Redemptive validity and the assessment of depression: singing songs to heavy hearts.

Greggo, Stephen P. ; Lawrence, Karyn

This investigation into the clinical utility of six contemporary depression instruments establishes a foundation for a theologically informed validity subtype. Redemptive validity is defined as 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 as creatures growing in dependence on the Creator. Ancient biblical wisdom argues that helping those with heavy hearts requires compassion, understanding, reflective words, and effective strategies (Prov. 25:20). Clinical settings can assess for depression using technology in as little as 74 seconds with remarkable criterion validity. Do such findings reflect Christian values and worldview? Will results sharpen perception of the faith aspects of a heavy heart in a manner consistent with Scriptural teaching? Depression symptoms may indicate spiritual heart health as a downcast emotional state connected to religious affections (Prov. 13:12). Building upon standard psychometric review, this utility survey displays how mental health clinicians can explore measures through the theological notion of redemptive validity to serve both the mental health needs and spiritual formation interests of clients committed to growth in their Christian lives.

  "Professor, the timing of Assessment and Evaluation conflicts with my
  internship site responsibilities. Is there a problem with taking an
  equivalent course online from a duly accredited institution? After
  all, there is thing actually theological about psychological
  assessment."

Before responding, I breathe and pray silently, striving to filter out rumblings of outrage stirring deeply within. There is an urge to articulate an empowerment vision that calls upon novice mental health professionals (MHPs) who are not psychologists to avoid role marginalization. MHPs should not be passive spectators when it comes to the use of clinically relevant, standardized, and semi-standardized assessment techniques. My reply flows from this growing conviction. "Sarah, let me take you on a tour to display how the good news of the gospel expands our understanding of validity and clinical utility."

This tour explores the relationship between measures that evaluate depression and the biblical admonition to speak wisely to those experiencing unrelenting pain in their innermost being. It commences with this premise. Assessment impacts case conceptualization. Therefore, thinking within the Christian faith begins with assessment method and technique, not treatment planning. The inclusion of a Christian theological worldview into clinical assessment is a multi-faceted and calculated undertaking. Beyond transmission of sound psychometric principles, a Christian orientation to appraisal demands the application of a redemptive lens to the entire undertaking--from instrument selection to implementation. Thus, it seems necessary to formulate a transferable language and process to convey the intricacies of expanding validity discussions into the realm of Christian faith, spirituality, and sanctification. What follows is a demonstration of one such method, which begins with Scripture and consistently applies a theological perspective to the systematic review of measures.

Clinical Discernment and a Heavy Heart

Like one who takes away a garment on a cold day, or like vinegar poured on soda, is one who sings songs to a heavy heart (Prov. 25:20, New International Version). This potent proverb makes its point through the declaration of an absurdity. Antonyms for "absurdity" include prudence, soundness, and sapience. Can one plunge into the absurd to secure wisdom? Both comparisons in the proverb suggest that it is utterly insensitive to offer happy songs to a suffering individual. Would a Good Samaritan rip off a homeless person's ragged jacket during a blistery Chicago winter storm? Would it be kind to concoct a mixture of noxious liquids to offer as aromatherapy? These actions inflict damage rather than bind wounds.

What alarms this counselor educator is that the very instruments that interns train to apply may lure some to sing unseasonable songs to heavy hearts. What a helper reflects as sound and scientific, based upon self-report symptom data, may translate in theological terms to nothing more than absurdity. Looking at depression measures through a theological lens exemplifies the impact of the Christian faith on decisions of clinical utility.

Henry's (1662/1714) classic commentary expounds on this noteworthy saying with perceptive pastoral direction. Those in the midst of great sorrow, whose hearts are burdened, troubled, or agonized, are most ideally comforted by "sympathizing with them, condoling with them, and concurring in their lamentation" (Henry, 1721/1996, p. 557). In a recent commentary, Waltke (2005) notes, "Seasonable songs can be therapeutic, but when sung unseasonably they are painful and damaging to the spirit. The sensitive know how and when to sorrow and when to rejoice" (p. 329). This biblical directive to match healing songs to mood is best taken in context. Proverbs 25 gathers together sayings on exerting self-control over the tongue to avoid provoking interpersonal clashes. This chapter includes the well-known phrase in verse 11, likening a "word fitly spoken" to the beauty of a sculpted golden apple artistically crafted against a background of silver. This is a fine mate to pair with verse 20 (Hughes & Laney, 2001). Counselors strive for suitable words to nurture therapeutic alignment and promote healing while simultaneously spurning phrases prone to inflict harm. Drawing upon the metaphors in this proverb, helpers do well never to remove recklessly a counselee's protective, defensive layers, thus exposing sensitive regions of inner hurt to further injury. In addition, helpers take precautions not to arouse needless images within those who are in sorrow, thus irritating painful controversies or exploiting vulnerable memories. Counselors endeavor to match inflection, mood, and intention with the message to promote restoration.

Proverbs 25:20 contains complex idioms for translation. The most common English translation of the Hebrew expression ra' in this verse is "heavy." In Proverbs 25:20, ra' is used as an adjective, but this word can also appear in noun or verb form. In its adjective form, it translates most often as "bad" or "evil," either in reference to specific actions, words, or thoughts, or more generally as immorality. Much less frequent is its reference to grievous or severe physical pain (Deut. 28:35; Job 2:7). The translation of ra' in Proverbs 25:20 as "heavy heart" points beyond physical pain to emotional discontent or misfortune (see also Neh. 2:1-2). This description denotes a dark covering that substantially alters the mind, emotions, rationality, inner consciousness, and will. Thus, this calamity of one's interior seems to coincide with the modern mental state of depression. Given this biblical perspective, how might contemporary assessment instruments assist or distract Christian counselors in approaching those with depression?

This investigation considers theologically the validity of assessement instruments for counseling that is decidely Christian. Mental health is viewed as a crucial public health concern and depression is one of the most common psychiatric disorders. Thus, depression assessment offers the potential to provide insight into other assessment-related diagnostic and treatment decisions. What proceeds is a template to implement biblical discernment and a procedure to conduct a theologically-oriented assessment instrument review. Vanhoozer (2005) describes the purpose of theology as the application of the canon of Scripture to minister Christian understanding. Thus, the intent of contemplating depression measures from a theological standpoint is to move Christian appraisal toward a canonical understanding of any assessment application incorporated into clinical settings.

Combining Theological and Psychometric Review

A counseling assessment instrument captures a defined data sample, quantifies findings, and places results in a logical format that can be reasonably understood within a defined spectrum. Validity is the psychometric term that addresses what type of inferences can be drawn from a particular test in terms of appropriateness, meaningfulness, and usefulness (American Education Research Association, American Psychological Association, & National Council on Measurement in Education, 1999). An assessment instrument is deemed valid if it actually delivers what it claims. The three major categories of psychometric validity are content (i.e., How well do the items reflect the overall domain?), construct (i.e., How correctly defined and operationalized are the key assumptions underlying the measure?), and criterion (i.e., How well do the scores correspond to related variables or conditions?) (Gregory, 2011; Whiston, 2009).

Beyond this essential trio, there are a range of additional validity subtypes that are frequently of interest. For example, incremental validity is a phrase coined to portray the added value of unique information contributed to the overall appraisal by a particular assessment instrument. If a scale captures information not readily obtained elsewhere, it has incremental validity (Haynes & Lench, 2003). Or, consider conceptual validty, which references the contribution of a measure to the formulation of a comprehensive and coherent description of the person (Groth-Marnat, 2009). Conceptual validity focuses on the person, not the test. A data source is conceptually valid when it contributes to the establishment of a unique hypothesis about the individual (Maloney & Ward, 1976). This theological review proposes a novel category, redemptive validity.

Redemptive validity (RV) is a term to reflect the inferences that can be made from a particular measure that are applicable and/or beneficial to the pastoral and Christian counseling mission of soul care. Redemption is a biblical theme that literally depicts being set free by the payment of a ransom. The essence of Christianity is that through his blood shed on the cross, the resurrected Jesus Christ liberated human beings from the penalty of sin (1 Pet. 1:18-19). Counselors utilize assessment to clarify a clinical conceptualization and establish expectations in order to restore functioning. When pursuing a Christ-honoring helping agenda, grace to promote healing pours out as a divine gift, removing the effects of sin and signaling the Lord's redemptive intent.

In a recent article directed to Christian MHPs and pastoral counselors, Vanhoozer (2010) illustrates the activity of Christian therapists in conjunction with his depiction of theodrama. Christian counselors engage in the God-glorifying mission of training clients to place their mind, heart, imagination, and will in submission to the biblical drama in convenantal relation with the God who speaks and acts. The definition of RV borrows from the language offered by Vanhoozer (2010) to summarize the mission of this soul care activity. RV is the effectiveness of an assessment measure that samples behavior or attitudes to provide insight into wise living in conformity with the reality and truth of Scripture as creatures growing in dependence on the Creator. An assessment measure can be said to have RV if it increases discernment, and furthers our ability to deliberate on and eventually do what it means to be crucified with Christ (Gal. 2:20). In other words, does the assessment instrument reveal aspects of a client's self-narrative that invite reflection from a gospel lens? RV is a cousin to conceptual validity since its emphasis is on the subject rather than the measure and on derived implications rather than the pure purpose of the instrument.

Application of the RV lens in utility review expands conventional psychometric scrutiny. The goal is to weave RV throughout the standard instrument review, looking at this dimension in accordance with established psychometric criteria. Thus, no finite list of RV criteria is proposed. Instead, RV alerts MHPs with a Christian worldview to include a thorough biblical and theological analysis when considering the application of a clinical assessment instrument. MH Ps should ponder personal doctrinal convictions along with the faith tradition of potential clients. Ideas that exemplify such an examination are located under the content, construct, and criterion validity headings as this easily blends with a customary utility appraisal.

Before exploring the faith implications of a psychological tool, it is crucial initially to appreciate both the correspondence and distinctions between a modern diagnostic category such as depression and related biblical teaching. The transposition of Christian worldview concepts with psychological constructs is a matter for detailed consideration (Greggo, 2011; Johnson, 2007; Roberts & Watson, 2010; Watson, 2008). From inside the biblical framework, the phrase heavy heart has a straightforward connection to other undesirable heart ailments such as sorrow (Prov. 15:13-15), sickness (Prov. 13:12), and suffering or affliction (Ps. 22:24--26) (Masri, Smith, Schaller, Smith, & Welch, 2000; Welch, 2000). In Scripture, these undesirable conditions, disturbing the center of human affection, tie in to the presence of sin in the corrupted creation or to the effects of entrenched sin on the activities of fallen creatures formed in the imago Dei (Kilner, 2010). Nonetheless, any humanly contrived association between individual transgressions and a suffering heart is a serious matter that requires the utmost of care (Welch, 2000). Specific causal links attempting to explain a grieving, hopeless, or heavy heart are often beyond the bounds of human comprehension (Job 36-41). Often, simple cause and effect links tend not only to appear blatantly reductionist, but are greeted with suspicion by those enduring suffering and pain.

For a vivid reminder that dedicated believers throughout the centuries have deeply pondered the condition of a distressed heart without a conclusive grasp of the source of the struggle, one can recall the illustration of Bunyan's (1681/1995) Slough of Despond:

  Sir, wherefore, since over this place is the way from the city of
  Destruction to yonder gate, is it, that this plat is not mended,
  that poor travellers might go thither with more security?" And he
  said unto me, "This miry slough is such a place as cannot be
  mended: it is the descent whither the scum and filth that attends
  conviction for sin doth continually run, and therefore it is
  called the Slough of Despond; for still, as the sinner is
  awakened about his lost condition, there arise in his soul many
  fears and doubts, and discouraging apprehensions. which all of
  them get together, and settle in this place: and this is the
  reason of the badness of this ground. (p. 22)

Or, review Lewis' (1940/2001) classic, where the myths and never-ending controversies regarding pain as "God's megaphone" are thoughtfully and compassionately considered (p. 93). The profound questions surrounding the cause of such suffering will continue to be a matter for serious prayer, vigorous Bible study, and philosophical consideration. Nonetheless, pastorally-oriented counseling for the afflicted demands a compassionate and immediate response.

In terms of KV, there are four areas for assessment consideration when faced with a client with a heavy heart. These are additional considerations, not competing spiritual alternatives or substitutions. It would be sorely regrettable if Christian helpers reacted to modern medical categories through the assertion of a hyper-spiritual perspective. Such a response would not produce a balanced, holistic, and sound appreciation of a suffering human created in the imago Dei as a bio-psycho-social-spiritual creature loved by the Creator. These applications are rooted in a Christian theological perspective. First, does the personal story of the client suggest that the symptoms of a heavy heart link to persistent disobedience or rebellion? A repentance perspective consistent with Psalm 51 may apply. Second, could a crucible of suffering produce character change consistent with the fruit of the Spirit (Gal. 5:22-23)? Is this an intensive season for "putting off and on" that would be supported and nurtured via counseling conversation? Consider a perspective regarding character and spiritual growth. Third, is there evidence of a season of purging where there is revision of theological expectations indicating a developmental shift in spiritual maturation? This would indicate a spiritual formation perspective (Coe, 2000). Finally, when attending deeply to the emotional dynamics within the afflicted, are there signals that the innermost affections, attachments, and longings of the heart are being perturbed? Deliberate on how those inner affections are under renewal and evaluate this experience from that standpoint of heart conditioning (Elliot, 2006).

Suffice it to say, both Scripture and Christian tradition contribute substantially to the understanding of any human experience associated with suffering, heartache, and a downcast soul. Seeking relief from this unpleasant condition is consistent across theological and psychological perspectives. However, the viewpoints may differ considerably concerning the resources for relief, the goal of restoration, and the target of redemptive activity. The discussion of particular links between the metaphor of a heavy heart and medical depression fits best under the heading of construct validity, addressed shortly. In laying the methodological groundwork, Proverbs 25:20 serves as the gateway to bring a Christian faith perspective to the foreground as we turn to consider contemporary measurement techniques.

Trends in the Assessment of Depression

Rapid Assessment Instruments (RAIs) expand coverage of the range of information systematically gathered, increase the specificity of symptoms, and establish a tangible baseline of functioning (Fisher & Corcoran, 2007). Digital assessment can provide instantaneous, comprehensive, and ongoing data regarding health symptoms. For example, in a recent German investigation involving 423 patients suffering fromysy-chosomatic and other medical conditions, a computer adapted test for depression (D-CAT) composed of 64 items was administered. The measure was constructed using Item Response Theory (IRT), permitting the processing of only those items immediately applicable to the patient's condition. The findings regarding the efficiency and reliability of the D-CAT were robust, favorable, and promising. Furthermore, patient acceptance of assessment via a personal digital assistant was overwhelmingly positive (Fliege et al., 2009). The finding, however remarkable, is that a reasonable, credible, and scientifically valid assessment of depression can be accomplished in 74 seconds on average. Online depression screenings, such as the one offered by Mayo Clinic, yield similar results and present items in an appealing, succinct, and user-friendly format (Mayo Clinic, n.d.).

Over the past 100 years, the modern psychology therapeutic enterprise has developed nearly 300 measures to detect and describe depression (Santor, Gregus, & Welch, 2006). Assessment methods include self-report inventories, structured/semi-structured interviews, ratings from multiple sources, and direct observation. The goals vary. Nonetheless, the majority of these measures can be placed within the following categories: screening, diagnosis and classification, symptom description and severity, clinical hypothesis testing, treatment planning, prediction of behavior, and treatment outcome (Nezu, Nezu, Friedman, & Lee, 2009). The selection of an appropriate instrument for a particular application is closely tied to the intention of the apprasial and psychometric features.

For this review a handful of depression measures were chosen as representatives to summarize trends. The selection of measures was strongly influenced by reports of clinical usage in Nezu, Nezu, Friedman, and Lee's (2009) review chapter, "Assessment of Depression." The Reynolds Adolescent Depression Scale (RADS II) was added to include a measure designed for an adolescent population. In addition, the Clinical Assessment of Depression (CAD) was incorporated due to its ability to both ascertain symptom severity and monitor significant areas for remediation.

The included measures are the restandardized Hamilton Rating Scale for Depression (GRID-HAMD), the Beck Depression Inventory II (BDI-II), the Zung Self-Rating Depression Scale (SDS), the Patient Health Question Depression Scale (PHQ-9), the Reynolds Adolescent Depression Scale, and the Clinicial Assessment of Depression (CAD). While these instruments differ in terms of psychometric qualities, overall each has sufficient reliability, validity, and utility to support extensive application. For full psychometric reviews of these instruments, see The Mental Measurements Yearbook. Relevant to the present considerations are the distinct applications of these depression instruments. The GRID-HAMD is predominent in psychiatric applications. The BDI-II is perhaps the most widely accessed scale used by MHPs. The SDS has extensive clinical popularity as well as international usage. The PHQ-9 has broad usage in primary care settings. The RADS II targets early detection with a focus on an adolescent population. The CAD offers subscales to fine tune treatment efforts.

Content Validity and Item Analysis through a Christian Lens

This investigation of depression assessments from the perspective of RV relies substantially on previous reviews and research relevant to psychometric critique. Santor, Gregus, and Welch (2006) conducted a comprehensive investigation of over 70 scales developed over the past 80 years. A detailed item analysis was conducted on frequently used instruments to determine the consistency of the operationalization of depressive symptomatology. The investigation of content validity identified specific symptoms included on these measures and established the proportion of items related to mood, behavioral, somatic, cognitive, and concentration symptoms. Santor, Gregus, and Welch (2006) state:

  These findings show that despite being intended as measures of the
  same underlying construct, the degree of variability across measures,
  in terms of the number of items used to assess different symptoms is
  substantial. Results suggest that the symptoms primarily assessed by
  measures of depression are worthlessness, depressed mood, and
  anhedonia, even though oniy depressed mood and anhedonia are
  considered core symptoms of depression. (p. 144)

From a measurement angle, this point is noteworthy because instruments by design reflect an adequate sample of behavior that fairly represents the content domain. Thus, this observation could prompt either a reconsideration of the item pool or the diagnostic criteria for depression. However, from a Christian theological perspective, awareness of the weight given to items measuring worthlessness draws attention for those who interpret the results to an embedded variable in depression measures, namely one related to self-evaluation and self-esteem. Historically and across denominational traditions, Christians are not in theological agreement concerning the consequences of the fall and the effects of sin. This explains why there is no simple way to reconcile psychological and theological understandings surrounding terms such as self-worth, pride, self-centeredness, feelings of inadequacy, and self-acceptance (Cooper, 2003). So, certain Christ-followers may take exception to items that target feelings of worthlessness due to convictions that avoid any appearance of pride or self-elevation. Others might have alternative notions regarding the optimal direction for remediation. This content validity finding intensified curiosity regarding a Christian appraisal, indicating a focused item analysis was necessary.

Items were pooled and coded according to the categories established by Santor et al. (2006) as shown in Table 1. The following descriptions were applied: mood symptoms (i.e., depressed mood and irritability), behavioral symptoms (i.e., suicide and anhedonia), somatic symptoms (i.e., appetite disturbance, sleep disturbance, low energy, and psychomotor retardation or agitation), cognitive symptoms (i.e., hopelessness and worthlessness), and concentration symptoms (i.e., poor concentration and decision-making). Item samples include: "I feel down-hearted and blue" (mood symptoms, SDS), "I feel like hurting myself" (behavioral symptoms, RADS II), "I never have any energy'' (somatic symptoms, CAD), "I feel my future is hopeless and will only get worse" (cognitive symptoms, BDI-II), and "I have great difficulty making decisions" (concentration symptoms, CAD).

TABLE 1

Item Analysis of Depression Assessment Instruments

               BDI-II    CAD   GRIM-HAMD   PHQ-9  RADS II    SDS

Symptom Type    N   %   N   %      n   %    n  %    n   %  N    %

Mood            4  19  14  28     11  17   1  10   10  33   5  25
Behavioral      4  19   9  18     13  20   3  30    6  20   3  15
Somatic         4  19   4   8     29  45   4  40    5  17   7  35
Cognitive       7  33  19  38     12  18   1  10    9  30   3  15
Concentration   2  10   4   8      0   0   1  10    0   0   2  10
Total (N=196)  21      50         65      10       30      20

From a counselor's standpoint, the distinctive emphasis within each measure could be useful for selection. The assessment measure of choice would be the one that offers the best fit with the clinician's conceptualization of depression. For example, assessment measures with disproportionately more items that reflect cognitive symptoms might be preferred by counselors with a cognitive behavioral theoretical orientation (e.g., BDI-II; CAD; RADS II). However, a setting that emphasizes medication might gravitate toward an instrument that specifies a greater number of somatic symptoms (e.g., GRIM-HAMD; SDS).

Consider the newly introduced notion of redemptive validity in conjunction with this item analysis. First, each measure directly assesses depression via specific content concerning the subject's current state of discontentment, discomfort, hopelessness, and physical distress. This indicates that the results represent a tangible description of life areas that are very much in need of the Lord's grace and restoration. A score in the clinical range on one of these measures signals to helpers just how desperately the counselee is in need of basic psychological food, refreshment, rest, and companionship from the Great Shepherd (Ps. 23).

Secondly, the cognitive items address core beliefs for exploration in counseling dialogue. The internalized schemas identified by the items may intersect with theological doctrine, Scriptural principles, or a cultural adaptation of Christianity. For example, consider cognitive items such as "I feel my future is hopeless and will only get worse" (BDI-II) or "I feel that I am useful and needed" (SDS). The beliefs and resulting emotions bound together with these statements have a bearing on how one's personal narrative flows from the grand gospel narrative of creation, fall, and redemption into the daily experience of being a child of God. The cognitive schema surfaced by the item alerts the therapist to matters for exploration as these themes appear in session material. Conversations surrounding everyday assumptions and personal beliefs relating to critical biblical themes such as sanctification, stewardship, and the hope of eternal life may be entirely appropriate and have therapeutic benefit. Beyond this cognitive layer, actual experience of a therapeutic relationship as a genuine expression of Christian community may be the balm that relieves and reconfigures the inner turmoil associated with these cognitions.

Finally, each measure contains specific items that highlight matters regarding substantial emotional turmoil. A common procedure on contemporary measures is to identify critical items that, when answered in a particular direction, necessitate immediate and specific follow-up. Typically, an item identified by the test developer as critical might suggest suicidal thoughts and/or threats to harm self or others. Attention is drawn to these items when the answer suggests a potential risk. In the interest of RV, counselors with Christian worldview convictions may identify items that signal a faith journey concern or a spiritual crisis. For the sake of discussion, let us identify these items as faith sensitive. In other words, it may be useful for Christian counselors who routinely use measures to identify discrete items that tap into core convictions by directly addressing spiritually-laden themes or concepts. Faith sensitive items may offer an entryway to a discussion of theological beliefs and faith practices.

The standard guideline for responsible test interpretation is not to place undue emphasis on any single item or subset of items not established as a distinct scale. Nevertheless, it is common clinical practice to underscore particularly potent items as dialogue starters. These can produce further insight via expanded verbal processing. Consider the items in Table 2. Select items may help stimulate faith and doctrinally-oriented conversation to detect theological distortions or practice applications. Christians who use these instruments may identify items for later query. Since the population served has worldview beliefs associated with Scriptural concepts that may blend into individual responses, items that connect to such beliefs will be useful signposts to direct a way toward further exploration. Consider the potential of items that relate to themes of forgiveness, subjective versus objective guilt, the future, suffering, sin, and revelation (Collins, 2007). These could provide a means to move counseling conversation, when clinically and ethically appropriate, toward one's dependence upon the Lord and/or understanding of Scripture. Beneath the opportunity to minister directly to thoughts and feelings in order to refine faith understanding, the relational aspects of therapy offer a means to stimulate innovative interpersonal connections as the Holy Spirit restores and recreates the heart. MHPs can select from a range of credible spiritually sensitive approaches for treatment that match well with the prominent concern (Aten, McMinn, & Worthington, 2011; Hook et al., 2010; Park & Slattery, 2010; Worthington, 2006).

TABLE 2

Faith-Sensitive Items

Measure    Item

BDI-II     I feel that I am a total failure as a person.
           I feel quite guilty all of the time.
           I feel I am being punished.
           I blame myself for everything bad that happens.
           I Feel utterly worthless.

CAD        No one seems to care about me.
           It feels like no one loves me.
           I feel like I am being punished.
           My life has no meaning.
           It seems that there is no hope for me.
           I feel like a complete failure.

GRIM-HAMD  How guilty have you been feeling this past week?
           Do you feel that your depression is a punishment for
           something bad you've done?
           Have you been hearing voices or seeing visions in the
           last week?

PHQ-9      You are a failure or have let yourself or your family
           down.

RADS II    I feel that no one cares about me. I feel loved.

SDS        I feel hopeful about the future.

Construct Validity: Aligning Depression and a Heavy Heart

A heavy heart is a biblical phrase that can be of use in contemporary Christian helping. A heavy heart describes the personal state in which sadness, grief, and/or ongoing suffering diminishes the anticipation of hope to such a dramatic extent that one has a palpable sense of separation from the previous experience of connection with God, others, and even self. The most familiar term in ordinary language for an affective condition of sadness, hopelessness, and being in a persistent or particularly down mood is depression. Increasingly, there is an association between any common language terminology that classifies a stubbornly persistent dark mood and depression as a medical condition (National Institute of Mental Health, n.d.). This is evidence of the "medicalization" of the human phenomenon of the state of living with a heavy heart. In a medical diagnostic context, depression is a classification of a legitimate illness. Depression reaches the threshold of being a medically defined mental health disorder when a person's low mood interferes with general functioning, physical well being, and interpersonal relationships (4th ed., text rev.; Diagnostic and statistical manual of mental disorders; American Psychiatric Association, 2000).

The assumption in this endeavor is that these divergent terms, depression and a heavy heart, admittedly distinct in derivation, usage, and precision, do actually represent an overlapping set of human psychological and affective states. The construct validity concern revolves around how the depiction of this human experience portrays the overlap. For the sake of pursuing the RV of assessment measures, this intersection from a theological perspective is vital.

Everyday language is so medically infused that the standard contemporary view of depression and a heavy heart could not be depicted as synonymous. An implicit assumption is made as language shifts from the general description of a metaphysical heart condition to a physical illness uncovered through the application of scientific instruments. The physical, chemical/neurological aspect of the human distress is granted priority. A client reference to a spiritual concern with a corresponding dark affective experience could be viewed as a faith crisis within the experience of depression.

Science explains the spiritual dilemma resolve the medical concern of depression and spiritual vitality is likely to return. From the vantage point of RV, this overlap of constructs with a dominant medical view could stir misguided interventions. What if the heavy heart experience is not solely a disturbance requiring remediation? This affectively painful experience may be related to a transition in re-creation or an adjustment in expectations in one's relationship with the Lord. This would capture a phrase used in spiritual direction, "dark night of the soul" (Coe, 2000, p. 293). In this instance, it would not be appropriate to apply a treatment approach that is limited to medication or the target of somatic symptoms. This type of heart condition, signaled by the clogging of negative affect, would benefit from solace within Christian fellowship, pastoral support, and Spirit-directed, Scripture-saturated, soothing comfort. The affective experience may be unwanted, overwhelming, and dark, yet it could be the doorway to a new phase in one's relationship with the Lord.

Counselors with Christian worldviews would do well to conceptually flip the way the constructs of depression and heavy heart are generally understood. The mental health condition of depression is a particular subheading of the broader biblical reference to the experience of a heavy heart. The psychiatric, technical description of depression as a bio-psycho-social disorder is thus a subtype of a broader bio-psycho-social-spiritual condition. This distinction is essential when exploring the of depression assessment because it maintains the integrity of these related and layered constructs.

Depression measures supply a quantitative description of an unwanted, disconcerting, and intense human experience. Since the language of depression is rooted in a medically-oriented worldview, there are assumptions regarding etiology and treatment that go beyond basic operational definitions (Welch, 2000). Therefore, it would be problematic to assume all experiences of a heavy heart are predominantly a mental health concern. There are alternative plausible explanations that offer different destinations for hope. Depiction of depression as the overarching conceptual framework is an example of medical reductionism. Such a practice, no matter how subtle or well intended, favors treatments that address symptoms primarily of medical concern. The clarification of language between these corresponding human experiences actually supports the construct validity of the reviewed depression assessment instruments. These instruments measure what they purport: a medically relevant, mental health condition. Christian helpers under the ministry of the Holy Spirit seek to be sensitive and sympathetic when ministering to individuals with hearts that are discouraged, despondent, and unnaturally burdened (Welch, 2000). However, conceptualizing all experiences of a heavy heart within a strictly medical framework increases the risk of singing an unsympathetic song to a heavy heart (Prov. 25:20). In terms of RV, Christians who utilize these instruments need to maintain clarity regarding a holistic and theologically consistent appreciation for the central condition of the human heart. The journey of the human heart follows a path of longing to secure rest in the grace of our Creator. Our role is to consider whether the self-report data on a depression measure contributes to a more detailed understanding of the central condition of the human heart or reveals ways that core affections may need to further rest in the grace of God. The implications of this discussion of construct validity become evident as the conversation proceeds to the matter of criterion validity.

Criterion Validity: Exploring Matters of the Heart

Assessment instruments for depression are constructed well if there is correspondence between the assigned score and the actual mood. This is tested for criterion validity purposes by determining how accurately the assessment measure anticipates the clinical appraisal of a trained clinician. Another method of establishing criterion validity is through the investigation of concurrent validity, or correlations with other established instruments known to detect the same underlying construct. The instruments selected for the item analysis in this review display adequate validity in this area.

A Christian conceptualization of the overall condition of the heart may enhance treatment, thus resulting in effective care. By implication, when using depression assessment instruments, supplemental information should be obtained to frame a comprehensive, holistic, and gospeloriented perspective. Clients who have indicated a desire for counseling that adheres to a Christian theological framework certainly deserve to have this expanded criterion perspective included in any collaborative treatment planning.

The Psalmist states firmly that a "broken spirit," as reflected by a broken and contrite heart, can actually be a desirable, favored condition that is welcomed by the Lord when offered as a sacrifice (Ps. 51:17). Submission, dependence, worship, and adoration are the means to a clean heart, restored spirit, and rejuvenated joy. The context of this particular Psalm suggests that the internal suffering is associated with personal transgression.

Other wisdom passages note alternative causes for heart infirmities such as the undermining, delay, or destruction of hope (Prov. 13:12). Hope is central in promoting heart health, but can be shattered through loss, abuse, betrayal, abandonment, financial ruin, persistent stress, delayed or denied dreams, or the physical groaning of a decaying body. Human beings are best described in reference to layered, hierarchical orders: biological, psychological, ethical, and spiritual. A holistic biblical view does not permit any of these layers to be viewed in independent operation. According to Christian psychology, soul care that addresses the lower orders can bring glory to God, yet Christian helpers aim to intervene at the highest level possible to stimulate ethico-spiritual change (Johnson, 2007). Johnson (2007) specifically references depression as an example of both the necessity and advantage of working with the lower orders without losing sight of the higher. No matter what forces converge to provoke the onset of a heavy heart, movement toward biblical wellness or shalom will likely forge a transition in one's relationship with the Lord. When trust is strained or shattered, faith is genuinely stretched. Feeling better aligns with the process of sanctification.

Essentially, the theologically astute Christian MHP will not seek to attune alone to the sigh of the heart in agony, but also to the hopeful breath of the Holy Spirit. The Comforter is available to refresh while guiding purposeful reformation and transformation in the midst of adversity. If the oppressed can no longer sense his presence, our helping function is to come alongside and represent accordingly.

Conclusions and Recommendations

Let us return to the opening assumption posed by the inquiring MHP student. Is it necessary to cultivate a theological perspective on psychological assessment? The core notion of validity considers what a measure intends to measure and how the information it produces is useful to a clinician (Groth-Marnat, 2009). Thus, when the therapeutic effort seeks to represent a Christian worldview, there are critical theological implications when selecting and using psychological measures. For ease of communcitation and to promote suitable Scriptural reflection during measurement selection, a theological validity lens has been proposed.

RV examines the effectiveness of an assessment instrument to sample behavior or attitudes to yield insight into wise living in conformity to the reality and truth of Scripture as creatures growing in dependence on the Creator. Stated differently, to what extent and in what way does the information gleened from the measure contribute to a fuller understanding of the state of the person as a bio-psycho-social-spiritual being from the vantage point of the good news of the gospel? What is gained by the measure to support the redemptive work of the Holy Spirit?

For the sake of demonstration, a sample assortment of standardized measures used to assess depression underwent an expanded utility review. Increased use of such instruments via technology can be anticipated in psychiatric, medical, primary care, and mental health settings. Furthermore, the general public has direct access to variations of these question sets via reputable outlets and may appear for treatment self-diagnosed (Mayo Clinic, n.d.). Self-report data is subject to a number of potential contaminating influences. Nonetheless, if the measures have adequate psychometric strength and are utilized responsibly, there is good reason to attend to obtained results. Counselors with Christian theological convictions are not forced to reject the results of such assessments due to worldview differences. Counselors may elect to adopt similar measures into routine practice to aid in the conceptualization of a client's behavioral, affective, and physical experience. It is necessary that Christians who counsel not succumb to the overwhelming cultural trend to "medicalize" the diverse experience of a heavy heart into the singular category of clinical depression. Assessment instruments aimed to discern the presence of depression meeting the conditions of an actual mental health concern may increase the risk of adopting this relevant but limited view.

When evaluating clinical instruments from the vantage point of RV, helpers are directed to follow the usual psychometric review procedures to determine utility by initially considering the published information regarding content, construct, and criterion validity. Instruments exhibiting reasonable validity characteristics are appropriate for clinical use. Each domain can be further evaluated through the lens of Christian doctrine as informed by Scripture and theology. The Clinical Assessment Instrument Christian Evaluation Form (CAICEF) was designed to guide this procedure and is available from the first author. Particularly for MHPs invested in a Christian worldview who have limited academic exposure to psychological appraisal, a grid for psychometric review that includes the notion of RV may be useful. Consider these four sample RV items from the CAICEF.

* Does the assessment instrument reveal aspects of a client's self-narrative that have implications for Christian identity and/or spiritual development?

* Does the assessment instrument contribute to a more detailed understanding of the central condition of the human heart or reveal ways that core affections may need to further rest in the grace of God?

* Does the assessment instrument provide insight into life issues or existential matters that reveal personality or character concerns that are an indication of areas for potential growth in spiritual development?

* Does the assessment instrument measure behaviors, attitudes or beliefs that Scripture directly addresses?

The end result of assessment well utilized is a more nuanced view of the client's quantified experience that can eventually be incorporated into a broad, comprehensive, and Christian appraisal of the condition of the heart. The prayer of the Christian helper is to discern how the Holy Spirit is engaged in redemptive, restorative, and recreative activity.

It would be absurd to conform to the world and adopt a Creator-less view of human experience. A well-formed medical perspective of depression may be instrumental in developing a plan for relief. Yet, it may be limiting if the Holy Spirit's intention is renewal. Our song to hearts that yearn for hope and refreshment must be in harmony with the cry of their soul and the melody of the Holy Spirit. May the Lord grant us ears to hear, voices that soothe, and hearts that strive to obtain Scripture-based wisdom.

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Author Note

GREGGO, STEPHEN P. Address: Trinity Evangelical Divinity School, 2065 Half Day Rd., Deerfield, IL 60015. Title: Professor of Counseling at Trinity Evangelical Divinity School. Degrees: BA, Psychology, Sociology; MA Theology, Denver Seminary; PsyD, State University of NY at Albany. Specializations: Pastoral and Christian Counseling; Groupwork and Assessment.

LAWRENCE, KARYN L. Address: Trinity Evangelical Divinity School, 2065 Half Day Rd., Deerfield, IL 60015. Title: Mental Health Counselor Intern. Degrees: BA, Psychology, Sociology, University of Wisconsin-Madison; MA, Mental Health Counseling, Christian Studies, Trinity Evangelical Divinity School. Specializations: Mental health counseling.

An earlier version of this paper was presented on November 17, 2010, at the 62nd Annual Meeting of the Evangelical Theological Society, in Atlanta, Georgia.

Stephen P. Greggo and 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, Deerfield, IL 60015. E-mail: [email protected]