M r. W, a 55-year-old married father with a history of major depressive and alcohol use disorders, was seen in a medical hospital following a selfinflicted gunshot wound (Kao et al., 2019). 1 Plagued with guilt over his drinking and extramarital affairs, the patient had found himself dwelling on the question of whether God could forgive him for his sins. In an effort to find the answer, he decided to "gamble with God" by playing Russian roulette with a gun loaded with one live bullet and five blanks. He reasoned that if God loved him, he would be spared. Mr. W pulled the trigger and was hit with the live bullet. He survived, although he required several weeks of hospitalization for severe facial injuries. How should Mr. W be approached in psychotherapy?As many of the chapters in this handbook have shown, spirituality can be a resource in treatment for people who are experiencing psychological problems. However, spirituality also has the potential to create or exacerbate mental health concerns, as we see in the story of Mr. W. Spirituality can be a source of problems that range from avoidance and denial to prejudice and aggression, to rigidity and extremism. There is, in short, a darker, seamy side to spiritual and religious life (see Pruyser, 1977). A growing body of research 1The name of Mr. W was altered to protect his confidentiality. Case descriptions in this chapter that come from Pargament and Exline (2022) are composites assembled from different clinical cases seen by the authors.Our thanks to the John Templeton Foundation for their support of our research on spiritual struggles (JTF No. 36094 and No. 55916).