Effectiveness of Spiritual Therapy on Loneliness Feeling in the Seniors Present at Nursing Homes

ORIGINAL ARTICLE Background: Moving away from family can cause psychological and emotional trauma for the elderly. Accordingly, the present study aimed to evaluate the effectiveness of spiritual therapy on loneliness feeling among the elderly in a nursing home in Isfahan. Methods: The method was quasi-experimental with a pretest-posttest design and a control group. The population of this study included all of the elderly in Sadeghieh nursing home in Isfahan in 2018. The sample of this study included 30 elderly people being selected by purposive sampling and then randomly included in the experimental and control groups (15 elderly people in each group). The experimental group received the therapeutic interventions related to spiritual therapy during eight sessions of 90 minutes every week for two months. Then, the subjects in both groups were re-tested. The used instruments included Russell’s loneliness questionnaire (1996). After collecting the questionnaires and extracting the raw data, data analysis was conducted using descriptive statistics and analysis of covariance by SPSS23 statistical software at 0.05 error level. Results: Spiritual therapy had a significant effect on loneliness among the elderly in the nursing home (p < 0.001). In this regard, this therapy could reduce the feelings of loneliness among the elderly in the nursing home. The effect of spiritual therapy on loneliness among the elderly in the nursing home was 53%. Conclusion: Based on the research findings, spiritual therapy can reduce loneliness feelings among the elderly by techniques, such as taking responsibility, assigning cases to God, strengthening the intentions, and deleting negative thoughts.


Introduction
Human is a thoughtful and social being whose life is associated with lots of ups and downs. He goes through various periods from birth to death entitled as transition from childhood to youth, middle age, and transition to old age. Such different periods of transition are of particular significance among different human cultures and societies and are addressed differently. Numerous studies were conducted on childhood, adolescence, and youth, while old age was less studied and identified as a sensitive phase of human life (Darvishpoor Kakhki et al., 2014(. Old age is a biological phenomenon which includes the aging and deterioration of human physiological structure. Such changes and physical exhaustion leave an effect on the human soul. The presence of old age and elderly population is inevitable in every society. An elderly person is someone whose physical strength has declined gradually and needs help for daily life. Since old age is a human phenomenon and a phase of life and human is a being with different social and individual aspects, thus his characteristics, interests, relationships, and interactions were studied in the field of psychological studies and social studies by the thinkers and experts in these sciences (Hshieh et al., 2018).
The occurrence of aging process, as well as some of the presence of some seniors in the nursing home leads to psychological damage to these people (Ghorbanali Pour & Esmaili, 2012). Therefore, the feelings of loneliness are considered as one of the factors that the elderly face (Heidari et al., 2016;Fazlolah Mirdrikvand et al., 2016;Bekhet & Zauszniewski, 2012). Many people experience the feelings of loneliness in all cultures, races and social classes, all ages and times. Though, this issue has not received much research attention in psychological literature (Wawrzyniak & Whiteman, 2011). The feelings of loneliness is a long standing situation of emotional helplessness that occurs when a person feels alienated, misunderstood, or rejected, or lacks a proper social model is suitable for activities, especially activities that provide a sense of social cohesion and emotional attachment (De Vlaming et al., 2010). According to this definition, the term the feelings of loneliness is limited to the helplessness due to the feeling of separation from others, not social isolation. Also, according to this definition, people who limit their contact with others, or those who prefer a secluded lifestyle do not necessarily experience the feelings of loneliness (Wiseman et al., 2006). There is a significant difference between being alone with a feeling of loneliness and it cannot even be assumed that being with others prevents feelings of loneliness. Objective loneliness refers to the physical state of being alone or socially isolated and is easily recognizable by any observer. The feeling of loneliness is a mental experience and depends on the individual's change of events. Also, there is a significant difference between keep away from people and the feeling of loneliness. Keep away from people involves making the choice to be alone deliberately for contemplation, meditation, or some purposeful activities. Contrary to the feeling of loneliness, keep away from people has a positive and pleasing meaning and can be associated with creativity. The meaning of living alone is not always suffering alone (Bergman & Segel-Karpas, 2018). In order to improve the psychological components of among the elderly, different educational and therapeutic methods have been used. Spirituality Therapy is one of these methods whose clinical efficacy is confirmed in various studies for various statistical populations such as the study conducted by Kamari & Fouladchang (2016); Bolhari et al. Spiritual therapy as a type of psychotherapy utilizes specific principles and spiritual-religious practices and helps patients reach a metaperception of themselves, the world, events, and phenomena and achieve health, and growth through their connection to the divine world (Richards & Bergin, 2004). According to the results reported by some studies conducted in this field, there is a significant relationship between spiritual well-being and physical and psychological well-being among chronic patients, and spirituality plays a prominent role in their physical and mental well-being, especially when exposed to acute and chronic illnesses. Many significant changes can be made in the activation of certain circuits of the brain by religious and spiritual experiences. Spirituality can help activate or deactivate brain systems for empathy or sympathetic care, and can also facilitate or inhibit brain systems for reflecting thoughts, self-awareness, and emotional selfregulation (Griffith, 2010).
Spiritual therapy is a kind of response to the obvious needs of clients and their explicit or implicit request for receiving this intervention or combining it with their common therapies. Spiritual intervention is realized when the therapist accepts and respects the clients' spiritual lives. Spiritual therapy is in line with religious or nonreligious spiritual perceptions and ideas and aims to deeply respect the autonomy and spiritual freedom of clients, empathy with the spiritual and religious belief of clients, flexibility and accountability to the spiritual values and needs of clients to decrease their psychological pain. Establishing a good relationship with clients, creating hope and expectation with treatment, increasing awareness, and regulating behavior are some techniques of spiritual therapy ) Richards et al., 2007).
According to the results of studies conducted on the psychological trauma in the seniors present in nursing home and the efficacy of spirituality therapies in reducing the psychological trauma of different individuals and also lack of research to investigate the effectiveness of spiritual therapies on the feeling of loneliness in the seniors present in nursing home, the researchers decided to investigate the effect of this treatment on the feeling of loneliness in the seniors present in nursing home. Therefore, the main question in this study is "Whether spirituality therapy has a significant effect on the feeling of loneliness among the seniors present in nursing home?

Methods
The method used in this study was quasiexperimental research design, control group pretestposttest design. The statistical population of the present study included all seniors present in nursing home, Sadeghiyeh center of Isfahan in 2018. Purposive non-random sampling was used in this study due to physical and psychological inability of all seniors present in present in nursing home to participate in the study. According to sampling method, 30 elderly people were selected using purposeful sampling from seniors present in Sadeghiyeh nursing home in Isfahan and were divided into two groups of experimental and control (15 elderly people in each group). 15 people were selected according to scientific sources (Delavar, 2010).
The experimental group received the therapeutic interventions related to spiritual therapy at eight sessions of 90 minutes every week for two months (table 1). While, the control group did not receive any intervention during the study. In the present study, inclusion criteria included having the necessary level of consciousness and cognition to participate in the study according to clinical interview and the results of review of medical records of the elderly, lack of chronic mental and personality disorders with respect to the elderly psychiatric file, willingness to participate in the study and having middle School degree as a minimum degree. Also, exclusion criteria in this study included having more than two absences, non-cooperation, and failure to perform predetermined assignments in the classroom and unwillingness to continue to be involved in the research process. In order to adhere to the research ethics, the elderly's consent to participate in the business intervention program was informed of all stages of the intervention. The control group was also assured that they would receive these interventions after completing the research process. The consent of all seniors to participate in the Although, the good validity and reliability reported was reported for this scale, a revised version of Russell et al. was presented in 1980 to fix the problems of the mentioned scale. They simplified the terms of the test and how to respond to it in the third version and changed the content of Article 4 from negative to positive. Also, they designed the test materials so that they can be implemented through interviews. The scale consisted of 20 questions which were rated on a 4-point Likert scale (1 = never 4 = always). The scores range of this scale is 20 to 80. Russell reported that the alpha coefficient is equal to 0.94 for this version (Russell, 1996). Bahraei et al. during a study concluded that Cronbach's alpha was 0.88 and the correlation coefficient between depression and loneliness scores was 0.67 (Bahraei et al., 2006). Internal consistency was obtained using Cronbach's alpha coefficient of 0.84 in this study.
After the necessary permits were obtained and the sampling process was performed (as mentioned), the selected seniors (30 individuals) were divided into two groups of experimental and control randomly (15 individuals in the experimental group and 15 individuals in the control group). The experimental group received the therapeutic interventions related to spiritual therapy at eight sessions of 90 minutes every week for two months. While, control group did not receive any intervention during the present study.
In order to analyze data in the table 2, descriptive and inferential statistics were used in this study. Descriptive statistics of mean and standard deviation and at the inferential statistics level, the Shapiro-Wilk test was used to test normality of the distribution of variables, Levin test for analysis of variance equality, and covariance analysis was used for research hypothesis testing. The pre-test variable was considered as the concomitant variable in the present study, because it could have a significant effect on the results of this study. IBM® SPSS® statistical software Statistical at the level of error 0.05 was used to analyze the statistical results.

Results
According to the results of demographic data, 6 individuals (20%) in the experimental group were male and 9 individuals (30%) were female. In the control group, 8 individuals (26.67%) were male and 7 individuals (23.33%) were female. Also, in the experimental group 5 individuals (16.6%) were 60-63 years old, 4 individuals (13.33% equivalent) were 64 to 67 years old and 6 individuals (20% equivalent) were over 68 years old.
The assumptions of parametric tests were evaluated before the results of analysis of covariance were presented. According to the results of Shapiro-Wilk test, the assumption related to the normality of the data distribution is confirmed (P > 0.05). Also, the Levene's test was used to test the variance homogeneity assumption, which its results were not significant, according to this result; the assumption related to the homogeneity of variances was met in the variables of cognitive avoidance and psychological distress (p < 0.05).
Also, it should be noted that for testing the assumption of homogeneity of regression slope, according to the results in the table 3, the interaction between the pre-test variable and grouping variable in the feelings of loneliness variable was not significant (p < 0.05), that is the assumption of homogeneity of regression slope in the variable of the feelings of loneliness was met.
As presented in the above So, it can be concluded that the mean scores of feeling of loneliness among the seniors present at nursing homes in Isfahan have been reduced by controlling the pre-test variable and training spiritual therapy program. The value of the effect of spirituality therapy training on the feeling of loneliness in the seniors present at nursing homes in Isfahan was 0.53 that is 53% of the changes in the variable of the feeling of loneliness among the seniors present in Isfahan nursing home are explained by group membership (spirituality therapy training).

Content Sessions
Getting to know each other, talking about therapeutic spirituality and its necessity in life, the role of belief and self-acceptance. First Paying attention to spiritual freedom to embrace God and the mission of the chosen people, being accountable and Planning for today and the future. Second Knowing the sins and confessing them to God. Recognizing the oppression to yourself or others and striving for a better life Third The assignment of the affairs to God and strengthening the will and eradicating negative thoughts that cause anxiety and cognitive factors and ways to deal with it and trying to replace positive behavior and thoughts Fourth Finding the meaning of love to yourself and others, studying the meaning of suffering. Empowering and resolving problems, expanding spiritual experience and reaching a peak of pleasure and expressing spiritual beliefs and experience, Continuous self-evaluation under the personal spiritual supervision.

Discussion
The present study was carried out aimed to investigate the effectiveness of spiritual therapy on the feeling of loneliness among the seniors present in Isfahan nursing home. According to the results, spirituality therapy had a significant effect on the feeling of loneliness in the seniors present in nursing home. That is this type of treatment can reduce the feeling of loneliness in these individuals. This result is consistent with the result reported by Kamari and Fouladchang; they concluded that spirituality therapy can improve life expectancy and life satisfaction. Also, Bolhari et al. (2012) have reported that group spirituality therapy can reduce psychological trauma in individuals. Also, the result of the present study is consistent with the results of Jimenez-Fonseca et al. (2018); they concluded that spirituality can have a significant effect on the relationship between psychological distress and psychological adjustment in individuals. Also, Barrera et al., (2012) during a study showed that cognitive-behavioral therapy combination, with emphasis on religion and spirituality, on the seniors with anxiety disorder, could reduce the significant symptoms of the disorder such as anxiety and secondary benefit due to this disorder in the experimental group. In explaining the present result, it can be said that enhancing positive traits such as patience and resistance to problems, better problem-solving ability, and achieving higher coping power is considered as one of the ways in which spirituality can lead to increased effectiveness. In fact, it seems that one of the reasons for the effect of spiritual therapy to be that the elderly gain a type of self-control with increasing religious orientation that prevents high effectiveness of external conditions on the individual, therefore, it will be less affected by inappropriate conditions and preserve their mental health. Through this process, the elderly are able to have a stronger relationship with God as a lifelong friend and thereby perceive less the feeling of loneliness due to receiving spiritual therapy. Furthermore, it should be noted that spiritual therapy helps seniors recover their future hope and this process leads to reduce their psychological burden. Because hopeful individuals act actively, rather than passively in dealing with their particular living conditions, such as living in a nursing home, also, they show less distress and more compliance (Ellison et al., 2009). Also, it can be concluded that hope and meaningfulness resulting from spirituality therapy have a significant effect on adaptation to the conditions and the stress resulting from it. Because it can be concluded that changes in the seniors' attitude and their interpretation of life is the most important special effect of spiritual therapy (Barrera et al., 2012). This change in beliefs has a significant effect on the cognitive appraisals of these individuals and is able to manage the negative events and stress resulting from it in a logical manner and the seniors will be able to achieve a stronger sense of security and adaptability through the connection to God and spiritual resources. Then, their ability to cope with mental and physical problems increases more efficiently, which in turn it leads to reduce the feeling of loneliness in these individuals. In another explanation, it should be noted that spirituality therapy helps seniors improve their ability to utilize their capital and spiritual resources to solve physical and mental problems and to have a better life, and makes possible mastering the environment, purpose and finding the right direction in life, self-acceptance and filling the semantic vacuum. Meaning and having goal in life help mental adjustment in the acute stages and consequences resulting from challenging situations (Richards et al., 2007).
In this method of treatment, it is believed that the efficacy and sustainability of treatment will significantly increase if the divine and spiritual teachings, especially the essential component of monotheism and a strong relationship with God, are combined with the findings of psychotherapy, because monotheism, more than any other factor, is able to integrate the personality (Kamari & Fouladchang, 2016). Also, it should be noted that spirituality therapy can increase one's inner endurance by using divine and spiritual teachings, especially the strong, spiritual and intimate relationship with God, and reduce the feeling of loneliness in the seniors.
This study had several limitations. Some of the most important are: the scope of the present study was limited to the seniors present in Sadeghieh nursing home in Isfahan, random sampling method was used, there was some uncontrolled variables such as the intelligence status of the seniors present in the study, and lack of follow-up stage, therefore it is recommended to carry out this study in other cities and regions and communities with different cultures, other seniors, control of the mentioned factors and use random sampling and implement follow-up stage in order to increase the power of generalizability of results.

Conclusion
Due to the effectiveness of spiritual therapy, it is recommended to use spirituality therapy as an appropriate and effective method in nursing homes due to the effectiveness of spirituality therapy on cognitive avoidance and psychological distress in the seniors present in the nursing home.

Conflict of interest
No conflict of interest has been reported by the authors in this study.