Spiritual Assessment: Identifying Client's Strengths

1. Best practices in spiritual assessment: Diverse approaches to identifying and operationalizing clients’ 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

2. Presentation Overview • Spirituality, religion, & culture • Spiritual assessment as a two-stage process • Brief spiritual assessment tools • Comprehensive spiritual assessment tools

3. Defining Spirituality and Religion How would you define: • Spirituality? • Religion?

4. Defining Spirituality and Religion Controversial: No agreement exists

5. Definitions of Spirituality among the general public (N= 100) Approximately 70% • Belief in God/seeking to grow close to God • Belief 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)

8. S R

9. Trends in Thinking about 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

10. Spiritual Assessment Rationales for conducting a spiritual assessment Two-stage process 2 brief assessment tools 5 comprehensive assessment tools strengths limitations

11. Rationales for Addressing Spirituality in Practice Settings Ethics Human rights Accrediting & agency requirements Knowledge of clients’ worldviews Respect for client autonomy Interest in clients’ strengths Related to positive outcomes

12. Spiritual Assessment: 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

13. Arguments against Brief Assessment Time Constraints Potential Coercion

14. Counterarguments 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

15. Why is it Important to Legitimize 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

16. Overt Hostility also Exists The God Delusion Richard Dawkins (2006)

17. “Should employers be blind to private beliefs?” (Dawkins, 2011) No! Advocates for discrimination based upon religious beliefs Ability 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

18. Religion is “…irrational...invested in ignorance and hostile to free inquiry...."  Christopher Hitchens in (2007) God Is Not Great: How Religion Poisons Everything

19. ‘Here, I offer further thoughts on how religion is “irrational” and “invested in ignorance”.’ Sam Harris http://newsweek.washingtonpost.com/onfaith/sam_harris/2007/09/religion_as_a_black_market_for.html

20. 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).

21. Hostility also Exists in the Helping Professions The Future of an Illusion Freud (1927) Religious beliefs psychopathology Albert Ellis

22. Legitimizing Spirituality • A brief assessment provides a mechanism to implicitly communicate the importance of spirituality to clients

23. The Joint Commission Assessment Requirements • The Joint Commission accredits most hospitals Spiritual assessment required for: • Emotional problems • Behavioral problems • Substance abuse problems • Receiving end-of-life care

24. Joint Commission [former] Requirements for a Brief Spiritual Assessment 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

25. 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?

26. Joint Commission 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

27. 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?

28. 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?

29. Two Models for Conducting a Brief Assessment iCARING FICA

30. iCARING Brief Assessment • importance • Community • Assets and Resources • Influence • Needs • Goals

31. iCARING Brief Assessment • importance I was wondering how important spirituality or religion is to you? • Community Do you happen to attend a church or some other type of religious or spiritual community? • Assets and Resources Are there particular spiritual beliefs and practices you find especially helpful in dealing with challenges?

32. iCARING Brief Assessment • Influence I was curious how your spirituality has shaped your understanding and response to your current situation? • Needs I was also wondering if there are any spiritual needs or concerns I could address? • Goals Looking ahead, I was wondering if you were interested in incorporating your spirituality into our work together? And if so, what would that look like?

33. FICA Model(Borneman, Ferrell, Puchalski, 2010) Faith or belief Importance Community Address

34. When to Move from a Brief to a Comprehensive Assessment? Four factors to consider: 1. Client self-determination 2. Practitioner level of cultural competence

35. When to move from a brief to a comprehensive 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”

36. You have Decided to Administer a Comprehensive Assessment: 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

37. Comprehensive Spiritual Assessment Tools: Overview, 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

38. Verbally 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

39. 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?

40. Interpretive Anthropological Framework • 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? • 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? • 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?

41. Interpretive Anthropological Framework 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? 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? 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?

42. Spiritual 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

43. Spiritual 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

44. Spiritual 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)

46. Spiritual 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.

47. Spiritual Lifemaps: Strengths(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

48. Spiritual 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

49. Spiritual 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