Health, Spirituality and Medical Ethics

Introduction
Family as the core and basis of society plays an important role in the mental health of children and members of the community. One of the most important crisis that families may face is divorce. Divorce¹ is a stressful life event both for parents and children (1). According to the literature, the lack of adjustment of children to their parental divorces can have detrimental effects on their psychological functioning (2). In this regard, the well-being of children is one of the most important psychological factors, which can be affected by parental divorce. Generally, psychological well-being² is defined as an effort toward perfection, aiming to attain the potential abilities of an individual. In this viewpoint, well-being means an attempt to improve, which is manifested in the realization of talents and capabilities of a person (3).
Divorce and the loss of the family social network can lead to the condition, in which the child feels unwelcomed, insecure, or non-respected. This can explain the emotional and behavioral problems of children in such families (4). In this regard, it seems necessary to provide useful interventions in solving emotional and psychological problems of such children. For instance, studies show that faith, performance of religious orders, and participation at religious rituals can effectively prevent and treat mental problems in individuals, thereby improving their well-being (5, 6).
Spirituality³ involves self-perceptions as well as a combination of personality factors and fundamental beliefs about existence and meaningfulness in life. These beliefs are related to various aspects of life, including social, physical, and psychological aspects (7). Spiritual therapy helps patients understand themselves, the world, events, and phenomenon using specific principles and spiritual-religious methods, thereby the link between these individuals and the meta-material world could lead to their health and growth (8).
In a research conducted to assess the role of religion and spirituality in mental health, it was shown that spirituality provides the grounds for peaceful relaxation through a proper and ideal system of discipline (9). Sajadi et al. (2017) marked that spiritual counseling affected the spiritual well-being of Iranian female patients with cancer (10). In addition, Taheri Kharame (2016) reported a positive significant relationship between spiritual well-being and problem-oriented coping strategies in a study entitled “The relationship between spiritual well-being and stress coping strategies in hemodialysis patients” (11). In another research carried out by Mackinlay and Burns (2017), it was concluded that individuals with higher spirituality had higher physical and mental health, as well as lower level of anxiety and fear of aging (12).
 Dadkhah Tehrani et al. (2015) detected a positive significant association between religious attitude and psychological well-being (13). Moreover, in a study conducted by Yonker et al. (2012), it was reported that individuals with higher spiritual and religious attitudes had lower high-risk behaviors, as well as higher psychological well-being and self-esteem (14). Kim et al. (2014) indicated that adolescents who had access to religious resources were less likely to be addicted to alcohol and marijuana (15).
Dehghan et al. (2015) showed that spiritual group therapy could positively increase the tolerance of students (16). Furthermore, Barzegarbafruei and Pakseresht (2014) performed a research to evaluate the effect of teaching spiritual therapy on psychological well-being and academic performance of female students of secondary school from the viewpoint of Islam. The findings suggested that teaching spiritual therapy can significantly increase the psychological well-being and academic performance of students in the interventional group (17). On the other hand, Ghahari et al. (2012) marked that cognitive-behavioral and spiritual-religious interventions had no effect on reduction of depression and anxiety in breast cancer female patients (18).
The family is the basis for well-being of children; accordingly, the relationships in this social institute affect the mental, physical, and social health of children (19). The most apparent quantitative and qualitative outcomes of divorce can be observed in children (20). New therapies making use of such effective methods as spiritual therapy facilitate the treatment of vulnerable people. Despite the emphasis of studies on the effectiveness of spirituality in the field of mental health, there is a dearth of research in this field as indicated in the review of the literature performed in the scientific databases of Iran (e.g., database of scientific information center of Jihad-universities, comprehensive humanities portal, national publications database, Iran’s science and technology research center, Islamic sciences bank and human sciences bank). There are a couple of studies performed by Dadkhah Tehrani et al. (13) and Barzegarbafruei and Pakseresht (17) on role of spirituality in psychological well-being; however, the study populations targeted in the mentioned studies are different from ours. Therefore, with this background in mind, the present research aimed to determine the effectiveness of spiritual group counseling on the psychological well-being of female children of divorced families.
 
Materials and Methods
This experimental study was conducted on a total of 20 girls with the age range of 12-16 years from divorced families using pretest-posttest control group design. The participants were students at schools in Karaj, Iran, during the academic year of 2017-2018. The study population were selected through convenience sampling technique. The subjects were divided randomly into two groups of experimental (n=10) and control (n=10). The inclusion criteria were the age range of 12-16 years, a divorced family, and willingness to participate in the research. On the other hand, the exclusion criteria were mental problems and attendance to other educational classes. To observe the ethical considerations, the objectives of the research were explained to the subjects and a written informed consent was obtained from the participants prior to the study. In addition, the students were assured of the confidentiality terms regarding their personal information. Moreover, the subjects were allowed to withdraw from the research at any time. Spiritual intervention for the experimental group included eight 2-hour sessions implemented twice a week.
The spiritual group counseling program was designed based on scientific texts and resources. In doing so, the most relevant articles to the objective of the present research as well as related books on the topic of spiritual skills were assessed for the purpose of the program (21, 22).
In this program, group counseling was conducted in accordance with advisory standards, meaning that the program aimed to empower the participants to discover their problems and encourage members to share their issues with others. In addition, it was targeted toward persuading the participants to listen to the problems and experiences of others, as well as sharing their problems in a group. This technique helps the subjects under the study to face their problems in group. According to the mentioned resources, some sessions were handled using spiritual interventions benefiting from feedback, direction, clarification. The members of the interventionist group were psychology master graduates, who passed their internship in the field of spiritual therapy under the supervision of a specialized supervisor in the field of spirituality and religion psychology.
In the first few sessions of group counseling, the members of the group were introduced to each other and were informed about the rules of the group. Afterwards, the learning materials related to spirituality were provided to the participants and common issues of the group members regarding separation of parents were identified. Following that, interventions were continued using the components of spirituality (self-awareness, goal, emotion-focused and problem-based coping, faith, forgiveness and Dhikr [mentioning]). At the end of each session, students were given assignments related to spirituality (Table 1).
In order to measure psychological well-being of the participants, the researchers used 84-item Ryff's Psychological Well-Being Scales (RSPWB) designed by Ryff in 1980 was applied. The original version of the questionnaire had 120 items; however, the revised versions were reduced to 84, 54, and 18-item questionnaires. Ryff believes that the 84-item version has a higher capability of determining the psychological well-being of respondents, compared to other versions of the scale. In the 84-item version, there are 14 items for each factor. In addition, the reliability of the questionnaire has been reported 0.81-0.85 using retest. The reliability of the subscales of the questionnaire is 0.76, 0.90, 0.87, 0.91, 0.90, and 0.93 for autonomy, environmental mastery, personal growth, positive relations with others, purpose in life, and self-acceptance, respectively.
In order to standardize the mentioned questionnaire in Iran, Bayani et al. (2008) applied the scale on a sample population consisting of 145 students of Islamic Azad University, Azadshahr branch. The reliability of the questionnaire was estimated 0.82 using re-test. The subscales of self-acceptance, positive relations with others, autonomy, environmental mastery, purpose in life, and personal growth had the reliability of 0.71, 0.77, 0.78, 0.77, 0.70, and 0.78, respectively, which was statistically significant (23).
 
 
 
Table 1. Syllabus of training sessions held for the experimental group

Sessions	Content
First	- Introducing the participants to each other - Familiarizing the group with the regulations of the class - Discussing self-awareness skill and individuals’ spiritual aspects - Assigning exercises related to the first session
Second	- Teaching the meaning of life and determining the goal of life - Assigning exercises related to the second session
Third	- Talking about problems of members, as well as re-establishing and identifying their divorce-related problems in the group
Fourth	- Recognizing the common divorce-related problems of the members - Providing feedback and teaching based on emotion-focused and problem-based coping strategies related to the common problems of the members - Assigning exercises related to the fourth session
Fifth	- Following up the exercises assigned in the previous session - Giving feedback and teaching based on emotion-focused and problem-based coping strategies related to the common problems of members - Assigning exercises related to the fifth session
Sixth	- Following up the exercises assigned in the previous session - Giving feedback and teaching based on the concept of God trust - Assigning exercises related to the sixth session
Seventh	- Following up the exercises assigned in the previous session - Giving feedback and teaching based on the concept of generosity   -Assigning exercises related to the seventh session
Eighth	- Giving feedback and teaching based on the concept of mentioning   - Summarizing the presented content in the whole sessions and the final session - Performing the posttest

 
Results
Table 2 tabulates the descriptive statistics, including mean and standard deviation of the scale along with its subscales, in both the pretest and posttest stages for the experimental and control groups. In this respect, the dependent and independent variables were psychological well-being and spiritual group intervention, respectively. In addition, the ANCOVA was applied for the better evaluation of results.
 
 
 
 
 
 
 
 
 
 
 
Table 2. Mean and standard deviation of research variables in the experimental and control groups

Post-test		Pre-test		Sub-scales	Variable
Control group	Experimental group	Control group	Experimental group
Mean (standard deviation)	Mean (standard deviation)	Mean (standard deviation)	Mean (standard deviation)
51.60 (10.47)	67.90 (8.50)	51.00 (11.22)	51.70 (11.60)	Self-acceptance	Psychological well-being
58.30 (8.38)	72.50 (6.50)	56.00 (6.06)	57.70 (7.63)	Positive relations with others
53.70 (7.70)	66.80 (6.16)	53.40 (5.10)	53.90 (6.20)	Autonomy
50.00 (10.38)	62.80 (7.77)	49.90 (12.46)	54.10 (5.91)	Environmental mastery
54.10 (6.38)	71.50 (9.09)	55.90 (13.37)	64.10 (8.62)	Purpose in life
56.40 (6.14)	71.20 (4.20)	53.20 (8.57)	60.40 (5.69)	Personal growth
324.10 (39.43)	412.70 (18.14)	319.40 (43.78)	341.90 (18.60)	Total scale

 
As can be seen in Table 3, the obtained results of the ANCOVA demonstrated that all four test statistics (i.e., Pillai's trace, Wilks Lambda, Hoteling’s trace, and Roy's largest root) were significant (F=4.60, P<0.03). Therefore, it seems that the linear combinations of the dependent variable were affected by the independent variable after adjusting the initial differences. In other words, the results of ANCOVA showed that the spiritual group intervention had an impact on linear combination of dependent variable subscales. Moreover, there was a significant difference between the two groups, meaning that spiritual group counseling affected the psychological well-being of female children of divorced families.
 
Table 3. Results of ANCOVA on moderated scores of research variables

Source	Test	Value	Hypothesis of degree of freedom	F	Degree of freedom	Level of significance
Group	Pillai's trace Wilks Lambda Hotelling's trace Roy's largest root	0.79 0.20 3.94   3.94	6 6 6   6	4.60 4.60 4.60   4.60	7 7 7   7	0.03 0.03 0.03 0.03

 
 
 
 
 
 
Discussion
The present study aimed to assess the effect of spiritual group counseling on psychological well-being of female children from divorced families. According to the results, this type of counseling could significantly improve the psychological well-being of the girls after their parental divorce (P<0.05). This means that spiritual group counseling increased the psychological well-being of the mentioned individuals, which is in line with the obtained results of the studies conducted by Sajadi et al. (2017), Taheri Kharami (2016), Mackinlay and Burns (2017), Dadkhah Tehrani et al. (2015), Fathi and Amrani (2016), Yonker et al. (2012), Kim et al. (2014), Dehghan et al. (2015), and Barzegarbafruei and Pakseresht (9-17). On the other hand, Ghahari et al. (2012) demonstrated that psychological-behavioral and spiritual-religious interventions could not significantly reduce the anxiety and depression of women with breast cancer (14), which was inconsistent with our findings.
Consequently, it is worth mentioning that children are the main victims of divorce (2). Children from divorced families often experience higher levels of stress in their environment, which trigger adjustment disorders (24). In the divorced families, there is an increased level of anxiety for children since divorce creates the fear of loneliness, changes in life situations, embarrassment, guilt, next separations, as well as the sustainable fear of unknown further problems (19).
With regard to the vulnerability of children, studies have shown that children, specifically female ones, become angry in dealing with the separation of their parents. They often try to act like young adults and even advise and blame others (25). In general, there is a lower level of mental health and psychological well-being in these individuals, compared to normal children (26). Regarding the psychological preparation of this vulnerable group, studies have demonstrated that group therapy could affect the increase of mental health in children from divorced families (4), which highlights the significance of group therapy.
The group therapy improves the communication skills of individuals and provides them with a useful support system. On the other hand, hearing the shared stories of others makes individuals realize that their problems are not unique to themselves and increase their hope (27). The presence of a child from a divorced family in a group, in which all members have the same problems, makes them feel less responsible for the separation of their parents. Moreover, it helps the individuals to have a better understanding of their feelings and less adjustment disorders (4). The use of spiritual group therapy can improve social supports, compatibility, and adjustment in the children (28).
Application of spirituality and religion in group counseling is associated with beneficial influences. First of all, such topics can create an in-depth conversation. In addition, the level of individuals’ tolerance in sharing their viewpoints or various spiritual beliefs can be increased by this method (29). Spirituality and religion discussions in group counseling can teach individuals to heal and grow at the time of anxiety (30).
In this regard, studies have indicated a relationship between spirituality and various outcomes, including psychological well-being as well as mental and physical health (31-33). In fact, spirituality can positively affect the sense of satisfaction in life (34). Spiritual intervention improves the psychological well-being of individuals by helping them to cope with life stressors with more kindness, gratitude, forgiveness, and calmness (35). Moreover, spiritual therapy boosts the sense of self-awareness, purpose in life, and compatibility with mental and physical problems in individuals which results in the increase in the adjustment level of individuals with life events, especially tensions in everyday life (36).
One of the spiritual interventions is determining the values and objectives of life. Current experimental studies have shown that having a strong sense of meaning is correlated with happiness and satisfaction in life (37). Another confirmed area of spiritual intervention is forgiveness, which helps clients to overcome their anger and increase their psychological well-being (37). Problem-solving strategies are another types of spiritual intervention, which can create the sense of meaning as well as indirect control over the events in the face of tension and tragedy. In other words, understanding the meaningfulness of life leads to the reduction of isolation and loneliness in individuals (33). Belief in God and mentioning are spiritual intervention strategies that promote health through a variety of ways, such as establishment of low-stressed lifestyle, promotion of autonomy, effectiveness, and positive emotions, as well as creation of perception that problems can be controlled by choosing effective coping strategies (22, 38).
According to the results of the current study, spiritual group counseling leads to higher level of psychological well-being in the children from divorced families. In other words, spiritual counseling can increase the values related to the subscales of self-awareness and purpose in life, which can result in higher adjustability of children. In addition, spiritual-coping strategy can affect the psychological well-being of these individuals by changing their attitude, creating a sense of relief, and having effective relations with others. Therefore, it is recommended that spiritual intervention can be used as a method to increase the psychological well-being of children from divorced families in all schools and mental clinics. However, the findings of this study were limited to a small-sized sample population. Moreover, there was no possibility to consider the time of divorce as an inclusion criterion.
 
Acknowledgments
Hereby, we extend our gratitude to the authorities of Alzahra University for their financial support.
Financial Resources
The present article was financially supported by Alzahra University.
 
Ethical Considerations
This article was extracted from a research project (academic institutional project) with the code of 97.3.96.
Conflicts of Interest
Authors declare no conflicts of interest.