Table 1.

Theme descriptions and illustrative quotes

Theme and subtheme	Description	Illustrative quotes
1. Meaning-making	The ways in which people utilise their religious and spiritual beliefs to try to make sense of their experiences of mental illness.	‘…when you don't know, it's harder to deal with. When you know it's a lot easier to deal with.’ (Heffernan et al., 2016, p. 352)
1.1 Multiple-explanations	The often contradictory explanatory frameworks that people grapple with to try to make sense of their mental health difficulties – e.g. religious/spiritual v. medical/clinical, which may conflict and lack integration.	‘The most conflicting message I had was the diagnosis of the psychosis like people saying it's ok God's got it in hand, everything's gonna be fine, and then they're saying no you're psychotic you need medication, other people saying no you don't need medication, yes you do, no you don't…. will somebody please just tell me what is going on.’ (Heffernan et al., 2016, p. 352)
1.2 Developmental journey	The ways in which people's perceptions about and relationships with spirituality are dynamic over time, e.g. changes in the ways spirituality is experienced, valued and expressed.	‘I tend to err on the side of it being a transformational process. So that I can work with it. Because if it's a mental illness, it shuts me down.’ (Nixon et al., 2010, p. 538)
		‘One of the things that I have actually gained from having a mental illness (is) that I…have looked at what this God stuff means.’ (Wilding et al., 2006, p.147)
1.3 Destiny v. autonomy	The level of choice and control people conceptualise themselves as having in relation to their religious or spiritual belief systems. On one end of this spectrum is the sense that what is happening is divinely intentioned, or as involving a sense of fate or destiny. On the other hand, a sense of choice and control, agency and freedom are important for some.	‘The illness is Allah's will … It is a trial … I pray to Allah everyday to make me feel better.' (Eltaiba and Harries, 2015, p. 732)
		‘Ming (fate) arranges our lives. If I have to stay in the hospital and suffer from this illness, that is my Ming.’ (Yang et al., 2012, p. 361)
		‘…it should be up to that person to have that choice… if you have belief in yourself and believe what you believe then it's not put into you… it's not forced.’ (Heffernan et al., 2016, p. 350)
2. Identity	The centrality of spirituality for many people's lives and core sense of self. Spirituality represents for many the core essence of who they are, shaping their identities through their experiences of illness, struggle, recovery and meaning-making. Participants draw on their spiritual frameworks to develop and negotiate a spiritual identity.	‘…to invalidate a person's spirituality no matter how distorted that is, is to invalidate that real core sense of self and I think once you do that you risk doing untold damage to somebody.’(Mental Health Foundation, 2002, p. 22).
		‘I just want to be loved for who I am.’ (Mental Health Foundation, 2002, p. 46)
3. Service provision	The ways in which people's spiritual needs are addressed or not within mental health care services and how people describe their interactions with services and mental health professionals.	‘I felt very alone and isolated in a strange environment, one which I hadn't experienced before and things were happening to me that I didn't know… I wanted some kind of stability within that and that was why my faith and religion were coming in at that time … I wanted to identify with it as soon as possible.’ (Mental Health Foundation, 2002, p. 20)
		‘(spiritual care's) very very important for mental health; sometimes it's the only thing that seems, that can maybe get through to someone. It's a different level of understanding, that goes beyond words, that goes beyond, something you can touch, it goes beyond all that…’ (Raffay et al., 2016, p. 5).
4. Talk about it	What people say they particularly need and yet may lack opportunities to do in relation to their experiences of spirituality and mental health difficulties, and how practitioners can better support people's spiritual needs.	‘Many people don't realise how devastating it is to be told that that's not real, that that's fantasy … Because to the people it is real and it needs to be treated as if it is real instead of just discarded and pushed aside, because it is a very big part of people … It's their core’ (Starnino, 2014, p. 127).
		‘The community psychiatric nurse was terrific. Although he was not a Christian, he asked me very, very pertinent questions about how I could reconcile my faith with what was happening to me and what God meant to me.’ (Mental Health Foundation, 2002, p. 23)
5. Interaction with symptoms	This theme describes how people's symptoms or mental health difficulties interact with their spirituality, sometimes in quite challenging and disruptive ways.
5.1 Interactive meaning-making	Often experienced as a clash of multiple or different realities which might involve experiencing visions, hearing voices from nonphysical entities or other unusual religious experiences or beliefs.	‘Even, to some extent, the spiritual stuff, as embarrassing as it is. I say embarrassing because I sort of, I don't really believe in a corporeal, nonbodied being [God]. I just don't believe that. On some level I don't believe that, and yet, I've experienced demon possession.’ (Jones et al., 2016, p. 494)
5.2 Spiritual disruption	The ways in which mental health symptoms sometimes intersect with people's spirituality resulting in challenging experiences or impeding people's ability to connect with their spirituality and spiritual practices.	‘The obsessions started last year, I started having thoughts about my faith, about the prophet, about God's creation. Then I started having doubts about making mistakes in my prayers or when I read verses of the Qura'an. I started repeating my prayers so many times that I had to miss school on many occasions.’ (Al-Solaim and Loewenthal, 2011, p. 175)
		‘…sometimes I lose my focus… I become quite lazy in sort of worshipping and doing my prayers and I can't concentrate.’ (Heffernan et al., 2016, p. 349)
6. Coping	This theme refers to the many and varied ways in which people utilise their spirituality to help them to deal with the challenges of their mental health problems. The process of coping may be experienced as an active process involving making persistent efforts to engage with spirituality and religious practices and to gain skills and acquire information. This process can be challenging and impeded by symptoms or struggles.	‘To improve things you need different skills. Skills could be acquired and could be lost with illness. I need to work on gaining skills and to change.' (Eltaiba and Harries, 2015, p. 731)
6.1 Spiritual practices	People engage with a variety of spiritual practices (e.g. prayer, meditation, mindfulness, attending a place of worship or quiet space, or reading religious or spiritual texts) to help them to cope with their mental health difficulties. These help people to strengthen their connection with their spiritual lives.	‘I feel really sad when bad things happen, but I sit, listen to the Qura'an, and feel better. My family is the same. Religion helps you adapt, prayer distances Satan from me and the more I pray the more God protects me.’ (Al-Solaim and Loewenthal, 2011, p. 178)
		‘Whenever I have a problem, I pray and fast.’ (Al-Solaim and Loewenthal, 2011, p. 179)
6.2 Spiritual relationship	People's relationship with God or a higher spiritual power is often central to their faith. It is described as the most important relationship of some people's lives and for this reason has crucial importance for coping during times of illness. This relationship can provide a sense of comfort, reassurance, protection, guidance and security as well as feelings of peace, strength, courage and the ability to feel more positive.	‘God became a friend… everything, I discussed with God… (He) put up with loads … it's how I survived.’ (Mental Health Foundation, 2002, p. 32)
		‘I really don't look to people. I look to God – because people are not able – they're able to help a certain amount, but the Lord has been my true strength … God has seen me through everything.’ (Sullivan, 1993, p. 130)
		‘It's God who helps me, I ask him for solutions and slowly he helps me, giving me the answers.’ (Salimena et al., 2016, p. 4)
6.3 Spiritual struggles	Sometimes people experience spiritual struggles or difficulty finding ways to cope. Common challenges include feelings of guilt or shame, or of stigma from spiritual communities.	‘I have actually said to God, why don't you just leave me … It was more comfortable when I didn't know.’ (Mental Health Foundation, 2002, p. 16)
		‘I have been told by a minister that he does not want the mentally ill in his church.’ (Moller, 1999, p. 8)
6.4 Preventing suicide	Sometimes people's faith, spirituality or relationship with God is the very thing that keeps them alive or from hurting themselves during their most difficult struggles with mental health problems.	‘God has saved my life.’ ‘Probably the biggest impact about my belief in God is when I have been suicidal… my faith has probably been the thing that's most kept me from hurting myself.’ (Rajakumar et al., 2008, p. 96)
		‘If I had no faith, I don't know how I'd get through it. No faith, no hope, no light at the end of the tunnel. I would end it.’ (Drinnan and Lavender, 2006, p. 324)