Clinical appraisal of spirituality: in search of rapid assessment instruments (RAIs) for Christian counseling.

Greggo, Stephen P. ; Lawrence, Karyn

Counseling that strives to be intentionally Christian invites expectations beyond problem resolution. It inspires hope of faith enhancement and spiritual enrichment. Given these core values for both clients and clinicians, it is worthwhile to adopt routine methods to locate common understandings, establish objectives, and track outcomes. Mental health professionals (MHPs) require strategic assessment techniques in order to direct helping endeavors towards such pivotal goals.

RAIs are semi-standardized measures with value for clinical practice due to accessibility, efficiency, and effectiveness. This investigation locates RAIs of spirituality and considers potential application in Christian counseling. This extended utility review routine is termed redemptive validity (RV) as the intent is to examine psychometrically sound assessment instruments through the lens of a theologically grounded Christian worldview. RV is the benefit derived from the use of assessment technology to promote wise living and foster change consistent with a client's Christian identity.

Utility investigations match instruments to specific purposes. Our objective is to locate select measures that blend seamlessly with a Christian worldview, add benefit to counseling that encourages faith maturation, and establishes markers to evaluate growth. The following assumptions guide this process. First, the implementation of spiritually-oriented assessments allows for the identification of clients with a clinically significant religious impairment (CSRI). A clinically significant religious impairment (CSRI) is the reduced functional ability to perform religious activities, achieve religious goals, or to experience religious states due to interference by the presence of a psychological disorder (Hathaway, 2003). Surfacing a CSRI makes an explicit link between spirituality and a mental health diagnosis. Beyond problem identification, a second reason is that clients with underlying faith values and traditions tend to invest more in counseling services when the process and goals align with their spiritual journey narrative (Turton, 2004; Worthington, Kurusu, McCullough, & Sandage, 1996). Therefore, the implementation of spiritually-oriented assessments, which acknowledge and utilize the spiritual experiences and resources of the client, will likely be appreciated by clients with Christian convictions; thus, contributing to positive therapeutic outcomes. Finally, clinical assessment done well enriches the therapeutic alliance as concerns are defined, values are clarified, and the direction for the partnership is developed (Sullivan, 1954). This survey identifies RAIs of spirituality that have the potential to reveal and organize information regarding CSRI functioning, contribute to the development of mutually defined outcomes, and offer a baseline from which to evaluate treatment progress.

Regrettably, counselors may underutilize standardized assessment due to restrictions on the use of psychological testing and role confusion related to the purpose. MHPs who are not psychologists may manifest ambivalent attitudes toward structured assessment. Further, heightened resistance to applied psychological assessment may be present amongst MHPs who practice within a Christian worldview. Regarding adoption, there may be suspicions regarding the validity of measures with a service population dedicated to traditional Christian views and values. In terms of evaluating outcomes, Scripture teaches that spiritual formation is exclusively under the domain of the Holy Spirit and gains are indications of divine grace (e.g., Gal. 5:22-26). The protest may then follow that an objective measure is, at best, a human work; but at its worse is judgmental, intrusive, condescending, and arrogant. The purpose of this exploration is to face such concerns with integrity through the application of a uniquely Christian utility review procedure. The RV procedure addresses the false dichotomy that spiritual formation is "Spiritled," while assessment is "man-led." By actively bringing the Holy Spirit into assessment selection, implementation, and interpretation, Christian MHPs can adopt both standardized and non-standardized measures of spirituality into customary clinical practice. This important venture may result not only in demonstrating gains in mental health outcomes with greater specificity, but also in greater intentionality regarding the pursuit of spiritual formation.

The Necessity for a Christian Assessment of Spirituality

These guidelines display the necessity for focused assessment in faith-attuned counseling.

Establish a Common Language and Clarify Theological Priorities

Talk therapy with intentions to be overtly religious according to Christian conventions necessitates respectful and thoughtful elucidation of differences in perspectives between the counselor and client. Not only does the global descriptor of "Christian" require a precise location within a doctrinal tradition and identifiable community, but the individual peculiarities of the client's faith identification and spiritual story need exploration. The era is past when a religious label or denominational affiliation can portray with reasonable accuracy a client's belief system, standards of spiritual maturity, or community-based behavioral practices. It is important to specify the meaning of religious terms, surface the underlying motivation for this faith pursuit, and identify preferred pathways to spiritual enrichment. For example, which, if any, of these reasonable objectives actually fits the intention of the client: achieving spiritual health (i.e., adaptability and optimal functioning), movement towards sanctification (i.e., progression in holy living), or advancement in Christian maturation (i.e., increased conformity to the image of Jesus Christ)? In contrast, a client may initially express an inclination to incorporate faith values within mental health treatment, but ultimately communicate that there be no disruption or destabilization of a familiar and personalized spiritual status quo.

Learning a client's spiritual history, faith preferences, and commitments is a critical assessment priority. However, Plante (2009) asserts that most MHPs do not adopt a systematic protocol to gather religious information. Without a solid grasp of the client's religious-spiritual history and recent habits obtained from intake forms or interview queries, it is impractical to select an appropriate instrument of spirituality. According to Plante (2009), clients with substantial religious history and devoutness require a detailed spiritual assessment prior to any incorporation of faith perspectives into the treatment approach. These important claims have critical ethical implications for MHPs whose niche population is decidedly Christian. When gathering routine information from clients, Christian counselors must also learn to thoroughly investigate spiritual history (Plante, 2009; Sperry, 2011).

Consider this quick mnemonic to prompt a basic interview sequence for gathering such information. Follow the acrostic FICA: faith, importance, community, address (Pulchalski, 2006). Do you consider yourself to be a person of faith and how do you describe your faith tradition? What importance does your faith have in your life? Are you participating in a church or faith community? How would you like me to address these spiritual matters in your care?

Specify Expectations for Christian Counseling

Clients who express inclinations toward Christian counseling have exceedingly diverse ideas about what such a request represents (Greggo & Sisemore, 2012; Johnson, 2010; McMinn, Staley, Webb & Seegobin, 2010). This request may be a declaration that all recommendations and helping techniques must rest directly on a biblical chapter or verse. Alternatively, the client might desire the grace associated with unconditional positive regard or perceive the therapist in a priestly or pastoral role. Phrases heard on a radio program, from a trusted friend, family member, or pastor may be parroted. The client's contention may indeed be that unless therapy is from a distinct brand the process itself is not trustworthy. Thus, given the diversity of these anticipations, it is essential to the therapeutic process that the MHP determine the unique expectations of the client. Such expectations might be addressed by asking the following questions: given the importance of your walk with Christ, what hopes and expectations do you have for our counseling efforts? Have you given thought to what distinctively Christian counseling will look like as we work on your particular concerns? The MHP is also likely to hold deep convictions about the implications of the Christian counseling label for treatment priorities, curative processes, and reliance on the triune Godhead. Therefore, during early clinical encounters, the MHP seeks to understand the client's expectations, strives to obtain sufficient agreement in procedure and outlook to enable a therapeutic partnership, and communicates to achieve reasonable informed consent (Turton, 2004).

Identify Faith-Linked Resources and Liabilities

There is recognition within a broad range of psychiatric and mental health services that spirituality, manifested in private or public religious formulations, is both potentially a source of conflict and a client resource (Pargament, 2007). Current perspectives describe spirituality as a combination of values (i.e., passions and moral convictions), vision (i.e., mission, calling, and purpose), and lived experience (i.e., subjective and emotional states) shaped and stimulated by an awareness of a transcendent force that may or may not include a distinct deity (Aten & Leach, 2009; Frame, 2003). The past decade has been marked with extensive development of evidence-based opportunities along with ethical parameters to incorporate a client's sacred worldview and cherished relationships into treatment (Aten, McMinn, & Worthing ton, 2011; Gold, 2010). The openness of MHPs to the recognition of persons as bio-psycho-social and spiritual is a refreshing shift for those who understand that achieving mental health, living out the tenants of Scripture, and demonstrating the fruits of the Spirit are mutually reinforcing pursuits. Beyond openness to therapy that addresses spiritual enhancement, there is a growing awareness among MHPs regarding our clinical responsibility to consider how beliefs about the sacred are operating for better or for worse (Pargament, 2007).

An assortment of credible measures exists to aid in investigating the dimensions of spiritual and religious themes and experience within a client's story (Hill & Pargament, 2008; Hill, Kopp, & Bollinger, 2007; Hill & Kilian, 2003; Standard, Sandhu, & Painter, 2000). The majority are tools designed to measure religiousness and spirituality throughout the lifespan, across traditions, and cultural and ethnic communities. The intended reporters are research participants who may hold individualistic or syncretistic conceptions of transcendence and moral experience. Inclusiveness and broad applicability in a measurement tool is indeed a virtue in research designs intended to expand understanding of religious experience or tease out the consequences of belief for health and wellness. As a result, such tools require additional scrutiny before their application within the narrow sub-specialty of counseling that by mutual agreement between counselor, client, and setting is unequivocally Christian. Given the broad range of core theological convictions and how these inform professional practice, the authors will clarify their assumptions. The Christian faith holds that God speaks through Scripture and in the Word made flesh. The triune God is no mere impersonal, transcendent force. The centerpiece of Christianity is a personal and self-revealing Creator who invites human beings, made in his image, into a transparent and authentic relationship with himself (Gen. 1:26-27; Jn. 3:16, 10:10; Rom. 1:16-17; 1 Jn. 1:1-9). When the adjective "Christian" becomes the qualifier that defines counseling, there is an intentional linking between worldview, theological beliefs, psychological perspectives, and values for living. The RV procedure is proposed to bring quality tools into helping relationships grounded in a robust Christian tradition.

Locating RAIs of Spirituality and Religiousness

The instruments selected for application into clinical practice meet the basic criteria for RAIs proposed by Fisher and Corcoran (2007). In direct therapy, a RAI is a semi-standardized measure that provides a concise, convenient, and credible means of capturing discrete data on an indicator related to the broader presenting concern. RAIs do not replace, but compliment other assessment methods such as behavioral observations, client logs, individualized ratings scales, physiological measures, or standardized self-report questionnaires (e.g., NEO Personality Inventory- 3, the Millon Clinical Multiaxial Inventory III, or the 16 Personality Factor Inventory). The divide between RAIs and other standardized measures is a matter of focus, pragmatics, and the availability of normative data. Generally, RAIs quantify observations, but do not produce standard scores for comparison with a broader norming sample. RAIs are short, quick to complete, transparent in focus, easy to score, and clinician friendly self-report measures. Additionally, RAIs are not unilateral in their theoretical orientation. Ultimately, they provide a structured opportunity to collect data in order to define an issue and make comparisons (Fisher & Corcoran, 2007). RAIs make it possible to meet contemporary clinical accountability standards by demonstrating treatment outcomes either directly to clients or other invested parties. Fisher and Corcoran's (2007) two-volume RAI collection spans nearly 900 pages with 471 measures for children, adults, and families on diverse issues from procrastination to threat appraisal to eating patterns to sexual attitudes. Remarkably, despite the scope of problems and concerns represented in these volumes, no RAIs of spirituality or religiousness are included.

A preliminary investigation located 21 measures of spirituality and religiousness with reasonable psychometric qualities and clinical potential (see Table 1). This list is the result of gleaning from existing reviews (Gold, 2010; Pargament & Krum rei, 2009; Plante, 2009; Hill & Pargament, 2008; Hill, Kopp, & Bollinger, 2007; Hill & Kilian, 2003; Hill & Hood, 1999). The procedure is a noteworthy deviation since the convention is to consult the Mental Measurements Yearbook (MMY). Only one measure was in the MMY database, suggesting that currently, tools that capture and categorize spiritual features are not tightly standardized nor commercially marketed. Therefore, it was necessary to browse the broader literature and locate comprehensive measurement reviews. Alternative lists and recommendations are located in Plante (2009); Gold (2010); Hill, Kopp, and Bollinger (2007); and Hill & Hood (1999).

The second phase took the identified measures through a utility screening procedure with four general considerations in mind: fit within the parameters of an RAI, acceptable to favorable psychometric properties, availability and accessibility, and the potential for application with a population that holds a Christian theological worldview. These tools reflect diverse operational definitions that quantify complex, emotionally-charged, multidimensional phenomena; namely religious and spiritual experience. Gauging which tool is a best fit for a given population requires careful consideration of the features of the client population and maintaining awareness for how particular MHPs are inclined to blend results into treatment.

The clinical setting prototypes were those with which the authors are affiliated. The first is a long-standing, outpatient mental health practice with an explicit Christian identity (www.ccahope.com) and the other, a counseling center at a denominational university (http://www.teds.edu/community-life/student-services/counseling.dot). Both settings have an established clientele who express a preference for counseling that reflects an evangelical, biblical, and wholly Christian foundation. The same screening procedure when undertaken with other agencies in view might result in a different selection of RAIs of spirituality. After all, a utility review looks beyond psychometric properties to consider these questions: what does this instrument add to the assessment process and will its results be beneficial to our clients? A utility search is not solely about the quality of the instrument. Rather, it is about locating the best fit between the measure, assessment purpose, resources, and client population.

In order to sharpen our grasp of construct validity and increase our appreciation for the distinct purpose of each instrument during the selection procedure, a categorical grid from an earlier research review was applied (Hill, Kopp, & Bollinger, 2007). This grid clarifies what each of the measures intends to accomplish. Eight dimensions of religiousness and spirituality fall under two overarching headings that essentially mirror the customary trait (i.e., long-term) and state (i.e., current experience) designations common in assessment discussion. Dispositional measures aim to uncover persistent patterns and leanings. The following are sub-dimensions under this heading: general scales, commitment inventories, and measures of developmental spiritual maturity. Functional measures capture everyday coping mechanisms, behaving, and feeling. Five sub-dimensions with a temporal focus follow: religious motivation, social and faith community participation, spiritual private practices, religious support, and spiritual coping. Each of these eight categories was represented by at least one measure in our secondary selection process. This procedure ensured a respectable range of measures representing diverse definitions of spirituality and religiousness.

This is the selected list of RAIs of spirituality and religiousness: Brief Multidimensional Measure of Religiousness and Spirituality (BMMRS), Religious Commitment Inventory-10 (RCI-10), Brief RCOPE, Santa Clara Strength of Religious Faith Questionnaire (SCSORF), Spiritual Well-Being Scale (SWBS), Springfield Religiosity Scale (SRS), Revised Religious Orientation Scale (RROS), Religious Support Scale (RSS), Duke Religion Index (DRI), and Spiritual Assessment Inventory (SAI).

In Search of RAIs with Redemptive Validity Potential

Counselors can incorporate a proposed validity subtype into their evaluation of measurement tools. MHPs are encouraged to take measurement theory to theology and then into clinical efforts that honor the Lord. Redemptive validity (RV) is the effectiveness of an assessment instrument that samples behavior or attitudes to provide insight into wise living in conformity with the reality and truth of Scripture for believers who desire to grow in reliance on the Creator. Specific criteria to consider in the RV rubric will vary according to faith tradition, doctrinal convictions, the therapeutic context, and the extent of the mutually determined spiritual life objectives. The recommendation is that when matters of faith are clinically relevant that MHPs identify RV factors and apply them with intentionality in assessment selection.

The authors' intent is to demonstrate the benefit of RV for routine instrument utility review. The Clinical Assessment Instrument Christian Evaluation Form (CAICEF) is a guided procedure to stimulate theological reflection on a psychological or behavior measure applied in Christian counseling (Greggo & Lawrence, 2012). It coaches users to follow the steps of a typical psychometric review. Namely, unless a measure displays satisfactory psychometric characteristics (reliability, validity, and normative data) it is unlikely to have any substantial research or clinical application. The CAICEF then moves further to ponder the theological implications of a measure's construct, content, and criterion-related validity features. RV is not a characteristic of the measure itself. Instead, it is a method to weigh the client experience, addressing the items as well as the language, underlying values, and data obtained by the measure against the Gospel story of creation, fall, redemption, and restoration. Previous reviews of these RAIs of spirituality and religiousness focus on the essential features and psychometric aspects of the instruments. The following summaries report RV and utility observations generated by comprehensive CAICEF reviews.

Brief Multidimensional Measure of Religiousness and Spirituality (BMMRS)

Features. The BMMRS is a general scale of both dispositional and functional religiousness and spirituality and is highly effective as research instrument. It has appeared in many investigations on how diverse religious and spirituality (R/S) pathways influence health and well-being (Fetzer, 1999). The stand-out feature is its multifaceted coverage of critical domains such as community or denominational affiliation, public and private practices, values and beliefs, coping, and social support. This measure is the product of extensive collaboration between social science and medical epidemiology experts. Thus, the BMMRS gleaned considerable benefit from psychometric investigations conducted on other measures for both its items and interpretive guidelines.

Utility and Redemptive Validity. There is validity support for the BMMRS factor structure. In addition, the measure is suitable for adults, college, and adolescent clients (Masters et al., 2009; Harris et al., 2008; Fetzer, 1999). Its multidimensional breadth and inclusive appeal are notable strengths that transfer well into clinical settings. Yet, these same features have a downside. As a RAI, the scoring and interpretation are not entirely forthright due to the number of subscales with differing methods of scaling. Further, while it does collect an impressive amount of information in 36 questions, it compromises specificity in what it measures. This may result in considerable ground for MHPs to cover in a follow-up interview. In terms of RV, several concerns surfaced. First, while the items can signal spiritual distress if negatively endorsed, they do not necessarily suggest adherence or resemblance to Christian orthodoxy if positively endorsed. Second, the intentionally pluralistic wording of certain items (i.e., "mediation"; "life as part of a larger spiritual force"; "working together with God as partner") may be off-putting or easily misunderstood by evangelical Christians. This has the potential to skew results within our target population. Third, while the private religious practice subscale does have items that evangelical Christians are likely to endorse (i.e., prayer and Scripture reading), the subscale has a narrow focus and is prone to a ceiling effect. It would be difficult to distinguish between highly religious evangelical Christians (i.e., those who engage in additional spiritual disciplines) and average discipleship practices (i.e., those who engage solely in the listed practices). Overall, despite its clear initial appeal for its comprehensiveness, the BMMRS in Christian counseling may tend to extend or distract, rather than focus follow-up client conversations.

Santa Clara Strength of Religious Faith Questionnaire (SCSORF)

Features. The SCSORF, a 10-item scale with a viable option to use only five items, quantifies a client's general faith intensity (Plante, 2009; Freiheit, Sonstegard, Schmitt, & Vye, C., 2006; Plante & Boccaccini, 1997a; 1997b). It rates the declaration of religious faith that can anchor one's identity. It has relatively few items that address everyday practice. Given its brevity and directness, the SCSORF is a model method to discern and document that a client is both suitable and amenable to counseling that explicitly incorporates a Christian worldview and spiritual resources.

Utility and Redemptive Validity. The SCSORF quickly supplies a self-report on one's depth of faith. Given its inclusive language, minimalist style, and ease of scoring, it could certainly blend easily into initial paperwork. Administration can be repeated to track religious faith as an outcome when counseling intentionally addresses this factor. The beauty of this tool is indeed its simplicity. Still, it may not be best choice for highly committed evangelicals who may desire items that allow for a more robust expression of priorities, degree of devotion, and cherished practices. It is a great fit for a religiously affiliated college setting where students might display a wide range of faith commitment.

Religious Commitment Inventory (RCI-10)

Features. As its name plainly states, the RCI-10 is a commitment yardstick that provides a quantified score for the degree of adherence between internalized religious beliefs and daily faith practice (Worthington et al., 2003). It is a prototypical RAI with a single focus, easy scoring, and plain interpretation. As is evident by the psychometric research that operationalizes this construct and reduces the item count from 64 to 10, the RCI displays adequate data to support its use in research and clinical practice. Normative data is available to differentiate low/high religious commitment using means and standard deviations. It is possible to compare obtained scores with a range of comparable populations, including clients in Christian counseling agencies.

Utility and Redemptive Validity. One objective of the RCI-10 developers was to tailor a psychometrically valid measure with utility for religiously committed clients (Worthington et al., 2003). Given its tight focus, uncomplicated format, and normative data, it offers considerable potential for clinical application in Christian settings. It does not appear that any specific item would cause difficulties with an evangelical Christian population. However, the frequent use of "religious" might be less than ideal given the recent rejection of this term by younger evangelicals who prefer the use of words such as "faith" or "spiritual journey." This may be a matter of face validity, yet acceptance of a measure by the service population is always a significant consideration. In regards to interpretation, a low score might indicate individuals who lack a faith tradition and reject religious beliefs or individuals with `low consistency between reported convictions and behavioral commitments. Thus, the RCI-10 does yield data useful to identify clients with CSRI even though the reasons for a low score require further investigation. The RCI-10 measures the degree to which an individual puts faith into action (Jas. 2:14-26). After clarification of the meaning of a low, midrange, or high score, the RCI-10 provides identifiable material to ground faith interventions that could increase the link between belief and action (i.e., fellowship, tithing, prayer, worship, etc.). This is critical. The RCI-10 provides a snapshot of only one spiritual dimension: consistency between belief and routine activity. Nonetheless, having a concrete, quantified sample of such behavior could readily result in a productive conversation with clients who desire an authentic walk with Jesus Christ.

Spiritual Well-Being Scale (SWBS)

Features. The SWBS is a general dispositional measure of spirituality and religiousness (Hill, Kopp, & Bollinger, 2007). It is the one instrument formally reviewed in the MMY (D'Costa, 1995; Schoenrade, 1995) and is available for bulk purchase (http://www.lifeadvance.com). Reviewers have cited one concern, namely that the measure has a ceiling effect when used with devoted religious people, which may indeed be an undesirable factor given our identified settings (Schoenrade, 1995; Boivin, Kirby, Underwood, & Silva, 1999). Its exceptional feature is the subscale division that separates religious well-being (RWB; e.g., "I believe that God loves me and cares about me.") and existential well-being (EWB; e.g., "I feel good about my future."; Plante, 2009). This tool has a substantial basis in theory and the constructs originally were explored on population samples with traditional Christian values (D'Costa, 1995; Boivin, Kirby, Underwood, & Silva, 1999). While the specificity of the pilot population could be a deficit for general research purposes, it is an asset given our target service population. In its long history, the measure has been a significant research tool with well-established ties to CAPS (Ellison, 1983; Paloutzian & Ellison, 1982).

Utility and Redemptive Validity. The SWBS is an efficient measure to estimate an individual's sense of spiritual well-being (SWB). The two subscales, EWB and RWB, may further identify and clarify spiritual distress. Having such information could function as a platform for dialogue on how the presenting problem may or may not be affecting SWB. Several items would function well as treatment outcome evaluation benchmarks in intentionally Christian counseling (e.g., "I don't find much satisfaction in private prayer with God"; "Life doesn't have much meaning"; "I believe there is some real purpose for my life").

Springfield Religiosity Scale (SRS)

Features. The SRS is a functional measure that aims to ascertain participation in a religious community or organization (Hill, Kopp, & Bollinger, 2007). The SRS took shape as a research tool for use with a geriatric population, although there is support for its broader use. Given the existing published information, the generalizability of the SRS is questionable given its nearly exclusive use with geriatric clients. At face value, this is an apparent strike against the measure for general practice. Developers set out to form a measure that would find a warm welcome in a population associated with Judeo-Christian traditions and where 90 percent of users were either Protestant or Catholic (Koenig, Smiley, & Gonzales, 1988). By design the instrument visibly reflects Christian beliefs and activities.

Utility and Redemptive Validity. The dimensions of religion included in the SRS are beliefs, rituals, experiences, knowledge, communal participation, spiritual well-being, and intrinsic religiosity. Unique to the SRS is that belief is associated with Christian orthodoxy. The measure contains four items to assess core positions on one's concept of God, the divinity of Jesus Christ, biblical authority, and the existence of the Devil. This feature alone increases its RV with the target population. Overall, the SRS provides clinicians with a multifaceted portrait of Christian spirituality. It would be suitable for adoption, with slight updating, as a formalized questionnaire. As such, the SRS would function as a conversation starter with discrete items as topics for consideration. In order to gain benefit from its factor structure, modification would be necessary to specify and streamline scoring procedures.

Revised Religious Orientation Scale (RROS)

Features. The RROS is a revised questionnaire based on Allport and Ross's (1967) Religious Orientation Scale, deriving its items from long-standing research that divides religiosity into extrinsic and intrinsic components (Plante, 2009; Gorsuch & McPherson, 1989). This is a functional measure that has acceptable psychometric properties and seeks to classify the motivation underlying faith (Hill, Kopp, & Bollinger, 2007; Hill, 1999b). It is a reasonable and brief RAI with clear-cut scoring.

Utility and Redemptive Validity. In terms of RV, its framework of extrinsic versus intrinsic motivation is unimpressive. The items press to uncover motives, but item endorsement in a particular direction would not reveal enough information to draw firm inferences. For instance, when answering an item on the importance of spending time in prayer, one might do these things because of a secure attachment to the Lord, a desire to be more Christ-like, or to display obedience. Another might do these things because of one's upbringing. The RROS builds on the assumption that one demonstrates a mature faith by endorsing intrinsic items. This assumption is too simplistic for a contemporary, culturally diverse clinical context.

Religious Support Scale (RSS)

Features. The RSS, with its 21 items, succinctly measures a single aspect of spiritual distress, namely religious support (Plante, 2009; Lazar & Bjorck, 2008). The item arrangement taps into three prime sources of support: religious community, spiritual leadership, and divine intervention. The language is intentionally inclusive, but no phrases appear troublesome for an evangelical population.

Utility and Redemptive Validity. The target construct of religious support would indeed be useful for select clients with particular clinical issues (i.e., depression, isolation, or social anxiety). Thus, with its pointed application, this measure may be a best fit when applied to specific cases, such as when an increased perception of social/spiritual support is an identified outcome in the treatment plan. The support aspect of faith, though critical and essential, may not be broad enough to warrant adoption of the RSS as a routine assessment tool.

Duke Religion Index (DRI)

Features. The 5-item DRI, designed for large-scale epidemiological research, rapidly captures estimates of three religious dimensions: organizational (i.e., one item on frequency of attendance at religious services); non-organizational (i.e., a single item on prayer and religious study); and intrinsic (i.e., three items from Hoge's (1972) Intrinsic Religiosity Scale measuring one's experience of the presence of the Divine). The psychometric evidence is supportive and extensive (i.e., 100 published studies; availability in 10 languages). It has been the key method to catalogue religious data on thousands of research participants across the entire span of adult development (Koenig & Bussing, 2010; Storch et al., 2004; Hill, 1999a). The authors caution against calculating a total score, although alternative scoring methods can generate a total score. For clinical use, the preferred approach would be to follow the authors' recommendation and look at each of its three scales separately. Use the first item to assess organizational participation, the second to gauge private devotional activity, and combine the last three to capture how the client merges faith into life as a whole. Given the brevity of the measure, it would be reasonable to collect results to evaluate change following counseling intervention.

Utility and Redemptive Validity. The language on this measure is broadly compatible with Christian traditions. Still, when applied in an explicit evangelical setting, the phrase "private religious activities" may be supplemented with "spiritual disciplines" to better capture an individual's solitary engagement in prayer, Scripture reading, and personal worship. Given its survey use design, the DRI could be tied to demographic forms and other information gathering techniques prior to the initial consultation or near the outset of the intake process. The clinician could then explore responses in an early interview. This compact tool is up-to-date, efficient, and shows promise as a basic objective method to launch further discussion into spiritual history and present experience.

Brief RCOPE

Features. The brief RCOPE is a 14-item abridgement of a comprehensive measure of religious coping that addresses five faith functions: search for meaning, control, spiritual comfort, spiritual intimacy, and life transformation (Pargament, Koenig, & Perez, 2000). This measure applies to the aftermath of an adverse event or significant season of illness or stress. An important assumption within the measure is that clients may demonstrate positive religious coping (PRC) or negative religious coping (NRC). This dispels the myth that all spirituality and religious activity is constructive and healthy. This measure identifies the dark side or dysfunctional forms of religious coping such as feeling punished or abandoned by God, attributing an experience to the devil's control, or questioning the power of God.

Utility and Redemptive Validity. In terms of RV, the Brief RCOPE has much to offer for clients who are in the midst of spiritual distress. Specifically, either low scores on PRC or a high score on NRS identifies spiritual distress. This may indicate the lack of dependence on or attachment to the Lord or ignorance of biblical truths (i.e., forgiveness, the character of God, etc.). Since this measure has a definitive functional aim and assumes adversity or suffering, it is not appropriate for all clients.

Spiritual Assessment Inventory (SAI)

Features. The SAI examines spiritual maturity by considering two primary dimensions: quality of relationship with God and awareness of God (Hall, Reise, & Haviland, 2007; Hall & Edwards, 2002; Hall & Edwards, 1996). It achieves a portrait of psychospiritual development through five subscales: awareness, realistic acceptance, disappointment, grandiosity, and instability. Using theoretical concepts from object relations and attachment theory, the SAI looks at spiritual maturation by investigating one's relationship with God. The norming population leans heavily on religiously committed college students, yet psychometric investigation supports its structure and items (Tisdale, 1999).

Utility and Redemptive Validity. The measure is 54 items and would be relatively easy for a client to complete. On the other hand, the effort and time a clinician would have to invest to calculate subscale scores and responsibly interpret the measure is more demanding. Upon close examination, it is misleading to classify the SAI as an RAI. It is a slightly more sophisticated tool that may be well worth the learning curve and additional assessment effort. Yet, with its theoretical underpinnings, complexity, and impression management scale, the SAI is a notch above the typical RAI in terms of standardardization. It is not a "pick-up and go" style instrument, the hallmark feature of an RAI.

Nevertheless, Hall and Edwards (1996) developed the SAI from a Judeo-Christian perspective with specific New Testament themes in mind. Its biblical relational view, based upon the imago Dei (Gen. 1:26), is its underlying theological and theoretical premise. Further, the authors build upon the theme of "love" based on the greatest commandment in Mk. 12:28-31. These features dramatically impact its RV. Therefore, the information gathered from the SAI is likely to be more informative concerning an individual's spiritual status, particularly in terms of one's security of attachment with the Lord. This SAI is a measure to apply with select clients when exploring critical spiritual formation and relational themes. Its value may become evident in settings where therapy tends to extend beyond crisis intervention and basic cognitive behavioral approaches.

Limitations and Best Practice

These general statements reflect consistent comments across the ten CAICEF reviews.

* Follow-up interviewing is necessary on noteworthy responses to address the origins and reasoning beneath the item content.

* An adequate assessment of spiritual history should accompany these assessments to identify faith affiliation, specific beliefs and practices, and noteworthy turning points (negative and/or positive). The clinician must probe and evaluate the immediate context of the stressors and their relationship to the client's spiritual state.

* Most RAIs lack detailed directions for interpretation. The responsibility for any explanation of content is the direct result of the astuteness of the counselor. Clinicians may require training on how best to blend spiritual matters ethically into counseling, especially when a spiritual/faith background of the client is not an identical match with the clinician. This is likely to be the case more often than not. Christianity has a wide range of distinctive formulations, cultural expressions, and ethnic traditions. RV is a way to line-up a measure to a target population. The next level of application is matching an instrument to a unique client.

* Given the transparency of RAIs, there is concern over potential response style distortions common to all self-report measures (i.e., faking good/bad; making a positive impression, etc.). The exclusive check for whether or not the assessment results are a valid representation of the individual comes from the judgment of the clinician.

* The concentrated focus of functional spiritual assessments means that the aim is to sample a specific domain. Thus, the results signal only a slice of actual spiritual distress. The counselor must pursue the concern via conversation to obtain a comprehensive perspective, ascertain the precise nature of the spiritual condition, and evaluate the extent of any distress.

* The normative data for these RAIs is limited. Sample size populations are characteristically small and there is no attempt to match the diversity ratios with recent census data. This raises a concern especially when these RAIs are put to use with racially and ethnically diverse clients such as international or ESL students. Developing local norms is a good procedure as well as remaining vigilant to the expression of cultural differences.

Spirituality Focused RAIs and Christian Counseling

A reasonable assortment of spiritually-focused RAIs is indeed available. Several have remarkable potential for application in counseling partnerships that by mutual agreement will be explicitly Christian. We conclude with four recommendations to adopt select RAIs. For the sake of illustration, after each recommendation there is discussion on how the results of this CAICEF review will inform the assessment protocols for the two agencies immediately relevant to the authors.

1. Document the appropriate fit of an overtly Christian approach by using an RAI to record the client's general religious and spiritual values, preferences, and presenting concerns.

A dispositional, spirituality-focused RAI could blend smoothly into the personal information forms that a client completes within customary intake procedures. Alternatively, RAI responses could be gathered when other standard assessments are administered or at the time of an initial consultation. An RAI of spirituality could be utilized in Christian counseling like a heath checklist functions prior to a primarily care visit. Such a decisive step would tie the client's request for service with a preference for a spiritually integrated approach. Three of the instruments reviewed are well suited for such a purpose (i.e., DRI, RCI-10, SCSORF). The choice for both the community practice and the university counseling center under consideration here is the DRI. Its wide application on national surveys lends it credibility, its quick five-item format makes it efficient, and its three subscale categories offer a neat bridge to key topics when taking a spiritual history. The RCI-10 does have the advantage of probing consistency between belief and practice, yet it lacks the conciseness and style to fit seamlessly with other intake forms. The causal but useful approach of the SCSORF would make it the optimal choice for the university counseling center if the population were primarily undergraduates. However, given the age and ethnic diversity of graduate students and staff who are frequently seen, the DRI was determined to be a better fit.

2. Select an RAI to assist in the establishment of quantifiable benchmarks regarding faith resources that will help to organize information regarding a client's spiritual journey and identify options to include in a treatment plan.

The use of scaling questions to establish clarity on disturbing issues or on the frequency of a behavior pattern is a common technique in early interviews. Once the means for rating a behavior is in place there is a method to track it over time. In Christian counseling, insight into religious commitment and practice is foundational. Thus, having a starting set of reliable items to obtain scaling information would be extremely constructive. Further, the procedure of posing sequenced questions about spiritual practices to clients serves as a prompt to take a closer inventory regarding these everyday routines. Several of the RAIs could launch this effort (i.e., SCSORF, DRI, SWBS, RCI 10). The selection of the DRI for both target settings intentionally dovetails with this second objective. The DRI establishes a sense of organization participation (i.e., attendance at a religious service), personal faith practices (i.e., prayer and bible study), and a client's intent to have religious beliefs regulate one's lifestyle. Thus, it offers a tangible introduction to explore and track select faith related matters in subsequent interviews.

3. Build a short list of "ready-to-roll" RAIs to address functional areas associated with a counseling agency's typical symptom profiles and presenting concerns. Utilize a focused instrument to heighten awareness of resources or to identify potential ways to expand support.

RAIs are a means to assess functioning in a circumscribed domain (i.e., depression, anxiety, procrastination, parenting style, etc.) to gain insight into the individual's unique manifestation of a concern or to objectively demonstrate progress (Fisher & Corcoran, 2007). In Christian counseling, it is no less important to address presenting concerns, yet there is often client interest in nurturing one's spiritual life in the midst of addressing the critical issue. It makes sense to identify areas of spiritual functioning that could help relieve the reason for referral or build resources to reduce its impact. Thus, clinicians may have measures readily accessible to expand insight on religious coping (i.e., Brief RCOPE), spiritual flourishing (i.e., SWBS, SAI), and supportive fellowship (i.e., SRS, RSS).

For our target Christian community mental health practice, the SRS could be a useful means to rapidly obtain an immediate impression of Christian orthodoxy and determine alignment with a faith community. This will require slight adjustment in the wording of SRS items and reorganizing the format for ease of review. It is legitimate to ask if the development of a fresh tool would be preferable. However, given the extensive effort to establish a reliable and valid measure for research purposes, it is reasonable to make modest modifications on a proven tool to extend its usage into clinical practice.

As is typical of a Christian university setting, our clinic commonly sees numerous clients who struggle with issues of sexual purity. Often the associated behaviors evoke shame, isolation, and avoidance of intimate Christian settings where accountability is readily available. The RSS identifies engagement with support areas such as one's faith community, spiritual leadership, and divine conversations. Therefore, the RSS could be a rapid means of tracking progress on counseling efforts to increase support in fellowship settings.

Both of our target clinical settings could readily make use of the SAI with its focus on one's relational attachment to God. Clients enter counseling with a stated problem focus. Nevertheless, it is common to explore the relational and spiritual reverberations more broadly in the context of an established therapeutic relationship. The community practice has a staff of veteran therapists who are disposed towards depth psychology and interpersonal cognitive approaches. In our Christian university clinic, identity and developmental transitions often bring relational/spiritual matters front and center. It is reasonable to explore this instrument fully by pilot use with select clients.

4. Use quantified ratings made evident in an RAI (i.e., total score, subscale, or single item) to identify and pursue specific faith development targets for intervention.

When client and counselor set an agenda to merge a desire for change with a call to holy living or deeper biblical obedience, then it is reasonable to have at least one therapeutic goal that relates directly to faith development. Any of these RAIs could be helpful in directing a counseling conversation in a productive direction for spiritual formation. Look closely at extreme ratings on select items or subscales that highlight an underutilized resource. In clinical dialogue, build off the language and item intent to arrive at a collaborative goal. For example, should the DRI reveal on its initial item that a client has no existing or vital community for worship, teaching, or fellowship, a treatment goal could be formulated that will explore and address this gap. There will likely be practical, relational, or clinical reasons for the absence of involvement in Christian community. Nevertheless, a redemptive aspect of counseling could be to realize participation in the living body of Jesus Christ (Heb. 10:23-25). In short, it may not be necessary or even productive to re-administer an entire RAI as an outcome measure. An increase in one's total score may not reveal spiritual maturation. It is utterly practical to use RAI results to establish specific and productive treatment objectives. This quality, mutually endorsed, and obtainable goal becomes a customized means to consistently track progress.

In conclusion, assessment is indeed an essential aspect of quality mental health service. Despite the dependence in Christian helping on the movement of the Holy Spirit and the experience of Divine grace, there is no reason to avoid the use of instruments that increase wise understanding and clarify behavioral change. What is imperative is that counselors learn to select the best measures possible. This begins as a technical process to explore psychometric strength and clinical utility. It reaches fulfillment in Christian counseling when a client is encouraged and blessed in their spiritual journey.

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Stephen P. Greggo

Karyn Lawrence

Trinity Evangelical Divinity School

Correspondence concerning this article should be addressed to Stephen P. Greggo, Department of Mental Health Counseling, Trinity Evangelical Divinity School, 2065 Half Day Road, Deerfield, IL 60015; [email protected]. This paper was presented on March 31, 2012 at the Annual Meeting of the Christian Association for Psychological Studies (CAPS) in Washington, DC.

Auhor Info

Rev. Stephen P. Greggo, PsyD, Psychologist, Professor of Mental Health Counseling at Trinity Evangelical Divinity School, and co-editor of Counseling and Christianity: Five Approaches (IVP, 2012). Dr. Greggo is invested in the intersection of pastoral care, contemporary counseling and evangelical Christian theology. He is currently exploring how mental health professionals can use assessment to promote quality clinical care that is distinctively Christian.

Karyn Lawrence, MA, Professional Counselor. Ms. Lawrence completed her clinical internship at the Trinity International University Counseling Center with a focus on assessment and spiritual formation.