+ All Categories
Home > Spiritual > Developing a Spiritual Assessment Toolbox

Developing a Spiritual Assessment Toolbox

Date post: 15-Jul-2015
Category:
Upload: jonathan-dunnemann
View: 734 times
Download: 0 times
Share this document with a friend
11
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 I t is increasingly recognized that health care pro- fessionals should consider conducting a spiri- tual assessment as part of holistic service provi- sion (Flante & Sharma, 2001).Assessment helps to provide effective, culturally sensitive services while concurrently providing a forum to explore spiri- tual strengths that might be used to ameliorate prob- lems or cope with difficulties. Spirituality is often a core animating principle in clients' view of reality; their spirituality, thus, often fosters a culturally dis- tinct worldview. Hindus, evangelical Christians, tra- ditional Catholics, Muslims, Mormons, Pentecostal Christians, and Orthodox Jews are all examples of populations who have developed distinct cultures. Clients'spiritual worldviews often guide their atti- tudes and behavior in a number of areas of signifi- cance to social workers, including their views on child care, communication norms, diet, family rela- tions, gender interactions, marital relations, medi- cal 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, pref- erably—is present (Hodge, 2002). Spiritual assess- ment provides a window into tbese worldviews and enables social workers to tailor services in a man- ner that respects tbis most important aspect of cli- ents' cultures. 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 treat- ment 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 ac- credits 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 spiri- tual assessment should determine tbe clients de- nomination 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 effec- tive as possible, spiritual beliefs and practices often bave to be taken into account. Adherents of the 314 CCC Code: 0360-7283/05 13.00 e200S National Auoclation of Social Worker}
Transcript

Developing a Spiritual Assessment Toolbox:A Discussion of the Strengths and Limitations

of Five Different Assessment MethodsDavid R. Hodge

Increasingly, social workers are being called on to conduct spiritual assessments, yet fewassessment methods have appeared in academic literature. This article reviews five

complementary assessment approaches that have recently been developed to highlight differentfacets of clients' spiritual lives. Specifically, one verbal model, spiritual histories, is discussed,along with four diagrammatic approaches: spiritual lifemaps, spiritual genograms, spiritualecomaps, 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 arepertoire 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

I t is increasingly recognized that health care pro-fessionals should consider conducting a spiri-tual assessment as part of holistic service provi-

sion (Flante & Sharma, 2001).Assessment helps toprovide effective, culturally sensitive services whileconcurrently providing a forum to explore spiri-tual strengths that might be used to ameliorate prob-lems or cope with difficulties. Spirituality is often acore animating principle in clients' view of reality;their spirituality, thus, often fosters a culturally dis-tinct worldview. Hindus, evangelical Christians, tra-ditional Catholics, Muslims, Mormons, PentecostalChristians, and Orthodox Jews are all examples ofpopulations who have developed distinct cultures.Clients'spiritual worldviews often guide their atti-tudes and behavior in a number of areas of signifi-cance to social workers, including their views onchild care, communication norms, diet, family rela-tions, gender interactions, marital relations, medi-cal care, recreation, and schooling. Many Muslims,for example, are uncomfortable receiving medicalservices from providers of the opposite sex unless amember of the same sex—a family member, pref-erably—is present (Hodge, 2002). Spiritual assess-ment provides a window into tbese worldviews andenables social workers to tailor services in a man-ner that respects tbis most important aspect of cli-ents' cultures.

In addition,a growing body of research indicatesthat spirituality is often a significant client strength(Jobnson, 2002; Koenig, McCuUougb, & Larson,2001). Spiritual assets, such as prayer, meditation,wonhip, scripture reading, clergy consultation, andspiritual groups, can facilitate coping, well-being,and recovery. A client wrestling with mental illness,for example, may find the support of a churcb groupinstrumental to his or ber recovery upon discharge.

Assessment provides a method of identifyingspiritual assets tbat can be operationalized in treat-ment and discharge planning. Consequently, socialworkers are being called on more often to conductspiritual assessments. Perhaps most prominently, theJoint Commission on Accreditation of HealthcareOrganizations QCAHO), tbe organization that ac-credits most hospitals and many otber health careproviders in the United States, now recommendsthat a spiritual assessment be conducted (fCAHO,2001). At a minimum,JCAHO stipulates that a spiri-tual assessment should determine tbe clients de-nomination as well as important spiritual beiiefiand practices.Tbe purpose of the initial assessmentis twofold. One goal is to identify tbe effect of client'sspirituality on service provision and client care. Asimplied earlier, for service provision to be as effec-tive as possible, spiritual beliefs and practices oftenbave to be taken into account. Adherents of the

314 CCC Code: 0360-7283/05 13.00 e200S National Auoclation of Social Worker}

Islamic faith, for example, may refrain from ingest-ing medicines containing alcohol or pork by-prod-ucts (Hodge, 2004a). A Hindu person's recoveryfrom schizophrenia might be aided by engaging inspiritual practices such as meditation and ritual of-ferings, sucb as puja, an act that shows reverence ofa 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 underwhich additional assessments are warranted so so-cial workers must use their own judgment. Twogeneral guidelines, however, may be useful in mak-ing such a determination. First, assessment is gen-erally called for when the norms of tbe client's faitbtradition relate to service provision and client care,as might occur witb Pentecostalism and mental ill-ness. Hearing tbe voice of God is considered nor-mative w ithin the Pentecostal tradition, for example,so hearing a voice external to oneself is not neces-sarily a manifestation of mental illness with Pente-costal Christians. In such cases, a comprehensiveassessment is necessary to determine whether tbevoices are, in fact, a sign of mental illness or arenormative, and quite possibly, a strength (Hodge,2004b).

Next, a comprehensive assessment should beconsidered when spirituality plays a central role,fiinctioningas an organizing principle,in the client'slife,The extent to which clients practice tbe tenetsof their faith tradition is one way to assess the cen-trality of spirituality in tbeir lives. For example, acomprehensive assessment may be warranted withCatholics who attend mass weekly or Muslims whopractice the five pillars.

Although social workers are called on increas-ingly to conduct spiritual assessments, relativelyfew assessment methods have been developed(Sherwood, 1998). Furthermore, studies indicatetbat most social workers bave received little, if any,exposure to spiritual assessment during their gradu-ate education (Canda & Furnian, 1999; Murdock,2004). Accordingly, this article introduces readersto a complementary set of assessment methods andreviews the strengths and limitations of each as-sessment approach. Botb clients and social work-ers bave a variety of needs and interests in any clini-cal context; consequently, some assessmentapproaches will work better in some situations.Thefamily of assessment tools reviewed in this articlewas deliberately designed to highlight different fac-

ets of clients' spiritual lives. Discussion of thestrengths and hmitations of each assessment methodis offered to belp social workers select the methodthat best fits the needs of a given situation. In ef-fect, this article provides social workers with an as-sessment "toolbox" from which practitioners canselect the most appropriate instrument.

The five assessment methods reviewed and com-pared are (1) spiritual histories (Hodge. 2001a),which is the only verbally based approach discussed,along with four pictorial approaches: (2) spirituallifemaps (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 toprovide comprehensive spiritual assessments. Read-en interested in an initial assessment model mayconsult Hodge (2004b) for a short, oral tool de-signed to meet the JCAHO standards for conduct-ing an initial spiritual assessment.Alternatively.it isalso possible to adapt these methods, particularlyspiritual ecomaps. to conduct an initial spiritualassessment.

It is important to note at the outset that sometopics cannot be discussed due to space limitations.Communications styles and many other facets ofbehavior can be influenced by one's spiritual andcultural background, for example. Obtaining somedegree of knowledge regarding a client's spiritualtradition before assessment is generally helpful. Itis. however, beyond the scope of this article topresent information on various spiritual traditions,guidelines for conducting an assessment in a spiri-tually competent manner, suggestions on appro-priate spiritual interventions, or even detailed ac-counts of each assessment approach. Interestedreaders are encouraged to obtain the original ar-ticles for information on these topics or consultthe works of other authors who address these sub-jects (Canda & Furman, 1999; Koenig, 1998a;Richards & Bergin, 2000; Van Hook, Hugen, &Aguilar,200I).

In addition, it is appropriate to specify the work-ing definition of spirituality and religion. Al-tbough various definitions of these two constructshave appeared in the literature, spirituality can beunderstood as individual's existential relationshipwith God (or perceived transcendence), and reli-gion can been seen as flowing from spirituality, theactual expression ofthe spiritual relationship in par-ticular beliefs, forms, and practices that have been

H O D G E / Developing a Spiritual Assessment Tooii)ox

developed in community with other individualswho share similar experiences of transcendence(Hodge, 2001a).Thus, spirituality and religion areoverlapping but distinct constructs (Canda &Furman. 1999).

SPIRITUAL HISTORIESOral spiritual histories are perhaps the most com-mon approach to assessment (Hodge, 2001a).Thismethod is analogous to conducting a family his-tory. In the spiritual history approach developed byHodge, two question sets are used to guide theconversation. Tbe purpose ofthe first question set,referred to as the Initial Narrative Framework, is toprovide practitioners with some tools to help cli-ents tell their stories, typically moving fiom child-hood to the present.

The second question set, referred to as the Inter-pretive Anthropological Framework, is designed toelicit spiritual information as clients relate their sto-ries.The framework is based on Nee's (1968) an-thropological understanding. In addition to soma(that is, the physical human body). Nee envisioneda soul, comprised of affect, will, and cognition, anda spirit, comprised of communion, conscience, andintuition. Although human beings are an integratedentity, consisting of body, soul, and spirit, it is pos-sible to distinguish the six dimensions of the souland spirit. Communion refers to spiritually basedrelationship. More specifically, it denotes the abilityto bond and relate to God or tbe client's perceptionof transcendence. Conscience relates to one's abil-ity to seme right and wrong. Beyond a person'scognitively held values, conscience conveys moralknowledge about the appropriateness of a given setof choices. Intuition refers to the ability to know—to come up with insights that bypass normal cog-nitive channels.

The anthropologically derived questions are de-signed to elicit information about each of tbe sixdimensions,providing a holistic spiritual assessment.As clients relate their spiritual narrative (promptedas necessary by questions drawn from the initialnarrative framework), they will tend to touch onsome of the dimensions listed in the interpretiveanthropological framework. Social workers can in-terject questions drawn from the anthropologicalframework into the dialogue to more fully exploreclients' spiritual reality in the natural flow of tbeconversation. In short, the narrative questions helpchents tell their stories and the interpretive anthro-

pological questions assist practitioners in elicitingimportant information as the stories unfold.

Strengths and Limitations ofSpiritual HistoriesFor verbally oriented people, spiritual histories mayprovide the best assessment method. In addition,the relatively unstructured format allows clients torelate their stories in a straightforward mannerwithout having to adapt their narratives to fit aparticular diagrammatic format. For example,whereas spiritual genograms require clients to cir-cumscribe their spiritual stories to fit the param-eters of a generational chart, spiritual histories al-low clients to express themselves in a manner thatis unique to their own experience. Spiritual histo-ries are also easy to conduct.The assessment modelis relatively easy to communicate to clients, andthe verbal format is conducive to building a thera-peutic alliance with clients.

Not all clients are verbally oriented, however.Some may prefer the pictorial assessment approachesdiscussed in later sections. Individuals who are ner-vous about sharing what is often a highly personaltopic may desire a diagrammatic approach that de-flects attention away from themselves and onto aninanimate object. Some clients prefer having a spe-cific framework around which to organize theirthoughts, such as a spiritual ecomap. Similarly, tbeprocess of conceptualizing and depicting one's spiri-tual journey pictorially may help to focus and ob-jectify spiritual assets, which can then be discussedand marshaled to address problems. Another limi-tation is the time spent exploring portions of theclient's spiritual history tbat may have limited util-ity in addressing the present problem with whichthe client is wrestling. In addition, more artisticclients may desire an assessment approach, sucb asspiritual lifemaps. that allows for a more creativeexpression of their spirituality.

SPIRITUAL LIFEMAPSSpiritual lifemaps represent a diagrammatic alter-native to spoken spiritual histories (Hodge, 2005b).More specifically, spiritual lifemaps are a pictorialdelineation of a client's spiritual journey. In a man-ner analogous to Augustine's {354-430AD/1991)Confessions, spiritual hfemaps are an illustrated ac-count of clients' relationship with God (or tran-scendence) 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 wberewe are going.

At its most basic level, a drawing pencil is used tosketch various spiritually significant life events onpaper,The method is similar to various approachesdrawn fiom art and family therapy in which a client'shistory is depicted on a "lifeline" (Tracz & Gehart-Brooks. 1999).To assist clients in the creative ex-pression of their spiritual journeys, it is usually bestto use a large sheet of paper (for example, 24" x36") on which to sketch the map. Providing draw-ing instruments of different sizes and colors is alsohelpful, as is offering a selection of various typesand colors of construction paper and popular peri-odicals. Providing these items, in conjunction withscissors, gjue, and rulers, allows clients to clip andpaste items onto the lifemap.

Spiritually significant events are depicted on apath, roadway,or a single line that represents clients'spiritual sojourn (Figure l).Typically, the path pro-ceeds chronologically, from birth to the present.Frequently, the path continues on to death and theclient's transition to the afterlife. Hand-drawn sym-bols, cut out pictures.and other material are used tomark key events along tbe journey. In keeping withmany spiritual traditions, which conceive materialexistence to be an extension ofthe sacred reality, itis common to depict important secular events onthe lifemap (for example, graduation, loss of a job.or a car accident), Evangelicals, for example, will notsee marriage or death as secular. Although it is oftennecessary to provide clients with general guidelines,client creativity should be encouraged.

To fully operationalize tbe potential of tbemethod, it is important to ask clients to incorpo-rate the various trials they have faced along withthe spiritual resources they have used to overcomethose trials. Hills, bumps, potholes, rain, clouds, andlightning, can be used to portray difficult life situ-ations. Delineating successful strategies that clientshave used in the past frequently suggests optionsfor overcoming present struggles.

Strengths and Limitations ofSpiritual LifemapsOfthe assessment methods reviewed in this article,spiritual lifemaps are perhaps the most client di-rected. The relatively secondary role that socialworkers play during this type of assessment offersimportant advantages. Less risk exists that socialworkers may jeopardize the therapeutic relation-

The pictorial lifemap affhrds practitioners

the opportunity to learn more about theclient's worldview, while focusing on

building therapeutic rapport.

ship through comments that are inadvertently of-fensive—an important consideration given that mostsocial workers have had minimal, if any, training inspiritual sensitivity (Canda & Furman, 1999).Thepictorial lifemap affords practitioners the opportu-nity to learn more about the client's worldview,wbile focusing on building therapeutic rapport byproviding an atmosphere that is accepting,nonjudgmental. and supportive during assessment.By placing a client-constructed media at the centerof assessment, the message is implicitly communi-cated that the client is a competent, proactive, self-directed, and fully engaged participant in the thera-peutic process. For clients for whom spirituality isa highly sensitive and significant area, lifemaps pro-vide a means of shifting the focus from the client toa more neutral object, a process that may help setclients at ease. In addition, individuals who are notverbally oriented may find pictorial expression moreconducive to their personal communication styles,and more creative individuals may feel that this as-sessment approach allows them to express theirspiritual journey in a manner that is more person-ally authentic. Lifemaps fit well with interventionsdrawn from existential therapy that emphasizes thebrevity of life, and they may be assigned as "home-work," saving valuable therapeutic time.

Some social workers, however, may feel so re-moved from the process that this assessment ap-proach makes poor use of therapeutic time. An-other significant hmitation is that many clients.suchas those who are more verbal, uncomfortable withdrawing, or prefer more direct practitioner—clientinteraction, may find the use of a largely nonverbal,pictorial method to be a poor fit with their currentneeds. In other situations, it may be important tounderstand the effects of spirituality in greaterbreadth (that is, among the wider family system) orin greater depth (that is, across generations). In suchsettings, spiritual genograms may be used.

SPIRITUAL GENOGRAMSSpiritual genograms provide social workers with atangible graphic representation of spirituality across

H O D G E / Developing a Spiritual Assessment Toolbox

at least three generations (Hodge. 2001 b) .Throughthe use of what is essentially a modified family tree,they help both practitioners and clients understandthe flow of historically rooted patterns through time.In short, spiritual genograms are a blueprint of com-piex intergenerational spiritual interactions.

The basic family system is delineated in keepingwith standard genogram conventions (McGoldrick,Gerson, & Shellenberger, 1999).Triangles or othergeometric shapes, however, can be inserted to des-ignate individuals who have played major spiritualroles but are not members of tbe immediate bio-logical family (for example, see "Ruth" in Figure2). To indicate clients' spiritual tradition, coloreddrawing pencils can be used to shade in the circlesand squares. Color coding provides a graphic "colorsnapshot" of the overall spiritual composition ofthe family system. Various colors can be used tosignify religious preference (for example. Muslim,New Age, none), or when the information inknown, denomination (for example. Assemblies ofGod) and subtradition (for example. Sunni,Sbiite).A circle representing a member ofthe Assembliesof God could be colored red and an individualwhose affiliation and beliefs are unknown could beleft uncolored. A change in an adult's religious ori-entation can be signified by listing the date ofthechange beside a circle, which is drawn outside thefigure, and filling in the space between the circleand the figure with the appropriate color.This pro-cedure indicates the stability and fluidity of theperson's beliefs over time. Using a similar approacb,changes in orientation from one's family of origincan be noted by coloring the vertical segment con-necting the child with the parents.

As is the case with spiritual lifemaps, spirituallymeaningful events can be incorporated,such as waterand spirit baptisms, confirmations, church mem-berships, and bar niitzvahs. Symbols drawn fromthe client's spiritual cosmology can be used to sig-nify these events. For instance, a member of tbePentecostal denomination might choose a dove todepict a deeper work of the Holy Spirit. A NewAge adherent might use a sunbeam to symbolize atime of profound spiritual enlightenment or an openset of scriptures might be used to indicate a devoutperson. In addition, this approach allows for shortsummary statements to denote events, personalstrengths, or other important information.

In addition to depicting religious beliefs, it isalso possible to include an affective component to

spiritual genograms (Hodge. 20(31 b). In other words,felt spiritual closeness between family members canbe illustrated.Lines with double-headed arrows 1«->1can be used to symbolize a relationship in whichindividuals experience a close reciprocal spiritualbond. The thickness of the line can indicate theintimacy or strength ofthe relationship. In situa-tions where the relationship is more hierarchicaland less reciprocal—as might occur with a grand-parent mentoring a grandchild—a single arrow-head (ijcan be used to depict the flow of spiritual

resources.

Strengths and Limitations ofSpiritual GenogramsSpiritual genograms may be particularly useful whenthe family system plays an especially significant rolein the client's life. For the social worker, they helpconnect spirituality to treatment plans. Poole (1998)suggested that genograms may be helpful withHispanic clients, for example, as they tend to showrespect for tradition. In addition, problems involv-ing family members or family-of-origin issues areoften effectively explored with spiritual genograms.For example, with interfaith couples experiencingspiritual conflicts, spiritual genograms can exposeareas of difference and highlight the respective spiri-tual strengths each person brings to the relation-ship. Genograms also may appeal to clients whoprefer a very structured assessment approach,

Spiritual genograms are relatively time consum-ing to construct, require a fair degree of practitio-ner involvement to explain and conduct the assess-ment, and place some limitations on how clientsrelate their spirituality. In situations where tbe familysystem or historical influences are of minor impor-tance, spiritual genograms may be an inappropriateapproach. Furthermore, because many clients donot connect past events with current difficulties,some clients may view genogram construction asan ineffective use of time (Kuehl, 1995).With suchclients, it may be more appropriate to use assess-ment approaches that focus on the "here and now"such as spiritual ecomaps.

SPIRITUAL ECOMAPSIn contrast with the previously discussed assessmenttools, spiritual ecomaps focus on clients' currentspiritual relationships (Hodge. 2000). The assess-ment approaches discussed earlier are similar in thesense that they are all designed to tap some portion

H O D G E / Developing a Spiritual Assessment Toolbox 319

Social workers should generally seek toexplore 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 typi-cally cover one to three generations of a client'sspiritual narrative. Conversely, spiritual ecomapsfocus on that portion of chents'spiritual story thatexists in present space. In other words, this assess-ment approach highlights clients' present, existen-tial relationship to spiritual assets.

In the center of a piece of paper, the immediatefamily system is typically portrayed as a circle, inkeeping with traditional ecogram construction(Hartman, 1995). Household family members canbe sketched inside the circle, with squares depict-ing males and circles representing females (Hodge,2000). Alternatively,separate ecomaps can be drawnfor each individual (Hodge & Williams. 2002). Onthe outskirts ofthe paper, surrounding the familysystem, significant spiritual systems or domains aredepicted as circles, with the names ofthe respectivesystems written inside the circles. Although clientsshould be encouraged to depict the domains thathold personal salience in their spiritual worldview,several spiritual systems have somewhat of a uni-versal application.

More specifically, social workers should gener-ally seek to explore clients' relationship with Godor transcendence, rituals, faith communities, andtranspersonal encounters. One's relationship withGod or transcendence is widely regarded as a keystrength, as are rituals, or codified spiritual prac-tices. Faith communities refer to various faith-basedgroups that individuals may associate with on a regu-lar basis, such as churches, mosques, synagogues,temples, fellowship groups, mid-week Bible stud-ies, youth groups, and singles associations.Transpersonal encounters refer to encounters withangels, demons, and other spiritual visitations.

The heart ofthe spiritual ecomap is the relation-ships between tbe family system and tbe spiritualsystems, which are represented by various types ofsketched lines, much like those discussed earlier inthe spiritual genogram section.Thicker lines repre-sent stronger or more powerful relationships. A

dashed line represents tbe most tenuous relation-ship, and a jagged line denotes a conflicted one. Anarrow is drawn on tbe line to indicate the flow ofenergy, resources, or interest. As is the case witb theotber diagrammatic approaches profiled bere, short,descriptive encapsulations, significant dates, or othercreative depictions, can also be incorporated ontothe map to provide more information about therelational dynamics.

Wben using ecomaps witb individuals, tbe ap-propriate type of line is drawn between tbe familysystem (that is, the figure representing the client)and the spiritual systems. Wben working with fami-lies, lines are drawn to tbe family system as a unitwhen the family shares a particular relationsbip incommon, or more fi^jquently, connections are drawnto individual family members depicting tbe vari-ous unique relationships between eacb family mem-ber and the various spiritual systems.

Strengths and Limitations ofSpiritual EcomapsSpiritual ecomaps are relatively easy to grasp con-ceptually, quick to construct, and perbaps mostimportant,readily focus on clients'current,existen-tial spiritual strengths {Hodge, 2000). This assess-ment approach may be ideal for operationalizingclients' spiritual assets in a timely fasbion becausetbe time spent in assessment is focused on tappinginto present spiritual resources. As is tbe case withall diagrammatic methods, spiritual ecomaps pro-vide an object that can serve as the focal point ofdiscussion, which can be an important consider-ation for those clients who find it less threatening tohave a concrete object as the focus of conversation.However, by virtue of tbeir design, ecomaps may beparticularly helpful in transferring attention fromtbe client to the concrete, diagrammatic assessmenttool because they focus on environmental systemsrather than,forexample,clients' life story. Althoughother approaches may implicitly emphasize the cli-ent,spiritual ecomaps exphcitly stress the systems inclients' environments (Hartman, 1995).

Spiritual ecomaps suffer from tbe same hmita-tions as other diagrammatic approaches relative toverbal spiritual histories. A diagrammatic approachmay hold little appeal to clients who want to talk.Altbougb relatively quick and simple to construct,ecomaps may not appeal to more creative individu-als, but clients can be encouraged to express tbeircreativity by adding symbols and other material to

320 Health & Social Vlhrk VOLUME JO, NUMBER 4 NOVEMBER 2005

the ecomap. In some situations, the focus on theclient's current, existential relationships to spiritualassets may result in a limited assessment that over-looks important historical facton. In some con-texts, an approach that examines current and his-torical resources on the same diagrammatic toolmay be useful.

SPIRITUAL ECOGRAMSSpiritual ecc^rams combine the assessment strengthsof spiritual ecomaps and genograms in a single as-

sessment approach {Hodge, 2005a). Ecograms tapinformation that exists in present space, much likea traditional spiritual ecomap, and also access infor-mation that exists across time.like a traditional spiri-tual genogram. Ecograms also depict the connec-tions between past and present functioning.Historical influences on current systems can be seenas well as present relationships with historical in-fluences (Figure 2).

Constructing spiritual ecograms is similar to fab-ricating genograms and ecomaps.The client is drawn

Figure 2: Diagrammatic Approaches to Spiritual Assessment

Frank Mary Don(21)

Madina

Spiritual StrengthsWorshipMusicPrayerDiscipkshipBible study

God's aclive, lovinginvolvement through the HolySpirit is a significant asset

Enjoys Sunday iwonhip; has a numberof positive

Faith \ relvionships in churchCommunity J and Bible study

groups, but also someconflictual ones

Soune, Adapted from Hodg*, D. R. (JOOSa). Spiritual ecogrimi: A new ass«unncnt imtruincni <or identifying cllenti' tplritual ttrengthi In spau ind time, famlllm InSociety, 86, 2B7-296.

HODGE / Developing a Spiritual Assessment Toolbox 321

in the center ofthe paper.The top half of the pageis used to chart the client's spiritual history throughtime as discussed in the section on spiritualgenograms. The bottom half of the page is used tochart the client's current relationships to spiritualresources as discussed in the ecomap section. Be-cause spiritual ecograms incorporate the hasic struc-ture of both spiritual genograms and ecomaps. Fig-ure 2 also serves to illustrate these latter twoapproaches as well.

As is the case with spiritual ecograms, the natureofthe relationships is symbolized with lines drawnbetween the client and the various systems. Uniqueto ecogmms, however, is the incorporation of thefamily history as a spiritual system. In other words,the family history can also be seen as a spiritualsystem alongside other spiritual systems such as God,rituals, and faith communities. Many ofthe peopleand events associated with the delineated historycontinue to exhibit a strong influence in the present.Consequently, in addition to sketching relationshipsbetween the client and the traditional ecomap sys-tems, lines are drawn connecting the client to vari-ous aspects ofthe family history.This allows clientsand practitioners to see the various connectionsbetween past and present functioning in one dia-grammatic assessment.

Strengths and Limitations ofSpiritual EcogramsThe primary asset of spiritual ecograms is theirability to illustrate current and historical resourcesas well as the connections between those strengthsin a single graphic rendering. This advantage maybe welcomed when working with populations inwhich the family system plays an important role.For instance, because ofthe sense of cohesion andinterdependency among Muslim family members(Hodge, 2004a), ecograms might be used to high-light present spiritual resources and important his-torical relationships, as both areas are often criticalfor understanding clients and helping them to ame-liorate their problems.

In some instances, however, social workers maydesire a simpler, more focused, diagrammatic as-sessment approach. Spiritual ecomaps, for example,are less time consuming to construct and may pro-vide all the information required in a given situa-tion. In other contexts, social workers may desireto use the limited amount of page space to amplifythe generational dynamics in a spiritual genogram.

Lifemaps also may provide a better assessment ap-proach with more artistically inclined clients, andspiritual histories may be hetter suited for moreverbally oriented clients.

CONCLUSIONSpirituality is often a critical factor in chents' lives.Among a sample of hospitalized older adults (N =542), 43 percent spontaneously offered a spiritualresponse when asked how they cope with theirmedical illness and other problems (Koenig, 1998b).When asked how important spirituality was as acoping mechanism, 40 percent reported that it wasthe most important factor that kept them going. Asone step toward ensuring that such assets facilitatetreatment rather than hinder it, this article has ap-prised readers of a series of qualitative assessmentmethods and reviewed their strengths and limita-tions in relation to one another.

It is important to note that other assessmentmethods exist (Sherwood, 1998). This article hasfocused on quahtative approaches,but several quan-titative instruments are also available. For readersinterested in quantitative approaches, valuable re-sources include compilations by the Fetzt-r insti-tute (1999) and especially HiU and Hood (1999).Among the more prominent instruments are theSpiritual Well-Being Scale, which measures psycho-logical dimensions of spiritual well-being, and theRehgious Orientation Scale, which measures thedegree of spiritual motivation within religious tra-ditions. Reviews on the validity, reliabiUty, devel-opment, and use of both instruments are provided,respectively,by Boivin, Kirby,Underwood,andSilva(1999) and Burris (1999). Readers interested inexploring the degree ofspiritual motivation withinor outside of a religious tradition can examine theIntrinsic Spirituality Scale (Hodge, 2003).

No single assessment approach, whether quali-tative or quantitative, is likely to be ideal in all situ-ations. Chents have diwirse needs and interests, asdo practitioners. An assessment method that workswell with one client may be inappropriate withanother. Ideally, social workers should be ac-quainted with several assessment methods beforeconducting a spiritual assessment. The five toolsreviewed here provide social workers with comple-mentary options so that health care workers arebetter equipped to serve their clients. Social work-ers can select the approach that best fits their needsin a given setting. \jBSl

Health & Social Work VOLUME JO. NUMBER 4 NOVEMBER 2005322

REFERENCESAugustine. (354-430/1991). Confessions (H. Chadwick.

Trans.). New York: Oxford University Press.Boivin, M.J., Kirby, A. L., Underwood, L. K.. & Silva, H.

(1999). Spiritual Weil-Being Scale. In P. C. Hill &R. W. Hood Jr. (Eds.), Measures of religiosity (pp. 382-385). Birmingham. AL: Religious Education Press.

Burris. C T (1999). Religious Orientation Scale. In P. C.Hill & R .W Hood Jr. (Eds.).M('iJinrfs of religiosity(pp. 144-154). Birmingham, AL: ReligiousEducation Press.

Canda. E. R., & Furman. L. D. (1999). Spiritual diversity insocial work praaice:The heart of helping. New York:Free Press.

Fetzer Institute. (1999). Multidittiensional measurement ofreligiousness/spirituality for use in health research: Areport of the Fet2er Institute/National Institute onAging Working Group. Retrieved August 7,2003,from http://www.fetzer.org/resources/FETZER_BOOK.pdf

Hartnian.A. (1995). Diagrammatic assessment of familyrelationships [Revisiting Our Heritage Series].Families in Society, 7(5(2), 111-122.

Hill.P. C , & Hood.R.W.Jr. (Eds.). (1999). Measures ofreligiosity. Birmingham, AL: Religious EducationPress.

Hodge, D. R. (2000). Spiritual ecomaps: A new diagram-matic tool for assessing marital and family spiritual-ity, ̂ owrnuf of Marital and Family Tlierapy, 26,22')~240.

Hodge. D. R. (2001a). Spiritual assessment:A review ofmajor qualitative methods and a new framework forassessing spirituality. Social IVork, 46,203-214.

Hodge, D. R. (2001b). Spiritual genograms: A genera-tional approach to assessing spirituality. Families inSociety, 82, 35-48.

Hodge, D. R. (2002). Working with Muslim youths:Understanding the values and beliefs of Islamicdiscourse. Children & Schools, 24,6—20.

Hodge, D. R. (2003).The Intrinsic Spirituality ScaletAnew six-item instrument for assessing the salience ofspirituality a.s a motivational construct._/i>»rHii/ ofSocial Service Research, 50(1), 41-61.

Hodge, D. R. (2004a). Social work practice with Muslimsin the United States. In A. T. Morales & B.W.Sheafor (Eds.), Social work: A profession of many faces(10th ed., pp. 443-469). Boston: Allyn & Bacon.

Hodge, D. R. (2004b). Spirituality and people withmental illness: Developing spiritual competency inassessment and intervention. Families in Society, 85,36-44.

Hodge, D. R. (2004c). Working with Hindu clients in aspiritually sensitive manner. Sodal Work. 49,27-38.

Hodge. D. R. (2005a). Spiritual ecograms: A newassessment instrument for identifying clients'spiritual strengths in space and across time. Familiesin Society, 86, 287-296.

Hodge. D. R. (2005b). Spiritual hfemaps: A client-centeredpictorial instrument for spiritual assessment,planning, and intervention. Social Work, 50,77-87.

Hodge. D R..& Witliams.T.R. (2002). Assessing AfricanAmerican spirituality with spiritual eco-maps.Families in Society, S3(5/6). 585-595.

Johnson. J. (2002). Taking care of later life: A matter ofjustice? British Journal of Social Work, 32, 739-750.

Joint Commission on Accreditation of HealthcareOrganizations. (2001,July 31). Spiritual assessment.In Standards frequently asked questions. RetrievedMarch 21,2002, from http://vinvw.jcaho.org/standard/pharmfaq_mpfrm.html

Koenig, H. G. (Ed.). (1998a). Handbook of religion andmental health. NewYork:Acadcmic Press.

Koenig, H. G. (1998b). Religious attitudes and practicesof hospitalized medically ill older adults. Internationaljournal of Geriatric Psychiatry, /.I, 213-224.

Koenig. H. G., McCuIlough, M. E.. & Larson. D. B.(2001). Handbook of religion and health. New York:Oxford University Press.

Kuehl, B. P. (1995).The solution-oriented genogram: Acollaborative approach.^fMrna/ of Marital and Family77jcra;7, 2/ , 239-250.

McGoldrick. M., Gerson. R.. & Shellenberger. S. (1999),Cenograms:Assessment and intervention (2nd ed.). NewYork:WW Norton.

Murdock,V. (2004. February 27-March 1). Religion andspirituality in gerontological social uvrk practice: Results ofa national sunvy. Paper presented at the 50th AnnualProgram Meeting, Council on Social WorkEducation, 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 andmental health outcomes. In T G. Plante & A. C.Sherman (Eds.), Faith and health: psychologicalperspectives (pp. 240-261). New York: Guilford Press.

Poole. D. L. (1998). Politically correct or culturallycompetent? Health & Social Work, 2.J. 163-166.

Richards, P. S., & Bergin. A. E. (Eds.). (200U). Handboitk ofpsychotherapy and religious diivrsity. Wa.shmgton, DC:American Psychological Association.

Sherwood, D. A. (1998). Spiritual assessment as a normalpart of social work practice: Power to belp andpower 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 FamilyPsychotherapy, /0(3), 61-63.

Van Hook, M.. Hugen. B., & Aguitar, M, A. (Eds.). (2001).Spirituality within religious traditions in social uvrkpractice. Pacific Grove, CA: Brooks/Cole.

David R. Hodge, PhD, is assistant professor, Arizona State

Uniivrsity-West Campus and a senior nonresident fellow atUniversity of Pennsylvania's Program for Research onReligion and Urban Civil Society. Correspondence can beaddressed to the author at Department of Social Work, P. O.Box 37WO, Phoenix,AZ 85069-7W0.

Originsl manuscript received June 30. 2003Final revision received December IS. 2003Accepted March 22, 2004

HODGE / Developing a Spiritual Assessment Toolbox 313


Recommended