https://dx.doi.org/10.24016/2025.v11.474
ORIGINAL ARTICLE
Religious and Spiritual Struggles and Mental Health Outcomes in Puerto Rico
Juan Aníbal González-Rivera 1*, Yazmín Álvarez-Alatorre 2
1 Ponce Health Sciences University, San Juan University Center, San Juan, Puerto Rico
* Correspondence: jagonzalez@psm.edu
Received: June 26, 2025 | Revised: October 18, 2025 | Accepted: October 19, 2025 | Published Online: October 19, 2025.
CITE IT AS:
González-Rivera, J. A., & Álvarez-Alatorre, Y. (2025). Religious and spiritual struggles and mental health outcomes in Puerto Rico. Interacciones, 11, e474. https://doi.org/10.24016/2025.v11.474
ABSTRACT
Introduction: Religious and spiritual struggles (RSS) are psychological conflicts related to an individual’s relationship with the divine, supernatural entities, or religious beliefs and communities. These struggles can cause emotional distress and negatively impact mental health. Objective: This study aimed to examine the relationship between different dimensions of RSS and mental health indicators among adults residing in Puerto Rico. Method: A correlational design was used with a convenience sample of 250 adult participants. Validated instruments were administered to assess religious and spiritual struggles, depression, anxiety, and flourishing. Results: Regression analyses showed that divine and demonic struggles significantly predicted levels of depression and anxiety, while RSS did not significantly relate to flourishing. Divine struggles emerged as the strongest predictor in both models. Conclusions: RSS, particularly those involving supernatural dimensions, are significantly associated with affective symptoms. These findings highlight the importance of addressing the spiritual dimension in clinical assessment and intervention, especially in culturally religious contexts such as Puerto Rico.
Keywords: religious struggles, spiritual struggles, depression, anxiety, well-being.
INTRODUCTION
Interest in understanding how spiritual and religious dimensions affect mental health has been increasing within the field of psychology in Puerto Rico (González-Rivera et al., 2019). Previous research has established an intricate connection between spirituality and psychological well-being (González-Rivera et al., 2017), depression (Currier et al., 2019), and anxiety (Álvarez-Alatorre et al., 2024). Although spirituality has historically been viewed as a source of comfort and resilience, recent work has taken a more nuanced approach, recognizing that spiritual experience can also be a source of psychological conflict and distress (Exline, 2013). Despite the wealth of literature linking spirituality to mental health outcomes, the specific ways in which religious and spiritual struggles relate to these outcomes remain comparatively underexplored in Latin America.
The role of spirituality as a resource in times of crisis—and as a pathway to resilience and recovery from adversity—is well documented (Koenig, 2018). Spiritual beliefs and practices can offer purpose, moral guidance, and supportive communities that are vital in regulating distress. However, when doubts or conflicts arise—whether as internal struggles about faith, questions about divine justice, or disagreements with others over spiritual matter associations with poorer mental health can emerge (Exline, 2013; Ano & Vasconcelles, 2005). We refer to these conflicts as religious and spiritual struggles (RSS).
Exline (2013) categorized RSS into three domains, which we present here from the broadest to the most personal. Supernatural struggles include demonic attributions (e.g., perceiving oneself as targeted by malevolent forces) and divine tensions (e.g., feeling punished, abandoned, or unloved by God). Interpersonal struggles arise from negative experiences with religious people or institutions, such as resentment toward organized religion or feeling mistreated in sacred contexts. Intrapersonal struggles comprise internal doubts and questions that surface when deeply held beliefs are challenged by new or contradictory information. Framed this way, RSS provides a conceptually coherent lens through which to consider their links with common affective outcomes.
A substantial body of research links RSS to depressive symptoms and to decreases in psychological adjustment. Prospective and clinical studies indicate that higher levels of spiritual conflict prospectively predict increases in depression and impaired functioning (Braam & Koenig, 2019; Bockrath et al., 2022), converging with earlier evidence that religious strain—guilt, alienation, discord—co-occurs with depression (Exline et al., 2000; Pargament et al., 2011; Currier et al., 2019). Conceptually, tensions in the perceived relationship with the divine may erode meaning, hope, and belonging, thereby heightening vulnerability to depressive affect. See also prevalence and correlations of RSS in clinical samples (Abu-Raiya et al., 2015; Murphy et al., 2016).
At the clinical level, some manifestations of RSS may resemble features seen in major depressive disorder—such as diminished interest or excessive guilt—especially within intrapersonal or moral struggle content (Currier et al., 2019; Exline, 2013). At the same time, RSS extends beyond any single diagnosis, capturing forms of distress that cut across categories. This overlap underscores the value of careful assessment to differentiate shared phenomenology while acknowledging distinct spiritually themed concerns in presentation.
Parallel findings are observed for anxiety: individuals reporting greater spiritual conflict tend to endorse higher anxious symptomatology (Ano & Vasconcelles, 2005; McConnell et al., 2006; Leavitt-Alcántara et al., 2023). Uncertainty about core beliefs, concerns about divine judgment, or perceptions of failing to meet spiritual standards can amplify worry and hypervigilance. These struggles may also foster a persistent preoccupation with meaning and purpose; appraising adverse events as spiritual punishment or testing can further intensify anxiety—particularly when circumstances feel uncontrollable (González-Rivera & Álvarez-Alatorre, 2021; Álvarez-Alatorre et al., 2024). For some, eschatological anxiety—fear of apocalyptic events or end-times scenarios—can emerge as a specific manifestation of spiritually themed worry.
By contrast, associations between RSS and positive mental health are weaker or inconsistent. A meta-analysis of longitudinal studies found robust effects of RSS on negative outcomes (depression, anxiety, post-traumatic stress) but non-significant shifts in positive indicators such as life satisfaction, optimism, and psychological well-being (Bockrath et al., 2022). Nonetheless, some work highlights potential growth-related processes, e.g., broadened perspectives, meaning-making, or internal dialogues—that can scaffold adaptation under specific conditions (Hill & Pargament, 2003; Zarzycka & Zietek, 2019; Zarzycka & Puchalska-Wasyl, 2020). These salutogenic pathways appear contingent on protective factors (e.g., support, resilience), which may explain their weaker and more variable linkage to RSS compared to negative effects.
Puerto Rico is an overwhelmingly Christian society in which religious identity, family life, and community belonging frequently intersect. In a 2014 Pew Research Center survey, 56% of island residents identified as Catholic and 33% as Protestant/Evangelical (about half of whom self-identify as born-again) (Krogstad et al., 2017). Across Latin America—including Puerto Rico—surveys also document high religious commitment (e.g., salience of religion, daily prayer, and service attendance) (Pew Research Center, 2014a, 2014b). In this milieu, religious worldviews commonly inform interpretations of suffering and pathways to help-seeking; for some Puerto Rican families, traditions such as Espiritismo and Santería remain culturally meaningful frames that may shape coping and contact with mental-health services (Harwood, 1977; Zerrate et al., 2022). Together, these features make Puerto Rico a pertinent context for examining how RSS relates to everyday mental-health indicators.
Building on the foregoing literature and the sociocultural context of Puerto Rico, the present study seeks to clarify how distinct religious and spiritual struggles (RSS)—divine, demonic, interpersonal, and intrapersonal—relate to key mental-health indicators in adults residing on the island. Prior work has consistently linked RSS to depression and anxiety, with more inconsistent associations for positive mental health (e.g., flourishing). However, evidence from Latin American contexts remains limited, and few studies have examined RSS subdimensions simultaneously, which would help clarify their unique associations with mental-health outcomes. Addressing this gap is especially relevant in Puerto Rico, where religious meanings are often interwoven with family, community life, and help-seeking practices, potentially shaping both the expression of RSS and their links to psychological well-being.
To address this gap, the present study (a) estimates associations among the four RSS dimensions and depression, anxiety, and flourishing, and (b) evaluates the unique predictive value of each RSS dimension when considered concurrently. This approach allows us to test whether supernatural forms of RSS (divine, demonic) exhibit stronger links with affective symptoms than interpersonal or intrapersonal struggles, and whether RSS account for variance in flourishing.
METHODS
Design
This study employed a correlational design outlined by Ato et al. (2013). The data-gathering process was carried out electronically, using a paid Facebook advertisement targeting 74,764 individuals as the recruitment strategy. This advertisement directed participants to the PsychData platform, where the survey was set up and organized, including the necessary informed consent. This consent covered the study's purpose, inclusion criteria, the voluntary nature of participation, potential risks and benefits, and the right of participants to withdraw from the study at any time.
Participants
A sample of 250 participants was reached through non-probabilistic availability sampling. The inclusion criteria were: (1) being older than 21 years of age, (2) believing in some divinity or higher power, and (3) residing in Puerto Rico. Table 1 presents the sociodemographic characteristics of the sample. In line with the inclusion criteria, which required belief in a divinity or higher power but did not require affiliation to a specific religion, the category “None” in the religious affiliation breakdown denotes unaffiliated theists (i.e., participants who believe in God/a higher power yet do not currently identify with or attend an organized religion).
To ensure adequate statistical power, we conducted an a priori power analysis in G*Power 3.1 (Faul et al., 2009) for the primary multiple regression models with four predictors, assuming a medium effect size (f² = .15), α = .05, and desired power (1 − β) = .80. The minimum required sample was N = 129. For planned bivariate analyses, detecting correlations of at least |ρ| = .20 with α = .05 and power = .80 required approximately N ≈ 193. Our final sample (N = 250) exceeded both thresholds, supporting adequate power for the planned analyses.
Table 1.Sociodemographic Data of the Sample (n=250).
|
Variables |
f |
% |
|
Sex |
||
|
Female |
184 |
73.6 |
|
Male |
66 |
26.0 |
|
Other |
1 |
0.4 |
|
Marital Status |
|
|
|
Married |
120 |
48.0 |
|
Single |
65 |
26.0 |
|
Divorced |
42 |
16.8 |
|
Cohabiting |
13 |
5.2 |
|
Widowed |
10 |
4.0 |
|
Academic Preparation |
|
|
|
High School or less |
14 |
5.6 |
|
Associate degree / Technical Course |
43 |
17.2 |
|
Bachelor's Degree |
89 |
35.6 |
|
Master's Degree |
70 |
28.0 |
|
Doctorate or equivalent degree |
34 |
13.6 |
|
Annual Income (dollars) |
|
|
|
$0 - $20,000 |
124 |
49.6 |
|
$21,000 - $30,000 |
55 |
22.0 |
|
$31,000 - $40,000 |
29 |
11.6 |
|
$41,000 - $50,000 |
19 |
7.6 |
|
$51,000 - $60,000 |
7 |
2.8 |
|
$61,000 or more |
16 |
6.4 |
|
Religion |
||
|
Catholic |
79 |
31.6 |
|
Protestant Christian |
119 |
47.6 |
|
Orthodox Christian |
2 |
0.8 |
|
Adventist |
4 |
1.6 |
|
Mormonism |
1 |
0.4 |
|
Buddhist |
1 |
0.4 |
|
Hinduism |
2 |
0.8 |
|
Spiritualism |
3 |
1.2 |
|
None |
39 |
15.6 |
Note. f = frequency distribution. Response conversion rate = 250 / 74,764 (recruited/outreach). The mean age of the participants was 47.04 years (SD = 13.66).
Instruments
General Data Questionnaire. An ad hoc questionnaire was developed to collect sociodemographic information (e.g., age, sex, education, income, and religious affiliation). In addition, it included the following items with explicit response formats: (a) “Do you consider yourself a religious person?” (Yes/No); (b) “How important is religion to you?” (4-point Likert scale: not at all important, somewhat important, important, very important); (c) “How often do you participate in congregational activities (e.g., worship, mass, religious services)?” (5-point frequency scale: never, once a year, monthly, weekly, daily); (d) “How often do you engage in private religious/spiritual practices (e.g., prayer, reading sacred texts)?” (same 5-point frequency scale: never, once a year, monthly, weekly, daily); and (e) “Do your religious beliefs influence your lifestyle?” (Yes/No).
Religious and Spiritual Struggles Brief Inventory (González-Rivera & Álvarez-Alatorre, 2021). This 14-item multidimensional inventory assesses four dimensions of RSS: divine (e.g., feeling abandoned by God), demonic (e.g., feeling tormented by a negative force), interpersonal (e.g., feeling hurt or offended by a religious person), and intrapersonal (e.g., questioning my religious/spiritual beliefs). Items are rated on a 5-point Likert scale: (1) never, (2) seldom, (3) several times, (4) many times, (5) always. No items are reverse scored. Higher scores indicate greater RSS. In this study, internal consistency was adequate for all subscales: divine (ω = .90), demonic (ω = .90), interpersonal (ω = .89), and intrapersonal (ω = .82).
The Patient Health Questionnaire-8 (PHQ-8). The PHQ-8 is a validated, widely used tool for assessing depressive symptoms (Kroenke et al., 2009). It's a brief variant of the PHQ-9, excluding the item on suicidal ideation for safer self-reporting. The PHQ-8 aligns with DSM criteria for Major Depressive Disorder, featuring eight items rated over the past two weeks on a four-point scale from (0) not at all to (3) nearly every day. Scores range from 0 to 24, with higher scores indicating more severe depression. Known for its diagnostic accuracy, simplicity, and brevity, the PHQ-8 is a valuable resource in both clinical practice and mental health research. In this study, the scale presented an adequate internal consistency index (ω = .91).
Generalized Anxiety Disorder-7 (GAD-7). The GAD-7 is a validated and commonly used instrument for assessing generalized anxiety symptoms (Spitzer et al., 2006). This tool consists of seven items that evaluate the frequency of anxiety-related symptoms experienced over the last two weeks. Respondents rate each item on a four-point scale, ranging from (0) not at all to (3) nearly every day. The total score, which can vary from 0 to 21, is calculated by summing the responses, with higher scores indicating greater anxiety severity. The GAD-7 is renowned for its clinical utility, straightforward administration, and effectiveness in both screening and monitoring generalized anxiety disorder, making it a vital tool in mental health research and clinical settings. In this study, the scale presented an adequate internal consistency index (ω = .93).
Flourishing Scale (Diener et al., 2010). This eight-item scale measures psychological well-being from an eudaimonic standpoint (for example, statements like I lead a purposeful and meaningful life, and I am optimistic about my future). It was used as a measure of positive mental health. Each item on this scale features a seven-point response range, extending from (1) strongly disagree to (7) strongly agree. The overall score can range between 8 and 56 points, with higher scores indicating greater resilience and psychological resourcefulness in an individual. In this study, the scale presented an adequate internal consistency index (ω = .95).
Data Analysis
First, descriptive analyses were conducted using the General Data Questionnaire. Then, to assess the relationships between the various sub-scales of RSS and their impact on mental health outcomes, several statistical analyses were performed using IBM SPSS v.29 statistical software. The normality of the variable distributions was assessed using normality tests, and since the distributions did not conform to normality, the Spearman correlation coefficient was used for bivariate correlations. The Spearman correlation coefficient was calculated to determine the relationship between the sub-scales of struggles (Divine, Demonic, Interpersonal, and Intrapersonal) and the scales of Flourishing, Depression, and Anxiety. We will use the recommendations of Taylor (1990): values below .35 indicate weak or low correlations, values between .36 and .67 indicate moderate correlations, values between .68 and .89 are high correlations, and, finally, values of .90 and above are very high correlations. Results were considered significant with a p-value of < .05.
Furthermore, multiple linear regression analysis was employed to investigate the predictive capacity of the sub-scales of RSS on the Flourishing, Depression, and Anxiety scales. Unstandardized coefficients (b), standard errors (SE), standardized coefficients (β), t-values, and significance values (p) were reported. 95% confidence intervals for the regression coefficients were estimated to assess the accuracy of the estimations. Statistical significance was established at p < .05. For each analysis, it was ensured that the relevant statistical assumptions were met before interpreting the results. Multicollinearity was assessed using the variance inflation factor (VIF) and tolerance. Residuals were examined to confirm homoscedasticity and independence. Effect sizes were interpreted according to Cohen's conventions for small (0.10), medium (0.30), and large (0.50) effects.
Ethical Considerations
Prior to their participation, individuals were presented with detailed information about the study, and they provided informed consent to indicate their voluntary agreement to participate. All data were collected and handled in strict adherence to privacy and confidentiality protocols. This study was conducted in full compliance with ethical standards and received ethical approval from the Institutional Review Board (IRB) at Ponce Health Sciences University, Ponce, Puerto Rico, under protocol number 2005036697.
RESULTS
Descriptive Analysis
The General Data Questionnaire indicated high religious commitment in the sample (see Table 2). About two thirds identified as religious (68.4%), and roughly three quarters rated religion as important/very important (76.0%). Weekly congregational participation was the modal pattern, and private religious/spiritual practice tended to be more frequent (often daily). Most participants reported that their religious beliefs influence their lifestyle (80.4%). Full category distributions are presented in Table 2.
Table 2. Religious Participation, Private Practice, and Belief Indicators (n=250).
|
Variables |
Category |
n |
% |
|
Consider yourself religious |
Yes |
171 (68.4) |
171 (68.4) |
|
No |
79 (31.6) |
79 (31.6) |
|
|
Importance of religion |
Very important |
131 (52.4) |
131 (52.4) |
|
Important |
59 (23.6) |
59 (23.6) |
|
|
Somewhat important |
38 (15.2) |
38 (15.2) |
|
|
Not at all important |
22 (8.8) |
22 (8.8) |
|
|
Congregational participation |
Daily |
35 (14.0) |
35 (14.0) |
|
Weekly |
103 (41.2) |
103 (41.2) |
|
|
Monthly |
25 (10.0) |
25 (10.0) |
|
|
Once a year |
43 (17.2) |
43 (17.2) |
|
|
Never |
44 (17.6) |
44 (17.6) |
|
|
Private religious/spiritual practice |
Daily |
110 (44.0) |
110 (44.0) |
|
Weekly |
48 (19.2) |
48 (19.2) |
|
|
Monthly |
23 (9.2) |
23 (9.2) |
|
|
Once a year |
17 (6.8) |
17 (6.8) |
|
|
Never |
52 (20.8) |
52 (20.8) |
|
|
Beliefs influence lifestyle |
Yes |
201 (80.4) |
201 (80.4) |
|
|
No |
49 (19.6) |
49 (19.6) |
Note. Percentages are based on the total sample (N = 250). Category counts were computed from reported percentages and may reflect minor rounding. Descriptive data derive from the General Data Questionnaire.
Correlation Analysis
Assumption testing indicated departures from normality across study scales (Shapiro–Wilk, all ps < .05). Accordingly, we computed Spearman rank-order correlations (ρ) with two-tailed tests (α = .05). As shown in Table 3, the four RSS subscales were intercorrelated at small-to-moderate magnitudes. Supernatural struggles (divine, demonic) displayed the largest positive associations with depression and anxiety and negative associations with flourishing. Interpersonal and intrapersonal struggles showed smaller correlations with the outcomes overall; links with flourishing were modest in magnitude. As expected, flourishing correlated negatively with depression and anxiety, whereas depression and anxiety were strongly and positively correlated. Exact coefficients and p-values are reported in Table 3.
Table 3.Correlations Spearman Rho (n=250).
|
|
1 |
2 |
3 |
4 |
5 |
6 |
|
1.Divine Struggles |
-- |
|||||
|
2.Demonic Struggles |
.396** |
-- |
||||
|
3.Interpersonal Struggles |
.304** |
.402** |
-- |
|||
|
4.Intrapersonal Struggles |
.503** |
.315** |
.363** |
-- |
||
|
5.Depression |
.379** |
.386** |
.236** |
.341** |
-- |
|
|
6. Anxiety |
.313** |
.318** |
.197** |
.277** |
.785** |
-- |
|
7.Flourishing |
-.294** |
-.295** |
-.143* |
-.169** |
-.443** |
-.321** |
Note. ** p < .001 (two-tailed); * p < .05 (two-tailed).
Religious and Spiritual Struggles and Mental Health Outcomes
We conducted three multiple linear regressions in which the four RSS subscales (divine, demonic, interpersonal, intrapersonal) were entered simultaneously to predict depression, anxiety, and flourishing. Table 4 reports unstandardized coefficients and model statistics.
Depression. The model for the depression was significant, F(4, 238) = 17.850, p < .001, R² = .231, indicating that approximately 23.1% of the variance in depression was explained. Divine struggles were the strongest unique predictor (b = 0.646, p < .001), followed by demonic struggles (b = 0.371, p = .006). Interpersonal and intrapersonal struggles were not significant (both with p value > 0.05). The effect size was medium, f ² = 0.300.
Anxiety. The model was significant, F(4, 238) = 10.86, p < .001, R² = .154. Divine (b = 0.406, p = .004) and demonic (b = 0.312, p = .020) struggles emerged as unique positive predictors; interpersonal and intrapersonal struggles were not significant (both with p value > 0.05). The effect size was medium, f ² = 0.182.
Flourishing. The model did not reach significance, F(4, 238) = 2.30, p = .059, R² = .037, indicating that RSS subscales did not explain a substantial proportion of variance in flourishing.
Table 4. Regression models with religious and spiritual struggles predicting mental health outcomes.
|
Outcome |
Predictor |
b |
SE |
β |
t |
p |
95.0% CI for b |
|
Depression |
Divine |
.646 |
.142 |
.322 |
4.553 |
<.001 |
(.367, 1.619) |
|
Demonic |
.371 |
.135 |
.188 |
2.756 |
.006 |
(.106, .926) |
|
|
Interpersonal |
.068 |
.096 |
.047 |
.709 |
.479 |
(-.121, .258) |
|
|
|
Intrapersonal |
.069 |
.131 |
.036 |
.527 |
.599 |
(-.189, .327) |
|
Anxiety |
Divine |
.406 |
.141 |
.213 |
2.883 |
.004 |
(.128, .638) |
|
Demonic |
.312 |
.133 |
.167 |
2.340 |
.020 |
(.049, .575) |
|
|
Interpersonal |
.059 |
.095 |
.043 |
.621 |
.535 |
(-.129, .247) |
|
|
|
Intrapersonal |
.144 |
.130 |
.080 |
1.104 |
.271 |
(-.113, .400) |
|
Positive mental health |
Divine |
-.665 |
.308 |
-.171 |
-2.162 |
.032 |
(-1.27, -.059) |
|
(Flourishing) |
Demonic |
-.383 |
.292 |
-.100 |
-1.313 |
.190 |
(-.958, .191) |
|
Interpersonal |
.153 |
.209 |
.054 |
.734 |
.464 |
(-.258, .564) |
Note. Bolded entries were statistically significant at p < 0.05 level; b = unstandardized regression coefficient; β = standardized regression coefficient; SE = Std. Error; CI = Confidence Interval.
DISCUSSION
This study aimed to clarify the complex dynamics between religious and spiritual struggles (RSS) and mental health outcomes in a Puerto Rican adult sample—an area of growing interest within the psychology of religion and spirituality. Correlational analyses showed significant associations between RSS and depression, anxiety, and flourishing, consistent with prior work indicating that spiritually themed conflict can function as a salient stressor with downstream effects on psychological well-being (Pargament, 1997; Exline, 2013).
Regression analyses provided a more differentiated picture. The model predicting depression was robust, accounting for 23.1% of the variance, with divine struggles emerging as the strongest unique predictor (β = .322, p < .001) and demonic struggles also contributing (β = .188, p = .006). This pattern is theoretically coherent with frameworks emphasizing meaning-making and perceived relationship to the sacred: appraisals of divine abandonment, punishment, or rejection can erode meaning, hope, and belonging—central buffers against depressive affect (Exline, 2013; Currier et al., 2019). Likewise, demonic attributions align with an external, uncontrollable attributional style that can reinforce helplessness or despair when suffering is assigned to malevolent forces.
The model predicting anxiety was also significant, explaining 15.4% of the variance, again identifying divine and demonic struggles as unique predictors. This aligns with evidence that spiritual conflict can amplify existential uncertainty, fear of divine judgment, and hypervigilance regarding religious standards—processes that intensify anxious arousal (Ano & Vasconcelles, 2005; Leavitt-Alcántara et al., 2023). In other words, anxiety in this context may index not only responses to ordinary stressors but also distress tied to sacred meanings and perceived supernatural threats.
By contrast, the model for flourishing—conceived as optimal functioning and eudaimonic well-being—did not reach significance, despite small bivariate relations. Converging with meta-analytic work (Bockrath et al., 2022), this suggests that RSS are more proximally linked to negative affective states than to positive functioning. Conceptually, flourishing may be more tightly coupled with protective resources (e.g., social support, purpose, spiritual resilience, emotion regulation; Fredrickson, 2001; Seligman, 2011) than with the mere presence/absence of struggle. Thus, even if reducing RSS alleviates distress, additional mechanisms may be required to generate gains in eudaimonia.
Effect sizes were medium in magnitude (f ² = .300 for depression; f ² = .182 for anxiety), underscoring the practical significance of these findings. Of note, the explained variance—while meaningful—also indicates residual variance left to be accounted for by other psychological, social, or cultural factors (e.g., coping styles, congregational support, or family stressors), which future research should test explicitly.
Clinical implications and diagnostic considerations
Some RSS experiences can mimic features commonly observed in mood disorders. Prior work notes that RSS may overlap with diagnostic criteria for major depressive disorder (Currier et al., 2019). For example, the search for ultimate meaning characteristic of intrapersonal struggles may accompany depressed mood and anhedonia (DSM Criteria A1–A2). Likewise, worthlessness and excessive/inappropriate guilt (Criterion A7) can resemble moral tensions when individuals wrestle with sacred standards (Exline, 2013). At the same time, RSS also encompass spiritually themed distress that transcends any single diagnosis, cutting across categories and interacting with cultural meanings, family norms, and community practices. These recommendations align with spiritually integrated approaches to care (Pargament, 2007).
Within Puerto Rico’s religious landscape—marked by high Christian affiliation and salient religious commitment—attributions of divine punishment or malevolent forces may heighten perceived uncontrollability, thereby amplifying anxiety and depressive affect. Given the sample profile and the presence of unaffiliated theists (see Table 2), distinguishing belief from institutional affiliation is clinically relevant when exploring spiritual resources and conflicts in Puerto Rican settings. Clinically, these considerations translate into two complementary tasks: differential assessment and integrative care. On the one hand, clinicians should separate overlaps (e.g., guilt-meeting depressive Criterion A7) from distinct RSS content (e.g., explicit sacred attributes or demonic concerns). On the other hand, routine screening for RSS (e.g., RSS-BI14) can inform case formulation, guide culturally sensitive psychoeducation (meaning-making without self-condemnation), and, when appropriate, support collaborative care with pastoral or community resources.
The null regression for flourishing suggests that alleviating RSS may not, by itself, yield immediate gains in positive functioning. Interventions might therefore pair symptom-focused strategies (e.g., cognitive work on punitive God images or demonic attributions, graded exposure to feared sacred themes) with strength-building components (values clarification, purpose cultivation, social connection) to target both distress reduction and eudaimonic growth.
In sum, this study adds to the growing literature on spirituality and mental health by highlighting the unique role of divine and demonic struggles in depressive and anxious symptomatology and by situating these dynamics within a Puerto Rican context. The findings support a holistic, context-attuned approach to mental health care that recognizes spiritual conflict as a legitimate and clinically relevant dimension of human suffering.
Limitations and Recommendations
While the findings of this study offer a meaningful contribution to the psychology of religion and spirituality, they must be interpreted considering several methodological limitations. First, the cross-sectional and correlational design limits causal inference. Although RSS were significantly associated with depression and anxiety, it is also possible that individuals experiencing these symptoms are more vulnerable to interpreting their spiritual experiences in negative or conflictual ways. Longitudinal studies are needed to clarify the directionality of these relationships and to determine whether RSS precedes or follow the onset of mental health difficulties.
Second, the sampling method was non-probabilistic and based on availability, which constrains generalizability. The sample was composed primarily of women with relatively high educational attainment, which may not reflect the broader Puerto Rican population. Moreover, recruitment relied on online advertising through social media, potentially excluding individuals with limited digital access or lower engagement with such platforms. Future studies should strive for more representative sampling that captures the full diversity of sociocultural, religious, and educational backgrounds across Puerto Rico.
Third, although the study used validated self-report instruments with strong internal consistency, reliance on self-report alone may introduce bias related to social desirability, recall limitations, or the underreporting of sensitive experiences. Incorporating clinician-administered diagnostic tools or qualitative interviews could deepen understanding of how RSS manifest in clinical settings and enrich the interpretive framework.
Finally, although the study differentiated between specific types of RSS—divine, demonic, interpersonal, and intrapersonal—it did not examine potential mediating or moderating variables that might influence the impact of these struggles on mental health. Variables such as positive religious coping, perceived spiritual support, or the quality of one’s relationship with a faith community may shape whether RSS become sources of psychological distress or catalysts for growth. Future research that integrates such factors would provide a more comprehensive view of the mechanisms underlying the association between RSS and mental health outcomes.
Considering these limitations, future investigations should conduct longitudinal research to examine the temporal evolution of spiritual struggles and their mental health consequences. There is also a need to broaden sample diversity by including participants across age groups, socioeconomic strata, religious traditions, and geographic regions. Additionally, exploring the role of protective factors—such as religious resilience, existential meaning-making, and supportive spiritual communities—could shed light on pathways of adaptation and recovery. Finally, clinical research should evaluate the benefits of incorporating spiritual-struggle assessments into routine psychological evaluations, particularly in highly religious populations. Such efforts would support the development of culturally sensitive, integrative approaches to mental health care that acknowledge the profound ways in which spiritual conflict intersects with emotional well-being.
ORCID
Juan Aníbal González-Rivera: https://orcid.org/0000-0003-0622-8308
Yazmín Álvarez-Alatorre: https://orcid.org/0000-0001-8989-1679
AUTHORS’ CONTRIBUTION
Juan Aníbal González-Rivera: Conceptualization, Methodology, Investigation, Writing – Original Draft, Review & Editing, Supervision, Formal Analysis, Project Administration
Yazmín Álvarez-Alatorre: Conceptualization, Investigation, Writing – Original Draft, Review & Editing
FUNDING SOURCE
Self-funded research.
CONFLICT OF INTEREST
The authors declare that there were no conflicts of interest in the preparation of this manuscript.
ACKNOWLEDGMENTS
Not applicable.
REVIEW PROCESS
This study has been reviewed by Ofir Shai and another external reviewer in double-blind mode. The editor in charge was David Villarreal-Zegarra. The review process is included as supplementary material 1.
DATA AVAILABILITY STATEMENT
Researchers and academics interested in accessing the research data may contact the corresponding author via email.
DECLARATION OF THE USE OF GENERATIVE ARTIFICIAL INTELLIGENCE
We used ChatGPT to translate limited sections of the manuscript. All AI-assisted outputs were checked for accuracy, edited by the authors, and approved in the final version. The authors take full responsibility for the content.
DISCLAIMER
The authors are responsible for all statements made in this article.
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Luchas religiosas y espirituales y medidas de salud mental en Puerto Rico
RESUMEN
Introducción: Las luchas religiosas y espirituales (LRE) son conflictos psicológicos relacionados con la relación de una persona con lo divino, con entidades sobrenaturales o con creencias y comunidades religiosas. Estas luchas pueden generar malestar emocional e impactar negativamente la salud mental. Objetivo: Este estudio tuvo como objetivo examinar la relación entre las distintas dimensiones de las LRE y los indicadores de salud mental en adultos residentes en Puerto Rico. Método: Se utilizó un diseño correlacional con una muestra por disponibilidad compuesta por 250 participantes adultos. Se aplicaron instrumentos validados para medir las luchas religiosas y espirituales, la depresión, la ansiedad y el florecimiento. Resultados: Los análisis de regresión mostraron que las luchas divinas y demoníacas predijeron significativamente los niveles de depresión y ansiedad, mientras que las LRE no mostraron relación significativa con el florecimiento. Las luchas divinas fueron el predictor más fuerte en ambos modelos. Conclusiones: Las LRE, particularmente las sobrenaturales, están significativamente asociadas a síntomas afectivos. Estos hallazgos subrayan la necesidad de considerar la dimensión espiritual en la evaluación e intervención clínica en contextos culturalmente religiosos como el puertorriqueño.
Palabras claves:Luchas religiosas, luchas espirituales, ansiedad, depresión, bienestar.