Psychological Trauma: Theory, Research, Practice, and Policy © 2016 American Psychological Association

2016, Vol. 8, No. 3, 375–383 1942-9681/16/$12.00 http://dx.doi.org/10.1037/tra0000105

When Trauma, Spirituality, and Mental Illness Intersect: A Qualitative

Case Study
Vincent R. Starnino
Indiana University-Purdue University—Indianapolis

Objective: Studies have identified spirituality to be a helpful resource for dealing with various types of
trauma experiences. This coincides with a heightened focus on the role of spirituality within trauma-
related theory (e.g., spiritual coping, meaning-making, and posttraumatic growth). Little remains known,
however, about the relationship between trauma and spirituality among people with severe psychiatric
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

disorders. Meanwhile, a high percentage of those with psychiatric disabilities are known to have trauma
This document is copyrighted by the American Psychological Association or one of its allied publishers.

histories, whereas a majority self-identify as spiritual and/or religious. Method: Two cases from a
hermeneutic phenomenological qualitative study of people with co-occurring psychiatric disabilities and
trauma histories are highlighted. Themes related to trauma and spirituality are discussed in-depth.
Results: Study participants drew upon a variety of spiritual coping strategies (e.g., prayer, meditation,
spiritual readings) to help deal with trauma experiences. Participants additionally experienced spiritual
struggles—a detailed account is given of a participant who was able to work through such struggles by
shifting to a less self-blaming spiritual worldview (e.g., shifted from believing in a “punishing God” to
viewing oneself as part of “oneness with humanity”). The study also examined the meaning-making
process and shows how concepts such as global and appraised meaning-making are applicable to people
with psychiatric disabilities. Finally, unique challenges related to posttraumatic growth are discussed
(e.g., intrusive ruminations and “voices” with spiritual themes). Conclusion: This study offers useful
examples of how spirituality and trauma can impact one another, and how people with psychiatric
disabilities draw upon spirituality to cope as they strive for recovery.

Keywords: trauma, spirituality, mental illness, meaning-making, posttraumatic growth

Supplemental materials: http://dx.doi.org/10.1037/tra0000105.supp

In recent years, policymakers have called attention to the high
rate of traumatic experiences among consumers of mental health
services concluding that a majority of those with psychiatric dis-
abilities are trauma survivors (Substance Abuse and Mental Health
Services Administration, 2014). This has led to a greater under-
standing of the impact that trauma can have on people’s ability to
respond effectively to treatment and an ongoing push for practi-
tioners to become more skilled at providing trauma-informed care.
Research studies have shown spirituality and religion to be helpful
resources for dealing with a variety of trauma events including
rape, sexual abuse, life-threatening illnesses, and loss of a loved
one (Shaw, Joseph, & Linley, 2005).This coincides with an ex-
pansion in trauma theory, with several scholars pointing to the
spiritual dimension as integral for understanding and treating
trauma (e.g., Calhoun, Cann, Tedeschi, & McMillan, 2000; Par-
gament, Desai, McConnell, & Calhoun, 2006; Park, 2005).
Despite these efforts, little is known about the relationship
between trauma and spirituality for people with the most severe
mental illnesses (SMIs; e.g., major depressive disorder, bipolar
This article was published Online First January 18, 2016.
Correspondence concerning this article should be addressed to Vincent R.
Starnino, School of Social Work, Indiana University-Purdue University—
Indianapolis, 902 West New York Street, Indianapolis, IN 46202. E-mail:
vstarnin@iupui.edu
disorder, schizophrenia)— existing studies and theories have given
little focus to this population. This is important considering studies
consistently report spirituality and/or religion play an important
role in the lives of most of those with psychiatric disabilities (e.g.,
approximately 90%; Corrigan, McCorkle, Schell, & Kidder, 2003)
and that a high percentage draw upon these to cope (e.g., over
80%; Tepper, Rogers, Coleman, & Malony, 2001). Further re-
search is needed to better understand the relationship between
trauma, spirituality, and SMI.
This article attempts to address this knowledge gap by briefly
exploring literature linking spirituality to recovery from SMI, as
well as existing theory on trauma and spirituality. Next, two cases
from a qualitative study are presented to illustrate the experience
of trauma and spiritualty for people with psychiatric disabilities.
Finally, findings from the case illustrations are linked back to the
literature to explore relevancy of existing theory.
Spiritual/Religious Coping
Spiritual/religious coping theorists recognize that many people
draw upon spiritual coping strategies during times of distress. In
Shaw et al.’s (2005) metareview of studies on the role of spiritu-
ality for people who have experienced trauma (e.g., sexual abuse,
serious medical illness), spirituality and religion were found to be
associated with meaning-making and self-growth following
trauma. Factors associated with spirituality functioning as a posi-
tive coping tool include viewing a higher power as a source of

375
 376 STARNINO
trust, believing in an afterlife, being part of a spiritual community,
and having an intrinsic style of religious belief (Shaw et al., 2005).
Scholars have begun to look at spiritual and religious coping
among people with SMI. A group of researchers from Geneva,
Switzerland conducted a study of 115 people with schizophrenia
receiving outpatient services and found that 71% of participants
used personal and community-based spiritual and religious-related
beliefs and practices for positive coping, including to help allay
depression and anxiety, prevent suicide, reduce substance use,
increase adherence to medications and psychosocial treatment,
experience a greater sense of self-fulfillment (i.e., hope, comfort,
enjoyment of life, self-respect), and to try to make sense of their
illness experience (Mohr, Brandt, Borras, Gilliéron, & Huguelet,
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2006). For 14% of the sample, the use of spiritual and religious
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coping was associated with negative effects, including “increased
delusions, depression, suicide risk, and substance abuse” (Mohr et
al., 2006, p. 1957).
Studies focusing on trauma and spirituality have similarly found
that spirituality and religion could function as a recovery-related
resource and/or an area of struggle (Exline & Rose, 2005; Parga-
ment et al., 2006). Pargament et al. (2006) reminded that not
everyone possesses the necessary spiritual resources to deal with
trauma effectively, pointing to three types of spiritual struggles
that could lead to distress and poor psychological adjustment.
These include interpersonal (e.g., conflict with one’s spiritual
community) and intrapersonal (e.g., religious-related doubts, fears,
or guilt) spiritual struggles, along with struggles with the divine
(e.g., feeling punished or abandoned by a divine source). Accord-
ing to spiritual coping experts, those who remain stuck in spiritual
struggles over a long period of time are at greater risk of experi-
encing long term mental health difficulties. However, those who
are able to change their spiritual coping strategies in response to
trauma are believed to be more likely to experience spiritual
struggles that are time-limited, and eventually grow from the
experience (Pargament et al., 2006).
Little has been written about spiritual and religious coping
among those who have experienced the dual issues of trauma and
SMI. In an early work, Fallot (1997) shared insights from individ-
ual and focus group interviews, as well as clinical discussions,
with female outpatient clients with SMI who had trauma histories.
The author found that many of the women interviewed relied on
their relationship with a sacred source to experience a sense of
safety and comfort, as well as strength to rebuild one’s sense of
self following trauma. They additionally relied on spirituality and
religion to experience a sense of hope, courage, gratitude, and
forgiveness, all of which contributed to their trauma recovery.
Fallot and Heckman (2005) later conducted a survey study con-
sisting of women trauma survivors dually diagnosed with a DSM-
related mental health issue and substance use disorder. The study
found that a majority of the sample used positive, as opposed to
negative, religious coping. There was no relationship found, how-
ever, between religious coping and past and current trauma, except
for repeated childhood sexual abuse, which was related to negative
religious coping (e.g., feeling abandoned by one’s sacred source).
Similarly, Harris et al. (2010) conducted a study that looked at the
relationship between prayer and posttraumatic growth and found
that those who experience interpersonal trauma (including sexual
abuse) had greater difficulty using prayer for positive coping.
Meaning-Making
According to meaning-making literature, trauma can challenge a
person’s sense of meaning, and, in some cases, lead to a sense of
meaninglessness (Triplett, Tedeschi, Cann, Calhoun, & Reeve,
2012). This was acknowledged in Fallot and colleagues’ (Fallot,
1997; Fallot & Heckman, 2005) work with dually diagnosed
women trauma survivors, as many of the women questioned their
religious faith following trauma. Some, however, were able to
work through their loss of meaning and eventually arrive at an
expanded spiritual understanding (e.g., trauma caused them to seek
spiritual wisdom which helped them become stronger) and life
purpose.
Park (2005, 2010) introduced a model explaining the meaning-
making process that people engage in following stressful life
events. It includes concepts such as “global meaning” (internal
cognitive structures that influence how one understands reality—
also referred to as global or core beliefs) and “global goals”
(“internal representations of desired outcomes that motivate people
in their lives”; Park, 2005, p. 709); along with “appraised mean-
ing,” which has to do with the meaning ascribed to a specific
event. According to Park (2005), spirituality and religion can be
central orienting systems for many people, forming the foundation
from which global beliefs and goals stem. These could also be
significant influencing factors in the initial appraised meaning that
is made following a traumatic event (e.g., a religious person who
interprets a traumatic event as being “God’s will”; or as “a pun-
ishment from God”). Spiritually and/or religiously-oriented indi-
viduals who experience discrepancy between their initial appraised
meaning and global meaning will either look to reappraise the
meaning of the event to fit with their existing global meaning-
making system (e.g., reinterpreting a trauma event as being an
opportunity for spiritual growth) or seek to make changes to their
global meaning system in effort to accommodate the trauma (e.g.,
no longer believing that God is all powerful; changing one’s
spiritual orientation; Park, 2005). Park’s meaning-making model
has yet to be applied to people with SMI who are trauma survivors.
One of the goals of the current study is to examine the model’s
relevance for this population.
Posttraumatic Growth
Posttraumatic growth (PTG) scholars believe that trauma expe-
riences, especially if severe enough, can cause a person to enter
into a state of disequilibrium in which previously held ways of
viewing the world come into question (e.g., “How could this
happen to me?”; Taku, Cann, Tedeschi, & Calhoun, 2009; Triplett
et al., 2012). The sense of discomfort that comes with being in
such a state can motivate a person to seek new ways of making
sense of, or arrive at a resolution for, what has occurred which
could lead to opportunity for positive growth.
Triplett et al. (2012) noted the key role of cognition, or thinking,
in the PTG process, distinguishing between “intrusive rumination”
and “deliberate rumination.” Intrusive rumination consists of the
often unpleasant thoughts and images that occur automatically and
beyond one’s control. Intrusive ruminations are believed to be a
natural way of processing traumatic life events. However, if con-
tinued over the long-term without resolution, such rumination is
not viewed as constructive, as a person is likely to experience more
severe and chronic trauma-related symptoms (Taku et al., 2009).
 TRAUMA, SPIRITUALITY, AND MENTAL ILLNESS
Deliberate rumination differs in that it involves a more reflective
and intentional effort to come to a meaningful understanding of the
trauma event(s). Deliberate rumination is viewed as contributory to
PTG. Scholars recognize that for many people, questioning and
ruminative thinking following trauma are based on spiritual/reli-
gious themes (Calhoun et al., 2000). The ability to adapt or change
one’s spiritually-related thinking in a manner that accommodates
the trauma event is viewed as a key factor for achieving PTG.
The PTG literature has thus far not given much focus to people
with SMI who have experienced trauma. As a result, little is
known about the role of spiritually-related ruminations for this
population. This is important considering that between 6% to 36%
of those with psychotic disorders have been found to experience
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delusions with spiritual content (i.e., “religious delusions”; Mohr
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& Huguelet, 2004). Mohr and Pfeifer (2009) noted that it can be
difficult to distinguish between a “false belief” and “strongly held
belief” that is idiosyncratic. In comparing psychotic-related and
mystical spiritual experiences, scholars point out in both cases a
person may experience a sense of “spiritual presence,” being
“outside time,” and/or an “altered sense of self” (Jackson, 2001, p.
166); as well as “abnormal feelings of importance” and/or a “belief
that one is being sent signs from God” (Chadwick, 2000, p. 42). A
distinguishing factor may be that the mystic intentionally delves
deeply into the spiritual realm and is well-prepared, whereas those
with psychotic disorders often enter unintentionally and unpre-
pared, potentially experiencing fragmentation as a result (Lukoff,
2005).
The terms spiritual emergency and spiritual crisis are used
interchangeably to refer to experiences in which a person could
temporarily lose touch with reality as a result of either engaging in
intense spiritual practices (e.g., intense meditation), experiencing
sudden religious conversion, or dealing with profound life issues
(e.g., loss of a close relationship; Lukoff, 2007; Huguelet & Mohr,
2009). Huguelet and Mohr (2009) reminded that a spiritual crisis
can function as a precipitating factor in psychosis for individuals
predisposed to developing psychotic disorders, and the two (spir-
itual crisis and psychotic symptoms) can become entangled. In
such cases, clinicians are urged to assess for, and treat, both the
underlying spiritual crisis and psychotic symptoms. For individu-
als who are not predisposed to developing a diagnosable psychotic
disorder, loss of reality due to a spiritual crisis/spiritual emergency
typically resolves within a few days with proper rest, nutrition,
support, and refraining from intense spiritual practices (Lukoff,
2007).
Considering the various types of spiritual experiences that are
possible, the clinical picture can be complicated when working
with people with SMI who have trauma histories. The source of a
person’s spiritual experiences (e.g., mystical state, spiritual crisis,
delusion) can be unclear. Also, little is known about the impact of
psychosis on a person’s ability to process trauma (engage in
ruminative thinking) and achieve PTG. The current study further
explores this area.
Below, two cases are presented from a recently published qual-
itative study (Starnino, 2011; Starnino & Canda, 2014). The main
focus of the original study was to better understand the role of
spirituality in the recovery process of people with psychiatric
disabilities. Research questions focused on the following: (a) how
participants define spirituality and religion, (b) current and past
spiritual activities and beliefs, (c) barriers and challenges related to
377
use of spirituality, and (d) spiritual meaning-making. Despite none
of the research questions asking directly about trauma, in the
context of sharing their stories several study participants men-
tioned experiencing trauma, whereas two participants shared ex-
tensively about the impact of trauma on spirituality, and vice versa.
This article focuses on a subset of findings related to “trauma and
spirituality.”
Methods
The study’s methodology was based on a hermeneutic phenom-
enological qualitative research approach (Moustakas, 1994; Pat-
ton, 2002; van Manen, 1990). Hermeneutic phenomenology is an
interpretive approach focused on gaining deep understanding of
how people subjectively experience a phenomenon, including the
meaning-making process. This fit the original study’s goal of
achieving deep understanding of the role of spirituality in recov-
ery, as well as the specific goal of comprehending how trauma and
spirituality impact one another among people with SMI.
Sampling and Recruitment
Participants were recruited from community mental health cen-
ters and consumer run organizations in a Midwestern state with the
assistance of agency leaders and staff. Eligibility criteria included
having a SMI diagnosis (e.g., schizophrenia, bipolar disorder,
major depression) and receiving services at one of the participating
agencies. Those who met the required criteria and were interested
in participating were invited to join (purposive sampling; Patton,
2002). The original study included 18 adults (12 female, six male).
Two interviews were conducted with each participant (approxi-
mately 2[1/2] to 3 hr total interview time for each). The study was
approved by the human subjects research Institutional Review
Board at the author’s university.
Data Analysis and Trustworthiness
An initial step of data analysis consisted of arranging the data
into broad theme categories— one of which was labeled spiritual-
ity and trauma. Initial coding of all of the data under the spiritu-
ality and trauma theme category was conducted by assigning codes
that closely represented participants’ statements. This resulted in
the creation of a codebook that was then used to code all data
systematically. Upon completing this step, it was discovered that
11 out of 18 participants revealed experiencing trauma. Types of
trauma mentioned include childhood abuse (including physical,
emotional and sexual abuse; eight participants) and being involved
in a serious accident either as a child or young adult (including
severe head injury from a fall, burn victim, and being in a coma
from a motor cycle accident; three participants). Several partici-
pants additionally mentioned having a SMI experience that was
traumatic. Mental illness-related trauma included trauma con-
nected to the actual mental illness experience (e.g., confusion and
turmoil associated with experiencing psychosis), a traumatizing
hospitalization experience (e.g., involuntary hospitalization, forced
medications, use of restraints), and trauma resulting from the
impact of having a SMI diagnosis (e.g., having one’s children
taken away, being unable to complete graduate school). Two
participants provided a great amount of detail about how their
 378 STARNINO

trauma and spirituality impacted one another. Additional analytic Findings: Exploring Themes in the Context of Two
steps were conducted with these two participants, forming the Life Journeys
basis for this article.
According to Patton (2002), data coding represents the descrip- This section includes stories highlighting key life events related
to trauma and spirituality for two study participants (James and
tive phase of analysis, which “builds a foundation for the inter-
Helen). Themes are presented in the context of each participant’s
pretive phase when meanings are extracted from data” (p. 465).
life journey. Major themes are classified into three categories
The next phase of data analysis included deeper level theme
including (a) spiritual coping, (b) meaning-making, and (c) recov-
development in which underlying meanings and patterns associ-
ery propensity. Theme categories include associated subthemes as
ated with each participant’s account were identified (e.g., the
described in Table 1. Some details of participants’ stories (e.g.,
subtheme “manner of use” describes how participants relied upon name, age) have been adapted to protect their identities. However,
spiritual coping; van Moustakas, 1994; van Manen, 1990). An the quotes provided are exact words from transcribed interviews.
additional strategy included drawing upon all supporting data to
create individual narrative accounts of participants’ journeys
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(Moustakas, 1994). This included rereading the original and coded

James’s Story
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transcripts, along with the deeper level themes developed during
the previously described level of analysis, to portray a narrative
representative of each participant’s lived experience of spirituality
and trauma. Narratives contained both descriptive and interpretive
elements and became an important data source for understanding
the meaning pattern within each person’s story. The creation of
narratives also facilitated comparison across the two cases in
which similarities and differences were identified.
Data analysis was influenced by both deductive and inductive
thinking (Thomas, 2003). For example, major themes related to
spirituality and trauma were influenced by the author’s a priori
knowledge of the literature (i.e., spiritual coping, meaning-making,
recovery propensity), while subthemes emerged deductively from
analysis of the transcribed data (e.g., types of spiritual coping and
meaning-making).
As part of a verification process, the study drew upon the
services of a methodological consultant with expertise in qualita-
tive research methods with whom the codebook, narratives, along
with a copy of the transcripts with thematic notes, were shared and
feedback given. In addition, a panel consisting of persons with
psychiatric disabilities, professionals, and supervisors from a local
mental health center was consulted for feedback at two separate
points during the study, including on a preliminary report of major
themes following analysis (a strategy recommended for establish-
ing credibility of findings; Lincoln & Guba, 1985). Further details
on methods and data analysis for this study are described else-
where (Starnino, 2011).
James is a 28-year-old Native American male. During child-
hood, he regularly attended sweat lodges and powwows and also
attended a Christian church with a grandparent. As a child, James
experienced anger issues and had fights at school. He began
consuming alcohol in his teen years. In his early 20s, James
became the primary caretaker for his grandmother who had cancer.
She died within a year of moving in with her. A week later, his
father died suddenly. This culminated in James consuming large
amounts of alcohol and becoming homeless. He soon began to
“hear voices” and ended up incarcerated. While in jail, James
reports hearing voices of “demons,” stating, “I was fighting de-
mons and everything. Because I thought the evil spirits were
telling me stuff like my family was dead, the world was going
through a purgatory, and I’m hearing people getting tortured.”
James fully believed that he was in the middle of “a battle between
good and evil.” His jail experience lasted over a month until he
was sent to a psychiatric hospital where he was diagnosed with
schizophrenia. James currently lives in a group home and takes
medications. However, he continues to hear voices of demons—
albeit not as strongly as in the past. James’s primary trauma
experiences include (a) the successive deaths of two close family
members, and (b) his ensuing jail experience in which he “battled
demons.”
James—Spiritual Coping
Spiritual activities and resources. James relies on a variety
of spiritual coping activities stemming from his Native American

Table 1
Theme Categories and Associated Subthemes for “Trauma and Spirituality”

Theme categories Associated subthemes and definitions

Spiritual coping Spiritual coping activities and resources include types of spiritually-related activities and resources that participants rely upon
in their daily lives.
Manner of use represents the manner in which participants utilize spiritual resources as they deal with their trauma and SMI.
Spiritual struggles gives focus to the nature of participants’ spiritual struggles and their ability to work through these in relation
to dealing with both trauma and SMI.
Meaning-making Meaning of severe mental illness represents the manner in which participants rely on spirituality to make meaning of their SMI.
Meaning of trauma focuses on how participants draw upon spirituality to find meaning related to trauma.
Meaning of life examines how participants rely upon spirituality to experience a sense of meaning and purpose in their lives in
general.
Recovery propensity Represents the degree of positive growth and recovery that a person has been able to achieve following trauma.
Note. SMI ⫽ severe mental illness.
 TRAUMA, SPIRITUALITY, AND MENTAL ILLNESS
and Christian roots including prayer, meditation, artwork, drum-
ming, peyote (in past), tea ceremony, flute music, positive affir-
mations, nature, sweat lodge, and gourd dance.
Manner of use. James tends to draw upon spiritually-related
activities and resources primarily for the purpose of (a) experienc-
ing a range of positive emotions (e.g., hope, gratitude, feeling
peace and calm, sense of freedom), and (b) dealing with ongoing
mental illness-related symptoms. Activities that help James expe-
rience an emotional lift include meditation, listening to Native
American drumming and flute music, and using positive affirma-
tions. In addition, he spoke about feeling “cleansed” and a sense of
“enlightenment” after engaging in a Native American sweat lodge
ceremony. James’s involvement in creating artwork based upon
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spiritual themes (e.g., paintings of “Guardian Spirits”) is especially
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meaningful. He describes how he benefits from engaging in this
activity:
James: When I finish artwork it gives me a sense that I
done something good.
Researcher: Okay, I understand.
James: Like I accomplished something, being success-
ful at something.
James draws regularly upon spirituality to help deal with un-
wanted symptoms, including voices, substance use, anxiety, and
suicidal thoughts. James recounts relying on prayer during the
traumatic experience in which he heard voices of “evil spirits”
while in jail: “. . .they [voices] were telling me, ‘You’re the
anti-Christ,’ stuff like that. I was like ‘No.’ I’d say ‘No, I’m good.’
They kept trying to get me to go to the evil, be evil. I kept praying
and stuff.” James is convinced that prayer helped him emotionally.
Finally, James relies on his spiritual beliefs to assist in his struggle
with alcohol use. He explains, “I believe in treating my body like
a temple. Not putting alcohol or stuff like that in me. I’m trying to
stay clean, take my medicines.”
Spiritual struggles. James’s biggest spiritual struggle is the
difficulty of spirituality and symptoms intersecting in the form of
voices, visions, and nonconsensual reality type of beliefs (e.g.,
hearing the voice of Demons; believing he is in a battle between
good and evil). This struggle is ongoing and continues to have a
major impact on his life. An additional spiritual struggle for James
occurs as a result of engaging in particular spiritual activities. For
example, James proclaims that although he finds reading the Bible
to be a helpful resource at times, it could also cause the voices to
intensify: “Sometimes if I do start reading the Bible, like in the
past, I start getting negative voices saying ‘What are you doing that
for? You know you’re not (sic) nothing.’” James acknowledges
that his struggle may be related to his tendency to become overly
focused on his thoughts. He explains, “If I get carried away with
it, carried away with a thought or something like that, I can get
delusional.”
James—Meaning-Making
Meaning of severe mental illness. James struggles on an
ongoing basis to make sense of the demonic voices that he expe-
riences. He has mixed feelings about how he should interpret the
voices, stating, “I don’t know if it’s all in my head or if I’m
supposed to take it seriously and think maybe these are spirits
379
trying to talk to me.” James has discussed the voices with a
therapist but cannot decide whether they might be real or not.
James likewise has not arrived at a definite conclusion regarding
the meaning of his SMI experience and schizophrenia diagnosis.
He simply acknowledges that “It’s hard for me to deal with” and
“only the Creator knows”
Meaning of trauma. When asked about how he makes sense
of his traumatic jail experience in which he believed he was in a
battle between good and evil, James reports that the experience
actually helped strengthen his spiritual beliefs. He explains, “It’s
made me a believer. I used to believe before that, but now I truly
do believe there’s good and evil out there . . . It made me believe
that there really is a Creator or God out there.” James reports that
his strengthened belief helps him to face ongoing life challenges
including housing issues, along with challenges related to mental
health symptoms and substance use.
Meaning of life. Despite experiencing an array of challenges,
James has managed to arrive at a place in which he believes that
his life is meaningful. He explains:
I believe there’s a reason for me to be alive, or I would have died. I’ve
tried to kill myself before in the past. That was because I couldn’t take
the symptoms I was getting. That’s how bad they used to be. I’d feel
real bad. I’d be crying a lot . . . But I never succeeded so I believe God
. . . I’m meant to do something because I didn’t succeed.
From the above excerpt, it is clear that James’s spiritual beliefs
allow him to be hopeful that his life is meaningful. However, he
remains unclear about what his specific purpose might be.
James—Recovery Propensity
At the time James’s participated in the study, 8 years had passed
since his jail experience and initial psychiatric hospitalization. For
a lengthy period, he had struggled with alcohol use and homeless-
ness. This resulted in inconsistent follow-up with mental health
treatments. James was hospitalized a few months prior to the
interviews and living in a group home. He appeared to be taking
positive steps toward his recovery in that he had not used alcohol
for 3 months and had been taking psychiatric medications regu-
larly. However, he continued to hear voices of demons on a daily
basis, and this posed a significant challenge to his recovery.
Helen’s Story
Helen is a 42-year-old Caucasian female. She had a Christian
upbringing in which she was introduced to a “vengeful God
image.” Helen was sexually abused by a family member beginning
in her early teen years and interpreted the abuse as a punishment
from God due to having “had sinned in some way.” While in
graduate school in her early twenties, Helen began to experience
flashbacks along with accusatory voices and hallucinations related
to the sexual abuse. She explains, “I heard voices saying that I was
selected . . . I believed I deserved what was happening to me.”
Eventually, Helen attempted suicide and experienced her first of a
string of psychiatric hospitalizations. This led to her becoming
homeless and unable to complete graduate schooling. About 10
years ago, Helen began to explore spiritual themes related to her
sexual abuse experience with a therapist. As a result, she was able
to “let go” of many of her negative religious interpretations and
 380
adopt a more adaptive spiritual framework. Helen currently has a
job and strong social support network, is involved in advocacy
work, and has not been hospitalized in several years. Her current
diagnosis is schizoaffective disorder (past diagnosis was PTSD).
Helen’s primary trauma experiences include (a) sexual abuse she
experienced as a teenager, and (b) psychotic symptoms and their
subsequent impact (i.e., repeated hospitalizations, homelessness,
and having to drop out of graduate school).
Helen—Spiritual Coping
Spiritual activities and resources. Helen’s spiritual activities
include reading self-help books with spiritual themes, spending
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time in nature, interacting with positive peers, keeping a gratitude
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journal, and meditation. These reflect her movement toward a
personalized spirituality.
Manner of use. Similar to James, Helen relies upon her
spirituality to experience positive thinking and emotions on a daily
basis. Helen, for example, describes the positive emotional impact
of keeping a gratitude journal:
It’s a spiritual thing where you sort of let go and just write down
things, like with me things come up that I hadn’t thought about before,
like “Maybe I should be more tolerant of people. Maybe I should be
less judgmental today when I start my day.” It’s more like you let your
mind go and just write . . . once you get it on paper it sort of releases
it.
Helen’s newly developed spiritual framework has helped her to
counter her past negative self-concept related to sexual abuse in
which she believed that she was alone and “unworthy” in the eyes
of God. Her renewed spiritual outlook, for example, is centered on
the idea that all beings are connected (e.g., “That oneness, yes, the
oneness that we’re all connected”). Helen’s belief in “connected-
ness” and “oneness” has resulted in her perceiving herself as a
“valued spiritual being,” similar to all beings.
Spiritual struggles. A primary area of spiritual struggle for
Helen was her longstanding interpretation of the sexual abuse as a
punishment from God, along with experiencing accusatory voices
and visions that followed a similar religious theme. Through time,
however, she managed to work through these struggles to a sig-
nificant degree. Helen acknowledges that medications played a
role in her recovery. However, she credits her work with a trusted
therapist and renewed spirituality as essential components. Her
“working through” included a process of exploring, and eventually
“letting go” of, some of the negative spiritually-related interpreta-
tions of the abuse that she had been carrying from her upbringing.
Eventually, Helen managed to develop a more positive spiritual
framework— one that allowed her to interpret the childhood abuse
in a less self-blaming manner. (See Meaning of Trauma section
below for further details).
Helen—Meaning-Making
Meaning of severe mental illness. Helen’s journey demon-
strates a progression in regard to how she makes sense of her SMI
experience. In the past, she believed that her mental illness was
God punishing her because of the abuse that she experienced. One
shift is that Helen has become more accepting of biological factors
(e.g., “The mental illness is just brain chemistry, misfiring in my
STARNINO
brain.”). However, her ability to move away from a self-
stigmatizing spiritual outlook to one that is more positive and
adaptive has had a large influence. Helen explains,
[In the past] I would think “Well, I am separate and I am different
because I have these challenges and the mental illness,” and then I
realized that everybody has something that they’re struggling with . . .
even though I’ve been diagnosed doesn’t mean that my struggles are
harder or worse than somebody who has not been diagnosed . . . It
goes back to viewing myself as part of the universe, as part of
humanity. Like saying to myself “Well, welcome to humanity, you
have depression today, welcome to humanity.”
Meaning of trauma. Helen’s sense of connectedness with a
higher source and the world around her, including to other people,
has allowed her to reframe the way she views the sexual abuse she
experienced. This is evident in the following quotes:
Before I would think, “God doesn’t like me.” Now I see myself as
being part of a greater, higher power that sort of makes me part of
humanity.
I believe that my [abusing family member] was sick and he took it out
on me.
Below, Helen discusses how her belief in reincarnation helps her
find meaning related to her trauma experiences:
I believe that everybody has a certain role that they have to play in life
and you have certain challenges that you’re supposed to work out.
And I do believe that when you die your spirit goes on to another
adventure and you continue to work on what you’re supposed to learn.
Helen’s belief in reincarnation plays a role in her being able to
reframe her trauma experiences as an opportunity for growth as
opposed to a “punishment”. Furthermore, her belief that “your
spirit goes on to another adventure” provides her with a sense of
hope that her experiences have ongoing significance beyond her
current life circumstances.
Meaning of life. As evidenced above, Helen has managed to
find deep meaning related to the adversities she has confronted
throughout her life. In addition to believing that life is meaningful,
Helen has a clear sense of life purpose, which is to help others who
have experienced similar life challenges.
I found out that there is a purpose in my life and I can do things that
I thought I couldn’t do before and I can help other people . . . I know
people that are still at the mental health center who have no hope in
their life, they feel like this is the best it’s going to get. It’s not very
good. And I want to say to them “Well, did you ever just get a phrase
in your head that will make you feel better,” like from the Course of
Miracles, I’m paraphrasing, but “Every situation, in every situation,
there can be a miracle happening.”
Throughout the past several years, Helen has managed to take
action in fulfilling her life purpose. She helps others through
involvement in peer-to-peer work and mental health advocacy.
Helen—Recovery Propensity
In addition to helping others, there were additional ways that
Helen’s spirituality was linked to her recovery. By being motivated
to grow spiritually, Helen became more willing to challenge her-
self and engage in activities that are independent from the mental
 TRAUMA, SPIRITUALITY, AND MENTAL ILLNESS
health system. At the time of the interviews, she had been em-
ployed for over a year and considered having a job in the com-
munity as providing a sense of purpose, and therefore a central
aspect of her recovery.
Discussion
Research studies and theoretically-based scholarly writings
point to spiritual coping as helpful for dealing with a variety of life
stressors, including the SMI experience (Huguelet & Koenig,
2009; Koenig, King, & Carson, 2012; Shaw et al., 2005). Aside
from Fallot and colleagues’ (Fallot, 1997; Fallot & Heckman,
2005) work with dually diagnosed women trauma survivors, little
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
focus has been given to spiritual coping among people with psy-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
chiatric disabilities with trauma histories. The current study pro-
vides insight into ways people with psychiatric disabilities utilize
positive spiritual coping to help deal with trauma, as participants
drew upon a wide array of spiritual resources to help experience a
range of positive emotions (e.g., hope, gratitude, forgiveness), deal
with mental illness-related symptoms (e.g., depression, “voices”,
alcohol use), and establish a positive self-identity (e.g., Helen
came to view herself as a “spiritual being” and “a soul”). This
finding mirrors current strengths and recovery-based approaches
which acknowledge spirituality as a potentially important resource
for people with SMI (Whitley & Drake, 2010).
Scholars have begun to take a closer look at the role of spiritual
struggles and their connection to the meaning-making and PTG
process (Pargament et al., 2006). The current study offers insights
about spiritual struggles among people with psychiatric disabilities
who have trauma histories, and the manner in which these are
worked through over time. Helen’s case is particularly informa-
tive, as she was able to eventually achieve positive integration of
her spirituality, trauma, and recovery. Her journey exhibited the
prototypical meaning-making process described in the literature
(Park, 2005, 2010). Helen’s global meaning prior to experiencing
trauma consisted of a belief in a vengeful God image. Once she
experienced sexual abuse, her appraised meaning of the trauma
was influenced by her existing negative spiritual lens which caused
her to believe that she was somehow a “sinner” and being “pun-
ished” by God—these are commonly noted spiritual struggles
among trauma survivors that can lead to poor mental health out-
comes if left unresolved (Pargament et al., 2006).
Eventually, Helen was able to address the trauma with a thera-
pist and change her appraised meaning (e.g., “It’s not my fault,”
“My [caregiver] was sick”). She was also able to change her global
meaning-making system by moving away from a belief in a
punishing God toward a more personalized spirituality based on
“oneness” and “connectedness to humanity.” As a result, Helen
was able to “let go” of the self-blame she was carrying. In addition
to changing her global beliefs, Helen also experienced a shift in her
global goals (e.g., goal of helping others with similar experiences).
Helen’s case is consistent with spiritual coping theory which posits
that flexibility of one’s spiritual beliefs through time is important
for being able to work through spiritual struggles and use one’s
spirituality as a positive resource for recovery (Pargament et al.,
2006).
James’s meaning-making process was less prototypical, as he
was unable to clearly articulate how he makes meaning. Never-
theless, he reported that his previous spiritual worldview was
381
somehow strengthened following his traumatic experiences and
that despite his life difficulties, he managed to experience a “felt
sense” that life is meaningful. Park (2010) similarly described a
“sense of having made sense” as being a common outcome asso-
ciated with meaning-making (p. 260). The study’s findings point to
Park’s (2005, 2010) meaning-making model as a potentially help-
ful framework for understanding the meaning-making process of
people with psychiatric disabilities who experience trauma. Fur-
ther research is needed to verify these findings.
PTG scholars emphasize the important role that cognition plays
in the growth process following trauma, including spiritually-
based cognitions (Taku et al., 2009; Triplett et al., 2012). Accord-
ing to the literature, intrusive rumination is considered a natural
part of the PTG process. However, it is important for a person to
eventually engage in a more reflective and intentional thinking
process in order for deeper healing to occur (i.e., deliberate rumi-
nation). The cases presented in this study illustrate that there can
be marked differences in the PTG process among people with
psychiatric disabilities. Helen’s PTG process closely mirrors what
is described in the literature, as she was initially flooded by
intrusive thoughts and images following her trauma, including
religious-related persecutory voices. With the help of a therapist
and medication treatment, however, she was eventually able to
engage in a more deliberate thinking process and achieve a rela-
tively high level of PTG. James primarily experienced strong
intrusive thoughts in the form of “evil voices.” As a result, it
remained a challenge for him to engage in deliberate rumination.
James’s case suggests that some people with SMI may have
difficulty benefitting fully from the emotional and cognitive pro-
cesses described in the PTG literature.
Practitioners could play an important role by supporting clients
who rely upon spirituality to deal with daily stressors, including
negative emotions and symptoms, and also by exploring ways in
which spirituality impacts self-concept. The latter is especially
important considering that people with SMI commonly develop a
negative self-concept due to experiencing both internalized and
externalized stigma. Recovery-oriented practice principles for ad-
dressing spirituality with people with SMI have been developed
(Starnino, Gomi, & Canda, 2014).
In addition to supporting clients’ recovery-related spiritual re-
sources, practitioners could assist clients with psychiatric disabil-
ities as they work through trauma-related spiritual struggles, in-
cluding struggles related to meaning-making. Both participants in
the current study mentioned benefiting from discussing spiritual
struggles with a trusted therapist. In neither case did the practitio-
ner dismiss their spiritual struggles as “negative spirituality.” Prac-
titioners who understand spiritual struggles as a natural part of the
spiritual growth process are more likely to refrain from dichoto-
mizing clients’ spiritual beliefs and experiences into oversimpli-
fied categories (e.g., viewing spiritual resources as “all good” and
spiritual struggles as “all bad”; Pargament et al., 2006). It is
important for practitioners to recognize that it is how one works
through spiritual struggles that is most important (Pargament et al.,
2006; Exline & Rose, 2005).
An exception may be clients who are in the midst of experienc-
ing intense psychotic symptoms. In such cases, it would seem to
make sense for clinicians to address the client’s symptoms first
before engaging in deep spiritual exploration and meaning-making
(Koenig, 2008). A challenge, however, is that although some
 382 STARNINO
scholars advocate for practitioners to be able to determine the
source of clients’ spiritual experiences and beliefs (e.g., “mystical”
vs. “spiritual crisis” vs. “mental illness-related”) to plan effective
treatment, there is no empirical evidence, or empirically validated
assessment tool, confirming that an accurate discernment can be
made (Huguelet & Mohr, 2009). The lines between what could be
considered “normal” versus “illness-related” spiritual expressions
are often blurred (Mohr & Pfeifer, 2009; Lukoff, 2005; Starnino &
Canda, 2014). This is highlighted in the case of James, whose
psychotic symptoms appeared to impact his spirituality in an
ongoing manner. However, he still managed to benefit through
engaging in spiritual practices (e.g., spiritual artwork). In addition,
James mentioned experiencing a spiritual teaching stemming from
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
his traumatic jail experience in which he heard voices of demons
This document is copyrighted by the American Psychological Association or one of its allied publishers.
(e.g., strengthened his belief in a Creator). Lukoff (2007) similarly
pointed out that a person may have authentic spiritual experi-
ences while simultaneously experiencing mental illness symp-
toms. (Further details available in online additional Supplemen-
tal Material A.)
Huguelet and Mohr (2009) advocate for practitioners to be open
to the possibility that some clients may need assistance in dealing
with a very relevant spiritual issue (spiritual crisis) that has be-
come entangled with psychotic symptoms. This may have been the
case with James early on when he experienced psychosis shortly
after the loss of two close family members. Mohr and Pfeifer
(2009), meanwhile, question the usefulness of the term religious
delusions, pointing to the stigmatizing effect that it can have on
clients. The authors maintain that rather than labeling clients’
beliefs as being true or false, practitioners should focus instead on
respectfully assessing the functional role of the client’s beliefs by
asking, “To what extent do the client’s spiritual or religious beliefs
assist with recovery, or contribute to poorer functioning?” The
answer to this question could give direction to treatment, which
may mean addressing clients’ spiritual issues, treating the mental
illness symptoms, or both.
Some might question what type of practitioner is best suited to
address clients with needs related to all three areas of spirituality,
trauma, and SMI. Pastoral counselors are often accustomed to
addressing the spiritual impact of trauma but not all are trained to
deal with SMI. Meanwhile, mainstream therapists are commonly
trained to work with SMI and trauma diagnoses but not all possess
the necessary knowledge, or comfort level, to deal effectively with
spiritual issues (Starnino et al., 2014). According to Huguelet and
Koenig (2009), mental health practitioners and pastoral counselors
can both play important roles by gaining specialized training
beyond that which is normally offered in graduate schooling and
by working collaboratively in effort to treat clients holistically.
Limitations and Conclusion
This article provides insights regarding the relationship among
spirituality, trauma, and SMI. The case presentations offer useful
examples of how spirituality and trauma can impact one another,
and how people with psychiatric disabilities draw upon spirituality
in the aftermath of trauma as they strive for recovery. In addition,
it appears that several concepts from existing theory addressing
trauma and spirituality (e.g., spiritual/religious coping, meaning-
making, PTG) have relevancy for people with psychiatric disabil-
ities. The current study supports findings from Harris et al., (2015)
showing that a majority of people with SMI are interested in
discussing spirituality with a mental health provider and are able to
do so in a manner that is both reliable and credible. This being
said, the mental health field would benefit from further research
and theory development to better understand the intersection of
psychiatric symptoms and spirituality, and its impact on trauma
recovery.
The study’s findings are not meant to be generalizable. A future
study with a larger sample is needed to determine the extent to
which observations from the current study apply to the wider
population of people with psychiatric disabilities. It is suspected
that a future study including a more culturally and religiously
diverse sample from a wider geographical region will demonstrate
additional pathways representing the manner in which spirituality
and trauma impact one another, and are navigated, in the lives of
people with psychiatric disabilities.
Despite limitations, this article is timely owing to an increased
recognition of the high rate of trauma histories among people
receiving mental health services, along with studies showing that
spirituality and/or religion plays a significant role in the lives of a
majority of those with psychiatric disabilities. There is a dearth of
research studies examining the relationship between trauma and
spirituality among those diagnosed with severe psychiatric disor-
ders. It is hoped that insights from the current study can be of
benefit to mental health practitioners who are considering incor-
porating the spiritual dimension as part of trauma treatment.
References
Calhoun, L. G., Cann, A., Tedeschi, R. G., & McMillan, J. (2000). A
correlational test of the relationship between posttraumatic growth,
religion, and cognitive processing. Journal of Traumatic Stress, 13,
521–527. http://dx.doi.org/10.1023/A:1007745627077
Chadwick, P. (2000). Spiritual experience or religious psychosis? Nursing
Times, 96, 42– 43.
Corrigan, P., McCorkle, B., Schell, B., & Kidder, K. (2003). Religion and
spirituality in the lives of people with serious mental illness. Community
Mental Health Journal, 39, 487– 499. http://dx.doi.org/10.1023/B:
COMH.0000003010.44413.37
Exline, J. J., & Rose, E. (2005). Religious and spiritual struggles. In R. F.
Paloutzian & C. L. Park (Eds.), Handbook of the psychology of religion
and spirituality (pp. 315–330). New York, NY: Guildford Press.
Fallot, R. D. (1997). Spirituality in trauma recovery. In M. Harris (Ed.),
Sexual abuse in the lives of women diagnosed with severe mental illness.
Newark, NJ: Harwood Academic Publishers.
Fallot, R. D., & Heckman, J. P. (2005). Religious/spiritual coping among
women trauma survivors with mental health and substance use disorders.
The Journal of Behavioral Health Services & Research, 32, 215–226.
http://dx.doi.org/10.1007/BF02287268
Halpern, J. H., Sherwood, A. R., Hudson, J. I., Yurgelun-Todd, D., & Pope,
H. G., Jr. (2005). Psychological and cognitive effects of long-term
peyote use among Native Americans. Biological Psychiatry, 58, 624 –
631. http://dx.doi.org/10.1016/j.biopsych.2005.06.038
Harris, J., Erbes, C., Engdahl, B., Tedeschi, R., Olson, R., Winskowski, A.,
& McMahill, J. (2010). Coping functions of prayer and posttraumatic
growth. The International Journal for the Psychology of Religion, 20,
26 –38. http://dx.doi.org/10.1080/10508610903418103
Harris, J., Nienow, T., Choi, A., Engdahl, B., Nguyen, X. V., & Thuras, P.
(2015). Client report of spirituality in recovery from serious mental
illness. Psychology of Religion and Spirituality, 7, 142–149. http://dx
.doi.org/10.1037/a0038538
 TRAUMA, SPIRITUALITY, AND MENTAL ILLNESS
Huguelet, P., & Koenig, H. G. (2009). Religion and spirituality in psychi-
atry. New York, NY: Cambridge University Press. http://dx.doi.org/10
.1017/CBO9780511576843
Huguelet, P., & Mohr, S. (2009). Religion/spirituality and psychosis. In P.
Huguelet & H. Koenig (Eds.), Religion and spirituality in psychiatry
(pp. 65– 80). New York, NY: Cambridge University Press. http://dx.doi
.org/10.1017/CBO9780511576843.006
Jackson, M. (2001). Psychotic and spiritual experience: A case study
comparison. In I. Clark (Ed.), Psychosis and spirituality: Exploring the
new frontier (pp. 165–190). London, UK: Whurr.
Koenig, H. G. (2008). Religion and mental health: What should psychia-
trists do? Psychiatric Bulletin, 32, 201–203.
Koenig, H. G., King, D., & Carson, V. B. (2012). Handbook of religion and
health (2nd ed.). New York, NY: Oxford University Press.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Lincoln, Y., & Guba, E. (1985). Naturalistic inquiry. Newbury Park, CA:
Sage.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Lukoff, D. (2005). Spiritual and transpersonal approaches to psychotic
disorders. In S. G. Mijares & G. S. Khalsa (Eds.), The psychospiritual
clinician’s handbook (pp. 233–257). New York, NY: Haworth Press.
Lukoff, D. (2007). Spirituality in the recovery from persistent mental
disorders. Southern Medical Journal, 100, 642– 646. http://dx.doi.org/
10.1097/SMJ.0b013e3180600ce2
Mohr, S., Brandt, P.-Y., Borras, L., Gilliéron, C., & Huguelet, P. (2006).
Toward an integration of spirituality and religiousness into the psycho-
social dimension of schizophrenia. The American Journal of Psychiatry,
163, 1952–1959. http://dx.doi.org/10.1176/ajp.2006.163.11.1952
Mohr, S., & Huguelet, P. (2004). The relationship between schizophrenia
and religion and its implications for care. Swiss Medical Weekly,
134(25–26), 369 –376.
Mohr, S., & Pfeifer, S. (2009). Delusions and hallucinations with religious
content. In P. Huguelet & H. Koenig (Eds.), Religion and spirituality in
psychiatry (pp. 81–96). New York, NY: Cambridge University Press.
http://dx.doi.org/10.1017/CBO9780511576843.007
Moustakas, C. E. (1994). Phenomenological research methods. London,
UK: Sage.
Pargament, K. I., Desai, K. M., McConnell, K. M., & Calhoun, L. G.
(2006). Spirituality: A pathway to posttraumatic growth or decline? In
R. G. Tedeschi (Ed.), Handbook of posttraumatic growth: Research &
practice (pp. 121–137). Mahwah, NJ: Erlbaum Publishers.
Park, C. L. (2005). Religion as a meaning-making framework in coping
with life stress. Journal of Social Issues, 61, 707–729. http://dx.doi.org/
10.1111/j.1540-4560.2005.00428.x
Park, C. L. (2010). Making sense of the meaning literature: An integrative
review of meaning making and its effects on adjustment to stressful life
events. Psychological Bulletin, 136, 257–301. http://dx.doi.org/10.1037/
a0018301
383
Patton, M. Q. (2002). Qualitative research and evaluation methods (3rd
ed.). London, UK: Sage.
Shaw, A., Joseph, S., & Linley, A. P. (2005). Religion, spirituality and
posttraumatic growth: A systematic review. Mental Health, Religion &
Culture, 8, 1–11. http://dx.doi.org/10.1080/1367467032000157981
Starnino, V. R. (2011). Severe mental illness and the recovery process:
Understanding the role of spirituality. ProQuest Dissertations Publish-
ing.
Starnino, V. R., & Canda, E. R. (2014). The spiritual developmental
process for people in recovery from severe mental illness. Journal of
Religion & Spirituality in Social Work, 33, 274 –299. http://dx.doi.org/
10.1080/15426432.2014.930626
Starnino, V. R., Gomi, S., & Canda, E. R. (2014). Spiritual strengths
assessment in mental health practice. British Journal of Social Work, 44,
849 – 867. http://dx.doi.org/10.1093/bjsw/bcs179
Substance Abuse and Mental Health Services Administration. (2014). TIP
57: Trauma-informed care in behavioral health service. Washington,
DC: Substance Abuse and Mental Health Services Administration Na-
tional Center for Trauma Informed Care.
Taku, K., Cann, A., Tedeschi, R. G., & Calhoun, L. G. (2009). Intrusive
versus deliberate rumination in posttraumatic growth across US and
Japanese samples. Anxiety, Stress and Coping: An International Journal,
22, 129 –136. http://dx.doi.org/10.1080/10615800802317841
Tepper, L., Rogers, S. A., Coleman, E. M., & Malony, H. N. (2001). The
prevalence of religious coping among persons with persistent mental
illness. Psychiatric Services, 52, 660 – 665. http://dx.doi.org/10.1176/
appi.ps.52.5.660
Thomas, D. R. (2003). A general inductive approach for qualitative data
analysis. Retrieved from http://aje.sagepub.com/content/27/2/237
.abstract
Triplett, K. N., Tedeschi, A. C., Cann, A., Calhoun, L. G., & Reeve, C. L.
(2012). Posttraumatic growth, meaning in life, and life satisfaction in
response to trauma. Psychological Trauma: Theory, Research, Practice,
and Policy, 4, 400 – 410. http://dx.doi.org/10.1037/a0024204
van Manen, M. (1990). Researching lived experience: Human science for
an action sensitive Pedagogy. Ontario: The State of New York Univer-
sity Press.
Whitley, R., & Drake, R. E. (2010). Recovery: A dimensional approach.
Psychiatric Services, 61, 1248 –1250. http://dx.doi.org/10.1176/ps.2010
.61.12.1248
Received June 8, 2015
Revision received November 6, 2015
Accepted November 16, 2015 䡲