716 vII. APPLICATIONS  AND  IMPLICATIONS
2013). Religious and spiritual struggles fall 
into several domains that include divine (e.g., 
anger at God, concern about divine retribu -
tion/punishment), intrapersonal (e.g., spiri -
tual doubts, facing moral imperfections), 
interpersonal (e.g., religious conflicts), and 
supernatural evil (e.g., demonic appraisals 
of negative events) struggles (Pargament, 
2007; Exline, 2013).
Religious and spiritual struggles are reli -
ably correlated with poor mental health. 
In a meta-  analysiss of 49 studies, Ano and 
Vasconcelles (2005) found a small but sig -
nificant association ( r = .22) between spiri -
tual struggle and negative psychological 
adjustment (e.g., negative mood, social dys -
function, anxiety, depression, anger, guilt). 
Moreover, these associations have been rep -
licated in Jewish (e.g., Rosmarin, Pargament, 
& Flannelly, 2009) and Muslim (e.g., Raiya, 
Pargament, Mahoney, & Stein, 2008) sam -
ples. Although many studies linking spiritu -
al/religious struggles and poor mental health 
rely on cross-  sectional data, researchers are 
beginning to apply longitudinal methods. 
For instance, spiritual struggle and loss of 
faith predicted less improvement in depres -
sion scores over 6 months in a sample of 145 
depressed adolescents (Dew et al., 2010). 
In a sample of college students, spiritual 
struggle severity was related to both growth 
and decline is well-being outcomes (Desai & 
Pargament, 2015; see also Wilt, Hall, Parga -
ment, & Exline [2017] for profiles of trajec -
tories of spiritual struggle change). The ways 
people perceive the divine and cope with 
such struggles predict spiritual growth and 
decline across time (Wilt, Stauner, Harriott, 
Exline, & Pargament, 2019), but additional 
studies are needed to disentangle effects.
In addition to the mere presence of spiri -
tual and religious struggles, negative reli -
gious coping is a maladaptive form of cop -
ing with life stressors that contributes to 
negative outcomes. Negative religious cop -
ing includes strategies such as demonic or 
divine punishment appraisals to understand 
negative events. In a meta-  analysis of eight 
studies examining negative religious coping 
and depression, the two were modestly cor -
related (r = .14; Smith, McCullough, & Poll, 
2003). Moreover, negative religious coping 
and spiritual struggle consistently predict 
outcomes in health-  related longitudinal studies. For example, cancer patients who 
experienced increases in anger toward God 
at a 1-year follow-  up had lower adjustment, 
and those with chronic and recurrent anger 
(i.e., high anger at both time points) had 
the highest levels of distress (Exline, Park, 
Smyth, & Carey, 2011). Baseline spiritual 
struggle has also been found to predict later 
anxiety and depression in children hospital -
ized for asthma symptoms (Benore, Parga -
ment, & Pendleton, 2008) and patients with 
congestive heart failure (Park, Brooks, & 
Sussman, 2009).
Spiritual struggle and negative religious 
coping can even affect mortality and health 
indicators. For example, spiritual struggles 
predicted inflammation and immune func -
tion, as indicated in excess plasma inter -
leukin-6 in cardiac surgery patients (Ai, 
Seymour, Tice, Kronfol, & Bolling, 2009). 
In a longitudinal study of ill older patients, 
demonic appraisals and spiritual discontent 
predict increased mortality 2 years later, 
even after researchers controlled for illness 
severity, mental health status, and demo -
graphics (Pargament, Koenig, Tarakesh -
war, & Hahn, 2001). Thus, the effects of 
religion and spirituality—  both positive and 
negative—  are substantial.
Religious Conversion 
and Spiritual  Transformation
Religious conversion has long been a topic 
of interest for researchers concerned with 
understanding personality and religion. Re -
ligious conversion can be counted as one of 
the first psychological topics to be scientifi -
cally studied (Starbuck, 1899), and the un -
derlying self processes of conversion receive 
considerable exposition in James’s (1902) 
seminal work, The Varieties of Religious 
Experience . Long-  standing interest in the 
study of religious conversions and spiritual 
transformations is in part attributable to 
the unique opportunity afforded by these 
phenomena to observe the dynamics of per -
sonality change. Due to a variety of factors, 
including genetic and environmental influ -
ences, person–  environment transactions, 
and crystallized self-  perceptions, researchers 
have found that adult personality is moder -
ately stable across the life course (Roberts & 
Nickel, Chapter 11, this volume). Religious/