Health, Spirituality and Medical Ethics

 

Introduction

M

arital infidelity is a devastating and shocking issue for couples (1). Most people condemn infidelity as immoral and inhumane; however, marital infidelity is a common issue in clinical and non-clinical settings, which is considered as one of the main causes of marital burnout and even divorce (2). Infidelity is defined as the violation of the marriage contract and behaving unfaithfully which is mainly divided into three types of emotional, sexual, and emotional-sexual infidelity (3). Marital infidelity has different prevalence rates which are probably due to differences in its



definitions; however, about 25% of married couples commit sexual infidelity (4). It should be noted that gender is an influencing factor in this regard since the results of the previous studies have shown that males tend to cheat more than females (3,4).
Disclosure of infidelity can lead to the physical and psychological distress of the victim. Even the children and guilty spouses suffer from the effects of infidelity (1). Marital infidelity can increase domestic violence and eventually lead to divorce (6,5). Moreover, it threatens mental health and increases depression, anxiety, and even causes post-traumatic stress disorder in the victim (7,8). Due to the experience of infidelity, the victim loses his or her mental peace and may even commit suicide (9,10).
After the disclosure of infidelity, the victim goes through various emotional phases and experiences cognitive impairment. The victims may recall all the memories of their relationship and tend to find the root cause of betrayal. Moreover, they believe that they do not deserve to be betrayed and consider infidelity a breach of trust and a violation of their rights. Under such circumstances, the victims may detest the unfaithful spouses and never be able to forgive them (11). Based on the results of a study, 74% and 60% of females and males found infidelity unforgivable, respectively, and 77% of the victims demanded the most severe punishment for the cheating spouse (12). It seems that forgiveness can play an important role in the health of the couples and the improvement of their marital relationship (13). Therefore, couples therapists are trying to encourage the victims to forgive the cheating spouse (14).
Infidelity has undeniable effects on marital relationships; however, it does not necessarily lead to divorce (3). Accordingly, couples therapists believe that models of therapy can improve the mental health of the victim, and therefore, restore the marriage (15). Spiritual-religious interventions are among the educational and therapeutic approaches that seem to be effective in the improvement of relationships between couples, one of whom experienced infidelity (16).
Spiritual-religious interventions are parts of the cultural traits that can give a meaningful and coherent structure to human experiences, behaviors, and values (17). In other words, spirituality is regarded as a particular vision and mindset that enhances adaptability to the present situation which improves the performance, increases the level of self-awareness, motivates righteous acts, considers the positive aspects of human affairs, and separates human beings from material and worldly life (18). Those who have spiritual-religious beliefs do not see themselves as left alone in a hostile world. Moreover, they always feel the presence of God as a supernatural power and do not feel lonely when facing challenges in life (19).
Spiritual and religious beliefs which have been regarded as very effective strategies in life can play an effective role in human physical, mental, and social well-being (20). These interventions can even have an effective influence on the treatment of incurable diseases (21). The results of a study performed by Brown et al. indicated that spiritual interventions could improve one's mental and emotional health (22). In addition to individual therapy, a spiritual-religious intervention can also be used in couples therapy. Since this kind of therapy broadens the couples' horizons and enhances their patience, it can help enrich their relationship (23,24). According to the results of a study carried out by Fincham et al., spiritual-religious practices can improve the quality of marital relationships (25). It should be noted that spiritual-religious beliefs and practices can also be harmful if they are accompanied by misbeliefs, negative coping mechanisms, misunderstandings, and miscommunication (26).
With this background in mind, disclosure of infidelity can disrupt the victim's peace of mind and increase the hatred of the guilty spouse. Such circumstances can cause more physical and psychological harm, and consequently, result in marital burnout and even divorce. Given the religious context of Iran, it seems that spiritual-religious interventions can be effective in this regard. Therefore, this study aimed to investigate the effectiveness of spiritual-religious interventions on increasing the sense of calmness and forgiveness in women who experienced marital infidelity.
Methods
This quasi-experimental study was conducted based on a pretest-posttest design with a control group. The study population consisted of all women who experienced marital infidelity in district 2, Tehran, Iran, during 2019. In total, 32 women who met the inclusion criteria were included in this study. Initially, 11 betrayed women were selected based on convenience sampling method as the study sample. These women were those who had responded the researcher, explained their problem, and sought advice via Instagram application. Since their husbands did not participate in couple therapy sessions, group therapy sessions based on spiritual-religious interventions were held for the participants to improve their conditions. Subsequently, to select the rest of the participants, the researcher used snowball sampling method in which s/he asked all previously chosen subjects to report those who had similar experiences. Following that, the other 21 participants were selected through telephone calls and interviews, and they were assigned randomly into intervention (n=16) and control (n=16) groups. It is worth mentioning that no sample attrition was reported in this study.
The inclusion criteria were: 1) spouse betrayal, 2) betrayal disclosure time between 2 months and 1 year, 3) high scores obtained from the study questionnaire, 4) female, 5) age range between 25 and 40 years, 6) no addiction, 7) no severe psychological disorders,8) lack of participation in psychotherapy sessions, and 9) no use of medication during the treatment sessions.
One of the reasons to choose the betrayal disclosure time between 2 months and 1 year was the homogenization of the intervention and control groups. Moreover, based on the experience of the author, in a period of fewer than two months, women suffer from tremendous shock and distress and lack emotional stability and may even decide to get divorce. Therefore, they are not ready to participate in the study or may not be as cooperative and involved in the intervention as necessary. On the other hand, in a period of more than 1 year, the betrayed women attempt to find ways to cope with their problem, calm themselves, and treat their spouse with forgiveness. They may also seek help from counselors, friends, colleagues, social networks, and books which may lead to some changes in their life. Therefore, a time period fewer than 1 year was selected to have a homogenous group that was also ready to participate in therapy sessions.
Regarding the ethical considerations, the participants were provided with an introduction to the content of the therapeutic sessions and their potential benefits. Moreover, they were all informed of the confidentiality of their information followed by obtaining written informed consent. Eventually, educational books and CDs on spiritual-religious therapy, meditation, and forgiveness were distributed among participants as gifts to thank them for their contribution to the study.
The intervention group was subjected to 11 training sessions based on the following therapeutic package developed by Dashtbozorgi et al. (27) and the approval of psychologists and counselors in the field of spiritual therapy. They were then requested to attend 11 2-h sessions (1 session per week), whereas the control group did not receive any intervention.
The following is a summary of the intervention sessions:
First Session: Introducing each other, discussing marital infidelity, 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, role of praying and religious beliefs in calmness, the experience of participants after saying prayers
Second Session: Self-awareness; intrapersonal communication; listening to 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 a 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, repentance, self-forgiveness, and forgiving others; refusing to take revenge, asking other to share their experience of repentance; talking about feelings after repentance (i.e., calmness); talking about God's grandeur and mercifulness and counting his blessings; impact of showing forgiveness towards your fellow human beings; sharing an experience of forgiveness by one of the participants followed by an expression of the feeling they had after that; confessing the sins; making a list of the guilt and those they have hurt; the ability to repent; and asking for forgiveness
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; 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, self-reliance, and self-esteem
Seventh Session: 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 and feeling the presence of God that causes mindfulness and prevents unconscious thoughts that lead to feeling sick and impulsive actions, strengthens wisdom, reason, and awareness; the influence of remembering God and saying prayers on mental health; learning what, how, and for whom to pray; learning how to express our deep suffering with God while having a 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
Tenth Session: Spiritual self-control by giving mastery to rational powers over other powers and seeking God's help; learning how to use rationality and law to control all aspects of human existence
Eleventh Session: Talking about death, what causes the fear of death, resurrection, afterlife, thanksgiving, faith, trusting in God; practicing and talking about thanksgiving and trusting and showing its steps; drawing a picture of the best view without keeping track of time, drawing a beautiful picture, ignoring the time; drawing a conclusion from the contents of all previous sessions; distributing and refilling the questionnaires; concluding the session
Positive Psychological States Questionnaire
This questionnaire was prepared and developed by Rajaee et al. in 2011. It includes 96 questions measuring 15 positive psychological states. The present study utilized the components of calmness (6 items) and forgiveness (7 items).This questionnaire is scored based on a Likert scale from 1 (strongly disagree) to 5 (strongly agree). Furthermore, Rajaee et al. confirmed the validity of the questionnaire using the opinions of professors and experts. Moreover, the reliability values of the questionnaire regarding calmness and forgiveness were obtained at 0.84 and 0.83 by Cronbach's alpha coefficient, respectively. Moreover, the reliability of the questionnaire was estimated at 0.83 by Cronbach's s alpha. These results indicate the good validity of the questionnaire (28). In the present study, Cronbach's alpha coefficients of 0.87 and 0.85 were obtained for calmness and forgiveness, respectively.
The data were analyzed in SPSS software (version 22) through descriptive (i.e., mean and standard deviation) and inferential statistics (i.e., analysis of covariance [ANCOVA]).
Result
According to the results, the mean±SD ages of the intervention and control groups were

Table2. Results of the analysis of covariance to investigate the effect of the intervention on the sense of calmness and forgiveness
Power	Sig	F	Mean squares	df	Sum of Squares	Source of changes	Variables
0.05	0.234	1.48	5.77	1	5.77	Pretest Effect	Calmness
0.78	0.001	99.47	387.57	1	387.57	Group
			3.89	28	109.09	Error
0.01	0.569	0.331	1.65	1	1.65	Pretest Effect	Forgiveness
0.77	0.001	94.98	475.52	1	475.52	Group
			5.006	28	140.17	Error

31.75±4.17 and 32.40±4.99 years, respectively.
Table 1 shows the variable scores (i.e., the sense of calmness and forgiveness) at pretest and posttest in the intervention and control groups. The ANCOVA was used to compare the means; however, the assumptions were initially evaluated in this study.

Table1. Variable scores at pretest and posttest in the intervention and control groups
Groups				Stage	Variables
Intervention		Control
Mean	Standard deviation	Mean	Standard deviation
12.75	1.77	13	1.30	Pretest	Sense of Calmness
21.43	2.03	14.26	1.94	Posttest
15.12	1.58	14.40	1.91	Pretest	Forgiveness
23.31	2.02	15.20	2.39	Posttest

 
One of the assumptions of ANCOVA is the normal distribution of scores. Accordingly, the Shapiro-Wilk test was used to evaluate the normality of the distribution of scores. The results showed that both groups obtained higher scores in terms of calmness and forgiveness (P<0.05). Therefore, the distribution of scores at pretest and posttest was normal in both groups. Furthermore, Levene's test was employed to investigate the homogeneity of variances in both groups. The results revealed that the amount of variance was not significant for calmness and forgiveness (P<0.05), confirming the assumption of the equality of variances. The results also showed no significant difference between the study groups regarding the scores at pretest (P<0.05).
Table 2 presents the results of the ANCOVA to investigate the effect of the intervention on the sense of calmness and forgiveness. According to the results, there is a significant difference between the control and intervention groups regarding the sense of calmness (F=99.47, P<0.05) and forgiveness (F=94.98, P<0.05). Moreover, the intervention group obtained higher scores at posttest, compared to the control group (Table 1).
Discussion
The present study aimed to evaluate the effectiveness of spiritual-religious interventions on increasing the sense of calmness and forgiveness in betrayed women. The results showed that spiritual-religious interventions were effective and increased the sense of calmness among this population. Staton-Tindall et al. reported that spirituality could increase the sense of calmness and psychological stability; moreover, it led to the improvement of one's ability to cope with harmful events in life (29). These results are consistent with the findings in the present study. Similarly, according to a study conducted by Ghotbabadi and Haji Alizadeh, spiritual-religious interventions could protect one from the difficulties of life and reduce psychological distresses (30).
Spiritual-religious practices and beliefs, such as prayer, remembrance of God, and engaging in enjoyable spiritual activities lead the person getting away from worldly life, as well as its pains and sufferings. These activities also widen one’s horizons, therefore, help maintain greater goals (18). The women who participated in the present study were cognitively and emotionally disturbed due to their unfortunate experiences, and therefore, had lost track of their lives and goals. They also had no peace of mind under such circumstances. Participation in these sessions helped the women find emotional stability and determine their own values in life. Accordingly, the identification of the values and goals led to their emotional and cognitive stability.
In fact, spiritual-religious interventions helped the participants avoid mental turmoil by building a brighter future, seeking help from divine power, presenting positivity and optimism, adopting and committing to the right course of life, and not getting caught up on life’s events (19). Furthermore, these interventions also encouraged them to find meaning in life and realize that suffering cannot destroy them; it can rather empower them and help them grow and improve their performance.
The results also reported that spiritual-religious interventions could increase the level of forgiveness in betrayed women. According to the results of the previous studies, spirituality and religion have positive effects on the level of forgiveness. The results of a study performed by Davis et al. have shown that lack of spiritual-religious practices is associated with less generosity; however, if spiritual-religious beliefs and practices are reinforced, individuals become more generous (31). In the same line, the meta-analysis results also revealed that spiritual-religious traits could increase the level of forgiveness in individuals (32).
Experience of infidelity can lead the victim to detest the guilty spouse and attempt to retaliate (11); however, spiritual-religious beliefs and practices can prevent the victims from doing so and even increase their love and affection. The betrayed women have learned that forgiving a cheating husband can improve their mental state and free them from the chains of hatred and revenge through spiritual-religious practices. Furthermore, these interventions teach individuals that forgiving can increase God's blessing upon them and provide them with greater support (27). Similarly, Quranic verses and Hadiths about forgiveness and its effect on life increased the women’s insight.
Interventions, such as refusing to take revenge and sharing the experience of forgiveness by the participants and expressing their feelings made them aware of the magnificence of forgiveness. They were provided with a view that all human beings are bound to make mistakes, and one of the characteristics of a faithful and righteous human being is to forgive the guilty person and gives him/her a second chance to make restitution. Additionally, they were assured to receive the positive consequences and spiritual benefits of this good deed. The results of the studies showed that spiritual beliefs could enhance the level of forgiveness in people, which in turn led to a sense of calmness and could even improve one’s life (33).
Conclusion
The results indicated that spiritual-religious interventions led the women to forgive their guilty spouse and achieve calmness by providing effective insights and beliefs and also encouraging betrayed women to practice spiritual practices. Due to the religious context of Iran, it seems that such interventions can be implemented easier with more effectiveness, compared to other contexts. Therefore, the therapists are recommended utilizing spiritual-religious interventions in their individual and marital therapies. Although this study paved the way for investigating the effect of spiritual-religious interventions on the calmness and forgiveness levels of betrayed women, it suffers from some limitations. Due to the use of convenience and snowball sampling methods, and the selection of women who had become aware of their husband's infidelity between 2 months and 1 year, there is a possibility of response bias. Therefore, the generalization must be made very cautiously. It is hoped that the results of this study will help the betrayed women in this regard.
Conflict of interest
The authors declare no conflict of interest.
Acknowledgements
The authors would like to express their sincere gratitude and appreciation to all professors and colleagues, as well as women who participated in this study.
 References
1. Hall JH, Fincham FD. Psychological distress: Precursor or consequence of dating infidelity?. Pers Soc Psychol Bull. 2009;35(2):143-59. Link
2. Soudani M, Karimi J, Mehrabizadeh M, Neisi AK. Effectiveness of emotion oriented couple therapy on reducing the damage caused by marital infidelity. J Res Behav Sci. 2013;10(4):258-68. [Persian] Link
3. Zare B. Review of studies on infidelity. Int Proceedings Econ Dev Res. 2011;19(2):182-6. Link
4. Blow AJ, Hartnett K. Infidelity in committed relationships ii: A substantive review. J Marit Fam Ther. 2005;31(2):217-33. Link
5. Conroy AA. Marital infidelity and intimate partner violence in rural Malawi: A dyadic investigation. Arch Sex Behav. 2014;43(7):1303-14. Link
6. Allen ES, Atkins DC. The association of divorce and extramarital sex in a representative US sample. J Fam Issues. 2012;33(11):1477-93. Link
7. Sweeney MM, Horwitz AV. Infidelity, initiation, and the emotional climate of divorce: Are there implications for mental health?. J Health Soc Behav. 2001;42(3):295-309. Link
8. Cano A, O'Leary KD. Infidelity and separations precipitate major depressive episodes and symptoms of nonspecific depression and anxiety. J cons clin psychol. 2000;68(5):774-81. Link
9. Fincham FD, May RW. Infidelity in romantic relationships. Curr Opin Psychol. 2017;13:70-4. Link
10. Vijayakumar L. Indian research on suicide. Indian J Psychiatry. 2010;52(Suppl1):S291. Link
11. Fife ST, Weeks GR, Stellberg‐Filbert J. Facilitating forgiveness in the treatment of infidelity: An interpersonal model. J Fam Ther. 2013;35(4):343-67. Link
12. Zhang N, Parish WL, Huang Y, Pan S. Sexual infidelity in China: Prevalence and gender-specific correlates. Arch Sex Behav. 2012;41(4):861-73. Link
13. Heintzelman A, Murdock NL, Krycak RC, Seay L. Recovery from infidelity: Differentiation of self, trauma, forgiveness, and posttraumatic growth among couples in continuing relationships. Couple Family Psychol. 2014;3(1):13-29. Link
14. Fife ST, Weeks GR, Stellberg‐Filbert J. Facilitating forgiveness in the treatment of infidelity: An interpersonal model. J Fam Ther. 2013;35(4):343-67. Link
15. Snyder DK, Baucom DH, Gordon KC. Treating infidelity: An integrative approach to resolving trauma and promoting forgiveness. New York, NY: Routledge; 2007. Link
16. Mahoney A. Religion in families, 1999–2009: A relational spirituality framework. J Marriage Fam. 2010;72(4):805-27. Link
17. Bagheri M, Chegeni ME, Negar FM. Reviews of the effectiveness of religious, spiritual and mental therapy on stress reduction, anxiety and depression in women with addicted spouse in Ilam city. J Res Relig Health. 2016;1(3):19-25. (Persian). Link
18. Damirchi ES, Mohammadi N, Ramezani S, Amanzad Z. The Effectiveness of spirituality group therapy on happiness and hardiness in elderly women. Ment Health. 2010;8(3):475-85. [Persian] Link
19. Behdost P, Kargar K, Ziaaddini Z, Salimi H. The Effectiveness of Spiritual-religious Psychotherapy on Love Trauma Syndrome and Acceptance in Female Students with Love Failure. Health Spiritual Med Ethics. 2019;6(2):45-51. Link
20. Koszycki D, Raab K, Aldosary F, Bradwejn J. A multifaith spiritually based intervention for generalized anxiety disorder: A pilot randomized trial. J Clinical Psychology. 2010;66(4):430-41. Link
21. Ironson G, Kremer H, Lucette A. Relationship between spiritual coping and survival in patients with HIV. J Gen Intern Med. 2016; 31(9):1068-76. Link
22. Brown DR, Carney JS, Parrish MS, Klem JL. Assessing spirituality: The relationship between spirituality and mental health. J Spiritual Ment Health. 2013;15(2):107-22. Link
23. Mahoney A, Cano A. Introduction to the special section on religion and spirituality in family life: Delving into relational spirituality for couples. J Fam Psychol. 2014;28(5):583-6. Link
24. Nelson JA, Kirk AM, Ane P, Serres SA. Religious and spiritual values and moral commitment in marriage: Untapped resources in couples counseling?. Couns Values. 2011;55(2):228-46. Link
25. Fincham FD, Lambert NM, Beach SR. Faith and unfaithfulness: Can praying for your partner reduce infidelity?. J Pers Soc Psychol. 2010;99(4):64959. Link
26. Weber SR, Pargament KI. The role of religion and spirituality in mental health. Curr Opin Psychiatry. 2014;27(5):358-63. Link
27. Dashtbozorgi Z, Sevari K, Safarzadeh S. Effectiveness of Islamic spiritual therapy on the feeling of loneliness and death anxiety in elderly people. J Aging Psychology. 2016;2(3):177-86. [Persian] Link
28. Rajaei AR, Khoynezhad GR, Nesayi V. Positive psychological state questionnaire. Islamic Azad University Press of Torbat-e-Jam Branch; 2011. [Persian]
29. Staton-Tindall M, Duvall J, Stevens-Watkins D, Oser CB. The roles of spirituality in the relationship between traumatic life events, mental health, and drug use among African American women from one southern state. Subst Use Misuse. 2013;48(12):1246-57. Link
30. SedaghatGhotbabadi S, Haji Alizadeh K. The effectiveness of spiritual-religion psychotherapy on mental distress (depression, anxiety and stress) in the elderly living in nursing homes. Health Spiritual Med Ethics. 2018;5(1):20-5. Link
31. Davis DE, Hook JN, Worthington Jr EL. Relational Spirituality and Forgiveness: The Roles of Attachment to God, Religious Coping, and Viewing the Transgression as a Desecration. J Psychol Christianity. 2008;27(4): 293-301. Link
32. Davis DE, Worthington Jr EL, Hook JN, Hill PC. Research on religion/spirituality and forgiveness: A meta-analytic review. Psycholog Relig Spiritual. 2013;5(4):233. Link
33. Hafnidar LC, Lin H. Forgiveness as a mediator for the relationship between spirituality and posttraumatic growth in Aceh conflict victims, Indonesia. Int J Soc Sci Human. 2012;2(3):237-41. Link