Health, Spirituality and Medical Ethics

Introduction

The rise in the incidence of mental health issues among children and teenagers can be attributed to several factors, including contemporary lifestyles, online environments, academic stressors [1], family dynamics with parents [2], conflicts [3], and economic inequality [4]. Conduct disorder (CD) is a psychiatric disorder with a notable likelihood of persistence into adulthood. CD is marked by ongoing and repetitive patterns of behavior that involve disregarding the fundamental rights of others or breaking significant age-appropriate social rules or norms [5]. The lifetime prevalence rate in the general population ranges between 2% and 10% and is consistent among different races and ethnic groups [6]. The condition is more frequently seen and easier to diagnose in boys due to their propensity for aggressive behavior, whereas in girls, it often presents as difficulties in interpersonal relationships [7]. CD is often linked to several risk factors, including oppositional defiant disorder, problems with verbal communication, rejection by one’s parents and neglect, and other types of child maltreatment, such as sexual abuse, inconsistent parenting, parental substance abuse and addiction, and issues with self-regulation [8].

The two key aspects that impact people with this condition are communication style and moral growth. Youths with CD disregard social norms and family expectations and, unlike their well-adjusted peers, fail to exhibit behaviors, such as altruism, teamwork, or community involvement. According to Xie et al. understanding moral principles is a prerequisite for adhering to them [9]. Key treatment programs for adolescents with CD include education on personal and social skills, family education, and pharmacological interventions, as stated by Boland et al. [5]. Spirituality therapy is a substantial and beneficial treatment approach.

Spiritual psychotherapy allows individuals to recover and enhance their personal and social well-being. Historically, the connections between religion, spirituality, and medicine are evident. Defining complex concepts, such as spirituality and religiosity, is difficult due to the lack of a universally accepted definition among researchers. Spirituality is viewed as a distinct and personal trait that fosters a connection between oneself and the world and others, and may involve a belief in a higher power or God. Spirituality refers to the personal and subjective experience of seeking and finding meaning, purpose, and connection in life. It often involves a sense of transcendence beyond oneself. Spirituality encompasses beliefs, practices, and values related to the sacred or divine. However, it can also be understood in a secular context as exploring one’s inner self, relationships, and the universe [10]. Beyond humanism, Koenig suggests that spirituality links humans to a higher, transcendent realm, while religion encompasses related beliefs, practices, and rituals, with God being the transcendent entity in question, as per Sargeant et al. [11, 12].

Abundant research indicates the significant influence of faith and spirituality on responding to life crises, dealing with illness, maintaining health, and overall well-being. Adapting to challenging circumstances is often facilitated by an individual’s spiritual nature, with faith being a potent catalyst for instilling hope. Spiritual therapy (SP) programs have been utilized to address a variety of psychological conditions, including stress, anxiety, depression, and personality disorders [13], CD [14], and physical ailments [15]. A notable absence exists among various SP methods, specifically a lack of one grounded in Islamic culture. Researchers have initiated creating treatment/training packages grounded in Islamic culture.

A distinct benefit of Islamic SP stems from its foundation in the Quran and the teachings of the Infallible (imam, religious leader, pontiff). The Islamic SP model focuses on enhancing coherence and unity across the client’s biological, psychological, and social aspects while prioritizing spiritual well-being. Islamic SP acknowledges pain and suffering. However, it fosters acceptance of life’s hardships by broadening individuals’ perspectives and understanding, and offering enlightenment regarding the underlying wisdom of life’s various aspects [16]. The components crucial to CD involve challenges relating to others, forming identity, and developing moral values. These three components are outlined in the definition of CD by Boland et al. [5] A teenager with CD has not yet reached the level of moral development required and struggles with social interactions and communication, largely due to a crisis surrounding their sense of identity. This study developed and verified an educational package based on Islamic SP for adolescents with CD.

Methods

The study’s central inquiry was to determine a model of SP grounded in Islamic principles. A content analysis approach was employed to address this query. The adolescents diagnosed with CD face obstacles and adversities, which were identified and extracted using the criteria outlined in the diagnostic and statistical manual of mental disorders, fifth edition (DSM-5), as well as the most recent empirical investigations.

Kirkpatrick posited the components of spiritual intervention were in the theoretical framework of God-attachment [17].

An expert panel was convened, comprising 14 faculty members from Rafsanjan Universities (Kerman City, Iran) from diverse academic institutions possessing expertise in psychology, ethics, Islamic studies, and Quranic and Hadith sciences. The panel was established through a convenience sampling method following the elucidation of study objectives and procurement of informed consent. The expert panel was responsible for assessing the degree to which each identified challenge faced by adolescents with CD corresponded with particular components of the spiritual intervention.

Characterized by a literature review, entailed the extraction of Quranic verses, narratives, and Hadiths of the Imams of Islam that corresponded with the thematic elements of Kirkpatrick’s spiritual intervention, sourced from the Quran, pertinent texts, and authoritative online resources, employing keywords such as ‘gratitude in Islam/Quran/Hadith,’ ‘self-awareness in Islam/Quran/Hadith,’ and ‘self-acceptance and love in Islam/Quran/Hadith.’

The compiled Quranic verses, Hadith, and narratives were assembled into a digital questionnaire and disseminated to the expert panel, who were requested to evaluate the alignment between each specific verse, tradition, or narrative and the associated components of the spiritual intervention. This phase was instrumental in validating the extracted concepts, utilizing the content validity ratio (CVR) and content validity index (CVI) as metrics for validation purposes [16, 18]. In the CVR assessment, following the provision of requisite elucidations to the experts, they were instructed to categorize the elements of the training package utilizing a triadic scale: “item is essential,” “item is useful but not essential,” and “item is not essential.” Subsequently, the CVR value was computed. Considering the number of experts (14 individuals), by Lawshe’s criteria [19], the threshold for an acceptable CVR value is established at 0.51. For the evaluation of the CVI, the experts were solicited to assess the “relevance,” “clarity,” and “simplicity” of each item employing a four-point scale: “Not relevant (1),” “somewhat relevant (2),” “relevant (3),” and “very relevant (4).” A CVI value exceeding 0.79 is considered acceptable [20] (Equation 1).

1.

In this context, ne=the number of experts who opted for the essential option, N=the aggregate number of experts, and x=the number of experts who selected the higher options (3 or 4, relevant and/or very relevant). A consortium of specialists assessed the reliability of the derived constructs [19, 21].

A comprehensive educational framework for SP, grounded in an Islamic paradigm, was formulated utilizing verses and narrations derived from the Quran and various scholarly texts, while integrating expert insights that align with the overarching research aims. At this stage, the instructional content of each session was meticulously assessed for its pedagogical efficacy and appropriateness for individualized teaching. The sessions were meticulously organized into a structure comprising 10 distinct steps and 13 sessions: 10 dedicated to the primary educational elements, one introductory session, one session for feedback, and one concluding summary session (Table 1). The efficacy of this training module was assessed in a separate segment of the research [22].

Results

Based on content analysis and expert opinions, ten constructs for spiritual intervention were identified: self-acceptance and self-love, self-expression, forgiveness, gratitude, understanding one’s life, love, God, parents, the role of evolution, and finding meaning in life. The Islamic SP educational package was created using Quranic Verses/hadiths, and expert views as part of the overarching study aim. The session content was structured into 10 steps and comprised 13 sessions, consisting of 10 core teaching sessions, one introductory session, one feedback session, and one summarizing session. The steps are adaptable, and their sequence is shown for clarity. Consequently, the package’s contents are determined by the client’s circumstances and the counsellor’s professional judgment (Table 1).

During the qualitative phase of this study, opinions from 14 specialists were collected. The mean age of the experts was 43.71±15.7 years, ranging from 35 to 58 years. Nine individuals (64.3%) were male, while 5 (22.7%) were female. Twelve experts (85.7%) were faculty members or instructors at universities and seminaries.

Inter-rater agreement was assessed using the Kappa coefficient, which was 0.81, indicating almost perfect agreement. The quantitative aspect of the study employed the CVR to evaluate the importance of each session’s content and the full educational package. The CVR values were deemed satisfactory according to Lawshe’s, with a CVR of 0.51 for 14 experts, and the content of all sessions attained the necessary score, specifically an overall package essentiality score of 0.1. Each session’s content was evaluated for validity, focusing on relevance, clarity, and simplicity, as measured by the CVI, with all items exceeding 0.78. The CVI scores were deemed acceptable following feedback and suggestions, resulting in all items being approved and confirming the content validity of the educational package (Table 2).

The data in Table 2 confirm that the Quranic Verses/hadiths connected to each of the ten elements of spirituality therapy were understandable, clear, and straightforward, and the subject matter experts verified their importance.

The educational components of Islamic SP were ranked according to priority based on experts’ opinions. The priority order was as follows: First; reverence for God and respect for one’s parents; second, expressing gratitude and appreciation; third, the importance of forgiveness; fourth, understanding and accepting God; fifth, gaining insight into life’s purpose; sixth, cultivating self-love; seventh, self-expression; eighth, love; ninth, understanding the meaning of life; and finally, human evolution (Table 3).

Discussion

The present study aimed to create and validate a SP educational package rooted in Islamic culture for adolescents. The results revealed the importance of Islamic SP (CVR=0.1), aligning with Eskandari et al. who developed and validated a tool for measuring spiritual health based on Islamic texts (CVR=0.86) [18]. Additionally, our findings were consistent with Sanagoei Zadeh, who assessed the content validity of a religious family therapy model with an Islamic-Iranian approach, yielding CVI and CVR coefficients exceeding 75% and 85%, respectively [16]. Numerous studies have indicated the effectiveness and benefits of integrating Islamic teachings from the Quran and Hadith into SP. This includes the integration of acceptance and commitment therapy with Islamic teachings [23], enriching marital life based on Islamic teachings [24], Quranic bibliotherapy [25], and the incorporation of Islamic principles into modern SP to improve the identity status of delinquent adolescents [2]. Agustina et al. introduced a new therapeutic approach called “Quranic Bibliotherapy,” is based on the Quranic scripture. This approach includes narratives, reflective processes, Quranic verses, informational materials, action-oriented steps, and transformative elements to address mental and spiritual concerns. Their study demonstrated the positive effects of this approach on mental health and spiritual well-being, providing valuable insights for therapists, researchers, and the Islamic community [25]. Haris integrated Islamic principles into contemporary SP, finding it beneficial for the identity development of delinquent adolescents [2]. Rashidzadeh evaluated an educational package focusing on spirituality and Islamic teachings, determining its effectiveness with a validity coefficient of 0.83 [26].

Previous research has indicated the advantages of incorporating Islamic principles from the Quran and hadiths into SP. Some researchers believe that due to the interconnected nature of religiosity, spirituality, and mental health, it is crucial to teach spiritual skills as a primary form of prevention [27].

Initial studies suggest that teaching respect for parents is essential. In this study, experts unanimously agreed that 100% of the Quranic verses extracted aligned with the educational goal of honoring parents. Mansoori et al. emphasized the importance of instilling respect for parents in children during their elementary school years [28]. Zhao noted that mutual respect and parent-child involvement are protective factors for adolescent development [29]. Improving parent-child relationships can be achieved by teaching respect for parents based on Quranic verses, warranting further research into intervention strategies. Notable examples of these verses can be found in Surah Al-Isra, verse 23.

Experts identified gratitude as the second most crucial factor, with 93% agreeing that the extracted passages aligned with the educational principles of gratitude. Several Quranic verses support this idea. Diniz et al. found that expressing gratitude can serve as a supplemental treatment for anxiety and depression, promoting positive emotions [30]. Calleja et al. also confirmed that gratitude is essential for spiritual well-being, redirecting focus from shortcomings to blessings and fostering a positive mindset [31].

Forgiveness is vital in Islamic SP, ranked third as the most essential component. Islamic teachings emphasize the importance of forgiving others to express God’s compassion. Forgiveness alleviates psychological burdens, enhances emotional well-being, and strengthens social connections. Saritoprak and Abu-Raiya noted that forgiveness in Islam contributes to spiritual well-being and social cohesion [32].

Experts have emphasized educational programs emphasizing self-disclosure and self-expression. In a study, self-assertion was emphasized as a crucial factor in reducing high-risk behaviors [33]. In addition, a study highlighted the significance of life skills, specifically self-expression, in behavioral change programs for adolescents [34]. A lack of self-expression also contributes to relative deprivation [35]. SP can enhance students’ mental health and self-assertiveness [36].

“Love” is another key component of Islamic SP. Many believe humans have an innate capacity for love due to God’s loving nature. Love is considered essential for overall happiness and life’s significance. Incorporating the concept of love into educational packages is crucial for effective SP. Among the ten educational modules, expressing the ‘concept of love’ was another component of Islamic SP. Humans believe that God is so lovable that He has recreated the attribute of love as an instinct. Therefore, true love is a part of God’s love [37]. Wong and Mayer elaborated on the meaning of love and argued that love is the core of human experiences and is central to finding meaning in life and well-being [38]. Wrigley-Carr viewed love in three components: Generosity, worship, empathy, and cooperation [39]. In this regard, Youngblood stated that a divine framework is necessary for spiritual psychotherapists to guide diverse populations in participating and meeting their existential, religious, and ritual needs [40]. Therefore, expressing the concept of love in an educational package is one of the important aspects of SP education.” The limitations of this study are the difficulty in accessing samples, potential bias in responding to research tools, and potential interventional variables affecting the results. It is suggested that Islamic SP packages be designed and used for other psychological components and variables, and other age groups. It is suggested that these training packages be localized based on the culture of each region.

Conclusion

It can be acknowledged that the Islamic SP training package has the necessary credits to enter counseling strategies. Therefore, mental health care institutions and providers must pay more attention to incorporating spiritual care into their clients’ health care programs.

Ethical Considerations

Compliance with ethical guidelines

This study was approved by the Ethics Committee of Islamic Azad University, Kerman Branch, Kerman, Iran (Code: IR.IAU. KERMAN.REC.1401.081).

Funding

This article was extracted from doctoral dissertation of Mohammadreza Mokhtaree, approved by Islamic Azad University, Kerman Branch, Kerman, Iran.

Authors' contributions

Conceptualization, methodology, investigation, writing the original draft, data collection, data analysis and funding administration: Mohammadreza Mokhtaree; Supervision: Zahra Zeinaddiny Meymand; Review & editing: Najmeh Hajipour Abaei and Mitra Kamyabi; Final approval: All authors.

Conflict of interest

The authors declared no conflicts of interest.

Acknowledgments

The authors are appreciate all the teenagers and their families who participated in this study. Additionally, they are grateful to the psychiatrists, psychologists, and the board of elites for their cooperation. Finally, they are grateful to the Research Deputy of Islamic Azad University, Kerman Branch.