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Implicit spiritual assessment: an alternative approach for assessing client spirituality.

It is increasingly realized that spirituality plays an important role in fostering health and wellness (Koenig, King, & Carson, 2012). To help social work practitioners understand this relationship in clients' lives, a spiritual assessment is commonly recommended as a routine component of practice (Canda & Furman, 2010; Furness & Gilligan, 2010). Administering a spiritual assessment--as part of a larger bio-psycho-social-spiritual assessment--provides a more holistic understanding of clients' realities, which in turn provides the basis for subsequent practice decisions.

As a result of the time constraints that exist in therapeutic settings, spiritual assessment is widely conceptualized as a two-stage process: a brief preliminary assessment followed--if clinically warranted--by an extensive comprehensive assessment (Canda & Furman, 2010; Pargament, 2007; Shafranske, 2005). The brief assessment consists of a few questions that are typically administered to all clients (for example, "I was wondering if you are interested in spirituality or religion?"). The purpose of the preliminary assessment is to determine the clinical relevance of spirituality and to ascertain whether a comprehensive assessment is needed. In situations where clients' spiritual beliefs and practices intersect service provision, practitioners can select from an array of comprehensive assessment tools to explore this intersection (Hodge & Limb, 2010).

Although this explicit approach to spiritual assessment represents an important contribution to the literature, it may not be effective with all clients (Nelson-Becker, 2005). Some clients may benefit from what might be called an implicit spiritual assessment. In this approach, the use of traditional spiritual or religious language is avoided. Instead, practitioners use terminology that is implicitly spiritual in nature to explore potentially relevant content. As such, an implicit assessment provides a method to identify and operationalize dimensions of clients' experience that may be critical to effective service provision but would otherwise be overlooked in an explicit spiritual assessment.

Approximately two-thirds of direct practitioners affiliated with NASW believe social workers need to become more knowledgeable about spirituality (Canda & Furman, 2010). Indeed, studies have repeatedly found that most direct practitioners report receiving minimal training in spirituality during their graduate educations (Canda & Furman, 2010; Sheridan, 2009). This article addresses this knowledge gap by orienting readers to the process of conducting an implicit spiritual assessment as a supplement to existing assessment approaches.

The article begins by defining spirituality and religion and noting contexts in which an implicit spiritual assessment may be particularly germane. The process of administering a spiritual assessment is discussed, and sample questions are provided to help practitioners implement this approach in practice settings. The article concludes by offering some suggestions for integrating an implicit assessment with more traditional explicit approaches to assessment.

CONCEPTUALIZING SPIRITUALITY AND RELIGION

Spirituality is understood and expressed diversely among social workers (Hodge & McGrew, 2006) and the general public (Gallup & Jones, 2000). One way to conceptualize spirituality is in terms of connectedness with what is perceived to be sacred or transcendent (Hodge, 2001; Koenig et al., 2012; Pargament, 2007). As such, spirituality can be seen as a fundamental human drive for transcendent meaning and purpose that involves connectedness with oneself, others, and ultimate reality (Canda & Furman, 2010; Crisp, 2010).

Religion can be conceptualized as a shared set of beliefs and practices that have been developed over time with people who have similar understandings of the sacred or transcendent (Geppert, Bogenschutz, & Miller, 2007; Koenig et al., 2012). These beliefs and practices, which are designed to mediate an individual's relationship with the sacred, are transmitted through community-based structures or organizations (Canda & Furman, 2010). These organizations can be traditional, such as the Catholic Church, or of more recent origin, such as the New Age or Syncretistic movement. As such, religion is relatively objective, concrete, and communally oriented, whereas spirituality tends to be more subjective, private, and personal.

Understood in this sense, spirituality and religion are overlapping but distinct constructs.

Spirituality is posited to be a universal human impulse that may or may not be expressed in religious forums (Derezotes, 2006). Thus, whereas spirituality is commonly manifested in an individual's relationship with God (Wuthnow, 2007), a person's connection with the transcendent may be displayed in many forms, including those that might be considered secular in nature (Crisp, 2010). In other words, the drive to construct a sacred reality is expressed in a variety of relationally oriented settings. This understanding of spirituality suggests two contexts in which an implicit spiritual assessment may be particularly germane.

CONTEXTS IN WHICH AN IMPLICIT ASSESSMENT IS ESPECIALLY RELEVANT

Research with various samples suggests most clients want to have their spiritual and religious beliefs integrated into the therapeutic conversation (Arnold, Avants, Margolin, & Marcotte, 2002; Dermatis, Guschwan, Galanter, & Bunt, 2004; Mathai & North, 2003; Rose, Westefeld, & Ansley, 2001, 2008; Solhkhah, Galanter, Dermatis, Daly, & Bunt, 2009). A brief preliminary assessment helps to legitimize the topic and provides a forum for clients to explore issues that might otherwise have remained undiscussed (Nelson-Becket, Nakashima, & Canda, 2007; Richards & Bergin, 2005). There are, however, at least two contexts in which an implicit spiritual assessment is particularly useful: (1) when spiritual language is perceived to be irrelevant, and (2) when practitioners' level of spiritual competence is questioned.

Spiritual Language Is Irrelevant

For some clients, the spiritual or religious language used in an explicit preliminary assessment does not resonate with their personal worldviews. As implied by the above conceptualization of spirituality, essentially anything can be imbued with transcendent significance (Crisp, 2010). In many cases, people construct a sense of meaning, purpose, and identity outside the confines of traditional spiritual and religious settings.

For example, the sacred can include art, collecting, gardening, sports, nature, and a myriad of other activities and entities (Griffith & Griffith, 2002; Pargament, 2007). These endeavors can provide a transcendent sense of meaning, purpose, and connectivity for some individuals. Although the beliefs and practices might be considered secular, they are effectively accorded a sacred role in clients' lives. In other words, the fundamental human drive to construct a sacred reality is manifested in secular activities that provide people with a transcendent sense of meaning and purpose in their lives (Crisp, 2010; Pargament, 2007).

For such individuals, typical spiritual terminology can seem like a culturally foreign language that is irrelevant to their lived experience. Indeed, some secular individuals consider the use of spiritual terminology to be offensive (Paley, 2008, 2010). Even though secular activities may serve what is essentially a spiritual function, these clients may be uncomfortable or even unwilling to discuss these functions in the context of an explicit spiritual assessment. In such cases, an implicit spiritual assessment provides a vehicle to identify the role of the sacred in clients' lives. Indeed, for such clients, an implicit assessment may be the only way their understanding of the sacred can be explored.

Clients' Perceptions of Practitioners' Level of Spiritual Competence

Alternatively, some clients may question practitioners' level of spiritual competence. Clients in this category are comfortable with spiritual language but are unsure about the degree to which they can trust practitioners with a topic that is often intensely personal and private (Lewis, 2001). In short, they are hesitant to trust practitioners with such a private dimension of their being until practitioners have demonstrated themselves to be competent and trustworthy handling spiritual issues (Richards & Bergin, 2005).

The helping professions have long struggled with the issue of spiritual diversity. Committed atheists from Freud (1927/1964) to Ellis (1980) have attempted to pathologize devout spiritual belief. Clients are often extremely sensitive to these biases and may assume practitioners hold similar views (Richards & Bergin, 2005). Indeed, concerns about practitioners' level of spiritual competence are underscored by the fact that most social workers report receiving little, if any, training on spirituality during their graduate educations (Sheridan, 2009). Practitioners may inadvertently communicate disrespect for clients' spiritual beliefs and practices because of a lack of training and awareness regarding potentially sensitive issues.

Consequently, some clients may indicate that they are uninterested in discussing spirituality during the initial preliminary assessment (Richards & Bergin, 2005). Trust may be developed over time, however, as clients interact with practitioners. An implicit assessment provides a way to gently ease into the topic at a later point in therapy. An implicit approach provides a forum in which practitioners can communicate interest, openness, receptivity, and respect for clients' beliefs and values (Canda & Furman, 2010). In other words, when clients question practitioners' level of spiritual competence, an implicit assessment may offer a way to build mutual trust and respect. The process of operationalizing such an assessment is discussed in the next section.

MOVING TOWARD AN IMPLICIT SPIRITUAL ASSESSMENT

It is important to note that assessment is, in a certain sense, an ongoing process (Canda & Furman, 2010). Although a biopsychosocial assessment is typically conducted at the beginning of therapy, practitioners must remain open to revising their initial suppositions as additional information is obtained during subsequent sessions. Similarly, one should remain open to the possibility that spirituality plays an important role in clients' lives, even though the initial preliminary assessment indicates that spirituality is not a salient life dimension.

Toward this end, practitioners' "spiritual radar" should be turned on throughout the counseling process. The aim is to develop sensitivity to interactions that suggest the possibility that spirituality is a relevant dimension in clients' lives (Griffith & Griffith, 2002). Particularly helpful in this regard is listening for implied spiritual content in clients' narratives and attending to emotional shifts in clients' affect as they relate their stories.

Listening for Language that Connotes the Spiritual

A key component in operationalizing an implicit spiritual assessment is listening for language that hints at the presence of the spiritual. As noted above, explicit spiritual language may not resonate with some clients. In the same way, practitioners may not pick up on implicitly spiritual language (Pargament & Krumrei, 2009). Accordingly, it is important to listen for phrasing that suggests the existence of spiritually relevant topics in the course of the clinical dialogue (Griffith & Griffith, 2002).

For example, speaking in extremes or using major polarities may offer insight into clients' spirituality (Pargament, 2007). When clients refer to something as faultless, perfect, or flawless, they may be attributing aspects of divinity to the entity. Alternatively, clients may fixate on the negative. For example, when clients demonize someone, it may be a sign that the individual has violated what is perceived to be sacred.

Language that parallels spiritual thoughts and behaviors can indicate the existence of spiritually significant content. Clients may describe beliefs, practices, and experiences that do not seem explicitly spiritual but reflect an underlying spiritual dimension. For example, clients may participate in certain activities on a regular basis that are perceived to be highly meaningful. Such activities may represent rituals or ceremonies and may serve a transcendent purpose in clients' lives, engendering a sense of profound meaning and purpose (Crisp, 2010).

In short, practitioners should listen carefully for terms and phrases that signal the presence of spiritual issues below the surface. Clients often describe thoughts, experiences, and feelings that parallel the spiritual. These descriptions can signify the existence of clinically relevant topics that require further exploration.

Attending to Emotional Shifts

In addition to listening to clients' language, practitioners should also attend to clients' emotions. Many people experience spirituality primarily through their feelings (Pargament & Krumrei, 2009). Indeed, spiritual experiences can produce especially strong emotions.

Encounters with the transcendent often engender positive feelings (Exline, Park, Smyth, & Carey, 2011). Interactions with the sacred frequently result in feelings of awe, reverence, and solemnity; pleasure, joy, and excitement; and meaning, hope, and purpose. Although positive emotions are perhaps more commonplace, interactions with the sacred can also produce negative emotions, such as anger, discouragement, and regret. For example, upon moving to a new geographic location, a client might express deep regret over having to give up a sacred activity that nourished her soul.

Practitioners should be alert for changes in client affect during the flow of conversation (Griffith & Griffith, 2002). The presence of an emotion may indicate that a spiritually relevant topic has been touched on. For example, a hint of emotion in a client who is otherwise depressed--such as a sparkle in the eye or a smile--may indicate that the practitioner has broached a spiritually relevant topic.

Understanding what elicits powerful emotions can provide important insights into clients' relationship with the transcendent. In addition to watching for these types of emotional displays, practitioners can also facilitate this process through active exploration (Crisp, 2010). The next section discusses how practitioners can facilitate such an assessment.

CONDUCTING AN IMPLICIT SPIRITUAL ASSESSMENT

When clients' language or affect raises the possibility that spirituality may be related to service provision, it is usually appropriate to explore this possibility in more depth. In such circumstances, it is critical that client autonomy be respected (Nelson-Becker, 2005). Effective therapy is predicated upon the creation and maintenance of a non-coercive atmosphere in which self-determination is respected (Richards & Bergin, 2005). Practitioners must carefully monitor clients' reactions to ensure they remain supportive of the process throughout the exploration.

With this caveat in mind, the possible presence of spirituality can be explored through the use of various questions that implicitly tap spirituality. Sometimes called psychospiritual (Pargament, 2007) or existential (Griffith & Griffith, 2002) questions, these items are designed to elicit content about clients' relationship to the sacred or transcendent dimensions in a context in which a more direct exploration of spirituality is contraindicated. Some sample questions for conducting an implicit assessment are provided in Table 1. Adapted from a variety of sources, these questions can be used to indirectly explore the role of spirituality (Canda & Furman, 2010; Griffith & Griffith, 2002; Hodge, 2001; Pargament, 2007; Pargament & Krumrei, 2009).

Toward this end, various questions from this table can be integrated into the flow of conversation as needed. In a traditional comprehensive assessment, it is common practice to flesh out clients' spiritual stories across their life spans, typically moving from childhood through to the present, and even on into the future (Canda & Furman, 2010; Hodge, 2001; Pargament & Krumrei, 2009). Although the questions are presented in keeping with this convention, it should be stressed that this framework may not be applicable when conducting an implicit assessment. Practitioners should be alert to the possibility that spirituality may be clinically relevant at any time and ask questions that invite a deeper exploration of spirituality when clients' words or emotions allude to the presence of the sacred.

The first set of questions--past spirituality--is designed to explore the intersection between spirituality and clients' past, and perhaps particularly, their family of origin. Understanding how transcendent dimensions of existence functioned in the past provides the context for understanding how these dimensions function in the present (Hodge, 2001). Similarly, understanding how clients coped with previous challenges suggests possible coping strategies that might be leveraged to ameliorate current problems (Canda & Furman, 2010).

The second set of questions--present spirituality--addresses client's contemporary experience of the transcendent. This set is broken into two related groups. As implied by the heading, the first group examines how perceptions of the transcendent are manifested. These questions may be particularly helpful in fleshing out clients' understanding of the sacred. The second group examines how spirituality may facilitate health, wellness, and coping. Questions from this group can be used to explore strategies that might be used to address problems. For example, in the face of present difficulties, rituals or practices that foster wellness may have been ignored. Identifying and reinstituting such salutary practices may assist clients on their journey toward wellness (Saleebey, 2009).

The final question set--future spirituality--explores the role of the transcendent in future plans. Future aspirations are also a part of clients' sacred narratives. In the same way that past and present beliefs can shape current beliefs and practices, clients' views regarding their future can also shape present functioning. Accordingly, the exploration of future plans, goals, dreams, and expectations can provide important therapeutic insights (Hodge, 2005).

It is important to note that there is no single method for asking these questions in therapeutic settings. Assessment is a complex, multilevel process in which every client affirms a unique understanding of reality (Furness & Gilligan, 2010). Accordingly, the questions should be adapted and integrated into the therapeutic conversation in a way that makes sense in the context of clients' individual value systems (Hodge, 2001). Asking implicit spiritual questions, listening for language that connotes the sacred, and attending to emotional shifts is a complex process that varies from setting to setting. Yet, as the following example illustrates, this process can lead to significant therapeutic breakthroughs.

Ken, a 50-year-old Latino male, sought therapy for persistent feelings of fatigue and depression. A preliminary assessment revealed no religious affiliation or interest in spirituality. Counseling produced little improvement. That changed, however, when the practitioner asked about practices that had formerly nourished his soul. A spark appeared in Ken's eyes, and the tone of his voice became slightly more animated as he spoke about the place that music once occupied in his life. In college, Ken had an extensive album collection, played in a band, and was immersed in the local music scene. As the demands of his accounting career steadily increased over the years, his passion for music was slowly pushed to the margins of his life. Sensitivity to the spiritual dimension allowed the practitioner to engage Ken in a discussion about how his drive for professional success had resulted in Ken's neglect of a sacred activity that helped animate his life. Facilitating Ken's transition toward a more personally authentic path that nurtured his soul became a central focus of subsequent sessions.

Assessment focuses on understanding the intersection between the sacred and wellness. The goal is to understand the relationship between clients' understanding of the transcendent and service provision. In some cases, this may entail moving from an implicit assessment to a comprehensive assessment, a topic discussed in the following section.

MOVING FROM AN IMPLICIT ASSESSMENT TO A COMPREHENSIVE ASSESSMENT

The administration of an implicit assessment may reveal the presence of spirituality as a clinically relevant factor. As the above example illustrates, some clients report secular activities that function as sources of spiritual meaning in their lives (Crisp, 2010). Alternatively, in situations where clients are initially hesitant to trust practitioners, an implicit assessment may reveal more traditional understandings of spirituality. In either case, it may be helpful to use a comprehensive assessment to provide better understanding of the role of spirituality in clients' lived experience.

A conceptual model for integrating an implicit assessment with an explicit spiritual assessment is depicted in Figure 1. As can be seen, the process begins with a brief preliminary assessment. If the brief assessment reveals that spirituality is potentially related to service provision, then the practitioner generally moves directly to a comprehensive assessment. If the brief assessment indicates spirituality is unrelated to service provision, the practitioner adopts an implicit approach exploring potential expressions of spirituality if clients' language or affect suggest such an exploration is warranted.

If an implicit assessment indicates that the transcendent plays a salient role in clients' lives, then one of the many comprehensive tools that have been developed can be used to flesh out clients' spiritual reality. A comprehensive tool can often be used regardless of whether or not clients view themselves as spiritual or secular. For example, in the latter case, a spiritual life map might be used to diagram clients' primary sources of meaning and hope over the course of their lives (Hodge, 2005). The life map can be assigned as homework, saving valuable therapeutic time, and discussed in the next session. The physical depiction of clients' sources of strength can elicit fresh therapeutic insights, uncover unoperationalized assets, and suggest new strategies to ameliorate problems.

Central to the assessment process, however, is the creation of a caring, respectful, spiritually empathetic environment (see Figure 1). Indeed, the success of the therapeutic enterprise itself rests upon the creation of such an atmosphere. Toward this end, it is critical to obtain clients' consent before moving to a comprehensive assessment. Because of the profoundly personal nature of spirituality, practitioners should carefully monitor clients' verbal and nonverbal responses to ensure they consent to the assessment process from start to finish.

In light of the sensitive nature of spirituality and the attendant potential for harm, the choice to address spirituality in a more in-depth manner calls for careful consideration. For example, practitioners might assess their level of competence regarding clients' spiritual beliefs and values (NASW, 2001). Similarly, practitioners should possess sufficient training to ensure any spiritual strategies used in therapeutic settings can be implemented in a professional manner (Hodge, 2011). In certain situations, the results of the initial assessment may suggest that referral to other practitioners with more expertise with a given population (or intervention) is in clients' best interests.

The discussion of cultural competency highlights the issue of practitioners' level of personal comfort with spirituality. For a variety of reasons, some social workers believe that spirituality should not be addressed in clinical settings (Canda & Furman, 2010). An implicit assessment offers such individuals a vehicle for discussing spirituality in a more oblique manner. While practitioners must ensure they possess sufficient levels of cultural competency to provide effective services, an implicit assessment provides therapists who are uncomfortable with traditional spiritual language a way to discuss clinically salient transcendent dimensions.

Another option that covers terrain similar to that of an implicit spiritual assessment is an explicit existential assessment. Readers interested in this approach might consult the work of Yalom (1980). Although all therapists can likely benefit from Yalom's work, practitioners who are uncomfortable with traditional spiritual language might find it especially helpful.

CONCLUSION

Traditional spiritual assessment approaches represent a good fit for many clients (Canda & Furman, 2010; Hodge & Limb, 2010). For some, however, these methods may not represent valid approaches. Such clients may be better served by an implicit spiritual assessment.

For example, when working with clients who believe spiritual language is irrelevant to their lived experience, an implicit spiritual assessment provides a means to explore the transcendent dimension. Similarly, an implicit assessment offers practitioners a way to build trust and rapport when clients are hesitant to trust practitioners with a highly sensitive subject. In short, an implicit assessment helps practitioners identify and operationalize dimensions of clients' experience that might otherwise be overlooked in a traditional assessment. Consequently, it is an approach that essentially all practitioners can benefit from incorporating into their "assessment toolbox."

Caption: Figure 1: Conceptual Model for Integrating an Implicit Assessment with an Explicit Spiritual Assessment

doi: 10.1093/sw/swt019

Original manuscript received February 4, 2012

Final revision received July 14, 2012

Accepted July 31, 2012

Advance Access Publication June 13, 2013

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David R. Hodge, PhD, is associate professor of social work, Arizona State University, and senior nonresident fellow, Program for Research on Religion and Urban Civil Society, University of Pennsylvania. Address correspondence to the author at Mail Code 3920, 411 N. Central Avenue, Phoenix, AZ 85004-0689.

Table 1: Implicit Spiritual Assessment Questions

Past spirituality

What sort of experiences stood out for you when you were growing
up?

When you think back, what gave you a sense of meaning (or purpose,
or hope for the future)?

When were you happiest (or most joyful)?

As you consider your life, what accomplishments are you
particularly proud of?.

How did you cope with challenging situations in the past?

Present spirituality

Understanding how the transcendent or sacred is manifested

When do you feel most fully alive?

Who/what gives you a sense of purpose and meaning in life?

What causes you the greatest despair/suffering?

Can you describe recent experiences (for example, "aha moments")
that sparked new insights?

What things are you most passionate about in life?

If you had a magic wand, what would you change to make your life
more meaningful?

What helps you feel most aware (or centered)?

Who/what do you rely on most in life?

Who/what do you put your hope in?

For what are you most deeply grateful?

To whom/what are you most devoted?

To whom/what do you most freely express love?

What pulls you down and discourages you?

When in your life have you experienced forgiveness?

What are your deepest regrets?

Who best understands your situation?

Understanding how spirituality facilitates health, wellness, and
coping

What rituals/practices are especially important (or significant) to
you?

What kinds of experiences provide you with the deepest sense of
meaning in life?

How do you commemorate special occasions/accomplishments?

At the deepest levels of your being, what strengthens (or nurtures)
you?

What sustains you through difficulties?

What sources of strength do you draw on to keep pressing forward?

What nourishes your soul?

Where do you find a sense of peace (or inspiration)?

When you are in pain (or afraid), where do you turn for comfort?

How have difficult situations changed your life for the better?

What gives you the strength to carry on day after day?

What helps you get through times of difficulty (or crisis)?

Who supports you in hard times? How so?

Future spirituality

What are you striving for in life?

What are your goals for the future?

If you had just a year to live, what are the most important things
you would like to accomplish?

Why is it important that you are here in this world?

After you are gone, what legacy would you like to leave behind?

How would you like people to remember you after you are gone?
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