Health, Spirituality and Medical Ethics

Introduction
Crime and delinquency are offending events in human society. Undoubtedly, their psychological aspects have been less studied compared to the other social, economic, political, and cultural dimensions (1). According to a study conducted by Walmsley, in 2013, more than 1.10 million people worldwide and 217,000 people in Iran were imprisoned whose physical and mental health assessment was important (2).
Studies have shown that long separation from community and family causes deep psychological trauma and disorders in individuals' mental health (3).In addition, according to studies conducted on prisoners, these people are more susceptible to suffer from physical and mental disorders compared to lay people (4). Given the fact that the prison is a place resulting in mental illness, it can be predicted that the prevalence of mental disorders in prisoners are much higher than that of people outside (5). As a result, different approaches should be used to prevent and reduce various disorders among prisoners.
Over recent decades, integrated treatment approaches have attracted psychotherapists' attention in order to adjust all individual's cognition, emotions, excitements, and behaviors concurrently leading to mental health(6). Monotheistic integrated therapy is a combination of the latest findings of psychotherapy in various domains, especially in humanistic therapy, religious and ethical doctrines that has been welcomed by psychologists (7).
The spiritual dimension is important for the attainment of an overall sense of health together with the other dimensions (8), and psychological and biological approaches are not sufficient to treat mental disorders (9).Therefore, the American Psychological Association has emphasized the clinical importance of religious and spiritual issues on the assessment of psychological disorders. In this regard, monotheistic integrated therapy has been introduced, which is a multidimensional and comprehensive approach in order to treat mood and anxiety, personality, and drug use disorders and the other abnormal behaviors (6).
Resilience is one of the factors associated with the concept of quality of life. Resilience refers to a dynamic process of adaptation to the bitter and unpleasant experiences in life (10). Zimmerman and Arunkumar (11) define resilience as the ability to recover from some real, experienced adversities. It is the ability to bounce back from some real, experienced adversity it is the ability to bounce back from some real, experienced adversity it is the ability to bounce back from some real, experienced adversity Seccombe (12) asserts that resilience as a protective factor stems from personality traits, supporting factors within the family, and social factors in people's lives. Resilient people have the ability to develop and create a set of coping strategies that support them in challenging situations (13).
Moreover, individuals' personality characteristics have significant influence on the kind of coping skills that people pick, which result in the use of different strategies (14). Several studies have shown that resilience plays a leading mediator role in the prevention or emergence of several psychiatric disorders, because it can ensure the mental health of individuals as well as its promotion (15).
Different anxiety disorders, guilty feelings, self-inner and interpersonal conflicts interact with religious attitudes. In other words, those who use more spiritual opinions and religious beliefs report fewer symptoms of behavioral disorders. Consequently, spiritual strategies can be used as complementary approaches along with other methods (16). In a study conducted by Rosenhan and Seligman, depression and anxiety were reported as the most common mental disorders among prisoners (17). Anxiety is a painful feeling that depends either on a traumatic situation or an unexpected risk which source is uncertain. It is also a kind of fear to lose one of the principled values of a person's life (18).This anxiety was defined by Speilberger (1983) as a transient mood (19). The loss of opportunities for progress in academic and working life and functional disability stem from adverse effects of anxiety (20).
Research show that depression is a well-known term and challenging issue in the field of mental health, especially among prisoners (17, 21, 22). The studies conducted in Iran have reported that prisoners are more susceptible to get depressed than the other people (23, 24, 25).This is due to the psychological stress which is derived from imprisonment and prison conditions which appears in the form of depression. Trevino et al.(26), found that religious attitudes have negative relationship with depression, anxiety, aggression, and hypochondria. Depression is a kind of mood disorder in which a person might feel undelighted, unpleasant, disappointed, and cannot feel happy (27).Therefore, it leads to a change in thoughts, feeling, behavior and general physical well-being (28)
Undoubtedly, common therapeutic interventions (i.e., medication and individual counseling) in prison would not lead to personal rehabilitation and effective reformation of criminals' thoughts and behavior. Religion spirituality and health studies reported that the use of Islamic teachings helps to find methods and skills to overcome depression and increase the level of individual's resistance to mental illness (29). Therefore, the present study intends to examine the effect of monotheistic integrated psychotherapy on the resilience, anxiety and depression levels among prisoners.
Monotheistic integrated therapy is a multidimensional and comprehensive approach that is recommended for the treatment of mood and anxiety, personality, drug use, and abnormal behavior disorders. With regard to this therapeutic intervention, attempts are made to integrate various psychotherapy techniques with Islamic spiritual-monotheistic doctrines. As a result, the individual’s values are revived leading to the integration and coordination of the whole personality of the person. The essential factor in mental health considering this approach is the personality coherence which is achievable through focusing on transcendental goals as well as religious and spiritual values. Given the fact that believing in God and the acceptance of religious beliefs play a decisive role in solving internal conflicts, integrating the personality, reducing abnormal behaviors, and increasing mental health in individuals, they should be used in the process of treatment of behavioral abnormalities (3.6).
 
Materials and Methods
This quasi-experimental study was of pretest-posttest control group design conducted on 80 literate prisoners with the age range of 20-40 years who were detained in Lahijan Prison in 2015 due to a street fighting. The subjects were assigned into experimental and control groups and subsequently a briefing session was held for the participants. The samples were selected using a completely census method, that was kind of a non-probability sampling method.
The inclusion criteria were: 1) the level of education, 2) age range of 20-40 years, and 3) imprisonment at least 8 months. The subjects who were unwilling to complete the questionnaires and absent for more than three sessions were excluded from the study. The respondents were all informed about the research process as well as the confidentiality of the data. They were also given the fact that their refusal to participate in the study would have no effect on their prison records and conviction period. Eventually, written informed consent obtained from each participants and the evaluation process began.

Connor-Davidson Resilience Scale

This 25-item scale was originally developed by Connor-Davidson and measured the resilience structure using a 5-point Likert scale scored 0 to 4. The minimum and maximum scores of the resilience level of the participants in this scale is was zero and 100, respectively. This instrument obtained a great level of reliability. The item scores were then added together for a total score. The higher the score, the more the resilience level of the respondent, and vice-versa.(30)
The questionnaire cut-off value was 50. In a study conducted by Ranjbar et al (31), the reliability of the questionnaire was estimated as 0.84 using Cronbach's alpha coefficient. In addition, Cronbach's alpha coefficient was obtained 0.87 in a study performed by Samani, Jokar and Sahragard (32). In the present study the structural validity of Connor-Davidson Resilience Scale was evaluated using factor analysis (p. 292) and the results showed that the items were loaded on a factor and the extracted factor explained 26.6% of the total variance. Cronbach's alpha coefficient of resilience inventory was 0.87 in a study carried out by Momeni and Alikhani (33).
State-Trait Anxiety Inventory
This questionnaire was developed by Spielberger et al, (34) with a high level of reliability and validity. With regard to 40 items, the first 20 questions examined the apparent anxiety state, including individual’s response-focused emotion, and the second 20 questions investigated the covert anxiety state, including general and ordinary feelings. In a study conducted by Khanipour et al (35), the reliability and validity of this scale were approved and the homogeneity of this test was obtained 0.66 by Cronbach's alpha. The validity of this questionnaire through the internal consistency of work with adults, students, and army recruits test was reported 0.86-0.95, and through the test-retest for schoolchildren and college students were 0.77 and 0.75, respectively (Antouni et al, 2002, quoted From 35). In the standardization stage in Iran, the validity of the test-retest for the anxiety trait scale ranged from 0.65 to 0.86 and the Cronbach's alpha coefficient for anxiety state was obtained as 0.92 (35). In addition, the reliability of this questionnaire was estimated in different studies, such as a study conducted by Roohy (36) in which the obtained reliabilities of the scale were 0.89 and 0.90, respectively. 
 
Beck Depression Inventory
This questionnaire was presented by Beck et al. to measure the level of depression (37). As a common tool, it included 21 items divided into three groups of emotional, cognitive, and physical symptoms of depression to assess its existence and severity. This standard test with high levels of reliability and validity has been used for many years to evaluate the symptoms of depression (37). According to a study performed by Fata, Birashk, Atef Vahid and Dobson in Iran(38), the Cronbach's alpha coefficient, the  correlation coefficient between the scores on the two halves of the test, and test-retest reliability coefficient obtained as 0.91, 0.89, and 0.94, respectively.
Research procedure
After the research objectives and the instruments were determined, the intervention training format was formulated. Monotheistic integrated therapy was considered the independent variable and resilience, anxiety and depression of the prisoners were assigned as dependent variables.
 
Monotheistic Integrated Therapy
The intervention was held in 90-minute sessions during 15 weeks. After the administration of the pre-test and the assignment of participants into experimental and control groups, monotheistic integrated intervention was conducted on the experimental group. However, the control group continued its routine program (common activities) and did not receive any treatment. They were just taken pre-test and post-test. In terms of monotheistic integrated therapy, personality coherence led to mental health through emphasizing and focusing on the transcendental goals and religious and spiritual values. In this approach, the concept of monotheism refers to a unifying value system that manages the direction of human life and saves him from the multiple personality style and loss of personality in the path of life .In addition, belief in God plays an effective role in controlling the most social deviations derived from uncontrolled instincts and tendencies such as incompatibility. The most important goal in monotheistic integrated therapy is complete and non-returnable recovery of mental disorders and behavioral abnormalities. Complete recovery has different dimensions and levels known as stages of change (39). In a study conducted by Sharifinia, the validity of the intervention package of monotheistic integrated therapy has been confirmed (39) and has been used in various studies (40, 41, 3, 6, 9).
 
The intervention content and research protocol
The treatment package proposed by Sharifinia (39) was used for performing interventions. Table 1 demonstrates the content of each session. A team consisted of a treatment director, a physician, a psychologist, a religious expert and a social worker were collaborated in implementing all the stages of the study.
 
 
Table 1. The session contents related to the monotheistic integrated intervention among prisoners

Subject and Purpose	Meeting sessions
Familiarity  with group members as well as the rules of  monotheistic integrated group therapy	First
Relaxation training: the ability to get relaxed in meetings and critical situations and the assessment of motivation for change in members	Second
Evaluation the members' problems and determining the treatment priorities: diagnosis of problems and the ability to set priorities	Third
Identification of the causes leading to suicidal tendencies and multiple strategies to prevent suicide	Fourth
Breaking the denial and strengthening the honesty and truthfulness and accepting the mistakes and other criticisms  and increasing the tolerance threshold
The role of the relationship with God and the sense of vitality and self-flourishing	Sixth
The sense of repentance , and engaging the spiritual dimension in the process of change	Seventh
Strengthening the spiritual states and promoting the relationship with God	Eighth
Deepening the spirit of  the worship of God	Ninth
Individual's duties and responsibilities in life	Tenth
Examining the aims and objectives of life and expanding social support network	Eleventh
Employment and entrepreneurship and increasing self-efficiency	Twelfth
Meditation and prayer, and the growth of spiritual feeling and self-control	Thirteenth
Forgiveness, forgiveness training, the benefits and consequences of forgiveness and mercy, the process of forgiveness, the practical uses of forgiveness and mercy	Fourteenth
Conclusion and result, evaluating the group therapy results by group members	Fifteenth

 
 
Results
According to the results, the following tables present data related to samples as well as the descriptive findings related to study variables including frequency, mean, and standard deviation. The results of Shapiro-Wilk test in terms of evaluating the normal distribution of variables in groups showed that Z statistic of this test was not meaningful for all variables (P> 0.05). Therefore, it can be concluded that the distribution of dependent variables is normal.
 
Table 2: Descriptive indicators of variables within the experimental and control groups

Post-test	Pre-test	Indicators	Variables
81.05 40 12.60	73.25 40 13.84	Mean Frequency Standard deviation	Experimental	Resilience
69.58 40 14.48	69.75 40 14.97	Mean Frequency Standard deviation	Control
63.23 40 9.29	76.20 40 2.29	Mean Frequency Standard deviation	Experimental	Anxiety
76.43 40 10.35	76.60 40 10.47	Mean Frequency Standard deviation	Control
16.90 40 9.67	25.18 40 12.16	Mean Frequency Standard deviation	Experimental	Depression
24.26 40 11.69	23.87 40 11.35	Mean Frequency Standard deviation	control

 
Table 2 shows the differences within the experimental post-test scores compared to those of pre-test in terms of the mean level of depression and anxiety; however, no significant differences were observed in mean levels of depression and anxiety of the control group in the post-test compared to the pre-test. In addition, the post-test mean scores of resilience within the experimental group increased significantly compared to the scores of the pre-test, whereas there were no differences regarding the post-test mean scores of resilience within control group compared to the pre-test scores. Inferential statistics including Levene's test was used for homogeneity and heterogeneity of variances in order to investigate the hypothesis of the research. Moreover, t-test was used to investigate the differences between means and analysis of one way ANOVA.
Table 3 demonstrates, that the results obtained from Levene's test are not significant regarding the resilience variable. Therefore, the assumption of homogeneity of variance was assigned. To examine the homogeneity of variances regarding depression and anxiety variables, Levene's test was used to confirm the significant level of Levene's test. According to the results in table 4, the significant level of the effect of monotheistic integrated therapy factor was obtained 0.0001. In other words, there were significant differences in terms of post-test scores between experimental and control groups. Therefore, the null hypothesis can be rejected at the 99% confidence level. As a result, the intervention based on the monotheism integrated therapy caused reduction in the levels of depression and anxiety among prisoners and it also led to the increase of resilience among them.
 
Table 3. Levene's test results to examine the homogeneity of variance related to variables

P-Value	df 2	df 1	Levene (F)	Variable
0.77	1	78	4.87	Resilience
0.13	1	78	2.32	Anxiety
1.00	1	76	14.07	depression

 
Table 4. One-way ANCOVA test results of resilience, anxiety and depression level scores

P-Value	F-value	MS	df	SS	Sources	Variables
0.0001 0.0001	95.35 19.24	7951.02 1604.51 83.38	1 1 77 80	7951.02 1604.51 6420.65 470763.00	Smooth Group Error total	Resilience
0.0001 0.0001	198.08 120.57	5434.33 3307.64 27.43	1 1 77 80	5434.33 3307.64 2112.42 401074.00	Smooth Group Error total	Anxiety
0.0001 0.0001	120.86 29.94	5400.01 1337.86 44.68	1 1 75 78	5400.01 1337.86 3351.02 42833.00	Smooth Group Error total	Depression

 
Discussion
The purpose of this study was to investigate the effect of monotheistic integrated psychotherapy on the resilience, anxiety, and depression levels among prisoners in Lahijan. According to the literature,  the positive attitude toward the existence of God and performing religious rituals have significant influence on mental health and the treatment of mental disorders (42, 43, 44). According to the findings in terms of the first research hypothesis, it was found that monotheistic integrated psychotherapy had a dramatic effect on the increase of the resilience level of prisoners (P<0.0001). The results of the present study are consistent with the findings of studies conducted by Sharifinia (6.41) and Sanaei (11). The effectiveness of monotheistic integrated therapy on resilience component means that the treatment has made the patients more tolerant and powerful against stress and life problems.
It also made them to be more realistic when faced with problems and difficulties. As a result, monotheistic integrated therapy can provide the basis for improving and reforming the prisoners' behavior. Moreover, it paves the way for prisoners to have a family re:union:. Therapeutic interventions provide intimacy, care, and attention to the individual, and help people to know and understand themselves in general and their abilities in particular. These interventions provide prisoners with opportunities for participation and cooperation in prison to practice and expand different life skills that are considered a source for increasing resilience.
The second hypothesis of the research was also confirmed regarding the results obtained from data analysis. In other words, monotheistic integrated psychotherapy had a significant effect on the reduction of depression levels among prisoners (P<0.0001). The findings are in line with previous study results (6, 9).  Tayyebi (9) investigated the effect of monotheistic integrated therapy on the reduction of mental stress among spouses of disabled veterans suffered from post-traumatic disorder. The results showed a dramatic mitigation of mental stress among patients implemented by this therapeutic approach as much as a cognitive-behavioral approach. Belief in God and following a religion are effective factors in reducing depression levels (45). Several studies have shown the effectiveness of psychotherapy interventions based on religion. Seyfi, Etemadi, and Shafi'abadi (46) showed that spiritual-based interventions led to the reduction of depression level in individuals. In a study performed by Aliakbari, Dehkordi et al. (47), a reverse association was observed between following religious beliefs and religious orientation and depression. According to studies carried out by Bonab et al. (48), Navidi, and Abdollahi (49), there was a negative correlation between depression and practical commitment to religious and Islamic beliefs among high school students in Tehran.
Furthermore, Mirnasab (50) revealed that trust in God was considered as one of the most important factors to deal with depression. Previous studies (51,52) showed that performing Islamic coping strategies, such as trust in God, recitation of God's name, patience, prayers, repentance, say prayer, and hope played leading roles in the alleviation of the depression levels among prisoners. Therefore, paying special attention to God should be implemented in psychotherapy interventions in order to prevent depression (52).
In terms of the second hypothesis, the prisoners had more passion for life and they got up more energetically without any sense of sadness or depression after the treatment. Therefore, the potential risks of depression, such as drug abuse, suicide, self-harm, aggression, irritability, and sleep disorders can be reduced using monotheistic therapy. This kind of intervention helps prisoners overcome their problems through understanding and changing their thoughts, behavior, and ineffective emotional responses. Based on the obtained findings, one can expect that people under treatment improve their social skills and inhibitory abilities in order to play more active roles with higher levels of responsibilities in their lives. According to the obtained results, the third hypothesis was confirmed. Monotheistic integrated psychotherapy had a significant effect on the reduction of anxiety levels among prisoners (P<0.0001). The findings were consistent with the results obtained from studies performed by Timmerman (53), Khanipur (35), and Norouzian et al. (44). Timmerman (53) evaluated the effect of social and problem solving skills as well as stress management training sessions on people who were exposed to a great load of stress. The results revealed a significant association between the training practices and the mitigation of stress and anxiety levels, in addition to the increase of sense of determination and reduction of the requests for help from others.
It can be concluded that monotheistic integrated therapy compensates some parts of human deficiencies and makes the individual to be aware of emotional coping strategies based on cognitive restructuring. In addition, this approach leads to changes in prisoners' cognitive skills and makes alterations among prisoners who have negative points of view, pessimism over others, irrational thoughts and prejudices.
It is worth noting that the enrichment of religious beliefs in patients leads to cognitive changes followed by behavioral changes in prisoners. As a result, their levels of anxiety and depression would reduce leading to the increase of resilience levels among prisoners. One of the limitations of this study was the lack of access to a greater sample in terms of age range (20-40 years old) for random sampling, and lack of the possibility of quarantining the control group in prison. Therefore, it is suggested that other studies pursue the implementation of monotheistic integrated psychotherapy in wider areas both on males and females in prisons. Given that the research sample consists of only 20-40 year old prisoners in Lahijan, it is suggested that this procedure be conducted on different age ranges of juveniles and delinquents. In addition, monotheistic integrated psychotherapy is recommended to be applied among the prisoners' family (for its indirect effects on prisoners).
With regard to the results of this study, it can be concluded that monotheistic integrated psychotherapy approach resulted in decreasing the level of anxiety and depression among prisoners and increasing their level of resilience. Therefore, the prison social workers and counselors can benefit more from monotheistic integrated therapy to prevent the occurrence of violence and reduce social damages in prison.
 
Conclusion
Monotheistic integrated psychotherapy enhances the psychosocial abilities and reduces many psychological problems using the anxiety management strategies. This ability helps people cope with conflicts and different situations in life effectively. This approach provides prisoners with efficient skills in terms of self-knowledge, the identification of goals and values, social communication, familiarity with the concept of anxiety and its coping strategies, and transformation of their knowledge, attitudes and values ​​into actual capabilities. These interventions inhibit the negative attitudes of individuals toward life, which results from the lack of religious beliefs, and in turn decrease the symptoms of mental disorders. Difficult and imprisoned conditions of life in prison can be of among risk factors for anxiety which threatens the mental health of individuals. Given the fact that anxiety is one of the most common mental disorders among prisoners, monotheistic integrated psychotherapy can be one of the best non-medicinal therapies for these individuals.
 
Acknowledgements
The authors would like to thank all respondents for their participation in this study.
 
 
Conflict of interest
The author declares no conflict of interest.