Health, Spirituality and Medical Ethics

Introduction
The growth of spirituality in the last few decades has been increasingly sought after by psychoanalysts, psychologists, and health professionals. The social ties and relationships resulting from the implementation of religious activities, such as the holy month of Ramadan, Hajj, and participation in Friday Prayers, facilitate the control and reduction of depression and anxiety. Spirituality allows for the promotion of psychological capacity and ability to cope with stress and problems, thereby improving mental health (1). Religious experiences, especially mystical ones, have a significant role in psychotherapy. In fact, spiritual experiences are a kind of 'awareness of the spiritual world', 'mysticism', 'culmination', and 'religious and spiritual experiences'.
The phenomenon of spirituality is a multidimensional structure, which consists of several parts. These components include spiritual or supra-spiritual dimension, meaning and purpose in life, having a mission and a sense of duty and commitment in life, sanctity of life, neglecting materialistic values, altruism, idealism, awareness of the tragedy of pain, disaster, and death, as well as the fruits of spirituality (2).
The family is one of the most important educational environments in the transfer and education of religious values (3). Therefore, given the fundamental and decisive role of parents in the lives of children, the present study aimed to investigate whether the loss or absence of a father has a detrimental effect on the religious values of the offspring. Although most of the studies have examined the importance of maternal role in the transfer of religious values, the importance of father's role in this regard has been recently studied (4-6).
According to the literature, the absence of a father-child relationship due to the father's death can induce a wide scope of negative impacts on child’s physical and mental health (7). Consequently, it seems that parent-child attachment theory can adequately explain such a relationship. According to Bowlby (1996), child’s initial interactions with the father's face are coded into mental representations, which include experiences, beliefs, emotional evaluations, and information processing rules. These mental representations affect the child's behaviors and expectations in interpersonal relationships (e.g., relationship with God) from the cradle to the grave (8).
In this regard, studies have shown that the mother-child attachment is different from father-child attachment, and that the attachment of the child to each parent results from the child's interaction experience with that parent (9). Therefore, paternal role and the time a father spends with his child are indicative of a safe father-child attachment (10). In addition, as stated by Biblaraz and Raftery, the 'Pathology of Matriarchy' obtained from the Moynihan Report shows that the absence of a father is harmful to children, especially to boys, because it represents children's' lack of financial resources, role models, and discipline in various areas (including religious education)  (4).
Research has shown that children separated from their fathers have a worse school performance and lower self-confidence, compared to those having their fathers alongside (4). Over the past decade, several studies have demonstrated the role of parental attachment in religious growth (11). Moreover, several studies have indicated the important role of parents in the establishment of a connection with God (11, 12).
Therefore, based on the attachment theory that recognizes the secure attachment face as a safe basis for environmental curiosity and cognitive discovery, it seems that the absence of the father's attachment face, and consequently the lack of safety, leads to the reduction of the search for cognitive discovery, (e.g., in the religious domain). Given the significance of father' absence in the attachment theory, this study aimed to investigate the role of father in the daily spiritual experiences of the children in order to clarify the importance of this role as a source of support and an agent for transferring the religious values.
 
Methods
This retrospective comparative study was conducted on 100 students with father and 50 fatherless students with the mean age of 15.88 years, selected from two male and female Shahed high schools in Zabol, Iran, in 2015. The fatherless volunteers were selected by referring to each class using convenience sampling technique. It is worth mentioning that the students had lost their fathers during the pre-school or elementary school (first grade) periods. In addition, they had Shi'a mothers, who adhered to religious principles and Islamic laws (e.g., prayers, fasting, and hijab), lived independently (i.e., without their parents or spouses), and did not marry again.
The sampling of the students with fathers was performed by matching them with fatherless subjects based on their Grade Point Average (over 15), socioeconomic status (income of 1-2 million Tomans and parents of non-academic education), and religion (Shia Islam). It should be noted that the group without fathers included the children whose fathers were dead rather than the poorly supervised students (e.g., with an imprisoned father) or those with divorced parents. Likewise, based on the students and teachers' reports, the group with fathers did not include children with a bad parent (e.g., father's addiction, imprisonment, and leaving the family).
After informing the participants about the research objectives and assuring them about the confidentiality of the information, their oral consent was obtained. The data were collected using the Daily Spiritual Experience Scale (DSES). The DSES was first developed by Underwood and Teresi to measure daily spiritual experiences and expresses concepts that are not restricted to any particular religious orientation (13). The items of this scale measure the daily spiritual experiences of individuals throughout life, instead of their specific beliefs and behaviors.
This instrument is rated on a 6-point Likert scale (i.e., almost always, always, often, sometimes, rarely, and never or almost never). This tool includes 16 parameters covering such concepts as relation, help of God, guidance of God, receiving God's love, feeling of amazement, gratefulness, as well as affection and compassion to God. It entails three subscales, namely God's presence, connection with God, and sense of responsibility towards others.
The reliability of the scale was reported as 0.94 and 0.95 using Cronbach's alpha coefficient and test-retest method, respectively (14). In another study, the reliability of this instrument was confirmed obtaining Cronbach's alpha coefficient of more than 0.9. The results of factor analysis also revealed a simple structure with three factors, namely God's presence, connection with God, and sense of responsibility towards others (13, 15). In the present study, all these three subscales showed a Cronbach's alpha coefficient of more than 0.8.
Results
The frequency distributions of the participants’ education level and gender are tabulated in Table 1. The majority of the students were in the first grade of high school. Accordingly, the results of the Chi-square test revealed no significant difference between the two groups in this regard (X²=0.01; P=0.9). Similarly, there was no significant difference between the male and females students in this respect (X²=0.01; P=0.96). The subjects had the mean age of 15.88 years (age range: 14-18 years), and 44% (n=66), 22% (n=33), 26% (n=39), and 8% (n=12) of them were majoring in the first, second, third, and pre-university grades of high school, respectively. Furthermore, 67.7% (n=100) of the students were male.
Table 1. Frequency distribution of the participants’ education level and gender in each study group

Education	Children with fathers	Children without fathers
First grade	22	44
Second grade	11	22
Third grade	13	26
Pre-university	8	8
Female	17	33
Male	33	67

 
To determine the difference between the groups with and without fathers in terms of spiritual experience, the Levene’s test was used to test the equality of variances of the dependent variable for the two groups in the spirituality subscales of sense of responsivity towards others (F=1.79; P>0.05), connection with God (F=0.64; P>0.05), and feeling God's presence (F=3.69; P>0.05). The Box’s M test was also utilized to investigate the equality of covariance matrices, which confirmed the given assumption.
Furthermore, the independent and interactive effects of gender and group (i.e., with and without father) on the spiritual experiences were analyzed using MANOVA. The results of this test revealed that group had a significant effect on spiritual experiences (P<0.05), while the gender effect was not significant in this regard (P>0.05). However, these two variables (i.e., gender and group) showed a significant interactive effect on spiritual experiences  (P<0.05). The investigation of spiritual experiences in each of the male and female groups was accomplished through the Student’s t-test. The results of this test demonstrated no significant difference between the two female groups of with and without fathers in this regard (P> 0.05). However, in case of males, the two groups were significantly different in terms of the spiritual experiences (P<0.05).
The mean and standard deviation of the spiritual experience subscales in the students with and without fathers are presented in Table 2. Connection with God and sense of responsivity towards others were the most and least frequently mentioned spiritual experiences, respectively. In addition, connection with God had the highest mean in both groups. On the other hand, the presence of God and sense of responsivity towards others had the lowest mean values in the fatherless and with father groups, respectively. The results of the t-test showed a significant difference between the two groups just in terms of feeling God's presence. In this regard, the fatherless group felt the presence of God during the day significantly less frequently than the group with father.

 
 
Table 2. Descriptive and statistical analysis of spiritual experience subscales in general and in each of the groups

Daily spiritual experiences	Total		Subjects with fathers		Subjects without fathers		t-test	Degree of freedom	P-value
	Mean	SD	Mean	SD	Mean	SD
Connection with God	5.09	0.67	5.04	0.71	5.12	0.65	0.63	146	0.52
Sense of responsibility towards others	4.32	1.01	4.42	0.98	4.28	1.02	0.73	135	0.46
Feeling God’s presence	4.5	0.77	4.32	0.92	4.60	0.66	2.36	146	0.02

 
As mentioned previously, the spiritual experiences were investigated in the males with and without fathers. As illustrated in Table 3, the fatherless boys (n=32) felt God's presence significantly less frequently than those with fathers (n=66). However, there was no significant difference between the two male groups in terms of the other two subscales (P>0.05). It should be noted that regarding the females, the two groups showed no significant difference regarding all three subscales (P>0.05).

 
Table 3: Comparison of the mean score of God's presence between the male students with and without fathers

Group	Daily spiritual experiences	Group	Number	Mean	Standard deviation	t-test	Degree of freedom	P-value
Male students	Feeling God’s presence	Without fathers	32	4.39	0.86	2.03	96	0.04
		With fathers	66	4.71	0.64

 
Discussion
As the findings of the present study indicated, the fatherless students experienced God’s presence less frequently than those with fathers, and this relationship was also significant in boys. The feeling of God's presence as a spiritual experience is one of the components of attachment to God, which is influenced by the child’s attachment to the parent (16). In this regard, Rizzuto  states that the inner images of the first caregiver (i.e., parents) forms the God image, which inhibits the negative feelings of harmful experiences through establishing connections with God (17).
Therefore, spirituality can be measured based on the objective relationships and child-parent attachment (16, 17). In this regard, several studies have shown that child's attachment to the father predicts his/her relationship with God (11, 12, 18). Consequently, the disconnection of the child-parent attachment (e.g., through death) affects the child's faith and religiosity. In other words, the individuals who have been separated from their parents due to their death may depart from God (12).
In a study conducted by King and Roeser (19), the religious orientations of the adolescents were concluded to be mostly affected by the fathers than the mothers. This finding justifies our result indicating the effectiveness of the presence of the father and the subsequent secure father-child attachment in transferring religious values and sense of God’s presence, especially in boys. Therefore, the therapists can encourage the fatherless children to establish a secure relationship with God through religious activities because the reconstruction of the relationship with God is transmitted to their interpersonal relationships with their spouse and friends (20).
The safe haven of attachment parenting strengthen the child’s ability to cope with the crisis. Regarding this, it is expected that despite the connection of the fatherless children with God (our results were also indicative of no difference between the two groups in this regard), they lack the primary basis of trusting to parent for dealing with the crisis and difficulties due to experiencing the anxiety caused by father’s absence; as a result, they do not feel God’s presence.
According to Sizelove, connection with God can be a result of one’s spiritual need (21). However, the sense of God's presence is based on the presence of the father and child’s attachment to him, which is experienced in another form at the time of the crisis through connection with God (11, 21).  Feenstra and Brouwer also believes that the process of spiritual experience is easier for the attached individuals. He also assumed that these individuals can better discover and process spiritual experiences and can faster integrate the beliefs and spiritual issues into their psychological structure (as a successful identity) than the unattached ones (22).
The parents play an important role in the religious and spiritual growth of the adolescents (19). The parents are the interpreters and key translators of religion for children. This effect is exerted both directly and indirectly through the socialization of religious customs and the influence of religion on parental behaviors, respectively (19). The lack of father prevents education, role modeling, and participation in religious practices and reduces the religious and spiritual growth in the fatherless children. However, given the compensatory effect of parental religiosity on the quality of connection with God (23), it is suggested that this issue be addressed in future research.
It is also recommended that the fatherless children dealing with more problem in life be provided with cultural measures targeted toward the strengthening of spiritual and religious teachings. The findings of this study were obtained through a cross-sectional analysis; regarding this, further studies may lead to more realistic and accurate results. On the other hand, the implementation of a similar study on samples of different age groups can be helpful in understanding the results. The role of the degree of maternal religiosity on the transfer of religious values was not investigated in the present study. The simultaneous investigation of both paternal and maternal roles can facilitate the comparison of the importance of father and mother’s presence in the spiritual experiences of the children.
 
Conclusion
The findings of the present study indicated the importance of the paternal role in the children’s feeling of God's presence and daily spiritual experiences. The attachment to parents as a basis for establishing attachment to and connection with God can indirectly contribute to the prevention of psychological problems caused by traumatic experiences. Therefore, there is an adaptive approach between the attachment to the parents and the attachment to God.
Moreover, the parents, especially the father, plays an important role in shaping the child’s connection with God through transferring the religious teachings. The absence of the father highlights the role of child-parent disconnection (e.g., through death) in the socialization of the religious values ​​(19). This underscores the importance of the role of a male successor (e.g., scientific communities and clergymen) for transferring the religious doctrines.
Acknowledgements
This research is the result of a personal study. The authors extend their gratitude to the officials of the Shahed high schools of Zabul and the individuals who cooperated in this study.
Conflict of interest
The authors declare no conflict of interest.
 
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