Effect of Spiritual-Religious Interventions on Anxiety, Depression, and Adjustment to Parental Divorce in Female High School Students

Introduction t is a common belief that marital life is a lifelong commitment; however, divorce challenges this belief and destroys marriages and subsequently families. In fact, the rate of divorce is rising and this can be very destructive (1). The divorce rate in Iran is very unfavorable, with 99852 divorces in 2007 and 174578 divorces in 2017 (2). At first glance, divorce is considered to be more harmful to the couple; however, children are not immune to its harmful effects (3, 4). Children who experience parental divorce undergo crisis, shock, and disruption of their sense of security and psychological well-being (5). Besides, it causes behavioral problems, and reduces their adaptability (7); however, the impact of divorce may vary with the age of the children (6). According to the results of a study conducted by Seijo et al., children of divorce were more likely to have symptoms of depression, anxiety, aggression, paranoid thoughts, social isolation, social exclusion, and I Abstract

educational/occupational problems (5). They feel guilty about the separation of their parents and cannot easily adapt themselves to their circumstances (8). Moreover, they may blame their father or mother and have bad feelings and reactions towards them (9).
Parental divorce mentally disturbs the children and causes them to have a bad attitude towards life, their parents, and even themselves, which can be improved through interventions (10). Based on previous research, religious and spiritual practices and beliefs can be helpful in coping with difficult situations (11,12). Moreover, spiritualreligious beliefs help one look at life and its challenges from a new positive perspective and also help them to deal with the problems of life more efficiently (13).
Spirituality has a prominent role and many important functions in life. The World Health Organization has also emphasized its importance and defined it as one of the aspects of health that is essential for humans (14). Spirituality and religion are similar and there is no clear-cut boundary between them. Griffiths and Griffiths have argued that spirituality causes humans to pay more attention to all their relationships, such as their relationship with God, other human beings, the whole universe, and non-material beings (15).
Those who have spiritual-religious beliefs do not see themselves as left alone in the world. Moreover, they always feel the presence of God as a supernatural power and do not feel lonely when facing challenges in life (16). According to previous studies, spirituality and religion can strengthen a person against the difficulties and adversities of life (17,18). Safara et al. in their study showed that spirituality can improve one's mental health (19). Furthermore, spiritualityand religion-based practices can empower people in the face of adversities and lifethreatening diseases (20). In addition, based on the findings of a study performed by Tuttle and Davis on the effects of spirituality and religion on marital life, spiritual-religious beliefs can enhance marital satisfaction and happiness, and improve couples' relationships (21). Regarding the familial aspect, Yeung and Chan in their research have shown that spiritual-religious beliefs and practices have a very positive effect on family processes, alleviate the psychological problems of family members, and develop the abilities and skills of children (22).
Given the abovementioned information, children of divorce face disturbances and disagreements caused by their current situation that can make their lives difficult and even destroy their individual, marital, and social lives in the future . Therefore, it is crucial to find ways to help them. However, it seems like little research has been conducted on this topic, while children of divorce, especially female children, need psychological interventions.
Given the religious context of Iran, it seems that spiritual-religious interventions can be effective in this regard. Nevertheless, as it has been indicated by previous research, it should not be overlooked that a misunderstanding of the content and principles of spirituality and religion, as well as incorrect use of spiritual and religious interventions, can cause more harm. Therefore, it is necessary to notice that spiritual-religious doctrines should be evaluated in every aspect of one's life (23). Consequently, the need to study the impact of spiritual-religious teachings on adolescents, especially females, with divorced parents seems necessary. The purpose of this study was to investigate the effectiveness of group spiritual-religious interventions on reducing psychological distress and enhancing adjustment to parental divorce in female children.

Methods
This quasi-experimental study was conducted based on a pretest-posttest design with a control group. The study population consisted of all female high school students whose parents had divorced in Malayer, Iran, in 2019. After referring to the State Welfare Organization and receiving a letter of introduction addressed to the Hadi Psychology and Counseling Center, a license (code: 16/40/3775) was obtained to be presented to schools. It was not possible to accurately estimate the number of all the female students whose parents were separated. Therefore, the samples were selected after examining the students' records in schools. When the number of reviewed documents reached 35, the researchers started to select the samples from them and formed two groups.
Therefore, after reviewing the files and making contact with the students and their families, 28 eligible students were selected using purposeful sampling method while seven students did not meet the inclusion criteria. In order to select the sample, the records of high school students were first reviewed and those whose parents had divorced were chosen. Afterward, the psychological and behavioral characteristics of the students were investigated, the parents with whom the children were living were contacted, the course of the research was explained to them, and their consent was obtained. Subsequently, children were interviewed in order to gain their consent as well. After selecting and identifying the subjects, they were randomly assigned to the intervention (n=14) and control(n=14) groups. There was no attrition in this study until the end of the course and the post-test stage.
The inclusion criteria were 1) passage of at most 2 years of the parental divorce, 2) female gender, 3) high school student, 4) residency with a parent, and 5) no severe psychological problems (based on the student's records and her psychological interview). On the other hand, the exclusion criteria consisted of absence for more than one session and a lack of willingness to participate in the study. In order to respect the ethical considerations, the parents and students were assured of the confidentiality of their information and the effectiveness of the interventions was explained for them. Moreover, their consent was obtained and an intervention course was also held for the control group. Furthermore, brochures and booklets on the effects of religion and spirituality in life were provided for the members of both groups.
The intervention group was subjected to 11 sessions of 2-hour training weekly, based on the following therapeutic package developed by Dashti Bozorgi et al. which was approved by the psychology professors. The training was conducted in summer from early July to late September and the sessions were held at the Hadi Consulting Center in Malayer.
The following is a summary of the intervention sessions: First Session: Introducing each other; expressing rules and expectations; discussing parents, married life and divorce; its physical and spiritual consequences, the concept of spirituality and religion and its impact on life; God, getting close to God and his effect on life; reproduction of the holy stories of the Quran by participants; the role of praying and religious beliefs in calmness; the experience of participants after saying prayers Second Session: Parent-child relationship; parental rights, rights of children; selfawareness; intrapersonal communication; listening to one's inner voice; assessing the needs and goals; knowing oneself, others, and one's abilities; focusing on positive thoughts and avoiding negative ones; reviewing past successful achievements; discussing the presence of transcendental knowledge and power for solving the problem; and fully entrusting oneself to the superior power of God Third Session: Interpreting life events regarding values, goals, and beliefs; talking about the sense of guilt, self-forgiveness, and forgiving others; refusing to take revenge; the impact of showing forgiveness towards your fellow human beings; sharing an experience of forgiveness by one of the participants Fourth Session: Emphasis on personal responsibility in overcoming barriers; examining one's personal traits and intrinsic qualities; self-compassion; improving interpersonal relationships; learning how to cope with social stress; promoting positive interaction with the environment; achieving intrinsic motivation; discussing ways to make others happy, and achieving spiritual excellence Fifth Session: Altruism; group spiritual activity; congregational prayer; focusing on blessings, thanksgiving, and its effects; learning how to smile and be kind Sixth Session: Creating enlightenment and insight to discover divine blessings inside and outside of ourselves; thinking wisely about blessings; and reaching happiness and its impact on promoting self-confidence, selfreliance, and self-esteem Seventh Session: Learning how to protect others, empathize with them, love them, care for them, do something positive for them every day, make them happy in order to help happiness grow; taking care of yourself physically, psychologically, and socially in order to reach spiritual self-care, discover its components, and keep it alive Eighth Session: Remembering God and asking for his forgiveness; learning what, how, and for whom to pray; learning how to express our deep suffering with God while having positive regard for God's wisdom Ninth Session: Emphasis on reality, the need for meaning and growth in life to maximize the motivation for change through building relationships based on empathy and mutual reliance to reach transcendental, growing, and meaningful goals; and accepting the wisdom of God in uncontrollable issues by practicing and following the pattern of recovery  (26). In the present study, the Cronbach's alpha coefficient of this scale was calculated at 0.82.

Child Behavior Checklist
This questionnaire was designed by Achenbach and is used to measure behavioral and emotional disorders in children and adolescents which consists of 113 questions and 8 subscales. However, in the present study, only the subscales of anxiety (14 items) and isolation/depression (8 items) were used. This questionnaire was scored based on a three-point scale consisting of 0 for inaccurate, 1 for partially correct, and 2 for completely correct. The range of scores for anxiety and isolation/depression was 0-28 and 0-14, respectively. Moreover, higher scores indicated more severe problems. According to a study performed by Minaei, this questionnaire has a desirable factor structure and good discrimination power. Furthermore, in the aforementioned study, the content validity of the questionnaire was confirmed and the Cronbach's alpha coefficient of its subscales ranged from 0.63 to 0.95 while its test-retest reliability ranged from 0.32 to 0.67 (27). Furthermore, the Cronbach's alpha coefficients for anxiety and depression were 0.80 and 0.78. The data were analyzed in SPSS software (version 22) using multivariate analysis of covariance (MANCOVA).

Result
Descriptive results showed that the mean values of age in the intervention and control groups were 13±0.67 and 13.21±0.80, respectively. Table 1 shows the mean and standard deviation of the intervention and control groups regarding anxiety, isolation/depression, and adjustment to parental divorce. The assumptions of MANCOVA were examined before its performance. Shapiro-Wilk test results showed that the distribution of research variables in pre-test and post-test stages was normal in both control and intervention groups. Moreover, the results of the Levin test showed that the assumption of homogeneity of variance was not violated and MANCOVA was applicable. Based on the results of Table 2, by controlling the pre-test effects in the intervention and control groups, no significant difference was observed regarding anxiety (F=24.82 and P<0.05), isolation/depression (F=4.50 and P<0.05), and adjustment to parental divorce (F=6.75, P<0.05). Moreover, according to results shown in Table 2, the post-test scores of the intervention group underwent a significant decrease and increase regarding the psychological distress and adjustment to parental divorce, respectively.

Discussion
The present study aimed to investigate the effectiveness of spiritual-religious interventions on psychological distress (anxiety and isolation/depression) and adjustment to parental divorce in female children of divorce. The results showed that spiritualreligious interventions can improve the psychological distress of female children in divorced families. In other words, spiritualreligious interventions can reduce anxiety and depression in female adolescents. Safara et al. in their study showed that spiritual interventions can improve psychological well-being in female adolescents, which is consistent with the findings of the present research (19). Furthermore, Weber et al. have shown that spiritual and religious beliefs and practices can promote mental health (28).
Spiritual and religious beliefs and practices broaden one's horizons. People who participated in this interventional session learned to look at the positive aspects of life and appreciate what they had. A positive outlook on life helps people to recognize that they still have many resources and opportunities, thereby it will lead to the improvement of their psychological distress. Spiritual-religious beliefs, practices, and behaviors cause one to perform activities that have positive and promising results.
Participation in prayers and remembrance of God can lead to a peaceful mental state (29). Similarly, Sullivan argues that spirituality and religion and their proper use can lead to mental health and the improvement of many mental disorders (30). Participation in this interventional course taught female children of divorced parents to recognize their priorities and act based on them. Moreover, they learned that if they blame themselves, their parents, or anyone else for the divorce (8,9), they should try to forgive and empathize with the guilty person which reduced their psychological distress.
Based on the results of this study, when female children of divorced parents were exposed to spiritual-religious doctrines, they were able to cope with parental divorce and its problems in a better way. In line with this research, Athari et al. in their study showed that spiritual and religious interventions can change one's lifestyle and make them adopt a healthier one (31). According to the findings of another study conducted by Simoni et al., spirituality and religion can help people adapt themselves to the difficulties in their lives and their incurable diseases (32).
Spiritual-religious interventions provide individuals with strategies to deal with stresses and challenges in life. The beliefs that the subjects of this research had about their current situation reduced their adaptability (8). Moreover, spiritual-religious interventions taught them not to see themselves alone in this world and handle their circumstances by feeling the presence of God and trusting in Him. Furthermore, spiritual and religious interventions gave them a clear view of a hopeful future and put them in a morally better position. Children of divorce considered the separation of their parents a very bad and horrible experience, but the spiritual teachings helped them seek meaning in it and try to reach something greater through this suffering. The training also helped them to improve their interpersonal relationships and deal with social stresses; therefore, they were able to better communicate with others and also improve their adaptability.

Conclusion
Overall, the results of this study showed that spiritual-religious interventions can reduce psychological distress and improve adjustment to parental divorce in female adolescents by broadening their horizons and providing effective coping strategies. In addition, spiritual and religious teachings can change the way people think and improve their lives. However, this result cannot be generalized due to the lack of consideration of the general population, random sample selection, and noncontrol of parent-child behavior. Nevertheless, the results of this study show the effectiveness of spiritual-religious interventions. It is hoped that it will attract the attention of healthcare professionals.

Conflict of interest
There is no conflict of interest in this study.