SPIRITUAL ASSESSMENT IN MARITAL AND FAMILY THERAPY: A METHODOLOGICAL FRAMEWORK FOR SELECTING FROM AMONG SIX QUALITATIVE ASSESSMENT TOOLS
Hodge, David R
Emerging professional and cultural developments underscore the importance of spiritual assessment. Most marriage and family therapists, however, appear to have received little training on the topic. Consequently, this article overviews a complementary family of six recently developed qualitative assessment approaches or tools, an initial brief assessment tool and five comprehensive assessment tools, and presents a methodological framework for using the six tools. To help decide whether or not a comprehensive assessment is warranted after conducting an initial brief assessment, two general guidelines are offered. Suggestions for selecting the appropriate comprehensive assessment tool are also presented, and summarized graphically in the form of a decision tree. The overall methodological framework is designed to be congruent with the recent spiritual assessments recommendations issued by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the largest healthcare accrediting organization in the United States.
Traditionally marriage and family therapy (MFT) has paid little attention to spirituality and religion (Harris, 1998; Prest & Keller, 1993). The paucity of attention is perhaps best illustrated by a 1992 published content analysis that examined every article in all volumes of 12 major family therapy journals (Kelly, 1992). This study found that just 2.6% (N = 94) of the surveyed articles included some reference to religion and, in most cases, the references were peripheral to the article’s primary themes.
The last 2 decades, however, have witnessed a growing interest in spirituality and religion in marriage and family forums. A thematic review of principal family therapy journals in 2000 indicated a growing number of publications had addressed spirituality and religion (Rivett, 2001). A systematic review of quantitative research on religion in six primary family therapy journals, covering the years 1995 to 1999, found that 13% included a measure of religion, a higher percentage than occurred in other fields such as psychology, gerontology, and mental health nursing (Weaver et al., 2002).
The emerging interest is also reflected in the views of MFTs and students. More specifically, among a random sample of clinical members of the American Association for Marriage and Family Therapy (AAMFT; N = 153), 72% indicated that spirituality was relevant to their clinical practice, and 54% indicated that they wanted to learn more about integrating spirituality into assessment and interventions (Carlson, Kirkpatrick, Hecker, & Killmer, 2002). Similarly, among a sample of graduate students in six AAMFT-accredited training programs (N = 52), 86% believed it was necessary to address spirituality if one really expected to help clients and 67% expressed a desire to learn about integrating spirituality into clinical assessment and interventions (Prest, Rüssel, & D’Souza, 1999).
The extant body of literature on spirituality and religion suggests that therapists’ interest in spiritual assessment is significant for at least four reasons: cultural competency, family strengths, client autonomy, and accrediting requirements. As numerous commentators have observed, families’ spiritual beliefs and practices often animate essentially every aspect of life (Bailey, 2002; Moncher & Josephson, 2004; Ripley, Worthington, & Berry, 2001; Walsh, 1999). For many Muslim families, for instance, Islamic beliefs and practices inform many, if not all, dimensions of family functioning (Hodge, 2004α). Similarly, members of many other faith groups have developed distinct cultures that reflect their spiritual understandings (Koenig, 1998; Richards & Bergin, 2000; Van Hook, Hugen, & Aguilar, 2001). By conducting a spiritual assessment to map the ways in which spirituality informs family functioning, therapists can enhance their level of cultural competency.
Second, an increasing body of research suggests that spirituality and religion are often important family strengths (Johnson, 2002; Koenig, McCullough, & Larson, 2001; Mahoney, Pargament, Tarakeshwar, & Swank, 2001; Pargament, 1997). Perhaps the best study on the relationship between religion and marriage is a meta-analytic review of research published in the 1980s and 1990s conducted by Mahoney et al. (2001). These authors found that various measures of religion were associated with lower rates of divorce, greater marital satisfaction, higher levels of marital commitment, and greater use of adaptive communication skills. Spiritual assessment provides a mechanism for identifying and marshalling spiritual and religious strengths that may be used to assist in the amelioration of problems.
Third, conducting a spiritual assessment can also be a way to operationalize the self-determination principles inherent in the AAMFT Code of Ethics (2001). Interest in spirituality is increasing among the general public (Gallup & Lindsay, 1999), and surveys of various client and potential client populations suggest that many, if not most, clients want to have their spiritual beliefs and values incorporated into the therapeutic dialogue (Bart, 1998; Larimore, Parker, & Crowther, 2002; Mathai & North, 2003; Rose, Westefeld, & Ansley, 2001). For instance, Gallup data reported by Bart (1998) indicated that 81% of the general public wanted to have their own spiritual values and beliefs integrated into the counseling process.
Finally, because of these and other factors, therapists are increasingly being called upon to conduct spiritual assessments. For instance, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO, 2001), the oldest and largest healthcare accrediting agency in the United States, now recommends that a spiritual assessment be conducted in many behavioral health organizations. Consequently, some therapists working in JCAHO-accredited settings may be asked to conduct spiritual assessments.
These four reasons suggest that therapists’ desire to learn more about spiritual assessment is well founded. Unfortunately, based on the two studies cited above, therapists and students appear to have received little training on spiritual assessment during their graduate education. Seventy-six percent of AAMFT members indicated that spirituality was not emphasized during their education (Carlson et al., 2002). Similarly, 92% of graduate students reported that they received no training in their clinical programs on integrating religion into practice settings (Prest et al., 1999).
To address this situation, in this article, I introduce readers to a recently developed set of six complementary spiritual assessment tools or approaches and present a methodological framework for selecting from among these various approaches. In concert with the JCAHO recommendations, these six qualitative assessment tools were deliberately designed to highlight different facets of clients’ spiritual lives. Both clients and therapists have a variety of needs and interests in any given therapeutic context. Consequently, certain assessment approaches will work better in some situations, whereas other approaches will be a more appropriate choice in other settings. This article reviews these six tools, two verbally based approaches and four diagrammatic approaches, and then suggests various criteria for evaluating which assessment tool to select.
Because the aim of this article is to acquaint therapists with a variety of assessment tools and how to select from among them, it is important to underscore at the outset that many relevant topics cannot be discussed because of space limitations. For instance, it is beyond the scope of this article to present information on various faith traditions, guidelines for spiritually competent assessment, 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 and/or to consult the works of other authors who address these subjects (Koenig, 1998; Richards & Bergin, 2000; Van Hook et al, 2001; Walsh, 1999). Finally, although this article focuses on qualitative approaches in keeping with the JCAHO recommendations, it is also important to note that many quantitative assessment approaches also exist.
Before reviewing the JCAHO recommendations, which provide a useful template for thinking about spiritual assessment, it is appropriate to define spirituality and religion. Although the two terms are often used interchangeably, it is possible to conceptualize them as overlapping, but distinct, constructs (Miller & Thoresen, 2003). Spirituality, for instance, can be defined as an individual’s existential relationship with God (or Ultimate Transcendence), whereas religion can be seen as flowing from spirituality, expressing the spiritual relationship in particular beliefs, forms, and practices that have been developed in community with other individuals who share similar phenomenological understandings of transcendent reality (Hodge, 2001e).
INITIAL BRIEF SPIRITUAL ASSESSMENT
In behavioral health, as well as many other healthcare settings, JCAHO (2001) generally recommends that a brief, initial spiritual assessment be conducted with all clients. Two primary goals inform the initial assessment. One goal is to identify the effect of clients’ spirituality on service provision and client care. As mentioned above, for service provision to be as effective as possible, spiritual beliefs and practices often have to be taken into account. Consequently, JCAHO stipulates that a spiritual assessment should determine, at a minimum, clients’ denomination, and important spiritual beliefs and practices.
Table 1 provides a brief, concise question set that is designed to elicit the information stipulated in the JCAHO requirements (Hodge, 20040). As can be seen, the questions emphasize the functional nature of spirituality in clients’ lives-how spirituality acts as a personal and environmental strength. Rather than focusing on the content of clients’ spiritual worldviews, assessment should generally be aimed at determining how clients’ spiritual beliefs and practices influence their functioning.
The second goal of the initial assessment is to determine whether an additional, more comprehensive spiritual assessment is required (JCAHO, 2001). To some extent, this determination will be based on contextual factors unique to each family. Two general guidelines, however, may be particularly useful in making a decision to proceed to a comprehensive assessment (Hodge, in press).
First, assessment is called for when the norms of the client’s faith tradition relate to service provision/ client care, as might occur with Pentecostalism and mental illness. Because hearing the voice of God is considered normative within the Pentecostal tradition, hearing a voice external to one’s self is not necessarily a manifestation of mental illness with Pentecostal Christians. In such cases, a comprehensive assessment is necessary to determine if the “voices” represent a manifestation of mental illness, are normative, or even represent a significant family strength.
Second, a comprehensive assessment should be considered when spirituality plays a central role, functioning as an organizing principle, in the client’s life. The degree to which clients practice the norms within their faith tradition is one way to assess the centrality of spirituality in a client’s life. For example, a comprehensive assessment may be warranted with Catholics who attend mass weekly or Muslims who practice the “five pillars.”
COMPREHENSIVE SPIRITUAL ASSESSMENT TOOLS
When the decision has been made with the family to conduct a comprehensive spiritual assessment, a choice must be made regarding which tool to use. Below, five complementary assessment approaches are presented that therapists may wish to consider: one verbally based approach (spiritual histories), followed by four diagrammatic or graphic approaches (spiritual lifemaps, spiritual genograms, spiritual ecomaps, and spiritual ecograms).
As mentioned above, verbally based spiritual histories represent one assessment approach (Hodge, 2001a). This method is analogous to conducting a family history. To guide the conversation, two question sets are used, as can be seen in Table 2. The purpose of the first question set, referred to as an “initial narrative framework,” is to provide therapists with some possible questions to help clients tell their stories, typically moving from childhood to the present.
The second question set, referred to as an “interpretive anthropological framework,” is designed to elicit spiritual information as clients relate their stories. The framework is based upon Chinese spirituality writer Nee’s (1968) anthropological understanding. In addition to the body, Nee envisions a soul, comprised of affect, will, and cognition, and a spirit, comprised of communion, conscience, and intuition. According to Nee, it is possible to differentiate the six dimensions of the soul and spirit. In other words, in addition to differentiating affect, will, and cognition, it is also possible to distinguish communion, conscience, and intuition.
Communion refers to spiritually based relationships. More specifically, it denotes the ability to bond and relate to God, or the client’s perception of Ultimate Transcendence. Conscience relates to one’s ability to sense 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 the six dimensions, providing a holistic spiritual assessment. As clients relate their spiritual narratives (prompted as necessary by questions drawn from the initial narrative framework), they will tend to touch upon some of the dimensions listed in the interpretive anthropological framework. Therapists can interface questions drawn from the interpretive anthropological framework into the dialogue to more fully explore clients’ spiritual reality in the natural flow of the conversation. In short, the narrative questions help clients tell their stories, whereas the anthropological questions assist therapists in eliciting important information as the stories unfold.
Spiritual lifemaps represent, in at least some sense, a diagrammatic alternative to verbally based spiritual histories (Hodge, 2005a). More specifically, spiritual lifemaps are a pictorial delineation of a client’s spiritual journey. In a manner analogous to renowned African writer Augustine’s (354-430/1991) Confessions, spiritual lifemaps are an illustrated account of clients’ relationship with God (or Transcendence) over time-a map of their spiritual life. Much like roadmaps, spiritual lifemaps tell us where we have come from, where we are now, and where we are going.
At its most basic level, drawing instruments are used to sketch various spiritually significant life events on paper. The method is similar to various approaches drawn from art and family therapy in which a client’s history is depicted on a “lifeline” (Tracz & Gehart-Brooks, 1999). To assist clients in the creative expression of their spiritual journeys, it is usually best to use a large sheet of paper (e.g., 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, glue sticks, and rulers, allow clients to clip and paste items onto the lifemap.
As can be seen in Figure 1, spiritually significant events are depicted on a path, a roadway, or a single line that represents a client’s spiritual sojourn. Each member of the family can construct their own lifemap or the family could jointly construct a single lifemap representing the family’s spiritual story. In the latter case, a single path can be used to represent the family’s spiritual journey. As implied above, hand-drawn symbols, cut-out pictures, and so on, are used to mark key events along the journey (e.g., death, loss of a job, etc.). Although it is often necessary to provide families with general guidelines, client creativity should be encouraged.
To operationalize the potential of the method fully, it is important to ask clients to incorporate the various trials they have faced into their lifemaps along with the spiritual resources they have used to overcome those trials. Hills, bumps and potholes, rain, clouds, lightning, and so on, can be used to portray difficult life situations. Delineating successful strategies that families have used in the past frequently suggests options for overcoming present struggles.
Although spiritual histories and lifemaps generally depict a single generation, spiritual genograms illustrate the flow of spiritual patterns across at least three generations in a manner analogous to traditional genograms (Hodge, 2001b). Through the use of what is essentially a modified family tree, they help both therapists and clients understand the flow of historically rooted patterns through time. In short, spiritual genograms represent a blueprint of complex 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 used to designate individuals who have played major spiritual roles but are not members of the immediate biological family (e.g., “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 (e.g., Muslim, New Age, none), or when the information is known, denomination (e.g., Assemblies of God) and/or subtradition (e.g., Sunni, Shiite). For example, a circle representing a member of the Assemblies of God could be colored red, whereas an individual whose affiliation and beliefs are unknown could be left uncolored. A change in religious orientation can be signified by listing the date of the change beside a circle that is drawn outside the figure and filling in the space between the circle and the figure with the appropriate color, a procedure that indicates the stability/fluidity of the person’s beliefs over time. Using a similar approach, 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 mitzvahs (Hodge, 2001b). Symbols drawn from the client’s spiritual cosmology can be used to signify these events. For instance, a dove might be used by a Pentecostal to depict a deeper work of the Holy Spirit, a sunbeam might used by a New Age adherent to symbolize a time of profound spiritual enlightenment, or an open set of scriptures might be used to indicate a devout person. In addition, short summary statements can be used to denote events, personal strengths, and so on.
In addition to depicting religious beliefs, it is also possible to include an affective component. In other words, felt spiritual closeness between family members can be illustrated on spiritual genograms. As illustrated in Table 3, the thickness of the line can indicate the intimacy or strength of the relationship with arrows indicating the flow of energy, resources, or interest. A single arrowhead can be used to depict the flow of spiritual resources in situations where the relationship is more hierarchical, as might occur with a grandparent mentoring a grandchild. Two arrowheads can be used to symbolize bidirectional relationships in which individuals experience a close reciprocal spiritual bond.
In contrast with the above assessment tools, spiritual ecomaps focus on clients’ current, existential, spiritual relationships (Hodge, 2000). The assessment approaches discussed above are similar in the sense that they are all designed to tap some portion of a family’s 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 a family’s spiritual story that exists in space. In other words, this assessment approach highlights clients’ present, existential relationships 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). As can be seen in Figure 3, 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 family member (Hodge & Williams, 2002). On the outskirts of the paper, surrounding the family system, significant spiritual systems or domains are depicted as circles, with the names of the respective systems written inside the circles. Although clients should be encouraged to depict the domains that hold personal salience in their spiritual worldview, there are a number of spiritual systems that are strengths in numerous faith traditions.
More specifically, therapists should generally seek to explore clients’ relationship with God or Transcendence, rituals, faith communities, and transpersonal encounters. As implied above, one’s relationship with God is widely regarded as a key strength as are rituals, or codified spiritual practices (Fiese & Tomcho, 2001). Faith communities refer to various faith-based communities that individuals may associate with on a regular basis, such as churches, mosques, synagogues, temples, fellowship groups, midweek Bible studies, youth groups, singles associations, and so on. Transpersonal encounters refer to encounters with angels, demons, and other spiritual visitations.
The heart of the spiritual ecomap is the relationships between the family system and the spiritual systems. These relationships are represented by various types of sketched lines, like those discussed in the preceding spiritual genogram section and summarized in Figure 3. A dashed line, for instance, represents the most tenuous relationship, whereas a jagged line denotes a conflicted one. As is the case with the other diagrammatic approaches profiled above, short, descriptive encapsulations, significant dates, or other creative depictions, can also be incorporated onto the map to provide more information about the relational dynamics.
Spiritual ecograms combine the assessment strengths of spiritual ecomaps and genograms in a single assessment approach (Hodge, 2005b). Ecograms tap information that exists in space, much like a traditional spiritual ecomap, as well as tapping information that exists across time, like a traditional spiritual genogram. In short, ecograms tap information that exists in space and across time. 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.
Constructing spiritual ecograms is similar to fabricating genograms and ecomaps (See Figure 4). The client or family system is drawn in the center of the paper. The top half of the page is used to chart the client’s spiritual history through time as discussed in the section on spiritual genograms. The bottom half of the page is used to chart the client’s current relationships to spiritual resources as discussed in the preceding ecomap section. As is the case with spiritual ecograms, the nature of the relationships is symbolized with lines drawn between the client and the various systems (see Table 3).
Unique to ecograms, however, is the incorporation of the family history as a spiritual system(s). In other words, the family history can also be seen as a spiritual system(s) alongside other spiritual systems, such as God, rituals, faith communities, and so on. Many of the people and events associated with the delineated history continue to exhibit a strong influence in the present. Consequently, in addition to sketching relationships between the client and the traditional ecomap systems discussed above, lines are also drawn connecting the client to various aspects of the family history. This allows clients and therapists to see the various connections between past and present functioning on one diagrammatic assessment.
SELECTING AN ASSESSMENT APPROACH
When considering which assessment approach to use, therapists typically consider a number of intertwined factors, such as their theoretical orientation, the service setting, the client’s presenting problem and relational style. In many cases, one or more of these factors will determine the choice of an assessment tool. Another consideration that may be helpful in selecting an assessment tool is whether it gathers intergenerational or present-focused information. More specifically, a consideration of the period of time each assessment instrument highlights may be helpful in selecting an assessment approach.
Timeframes are significant for at least two reasons. First, choosing a timeframe that represents an appropriate fit with the client system may help to ensure the validity and reliability of the assessment. Validity and reliability refer, respectively, to the accuracy and consistency of the information obtained during assessment (Gilbert & Franklin, 2003). Put differently, they address the trustworthiness of the assessment (Duffy & Chenail, 2004).
Although the protocols for evaluating the trustworthiness of information derived through quantitative assessment instruments are widely agreed upon, the situation is more fluid for qualitative approaches (Denzin & Lincoln, 2003). One approach is provided by Franklin and Jordan (1995), who suggest seven criteria for evaluating the trustworthiness of assessment information. Items to be considered include the degree to which the depicted metaphors, pictures, and patterns make sense as a part of a coherent story, the extent to which collaboration occurred with the client in the discussion and interpretation of the problem, and the degree to which the practitioner attempted to falsify her preconceived interpretations.
The accuracy and consistency of the information gathered during assessment is likely to be enhanced if the assessment focuses on the period of time that is of therapeutic interest. If the assessment covers a time period that is largely unrelated to the problems at hand, the trustworthiness of the assessment may be compromised to some extent. Error may be increased by either a lack of pertinent data or the incorporation of extraneous data into the assessment process.
The second reason that timeframes are relevant relates to what some have called social validity (Foster & Mash, 1999). Social validity can be understood as the degree to which clients perceive the assessment to be appropriate, acceptable and relevant to their life situation. Sufficient social validity must be established for clients to remain engaged in the therapeutic process and higher levels are preferred.
Social validity can potentially be accentuated or mitigated by the timeframe that is covered during assessment. In addition, other factors can also influence social validity, such as the degree to which clients gravitate toward verbal or nonverbal communication modes. Obviously these, and other factors, should also be considered when deciding which assessment approach to select.
Figure 5 provides a visual summary of what an assessment decision tree organized by time might look like. The first decision is to determine whether or not a comprehensive assessment is warranted after taking into account the two guidelines discussed above and any other relevant contextual information. Assuming a comprehensive assessment is called for, the next consideration is the saliency of historical influences. In many situations, intergenerational or historical factors will drive the decision-making process regarding which assessment tool to choose.
For many populations, such as Muslims, (Daneshpour, 1998), Hindus (Hodge, 2004c), and Hispanics (Poole, 1998), the term “family” often goes beyond the traditional western meaning of a “nuclear family” to include what are commonly referred to as extended family members. A high degree of cohesion and interdependency often exists within these extended family systems. Using an intergenerational assessment approach provides valuable information on how the family’s spirituality affects relationship dynamics, family rules, and their worldview. It also demonstrates respect for the importance of extended family members, which can enhance levels of social validity.
Problems involving family members or family-of-origin issues are also often effectively explored with intergenerational assessment instruments. For example, interfaith couples experiencing conflicts over which of their family blueprints or faith perspectives will guide their own family might benefit from such an approach. Differences in family backgrounds are effectively illustrated as well as any commonalities in their belief systems. They also help to identify the respective spiritual strengths each person brings to the relationship, such as the existence of older mentors that could be tapped to find solutions to their conflict.
Once a consensus has been reached regarding the use of an intergenerational approach, a decision must be made to use either a spiritual genogram or a spiritual ecogram. Spiritual genograms are typically constructed more quickly than spiritual ecograms. Consequently, spiritual genograms may be preferred in situations in which historical factors are of primary interest.
However, in many situations the family’s relationship to present spiritual systems may also be therapeutically relevant. As noted above, the primary asset of spiritual ecograms is their ability to illustrate current and historical resources as well as the connections between those strengths. When clients’ relationships to present spiritual systems are also an important consideration, it is likely worth the extra time to construct a spiritual ecogram.
Another issue to consider when choosing between a spiritual genogram and a spiritual ecogram is client acceptance of an exclusively intergenerational approach. Kuehl (1995) suggests that many clients do not connect past events with current difficulties and, consequently, some clients may view genogram construction as an ineffective use of time. Thus, even though an exploration of generational factors may be warranted from the therapist’s perspective, using a spiritual genogram in such situations may result in losing the family. Conversely, clients generally understand the logic of exploring their relationship to present systems to solve present problems. Thus, using an ecogram may enable the therapists to establish sufficient social validity to keep the family engaged with the instruments’ delineation of present systems while simultaneously exploring historical dimensions that are also relevant to the problem.
Present/Life History-Oriented Approaches
If more present-oriented factors are considered to be of primary importance compared to intergenerational/historic influences, then therapists may wish to consider spiritual ecomaps, spiritual lifemaps, or spiritual histories. To decide from among these three methods, consideration might be given to the relevance of present relationships versus life history.
In many instances, present relationships may be of primary importance. For instance, therapists working in managed care settings, or working from a brief therapeutic perspective, may wish to restrict assessment to an examination of current relationships. In such instances, spiritual ecomaps provide an ideal assessment approach, because they focus on clients’ relationships to current, existential spiritual strengths. Ecomaps can be constructed quickly and are relatively easy to grasp conceptually. As noted above, families generally understand the need to explore present relationships to ameliorate present problems.
Another factor that may minimize clients’ resistance to spiritual ecomaps is the instrument’s emphasis on environmental systems. As is the case with all diagrammatic methods, spiritual ecomaps provide an object that can serve as the focal point of discussion. This can be an important consideration for those clients who may be hesitant to discuss a highly personal topic-such as their spirituality-with therapists (Hodge, 2000). In such situations, clients may find it less threatening to have a concrete object that functions as the focus of conversation. Although this may be true for any diagrammatic instrument, by virtue of their design, ecomaps may be particularly helpful in transferring attention from the client to the diagrammatic assessment tool, given that ecomaps focus on environmental systems rather than, for example, the client’s life story.
If initial assessment suggests that some degree of life history is important, then therapists may wish to consider using either a spiritual lifemap or conducting a spiritual history. At one level, this represents a choice between a diagrammatic method and a more verbally based approach. Other factors exist, however, that therapists may wish to consider.
Spiritual lifemaps are perhaps the most client-directed of the assessment tools profiled in this article, which in turn, suggests a number of implications (Hodge, 2005a). First, spiritual lifemaps may hold particular appeal to more artistically oriented clients, given that maps provide a creative forum in which clients can express themselves. Second, by placing a client-constructed medium at the center of assessment, the message is implicitly communicated that the client is a competent, proactive, self-directed, fully engaged participant in the therapeutic process. Third, lifemaps may lend themselves well to being assigned as homework in many situations, which in turn can save valuable therapeutic time. Fourth, the collective process of constructing a lifemap together as a family may help build unity and cohesion among disengaged families.
As is the case with all diagrammatic approaches, the concrete depiction of spiritual strengths can foster the adoption of new salutary narratives as clients see an array of assets physically depicted in front of them (Moon, 1994; Richert, 1999). The visual depiction of strengths serves to underscore their reality in clients’ lives, making them more likely to use their strengths to ameliorate their present problem. Spiritual lifemaps, however, may be especially effective at fostering the adoption of more beneficial narratives as clients have the opportunity to reevaluate their life-scripts through a spiritual lens (Pargament, 1997). Past events that may be viewed as failures can be reframed as learning, growth-producing experiences (or even triumphs) when seen through a spiritual grid. In other words, the approach often gives therapists ample content that can be used to help clients rewrite their narratives.
Finally, the fact that clients play a primary role in this assessment approach necessarily means that therapists play a secondary role. The secondary role can provide important advantages in light of the lack of training most therapists seem to have received during their graduate educations (Carlson et al., 2002; Prest et al., 1999) and the level of discomfort many therapists may feel when addressing spirituality (Miller, Korinek, & Lvey, 2004). For instance, less chance exists that inadvertently offensive comments will be made during therapy. The assessment process provides an opportunity to learn the symbols and language inherent in the family’s spiritual worldview which can then be adopted in subsequent interactions while simultaneously allowing the therapists space to become more comfortable with clients’ cosmologies. In essence, the lifemap enables clients to educate therapists on their spiritual worldview, increasing the therapist’s spiritual competence.
For many clients, however, spiritual histories may represent the best assessment option. More verbally oriented persons, particularly those who thrive on interpersonal interactions, may find verbally based spiritual histories to offer the best fit with their personality. In addition, the relatively nonstructured 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, spiritual genograms, spiritual ecograms, and spiritual ecomaps all require clients to circumscribe their spiritual experiences to fit the parameters prescribed by the instrument, whereas spiritual histories allow clients to express themselves in a manner that is unique to their own experience. Given that some evidence suggests that information may be storied narratively in the mind (Strickland, 1994), spiritual histories may offer an assessment approach that feels more natural to clients. Spiritual histories are also relatively easy to conduct, the assessment model is relatively easy to communicate to clients, and the verbal format is generally conducive to building a therapeutic alliance with clients, particularly if therapists are comfortable interacting with the family’s spiritual cosmology. Because of the fluid nature of the spiritual history assessment process, therapists can easily weave questions about how the client’s spirituality relates to their present problem.
It is important to emphasize that the above framework represents a malleable assessment template. In other words, it represents just one way to think about the assessment process. In many contexts, factors other than those discussed above will influence the choice of an assessment approach. It is also important to note that many other qualitative approaches exist in addition to the tools discussed in this article (Hodge, 2001a; Sherwood, 1998). Ideally, therapists are encouraged to familiarize themselves with a number of assessment tools, their respective strengths and weaknesses, and then select the instrument that best serves clients’ interests.
QUANTITATIVE ASSESSMENT APPROACHES
As part of this process, therapists may wish to consider quantitative instruments. Such instruments are generally inappropriate in settings that call for an assessment that meets the JCAHO recommendations. Quantitative assessment tools can, however, often be of use in other venues. They can also supplement qualitative approaches by tapping distinct dimensions of client functioning.
Among the more widely used measures in clinical settings is the Spiritual Well-Being Scale (Ellison & Smith, 1991; Paloutzian & Ellison, 1982). This 20-item scale measures two psychological dimensions of well-being. The vertical dimension assesses the quality of one’s existential relationship with God, whereas the horizontal dimension assesses the quality of one’s relationships with other people. The scale may be a particularly useful tool for identifying individuals experiencing distress in their personal and/or spiritual functioning as well as a general lack of well-being. It may be most appropriate for theistic individuals given the use of the term “God” in the items that tap the horizontal dimension. Within these parameters, however, the scale is designed to be nonsectarian.
Another widely used tool is the 21-item Religious Orientation Scale (Allport & Ross, 1967). This scale is designed to assess the degree to which religion functions as a “master motive.” Put differently, it can be used to assess the degree to which respondents are motivated by their spirituality among those who express their faith in traditional religious forms. Reviews on the validity, reliability, development, and use of both the Spiritual Well-Being Scale and the Religious Orientation Scale are provided, respectively, by Boivin, Kirby, Underwood, and Silva (1999) and Burris (1999).
A more recently developed instrument is the Intrinsic Spirituality Scale (Hodge, 2003). In a manner similar to the Religious Orientation Scale, this short 6-item measure assesses spiritual motivation. In contrast to the above two scales, this measure is designed to work with both theistic and nontheistic populations. It was developed to tap levels of spiritual motivation among individuals who express their spirituality within religious frameworks as well as among those who express their spirituality outside of religious settings.
In addition to these three scales, many other approaches have been developed. Readers interested in quantitative assessment options may wish to consult compilations by the Fetzer Institute (1999) and Hill and Hood (1999). As is the case with qualitative approaches, the more instruments of which therapists are aware, the better equipped they are to provide holistic services.
Most MFTs believe that spirituality should be considered in therapy (Carlson et al., 2002; Jensen & Bergin, 1988; Prest et al., 1999). Yet, even though therapists are aware of the link between spirituality and mental health, research also suggests a certain hesitancy exists regarding integrating spirituality into therapy (Carlson et al.). Carlson et al. suggested this hesitancy may be due to lack of training.
To help orient therapists to the topic, this article has reviewed six different assessment approaches and proposed a methodological framework for using this complementary family of assessment tools. This framework helps therapists move beyond a one-size-fits-all approach to assessment. By familiarizing themselves with a number of assessment options, therapists are better equipped to select the assessment tool that provides the best fit between the extant clinical needs and clients’ interests.
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David R. Hodge
Arizona State University-West
David R. Hodge, PhD, Department of Social Work, Arizona State University-West.
Correspondence can be addressed to David Hodge, ASU-West, Department of Social Work, P. O. Box 37100, Phoenix, Arizona, 85069-7100.
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