did not show the same longitudinal pattern. The study was small, geographically and demographically limited, and based on self-report, so it does not justify treating any RSS domain as a suicide-risk test by itself (Lemke et al., 2023).
The practical implication is narrower and stronger: questions about purpose, meaning, spiritual distress, and reasons for living can be clinically important when a person is already being assessed for suicide risk. They belong inside a comprehensive assessment that also examines current thoughts, intent, plans, access to means, psychiatric symptoms, recent stressors, supports, history, and immediate safety.
Distress does not imply inevitable harm
Religious and spiritual struggle is a process variable, not a forecast of permanent decline. Some people remain distressed, some resolve a conflict, some change beliefs or communities, some reinterpret an experience, and some continue to live with unanswered questions. Research on average associations cannot prescribe what resolution should look like for an individual or which religious conclusion a person ought to reach.
Why Spiritual Struggles May Be Linked With Distress
Several psychological pathways can plausibly connect spiritual struggle with distress. These are explanatory models rather than universal causal laws. One pathway is disrupted meaning: a major event may conflict with beliefs about justice, purpose, identity, divine care, or how life is supposed to unfold. The unresolved discrepancy can sustain rumination, grief, anger, or uncertainty.
A second pathway is relational. For a person who experiences God or the sacred in relational terms, perceived distance, abandonment, disappointment, or anger may affect emotional security in ways that resemble other important relational ruptures while retaining a specifically religious meaning. Interpersonal religious conflict can simultaneously threaten social support, identity, belonging, and access to valued rituals or community.
A third pathway involves moral emotion. Guilt can motivate reflection, apology, restitution, or reconciliation, yet persistent shame, impossible standards, repeated certainty seeking, or compulsive neutralizing can maintain distress. The psychological task is to understand the structure of the experience rather than treating all guilt as pathological or all guilt as beneficial.
A fourth pathway involves uncertainty. Doubt can be intellectually productive, emotionally neutral, painful, or obsessional. Distress may rise when uncertainty becomes tied to catastrophic consequences, social exclusion, identity instability, or a repetitive demand for certainty that cannot be satisfied. Different mechanisms can therefore produce superficially similar statements such as “I am struggling with my faith.”
Development, Identity, and Cultural Context
Religious and spiritual struggles are embedded in development and culture. Questions that arise in adolescence may differ from those that emerge after marriage, parenthood, migration, illness, bereavement, aging, or a change in religious affiliation. The same words can also carry different meanings across denominations, religions, spiritual traditions, families, and societies.
Cultural context is especially important for domains that refer to God, evil, sin, ritual, authority, or community. A competent assessment asks what an experience means within the person's own tradition, whether it is shared or recognized in that community, how the person interprets it, and what effect it has on functioning. Clinicians should not use unfamiliarity with a belief as a proxy for psychopathology.
Religious and spiritual struggle research also extends beyond committed theists. In two large samples, Sedlar and colleagues studied self-identified atheists and found that interpersonal and ultimate-meaning struggles occurred at levels similar to theists, while several explicitly theistic domains were less common. Among atheists, moral and ultimate-meaning struggles were associated with distress, and ultimate-meaning struggle retained associations with lower well-being and greater distress after controlling for neuroticism (Sedlar et al., 2018).
That evidence does not erase differences between religious and nonreligious worldviews. It shows why researchers should avoid treating “religious,” “spiritual,” “atheist,” “agnostic,” and “nonreligious” as interchangeable categories. Measures developed in one cultural or theological environment may not capture experience equivalently in another.
How Religious and Spiritual Struggles Are Measured
The 26-item Religious and Spiritual Struggles Scale
The original RSS contains 26 items organized into the six domains described above. Its development included factor-analytic work in two adult samples and confirmatory testing in a large undergraduate sample. The resulting scale provided evidence for a six-factor structure and for convergent, discriminant, and predictive validity (Exline et al., 2014).
A scale score can help researchers quantify patterns and can help clinicians structure inquiry when the measure is appropriate to the setting. It does not tell a clinician why a person endorsed an item, whether the belief is theologically normative, whether the person has a mental disorder, or what intervention is indicated. Those questions require conversation and context.
The five-item RSS-5
The RSS-5 was designed as a much shorter measure for research and clinical settings. It contains one item each for divine, interpersonal, moral, doubt, and ultimate-meaning struggle. It does not include a demonic-struggle item, so it does not reproduce all six domains of the full RSS. Across three samples—711 adults selected for elevated depression symptoms in prior datasets, 303 undergraduates, and 121 adults seeking psychotherapy and/or primary care—the RSS-5 showed internal-consistency estimates from .77 to .85 and evidence of construct validity (Salcone et al., 2025).
Its brevity is an advantage when assessment time is limited, but brevity also narrows content. A five-item screen cannot represent the full narrative, cultural, theological, relational, or clinical meaning of a struggle. It is best understood as a prompt for further assessment or a research indicator, not a stand-alone diagnostic instrument.
Measurement limitations
Religious and spiritual measures face challenges that are common in cross-cultural psychology and especially important here. Words such as God, sacred, sin, spiritual, meaning, or evil do not have identical meanings across traditions. Some people use relational language for the divine; others do not. Some traditions emphasize communal practice, others personal devotion, and many people combine several identities or sources of meaning.
Samples also matter. Much of the foundational RSS literature was developed in U.S. populations, including college and community samples. A scale can have strong psychometric performance in one population and still require further validation before researchers assume equivalent meaning, thresholds, or factor structure in another language, religion, culture, age group, or clinical setting.
When Spiritual Struggle Is Not a Mental Disorder
Religious doubt, moral concern, spiritual dryness, anger toward God, questions about suffering, conflict with a faith community, or uncertainty about meaning can occur in psychologically healthy people. These experiences can be painful and still remain part of ordinary religious, spiritual, moral, or developmental life.
Clinical assessment becomes relevant when the person is suffering substantially, daily functioning is impaired, symptoms persist or escalate, safety is affected, or the struggle appears within a broader syndrome such as OCD, major depression, an anxiety disorder, trauma-related symptoms, mania, or psychosis. Diagnosis depends on patterns of symptoms, duration, impairment, differential assessment, and cultural context—not on the religious content of a belief alone.
Clinical Boundaries: OCD, Psychosis, Depression, and Anxiety
Spiritual struggle and scrupulosity OCD
Moral or religious concern can resemble scrupulosity when both involve guilt, fear of wrongdoing, or repeated questions about whether one has acted correctly. The distinguishing clinical issue is the broader obsessive-compulsive pattern. OCD involves recurring unwanted obsessions, compulsions or both, and clinically significant distress or interference; religious themes can occur among many possible obsessional themes (NIMH).
A person with ordinary religious guilt may seek forgiveness or make a proportionate repair and then move forward. In scrupulosity, the person may become caught in repetitive checking, confession, reassurance seeking, mental review, ritualized prayer, avoidance, or attempts to reach impossible certainty. For a detailed clinical discussion, see Scrupulosity OCD: What Is It? Religious Obsessions, Moral Fear, Rituals, Guilt, and Treatment.
Spiritual experience and psychosis
Religious language can also appear in psychosis, but religious belief is not equivalent to delusion. Psychosis refers to a syndrome involving a loss of contact with reality, with symptoms such as delusions, hallucinations, and disorganized thinking or perception (NIMH). A competent assessment considers the whole clinical picture, including changes from baseline, functional decline, thought organization, behavioral changes, distress, safety, cultural congruence, and whether experiences are shared or understood within the person's community.
This distinction protects both clinical accuracy and religious dignity. A clinician can take unusual experiences seriously without making metaphysical judgments and can respect religious interpretations while assessing whether the person also has symptoms requiring psychiatric care. See Psychosis: Symptoms, Causes, Types, and When to Seek Help for the broader clinical syndrome.
Depression and anxiety
Spiritual struggle may coexist with depressed mood, loss of interest, hopelessness, anxiety, sleep disruption, concentration problems, or social withdrawal. Those symptoms deserve their own clinical assessment. A high spiritual-struggle score neither proves a depressive or anxiety disorder nor explains all of a person's symptoms.
The direction of influence can also run both ways. Severe depression may make previously meaningful beliefs feel emotionally inaccessible. Anxiety may intensify uncertainty and threat appraisal. Social rejection may increase both spiritual conflict and depressive symptoms. Longitudinal studies improve temporal inference, but individual formulation remains necessary.
What Clinicians Can Do
Faith-sensitive care begins with respectful inquiry. Clinicians can ask whether religion, spirituality, or a nonreligious worldview is important to the person; whether it currently provides support, creates conflict, or both; whether the client wants it included in treatment; and which words or practices are appropriate in that person's tradition.
Religion and spirituality are recognized in the psychology literature as dimensions of human diversity that require specific competence. Vieten and Lukoff argue that psychologists need knowledge, attitudes, and skills for working with spiritual and religious diversity rather than assuming competence follows automatically from general multicultural training (Vieten & Lukoff, 2022).
Good clinical practice separates exploration from persuasion. The therapist's role is to understand how beliefs and practices function in the client's life, identify sources of support and conflict, examine psychological processes that maintain distress, and work toward the client's own treatment goals. Therapy should not be used to recruit a client into or out of a religion.
When appropriate and with the client's consent, collaboration with clergy, chaplains, spiritual directors, or other trusted community figures can complement psychotherapy. Their roles are different. A faith leader may offer theological guidance, ritual, pastoral care, or community support, while a licensed mental-health clinician assesses and treats psychological disorders within professional scope. Collaboration works best when responsibilities, confidentiality, and consent are explicit.
For clients with OCD, psychosis, severe mood symptoms, trauma, or other clinical conditions, religious or spiritual concerns should be integrated into evidence-based care rather than substituted for it. Respect for faith and appropriate psychiatric or psychological treatment can coexist.
When to Seek Professional Help
Professional support is worth considering when spiritual or religious conflict is causing persistent distress, disrupting sleep or work, damaging relationships, making ordinary decisions difficult, producing repeated compulsive rituals or reassurance seeking, or occurring alongside significant depression, anxiety, trauma symptoms, mania, psychosis, substance problems, or other major changes in functioning.
A clinician with spiritual and religious competence can help clarify whether the main problem is a spiritual struggle, a mental-health condition, a relational or community conflict, or several processes interacting at once. The goal is accurate understanding and useful care, not evaluation of the truth or worth of the person's faith.
If spiritual distress is accompanied by suicidal thoughts, self-harm, or an immediate inability to stay safe, seek urgent help. Contact local emergency services or a crisis service in your country. In the United States and its territories, the 988 Suicide & Crisis Lifeline is available by call, text, or chat.
Frequently Asked Questions
Are religious and spiritual struggles a mental disorder?
No. Religious and spiritual struggle is a psychological research construct describing conflict or tension involving religious, spiritual, sacred, moral, relational, or ultimate-meaning concerns. It is not a DSM or ICD diagnosis. A mental disorder is assessed from a broader pattern of symptoms, duration, impairment, safety, context, and differential diagnosis.
What are the six types of spiritual struggle?
The original RSS model distinguishes divine, demonic, interpersonal, moral, doubt, and ultimate-meaning struggles. These categories can overlap and are measurement domains rather than separate illnesses (Exline et al., 2014).
Does religious doubt mean someone is losing faith?
Not necessarily. Doubt can be temporary, reflective, developmental, emotionally painful, intellectually productive, or part of a larger identity transition. Psychology can study the experience and consequences of doubt without prescribing the religious conclusion a person should reach.
Is religious guilt the same as scrupulosity OCD?
No. Moral or religious guilt can be proportionate to a person's values and circumstances. Scrupulosity is an OCD presentation characterized by an obsessive-compulsive pattern: intrusive unwanted fears and repetitive behaviors or mental acts aimed at reducing distress or achieving certainty. Diagnosis requires clinical assessment, not the presence of guilt alone.
Can atheists or nonreligious people have spiritual struggles?
Yes, depending on how the construct is defined and measured. Research among self-identified atheists has documented interpersonal, moral, and ultimate-meaning struggles, although explicitly theistic domains are less applicable or less common. This reinforces the need to use language that fits the person's worldview (Sedlar et al., 2018).
Can a spiritual struggle cause depression or anxiety?
Research supports an association and a small average prospective link between greater struggles and later negative psychological adjustment, but it does not establish one simple causal pathway. Depression, anxiety, stress, social conflict, illness, and other factors can also intensify spiritual struggle. Individual assessment is needed (Bockrath et al., 2022).
Can therapy discuss religion without challenging a client's beliefs?
Yes. Culturally competent psychotherapy can explore religious and spiritual resources, conflicts, practices, relationships, and meanings while respecting client autonomy. The purpose is to understand the client's experience and treatment goals, not to prove or disprove religious beliefs. Competence in this area is a recognized professional concern in psychology (Vieten & Lukoff, 2022).
Does the RSS-5 measure all six struggle domains?
No. The five-item RSS-5 assesses divine, interpersonal, moral, doubt, and ultimate-meaning struggles. The demonic domain from the original six-factor RSS is not represented in the RSS-5. The short form is useful for brief assessment and research, but it offers less content coverage than the full scale (Salcone et al., 2025).
Related Articles
Scrupulosity OCD: What Is It? Religious Obsessions, Moral Fear, Rituals, Guilt, and Treatment — the clinical owner for obsessive religious and moral fears, compulsions, certainty seeking, and treatment.
Psychosis: Symptoms, Causes, Types, and When to Seek Help — the clinical owner for psychotic symptoms, evaluation, causes, and care.
Measuring Religiosity and Spirituality: Research Instruments — the EN-47 methods owner for RSS/RSS-5, Brief RCOPE, religiosity/spirituality measures, scoring, and measurement limitations.
References
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