Developing a Spiritual Assessment Toolbox: A Discussion of the Strengths and Limitations of Five Different Assessment Methods David R. Hodge Increasingly, social workers are being called on to conduct spiritual assessments, yet few assessment methods have appeared in academic literature. This article reviews five complementary assessment approaches that have recently been developed to highlight different facets of clients' spiritual lives. Specifically, one verbal model, spiritual histories, is discussed, along with four diagrammatic approaches: spiritual lifemaps, spiritual genograms, spiritual ecomaps, and spiritual ecograms. An overview of each approach is provided along with a discussion of its relative strengths and limitations. The aim here is to familiarize readers with a repertoire of spiritual assessment tools so that the most appropriate assessment method in a given client-practitioner setting can be selected. KEY WORDS: assessment; religion; spirituality; spiritual sensitivity; spiritual strengths t is increasingly recognized that health care professionals should consider conducting a spiritual assessment as part of holistic service provision (Flante & Sharma, 2001).Assessment helps to provide effective, culturally sensitive services while concurrently providing a forum to explore spiritual strengths that might be used to ameliorate problems or cope with difficulties. Spirituality is often a core animating principle in clients' view of reality; their spirituality, thus, often fosters a culturally distinct worldview. Hindus, evangelical Christians, traditional Catholics, Muslims, Mormons, Pentecostal Christians, and Orthodox Jews are all examples of populations who have developed distinct cultures. Clients'spiritual worldviews often guide their attitudes and behavior in a number of areas of significance to social workers, including their views on child care, communication norms, diet, family relations, gender interactions, marital relations, medical care, recreation, and schooling. Many Muslims, for example, are uncomfortable receiving medical services from providers of the opposite sex unless a member of the same sex—a family member, preferably—is present (Hodge, 2002). Spiritual assessment provides a window into tbese worldviews and enables social workers to tailor services in a manner that respects tbis most important aspect of clients' cultures. I 314 In addition,a growing body of research indicates that spirituality is often a significant client strength (Jobnson, 2002; Koenig, McCuUougb, & Larson, 2001). Spiritual assets, such as prayer, meditation, wonhip, scripture reading, clergy consultation, and spiritual groups, can facilitate coping, well-being, and recovery. A client wrestling with mental illness, for example, may find the support of a churcb group instrumental to his or ber recovery upon discharge. Assessment provides a method of identifying spiritual assets tbat can be operationalized in treatment and discharge planning. Consequently, social workers are being called on more often to conduct spiritual assessments. Perhaps most prominently, the Joint Commission on Accreditation of Healthcare Organizations QCAHO), tbe organization that accredits most hospitals and many otber health care providers in the United States, now recommends that a spiritual assessment be conducted (fCAHO, 2001). At a minimum,JCAHO stipulates that a spiritual assessment should determine tbe clients denomination as well as important spiritual beiiefi and practices.Tbe purpose of the initial assessment is twofold. One goal is to identify tbe effect of client's spirituality on service provision and client care. As implied earlier, for service provision to be as effective as possible, spiritual beliefs and practices often bave to be taken into account. Adherents of the CCC Code: 0360-7283/05 13.00 e200S National Auoclation of Social Worker} Islamic faith, for example, may refrain from ingesting medicines containing alcohol or pork by-products (Hodge, 2004a). A Hindu person's recovery from schizophrenia might be aided by engaging in spiritual practices such as meditation and ritual offerings, sucb as puja, an act that shows reverence of a god, spirit, or other divine being (Hodge. 2004c). Another goal is to identify whether an additional, more comprehensive spiritual assessment is required. JCAHO does not stipulate the conditions under which additional assessments are warranted so social workers must use their own judgment. Two general guidelines, however, may be useful in making such a determination. First, assessment is generally called for when the norms of tbe client's faitb tradition relate to service provision and client care, as might occur witb Pentecostalism and mental illness. Hearing tbe voice of God is considered normative w ithin the Pentecostal tradition, for example, so hearing a voice external to oneself is not necessarily a manifestation of mental illness with Pentecostal Christians. In such cases, a comprehensive assessment is necessary to determine whether tbe voices are, in fact, a sign of mental illness or are normative, and quite possibly, a strength (Hodge, 2004b). Next, a comprehensive assessment should be considered when spirituality plays a central role, fiinctioningas an organizing principle,in the client's life,The extent to which clients practice tbe tenets of their faith tradition is one way to assess the centrality of spirituality in tbeir lives. For example, a comprehensive assessment may be warranted with Catholics who attend mass weekly or Muslims who practice the five pillars. Although social workers are called on increasingly to conduct spiritual assessments, relatively few assessment methods have been developed (Sherwood, 1998). Furthermore, studies indicate tbat most social workers bave received little, if any, exposure to spiritual assessment during their graduate education (Canda & Furnian, 1999; Murdock, 2004). Accordingly, this article introduces readers to a complementary set of assessment methods and reviews the strengths and limitations of each assessment approach. Botb clients and social workers bave a variety of needs and interests in any clinical context; consequently, some assessment approaches will work better in some situations.The family of assessment tools reviewed in this article was deliberately designed to highlight different fac- H O D G E / Developing a Spiritual Assessment Tooii)ox ets of clients' spiritual lives. Discussion of the strengths and hmitations of each assessment method is offered to belp social workers select the method that best fits the needs of a given situation. In effect, this article provides social workers with an assessment "toolbox" from which practitioners can select the most appropriate instrument. The five assessment methods reviewed and compared are (1) spiritual histories (Hodge. 2001a), which is the only verbally based approach discussed, along with four pictorial approaches: (2) spiritual lifemaps (Hodge, 2005b), (3) spiritual genograms (Hodge,2001b),(4) spiritual ecomaps (Hodge,2000; Hodge &Williams,2002).and (5) spiritual ecograms (Hodge, 2005a).These methods are ail designed to provide comprehensive spiritual assessments. Readen interested in an initial assessment model may consult Hodge (2004b) for a short, oral tool designed to meet the JCAHO standards for conducting an initial spiritual assessment.Alternatively.it is also possible to adapt these methods, particularly spiritual ecomaps. to conduct an initial spiritual assessment. It is important to note at the outset that some topics cannot be discussed due to space limitations. Communications styles and many other facets of behavior can be influenced by one's spiritual and cultural background, for example. Obtaining some degree of knowledge regarding a client's spiritual tradition before assessment is generally helpful. It is. however, beyond the scope of this article to present information on various spiritual traditions, guidelines for conducting an assessment in a spiritually competent manner, suggestions on appropriate spiritual interventions, or even detailed accounts of each assessment approach. Interested readers are encouraged to obtain the original articles for information on these topics or consult the works of other authors who address these subjects (Canda & Furman, 1999; Koenig, 1998a; Richards & Bergin, 2000; Van Hook, Hugen, & Aguilar,200I). In addition, it is appropriate to specify the working definition of spirituality and religion. Altbough various definitions of these two constructs have appeared in the literature, spirituality can be understood as individual's existential relationship with God (or perceived transcendence), and religion can been seen as flowing from spirituality, the actual expression ofthe spiritual relationship in particular beliefs, forms, and practices that have been developed in community with other individuals who share similar experiences of transcendence (Hodge, 2001a).Thus, spirituality and religion are overlapping but distinct constructs (Canda & Furman. 1999). SPIRITUAL HISTORIES Oral spiritual histories are perhaps the most common approach to assessment (Hodge, 2001a).This method is analogous to conducting a family history. In the spiritual history approach developed by Hodge, two question sets are used to guide the conversation. Tbe purpose ofthe first question set, referred to as the Initial Narrative Framework, is to provide practitioners with some tools to help clients tell their stories, typically moving fiom childhood to the present. The second question set, referred to as the Interpretive Anthropological Framework, is designed to elicit spiritual information as clients relate their stories.The framework is based on Nee's (1968) anthropological understanding. In addition to soma (that is, the physical human body). Nee envisioned a soul, comprised of affect, will, and cognition, and a spirit, comprised of communion, conscience, and intuition. Although human beings are an integrated entity, consisting of body, soul, and spirit, it is possible to distinguish the six dimensions of the soul and spirit. Communion refers to spiritually based relationship. More specifically, it denotes the ability to bond and relate to God or tbe client's perception of transcendence. Conscience relates to one's ability to seme right and wrong. Beyond a person's cognitively held values, conscience conveys moral knowledge about the appropriateness of a given set of choices. Intuition refers to the ability to know— to come up with insights that bypass normal cognitive channels. The anthropologically derived questions are designed to elicit information about each of tbe six dimensions,providing a holistic spiritual assessment. As clients relate their spiritual narrative (prompted as necessary by questions drawn from the initial narrative framework), they will tend to touch on some of the dimensions listed in the interpretive anthropological framework. Social workers can interject questions drawn from the anthropological framework into the dialogue to more fully explore clients' spiritual reality in the natural flow of tbe conversation. In short, the narrative questions help chents tell their stories and the interpretive anthro- pological questions assist practitioners in eliciting important information as the stories unfold. Strengths and Limitations of Spiritual Histories For verbally oriented people, spiritual histories may provide the best assessment method. In addition, the 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. For example, whereas spiritual genograms require clients to circumscribe their spiritual stories to fit the parameters of a generational chart, spiritual histories allow clients to express themselves in a manner that is unique to their own experience. 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. Not all clients are verbally oriented, however. 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, such as a spiritual ecomap. Similarly, tbe 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. Another limitation is the time spent exploring portions of the client's spiritual history tbat may have limited utility in addressing the present problem with which the client is wrestling. In addition, more artistic clients may desire an assessment approach, sucb as spiritual lifemaps. that allows for a more creative expression of their spirituality. SPIRITUAL LIFEMAPS Spiritual lifemaps represent a diagrammatic alternative to spoken spiritual histories (Hodge, 2005b). More specifically, spiritual lifemaps are a pictorial delineation of a client's spiritual journey. In a manner analogous to Augustine's {354-430AD/1991) Confessions, spiritual hfemaps are an illustrated account of clients' relationship with God (or transcendence) over time—a map of their spiritual life. Much hke road maps, spiritual lifemaps tell us where Health & Social Work VOLUME 30, NUMBER 4 NOVEMBER 2005 we have come fiom, where we are now, and wbere we are going. At its most basic level, a drawing pencil is used to sketch various spiritually significant life events on paper,The method is similar to various approaches drawn fiom art and family therapy in which a client's history is depicted on a "lifeline" (Tracz & GehartBrooks. 1999).To assist clients in the creative expression of their spiritual journeys, it is usually best to use a large sheet of paper (for example, 24" x 36") on which to sketch the map. Providing drawing instruments of different sizes and colors is also helpful, as is offering a selection of various types and colors of construction paper and popular periodicals. Providing these items, in conjunction with scissors, gjue, and rulers, allows clients to clip and paste items onto the lifemap. Spiritually significant events are depicted on a path, roadway,or a single line that represents clients' spiritual sojourn (Figure l).Typically, the path proceeds chronologically, from birth to the present. Frequently, the path continues on to death and the client's transition to the afterlife. Hand-drawn symbols, cut out pictures.and other material are used to mark key events along tbe journey. In keeping with many spiritual traditions, which conceive material existence to be an extension ofthe sacred reality, it is common to depict important secular events on the lifemap (for example, graduation, loss of a job. or a car accident), Evangelicals, for example, will not see marriage or death as secular. Although it is often necessary to provide clients with general guidelines, client creativity should be encouraged. To fully operationalize tbe potential of tbe 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. Hills, bumps, potholes, rain, clouds, and lightning, can be used to portray difficult life situations. Delineating successful strategies that clients have used in the past frequently suggests options for overcoming present struggles. Strengths and Limitations of Spiritual Lifemaps Ofthe assessment methods reviewed in this article, spiritual lifemaps are perhaps the most client directed. The relatively secondary role that social workers play during this type of assessment offers important advantages. Less risk exists that social workers may jeopardize the therapeutic relation- H O D G E / Developing a Spiritual Assessment Toolbox The pictorial lifemap affhrds practitioners the opportunity to learn more about the client's worldview, while focusing on building therapeutic rapport. ship through comments that are inadvertently offensive—an important consideration given that most social workers have had minimal, if any, training in spiritual sensitivity (Canda & Furman, 1999).The pictorial lifemap affords practitioners the opportunity to learn more about the client's worldview, wbile focusing on building therapeutic rapport by providing an atmosphere that is accepting, nonjudgmental. and supportive during assessment. By placing a client-constructed media at the center of assessment, the message is implicitly communicated that the client is a competent, proactive, selfdirected, and fully engaged participant in the therapeutic process. For clients for whom spirituality is a highly sensitive and significant 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. In addition, individuals who are not verbally oriented may find pictorial expression more conducive to their personal communication styles, and more creative individuals may feel that this assessment approach allows them to express their spiritual journey in a manner that is more personally authentic. Lifemaps fit well with interventions drawn from existential therapy that emphasizes the brevity of life, and they may be assigned as "homework," saving valuable therapeutic time. Some social workers, however, may feel so removed from the process that this assessment approach makes poor use of therapeutic time. Another significant hmitation is that many clients.such as those who are more verbal, uncomfortable with drawing, or prefer more direct practitioner—client interaction, may find the use of a largely nonverbal, pictorial method to be a poor fit with their current needs. In other situations, 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. SPIRITUAL GENOGRAMS Spiritual genograms provide social workers with a tangible graphic representation of spirituality across at least three generations (Hodge. 2001 b) .Through the use of what is essentially a modified family tree, they help both practitioners and clients understand the flow of historically rooted patterns through time. In short, spiritual genograms are a blueprint of compiex intergenerational spiritual interactions. The basic family system is delineated in keeping with standard genogram conventions (McGoldrick, Gerson, & Shellenberger, 1999).Triangles or other geometric shapes, however, can be inserted to designate individuals who have played major spiritual roles but are not members of tbe immediate biological family (for example, see "Ruth" in Figure 2). To indicate clients' spiritual tradition, colored drawing pencils can be used to shade in the circles and squares. Color coding provides a graphic "color snapshot" of the overall spiritual composition of the family system. Various colors can be used to signify religious preference (for example. Muslim, New Age, none), or when the information in known, denomination (for example. Assemblies of God) and subtradition (for example. Sunni,Sbiite). A circle representing a member ofthe Assemblies of God could be colored red and an individual whose affiliation and beliefs are unknown could be left uncolored. A change in an adult's religious orientation can be signified by listing the date ofthe change beside a circle, which is drawn outside the figure, and filling in the space between the circle and the figure with the appropriate color.This procedure indicates the stability and fluidity of the person's beliefs over time. Using a similar approacb, changes in orientation from one's family of origin can be noted by coloring the vertical segment connecting the child with the parents. As is the case with spiritual lifemaps, spiritually meaningful events can be incorporated,such as water and spirit baptisms, confirmations, church memberships, and bar niitzvahs. Symbols drawn from the client's spiritual cosmology can be used to signify these events. For instance, a member of tbe Pentecostal denomination might choose a dove to depict a deeper work of the Holy Spirit. A New Age adherent might use a sunbeam to symbolize a time of profound spiritual enlightenment or an open set of scriptures might be used to indicate a devout person. In addition, this approach allows for short summary statements to denote events, personal strengths, or other important information. In addition to depicting religious beliefs, it is also possible to include an affective component to H O D G E / Developing a Spiritual Assessment Toolbox spiritual genograms (Hodge. 20(31 b). In other words, felt spiritual closeness between family members can be illustrated.Lines with double-headed arrows 1«->1 can be used to symbolize a relationship in which individuals experience a close reciprocal spiritual bond. The thickness of the line can indicate the intimacy or strength ofthe relationship. In situations where the relationship is more hierarchical and less reciprocal—as might occur with a grandparent mentoring a grandchild—a single arrowhead (ijcan be used to depict the flow of spiritual resources. Strengths and Limitations of Spiritual Genograms Spiritual genograms may be particularly useful when the family system plays an especially significant role in the client's life. For the social worker, they help connect spirituality to treatment plans. Poole (1998) suggested that genograms may be helpful with Hispanic clients, for example, as they tend to show respect for tradition. In addition, problems involving family members or family-of-origin issues are often effectively explored with spiritual genograms. For example, with interfaith couples experiencing spiritual conflicts, spiritual genograms can expose areas of difference and highlight the respective spiritual strengths each person brings to the relationship. Genograms also may appeal to clients who prefer a very structured assessment approach, Spiritual 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 tbe 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 (Kuehl, 1995).With such clients, it may be more appropriate to use assessment approaches that focus on the "here and now" such as spiritual ecomaps. SPIRITUAL ECOMAPS In contrast with the previously discussed assessment tools, spiritual ecomaps focus on clients' current spiritual relationships (Hodge. 2000). The assessment approaches discussed earlier are similar in the sense that they are all designed to tap some portion 319 Social workers should generally seek to explore clients' relationship with God or transcendence, rituals, faith communities, and transpersonal encounters. of clients' spiritual story as it exists through time. Spiritual histories, lifemaps, and genograms typically cover one to three generations of a client's spiritual narrative. Conversely, spiritual ecomaps focus on that portion of chents'spiritual story that exists in present space. In other words, this assessment approach highlights clients' present, existential relationship to spiritual assets. In the center of a piece of paper, the immediate family system is typically portrayed as a circle, in keeping with traditional ecogram construction (Hartman, 1995). Household family members can be sketched inside the circle, with squares depicting males and circles representing females (Hodge, 2000). Alternatively,separate ecomaps can be drawn for each individual (Hodge & Williams. 2002). On the outskirts ofthe paper, surrounding the family system, significant spiritual systems or domains are depicted as circles, with the names ofthe respective systems written inside the circles. Although clients should be encouraged to depict the domains that hold personal salience in their spiritual worldview, several spiritual systems have somewhat of a universal application. More specifically, social workers should generally seek to explore clients' relationship with God or transcendence, rituals, faith communities, and transpersonal encounters. One's relationship with God or transcendence is widely regarded as a key strength, as are rituals, or codified spiritual practices. Faith communities refer to various faith-based groups that individuals may associate with on a regular basis, such as churches, mosques, synagogues, temples, fellowship groups, mid-week Bible studies, youth groups, and singles associations. Transpersonal encounters refer to encounters with angels, demons, and other spiritual visitations. The heart ofthe spiritual ecomap is the relationships between tbe family system and tbe spiritual systems, which are represented by various types of sketched lines, much like those discussed earlier in the spiritual genogram section.Thicker lines represent stronger or more powerful relationships. A 320 dashed line represents tbe most tenuous relationship, and a jagged line denotes a conflicted one. An arrow is drawn on tbe line to indicate the flow of energy, resources, or interest. As is the case witb the otber diagrammatic approaches profiled bere, short, descriptive encapsulations, significant dates, or other creative depictions, can also be incorporated onto the map to provide more information about the relational dynamics. Wben using ecomaps witb individuals, tbe appropriate type of line is drawn between tbe family system (that is, the figure representing the client) and the spiritual systems. Wben working with families, lines are drawn to tbe family system as a unit when the family shares a particular relationsbip in common, or morefi^jquently,connections are drawn to individual family members depicting tbe various unique relationships between eacb family member and the various spiritual systems. Strengths and Limitations of Spiritual Ecomaps Spiritual ecomaps are relatively easy to grasp conceptually, quick to construct, and perbaps most important,readily focus on clients'current,existential spiritual strengths {Hodge, 2000). This assessment approach may be ideal for operationalizing clients' spiritual assets in a timely fasbion because tbe time spent in assessment is focused on tapping into present spiritual resources. As is tbe case with all diagrammatic methods, spiritual ecomaps provide an object that can serve as the focal 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 tbeir design, ecomaps may be particularly helpful in transferring attention from tbe client to the concrete, diagrammatic assessment tool because they focus on environmental systems rather than,forexample,clients' life story. Although other approaches may implicitly emphasize the client,spiritual ecomaps exphcitly stress the systems in clients' environments (Hartman, 1995). Spiritual ecomaps suffer from tbe same hmitations as other diagrammatic approaches relative to verbal spiritual histories. A diagrammatic approach may hold little appeal to clients who want to talk. Altbougb relatively quick and simple to construct, ecomaps may not appeal to more creative individuals, but clients can be encouraged to express tbeir creativity by adding symbols and other material to Health & Social Vlhrk VOLUME JO, NUMBER 4 NOVEMBER 2005 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 facton. In some contexts, an approach that examines current and historical resources on the same diagrammatic tool may be useful. SPIRITUAL ECOGRAMS Spiritual ecc^rams combine the assessment strengths of spiritual ecomaps and genograms in a single as- sessment approach {Hodge, 2005a). 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 (Figure 2). Constructing spiritual ecograms is similar to fabricating genograms and ecomaps.The client is drawn Figure 2: Diagrammatic Approaches to Spiritual Assessment (21) Frank Mary Don Madina Spiritual Strengths Worship Music Prayer Discipkship Bible study God's aclive, loving involvement through the Holy Spirit is a significant asset Faith Community \ J Enjoys Sunday i wonhip; has a number of positive relvionships in church and Bible study groups, but also some conflictual ones Soune, Adapted from Hodg*, D. R. (JOOSa). Spiritual ecogrimi: A new ass«unncnt imtruincni »rHii/ of Social Service Research, 50(1), 41-61. Hodge, D. R. (2004a). Social work practice with Muslims in the United States. In A. T. Morales & B.W. Sheafor (Eds.), Social work: A profession of many faces (10th ed., pp. 443-469). 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Paper presented at the 50th Annual Program Meeting, Council on Social Work Education, Anaheim. CA. Nee.W. (1968). Vie spiritual man (Vols. 1-3). New York: Christian Fellowship Publishers. Plante,T. G., & Sharma, N. K. (2001). Religious faith and mental health outcomes. In T G. Plante & A. C. Sherman (Eds.), Faith and health: psychological perspectives (pp. 240-261). New York: Guilford Press. Poole. D. L. (1998). Politically correct or culturally competent? Health & Social Work, 2.J. 163-166. Richards, P. S., & Bergin. A. E. (Eds.). (200U). Handboitk of psychotherapy and religious diivrsity. Wa.shmgton, DC: American Psychological Association. Sherwood, D. A. (1998). Spiritual assessment as a normal part of social work practice: Power to belp and power to harm. Social Work & Christianity, 25(2), 80-100. Tracz. S. M.. & Gehart-Broob. D. R. (1999).The lifeline: Using art to illustrate history. JoMma/ of Family Psychotherapy, /0(3), 61-63. Van Hook, M.. Hugen. B., & Aguitar, M, A. (Eds.). (2001). Spirituality within religious traditions in social uvrk practice. Pacific Grove, CA: Brooks/Cole. David R. Hodge, PhD, is assistant professor, Arizona State Uniivrsity-West Campus and a senior nonresident fellow at University of Pennsylvania's Program for Research on Religion and Urban Civil Society. Correspondence can be addressed to the author at Department of Social Work, P. O. Box 37WO, Phoenix,AZ 85069-7W0. Originsl manuscript received June 30. 2003 Final revision received December IS. 2003 Accepted March 22, 2004 313
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