Effects of Spiritual-Religion Interventions on Complicated Grief Syndrome and Psychological Hardiness of Mothers with Complicated Grief Disorder

Introduction oss of a loved one is a very painful experience that can cause grief (1). Grief is a psychological reaction to the loss of a loved one that can appear in many different forms (2). Different forms of grief are not considered as disorder per se, since grieving for such a loss is normal (3). However, some people may still remain mournful for years after the passage of the normal course of grieving (4). In this case, the person develops complicated grief, which is characterized by separation anxiety and includes loss-related thoughts, feelings, and behaviors that complicate the mourning process. Under such circumstances, the person shows symptoms, such as disbelief, difficulty in accepting reality, and the painfulness and bitterness of loss, and manifests an excessive desire to pursue the deceased (5, 6). Recently, a great deal of attention has been paid to complicated grief as a disorder characterized by symptoms, such as loss-related disturbing L Abstract

Introduction thoughts (more than a year after experiencing loss), emotional pain, distressing yearnings, extreme feeling of loneliness and emptiness, avoiding activities that distract one from the thought of the deceased, unusual sleep disturbances, and reduced interest in personal activities (7,8).
Complicated grief can cause a lot of disturbances in the individual (6). Moreover, the loss of a child causes a severe and incomparable kind of grief (9). In such a situation, if one is in a good psychological state, she/he can cope with grief, which is called psychological hardiness (10). Disturbing events have different effects so that if one possesses a high level of psychological hardiness, the severity of these effects will be very low. Psychological hardiness means showing endurance, ability, and tolerance in the face of difficult situations (11). People with psychological hardiness have the power to control their life events and instead of avoiding problems, consider them as opportunities for improvement (12). Hardiness is a protective shield against the complexity of various situations, such as the experience of grief. People with psychological hardiness can adapt themselves to the problems and pressures caused by grief (13).
Psychological approaches have sought to enhance the mental capacity of humans. In addition, religion and spirituality have sought to make human beings stronger in the face of difficulties of life. Nowadays, the combination of spiritual-religious interventions with psychology has taken a valuable step in helping human beings (14). Spirituality is defined as a journey towards discovering and realizing one's fundamental aspirations as well as a search for divinity. Spirituality is an individual's inner orientation towards a transcendent reality that connects everything and makes them into a single harmony (15). Spiritual-religious interventions can give human experiences, behaviors, and values a coherent structure and make them meaningful (16). Spirituality and religion can result in an increase of one's adaptability to the environment, enhancement of activities, increase of self-awareness, performance of righteous acts, focus on the positive aspects of activities, and transcendence from material life (17).
Spiritual-religious beliefs help people not to see themselves alone in the world and always feel the presence of God as a superior power (18). Spiritual-religious beliefs can reduce psychological problems by reinforcing psychological processes (19)(20)(21). Ahles et al. in their study showed that spiritual-religious attitudes can act as a mediator and reduce depression by increasing resistance against stress and tensions of life (22). Gonçalves et al. in their systematic review also showed that spiritual-religious interventions can have positive effects on mental health (23).
According to the findings, people who are inflicted with complicated grief disorder suffer from many different problems and it is necessary to plan interventions in order to help them. Given the effectiveness of spiritualreligious interventions and the religious context of the country, it seems that these interventions can help the individuals with complicated grief disorder. According to the literature review, there have been very few interventions on complicated grief disorder. Moreover, these studies have used different therapeutic approaches (24). Furthermore, no research has been performed on the effectiveness of spiritual-religious interventions on complicated grief disorder in mournful mothers. It should be mentioned that the studies which have used spiritual-religious interventions have investigated variables other than complicated grief disorder syndrome (9). Given the aforementioned conditions, it can be said that the present study differs from the previous ones. The present study aimed to investigate the effectiveness of spiritual-religious interventions on complicated grief syndrome and psychological hardiness in mothers inflicted with this syndrome.

Methods
The present semi-experimental research with pretest-posttest and control group was performed on all mothers with complicated grief disorder in 2019 in Karaj. For the purposes of the study, the researcher visited cemeteries of Karaj for 2 months and then selected the subjects using purposeful sampling method. In this regard, the researcher identified the mournful mothers and established a relationship with them. Finally, a total of 28 eligible mothers were included in the study. After sampling, the participants were randomly divided into intervention (n=14) and control (n=14) groups. Each sample had a personal information form, and all of the forms were placed on top of each other. In order to randomly divide the participants, the researcher randomly selected 14 out of 28 personal information forms for the intervention group. The inclusion criteria consisted of 1) infliction with complicated grief syndrome based on the interviews, 2) experience of child loss, 3) female gender, and 4) lack of medication usage during the interventions. The intervention group received intervention based on a protocol developed by Dashtbozorgi et al. which consisted of eleven weekly 2-hour sessions (25). It should be noted that ethical considerations were respected by informing the participants of the content of the intervention sessions and their potential results. Moreover, it was emphasized that their information is kept confidential and they are free whether or not to participate in the study. In addition, verbal informed consent was obtained from the participants. Finally, in order to respect the ethical considerations regarding the control group, after the completion of the intervention, a few intervention sessions were held for the control group as well.
First Session: Introduction, discussion on grief and grieving process, concept of spirituality and religion and its impact on one's life, God, ways of getting closer to God and its impact on one's life, recitation of holy stories of Quran by the participants, role of praying and religious beliefs, experiences of participants of calmness after praying. Second Session: Self-awareness and self-communication, listening to one's inner voice, assessing one's needs and goals, knowing yourself, others, and your abilities, practicing positive thoughts and avoiding negative ones, investigation of successes, discussion about the existence of a spiritual knowledge and power to solve the problem, total submission to a superior power. Third Session: Meaningfully interpreting life events regarding values, goals, and beliefs; talking about feeling guilty, repentance, selfforgiveness, and forgiving others; refusing to take revenge from others; asking others about their experiences, and expressing one's feelings after repentance; calmness; describing God's greatness and mercifulness, and counting blessings; the impact of forgiving others; reciting an example of the forgiveness that the participants have experienced and the aftermath feeling; confession to one's errors; making a list of one's errors and those who they have hurt; the ability to make up for it; asking for forgiveness. Fourth Session: Emphasis on the acceptance of personal responsibility in combating barriers and investigating individual and intrinsic traits, compassion for self, improving interpersonal relationships and learning how to cope with social tensions, promoting satisfaction through positive interaction with the environment, achieving inner reinforcement, discussion on ways of pleasing others and attaining spiritual excellence. Fifth Session: Kindness, group spiritual activities, congregational prayer, focus on what one has in life, thanksgiving and its effects, encouraging smile and kindness. Sixth Session: Provision of enlightenment and discernment to discover inner and outer divine blessings, reasonable thinking about them and reaching happiness and its impact on promoting self-belief, self-reliance, and selfesteem. Seventh Session: Learning how to protect others; empathy; loving others; caring for others; doing something positive for others every day; making others happy to spread happiness; physical, psychological, and social self-care in order to reach one's spiritual self, discover its components, and keep it alive. Eighth Session: remembering God and feeling His presence which make the mind work purposefully and suppresses automatic thoughts which create sick feelings and cause unthoughtful actions, reinforces reason, wisdom, and awakening; discussion on the influence of remembering God and praying, on mental health; learning how, what, and for whom to pray; learning how to invoke God; talking about one's deep suffering with God with a positive regard for the wisdom of God. Ninth Session: Emphasizing reality and the need for the existence of meaning and growth in life to maximize the motivation for change by building empathy and mutual trust for reaching transcendental, growing, and sustainable goals; accepting the wisdom of god on issues that can't change with practical exercises and drawing a pattern of recovery. Tenth Session: Spiritual self-control by giving control to rational powers over other powers and seeking help from God, learning how to submit all aspects of human existence to reason and law. Eleventh Session: Discussion on death, causes of the fear of death, resurrection and afterlife, thanksgiving, faith, trusting in god, the manner of thanksgiving, and trusting God; drawing its steps; drawing a picture of the best view without looking at the clock; drawing a beautiful picture; disregarding time; concluding all of the sessions; distributing and refilling the questionnaires; closing the session.

Inventory of Complicated Grief
This questionnaire was developed by Prigerson et al. with 19 items assessing symptoms of complicated grief. This questionnaire is scored based on a Likert scale ranging from 0 (never) to 4 (always) so that the highest score indicates the most severe grief. In a study performed by Prigerson et al, this questionnaire acquired desirable reliability and validity (26). Regarding domestic studies, Mousavi et al. showed that the validity of the questionnaire was desirable and the Cronbach's alpha coefficient was estimated at 0.90 (27). In the present study, the Cronbach's alpha coefficient of this questionnaire was obtained at 0.87.

Personal Views Survey Questionnaire
This questionnaire is designed by Kobasa et al. and measures the degree of psychological hardiness in individuals. This questionnaire consists of 50 items and three subscales, namely control, commitment, and challenge. This questionnaire is scored based on a Likert scale ranging from 0 (completely disagree) to 5 (completely agree) so that the highest score shows more hardiness. Based on previous studies, the three components of commitment, control, and challenge have an alpha coefficient of 0.70, 0.52, and 0.52, respectively. Moreover, this coefficient was obtained at 0.75 for the whole scale. The validity and reliability of the scale have been confirmed in domestic studies and its reliability has been obtained by Cronbach's alpha for the whole scale and the subscales of commitment, control, and challenge at 0.88, 0.64, 0.72, and 0.70, respectively. (28). In the present study, Cronbach's alpha coefficient of the whole scale was obtained at 0.83.
The collected data were analyzed in SPSS software (version 26) using the analysis of covariance (ANCOVA).

Result
Descriptive results showed that the mean and standard deviation of the age of the intervention and control groups were 39.07±6.53 and 36.42±5.45, respectively. Table 1 shows the mean and standard deviation of the intervention and control groups regarding the study variables. The mean and standard deviation of the intervention group in the pre-test stage regarding complicated grief and psychological hardiness were 60.42±4. 16 and 53.50±4.62, respectively. Moreover, the post-test corresponding values in this group were 76.85±6.18 and 85.71±5.19, respectively. One-way ANCOVA was used to examine the significance of this change, as shown in Table 2.
Before performing one-way ANCOVA, it is necessary to first check the normality and homogeneity of the variances of the groups to see if they are confirmed. In this regard, the Kolmogorov-Smirnov test was used to evaluate the normality of score distribution. The results showed that the distribution of complicated grief disorder and psychological hardiness scores was higher than 0.05 in both groups. This result indicates that the score distribution of these two variables in pre-test and post-test stages is normal in both control and experimental groups. Furthermore, Levene's test was used to evaluate the homogeneity of variances. The results were not significant for complicated grief and psychological hardiness which shows the homogeneity of the variances. Based on the results (Table 2), there was a significant difference between the intervention and control groups regarding complicated grief (F=31.96 and P=0.0096) and psychological hardiness (F=39.09 and P=0.001). Moreover, the results (Table 1) showed that regarding the complicated grief disorder and psychological hardiness, the post-test scores of the intervention group underwent a significant decrease and increase, respectively.

Discussion
The present study aimed to investigate the effectiveness of spiritual-religious interventions on complicated grief disorder and the psychological hardiness of mothers inflicted with complicated grief syndrome. The results showed that spiritual-religious interventions significantly reduced complicated grief disorder. Similarly, a study performed by Nematipour and Golzari indicated that using spiritual-religious approaches in psychological interventions can improve the psychological processes of grief (9). Moreover, Fattahi et al. in their study indicated that Islamic grief therapy and the use of religious interventions can reduce the behavioral issues of grieving individuals (24).
According to the above-mentioned results, spiritual-religious interventions can reduce the severity of complicated grief disorder by providing mournful mothers with a bright perspective. The mothers who have lost a child feel lonely in the world (7,8). However, spiritual-religious interventions can make them feel the presence of God and His higher power more than before and not see themselves alone in the world. These mothers learned to turn to pursue spirituality and spiritual practices and try to get closer to God, instead of seeking their lost child. Spiritual-religious interventions taught the subjects to pursue more realistic and transcendent goals rather than considering life meaningless. Mothers suffering from complicated grief disorder were often reluctant to pursue their personal activities and lives (8). Spiritual-religious practices and beliefs such as prayer, meditation, and engaging in enjoyable spiritual activities lead people away from their empty lives, suffering, and pain and cause one to tend toward creative and valuable activities (17). Interventions, such as meaningfully interpreting the death of one's child, expanding one's understanding of divine fate, and positively paying attention to the wisdom of God caused them to gain greater acceptance of the loss of their child. Moreover, encouraging the participants to accept their responsibilities, have self-compassion, and positive interaction with others made them feel better about themselves and others and also helped reduce the symptoms of complicated grief, significantly.
Other results of this study showed that spiritual-religious interventions increased the psychological hardiness of mothers with complicated grief. Staton-Tindall et al. in their study showed that spirituality can act as an effective force against traumatic life events and increase mental health (29). Sadri DamirchiE et al. in a study conducted on the elderly showed that spiritual therapy can increase the psychological hardiness in the elderly (30).
Accordingly, spiritual-religious interventions increased the resilience of grieving mothers and enabled them to firmly face the challenges of life. Spiritual therapy by providing distressed mothers with an enlightened insight for discovering inner and outer blessings of God, rational thinking about them, and striving to promote self-belief, self-reliance, and selfesteem (25) helped them elevate their mental health.
Spiritual-religious interventions can help individuals look at negative aspects and events of life differently and assess them in a different way. These interventions strengthen the individuals and increase their psychological hardiness (31). Teaching the belief that God is watching over us at all times and will not neglect us, strengthened the participants in face of the challenges of life and helped them feel that they can have more control over their lives.

Conclusion
In conclusion, the results of the present study showed that spiritual-religious interventions can reduce complicated grief disorder and increase the psychological hardiness or capacities of mothers suffering from this disorder. This result demonstrates the powerful effect of spiritual-religious interventions on reducing the effects of the most destructive and traumatic life events. In other words, the results of this study indicate the efficacy of the used therapeutic protocol. Due to the religious context of the country and its high acceptance of such interventions, it is recommended that therapists use the same therapeutic plan in their therapeutic activities. However, caution should be exercised in generalizing the results due to the lack of random sampling and the use of purposeful sampling method which reduces the control over the exasperating and intervening variables, and the use of questionnaire tools that the subjects may have answered to with bias. It is recommended for further studies to compare and combine the effects of spiritual-religious interventions and other therapeutic approaches on complicated grief disorder while controlling the limitations of the present study. Moreover, given the presence of depression syndrome and physical problems in mothers suffering from complicated grief disorder, it is suggested that the effect of spiritual-religious interventions on these dimensions be investigated in future studies. The present research hopes to provide a context for the development of spiritualreligious interventions regarding complicated grief and other disorders.