Best practices in spiritual assessment: Best practices in spiritual assessment: Diverse approaches to identifying and operationalizing Diverse approaches to identifying and operationalizing

clients’ spiritual, religious, and cultural strengthsclients’ spiritual, religious, and cultural strengths

David R. Hodge, Ph.D.Professor

School of Social Work

Arizona State University &

Senior Nonresident Fellow

Program for Research on Religion and Urban Civil Society, University of Pennsylvania

Presentation OverviewPresentation Overview

Spirituality, religion, & culture

Spiritual assessment as a two-stage process – Brief spiritual assessment tools– Comprehensive spiritual assessment tools

Defining Spirituality and ReligionDefining Spirituality and Religion

How would you define:

Spirituality?

Religion?

Defining Spirituality and ReligionDefining Spirituality and Religion

Controversial:

No agreement exists

Definitions of Spirituality Definitions of Spirituality among the general public (N= 100)among the general public (N= 100)

Approximately 70% Belief in God/seeking to grow close to GodBelief in a higher power or something beyond

oneself/sense of awe and mystery in the universe

Approximately 30% No mention of the transcendent

(Gallup & Jones, 2000)

S R

Trends in Thinking about Trends in Thinking about Spirituality, Religion & Culture Spirituality, Religion & Culture

Spirituality – Individually oriented – Relationship with God, Transcendent, or sacred

Religion – Communal– Shared beliefs and practices related to spirituality – Developed over time

Culture – Religion can function as a culture– Evangelical Christianity, Catholicism, Islam, Hinduism

Spiritual AssessmentSpiritual Assessment

Rationales for conducting a spiritual assessment Two-stage process 2 brief assessment tools 5 comprehensive assessment tools

• strengths

• limitations

Rationales for AddressingRationales for Addressing Spirituality in Practice Settings Spirituality in Practice Settings

1. Ethics

2. Human rights

3. Accrediting & agency requirements

4. Knowledge of clients’ worldviews

5. Respect for client autonomy

6. Interest in clients’ strengths

7. Related to positive outcomes

Spiritual Assessment: Spiritual Assessment: A Two-stage Process A Two-stage Process

Brief Assessment – first stage

Universal

For purposes of determining:

the impact of spirituality, if any, on the provided care/services and

if further (i.e., comprehensive) assessment is needed

Arguments against Brief Assessment Arguments against Brief Assessment

Time Constraints

Potential Coercion

Counterarguments Counterarguments for Brief Assessment for Brief Assessment

Minimal time investment

Clients appreciate being asked about S/R– Even clients that have no interest in S/R

Enhanced client satisfaction Coping Wellbeing Increased appointment attendance

(Huguelet, et al., 2011; Kristeller et al., 2005)

Legitimize spirituality

Why is it Important to Legitimize Why is it Important to Legitimize Spirituality in Practice Settings?Spirituality in Practice Settings?

Many clients believe helping professionals will not respect their spiritual values

Where to these perceptions come from? – The dominant culture is largely secular

Television Movies K-12 Universities News media

Overt Hostility also Exists Overt Hostility also Exists

The God Delusion Richard Dawkins (2006)

“Should employers be blind to private beliefs?” (Dawkins, 2011)

No!Advocates for discrimination based upon

religious beliefsAbility to hold religious and secular views

simultaneously is an “indicator that there is something wrong with his head.”

http://www.boingboing.net/2011/01/24/should-employers-be.html

Religion is

“…irrational...invested in ignorance and hostile to free inquiry...." 

Christopher Hitchens in (2007) God Is Not Great: How Religion Poisons Everything

‘Here, I offer further thoughts on how religion is “irrational” and “invested in ignorance”.’

Sam Harrishttp://newsweek.washingtonpost.com/onfaith/sam_harris/2007/09/

religion_as_a_black_market_for.html

In The End of Faith, Sam Harris (2004) states that people of faith are: mad, psychotic and delusional and should be systematically disenfranchised.

A self-described atheist was assigned to review the book for New York Times. The reviewer commented that she felt relieved, vindicated and personally understood in the process of reviewing the text, and labeled it an “important book” (Angier, 2004).

Hostility also Exists Hostility also Exists in the Helping Professions in the Helping Professions

The Future of an Illusion   Freud (1927)

Religious beliefs psychopathology Albert Ellis

Legitimizing SpiritualityLegitimizing Spirituality

A brief assessment provides a mechanism to implicitly communicate the importance of spirituality to clients

The Joint Commission Assessment The Joint Commission Assessment Requirements Requirements

The Joint Commission accredits most hospitals

Spiritual assessment required for:

– Emotional problems – Behavioral problems – Substance abuse problems– Receiving end-of-life care

Joint Commission [former] Joint Commission [former] Requirements for a Brief Spiritual Requirements for a Brief Spiritual

AssessmentAssessment

Assess three areas: Denominational affiliation Spiritual beliefs Spiritual practices

For purposes of determining: the impact of spirituality, if any, on the provided

care/services and if further (i.e., comprehensive) assessment is needed

If you were tasked with coming up with a brief spiritual assessment model (3 to 6 questions) to comply with the Joint Commission's standards, what would it look like?

Joint CommissionJoint Commission Suggested Questions Suggested Questions

Examples of elements that could be but are not required in a spiritual assessment include the following questions directed to the patient or his/her family:

http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFaqId=290&ProgramId=47

Who or what provides the patient with strength and hope? Does the patient use prayer in their life? How does the patient express their spirituality? How would the patient describe their philosophy of life? What type of spiritual/religious support does the patient desire? What is the name of the patient's clergy, ministers, chaplains, pastor,

rabbi? What does suffering mean to the patient? What does dying mean to the patient? What are the patient's spiritual goals? Is there a role of church/synagogue in the patient's life? How does your faith help the patient cope with illness? How does the patient keep going day after day? What helps the patient get through this health care experience? How has illness affected the patient and his/her family?

If you were tasked with coming up with a brief spiritual assessment model (3 to 6 questions) to comply with the Joint Commission's standards, what would it look like?

Two Models for Conducting Two Models for Conducting a Brief Assessment a Brief Assessment

iCARING

FICA

iCARING Brief AssessmentiCARING Brief Assessment

importanceCommunityAssets and ResourcesInfluenceNeedsGoals

iCARING Brief AssessmentiCARING Brief Assessment

importanceI was wondering how important spirituality or

religion is to you?

CommunityDo you happen to attend a church or some other

type of religious or spiritual community?

Assets and ResourcesAre there particular spiritual beliefs and practices

you find especially helpful in dealing with challenges?

iCARING Brief AssessmentiCARING Brief AssessmentInfluenceI was curious how your spirituality has shaped your

understanding and response to your current situation?

NeedsI was also wondering if there are any spiritual needs

or concerns I could address?

GoalsLooking ahead, I was wondering if you were

interested in incorporating your spirituality into our work together? And if so, what would that look like?

FICA ModelFICA Model(Borneman, Ferrell, Puchalski, 2010)(Borneman, Ferrell, Puchalski, 2010)

Faith or belief

Importance

Community

Address

When to Move from a Brief to a When to Move from a Brief to a

Comprehensive Assessment?Comprehensive Assessment?

Four factors to consider:

1. Client self-determination

2. Practitioner level of cultural competence

When to move from a brief to a When to move from a brief to a comprehensive assessmentcomprehensive assessment

3. The degree to which the norms of the client’s faith tradition intersect service provision

– A Native client facing a possible diagnosis of mental illness who reports hearing the Creator’s voice on a regular basis

4. The salience of spirituality in the client’s life– Catholics who attend Mass weekly – Muslims who practice the “five pillars”

You have Decided to Administer a You have Decided to Administer a Comprehensive Assessment: Comprehensive Assessment:

Now What? Now What?

What assessment tool to use?

The same tool for each client?

Contextual factors include:

Clients’ presenting problem, communication style, cultural background

Practitioner’s theoretical orientation, working environment, available time

Comprehensive Spiritual Assessment Tools: Comprehensive Spiritual Assessment Tools: Overview, Strengths, and LimitationsOverview, Strengths, and Limitations

Verbally based instrument: Spiritual histories

Diagrammatic instruments: Spiritual lifemaps Spiritual genograms Spiritual eco-maps Spiritual ecograms

Decision tree

An alternative approach to assessment

Verbally Based Spiritual HistoriesVerbally Based Spiritual Histories

Analogous to a family history

Two parts, or two question sets• Initial Narrative Framework--provides practitioners with some

tools for assisting clients in the telling of their spiritual narratives

• Interpretive Anthropological Framework--A second set of anthropological questions, based upon the spiritual anthropology developed by Chinese spirituality writer Watchman Nee (1968), is provided to help pracitioners explore clients’ spiritual reality as clients relate their spiritual stories

Initial Narrative Framework

1. Describe the religious/spiritual tradition you grew up in. How did your family express its spiritual beliefs? How important was spirituality to your family? Extended family?

2. What sort of personal experiences (practices) stand out to you during your years at home? What made these experiences special? How have they informed your later life?

3. How have you changed or matured from those experiences? How would you describe your current spiritual or religious orientation? Is your spirituality a personal strength? If so, how?

Interpretive Anthropological Framework

1. Affect: What aspects of your spiritual life give you pleasure? What role does your spirituality play in handling life’s sorrows? Enhancing life’s joys? Coping with life’s pain? How does your spirituality give you hope for the future? What do you wish to accomplish in the future?

2. Behavior: Are there particular spiritual rituals or practices that help you deal with life’s obstacles? What is your level of involvement in faith-based communities? How are they supportive? Are there spiritually encouraging individuals that you maintain contact with?

3. Cognition: What are your current religious/spiritual beliefs? What are they based upon? What beliefs do you find particularly meaningful? What does your faith say about personal trials? How does this belief help you overcome obstacles? How do your beliefs affect your health practices?

4. Communion: Describe your relationship with God. How does God communicate with you? How have these experiences encouraged you? Have there been times of deep spiritual intimacy? How does your relationship help you face life challenges? How would God describe you?

5. Conscience: How do you determine right and wrong? What are your key values? How does your spirituality help you deal with guilt (sin)? What role does forgiveness play in your life?

6. Intuition: To what extent do you experience intuitive hunches (flashes of creative insight, premonitions, spiritual insights)? Have these insights been a strength in your life? If so, how?

Interpretive Anthropological FrameworkInterpretive Anthropological Framework

Spiritual Histories: StrengthsSpiritual Histories: Strengths

Easy to conduct Appeal to more verbally oriented clients Concept easy for clients to understand Relatively non-structured format allows clients to relate

their stories in a straightforward manner Allows opportunity to build therapeutic alliance with

clients Central ideas can readily be integrated into a general

assessment Generally covers a clinically appropriate time span

Spiritual Histories: LimitationsSpiritual Histories: Limitations

Not all clients are verbally oriented Face to face interaction may increase client nervousness

about sharing an intimate topic, such as spirituality Some clients may prefer a more structured format Time may be spent exploring parts of clients’ stories that

have little relevance to presenting problems May not cover all pertinent aspects of clients’ spiritual

strengths (i.e., generational strengths may be overlooked) Little opportunity for individual, artistic expression

Spiritual LifemapsSpiritual Lifemaps

A diagrammatic alternative to verbally-based spiritual histories

An illustrated account of the client’s relationship with God over time--a map of the client’s spiritual life

Constructed using paper, pencils, coloring markers, and other media

Much like road maps, spiritual lifemaps tell us where we have come from, where we are now, and where we are going to (i.e., life review)

Help God! I just can’t make it

SPIRITUAL AWAKENING!

God’s hand IS on my life

Spiritual Strengths Promise Keepers

Mentoring program Spiritual meditation

Baptized in the Holy Spirit!

Mentoring Award

18

20s

29

30

36

42

Spiritual Lifemap

Dad died

32

Spiritual Lifemaps: StrengthsSpiritual Lifemaps: Strengths

May be of interest to more artistically oriented clients Highly client-directed May appeal to less verbal clients Possible to assign as homework Lends itself well to existential interventions that

emphasize the shortness of life Placing a client-constructed media at the center of the

assessment process communicates the message that the client is a competent, pro-active, self-directed, fully engaged participant.

Spiritual Lifemaps: StrengthsSpiritual Lifemaps: Strengths(cont.)(cont.)

For clients for whom spirituality is a highly personal and sensitive area, lifemaps provide a means of shifting the focus from the client to a more neutral object, a process that may help set clients at ease

Less risk exists that practitioners may jeopardize the therapeutic relationship through comments that are inadvertently offensive

Counselors can focus on building therapeutic rapport by providing an atmosphere that is accepting, nonjudgmental, and supportive during assessment

Spiritual Lifemaps: LimitationsSpiritual Lifemaps: Limitations

Practitioners may feel so removed from the process that this assessment approach makes poor use of therapeutic time

Clients who are more verbal, uncomfortable with drawing, or prefer more direct practitioner/client involvement may find the use of a largely non-verbal, pictorial instrument to be a poor fit with their needs

Individualistic—provides little information on generational assets

Spiritual GenogramsSpiritual Genograms

Depict a graphical representation of spirituality across at least three generations

Colors are used to depict individuals’ spiritual traditions and symbols are used to portray affiliations, devoutness, spiritual awakenings, changes in affiliation, relationships between family members, significant spiritual others, etc.

The end result is a graphic “color snapshot” of the overall spiritual composition of the family system that helps both practitioners and clients understand the flow of historically rooted spiritual patterns through time

Nominal Inactive 18-25yrs attender Active 25yrs-- Fred Sarah David Stacy Reggie Carol Jane [17] 82 Kevin Rachel Frank Hannah Sue Bea Karen

Strict! [21] married in their early 30s Ruth Youth Mark Alice pastor Beth Married three years—frequent marital conflict Beth hospitalized for depression

1st

19

28

vision

Beth’s strengths Worship music Psalm writing Experiences of God’s love Spiritual biographies Mentoring relationship with Ruth

Spiritual Genogram

Mark’s strengths Mentoring relationship with David

Depicting Relational Information in Diagrammatic Form _________________________________________________________ Tenuous relationship

Weak or frail relationship

Normal relationship

Strong relationship

Conflicted relationship

Flow of energy, resources or interest

Bi-directional flow of energy or resources

Spiritual Genograms: StrengthsSpiritual Genograms: Strengths

Highlights generational assets

May be particularly useful when the family system plays a significant role in the client’s life

Problems involving family members or family of origin issues are often effectively explored with spiritual genograms (e.g., marriage problems)

Implicitly shows respect for members of the family system

May hold appeal for clients who desire a very structured approach

Spiritual Genograms: LimitationsSpiritual Genograms: Limitations

Relatively time consuming to construct

Require a fair degree of practitioner involvement to explain and conduct the assessment

Place some limitations on how clients relate their spirituality Difficult to incorporate concepts into traditional genogram assessment

Some clients may not understand the need to explore past events, wishing to focus on present strengths that can be operationalized to address current problems

Spiritual Eco-mapsSpiritual Eco-maps

While spiritual histories, lifemaps, and genograms all tap some portion of a client’s spiritual story as it exists through time, spiritual eco-maps focus on that portion of a client’s spiritual story that exists in present space

The client is drawn as a circle in the center of the paper and the spiritual systems are drawn around the client

Although possible to add symbols, etc., the heart of the spiritual eco-map is the relationships between the client system and the spiritual systems, which are represented by various types of sketched lines

Spiritual Ecomap

6/4/88

Faith

Com m unity Trans-

personal Beings

Father’s Spiritual T radition

Spiritual Leader

Rituals

42 38

9

38 2/8/85

16

Premonition Post-death experience

Others

4/21/92

Wife’s dramatic

conversion 8/1/94

M other’s Spiritual T radition

Wife’s occasional encounters with angels

God

Depicting Relational Information in Diagrammatic Form _________________________________________________________ Tenuous relationship

Weak or frail relationship

Normal relationship

Strong relationship

Conflicted relationship

Flow of energy, resources or interest

Bi-directional flow of energy or resources

Spiritual Eco-maps: StrengthsSpiritual Eco-maps: Strengths Focuses upon clients’ current, existential, spiritual strengths

Quick to construct

Relatively easy to grasp conceptually

Since eco-maps focus on environmental systems rather than, for example, clients’ life stories, eco-maps may be particularly helpful in transferring attention from the client to the concrete, diagrammatic assessment tool

Easy to incorporate concepts into a traditional assessment

Spiritual Eco-maps: LimitationsSpiritual Eco-maps: Limitations

Eco-maps may not appeal to more creative individuals, or clients wishing to express their spiritual journey in a less structured format

The focus on the client’s relationships to spiritual assets in present space may result in a limited assessment that overlooks important historical factors

Spiritual Spiritual EcogramsEcograms Ecograms tap information that exists in space, much

like a traditional spiritual eco-map, as well as tapping information that exists across time, as occurs with a traditional spiritual genogram

Historical influences on current systems can be seen as well as present relationships with historical influences

The client is drawn in the center of the paper, with the top of the page used to chart the family tree, while the bottom half is used to portray the client’s relationships to present spiritual systems

Spiritual Ecogram

Mustafa Sarah Tariq Sahar

Ali Fatima Sahar Nadia Ada

Mosque

Muslim youth

Prayer

Allah

School youth

Phys-Ed

School food

- Few friends - Classmates unkind

Strengths - God - Learning - Grandmother - Muslim friends

Challenges - Stomach pains - Headaches

From Pakistan

To America

Spiritual Ecograms: StrengthsSpiritual Ecograms: Strengths

The primary asset of spiritual ecograms is their ability to illustrate current and historical resources as well as the connections between those strengths

Ecograms represent a completely new model for assessment and can be used to conduct a general assessment

As is the case with eco-maps, it is relatively easy to incorporate one or more spiritual systems into a general assessment

Spiritual Ecograms: LimitationsSpiritual Ecograms: Limitations

Somewhat complex and may gather extraneous information

Spiritual eco-maps, for example, are less time consuming to construct and may provide all the information that is required in a given situation.

In other contexts, practitioners may desire to use the limited amount of page space to amplify the generational dynamics in a spiritual genogram

Choosing between Assessment MethodsChoosing between Assessment Methods

Choice dependent upon:

Nature of presenting problem Client’s communication style Client’s cultural background Practitioner’s theoretical orientation The physical environment The time available for assessment

If you are interested in further information on this topic, you might want to consider my recent book:

Spiritual Assessment in Social Work and Mental Health Practice

The webpage for the book ishttp://cup.columbia.edu/book/spiritual-assessment-

in-social-work-and-mental-health-practice/9780231163965

If you use the promo code “HODSPI” to buy the book from this site you should receive a 30% discount. Please feel free to pass this along.