mental health AIDS

Spring 2007 Newsletter / Volume 8, Issue 3

All That Is Sacred: A Primer on Spiritual Assessment

"The sacred is what distinguishes religion and spirituality from other phenomena.
... The sacred is the common denominator of religious and spiritual life."

---- Hill & Pargament, 2003, p. 65

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Loue and Sajatovic (2006) analyzed data drawn from 41 Puerto Rican women living with severe mental illness (SMI) in northeastern Ohio and found that "[a] large proportion of the participants reported that their religious or spiritual beliefs were critical to their coping, had influenced them to reduce [HIV] risk, and/or provided them with needed social support" (p. 1168). According to the investigators, these data

suggest that including a spirituality/religio[usness] ... component in [secular] HIV prevention programs designed for Latinas may be critical to the initiation and maintenance of risk reduction behaviors, e.g., reducing the number of sexual partners and abstaining from drug use.

Including a spiritual component in such programs may encourage Hispanic [women with] SMI ... to utilize their religious and spiritual beliefs in coping. Coping may include self-acceptance regardless of past actions (e.g., substance use); identification of effective strategies to address the challenges of mental illness (e.g., medication management adherence, social isolation, unstable living circumstances); and the development of skills to identify and effectively address situations that may heighten HIV risk.

Many ... [study] participants used religious precepts to establish behavioral standards for themselves. The incorporation of spiritual or religious routines into daily living regimens may provide [persons with] SMI ... with structure and predictability in their lives, which are often characterized by disorganization and unpredictability. Gradually, the increased predictability and structure may help to decrease impulsivity, establish boundaries, and reduce HIV risk behaviors.

Participation in spiritual or religious activities with others may also provide a sense of community for [persons with] SMI ... who have been socially isolated, institutionalized, or victimized in exploitative relationships. ... The resulting social support may help individuals to transform their core identity from that of victimized mentally ill persons to that of loved and valued individuals. This metamorphosis may be critical to the development of a sense of self-efficacy in decision[-]making. This enhanced sense of community may be particularly important to Hispanic [women with] SMI who may have lost a sense of community or support as the result of migration. The development of a healthy social support system may provide assistance with tangible needs, thereby reducing the need to engage in survival behaviors that may increase HIV risk, such as trading sex for food, shelter, or safety. (pp. 1176-1177)

Loue and Sajatovic stress that "the spiritual components of an HIV prevention intervention must encompass elements of faith that may be common to a wide range of individuals and be sufficiently broad to suggest and allow diversity of belief, including a conceptualization of spirituality that does not require a belief in a higher power" (p. 1177). Additionally, when working with persons with SMI, "[p]ractitioners must have sufficient familiarity with the relevant religious precepts to allow them to distinguish their patients' religious beliefs and rituals from delusions and compulsions ..." (p. 1177; see sidebar). One way to gather the information needed to discern spiritual content reflective of mental illness is to conduct a spiritual assessment.

Are You Spiritual Assessment Savvy?

According to Richards and Bergin (2005), "[a] religious-spiritual assessment should be embedded in a multilevel, multisystemic assessment strategy" (p. 234). This recommendation extends to work conducted with persons living with HIV/AIDS, because "[v]irtually every study on religion and spirituality conducted among men and women with HIV attests to the significance of ... [these] construct[s] for these individuals" (Pargament et al., 2004, p. 1202). Moreover, "[a] small but growing body of empirical evidence indicates that religiousness and spirituality play an important role in the health and well-being of people living with HIV" (Pargament et al., 2004, p. 1207).

How might one then proceed with such an assessment process? "Given ... the fact that research and clinical experience with religious-spiritual assessment … [are] still in an early state," Richards and Bergin observe that "therapists must rely heavily on clinical wisdom and hunches when deciding what religious and spiritual information to seek about their clients" (p. 224).

Fortunately, some clinical guidance has been offered by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). JCAHO, an independent, not-for-profit organization that evaluates and accredits nearly 15,000 health care organizations and programs in the United States, now requires the administration of a spiritual assessment (JCAHO, 2004). Hodge (2004, 2006) has outlined a two-stage spiritual assessment process based on JCAHO requirements that may also be of use in non-JCAHO-accredited settings.

Initial or Brief Spiritual Assessment

Hodge defines spiritual assessment as "the process of gathering, analyzing, and synthesizing spiritual and religious information into a specific framework that provides the basis for, and gives direction to, subsequent practice decisions. ... " (Hodge, 2006, p. 318). He suggests that clinicians begin with an "initial" or "brief" spiritual assessment. "The purpose of the initial assessment is twofold. One goal is to identify the effect of client's spirituality on service provision and client care. ... [F]or service provision to be as effective as possible, spiritual beliefs and practices often have to be taken into account. ... Another goal is to identify whether an additional, more comprehensive spiritual assessment is required" (Hodge, 2005a, pp. 314-315).

"At a minimum, the brief assessment should include an exploration of three areas: (1) denomination or faith tradition, (2) significant spiritual beliefs, and (3) important spiritual practices" (Hodge, 2006, p. 318). Hodge's model conforms to JCAHO's spiritual assessment recommendations and consists of four questions:

1. I was wondering if spirituality or religion is important to you?
2. Are there certain spiritual beliefs and practices that you find particularly helpful in dealing with problems?
3. I was also wondering if you attend a church or some other type of spiritual community?
4. Are there any spiritual needs or concerns I can help you with? (Hodge, 2006, p. 319)

Hodge encourages clinicians to phrase their questions in this neutral manner, which validates the experiences of clients who are spiritual, religious, both, or neither. After assessing the client's response to the first question, clinicians may decide to divide the second question

into two discrete items for more specificity in terms of beliefs and practices (e.g., "Are there certain spiritual beliefs that are particularly helpful in dealing with problems?" "Are there particular spiritual practices that you find especially useful when facing difficult circumstances?"). In other words, if clients' replies suggest that spirituality is a significant factor in their personal ontology, exploring the belief and practice dimensions separately may yield more clinically useful information. Similarly, if previous responses warrant, it may also be helpful to ascertain how often clients engage in spiritual or religious practices and the salience of the practices to clients. (Hodge, 2004, pp. 38-39)

With regard to the question on attendance at a church or other spiritual community, "[i]f the client attends a mosque, for example, then that term would be used in all subsequent conversation" (Hodge, 2006, p. 319).

The final question inquires about clients' spiritual needs. "In addition to asking about religious needs in a general, nonspecific sense, it may be helpful to list some common spiritual needs (e.g., 'Are there any spiritual needs I can help you address such as arranging a visit from the chaplain or your pastor?')" (Hodge, 2004, pp. 38-39).

Moving to a Comprehensive Spiritual Assessment

"At least four somewhat interrelated factors may bear on the decision to move from a brief to a comprehensive assessment. It should be noted at the outset that these four guidelines are often held in tension with, and inform, one another. In brief, these four principles can be summarized as respect for client self-determination, the practitioner's ability to provide culturally competent services, the degree to which the norms of the client's faith tradition relate to service provision, and salience of spirituality in the client's life" (Hodge, 2006, p. 320).

• Client self-determination: Hodge emphasizes that "it is important to obtain clients' consent before proceeding with a spiritual assessment. Although many clients may be willing to answer the relatively few questions involved in a brief assessment, informed consent should be obtained again before proceeding with a comprehensive assessment. Indeed, it is perhaps best to view informed consent as an ongoing process in which practitioners continuously monitor clients' responses to ensure that they remain fully supportive of the continuing dialogue" (Hodge, 2006, p. 320). Hodge does suggest, however, that "[c]lient reluctance to proceed with an assessment ... can be sensitively explored, a process that is especially advisable when the other guidelines point toward the importance of a comprehensive assessment" (Hodge, 2006, p. 323).

• Clinician cultural competence: According to Hodge, "if an initial assessment indicates the presence of a culturally different worldview that the practitioner may have difficulty working with in a culturally sensitive manner, then it may be advisable to refrain from conducting a comprehensive assessment. ... Consequently, serious consideration should be given to referring the client to another practitioner who has the necessary skills and knowledge to work with the particular client population in a culturally competent manner" (Hodge, 2006, p. 321).

• Spiritual norms and their relationship to service provision: While conducting the initial assessment, clinicians in Hodge's view should remain

alert to various indicators that might suggest a connection between the client's spirituality and possible diagnoses, interventions, or other aspects of service provision. Making such connections typically requires ... some degree of knowledge regarding common norms extant in various denominations and faith traditions. ... If the initial assessment suggests the existence of certain spiritual beliefs and practices that may relate to later treatment decisions, then further assessment is warranted to clarify the exact nature of the relationship between the value in question and possible treatment decisions. (Hodge, 2006, p. 322)

• Spiritual salience in client's life: "Finally," according to Hodge, "a comprehensive assessment might be considered when spirituality plays a central role in the client's life. ... [I]f the initial assessment suggests that spirituality functions as an organizing principle in the client's life, then further assessment may be appropriate" (Hodge, 2006, pp. 322-323).

Five Complementary Comprehensive Spiritual Assessment Tools

Hodge (2005a) reviews and compares five comprehensive spiritual assessment tools that highlight various facets of a client's spiritual life. One tool – the spiritual history – is the only approach that is conducted in an exclusively verbal manner. The other four tools – the spiritual lifemap, spiritual genogram, spiritual ecomap, and spiritual ecogram – are diagrammatic or pictorial in nature. Given space limitations here, readers are encouraged to consult Hodge's original articles (cited below) for detailed accounts of each assessment approach. The following brief descriptions may, however, assist clinicians in selecting the assessment tool most appropriate to the clinical setting as well as the needs and interests of individual clients.

Spiritual histories (Hodge, 2001a) are conducted much like traditional family histories in which clients describe their spiritual journeys. "For verbally oriented people, spiritual histories may provide the best assessment method. ... [T]he relatively unstructured format allows clients to relate their stories in a straightforward manner without having to adapt their narratives to fit a particular diagrammatic format. ... Spiritual histories are also easy to conduct. The assessment model is relatively easy to communicate to clients, and the verbal format is conducive to building a therapeutic alliance with clients" (Hodge, 2005a, p. 316). Of course,

[n]ot all clients are verbally oriented ... [and] some may prefer the pictorial assessment approaches discussed in later sections. Individuals who are nervous about sharing what is often a highly personal topic may desire a diagrammatic approach that deflects attention away from themselves and onto an inanimate object. Some clients prefer having a specific framework around which to organize their thoughts[; for others,] ... the process of conceptualizing and depicting one's spiritual journey pictorially may help to focus and objectify spiritual assets, which can then be discussed and marshaled to address problems. (Hodge, 2005a, p. 316)

Spiritual lifemaps (Hodge, 2005c) cover the same time span as spiritual histories, but in a pictorial format that may be appealing to clients who are more artistic or less verbally oriented. "Much like road maps, spiritual lifemaps tell us where we have come from, where we are now, and where we are going. ... To fully operationalize the potential of this method, it is important to ask clients to incorporate the various trials they have faced along with the spiritual resources they have used to overcome those trials. ... Delineating successful strategies that clients have used in the past frequently suggests options for overcoming present struggles" (Hodge, 2005a, pp. 316-317).

"The pictorial lifemap affords practitioners the opportunity to learn more about the client's worldview, while focusing on building therapeutic rapport by providing an atmosphere that is accepting, nonjudgmental, and supportive during assessment. ... Lifemaps ... may [also] be assigned as 'homework,' saving valuable therapeutic time" (Hodge, 2005a, p. 317). For some clients, however, "it may be important to understand the effects of spirituality in greater breadth (that is, among the wider family system) or in greater depth (that is, across generations). In such settings, spiritual genograms may be used" (Hodge, 2005a, p. 317).

Spiritual genograms (Hodge, 2001b) "chart the flow of spirituality over the course of at least three generations and may be particularly appropriate in situations in which the extended family plays a more central role" (Hodge, 2004, p. 39). Genograms serve as "a blueprint of complex intergenerational spiritual interactions ... [and] may appeal to clients who prefer a very structured assessment approach" (Hodge, 2005a, p. 319). At the same time,

[s]piritual genograms are relatively time consuming to construct, require a fair degree of practitioner involvement to explain and conduct the assessment, and place some limitations on how clients relate their spirituality. In situations where the family system or historical influences are of minor importance, spiritual genograms may be an inappropriate approach. Furthermore, because many clients do not connect past events with current difficulties, some clients may view genogram construction as an ineffective use of time ... . With such clients, it may be more appropriate to use assessment approaches that focus on the 'here and now,' such as spiritual ecomaps. (Hodge, 2005a, p. 319)

Spiritual ecomaps (Hodge, 2000; Hodge & Williams, 2002) "depict the … [clients'] present, existential relationships with key spiritual variables in their environment and, consequently, may be useful for more present-focused clients who are interested in exploring current spiritual strengths rather than historical influences" (Hodge, 2004, p. 39), the latter common to spiritual histories, lifemaps, and genograms.

Spiritual ecomaps are relatively easy to grasp conceptually, quick to construct, and perhaps most important, readily focus on clients' current, existential spiritual strengths ... . This assessment approach may be ideal for operationalizing clients' spiritual assets in a timely fashion because the time spent in assessment is focused on tapping into present spiritual resources. As in the case with all diagrammatic methods, spiritual ecomaps provide an object that can serve as the focus point of discussion, which can be an important consideration for those clients who find it less threatening to have a concrete object as the focus of conversation. However, by virtue of their design, ecomaps may be particularly helpful in transferring attention from the client to the concrete, diagrammatic assessment because they focus on environmental systems rather than, for example, clients' life stor[ies] ... . Although other approaches may implicitly emphasize the client, spiritual ecomaps explicitly stress the systems in clients' environments ... .

Spiritual ecomaps suffer from the same limitations as other diagrammatic approaches relative to verbal spiritual histories. A diagrammatic approach may hold little appeal to clients who want to talk. Although relatively quick and simple to construct, ecomaps may not appeal to more creative individuals, but clients can be encouraged to express their creativity by adding symbols and other material to the ecomap. In some situations, the focus on the client's current, existential relationships to spiritual assets may result in a limited assessment that overlooks important historical factors. In some contexts, an approach that examines current and historical resources on the same diagrammatic tool may be useful. (Hodge, 2005a, pp. 320-321)

Spiritual ecograms (Hodge, 2005b) "combine the assessment strengths of spiritual ecomaps and genograms in a single assessment approach ... . Ecograms tap information that exists in present space, much like a traditional spiritual ecomap, and also access information that exists across time, like a traditional spiritual genogram. Ecograms also depict the connections between past and present functioning. Historical influences on current systems can be seen as well as present relationships with historical influences ..." (Hodge, 2005a, p. 321).

The primary asset of spiritual ecograms is their ability to illustrate current and historical resources as well as the connections between those strengths in a single graphic rendering. This advantage may be welcomed when working with populations in which the family system plays an important role. ... In some instances, however, ... [clinicians] may desire a simpler, more focused, diagrammatic assessment approach. Spiritual ecomaps, for example, are less time consuming to construct and may provide all the information required in a given situation. In other contexts, ... [clinicians] may desire to use the limited amount of page space to amplify the generational dynamics in a spiritual genogram. Lifemaps also may provide a better assessment approach with more artistically inclined clients, and spiritual histories may be better suited for more verbally oriented clients. (Hodge, 2005a, p. 322)

With regard to family spiritual assessment, "[a]lthough all the approaches can be used with families, perhaps spiritual genograms, ecomaps, and ecograms are best suited for family therapy" (Hodge, 2004, p. 39).

Exercise Caution When Using Quantitative Instrumentation

At the present time, there exists "an impressive array of measures of religious and spiritual experience for the numerous domains of the religious and spiritual experience" (Hill, 2005, p. 55). In fact, "Hill and Hood (1999) reviewed 125 measures of religion and spirituality from 17 different categories (e.g., beliefs, attitudes, religious orientation, faith development, fundamentalism, attitudes toward death, congregational involvement, and satisfaction)" (Hill & Pargament, 2003, p. 66). Additional quantitative measures of such constructs as perceived closeness to God, religious orientation and motivation, religious support, and religious and spiritual struggle are outlined by Hill and Pargament (2003). Scales that have demonstrated reasonably strong psychometric properties are also highlighted by Hill (2005).

Yet, it must be emphasized that "religious and spiritual measures designed for clinical populations ... are rare" (Hill, 2005, p. 44). "Because most religious and spiritual measures have not been adequately validated in clinical situations," Richards and Bergin (2005) stress that "therapists should use them only after carefully examining them and personally verifying their suitability for their clients. Even then, therapists should interpret these measures tentatively. Normative data are so limited for most of these measures that sharing normative comparisons with clients should be avoided. At most, these measures should be used only to give therapists some tentative insights into their clients and perhaps as a tool to help clients engage in exploration and self-discovery" (p. 241).

– Compiled by Abraham Feingold, Psy.D.

References

Hill, P.C. (2005). Measurement in the psychology of religion and spirituality: Current status and evaluation. In R.F. Paloutzian & C.L. Park (Eds.), Handbook of the psychology of religion and spirituality (pp. 43-61). New York: Guilford Press.

Hill, P.C., & Hood, R.W., Jr. (Eds.). (1999). Measures of religiosity. Birmingham, AL: Religious Education Press.

Hill, P.C., & Pargament, K.I. (2003). Advances in the conceptualization and measurement of religion and spirituality: Implications for physical and mental health research. American Psychologist, 58(1), 64-74.

Hodge, D.R. (2000). Spiritual ecomaps: A new diagrammatic tool for assessing marital and family spirituality. Journal of Marital & Family Therapy, 26(2), 217-228.

Hodge, D.R. (2001a). Spiritual assessment: A review of major qualitative methods and a new framework for assessing spirituality. Social Work, 46(3), 203-214.

Hodge, D.R. (2001b). Spiritual genograms: A generational approach to assessing spirituality. Families in Society, 82(1), 35-48.

Hodge, D.R. (2004). Spirituality and people with mental illness: Developing spiritual competency in assessment and intervention. Families in Society, 85(1), 36-44.

Hodge, D.R. (2005a). Developing a spiritual assessment toolbox: A discussion of the strengths and limitations of five different assessment methods. Health & Social Work, 30(4), 314-323.

Hodge, D.R. (2005b). Spiritual ecograms: A new assessment instrument for identifying clients' strengths in space and across time. Families in Society, 86(2), 287-296.

Hodge, D.R. (2005c). Spiritual lifemaps: A client-centered pictorial instrument for spiritual assessment, planning, and intervention. Social Work, 50(1), 77-87.

Hodge, D.R. (2006). A template for spiritual assessment: A review of the JCAHO requirements and guidelines for implementation. Social Work, 51(4), 317-326.

Hodge, D.R., & Williams, T.R. (2002). Assessing African American spirituality with spiritual ecomaps. Families in Society, 83(5-6), 585-595.

Joint Commission on Accreditation of Healthcare Organizations. (2004, January 1). Does the Joint Commission specify what needs to be included in a spiritual assessment? Retrieved January 7, 2007 from http://www.jointcommission.org.

Loue, S., & Sajatovic, M. (2006). Spirituality, coping, and HIV risk and prevention in a sample of severely mentally ill Puerto Rican women. Journal of Urban Health, 83(6), 1168-1182.

Pargament, K.I., McCarthy, S., Shah, P., Ano, G., Tarakeshwar, N., Wachholtz, A., Sirrine, N., Vasconcelles, E., Murray-Swank, N., Locher, A., & Duggan, J. (2004). Religion and HIV: A review of the literature and clinical implications. Southern Medical Journal, 97(12), 1201-1209.

Richards, P.S., & Bergin, A.E. (2005). Religious and spiritual assessment. In P.S. Richards & A.E. Bergin (Eds.), A spiritual strategy for counseling and psychotherapy, 2nd ed. (pp. 219-249). Washington, DC: American Psychological Association.

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Discerning Spiritual Content Reflective of Mental Illness

As Hodge (2004) observes, the Diagnostic and Statistical Manual of Mental Disorders, 4th edition – text revision (DSM-IV-TR; American Psychiatric Association, 2000)

provides guidelines for distinguishing between content that reflects psychosis and content that is normative in the area of spirituality (e.g., a client who reports that he or she hears God's voice). First, note the client's spiritual identity and associated worldview (e.g., Pentecostal, which is open to metaphysical phenomena). Second, understand to what extent the client's manifestation is normative within the context of the client's spiritual worldview (e.g., within the context of a Pentecostal worldview, hearing God's voice is a normal occurrence and therefore not necessarily a manifestation of psychosis). It is also important to emphasize that even if the metaphysical experience reported by the client appears to be abnormal within the context of their worldview, the experience should be assessed in light of the person's overall functioning ... .

It is not always clear, however, exactly what constitutes normative spiritual experiences within the client's spiritual worldview. In cases in which doubt exists, ... [clinicians] should seek out collaborations with clergy ... . In addition to providing individual services that address clients' needs, and linking clients to social support resources in their spiritual communities, clergy are typically able to provide information about what are considered appropriate expressions of spirituality in a given spiritual tradition.

It is important to emphasize that clergy from the client's specific tradition should be consulted. ... As in other matters, it is often clients themselves who are the best source of information about appropriate candidates for collaboration. (p. 41)

Hodge stresses that, "[a]lthough psychosis can be manifested in spiritual content, ... spirituality is positively associated with mental health ... [and] spirituality is often a key component in recovery from mental illness. ... [Clinicians] can facilitate the recovery process by helping clients operationalize their spiritual strengths. Conducting an assessment, particularly a complete spiritual assessment, is likely to uncover strengths and resources that can be tapped to foster recovery" (p. 41).

References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.

Hodge, D.R. (2004). Spirituality and people with mental illness: Developing spiritual competency in assessment and intervention. Families in Society, 85(1), 36-44.

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