Spiritual Growth and Mental Health Gains: Benefits of Awakened Awareness for U.S. College Students at Three-Month Follow-Up

Abstract

Previous research has documented broad benefits of spiritual intervention programs, including improved spirituality and ameliorated mental health symptoms. However, long-term follow-up examinations of such interventions have yet to be conducted. This study reports on changes in psychological and spiritual variables from posttest to 3-month follow-up in a sample of U.S. undergraduate students. N = 84 undergraduate students ages 18–25 (M = 19.75, SD = 1.6; 69 female, 11 male, and 4 nonbinary) received Awakened Awareness for Adolescents (AA-As), a spirit–mind–body (SMB) intervention composed of 8 weekly 90-min sessions, and completed measures of spirituality (spirituality, spiritual growth, spiritual decline, and Awakened Awareness) and mental health (depression, anxiety, and posttraumatic stress) at posttest and again at 3-month follow-up. Paired-sample t-tests revealed maintenance of spiritual improvements (Awakened Awareness, spiritual growth, and relational spirituality with the Higher Power) with the exception of reversal of spiritual decline and significant ongoing improvements in clinical measures in the months following posttest. Additionally, we observed a moderating effect such that changes in spiritual decline after posttest were associated with follow-up posttraumatic stress. An ongoing lived transcendent relationship with the Higher Power, Awakened Awareness, and spiritual growth appears to offer sustained protection at three-month follow-up against depression and symptoms of trauma. Our findings support the efficacy of AA-A as well as the need for ongoing SMB wellness resources.

1. Introduction

College students’ physical and mental health has steadily decreased over the last 50 years in the United States, with 63.9% of freshmen rating themselves “above average” or in “the highest 10%” physical health in 1985 compared to 55.2% in 2015 (Eagan et al. 2016). Similarly, 63.6% of freshmen who rated themselves above average or higher in emotional health in 1985 decreased to 57.1% in 1995, 54.3% in 2005, 50.6% in 2015 (Eagan et al. 2016), and most recently to 44.3% in 2018 (Stolzenberg et al. 2019). With over 60% of college students meeting criteria for at least one mental health problem (Flannery 2023; Lipson et al. 2022), 27% of American college students meeting criteria for a DSM/ICD diagnosis (Auerbach et al. 2018), and rates of suicidal ideation ranging from 7 to 11.3% for young adults and college students (Substance Abuse and Mental Health Services Administration 2021; Casey et al. 2022), increasing access to mental health services, including preventative and treatment interventions, is critical. During and after the COVID-19 pandemic, this need only increased, with college students reporting increased externalizing and attention problems, worse mood, and fewer wellness behaviors (Copeland et al. 2021).

While symptoms of mental illness in college students are a significant predictor of poorer academic, health, and behavioral outcomes, 40% of college students still report that they would not contact a professor, advisor, or other staff at their school if their mental health symptoms were to interfere with their performance (Gannon et al. 2025). Recent evidence has suggested that student perceptions of their university’s “mental health climate”, or campus social norms related to mental health, have a significant influence on the likelihood of college students to seek campus psychological services. A college campus’s mental health climate is comprised the student’s perception of the prioritization of mental health by the institution, the willingness of staff to listen and support academic-related mental health distress, the accessibility of mental health resources, stigma around mental health care, and the expectation that significant stress is a prevalent and normative aspect of the collegiate experience and thus not worthy of additional support (Dutton 2023). When students perceive the mental health climate of their institution to be unsupportive, they are significantly less likely to seek out support, even when their symptoms interfere with their academic performance (Gannon et al. 2025). Furthermore, many college students are facing a range of social injustices including food and housing insecurity, discrimination, and other social determinants of mental health that are contributing to the current mental health crisis of emerging adults.

In response to the increasing crisis of student mental health, universities have identified a need for increased mental and physical resources to offer to emerging adults, from preventative measures to treatment and crisis interventions. The demand for mental health services on college campuses is increasing, and administrators in higher education are seeking effective and more cost-efficient support services than individual therapy (Abrams 2022) to include access to support for the emerging adult challenges that are not strictly forms of clinical (or subclinical) level pathology. Among these, preventative wellness interventions may be uniquely positioned to serve the needs of college students as they navigate existential challenges and significant developmental processes involved in emerging adulthood.

Wellness interventions for mental health are distinct from and complementary to the medical model, which places the disorder in the foreground and the individual in the background, a perspective that can be vital and important for certain treatments. By contrast, the wellness model places the individual in the foreground and views ailments, diseases, and disabilities as relevant context (Stuifbergen et al. 2010; Heggdal and Lovaas 2018; Stepanovic and Mettler 2018). In addition to this conceptual stance in approach, the wellness model offers multiple benefits for the college student and for educational institutions at large. Person-centered wellness interventions are more likely to be experienced as empowering and personal as they provide the individual the opportunity to opt in and to become an active and responsible participant in their own health and wellbeing. Wellness interventions may also incur fewer personal and institutional costs, as they serve as preventive measures for engaging in higher levels of healthcare and may be more widely applicable to individuals, rather than medical treatments, which tend to be highly specialized. But does wellness have anything to do with prevention or forestalling the worsening of mental health problems? Notably, some research has indicated that while all individuals stand to benefit from mental health and wellness interventions, those with higher rates of pathology see greater improvements (Scalora et al. 2022).

However, not all wellness interventions are created equally. Despite the fact that the model of whole person wellness that is widely accepted as the most comprehensive (Swarbrick 2006) and endorsed by SAMHSA specifically identifies spirituality as a core dimension of wellness, to date, the spiritual domain (alongside the intellectual domain) is the least likely domain to be incorporated into evidence-based or experimental wellness interventions (Zechner et al. 2019). While most clinicians realize religion is helpful, psychologists are much less spiritual than the clients they serve (Delaney et al. 2013) and so may be reluctant to incorporate their patients’ spirituality into their work. This discrepancy between theory and practice is particularly salient in light of the well-documented evidence-based mental and physical health benefits of personal spirituality. These lost benefits of exclusively secular wellness interventions are particularly visible in emerging adult populations such as college students.

What outcomes are lost by foreclosing discussion of spirituality? College students who report higher spirituality also report greater overall health, more frequent exercise, greater life satisfaction, lower likelihood of smoking tobacco, and less frequent alcohol use (Nelms et al. 2007). Spirituality and religious engagement have also been associated with greater academic performance in college students, particularly in minority students who may face additional challenges in traditional education systems (Walker and Dixon 2002).

The need to support spirituality on college campuses is pronounced and worsening. Despite the mental and physical benefits of spirituality and engagement with religious practices, college students in the US have steadily declined in their affiliation with religion over the last 50 years. In 1966, just 6.6% of college freshmen reported not being affiliated with any religion. In 1985, that number rose to 9.4%, then 17.4% in 2005, 29.6% in 2015, and 31.1% in 2018 (Eagan et al. 2016; Stolzenberg et al. 2019). Today, 36% of college students report never attending religious services (Foundation for Individual Rights and Expression 2025).

The current need for spiritually integrated interventions is exacerbated by the prevalence of trauma in college students. In a sample of 180 US college students, those who had experienced more frequent life events, regardless of whether they were perceived as positive or negative, reported lower spirituality, lower meaning and direction in life, and at the same time a greater eagerness to “get more out of life” (Muller and Dennis 2007). In other words, in the context of greater instability that is often a natural condition of the common college experience, students may be searching for connection and meaning and not have the resources or awareness of this desire to mobilize these needs. As such, educational institutions have an opportunity to provide opportunities for students to engage in holistic spiritually integrated wellness that may not be otherwise accessible.

What models exist to direct the support of spiritual growth that are inclusive, pluralistic, and constitutional? Overall, most campus efforts aimed at spiritual support are anchored in a specific faith tradition that is aligned with the university’s mission. On campuses without a religious mission statement, there has been little progress in developing spiritual support, with a small number of exceptions. In a pilot study, Winding Road was developed for college students specifically to help navigate spiritual struggles and has shown encouraging preliminary results (Dworsky et al. 2013). The sanctification of relationships as an active practice has been explored by Mahoney and colleagues (2019). A universal notion of relational spirituality is woven into the treatment processes at the Danielson Institute by Sandage, Strovos, and colleagues (2018). Our previously published university-based wellness intervention, Awakened Awareness for Adolescents (AA-A), has shown promising preliminary evidence for strengthening spiritual awareness, which then ameliorates symptoms of trauma and depression.

1.1. Awakened Awareness for Adolescents

In the Awakened Awareness intervention, spirituality is understood as a deepened recognition of a reciprocal relationship with a High Power and a felt sense of the sacred in everyday life (Barton and Miller 2015). Awakened Awareness involves a shift in perception—from a limited focus on achievement and external accomplishments to a broader a spiritual awareness that emphasizes inner growth and connection to one’s higher self and transcendent or divine presence, offering a foundation for meaning, purpose, and well-being (Anderson et al. 2023; Scalora et al. 2022). Awakened Awareness has been shown to have common neural correlates that are universal to all human beings, and yet still gain strength in response to support and practice. The empirically supported AA-A program is designed to foster the innate neural seat of Awakened Awareness and consists of eight weekly 90-min group sessions led by two co-facilitators, incorporating key spiritually foundational processes to support natural spiritual individuation when delivered to adolescents and emerging adults. The AA model has been implemented and studied in several settings and populations (Mastropieri et al. 2015; Schussel and Miller 2013; Miller and Athan 2007), and AA-A is its adaptation for adolescents and emerging adults (Scalora et al. 2022). Through the incorporation of a fundamentally spiritual perspective of oneself, others, and the world, awareness can be expanded from the often defaulted “achievement awareness” to incorporate an “Awakened Awareness” of lived reality. The former places an emphasis on attaining achievements as a way to develop self-worth, and the latter is an enhanced capacity to see and interact from a spiritual perspective that underscores inherent worth and connection to one’s higher self and a loving Higher Power. The Awakened Awareness mindset is accessible to all and may provide better psychological, social, emotional, and physical functioning.

Meditations are integrated throughout each AA-A session, with each meeting beginning and ending with meditation, and a longer meditation practice occurring approximately midway through the session. In addition to guided meditations, participants engage in self-reflection through written journal prompts and cultivate relational spirituality through mindful sharing and listening with fellow group members.

Central to the intervention is the opportunity via guided visualization meditations for participants to explore concepts of an inherently loving Higher Power, of the higher self, and the recognition of the higher self in others. This shared language was incorporated to enable discussion of shared experiences between participants while honoring the individual journeys of each participant. Between sessions, students were provided with reflective practices and recordings of guided meditations. While the historical contexts for contemplative practices were discussed and the traditions from which the practices were originated from were provided to participants, a defining feature of AA-A that likely enabled the feasibility and acceptability of the program is that participants are able to attend regardless of their current spiritual development, presence or absence of spiritual struggle, history of or novelty to meditative practices, experience or lack thereof with religion or contemplative practices, or previous ignorance or awareness of the concepts explored in AA-A. This wide and inclusive net is a characteristic feature of wellness interventions.

A previously published initial open trial of AA-A revealed significant pre-post benefits on mental health and spiritual wellbeing measures. In terms of clinical variables, depression symptoms significantly decreased from pretest (M = 8.55, SD = 5.21) to posttest (M = 7.32, SD = 5.17, t(76) = 2.23, z = 0.26, p = 0.029); anxiety symptoms significantly decreased from pretest (M = 8.72, SD = 6.11) to posttest (M = 7.01, SD = 5.01, t(76) = 2.84, z = 0.32, p = 0.012); and posttraumatic stress symptoms significantly decreased from pretest (M = 39.13, SD = 12.61) to posttest (M = 33.52, SD = 11.32, t(76) = 4.89, z = 0.56, p < 0.01). With regard to spiritual variables, spirituality significantly increased from pretest (M = 95.91, SD = 21.72) to posttest (M = 105.66, SD = 19.97, t(76) = −5.34, z = 0.61, p < 0.001); Awakened Awareness significantly increased from pretest (M = 33.04, SD = 7.49) to posttest (M = 37.16, SD = 6.97, t(76) = −4.97, z = 0.72, p < 0.001); spiritual growth did not significantly increase from pretest (M = 100.32, SD = 47.47) to posttest (M = 109.81, SD = 47.91, t(76) = −1.82, z = 0.21, p = 0.288); and spiritual decline significantly decreased from pretest (M = 30.96, SD = 14.00) to posttest (M = 21.55, SD = 11.17, t(76) = 5.42, z = 0.62, p < 0.001).

These effects were moderated by significantly increased scores of spiritual awareness, as measured by levels of Awakened Awareness, relational spirituality, and the “reversal” of spiritual decline (Scalora et al. 2022; Anderson et al. 2023; Mistur et al. 2025). AA-A has even been shown to be feasible and effective in an online synchronous format (Mistur et al. 2025).

But does this improvement persist beyond the intervention period? When the support of the group is removed, to what extent do these changes remain stable? In this study, we examine whether AA-A, as a college-based foundationally spiritual support program, offers longer-term wellness outcomes, namely prevention against depression and trauma-related symptoms. However, to date, no research has examined whether the psychological and spiritual benefits experienced by AA-A participants extend beyond the eight-week intervention period.

1.2. Current Study

The primary aim of this study is to examine whether the benefits previously published from pretest to posttest are improved, sustained, or diminished following the intervention. This examination is critical for the ongoing implementation and adaptation of AA interventions, as it provides facilitators and institutions with insights into the clinical and health-related return on investment for students who complete the eight-week AA-A program. These questions may inform whether offering follow-up interventions or longer-term groups could provide additional benefits to college students

An additional aim of this study is to examine whether changes in spiritual decline are associated with improvements in posttraumatic stress in the 3 months following the intervention. Previous research has identified a cross-sectional moderating effect of spiritual decline on posttraumatic stress, demonstrating that among college students with exposure to potentially traumatic events, those experiencing higher levels of spiritual decline reported significantly higher posttraumatic stress symptoms than those with lower levels of spiritual decline (Crete et al. 2020). However, causation cannot be inferred from cross-sectional correlations. Thus, further research is needed to determine whether improvements in spiritual decline may be associated with the amelioration of posttraumatic stress symptoms. In other words, to examine whether participants who improve in spiritual decline also improve in their symptoms in the months following the intervention. The findings of this investigation may have important implications for both spiritually focused interventions and trauma-related interventions. To date, no studies have examined whether changes in spiritual decline are associated with changes in posttraumatic stress symptoms over time, particularly within the context of a spirit–mind–body intervention such as AA-A.

2. Materials and Methods

2.1. Participants

This research was approved by the Institutional Review Board (IRB) for the Protection of Human Subjects at Teachers College, Columbia University. All subjects gave informed consent to participate in the study. Participants were 18 to 25-year-old students enrolled at two sister universities in a northeast urban setting who participated in AA-A from fall 2018 to spring 2022. Recruitment was conducted through the distribution of printed and digital flyers, which were disseminated on campus and emailed to various student and university organizations.

AA-A programs were offered each semester in 2–3 closed groups for 90 min weekly over eight weeks. From fall 2018 through fall 2019, these groups were conducted in person. In spring 2020, the program began in person but transitioned to an online format after two sessions due to the COVID-19 pandemic. From fall 2020 through spring 2021, all groups were delivered online. Given the disruption in program delivery method during spring 2020, this study examines only participants who completed the intervention delivered entirely in-person or entirely online.

Participants completed surveys of the psychological and spiritual measures described below at the following time points: before the first session of AA-A (pretest), following the last session of AA-A (posttest), and three months following the last session of AA-A (3-month follow-up). These measures were collected electronically via Qualtrics surveys. Participants received compensation for their time directly following the completion of each assessment battery at the three time points, provided in the form of Amazon gift cards.

Participants who attended >4 sessions and completed pretest and posttest measures were considered “completers” in the program. Completers who attended AA-A in-person from fall 2018 to fall 2019 (n = 77) and online from fall 2020 to spring 2021 (n = 39) were pooled (n = 116), and a total of N = 84 participants from that pool also completed 3-month follow-up measures for a total 72% follow-up completion rate. This study examined the 84 participants who completed all three time points.

2.2. Measures

2.2.1. Demographics

The following demographic variables were collected from participants: gender, age, race/ethnicity, sexual orientation, personal and household income, employment status, and domestic or international student status. Information was also collected on participants’ religion, religious attendance, and the personal importance of religion/spirituality.

2.2.2. Assessment of Depression

Symptoms of depression were measured using the PHQ-9, which has shown excellent internal reliability (Cronbach’s α = 0.89), and test–retest reliability (r = 0.84) via mental health professional validation interviews (Kroenke et al. 2001). The PHQ-9 has shown construct validity in associations with self-reported disability days (r = 0.39), health care utilization (r = 0.24), and symptom-related difficulties in activities in relationships (r = 0.55) in a sample of 3000 adult primary care patients in the US. This measure has been further validated in a diverse sample of 857 university students in the US (Keum et al. 2018), which found PHQ-9 scores to be negatively correlated with emotional wellbeing (r = −0.597), psychological wellbeing (r = −0.531), and social wellbeing (r = −0.406) and positively correlated with alcohol use (r = 0.100). The measure consists of 9 items inquiring how often respondents have been bothered by problems presented in the items, with responses on a scale from 0 (“not at all”) to 3 (“nearly every day”). Thus, respondents’ overall scores can range from 0 to 27. The authors of the scale suggest several cutoff scores, with 0–4 indicating no depression symptoms, 5–9 indicating mild depression symptoms, 10–14 indicating moderate depression, 15–19 indicating moderately severe depression, and 20–27 indicating severe depression.

2.2.3. Assessment of Anxiety

Symptoms of anxiety were measured using the GAD-7, which is widely used and originally validated in a sample of over 2500 US adults recruited through primary care sites (Spitzer et al. 2006). The measure has excellent internal reliability (Cronbach’s α = 0.92) and good test–retest reliability (intraclass correlation = 0.83). GAD-7 scores showed construct validity via correlation with functional impairments, disability days (r = 0.27), clinic visits (r = 0.22), and symptom-related difficulty with activities and relationships (r = 0.63). The GAD-7 showed convergent validity with other measures of anxiety and discriminant validity from the PHQ-8 for depression. The GAD-7 has also been further validated in a college student sample (White and Karr 2023), with excellent internal reliability (Cronbach’s α = 0.91), evidence of convergent validity with the State–Trait Anxiety Inventory (r = 0.70) and discriminant validity with the Behavioral Inhibition and Activation Scale (r = −0.04). The GAD-7 consists of 7 items asking respondents to indicate how much over the last 2 weeks the following symptoms have bothered them, on a scale of 0 (“not at all”) to 3 (“early every day”). Total scores from the GAD-7 range from 0 to 21, and the authors suggest cutoff scores of 5, 10, and 15 to indicate mild, moderate, and severe levels of anxiety based on maximizing both sensitivity and specificity.

2.2.4. Assessment of Posttraumatic Stress Symptoms

Posttraumatic stress symptoms (PTSs) were measured using the Posttraumatic Checklist–Civilian version (PCL-C; Weathers et al. 1993). The PCL-C assesses symptoms of posttraumatic stress disorder in civilian populations. The symptoms assessed include emotional numbing, hypervigilance, and intrusive thoughts related to stressful events. Participants are asked about these symptoms in relation to “stressful experiences”. The measures include 17 items on a 5-point Likert scale, and research has indicated the measure has strong internal consistency (Cronbach’s α = 0.94) and test–retest reliability (r = 0.88–0.92) (Ruggiero et al. 2003).

2.2.5. Assessment of Spirituality

The Delaney Spirituality Scale (SS; Delaney 2005) was used to measure levels of personal spirituality. The SS was designed as “a holistic instrument that attempts to measure the beliefs, intuitions, lifestyle choices, practices, and rituals representative of the human spiritual dimension and is designed to guide spiritual interventions” and so is uniquely positioned to measure outcomes in this study. The SS includes 23 items on a 6-point Likert scale (from 1, “strongly disagree,” to 6, “strongly agree”) with total scores ranging from 23 to 138. The SS was found to have a high content validity index of 94% via content expert reviewers and has shown high internal consistency (Cronbach’s α = 0.94) and acceptable test–retest reliability (r = 0.84) in a sample of 240 adults with chronic illnesses (Delaney 2005).

2.2.6. Assessment of Spiritual Growth and Decline

The Spiritual Transformation Scale (STS; Cole et al. 2008) was developed to assess changes in spirituality as a response to negative life events. The scale has been reported with strong internal reliability (Cronbach’s α = 0.98) and test–retest reliability (r = 0.85). The scale includes two subscales: spiritual growth (29 items) and spiritual decline (11 items). Each item is on a scale of 1 (“it is not at all true for you”) to 7 (“it is true for you a great deal”) with a total range of 29–203 for spiritual growth (higher scores indicating greater spiritual growth) and 11–77 (higher scores indicating greater spiritual decline) for spiritual decline. No studies, to the authors’ knowledge, have attempted to validate the measure in a college sample. In the original validation of the measure with a sample of adults with a cancer diagnosis, respondents were prompted to reflect on whether perceived changes were observed “since your diagnosis of cancer”. In the current study, participants were not given a time point at pretest and at posttest were prompted to reflect on changes “since the beginning of the program” and at the 3-month follow-up, “since the end of the program”. The STS measures perceived sense of personal spiritual growth and decline across four domains: world view, goals/priorities, sense of self, and relationships.

2.2.7. Assessment of Awakened Awareness

The Awakened Awareness scale was used to assess Achievement and Awareness-oriented perspectives. This 10-item 5-point Likert scale measure has previously demonstrated high internal consistency in a college sample (Cronbach’s α = 0.81; Scalora et al. 2022). Validity of the measure is forthcoming. Higher scores on this measure indicate higher levels of Awakened Awareness, with total scores ranging from 1 to 50.

2.3. Statistical Analyses

All statistical analyses were conducted via SPSS version 29. Chi-Square analyses were utilized to compare demographic, clinical, and spiritual variables between completers who did submit follow-up data (n = 84) and those who were lost to follow-up (n = 32).

Paired-sample t-tests were conducted to identify significant differences between posttest and 3-month follow-up scores of spiritual (spirituality, Awakened Awareness, spiritual growth, and spiritual decline) and clinical (depression, anxiety, and depression) variables. Z scores were calculated to examine the magnitude of the effect size.

A hierarchical linear regression was then conducted to examine whether improvements in spiritual decline between posttest and 3-month follow-up predict improvements in posttraumatic stress between posttest and the 3-month follow-up. Preliminary analyses were conducted to test assumptions of normality, linearity, multicollinearity, and homoscedasticity. The dependent variable was posttraumatic stress at the 3-month follow-up. The hierarchical regression consisted of 3 blocks: block 1 included frequency of exposure to potentially traumatic events (PTEs), block 2 included posttraumatic stress at posttest, and block 3 included changes in spiritual decline from posttest to the 3-month follow-up.

3. Results

Chi-square analyses revealed three significant baseline differences between those who completed follow-up data and those who did not complete follow-up data. Participants who were born in the United States, participants who were employed, and participants who had a PHQ-9 score below 10 at baseline were more likely to complete the follow-up data. There were no other significant differences between groups on demographic, clinical, and spiritual variables. See demographics in

Table 1. Sociodemographic characteristics of participants.

Characteristics	n	%
Gender
Female	69	82.1
Male	11	13.1
Nonbinary	4	4.8
Sexual Orientation
Straight	50	59.5
Gay/Lesbian	10	11.9
Bisexual	17	20.2
Questioning	3	3.6
Prefer not to answer/other	4	4.8
Ethnicity
American Indian	1	1.2
African American/Black	13	15.5
Asian	18	21.4
Latino/a	7	8.3
White/Caucasian	32	38.1
Polynesian	1	1.2
Multiracial	11	13.1
Other	1	1.2
Religious Affiliation
Buddhist	1	1.2
Eastern Orthodox	2	2.4
Hindu	2	2.4
Jewish	7	8.3
Muslim	2	2.4
Protestant Christian	11	13.1
Roman Catholic	11	13.1
Other	7	8.3
None	41	48.8
Marital Status
Married	1	1.2
Unmarried	83	98.8
Employment Status
Employed	40	47.6
Unemployed	44	52.4
Importance of Religion or Spirituality
Highly Important	18	21.4
Moderately Important	25	29.8
Slightly Important	24	28.6
Not Important at All	17	20.2

Note. n = 84. Age: M = 19.75, SD = 1.6.

.

3.1. Clinical Measures

Posttest and 3-month follow-up scores on depression, anxiety, and posttraumatic stress can be found in

Table 2. Paired-sample t-tests of clinical variables.

			t-Test
Characteristic	M	SD	t	p	n	z
Depression			2.12	0.037 *	84	0.25
Posttest	7.45	5.24
3-Month Follow-up	6.45	5.3
Anxiety			2.25	0.027 *	84	0.27
Posttest	6.82	4.09
3-Month Follow-up	5.65	4.9
Posttraumatic Stress			3.27	<0.001 **	84	0.39
Posttest	34.71	11.6
3-Month Follow-up	31.54	11.5

Note. * indicates a significant result at the 0.05 confidence level. ** indicates a significant result at the 0.01 confidence level.

. Each of the measures saw overall mean decreases from posttest to the 3-month follow-up, indicating that participants reported significantly decreased symptoms of depression, anxiety, and posttraumatic stress following the intervention. In other words, college students continued to improve, showing mounting improvements in AA-A beyond termination to three-month follow-up.

3.2. Spiritual Measures

Mean spiritual measures at posttest and 3-month follow-up can be found in

Table 3. Paired-sample t-test of spirituality variables.

			t-Test
Characteristic	M	SD	t	p	n	z
Spirituality			0.83	0.408	84	0.10
Posttest	105.92	20.34
3-Month Follow-up	104.77	18.91
Awakened Awareness			0.26	0.799	67	0.03
Posttest	35.80	7.02
3-Month Follow-up	35.85	6.77
Spiritual Growth			0.93	0.354	84	0.11
Posttest	114.23	49.11
3-Month Follow-up	110.58	50.48
Spiritual Decline			−2.05	0.040 *	84	0.24
Posttest	23.48	11.25
3-Month Follow-up	26.29	13.99

Note. * indicates a significant result at the 0.05 confidence level.

. Spirituality, Awakened Awareness, and spiritual growth did not change significantly from posttest to 3-month follow-up, showing stability. In other words, students continued to perceive a spiritual reality and continued to challenge themselves to grow spiritually. At the same time, without the support of the group, spiritual decline significantly increased from posttest to 3-month follow-up, suggesting that without the spiritual support in a time of quest and challenge and without the support of the spiritually grounded group, spiritual struggles may mount.

3.3. Spiritual Decline and Posttraumatic Stress Symptoms

There were no main effects of baseline trauma exposure on 3-month follow-up posttraumatic stress symptoms in Block 1 (

Table 4. Hierarchical regression for posttraumatic stress at 3-month follow-up.

Variable	B	SE B	β	R2	ΔR2
Block 1				0.011	0.011
Constant	<0.001	0.109
Trauma Exposure	0.107	0.11	0.107
Block 2				0.498	0.487 **
Constant	0.009	0.078
Trauma Exposure	−0.015	0.08	−0.015
Posttest PCL Score	0.711 **	0.08	0.708 **
Block 3				0.534	0.036 *
Constant	0.009	0.076
Trauma Exposure	−0.016	0.077	−0.016
Posttest PCL Score	0.702 **	0.078	0.699 **
Δ Spiritual Decline	0.191 *	0.076	0.19 *

Note. * p < 0.05. ** p < 0.01. n = 84.

). In Block 2, posttest posttraumatic stress was found to be predictive of posttraumatic stress at the 3-month follow-up (β = 0.708, t = 8.86, p < 0.001). In Block 3, change in spiritual decline from posttest to 3-month follow-up was found to significantly predict 3-month follow-up posttraumatic stress symptoms when controlling for trauma exposure and posttest posttraumatic stress symptoms (β = 0.708, t = 2.482, p = 0.015). The overall model predicts 53.4% of the variance in 3-month posttraumatic stress, with changes in spiritual decline accounting for a unique 3.6% of the variance. This association is positive, indicating that participants who increase in spiritual decline are more likely to increase in posttraumatic stress or conversely, those who experience less or no spiritual decline following the intervention are less likely to experience as many posttraumatic stress symptoms.

4. Discussion

At three-month follow-up, AA-A demonstrated (1) ongoing strength of spiritual life (carrying value in and of itself) and (2) sustained decreases in levels of symptoms of depression, anxiety, and trauma symptoms, reinforcing a longer-term effectiveness of AA-A on psychopathology as a spiritual wellness intervention. The ongoing strength of spirituality is supported by findings that at three-month follow-up, the improvement in college students’ level of spirituality at termination of the intervention continues to be maintained, as measured by Awakened Awareness as well as validated measures of spiritual growth and relational spirituality. The moderating effects of spirituality on psychopathology at three-month follow-up show that increasing spirituality in college students continues to provide enduring protection against these mental health problems.

A subset of college students, however, who initially present with more severe post-traumatic stress symptoms, appear to need ongoing spiritual support to maintain these gains. Specifically, at three-month follow-up at the level of a trend, the improvement or “reversal” of spiritual decline started to backslide specifically in people who reported higher levels of trauma. This finding suggests that for college students with higher levels of trauma symptoms and traumatic life events, there may be a need to maintain and sustain spiritual support.

These results have several implications that are highlighted here with quotes from AA-A participants who have consented to have their experiences shared.

First, AA-A appears to foster lasting spiritual awareness, as evidenced by the sustained growth in spirituality and improvements in relational spirituality, observed three months after the conclusion of the program. The following participant shared how they were able to use Awakened Awareness to process a breakup during and after the semester they engaged in AA-A:

“I also broke up with my significant other at the end of the semester. That was a really hard decision for me to make, just because I felt like I didn’t really know what the right thing to do was in the situation. I was relying a lot on that awakened voice within me. During that time I was meditating a lot and journaling and just trying to figure out what I thought and what I want for my goals, for the future and also in that moment. I think the group gave me the tools to figure out what I want. I think that just being here and transitioning after semester, like I really feel settled now.

I think with the break up I had, I think [I was] trying to frame that in my mind that that wasn’t a failure, like that a relationship failed just because it ended, and that all the things that that relationship served me. The person that I still do have in my life, even though it’s different now, and how much I learned from that, and the ways that, I don’t know, even … He’s a writer and I read so many books because of him… He inspired me”.

Second, improvements in spiritual awareness offer sustained reductions in depression, anxiety, and trauma-related symptoms. However, for students with higher levels of trauma symptoms, continued support is needed to maintain the reversal of spiritual decline associated with trauma-related symptoms.

This engages us in a dialectic; that sporadic or “as-needed” communal spiritual engagement can improve spirituality but that without some ongoing spiritual support, a sense of spiritual decline or stagnancy can (re-)emerge. This is consistent with the wisdom of many faith traditions’ emphasis on regular practices as well as the clinical science that corroborates the mental and spiritual benefits of regular, communal, contemplative, transcendent, and spiritual practices.

The findings that spirituality, spiritual growth, and Awakened Awareness were maintained in the months following, while reversal of spiritual decline was not, suggest that the relational aspect of the program may be essential to targeting spiritual decline. This indicates a qualitative and experiential difference between having knowledge/wisdom/tools and having a psychologically safe environment or community that provides the space and fosters the exchange of ideas, reciprocal practices, emotional support, and interactive perspective taking. In other words, it is valuable to walk a spiritual path alone and understand and learn spiritual concepts and ideas, yet, also, there is great support to be derived in a spiritual community in which to find relational spirituality, gain new understanding, and deepen and share communal transcendent practices on an ongoing basis. These implications are corroborated by the following participant’s reflection:

“I just really enjoyed going every week, knowing that it was a space where people were caring about you kind of. I don’t know, I feel like things are so busy, and it’s all, “you have to do this, and you have to do this”. It was just really nice to come to a space that was focused on wellbeing, and people that were interested in how I was doing. That to me kind of stood out the most as what I enjoyed from it”.

Third, while group AA-A is not intended as stand-alone treatment for any psychological disorder, long-term improvements in mental health are seen both during the program and in the months following, indicating that the program may be providing participants with a spiritual way of being, pathways of spiritual engagement with the transcendent, and an Awakened Awareness mindset in which they can independently engage an ongoing basis and potentially aid in adjusting to the many transitions in emerging adulthood.

The following participant shares how the intervention was helpful for him following the sudden loss of his cousin and how he was able to reconnect with the joy in his academic studies:

“Before the group, I was going through some emotional situations with the death of my cousin in the past semester. I was here and I couldn’t go back for his funeral, because I had classes and things. It happened midway through spring semester of junior year and, I don’t know, I just went inside of my shell, and things seemed to be happening outside of my control. So I was like, ‘Hey, maybe this [AA-A] might help me control the emotions,’ and I don’t know, just learn how to cope with it a little bit better. I think, probably, the most important part, apart from the meditation, was just being able to talk about issues that were going on during the semester. Then listening to other people. I think that, probably, helped a lot, because I tend to be pretty reticent. So I don’t talk to a lot of my friends a lot. My friends know, but I’ve never sat down and talked to any of them about how I felt or anything, nor have I talked to my mom, or grandparents. So it was good to just talk about those things And with regard to the [awakened] lenses... I think that helped a lot, to just reorient myself and focus on what I enjoy a lot. Now, I feel the joy for computer science is coming back, and other things”.

4.1. Limitations

While changes in participants are assessed over time within the context of a highly ecologically valid study, it is important to note the absence of a control group in this open-trial study design due to the strong ethical concerns of denying spiritual support to rapidly growing students who otherwise may not access spiritual support (as it is yet to emerge as a current standard of care on campuses). As a result, it cannot be conclusively determined that the observed changes are singularly attributable to the intervention.

Due to sample size limitations, statistical moderation was not testable with this dataset. However, future applications of spiritually focused interventions may benefit from studying follow-up effects and their contingencies, including whether the benefits of continued spiritual practice help support maintenance and continued treatment gains in both intervention responders and non-intervention responders. Additionally, the generalizability of this sample is limited as data were collected from two urban highly competitive sister universities; future research might explore the potential benefits of AA-A across multiple sites.

4.2. Conclusions

Awakened Awareness (AA-A) is a campus-based spiritual intervention designed to enhance spiritual awareness in college students—a perceptual capacity that, as demonstrated by the current study, is sustained through a three-month follow-up. Awakened Awareness includes perception of relational spirituality, an ongoing dynamic relationship with the Higher Power (G-d, Jesus, the Universe, whatever might be the students’ own sacred words to describe this relationship). An ongoing lived transcendent relationship with the Higher Power and spiritual growth appear to offer ongoing protection at three-month follow-up against depression and symptoms of trauma.