J Relig Health DOI 10.1007/s10943-011-9541-1 ORIGINAL PAPER
Psychological Distress Among Religious Nonbelievers: A Systematic Review Samuel R. Weber • Kenneth I. Pargament • Mark E. Kunik James W. Lomax II • Melinda A. Stanley
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Springer Science+Business Media, LLC 2011
Abstract Studies of religious belief and psychological health are on the rise, but most overlook atheists and agnostics. We review 14 articles that examine differences between nonbelievers and believers in levels of psychological distress, and potential sources of distress among nonbelievers. Various forms of psychological distress are experienced by nonbelievers, and greater certainty in one’s belief system is associated with greater psychological health. We found one well-documented source of distress for nonbelievers: negative perceptions by others. We provide recommendations for improving research on nonbelievers and suggest a model analogous to Pargament’s tripartite spiritual struggle to understand the stresses of nonbelief. Keywords
Religion Atheism Agnosticism Mental health Psychological distress
Samuel Weber was a medical student at Baylor College of Medicine when he worked on this project. S. R. Weber (&) Department of Psychiatry, The Ohio State University, 1670 Upham Drive, Columbus, OH 43210, USA e-mail:
[email protected] K. I. Pargament Bowling Green State University, Bowling Green, OH, USA M. E. Kunik M. A. Stanley VA HSR&D Houston Center of Excellence, Houston, TX, USA M. E. Kunik M. A. Stanley Michael E. DeBakey VA Medical Center, Houston, TX, USA M. E. Kunik J. W. Lomax II M. A. Stanley Baylor College of Medicine, Houston, TX, USA M. E. Kunik M. A. Stanley VA South Central Mental Illness, Research, Education and Clinical Center, Houston, TX, USA
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Introduction Religious belief has become increasingly recognized as a significant factor contributing to individual well-being. A growing body of literature links religious belief to improvements in physical health (Koenig et al. 2001), mental health (Koenig 1998), and coping (Pargament 2001). While this has led some to conclude that being religious is generally beneficial for physical and mental health (Koenig et al. 2001), this conclusion overlooks two key qualifiers. First, some forms of religious belief and behavior have been associated with increased symptoms of psychological distress. Religious doubt (Krause and Wulff 2004) and feelings of alienation from God (Trevino et al. 2010; Exline et al. 2000) have been associated with increased depressive symptoms. Unpleasant personal encounters in church settings are commonly associated with distress, particularly among clergy and the elderly (Krause et al. 1998, 2000; Nielsen 1998). Negative religious coping (i.e., a punishing God, demonic reprisals) is associated with lower quality of life and increased depression when compared to other religious coping strategies (Meisenhelder and Marcum 2004; Koenig et al. 1992; Pargament et al. 1998, 2001, 2004; Smith et al. 2000). A growing body of literature has examined spiritual struggles and their defining elements, including troubled relationships with God, negative social encounters in religious settings, and chronic religious doubting (Ellison and Lee 2010; Exline 2002; Pargament et al. 2005). Second, although higher levels of religiousness among people with at least a minimum level of religiousness may contribute to individual well-being, we do not know whether non-religiousness is deleterious to psychological functioning. The literature has generally focused on people with at least a minimal level of religiousness. Studies at times exclude religious nonbelievers from participation or do not sample them in sufficient numbers to allow conclusions about this subgroup (Krause and Wulff 2004; Meisenhelder and Marcum 2004; Pargament et al. 2004, Krause et al. 1998; Pargament 2001). As the study of religion and health becomes more refined, we must not overlook the well-being of religious nonbelievers (a growing subpopulation within the United States (Pew Forum on Religion & Public Life 2009)). The purpose of this study was to review studies evaluating differences between religious nonbelievers and believers in levels of psychological distress and to identify potential sources of distress among nonbelievers. Whitley reviewed literature on atheism and mental health in 2010 and found no articles that fit his search criteria (Whitley 2010). His review was limited by a narrow set of search terms (atheis*, religi*, mental health, and psychiat*) used within a single database (Medline). Our study is distinct from Whitley’s in our broader perspective on nonbelievers (including atheists and agnostics) and our focus on symptoms and potential sources of psychological distress. Our decision to include both atheists and agnostics in this review reflects a conscious effort to obtain a comprehensive picture of nonbelief, including differing levels of certainty (i.e., atheists as certain nonbelievers, agnostics as uncertain nonbelievers). This review aims to provide an overview of the literature on psychological distress among nonbelievers and to identify other health states of nonbelievers that need further study.
Methods We searched the PsycINFO and PubMed databases, using the following search terms: atheis*, agnosti*, apostasy, apostate, and deconversion. The resultant group of articles was then further culled to limit articles to those with abstracts, written in English, and published
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from 1980 to the present, excluding books and dissertations. After reviewing all titles and abstracts, we selected articles that met our focus on symptoms and potential sources of psychological distress among religious nonbelievers. Criteria for inclusion in this review were established as follows: studies were to be primary research and have some form of measurable or interpretable outcome. By mutual consensus, we eliminated articles from the pool because they did not meet our inclusion criteria. We then examined the reference lists of the identified articles for possible additional articles for inclusion.
Results The results of our search are shown in Fig. 1. After examining all studies for definitions and measurements of religious nonbelief, we divided the results into two broad categories: studies dealing with differences between religious nonbelievers and believers in levels of psychological distress (ten articles) and studies dealing with potential sources of distress among nonbelievers (four articles). PsychInfo search
PubMed search
663 articles
328 articles
Eliminated articles without abstracts, non-English articles, articles published before 1980, books, dissertations = 349
Eliminated articles not in English = 260
Eliminated articles based on review of titles and abstracts for focus on symptoms and potential sources of psychological distress among religious nonbelievers = 2*
Eliminated articles based on review of titles and abstracts for focus on symptoms and potential sources of psychological distress among religious nonbelievers= 31
Eliminated studies not primary research and/or without measurable or interpretable outcome = 11
Searched reference lists of 11 identified articles for additional articles = 3
14 articles for review
Fig. 1 Results of literature search using the terms atheis*, agnostic*, apostasy, apostate, and deconversion. *These two articles were duplicates of two found in the PsychInfo search
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Definitions and Measurements of Religious Nonbelief Most of the articles defined religious nonbelief in terms of religious self-identification, such as atheism, agnosticism, no religion, religiously unsure, humanism, or rationalism (Baker and Cruickshank 2010; Exline et al. 2011; Hunter 1998, 2001; Jenks 1986; Mochon et al. 2011; Schmidt et al. 2007; Wilkinson and Coleman 2010). Atheists were variously defined as people who ‘‘… definitely did not believe in life after death’’ (Lundh and Radon 1998, p. 489); scored less than 4 of 7 on a scale of agreement with the statement, ‘‘I believe God exists’’ (Exline et al. 1999); and/or affirmed the statement, ‘‘I don’t believe in God’’ (Edgell et al. 2006). However, absolute disbelief in God did not always characterize atheists; for example, in one group of self-identified atheists, 94.9% did not believe in God, but the remaining minority indicated that they were unsure (James and Wells 2002). Agnostics were defined as spiritual but not religious (O’Connell and Skevington 2010) or uncertain about life after death (Lundh and Radon 1998). Atheists and agnostics were occasionally grouped together as a single category of subjects (Exline et al. 2011). Nonbelieving Jews ‘‘… identified themselves as being either agnostic or atheist, while at the same time maintaining their identification with the Jewish community’’ (Herzbrun 1999). Certainly, many nonbelieving Christians find themselves in a similar position of continued identification with the Christian community; but none of the articles we reviewed explicitly mentioned such a group. Conversely, some who do not feel part of a denomination may still hold religious beliefs. Most articles from our sample measured religious nonbelief by means of a survey or questionnaire item labeling one’s religious identification as atheist, agnostic, or not religious (Baker and Cruickshank 2010; Edgell et al. 2006; Herzbrun 1999; Hunter 1998, 2001; Jenks 1986; O’Connell and Skevington 2010; Schmidt et al. 2007). Some studies used more standardized scales to determine belief status, such as the Royal Free Hospital’s Beliefs and Values scale (Wilkinson and Coleman 2010) or a religiosity scale (Mochon et al. 2011). One researcher asked subjects to rate how strongly religious they were (Exline et al. 2011), whereas others examined the certainty of their sample’s nonbelief (James and Wells 2002). Others asked patients about their ideas regarding life after death (Lundh and Radon 1998). One study included multiple measures of nonbelief: scales of God belief, religious belief salience, religious participation, and feelings of alienation from God (Exline et al. 1999). How Nonbelievers Differ from Believers in Levels of Psychological Distress Differences between nonbelievers and believers in levels of psychological distress varied across the ten studies in this category, with two demonstrating more distress among nonbelievers, three suggesting less or equivalent distress among nonbelievers, and five producing mixed results (Table 1). Of the studies showing more distress among nonbelievers, one examined a sample of US undergraduate students and showed that nonbelievers had greater difficulty forgiving God (Exline et al. 1999). Another study collected questionnaire responses from undergraduate psychology students, a general social survey, and research advertisement respondents and demonstrated that nonbelievers have more anger toward God than do believers (Exline et al. 2011). While it may sound paradoxical for nonbelievers to be angry with or withhold forgiveness from God, some nonbelievers have a previous history of religious belief; a small minority of self-defined atheists remain ‘‘unsure’’ about whether God exists; and these studies were structured in a way that allowed nonbelievers to respond to a hypothetical God rather than express actual feelings
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Nonbelief defined
Nonbelievers: scored less than 4 of 7 on a scale of ‘‘I believe in God’’
Self-identified religious affiliation: atheist, agnostic, none, atheist/ agnostic
Author
Exline et al. (1999)
Exline et al. (2011)
Results Difficulty forgiving God Nonbelievers reported significantly greater difficulty forgiving God than believers.
Anger toward God Studies 1, 2, 3: Religious nonaffiliates reported more anger toward God than affiliates. Study 4: Religious nonaffiliates reported more negative feelings toward God than affiliates. Study 5: did not involve nonbelievers
Study Design US undergraduate college students, summer–fall 1997, N = 200 (4% atheist/agnostic, 4% no religious affiliation, 5% unsure)
Study 1: National Opinion Research Center General Social Survey, 1988, N = 1481 (8% no religion) Study 2: Ohio undergraduate psychology students, N = 189 (14% atheist/agnostic) Study 3: Ohio undergraduate psychology students, N = 446 (12% agnostic, 7% atheist, 7% no religion) Study 4: Advertisement respondents, N = 244 (6% no religion, 3% atheist/agnostic) Study 5: no information on nonbelievers
Measurement Tools Beck depression inventory Beck anxiety inventory State trait anger scale Blaine and Crocker’s religious belief salience measure 17-item scale of religious participation 5-item scale of feelings of alienation from God 6 items measuring forgiveness of God, self, and others Study 1: 7-item scale of anger toward God Study 2: 10 items measuring emotion toward God; 10 items measuring cruelty attributions Study 3: Blaine and Crocker’s religious belief salience measure; Center for Epidemiological Studies—Depression Scale Study 4: Center for Epidemiological Studies—Depression Scale; Satisfaction With Life Scale; Impact of Event Scale; measure of physical symptoms Study 5: did not involve nonbelievers
Table 1 Differences between nonbelievers and believers in levels of psychological distress
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Negative beliefs about death Increased Catholic and atheist anxiety: death as pain and loneliness, death as failure, superstitious beliefs Increased atheist anxiety: death as forsaking dependents ? guilt, death as courage Decreased atheist anxiety: indifference to death Affect and Adjustment: Death anxiety Death depression scale: atheists and agnostics scored higher than religious Stroop task: no anxiety difference between 3 groups for deathrelated words Spiritual well-being compared between believing and nonbelieving Jews Both groups showed significant spiritual health, able to identify awe, tragedy, and a purpose in life. Spiritual health did not preclude struggles around issues of faith.
Cross-sectional study, atheists recruited from atheist/agnostic and secular organizations, N = 303 (197 atheists)
Swedish study, N = 45 (15 atheists, 15 agnostics)
Jewish study (interviews), 4 days-5 weeks, N = 18 (9 nonbelievers)
The Death Perspective Scale The Death Beliefs Questionnaire The Symptom Interpretation Questionnaire The Health Anxiety Questionnaire The Somatosensory Amplification Scale Short Scale EPQ-R (personality traits)
Death Depression Scale Stroop interference task
Semi-structured interviews (face-to-face or email), including 10 questions on faith development and spiritual wellbeing
Atheists: no definition included; 94.9% indicated no belief in God; remainder unsure
Atheists: subjects who definitely did not believe in life after death Agnostics: subjects who were uncertain about life after death
Nonbelieving Jews: identified themselves as agnostic or atheist, while maintaining identification with the Jewish community
Lundh and Radon (1998)
Herzbrun (1999)
James and Wells (2002)
Results
Study Design
Measurement Tools
Nonbelief defined
Author
Table 1 continued
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Quality of Life study Spiritual quality of life: lowest in atheists More important to agnostics than atheists: spiritual connection, meaning of life, faith, awe, and wholeness Atheists and agnostics share: meaning in life and spiritual strength moderately important Religious: lower negative feelings, better personal relationships than agnostics. Levels of depressive symptoms No significant difference between all groups
British study, mailed questionnaires over 3 months, N = 285 (122 agnostic, 55 atheist)
British study, November 2007– February 2008, N = 471 (130 atheists, 104 agnostics)
Italian study, 1-6 days after Pope’s death, N = 526 (76 atheists)
British case series (interviews), atheists recruited from the British Humanist Association, N = 19 (11 atheists)
World Health Organization Quality of Life—Spiritual, Religious, and Personal Beliefs questionnaire
63-item questionnaire: Demographics Depression-Happiness Scale (DHS) Salience Scale Measurement of frequency of religious practices Scale analyzing beliefs about treatments for depression Modified version of (2004) questionnaire of Luminet et al.
Beliefs and Values scale Hospital Anxiety and Depression scale
Agnostics: ‘‘spiritual but not religious’’ Atheists
Self-reported religious affiliation: atheist, agnostic
Self-identified religious affiliation: atheist
Self-identified religious affiliation: atheist (score less than or equal to 26 on Beliefs and Values scale)
O’Connell and Skevington (2010)
Baker and Cruickshank (2010)
Schmidt et al. (2007)
Wilkinson and Coleman (2010)
Coping in old age All participants coping well with old age, judged by Lazarus’ eight principles of successful aging
Psychological reactions to the death of Pope John Paul II Atheists: less intense negative emotions (sadness, fear, anxiety, anger, guilt) and more boredom compared with Catholic believers
Results
Study Design
Measurement Tools
Nonbelief defined
Author
Table 1 continued
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Nonbelief defined
Self-reported religious affiliation: atheists, agnostics, no religious affiliation/none
Author
Mochon et al. (2011)
Table 1 continued Results Certainty of belief and happiness 47.3% of religious less happy than atheists 21.9% of religious less happy than agnostics 14.4% of religious less happy than those who report no affiliation The highest levels of well-being result from the highest levels of certainty in one’s belief system.
Study Design Online study, N = 6465 (133 agnostics, 68 atheists, 593 no religion)
Measurement Tools Religiosity scale by Blaine and Crocker (1995) 7 measures of well-being
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toward God. Certain perspectives on death, such as guilt over leaving dependents behind, uniquely correlated with death anxiety among a sample of atheists compared with Catholics (James and Wells 2002). In a Swedish study, atheists and agnostics scored higher on the Death Depression Scale (which is actually a more representative measurement of anxiety than depression) than did believers, indicating greater death anxiety in the nonbelieving groups (Lundh and Radon 1998). During a series of semi-structured interviews, Jews who had lost their faith described a sense of isolation, a desire to conceal their nonbelief from the Jewish community, and the perception that they were alone in their distress. (Herzbrun 1999) In a British study that collected responses to the World Health Organization Quality of Life—Spiritual, Religious, and Personal Beliefs questionnaire over 3 months, religious people reported lower negative feelings in general and better personal relationships than agnostics, and atheists had a lower level of spiritual quality of life than believers and agnostics (O’Connell and Skevington 2010). In contrast, seven articles pointed out instances in which nonbelievers experienced comparable or less distress than their believing counterparts. For example, no significant difference in depressive symptoms was noted between groups of atheists, agnostics, Christians, and Muslims among British respondents to a questionnaire (Baker and Cruickshank 2010). One study of atheists recruited from atheist/agnostic and secular organizations showed that an attitude of ‘‘indifference toward death’’ correlated with less anxiety about death among atheists than among believers (James and Wells 2002). Although atheists and agnostics scored higher than believers in a Swedish study that used the Death Depression Scale, the same study found no difference between the groups’ anxiety levels when measured using a Stroop interference task (Lundh and Radon 1998). Also of note, Italian atheists experienced a less intense negative emotional reaction to negative religious news (e.g., death of Pope John Paul II) than did believing Catholic respondents (Schmidt et al. 2007). Among 19 British interviewees, atheists and believers were found to cope equally well with the challenges of old age, by compensating for losses, actively engaging in purposeful striving, and retaining positive self-regard (Wilkinson and Coleman 2010). Despite experiencing some struggle centering on their disbelief, a sample of nonbelieving Jews were as spiritually and psychologically healthy as their believing counterparts, as measured by their sense of awe, purpose in life, and awareness of tragedy. (Herzbrun 1999). British atheists and agnostics that responded to a questionnaire on spiritual quality of life stated that ‘‘meaning in life’’ and ‘‘spiritual strength’’ were moderately important to them. (O’Connell and Skevington 2010). Several of these articles demonstrate that strength of conviction, be it atheistic or religious, correlates with improved psychological health. Degree of inner conviction is associated with degree of well-being: for example, strong atheistic beliefs are comparable to strong religious beliefs in helping people cope with the challenges of aging (Wilkinson and Coleman 2010). Christians with high levels of religious saliency have significantly lower levels of depressive symptoms. (Baker and Cruickshank 2010) Just as greater conviction correlates with better health, less certainty of belief has been associated with decreased well-being. Religious adherents with low certainty of belief may be less happy than nonbelievers, with 47.3% of religious respondents to an online study reportedly less happy than atheists, 21.9% less happy than agnostics, and 14.4% less happy than those with no religious affiliation (Mochon et al. 2011). These studies demonstrate a clear correlation between strength of conviction in one’s religious (or nonreligious) worldview and psychological well-being, with both the most and least religious individuals experiencing the best health. This literature has some major limitations. Several of the studies had small samples (Lundh and Radon 1998; Herzbrun 1999; Wilkinson and Coleman 2010), and others had
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relatively low participation rates by nonbelievers (Exline et al. 1999, 2011). In addition, contradictions between studies of death anxiety (James and Wells 2002; Lundh and Radon 1998) and spiritual quality of life (O’Connell and Skevington 2010; Herzbrun 1999) may be due to a lack of consistency in the measurement tools used to quantify those variables. Despite these limitations, several robust points emerge from the literature. A clear association has been demonstrated between nonbelievers and increased anger at (Exline et al. 2011) and nonforgiveness of (Exline et al. 1999) God. Multiple studies demonstrate that those with the greatest strength of conviction in their religious (or nonreligious) worldview experience the greatest psychological health (Wilkinson and Coleman 2010; Baker and Cruickshank 2010; Mochon et al. 2011). Potential Sources of Psychological Distress in Nonbelievers That nonbelievers are generally viewed more negatively than believers by those around them is demonstrated by four studies in our sample (Table 2). These negative perceptions are potential sources of distress for nonbelievers, as research has linked negative societal attitudes toward specific groups (i.e., nonbelievers) with social exclusion (Edgell et al. 2006), inequality (Edgell et al. 2006), and the internalization of negative perceptions (Jenks 1986). College-age believers consistently evaluated Christians more highly than atheists, even when they saw examples of Christians behaving negatively (e.g., ignoring, cheating, or refusing to help the participant) and atheists behaving positively (e.g., helping or being generous toward the participant) (Hunter 1998, 2001). University students also perceived atheists less favorably than Catholics in terms of moral rightness, education, social status, political views, parenting styles, life satisfaction, and control over one’s life (Jenks 1986). In response to a nationwide telephone survey, a large number of Americans stated that they were likely to disapprove of their children marrying atheists, and many felt that atheists were the group ‘‘… least likely to share their vision of American society’’ (Edgell et al. 2006, p. 212). Our literature search yielded only one potential source of psychological distress among nonbelievers: perceptions of nonbelievers by others. Of the four studies examining perceptions of nonbelievers by others, three restricted participation to university students (Hunter 1998, 2001; Jenks 1986), limiting the generalizability of their results. Despite this shortcoming, all four studies were consistent in their findings: society at large perceives nonbelievers more negatively than believers.
Discussion Regarding levels of psychological distress, nonbelievers are more likely than believers to struggle with anger toward God (Exline et al. 2011) and difficulty forgiving God (Exline et al. 1999). However, in terms of responding to the death of a public religious figure (Schmidt et al. 2007), coping with the challenges of old age (Wilkinson and Coleman 2010) and overall happiness (Baker and Cruickshank 2010), they are just as well or better off than their believing counterparts. Conflicting positives and negatives arise when nonbelievers are compared with believers for death anxiety (James and Wells 2002; Lundh and Radon 1998) and spiritual quality of life (O’Connell and Skevington 2010; Herzbrun 1999). The mixed picture that emerges may be due to inconsistencies in the measurement of nonbelief, differing measures of distress, or the variety of sample sizes of each study.
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J Relig Health Table 2 Sources of psychological distress among religious nonbelievers Author
Nonbelief defined
Measurement tools
Study design
Results
Hunter (1998)
Atheists described in fictional vignettes
7-point Likert scale Self-Description Questionnaire III
University of Otago student members of Christian Union Organization, N = 141
Perceptions of atheists by others: Regardless of the behavior described in the vignettes, participants evaluated Christians higher than atheists.
Hunter (2001)
Atheists described in fictional vignettes
7-point Likert scale Self-Description Questionnaire III
New Zealand university student members of University Christian Union organizations (protestant), N = 180
Perceptions of atheists by others: Respondents evaluated (a) in-group [Christian] targets who behaved (?) more highly than outgroup [atheist] members who behaved (?), and (b) in-group (-) more highly than out-group (-)
Jenks (1986)
Atheists: one of four distinct social groups evaluated in a questionnaire
Questionnaire: estimates on characteristics of Republicans, Catholics, homosexuals, and atheists; their own positions on various issues
US undergraduate sociology students, N = 146
Public perceptions of atheism as deviant: Atheists perceived as deviant in terms of right/wrong, education, social status and political views, parenting styles, life satisfaction, and control over one’s life
Edgell et al. (2006)
Atheists: one social group evaluated as part of a telephone survey
National telephone survey: (1) this group does not at all agree with my vision of American society, (2) I would disapprove if my child wanted to marry a member of this group In-depth interviews in 4 US cities
The American Mosaic Project 2003 national (telephone) survey data, summer 2003, N = 2081
Perceptions of atheists by others: 39.6% of Americans say atheists are ‘‘least likely to share their vision of American society’’ (39.6%) 47.6% of Americans are likely to disapprove of their children marrying atheists (47.6%)
Interestingly, there appears to be a correlation between strength of conviction in one’s religious (or nonreligious) worldview and psychological well-being (Wilkinson and Coleman 2010; Baker and Cruickshank 2010; Mochon et al. 2011). This correlation is supported by findings connecting greater existential certainty with decreased depressive symptoms (Riley et al. 2005). Relative to patients self-labeled as spiritual or religious, patients unsure about religion had the highest rates of drinking and the least amount of improvement after being treated in Alcoholics Anonymous (Tonigan et al. 2002). Similarly, subjects deconverting
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from a place of religious conviction to the unsure worldview of apostasy reported poorer quality of life than individuals who retained their religious convictions (Brinkerhoff and Mackie 1993). This seems to indicate a bimodal relationship between religiosity and health, with the greatest health experienced by the most and least religious individuals. Although believers and nonbelievers tend to be grouped together as static groups, these data indicate that not all believers (or nonbelievers) are alike and that strong atheists appear to enjoy the same psychological benefits as strongly religious individuals. Regarding potential sources of psychological distress among nonbelievers, we found four studies that demonstrated a widespread negative bias against nonbelievers (Hunter 1998, 2001; Jenks 1986; Edgell et al. 2006). One indicated that this level of disapproval placed atheists at the top of Americans’ list of problematic groups, representing levels of public rejection higher than that of Muslims in post-9/11 America (Edgell et al. 2006). While recent decades have seen a marked improvement in societal attitudes toward diverse racial and religious minorities, atheists continue to fall short in terms of public acceptance. Such a level of nonacceptance is certainly a potential source of distress for nonbelievers as they attempt to integrate into society. Promisingly, some research has shown that, as religious believers perceive an increase in atheist prevalence, anti-atheist prejudice decreases (Gervais 2011). Additional research needs to explore moderators of these negative beliefs, ways such attitudes impact behaviors, and the effects that these common perceptions have on the psychological well-being of nonbelievers. Our literature review uncovered only one potential source of psychological distress among religious nonbelievers (negative perceptions of nonbelievers by others), but other sources might certainly exist. Interactions with believing family and friends, decisions regarding the rearing of children by mixed believer/nonbeliever couples, doubts about one’s disbelief, and the search for meaning in life without a religious system are all potential mediators of psychological distress for nonbelievers that would be interesting to investigate. This systematic review shows that various forms of psychological distress are experienced by religious nonbelievers. However, relatively little has been done to study nonbelievers, and we know little about their psychological health. There is a need for more studies and conceptual models to guide our understanding and care of this overlooked population. With an ever-increasing number of nonbelievers in the United States (Pew Forum on Religion & Public Life 2009), their health deserves increased scientific attention, with the same rigor and sophistication that the study of those with religious belief has received (Koenig and Larson 2001). The work of Pargament and others provides a dynamic model for understanding the psychological struggles of religious believers and may be a useful starting point for development of a model of struggles among nonbelievers (Pargament et al. 2005). The model of Pargament et al. divides spiritual struggles into three categories: intrapsychic struggles of doubt, interpersonal struggles of cooperation, and the divine struggles of understanding God. This approach provides a nuanced view of the complex phenomenon of religious belief and its associated struggles. A similar model may be helpful in improving our understanding of religious nonbelievers. Rather than viewing nonbelief as a static endpoint, nonbelief and the associated psychological stresses may be a more dynamic, multifaceted process, including: (1)
Interpersonal struggles: Nonbelievers must learn to live, work, and cooperate with others who maintain systems of religious belief. The difficulty of achieving a full, cooperative equality has been demonstrated by the literature, which shows persistent negative perceptions of nonbelievers by others (Hunter 1998, 2002; Edgell et al. 2006; Jenks 1986).
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(2)
(3)
Intrapsychic struggles: Just as believers may doubt the existence of God or the truthfulness of religious claims, nonbelievers may doubt their decision to live without religion or struggle to find their moral compass. Studies demonstrating anger and difficulty forgiving God (Exline et al. 1999, 2011) and difficulty adjusting to a nonbelieving worldview (Herzbrun 1999) support the idea that nonbelievers have unique intrapsychic struggles. Divine struggles: Although most nonbelievers have jettisoned traditional beliefs about God, many still struggle to find meaning in life (O’Connell and Skevington 2010), maintain awe in their existence (Herzbrun 1999) and face aging and death with strength and courage (James and Wells 2002; Lundh and Radon 1998; Wilkinson and Coleman 2010).
We believe that application of the model of Pargament et al. to struggles of nonbelief will enable healthcare researchers to more accurately and uniformly describe the psychological stressors unique to nonbelievers and their health care. Some nonbelievers may be comfortable with their nonbelief, while others may struggle with it. It would be a mistake to assume that nonbelief is a fixed and final state for everyone. This review has some limitations. The number of studies that met criteria for inclusion was low. We focused on psychological distress among nonbelievers; it is possible that a broader approach (e.g., nonbelievers and health) would have yielded a greater number of articles for review. Additionally, the studies we selected were from dissimilar scientific disciplines, including psychological, medical, and sociological literature. In addition to the limitations of our review, the literature itself has some limitations. Most articles in our sample included definitions and measurements of religious nonbelief. The definitions provided were generally not detailed or thorough, and the measurements used were not consistent or standardized. Clear, consistent definitions of nonbelief should be included in future studies to ensure that results are interpreted within the correct context. Descriptions of and reasons for choosing measurement tools for quantifying nonbelief would add depth and reproducibility to further research and might prove particularly important in studying the strength of conviction in one’s beliefs.
Conclusion Religious belief is a complex component of individual psychological well-being. Though higher levels of religiousness among people with a basic level of religiousness may contribute to individual well-being, it does not follow that nonreligiousness is necessarily deleterious to psychological functioning. With religion receiving greater consideration in the psychology literature than ever before, it is our hope that efforts can be made to increase attention to the opposite side of the belief coin. Religious nonbelievers have stresses and struggles unique to their situation. The use of a dynamic model of nonbelief analogous to the model of spiritual struggle of Pargament et al. (Pargament et al. 2005) may improve the depth and usefulness of future literature examining the psychological well-being of nonbelievers. Acknowledgments This work was partly supported by the VA HSR&D Houston Center of Excellence (HFP90-020). The views expressed reflect those of the authors and not necessarily those of the Department of Veterans Affairs/Baylor College of Medicine.
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